Every changed claim, and why

Before: id: "turkiye", name: "Turkiye", region: "Eastern Mediterranean",

After: id: "turkiye", name: "Turkiye", region: "Europe",

Before: "The highest regional performer in the comparator set, and the case where service building and reimbursement are documented in sequence."

After: "The highest-consuming middle-income comparator outside South Asia, and the case where service building and reimbursement are documented in sequence."

Before: subtitle: 'Eastern Mediterranean outlier'

After: subtitle: 'WHO European Region comparator'

Before: mechanism: 'Consumes 24.19 MME per 1,000 per day, 6.5 times Pakistan and the highest EMR performer in the comparator set. The only regional case in the dataset that broke away from the pattern.'

After: mechanism: 'Consumes 24.19 MME per 1,000 per day, 6.5 times Pakistan, and sustained that level from 2015 to 2019 (25.37 to 24.19). It sits in the WHO European Region, so it is a middle-income comparator rather than a regional peer.'

Before: question: 'What regulatory, reimbursement or service change preceded the rise, and in what order?', sourceIds: ['3'] },

After: question: 'What regulatory, reimbursement or service changes built and sustained this level, and in what order?', sourceIds: ['3'] },

Before: whyCandidate: 'Consumes 6.5 times Pakistan\u2019s level while sitting in the same WHO region, and is the highest EMR performer in the comparator set.', question: 'What regulatory, reimbursement or service change preceded the rise, and in what order?'

After: whyCandidate: 'Consumes 6.5 times Pakistan\u2019s level, sustained from 2015 to 2019, as a middle-income country in the WHO European Region.', question: 'What regulatory, reimbursement or service changes built and sustained this level, and in what order?'

Before: { body: 'Pakistan Medical Commission', role: 'Licensure and registration, successor to PMDC under the 2020 act.', whatToSeek: 'Whether continuing education is mandatory for renewal, and whether PMC accredits providers.' }

After: { body: 'Pakistan Medical and Dental Council (PM&DC)', role: 'Licensure and registration of doctors and dentists.', whatToSeek: 'Whether continuing education is mandatory for renewal, and whether PM&DC accredits providers.' }

Before: { body: 'Pakistan Medical Commission', domain: 'Licensure and registration under the 2020 act', relevance:

After: { body: 'Pakistan Medical and Dental Council (PM&DC)', domain: 'Licensure and registration', relevance:

Before: { abbr: 'PMC', meaning: 'Pakistan Medical Commission' }

After: { abbr: 'PM&DC', meaning: 'Pakistan Medical and Dental Council' }

Before: { body: 'Ministry of Narcotics Control', domain:

After: { body: 'Ministry of Interior and Narcotics Control', domain:

Before: replaced state-by-state licensing with a single national license. National consumption

After: replaced multiple state licences with a single state-level Recognised Medical Institution approval from the State Drug Controller, under uniform central rules. National consumption

Before: established Recognized Medical Institutions permitted to stock and dispense them, and replaced the multi-license regime with a single national license.', sourceIds: [] }

After: established Recognized Medical Institutions permitted to stock and dispense them, and replaced the multi-license regime with a single state-level Recognised Medical Institution approval from the State Drug Controller, under uniform central rules.', sourceIds: ['50'] }

Before: replaced state-by-state licensing with a single national license.

After: replaced multiple state licences with a single state-level Recognised Medical Institution approval from the State Drug Controller, under uniform central rules.

Before: dimension: "regulation", sourceIds: ["11"], note: "The 2014 NDPS amendment

After: dimension: "regulation", sourceIds: ["11", "50"], note: "The 2014 NDPS amendment

Before: verdict: 'Highest transferability. A clause structure Pakistani advocates can adapt directly.', sourceIds: ['11'] }

After: verdict: 'Highest transferability. A clause structure Pakistani advocates can adapt directly.', sourceIds: ['11', '50'] }

Before: dimension: "delivery", figureIds: [ "jordan_home_care_teams", "jordan_hospital_support_teams", "jordan_inpatient_units", "jordan_outpatient_facilities", ], sourceIds: ["48"], note: "The regional atlas also records one inpatient hospice.", },

After: dimension: "delivery", sourceIds: ["48"], note: "The 2021 regional atlas reports how widely each type of service is spread on an ordinal scale, so those values are not counts and are not shown as counts here.", question: "How many specialised palliative care services operate in Jordan, and what is the rate per 100,000 people?", },

Before: (register entry jordan_home_care_teams)

After: (removed)

Before: (register entry jordan_hospital_support_teams)

After: (removed)

Before: (register entry jordan_inpatient_units)

After: (removed)

Before: (register entry jordan_outpatient_facilities)

After: (removed)

Before: id: 'jordan_opioid_consumption', label: 'Opioid consumption, morphine equivalent', value: 3.8, unit: 'mg per person per year', entity: 'Jordan', year: '2021', grade: 'verified', sourceIds: ['48'], note: 'As reported in the 2021 regional atlas. The underlying consumption year is not labelled in the atlas.', claimType: 'observed', confidence: 'high', status: 'active'

After: id: 'jordan_opioid_consumption', label: 'Opioid consumption, morphine equivalent', value: 3.8, unit: 'mg per person per year', entity: 'Jordan', year: '2021', grade: 'verified', sourceIds: ['48'], note: 'As reported in the 2021 regional atlas. The underlying consumption year is not labelled in the atlas.', claimType: 'observed', confidence: 'unresolved', status: 'needs-review'

Before: Non-emergency US personnel ordered to depart the Lahore and Karachi consulates on March 3, 2026.'

After: Non-emergency US personnel were ordered to depart the Lahore and Karachi consulates on March 3, 2026. That order dates from March 2026; re-check the current advisory and consulate status before relying on it.'

Before: Level 3 advisory with ordered departure from two consulates. National internet throttling.

After: A Level 3 advisory, and an ordered departure from two consulates in March 2026 that shows how fast the posture can change. National internet throttling.

Before: question: 'A Level 3 advisory and an ordered departure. Is this responsible right now?',

After: question: 'A Level 3 advisory, and an ordered departure in March 2026. Is this responsible?',

Before: forcingCondition: 'Level 3 advisory and the March 2026 ordered departure.' }

After: forcingCondition: 'Level 3 advisory, and the March 2026 ordered departure as evidence that posture can change within days.' }

Before: (absent)

After: (held for review)

Before: heroSigFoot: 'Both bars are drawn to the same scale. Nothing has been exaggerated to make the point.'

After: heroSigFoot: 'Both bars are drawn to the same scale. Sales-based proxy, not a measure of palliative access.'

Before: comparatorCaption: 'Morphine milligram equivalents per 1,000 inhabitants per day, 2019. Switch the scale.

After: comparatorCaption: 'Morphine milligram equivalents per 1,000 inhabitants per day, 2019. Sales-based proxy, not a measure of palliative access. Switch the scale.

Before: "A negative control. Consumption sits below Pakistan at roughly ten times the income per head."

After: "A low-consumption comparator. Recorded opioid sales sit below Pakistan's despite a much higher income per head."

Before: whyHere: "The second negative control in the regional comparator set."

After: whyHere: "A second low-consumption comparator in the regional set."

Before: subtitle: 'Negative controls'

After: subtitle: 'Low-consumption comparators'

Before: whyCandidate: 'Negative controls. Both consume less than Pakistan, and Saudi Arabia at roughly ten times the income per head.'

After: whyCandidate: 'Low-consumption comparators. Both record lower opioid sales than Pakistan, and Saudi Arabia at a much higher income per head.'

Before: (register entry mortality_incidence_ratio)

After: (register entry mortality_incidence_ratio)

Before: figureId: 'mortality_incidence_ratio', sourceIds: ['15'] }

After: figureId: 'mortality_incidence_ratio', sourceIds: ['14'] }

Before: { text: 'Counts verified. Ratios modeled from those counts.', sourceIds: ['14'] }, { text: "Independent burden-of-disease analysis places Pakistan's ratio near 0.65 against a global average near 0.52.", sourceIds: ['15'] },

After: { text: 'Counts are GLOBOCAN 2024 modeled estimates. Ratios are computed from those estimates.', sourceIds: ['14'] },

Before: detail: 'ecancer. Mortality to incidence ratio near 0.65 against a global 0.52.'

After: detail: 'ecancer. Burden-of-disease trends for Pakistan, 1990 to 2019.'

Before: cancer_new_cases: "New cancer diagnoses recorded every year.",

After: cancer_new_cases: "New cancer cases a year, estimated (GLOBOCAN 2024, modeled).",

Before: description: 'New cancer cases nationally each year, against 119,742 deaths.'

After: description: 'New cancer cases a year, estimated (GLOBOCAN 2024, modeled), against an estimated 119,742 deaths.'

Before: (breast only)

After: (held for review)

Before: (register entry oop_share_exact)

After: status=needs-review, confidence=unresolved, reviewReason=Audit reports GHED 2020 = 55.24 and 2023 = 52.93, and NHA 2021-22 = 46.71; the register holds 54.3. Re-read GHED and NHA.

Before: (register entry oop_share)

After: status=needs-review, confidence=unresolved, reviewReason=Rounded form of oop_share_exact; same audit conflict.

Before: (register entry under5_mortality)

After: status=needs-review, confidence=unresolved, reviewReason=Audit reports UN IGME 2023 = 57.8 and 2024 = 56.0; the register holds 58.5 for 2023. Re-read the IGME series.

Before: (register entry ncd_share_of_deaths)

After: refYear=2016

Before: 61 (census 2023; source detail says 61.12)

After: (held for review)

Before: 38.77 (2022)

After: (held for review)

Before: (register entry 1)

After: title=Krakauer EL, Kwete XJ, Rassouli M, Arreola-Ornelas H, Ashrafizadeh H, Bhadelia A, et al., detail=Palliative care need in the Eastern Mediterranean Region and human resource requirements for effective response. PLOS Global Public Health 2023;3(11):e0001980. DOI 10.1371/journal.pgph.0001980. Estimates for 2015 using the Lancet Commission serious health-related suffering method: about 3.2 milli

Before: (register entry 3)

After: pmid=35366408, accessed=2026-09-25

Before: (register entry 12)

After: title=Merriman A, Mwebesa E, Zirimenya L., detail=Improving access to palliative care for patients with cancer in Africa: 25 years of Hospice Africa. Ecancermedicalscience 2019;13:946. DOI 10.3332/ecancer.2019.946. Nurse and clinical officer prescribing authority; free government oral morphine; local manufacture from 2011., year=2019, doi=10.3332/ecancer.2019.946, pmid=31552119, url=https://pmc.nc

Before: (register entry 15)

After: title=Bhojwani KM, Raheem A, Khan UT, Javid F, Tanweer D, Rehmani N, et al., detail=Trends in cancer burden in Pakistan: a 30-year analysis from the Global Burden of Disease Study (1990-2019). Ecancermedicalscience 2026;20:2060. DOI 10.3332/ecancer.2026.2060. The introduction cites GLOBOCAN-based analyses giving South Asia, including Pakistan, a mortality to incidence ratio near 0.65 against about

Before: (register entry 36)

After: title=Amandua J, Kimaro MS, Mwebesa E, Taremwa IM, Atuhairwe C., pmid=31167656, url=https://pmc.ncbi.nlm.nih.gov/articles/PMC6551873/, accessed=2026-09-25

Before: BMC Palliative Care 2019;18:52. DOI 10.1186/s12904-019-0434-5.

After: BMC Palliative Care 2019;18(1):48. DOI 10.1186/s12904-019-0434-5.

Before: (register entry 39)

After: title=Kutluk T, Ahmed F, Cemaloğlu M, Aydın B, Şengelen M, Kirazlı M, et al., year=2021, doi=10.3332/ecancer.2021.1321, pmid=35047072, accessed=2026-09-25

Before: detail: 'Progress in palliative care for cancer in Turkiye: a review of the literature. PubMed Central PMC8723752.

After: detail: 'Progress in palliative care for cancer in Turkey: a review of the literature. Ecancermedicalscience 2021;15:1321. DOI 10.3332/ecancer.2021.1321. PubMed Central PMC8723752.

Before: (register entry 42)

After: title=Chowdhury MK, Ahmad N, Biswas FN, Farheen N, Ferdous L, Akter KM, Connor SR., doi=10.1177/26323524211063217, pmid=34950874, url=https://pmc.ncbi.nlm.nih.gov/articles/PMC8689427/, accessed=2026-09-25

Before: Palliative Care and Social Practice, 2021. Evaluation

After: Palliative Care and Social Practice 2021;15:26323524211063217. DOI 10.1177/26323524211063217. Evaluation

Before: (register entry 46)

After: title=Sivalingam N, Lim RBL, Rampal L., pmid=34031323, accessed=2026-09-25

Before: Medical Journal of Malaysia 2021;76(3):279-281.

After: Medical Journal of Malaysia 2021;76(3):279-283.

Before: (register entry 47)

After: pmid=37981855, url=https://pmc.ncbi.nlm.nih.gov/articles/PMC11102529/, accessed=2026-09-25

Before: (register entry 94)

After: year=2018, pmid=28797863, accessed=2026-09-25

Before: (register entry 49)

After: pmid=36184640, url=https://pmc.ncbi.nlm.nih.gov/articles/PMC9528121/, accessed=2026-09-25

Before: source 11 (Pallium India, tier 3)

After: source 158 (Jacob & Mathew, J Glob Oncol 2017, PMC5735975)

Before: (register entry india_morphine_1985)

After: sourceIds=['158'], method=Annual morphine consumption reported by India to the INCB, as compiled by the Pain and Policy Studies Group and quoted by Jacob and Mathew (2017)., lastChecked=2026-09-25

Before: (register entry india_morphine_1997)

After: sourceIds=['158'], method=Annual morphine consumption reported by India to the INCB, as compiled by the Pain and Policy Studies Group and quoted by Jacob and Mathew (2017)., lastChecked=2026-09-25

Before: (register entry india_morphine_2014)

After: sourceIds=['158'], method=Annual morphine consumption reported by India to the INCB, as compiled by the Pain and Policy Studies Group and quoted by Jacob and Mathew (2017)., lastChecked=2026-09-25

Before: (register entry palliative_need)

After: method=Lancet Commission serious health-related suffering method applied to 2015 mortality data (Krakauer et al. 2023)., note=Krakauer et al. report about 869,000 for 2015; rounded here. The 2021 EMRO atlas gives a consistent figure., lastChecked=2026-09-25, reviewBy=2027-09-25

Before: (register entry emr_regional_need)

After: value=3200000, method=Lancet Commission serious health-related suffering method applied to 2015 mortality data (Krakauer et al. 2023)., note=Regional total for 2015, not Pakistan's own figure. WHO EMRO (2025) uses a different total of about 2.4 million., lastChecked=2026-09-25, reviewBy=2027-09-25

Before: paired with source 1

After: own entry, source 2, under review

Before: (register entry opioid_us_2019)

After: method=IQVIA MIDAS pharmaceutical sales data for opioid analgesics, in morphine milligram equivalents per 1,000 inhabitants per day (Ju et al. 2022; abstract read September 2026). A sales-based proxy for availability, not a measure of palliative access., limitations=Per the audit, Pakistan data cover the retail sector only (appendix S1); the appendix and the country table values could not be read

Before: (register entry opioid_uk_2019)

After: method=IQVIA MIDAS pharmaceutical sales data for opioid analgesics, in morphine milligram equivalents per 1,000 inhabitants per day (Ju et al. 2022; abstract read September 2026). A sales-based proxy for availability, not a measure of palliative access., limitations=Per the audit, Pakistan data cover the retail sector only (appendix S1); the appendix and the country table values could not be read

Before: (register entry opioid_turkiye_2019)

After: method=IQVIA MIDAS pharmaceutical sales data for opioid analgesics, in morphine milligram equivalents per 1,000 inhabitants per day (Ju et al. 2022; abstract read September 2026). A sales-based proxy for availability, not a measure of palliative access., limitations=Per the audit, Pakistan data cover the retail sector only (appendix S1); the appendix and the country table values could not be read

Before: (register entry opioid_pk_2019)

After: method=IQVIA MIDAS pharmaceutical sales data for opioid analgesics, in morphine milligram equivalents per 1,000 inhabitants per day (Ju et al. 2022; abstract read September 2026). A sales-based proxy for availability, not a measure of palliative access., limitations=Per the audit, Pakistan data cover the retail sector only (appendix S1); the appendix and the country table values could not be read

Before: (register entry opioid_pk_2015)

After: method=IQVIA MIDAS pharmaceutical sales data for opioid analgesics, in morphine milligram equivalents per 1,000 inhabitants per day (Ju et al. 2022; abstract read September 2026). A sales-based proxy for availability, not a measure of palliative access., limitations=Per the audit, Pakistan data cover the retail sector only (appendix S1); the appendix and the country table values could not be read

Before: (register entry opioid_india_2019)

After: method=IQVIA MIDAS pharmaceutical sales data for opioid analgesics, in morphine milligram equivalents per 1,000 inhabitants per day (Ju et al. 2022; abstract read September 2026). A sales-based proxy for availability, not a measure of palliative access., limitations=Per the audit, Pakistan data cover the retail sector only (appendix S1); the appendix and the country table values could not be read

Before: (register entry opioid_india_2015)

After: method=IQVIA MIDAS pharmaceutical sales data for opioid analgesics, in morphine milligram equivalents per 1,000 inhabitants per day (Ju et al. 2022; abstract read September 2026). A sales-based proxy for availability, not a measure of palliative access., limitations=Per the audit, Pakistan data cover the retail sector only (appendix S1); the appendix and the country table values could not be read

Before: (register entry opioid_saudi_2019)

After: method=IQVIA MIDAS pharmaceutical sales data for opioid analgesics, in morphine milligram equivalents per 1,000 inhabitants per day (Ju et al. 2022; abstract read September 2026). A sales-based proxy for availability, not a measure of palliative access., limitations=Per the audit, Pakistan data cover the retail sector only (appendix S1); the appendix and the country table values could not be read

Before: (register entry opioid_egypt_2019)

After: method=IQVIA MIDAS pharmaceutical sales data for opioid analgesics, in morphine milligram equivalents per 1,000 inhabitants per day (Ju et al. 2022; abstract read September 2026). A sales-based proxy for availability, not a measure of palliative access., limitations=Per the audit, Pakistan data cover the retail sector only (appendix S1); the appendix and the country table values could not be read

Before: (register entry opioid_turkiye_2015)

After: method=IQVIA MIDAS pharmaceutical sales data for opioid analgesics, in morphine milligram equivalents per 1,000 inhabitants per day (Ju et al. 2022; abstract read September 2026). A sales-based proxy for availability, not a measure of palliative access., limitations=Per the audit, Pakistan data cover the retail sector only (appendix S1); the appendix and the country table values could not be read

Before: (none)

After: conflicts[] entry citing source 49

Before: (register entry palliative_coverage)

After: label=Share of people in need receiving palliative care, WHO Eastern Mediterranean Region, entity=Eastern Mediterranean Region, geography=Eastern Mediterranean Region, claimType=modeled-estimate, reviewReason=Regional statement from WHO EMRO 2025; confirm its data year and method in the source before it leaves review.

Before: (absent)

After: (held for review)

Before: { value: '<1%', description: 'Of those who need palliative care reach any service.', figureId: 'palliative_coverage', sourceIds: ['2'] }

After: { value: '<1%', description: 'Across the WHO Eastern Mediterranean Region, of those who need palliative care reach any service. Pakistan has no national estimate.', figureId: 'palliative_coverage', sourceIds: ['2'] }

Before: waffleNote: "Need applies to 2015, the reference year of the underlying regional estimate. Coverage below one percent is stated for Pakistan specifically. The Eastern Mediterranean regional total of roughly 2.4 million is a different number and is not Pakistan's.",

After: waffleNote: "Need applies to 2015 and is modeled (Krakauer et al. 2023). Pakistan has no national estimate of how many people in need reach a service. Across the WHO Eastern Mediterranean Region, WHO EMRO (2025) reports that fewer than one percent do; that is a regional figure, not Pakistan's.",

Before: waffleCaption: 'One thousand squares. Each represents roughly 870 people who need palliative care this year. Five are lit.',

After: waffleCaption: 'One thousand squares. Each represents roughly 870 people who needed palliative care in 2015, by the modeled estimate. None is lit, because no national estimate of coverage exists.',

Before: lede: 'The need estimate is modeled. The coverage figure is not. Both point the same direction.' }

After: lede: 'The need estimate is a 2015 model. No national coverage estimate exists; the only published coverage figure is regional.' }

Before: { value: '~870,000', description: 'People needing palliative care each year.', figureId: 'palliative_need', sourceIds: ['1'] }

After: { value: '~870,000', description: 'An estimated number of people a year needing palliative care (2015 model).', figureId: 'palliative_need', sourceIds: ['1'] }

Before: (register entry medical_schools_total)

After: sourceIds=['48'], reviewReason=Re-cited to the 2021 regional atlas per the audit; confirm the value and data year in the atlas table.

Before: (register entry medical_schools_mandatory_palliative)

After: sourceIds=['48'], status=needs-review, confidence=unresolved, reviewReason=Re-cited to the 2021 regional atlas per the audit, with the nursing count (5 of 125); confirm both in the atlas table.

Before: sublabel: 'Nursing schools: 5 of 125. Both counts require re-dating with partners.', value: '10', disputed: true, sourceIds: ['25'] }

After: sublabel: 'Nursing schools: 5 of 125. Both counts come from the 2021 regional atlas and need re-dating with partners.', value: '10', disputed: true, sourceIds: ['48'] }

Before: (register entry cpsp_accredited_sites)

After: label=CPSP palliative and pain fellowship programmes, value=9, unit=fellowship programmes, sourceIds=['25'], note=As cited in a 2022 letter from CPSP listings., claimType=observed, status=active, confidence=moderate, grade=verified

Before: (register entry p1)

After: (register entry p1)

Before: (register entry p4)

After: (register entry p4)

Before: (register entry india_prescriber_training_days)

After: label=Hands-on training required before a physician may prescribe oral morphine, Kerala, entity=India (Kerala), geography=Kerala, India, sourceIds=['51'], note=Describes practice in Kerala. National rules require training in pain relief and palliative care but do not set a length.

Before: (register entry firewall_industry_losses)

After: label=Projected industry losses from connectivity slowdown (industry association projection), unit=million USD, up to, claimType=modeled-estimate, confidence=low

Before: (register entry firewall_slowdown)

After: status=needs-review, confidence=unresolved, reviewReason=Audit reports conflicting 2026 accounts of the firewall (a shutdown report and an official denial). Re-check the current status before use.

Before: slowed connectivity by up to 40 percent, with industry losses estimated above $300 million. Outages recur around protests.'

After: slowed connectivity by up to 40 percent, with industry losses projected at up to $300 million by the software industry association. Its status in 2026 is disputed, and outages recur around protests.'

Before: CPSP is the sole postgraduate specialty credentialing body, with 75 fellowship specialties across roughly 263 accredited institutions.'

After: CPSP is the largest postgraduate specialty credentialing body, with 75 fellowship specialties across roughly 263 accredited institutions; universities also award PM&DC-recognised MD and MS degrees.'

Before: (absent)

After: (held for review)

Before: cited without a URL

After: (needs review)

Before: { name: 'Dr Haroon Hafeez', role: 'Shaukat Khanum · Lahore', description: 'Leads the CPSP-approved two-year palliative medicine training program. The single most consequential call.', sourceIds: ['5'] }

After: { name: 'Palliative medicine training program', role: 'Shaukat Khanum Memorial Cancer Hospital · Lahore', description: 'Runs the CPSP-approved two-year palliative medicine training program. No contact has been made.', sourceIds: ['5'] }

Before: { name: 'Prof. Nafisa Tahir', role: 'NUMS · Postgraduate Certificate', description: "Supervises Pakistan's first structured online palliative certificate. The accreditation precedent to follow.", sourceIds: ['7'] }

After: { name: 'Postgraduate Certificate in Palliative Care', role: 'National University of Medical Sciences (NUMS)', description: "Pakistan's first structured online palliative certificate, and the accreditation precedent to study. No contact has been made.", sourceIds: ['7'] }

Before: Holds the only documented home-based arm.'

After: Runs a documented home-based arm. No contact has been made.'

Before: $12.7 billion unobligated; Fogarty leadership change April 2025.

After: $12.7 billion unobligated.

Before: totaling $12.7 billion unobligated. Fogarty leadership was removed in April 2025.'

After: totaling $12.7 billion unobligated. Later appropriations and the Fogarty International Center's status must be re-checked before use.'

Before: (absent)

After: (held for review)

Before: open

After: (still open; held for review)

Before: 4th cohort (source 7)

After: (held for review)

Before: (register entry 24)

After: title=Tripodoro VA, Fidalgo JFL, Pons JJ, Connor SR, Garralda E, Bastos F, et al., detail=First-ever global ranking of palliative care: 2025 world map under the new WHO framework. Journal of Pain and Symptom Management 2025;70(5):447-458. DOI 10.1016/j.jpainsymman.2025.07.026. Classifies 201 countries into four levels (Emerging, Progressing, Established, Advanced). Abstract read; the abstract does

Before: Historical consumption: 716 kg 1985, 18 kg 1997, 278 kg 2014.'

After: '

Before: detail: 'Training in palliative care in nursing and medical schools in Chile. Revista Medica de Chile

After: detail: 'Training in palliative care in nursing and medical schools in Chile [translated title]. Revista Medica de Chile

Before: year 2025

After: (held for review)

Before: 8 July 2015

After: (held for review)

Before: (unflagged)

After: (held for review)

Before: { text: 'Counts are GLOBOCAN 2024 modeled estimates. Ratios are computed from those estimates.', sourceIds: ['14'] },

After: { text: 'Counts are GLOBOCAN 2024 modeled estimates. Ratios are computed from those estimates.', sourceIds: ['14'] }, { text: 'A 2026 review of Global Burden of Disease trends cites GLOBOCAN-based analyses placing South Asia, including Pakistan, near 0.65 against about 0.52 globally. That is a regional figure, not a Pakistan result of the review.', sourceIds: ['15'] },

Before: (register entry cancer_new_cases)

After: method=IARC GLOBOCAN 2024 national estimate for Pakistan (modeled), from the Global Cancer Observatory country fact sheet.

Before: (register entry cancer_deaths)

After: method=IARC GLOBOCAN 2024 national estimate for Pakistan (modeled), from the Global Cancer Observatory country fact sheet.

Before: (register entry cancer_5yr_prevalence)

After: method=IARC GLOBOCAN 2024 national estimate for Pakistan (modeled), from the Global Cancer Observatory country fact sheet.

Before: (register entry population_pk)

After: method=Enumerated count from the Seventh Population and Housing Census, 2023 (Pakistan Bureau of Statistics).

Before: (register entry rural_share)

After: method=Enumerated count from the Seventh Population and Housing Census, 2023 (Pakistan Bureau of Statistics).

Before: (register entry health_spend_gdp_share)

After: method=Pakistan National Health Accounts 2021-22, total health expenditure as a share of GDP.

Before: kicker: 'Palliative Care Certificate · Pakistan', dateline: 'Design playbook v3.0 · August 2026', headline: 'Teaching pain relief where there is ', headlineHighlight: 'no morphine', deck: 'About 870,000 people in Pakistan need palliative care each year. Fewer than one percent reach a service. The limiting factor is not what clinicians know.',

After: kicker: 'Pakistan Palliative Care Certificate (proposed) · Design dossier', dateline: 'Design playbook v3.0 · August 2026', headline: 'Designing palliative care education for systems where ', headlineHighlight: 'medicine access, regulation and service capacity constrain practice.', deck: 'Pakistan has a large, incompletely measured palliative care need. Published evidence points to

Before: (register entry f1)

After: (register entry f1)

Before: (register entry f2)

After: (register entry f2)

Before: body: 'A CPSP-approved two-year palliative program runs at Shaukat Khanum. NUMS has run a certificate since 2021. Arrive as a collaborator or do not arrive.', anchor: '#s4' },

After: body: 'A CPSP-approved two-year palliative program runs at Shaukat Khanum, and NUMS has run a certificate since 2021. The design builds on these programs as a collaborator; no contact has been made.', anchor: '#s4' },

Before: (register entry f4)

After: (register entry f4)

Before: National internet throttling. Design accordingly.'

After: Recurrent internet disruption, with its 2026 status disputed. Design accordingly.'

Before: (register entry f6)

After: (register entry f6)

Before: comparatorFinding: "Saudi Arabia consumes 1.24 MME per 1,000 per day. Egypt consumes 0.61. Both sit below Pakistan's 3.71, and Saudi Arabia's income per head is roughly an order of magnitude higher. Poverty does not explain the analgesic gap in this region. Regulation, procurement design and prescriber culture explain more of it. That is the argument for the program, and it is also the reason the

After: comparatorFinding: "Saudi Arabia records 1.24 MME per 1,000 per day and Egypt 0.61, against Pakistan's 3.71 (2019, sales-based proxy), and Saudi Arabia's income per head is much higher. Program hypothesis: income alone is an insufficient explanation, and regulation, procurement design and prescriber practice are plausible contributors. If they are, they are policy choices that can change, and the

Before: mechanism: "Both consume less than Pakistan at 1.24 and 0.61 MME per 1,000 per day. Saudi Arabia does so at roughly ten times Pakistan's income per head.",

After: mechanism: "Both record lower opioid sales than Pakistan, at 1.24 and 0.61 MME per 1,000 per day (2019). Saudi Arabia does so at a much higher income per head.",

Before: { mechanism: 'Price ceilings deter manufacture', evidence:

After: { mechanism: 'Price controls may deter manufacture (hypothesis)', evidence:

Before: evidence: 'Narcotics are governed under the Control of Narcotic Substances Act 1997 across four bodies: the narcotics control ministry, the Anti-Narcotics Force, the drug regulator and provincial drug authorities.'

After: evidence: 'Narcotics are governed under the Control of Narcotic Substances Act 1997, with roles for the federal narcotics ministry, the Anti-Narcotics Force, the drug regulator and provincial drug authorities, among others. The full procurement pathway has not been mapped.'

Before: evidence: 'No clear statute or case law was identified governing advance directives, resuscitation orders, surrogate decision-making or withdrawal of life support.'

After: evidence: 'This review did not identify a clear statute or case law governing advance directives, resuscitation orders, surrogate decision-making or withdrawal of life support. A qualified Pakistani health-law expert must confirm whether any exists.'

Before: and operates the country's only well-documented home-based arm."

After: and operates a documented home-based arm."

Before: Poverty does not explain the analgesic gap in this region. Regulation, procurement design and prescriber culture explain more of it.

After: Evidence / Interpretation / Decision implication, labelled PROGRAM HYPOTHESIS

Before: lede: 'Twenty-six weeks, hybrid, asynchronous-first, aligned to the existing NUMS structure so recognition is a conversation rather than a campaign.' }

After: lede: 'Twenty-six weeks, hybrid, asynchronous-first, modeled on the existing NUMS certificate structure so that recognition can be discussed with an existing precedent in view.' }

Before: lede="Twenty-six weeks, hybrid, asynchronous-first, aligned to the existing NUMS structure so recognition is a conversation rather than a campaign."

After: lede="Twenty-six weeks, hybrid, asynchronous-first, modeled on the existing NUMS certificate structure so that recognition can be discussed with an existing precedent in view."

Before: <h3 className="mt-14 font-display u-lede font-semibold">Funding fit</h3>

After: <h3 className="mt-14 font-display u-lede font-semibold">Candidate fit (no contact made)</h3>

Before: {["Source", "Fit", "Note"].map((h) => (

After: {["Source", "Candidate fit (no contact made)", "Note"].map((h) => (

Before: footer1: 'Pakistan Palliative Care Certificate · Design playbook v3.0',

After: footer1: 'Pakistan Palliative Care Certificate (proposed) · Design playbook v3.0',

Before: title: "Pakistan Palliative Care Certificate: Design Playbook",

After: title: "Pakistan Palliative Care Certificate (proposed): Design Playbook",

Before: name: "Pakistan Palliative Care Certificate: Design Playbook",

After: name: "Pakistan Palliative Care Certificate (proposed): Design Playbook",

Before: export const endpoints: Endpoint[] = [ { level: 'Primary', measure: 'Proportion of graduates whose institution initiates a documented opioid procurement or formulary action attributable to the program', window: '12 months', sourceOfData: 'Institutional pharmacy records, verified by Pakistani facul

After: Reformulated: contribution analysis, service minimum criteria, policy-stage ladder, non-punitive diversion protocol; added stockout days, pain reassessment, referral-to-assessment time, reach by province, cadre, gender and setting

Before: (none)

After: "Not legal advice..." notice on the legal risk and the regulatory map

Before: "N of 6 sourced"

After: "N domains reviewed · X high-confidence · Y dated estimates · Z material gaps", computed from v2 fields

Before: (none)

After: "Working design dossier. Some national estimates are dated, modeled or secondary. Every figure shows its evidence type, data year and last-checked date."

Before: Security, funding and connectivity scattered across risks and findings

After: One module with owner, last checked and review-by date for travel, funding, connectivity and data protection

Before: mechanism: 'Frequently cited as a case of opioid regulatory liberalization within a controlled political environment. No figures verified for this document.', question: 'Did the regulatory change precede service growth or follow it?', sourceIds: [] },

After: mechanism: 'Regulatory liberalization inside a controlled political environment, carried by ministerial instruments rather than statute, and paired with prescriber training. Recorded morphine use rose between 2005 and 2014.', question: 'Did the regulatory change precede service growth or follow it?', figureIds: ['vietnam_morphine_ddd_2005', 'vietnam_morphine_ddd_2014', 'vietnam_physicians_trai

Before: mechanism: 'Cited for embedding palliative care into a national community health worker cadre rather than building a specialist service first. No figures verified for this document.', question: 'Does the community health worker route substitute for prescriber-scope reform or depend on it?', sourceIds: [] },

After: mechanism: 'Cited for embedding palliative care in a national community health system under a standalone policy. In the one full-text study, prescribing training went to doctors and pharmacists, alongside a procurement framework and referral protocols.', question: 'Does the community health worker route substitute for prescriber-scope reform or depend on it?', figureIds: ['rwanda_prescribing_t

Before: mechanism: 'Muslim-majority, middle-income, with a specialty credentialing structure comparable to CPSP. No figures verified for this document.', question: 'Did formal specialty recognition drive service growth, or follow it?', sourceIds: [] },

After: mechanism: 'Muslim-majority, middle-income, with a specialty credentialing structure comparable to CPSP. Oral morphine is stocked in nearly every public hospital, but only a minority run a formal palliative service, and most opioid growth was methadone.', question: 'Did formal specialty recognition drive service growth, or follow it?', figureIds: ['malaysia_hospitals_oral_morphine', 'malaysia_

Before: mechanism: 'Eastern Mediterranean peer with a single dominant anchor cancer institution. No figures verified for this document.', question: 'Can one anchor institution substitute for national policy, and for how long?', sourceIds: [] },

After: mechanism: 'Regional peer with a single dominant anchor cancer institution and a national strategy, where recorded consumption remains low. The consumption figure is under review for its data year.', question: 'Can one anchor institution substitute for national policy, and for how long?', figureIds: ['jordan_opioid_consumption'], sourceIds: ['48', '49'] },

Before: verdict: 'Moderate. Closest peer, thinnest published evidence base. Worth direct contact rather than citation.', sourceIds: [] },

After: verdict: 'Moderate. Closest peer, thinnest published evidence base.', figureIds: ['bangladesh_morphine_2020', 'bangladesh_narayanganj_trainees'], sourceIds: ['52', '43', '41'] },

Before: lede: 'No real patient appears below. Every parameter is a cited national figure. Click any stage.' }

After: lede: 'No real patient appears below. Every parameter is a cited figure, and each says whether it is national or regional. Click any stage.' }

Before: title: 'Eight hundred seventy thousand people, ', titleHighlight: 'one service network',

After: title: 'An estimated 870,000 people, ', titleHighlight: 'and no national count of who is reached',

Before: title: 'The program is a ', titleHighlight: 'supply problem wearing an education costume', lede: 'Teaching titration into an empty formulary moves test scores. It does not move pain scores.' }

After: title: 'Medicine access and regulation ', titleHighlight: 'constrain what training can change', lede: 'Training cannot reliably improve pain outcomes where medicines, prescribing authority and service pathways remain constrained. The program tests education coupled with institutional change.' }

Before: lede: 'Arrive as a collaborator on an existing effort. The founder posture is both wrong and easy to disprove.' }

After: lede: 'The design builds on existing programs as a collaborator. No contact has been made with any of them.' }

Before: title: "One statute moved a country's ", titleHighlight: 'morphine curve',

After: title: 'What other systems changed, and ', titleHighlight: 'what it coincided with',

Before: { text: 'Ratios are modeled from verified 2019 values. 2015 values

After: { text: 'Ratios are computed from 2019 sales values. 2015 values

Before: A different metric and data basis from the sales series, but it places Saudi Arabia among the highest-consuming countries in the region.' }]

After: A different metric and data basis from the sales series; the same study reports a regional average of 2.40 mg per capita.' }]

Before: Every figure retains its grade and source.

After: Every figure shows its evidence label and source.

Before: Every figure in this document with its grade and the sources

After: Every figure in this document with its evidence label and the sources

Before: every figure with its grade, the source register

After: every figure with its evidence label, the source register

Before: blurb: "Every cell, with its grade and citation."

After: blurb: "Every cell, with its evidence label and citation."

Before: verified / modeled / illustrative definitions

After: v2 label definitions

Before: openQuestions: 'Where a figure could not be confirmed, it does not appear as a claim. It appears as an item on the launch gate in section 10, with a named owner.

After: openQuestions: 'Where a figure could not be confirmed, it carries the UNDER REVIEW label with its reason, or appears as an item on the launch gate in section 10 with a named owner.

Before: (register entry opioid_turkiye_2015)

After: status=conflicting-sources, confidence=moderate

Before: { dimension: "delivery", figureIds: ["ncd_share_of_deaths"], question:

After: { dimension: "delivery", question: