WMJ_02_2025

Official Journal of The World Medical Association, Inc. Nr. 2, June 2025
vol. 71
Contents
Editorial   3
WMA Council Report Montevideo, Uruguay, 24-26 April 2025   4
WMA Council Resolutions   9
Information about the 76th WMA General Assembly, Porto 2025   13
Report of the WMA Environment Caucus   14
Unravelling MAiD in Canada: Euthanasia and Assisted Suicide as Medical Care   15
Voluntarily Stopping Eating and Drinking as a Self-Chosen Path for End of Life   19
The Great Silence: The Doomsday Clock is Ticking   23
Interview with National Medical Associations’ Leaders of the Asian Region   28
Strengthening National Advocacy through Global Health Policy:
The Strategic Role of the Trinidad and Tobago Medical Association   36
Transformation of Kenya’s Health Financing: A Journey towards Equity and Access   38
Bridging the Gap: Strategies to Address the Human Resource Shortage
in Dentistry across Sub-Saharan Africa  43
Digital Health Applications in the Chinese Health System   47
WMA Members Recognise International Nurses Day 52
Invitation to the Southeast European Medical Forum 64
WORLD MEDICAL ASSOCIATION OFFICERS,
CHAIRPERSONS AND OFFICIALS
Dr. Ashok PHILIP
President
Malaysia Medical Association
4th Floor, MMA House,
124 Jalan Pahang
53000 Kuala Lumpur
Malaysia
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
Dr. Philippe CATHALA
Chairperson,
Finance and Planning Committee
Conseil National de l’Ordre des
Médecins (CNOM) France
4 rue Léon Jost
75855 Paris Cedex 17
France
Dr. Jacqueline KITULU
President- Elect
Kenya Medical Association
KMA Centre, PO Box 48502,
Chyulu Road, 4th Floor, Upper Hill
Nairobi
Kenya
Dr. Tohru KAKUTA
Vice-Chairperson of Council
Japan Medical Association
113-8621 Bunkyo-ku, Tokyo
Japan
Dr. Zion HAGAY
Chairperson,
Socio Medical Affairs Committee
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.,
P.O. Box 3566
52136 Ramat-Gan
Israel
Dr. Lujain ALQODMANI
Immediate Past President
Kuwait Medical Association
123 Fifth Avenue,
1202
Kuwait
Mr. Rudolf HENKE
Treasurer
German Medical Association
(Bundesärztekammer)
Herbert-Lewin-Platz 1
(Wegelystrasse)
10623 Berlin
Germany
Dr. Jacques de HALLER
Chairperson,
Associate Members
Swiss Medical Association
(Fédération des Médecins Suisses)
Elfenstrasse 18, C.P. 300
3000 Berne 15
Switzerland
Dr. Jung Yul PARK
Chairperson of Council
Korean Medical Association
Samgu B/D 7F 8F 40
Cheongpa-ro,
Yongsan-gu
04373 Seoul
Republic of Korea
Dr. Christofer
LINDHOLM
Chairperson,
Medical Ethics Committee
Swedish Medical Association
(Villagatan 5) P.O. Box 5610
SE – 114 86 Stockholm
Sweden
www.wma.net
OFFICIAL JOURNAL OF THE WORLD
MEDICAL ASSOCIATION
Editor in Chief
Dr. Helena Chapman
Milken Institute School of Public Health, George Washington University, United States
editor-in-chief@wma.net
Assistant Editor
Mg. Health. sc. Maira Sudraba-Sangovica
Latvian Medical Association
lma@arstubiedriba.lv, editor-in-chief@wma.net
Journal design by
Erika Lekavica
dizains.el@gmail.com
Publisher
Latvian Medical Association
Skolas Street 3, Riga, Latvia
ISSN 0049-8122
Opinions expressed in this journal – especially those in authored contributions –
do not necessarily reflect WMA policies or positions
3
Editorial
Editorial
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The recent publication of the World Health Organization
(WHO)’s World Health Statistics Report 2025 highlighted
the substantial impacts of the coronavirus disease 2019
(COVID-19) pandemic on morbidity and mortality rates,
with a reported reduced global life expectancy by 1.8 years.
Although global initiatives have successfully led to reductions
in tobacco and alcohol consumption and exposure to particulate
matter (PM2.5
) emissions, one primary setback remains the
limited coverage of essential health services. The urgent call
to renew political commitment and investment in primary
healthcare can help reinforce local and national capacity to
target health priorities and address existing inequalities. Using
the One Health framework, timely evidence-based data can
offer a starting point for policy development and community
health interventions, help combat misinformation and
disinformation, and ultimately build health system resiliency
throughout countries.
Understanding these challenges, global health leaders have
collaborated on the development of landmark decisions and
scientific advancements that directly influence health systems.
First, the Pandemic Agreement was negotiated at the 78th
World Health Assembly, confirming global commitment
to support prompt and equitable responses for pandemic
preparedness. Second, the World Meteorological Society’s
Global Annual to Decadal Climate Update (2025-2029) confirmed
that global climate estimates are projected to increase to
near-record levels over the next five years, which can impact
national economies and sustainable development. Third, the
Global Early Warnings for All Multi-Stakeholder Forum,
which fused outcomes from five regional events held between
October 2024 to February 2025, helped facilitate collective
discussion on overall progress and novel solutions toward the
implementation of the Early Warnings for All initiative
and Sendai Framework for Disaster Risk Reduction (2015-
2030). To support these global efforts, the World Medical
Association (WMA) has shared nine press releases that
advocate for protecting health professionals during conflicts,
investing in the health workforce, and highlighting global
progress on the historic Pandemic Agreement.
As WMA members met at the 229th WMA Council
Meeting, which was held from 24-26 April 2025, in
Montevideo, Uruguay, they celebrated individual and joint
leadership achievements, discussed complex topics related to
medical education and ethics, and identified pressing health
issues for ongoing discussion. WMA members presented
high-level overviews of selected regional
events, where they presented scientific talks and
contributed to group discussions. These leadership
activities demonstrate that WMA members have significant
footprints – and voices – within their specialty, countries,
regions, and the world.
In this issue, Ms. Magda Mihaila prepared a comprehensive
summary of the WMA proceedings and included four
adopted resolutions, and Dr. Ankush Bansal shared the report
of the WMA Environment Caucus. Dr. Ramona Coelho and
colleagues provided a comprehensive overview of a
multidisciplinary volume that examines medical assistance
in dying (MAiD) in Canada. Mr. van Dijk and colleagues
offered valuable insight on the option of voluntary stopping
eating and drinking in the end of life. Dr. Steve Robson and
Dr. Hilary Bambrick described the historical context of the
‘doomsday clock’.
Also, WMA members highlighted health advocacy efforts,
addressed existing challenges, and described emerging
technology across the Americas, African, and Asian health
systems. Dr. Saksham Mehra showcased how the Trinidad and
Tobago Medical Association has reinforced national advocacy
through global health policy, with special focus on climate
and health topics. Dr. Diana Marion provided a historical
review on health financing reforms in the Kenya health
system. Dr. Cliffland Mosoti and Dr. Marie-Claire Wangari
discussed shortages in dental professionals and the need for
interprofessional collaborations between medical and dental
professionals in sub-Saharan Africa. Finally, Dr. Yali Cong
and Mr. Chunqi Liang offered a critical analysis on
incorporating digital health applications in the Chinese health
system.
WMA members, who represent more than 114 national
medical associations (NMAs), collectively exemplify medical
excellence and leadership across nations and geographic
regions. In this issue, four NMA leaders of the Asian region
described leadership experiences, ongoing NMA activities, and
perceived strengths and challenges in medical education. Also,
WMA members representing eight countries of the African,
Americas, Asian, and Pacific regions shared their perspectives
on the fundamental role of the nursing profession to strengthen
health systems, in efforts to commemorate International Nurses
Day. These professional and personal testimonies describe
health professionals’ remarkable achievements and encountered
challenges while seeking to prioritise patient-centred care and
improve healthcare service delivery.
We are eager to join discussions and networking at the 76th
WMA General Assembly in Porto!
Helena Chapman, MD, MPH, PhD
Editor in Chief, World Medical Journal
editor-in-chief@wma.net
4
The 229th WMA Council session
of the World Medical Association
(WMA) convened in the city of
Montevideo, Uruguay, from 24-26
April 2025 (Photo 1).
Uruguay’s Vision for Health Equity
On 24 April, just ahead of the
Council’s formal proceedings, Dr.
José Minarrieta, President of
the Executive Committee of the
Sindicato Médico del Uruguay,
joined WMA leaders for a joint
press conference. Addressing leading
Uruguayan media outlets, the panel
tackled timely questions around the
ethical and operational pressures
facing healthcare systems worldwide–
particularly in conflict settings.
From safeguarding medical neutrality
to addressing inequities in care
delivery, the press event underscored
a growing consensus: as violence
and polarisation threaten the
stability of many health systems, the
responsibility of the global medical
profession to uphold ethical norms
becomes all the more urgent. Dr.
Minarrieta’s remarks echoed those
of WMA leaders, reaffirming the
indispensable role of physicians,
not only as caregivers but also as
advocates for humanity under strain.
The Council welcomed an address
by Uruguay’s Minister of Public
Health, Dr. Cristina Lustemberg,
who offered an overview of the
country’s healthcare landscape. A
total of 18 years after the creation of
the National Integrated Health
System, Uruguay remains committed
to universal health coverage, with
a focus on equity, quality, and long-
term sustainability. Dr. Lustemberg
acknowledged both successes and
continuing challenges, noting that
while structural reform has yielded
expanded access and improved
standards, issues such as mental
health–particularly suicide prevention
and physician burnout–require
urgent attention. She emphasised
the need for a more collaborative
care model, rooted in strong
partnerships between physicians,
nurses, and allied professionals.
Reaffirming Uruguay’s solidarity
with health professionals in zones
of conflict, Dr. Lustemberg voiced
hope that the Global Pandemic
Agreement, years in the making,
would soon be formally adopted. Her
presence and message offered not
just a national case study, but also a
reaffirmation of values at the heart of
the WMA’s mission: equity, dignity,
and ethical care, even in the most
trying of circumstances.
Junior Doctors Network
On 22 April, the Junior Doctors
Network (JDN) convened its Spring
Meeting in the same city where it was
first convened in 2011. Organised as
a hybrid event, the meeting brought
together early-career physicians from
around the world for two days of
intense dialogue, intergenerational
engagement, and cross-border
solidarity.
The gathering provided ground for
reflection and momentum, as JDN
members connected directly with
WMA leaders and working group
chairs, exchanging experiences and
advocating for a more inclusive and
responsive global health system. One
of the event’s highlights was the
Non-Communicable Diseases panel,
in which participants discussed the
critical role that junior doctors play
in direct patient care as well
as prevention, advocacy, and
policymaking. In a featured
interview with the Sindicato Médico
del Uruguay, Dr. Pablo Estrella
Porter, Chair of the JDN, offered
his perspective on the challenges
facing junior doctors today. From
precarious employment conditions
to underrepresentation in decision-
making forums, he outlined a
roadmap for change rooted in ethics,
equity, and leadership. His message
was clear: supporting the next
generation of physicians is essential
for building stronger, fairer health
systems.
WMA Environment Caucus
The meeting of the WMA
Environment Caucus, chaired by Dr.
Ankush Bansal, head of the WMA
Workgroup on Environment, offered
a space for delegates and observers
to examine the urgent intersection
of environmental policy and human
health. The session included a report
on the recent WHO Second Global
Conference on Air Pollution and
Health by Dr. Lujain Alqodmani,
WMA Immediate Past President,
and a keynote address on the role of
health professionals in addressing
the health impacts of fossil fuels
by Dr. Ned Ketyer, President of
Physicians for Social Responsibility
Pennsylvania. The meeting fostered
open exchange among WMA
Magda Mihaila
WMA Council Report
Montevideo, Uruguay, 24-26 April 2025
WMA Council Report
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5
members on best practices and
reaffirmed the profession’s role in
advocating for environmental health
and planetary well-being.
Associate Members
The meeting, led by Dr. Jacques de
Haller, chair of the WMA Associate
Members, showcased the broad
involvement of Associate Members
across multiple dimensions of WMA
activity. Dr. de Haller presented his
Chair’s report, followed by updates
from two key networks – the JDN
and the Past Presidents and Chairs
of Council Network (PPCN) –
which collectively emphasised that
intergenerational exchange and
leadership continuity were central
themes echoed throughout the
Council session.
Of particular note was the
participation of Associate Members
in WMA taskforces and workgroups.
Dr. Ankush Bansal reported on
developments from the Workgroup
on Environment, reinforcing the link
between environmental justice and
global health ethics. Dr. Jon Snaedal
(PPCN) delivered updates on the
Workgroup on Medical Neutrality
and on the Associate Members-
led initiative addressing the needs
of aging physicians, an increasingly
important topic as healthcare systems
face demographic shifts within
the profession itself. The meeting
also reflected on recent Associate
Members hosted webinars, with
participants encouraged to submit
ideas for future topics.
229th WMA Council Session
Election of Chair of Council
The Council opened with a moment
of both continuity and change. Dr.
Jack Resneck Jr. (American Medical
Association) was elected Chair of
the Council, succeeding Dr. Jung Yul
Park (Korean Medical Association),
whose term had been defined
by persistent advocacy during a
politically turbulent era in his
own country. Dr. Resneck’s
appointment set the tone for a
session that would place great
emphasis on principled leadership
and the defense of professional
autonomy.
In his inaugural remarks, Dr. Resneck
acknowledged the rising threats
to medical freedom and to the
legitimacy of scientific institutions
worldwide. He promised to serve
as a neutral voice in his new role
and highlighted the importance of
remaining focused on the important
work of the WMA and making the
medical profession around the world
aware of this work.
President’s Interim Report
In his interim report to the Council,
the WMA President, Dr. Ashok
Philip, provided a comprehensive
overview of his activities from
October 2024 through March 2025,
a period marked by international
engagement and growing diplomatic
alignment around medical ethics.
Since the WMA General Assembly
in Helsinki, Dr. Philip has
represented the Association at a
series of high-level meetings
across regions and cultures.
In Paris, he attended sessions
of the Conseil National de
l’Ordre des Médecins (CNOM),
where he held discussions with
leaders of several Francophone
medical associations. Notably, the
Lebanese Medical Association
expressed both a request for
institutional support and a strong
interest in joining the WMA –
a development that Dr. Philip
welcomed as a testament to the
WMA’s enduring relevance in
regions facing political and health
system strain.
InEastAsia,Dr.PhilipjoinedDr.Otmar
Kloiber, WMA Secretary General,
and Dr. Jung Yul Park, Chair
of Council, at a symposium on
Universal Health Coverage in
Taipei, Taiwan. The event
underscored the WMA’s ongoing
role in shaping global debates on
access, equity, and sustainability
in health systems. One of the
more politically sensitive visits
was to Jakarta, where Dr. Philip
participated in the triennial meeting
of the Indonesian Medical
Association, in the context of recent
threats to its autonomy.
Dr. Philip concluded his report by
highlighting his participation in
the Global Patient Safety Summit
in Manila, Philippines, where
discussions cantered on a critical but
often overlooked dimension of care:
the psychological safety of health
professionals. The issue, he noted, is
increasingly urgent in a world where
clinicians face not only medical
risk, but also moral injury, burnout,
and systemic neglect.
Secretary General’s Report
The WMA Secretary General, Dr.
Kloiber, highlighted the exceptionally
positive response to the newly
revised Declaration of Helsinki – a
foundational document in global
medical ethics. Since its adoption,
the revised text has drawn
considerable attention from a wide
cross-section of the international
medical community. Requests for
presentations and discussions have
come from academic institutions,
ethics committees, industry
associations, and regulatory bodies,
who were eager to engage
with its implications. He emphasised
that this substantial feedback has
signalled the Declaration’s continued
resonance in a rapidly evolving
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clinical research environment.
Dr. Caline Mattar, WMA Advisor,
Dr. Julia Tainijoki, Senior Policy
Advisor, and Dr. Lujain Alqodmani,
Immediate Past President, presented
updates on several of the WMA’s
thematic priorities. Their joint
presentation offered a dynamic
overview of the Association’s work
in critical public health and policy
areas. These areas included WMA-
led initiatives on antimicrobial
resistance, efforts to address health
workforce shortages and migration
trends, ongoing input into the
drafting of the WHO’s Pandemic
Agreement, and sustained advocacy
on non-communicable diseases and
air pollution. In particular, the group
highlighted the WMA’s proactive
role in organising side events
during the World Health Assembly
(WHA) in Geneva, designed to
elevate the physician perspective
in global health negotiations.
World Medical Journal
The Journal’s December 2024
and March 2025 issues featured
insightful analyses, commentaries,
and meeting reports from
WMA/JDN members and
invited leading experts
representing 19 countries. The
collective article, with thematic
coverage commemorating
International Doctors’ Day and
World Cancer Day, showcased
physicians’ leadership, public
health advocacy across 17
countries. These editions also
integrated WMA declarations and
statements, regional reports, and
timely scientific articles, reflecting
the Journal’s commitment to
advancing global health dialogue.
The Journal’s editorial team
continues to welcome new voices
and encourages national medical
associations to submit brief articles
for upcoming articles and collective
features.
Finance and Planning Committee
The Council approved the pre-
audited financial statement for 2024
and authorised the continuation of
the audit process.
In a show of solidarity, the Council
waived 2025 membership dues for
the Myanmar Medical Association
and approved a partial waiver for
the Royal Dutch Medical
Association moving forward. These
gestures reflected the WMA’s
commitmenttoinclusiveparticipation
despite economic hardship.
Looking ahead, the Council
confirmed the timeline for
the development of the
WMA Strategic Plan for
2026–2030, with final adoption
expected at the General
Assembly in Porto, Portugal.
The Council finalised upcoming
statutory meetings: Rio de
Janeiro was selected to host the
235th Council session in 2027,
Istanbul was confirmed for
the 238th Council session in 2028,
and the scientific session at the
General Assembly in Rotterdam
(2026) was confirmed with the
“Moral Distress and its Effect on
Healthcare Workers” theme.
The Council endorsed the admission
of two new constituent members: the
Canadian Medical Association and
the Lebanese Order of Physicians.
Both applications will proceed to
the General Assembly for final
approval. Other items approved
included a revision to the JDN
Terms of Reference, the creation
of a workgroup on health-related
crises, and a workgroup to revisit the
option of hybrid sessions.
Medical Ethics Committee
The Council considered the
committee’s report in full, including
a proposed friendly amendment to
the draft resolution on the Ethical
Framework of Healthcare. The
amendment was accepted without
opposition, and the updated
resolution was approved for
immediate release.
The Council approved a revised
version of the WMA’s Ethical
Guidelines for the International
Migration of Health Workers,
which was forwarded to the General
Assembly. In light of increasing
global mobility and health workforce
shortages, the document reaffirms
ethical obligations on both source
and destination countries.
A new workgroup was initiated
to explore the WMA’s stance on
medical neutrality in armed conflict,
responding to continued reports of
violence against medical personnel.
Associations from France, Kenya,
South Africa, Switzerland, United
States, and Uruguay joined the
group.
The WMA Statement on Conflict
of Interest was sent out for
membership-wide consultation,
acknowledging the growing
complexity of ethical practice in
research and clinical partnerships.
The Council agreed to launch a full
revision process of the Declaration
of Taipei, which addresses ethical
concerns related to health databases
and biobanks, which extends the
Declaration of Helsinki – Ethical
Principles for Research Using
Human Participants – into the
virtual world. The Israeli Medical
Association volunteered to chair
this workgroup, supported by
a coalition of national medical
associations (NMAs), the Past
Presidents Network, and the
Associate Members.
In addition, the Council affirmed
several policy review actions for
2025, including revisions to key
WMA Council Report
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7
documents on mental illness, patient
advocacy, and confidentiality, as
well as reaffirmation – with minor
updates – of the Declaration of
Lisbon and the Resolution on the
Designation of an Annual Medical
Ethics Day.
Socio-Medical Affairs Committee
The WMA Statement on Obesity was
forwarded to the General Assembly.
This consolidated and replaced
two older statements to reflect
current understanding and ethical
approaches to prevention and care.
The Council supported the initiatives
of the Workgroup on Environment,
which was renewed for another
term, and agreed to circulate draft
policies on physician well-being,
task shifting, and the use of artificial
intelligence in medicine. New
statements on mental health, ageing,
transgender care, and dementia will
undergo further consultation.
The Council approved several
urgent resolutions for immediate
release.
Ethical Framework of Healthcare
The proposed WMA Resolution to
Uphold the Ethical Framework of
Healthcare was a timely reaffirmation
of the profession’s core ethical
principles amidst rising global
pressure on physicians and health
systems. With growing concerns
over political interference,
misinformation, and the
commercialization of care delivery,
the Council swiftly accepted and
assigned the resolution to the
Medical Ethics Committee for
consideration.
Global Health Funding
The proposed WMA Council
Resolution on Public Health
Funding Worldwide was submitted,
highlighting the need for sustained,
equitable investment in public
health systems, particularly in low-
and middle-income countries. In a
context shaped by the aftermath of
the COVID-19 pandemic and the
impending adoption of the WHO
Pandemic Agreement, the Council
flagged the importance of this issue
and adopted this resolution.
Role of Physician Assistants
The proposed WMA Council
Resolution on the Role of
Physician Associates and Other Non-
Physician Providers in the United
Kingdom and Other Countries
reflected broader international
questions around task shifting,
scope of practice, and accountability
in healthcare. Delegates
acknowledged the topic’s relevance
not only to the United Kingdom,
but also to many health systems
grappling with workforce shortages
and reform pressures. Recognising
the increasing professional concern
related to the evolving role of non-
physician providers, the Council
adopted this resolution as a matter of
urgency.
Riot Control Agents and Human
Rights Violations in Turkey
The proposed WMA Council
Resolution on the Use of Riot
Control Agents and Human Rights
Violations against Protesters in
Turkey drew attention to reports
of excessive force and breaches of
medical neutrality, with implications
for both human rights advocacy and
the safety of health professionals
in protest and conflict zones. The
Council adopted this resolution.
Collaboration with the World
Health Organization (WHO)
In anticipation of the 78th WHA,
the WMA Senior Policy Advisor,
Dr. Clarisse Delorme, updated the
Council on the Association’s
contributions to upcoming World
Health Professions Alliance
(WHPA) side events and official
interventions. Joint statements
were prepared on universal health
coverage, climate change, and global
emergency preparedness. The WMA
will continue to make contributions
to the topics of non-communicable
diseases, mental health, and social
connection.
The WMA Secretary General,
Dr. Otmar Kloiber, highlighted
the symbolic significance of the
forthcoming pandemic treaty –
expected to be signed during the
WHA – while also sounding an
alarm on the funding shortfalls
facing the WHO following the
withdrawal of U.S. support. He
expressed concerns that unless other
countries increase their contributions,
the WHO may be forced to scale
back or eliminate entire departments,
risking the erosion of hard-won
gains in health workforce policy and
ethical governance.
Other Business
Dr. Jesse Ehrenfeld (American
Medical Association) congratulated
Chair of Council, Dr. Jack Resneck,
on his first session and thanked
the hosts in Montevideo for their
hospitality. As his tenure on the
Council concluded, he expressed
the American Medical Association’s
continued commitment to
international engagement despite
inward-facing trends in U.S. politics.
Dr. Jung Yul Park (Korean Medical
Association) introduced Dr.
Haejoo Lee, who gave a stark and
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8
sobering account of the crisis
facing physicians in the Republic of
Korea. She described how sweeping
government reforms – instituted
without medical consultation –
have led to untenable working
conditions, mass resignations of
medical residents, and threats of
reprisal, including license suspension
and physical intimidation. She
called on the WMA to stand in
solidarity with Korean physicians
who continue to demand basic
protections and professional dignity.
Dr. Kitty Mohan (British Medical
Association) raised structural
concerns regarding gender
representation, noting the absence
of female voting members on the
Executive Committee. She urged
colleagues to reconsider internal
procedures to ensure that meaningful
inclusion is achieved. The WMA
Immediate Past President, Dr.
Lujain Alqodmani, echoed her
sentiments.
The Council also viewed a
preview video of upcoming WMA
webinars on artificial intelligence,
introduced by Dr. Ehrenfeld, as well
as an official video invitation from
the Serbian Medical Chamber to
attend the 232nd Council Session in
Belgrade, Serbia, in April 2026.
Adjournment
As the session drew to a close,
WMA Secretary General, Dr. Otmar
Kloiber, announced his intention to
retire following the 232nd Council
Session in Belgrade, Serbia, in April
2026. His words marked not just
the conclusion of a meeting, but
also the beginning of a transition in
leadership after years of steadfast
service. Dr. Kloiber pledged to
ensure a seamless handover,
reflecting the same commitment
and integrity that have defined his
tenure. The moment was met with
heartfelt appreciation – recognition
that his leadership has been
foundational to the WMA’s global
voice in medical ethics, policy, and
solidarity.
Magda Mihaila, BS
WMA Communication and
Information Manager
World Medical Association
magda.mihaila@wma.net
Photo 1. Group photo at the Radisson Montevideo Victoria Plaza Hotel during the 227th Council Session in Montevideo. Credit: WMA
WMA Council Report
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9
WMA COUNCIL RESOLUTION TO UPHOLD THE
ETHICAL FRAMEWORK OF HEALTHCARE
Adopted by the 229th WMA Council
Session, Montevideo, Uruguay,
April 2025
PREAMBLE
Pillars of medicine which were until
recently considered unquestionable, such
as scientific evidence, human dignity and
solidarity, are being increasingly challenged
by the expansion of ideologies and political
positions that reject or deny them.
In this context, the ability of physicians to
work ethically and to follow the rules of
the profession is threatened, as is also the
autonomy of the profession; the intervention
of politics, of the judiciary system or of the
police in the care process is increasingly
becoming a reality in many parts of the
world.
The pressure exists on physicians being
forced by their governments to treat
detained patients in an unethical manner.
There is also outright violence against
healthcare personnel and healthcare facilities
in areas with armed conflicts and other
emergencies.
Pressure put on the professional autonomy
of the physicians and on their ability to
follow their ethical rules can negatively
impact the quality of the care provided, and
can finally compromise the population’s trust
in the profession.
The World Medical Association was
founded with the explicit aim of setting the
highest ethical and humanist standards for
medicine throughout the world.
These standards are being challenged by
ideologies and political stances that reject
the societal achievements of the last 80
years.
These high ethical and humanist standards
must, however, forcefully continue to be
upheld by the medical profession with clear
determination and strength.
RECOMMENDATIONS
1. The World Medical Association and all
its Constituent Members are strongly
committed to upholding the ethical
standards of the medical profession,
as they have been established by the
profession itself during the last 80
years.
2. It is an essential role of the WMA and
of its Constituent Members to advocate
for a legal framework for healthcare
in all our countries, which respects
the ethical rules of our profession and
allows practicing medicine according to
them.
3. The WMA urges governments to
secure the safety and lives of health
care personnel whatever the actual
circumstances, thereby enabling them
to fulfill their duty to help any patient
in need and act according to their
ethical principles.
4. The WMA must actively advocate for
the honor of the medical profession
and the rights of medical personnel
and of the patients wherever these are
under threat.
5. It is the duty of the WMA and
of all its Constituent Members to
support individual physicians and their
organizations whenever their ability
to follow the ethical rules set by the
WMA is threatened or limited by
undue political or judiciary pressure.
6. The World Medical Association and
all its Constituent Members strongly
support and foster scientific, fact-based
medicine, including evidence-based
therapeutic and public health measures.
7. The World Medical Association calls
for respect for the independence of
research, in accordance with the ethical
principles imbedded in its Declaration
of Helsinki.
WMA COUNCIL RESOLUTIONS
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10
WMA COUNCIL RESOLUTION ON THE ROLE
OF PHYSICIAN ASSOCIATES AND OTHER
NON-PHYSICIAN PROVIDERS IN THE UNITED
KINGDOM AND OTHER COUNTRIES
Adopted by the 229th Council session,
Montevideo, Uruguay, April 2025
PREAMBLE
The World Medical Association and its
constituent members share the British
Medical Association’s concerns about the
way in which non-physician practitioners
including PAs (physician associates or
physician assistants) and AAs (anaesthesia
associates) have been introduced in the
United Kingdom and other countries and
makes the following recommendations in
light of the independent ‘Leng Review’ into
PAs and AAs commissioned by the UK
government and other similar reviews.
RECOMMENDATIONS
In the interest of patient and clinician safety
and to ensure broad clarity of understanding,
the WMA affirms that:
1. The terminology used for physician
associates and anaesthesia associates is
confusing. These roles must be titled
‘assistants’ rather than ‘associates’ to
make it clear that they assist physicians.
2. Terms previously used for physicians
such as ‘medical professionals’ and
‘medical practitioners’ should not be
expanded to include PAs and AAs,
nor should they be described as being
‘medically trained’ or ‘trained to the
medical model’. This is because it
is proving to be confusing for the
public and misleading for physician
supervisors and other members of
the multi-disciplinary team who
may wrongly presume that assistants
have the same knowledge, skills and
expertise of a physician, with adverse
consequences for patients.
3. PAs and AAs should work under the
supervision of physicians and within
clearly defined scopes of practice
with clear limits, and should undergo
regular quality assurance and appraisal.
Physicians and their representative
bodies should be properly consulted on
any proposed changes to these scopes
given such roles utilise a limited subset
of skills and knowledge of physicians.
4. PAs and AAs should be deployed to
assist rather than replace physicians.
5. The training of PAs and AAs should
not be prioritised at the expense of
training for physicians and medical
students, including the funding for
such training.
WMA COUNCIL RESOLUTIONS
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11
WMA COUNCIL RESOLUTION ON PUBLIC
HEALTH FUNDING WORLDWIDE
Adopted by the 229th WMA Council
Session, Montevideo, Uruguay, April 2025
PREAMBLE
Health care all over the world is under
threat. Funding that has improved health
by securing vaccines, medicines and health
care professionals is being cut back or
even completely dismantled. This creates
a huge health risk, not only for those that
cannot afford the costs themselves but also
because this will increase the spread of
communicable diseases like HIV, TB and
malaria, and so puts everyone at risk. This
is in addition to the threat that is caused by
armed conflicts.
The WMA calls upon the leaders of the
world to restore basic health care funding
together. If the world sits back, we shall be
confronted with a large increase of diseases
and deaths.
Countries like the USA have made huge
efforts in the last decades. Now, all nations
shall have to contribute together to rescue
our basic health system for those in need.
RECOMMENDATION
The World Medical Association urges world
leaders to contribute together to the funding
of public health facilities that improve
health by securing vaccines, medicines and
health care professionals and by doing
so, help prevent a potential increase in
the spread of communicable diseases like
HIV, TB and malaria, which pose a risk
to everyone. Nations have to contribute
together to rescue basic healthcare systems
for those in need.
WMA COUNCIL RESOLUTIONS
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12
WMA COUNCIL RESOLUTION ON THE USE OF
RIOT CONTROL AGENTS AND HUMAN RIGHTS
VIOLATIONS AGAINST PROTESTERS IN TURKEY
Adopted by the 229th WMA Council
Session, Montevideo, Uruguay,
April 2025
PREAMBLE
In response to the arrest of Istanbul’s mayor,
Ekrem İmamoğlu, and other opposition
figures last March, important demonstrations
are taking place across Turkey. Media reports
the use of tear gas, plastic bullets, and water
cannons by the police as weapons against
demonstrators and passers-by of all ages,
including children.
The documented severe short-term and
long-term health consequences of tear
gas and other riot control agents include
respiratory distress, ocular damage, skin
irritation, and potential psychological
trauma, affecting not only protesters but also
bystanders, residents, and medical personnel.
Ill-treatment and other practices contrary to
international standards, such as the United
Nations Standard Minimum Rules for the
Treatment of Prisoners (the Nelson Mandela
Rules) and the WMA Ethical Guidelines,
were also reported, in particular:
• Detainees were handcuffed behind their
backs by police and searched while still
handcuffed.
• Physicians are being forced to carry out
medical examinations on detainees in
conditions likely to compromise their
professional ethics, their independence,
and the well-being of the detainees.
RECOMMENDATIONS
Recalling WMA ethical principles and
its commitment to the health and human
rights of all people, including the right
of peaceful assembly, the Council of the
WMA, meeting in Montevideo on 24-25
April 2025:
• Denounces the inappropriate use of
riot control agents which risks the lives
of those targeted and exposes people
around, amounting to a potential breach
of human rights standards, as stated
in WMA Statement on Riot Control
Agents.
• Unequivocally condemns any pressure
or coercion exerted upon physicians
to perform medical examinations of
detainees in detention centers.
The WMA Council, therefore, urges the
Turkish authorities to:
• Immediately cease the use of tear gas and
other riot control agents against peaceful
protesters.
• Ensure unimpeded access to medical care
for all injured individuals during protests,
and refrain from any actions that obstruct
or endanger medical personnel.
• Ensure that health professionals can
carry out their work in accordance with
their ethical obligations, without fear of
reprisals.
• Respect and protect the rights of peaceful
protesters.
• Conduct thorough and impartial
investigations into allegations of human
rights abuses against protesters, and hold
perpetrators accountable.
WMA COUNCIL RESOLUTIONS
BACK TO CONTENTS
13
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Dear colleagues of the World
Medical Association,
On behalf of the Ordem Dos
Médicos (Order of Physicians), we
cordially invite you to participate
in the 76th General Assembly of
the World Medical Association,
which will be held on 8-11
October 2025, in Porto, Portugal.
The Ordem Dos Médicos is honored
and humbled to serve as the host
for this event, and we are excited to
share the promotional video (https://
youtu.be/_s5YfMmks4M). Our
team has prepared a robust agenda
of significant themes related to
our medical profession, as well as
leisure activities to learn about our
city, its culture, and its hospitality.
Please mark your calendars and join
us in Porto for this exciting event.
Ordem Dos Médicos
Porto, Portugal
https://ordemdosmedicos.pt/
ordemdosmedicos@ordemdosmedicos.pt
Information about the 76th WMA General Assembly,
Porto 2025
Information about the 76th WMA General Assembly, Porto 2025
14
The Environment Caucus met on
23 April 2025 during the 229th
Council Meeting of the World
Medical Association (WMA) in
Montevideo, Uruguay. A total of 17
members (15 in-person, 2 virtual)
attended the meeting. The purpose
of the Environment Caucus is to
educate members about pressing
environmental concerns, collectively
share ideas and local challenges, and
highlight best practices experienced
by members.
The Environment Caucus meeting
opened with a general discussion of
the geopolitical developments since
the General Assembly in Helsinki,
Finland, notably the United States
(U.S.) presidential election. Dr.
Ankush Bansal, Chair of the
WMA Workgroup on Environment
and of the Environment Caucus,
summarised the pertinent
developments since January 2025,
including the U.S withdrawal from
the Paris Agreement and World
Health Organization (WHO) and
funding halt to the U.S. Agency
for International Development
(USAID). The subsequent
discussion focused on next global
steps to ensure continued progress
on climate change mitigation and
adaptation, global health resources
and alliances, education, information
sharing (including battling
misinformation and disinformation),
and addressing health inequities.
Although some members focused on
increased educational opportunities
and positive messaging, several
members from other high-income
countries were enthusiastic to
actively contribute to next global
steps. The take-home message was
that this complex situation required
further research, analysis, political
and grassroots action, and multi-
sector commitments by high-income
countries.
Dr. Lujain Alqodmani, the WMA
Immediate Past President, presented
a report on her attendance as the
WMA representative to the WHO
2nd Global Conference on Air
Pollution and Health, which was
held on 25-27 March 2025 in
Cartagena, Colombia. While no
firm commitments materialised
from this event, she commented that
the ongoing discussion confirmed
aspirations to reduce air pollution,
primarily from fossil fuel sources,
and to share key updates at future
conferences.
The keynote address was presented
by Dr. Ned Ketyer, a retired
pediatrician from the Pittsburgh,
Pennsylvania area in the U.S., living
in close proximity to the Marcellus
Shale hydraulic fracturing sites.
He is a member of the Council
on Environmental Health and
Climate Change for the American
Academy of Pediatrics and serves
as President of the Pennsylvania
Chapter of Physicians for Social
Responsibility (PSR), the U.S.
affiliate for International Physicians
for the Prevention of Nuclear War.
Notably, climate change represents
one of the two primary missions of
PSR. This presentation was well-
received and highlighted research
data on hydraulic fracturing from
Pennsylvania, Colorado, and Canada.
It also provided insight into the
dangers of fossil fuel production
and the role of health professionals
in protecting the public from these
hazards.
Finally, the Environment Caucus
concluded with an open exchange
of ideas and best practices. Notably,
Dr. Bansal presented his local
experience of air pollution from
the burning of sugarcane harvests
in Florida. He described published
health surveillance data by physicians
and public health scientists on its
direct effects on school and work
absenteeism, childhood asthma,
adult cardiovascular and respiratory
health, allergy triggers, neurological
symptoms, and premature death.
He also pointed out the health
inequities exist primarily among
specific racial and socioeconomic
groups.
The Environment Caucus is open to
all interested attendees of the WMA
Council and General Assembly
meetings. The next Environment
Caucus meeting will be held on 9
October 2025, in Porto, Portugal.
Ankush K. Bansal, MD, FACP,
FACPM, SFHM, DipABLM
Immediate Past Chair, WMA
Workgroup on Environment
and Environment Caucus
President-Elect, Physicians for Social
Responsibility (United States)
Volunteer Clinical
Associate Professor of Medicine,
Herbert Wertheim College of Medicine,
Florida International University,
Miami & Loxahatchee,
Florida, United States
BACK TO CONTENTS
Report of the WMA Environment Caucus
Report of the WMA Environment Caucus
Ankush K. Bansal
15
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Unravelling MAiD in Canada: Euthanasia
and Assisted Suicide as Medical Care
Unravelling MAiD in Canada
We are pleased to present
Unravelling MAiD in Canada:
Euthanasia and Assisted Suicide as
Medical Care, a multidisciplinary
volume examining the complex
ethical, legal, social, and medical
practice questions surrounding
Medical Assistance in Dying
(MAiD) in Canada [1]. Bringing
together a diverse group of scholars,
practitioners, cultural backgrounds,
and persons with lived experience,
this book offers an in-depth
exploration of far-ranging aspects
of Canada’s rapidly expanding
MAiD regime. Canada is quickly
becoming a global point of focus for
any jurisdiction considering assisted
suicide and euthanasia policies.
This volume should be of broad
international interest, as it reveals
key concerns both with legalizing
assisted dying, as well as the flawed
processes that have fueled Canada’s
MAiD expansion.
Since its legalisation in 2016,
Canada’s MAiD regime has
expanded rapidly, with significant
implications for medical practice,
health law and policy, and vulnerable
populations [2]. Criminal Code
amendments lifted the absolute
prohibition on homicide and
aiding suicide, initially creating a
route for euthanasia and assisted
suicide for those approaching their
death. Both assisted suicide and
euthanasia are included in the
term medical assistance in dying.
This made Canada one of a small
number of jurisdictions worldwide
to legalize both practices–and
notably, one where euthanasia,
rather than assisted suicide, is the
default method. Of over 15,000
annual MAiD deaths, almost
all were euthanasia, a lethal
injection administered by medical
practitioners or nurse practitioners;
fewer than a handful were self-
administered assisted suicides via
prescription of lethal medication.
Canada’s approach has been
internationally distinct not only for
its scope, but also for the process
through which it was enacted.
Unlike most jurisdictions where
assisted dying was introduced
following extended legislative
debate or referendum – such as in
New Zealand – Canada’s initial
legalisation followed a judicial ruling.
The Supreme Court’s 2015 Carter
decision found that the absolute
prohibition of assisted dying
violated constitutional rights and
required the development of MAiD
in some restricted circumstances
[3]. A more recent expansion
in 2021, beyond the end-of-life
context, also occurred ostensibly in
response to a lower court decision,
issued by a single judge in Quebec.
Despite the ruling having no
binding authority nationwide, the
Trudeau government voluntarily
chose not to appeal the decision
and instead pushed forward with
MAiD expansion across the entire
country, rushing legislation through
Parliament during the coronavirus
disease 2019 (COVID-19)
pandemic. The legislation created a
new MAiD pathway, Track 2, that
did not include the “reasonably
foreseeable death” safeguard, which
had protected non-dying Canadians
from being euthanized.
Currently, Canada has the fastest
growth rate of euthanasia deaths
globally, with the province of
Quebec emerging as the jurisdiction
with the highest percentage (over
7%) of administered deaths relative
to overall mortality in the world.
Canada has also seen a notable
expansion of its legislation in a
short period of time. As mentioned
above, the initial safeguard requiring
a person accessing MAiD to be
near the end-of-life was removed
Ramona Coelho K. Sonu Gaind Trudo Lemmens
16
BACK TO CONTENTS
in 2021, and MAiD is now
accessible to persons with physical
disabilities who are not near death.
The 2021 law also eliminated other
safeguards, such as a mandatory
10-day reflection period and the
firm requirement of confirming
consent immediately prior to
receiving the lethal injection. In
2027, the government plans to
extend eligibility to those suffering
solely from mental illness or
addictions. In Quebec, MAiD is
already available on the basis of
advance requests for persons who
have lost capacity–even though
such provisions remain prohibited
under the federal Criminal Code.
Remarkably, the former Trudeau
government indicated that it would
not launch any legal action to
challenge the new Quebec law,
even while acknowledging that
the provincial law clearly violated
federal legislation [4].
One of the striking things, as
discussed in several chapters in our
volume and also elsewhere, is that
even more than in other liberal
euthanasia regimes, such as Belgium
and the Netherlands, Canada’s law
and policy emphasise the need
to ensure broad access to MAiD,
rather than protecting patients
against wrongful death [5,6]. MAiD
is not a last resort, and people who
satisfy the broad access criteria
can have MAiD, even if standard
effective therapies and social
support measures could provide
relief but have not been tried or are
inaccessible. The federal government
has also extensively relied on
individuals and organisations for
policy guidance who have been
pushing for the most flexible
and open interpretation of the
MAiD law. Rather than providing
necessary clinical or medical input,
many professional medical and
psychiatric organisations have
uncritically accepted, or propagated,
the contested claim that there is a
broad right to MAiD and that
access must be facilitated. At the
same time, these professional
organisations have failed to provide
the medical evidence that would
typically be an expectation in
consultations for any medical
procedure. They have also refused
to provide known evidence of
risks to potentially suicidal
individuals seeking death and being
euthanised.
Canada’s MAiD trajectory has
drawn significant national and
international human rights scrutiny.
In March 2025, the United Nations
(UN) Committee on the Rights
of Persons with Disabilities issued
a report with observations that
included a recommendation for
Canada to repeal Track 2 MAiD
(for those not near death) and to
revoke the planned 2027 expansion
[7]. It further recommended against
extending MAiD to mature minors
or permitting advance requests
and improving the monitoring of
the practice and the safeguards.
This is not the first time Canada’s
regime has been condemned for
being based on ableist assumptions
and for failing to account for
risks to marginalised populations.
Several UN human rights experts,
the Canadian Human Rights
Commissioner, and numerous
disability rights and social justice
organisations have raised serious
concerns regarding its direction
and impact in the years since its
legalisation.
MAiD monitoring is largely
post-factum and based on self-
reporting by MAiD providers to
federal, and in some provinces to
provincial agencies, which limits its
effectiveness. Still, Health Canada
MAiD and other provincial reports
provide relevant information, such
as: how many people received
MAiD; the percentage of persons
dying by MAiD per province; what
motivates people to ask for it; the
underlying conditions; how many
requests were rejected (less than
10%); and the profile of MAiD
providers; and some socio-economic
data.
In 2024, the Chief Coroner of
Ontario, Canada’s largest province
with approximately 40% of the
population, established a MAiD
Death Review Committee – of
which two of us are members –
to review selected MAiD cases
identified by the Chief Coroner’s
MAiD Review Team. Committee
members contribute their expertise
to help inform recommendations
for future MAiD practice, aimed at
improving public safety. Particularly
these Coroner reports, along with
numerous investigative journalism
reports, document how some
patients are receiving MAiD in
circumstances where their suffering
is largely driven by structural
inequalities, including factors such
as poverty, loneliness, feelings of
being a burden, inadequate medical
and social support, and even obesity
[8-11].
Health Canada’s report on the
2023 MAiD practice reveals that,
for nearly half of the 622 Track
2 MAiD deaths (those not near
death), loneliness or isolation was
identified as a key component of
their unbearable suffering [12].
In over 45% of all MAiD deaths,
people also cited the perception of
being a burden on family, friends,
or caregivers. Several Chief Coroner
of Ontario MAiD Death Review
reports also contain case narratives
that highlight, at times, highly
questionable informed consent and
capacity assessment procedures by
MAiD providers.
Unravelling MAiD in Canada
17
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Despite growing concerns about
whether Canada’s MAiD expansion
has already gone too far, the legacy
legislation from the Trudeau
government remains active, pushing
for further MAiD expansion to
Canadians suffering solely from
mental illness and addictions by
2027. This expansion has already
been delayed twice: first by one
year in 2023, and then by three
years in 2024. It remains to be
seen whether the newly elected
Carney government will continue
to be influenced by those lobbying
for the widest possible MAiD
expansion, or whether it will
recognize emerging concerns and
adopt a more balanced approach.
Unravelling MAiD in Canada
seeks to inform and elevate the
ongoing conversation by providing
an in-depth discussion of various
components of the MAiD law,
policy, and practice. The volume
features contributions from disability
authors and professionals across
fields such as medicine, psychiatry,
law, policy, and ethics, offering a
range of professional, cultural and
Indigenous perspectives grounded
in scholarship, medical practice,
governmental policymaking, and
lived experience. It also provides
detailed testimony on the rapid
development of Canadian MAiD
law and policy, which serves as a
cautionary tale to other countries
that are currently debating the
legalisation of euthanasia and
assisted suicide, or the expansion
of existing legislation. Particular
attention is given to the effects of
MAiD on marginalised populations,
including those affected by
systemic discrimination based
on Indigeneity, age, disability,
and mental health status. Several
chapters highlight how unmet
social and healthcare needs may
influence individuals to seek MAiD
– not as a free choice, but as a
response to inadequate supports.
As editors who have engaged
directly in legislative and public
discourse – especially in the years
following Carter – we felt a strong
need to convene this conversation
in a comprehensive and scholarly
format. Many of us could not have
anticipated, even 15 years ago, that
this issue would become so central
to Canadian healthcare, health
policy, and to our very lives. Yet its
significance has grown, compelling
us and many contributors to focus
their academic and professional
efforts on understanding and
addressing its implications.
We are deeply grateful to the
contributors who have shared their
expertise and voices in this volume,
offering essential perspectives that
have too often been absent from
public discourse. We hope this
book will serve as a meaningful
resource for scholars, clinicians,
policymakers, and members of the
public who wish to engage critically
with the evolving Canadian
experience of MAiD. We warmly
invite readers to explore this volume
and to join the broader national
and international dialogue on this
urgent and deeply complex issue.
References
1. Coelho R, Gaind KS, Lem-
mens T. Unravelling MAiD in
Canada: euthanasia and assisted
suicide as medical care. Mon-
tréal: McGill-Queen’s Univer-
sity Press; 2025. Available from:
https://www.mqup.ca/unrav-
elling-maid-in-canada-prod-
ucts-9780228023692.php
2. Government of Canada. Medi-
cal assistance in dying: overview
[Internet]. 2024 [cited 2025 May
4]. Available from: https://www.
canada.ca/en/health-canada/ser-
vices/health-services-benefits/
medical-assistance-dying.html
3. Supreme Court of Canada. Cart-
er v Canada (Attorney General)
(2015) SCC 5. 2015 [cited 2025
May 4]. Available from: https://
decisions.scc-csc.ca/scc-csc/scc-
csc/en/item/14637/index.do
4. The Canadian Press. Canada
won’t stop advanced requests for
assisted dying in Quebec, will
launch consultations on changes
to law [Internet]. The Gazette.
2024 [cited 2025 May 4]. Avail-
able from: https://www.montreal-
gazette.com/news/article560106.
html
5. Lyon C, Lemmens T, Kim SYH.
Canadian Medical Assistance
in Dying: provider concentra-
tion, policy capture, and need
for reform. Am J Bioethics.
2025;25(5):6-25.
6. Lemmens T. When death be-
comes therapy: Canada’s trou-
bling normalization of health care
provider ending of life. Am J Bio-
ethics 2023;23(11):79-84.
7. United Nations Committee on
the Rights of Persons with Dis-
abilities.Concluding observations
on the combined second and third
periodic reports of Canada. CRP-
D/C/CAN/2-3. Geneva: UN;
2025. Available from: https://
tbinternet.ohchr.org/_layouts/15/
treatybodyexternal/Download.as-
px?symbolno=CRPD%2FC%2F-
CAN%2FCO%2F2-3&Lang=en
8. Gaind KS. MAiD and marginal-
ized people:coroner’s reports shed
light on assisted death in Ontar-
io [Internet]. The Conversation.
2024 [cited 2025 May 4]. Availa-
ble from: https://theconversation.
com/maid-and-marginalized-
Unravelling MAiD in Canada
18
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people-coroners-reports-shed-
light-on-assisted-death-in-on-
tario-241661
9. Coelho R. Rushing to death
in Canada’s MAiD regime:
Ramona Coelho for Inside
Policy [Internet]. Macdon-
ald-Laurier Institute. 2025 [cit-
ed 2025 May 4]. Available from:

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rushing-to-death-in-canadas-
maid-regime-ramona-coelho-
for-inside-policy/
10. Cheng M, Wang A. Private
forums show Canadian doc-
tors struggle with euthanizing
vulnerable patients [Internet].
Associated Press. 2024 [cited
2025 May 4]. Available from:
https://apnews.com/article/
euthanasia-ethics-canada-doc-
tors-nonterminal-nonfatal-cas-
es-dfe59b1786592e31d9eb3b-
826c5175d1
11. Raikin A. No other options [In-
ternet]. The New Atlantis. 2024
[cited 2025 May 4]. Available
from: https://www.thenewat-
lantis.com/publications/no-oth-
er-options
12. Health Canada. Fifth annual re-
port on Medical Assistance in
Dying in Canada. Ottawa: Gov-
ernment of Canada; 2023. Avail-
able from: https://www.canada.
ca/en/health-canada/services/
publications/health-system-ser-
vices/annual-report-medical-as-
sistance-dying-2023.html
Disclosures
RC and TL are members of the
Ontario MAiD Death Review
Committee. RC, SG, TL presented
as expert witnesses for federal
parliamentary committees on
MAiD. SG and TL were members
of the Council of Canadian
Academies Expert Panel on MAiD.
SG and TL were expert witnesses
for the Attorney General in the
Truchon and Lamb cases. SG was
Former Physician Chair Assisted
Dying Team, Humber River
Hospital.
Authors
Ramona Coelho, MDCM, CCFP
Adjunct Research Professor, Family
Medicine, Schulich School of Medicine
and Dentistry, Western University
Senior Fellow of Domestic and Health
Policy, MacDonald Laurier Institute
London, Ontario, Canada
drramonacoelho@gmail.com
K. Sonu Gaind, MD,
FRCP(C), DFAPA
Professor, Temerty Faculty of
Medicine, University of Toronto
Chief of Psychiatry Sunnybrook
Health Sciences Centre
Toronto, Ontario, Canada
sonu.gaind@utoronto.ca
Trudo Lemmens, LicJur
LLM (Bioethics), DCL
Professor and Scholl Chair in Health
Law and Policy, Faculty of Law
and Dalla Lana School of Public
Health University of Toronto
Toronto, Ontario, Canada
Trudo.Lemmens@utoronto.ca
Unravelling MAiD in Canada
19
Voluntarily Stopping Eating and Drinking as
a Self-Chosen Path for End of Life
Voluntarily Stopping Eating and Drinking
Over the past few decades, patients
have had an increased desire for
autonomy and control, including
control over the final stages of
their lives. One available option
is voluntary stopping eating and
drinking (VSED), which refers to
the decision made by a person to
stop eating and drinking for the
purpose of hastening the end of
life. VSED is different from people
who gradually eat and drink less as
a result of a terminal illness or those
who refuse food or liquid intake in
the context of a hunger or thirst
strike.
In the Netherlands, an estimated
0.4-2.1% of all deaths are attributed
to VSED, where the majority of
cases are women over the age of 80
[1-3]. Of all reported VSED cases
in the nation, approximately 60% are
linked to a serious physical illness,
and 12-30% have associations
with (incipient) dementia. In
cases with no serious physical or
psychiatric disorder (25%), there
is an accumulation of age-related
complaints or problems with a
‘fulfilled life’.
Patients may choose VSED due
to physical complaints (especially
fatigue and pain), but other
factors may include feelings of
having no purpose in life, suffering
from life, having a fulfilled life,
dependency, disability, and loss of
dignity. In the Netherlands, reports
have shown that a total of 19-45%
of cases where people died from
VSED had made an earlier request
for euthanasia to their attending
physicians, although it is unknown
why the request for euthanasia was
not granted [3-5]. The only other
country where prevalence of VSED
is studied is Switzerland (estimated
prevalence 0,5-0,7%) [6,7].
In January 2024, the Royal Dutch
Medical Association (KNMG)
revised the Caring for People
who Stop Eating and Drinking to
Hasten the End of Life guideline
from 2014 (https://www.knmg.nl/
download/guide-caring-for-people-
who-stop-eating-and-drinking-to-
hasten-the-end-of-life), as a revised
resource for healthcare providers on
how to inform and care for patients
who choose VSED. To complement
this clinical guideline, the KNMG
prepared the Stopping Eating and
Drinking to Die Sooner (Stoppen
met eten en drinken om eerder te
overlijden) brochure (https://www.
knmg.nl/download/publieksbrochure-
stoppen-met-eten-en-drinken-om-
eerder-te-overlijden), so that patients
and their families can make well-
informed decisions about VSED
and their end of life care.
Right to Self-Determination
All people with the decisional
capacity have the right to choose
VSED, a choice they can make
for themselves without depending
on the consent of others. The
reason why people are allowed
to choose VSED is based on the
right to self-determination (every
person is entitled to make their
own decisions about their own
life), which is enshrined in Article
10 of the Dutch Constitution
and Article 8 of the European
Convention on Human Rights (the
right to respect for one’s private
life). A competent patient’s refusal
of treatment (including VSED)
must be respected, as disregarding
this decision would ultimately
imply administering nutrition or
fluids to people against their will.
Various constitutional and human
rights oppose this action, including
the right to physical integrity,
which is described in Article
11 of the Dutch Constitution.
Gert van Dijk Veelke Derckx Alexander de Graeff
BACK TO CONTENTS
20
Voluntarily Stopping Eating and Drinking
Provision of Information by
Healthcare Providers
Since patients are increasingly
seeking information on how to
maintain control over their own
end of life, they should have access
to reliable information to be well-
informed of their options. When
patients share their death wish with
a healthcare provider, it is important
to inquire about the rationale of
this wish. For example, a death
wish may simply be a request for
help or stem from a mental illness
or existential distress. In that case,
it may be desirable to refer patients
to seek a consultation with mental
health services, spiritual caregivers
or other forms of assistance. Patients
with a death wish may be unaware
of options (like VSED) or may
have inaccurate information based
on misconceptions or myths. This
situation may also raise questions as
to whether physicians are allowed or
prohibited from educating patients
about VSED as well as other end of
life options.
When competent patients and
their families have questions about
end of life options, we believe
that healthcare providers have a
responsibility to inform and educate
them about all relevant end of life
options (including VSED). If VSED
is discussed, healthcare providers
should provide information about
the preparation and course of the
VSED process, its advantages and
disadvantages, any problems that
should be expected, and available
professional support (including
psychological health services). This
clinical encounter can foster a
space for patients to understand all
available options and tools to make
an informed and well-considered
decision about their own end of life,
as well as healthcare providers to
encourage shared decision-making
and strengthen patients’ autonomy.
(Assistance with) Suicide?
The question may arise as to
whether or not VSED is considered
to be (a specific form of) suicide.
After all, by stopping eating and
drinking, patients are hastening
the end of their own life. However,
linking VSED to forms of suicide
remains a controversial topic in the
literature [8]. Even if VSED is a
considered as a form of suicide, it
differs from other forms of suicide
in several ways. First, VSED cannot
be an impulsive act, and dying
is gradual and not aggressive or
violent. Second, patients have the
option to change their mind during
the process, and this voluntary
nature is better guaranteed than
with (other forms of) suicide.
However, we believe that making
a decision on whether VSED
is a specific form of suicide is
unnecessary, as it is not relevant to
the question of whether physicians
should or should not provide care
to patients who choose VSED. In
our perspective, caring for patients
during VSED is a form of palliative
care aimed to alleviate suffering
and not hasten death, which should
be provided in all situations where
people suffer. Furthermore, even
if VSED would be considered a
form of suicide, this would not
automatically make it morally wrong
[9].
In our opinion, there is no morally
relevant distinction between
palliative care for people who
choose VSED and those who select
other end of life options. After
all, such a distinction would mean
that people who choose VSED are
denied adequate symptom relief.
The ‘own fault’ perception should
not play a role in considering
whether someone’s complaints
should be remedied. All people who
suffer have the right to relief from
that suffering, even if that suffering
is the result of a personal choice,
such as VSED.
Course
Most patients who choose VSED
as the end of life option usually
die within one to three weeks upon
the initiation of VSED [2,10,11].
With proper care, death usually
occurs with relatively few symptoms
and suffering. During this period,
patients may reconsider their
decision and start eating or drinking,
so death may be postponed.
The process of dying occurs in
three phases, which gradually merge
into one another. The first phase
(three to four days) is defined when
eating and drinking are acutely or
gradually stopped, and the feeling of
hunger usually disappears, provided
that no carbohydrates are ingested.
During the middle phase (variable
length) pain or signs of delirium can
occur. Painkillers and sleeping pills
are the most commonly prescribed
palliative medication. Although
thirst is generally not a prominent
complaint, proper oral care is
essential to prevent and alleviate
complaints of thirst or dry mouth.
The final phase (several days) is
comparable to the dying phase of a
terminal illness.
Conscientious Objections
Healthcare providers can have
moral objections to providing care
to people who choose VSED,
as they may think that they are
cooperating in someone’s suicide.
Stopping to offer food and drink
because the patient chooses to
hasten the end of life can also make
healthcare providers feel that they
are providing poor clinical care.
In that case, the patient’s choice
conflicts with the caregiver’s beliefs
or personal values and norms, which
BACK TO CONTENTS
21
Voluntarily Stopping Eating and Drinking
may cause conscientious objections
for a caregiver.
However, healthcare providers have
a duty to act as a ‘good healthcare
provider’ even if they disagree
with their patient’s choice that
leads to health problems and/or
hastening the end of life. Therefore,
when a healthcare provider has
conscientious objections, according
to the Dutch Code of Conduct for
doctors, care must be transferred
to another healthcare provider who
is willing to provide the necessary
care. The initial healthcare provider
must, however, continue to provide
care until the moment of transfer to
this colleague.
Palliative Sedation
VSED can result in one or more
refractory symptoms, such as
thirst, delirium and exhaustion.
If existential suffering can no
longer be relieved by, for example,
conversations or spiritual support,
this suffering may also be refractory.
Existential suffering may thus be
part of the refractory symptoms that
lead to unbearable suffering of the
patient. If the patient ingests little
or no fluids, the criterion of a life
expectancy of a maximum of two
weeks is met. In these situations,
palliative sedation may therefore
be an option, provided that the
conditions of the Dutch Guideline
on Palliative Sedation are met [12].
Natural Death
Since opinions differ on whether
VSED qualifies as a form of
suicide, there may be uncertainty
about how to complete the death
certificate. In the Netherlands, the
death of a patient who dies from
VSED is seen as a natural death,
and therefore does not have to be
reported to the municipal medical
examiner. The direct cause of death
is recorded on the death certificate
as ‘deliberate refusal to eat and
drink’. Notably, the clinicians in
the United States published a
comprehensive guideline for VSED,
considering VSED as a natural
death [13]. It is partly based on the
original 2014 KNMG guideline, but
adapted to the U.S. health system
context, especially with regard to
legislation, healthcare organization,
and attitudes towards end-of-life
care. In other jurisdictions, the legal
situation regarding VSED might be
different.
Conclusion
Moving into the future, it is likely
that doctors and other healthcare
providers will be confronted more
often with patients who would like
to explore options for controlling
their end of life care. They should
correctly inform patients about
the various clinical care options,
including VSED, and carefully guide
them in the event of a decision
to choose VSED. If healthcare
providers have conscientious
objections in providing care to
people who choose VSED, then
care must be transferred to a
healthcare provider who is willing
to provide the necessary care.
References
1. Chabot BE,Goedhart A.A survey
of self-directed dying attended by
proxies in the Dutch population.
Soc Sci Med. 2009;68:1745-51.
2. Bolt EE, Hagens M, Willems
D, Onwuteaka-Philipsen BD.
Primary care patients hastening
death by voluntarily stopping eat-
ing and drinking. Ann Fam Med.
2015;13(5):421-8.
3. Hagens M, Pasman HRW,
van der Heide A, Onwutea-
ka-Philipsen BD. Intentional-
ly ending one’s own life in the
presence or absence of a medical
condition: a nationwide mortali-
ty follow-back study. SSM Popul
Health. 2021;15:100871.
4. Chabot BE. Auto-euthanasia.
Hidden death paths in conversa-
tion with relatives. Amsterdam:
Bert Bakker Publishers; 2007.
5. Bolt EA, Hagens M, Willems
DL, Onwuteaka-Philipsen BD.
Conscious abstinence from food
and drink. Ned Tijdschr Ge-
neeskd. 2015;160:D84.
6. Stängle S, Schnepp W, Büche
D, Häuptle C, Fringer A. Fam-
ily physicians’ perspective on
voluntary cessation of eat-
ing and drinking: a cross-sec-
tional study. J Int Med Res.
2020;48(8):300060520936069.
7. Stängle S, Büche D, Häuptle
C, Fringer A. Experiences, per-
sonal attitudes, and profession-
al stances of Swiss health care
professionals toward voluntary
stopping of eating and drinking
to hasten death: a cross-sectional
study. J Pain Symptom Manage.
2021;61(2):270-8.e11.
8. Moskop JC. Voluntarily stopping
eating and drinking: conceptual,
personal, and policy questions. J
Med Philos. 2021;46(6):805-26.
9. Menzel PT. Ethical issues. In:
Quill TE, Menzel PT, Pope
TM, Schwarz JK, eds. Voluntar-
ily stopping eating and drinking.
New York: Oxford University
Press; 2021.
10. Chabot BE. Auto-euthanasia:
hidden death paths in conversa-
tion with relatives. Amsterdam:
Bert Bakker Publishers; 2007.
Dutch.
BACK TO CONTENTS
22
Voluntarily Stopping Eating and Drinking
BACK TO CONTENTS
11. Ganzini L, Harvath TA, Jackson
A, Goy ER, Miller LL, Delo-
rit MA. Experiences of Oregon
nurses and social workers with
hospice patients who requested
assistance with suicide. N Engl J
Med. 2002;347(8):582-8.
12. Stichting PZNL.Dutch guideline
on palliative sedation [Internet].
2022 [cited 2025 Apr 1]. Dutch.
Available from: https://palliaweb.
nl/richtlijnen-palliatieve-zorg/
richtlijn/palliatieve-sedatie
13. Wechkin H, Macauley R, Men-
zel PT, Reagan PL, Simmers N,
Quill TE. Clinical guidelines for
voluntarily stopping eating and
drinking (VSED). J Pain Symp-
tom Manage. 2023:66(5):e625-
31.
Authors
Gert van Dijk, MA
Ethics policy advisor, Royal
Dutch Medical Association
Utrecht, The Netherlands
g.van.dijk@fed.knmg.nl
Veelke Derckx, LLM, PhD
Health law advisor, Royal
Dutch Medical Association
Utrecht, The Netherlands
V.Derckx@fed.knmg.nl
Alexander de Graeff, MD, PhD
Department of Medical Oncology,
University Medical Centre Utrecht
Academic Hospice Demeter
De Bilt, The Netherlands
A.deGraeff-2@umcutrecht.nl
23
“It is very difficult to predict –
especially the future.” – Attributed
to Nobel prize-winning Quantum
physicist Neils Bohr
In January 2025, the famous
‘doomsday clock’ was reset to 89
seconds to midnight, the closest
ever to human extinction. As a
metaphor that was inaugurated in
the aftermath of the Second World
War, the doomsday clock represents
how close humanity was to self-
destruction amidst nuclear weapons
[1]. This concern was recognised
by a number of Manhattan Project
atomic scientists from the University
of Chicago who inaugurated the
Bulletin of the Atomic Scientists
(https://thebulletin.org/) in 1945.
In the 2025 Doomsday Clock
Statement, the atomic scientists
expressed the following sentiment:
“In 2024, humanity edged ever closer
to catastrophe… despite unmistakable
signs of danger, national leaders and
their societies have failed to do what is
needed to change course. Consequently,
we now move the Doomsday Clock
from 90 seconds to 89 seconds to
midnight—the closest it has ever been
to catastrophe. Our fervent hope is
that leaders will recognize the world’s
existential predicament and take bold
action to reduce the threats posed by
nuclear weapons, climate change, and
the potential misuse of biological science
and a variety of emerging technologies”
[2].
By the end of the Second World
War, the World Medical Association
(WMA) was established in 1947,
motivated by physicians who had
been involved in the chaos and
destruction of two global conflicts
within their lifetimes. The practice
of medicine in wartime had placed
a severe strain on the profession
as well as its practitioners, with
many nearly impossible decisions
compromised by resource constraints
and military necessity. At the time,
since few medical organisations
explicitly stated their professional
obligations, the WMA’s highest
priorities were to develop a code
of ethics for medical practice and
a personal ‘pledge’ for individual
doctors to guide their approach
to medical care. By the end of the
1940s, the WMA had released first
iterations of the International Code
of Medical Ethics (“A doctor must
always bear in mind the obligation
of preserving human life”) and the
Declaration of Geneva (“I solemnly
pledge myself to consecrate my life to
the service of humanity”) [3]. Notably,
the revised International Code of
Medical Ethics clearly articulates
the principle that each physician
“has a responsibility to contribute
to the health and well-being of the
populations the physician serves and
society as a whole, including future
generations” [4].
In the current global environment,
an obligation to the health and
well-being of the current and future
generations imposes an extraordinary
responsibility on physicians. It goes
well beyond that of simply providing
healthcare to individual patients and
within individual health systems,
as it assumes a scope of practice
that is expansive and perpetual for
every physician. Observed from
the highest level, transcending
on the health of our individual
communities, the emerging concept
of planetary health recognises a
transnational collaboration that
promotes health for humans and
the Earth’s biosphere (‘life support’)
[5,6]. However, is there certainty
that human society will continue?
Published before the coronavirus
disease 2019 (COVID-19)
pandemic, an analysis of existential
risk to Homo sapiens estimated a 10-
20% risk of species extinction by the
end of this century [7]. Our species,
however, has likely existed for more
than 150,000 years and survived
many natural hazards over this
timescale [8]. Yet some pessimism
remains, as expressed by scientists
[7]:
“Our longevity as a species offers
no… grounds for confident optimism.
Consideration of specific existential-
risk scenarios bears out the suspicion
that the great bulk of existential risk
in the foreseeable future consists of
BACK TO CONTENTS
The Doomsday Clock is Ticking
The Great Silence: The Doomsday Clock is Ticking
Steve Robson Hilary Bambrick
24
anthropogenic existential risk – that is,
those arising from human activity.”
We have entered an epoch
where many existential risks to
human civilization are potentially
self-inflicted and interactive,
compounding the total risk through
complex systemic feedback [9].
Where is Everyone?
Italian-American physicist and
Manhattan Project member, Enrico
Fermi, was awarded the Nobel
Prize in Physics in 1938, and posed
the famous question: “Where is
everyone?” [10]. Fermi posited
that since the universe is over 13
billion years old, any pre-existing
civilization should have colonised
much of the universe, yielding
abundant evidence of life beyond
Earth. Yet despite a substantial
global effort over many decades,
there is no evidence of life beyond
our planet.
The ‘great silence’ of the universe
beyond Earth troubled many
scientists, including American
astronomer, David Brin. In the
early 1980s, his mathematical
analysis–the sheer number of
potentially biophilic planets would
favour the emergence of life, yet
we see no evidence beyond Earth
– led him to hypothesise that the
lifespan of technological species
is short [11]. In response, Robin
Hanson, an economist at George
Mason University (United States),
published a paper entitled, ‘The
great filter: Are we almost past it?’,
noting that “life on Earth seems to
have adapted its technology to fill
every ecological niche it could…[and]
species have consistently expanded into
newly-opened frontiers” [12].
Expanding beyond Earth, Hanson
pointed out that, “We have had great
success at explaining the behavior of
our… solar system, nearby stars, our
galaxy, and even other galaxies, via
simple ‘dead’ physical processes, rather
that the complex purposeful processes
of advanced life.” He proposed the
idea that a ‘great filter’ operates
between the emergence of single
cell life forms and the ‘explosion’
of intelligent civilisation beyond
its home planet. Brin, Hanson,
and other scientists have expressed
their great concern for our species
with the failure to detect signs of
life elsewhere. Hanson shared his
sentiment about the future [12]:
“We should fear for our future…No
alien civilizations have substantially
colonized our solar system or systems
nearby. Thus among the billion
trillion stars in our past universe, none
has reached the level of technology and
growth that we may soon reach. This
one data point implies that a Great
Filter stands between ordinary dead
matter and advanced lasting life. And
the big question is: How far along this
filter are we?”
Although the formal and
informal analyses of physicists,
mathematicians, and economists,
such as Fermi, Brin, and Hanson,
are difficult to interpret and not
necessarily generalizable, limited
proof for any long-term survival of
complex, purposeful species across
a cosmic population is concerning.
Physicians should take this evidence
as a poor prognostic sign.
Medicine and our Species
If the medical profession has a
clear-cut ethical obligation for
“future generations,” then physicians
should make every effort to ensure
that future generations will actually
exist [3]. How can the medical
profession collectively maximise
this chance? First, it is worth
remembering that the Bulletin of the
Atomic Scientists first unveiled the
existential ‘doomsday clock’ at the
same time that the WMA released
its International Code of Ethics
for physicians. Second, while we
perceive that modern Homo sapiens
have survived over time, 99% of
species that have ever existed are
now extinct [13]. Indeed, a number
of epochs in Earth’s history have
hosted mass extinctions, and there is
a concern that we may be living in
such an epoch now with extensive
biodiversity loss [14].
If we consider our position as a
species using the framework of
planetary boundaries, it is likely
that we have transgressed six
(anthropogenic climate change,
biosphere integrity, land system
change, freshwater availability,
biochemical flows, novel entities)
of the nine boundaries [15,16].
Of the three that have not yet
been breached (ocean acidification,
atmospheric aerosol loading,
stratospheric ozone depletion), ocean
acidification is approaching the ‘safe
operating zone’ edge, due to the
absorption of atmospheric carbon
emissions and the burning of fossil
fuels. Furthermore, the mechanisms
(‘great filters’) that could be
associated with the extinction
of Homo sapiens can include
future pandemics, environmental
degradation and climate change,
armed conflict, and natural disasters
(including a large object from space
striking Earth) [17].
Historical records have illustrated
high mortality rates due to infectious
disease outbreaks, including the
more than 50 million global deaths
during the 1918 influenza pandemic.
Specifically, analyses suggest that
during the COVID-19 pandemic,
the high mortality rate in high-
income countries was potentially
preventable as it was attributed to
polarization and noncompliance
to recommended preventive
The Doomsday Clock is Ticking
BACK TO CONTENTS
25
actions [18,19]. Urbanisation,
increased human-animal contact,
anthropogenic climate change,
health workforce shortages, and
travel remain risk factors associated
with future pandemics [20,21].
Across the 20th century, an estimated
231 million deaths resulted from
wars and armed conflicts (“killed or
allowed to die by human decision”)
[22]. Lili Xia and colleagues have
predicted that looking forward in
an increasingly unstable world, the
long-term effects of a major nuclear
exchange would cost five billion
lives [23]. We now hear concerns
that nuclear conflict is becoming
more likely, with many international
actors either attempting to acquire
atomic weapons for the first time,
or expanding existing arsenals [24].
Kamran Abbasi and colleagues
highlighted that “Current nuclear
arms control and non‐proliferation
efforts are inadequate to protect the
world’s population against the threat
of nuclear war by design, error, or
miscalculation” [25]. Notably, the
former U.S. Defense Secretary
Robert McNamara expressed
that the world was spared from a
large-scale nuclear conflict in the
last century, due to good fortune,
not specific military leadership or
technology: “We lucked out. It was
luck that prevented nuclear war” [26].
Lessons from Space
At least one of the planet’s mass
extinctions was likely caused by
the impact of an object from space.
As the best-known example, the
Chicxulub crater in the Yucatan
Peninsula of Mexico occurred 66
million years ago, and it appears to
have led directly to the extinction
of 88% of all land-dwelling life
forms (including dinosaurs) [27].
The historical record, however,
depicts an example of near-misses
to the planet. In 2013, a 20-metre
meteor, travelling at an estimated 19
km/s, entered the atmosphere over
the Russian town of Chelyabinsk,
generating a shock wave sufficient
to damage over 7,000 buildings
and caused over 1,600 people to be
injured and hospitalised [28].
The astrophysics community
recognizes cosmic impacts as a
potential risk to humanity, which
has prompted coherent mitigation
responses. Careful analysis has
been performed to provide precise
estimates of the risk of impacts
and detailed mapping of near-
earth objects (NEOs) – those
large enough to cause significant
harm and with an orbit likely
to bring them into proximity to
the Earth – has underpinned an
impressive international collective
effort to map NEOs [29-31]. First
steps have been undertaken by the
National Aeronautics and Space
Administration (NASA) with a
test mission to alter the course
of Dimorphos, the 160-metre-
wide moon of a larger asteroid.
The Double Asteroid Redirection
Test (DART) spacecraft struck
Dimorphos and nudged it closer to
its partner, Didymos, shortening its
nearly 12-hour orbital period by 32
minutes [32].
Recognising and Responding to
the Great Silence
Compared to other species, Homo
sapiens have an extraordinary
advantage with a capacity for
reflection, shared knowledge in
story-telling through generations,
and imagining the future. We
recognize the urgent need to
respond to existential multiple
and compounding threats – like
climate change, pandemics, and
armed conflicts – and collectively
manage and mitigate their
impacts [33]. These efforts will
require strong institutional and
political responses as well as global
collaboration and cooperation,
especially with the astronomical
and medical communities [34,35].
The astronomical community
has demonstrated how to address
these existential risks by alerting
us about the surrounding silent
universe that points to a sombre
prognosis for our species. The
medical profession utilises guiding
documents, like the International
Code of Ethics and the Declaration
of Geneva, to encourage physicians
to reflect on their ethical obligation
to support future generations.
Together, the astronomical
and medical communities can
collaborate on increasing awareness
of these existential threats, as
the stakes are very high indeed.
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Authors
Steve Robson, MPH, MD, PhD
Immediate Past President,
Australian Medical Association
Barton, Australia
Steve.Robson@avant.org.au
Hilary Bambrick, PhD
Director, National Centre for
Epidemiology and Population Health,
Australian National University
Canberra, Australia
Hilary.Bambrick@anu.edu.au
BACK TO CONTENTS
The Doomsday Clock is Ticking
28
Interview with National Medical Associations’
Leaders of the Asian Region
Interview with National Medical Associations’ Leaders of the Asian Region
Dr. Slamet Budiarto, Dr. Kalwinder
Singh Khaira, Dr. Anil Bikram
Karki, and Dr. Prakitpunthu
Tomtitchong, the Presidents of
the National Medical Associations
(NMAs) of Indonesia, Malaysia,
Nepal, and Thailand, respectively,
join the interview with Dr. Helena
Chapman, WMJ Editor in Chief.
They share their perspectives
on their leadership experiences,
ongoing NMA activities, strengths
and existing challenges in medical
education, and how the World
Medical Association (WMA) can
support NMA initiatives in the
Asian region.
As you reflect upon your journey
as NMA president, please describe
one memorable experience, one
challenge and how you resolved the
challenge, and one hope for the
future of medicine.
Indonesia: As President of the
Indonesian Medical Association, one
of the most meaningful experiences
was leading the organisation in
responding to the controversial
Health Bill (Law No. 17/2023)
that was adopted in August 2023
[1]. This process involved the
consolidation of more than 200,000
members to convey the aspirations
of the medical profession collectively
to policymakers through hearings,
public discussions, and legal
channels. Our biggest challenge is
maintaining the independence of the
medical profession amidst intense
political dynamics and diverse
public narratives. Our NMA choses
the constitutional path through
an ongoing judicial review to the
Constitutional Court, which reflects
our commitment to the supremacy
of law and the importance of
maintaining the dignity of the
medical profession as the guardian
of ethical and high-quality health
services. Finally, my hope for the
future of medicine is the creation
of a fair and evidence-based system
that ensures the welfare of patients
and health professionals. Indonesian
Medical Association members
continue to strive to create space
so that doctors are not only
implementers, but also architects of
a sustainable health system.
Malaysia: One memorable
experience was when the Malaysian
Medical Association (MMA)
members held a peaceful assembly
on 6 May 2025, offering a space for
a total of 11 medical associations
to highlight and discuss issues
affecting private practitioners in the
country [2]. This event, which was
the first of its kind, demonstrated
the determination of Malaysian
doctors. One major challenge was
how to convey these longstanding
issues to the Prime Minister,
while maintaining unity among all
doctors nationwide. Our MMA
leaders overcome this challenge by
taking the lead, uniting all other
associations, and preparing and
submitting a memorandum. Finally,
our hope for the future of medicine
is that the values of service and
empathy towards patients remain
strong, while the medical fraternity
continues to be vocal and united in
advocating for policies that benefit
the public.
Nepal: Reflecting on my tenure
as NMA President, I have had
memorable experiences, faced
challenges, and envisioned a better
Slamet Budiarto Anil Bikram Karki Kalwinder Singh Khaira
BACK TO CONTENTS
Prakitpunthu Tomtitchong
29
future for medicine. A defining
moment was being elected as the
President-Elect of Confederation
of Medical Associations in Asia
and Oceania (CMAAO), a proud
achievement that strengthened
Nepal’s presence in global medical
leadership. At the same time, one
major challenge was the rising
violence against health professionals.
To address this challenge, we took
a firm stand – protesting through a
call of duty, raising public awareness,
and legally pursuing perpetrators.
Filing cases in court sent a strong
message that such acts would not
be tolerated. Looking ahead, I see
great promise in the new Doctors’
Act under drafting, which will help
ensure better pay, standardised care,
and stronger legal protections for
medical professionals, paving the
way for a more secure and respected
healthcare system in Nepal.
Thailand: One of the most
memorable experiences during and
even before my presidency was
leading the nationwide initiative to
promote physician resilience during
the height of the coronavirus disease
2019 (COVID-19) pandemic. As
frontline healthcare professionals
faced physical exhaustion and
emotional and ethical distress, the
Medical Association of Thailand
(MAT) launched a coordinated
campaign across all regions of
Thailand to provide mental health
support, peer counselling, and
practical well-being resources
(including life insurance), for
all physicians serving the Thai
population during the COVID-19
pandemic. Notably, our fundraising
efforts since 2020 allowed us to
help support the dedicated efforts
of over a million nurses and Village
Health Volunteers (backbone of
primary healthcare) in Thailand.
How would you describe the
current opportunities for NMA
members to help influence health
care policy-making activities in
your country?
Indonesia: The opportunities for
Indonesian Medical Association
members to influence healthcare
policy-making are increasingly
relevant, yet challenging. The
ongoing healthcare reform process
– including the passing of the new
Health Law (Law No. 17/2023) –
has sparked active participation from
the medical community. Although
many of the profession’s aspirations
have not been fully accommodated,
the space for participation
remains open, particularly through
constitutional channels and public
advocacy. We believe that physician
involvement in policy not only
strengthens the healthcare system,
but also ensures that important
decisions remain based on ethical
principles and patient safety. This
is where the role of the NMA
becomes vital – strengthening the
profession’s voice in the complex
flow of public policy.
Malaysia: The Malaysian Medical
Association (MMA) has been able
to successfully convey its views
on healthcare policies affecting
both the public and the medical
fraternity, directly by engaging with
the government, and indirectly
by articulating views through
press releases for the benefit of
the public and health authorities.
In the past, MMA leaders have
also independently organised and
conducted peaceful assemblies to
express their views on pressing
health topics, which were permitted
and perceived positively by the
government.
Nepal: The Nepal Medical
Association and its members have
been always been proactive and
influential in health policy making,
including the launch of the human
papillomavirus (HPV) vaccination
programme, Nepal Cancer Control
Strategy 2024-2030, Health Service
Act, and the National Medical
Education Act of 2018 [3,4]. We are
involved in the ongoing drafting
process of the Drugs Act, Health
Care Workers Protection Act, National
Public Health Act, and various
digital health policies. Each year,
we support the National Health
Summit, as an opportunity to
engage in policy dialogues, including
national disease prevention and
control, with multiple stakeholders
and member societies. Our members
represent various leadership roles
across the government, non-
governmental organizations, and
academic sectors.
Thailand: The Medical Association
of Thailand (MAT) maintains
an advisory role in several key
governmental bodies, including the
Ministry of Public Health (MoPH),
the Medical Council of Thailand,
and the National Health Security
Office (NHSO), which oversees
universal health coverage (UHC).
The establishment of UHC is one
of Thailand’s proudest national
achievements, ensuring that every
citizen has access to essential health
services without suffering financial
hardship. However, sustaining and
strengthening UHC in the face of
rising healthcare costs, demographic
shifts, and constrained public
budgets remains a serious challenge.
We believe that addressing the
funding challenge requires a multi-
pronged, evidence-informed, and
collaborative approach.
Recognising the urgent need to
address junior doctor burnout as
a systemic issue, MAT members
collectively advocate for safer
work hours and improved mental
health support, including the use
of artificial intelligence applications
for mental health screening
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Interview with National Medical Associations’ Leaders of the Asian Region
30
among medical personnel, to Thai
policymakers. We are committed
to fostering a respectful training
culture, promoting work-life balance,
empowering junior doctors to have
a voice in policymaking activities,
and ultimately creating a healthier,
more sustainable environment
for personal and professional
excellence. Currently, we have been
collaborating on a research project
on mental health (e.g. depression,
stress) with Thai medical students
and the MAT Junior Doctors
Network (JDN), and we will
present the research findings
through two e-poster presentations
at the Association for Medical
Education in Europe (AMEE)
conference in August 2025, in
Barcelona, Spain.
How do perceive the physician-
patient relationship and rapport
in the clinical setting in your
country?
Indonesia: The doctor-patient
relationship in Indonesia is the
main foundation of quality and
ethical healthcare. In the midst
of a health system that still faces
major challenges, such as limited
resources and high patient burden,
doctors continue to strive to build
trust and good communication with
patients. As physicians, we view this
closeness not only as an ordinary
clinical interaction, but also as a
valuable partnership that bestows
respect and understands the needs
of each party. Doctors must be able
to provide clear explanations, involve
patients in medical decision-making,
and respect patients’ right to receive
transparent information.
However, there are real challenges,
including limited consultation
time due to high patient volumes
and various systemic pressures.
To that end, Indonesian Medical
Association members continue to
encourage more effective doctor-
patient communication training, as
well as advocacy for improvements
to the service system, so that doctors
have more space for compassionate
interactions with patients. We
believe that strengthening the
doctor-patient relationship will
increase treatment adherence, reduce
misunderstandings, and ultimately
improve patient health outcomes.
This is our NMA commitment
to making medical services in
Indonesia not only clinically
effective, but also dignified and full
of empathy.
Malaysia: Across the public and
private sectors in Malaysia, the
rapport between doctors and
patients is strong, and patients
have a high level of trust in their
doctors. This positive relationship
and support is the result of years of
dedicated service by physicians, who
have consistently provided quality
care to all patients.
Nepal: The physician-patient
relationship was once built on great
trust, where physicians were regarded
as caregivers and even revered as
highly as God. In recent times,
however, there has been a significant
shift in the physician-patient
relationship, leading to increased
differences and distance related
to this rapport. As government
healthcare settings have observed
surges in outpatient visits, due to
health insurance and other schemes,
the number of health professionals
has remained the same. With a
higher physician-patient ratio,
physicians have less time to spend
with patients, which challenges
shared medical decision-making
due to communication challenges
like misinformation. Moreover, the
private healthcare sector is often
perceived as profit-driven, which
has contributed to growing mistrust
between patients and physicians.
Hence, these combined factors have
strained the once-strong physician-
patient relationship, highlighting
the need for systemic improvements
in healthcare communication and
accessibility.
Thailand: In the Thai culture,
physicians are generally held in high
regard among society, and patients
often seek guidance from their
doctors on medical treatment and
reassurance. However, as healthcare
becomes more complex and time-
constrained, maintaining this
rapport is increasingly challenged
nowadays, which can negatively
impact the physician-patient
relationship and lead to malpractice
lawsuits and risk of workplace
violence. The Medical Association
of Thailand (MAT) members
support the Health Care in Danger
(HCID) (https://healthcareindanger.
org/hcid-project/), as a movement
supported by the International Red
Cross and Red Crescent to ensure
workplace safety for healthcare
service delivery. Furthermore, MAT
members are committed to
promoting effective communication,
time management, shared decision-
making, and cultural sensitivity
through medical education and
professional development (including
the integration of electronic health
records), to ensure that physician-
patient relationships remain a
cornerstone of high-quality, ethical
care in Thailand.
How would you describe the
anticipated challenges in medical
education over the next decade
in your country?
Indonesia: One of the biggest
challenges in medical education
in Indonesia today is related to
the development and training of
specialists. Residency facilities are a
key element in producing competent
health professionals who provide
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Interview with National Medical Associations’ Leaders of the Asian Region
31
quality specialist health services
across the nation. The Indonesia
Ministry of Health has recently
approved the Health Bill (Law No.
17/2023) in August 2023, which
significantly limits and even stops
several residency facilities [1]. This
policy can significantly impact the
process of education and specialist
training in the country and reduce
the availability of specialists in
various regions. Our NMA has
submitted an official letter to
the President of the Republic of
Indonesia, requesting the formal
review of this policy for the sake
of the continuity of quality and
equitable specialist education
throughout Indonesia.
Second, our NMA recognizes
the need to build more robust
connections among the Ministry
of Health, educational institutions,
teaching hospitals, and professional
organizations to find the best
solution that maintains the quality
and continuity of specialist doctor
education. Third, our NMA
supports the adaptation of medical
curriculum and learning methods to
the latest developments in medical
science and medical technology,
as well as guarantee an even
distribution of specialists throughout
the Indonesian archipelago. The
Indonesian Medical Association
is committed to continuing to
encourage improvements in policies
that support the training and
expansion of specialists so that
competent medical personnel are
responsive to community health
needs of the future.
Malaysia: The intake of medical
students in Malaysia is declining,
due to concerns related to job
security and career progression. This
trend may affect the viability of
some medical colleges and lead to
a further reduction in the number
of doctors being trained in the
country. In addition, technological
advancements of artificial
intelligence will also transform the
way medical education is delivered,
which must adapt to incorporate
these emerging technologies. While
this shift is necessary, the use of
artificial intelligence will give rise to
ethical and medico-legal issues that
need to be addressed collectively
within our medical community.
Nepal: Medical education in Nepal
is undergoing significant changes
and challenges. In the past, the
medical profession followed a
strict hierarchy, and the essence
of medical education was rooted
in service and respect. However,
with the privatisation of medical
education and increasing numbers
of students seeking their education
abroad, the field has become
monetised. Second, while the Nepal
Ministry of Education supports a
high national investment in medical
scholarships, the retention of these
medical graduates in Nepal remains
low. Third, medical curricula require
consistent revisions to maintain
robust academic programs that align
with the Ministry of Education
requirements and prepare medical
students to use novel technologies
to address emerging global risks.
Fourth, medical residents endure
long working hours without proper
food and rest, which increases
risk of mental stress (including
burnout and suicide), rising security
concerns, and violence against
doctors. They receive low salaries
for their clinical schedules: NPR
18,000 (approximately US$150)
for students in private colleges
and NPR 48,000 (approximately
US$300) for students in government
medical colleges. Finally, the bond
system and the long duration of
medical education pose significant
challenges. Nepal follows a 6+3+3
system, with an additional two years
of mandatory service, making the
age of graduation relatively high.
Over time, this prolonged training,
coupled with better opportunities
abroad, may reduce interest in
pursuing medicine in Nepal, hence
exacerbating the issue of brain
drain and leading to a scarcity of
physicians.
Thailand: With the help of the
WMA, Thailand hosted the World
Federation for Medical Education
(WFME) conference from 25-28
May 2025 in Bangkok, Thailand.
Over the next decade, we anticipate
several significant challenges in
medical education, including
adapting medical curricula to
rapidly advancing technologies (e.g.
artificial intelligence, telemedicine),
addressing disparities in training
quality between urban and rural
institutions, and responding to
the evolving healthcare needs of
an aging population. Additionally,
there is an urgent need to foster
resilience, empathy, and ethical
leadership in junior physicians amid
increasing stress and burnout, which
can lead to increased resignations
in the postgraduate years. Ensuring
that medical education remains
patient-centred, socially accountable,
and globally relevant will require
close collaboration among academic
institutions, regulatory bodies, and
professional associations like the
Medical Association of Thailand.
From the medical education
perspective, how has your NMA
responded to the existing and
emerging health challenges within
your country?
Indonesia: The Indonesian
Medical Association views that
medical education must always
be relevant and responsive to the
dynamics of ever-evolving health
challenges – both existing (e.g.
non-communicable diseases) and
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Interview with National Medical Associations’ Leaders of the Asian Region
32
emerging (e.g. pandemics, climate
change, zoonoses, antimicrobial-
resistance) risks. In this context,
we emphasize the importance of
competency- and evidence-based
curriculum reform, with stronger
integration of public health, global
health, environmental health, and
health emergency response. Medical
education can no longer focus solely
on individual clinical aspects, but
rather must be able to equip doctors
with systemic thinking, leadership,
and cross-sector communication
skills.
The Indonesian Medical Association
encourages strengthening networks
between medical schools and
primary and referral healthcare
facilities, so that students and
junior doctors are exposed to real-
time health challenges in clinical
and community settings. These
efforts include involvement in
disaster response, disease outbreak
investigations, and health promotion
and disease prevention interventions
oriented towards increasing the
capacity of the healthcare system
as a whole. Furthermore, NMA
leaders actively encourage doctors
and educational institutions to
become consumers and producers
of knowledge through local research
that is relevant to the Indonesian
context. We believe that scientific
independence is an important part
of the resilience of the national
health system in facing ever-
changing challenges. Institutionally,
the Indonesian Medical Association
also collaborates with other
stakeholders to advocate for
adaptive, inclusive, and community-
oriented medical education policies.
We want to ensure that medical
graduates are clinically prepared and
become “change agents” in facing
current and future health challenges.
Malaysia: The Malaysian Medical
Association (MMA) has always
been forefront with public visibility,
highlighting key health issues that
arise in the country by issuing public
statements and providing advice on
emerging health concerns. For the
medical fraternity, MMA members
consistently organise continuing
medical education (CME) sessions
and webinars for the medical
community, as opportunities to
share scientific updates and enhance
overall knowledge.
Nepal: The Nepal Medical
Association is an officiating
member of the Medical Education
Commission, where we relentlessly
advocate for the health and education
ministries to act on timely reforms
for medical curricula (including
the five-year superspecialty),
equal stipends, and removing
the mandatory bonded service
program. Recently, we organised a
National Health Summit, uniting
stakeholders (ministers, medical
college representatives, Medical
Education Commission) in public
dialogue, where we discussed key
issues like stipend delays, rote-
learning curricula, and exploitative
bonds for residents. By spotlighting
the gaps between what is needed
and what exists, we collectively
drive accountability for widespread
systemic change. Although
resistance persists, these efforts
have ignited discussions on
modernising training, ensuring
fair compensation, and aligning
education with Nepal’s evolving
health needs.
Thailand: The Medical Association
of Thailand (MAT) has responded
to both existing and emerging health
challenges by promoting the One
Health concept in emphasising the
need for curricula reform, capacity
building, and interprofessional
collaboration. First, MAT members
have worked closely with Thai
Veterinary Medical Association
(TVMA) members to host the
4th One Health International
Conference (OHIC) from 3-4
December 2026 in Bangkok,
Thailand. Second, MAT members
have collaborated with the Medical
Council of Thailand and academic
institutions (e.g. 14 of the Royal
Colleges) to integrate priority health
issues, such as non-communicable
diseases, mental health, aging,
and pandemic preparedness, into
undergraduate and postgraduate
medical training. Finally, they
have supported the adoption of
competency-based education, digital
learning platforms, and community-
based clinical rotations to prepare
future physicians to serve diverse
and underserved populations.
Through these efforts, the MAT
ensures that Thai medical education
remains responsive, resilient, and
aligned with the real-world needs of
our healthcare system.
From your perspective and
national experiences, how has the
COVID-19 pandemic affected
medical education in your country?
Indonesia: The COVID-19
pandemic has had a significant
impact on all aspects of medical
education in Indonesia. The
traditional delivery of medical
education was forced to transform,
as the teaching and learning
process quickly shifted to an online
platform. Since few institutions
had adequate digital infrastructure,
and few lecturers and students
were technically and pedagogically
ready for complete virtual learning.
Similarly, limited direct clinical
practice, due to hospital restrictions,
led to minimal exposure to real-
world clinical cases for medical
students and junior doctors.
Despite these challenges, the
pandemic has driven innovation,
highlighting the need for a
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Interview with National Medical Associations’ Leaders of the Asian Region
33
resilient and adaptive medical
education system. Many educational
institutions have developed hybrid
learning methods, utilised digital
simulations, and integrated curricula
with global health issues such as
epidemiology, disaster response,
and risk communication. Medical
students have also been involved
in various social and community
education activities, strengthening
their role as future clinicians
and “change agents” in public
health. The Indonesian Medical
Association continues to encourage
strengthening the capacity of
educational institutions to be better
prepared for future crisis situations,
by encouraging curriculum
flexibility, reinforcing educational
technology, and fostering ethics and
empathy when managing emergency
situations. We believe that the
COVID-19 pandemic offered a
test and opportunity to accelerate
medical education reform and health
system responsiveness in Indonesia.
Malaysia: The experiences of
the COVID-19 pandemic have
motivated the Malaysian Medical
Association and the wider medical
community to emphasize preventive
medicine and the importance of
adhering to preventive practices
(e.g. social distancing, proper cough
etiquette when ill) and policies
during medical education and
training.
Nepal: The COVID-19 pandemic
disrupted medical education
severely, where clinical training
halted as hospitals prioritised
emergencies, and online learning
exposed rural-urban digital divides.
While telemedicine training and
virtual case discussions offered
partial solutions, hands-on skill gaps
widened. Although the prolonged
distance education challenges
affected some nations that relied
on remote learning, our education
system is trying to adapt hybrid
learning environments. Resident
doctors faced dual burdens –
frontline COVID-19 duties and
systemic neglect – as governments
denied them fair stipends or worker
status, which further worsened
exploitation. The crisis exposed
flaws, as the rigid, theory-heavy
curricula failed to teach adaptability
or crisis response. The Nepal
Medical Association advocated
for hybrid learning, mental health
support, and curriculum reform to
integrate key lessons learned during
the pandemic. However, sustainable
change demands investment in
infrastructure, faculty training, and
policy reforms to prepare future
doctors for evolving challenges.
Thailand: The COVID-19 pandemic
significantly disrupted medical
education in Thailand, prompting
a rapid shift to online learning and
limiting hands-on clinical training.
This transition led to reduced
confidence among students in their
clinical skills and increased levels of
stress and anxiety. In one national
cross-sectional study, researchers
reported significantly high
prevalence of burnout among Thai
medical interns, resulting in poor
work performance and professional
discontent [5]. In response, Thai
medical schools incorporated
simulations into didactic learning,
enhanced mental health support and
faculty mentorship, and advocated
for oversight on clinical schedules.
Despite disruptions experienced
during the pandemic, digital
technological advancements have
helped build resiliency in Thai
medical education, such as e-learning
platforms, simulation-based learning,
and telemedicine applications in
clinical diagnoses, which support
the healthcare innovations proposed
in the Thailand 4.0 Strategy [6].
How does your NMA leadership
implement the WMA policies in
the organization?
Indonesia: Using an adaptive and
strategic approach, Indonesian
Medical Association leadership
implements WMA policies through
four main pillars, with aims to
reinforce ethical guidelines and
propel medical education reform
in Indonesia. First, we harmonize
the ethical principles of the WMA
with local values, so that they
remain relevant in the social and
cultural context of Indonesia. This
integration ensures that global
ethical standards are accepted and
implemented effectively by all
doctors. Second, we actively convey
information related to ethical
policies, the social role of doctors,
and health promotion and disease
prevention approaches through
seminars, training, and internal
communication media. Third, the
Indonesian Medical Association
is actively involved in the WMA
forum and other regional networks,
such as the Confederation of
Medical Associations in Asia
and Oceania (CMAAO) and the
Medical Association of South
East Asian Nations (MASEAN).
This collaboration enriches our
perspectives and strengthens the
organization’s capacity to address
transnational issues, including
climate change, health crises, and
medical ethics. Fourth, we apply
the WMA values when advocating
for medical education reform,
particularly around high tuition
costs, resident rights and well-being,
excessive workloads, and protection
from bullying, to help create a just
and humane education system.
Malaysia: The Malaysian Medical
Association (MMA) shares the
WMA declarations, policies, and
statements with MMA members
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Interview with National Medical Associations’ Leaders of the Asian Region
34
and frequently with the public.
Nepal: The Nepal Medical
Association actively integrates
WMA policies – such as ethical
medical practice, patient rights,
and physician autonomy – into
our national framework through
advocacy, training, and policy
alignment. For instance, we adopt
the WMA Declaration of Geneva
(physician oath) and Helsinki
Declaration (research ethics) in
medical education reforms, ensuring
that curricula emphasize human
dignity and informed consent.
We advocate for laws protecting
doctors from violence, which reflects
the WMA’s stance on safe work
environments. During crises like
the COVID-19 pandemic, WMA
guidelines on equitable vaccine
access helped shape our public
health campaigns.
Our Association also addresses
climate action and other global
challenges, where we advocate
for policies that support plastic-
free initiatives and promote
environmental sustainability.
The WHO’s funding crisis and
geopolitical conflicts, such as the
Israel-Gaza war, further impact
global health priorities, underscoring
the need for strong international
cooperation. Collaborating with
the WMA also strengthens our
capacity-building workshops on
emerging issues like the ethics of
artificial intelligence, climate health,
and crisis preparedness, bridging
global standards with Nepal’s health
system and needs.
Thailand: The Medical Association
of Thailand (MAT) ensures that
WMA policies are actively integrated
into our organisational practices
through alignment, advocacy,
and capacity building. First, we
formally align the MAT’s ethical
guidelines, continuing professional
development (CPD) programs, and
public health stances with core
WMA declarations, such as the
Declaration of Geneva, the revision
of the Declaration of Helsinki,
the International Code of Medical
Ethics, and various statements on
human rights, equity, and physician
well-being. Second, we use WMA
policy frameworks to guide our
advocacy on key national issues,
including health equity, pandemic
preparedness, Health Care in
Danger (HCID), UHC, and patient
safety. Third, we incorporate WMA
principles into leadership training,
JDN activities, and academic events,
helping Thai physicians internalise
global standards in professionalism,
ethics, and social accountability.
Recently, MAT leadership
integrated the WMA policies into
the Regional Meeting in Asia on
the International Code of Medical
Ethics (ICoME) on 7-8 June
2022 in Bangkok, Thailand. They
also actively participated in the
WMA Working Group on Organ
Procurement from 2023-2024, and
the results were presented at the
226th WMA Council Session in
April 2024 in Seoul, Republic of
Korea.
How can the WMA support the
ongoing NMA activities in your
country?
Indonesia: The WMA can play a
strategic role in supporting the
Indonesian Medical Association’s
activities in three main ways:
strengthening international
advocacy, transferring knowledge
and best practices, and facilitating
institutional capacity. First, the
WMA’s support in voicing the
importance of the independence
of the medical profession and the
integrity of health systems to the
global community and multilateral
institutions will strengthen our
position in national advocacy,
especially amidst complex regulatory
and political challenges. Second,
the WMA can facilitate the cross-
country exchange of experiences
on medical education, professional
ethics, and health systems, including
responding to climate change,
antimicrobial resistance, and other
health crises. Third, the WMA’s
continued support of leadership,
ethics, and global health policy
training will strengthen the
capacity of the Indonesian Medical
Association cadres in managing
organizations and contributing
effectively at national and
international levels.
Malaysia: Throughout the year,
the WMA invites NMA leaders
and JDN members to attend and
participate in its formal meetings
and webinars, which can help foster
leadership development and enhance
understanding of WMA policies.
Moving forward, the WMA can
further help support doctors’ training
by exposing them to its various
WMA committees. In turn, doctors
can share this acquired knowledge
with their colleagues, and they can
collectively leverage their expertise
to develop new initiatives.
Nepal: The Nepal Medical
Association seeks the WMA’s
support in JDN training and
education, ensuring that young
doctors receive quality learning
opportunities and global exposure.
We urge waivers on various charges
for less-developed countries like
Nepal, as financial constraints
should not hinder participation in
international medical initiatives.
Additionally, we advocate for
greater representation in WMA
councils and meetings, allowing
voices from resource-limited
nations to be heard in global
policy discussions. Furthermore,
we expect the WMA to morally
support and provide financial
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Interview with National Medical Associations’ Leaders of the Asian Region
35
assistance for critical association’s
campaigns and help address our
challenges, including advocacy for
doctors’ rights, workplace safety, and
healthcare reforms. We encourage
WMA leaders to visit Nepal,
fostering stronger collaboration,
knowledge exchange, and direct
engagement with our medical
community.
Thailand: The Medical Association
of Thailand (MAT) believes that
the WMA can play a valuable role
in supporting our ongoing activities
by serving as a strategic partner
in both advocacy and capacity
building. First, WMA’s global
policy frameworks, such as those on
physician ethics, health equity, digital
health, and climate-related health
risks, help reinforce our national
initiatives by lending international
legitimacy and alignment with
global standards. Second, we
welcome WMA’s continued
support in providing technical
expertise, training opportunities, and
leadership development, particularly
for junior physicians and future
health leaders. Third, WMA can
facilitate global exchanges that
allow Thai physicians to learn from
other NMAs and share innovations,
especially regarding mental health,
workforce resilience, and ethical
responses to emerging technologies.
Lastly, WMA’s unified voice on
global health issues strengthens
our advocacy at both national
and regional levels, where we can
collectively elevate the impact of
NMA-led efforts and help shape
more resilient, ethical, and equitable
health systems.
On behalf of the MAT, we
are honoured to invite WMA
members to attend the WMA
General Assembly 2027, which
will be held from 20-23 October
2027, in Bangkok, Thailand. We
look forward to welcoming global
medical leaders to share and
exchange ideas, strengthen ethical
practice, and advance our shared
vision for global health. Please
join us in Bangkok for meaningful
dialogue and warm Thai hospitality!
References
1. Gamalliel N, Fuady A.
Indonesia’s new health law:
lessons for democratic health
governance and legislation.
Lancet Reg Health Southeast
Asia. 2024;23:100390.
2. Focus Malaysia. MMA: No
May 6 “symbolic walk” of
healthcare practitioners, “just
peaceful gathering of mostly
GPs” [Internet]. 2025 [cited
2025 May 31]. Available from:
https://focusmalaysia.my/mma-
no-may-6-symbolic-walk-of-
healthcare-practiitioners-just-
peaceful-gathering-of-mostly-
gps/
3. Neupane D, Jaiswal LS, Koirala
S. Nepal set to launch historic
HPV vaccination programme.
Lancet. 2025;405(10476):375
4. World Health Organization.
Advocacy meeting for
integration of HPV vaccination
in the national routine
immunization program
[Internet]. 2025 [cited 2025
Feb 1]. Available from: https://
www.who.int/nepal/news/
detail/30-01-2025-advocacy-
meeting-for-integration-of-hpv-
vaccination-in-the-national-
routine-immunization-program
5. Surawattanasakul V, Siviroj
P, Kiratipaisarl W, Sirikul W,
Phetsayanavin V, Pholvivat
C, et al. Physician burnout,
associated factors, and their
effects on work performance
throughout first-year internships
during the COVID-19
pandemic in Thailand: a cross-
sectional study. BMC Public
Health. 2025;25(1):1967.
6. Ministry of Industry, Royal
Thai Government. Thailand
4.0 strategy [Internet]. 2017
[cited 2025 May 31]. Available
from: https://dig.watch/resource/
thailand-4-0-strategy
Authors
Slamet Budiarto, MBBS, SH, MHKes
President,
Indonesian Medical Association
Jakarta, Indonesia
pbidi@idionline.org
Anil Bikram Karki, MD
President, Nepal Medical Association
Senior ENT Consultant, B.P.
Koirala Memorial Cancer Hospital
Kathmandu, Nepal
nma@nma.org.np
Kalwinder Singh Khaira,
B.Sc, MBBS, FRCP
President,
Malaysian Medical Association
Kuala Lumpur. Malaysia
khaira111@yahoo.com
Prakitpunthu Tomtitchong,
MD, MSc, PhD, FRCST
President,
Medical Association of Thailand
Bangkok, Thailand
mat.thailand2464@gmail.com
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Interview with National Medical Associations’ Leaders of the Asian Region
36
In an era marked by profound
global interconnectivity, the
boundaries between national and
international public health priorities
have become increasingly permeable.
The Trinidad and Tobago
Medical Association (T&TMA),
as the premier professional body
representing registered medical
practitioners in Trinidad and
Tobago, has recognised the need to
harmonize its local advocacy with
broader global health imperatives.
Guided by its core mission to
Teach, Treat, Mentor, and Advocate,
the Association continuously seeks
to elevate the standards of medical
practice and contribute meaningfully
to global health discourse.
Through mechanisms such as Small
Working Groups (SWGs) and the
planned formulation of the official
policy document, the Association
is laying the groundwork to ensure
that its positions on key issues are
evidence-informed, contextually
relevant, and globally engaged.
This strategic policy development
framework is an initiative of
the T&TMA External Affairs
Committee, which has led efforts to
align the Association’s local advocacy
with global health priorities. Central
to this is the recognition that
global health priorities must inform
advocacy efforts that are locally
relevant, serving as a bridge between
domestic health concerns and the
broader global discourse – ensuring
that Trinidad and Tobago’s medical
voice contributes meaningfully.
Aligning with Global Health
Priorities
The T&TMA has formally
acknowledged the significance
of global health priorities as an
organising principle for advocacy
and policy development. In 2025,
the Council of the Association
identified three primary global
health focus areas – mental health,
universal health coverage, and
climate change and health – as the
key themes for this term. These
areas reflect both global urgencies
and national relevance, and they
will serve to guide the Association’s
strategic planning and public
advocacy efforts.
Mental health, long under-resourced
in many healthcare systems, has
gained critical attention in light of
increasing psychosocial stressors,
economic instability, and the
aftermath of the coronavirus disease
2019 (COVID-19) pandemic [1].
Universal health coverage represents
a foundational goal of equity and
accessibility, reinforcing the right
of every citizen to receive quality
health services without financial
hardship [2]. Climate change, with
its far-reaching implications for
environmental stability, disease
transmission, and disaster resilience,
has emerged as a cross-cutting
determinant of health [3]. Although
these focus areas are not yet the
subject of finalised policy document,
they represent the thematic
direction for future policy work.
They underscore the Association’s
commitment to staying relevant
within the global health community
and aligning with the local context
within Trinidad and Tobago.
Policy Documents as Instruments
of Advocacy
At the heart of the T&TMA’s
advocacy strategy lies the policy
document – a formal articulation of
the Association’s official stance on
critical health issues. This document
serves dual purposes: to inform
internal decision-making and
provide a credible foundation for
external advocacy. It is meticulously
crafted through research, stakeholder
consultations, and professional
input to ensure both relevance and
authority.
In a policy environment where
evidence-based and strategically
articulated positions command
influence, the creation of this
framework represents both a
necessity and a hallmark of
professional leadership. To ensure
integrity and rigor, the development
of policy document follows a
standardised process, including
the establishment of a SWG
dedicated to a specific priority area.
SWG members are selected for
their subject matter expertise and
commitment to the Association’s
mission. Each SWG is coordinated
by an appointed individual selected
by the President in consultation
with the External Affairs Chair –
a testament to the deliberate and
high-level oversight invested in the
process.
Climate Change and Health: A
Priority Area
Of the three global health focus
areas identified for this term,
climate change and health has
Strategic Role of the Trinidad and Tobago Medical Association
Strengthening National Advocacy through Global Health Policy:
The Strategic Role of the Trinidad and Tobago Medical Association
Saksham Mehra
BACK TO CONTENTS
37
BACK TO CONTENTS
Strategic Role of the Trinidad and Tobago Medical Association
been selected as a thematic priority
for initial policy development.
Trinidad and Tobago, as a Small
Island Developing State (SIDS),
faces unique vulnerabilities to
environmental disruption – from
extreme weather events and sea-
level rise to shifts in disease ecology
and public infrastructure stress [4].
These challenges highlight the need
to better understand and respond to
the health impacts of environmental
change.
In response, the T&TMA has
established a SWG tasked with
drafting a formal T&TMA Policy
Document on Climate Change and
Health. This document will serve as
a strategic guide to understanding
and addressing the intersections
between environmental change and
public health within the national
context. It will also act as a platform
for the association’s advocacy efforts
with relevant stakeholders and
the broader public. The SWG’s
responsibilities include reviewing
global and local evidence, consulting
with experts, and aligning their
findings with national health
objectives. The Policy Reviewing
Committee, appointed by the
President in consultation with the
External Affairs Chair, ensures that
the policy content is evidence-based,
context-sensitive, and aligned with
optimal health frameworks.
Strengthening Capacity through
Structured Processes
The policy development framework,
adopted by the T&TMA, reflects
a deliberate and strategic approach
to institutional governance. It is an
effective model of how professional
medical associations translate
broad global priorities into locally
relevant advocacy. The structured
use of SWGs, oversight from high-
level appointees, and commitment
to evidence-based review ensures
that the Association’s voice is both
informed and authoritative.
Importantly, this process cultivates
leadership and professional
engagement among members. By
involving professionals in policy
development, the T&TMA provides
opportunities for mentorship, skill
development, and interdisciplinary
collaboration. The approach
supports the Association’s broader
mission to build capacity within the
medical community and reinforce its
role as a proactive and responsible
health leader.
Conclusion
The T&TMA continues to
demonstrate institutional foresight
and professional leadership through
its structured engagement with
global health priorities. By aligning
its national advocacy efforts with
key international themes – mental
health, universal health coverage,
and climate change and health –
the Association exemplifies a model
of how localised health policy by a
national medical association can be
informed by global imperatives. The
establishment of Small Working
Groups and the creation of policy
documents are not only practical
tools for advocacy, but also symbolic
of a deeper commitment to ethical
governance and public service.
As Trinidad and Tobago navigates
the complexities of contemporary
public health, the role of a strong,
strategic, and globally connected
medical association becomes ever
more vital. The T&TMA’s initiative
to begin with climate change and
health underscores both the urgency
of environmental challenges and
the Association’s responsiveness to
evolving threats. Through deliberate
policy engagement and member
empowerment, the T&TMA affirms
its place as a key stakeholder in the
national and global health landscape.
References
1. World Health Organization.
Mental health and COV-
ID-19: early evidence of the
pandemic’s impact [Internet].
Geneva: WHO; 2022. Avail-
able from: https://www.who.
int/publications/i/item/WHO-
2019-nCoV-Sci_Brief-Mental_
health-2022.1
2. World Health Organization.
Universal health coverage (UHC)
[Internet]. 2023 [cited 2025 May
10]. Available from: https://www.
who.int/news-room/fact-sheets/
detail/universal-health-cover-
age-(uhc)
3. Intergovernmental Panel on Cli-
mate Change. Climate Change
2023: Synthesis Report. Gene-
va: IPCC; 2023. Available from:
https://www.ipcc.ch/report/ar6/
syr/
4. World Health Organization.
Health and climate change: coun-
try profile 2020: Trinidad and
Tobago. Geneva: WHO; 2020.
Available from: https://www.
who.int/publications/i/item/
health-and-climate-change-
country-profile-2020-trinidad-
and-tobago
Saksham Mehra, BMSc, MBBS
External Affairs Chair,
Trinidad and Tobago Medical
Association (T&TMA)
Trinidad and Tobago, West Indies
mehrasaksham1@gmail.com
38
The attainment of health equity
and access requires robust health
financing mechanisms, including
diverse health revenue collection
strategies, reducing catastrophic
health spending through proper
risk pooling, and prioritising
health service purchasing. Over
the last few decades, health
leaders have seen a rise in global
health expenditure from US $3.5
trillion to US $8.0 trillion in 2016
[1]. Low- and middle-income
countries (LMICs) account for a
disproportionate share of disease
burden, and a large disparity exists
between LMICs and high-income
countries (HICs) [2].
Similar to many African
countries, health financing in
Kenya has undergone significant
transformations over many decades,
shifting from a predominantly
government-funded system in the
early post-independent era to a
more diversified and structured
financing model in the 21st century.
These changes have been driven
by the need to enhance healthcare
access, improve financial protection,
and attain health-related sustainable
development goals (SDG), especially
universal health coverage (UHC).
This article explores the historical
evolution, key reforms, and their
impact on health financing in
Kenya, highlighting challenges
and exploring future prospects in
achieving health equity.
Early Post-independence Era
In post-independence Kenya (1963-
1989), the government primarily
financed the healthcare system
through general taxation. The
existing user fees were abolished,
and the state provided free medical
services in public hospitals, ensuring
access for the majority of the
population. In 1966, the government
introduced a mandatory National
Hospital Insurance Fund (NHIF) to
provide coverage of basic healthcare
services to all formal sector
government employees. Economic
challenges in the 1980s necessitated
the implementation of Structural
Adjustment Programs (SAPs) by the
World Bank and the International
Monetary Fund (IMF), leading to
a decline in government healthcare
expenditure. These programs
required liberalisation of the
economy in developing countries,
with catastrophic impacts on health
financing in Kenya.
Introduction of User Fees
One of the most significant policy
shifts occurred in 1989. With
the aim of improving revenue
generation, the government re-
introduced user fees under the
cost-sharing policy. This action
had adverse effects, including
reduced access to healthcare
services, especially among vulnerable
population’s (e.g. children, women),
unaffordability of healthcare services
especially in rural communities, and
increased morbidity and mortality
rates among affected communities.
This policy exacerbated existing
disparities in healthcare access,
further highlighting the need for
a more equitable and sustainable
healthcare financing system in the
country.
Second National Health Sector
Strategic Plan (2005–2010)
The Second National Health Sector
Strategic Plan (NHSSP-II) (2005–
2010) was developed in 2005, with
the aim of enhancing efficiency
in healthcare service delivery.
The plan adopted a sector-wide
approach in devising strategies
meant to effectively operationalize
the Kenya Health Policy Framework
(1994) [3]. The major priorities
of this plan were primary
healthcare, improvements in health
infrastructure, human resource
development, and mechanisms for
financial risk protection [4].
The need for NHSSP-II was
informed by deteriorating health
indicators, including rising
infant and child mortality rates,
significant decline in the utilisation
of public healthcare services (e.g.
new consultations per person as
0.6 in 1990 and 0.4 in 1996),
reduced doctor-to-population ratio,
and stagnation of public sector
contributions to healthcare (e.g. per
capita health expenditure dropping
from US $12 in 1990 to US $6
in 2002) [4]. Furthermore, poverty
levels increased from 47% in 1999
to 56% in 2002, exacerbating
barriers to healthcare access.
NHSSP-II: Achievements and
Challenges
The implementation of NHSSP-
II marked significant progress in
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Transformation of Kenya’s Health Financing
Transformation of Kenya’s Health Financing:
A Journey towards Equity and Access
Diana Marion
39
strengthening Kenya’s healthcare
system, particularly in health
financing and service delivery. Some
of the key achievements included
increased investments in healthcare
infrastructure, expanded access to
medical services and enhanced
efficiency and reach of the NHIF.
In addition, the introduction of a
community health strategy played a
pivotal role in strengthening primary
healthcare at the grassroots level.
Despite these advancements,
high out-of-pocket expenditures
continued to burden many
households contributing about
26.1% of total health expenditure,
and thus limiting access to essential
healthcare services [5]. Health
insurance coverage remained
inadequate, particularly among
informal sector workers, with about
19% of the population having
insurance coverage, leaving a
significant portion of the population
without financial protection [5].
Furthermore, the heavy reliance
on donor funding (e.g. 23.4% of
total health expenditure) created
sustainability concerns, making
long-term health financing
vulnerable to external economic,
policy, and political shifts, which
ultimately underscored the need for
continued reforms [5].
The NHIF Reform
Established in 1966 to provide basic
medical coverage for formal sector
employees, the NHIF has undergone
several reforms aimed at expanding
its coverage and improving service
delivery. First, the NHIF Act No.
9 of 1998 transformed it from a
ministerial department into a state
corporation, allowing it to expand
its scope beyond inpatient services
to outpatient services. Income-
tiered insurance provisions were also
amended to expand coverage among
the informal sector workers who
were required to make voluntary
contributions, as opposed to formal
workers whose contributions are
mandatory [6]. Second, the Civil
Servants Scheme (CSS) (2012)
provided an expanded coverage to
formal sector government workers
and their dependents, whose funds
were managed separately from
NHIF funds, and beneficiaries
enjoyed a comprehensive benefit
package [7]. Third, the Linda Mama
Programme, established in 2013
and placed under the responsibility
of NHIF in 2016, offered free
maternity services in all public
healthcare facilities [8]. Fourth,
the Health Insurance Subsidy for
the Poor (HISP) pilot program,
initiated in 2015, provided fully
subsidised comprehensive cover to
selected orphans and vulnerable
children under government cash
transfer scheme [6]. Finally,
the UHC policy of 2018 was
adopted with mandatory NHIF
enrollment for civil servants and
other public sector workers, which
increased financial protection
for employees and introduced
biometric registration and e-claims
processing to enhance efficiency and
transparency [9].
Beyond 2023: The Social Health
Authority (SHA)
To further enhance sustainability
and equity of health financing
mechanisms, the government
introduced further reforms
leading to the establishment
of the Social Health Authority
(SHA) through the SHA Act
[10]. Under one umbrella body,
the SHA created three funds –
primary healthcare, social health
insurance, and emergency, chronic,
and critical illness funds. It is
designed to provide UHC for all
Kenyan citizens, regardless of their
employment status, by pooling
resources, spreading financial
risk across the entire population,
reducing out-of-pocket expenses,
reducing dependency on donor
funding and improving access
to quality healthcare services.
Nonetheless, it is important to
consider potential challenges and
unintended consequences that may
arise from such significant structural
changes in healthcare financing.
The success of these reforms will
depend on effective implementation,
ongoing evaluations, and necessary
readjustments.
Kenya Vision 2030 and Health
Financing
Kenya has made significant strides
in healthcare reforms, aligning its
efforts with Kenya Vision 2030 and
the SDGs to achieve UHC. The
adoption of the 2030 Agenda for
Sustainable Development in 2015
reinforced Kenya’s commitment to
global goals such as ending poverty
(SDG 1), reducing inequality (SDG
10), addressing climate change
(SDG 13), and ensuring healthy
lives and promoting well-being for
all (SDG 3).
Kenya Vision 2030 has influenced
healthcare infrastructure
development by emphasising
the need for comprehensive and
interoperable health information
systems that support primary and
secondary healthcare roles [11]. For
example, in rural areas of Kenya,
the investment in Level 5 hospitals
has led to an increase in the number
of specialised medical services
available to residents who previously
had to travel long distances for
care. Additionally, the rehabilitation
of health centers has allowed for
better preventative care and early
intervention, ultimately reducing the
burden on higher-level facilities and
improving overall health outcomes
in these underserved communities.
Furthermore, the implementation
of electronic health records has
streamlined patient care and
improved communication among
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Transformation of Kenya’s Health Financing
40
different healthcare providers.
Although Kenya is on track to
provide quality healthcare services
to all its citizens, there is a gap
in structured guidelines for the
development and implementation
of digital health policies across the
African continent.
A Roadmap to UHC
Kenya’s commitment to achieving
UHC was further reinforced
through the Kenya Health Policy
(2014–2030), which aimed at
attaining the highest possible health
standards in a manner responsive to
population needs [12]. The policy
set ambitious targets, including
increasing life expectancy from 60
years in 2010 to 72 years by 2030
and reducing annual deaths per
1,000 persons from 10.6 to 5.4
[12]. Additionally, the Kenya Health
Sector Strategic and Investment Plan
(KHSSP) (2013–2017) emphasised
preventive, promotive, curative, and
rehabilitative care to reduce the
financial burden of healthcare on
households [13]. The integration of
SDGs into Kenya’s health policies
has influenced the health financing
reforms for UHC by providing an
enabling environment for necessary
legislation, reforming health
financing organisations, and revising
national health policies to align with
national commitments to UHC.
Towards Health Equity
At the heart of Kenya’s health
financing reforms is a commitment
to addressing disparities in
healthcare access, particularly
among vulnerable populations,
rural communities, and underserved
regions. Over the past decade, the
Kenyan government has undertaken
significant policy initiatives to
address financial barriers and
improve health equity. The reforms
introduced under NHSSP-II,
NHIF, and subsequent transition
to the SHA, as well as enshrining
healthcare as a constitutional right
of every Kenyan citizen, underscores
this commitment to health equity.
The Constitution of Kenya (2010)
introduced a transformative legal
framework that reinforced a rights-
based approach to healthcare.
Under Article 43, healthcare was
recognised as a fundamental human
right, placing an obligation on
the state to ensure accessible and
affordable healthcare for all citizens
[14]. The devolution of healthcare
services to county governments
improved resource distribution,
helping to reduce regional
disparities and enhance equity in
service delivery. However, this is still
fraught with challenges including
mismanagement and understaffing
of the health workforce and
inadequate funding [15].
The Free Maternity Services (FMS)
Policy (2013), later renamed
Linda Mama Initiative (2016),
abolished user fees for all Kenyan
women seeking maternity care in
public health facilities leading to
increased institutional deliveries
vis-a-vis unsafe home deliveries.
The government also rolled out
the UHC Pilot Program (2018)
in four counties (Kisumu, Nyeri,
Isiolo, Machakos), which offered
free healthcare services to registered
members, with lessons learned
informing the nationwide rollout.
In order to improve the digital and
physical infrastructure, the Health
Infrastructure Development and
Digital Health Innovations Policies
were adopted and implemented
in 2023. Investments in Level
5 hospitals and rehabilitation of
health centers under Kenya Vision
2030, as well as the implementation
of e-health systems, improved
healthcare accessibility, particularly
in marginalised regions, streamlined
NHIF reimbursements, reduced
fraud, and improved accountability
in healthcare financing. In addition,
through the Public-Private
Partnerships and Health Insurance
Innovations, Kenya has partnered
with various private organisations
and companies to provide quality
and subsidised services to its
citizens and improve the health
infrastructure. These efforts included
the Managed Equipment Service
partnership (2015) that leases
and maintains specialised medical
equipment across county hospitals
[16].
Conclusion and Recommendations
Kenya’s health financing journey
reflects significant progress in
improving healthcare access,
financial protection, and health
equity. Despite these advancements,
significant health financing
challenges still exist. Government
spending on healthcare accounts for
only about 6.7% of total healthcare
spending, which is less than half of
the 15% benchmark recommended
by the Abuja Declaration, thus
limiting resources available for
critical health services [6]. High
out-of-pocket expenditures persist,
placing a financial burden on
many Kenyans and restricting
access to necessary medical care.
Although NHIF has expanded its
coverage, informal sector workers
and vulnerable populations remain
underinsured with high attrition
rates from the pool. Furthermore,
inefficiencies and corruption within
health financing institutions,
including NHIF (now SHA),
undermine service delivery and trust
in the system.
To achieve sustainable health
financing and equitable healthcare
access, the Kenyan government must
implement strategic reforms geared
towards addressing these challenges.
BACK TO CONTENTS
Transformation of Kenya’s Health Financing
41
Increasing government investment
in healthcare will reduce reliance
on out-of-pocket spending and
enhance service delivery. Expanding
coverage to informal sector
workers, improving governance, and
increasing efficiency are essential
steps to strengthening SHA.
Public-private partnerships should
be leveraged further to attract
investment from private insurers,
donors, and non-governmental
organizations and boost health-
financing resources. Additionally,
embracing investment in digital
health technologies, such as
mobile health financing and digital
insurance platforms, will enhance
accessibility and transparency. Policy
reforms supporting sustainable
UHC and integrating community-
based health insurance schemes will
be crucial in achieving long-term
health goals.
Ongoing reforms and innovative
financing models hold promise
for realising the country’s long-
term health objectives under
the Kenya Vision 2030 and the
SDGs, especially UHC. Effective
implementation strategies, periodic
evaluations, skilled workforce,
and proper resource allocation
will be critical in the success of
these reforms. Through enhanced
government commitment, effective
health financing strategies, and
robust partnerships, the Kenyan
government can take forward steps
to expand accessible and affordable
healthcare for all its citizens.
References
1. Chang AY, Cowling K, Micah
AE, Chapin A, Chen CS, Ikilezi
G, et al. Past, present, and future
of global health financing: a re-
view of development assistance,
government, out-of-pocket, and
other private spending on health
for 195 countries, 1995–2050.
Lancet. 2019;393(10187):2233-
60.
2. Asante A,Wasike WSK,Ataguba
JE. Health financing in Sub-Sa-
haran Africa: from analytical
frameworks to empirical evalua-
tion. Appl Health Econ Health
Policy. 2020;18(6):743-6.
3. Muga R, Kizito P, Mbayah M,
Gakuruh T. Overview of the
health system in Kenya [Inter-
net]. Demographic and Health
Surveys. 2005 [cited 2025 Apr
1]. Available from: https://www.
dhsprogram.com/pubs/pdf/
spa8/02chapter2
4. Ministry of Health, Government
of Kenya. The Second National
Health Sector Strategic Plan of
Kenya: NHSSP II, 2005-2010.
Nairobi; Government of Kenya;
2005. Available from: https://
www.policyvault.africa/policy/
the-second-national-health-
sector-strategic-plan-of-kenya-
nhssp-ii/
5. Barasa E, Nguhiu P, McIntyre
D. Measuring progress towards
Sustainable Development Goal
3.8 on universal health coverage
in Kenya. BMJ Glob Health.
2018;3(3):e000904.
6. Barasa E, Rogo K, Mwaura N,
Chuma J. Kenya national hospital
insurance fund reforms: impli-
cations and lessons for universal
health coverage. Health Syst Re-
form. 2018;4(4):346-61.
7. National Health Insurance Fund.
Comprehensive medical insur-
ance scheme for civil servants
and disciplined services hand-
book [Internet]. 2022 [cited 2025
Apr 1]. Available from: https://
publicworks.go.ke/sites/default/
files/2022-09/CIVIL_SERV-
ANTS_HANDBOOK.pdf
8. Orangi S, Kairu A, Ondera J,
Mbuthia B, Koduah A, Oyugi
B, et al. Examining the imple-
mentation of the Linda Mama
free maternity program in Ken-
ya. Int J Health Plann Manage.
2021;36(6):2277-96.
9. Ng’ang’a W, Mwangangi M,
Gatome-Munyua A. Health re-
forms in pursuit of universal
health coverage: lessons from
Kenyan bureaucrats. Health Syst
Reform. 2024;10(3):2406037.
10. Government of Kenya. The So-
cial Health Insurance Act No.
16 of 2023 [Internet]. 2023 [cit-
ed 2025 Apr 1]. Kenya Gazette
Supplement Acts, 2023. Availa-
ble from: https://www.kenyalaw.
org/kl/fileadmin/pdfdownloads/
Acts/2023/TheSocialHealthIn-
suranceAct_2023.pdf
11. Mburu S, Kamau O. Framework
for development and implemen-
tation of digital health policies
to accelerate the attainment of
Sustainable Development Goals:
case of Kenya eHealth policy
(2016-2030). J Health Inform
Afr. 2018;5(2).
12. Ministry of Health, Govern-
ment of Kenya. Kenya Health
Policy 2014-2030 [Internet].
2014 [cited 2025 Apr 1]. Avail-
able from: https://arua-ncd.org/
wp-content/uploads/2022/10/
kenya-health-policy.pdf
13. Government of Kenya. Health
Strategic Plan and Investment
Plan (KHSSP), July 2013 – June
2017 [Internet]. 2013 [cited 2025
Apr 1]. Available from: https://
extranet.who.int/countryplan-
Transformation of Kenya’s Health Financing
42
ningcycles/sites/default/files/
planning_cycle_repository/ken-
ya/kenya_health_strategic_plan2.
pdf
14. Government of Kenya. Laws of
Kenya: the Constitution of Kenya
[Internet]. 2022 [cited 2025 Apr
1]. Available from: https://keny-
alaw.org/kl/fileadmin/pdfdown-
loads/TheConstitutionOfKenya.
pdf
15. Masaba BB, Moturi JK, Taiswa J,
Mmusi-Phetoe RM. Devolution
of the healthcare system in Ken-
ya: progress and challenges. Pub-
lic Health. 2020;189:135-40.
16. Patolawala M. Transforming
Kenya’s healthcare system: a PPP
success story. World Bank Blogs.
2017 [cited 2025 Apr 1].Available
from: https://blogs.worldbank.
org/en/ppps/transforming-ken-
ya-s-healthcare-system-ppp-suc-
cess-story
Diana Marion, MBChB, MMed
OBSGYN, MBA HLM
Secretary General,
Kenya Medical Association
Gynaecological Oncology Fellow,
Department of Obstetrics and
Gynaecology,
University of Nairobi
Nairobi, Kenya
mariondndoc@gmail.com
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Transformation of Kenya’s Health Financing
43
Sub-Saharan Africa faces a critical
shortage of dental professionals,
particularly dentists, significantly
limiting access to oral health care
and negatively affecting general
health outcomes. Compared to the
global average of one dentist per
5,000 people, the region reported
just 3.3 dentists per 100,000
between 2014 and 2019, with some
countries having only one dentist
per 150,000 people [1]. Such
stark disparities leave populations
vulnerable to undiagnosed and
untreated conditions like caries,
periodontal disease, and oral cancers,
underscoring the urgent need for
strategic interventions to bolster the
dental workforce.
Oral health profoundly affects an
individual’s physical, emotional,
social, and economic well-being
[1]. Beyond basic functions such
as nutrition and communication,
poor oral health contributes
significantly to systemic conditions
like diabetes, cardiovascular diseases,
and adverse pregnancy outcomes
[2]. For physicians, recognising
the connection between oral
and general health is crucial for
comprehensive patient care and
timely interventions, reinforcing
the necessity of interprofessional
collaboration between medical and
dental practitioners.
Despite the clear importance,
access to oral healthcare remains a
challenge, especially in remote and
underserved regions. This article
identifies key barriers, including
educational gaps, workforce
distribution challenges, infrastructure
deficits, and policy neglect, and
proposes actionable strategies
and case studies demonstrating
successful approaches. By adopting
an integrated and collaborative
framework, stakeholders, including
physicians, can contribute to
targeted, sustainable improvements
in oral healthcare delivery, enhancing
overall health equity across sub-
Saharan Africa.
Challenges to Providing Oral
Health Care
In sub-Saharan Africa, the dental
workforce is severely constrained
by underdeveloped educational
infrastructure, limited governmental
support, and the migration of
dental professionals to urban
centres or abroad in search of
better opportunities. These global
disparities in dental care access
are rooted in systemic issues that
can lead to persistent inequities
and poor oral health outcomes
among vulnerable populations.
These challenges include limited
availability of dental care, inadequate
educational infrastructure, workforce
imbalance, and insufficient
investment in healthcare policies.
Limited Availability of Dental Care
Understanding the impact of
OHL on a person’s capacity to
use preventive oral health practices
and access and navigate the oral
health treatment system is essential
[3]. Access to care is crucial in
promoting health-seeking behaviour
and improving health intervention
outcomes. Poor oral health literacy
can lead to misunderstandings about
the importance of preventive care,
such as regular brushing, flossing,
and dental check-ups. Additionally,
individuals with limited OHL may
struggle to understand treatment
options, follow post-treatment
instructions, or even locate
appropriate dental services, further
exacerbating oral health disparities.
Inadequate Educational Infrastructure
Across most sub-Saharan African
countries, undergraduate training in
dentistry is only offered in a few
public universities [4]. With the
strict admission requirements and
intensive dentistry curriculum, fewer
students complete training and enter
the workforce. Furthermore, many
institutions have limited numbers
of qualified faculty, outdated
training equipment, and inadequate
governmental funding [4]. This lack
of prioritization in human resources
for health significantly limits access
to oral healthcare services.
Workforce Imbalance
A significant workforce imbalance
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Human Resource Shortage in Dentistry across Sub-Saharan Africa
Bridging the Gap: Strategies to Address the Human Resource
Shortage in Dentistry across Sub-Saharan Africa
Cliffland Mosoti Marie-Claire Wangari
44
BACK TO CONTENTS
Human Resource Shortage in Dentistry across Sub-Saharan Africa
exists as dental professionals are
concentrated in urban areas, driven
by better infrastructure, higher
salaries, and access to professional
growth opportunities. This
imbalance leads to health disparities,
leaving rural and underserved
regions without adequate access
to care [5]. Furthermore, the
emigration of professionals seeking
better opportunities abroad
exacerbates the shortage of trained
dentists (brain drain), limiting the
capacity to expand oral healthcare
services [6].
Insufficient Investment in Healthcare
Policies
Oral health is frequently overlooked
in national healthcare policies,
resulting in insufficient investments
in dental infrastructure and
workforce development [6]. The
absence of structured policies
for integrating oral health into
primary healthcare systems further
deepens these disparities. This
neglect contributes to a fragmented
healthcare system, where oral
health services remain isolated from
general health services, restricting
their accessibility and effectiveness.
As a result, vulnerable populations
are disproportionately affected,
with limited opportunities for early
intervention and preventive care.
Strategies to Address the Academic
and Practice Gap
Expanding dental education
programs, fostering public-private
collaboration, and leveraging
technology to improve access to care
are essential strategies for addressing
the gap between academic
training and practical application
in dentistry. Bridging this gap is
crucial for achieving universal oral
health coverage, a key component
of universal health coverage (UHC),
and for improving the overall
quality of life in sub-Saharan Africa.
Strengthening policy, health, and
education systems, while adopting
innovative workforce models, is
necessary to support this goal.
Expanding Educational Opportunities
Innovative approaches, such as
modular and community-based
education, can help reach a wider
pool of students and increase the
number of public and private
universities with dentistry programs
[7]. Scholarships and financial
incentives aimed at students from
rural areas may encourage them
to pursue dental careers and
return to serve their communities.
Standardisation of training can
help maintain high professional
standards, preventing unregulated
short-course training programs that
can compromise patient safety.
Enhancing Workforce Retention
Governments can implement
policies to improve remuneration,
benefits, and career development
opportunities for dentists. Rural
service programs offering incentives,
such as housing, employment
allowances, and student loan
forgiveness, have been shown to
encourage professionals to work in
underserved areas [7]. Workforce
planning can focus on ensuring
that primary healthcare centres
have stationed dentists under public
health service programs, public-
private partnerships, and private
healthcare access systems.
Leveraging Technology
As tele-dentistry platforms can
facilitate consultations and basic care
in remote regions, mobile dental
clinics can provide preventive and
treatment services to underserved
populations [8]. Investments in
these technologies can dramatically
improve access to dental care
and mitigate workforce shortages.
Transitioning from curative to
preventive treatment can be greatly
aided by remote oral screening, as
frequent population screening can
help decrease risk of oral health
pathologies.
Fostering Public-Private Partnerships
To optimize the achievement of the
national health objectives, public-
private partnerships in health
seek to strengthen the national
health system by utilising the
capabilities and full involvement
of the private health sector. The
major goal of a partnership is to
create a pluralistic health care
delivery system that is functionally
integrated and operates sustainably
by investing in each partner’s
comparative advantages and making
the most equitable use of available
resources. Collaboration between
governments, private entities, and
non-governmental organisations can
increase resources for dental care
delivery by funding dental services,
providing training opportunities,
and raising community awareness
about the importance of oral
health [9]. Increasing the number
of skilled dental professionals will
offer additional clinical support and
services to the wider community.
Integrating Oral Health into Primary
Healthcare
Incorporating basic dental care
into primary healthcare systems
can significantly expand access to
care. Training primary healthcare
professionals to screen for dental
issues and make appropriate
referrals enhances early detection
and timely intervention. Oral
health care supports health equity
by emphasising disease prevention
and health promotion through
risk assessment, oral evaluations,
45
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Human Resource Shortage in Dentistry across Sub-Saharan Africa
preventive interventions, patient
education, effective communication,
and interprofessional collaboration.
Case Studies and Success Stories
By studying case studies on real-
world scenarios related to service
delivery, physicians can critically
analyse complex health challenges
and discuss lessons learned from
novel interventions. This article
provides four case studies that
examine addressing human resource
shortages in dentistry in Ethiopia,
Kenya, Rwanda, and South Africa.
These examples offer valuable
insights into context-specific
strategies that can be adapted and
scaled to strengthen oral health
systems in other low-resource
settings. They also highlight
the importance of multisectoral
collaboration, innovative training
models, and policy reforms in
building sustainable oral health
workforces. Understanding these
interventions can guide future
efforts to improve equitable access
to dental care across similar contexts.
Ethiopia’s Health Extension Program
The Ethiopia Ministry of Health
launched the Ethiopia’s Health
Extension Program (HEP) in rural
areas in 2003, to address gaps in
healthcare delivery by leveraging
the community health workforce
[10]. Although initially focused
on general healthcare needs, the
Ethiopia Ministry of Health later
integrated oral health education and
basic dental care services in 2004-
2005. Health extension workers,
who receive training in oral hygiene
promotion, early detection of dental
diseases, and referral systems,
had four main responsibilities
– 1) illness prevention, 2)
environmental sanitation, hygiene,
and control, 3) health education
and communication, and 4)
family health services [10]. By
incorporating oral health into
primary healthcare, this program
has successfully reduced the burden
of untreated dental conditions
by improving early detection and
patient education, making oral
health services more accessible to
underserved populations.
Kenya’s Mobile Dental Clinics
In Kenya, dental healthcare
disparities have been alleviated by
deploying mobile dental clinics
to underserved areas, which are
equipped with basic diagnostic and
treatment tools and general services
(e.g. dental checkups, fluoride
treatments, extractions, minor
restorative procedures). Operated by
a mix of government and private-
sector initiatives, these mobile units
have served patients in remote and
low-income communities where
permanent dental facilities are
unavailable. Since their introduction
in the early 2010s, these mobile
clinics have increasingly become a
cornerstone of outreach dental care.
Programs like the Smiles for Schools
Initiative, launched in 2016, have
also integrated mobile dentistry into
school health programs, providing
preventive care to children. The
success of mobile clinics in Kenya
has demonstrated the potential of
mobile healthcare in expanding
access and improving oral health
outcomes in rural regions [11].
Rwanda’s Rural Healthcare
Investments
The Rwanda Ministry of Health
has made significant strides in
healthcare accessibility, particularly
in rural areas, by investing in health
infrastructure, training healthcare
professionals, and implementing
policies to retain medical personnel.
In 2011, the Rwanda Ministry of
Health incorporated oral health
into its broader healthcare strategy
by funding dental programs,
deploying community-based oral
health professionals, and equipping
rural clinics with basic dental
care tools. Additionally, Rwanda’s
investments in telemedicine and
mobile healthcare units have helped
reach remote communities. These
initiatives have increased dental
care accessibility, making Rwanda
a model for other nations seeking
to bridge healthcare gaps through
strategic workforce planning and
infrastructure development [12].
South Africa’s Public-Private
Partnerships
In 1999, South Africa established
a formal public-private partnership
framework within the National
Treasury, aligning with a global
rise in initiatives that seek to
leverage expertise between both
public and private sectors. The
South Africa Ministry of Health
has since utilised these partnerships
to bolster the oral healthcare
sector. Collaborations between
government bodies, private dental
institutions, and non-governmental
organisations have led to increased
funding, expanded training facilities,
and improved service delivery. By
working with private providers,
the government has been able to
offer subsidised dental care, making
services more accessible to low-
income communities. Furthermore,
partnerships between private dental
schools and public hospitals have
created internship opportunities that
enhance practical training for dental
students, reduce patient backlogs,
and expand the pool of qualified
dental professionals [13].
Conclusion
The shortage of dental professionals
in sub-Saharan Africa remains
a critical barrier to equitable
and comprehensive healthcare.
Addressing this gap through
expanded educational opportunities,
46
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Human Resource Shortage in Dentistry across Sub-Saharan Africa
workforce retention strategies,
technological innovations, and
integration of oral health into
primary care systems will improve
health outcomes and support
progress toward UHC. For
physicians and health leaders, oral
health must be viewed as a vital
component of systemic health.
Strengthening interprofessional
collaboration between medical and
dental professionals through shared
training, early referrals, and policy
advocacy, will ensure that oral health
is no longer treated in isolation.
By embracing oral health as a core
element of patient care, the medical
community can help advance health
equity across Sub-Saharan Africa
and beyond.
Acknowledgement:
We thank Dr. Bonnke Arunga,
who serves as convener of
the Social Responsibility and
Welfare Committee of the Kenya
Medical Association, for his
contributions to the technical
editing of the manuscript.
References
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Weyant RJ, Daly B, Venturelli R,
Mathur MR, et al. Oral diseases:
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2. Öçbe M, Çelebi E, Öçbe ÇB.
An overlooked connection: oral
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3. Bersell CH. Access to oral
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5. Ogunbodede EO, Kida IA, Mad-
japa HS, Amedari M, Ehizele A,
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qualities between rural and urban
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proving access to oral health
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served populations. Washington,
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org/10.17226/13116
7. Walker MP, Duley SI, Beach
MM, Deem L, Pileggi R, Samet
N, et al. Dental education eco-
nomics: challenges and inno-
vative strategies. J Dent Educ.
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8. Mosha HJ. Increasing quali-
ty and access to oral health care
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Digital innovation in oral health
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Open Journal of Stomatology.
2025;15(1):1-24.
10. Haileamlak A, Ataro I.The Ethi-
opian Health Extension Program
(HEP) is still relevant after 15
years of implementation, al-
though major transformation is
essential to sustain its gains and
relevance. Ethiop J Health Sci.
2023;33(Spec Iss 1):1-2.
11. Siringi S. Kenya embarks on a
campaign to improve oral health.
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Finkelman M, Ntaganira J, Mor-
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Authors
Cliffland Mosoti, BDS
Graduate Student, Master of Public
Health (Applied Epidemiology),
Amref International University
Dentist, Implant Practitioner
Assistant Secretary General,
Kenya Dental Association
Nairobi, Kenya
mosoticliffland@gmail.com
Marie-Claire Wangari, MBChB
Graduate Student in Global Health,
Liverpool School of Tropical Medicine
Liverpool, United Kingdom
Independent Global Health Consultant
WMA-JDN Immediate Past
Chair (2024/2025)
Nairobi, Kenya
mcwangari.wm@gmail.com
47
Digital health, which is broadly
defined as “the use of information
and communication technologies in
medicine and other health professions
to manage illnesses and health risks
and to promote wellness,” incorporates
electronic health (eHealth), mobile
health (mHealth), telemedicine,
and advanced computer science
fields (e.g. big data, bioinformatics,
genomics) [1]. Technological
advancements in telemedicine were
observed during the coronavirus
disease 2019 (COVID-19)
pandemic, as social restrictions
across communities expanded the
use of digital health technologies for
medical consultations [2]. Although
digital health has improved its
population health applications, some
concerns remain on data privacy,
doctor patient trust, equity, and
overreliance on artificial intelligence
(AI).
In October 2022, as part of the
73rd World Medical Association
(WMA) General Assembly,
members reviewed and adopted the
WMA Statement on Digital Health
[1]. This statement innovatively
combined three different
documents – WMA Statement
on Guiding Principles for the Use
of Telehealth for the Provision of
Health Care in 2009, WMA
Statement on Mobile Health in
2015, and WMA Statement on the
Ethics of Telemedicine in 2018 –
and described updates to key ethical
standards. It also highlighted the
use of digital health (namely,
mHealth and telemedicine) as
it relates to physician autonomy,
patient-physician relationships,
informed consent, quality of care,
clinical outcomes, confidentiality
and data security, and legal
principles. Although AI is
incorporated in its conceptual
definitions, it is not highlighted
as a focus area since ethical
consensus was not reached, leaving
the topic open for discussion.
Over the past decade, Chinese
physicians have recognised
challenges in the widespread
implementation of mHealth, as the
elder population is less familiar with
smartphones and poor data quality
cannot be used for medical services.
As Chinese physicians and patients
are open to AI applications, they
are curious about how this WMA
statement can guide clinical care.
To explore the ethical concerns,
the Chinese Medical Association
(CMA) established a core working
group and multidisciplinary advisory
group between the Medical Ethics
and Medical Engineering Branches,
regularly shared perspectives and
research on AI, and incorporated
norms for the physician-patient
relationship in telemedicine and
AI. This article will present key
elements of the WMA Statement
on Digital Health and highlight
practical scenarios for incorporating
telemedicine (including internet
hospitals) and AI applications into
the Chinese health system.
Telemedicine in the Chinese
Health System
Due to the development of
information technology (IT),
telemedicine has significantly
improved the efficiency of medical
resource utilization, increased
accessibility and availability of
healthcare services to urban and
rural communities, and reduced
healthcare expenditure and patients’
financial burden. Over the past
few years, Chinese health leaders
have noticed that county centers
and general hospitals have received
financial support from the local and
central government. Also, they noted
that high-quality medical resources
are concentrated in urban areas,
while rural areas lag behind with
few health professionals to manage
complex health needs. With the
urgent need to strengthen primary
care services across the nation, they
recognised the need to adapt the
three-tier medical network from
the 1970s to an internet-based
diagnosis and treatment network
with physicians providing follow-
up services for acute and chronic
conditions.
In 2017, the State Government
issued the Guiding Opinions of the
General Office of the State Council
on Promoting the Construction and
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Digital Health Applications
Digital Health Applications in the Chinese Health System
Yali Cong Chunqi Liang
48
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Development of Medical Alliances
policy, which promoted the
construction of medical alliances
to further decentralise high-
quality medical resources and
strengthen primary care through
telemedicine [3]. The policy
proposed aims to increase access to
essential medical resources of large
hospital platforms by developing
telemedicine collaboration networks
reaching remote and impoverished
areas. Although substantial
progress has been achieved to date,
further discussions with experts
are necessary to help identify
existing gaps and develop relevant
interventions.
To support this national health
system reform, CMA members
visited several community health
centers in the Xinjiang Uygur
Autonomous Region in August
2024 and March 2025, noting that
each center was equipped with a
telemedicine room connected to
county (or higher-level) hospitals.
Through the formation of medical
alliances between urban and rural
areas, urban tertiary public hospitals
served as the main units and could
send expert teams to county-level
hospitals. For example, between
December 2020 and April 2022,
the Ningbo-Kuke medical alliance
platform conducted approximately
300 consultations and 4,080
two-way referrals for Xinjiang,
successfully linking two hospitals in
Ningbo with four hospitals and 18
primary care institutions in Xinjiang
[4].
The WMA Statement on
Digital Health summarised nine
key ethical and legal principles
related to digital health, while
simultaneously describing and
discussing primary ethical concerns
from various social contexts. As
next steps, health professionals
worldwide can directly apply these
principles in their respective health
systems. Specifically, the authors
have selected and analysed the
incorporation of three described
principles (data privacy and security,
physician-patient communication
and trust, payment policies) – as
well as the integration of traditional
Chinese medicine – demonstrating
their importance and application
within the Chinese health system.
Meanwhile, further reflection on
challenges to implement these
principles in clinical practice
remains an important part of the
CMA goals.
1) Data Privacy and Security
Data safety. Data privacy and
security can have ethical, legal, and
security challenges, especially as
telemedicine involves at least four
main parties (patient, local doctor,
third-party institutions, remote
doctor). Special measures must be
enforced to strengthen the security
management of data collection,
storage, and use in telemedicine
services. Clinical case discussions
with third parties should involve the
sharing of highly sensitive personal
health data, which may violate
patients’ privacy rights if obtained or
leaked without authorisation. As the
WMA statement (“Confidentiality
and Data Security” section)
highlights data privacy and security
topics, it provides strong guidance
to protect against potential security
breaches and support capacity
building programs for privacy
officers.
• Articles 29, 30, and 31 emphasise
that the collection, storage,
protection, and processing
of digital health users’ data,
especially personal health data,
must ensure valid informed
consent and guarantee patients’
rights. If data breaches occur,
patients must be notified
immediately in accordance with
the law.
• Article 32 supports the presence of
privacy officers or data protection
authorities, with whom patients
can contact for protection, if their
privacy rights are violated.
These four articles stress the
need to consider legal and ethical
requirements of digital health
applications across health systems.
The Chinese health system is
currently working to improve
data security in clinical practice,
including training a team of data
officers to lead the work of data
privacy and security in China.
2) Physician Autonomy and Physician-
Patient Communication and Trust
Communication. The physician-
patient relationship is one priority
area for health professionals,
as patient satisfaction is an
important evaluation criterion
for physicians and hospitals. As
the WMA statement (“Patient-
physician Relationship” section)
addresses physician-patient
communication and trust topics, it
offers practical guidance on how to
maintain and improve harmony of
physician-patient-relationships.
• Article 9 addresses acceptable
boundaries in the patient-
physician relationship necessary
for the provision of optimal in-
person and virtual care. Physicians
should inform patients about
their availability and recommend
services when unavailable, as the
continuous availability of digital
healthcare can interfere with a
physician’s work-life balance.
• Article 11 states that face-to-face
consultations should remain the
gold standard for clinical practice,
requiring a physical examination
Digital Health Applications
49
prior to establishing a diagnosis,
or efforts to reinforce a trusting
physician-patient relationship.
• Article 14 addresses the trust and
respect in the physician-patient
relationship, especially as third
parties (‘surrogates’) like family
members become involved.
• Article 15 states that physicians
should give clear and explicit
direction to patients during the
telemedicine encounter, as they
are responsible for any required
follow-up and healthcare services.
• Article 17 addresses proper
informed consent, requiring that
patients are fully informed about
how telemedicine works, how to
schedule appointments, privacy
concerns, risk of technological
failures (including confidentiality
breaches), possible secondary
uses of data, and policies for
prescribing medications and
coordinating care with other
health professionals.
Quality of care. In the Chinese
culture, although virtual
communication with physicians is
convenient, limited body language
and emotional expressions may
affect effective communication and
emotional connections between
physicians and patients. Also, the
overreliance on online diagnoses and
treatments may distance physician-
patient relationships, as patients may
be unable to judge the qualifications
and diagnostic abilities of remote
physicians, which can raise concerns
about telemedicine safety, reliability,
and clinical effectiveness. Moreover,
since telemedicine involves at
least two doctors, the rights and
obligations in the physician-patient
relationship may overlap and lead to
ethical issues.
The WMA statement (“Quality of
Care” section) describes the rights
and responsibility topics for different
roles of physicians. In the Chinese
context, the remote physician only
acts as a consultant, bearing the
obligation of consultations and
advice, while the local physician
and the patient form a physician-
patient relationship, bearing full
responsibility for remote medical
accidents. If the local physician
does not accept the guidance of the
remote doctor, however, patients’
treatment may be delayed, leading to
poor health outcomes.
• Article 16 addresses consultations
between two or more professionals,
stating that the primary physician
remains responsible for the
patient’s care and coordination.
• Article 22 states that physicians
should be aware of and respect
the particular challenges and
uncertainties that may arise
when in contact with patients
through telecommunication. They
should recommend direct patient-
physician contact whenever
possible, especially if they believe
that this contact is in the patient’s
best interests and will improve
treatment compliance.
Considering China’s numerous
local language and dialects,
efforts are required to overcome
any communication barriers and
ensure that accurate and effective
information can be exchanged
between physicians and patients.
Different legal systems may define
the legal relationships between
patients and local doctors (typical
physician-patient relationship),
local doctors and remote doctors
(consulting and collaborative
relationship), and patients and
remote doctors [5]. Sometimes, poor
network quality, insufficient software
functionality, and low convenience of
use can severely impact the quality
of diagnosis or consultation, reducing
trust in primary care doctors and
remote consultations [6].
• Article 24 emphasizes that
patient satisfaction with remote
consultations depends on
continuous monitoring and
improving quality of service to
achieve the best possible health
outcomes.
Currently, the Chinese health system
is working to improve technology
and regulation standards, to fulfill
the advantage of telemedicine as
much as possible.
3) Payment Policies
Over the past few years, telemedicine
services have expanded to include
internet hospitals as a medical model
that has been widely adopted across
China. The general population
embraces digital health technology,
hoping that it can help to reduce
healthcare and travel costs, especially
for low-income communities. Some
reimbursement policies, however,
will require further review as they
are not well incorporated into the
health system.
• Article 34 states that
reimbursement models must
be set up in consultation with
national medical associations and
healthcare providers to ensure
that physicians receive appropriate
reimbursement for providing
digital health services.
Currently, China’s medical insurance
payment policies for telemedicine
services are not yet fully developed,
and some telemedicine service items
cannot be reimbursed. To promote
the popularisation and development
of internet-based medical services,
eligible internet-based medical
services should be included in the
scope of medical insurance payments
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50
to reduce the financial burden on
patients. Hence, it is essential to
address the coordination of online
payments and medical insurance,
approval of cross-province medical
treatment, and application of laws
in cases of medical accidents or
disputes during telemedicine should
be clarified and addressed.
4) Integration of Traditional Chinese
Medicine
The Chinese health system strongly
advocates for better integration
of traditional Chinese medicine
(TCM) services, ensuring the quality,
safety, and regulation of online
services, sales, and distribution
(e.g. herbs), and it is encouraged
to deliver services through
telemedicine tools. TCM is trusted
more by patients, especially by the
elderly, patients living with chronic
diseases, and disabled. Several
studies have shown that TCM
can improve patients’ compliance
to healthcare recommendations
and raise their quality of their life,
as well as alleviate health system
challenges, such as insufficient
medical resources and inconvenient
medical treatment [7]. Although the
WMA statement did not mention
traditional or alternative therapies,
the CMA working group aims
to further specify the principles
of integrating digital health in
TCM practice when discussing the
Chinese context.
Expanding Digital Health in the
Chinese Health System
AI applications are increasingly
demonstrated as a supportive tool
for physicians in more clinical areas
by enhancing disease diagnosis
and treatment for patient care
[8]. First, AI can automatically
analyse electronic medical records
through natural language processing
technology, which can help balance
differences in doctors’ diagnostic
findings and hence improve clinical
standards. Second, AI can analyse
patients’ genetic information,
medical history, and lifestyle
habits, creating more precise and
personalised treatment plans to
improve treatment effectiveness and
reducing adverse drug reactions.
Third, through wearable devices and
remote monitoring technologies,
AI can monitor patients’ real-time
physiological indicators, promptly
detect abnormalities, and provide
warnings and personalised health
advice, which can support health
monitoring, risk assessment, and
disease prevention. Finally, AI can
help accelerate drug development
in clinical practice and help doctors
complete medical recording with
summarised discharge summaries
and disease analyses.
However, four specific ethical
concerns should be carefully
considered when expanding AI
applications in digital health.
1. Intelligent imaging-assisted
diagnosis and treatment systems
require the collection and
processing of large amounts
of patient imaging data. How
can we ensure that the privacy
and security of patient data are
maintained during model training
and deployment?
2. Informed consent for patients
and physicians can raise
diverse questions ranging from
individuals who have access to
AI application. Should patients
have the right to know that they are
receiving AI-assisted treatment? At
the same time, do physicians have
an obligation to inform patients the
limitations of AI technology and the
potential risks that may exist? What
are the best practices for doctors to
fully explain the role and limitations
of AI technology to patients and
respect their right to choose?
3. Since training data for AI
models primary originate from a
specific region or population, data
collection may be biased, leading
to false positives or negatives.
Multimodal AI models are
usually more complex, making it
difficult to explain their decision-
making processes, which increases
the difficulty of identifying and
correcting algorithmic biases
and makes accountability more
challenging. When intelligent
imaging-assisted diagnosis and
treatment systems misdiagnose
a case, the issue of responsibility
becomes prominent.
4. Doctors may over-rely on
AI systems that can weaken
doctors’ diagnostic abilities
and accumulation of clinical
experiences. How will widespread
AI applications influence
traditional medical skills (e.g. image
interpretation)?
Conclusion
The Article 6 of the WMA
Statement on Digital Health
clearly indicated that “the scope
and application of digital health,
telemedicine or tele health are context-
dependent. Factors such as human
resources for health, size of service
area and level of healthcare facilities
should also be taken into consideration”
[1]. By considering the ethical
concerns and suggestions of digital
health applications, including nine
evidence-based recommendations,
the CMA can continue to lead
efforts to improve digital healthcare
services across the nation. By
understanding the principles of the
WMA Statement on Digital Health
in the context of Chinese health
system, Chinese physicians can
engage in collective discourse, reflect
on existing gaps, and implement
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51
approaches to accelerate progress in
digital healthcare service delivery.
Likewise, the CMA seeks to
encourage formal opportunities with
the WMA to facilitate knowledge
sharing across national member
associations.
References
1. World Medical Association.
WMA Statement on Guiding
Principles for the Use of Tele-
health for the Provision of Health
Care [Internet]. 2022 [cited 2025
Mar 3]. Available from: https://
www.wma.net/policies-post/
wma-statement-on-guiding-prin-
ciples-for-the-use-of-telehealth-
for-the-provision-of-health-care/
2. Yeung AWK, Torkamani A, Butte
AJ,GlicksbergBS,SchullerB,Rod-
riguez B, et al. The promise of dig-
ital healthcare technologies. Front
Public Health. 2023;11:1196596.
3. General Office of the State
Council, Government of China.
Guiding Opinions of the Gener-
al Office of the State Council on
Promoting the Construction and
Development of Medical Allianc-
es Policy [Internet]. 2017 [cited
2025 Mar 23]. Chinese. Availa-
ble from: https://www.gov.cn/
zhengce/content/2017-04/26/con-
tent_5189071.htm
4. Guohua M, Jizhou D, Jitong L,
Bihua Y. Research on the practice
of a cross-regional new medical
alliance’s telemedicine platform
in assisting medical aid to Xin-
jiang. China Medical Herald.
2023;20(03):192-6.
5. Xuanlin L, Sijia S. Research on
telemedicine and its legal regu-
lation. Chinese Medical Ethics.
2017;30(11):1317-21.
6. Lixia H. Practice and evaluation of
medical alliance teleconsultation
platforms. Computer Knowledge
and Technology. 2025;21(02):100-
7.
7. Yan Y. The role of traditional Chi-
nese medicine telemedicine service
in the management of chronic dis-
eases in the elderly.TCM Manage-
ment. 2025;33(02):121-3.
8. Li R, Yang Y, Wu S, Huang K,
Chen W, Liu Y, et al. Using ar-
tificial intelligence to improve
medical services in China. Ann
Transl Med. 2020;8(11):711.
Acknowledgments
The authors would like to recognise
the CMA working group members
Kun Zheng, Bin Li, Jingyi Feng,
Caixian Zheng, Yunxin Zheng,
and Qingli Zhou from the CMA
Medical Engineering Branch, as
well as Haihong Zhang, Ping Ji,
Antao Ye, Xinming Dong, and
Junrong Liu from the CMA
Medical Ethics Branch. They
appreciate the support of Weili
Zhao who helped establish
connections with the two CMA
branches.
Authors
Yali Cong, PhD
Health Science Center,
Peking University
Beijing, China
ethics@bjmu.edu.cn
Chunqi Liang, MBA
Deputy Secretary General,
Chinese Medical Association
Beijing, China
weilizhao@cma.org.cn
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52
The nursing profession, with
an estimated 29 million nurses
worldwide, represents a fundamental
pillar of global health systems,
directly enhancing healthcare service
delivery, economic growth, and
health policy reform. Nurses, who
comprise half of the global health
workforce, serve across diverse
primary care and specialty services,
contribute to direct patient care in
hospital and community settings,
and promote optimal health and
well-being throughout the lifespan
[1]. Amidst changing health
system priorities, nurses exemplify
key health leaders who can help
harmonize multidisciplinary health
teams in clinical practice to foster
interprofessional collaborations,
prioritize patient-centred care, and
advocate for safe and productive
work environments.
As the founder of modern nursing,
Florence Nightingale (1880-1910)
cared for wounded soldiers during
the Crimean War (1853-1856),
often remembered as the “Lady of
the Lamp” as she carried a lamp
during her night shift assessments.
She also stressed the importance of
sanitation practices in patient care,
applied her mathematical knowledge
to public health data collection (e.g.
mortality rates), and established
the first professional nursing school
(St. Thomas’ Hospital in London,
1860) [2]. Through her dedicated
efforts, she inspired a movement
of scientific inquiry and holistic
examination of social determinants
of health, expanding our
understanding of health promotion
and disease prevention strategies.
Over the past five years, significant
policy initiatives have streamlined
the nursing profession as an integral
part of global health systems.
First, the World Health Assembly
(WHA) approved the document
A72/54 Rev.1 in 2019, designating
2020 as the International Year of
the Nurse and the Midwife [3].
Second, the WHA adopted the
decision WHA73(30) (Human
resources for health) in 2020, which
recognised 2021 as the International
Year of Health and Care Workers
[4]. The “Protect. Invest. Together.”
theme was widely promoted
for this celebration, as a tribute
to global health professionals’
steadfast dedication to patient care
during the coronavirus disease
2019 (COVID-19) pandemic.
Finally, the WHA accepted the
resolutions WHA74.14 (Protecting,
safeguarding and investing in the
health and care workforce) and WHA
74.15 (Strengthening nursing and
midwifery: investments in education,
jobs, leadership and service delivery)
in 2021 [5]. Recognising that
investment in the nursing profession
was essential for health systems, the
WHA adopted the Global Strategic
WMA Members Recognise International Nurses Day
WMA Members Recognise International Nurses Day
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Africa
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WMA Members Recognise International Nurses Day
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Directions for Nursing and Midwifery
2021-2025 in 2021, later extended
to 2030, as a framework to guide
and monitor progress related to four
policy areas (e.g. education, jobs,
leadership, service delivery) [5,6].
The State of the World’s Nursing 2025
report highlighted the projected
global shortage of 5.8 million nurses
by 2030, coupled with the uneven
distribution across geographic
regions, which will strain how health
systems in low- and middle-income
countries serve national needs [7].
As health professionals remain
challenged by limited institutional
resources, inadequate staffing,
excessive work schedules, and
unsafe work environments – acutely
observed during the COVID-19
pandemic – they may experience
physical and mental health strain
(including burnout), low job
satisfaction, high staff turnover or
migration to high-income countries.
Investment in nursing education,
training, and mentorship can help
address workforce shortages as well
as enhance overall job satisfaction
and retention, amidst emerging
global challenges such as aging
demographics, communicable and
non-communicable diseases, and
extreme weather events.
International Nurses Day (https://
w w w. i c n . c h / h o w – w e – d o – i t /
campaigns/international-nurses-day)
is observed annually on 12 May, in
commemoration of the anniversary
of Florence Nightingale’s birth. The
“Our Nurses. Our Future. Caring for
nurses strengthens economies” theme
emphasizes the essential role of
the nursing health workforce on
health system resiliency, economic
productivity, and community health
and well-being. To support the
sustainable nursing workforce well-
being, the International Council
of Nurses published the Caring for
Nurses Agenda that identified seven
key focus areas: 1) ensure adequate
staffing and skill mix for effective
care; 2) invest in the right resources
and equipment; 3) provide safe
and decent working conditions;
4) support education, professional
development, and optimal scope of
practice; 5) build supportive, high-
performing organizational cultures;
6) improve access to healthcare
and well-being support; and 7)
provide nurses with fair, competitive
compensation [8]. This resource
offers recommended interventions
that can help nations develop
relevant policies and implement
local and national initiatives that
strengthen the nursing health
workforce.
In this article, physicians from eight
countries – Argentina, Colombia,
Ivory Coast, Malaysia, Myanmar,
Philippines, South Africa, and
Trinidad and Tobago – described
national policies that underscore
the need for a competent nursing
workforce with high-quality
education and training programs,
mentorship, and networking
opportunities. They highlighted
local activities that promote nursing
excellence and honour nurses’
contributions to health promotion
and disease prevention across health
institutions and community settings,
which can ultimately improve
retention and recruitment of the
nursing workforce.
Argentina
As the backbone of global health
systems, nursing professionals
represent key leaders in health
education, health promotion, and
disease prevention, caring for
people of all ages in clinical and
community settings. In Argentina,
with a health system serving an
estimated 45 million habitants, the
density of nursing and midwifery
personnel (per 10,000 population)
increased from 20.5 in 1992 to 47.5
in 2023 to 47.5 in 2023 [9]. This
increasing trend is also attributed
to the estimated 85,000 students
who are pursuing their nursing
education at 61 public and private
institutions across the nation [10].
Although the nursing profession is
widely recognised as a fundamental
component of the national health
system, nurses have reported that
they experience prolonged working
hours, low wages, lack of workplace
security and safety, and stressful
clinical responsibilities, which can
negatively influence physical and
mental health and well-being [11].
Since the 19th century, the
government of Argentina has
supported the nursing profession
with several key historical events
and policies. First, the first nursing
school (Nursing School of the
British Hospital) was established
in 1890, led by Dr. Cecilia
Grierson (first female Argentinian
physician) [12]. Second, the Nursing
Federation of Argentina (Federación
Argentina de Enfermería, FAE)
(https://www.fae-web.com.ar/) was
founded in 1965, with the objective
to promote nursing education and
practice, support relevant nursing
policies, and defend clinical
workplace conditions. Finally, the
Law No. 24.004 (Ley Nº 24.004)
was adopted in 1991, providing
a framework for professional
guidelines of the nursing profession
(professional or auxiliar) [13]. To
support this policy (including three
other educational and professional
policies), the Law No. 27.712 (Ley
Nº 27.712) was approved in 2023,
which aimed to expand high-quality
nursing education and training and
boost academic enrollment across
universities in the country [14].
In Argentina and across the
Americas region, physicians can
offer their voice to promote
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WMA Members Recognise International Nurses Day
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the indispensable role of nurses
in the clinical and community
workplace. Nurses can lead across
health institutions and professional
organisations, accelerating
community and national action to
ensure. Developing robust nursing
education and training programs
across academic institutions can
help recruit and retain nursing
professionals in the health system.
Political commitment should ensure
that nursing professionals represent
an integral part of the healthcare
solution to identifying and
implementing best clinical practices
in healthcare service delivery across
urban and rural communities.
Together, all health professionals
can contribute their expertise and
support the provision of safe and
high-quality patient-centered care.
Colombia
The nursing profession, which
focuses on the comprehensive
care of the individual, family,
and community, aims to promote
health, prevent illness, intervene in
treatment and recovery, alleviate
pain, and contribute to well-being
and dignity. The Colombia Ministry
of Health and Social Protection has
reported that of the 717,456 health
professionals in 2018, 337,962
(47%) were professionals and
specialists (including 66,095 nurses),
and 379,494 (53%) assistants and
technicians [15]. Health leaders
have conveyed that more than 80%
of the nursing workforce as women,
noting that they often express a
lack of support networks (serving
as heads of households) as well as
double workload and emotional
burden between the workplace and
home [15]. Notably, the density of
nursing professionals has increased
from 11.5 in 2015 to 14.6 in 2020
(per 10,000 population), despite a
geographic disparity affecting rural
regions (e.g. La Guajira, Chocó,
Amazonas, Putumayo).
The Colombia Ministry of Health
and Social Protection has prioritised
the formalisation of the nursing
workforce, as efforts to improve
working conditions and recognise
their strategic role in the health
system. First, the nursing profession
was formally established by Law
266 of 1996 (Ley 266 de 1996),
grounded in ethics, science, and
theory [15]. Second, the National
Nursing Plan 2020-2030 (Plan
Nacional de Enfermería 2020-2030)
was approved in 2019, establishing
a framework to strengthen working
condition and promote research
and professional development
[16]. Third, health leaders adopted
the Resolution No. 755 of 2022
(Resolución No. 755 de 2022), which
launched the National Nursing
Human Talent Policy and Strategic
Plan 2020-2030 (Política Nacional de
Talento Humano de Enfermería y Plan
Estratégico 2020-2030), providing
key guidelines for strengthening
nursing talent in Colombia through
distribution, professional leadership,
and training [15].
Furthermore, in 2023, the Colombia
Ministry of Labor initiated the
development of labor agreements
for health professionals within the
health system, prioritising nursing
personnel and their professional
recognition. As a result, more than
200 employees (e.g. laboratory
technicians, nurses, paramedics)
at one Barranquilla clinic (Clínica
Altos de San Vicente) converted
their employment status as union
contractors to permanent staff [17].
In 2024, over $269,090 million
Colombian pesos (estimated
US $64,000) were allocated to
strengthen access and availability of
primary care services in rural and
remote communities through the
implementation of Basic Health
Teams.
As physicians in Colombia and
around the world, we cannot
continue to be silent observers
to the historical invisibility of
nursing professionals in the clinical
workplace. We must actively support
the nursing profession, demand fair
working conditions, and promote
their contributions in local and
national leadership positions. Their
work represents the operational core
of the health system, which must be
recognised through timely political,
labor, and educational decisions
that guarantee their dignity.
Health systems are dependent on
the indispensable role of nursing
professionals in patient care, and
defending their rights is promoting
public health.
Ivory Coast
In the Ivory Coast, International
Nurses Day is a moment of both
national pride and urgent reflection.
For physicians and the broader
health community, it serves as
an opportunity to recognise the
foundational role that nurses play in
the Ivorian healthcare system, often
under strenuous conditions and
with limited recognition. Nurses are
the first point of contact for most
patients, particularly in primary
health centres (centres de santé
urbains ou ruraux), maternity wards,
and rural mobile clinics across
the country. Although nurses are
recognised as pillars of the health
system, however, they are often
excluded from decision-making
processes, and their voices remain
underrepresented in the national
policy dialogue.
According to the Ivory Coast
Ministry of Health, a total of
32,000 nurses and midwives were
employed in the health system
in 2023, with the majority
concentrated in urban regions (e.g.
Abidjan, Bouaké, San Pedro) leaving
underserved rural areas (e.g. Cavally
and Bounkani regions) [18]. One
recent study conducted among
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180 health professionals, including
113 nurses and midwives in the
paediatric departments of university
hospitals in Abidjan, revealed the
significant psychological strain
caused by high workload, which
was further exacerbated without
social support [19]. These findings
underscore the mental burden that
nurses and other health professionals
may face in overwhelmed hospital
settings, which highlight the urgent
need for better organisational
support systems.
In response to these longstanding
challenges, the Ivorian government
and civil society have launched
several targeted initiatives to
support and empower the nursing
workforce. First, they adopted the
Strategic Plan for the Development
of Human Resources for Health
(2023–2027), which aims to train,
recruit, and deploy over 6,000
new nurses by 2027, particularly
in underserved regions [20].
The plan includes incentives for
nurses to work in remote areas,
such as housing allowances,
accelerated promotion tracks, and
training scholarships. Second,
they established the National
School and University Health
Program (Programme National
de Santé Scolaire et Universitaire,
PNSSU), which integrates nurses
into over 500 schools nationwide
as frontline actors in adolescent
health, mental health education,
nutrition screening, and vaccinations
[21]. Third, the National Order of
Nurses of the Ivory Coast (Ordre
National des Infirmiers de Côte
d’Ivoire, ONICI) has partnered
with the Virtual University of Côte
d’Ivoire (Université Virtuelle de
Côte d’Ivoire, UVCI) to launch
a digital continuing education
platform, allowing nurses to
follow accredited training courses
online – a game-changer for rural
health professionals. Finally, nurses
regularly coordinate impactful
community campaigns, such as the
“Free Screening Campaigns for
Diabetes and High Blood Pressure”
in Yamoussoukro and Man, leading
to the screening of thousands
of adults in 2024. Also, ONICI
members led “Nurses Week 2024”,
with workshops on workplace safety,
digital health, and interprofessional
collaboration, culminating in a
White Paper sent to the National
Assembly.
Physicians in the Ivory Coast
stand in solidarity with our nursing
colleagues and are committed
to promoting their recognition,
protection, and inclusion within
the health system. We call for the
full implementation of the Nurses’
Statute, a long-awaited legal
framework that would secure fair
wages, better working conditions,
and a clear career progression
for nurses working in public and
private sectors. We also advocate for
more interprofessional leadership
programs, where nurses and doctors
can co-develop public health
strategies, particularly in areas such
as maternal health, mental health,
and non-communicable diseases.
At a regional level, West African
countries should consider the mutual
recognition of nursing diplomas,
easing mobility and knowledge
exchange across borders, especially
in humanitarian or post-crisis
settings. Globally, physicians must
join advocacy movements calling
for increased international funding
for nursing education, particularly
in sub-Saharan Africa, where
demographic pressure and disease
burden remain high. Reflecting on
the “Our Nurses. Our Future.” theme,
we must remember that caring for
our nurses is about building a health
system that is sustainable, equitable,
and people-centred. The future of
health in the Ivory Coast will be
shaped by how well we care for
our health professionals – especially
nurses – who care for us.
Malaysia
International Nurses Day holds
deep significance for physicians
in Malaysia. Nurses are the pillar
of our healthcare system — the
unsung heroes who are often
overlooked despite being at the
frontlines of patient care. They work
under immense pressure, balancing
rising patient expectations, medico-
legal risks, and complex clinical
responsibilities [7]. In Malaysia,
with over 95% of the nursing
workforce as women, many
forget that behind the uniform,
they are also mothers, daughters,
sisters, and wives — individuals
who must balance their personal
responsibilities with delivering the
best care possible. This human
reality must be widely acknowledged
and addressed in national planning,
policy, and healthcare workforce
reform. With a population of over
33 million, Malaysia had more
than 117,000 registered nurses as
of 2022 — with approximately
61% in the public sector and 32%
in the private sector [22]. Despite
this, the country continues to face
a growing workforce shortage, with
more than 6,800 vacancies reported
in the public healthcare system in
2023. This shortage is linked with
overburdened clinical workloads,
limited career progression,
and negative public perception
(especially after the pandemic),
which significantly impacts nursing
recruitment [23].
Malaysia is actively addressing
long-standing challenges in its
nursing workforce through targeted
policy initiatives. The Ministry
of Health has implemented the
National Strategic Plan for Nursing
Development (Pelan Strategik
Perkembangan Kejururawatan
56
WMA Members Recognise International Nurses Day
BACK TO CONTENTS
Kebangsaan) (2021–2025), which
aims to strengthen professional
standards, expand specialisation, and
improve nursing recruitment and
retention. In the private sector, acute
shortages of nurses — especially
after the COVID-19 pandemic —
prompted the government to make
a major policy shift in 2023 [24].
Previously, internationally-trained
nurses were largely restricted from
practicing in Malaysia unless they
held post-basic qualifications and
fulfilled strict regulatory conditions
set by the Malaysia Nursing Board.
However, under a temporary
exemption policy effective from
1 October 2023 to 30 September
2024, the Malaysia Ministry of
Health allowed private healthcare
facilities to employ internationally-
trained nurses without post-basic
qualifications. This permission
came with a strict condition:
internationally-trained nurses must
not exceed 40% of the total nursing
workforce at any private facility, and
all must pass the Malaysian Nursing
Board Qualification Examination
for Foreign-Trained Nurses [25].
As physicians, we must work hand in
hand with nurses to strengthen the
delivery of care. Nurses are not just
technical support — they are care
leaders, educators, and community
builders. Support for their work-life
balance and private roles must also
be integrated into workplace culture
so they can thrive both personally
and professionally. In 2025, with
Malaysia chairing the Association of
Southeast Asian Nations (ASEAN)
Summit, Malaysian leaders are
in a position to push for regional
solidarity in supporting nursing
systems across Southeast Asia. From
Sabah to Sarawak, we can share real
stories of nurses walking through
jungle trails, taking boats across
rivers, and conducting home visits
in underserved areas. These realities
are not unique to Malaysia alone,
and widely shared across Southeast
Asia with over 600 million
people. At the Malaysian Medical
Association (MMA), we continue
to support initiatives that highlight
nurses’ contributions to clinical care
within hospitals and communities,
call for fairer policies, and promote
interdisciplinary collaboration to
build a stronger, more equitable
health system [26].
Myanmar
International Nurses Day in
Myanmar holds profound
significance, representing a moment
to honour nurses who continue
to promote health, protect the
sick, and support communities
despite immense personal risk
and hardship amidst the current
military coup. Nurses in Myanmar
have demonstrated extraordinary
resilience, often working in
dangerous conditions, facing staff
shortages, and managing the
psychological toll of conflict and
displacement. The tragic testimonies
of nurses – including physical harm
in the workplace or interrogation
centres – underscore the
unimaginable daily stress and fear
that they endure under military coup
[27-30]. In 2021, the International
Council of Nurses published a
statement that condemns all forms
of violence against healthcare
organizations and their staff, as they
endanger the health and human
rights of the people of Myanmar
and represent a violation of the
Geneva Conventions [31].
The Myanmar health system has
faced critical nursing shortages,
particularly exacerbated by the
COVID-19 pandemic and the
ongoing military coup, with rural
and frontline regions suffering the
most severe deficits. In 2022, one
recent World Health Organization
(WHO) report highlighted the
severe strain on the nursing and
midwifery personnel (per 10,000
population) over the past two
decades, declining from 7.7 in 2005
to 2.0 in 2022 [9]. To navigate this
burden, the Myanmar’s National
League for Democracy government,
led by the State Counsellor, has
taken forward steps to improve
leadership and enhance the quality of
healthcare service delivery. First, the
government established new medical
universities and nursing/midwifery
schools to enhance the training
and supply of nurses and midwives
in response to growing demand.
Second, the nursing curriculum
was revised to better prepare nurses
with clinical competencies and skill
sets to meet the evolving healthcare
demands. Third, the government
supported comprehensive continuing
nursing education programs to
empower nurses to maintain up-
to-date on clinical knowledge and
best practices. Leaders also provided
incentives for nurses serving in
marginalised areas, as well as
expanded opportunities for overseas
training with improved access to
international examinations.
As physicians in Myanmar and
across the globe, our call to action
addresses initiatives that can ensure
access to mental health support and
result, considering the psychological
toll of the military coup and stressful
working conditions for all health
professionals. Specifically, we can use
our voices to highlight the plight
and heroism of Myanmar nurses,
mobilising international solidarity
and resources to support their
physical and mental health during
this conflict. Although international
humanitarian law explicitly protects
medical personnel and facilities
during conflict, Myanmar military
and security forces attacks on
hospitals and nurses violate these
protections and are recognised
as war crimes under the Geneva
57
WMA Members Recognise International Nurses Day
BACK TO CONTENTS
Conventions and the Rome Statute
of the International Criminal
Court. We urge Member States
and international organisations, like
the United Nations, World Medical
Association (WMA), and WHO, to
provide resources for documentation,
legal support, and humanitarian
assistance to affected nurses and
their families. International Nurses
Day in Myanmar is a powerful
reminder of the courage and
commitment of nurses working
under fire. The international medical
community must unite to support,
protect, and empower Myanmar
nurses – today and for the future.
Philippines
International Nurses Day serves as
an important reminder for Filipinos
to honour nurses both locally and
abroad, who serve as the backbone
of the healthcare system. This
day offers a special opportunity
to recognize the compassion,
dedication, and resilience of nurses,
who are critical in delivering patient
care. As of 2024, the Philippine
Statistics Authority estimates that
there are approximately 509,297
licensed nurses in the Philippines,
where an estimated 50-60% of
nurses are working locally, since
many nurses are migrating abroad
in search of better opportunities
[32]. This persistent shortage of
nurses in local hospitals, especially
in rural and underserved areas, has
led to increased workloads and staff
burnout.
Several initiatives have been
launched to address these
challenges. First, the “Magna Carta
of Public Health Workers” (Republic
Act No. 7305) safeguards the rights
and benefits of nurses and other
health professionals [33]. Second,
the Department of Health (DOH)
launched the “Nurses Deployment
Program,” which assigns nurses to
remote and rural areas to improve
healthcare access and augment
staffing in primary and secondary
hospitals. Third, the Presidential
Communications Office (PCO)
nationally honoured Filipino nurses
for their “invaluable contributions”
and “tireless service” to society
in a public tribute [34]. Also,
to sustain workforce readiness,
health institutions are integrating
universal health coverage training
into onboarding and continuing
education, ensuring that nurses and
other healthcare professionals are
equipped to support universal health
coverage implementation effectively
[35].
Professional organizations have
also paved the was to showcase
the valuable contributions of the
nursing profession in the country.
The Filipino Nurses United (FNU)
led a grassroots movement during
International Nurses Day 2024,
organising advocacy campaigns that
called for government reforms to
increase wages, ensure safe nurse-to-
patient ratios, regularize contractual
nurses, and conduct mass hiring
to address chronic understaffing
[36]. Also, the Philippine Nurses
Association (PNA) (https://www.
facebook.com/pnaph.org) continues
to champion the global competence,
welfare, and positive professional
image of every Filipino nurse. As
PNA members regularly organise
events, awards, and conferences,
they coordinated the 9th Summer
Conference in May 2025, featuring
the Heroic Nurse (“Bayaning Nars”)
award ceremony for outstanding
contributions to healthcare and
nursing leadership across the
country.
Our call to action as physicians
is clear: we must advocate for
stronger protection of nurses’ rights,
support policies that ensure fair
wages and safe working conditions,
and cultivate a culture of mutual
respect. Filipino physicians and
nurses engage in interprofessional
collaboration to ensure that the
ultimate goal of patient safety is
achieved in all levels of healthcare
in the Philippines. On a regional
and global scale, we must work
together to enhance nursing
education, promote nurses into
higher leadership roles, and fully
recognize their indispensable role
in strengthening health systems.
These collective efforts-grounded
in solidarity, equity, and shared
purpose-are critical not only to
addressing the ongoing health
workforce crisis, but also to
ensuring the long-term resiliency
of our health systems. Only
through genuine investment in
and recognition of our nurses can
we hope to realize the vision of
universal health coverage, where
every Filipino has access to safe,
quality, and affordable healthcare
services.
South Africa
In the South Africa’s healthcare
system, nurses are essential
health professionals who work
collaboratively with the healthcare
team to provide high-quality patient
care. Nurses serve in a variety of
capacities within the healthcare
system, including contributing
to improving primary healthcare
services, leading as frontline
workers during the COVID-19
pandemic, and helping to control
HIV transmission with the WHO-
recommended “Universal Test
and Treat” policy [37]. Academic
nursing programs at universities and
hospitals, regulated by the South
African Nursing Council (SANC),
is internationally recognised as
high-quality training, which is why
many South African trained nurses
are employed worldwide [38]. With
an estimated 10.4 nursing and
58
midwifery personnel (per 10,000
population), nurses face a myriad
of workplace challenges, including
workforce shortage, unemployment,
low pay, burnout, and violent acts by
patients or criminals [39,40].
To support nursing education
and training in South Africa,
the Government of South Africa
adopted the National Health Act
2003 (Act No. 61 of 2003) and
Nursing Act 2005 (Act No. 33 of
2005), to help regulate the nursing
profession through the South
African Nursing Council (SANC)
[41,42]. Among many roles,
the SANC implements national
health policies related to nursing,
maintains the national registry
of the nursing workforce, reports
disciplinary outcomes related to
incidents of misconduct, violations
or poor performance, ensures
compliance to respecting patients’
constitutional rights, and prepares
strategic reports to the Ministry of
the National Department of Health.
In its regulatory role, the SANC
oversees nursing education and
practice by conducting inspections,
monitoring the quality of training
programs, evaluating criteria for
academic accreditation, setting
practice standards, and taking
disciplinary action where necessary
to protect the public. Furthermore,
with workforce shortages across the
South Africa health system, task
shifting from physicians to nurses
has emerged as a preventative
medicine approach to ensure access
to care for communicable and
non-communicable diseases [43].
Consequently, primary healthcare
nurses, especially in public sector
clinics, are typically managed by
nurses, who support physicians by
providing direct patient care for
outpatient visits (e.g. minor ailments,
chronic disease management)
and referring complicated cases
to general practitioners (medical
officers) in the respective districts
[44].
Reflecting on the indispensable role
of nurses within the South Africa’s
healthcare system, the National
Department of Health, provincial
health departments, professional
councils, healthcare institutions,
and civil society must prioritise
their protection, employment,
fair remuneration, and mental
health and well-being. Sustainable
investments should be made to
absorb unemployed qualified
nurses into the healthcare system,
particularly in underserved areas,
and guarantee improved security
infrastructure and responsive
policies. Furthermore, cross-sectoral
efforts can help tackle health
professionals’ burnout risk and other
mental health challenges, offering
access to psychosocial support and
safer working conditions. Moving
forward, South Africa cannot
achieve universal health coverage
and health system resilience without
a robust, protected, and empowered
nursing workforce to support the
diverse healthcare needs of citizens.
Trinidad and Tobago
International Nurses Day in
Trinidad and Tobago is a moment
of national reflection and gratitude
for a workforce that forms the
backbone of our health system.
For physicians in our country,
it is a time to acknowledge the
tireless dedication of nurses who
often serve on the frontlines,
particularly during crises such as the
COVID-19 pandemic. According to
the Trinidad and Tobago Registered
Nurses Association (TTRNA)
(https://ttrna.org/), the shortage
of nearly 3,000 nurses in the
public health sector has led to an
increased workload for existing staff,
higher burnout rates, and delayed
patient care [45]. The ongoing
migration of nurses to countries
with more favourable compensation
and working conditions continues
to pose a serious challenge to
sustaining our local workforce.
In response to the nationwide
shortage, policy, academic, and
community initiatives have been
implemented to strengthen and
celebrate the role of nurses in
Trinidad and Tobago. First, the
Nurses and Midwives Registration
(Amendment) Bill of 2014 (Act No.
8 of 2014) aimed to modernise
the regulatory framework, include
provisions for the temporary
registration of overseas-trained
nurses and midwives, and grant
greater authority to the Nursing
Council of Trinidad and Tobago.
With goals to enhance the
regulation of practice, accreditation,
and registration, the amendment
has helped align the country
with international standards,
reflecting national progress and
the development of legislation to
support this vital sector of Trinidad
and Tobago’s healthcare system [46].
Second, the University of the
West Indies (UWI) has recognised
the need to enhance midwifery
services with a specialised Bachelor
of Science in Midwifery (BSM)
program, with courses that promote
clinical competencies and leadership
among mid-career nurses [47].
Finally, the “Nursing Now Trinidad
and Tobago” national campaign,
initiated in 2018, has intended
to raise the profile and status of
nursing, empowering nurses to
collectively tackle emerging health
challenges [48]. These national
actions show promising steps
towards elevating the profession’s
visibility and support within the
health framework.
As physicians, our call to action is
clear – collaborate, advocate, and
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WMA Members Recognise International Nurses Day
59
innovate. We must advocate for
equitable working conditions, invest
in interdisciplinary training with
nurses, and support research and
policies that ensure retention and
professional development. Regionally
and globally, health organisations
must amplify the voice of nurses
in health policy discussions and
promote nurse-led models of care.
Our commitment must be more
than symbolic; it must be systemic
and sustained to secure a healthier
future for all.
Conclusion
The global observation of
International Nurses Day represents
a crucial moment to recognise the
fundamental role of the nursing
profession across health systems
and advocate for sustainable
investment in nursing education,
training, and mentorship. As pivotal
community voices, nurses share
their clinical expertise through
empathetic communication with
patients, by fostering safe and
serene environments, humanistic
behaviours, and reassurance that
minimizes fear or discomfort [49].
With lessons learned during the
COVID-19 pandemic, reinforcing
the importance of a strong nursing
workforce will be crucial to prepare
for and manage the complex health
challenges affecting community
health and well-being [7]. Notably,
collective action across health
systems can accelerate progress
toward reducing the projected global
shortage of 5.8 million nurses to 4.1
million nurses by 2030 [50].
The “Our Nurses. Our Future.
Caring for nurses strengthens
economies” theme provides a space
for health professionals to reflect
on the numerous ways that the
nursing workforce continues to
galvanise positive change across
national health systems. Health
professionals should better
understand nurses’ lived experiences
in promoting patient-centred care
across hospital and community
settings, including efforts to develop
relevant clinical guidelines, lead
educational programs, and support
advocacy efforts [51]. These
personal testimonies capture their
“caring actions” in clinical practice
– developing therapeutic nurse-
patient relationships, looking beyond
patients’ physical needs, motivating
patients toward success, and
promoting patient self-care – which
mark nurses’ commitment and
dedication to the improving health
outcomes [51]. These attributes
reflect Florence Nightingale’s words:
“Nursing is an art: and if it is to be
made an art, it requires an exclusive
devotion as hard a preparation, as any
painter’s or sculptor’s work.”
As next steps, WMA members can
drive national and global discourse
to analyse health systems’ priorities,
achievements, and challenges,
promote interprofessional education,
and advocate for opportune health
policies that can revolutionize
high-quality health service delivery.
This collective article highlights
inspirational efforts across countries
to promote nursing excellence and
support political commitment for
the nursing profession. Specifically,
it demonstrates that physicians can
help build collaborative workplace
environments that enhance
physician-nurse collaborations and
prioritize patient-centred care across
the African, Americas, Asian, and
Pacific regions.
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Authors
Damion Basdeo, MBBS, MRCP
(UK), Acute Medicine SCE (UK)
Editorial Chair and Past President,
Trinidad and Tobago Medical
Association (T&TMA)
Trinidad and Tobago, West Indies
Maria Minerva Calimag,
MD, MSc, PhD
Departments of Pharmacology and
Clinical Epidemiology, Faculty
of Medicine and Surgery,
University of Santo Tomas
Immediate Past President,
Philippine Medical Association
Manila, Philippines
Helena Chapman, MD, MPH, PhD
Milken Institute School
of Public Health,
George Washington University
Washington DC, United States
Maymona Choudry, MD, MPH
School of Medicine, Ateneo de
Zamboanga University,
Zamboanga City, Philippines
Basilan Medical Center,
Basilan, Philippines
Jorge Coronel, MD
Medical specialist in Intensive Therapy
President, Confederación
Médica Latinoamericana y del
Caribe (CONFEMEL)
Vice President, Confederación Médica
de la República Argentina (COMRA)
Salta, Argentina
Saksham Mehra, BMSc, MBBS
External Affairs Chair,
Trinidad and Tobago Medical
Association (T&TMA)
Trinidad and Tobago, West Indies
Anderson N’dri, MD
Psychiatry resident, Psychiatric
Hospital of Bingerville
University Felix Houphouët
Boigny of Cocody
Chair person, JDN Ivory Coast
Abidjan, Republic of Ivory Coast
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WMA Members Recognise International Nurses Day
63
Mhlengi Vella Ncube, PhD
Head, Unit for Health
Policy and Research
South African Medical Association
Pretoria, South Africa
Ana Maria Soleibe Mejía, MD
Especialist in Public Economy
President, Federación Médica Colombia
Bogotá, Colombia
Thirunavukarasu Rajoo, MD, MBA
President-Elect, Malaysian
Medical Association
Founder & CEO, Careclinics
Healthcare Services
Kuala Lumpur, Malaysia
Wunna Tun, MBBS, MD
Fellow, Medical Education
JDN Secretary
Yangon, Myanmar
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WMA Members Recognise International Nurses Day
64
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Invitation to the Southeast European Medical Forum