Shared health challenges, political divides: can South Asia heal itself?

Abstract

South Asia, with a population of 2.078 billion people (25.29% of the global population),¹ is facing challenges in achieving Sustainable Development Goal (SDG) 3 targets, with most countries scoring around 60% on the SDG 3 index. ²  This region, accounting for a substantial share of global health issues, presents challenges that extend beyond its borders, affecting international health policies and economic stability. The region faces a dual burden of communicable and non-communicable diseases (NCDs). In 2019, it accounted for nearly half of all global cases of drug-susceptible tuberculosis and multidrug-resistant tuberculosis.³ By 2023, India (26%) and Pakistan (6.3%) were among the five countries contributing for 56% of global TB cases. ⁴ Similarly, NCDs, such as diabetes mellitus, stroke, and heart diseases, are highly prevalent in South Asia, with India and Pakistan among the leading contributors to the global diabetes burden. ^5-7 Maternal and child health challenges also persist in South Asia, with only 46% of women receiving comprehensive maternal and neonatal health services, with Afghanistan reporting the lowest coverage at 2.8%.⁸ Antenatal care utilization remains low, with no significant improvement across SAARC countries from 2015 to 2030.⁹ The region continues to have one of the highest maternal mortality ratios, with significant disparities; for instance, the Maldives reports high antenatal care utilization (96.83%) compared to Bangladesh (47.01%).¹⁰ 

This analysis highlights that, despite individual country efforts to drive change, South Asia has collectively fallen short of achieving its regional health targets. The impact of COVID-19 further exacerbated the situation, emphasizing the urgency of addressing these challenges. Progress remains hindered by many factors like weak health systems, socio-economic inequities, poor governance, environmental challenges, rising disease burden, and barriers to healthcare access and quality. ^11-14 Beyond these structural challenges, health progress in South Asia is further adversely affected by poor regional cooperation, driven by geopolitical disputes, religious conflicts, and deep-rooted mistrust among member nations.^15,16 Ongoing military tensions between India and Pakistan, along with civil unrest in Afghanistan and Sri Lanka, have severely impacted public health initiatives and resource allocation across South Asia. Political instability and regional conflicts disrupt healthcare services by diverting resources from essential medical care, leading to reduced access and underutilization of healthcare facilities. Economic instability further burdens both patients and health systems, as poor-quality care increases out-of-pocket expenses, delays treatment, and worsens health outcomes. Strengthening health infrastructure and ensuring stability are crucial to mitigating these effects and improving healthcare indicators.^17,18

The division of South Asia into two separate WHO regions—South-East Asia Region (SEAR) and Eastern Mediterranean Region (EMR)—remains a major barrier to regional health collaboration. Influenced by geopolitical tensions, such as Pakistan’s placement in EMRO due to its disputes with India,¹⁹ this structure has undermined India-Pakistan health cooperation, limiting collaboration, disease control, and resource sharing. The SEAR-EMRO divide further weakened the region’s COVID-19 response; while India’s vaccine production supported SEAR countries, Pakistan and Afghanistan (EMRO) faced high-cost import dependency and limited access. Disrupted supply chains and lack of cross-border coordination led to delays and deepened disparities.^20,21 A unified, regionally grounded approach could strengthen health cooperation, policy integration, and public health outcomes across South Asia.

Established in 1985, the South Asian Association for Regional Cooperation (SAARC) aimed to foster economic growth, social progress, and regional collaboration, including in health. However, geopolitical tensions, particularly between India and Pakistan, have largely rendered it ineffective, with many viewing it as defunct.²² Meanwhile, China’s growing influence in South Asia’s health sector, especially through COVID-19 vaccine diplomacy, has intensified regional competition, challenging India’s "Neighbourhood First" policy.²³ Pakistan’s partnership with China through the China-Pakistan Economic Corridor (CPEC) has expanded into healthcare through the China-Pakistan Health Corridor, promoting bilateral investment and infrastructure development. ²⁴Additionally, Bangladesh and Pakistan have shown signs of diplomatic revival, 53 years after Bangladesh’s independence.²⁵ Given these shifting dynamics, reviving SAARC has become a timely and strategic imperative. While India’s re-engagement remains cautious, there are signs of evolving perspectives amid changing geopolitical and health landscapes.²⁶ Lessons from regional models like the European Union (EU) and Association of Southeast Asian Nations (ASEAN), which have successfully pursued collaborative public health strategies despite internal divides, demonstrate that regional cooperation is both feasible and essential.²⁷

Given the current health crises and deep trust deficit among South Asian nations, there is an urgent need for multilateral engagement to pursue the shared goal of health for all South Asians. Countries must set aside political reservations and commit to both short- and long-term strategies, such as establishing a regional health task force, revitalizing the SAARC Development Fund for joint financing, and developing a shared resource framework to strengthen health systems collectively. International support from organizations such as the World Health Organization and UNICEF can further boost these efforts, but the region must first take ownership through self-help and coordinated action. There is also a pressing need to prioritize research on shared health challenges, a trend reflected in leading global journals like BMJ and The Lancet, which have featured special issues and articles on strengthening regional health systems in South Asia. 

Health diplomacy must now take the lead—not only to improve healthcare delivery—but to serve as a bridge to peace and cooperation in the region. The active involvement of civil society, media, and public advocacy is vital to holding government’s accountable and driving meaningful change. Now is the time to act—not only for better health—but for the long-term stability and future of South Asia.