Three countries, three migration crises, one invisible population in every health database.
The South Caucasus sits at one of the most consequential migration crossroads in the WHO European Region. Within a 200km radius, Georgia manages its largest emigration wave on record (−71,584 net emigration in 2023), Armenia absorbs 100,000+ Nagorno-Karabakh refugees from September 2023, and Azerbaijan implements the Great Return — a resettlement programme of up to 658,000 IDPs to liberated territories — with no health tracking system in place. These three simultaneous events are the largest displacement-related public health events in the European Region outside Ukraine. They are occurring in systems where migration status is recorded in zero national health databases.

PHIG MHSS v6.0 Framework: All three assessments use the same 19-indicator instrument across 6 WHO Health System Building Blocks (Country Context, Governance B1, Financing B2, Workforce B3, Service Delivery B4, Health Information Systems B5) plus cross-cutting dimensions (AAAQ+Trust Savas 2024, UHC Coverage Cube Stevenson Lancet 2024, Duty Bearer compliance, WHO Competency Standards 2021, Cosmopolitan UHC, Climate-migration nexus, Digital health inclusion). Scores on a 1–4 scale: 1=Critical gap, 2=Significant gap, 3=Adequate, 4=Strong. These are independent PHIG researcher assessments — not government self-assessments, not official WHO positions. Political neutrality is maintained throughout.

The financing gap between the three South Caucasus countries is wider than any other dimension in this assessment. Azerbaijan’s $1.2B health budget dwarfs Armenia’s $280M. Georgia’s UHCP reduced OOP from 82% to 31% — a reform achievement comparable to Thailand 2001. Armenia’s 83% OOP is the highest in the WHO European Region, in a system entirely dependent on state budget allocations. The shared failure: none of the three have published a cost-of-exclusion analysis for any migrant or IDP population, despite caseloads ranging from 30 to 90+ years old.

The South Caucasus nurse:physician ratio crisis is the most structurally damaging workforce finding in this assessment and the most ignored in regional health policy dialogue. All three countries have nurse:MD ratios below the WHO European Region norm of 2.5:1 — with Georgia’s 1.05:1 the lowest recorded in the entire region. This is the direct consequence of two decades of post-Soviet medical training that produced physicians but systematically undervalued nursing, compounded by selective nurse emigration. No country in the South Caucasus has a nursing retention strategy, a health worker return incentive, or a bilateral health worker mobility agreement.

Cardiovascular disease is the leading cause of death in all three South Caucasus countries, accounting for 47–49% of all-cause mortality — compared to the WHO European Region average of approximately 43%. The shared risk driver is hypertension-attributable CVD in systems where outpatient NCD medicines are either excluded from coverage (Georgia) or entirely out-of-pocket in systems with 65–83% OOP (Armenia, Azerbaijan). The divergent risk profiles relate to specific displacement-linked conditions: PTSD in Armenia (100K+ September 2023 displaced; 40–70% estimated prevalence) and Azerbaijan (658K IDPs; 30–60% estimated); TB in Georgia (59/100K — above EUR average); and acute trauma from land-mine injuries in Azerbaijan’s return areas.

Why this matters: The HIS critical gap makes every other gap unmeasurable, untargetable, and unaccountable. Without migration-disaggregated data, no South Caucasus government can calculate the cost of excluding migrants from primary care, measure whether health reforms reached IDP or refugee populations, track PTSD among the September 2023 Karabakh displaced, or document whether Great Return returnees are receiving the services their legal entitlement promises. Policy without surveillance is advocacy; evidence-based health equity requires data. The structural opportunities: Georgia’s EHR (design window 2024–26), Azerbaijan’s MHI Phase 2 (design window 2026), and Armenia’s new health information strategy — all three are closing within 12–24 months. After these windows, architecture locks for a decade.

Shared finding: All three South Caucasus states ratify international instruments and commit to WHO frameworks without producing domestic operationalisation. The pattern is consistent across the 1951 Convention, ICESCR Article 12, GCM Objective 15, and WHO GAP 2019–2030. This is not a capacity gap — all three countries have functional ministries of health and legal drafting capacity. It is a prioritisation gap: migration health has not been placed on the political agenda as a domestic policy deliverable.

Discussion — The South Caucasus paradox: This assessment finds a region that is simultaneously more exposed to migration-related health challenges than almost any other sub-region in the WHO European Region, and more systematically unable to see those challenges in its health data than comparable middle-income regions in Eastern Europe, Central Asia, or the Eastern Mediterranean. The combination of three simultaneous displacement events (Georgian emigration, Armenian 2023 influx, Azerbaijani Great Return), a nurse:physician inversion across all three countries, and universal HIS failure creates a compounding regional vulnerability. The assets are real: Georgia’s EU accession leverage, Azerbaijan’s fiscal capacity, Armenia’s diaspora mobilisation potential, and a low hostile environment across all three systems. The gap between these assets and their application to migration health equity is a political prioritisation gap, not a technical or financial one.

Methodology: PHIG Country Health & Migration Assessment Tool v6.0. All three country assessments conducted by the same assessor (Prof. G. Pkhakadze) using the same 19-indicator instrument to ensure comparability. Data sources for each country: WHO HSiA 2024, WHO GHO 2024, national statistical offices (GeoStat, ArmStat, StatComm AZ), IDMC Global Report 2024, UNHCR country profiles, IOM country profiles, national health strategies (reviewed in full), MIPEX 2023, World Bank Health Nutrition and Population Data 2024, OECD Health at a Glance Europe 2024. Framework references: AAAQ+Trust (Savas et al. 2024); UHC Coverage Cube (Stevenson et al. Lancet 2024); WHO Competency Standards for Refugee and Migrant Health (WHO/Europe 2021); UCL-Lancet Commission on Migration and Health 2026; Bozorgmehr et al. BMJ Global Health 2023; O’Neill et al. Lancet 2023; Metzl & Hansen (2014); Tervalon & Murray-García (1998); CCIRH systematic review CMAJ 2011; ASID/RHeaNA protocol Nov 2025. Political neutrality is maintained throughout: this assessment takes no position on any territorial dispute or political conflict in the region. All displacement figures are sourced from IDMC, UNHCR, and national registries as stated.