In the early weeks of January 2012, a report of four cases of tuberculosis from Mumbai, India, stirred up a storm.1 India bears a giant's share of the world's multidrug-resistant tuberculosis (MDR-TB) burden, but these cases were different even though they came from a centre (Hinduja Hospital and Research Center) which has been reporting on the alarming escalation in drug-resistant TB in Mumbai over the last two decades. (Editorial)

Pakistan’s enormous macroeconomic, internal, and human security challenges coexist alongside the opportunity created by a huge desire for change. With democracy taking root and a new constitutionally ushered era in state governance, The Lancet Series about Pakistan and health focuses on health as a nation-building and social-welfare agenda at a time of unprecedented social upheaval and economic hardships in the country. We call for a unified vision for the goal of universal and equitable health access. We provide recommendations for six objectives for policy and action.

Globally, Pakistan has the third highest burden of maternal, fetal, and child mortality. It has made slow progress in achieving the Millennium Development Goals (MDGs) 4 and 5 and in addressing common social determinants of health. The country also has huge challenges of political fragility, complex security issues, and natural disasters. We undertook an in-depth analysis of Pakistan’s progress towards MDGs 4 and 5 and the principal determinants of health in relation to reproductive, maternal, newborn, and child health and nutrition.

Pakistan has undergone massive changes in its federal structure under the 18th Constitutional Amendment. To gain insights that will inform reform plans, we assessed several aspects of health-systems performance in Pakistan. Some improvements were noted in health-systems performance during the past 65 years but key health indicators lag behind those in peer countries. 78·08% of the population pay out of pocket at the point of health care. The private sector provides three-quarters of the health services, and physicians outnumber nurses and midwives by a ratio of about 2:1.