Disparities among the developed and under-developed or developing countries are gross, and the gap is gradually being widened in some areas; as is the case inter-country as well as intra-country. Children belonging to the poor quintiles are more vulnerable compared to their counterpart children belonging to richer quintiles, due to multiple challenges like malnutrition leading to weaker immunity, more exposure to risky and hazardous environments, and lesser or no access to both preventive and curative health. Efforts to improve the health outcomes through provision of subsidy for health services also usually doesn’t reach the vulnerable, and those not in need frequently benefit from such subsidies [26].

A study published in 2016 showed significant variation in coverage and inequalities across various regions of Afghanistan. These results are quite the expected ones, and highlight the fact that comparative availability and accessibility of health services is better in urban areas [18]. According to WHO, the disparity among high- and low-income countries for neonatal death is fairly large and it continues to increase. Another study states that, while there is little doubt that lower income is one of the major factors underlying inequitable access to services, the overall situation is quite complicated; as multiple factors like geography, economy and ethnicity exist as determinants of inequity, and their simultaneous presence in certain cases makes the situation complex. Further to this, the importance of one or the other determinant in relation to the other determinants may vary with the passage of time [27].

In an Ethiopian study, it was noted that geography over-rides the economic factors as the health facilities are at a distance from the population, making access difficult even for those who do not have economic issues. Thus, the risk of child (or newborn) mortality does not correlate with the income groups; and rather correlates with the type of residence i.e. rural versus urban [28]. Studies in India also showed that the underprivileged groups like the financially weak, poorly literate, or living in rural areas, had limited access to healthcare services, thus leading to poorer outcomes for health [29, 30]. Similar findings were observed in this study, in the case of Pakistan and for the provinces except for Balochistan where the inequities continue to prevail in the same ratio throughout the last decade. This is an important finding, for the Government as the number of health facilities in this province need to be increased to ensure adequate geographical coverage. The yardsticks for establishment of new health facilities in such areas should be geographical distances rather than population size.

A comparative study of 14 developing, low- and middle-income countries that had undertaken at least two Demographic and Health Surveys during the 1980s and 1990s was done by Minujin and Delamonica. These countries had shown progress in child survival and decline in mortality. Out of the 14 countries, broadening of gap in child mortality amongst the richest versus poorest wealth quintiles was observed in eight [31]. Most of these 14 countries have similar rural-urban and rich-poor divides as in Pakistan. PDHS for Pakistan shows that the gap between the richest and poor wealth quintiles has increased from 2012 to 13 to 2017–18; and the overall neonatal mortality has declined from 58 to 42 per 100,000 live births nationally during the same interval. This could be an alarming indicator for quality of services being provided even in the urban areas.

Geographic and ethnic disadvantages also result in lack of access to healthcare services; as much as the economic disadvantages. Therefore, health systems should consider these three determinants to provide preventive services like integrated management of newborn and childhood illnesses (IMNCI), vaccinations, and other interventions for newborn care through an equity-focused approach [6].

Inequities between the populations at the lower and higher end of the risk spectrum are further aggravated due to limited availability of effective interventions for the most marginalized children, as highlighted by Tugwell et al. [32]. Systematic reviews of demographic and health surveys show consistent inequities in child health across multiple countries [33, 34]. The study conducted in Afghanistan discussed that unfair inequities and inequalities in service provision, access to services, and product availability to different segments of the population lead to societal inequities [18].

Kruk et al. concluded that “redistributive health policies that promote pro-poor distribution of health services may reduce the gap in under five mortalities between rich and poor in low-income and middle-income countries”. They highlighted the importance of targeting of newborn and child health services to the poor strata of the population, enabling the poor to gain from global efforts to attain the Millennium Development Goals (and now Sustainable Development Goals) [35].

Despite the fact that the inequities and inequalities are declining, the ongoing trend of service coverage for the disadvantaged groups are not at a sufficient pace to accelerate progress towards achieving the goals of universal health coverage (UHC) by 2030, as evidenced by Amouzou et al., and this calls for an urgent need for more robust and effective strategies for equitable access and coverage across all population segments, if the goals for UHC are to be achieved [36].

The National Health Vision for Pakistan (2016–25) mentions the challenges in access in urban areas, and for the poor, and also highlights the issue of inequities in coverage of health services as well as access to healthcare. This vision document encourages equity based and pro-poor approach for all interventions in the health sector, with special emphasis on inequities regarding maternal, neo-natal and child health services. Special initiatives are recommended to be implemented through an equity focused approach, i.e. by specifically targeting the rural areas, urban slums, and the lower segments of the population. Initiatives like provision of round the clock obstetric and neo-natal care at primary level, such as done under the Integrated Reproductive, Maternal, Newborn & Child Health and Nutrition Program (IRMNCHNP) in the Punjab province [22] may be considered for replication in other provinces as well as the improvements observed in maternal and neo-natal health in Punjab are attributed to the interventions done under this program.

The coverage of health services, especially from the perspective of neo-natal health, has improved in the country as evidenced through the PDHS (Table 1). The Government now needs to focus more towards improving the quality of care at primary care level, so that the mortality due to common and easily preventable causes i.e. complication of pre-term birth (mostly hypothermia), sepsis and asphyxia can be minimized [14].

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