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Malnutrition among children is one of the major health challenges in Pakistan. The National Nutritional Survey 2018 revealed that 44% of children are stunted. Different circumstances surrounding a child's birth can lead to inequality of opportunity in early childhood, with significant nutritional inequalities between rural and urban areas. This study aims to identify the drivers of inequality of opportunity in stunting among children under-five years of age in Pakistan. This study used Pakistan Demographic and Health Survey, 2017-18 to identify the factors contributing to inequality of opportunity in child's stunting. The Dissimilarity index (D-index), along with Oaxaca decomposition, and Shapely decomposition were employed to measure and decompose inequality in opportunity in stunting. Regional variations in stunting among children under various circumstances were analyzed using Geographic Information System or GIS. The burden of stunting is exceptionally high in Pakistan, with the prevalence in rural areas significantly exceeding that in urban areas from 1990 to 2018. Shapley decomposition of the contributors to inequality in opportunity indicates that maternal education accounted for 24% of total inequality among rural children and 44% among urban children. Water and sanitation contributed 22% to overall inequality in rural areas but only 2% in urban areas, highlighting the critical role of inadequate water and sanitation in rural settings. The wealth index was a predominant contributor to inequality both nationally and in urban areas. Southern regions exhibit a higher prevalence of stunting and a greater proportion of households lacking adequate water and sanitation. Additionally, the concentration of uneducated mothers and stunted children is notably high in Balochistan and Sindh. The lack of maternal education, inadequate access to water and sanitation services, and lower socio-economic status are key factors contributing to inequality of opportunity in stunting among children under five in Pakistan. Understanding the critical role of these circumstances can help policymakers address the situation and implement concrete steps to enhance equal opportunities for child health.

Background In India, Out-of-pocket expenses accounts for about 62.6% of total health expenditure - one of the highest in the world. Lack of health insurance coverage and inadequate coverage are important reasons for high out-of-pocket health expenditures. There are many Public Health Insurance Programs offered by the Government that cover the cost of hospitalization for the people below poverty line (BPL), but their coverage is still not complete. The objective of this research is to examine the effect of Public Health Insurance Programs for the Poor on hospitalizations and inpatient Out-of-Pocket costs. Methods Data from the recent national survey by the National Sample Survey Organization, Social Consumption in Health 2014 are used. Propensity score matching was used to identify comparable non-enrolled individuals for individuals enrolled in health insurance programs. Binary logistic regression model, Tobit model, and a Two-part model were used to study the effects of enrolment under Public Health Insurance Programs for the Poor on the incidence of hospitalizations, length of hospitalization, and Out-of- Pocket payments for inpatient care. Results There were 64,270 BPL people in the sample. Individuals enrolled in health insurance for the poor have 1.21 higher odds of incidence of hospitalization compared to matched poor individuals without the health insurance coverage. Enrollment under the poor people health insurance program did not have any effect on length of hospitalization and inpatient Out-of-Pocket health expenditures. Logistic regression model showed that chronic illness, household size, and age of the individual had significant effects on hospitalization incidence. Tobit model results showed that individuals who had chronic illnesses and belonging to other backward social group had significant effects on hospital length of stay. Tobit model showed that days of hospital stay, education and age of patient, using a private hospital for treatment, admission in a paying ward, and having some specific comorbidities had significant positive effect on out-of-pocket costs. Conclusions Enrolment in the public health insurance programs for the poor increased the utilization of inpatient health care. Health insurance coverage should be expanded to cover outpatient services to discourage overutilization of inpatient services. To reduce out-of-pocket costs, insurance needs to cover all family members rather than restricting coverage to a specific maximum defined.

Abstract Background: India is taking steps to provide Universal Health Coverage (UHC). Out-of-pocket (OOP) health care payment is the most important mechanism for health care payment in India. This study aims to investigate the effect of OOP health care payments on catastrophic health expenditures (CHE). Methods: Data from the National Sample Survey Organization, Social Consumption in Health 2014 and 2018 are used to investigate the effect of OOP health expenditure on household welfare in India. Three aspects of catastrophic expenditure were analyzed in this paper: (i) incidence and intensity of 'catastrophic' health expenditure, (ii) socioeconomic inequality in catastrophic health expenditures, and (iii) factors affecting catastrophic health expenditures. Results: The odds of incidence and intensity of CHE were higher for the poorer households. Using the logistic regression model, it was observed that the odds of incidence of CHE was higher among the households with at least one child aged less than 5 years, one elderly person, one secondary educated female member, and if at least one member in the household used a private healthcare facility for treatment. The multiple regression model showed that the intensity of CHE was higher among households with members having chronic illness, and if members had higher duration of stay in the hospital. Subsidizing healthcare to the households having elderly members and children is necessary to reduce CHE. Conclusion: Expanding health insurance coverage, increasing coverage limits, and inclusion of coverage for outpatient and preventive services are vital to protect households. Strengthening public primary health infrastructure and setting up a regulatory organization to establish policies and conduct regular audits to ensure that private hospitals do not increase hospitalizations and the duration of stay is necessary.

Background Pakistan is currently experiencing a double burden of disease. Families with members having both communicable and noncommunicable diseases are at a greater risk of impoverishment due to enormous out-of-pocket payments. This study examines the percentile distribution of the determinants of the out-of-pocket expenditure on the double disease burden. Method The study extracted a sample of 6,775 households with at least one member experiencing both communicable and noncommunicable diseases from the Household Integrated Economic Survey 2018-19. The dataset is cross-sectional and nationally representative. Quantile regression was used to analyze the association of various socioeconomic factors with the OOP expenditure associated with double disease burden. Results Overall, 28.5% of households had double disease in 2018-19. The households with uneducated heads, male heads, outpatient healthcare, patients availing public sector healthcare services, and rural and older members showed a significant association with the prevalence of double disease. The out-of-pocket expenditure was higher for depression, liver and kidney disease, hepatitis, and pneumonia in the upper percentiles. The quantile regression results showed that an increased number of communicable and noncommunicable diseases was associated with higher monthly OOP expenditure in the lower percentiles (10th percentile, coefficient 312, 95% CI: 92–532), and OOP expenditure was less pronounced among the higher percentiles (75th percentile, coefficient 155, 95% CI: 30–270). The households with older members were associated with higher OOP expenditure at higher tails (50th and 75th percentiles) compared to lower (10th and 25th percentiles). Family size was associated with higher OOPE at lower percentiles than higher ones. Conclusion The coexistence of communicable and noncommunicable diseases is associated with excessive private healthcare costs in Pakistan. The results call for addressing the variations in financial costs associated with double diseases.

South Asia’s worsening air pollution crisis represents one of the most urgent public health and environmental challenges of the 21st century. Nearly two billion people—over one-quarter of the global population—reside in this region, where air quality levels routinely exceed World Health Organization (WHO) guidelines by factors of 10 to 15. This has translated into an unprecedented health burden, with approximately two million premature deaths annually, widespread chronic respiratory and cardiovascular disease, and rising economic losses. According to recent World Bank estimates, welfare losses amount to over 5% of regional GDP, a figure far exceeding the projected costs of coordinated mitigation. Despite this, South Asia continues to lack a binding regional framework capable of addressing its shared airshed. Existing cooperative efforts—such as the Malé Declaration on Control and Prevention of Air Pollution (1998)—have provided a useful platform for dialog and pilot monitoring, but they remain voluntary, under-resourced, and insufficient to manage the transboundary nature of the crisis. National-level programs, including India’s National Clean Air Programme (NCAP), Bangladesh’s National Air Quality Management Plan (NAQMP), and Nepal’s National Air Quality Management Action Plan (AQMAP), demonstrate domestic commitment but are constrained by fragmentation, limited financing, and lack of regional integration. This gap represents the central knowledge and governance challenge that prompted the present commentary. To address it, we propose a dual-track architecture designed to institutionalize binding regional cooperation. Track A would establish a United Nations-anchored South Asian Transboundary Air Pollution Protocol, under the auspices of the United Nations Environment Programme, the World Health Organization (WHO), and the United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP). This protocol would codify legally enforceable emission standards, compliance committees, financial mechanisms, and harmonized monitoring. Track B would establish a South Asian Association for Regional Cooperation (SAARC) Prime Ministers’ Council on Air Quality (SPMCAQ) to provide political leadership, align domestic implementation, and authorize rapid responses to cross-border haze events. Lessons from the Indian Ocean Experiment, the ASEAN Agreement on Transboundary Haze Pollution, and Europe’s Convention on Long-Range Transboundary Air Pollution demonstrate that legally binding agreements combined with high-level political ownership can achieve durable reductions in pollution despite geopolitical tensions. By situating South Asia within these global precedents, the proposed framework provides a pragmatic, enforceable, and politically resilient pathway to protect health, reduce economic losses, and deliver cleaner air for nearly one-quarter of humanity.

Problem Despite flagship programs like Janani Suraksha Yojana (JSY) and Pradhan Mantri Matru Vandana Yojana (PMMVY), India faces persistent maternal health inequities driven by fragmented legal frameworks, workforce deficiencies reflected by the 88% shortage of health workers in Primary Healthcare Centers, and weak community reinforcement mechanisms. Comparison Cuba achieves near-universal maternal health outcomes through constitutional health guarantees, integrated three-tier service delivery, residential maternity homes, and intensive community-based follow-up—all despite economic constraints. Key insight Using the PRECEDE model reveals that Cuba’s success stems from synergistic enabling factors—rights-based legal framework, reinforcing factors—maternity homes, postnatal surveillance, social accountability, and predisposing factors—health literacy, cultural norms. Recommendation India should adopt a rights-based constitutional amendment, establish residential maternity support centers for high-risk pregnancies, implement systematic postnatal home visits, and transition from conditional schemes to universal public provisioning to achieve equitable maternal health outcomes.

Introduction High percentage of OOP (Out-of-Pocket) costs can lead to poverty and exacerbate existing poverty, with 21.9% of India's 1.324 billion people living below the poverty line. Factors such as increased patient cost-sharing, high-deductible health plans, and expensive medications contribute to high OOP costs. Understanding the poverty-inducing impact of healthcare payments is essential for formulating effective measures to alleviate it. Methods The study used data from the 75th round of the National Sample Survey Organization (Household Social Consumption in India: Health) from July 2017-June 2018, focusing on demographic-socio-economic characteristics, morbidity status, healthcare utilization, and expenditure. The analysis included 66,237 hospitalized individuals in the last 365 days. Logistic regression model was used to examine the impact of OOP expenditures on impoverishment. Results Logistic regression analysis shows that there is 0.2868 lower odds of experiencing poverty due to OOP expenditures in households where there is the presence of at least one child aged 5 years and less present in the household compared to households who do not have any children. There is 0.601 higher odds of experiencing poverty due to OOP expenditures in urban areas compared to households in rural areas. With an increasing duration of stay in the hospital, there is a higher odds of experiencing poverty due to OOP health expenditures. There is 1.9013 higher odds of experiencing poverty due to OOP expenditures if at least one member in the household used private healthcare facility compared to households who never used private healthcare facilities. Conclusion In order to transfer demand from private to public hospitals and reduce OOPHE, policymakers should restructure the current inefficient public hospitals. More crucially, there needs to be significant investment in rural areas, where more than 70% of the poorest people reside and who are more vulnerable to OOP expenditures because they lack coping skills.

Background The increased socioeconomic inequality in catastrophic health expenditure (CHE) disproportionately affects disadvantaged populations, subjecting them to financial hardships, limiting their access to healthcare, and exacerbating their vulnerability to morbidity. Objectives This study examines changes in socioeconomic inequality related to CHE and analyzes the contributing factors responsible for these changes in Pakistan between 2010-11 and 2018-19. Methods This paper extracted the data on out-of-pocket health expenditures from the National Health Accounts for 2009-10 and 2017-18. Sociodemographic information was gathered from the Household Integrated Economic Surveys of 2010-11 and 2018-19. CHE was calculated using budget share and the ability-to-pay approaches. To assess socioeconomic inequality in CHE in 2010-11 and 2018-19, both generalized and standard concentration indices were used, and Wagstaff inequality decomposition analysis was employed to explore the causes of socioeconomic inequality in each year. Further, an Oaxaca-type decomposition was applied to assess changes in socioeconomic inequality in CHE over time. Results The concentration index reveals that socioeconomic inequality in CHE decreased in 2018-19 compared to 2010-11 in Pakistan. Despite the reduction in inequality, CHE was concentrated among the poor in Pakistan in 2010-11 and 2018-19. The inequality decomposition analysis revealed that wealth status was the main cause of inequality in CHE over time. The upper wealth quantiles indicated a positive contribution, whereas lower quantiles showed a negative contribution to inequality in CHE. Furthermore, urban residence contributed to pro-rich inequality, whereas employed household heads, private healthcare provider, and inpatient healthcare utilization contributed to pro-poor inequality. A noticeable decline in socioeconomic inequality in CHE was observed between 2010 and 2018. However, inequality remained predominantly concentrated among the lower socio-economic strata. Conclusion These results underscore the need to improve the outreach of subsidized healthcare and expand social safety nets.

Background: The framework of measuring effective coverage is conceptually straightforward, yet translation into a single metric is quite intractable. An estimation of a metric linking need, access, utilization, and service quality is imperative for measuring the progress towards Universal Health Coverage. A coverage metric obtained from a household survey alone is not succinct as it only captures the service contact which cannot be considered as actual service delivery as it ignores the comprehensive assessment of provider–client interaction. The study was thus conducted to estimate a one-composite metric of effective coverage by linking varied datasets. Methods: The study was conducted in a rural, remote, and fragile setting in India. Tools encompassing a household survey, health facility assessment, and patient exit survey were administered to ascertain measures of contact coverage and quality. A gamut of techniques linking the varied surveys were employed such as (a) exact match linking and (b) ecological linking using GIS approaches via administrative boundaries, Euclidean buffers, travel time grid, and Kernel density estimates. A composite metric of effective coverage was estimated using linked datasets, adjusting for structural and process quality estimates. Further, the horizontal inequities in effective coverage were computed using Erreygers’ concentration index. The concordance between linkage approaches were examined using Wald tests and Lin’s concordance correlation. Results: A significantly steep decline in measurement estimates was found from crude coverage to effective coverage for an entire slew of linking approaches. The drop was more exacerbated for structural-quality-adjusted measures vis-à-vis process-quality-adjusted measures. Overall, the estimates for effective coverage and inequity-adjusted effective coverage were 36.4% and 33.3%, respectively. The composite metric of effective coverage was lowest for postnatal care (10.1%) and highest for immunization care (78.7%). A significant absolute deflection ranging from −2.1 to −5.5 for structural quality and −1.9 to −8.9 for process quality was exhibited between exact match linking and ecological linking. Conclusions: Poor quality of care was divulged as a major factor of decline in coverage. Policy recommendations such as bolstering the quality via the effective implementation of government flagship programs along with initiatives such as integrated incentive schemes to attract and retain workforce and community-based monitoring are suggested.

Introduction: Non-communicable diseases (NCDs) represent a major global health challenge, particularly in low- and middle-income countries like India, with significant gender disparities in mortality and disease burden. This study aims to investigate these disparities, using data from national health surveys, to inform gender-specific public health strategies and align with global health goals. Methodology: The study uses data from the Longitudinal Aging Study in India (LASI) and National Family Health Surveys (NFHS-4 and NFHS-5). Result: The results from the Longitudinal Ageing Study in India (LASI) and National Family Health Surveys (NFHS-4 and NFHS-5) indicate significant demographic and health-related variations among 65,562 participants. Key findings show gender disparities in lifestyle habits such as alcohol and tobacco use, and differences in health outcomes across age, education, and socioeconomic status. Notably, an increase in NCD prevalence, particularly hypertension and diabetes, was observed from NFHS-4 to NFHS-5, highlighting evolving health challenges in India. Conclusions: The study emphasizes the importance of gender in the prevalence and management of non-communicable diseases (NCDs) in India, advocating for public health strategies that address gender differences, socio-economic factors, and urban-rural disparities to achieve health equity.