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We discuss how to estimate the interplay between genes (nature) and environments (nurture), with an empirical illustration of the moderating effect of school starting age on one's genetic predisposition towards educational attainment. We argue that gene-environment ( G × E ) studies can be instrumental for (i) assessing treatment effect heterogeneity, (ii) testing theoretical predictions, and (iii) uncovering mechanisms, thereby improving understanding of how (policy) interventions affect population subgroups. Empirically, we find that being old-for-grade and having a higher genetic propensity for education benefits children on assessment tests as they progress through school. In this setting, families appear to increase genetic inequalities while schools seem to reduce them.
The application of chaos theory has positive results in different fields of science. Its nonlinear modeling properties and its vision of dynamic systems have enabled it to capture complex relationships in fields such as physics, financial econometrics, social systems and mathematical demography. This paper reviews the implication of chaos theory in the medical sciences. We carried out a systematic literature review under Cochrane’s international standards. A search strategy was executed with indexed terms (MeSH, DeCS and Emtree) that varied according to each database (Embase, MEDLINE, SciELO, LILACS). The PROSPERO registration number was CRD42023491407. In total, 2598 articles were retrieved, of which 20 were included. Algorithmic applications of chaotic systems were diverse. The medical fields with the largest studies were cardiology, neurology and oncology. The most used software was Matlab, however, in all cases, except one, we did not find open-source codes related to the studies. We found a wide heterogeneity in the studies reviewed, and this was reflected in the scope of research results. While some papers focus on proving the existence of chaotic behavior or understanding the nature of the phenomena being studied, others propose practical implications, such as in prescribing medicines and organizing health units. Not applicable. The online version contains supplementary material available at 10.1186/s42490-026-00111-0.
Developmental plasticity refers to biological adaptations, most often prenatally, to environmental cues. These can help organisms adapt to similar postnatal environments, with health benefits if prenatal and postnatal conditions match. While associations between various prenatal exposures and adverse offspring health have been documented, the interaction between prenatal and postnatal conditions remains less understood. We address this gap by examining whether pre- and postnatal drought exposures interact in their impact on cognitive performance, as early-life nutrition is a critical factor for cognitive development. Standardized math and reading scores from 11-16 year-olds in rural India (N = 2,032,917) from the 2007-2018 Annual Status of Education Report (a cross-sectional cognitive assessment household survey) were combined with University of Delaware Terrestrial Precipitation data. Given the high reliance on rainfed agriculture in the setting, rainfall levels below the 20th percentile of the district-specific long-term mean served as a proxy for nutritional adversities in a quasi-experimental study setup. We show that early-life droughts adversely impact cognitive function. We find positive interaction terms between prenatal and postnatal drought exposures, suggesting that children already exposed to droughts prenatally are better equipped for postnatal droughts. The findings of this study align with the predictions around phenotypic plasticity, i.e., that prenatal conditions prepare organisms for similar postnatal challenges. However, given the increasing unpredictability of the climate, such alignments cannot be planned or anticipated, implying frequent mismatches between prenatal and postnatal conditions. Pregnancy and the first years of life are critical periods for brain development, and adequate nutrition is essential during these times. In many regions, agriculture relies on rainfall, and droughts can cause nutritional shortages. We analyzed math and reading test results of two million children aged 11–16 years in rural India to understand how nutrition before and after birth affects later-life learning. We found that the combination of these two periods matters: droughts in early life generally lead to worse test results, but a drought during pregnancy cushions the effect of a drought a few years later. This is in line with the concept of Predictive Adaptive Responses in humans: biological adaptations to prenatal environmental cues can help prepare for later-life environmental conditions.
Malignant neoplasms of the salivary glands are a heterogeneous group of cancers that include more than 24 malignant histological types in the salivary glands, with different genetic, morphological, and immunohistochemical features and clinical behavior. A retrospective population-based analysis of salivary gland cancers diagnosed between 1994 and 2018 was performed, using data from the Girona and Tarragona cancer registries. Crude incidence rates, European and world-age-standardized incidence rates and incidence trends, measured as the annual percentage change, were estimated. Observed and net survival at 5 and 10 years and 10-y/5-y conditional survival were calculated. The analysis was focused on histological type. A total of 301 cases were recorded in the provinces of Girona and Tarragona during 1994-2018, of which 51.5% were in men and 76.1% in the parotid salivary gland. The most common histology type was the squamous cell carcinoma (17.9%) followed by the mucoepidermoid carcinoma (16.9%). Incidence was 9.2 cases per 1,000,000 person-years for all salivary gland tumors. A decrease in incidence for all cases and in most of the histology types specifically, was observed. For the cohort, the 10-year observed and net survival rates were 37.3 and 55.5%, respectively. Acinar cell carcinoma was the histology with better prognosis at 10 years. A decrease in the overall incidence of cases has been observed, which may be due to better diagnostic or registration accuracy along with changes in exposure to etiological factors such as smoking. Net survival at 10 years was 55.5% for the entire cohort.
Pediatric pneumonia remains a major cause of morbidity and mortality in low- and middle-income countries (LMICs), imposing both health and financial burdens. While the clinical aspects of pediatric pneumonia are well-studied, less attention has been paid to its economic implications for households, particularly regarding out-of-pocket (OOP) expenditure. This paper synthesizes current evidence from Kenya, India, Bangladesh, and Vietnam and introduces a proposed econometric framework designed to identify cost determinants and model policy interventions. The framework integrates microeconomic data, identifies cost determinants, and models the effects of clinical and policy factors (e.g., intensive care, vaccination, insurance coverage) on household expenditures. Simulated results illustrate potential findings from such an approach. Existing studies show substantial variability in hospitalization costs, with OOP payments ranging from US$30 to US$250 per episode, often exceeding 20% of monthly household income. Econometric modeling using generalized linear models (GLMs) and difference-in-differences (DiD) can disentangle the impact of hospital practices, disease severity, and policy interventions. Simulated regression results demonstrate that length of stay, intensive care admission, and absence of insurance significantly increase household costs, while pneumococcal conjugate vaccine (PCV) introduction reduces both admissions and financial burden. Hospitalization for pediatric pneumonia imposes significant OOP costs on households in LMICs. An econometric framework provides rigorous tools to estimate cost drivers, evaluate policy impacts, and guide equitable health financing reforms.
The costs associated with advanced Parkinson's disease (aPD) extend beyond direct medical expenditure. As symptoms become more severe, professional and informal personal care costs are likely to exceed those incurred for medical and pharmacological treatment. The objective of this analysis is to explore the impact of treatment with subcutaneous foslevodopa/foscarbidopa (LDp/CDp) on the societal cost impact in the UK, France, Germany, Spain, and Canada. A model was developed to aggregate expected costs incurred by a cohort with aPD over a 5-year time frame. Resource use for direct medical, non-medical, and informal care are estimated from a real world data source (Adelphi), mapped to the severity of disease as estimated by the extent of OFF-time experienced by patients. Indirect societal costs are estimated from published literature. Unit costs for each of the included countries are then applied to these resource use estimates. Symptom progression of individuals within the cohort are derived from a previously developed Markov model, which captures the differential effect on OFF-time of LDp/CDp versus best medical treatment (BMT). Overall costs for aDP patients were shown to rise over the 5-year time horizon, as symptom progression occurred. The use of LDp/CDp incurred greater drug costs than BMT, but, by delaying exacerbation of OFF-time, this additional cost was more than offset by other savings - principally attributable to professional and informal care. Aggregated results showed a net cumulative saving of €96,273 per patient over the 5 year time horizon. Results for the five individual countries evaluated ranged from €50,297 to €135,208 per patient saving. LDp/CDp has been shown to significantly improve OFF-time burden in patients with aPD, compared with BMT. Once the costs of professional and informal care are taken into account, the additional acquisition costs of LDp/CDp are more than offset, yielding a net societal saving.
Studies of the COVID-19 pandemic revealed differences in the clinical course between paediatric and adult patients. In-depth research on whether T follicular cells support these observations is still ongoing. Circulating Tfh and Tfr cells were examined to identify specific immune responses in paediatric and adult individuals who recovered from asymptomatic to mild SARS-CoV-2 infection. Circulating Tfh and Tfr cells were evaluated by flow cytometry. To evaluate specific anti-SARS-CoV-2 immune responses, anti-Spike RBD IgG antibodies were measured by an enzyme-linked fluorescent assay, anti-Spike neutralizing activity - by an in vitro cell-based assay, and IFN-γ T cell responses were evaluated via ELISpot assay. Age-specific differences in the profiles of the CXCR5+CD4+ T cells that distinguish them from CXCR5- counterparts were detected. An increased percentage of cTfr cells and decreased percentage of cTfh cells was observed in the paediatric group, which resulted in a decreased cTfh/cTfr ratio. Increased proportions of ICOS- and HLA-DR-expressing cTfh and cTfr cells were also observed, consistent with the high proportion of antibody-responders among children. In contrast, a greater percentage of adults than children exhibited IFN-γ-positive T cells in response to the four viral peptides. In adult responders, a good correlation was found between the presence of plasmablasts and the cTfh/cTfr ratio. Antibody neutralizing capacity did not differ between children and adults. Circulating Tfh and Tfr cells exhibit specific age-dependent differences, which may contribute to the immunologic background of the clinical symptoms of SARS-CoV-2 infection.
Despite long-standing policy efforts to align population distribution with water availability, the mechanisms linking water resources to population patterns remain poorly understood. Existing studies largely emphasize climatic shocks or assume a positive water-population relationship, leaving the structural drivers of misalignment underexplored. This study addresses this gap by developing an analytical framework that elucidates how water resources influence population distribution through ecological, economic, and environmental paths, grounded in the functional roles of water resources and push-pull theory. Using panel data from 271 prefectures between 2012 and 2021, we assess water-population coordination with Lorenz curve and Gini coefficient and identify causal mechanisms through econometric and path analyses. The results reveal a persistent and counterintuitive negative association between water resource availability and population density, with no evidence of convergence over time. This relationship is driven primarily by ecological and environmental paths, while the economic path is insignificant. Notably, these paths converge in a "dual reduction" mechanism whereby greater water endowment expands green space and reduces wastewater discharge, both contributing to lower population density. These findings challenge the conventional carrying-capacity logic that treats water abundance as a demographic advantage and instead highlight water's role in ecological upgrading and structural transformation. Methodologically, this study advances the literature by integrating a multi-path mechanism framework, while theoretically it reconceptualizes the water-population nexus beyond simple hydrological determinism. The results suggest the need to reassess the "Determining Population on Water" approach and to prioritize ecological and environmental paths, especially green space expansion and wastewater reduction, to improve water-population coordination in water-scarce regions.
Meningitis remains the leading infectious cause of neurological disabilities globally, disproportionately affecting children younger than 5 years and populations in the African meningitis belt. Whereas previous global estimates focused on ten pathogen categories, this study presents the most comprehensive analysis to date, assessing the meningitis burden attributable to 17 causative pathogens based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 framework. GBD is a systematic, scientific effort aimed at quantifying the comparative magnitude of health loss caused by diseases, injuries, and risk factors across age groups, sexes, and geographical locations over time. We estimated meningitis mortality using the Cause of Death Ensemble model (CODEm) and morbidity using DisMod-MR 2.1, incorporating data from vital registration, verbal autopsy, surveillance, hospital data, and systematic reviews. Aetiology-specific estimates were generated with pathogen-linked case-fatality ratios and splined binomial regression models. Risk factor attribution was based on established risk-outcome pairs and population attributable fractions. In 2023, there were 259 000 (95% uncertainty interval 202 000-335 000) global deaths and 2·54 million (2·20-2·93) incident cases of meningitis. Children younger than 5 years accounted for more than a third of deaths (86 600 [53 300-149 000]). Streptococcus pneumoniae, Neisseria meningitidis, non-polio enteroviruses, and other viruses were the leading causes of death, while non-polio enteroviruses caused the most cases. The four WHO-defined preventable meningitis pathogens of interest (S pneumoniae, N meningitidis, Haemophilus influenzae, and Group B streptococcus) contributed to 98 700 deaths (77 000-127 000) and 594 000 cases (514 000-686 000). Low birthweight, short gestation, and household air pollution were the top risk factors for meningitis-related mortality. Although mortality and incidence have declined significantly since 1990, progress is insufficient to meet WHO 2030 targets. Despite marked progress in reducing bacterial meningitis via global vaccination campaigns, a substantial meningitis burden persists, attributable both to common pathogens such as S pneumoniae and N meningitidis and to emerging non-bacterial pathogens such as Candida spp and drug-resistant fungi. Achieving WHO goals will require sustained investment in surveillance, vaccination, maternal screening, and health-system strengthening, especially in high-burden settings. Gates Foundation, Wellcome Trust, and UK Department of Health and Social Care.
This study aimed to identify the levels and risk factors associated with physical and emotional violence that women in Türkiye have been subjected to simultaneously by their husbands/partners at some point in their lives. Bivariate probit regression analysis was employed to determine the factors associated with women's experiences of physical and emotional violence inflicted by their husbands/partners. In this study, the cross-sectional data of the National Research on Domestic Violence against Women in Türkiye conducted in 2014 by the Institute of Population Studies of Hacettepe University were used. The survey questionnaires of The National Research on Domestic Violence against Women in Türkiye were implemented by the research team. The number of samples to be considered was calculated as 6458. The sampling of the research was carried out using cluster sampling. The weights calculated in accordance with the sample design of the research were added to these data sets. The study revealed that 33 % of women experienced physical violence, while 41 % faced emotional violence. Women living in the central region, those with children, and those whose educational level exceeded that of their husband/partner were found to have a higher likelihood of experiencing both forms of violence. It was determined that young women were less likely to be exposed to physical and emotional violence. As women's educational level and health status improve, their likelihood of being exposed to physical and emotional violence decreases. The findings of the study reveal that these forms of violence are interconnected and underscore the importance of devising effective strategies to lower the risk for women who are more susceptible to experiencing physical and emotional violence in the future. Conducting more comprehensive research on these forms of violence in Türkiye from diverse perspectives could serve as a crucial guide in identifying key areas that require immediate attention for addressing this issue. The study results demonstrate that effective strategies to protect women at risk-such as gender equality campaigns, the widespread implementation of violence screening protocols in health check-ups, and increasing the capacity of shelters-must be urgently implemented by policymakers, healthcare professionals, social workers, and local organizations. In particular, the use of standardized violence assessment tools during routine examinations in healthcare facilities can provide an effective method for early intervention and referral. In addition, training healthcare personnel to identify and support victims of violence will enhance the effectiveness of this process. Conducting multidisciplinary, comprehensive research to understand the socio-cultural and structural dynamics of domestic violence in Türkiye will serve as an indispensable guide in determining priority areas in combating violence and will offer evidence-based solutions to all relevant stakeholders.
Computerized adaptive tests (CATs) play a crucial role in educational assessment and diagnostic screening in behavioral health. Unlike traditional linear tests that administer a fixed set of pre-assembled items, CATs adaptively tailor the test to an examinee's latent trait level based on their previous responses. We introduce a novel CAT system that builds on recent advances in Bayesian multivariate IRT. Our approach leverages direct sampling from the latent factor posterior distributions, significantly accelerating existing information-theoretic item-selection methods by eliminating the need for computationally intensive Markov chain Monte Carlo simulations. To address the potential suboptimality of one-step-ahead item-selection rules, we also develop a double deep Q-learning algorithm that efficiently learns an optimal item-selection policy offline using a calibrated item bank. Through simulation and real-data studies, we demonstrate that our approach not only accelerates existing item-selection methods but also highlights the potential of reinforcement learning (RL) in CATs. Notably, our Q-learning-based strategy consistently achieves the fastest posterior variance reduction, leading to earlier test termination. These results demonstrate the promise of combining exact posterior sampling with RL to deliver scalable, high-precision CATs.
Mental health problems are increasingly prevalent among adolescents and young adults and represent a major public health challenge closely aligned with the United Nations Sustainable Development Goal 3 (Good Health and Well-being). Lifestyle-related and social factors, such as diet, physical activity, and social support, are closely related to emotional well-being during this critical life stage. This study examines the association between dietary habits, physical activity, and mental health among Catalan adolescents aged 15 to 25 years in Catalonia, within a population-based public health framework. Data were drawn from the 2022-2023 Catalan Health Survey (ESCA), including 855 participants aged 15-25. Weighted logistic regression analyses were used to assess associations between clinically diagnosed anxiety and depression and key personal and behavioral characteristics including age, sex, physical activity, social support, and diet. Overall, 85.7% anxiety-free and 93.2% depression-free. Poorer mental health status was associated with female sex, older age, and frequent consumption of red or processed meats. In contrast, regular vigorous physical activity and strong social support were consistently associated with higher likelihood of reporting good mental health. These findings underscore the relevance of modifiable lifestyle and social determinants in promoting mental well-being among young people. From a public health perspective, interventions that encourage physical activity, healthy dietary habits, and social connectedness may contribute to advancing Sustainable Development Goal 3 by reducing the burden of anxiety and depression in youth populations.
Pakistan's agricultural sector is increasingly vulnerable to climate change-induced shocks, posing serious risks to farm incomes and rural livelihoods. Although crop insurance has been promoted as a key risk-mitigation instrument, and several public and private schemes have been introduced-particularly in Punjab-farmer participation remains strikingly low. This study provides one of the first systematic assessments of farm households' perceptions of climate-related risks, their awareness of crop insurance, and the coping mechanisms they adopt in response to climatic shocks. The analysis draws on primary survey data from 324 farmers across 27 mouzas (villages) in the districts of Bahawalpur, Gujrat, and Faisalabad. Descriptive findings reveal a pronounced perception-adoption gap: while 84% of respondents view climate hazards as a major threat to agriculture, only 21% are aware of crop insurance schemes, and fewer than 3% have ever purchased coverage. In the absence of formal insurance, farmers predominantly rely on informal credit networks, valued for their accessibility, flexibility, and trust-based nature. Econometric estimates using logit and probit models indicate that education and financial inclusion significantly increase the likelihood of insurance awareness, underscoring the central role of financial literacy in shaping adaptation decisions. Overall, the results highlight a substantial disconnect between farming communities and formal risk-management institutions in Pakistan. The study emphasizes the need for localized awareness campaigns, simplified enrolment procedures, credible institutional delivery mechanisms, and innovative public-private partnerships to position crop insurance as an effective resilience-building tool in Pakistan's climate-vulnerable agricultural sector.
This article describes a project-level dataset of approved projects recorded under the Special Development Program for Local Authorities "Antonis Tritsis" in Greece, as captured in the Ministry of the Interior administrative platform up to August 2025. The dataset contains one record per approved project, including information on the implementing beneficiary, beneficiary type, NUTS-2 region, thematic call, approval date and approved budget. It supports the systematic analysis of the territorial and thematic distribution of local government investment, including the concentration of projects and approved funding across regions and thematic calls. The dataset can be reused for descriptive, spatial and comparative analyses of public investment allocation in local development programmes, as well as for econometric studies related to regional development and public finance.
Capivasertib plus fulvestrant has emerged as a promising targeted therapy for HR+/HER2- advanced breast cancer (ABC). This study evaluated the cost-effectiveness of capivasertib plus fulvestrant vs. fulvestrant monotherapy in PI3K/AKT/PTEN pathway-altered patients with HR+/HER2- ABC from a U.S. payer's perspective. A partitioned survival model with three health states (progression-free, progressive disease, and death) was developed over a 5-year time horizon. Progression-free survival (PFS) and overall survival (OS) data were derived from the CAPItello-291 trial (NCT04305496). Utility, disutility, and direct medical costs were obtained from published literature and the Centers for Medicare and Medicaid Services. Capivasertib cost was based on wholesale acquisition cost. Costs were presented in 2025 U.S. dollars. Both costs and outcomes were discounted by 3%. Incremental cost-effectiveness ratios (ICERs) based on quality-adjusted life-year (QALY) gained and equal value of life years gained (evLYG) were compared using a willingness-to-pay (WTP) threshold of $150,000. Sensitivity analyses, scenario analyses (10-year horizon and phase II trial data) and threshold analysis were conducted. Capivasertib plus fulvestrant yielded more QALYs (1.89 vs. 1.29) and life years (3.31 vs. 2.49) but higher costs ($539,625 vs. $158,679) than fulvestrant alone, resulting in ICERs of $636,455/QALY gained and $459,358/evLYG over a 5-year time horizon. The cost of capivasertib ($28,332/4 weeks) had the greatest impact and would need to be reduced to $5,598/4 weeks to achieve cost-effectiveness. Extrapolation of survival data reflects limited long-term trial data and increases uncertainty surrounding model parameters. Efficacy based on clinical trials may differ from real-world effectiveness. Despite clinical benefits, capivasertib plus fulvestrant was not cost effective at current price from a U.S. payer's perspective. The cost of capivasertib per 4 weeks would be required to decrease by ∼80% from $28,332 to $5,598 (about $87 per 200 mg) to meet the WTP threshold of $150,000. Capivasertib plus fulvestrant is a new targeted treatment for patients with a specific type of advanced breast cancer that has certain genetic alterations. This study assessed the economic value of this combination compared to fulvestrant monotherapy from a U.S. payer’s perspective. Our analysis found that capivasertib extended the period of health for patients at a very high cost. Specifically, capivasertib cost an additional $380,946 compared to standard therapy. This resulted in a cost of $636,455 per quality-adjusted life year gained (a measure of both the length and quality of life), which is significantly higher than the $150,000 typically considered cost-effective or good value in the U.S. Therefore, while patients receiving capivasertib plus fulvestrant gained more clinical benefits, the current price remains a significant barrier to its cost-effectiveness in the U.S. healthcare system.
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In this paper, we explore how media covers and frames fishery issues. Focusing on the German Baltic fishery, we use methods from computational linguistics, political science, and fisheries science to analyze almost 1800 newspaper articles from 2009 to 2021. We document four key results. First, political events-rather than scientific policy advice-drive media reporting. Second, fishery representatives are mentioned more often than environmental non-governmental organizations (eNGOs) and with a much higher level of personalization and emotionalization. Third, reductions in European Union (EU) fishing quotas are followed by negative media sentiment, even though the status of the Baltic ecosystem would improve. Fourth, media portrayal of relevant stakeholder groups is consistent with the existence of two opposing coalitions: one emphasizing the socio-economic viability of the fishery and one advocating for the ecosystem's ecological health. Overall, we find evidence that newspapers tend to act as "advocates" of the fishers' interests and concerns.
In the context of increasing global challenges to food security, including climate change, economic disruptions, and supply chain instability, the digital transformation of agricultural circulation systems has attracted growing attention as a potential driver of sustainability and resilience. Using panel data from 30 Chinese provinces spanning 2013-2022, this study empirically examines the impact of digital transformation of circulation (DTC) on the sustainable resilience of food systems (SRFS). A fixed-effects model is employed, complemented by spatial econometric models, mediating effect analysis, and threshold models to capture spatial spillovers, underlying mechanisms, and nonlinear effects. The results indicate that DTC significantly enhances SRFS by optimizing the structure of the food industry, and these findings remain robust after addressing endogeneity and conducting sensitivity analyses. Spatial analysis reveals pronounced heterogeneity in spillover effects: DTC exerts a negative indirect effect on geographically adjacent regions, while generating positive spillovers for regions with strong agricultural trade linkages. Mechanism analysis shows that these effects are driven by the alleviation of factor market distortions and the promotion of industrial convergence. Furthermore, the impact of circulation digitalization on SRFS exhibits diminishing marginal effects and a threshold effect associated with agricultural industrial agglomeration. Taken together, the findings underscore the importance of circulation digitalization in strengthening food system resilience and provide empirical support for the design of more targeted and differentiated digital development strategies in agriculture.
This article examines the financial impact of occupational cancer resulting from pesticide exposure and other carcinogenic agents in the floriculture sector of Cundinamarca, Colombia. It begins with a literature review covering (the) industry context, key occupational health factors, labor costs, and human capital. Based on this review, the study identifies gaps in the economic analysis of work-related illnesses such as cancer, particularly regarding hidden costs.  Method: Using a quantitative explanatory approach, the research applies a multiple linear regression model to a dataset of 7,300 observations, analyzing absenteeism, labor costs, and worked days in relation to productivity. The findings show a (59%) drop in productivity per diagnosed worker, leading to increased costs. The model yields an R² of (0.876), statistically supporting the hypothesis. The study confirms the existence of hidden costs such as absenteeism, employee replacement, and medical expenses that are not reflected in financial statements.
China has achieved notable progress in economic and social development over the past decade. However, regional disparities—especially in Health Service Development Level (HSDL)—remain significant, challenging national health goals and public health sustainability. This study evaluates China’s HSDL, explores causes of regional inequality, and proposes policy recommendations to optimize resource allocation and address health disparities. We used panel data from 31 provinces (2012–2021) to build a composite HSDL index via the CRITIC weighting method. Dagum’s Gini coefficient measured regional disparities, and kernel density estimation analyzed distribution patterns. Moran’s I index assessed spatial autocorrelation. Traditional and spatial Markov chain models examined dynamic transitions, while spatial econometric models (SDM, SEM, SAR) explored spatiotemporal evolution and convergence. From 2012 to 2021, China’s HSDL rose steadily, peaking in 2020, mainly due to coordinated health policies and COVID-19 responses. Eastern provinces maintained high HSDL, while western regions improved significantly through health poverty alleviation efforts, narrowing interregional gaps. In 2021, a slight decline was observed, likely due to reduced public health investment and shifting policy priorities post-pandemic. Spatial analysis showed clustering of high HSDL in the east, with notable internal disparities in the west. Markov model comparisons revealed strong transition inertia and lock-in effects, especially in low-HSDL regions. Spatial econometric models confirmed a trend of spatial convergence, with shrinking gaps among eastern, central, and western areas. Despite national progress in HSDL, regional imbalances and unequal resource distribution persist, particularly in western provinces. Future strategies should focus on balanced development by improving basic healthcare services, promoting equitable resource allocation, and enhancing targeted policy support for underserved regions. The online version contains supplementary material available at 10.1186/s12913-026-14426-0.