ArticleBMJ global health2026
Air pollution, urban environmental quality and health expenditures: evidence from industrial cities in Iran.
Article in BMJ global health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
introductionRapid industrialisation and urbanisation can worsen air quality and increase the financial pressure on health systems. However, city-level evidence on how fine particulate matter (PM2.5) and urban environmental characteristics relate to healthcare expenditures remains limited in middle-income settings.
methodsWe conducted an ecological panel study of 10 industrial cities in Iran (2011-2024). We assembled city-year data on per-capita healthcare expenditures and key urban characteristics from municipal statistical yearbooks and linked them to annual PM2.5 estimates. We fitted log-log panel models with city random effects and year fixed effects using robust inference. Sensitivity analyses included leave-one-city-out re-estimation and an alternative specification replacing income with the household-income Gini coefficient.
resultsPer-capita healthcare expenditures were positively associated with PM2.5 (elasticity=0.37; p=0.057), per-capita income (=0.18; p=0.020), population density (=0.28; p=0.010), and the share aged ≥60 years (=1.05; p=0.008). The association for green space was small and sensitive to specification (=0.05; p=0.034 in the baseline model and not statistically significant when lagged), while per-capita healthcare facilities were not statistically significant. In the inequality model, the Gini coefficient was positively associated with healthcare expenditures (p=0.002).
conclusionsHigher ambient PM2.5, urban density, population ageing and income inequality were associated with higher healthcare expenditures in this city-level panel analysis. These findings suggest that coordinated policies combining emission control, health-system strengthening (particularly preventive and primary care), and improved quality and equitable access to urban green infrastructure may help curb growth in healthcare spending in rapidly industrialising and urbanising settings.
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