A new government report concedes that vehicles are the most prominent source of pollution within Delhi, and that the mandatory pollution-under-control (PUC) certificates are not a true representative of emissions.

DELHI – India’s Commission for Air Quality Management (CAQM) has identified the main sources of Delhi’s severe air pollution and admitted that there are critical gaps in current control measures, in response to a deadline set by the Supreme Court. 

The report, completed in a fortnight, synthesises findings from multiple research institutions to create the first unified assessment of what is polluting the capital. 

The Supreme Court-mandated report reveals that the city’s main air pollution sources are: transport (23%), secondary particulates (27%), and dust (15-27%). Winter PM2.5 levels are 35 times the World Health Organization (WHO) guidelines, despite decade-long efforts.

The report comes after the Supreme Court criticised CAQM on 2 January, for delays in identifying causes and finding long-term solutions to Delhi’s “worsening” air quality.

What sets this report apart from earlier studies is that it synthesises previous assessments to arrive at one unified set of numbers. The agency achieved this by bringing together researchers from government agencies, Indian Institutes of Technology, research institutes, NGOs and think-tanks.

The Chief Justice of India criticised the CAQM earlier this year, saying that it “appears to be in no hurry either to identify the causes or to find long-term solutions” to Delhi’s pollution.

The court added that the CAQM is obligated to bring domain experts together to arrive at a uniform and unanimous opinion on the causes of the “worsening” air quality.

Government concedes major gaps 

The CAQM’s report is also significant because it concedes several critical gaps in Delhi’s pollution control efforts. These range from conceding that PM2.5, or fine particulate matter pollution, is the “worst” pollutant to accepting that the pollution-under-control (PUC) certificates don’t check all key pollutants emitted by vehicles.

The panel included experts from government institutions as well as independent research organisations, including the Centre for Study of Science, Technology and Policy (CSTEP), Council on Energy, Environment and Water (CEEW), Urban Emission, Centre for Science and Environment (CSE) and The Energy and Resources Institute (TERI). 

The report has released two important data sets. The first shows that there has been a decline since 2016 in the annual average level of PM2.5. But the trendline (in blue in the chart below) has been almost flat since 2019, the year that the Indian government launched the National Clean Air Programme (NCAP).

Delhi’s PM2.5 air pollution has hovered around 100 micrograms per cubic metre for the last seven years, which is 2.5 times India’s safe standard but 20 times the WHO’s safe guidelines.

Source: Based on data from CAQM

Main sources of Delhi’s air pollution

Delhi’s air pollution in winter and summer is starkly different, with winter pollution being more than twice as severe.

The largest contributor to Delhi’s winter PM2.5 pollution is secondary particulate matter (27%), tiny particles formed in the air from gaseous emissions from vehicles, industries, and biomass burning.

Among primary sources, transport vehicles contribute 23% while biomass burning, including burning solid fuels for cooking and warmth and crop residue burning, adds 20%. Dust from roads, construction, and demolition accounts for 15%, and industrial emissions contribute 9%.

In summer, dust becomes the dominant source, causing 27% of PM2.5 levels, driven by dry conditions and construction activity. Transport contributes 19%, secondary particulate matter causes 17%, and industrial emissions rise to 14%. Biomass burning drops to 12% during this period.

Source: CAQM, Delhi

Delhi’s average winter PM2.5 concentration is 178 micrograms/m³, which is more than 35 times the WHO safe guideline of 5, and over four times India’s national standard of 40. Summer levels average 73, which is still nearly 15 times the WHO guideline and almost double the Indian standard. Data is based on 2021-2025 measurements.

However, CAQM says that the number of days where pollution was below the daily national standard of 60 micrograms has increased from 97 days in 2018 to 156 in 2025.

Why is transport so high?

The report points out that transport “repeatedly emerges as the most prominent pollution source within Delhi”. The transport source category includes off and on-road vehicles; petrol, diesel and CNG-powered vehicles.

There are several sources and reasons for vehicular pollution being so high:

  • Older fuel standards: Bharat Stage (BS) 4, 3, 2, 1 and pre-BS vehicles are more polluting than the latest, BS 6 standard.
  • Older vehicles: Particularly those operating beyond their regulatory lifespan of 10 or 15 years – for petrol and diesel respectively – are more polluting due to engine deterioration and compromised emission control performance.
  • Fuel type: Diesel vehicles are a major source of particulate matter and oxides of nitrogen and sulphur, whereas CNG vehicles predominantly emit oxides of nitrogen.
  • Traffic congestion: Pollution is determined not just by technology but also by driving conditions. Congested and slow-moving traffic leads to inefficient combustion, resulting in higher emissions per vehicle, whereas operation at optimal speeds enables more efficient combustion and lower emission rates.

Government admits critical gaps 

Significantly, the report concedes several gaps in controlling pollution. Presenting these gaps in a report for the Supreme Court is important because these have rarely been acknowledged at such a high level.

First, the report admits the current pollution checks or PUC certificates are “not a true representative of emissions” as they don’t measure particulate matter pollution – although this has been cited repeatedly by the Delhi local government as a measure that controls pollution.

Second, it accepts that PM2.5 is the most prominent pollutant that determines Delhi’s air quality index (AQI). This is in sharp contrast to the NCAP, which prioritises the reduction of PM10, not the more lethal PM2.5. Delhi government also has a push to reduce PM10, primarily dust, through the use of hundreds of expensive water sprinklers.

Third, the report says that data on the sources of pollution in Delhi’s larger neighbourhood (NCR) is sparse, so the report’s meta-analysis is taken as indicative.

Fourth, the supply of grid electricity across Delhi’s neighbourhood is “unreliable” which is why the use of diesel generators (DG) has increased substantially. It calls older or poorly maintained DGs “super-emitters” and warns that they result in direct, ground-level exposure to emissions.

Around 6 to 11% of Delhi’s air pollution is caused by “other” sources. These include cremations where wood is used, hotels and restaurants which use solid fuels like wood and coal, aircraft emissions during taxiing, landing and take-off, and brick kilns in and around Delhi.

Depending on the season, they are equally dangerous because they create local hotspots close to residential areas. These are a significant challenge because the CAQM says these are highly sensitive to enforcement.

What’s the plan to cut Delhi’s pollution?

The CAQM has asked four institutes, three of them government-backed, to develop a new emission inventory – a database of how much pollution is being pumped into the air and from which sources.

This study will be led by the Automotive Research Association of India (ARAI), which may raise some questions about a conflict of interest. While the association is under the government’s administrative control, many ARAI officials and members are from major vehicle manufacturers. Given that vehicles are a significant source of pollution, this could compromise ARAI’s ability to assess vehicular pollution. 

The other three institutes are IIT-Delhi, the Indian Institute of Tropical Meteorology (IITM, Pune), and The Energy and Resources Institute (TERI).

Air pollution beyond Delhi

This new push by the Supreme Court to improve Delhi’s air quality could have lessons for the wider area of north India or the Indo-Gangetic Plains (IGP), which the CAQM calls an emissions hotspot. This is 18% of India’s landmass, home to 40% of the country’s 1.4 billion population, and accounts for 35% of the emissions.

A still wider picture comes from the World Bank’s new report, A Breath of Change: Solutions for Cleaner Air in the Indo-Gangetic Plains and Himalayan Foothills. 

Almost a billion people across five countries – Bangladesh, Bhutan, India, Nepal, and Pakistan – live in this area, and around one million people die prematurely every year from polluted air. 

The World Bank calls for regional cooperation, which is easier said than done in one of the world’s most geopolitically sensitive neighbourhoods.

India’s capital is roughly in the centre of this region. Fixing Delhi’s air can provide a template and impetus to go big.

Image Credits: Chetan Bhattacharji.

IGWG co-chair Matthew Harpur and WHO Assistant Secretary General Dr Chikwe Ihekweazu.

The World Health Organization (WHO) negotiations on the world’s first Pathogen Access and Benefit Sharing (PABS) system resumed in Geneva on Tuesday – with only two more weeks of formal negotiations left before the May deadline.

Symbolically, this week’s talks resumed on the first anniversary of US President Donald Trump’s announcement that his country would no longer be part of the WHO, and amid a flurry of US bilateral agreements with African countries that exchange health aid for access to pathogen information – posing a direct challenge to the PABS system being negotiated.

Over the next three days, WHO member states will hold a series of informal and formal talks focusing mainly on the scope and objectives of the PABS system, use of terms and governance issues.

Dr Chikwe Ihekweazu, WHO Assistant Director-General for Health Emergencies, told the meeting at its start on Tuesday that the negotiations are a priority for WHO.

“In an ever-divided world, we are guardians of public health, and we need to protect it from politicisation,” said Ihekweazu.

“The future of multilateralism depends on the very discussions you have in this room over the next few months. Let the determination that led you to adopting the [Pandemic] Agreement see you through this week successfully.”

Crunch time

While acknowledging that divergent views were still evident in the informal meetings held over the past few weeks, “I do see a lot of positive movement that I think we can be very proud of”, he added.

“It’s no secret that crunch time has started, and before we know it, the [World Health Assembly] will be upon us. After this week concludes, you will be left with around two weeks of formal meetings. Please use every minute and use the informal period to iron out the differences that persist and come closer together on landing zones.”

A PABS system would set out how to share pathogens and their genetic information, along with any benefits that may arise from their use, including the development of vaccines and medicines. 

Meanwhile, the US has signed 15 MOUs have been signed with African countries – the latest being with Malawi on 14 January. The agreements provide opportunities for US companies to provide logistics, data, and supply-chain support and several have been concluded alongside trade agreements.

The MOUs are the precursor to five-year grants that involve a rapid transfer of responsibility for domestic health programmes from the US to donor countries from year two of the agreement.

Protestors gathered outside USAID headquarters in Washington DC in March after employees were informed via email to not come in to work.

One year ago today (20 January), the Trump administration exploded the global health sector by immediately “pausing” all aid for 90 days – and dispensing with 83% of US Agency for International Development (USAID) projects six weeks later.

Trillionaire Elon Musk and his Department of Government Efficiency (DOGE) “chainsawed” at USAID projects and contracts, folding the fractured remains of the agency that once saved millions of lives into the US State Department, which has little expertise to manage global health projects.

US Secretary of State Marco Rubio and Musk claimed that life-saving projects were exempted from the waiver, but this is simply not true.

The US President’s Emergency Plan for AIDS Relief (PEPFAR) supported some 20 million people on antiretroviral medicine.

After the “pause” was announced, HIV clinics across sub-Saharan Africa were issued with immediate “work stop” letters and closed within days as they had no money to pay staff, cutting people off from access to antiretroviral medicine. 

Dr Tedros Adhanom Ghebreyesus, the World Health Organization (WHO) Director General, described the US actions as the “greatest disruption to global health finance in memory”, “sowing chaos”, threatening to roll back decades of progress on infectious and neglected diseases.

Elon Musk brandishing a chainsaw given to him by Argentinian President Javier Milei (right) to cut US government programmes. Despite bragging that he had saved the US government billions, most of his claims were untrue, according to a New York Times investigation.

Death tracker

To date, 757,314 people – the majority children – have died from the funding cuts, according to ImpactCounter, which tracks the effect of USAID cuts via sophisticated modelling tools. That is 88 deaths every hour.

Modelling the effect of the 90-day pause on HIV in sub-Saharan Africa, ImpactCounter estimates that 159,000 adults may have died in that region alone as a result of the suspension of aid by USAID and PEPFAR. 

There are also almost a million more malaria cases, over 700,000 affecting children, due to aid cuts.

What was also untrue was Musk’s claim that DOGE had saved the US government $1trillion by last October. 

Of DOGE’s published list of cancelled contracts and grants, the 13 biggest were all incorrect, according to the New York Times. The top two were Defence Department contracts worth $7.9 billion that have not been terminated.

WHO withdrawal

One year ago, Trump also withdrew the US from the World Health Organization (WHO). To date, the US has failed to pay millions in membership fee arrears, breaking an agreement it struck with the WHO back in 1948.

In 2023, the US contributed around a quarter of WHO’s budget in both assessed (mandatory membership fees) and voluntary contributions. Thus, its withdrawal severely disrupted the work of the WHO, which had to spend the past year whittling away at staff and programmes to make ends meet. It is still 25% short of the 2025/26 budget.

As WHO Director General Dr Tedros Adhanom Ghebreyesus has said several times, it is a country’s right to stop funding organisations and programmes, but this needs to be done in a “planned and orderly way” to minimise service disruptions.

The US withdrawal from WHO also meant that the Global Polio Eradication Initiative no longer had access to the US Centers for Disease Control (CDC) specialised polio laboratory, and had to find other labs to test for polio.

In addition, the US pulled its support for UNAIDS, which lost almost 80% of its project funding.

The Heritage Foundation, which authored Project 2025, the governance blueprint being followed by the Trump administration, asserted in 2023 that HIV/AIDS is “primarily a lifestyle disease”,  “except in cases of rape or maternal transmission”.

This appears to be informing the position of the Trump administration, as it has shifted its approach to HIV to focus on mothers and babies.

‘America First’ Global Health Strategy

US official and former DOGE leader Brad Smith (right) at a meeting to discuss a bilateral agreement with Kenya. Smith has been leading the implementation of the new ‘America First’ Global Health Strategy.

Last September, the US State Department published its America First Global Health Strategy to replace PEPFAR and USAID. The strategy is focused on making “America safer, stronger, and more prosperous” via bilateral memorandums of understanding (MOUs) with previous aid recipients.

At around that time, the US State Department also extended “bridging finance” to some PEPFAR recipients who had been left in crisis for eight months following the aid freeze and subsequent closure of USAID.

These MOUs make health aid contingent on recipient countries agreeing to provide the US with rapid access to information about any “novel and emerging infectious diseases with epidemic or pandemic potential”. This is a direct challenge to the WHO’s Pandemic Agreement, the final piece of which – about pathogen access and benefit-sharing – is currently being negotiated in Geneva.

So far, 15 MOUs have been signed with African countries – the latest being with Malawi on 14 January. Several have been concluded alongside trade deals, while others – including with Zambia and the Democratic Republic of Congo (DRC) – have been delayed until the US gets more favourable access to their minerals.

The agreements provide opportunities for US companies to provide logistics, data, and supply-chain support.

The MOUs are the precursor to five-year grants that involve a rapid transfer of responsibility for domestic health programmes from the US to donor countries from year two of the agreement. However, part of the responsibility countries will have to shoulder is a large network of epidemiologists, data capturers and laboratories to meet the US demand for rapid information about pathogens.

An extract from the US-Kenya MOU.

Non-governmental organisations (NGOs) that were previously key to community outreach and service provision are not mentioned in the MOUs, and the most recent agreement with Malawi notes that the MOU “marks a critical shift away from parallel NGO delivery systems and the healthcare workforce structures they created, restoring responsibility for those resources to the national government”.

However, in the MOUs with Nigeria and Uganda, Christian organisations delivering health services are specifically mentioned as key to the agreements.

The MOUs have been concluded in haste, with vague disease targets, as countries’ PEPFAR bridging finance runs out on 31 March, and the new MOUs are supposed to kick in on 1 April.

Silver lining: Rejection of aid dependency

While many African countries, in particular, will struggle to take full responsibility for health service delivery, the withdrawal of US assistance has seen a renewed call from several African leaders to move away from aid dependency.

Ghana’s President John Mahama welcoming delegates to the Africa Health Sovereignty Summit in August.

On average, African Health Ministers only have $40 per capita for health expenditure and only two countries reached a goal set in 2001 for countries to spend 15% of their budgets on health.

Several African initiatives have developed from the aid crisis, starting with a High-Level Health Financing Conference in Addis Ababa last February, hosted by Rwandan President Paul Kagame, the African Union’s (AU) Champion on Domestic Health Financing. This discussed alternative domestic sources of health funding, and has since resulted in a ministerial group on this issue.

In March, Africa CDC launched a new financing guide for member states, which will focus on “updating national health financing plans in 30 countries, piloting innovative revenue mechanisms, and launching transparency dashboards”.

In parallel, Wellcome Trust hosted a series of regional meetings and papers on global health reform, which map out how to move away from aid dependence to “a sustainable and equitable global health system that supports a healthier future for everyone”.

Image Credits: Reuters Youtube.

Student midwife preceptors proudly display their certificates after completing a one-week leadership training course at Makeni Government Hospital.

When I first stepped into a maternity unit in a government hospital in Sierra Leone as a Seed Global Health midwife educator, I was met by a group of student midwives from different training institutions. 

Mostly women, some held onto their notebooks and avoided eye contact. Many were transitioning from nursing into midwifery, while others had entered the profession directly. 

When I asked why they had chosen this path, only a few spoke softly about saving mothers and newborns. Most remained silent. 

During clinical rounds, their eagerness to learn hands-on skills was clear, yet limited access to skilled preceptor midwives left mentorship gaps, disconnecting theory from confident, evidence-based care at the bedside.

At the same time, my interactions with local health workers revealed a country deeply committed to transforming maternal and newborn health. 

Between 2020 and 2023, Sierra Leone’s maternal mortality ratio fell from 443 to 354 deaths per 100,000 live births, progress that I believe reflects a growing investment in the health workforce and in midwifery in particular. 

Bold policy choices

At the heart of this progress are bold policy choices. In 2023, Sierra Leone enacted the Nursing and Midwifery Act, established the Sierra Leone Nursing and Midwifery Council, and set an ambitious goal to add 3,000 midwives to the workforce by 2030. 

These steps formally recognized midwifery as a profession and created a stronger foundation for training, regulation, and professional growth. As someone who came to Sierra Leone eager to support midwives, I felt deeply encouraged by the country’s commitment and the momentum that was already building.

As a midwife educator, I have seen how this commitment is taking shape on the ground. Together with Seed Global Health, the Ministry of Health, and our partner midwifery schools, I work to strengthen midwifery education so that graduates are confident and practice-ready from day one. 

Seed has committed to training 1,100 midwives and to supporting innovations that improve the quality of both teaching and clinical mentorship.  

One of the most impactful of these innovations is midwifery “preceptorship”, a concept I was introduced to in Sierra Leone. This is a structured mentorship model that pairs experienced midwives with students and newly qualified practitioners to strengthen skills, confidence, and compassionate care at the bedside.  

Skill gaps

There are gaps in the clinical skills of both graduating and practicing midwives, as highlighted in the State of the World’s Midwifery Report (2021). These gaps include the ability to respond quickly and effectively to obstetric emergencies, provide safe and attentive care after birth, and perform essential lifesaving hands-on tasks with confidence. 

These skills gaps cause delays in recognizing complications, inconsistent support during labor, or lack of confidence in critical procedures, which put lives at risk. Programs like preceptorship and continuous mentorship are fundamental in elevating the quality of services mothers and newborns receive.

Preceptors are experienced midwives who mentor and guide students and newly qualified midwives, helping them translate theory into practice and grow in confidence at the bedside. Their role goes beyond supervision; they nurture critical thinking, compassion, and professionalism in the next generation of health workers. 

I see preceptorship contributing to a revolution that is emerging within Sierra Leone’s health system and shaping the future of midwifery and maternal and newborn health.

Building confident, competent care

Lilian Nuwabaine mentors a student midwife preceptor during a hands-on simulation on breech delivery at the Makeni School of Midwifery.

A key part of my work is teaching preceptorship, ensuring experienced midwives are equipped to mentor students effectively. By collaborating with faculty, preceptors, and students alike, this approach ensures that no student learns in isolation and no midwife works without guidance, helping build a confident, competent maternal and newborn health workforce. 

Unlike before, when students often had to observe passively or learn by trial and error, the preceptorship model provides structured mentorship, feedback, and opportunities to apply classroom knowledge in a supportive environment.

During a daytime shift in the labour ward last year, I watched a student midwife hesitate at the bedside of a woman in active labour. She knew the steps for monitoring labour using the labour care guide, but her hands trembled as she decided what to do next. 

Before preceptorship, moments like this often ended with students stepping back to observe. This time, a Seed-trained preceptor stood beside her, asking gentle guiding questions and encouraging a systematic assessment, documentation, and reassurance of the woman in labour. I watched with pride as the student completed the assessment, identified slow labour progress, and escalated appropriately.

Bridging the gap

 With their wealth of experience and training in both clinical excellence and teaching, preceptors bridge the gap between classroom learning and real patient care. They model respectful, compassionate care on the ward, ensuring that by graduation, students are confident and practice-ready from day one. 

Preceptors also mentor in-service midwives, continuously strengthening the quality of care through both practice and teaching.

The ripple effect of this training is transformational. Training and growing the midwifery workforce means more midwives and better outcomes for mothers and newborns in Sierra Leone.

To date, 20 preceptors have been trained in Sierra Leone and another 40 have just completed a one-year preceptorship program across Seed’s three partner schools in the country. 

The preceptorship training program has recently been granted diploma status by the Ministry of Health, and the potential maternal health gains from this development are immense for Sierra Leoneans. 

The move signals a national commitment to strengthening the country’s maternal health workforce and accelerating progress toward its goal of training more midwives to close workforce shortage and care gaps.

Positive impact

I have already witnessed positive maternal and newborn outcomes as a direct result of the midwife preceptorship program. Recently, during the morning briefing where maternity staff gather and night staff present patients’ conditions with a focus on critical cases and how they were managed, gaps identified and action points proposed, a loud bell rang signaling an emergency. 

A pregnant woman had been rushed in from the antenatal clinic, convulsing. The atmosphere shifted instantly; urgency filled the room. I assisted while watching our midwife preceptees and preceptors take charge with calm confidence. 

Two of the midwife preceptees gently positioned the woman on her left side to protect the airway, then put two large-bore cannulas, while another quickly checked her blood pressure and called out the reading. 

Under the guidance of one of the preceptors on the drug, dose, route and duration, one of the student midwives got magnesium sulphate, drew it up and administered it to manage convulsions and oxygen was applied. 

With additional, systematic measures taken step by step, they stabilized the mother, who was suffering from eclampsia. Each of these preceptors had undergone training not only in clinical skills but also in how to respond, teach, and lead under pressure, and it was evident in how they were able to act swiftly and save the mother and her baby. 

Moments like these reminded me that preceptorship is not a luxury; it is a necessity because it saves lives.

Looking ahead

Like Sierra Leone, my home country of Uganda faces challenges with clinical midwifery education, midwifery mentorship, and a shortage of highly skilled midwives, while those in service often work with limited resources to provide optimal care. 

They also face emerging health conditions linked to the impacts of climate change, further straining their ability to deliver quality services to mothers and newborns. 

I would like to see the preceptorship program replicated in Uganda and other low-resource countries. This way, more midwives would be trained, upskilled, and empowered to adapt to the daily health challenges such contexts encounter, ultimately saving more lives.

My experience here in Sierra Leone shows me that across sub-Saharan Africa, a quiet revolution is taking shape, one driven by skilled health workers who, with the right training, resources, and opportunity to flourish, can transform care from the ground up. 

Their impact is redefining what health systems can achieve when health workers are prioritized and invested in. When health workers thrive, health systems do too.

Every day, I’m reminded that preceptorship is more than a program. It’s a lifeline that empowers midwives, strengthens care, and helps ensure safer, more positive birthing experiences for mothers. 

Watching this transformation unfold is deeply fulfilling for me as a midwife educator.

Lilian Nuwabaine is a midwife educator in Sierra Leone and recipient of the 2025 Episteme Award, an international award from the Sigma Nursing Society presented to a nurse scientist* or team of nurse scientists for highly significant research, acknowledging a breakthrough in nursing knowledge development that impacts the underserved.

 

 

Image Credits: SEED.

Chimamanda Ngozi Adichie at the Dior Haute Couture Spring/Summer 2020.

LAGOS – On 6 January, literary icon Chimamanda Ngozi Adichie lost one of her 21-month-old twin boys at Euracare, an elite private hospital in Lagos, Nigeria.

Adichie alleges “criminal negligence”, specifically an overdose of propofol and oxygen deprivation, leading to the death of her son, Nkanu Nnamdi. The hospital maintains it followed “international standards” and has commenced an investigation.

“The death of young Nkanu once more exposes the fragility of the Nigerian healthcare system,” wrote Dr Adaeze Oreh, health commissioner for Rivers State, on the X platform.   

In the past month, Nigerian-British boxer Anthony Joshua relied on bystanders to walk him into a police truck without an ambulance in sight after a car crash that killed two of his friends.

“Fragmented, weak, and heavily injured by systemic gaps, daily keeping the lights on and doors open in many healthcare institutions can be fraught with numerous lapses and compromises,” wrote Oreh. 

Nigeria is estimated to lose $1.3 billion annually to reverse “medical tourism” – citizens seeking healthcare outside the country. 

A review of federal budgets since 2023 shows that government health expenditure has never been more than 6%, ignoring the 15% target for health expenditure set by African leaders in the Abuja Declaration back in 2001.

As Health Minister Muhammad Ali Pate pushes towards Universal Health Coverage (UHC) anchored on the new Sector-Wide Approach (SWAp), he faces the challenge of running a sophisticated framework over a primitive system.

The cost of survival 

Dr Adaeze Oreh, Commissioner for Health for Rivers State, speaking at the launch of the Budgit NG State of States 2024 Report in Abuja, Nigeria.

Fiscal retreat has entrenched a system where access is determined solely by purchasing power. With households forced to bear nearly 80% of medical costs out-of-pocket, healthcare spending has become a contributor to poverty. 

The 2025 UHC Global Monitoring Report by the WHO and World Bank confirms this reality, warning that financial hardship is intensifying for the world’s poorest, with an estimated 4.6 billion people globally still lacking access to basic health services and 1.6 billion people further pushed into poverty due to out-of-pocket health expenses.

Yet, money is only part of the crisis.

“Without enforcing standards for workforce support, data management, and governance, pouring cash into the sector is like throwing money to the wind,” Oreh, the Rivers State Commissioner for Health, told Health Policy Watch.

This structural void has collapsed the referral hierarchy. 

“The teaching hospital system, designed to be the final referral point for complex cases, has been ‘bastardized’ into handling primary care overflow,” wrote Dr Popoola Daniel, a medical doctor based in Nigeria, via his X account.

Instead of focusing on research and specialist care, tertiary centers are clogged with uncomplicated cases. 

A 2025 review by the African Health Observatory Platform (AHOP) found that the Nigerian health system is performing at only 45% of its capacity – below the WHO African Region average of 52.9% – with 80% of health infrastructure classified as dysfunctional.

The exodus and the exhausted

This dysfunction drives a massive “brain drain”, with the Nigeria Health Statistics Report 2024 revealing a 200% surge in health workforce migration.

In 2024 alone, over 4,000 doctors and dentists migrated, with the United Kingdom absorbing more than half of them.

The mass exodus has left a doctor-to-patient ratio of 1:9,083, way higher than the recommended 1:6000 ratio.

With the rapid exit of skilled professionals, trust in local capacity has weakened. The wealthy go abroad to access better healthcare. The late former Nigerian President Muhammadu Buhari spent over 200 days on medical trips abroad, including a 104-day stretch in London. 

Adichie’s son was also reportedly being prepared for evacuation to Johns Hopkins Hospital in the United States. Euracare, despite its elite status, was functioning merely as a diagnostic stopgap.

The clinicians who stay to practise in Nigeria are overstretched. “There are times I work until I cannot think again,” Daniel wrote. 

Doctors reportedly work up to 120 hours a week for as little as ₦750 ($0.52) per hour. In September 2023, a resident doctor at Lagos University Teaching Hospital died after a 72-hour shift after weeks of overwork. Nigeria does not have regulations protecting doctors from overwork.

A ‘SWAp’ for survival 

Dr Muhammad Ali Pate at the Joint Annual Health Sector-Wide Review 2025.

Pate became Minister of Health in August 2023, and in his first year, he operationalised the Nigeria Health Sector Renewal Investment Initiative (NHSRII). This strategy aims to end the fragmentation that has historically paralyzed the sector through the Sector-Wide Approach (SWAp). 

This ensures that stakeholders align with a single master plan, allowing the Ministry to streamline governance and channel resources where they are most needed.

At the November 2025 Joint Annual Review, the Ministry presented its progress towards SWAp with a reported 17% reduction in maternal mortality and a 12% decline in newborn deaths within 172 high-burden Local Government Areas.

It also highlighted renewed public confidence in PHCs, with a rise in visits from 10 million visits in early 2024 to 45 million in mid-2025.

Reality check: Budget cuts

But the path to Universal Health Coverage (UHC) by 2030 is mined with fiscal contradictions. While the SWAp demands “One Budget,” the federal government allocated just 4.2% to health in the 2026 budget.

Worse, family planning funding was slashed by 97% in 2025, a cut that came at a time when the country was grappling with the exit of a critical funder, the United States Agency for International Development (USAID), from family planning support programs.

The human cost of this underfunding is a workforce in freefall as the high doctor-to-patient ratio means that the remaining staff are burned out.

Oreh argues that Nigeria can circumvent these circumstances through the active participation of the state government.

“The beauty of a truly federal system… is that despite budgetary constraints, the SWAp agenda can effectively bridge the gaps between policy and patient safety if committedly adopted by the subnational,” Oreh said.

“The key lies in state-level implementation driven by national regulatory standards. If this occurs, the power of the collective will lead to exponential improvements… towards UHC 2030.”

Skeleton without flesh

Nkanu’s death is not an anomaly. In her statement, Adichie alleges that there have been two previous instances where the same anesthesiologist reportedly overdosed children. 

Yet, as is often the case, it has taken a high-profile case to force a brutal confrontation with the urgent structural reforms required to save the country’s health sector.

Minister Pate’s SWAp offers a logical framework to halt the decay in pursuit of Universal Health Coverage by 2030. The scorecard from the Joint Annual Review proves that the methodology can work.

But SWAp is currently a skeleton without flesh, as key components – funding, workforce, and regulation – are missing.

Regulators are pivoting from monitoring toward establishing AI-principles in drug development.
Regulators are pivoting from monitoring toward establishing AI principles in drug development.

The European Medicines Agency (EMA) and the US Food and Drug Administration (FDA) have jointly established new AI principles in drug development to reduce regulatory divergence between the major markets of the European Union and the United States.

Industry associations have applauded the landmark accord, as it strengthens harmonisation across the regions – but emphasise that more concrete steps are needed.

With AI technologies becoming increasingly embedded in evidence generation or analysis in drug development, regulators are pivoting from monitoring to establishing principles-based guardrails to improve the accountability, integrity, and performance of the new technology.

The accord is likely to have a significant effect on global AI use in drug development, as the regulatory weight of the EMA and the FDA decisions sets global standards.

AI principles are ‘first step in renewed cooperation’

Olivér Várhelyi, European Commissioner for Health and Animal Welfare, hailed the new guidelines as an important step.
Olivér Várhelyi, European Commissioner for Health and Animal Welfare, hailed the EMA/FDA guidelines as a first step in a renewed EU-US cooperation.

The AI principles, published on Wednesday, (14 January), mark the culmination of a process that began two years ago to address the regulatory divergence between the major markets EU and the US. This was proving to be a significant barrier to digital innovation in pharma.

“The guiding principles of good AI practice in drug development are a first step of a renewed EU-US cooperation in the field of novel medical technologies,” said Olivér Várhelyi, European Commissioner for Health and Animal Welfare,

The goal is to preserve a “leading role in the global innovation race, while ensuring the highest level of patient safety,” he emphasised.

Industry associations welcome the accord

“We view the joint work of the EMA and FDA on developing these principles as a positive and important step toward global regulatory convergence,” the European Federation of Pharmaceutical Industries and Associations (EFPIA) told Health Policy Watch.

With memberships of 36 national associations and 40 pharmaceutical companies, EFPIA represents the business interests of the biopharmaceutical industry operating in Europe.

A press query with the Pharmaceutical Research and Manufacturers of America remained unanswered.

The ten guiding principles published in a joint decision by EMA and FDA.
EMA and FDA published AI principles in January to establish guardrails for drug development.

The AI principles aim to govern the use of the new technology across its entire lifecycle in drug development – from early-stage drug discovery and clinical trials to manufacturing and post-market safety monitoring.

This is to ensure that patient safety and ethical integrity remain paramount, emphasising a human-centric approach and oversight, as the US and EU regulatory bodies state.

With the new principles, the EMA and the FDA aim to dismantle the “AI black box”, as industry experts call it, with users and patients often failing to understand the process behind the generation of results.

According to the authorities, AI must be applied in well-defined contexts and be understandable: pharmaceutical or biotechnology companies are expected to use plain language to explain AI limitations and underlying data, while adhering to the protection of privacy and sensitive information.

AI principles to enhance accountability

The AI-principles address “shadow use” of AI in the industry.
The joint document addresses “shadow use” of AI in the industry.

Crucially, the joint document addresses a major issue in pharmaceutical operations known by industry experts as “shadow use”, namely that analysts are already working with large language models (LLMs) for daily tasks while leadership regularly looks the other way. This is to be countered by better oversight.

The provisions also aim to ensure clinical teams understand the technical tools being used by analysts by mandating that data scientists are integrated with clinical leads throughout the lifecycle of drug development.

Moreover, instead of single validation, continuous monitoring for “data drift” is required – a phenomenon where an AI’s performance degrades over time as the underlying data environment changes.

High-level declaration needs further steps

On 16 January 2026, EMA and FDA released Guiding principles of good AI practice in drug development.
On 16 January 2026, EMA and FDA released Guiding principles of good AI practice in drug development.

As the new AI principles are strategically designed to align with existing regulations, the guiding principles do not fundamentally change how AI is already being used by European industry, EFPIA explains.

However, they create the basis for a unified language in medical technology development, possibly with wide-ranging implications for global AI regulation in drug development.

“They help create a more coherent environment for scaling AI tools globally and for engaging with regulators in a consistent manner,” said the EFPIA.

While the guidelines mark a good foundation for the industry to lower the risk of duplicative or divergent requirements across regions, the AI principles remain high-level. Further steps toward concrete shared terminology, definitions, and concepts across regions are needed. Some of which are to be expected this year.

Image Credits: European Union/Christophe Licoppe, European Union/Frédéric Garrido-Ramirez, Felix Sassmannshausen, European Union/Barcelona Supercomputing Center , EMA.

The Africa CDC’s Professor Yap Boum told the media this week that the controversial trial has been cancelled.

A controversial clinical trial on the effects of the hepatitis B vaccine on babies in Guinea-Bissau has been “cancelled”, according to Dr Yap Boum of Africa Centres for Disease Control and Prevention (CDC).

However, this has been contested by the US Department of Health and Human Services (HHS), which is funding a Danish group to conduct the study, according to CIDRAP.

An HHS official told CIDRAP that researchers are still working on the study protocol, the official said, adding, “we are proceeding as planned.”

But Boum told a media briefing on Thursday that there were “ethical challenges” with the trial design, and Africa CDC had engaged with the health ministry of Guinea-Bissau about it.

“Our information is that the study has been cancelled,” said Boum, who added that while the continent needs research about vaccines, including hepatitis B, “this has to be done within the norms, so we are glad that at this point, the study has been cancelled”.

Boum, Africa CDC’s deputy incident manager for mpox who often stands in for the Africa CDC Director-General at media briefings, added that there would be “more engagement” with Guinea-Bissau.

The US Centers for Disease Control and Prevention (CDC) awarded Bandim Health Project at the University of Southern Denmark a $1,6 million five-year grant to study the “optimal timing and delivery of monovalent hepatitis B vaccinations on newborns in Guinea-Bissau”, according to the US HHS federal register.

The trial aimed to enrol 14,000 newborns in a “randomized controlled trial to assess the effects of neonatal Hepatitis B vaccination on early-life mortality, morbidity, and long-term developmental outcomes”, according to HHS register.

Half the babies would be vaccinated at birth, while the other half would get vaccinated six weeks later – which has raised ethical questions from researchers across the globe.

However, the World Health Organisation (WHO) has recommended universal birth hepatitis B vaccinations since 2009. Hepatitis B vaccination usually involves a series of three or four injections, and clinical trials have already established the best intervals for the vaccinations.

‘Non-specific effects’ of vaccines

One of the leaders of the Bandim Health Project at the University of Southern Denmark, Dr Christine Stabell Benn, is an adviser to the US Advisory Committee on Immunization Practices (ACIP), which recently resolved to stop recommending hepatitis B vaccines to US newborns. 

Stabell Benn’s research has focused on the “non-specific effects” (NSE) of vaccines. They have conducted trials involving thousands of children in Guinea-Bissau and Denmark, and assert that all vaccines should also be tested for NSEs.

The journal Vaccine recently published a scathing comprehensive review of 13 trials conducted by Bandim, which showed that their trials have been unable to show non-specific effects for measles, tuberculosis, diphtheria, tetanus, and whooping cough vaccines.

“We were surprised to find several instances of questionable research practices, such as unpublished primary outcomes, outcome switching, reinterpretation of trials based on statistically fragile subgroup analyses, and frequent promotion of cherry-picked secondary findings as causal, even when primary outcomes yielded null results,” according to the review, which was headed by Dr Henrik Støvring of the Department of Biomedicine, at Aarhus University in Denmark.

Study ‘manipulation’

Meanwhile, several high-profile health experts condemned the trial.

“[Robert F Kennedy Jr], the Secretary of Health and Human Services, will soon conduct his own Tuskegee experiment,” US paediatrician Dr Paul Offit, co-inventor of a rotavirus vaccine, wrote on his Substack platform.

“He has chosen the resource-poor nation of Guinea-Bissau, West Africa, to do it. Guinea-Bissau is currently overwhelmed by hepatitis B virus. About 18% of the population is infected,” added Offit, director of the Vaccine Education Center and an attending physician at Children’s Hospital of Philadelphia and a professor of both Paediatrics and Vaccinology at the University of Pennsylvania.

“RFK Jr. has manipulated the study to support his unsupportable, science-resistant beliefs about harms caused by the hepatitis B vaccine,” added Offit, who noted that as the study is single-blinded, researchers will know which children received a birth dose of the vaccine.

“This allows for investigator bias, where the investigator might find vague neurodevelopmental problems in the birth-dose group but not the six-week group,” he added.

Professor Gavin Yamey, director of the Center for Policy Impact in Global Health at Duke University, argues that “it is unethical to do a randomized controlled trial in which you withhold a proven, life-saving vaccine from newborn babies”.

Currently, babies in Guinea-Bissau only receive the hepatitis B vaccination from six weeks’ old. But some 11% of children in the country are already infected with hepatitis B by the age of 18 months, so the government has resolved to introduce vaccination at birth from 2027, as recommended by the WHO.

Bandim says its trial will stop enrolling participants when the government rollout of the hepatitis B vaccine to newborns starts. They will follow their cohort for five years, primarily to compare “overall mortality and hospitalisations,” and “secondary outcomes”, looking at “atopic dermatitis and neurodevelopment”, according to a Bandim media release.

Life-saving vaccines, maternal and child health, and programs fighting TB, malaria, and HIV/AIDS are included in the proposed bill.

The $9.4 billion package agreed to by the US Senate and House Appropriations Committees, is more than double the $3.7 billion requested by the Trump Administration, and signals bipartisan support for maintaining significant global health aid – although the package still must be approved by both Senate and House, and could also be vetoed by president following passage. 

The $9.4 billion package agreed to by Congressional leaders in the US House and Senate is less than the $12.4 billion allocation in 2024 and 2025. But it’s still $5.7 billion more than called for last September by US President Donald Trump in his America First Global Health Strategy. 

The House and Senate have yet to vote on the spending bill, and face a 30 January deadline to pass the federal funding. The legislation would then have to clear the President’s desk before becoming law.

The global health allocations are part of a larger $50 billion foreign aid spending package for the 2026 fiscal year. That foreign aid bill, while a 16% cut from 2024, is nearly $20 billion more than what the Trump Administration initially requested.

The broader bill also includes $5.4 billion in funding for humanitarian assistance. Some of the funds from that pot will also be dedicated to health – in areas such as food security and nutrition, shelter protection, and  water, sanitation and hygiene (WASH). And it also includes a nod to the Trump administration’s plan to offer low- and middle-income countries some $11 billion in direct bilateral assistance  – some of which will also be channeled into health. The bilateral deals replace some of the assistance provided previously under USAID, which boasted a budget of around $44 billion in 2023, shortly before Trump abruptly dismantled it last year, making the US the world’s largest overseas donor. 

Funding for HIV/AIDS, malaria, family planning

US global health funds 2026
Of the $9.4 billion, some $5.88 billion is dedicated to fighting HIV/AIDS – with about $4.5 billion allocated to PEPFAR (not named here), and the rest to Global Fund, UNAIDS, and related activities.

Of the $9.4 billion earmarked in the bill specifically for global health programs, some $5.9 billion would be allocated to HIV/AIDS – with $1.25 billion channelled through the Global Fund to Fight TB, AIDS and Malaria, $45 million to UNAIDS, and $4.5 billion through the President’s Emergency Plan for AIDS Relief (PEPFAR), the flagship US program founded in 2003. 

While that is still less than the $7.1 billion level of support to the three agencies under the 2024 Biden administration, it’s a major increase from the $2.9 billion for HIV/AIDS requested by Trump. At the same time, the bill also calls for PEPFAR, founded by former US President George Bush, to transition to a largely self-reliant program of national governments over the coming years. 

In terms of other global health priorities: $795 million is dedicated to malaria, and $379 million for tuberculosis; $85 million is earmarked for polio.

Strikingly, some $524 million for family planning and reproductive health services are also included in the funding package – despite the historic reticence of conservatives to fund such programs. 

And although the administration has ordered a US withdrawal from the UN Population Fund (UNFPA), Congress allocated $32.5 million for the organization, as part of the family planning funds. The bill does stipulate that the agency cannot spend these monies on China – and that if the Trump administration makes good on its plan to withdraw from UNFPA, the money should then be transferred to other global health programs. 

Allocations are earmarked for “Global Health Security,” $615.6 million for organizations like Pandemic Fund and the Coalition for Epidemic Preparedness Innovations (CEPI). These funds could also be used in the event of a public health emergency.

Funds will also go to neglected tropical diseases (NTDs) and nutrition.

New ‘National Security Fund’ also includes health components

In another twist, support for family planning, reproductive health and countering child marriage is also supported through a new “National Security Fund” of $6.77 billion that Congress aims to create – to “combat China’s influence” among other things.

The fund, which also includes monies for clean cook stoves, a Young African Leaders Initiative, peace process monitoring, trade capacity building, and assorted other priorities, specifies that at least 15% of the fund should go to the African continent. 

Bipartisan support, but with different takes 

Remarkably, both sides of the aisle – and congressional chambers – came together for the bill in a show of bipartisanship, and an exertion of Congress’s power of the purse. 

House and Senate Republicans are positioning the agreement as a win for reducing overall foreign aid spending – in this case by about 16% – while also countering growing Chinese influence and advancing President Trump’s foreign policy vision.

The bill is an “unprecedented reduction of spending” while still aligning with the “America First agenda,” said House Appropriations Chair, Representative Tom Cole (R-OK). 

Cole lauded the foreign aid bill’s larger design, saying it “eliminates wasteful spending on DEI or woke programming, climate change mandates, and divisive gender ideologies at the State Department,” and “holds the United Nations accountable.” The Republican Chair also noted that the bill “confronts human trafficking; provides support, funds, or assistance for Israel, Egypt, Jordan, and Taiwan; and denies China access to U.S.-backed resources.”

But for those across the aisle, the very act of funding global health programs resists the Trump administration’s fiery aid trajectory. 

The “[b]ill rejects Trump’s decimation of the U.S. foreign assistance enterprise— renewing bipartisan investments in American leadership and reasserting congressional control; Supports key global health, humanitarian, and development investments and rejects extreme House Republican riders,” reads a summary by Senator Patty Murray (D-WA), Vice-Chair of the Senate Appropriation Committee.

“While including some programmatic funding cuts, the bill rejects the Trump administration’s evisceration of U.S. foreign assistance programs and reaffirms bipartisan support for the full range of international initiatives long promoted by Congress to advance U.S. interests.”

WHO is not funded at all

Notably absent in the bill is any mention of funding for the World Health Organization, from which the Trump administration is in the process of withdrawing. Nor, is there provision in the bill for paying the $260.6 million in unpaid dues to the organization – for which the US is in arrears – before the pullout date later this month. See related story here. 

Member States to Discuss US Withdrawal from WHO as Failure to Pay Fees Violates Agreement

 

This story was updated 16 January to include stipulations on UNPFA funding.

Image Credits: WHO, Senate Appropriations.

2025 was among the top three warmest years on record, according to the World Meteorological Organization (WMO).

The year 2025 was among the top three warmest years on record, according to the latest update from the World Meteorological Organization (WMO).

Depending on the data set being used, the year was either the second or third warmest year on record.

The UN agency for monitoring the atmosphere also confirmed that the past 11 years have been the 11 warmest on record, and ocean heating continues unabated.

The global average surface temperature in 2025 was 1.44°C (with a margin of uncertainty of ± 0.13°C) above the 1850-1900 average that is used as a pre-industrial era baseline, WMO reported.

“The year 2025 started and ended with a cooling La Niña and yet it was still one of the warmest years on record globally because of the accumulation of heat-trapping greenhouse gases in our atmosphere. High land and ocean temperatures helped fuel extreme weather – heatwaves, heavy rainfall and intense tropical cyclones, underlining the vital need for early warning systems,” said WMO Secretary-General Celeste Saulo.

This update from the WMO comes less than two months after global leaders met in Brazil’s Belém for the annual UN climate conference, COP30. It confirms that the climate action so far is proving to be woefully inadequate as the streak of extraordinary global temperatures continues unabated.

A robust data set

Annual global mean temperature anomalies relative to the 1850-1900 average shown from 1850 to 2025 for eight datasets as shown in the legend.

What makes this data robust is that it is a consolidated analysis of eight different global datasets. Two of these datasets ranked 2025 as the second warmest year in the 176-year record, and the other six ranked it as the third warmest year.

The past three years, 2023-2025, are the three warmest years in all eight datasets. The consolidated three-year average 2023-2025 temperature is 1.48 °C (with a margin of uncertainty of ± 0.13 °C) above the pre-industrial era. The past 11 years, 2015-2025, are the 11 warmest years in all eight datasets.

“WMO’s state of the climate monitoring, based on collaborative and scientifically rigorous global data collection, is more important than ever before because we need to ensure that Earth information is authoritative, accessible and actionable for all,” said Saulo.

The update was timed to coincide with the release of global temperature announcements from the respective dataset providers.

One of the eight datasets is one from the National Oceanic and Atmospheric Administration (NOAA), the US agency that has had its funding cut by the Trump administration. Other data sets are from the European Union, Japan, China and the UK.

Six of the eight datasets are based on measurements made at the weather stations, and by ships and buoys using statistical methods to fill gaps in the data. Two of the datasets combine past observations, including satellite data, with models to generate a consistent time series of multiple climate variables, including temperature.

The actual global temperature in 2025 was estimated to be 15.08°C, but there is a much larger margin of uncertainty on the actual temperature at around 0.5°C than on the temperature anomaly for 2025, WMO said.

Oceans continue to heat

Ocean heat content continued to rise in 2025.

Roughly 90% of excess heat in the atmosphere is absorbed by the world’s oceans, warming them in the process. This makes ocean heat a critical indicator of climate change.

A separate study published in Advances in Atmospheric Sciences reports that ocean temperatures were also among the highest on record in 2025, reflecting the long-term accumulation of heat within the climate system. And while warming temperatures affect life on Earth, the warming oceans pose a threat to the coral reefs and life in the water.

From 2024-2025, the global upper 2000m ocean heat content (OHC) increased by ∼23 ± 8 Zettajoules relative to 2024, according to the study led by Lijing Cheng with the Institute of Atmospheric Physics at the Chinese Academy of Sciences. That is around 200 times the world’s total electricity generation in 2024.

Regionally, about 33% of the global ocean area ranked among its historical (1958–2025) top three warmest conditions. Another 57% fell within the top five, including the tropical and South Atlantic Ocean, Mediterranean Sea, North Indian Ocean, and Southern Oceans, underscoring the broad ocean warming across basins.

While the global annual mean sea surface temperature (SST) in 2025 was 0.12 ± 0.03°C lower than in 2024, it was 0.49°C above the 1981–2010 baseline, showing long-term warming trends.

State of the Global Climate 2025 report

A climate change protest

While the current update was meant to give an indication of the global temperature trend, WMO’s State of the Global Climate 2025 report to be issued in March will go further.

WMO will provide a detailed breakdown of key climate change indicators, including greenhouse gases, surface temperatures, ocean heat, sea level rise, glacier retreat and sea ice extent.

The datasets being relied by the WMO provide a near-complete global picture of near-surface measurements using statistical methods to fill gaps in data-sparse areas such as the polar regions.

Image Credits: WMO, WMO, WMO, Markus Spiske/ Unsplash.

Vaccine hesitancy gave way to more acceptance once jabs and public information on safety was available.
A health worker getting vaccinated against COVID-19 in Bulgaria in 2021.

Fears over the side effects of COVID-19 jabs, which led to initial vaccine hesitancy, mostly gave way to acceptance in the course of the pandemic, with only a small minority remaining unvaccinated due to deep-seated mistrust, a new major study published in The Lancet finds.

For the first time, the study “Profiling vaccine attitudes and subsequent uptake in 1.1 million people in England” compared attitudes towards vaccinations with actual vaccination behaviour on a large scale. Based on the findings, health policy experts call for evidence-based, group-specific and long-term communicative approaches to counter vaccine hesitancy.

Many of the initially hesitant individuals chose a wait-and-see approach. They were driven by concerns over side effects and efficacy, but eventually opted for the jab as real-world evidence of safety and efficacy grew.

The benefit of vaccination was recognised by the majority of those initially hesitant, mainly due to public health communication, community outreach and vaccine rollout itself.

“Our findings suggest that most COVID-19 vaccine hesitancy was rooted in concrete concerns that can be addressed and successfully overcome with time and increasing availability of information,” according to the principal authors, Paul Elliott, who is Chair in Epidemiology and Public Health Medicine at the Imperial College in London, and Marc Chadeau-Hyam, Professor of Computational Epidemiology and Biostatistics.

Vaccine hesitancy plummeted once information was available

Vaccine hesitancy plummeted with rollout and information available
Vaccine hesitancy plummeted with the vaccine rollout and information.

According to the data, vaccine hesitancy decreased for the vast majority of initially hesitant individuals in the course of the COVID-19 pandemic.

Over time, 3.3% of all participants were categorised as hesitant towards the COVID-19 vaccine. Individuals were classified as “vaccine-hesitant” if they stated they would refuse the vaccine, had already refused it, or had not yet decided.

Their number fluctuated, plummeting from 8% in January 2021 to 1.1% at the start of 2022, before rising again to 2.2% in February 2022. This slight rise might be the result of “pandemic fatigue” or a shift in “personal risk perception” in the course of the Omicron wave.

The study data is based on the Real-time Assessment of Community Transmission (REACT) studies, which monitored the prevalence of SARS-CoV-2 in England during the COVID-19 pandemic from 1 May 1, 2020, to 31 March, 2022, in random samples of the population.

The researchers linked consecutive survey data from 1.1 million adults in England to official National Health Service (NHS) health records. The participant questionnaires included queries about vaccination status and attitudes toward vaccines, significantly enabling a comparison. However, the results may under-represent the most radical critics, who often avoid scientific surveys.

Concrete health concerns caused vaccine hesitancy

Vaccine hesitancy was mainly driven by concerns over side effects and efficacy.
Vaccine hesitancy was mainly driven by concerns over health concerns, side effects and efficacy.

Vaccine hesitancy was mainly grounded in concrete concerns about effectiveness and side effects, perception of low risk from COVID-19, mistrust of vaccine developers, and fear of vaccines – sometimes as a result of misinformation, the researchers found.

The most prevalent categories of hesitancy, related to effectiveness and health concerns, declined substantially over time as  65% of hesitant participants received one or more vaccinations by May 2024.

The reasons for initial vaccine hesitancy varied by demographic. Men were more likely to perceive themselves as not being at risk (17.9% versus 10.2% of women), while women more frequently cited concerns regarding fertility (21.2% versus 8.4% of men). Younger participants more frequently cited a fear of needles.

Socio-economic deprivation and institutional mistrust are primary drivers of the reluctance to get a jab. Notably, Black participants were three times more likely to express hesitation than White participants.

Experts interpreting the study also suggest this mistrust is frequently rooted in negative healthcare experiences or historically unequal treatment. Significantly, non-White participants were ultimately no less likely to be vaccinated at a later date.

Communicative approaches key to successful campaigns

Vaccine hesitancy is best countered by transparent, long-term, and evidence-based information provision, public health expert Sarah Eitze emphasises.
Vaccine hesitancy is best countered by transparent, long-term, and evidence-based information provision, according to public health expert Sarah Eitze, researcher at the Institute for Planetary Health Behaviour (IPB) at the University of Erfurt in Germany.

Although the researchers did not test the success of specific communication efforts or interventions to shift attitudes toward vaccinations, the findings can be used in public health policy and future vaccination campaigns, according to Sarah Eitze, deputy director of the WHO Collaborating Centre for Behavioural Research in Global Health.

Transparent, continuous, and evidence-based information provision has proven to be effective, explained Eitze, who is a researcher at the Institute for Planetary Health Behaviour (IPB) at the University of Erfurt (Germany).

“Optimal communication about vaccination is most successful when we take a more evidence-based, target group-specific and long-term approach,” said Eitze.

“The study shows that not every form of vaccine scepticism works in the same way. While uncertainty about information can often be addressed effectively, deeply rooted attitudes of rejection based on mistrust of institutions or science are much more difficult to overcome.”

Image Credits: European Union/Martin Matev, Felix Sassmannshausen, European Union/Martin Matev, Lisa Wollenschläger/University of Erfurt.