The autoregressive distributed lag (ARDL) in the form of Error Correction Mechanism (ECM) was used to verify the validity of the EKC hypothesis and the impacts of the variables in the short and the long run alike. Furthermore, the Toda-Yamamoto Granger causality test was carried out to identify the direction of causality between the variables. From ARDL-ECM estimation, the EKC was confirmed (inverted U-shaped curve between income growth and CO2 emissions) only in Argentina in the long run but not in Brazil and Chile. Based on the findings, renewable energy can have a great potential in reducing CO2 emissions in the future, but this advantage has not been fully exploited yet since a significant negative impact on CO2 emissions was only found in Chile. Also, the use of other less carbon-intensive energy sources such as natural gas and hydropower if they could be combined with renewable energy would be of great benefit and contribute to enhancing environmental quality and energy security in the short and the medium term and to successful low-carbon energy transition in the long run in Argentina, Brazil, and Chile.In this paper, the effects of economic growth and four different types of energy consumption  on environmental quality in terms of carbon dioxide (CO Accordingly, the country´s environmental quality will be getting worse and worse. Although the LAC region has one of the cleanest electricity mixes in the world thanks to the high share of hydropower in their electricity generation process,2 emitted by energy sectors has increased remarkably and it is expecting to keep growing by 132 percent between 2010 and 2050  mainly consists of middle- and low-income developing countries. Growing economy is a critical issue ahead of them to close the social gap with advanced countries and enhance standards of living by addressing high levels of poverty and income inequality prevailing in this region. However, economic growth is usually accompanied by more energy demand and energy consumption due to economic activities increasing. This implies that the more COSecond, LAC is highly vulnerable to extreme weather eventsBased on our observation and analysis, diversifying energy mix of LAC countries by incorporating more renewable energy sources  can be a good strategy to keep their economy growing without environmental degradation. This is because renewable energy brings about numerous advantages such as energy security in the sense that it contributes to reducing the high dependence on fossil fuels , increasing accessibility to energy for poor households in remote areas, reducing GHG emissions and consequent enhancement of environmental quality, taking attractions of foreign investments on energy sectors, and creating green jobs by investments on renewable energy deployment  hypothesis during the period of 1975–2018 was verified in 3 Latin American countries: Argentina, Brazil, and Chile, during the period of 1975–2018. They are selected on the basis of the reasons following. On the one hand, they represent the lion’s share of the Latin American economy due to their large size of GDP in the region.The main contributions of our study to existing literature are twofold.First, to the best of our knowledge, it is the first study that investigates the impacts of energy consumption in a disaggregated manner  for Argentina, Brazil, and Chile such that it allows us to examine more specifically the impact of each of them on environmental quality in the framework of the EKC. In previous studies of the impacts of energy consumption on environmental quality in Latin American region in the framework of the EKC  and trade openness, respectively, in these three countries. Why these two variables should be included in our estimation is that they are critically important to determining the level of COThe remainder of the paper is organized as follows. “2 emission levels begin to decrease, and after reaching a certain threshold income (turning point of EKC), the relation between economic growth and pollution level turns into negative. At this moment, lavish investments in innovative technology and green infrastructure are made to prevent environmental degradation which leads to further improvement in environmental quality. This is known as a technological effect.The formal analysis of the nexus between income growth and environmental degradation began with the study of Grossman and Krueger . AccordiRegarding validity of the EKC, there has been no consensus among the researchers. The estimation results differ largely across countries or regions, the time period considered, and econometric techniques used. Some researchers found evidence of the EKC relationship in both developed and in developing countriesIn relation to the LAC region, the presence of the EKC relationship is ambiguous. Some authors found only partial validation of the EKC. Albulescu et al.  investigNo evidence of the EKC hypothesis in the LAC countries was also confirmed in several studies. Zilio and Recalde  analyzed2 emissions) in the LAC region.However, Hanif  could ve2 emissions under the framework of the EKC. For trade openness, Ozatac et al.  both in the short and the long run and unidirectional causality from trade openness to carbon emissions. For agricultural lands, Gokmenoglu and Taspinar  and they also confirmed EKC hypothesis for Pakistan. Gokmenoglu et al. , in addition to agricultural land and trade openness as control variables in our regression model  as we can see in Fig. In Fig. In this section, we proceed to estimate the impacts of different energy consumption and economic growth on environmental quality in the framework of the EKC in Argentina, Brazil, and Chile. To this point, 3 models were estimated using the following equations:In model 1, we include only GDP, squared GDP, and different sources of energy consumption in our regression model while in models 2 and 3 we added agricultural land and trade, respectively, as our control variables to test the robustness of our estimation results.Our estimation process consists of six steps: unit root test, cointegration bounds test, ARDL-ECM estimation, postestimation tests, CUSUM and CUSUMSQ tests, and lastly the Toda-Yamamoto Granger causality test.To test formally the stationarity and the presence of unit root problem, we performed the Zivot-Andrews test  is very strong in Argentina, Brazil, and Chile. The As we can see in Table To estimate the short-run and long-run elasticities of variables, the ARDL-ECM was used. The ARDL method was first developed by Pesaran and Shin , and sinThree ARDL models used in our estimation can be written as follows:2pc (− 1), namely, To assess the speed of adjustment, namely, how fast the economy recovers from the shock and back to equilibrium and to estimate the short- and long-run elasticities . Regarding LnAgriland, it has a significant positive impact on carbon emissions in both the short and long run. In model 2, a 1% increase in agricultural land leads to an increase of CO2 emissions by about 0.52% and 0.46% in the short and long run, respectively, while in model 3, LnAgriland has short-term and long-term elasticities of 0.34% and 0.26%, respectively. Land use change, mainly due to the expansion of agricultural land and deforestation, is an important factor to be taken into account in terms of CO2 emissions in Argentina. This is because Argentinian economy relies heavily on commodity exports  and CO2 emissions caused by land use change are expected to keep growing in the foreseeable future. Regarding the ECT, it has a negative sign and statistically significant at 1% level in all three models. This shows that there is a long-run equilibrium relationship among the variables we used in our regression models, which supports the results of cointegration test implemented before. Furthermore, the coefficient of ECT tells us about the speed of adjustment. In Argentina, all three estimated models were found to have a relatively high speed of adjustment . This means that disequilibrium caused by shock is corrected in the following period by about 76.8%, 87.9%, and 79% in models 1, 2, and 3, respectively.BrazilIn the case of Argentina, we could confirm the validity of the EKC in the long run as the coefficients of LnGDPpc and LnGDPpc2 were positive and negative, respectively, in all three models we analyzed . In relation to LnHydropc, it has a statistically significant negative impact on carbon dioxide emissions both in the short and long run in all three models. In addition, we observed that the negative impact of LnHydropc on LnCO2pc was stronger in the long term than the short term as absolute values of the long-term elasticities were systematically greater than those of the short-term elasticities in all three models. This finding suggests that the generation of electricity from hydro energy sources keeps playing a key role in the decarbonization of the Brazilian economy in the future. Regarding LnRECpc, we found that it only has a significant impact on LnCO2pc in the long run in model 2. However, contrary to our belief, the long-term elasticity of LnRECpc had a positive sign (0.026) which means that a 1% increase in LnRECpc leads to an increase of LnCO2pc by about 0.026%. This result suggests that consumption of non-conventional and new renewable sources  still does not have a significant impact on the reduction in carbon dioxide emissions and more targeted energy policy is required to promote energy consumption from clean energy sources and to increase the share of renewables in energy mix in Brazil. Regarding LnAgriland and LnTrade, the estimation results tell us that they do not have significant impact neither in the short nor the long term in three models. Lastly, the signs of ECT were negative and statistically significant at 1% level in all models supporting the previous cointegration bounds test results. Also, we observed a high speed of adjustment in each model .ChileIn the case of Brazil, we found a U-shaped curve between economic growth and CO2 emissions in Chile is less than that of Argentina and Brazil. Regarding LnNGaspc, it has a significant positive impact on LnCO2pc only in the short run. With relation to LnHydropc, it has a negative impact on carbon emissions in models 2 and 3 in the long run  while in the short run it leads to a reduction in carbon emissions by about 0.087%, 0.115%, and 0.181% in models 1, 2, and 3 with a statistical significance level of 10%, 1%, and 1%, respectively, when LnHydropc increases by about 1%. With regard to LnRECpc, it has a negative sign and statistically significant at least 10% level in models 2 and 3 both in the short and long run  has a significant negative impact at 5% significance level). It is worth noting that Chile is the only one among the three countries in our investigation where renewable energy consumption has a significant negative impact on carbon dioxide emissions although the absolute value of its elasticities is relatively small in comparison with that of fossil fuels . Therefore, it is important that the Chilean government implements adequate energy policy such that it allows to keep promoting and providing incentives among the citizens in the use of renewable energy. Moreover, government should make efforts to facilitate the financing of large-scale renewable energy deployment and the integration of renewable energy sources in energy mix in short and medium term to fully enjoy its benefits in the long term. Regarding LnAgriland, we found an unusual large negative impact on CO2 emissions in the long run. The estimation results tell us that a 1% increase in LnAgriland leads to a reduction in LnCO2pc by about 2.009% and 2.616% in models 2 and 3, respectively. If we compare the impact of LnAgriland on carbon emissions in Chile with that in Argentina and Brazil, the difference between them is very clear . This result may suggest sustainable agricultural practices carried out in Chile in comparison with Argentina or Brazil during the period of our study. Regarding LnTrade, it leads to an increase of LnCO2pc by about 0.125% and 0.174% in the short and long run, respectively, when there is a 1% increase in LnTrade. Lastly, ECT(− 1) tells us that there is a long-run equilibrium relationship among the variables in our regression models since it has a negative sign and statistically significant at 1% level. Moreover, we could observe that the speed of adjustment of three models in Chile is relatively slower if we compare ECT(− 1) of Argentina and Brazil meaning that, when the shock takes place, the Chilean economy returns to its equilibrium level at slower pace than Argentinian or Brazilian case.In the case of Chile, we found a U-shaped curve relationship between economic growth and carbon dioxide emissions in models 2 and 3 in the short and long run . Regarding energy consumption, LnOCpc exerts a positive effect on carbon dioxide emissions both in the short and long run. However, we noticed that the elasticities of LnOCpc were systematically lower in comparison with Argentina and Brazil . In other words, the negative impact of oil consumption on environmental quality in terms of COAfter the estimation of our models by using ARDL-ECM technique, we carried out postestimation tests to see whether the models estimated are well behaved  was examined.After having confirmed the cointegration relationships among the variables by means of cointegration bounds test and having estimated the short- and long-run effects by using the ARDL-ECM method, the last step of our analysis consists in determining the direction of causality between the variables with the help of the Toda-Yamamoto Granger causality test. The advantage of using this test is that it can be used regardless of stationarity of the variables, so we do not need to transform variables into the first differences in case the variables are not stationary at levels. In the Toda-Yamamoto Granger causality test, we exclusively centered our attentions to two different directions of causality relationships: on the one hand, the direction of causality between LnCO2pc was Granger caused by economic growth (proxied by LnGDPpc), LnOCpc, LnNGaspc, and LnHydropc. We also found a bidirectional relationship between LnAgriland and LnCO2pc. This finding supports our previous estimation results that both economic growth and energy consumption contribute importantly to carbon dioxide emissions. Regarding the direction of causality between economic growth and energy consumption, both LnOCpc and LnNGaspc are Granger caused by economic growth (conservation hypothesis) while in the case of LnHydropc and LnRECpc growth hypothesis was being fulfilled, namely, country’s income level determines energy consumption from hydroelectricity and renewable energy. In the case of Brazil, we found a unidirectional causality running from LnGDPpc, LnRECpc, LnAgriland, and LnTrade to LnCO2pc. It is worth noting that we could not find any evidence of the causality relationships between LnOCpc and LnHydropc with LnCO2pc which is quite surprising since according to our previous ARDL-ECM estimation both oil and hydroelectricity consumption had a significant impact on carbon dioxide emissions in both the short and long term. In relation to the nexus energy consumption-economic growth, the conservation hypothesis was met for LnOCpc and LnRECpc; in other words, there is a unidirectional causality running from per capita oil consumption and per capita renewable energy consumption to economic growth. Besides, we observed that LnAgriland had a bidirectional causality relationship with economic growth. In the case of Chile, LnCO2pc is Granger caused by LnHydropc and LnRECpc which is consistent with our ARDL-ECM estimation results obtained previously. However, we could not verify the causality between economic growth and LnOCpc with LnCO2 as in previous ARDL-ECM estimation. In relation to economic growth, we found that LnAgriland, LnNGaspc, LnHydropc, and LnRECpc Granger cause LnGDPpc. In the case of the latter, bidirectional causality relationship was also confirmed. Lastly, we could observe conservation hypothesis between LnGDPpc and LnOCpc, in other words, a unidirectional causality running from economic growth to oil consumption.As we can see in Table To avoid catastrophic consequences of global warming, more efforts should be made to reduce carbon dioxide emissions known as the major factor precipitating global warming. For developing middle-income economies such as LAC countries, the energy demand and the use of natural resources are expected to be highly demanded in the process of their economic growth, which stimulates increase in carbon emissions and waste leading to environmental degradation. To alleviate the negative impacts of economic growth on environmental degradation and achieve a climate resilient, inclusive economic growth in the LAC region, a transition from polluting energy sources to clean energy sources might be a good strategy to achieve the goals mentioned above. In this study, we thoroughly examined the impacts of economic growth, consumption of four different types of energy sources, namely, oil, natural gas, hydroelectricity, and unconventional renewable energy , in addition to agricultural land and trade openness as control variables on environmental quality in the framework of the EKC for a set of 44 year time series data (1975–2018) of 3 LAC countries: Argentina, Brazil, and Chile based on the recognition of the importance decoupling economic growth from environmental degradation and of the critical role energy consumption patterns play in the evolution of the economy in terms of carbon dioxide emissions.2 emissions. This result suggests that the evidence of the EKC is not robust in these three economies, and especially in the case of Brazil and Chile, the careful attention should be paid to monitor the evolution of CO2 emissions in the long run since it also shows an increasing trend as the economy grows after having reached a certain threshold level of income. In relation to the impacts of consumption of four different types of energy on environmental degradation, fossil fuel sources, especially oil, were found to have a strong positive impact on CO2 emissions in Argentina, Brazil, and Chile in both the short and long run. As for natural gas, its consumption leads to an increase in CO2 emissions in three countries together  but it has a significantly lower impact on environmental degradation than oil consumption as both the short and long-term elasticities of consumption of natural gas with respect to CO2 emissions are quite lower than those of oil in absolute values. This finding implies that natural gas might be served as an intermediate backup energy source good enough in the short and medium term on the way to their low-carbon energy transition (shift from dirty energy sources to clean renewable energy sources) which ultimately aims at reaching net zero carbon emissions target by 2050 documented in the Paris Agreement in 2015. That is because natural gas emits significantly less amounts of CO2 in comparison with other fossil fuels such as coal and oil and it can support and complement renewable energy sources as backup energy even when intermittence issue is present. However, careful attention should be made by governments to avoid potential lock-in fossil fuel-based technologies and path dependence in the long run as use of natural gas might discourage investments in renewable energy deployment and could become a stumbling block to innovation in clean energy technology. Regarding hydroelectricity consumption, it contributes to reducing CO2 emissions in Brazil and Chile in both the short and long run while in Argentina its meaningful impact is not manifested . This finding emphasizes that hydropower will continue to play an important role in reducing CO2 emissions in Brazil and Chile in the future and also combining with another clean energy sources such as the renewables could help to enhance energy security in terms of diversification of energy mix and responding to growing energy demands caused by population growth and economic activities in these economies. With respect to renewable energy consumption, only in Chile, we could verify a significant negative impact on CO2 emissions in models 2 and 3 in the short and long run  while in Argentina and Brazil renewable energy consumption had a significant impact only in the long run , but unlike our expectation, it had a positive sign, so in this regard, significant efforts should be made by governments to increase the share of renewables in the primary energy consumption in their economies. It would be a challenging issue for governments to find feasible approaches to achieving the goals. One possible approach we suggest is to increase awareness to the benefits of using renewable energy sources among consumers . Another approach we suggest is based on making customers change their behaviors in using energy sources through carbon pricing and gradual elimination of subsidies to fossil fuels which are already high in these economies (the revenues obtained from the former can be used to provide more targeted support to low-income households affected by the latter).According to the estimation results of ARDL-ECM, we only could verify the EKC hypothesis (inverted U-shaped curve) in Argentina in the long run but not in the others, Brazil and Chile, where the U-shaped curve relationship was found between economic growth and CO2 emissions along with their economic growth in Argentina, Brazil, and Chile on the basis of the conservation hypothesis saying that the reduction in oil consumption does not hinder economic growth in these countries. Furthermore, our findings recommend that energy consumption from natural gas, hydropower, and renewables leads to economic growth in Argentina and Chile ; thus, increased energy consumption of these 3 energy sources might help to boost economic growth along with achieving environmental protection goal in Argentina and Chile.Regarding the direction of causalities between economic growth and energy consumption, the Toda-Yamamoto Granger causality test tells us that there is a unidirectional causality running from LnHydropc to LnGDPpc (growth hypothesis) while for the opposite direction, namely, a unidirectional causality running from economic growth to energy consumption was found in LnOCpc and LnRECpc, respectively (conservation hypothesis) in Argentina. In Brazil, we could verify the conservation hypothesis in LnOCpc and LnRECpc. In Chile, we found that conservation hypothesis held for LnOCpc while the growth hypothesis was found to be valid for LnNGaspc, LnHydropc, and LnRECpc. These findings tell that oil consumption can be drastically reduced and replaced by other clean energy sources with significantly less CO2 emissions and boosting economic growth in the LAC region.In our study, we considered renewable energy consumption in its entirety without specific considerations on types of energy sources in separate: solar, wind, geothermal, and bioenergy. For further investigation, more specific and sophisticated approaches are required to clarify the effects of specific renewable energy sources on carbon emissions and their nexus with economic growth in LAC countries. Also, more studies are expected to investigate the impacts of adopting abatement technologies such as Carbon Capturing Utilization and Storage (CCUS) and digital technologies and their potential synergistic impacts with renewable energy consumption on reducing CO


Universal Health Coverage (UHC), initiative from the World Health Organization (WHO), is a means to provide the human right to health by providing essential health services to everyone, enabling disease prevention, treatment, rehabilitation, and palliative care. In line with the WHO recommendations, the UHC was first introduced in Pakistan in Khyber Pakhtunkhwa (KP) province under the name ‘Sehat Sahulat Programme’ (SSP), literally ‘Health Facility Program’ in 2015. The provincial Government in Punjab approved a similar initiative in Punjab, the largest province (by population) of the country, and the program was later rolled out in Islamabad Capital Territory (ICT), Azad and Jammu Kashmir (AJK), Gilgit Baltistan (GB), Sindh, and Baluchistan provinces leaping into the nation-wide coverage. This article provides a current overview of the UHC initiative in Pakistan, analyses its progress in appraising key milestones, and makes recommendations to achieve a robust universal health coverage across Pakistan. Nearly half of the world’s population is unable to access basic health facilities due to the enormous cost of health services. More than 930 million people spend more than 10% of their household income to access health services. More than 100 million people are pushed into extreme poverty every year due to expenditure in acquiring necessary healthcare [In the last decade, there has been much emphasis on the institutions, organizations, physical, financial, and human sources integrated with health services that could meet the health care need of the population. It is estimated that 95% of maternal and child deaths occur in 75 low and middle-income countries (LMICs) that have only 62% of the trained health care workers . Non-comUniversal Health Coverage (UHC), initiative from the World Health Organization (WHO), is a means to provide the human right to health by providing essential health services to everyone, enabling disease prevention, treatment, rehabilitation, and palliative care. The delivery of the services mentioned above require competent and skillful health care workers and a supportive workplace to provide necessary health services effectively. In UHC, every citizen can access necessary healthcare to treat diseases and are protected from the out-of-pocket health expenditures. UHC has been the target of the nations under the umbrella of sustainable development goals (SDGs) since 2015. In 2019, the participating countries ensured the implementation of UHC in the United Nations’ high-level meeting on this subject. The delivery of essential health services to more than one billion people has also been one of the WHO strategic goals for 2022. Under this program, one billion people worldwide needed access to standardized health services every five years from 2015 to 2030. The UHC from WHO will be fully aligned with SDG indicator 3.8.1 , calculated based on tracer interventions for reproductive, maternal, newborn, and child health; infectious diseases; and noncommunicable diseases, for which the data were already available. Their work on UHC focuses on achieving UHC, including financial risk protection, access to essential healthcare services of acceptable quality, and access to safe, effective, and affordable essential medicines and vaccines for all.With the active participation of the World Bank, WHO has developed an effective model to track the progress of UHC considering (a) the proportion of the population that can access healthcare services, and (b) the proportion of the population that spends a considerable amount of household income on healthcare .WHO has, therefore, divided UHC into sixteen essential healthcare services under four major indicators. The first indicator is reproductive and newborn health. In this indicator, the reproductive health of the population was provided, including family planning. Antenatal and delivery care was also included in this domain. Moreover, after childbirth, immunization care and subsequent complications such as prevention and treatment from pneumonia care were also included. The second indicator was infectious diseases treatment. In this indicator, infectious diseases such as tuberculosis, human immunodeficiency virus (HIV), prevention techniques against malaria, and sanitation techniques were stressed. The third indicator was non-communicable diseases. Hypertension, diabetes mellitus, cervical cancer, and smoking-related healthcare services are included in this indicator. In addition, health screening, disease prevention, and treatment facilities were also included. Finally, the last indicator was the health services capacity and access. This indicator stressed the availability of basic-level hospitals, appropriate healthcare worker population, access to essential medicines, and health security according to the international norms and regulations .Reich et al. previously classified four distinct groups of LMICs at different points along the UHC ladder; the first group is comprised of countries  which are struggling to integrate the UHC agenda within their national policy, and thus are found at the bottom of the UHC ladder; the second group is comprised of countries  with noticeable progress toward UHC that are still experiencing huge gaps in the coverage; the third group is comprised of countries , who have attained the key UHC goals but are struggling to sustain . FinallyThis article provides a current overview of UHC initiative in Pakistan, analyses its current progress in appraising key milestones, and makes recommendations to achieve robust universal health coverage across Pakistan.Pakistan, a low to middle-income country (LMIC) in the South Asian region, has a population of more than 220 million . PakistaHistorically, Pakistan has poor health outcomes amid poor quality of public health facilities, limited access and utilization of health services, poor quality of care, and limited accountability in the public sector. Health indicators such as neonatal mortality rate, infant mortality rate and maternal mortality ratios were among the worst in most rural districts of Pakistan, which constitutes the majority of the population in Pakistan. Only a fraction of the women has access to postnatal care within health center for at least 12 h following birth, with a significant number of births still taking place outside health facilities . The heaIn line with the WHO recommendations on UHC, the provincial government of the Khyber Pakhtunkhwa (KP) first started the ‘Sehat Sahulat Program’ (SSP), literally ‘Health Facility Program’, under the umbrella of Universal Health Coverage (UHC) in 2015. Under this initiative, the ‘Sehat Insaf Cards’ were issued to the family in three phases to extend the coverage throughout the KP province. The objective of the SSP was to provide healthcare to more than 4 billion residents in all 35 districts of the KP province . Under tThe State Life Insurance Corporation (SLIC) administers the SSP program in Pakistan. It is fully subsidized by the government, which pays a fixed premium per eligible family to the SLIC, who then manages the in-patient healthcare expenditure of the registered users. Under the arrangements, ninety per cent of any unspent net premium is refunded to the government at the end of the three-year contract .The actuarial analysis of the SSP was commissioned by the Deutsche Gesellschaft fur Internationale Zusammenarbeit (GIZ) on behalf of the Government of Germany . The anaThey also studied the impact of demographics  on the incidence rates , cost of claims and the length of hospital stay. It was noted that the incident rates were surprising compared to both the developed (OECD/EU) and new economies (Thailand and Mexico), hence were the key determinant of the claim costs and expenses. The project premiums were based on target populations and UN census data; therefore, the significant changes in the age, sex, or geographical locations can have enormous implications for the claim costs and premiums.The indicative premium was projected as Rs. 1755 per family per annum for the three years from 2019 to 2021 . Using the stress testing model, a −5 to +46% variation in premium was considered up to a maximum of 146% if the utilization were to increase when the scheme matures. This led to a range of Rs. 1674 to 2569 ($9 to $14) per family per annum, discounting the extreme scenario. The report acknowledged that the scheme is likely to go into rapid expansion and the ‘risk premium’ will be insufficient to cover the expected claims and would require an increase for the 2019–2021 period. The pooled financial resources and risks in a unified program are likely to reduce the statistical variability. The report recommended regular monitoring of incidence rates and key variables such as family size and detailed reanalysis biennially. The current model was mainly based on fee-for-service reimbursement of hospital bills, where the report emphasized introducing alternative payment mechanisms to identify inconsistencies and potential fraud. The actuarial analysis was primarily aimed at identifying financial risks by modeling and assumptions that were critical to managing the financial risks. It was, therefore, aimed to maintain the financial sustainability of the program to ensure that upon expansion, an increasing number of citizens will have access to affordable and quality healthcare in Pakistan.The success of UHC in its preliminary phase has resulted in its expansion to the country’s largest province (by population), with the Government of Punjab allocating Rs. 65 billion to implement SSP on 9 December 2020, with plans to provide a ‘Sehat Insaf Card’ to families in all 36 districts across Punjab . Punjab’Furthermore, on 28 December 2020, the Prime Minister (PM) of Pakistan announced the extension of the SSP program to the people of Azad Jammu and Kashmir (AJK) in more than 350 eligible hospitals in Pakistan; over a million families were expected to benefit from this initiative .Currently, the SSP only provides coverage to the families living below the poverty line, i.e., earning less than $2/day, equivalent to 32.5 poverty means test scores from the National Socio-economic Registry (NSER) of Pakistan  that wasThe persons with disabilities and transgender people on the register of the National Database and Registration Authority (NADRA) across Pakistan were offered universal access to the SSP. The program covered a wide range of secondary and tertiary care in hospitals . The proAs of 8 March 2022, over 27 million families are registered with the program across different provinces in Pakistan . In addiThe rollout in the province of Sindh was lately started, with SSP was offered initially in eight districts, mainly across rural Sindh, benefitting over half a million families. However, the full provincial rollout was still awaited. Sindh is the second-largest economy in Pakistan after Punjab. Karachi, the most populous city and the main financial hub of Pakistan is the provincial capital of the Sindh. It is a significant part of Pakistan’s industrial sector and contains two of its major commercial seaports. Most of the interior Sindh is an agriculture-based economy.Baluchistan, situated in the southwest of Pakistan, is the largest province of Pakistan geographically but is the least populated. It is a provincial capital, and the largest city is Quetta. The provincial economy is dominated by natural resources, mainly natural gas. Baluchistan is also home to the Gwadar port on the Arabian sea, which has major economic importance. The Baluchistan province is also lagging, with the program being rolled out across six districts with over a hundred thousand families initially registered.The provincial governments in Sindh and Baluchistan subsequently withdrawn their funding but hope to rejoin the national drive soon to enable their residents to benefit from the universal health coverage enabling Pakistan to meet the WHO milestones by 2023 . In addiThe program has expanded across Punjab province at a very fast pace, particularly extending the coverage to the southern region that has been underprivileged for a long period, with recent extensions to Bahawalpur, Faisalabad, and Multan divisions and further extensions planned in Gujranwala and Sargodha by the end of March 2022, offering coverage to 30 million families in Punjab only .Following constitutional reforms in 2010, health services was devolved into provincial administration with an aim to provide equitable health access to all citizens of Pakistan, and fairness in health financing and responsiveness to healthcare needs at a local level . The fedUnfortunately, Sindh and Baluchistan governments did not fund the UHC initiatives provincially, a major hindrance in offering UHC to ~60 million citizens resident in Sindh and Baluchistan constituting ~30% of Pakistani population. It is, however, hoped that the provincial governments will start their own provincial initiatives , leadingOne of the key limitations of the program repeatedly complaint about by the families is the incompatibility of the costs of treatment in private sector hospitals and caps within the system; many patients were turned away without any treatment when the family was unable to pay the difference. There had been reports of families travelling from remote districts to provincial capitals for specialized treatments such as chemotherapy and have been denied due to incompatibility between the treatment costs and financial limits set in the system . This woAs the program expands further into urban districts, the risks mitigation strategies recommended by the actuarial analysis are necessary. The higher incidence rates and claims are likely to outpace premiums creating a financial deficit for the state insurer, which would need subsidiaries from other insurances or governmental fundings that may put the whole program at risk.It was also suggested that extending the program to include private insurers could be beneficial in mitigating the risk in addition to increasing the capacity. The inclusion of private insurers can also help control tiered pricing structure from private hospitals and care providers, where state insurer is at risk of paying more than the over-the-counter price for a private patient. However, the rapid expansion without increasing the capacity and institutional negotiated pricing structure, the potential financial deficit may threaten the long-term sustainability of the program .UHC, initially introduced in Pakistan in Khyber Pakhtunkhwa (KP) province, has rapidly spread nationally, currently providing universal access to healthcare to all families currently domiciled in KP, AJK and Tharparkar district (Sindh), transgenders  and peoples with disability , irrespective of their financial status. The facility is also available to eligible families domiciled in GB and ICT regions, with plans to expand the coverage in GB to universal access in the next phase. The families in Sindh and Baluchistan at large are unable to benefit from the program; however, the Sindh government is already considering to launch their own provincial initiative. The key limitations and challenges that the program currently faced mainly include the incompatibility of the costs of treatments and reimbursement caps and the restricted availability of health facilities and treatment options in rural districts. As the program expands rapidly, the risk mitigation strategies are necessary to avoid a financial deficit amid higher incidence rates and claims outpacing premiums. These strategies may include subsidiaries from other insurances or governmental fundings, inclusion of private insurers, tiered pricing structure and negotiated reimbursement rates with private sector at or below the over-the-counter price. It is feared that a rapid expansion without an adequate increase in the capacity and institutionally negotiated pricing structure could lead to a potential financial deficit, which may threaten the long-term sustainability of the program. Nonetheless, UHC in Pakistan has already shown to increase access to quality healthcare for the most vulnerable in the society and to reduce health disparities. The sustainability of these achievements will require the commitment and continual efforts of all key stakeholders in the government and the private sector.


In the second stage of the Electronic Health Record Sharing System (eHRSS) development, a mobile app  was launched to further enhance collaborative care among the public sector, the private sector, the community, and the caregivers.This study aims to investigate the factors associated with the downloading and utilization of the app, as well as the awareness, perception, and future improvement of the app.P<.20) will be included in a subsequent multivariable regression analysis model. All P values ≤.05 will be considered statistically significant in multiple logistic regression analysis. The structural equation modeling was performed to identify interactions among the variables.We collected 2110 surveys; respondents were stratified into 3 groups according to their status of enrollment in the eHRSS. The primary outcome measure was the downloading and acceptance of the eHealth app. We collected the data on social economics factors, variables of the Technology Acceptance Model and Theory of Planned Behavior. Any factors identified as significant in the univariate analysis (P<.001). Attitude  and perceived norm; β=.37; P<.001) played important roles in determining behavioral intention, which could predict the downloading and acceptance of the eHealth app .The respondents had an overall high satisfaction rate and a positive attitude toward continuing to adopt and recommend the app. However, the satisfaction rate among respondents who have downloaded but not adopted the app was relatively lower, and few of them perceived that the downloading and acceptance processes are difficult. A high proportion of current users expressed a positive attitude about continuing to adopt and recommend the app to friends, colleagues, and family members. The behavioral intention strongly predicted the acceptance of the eHealth app (β=.89; Despite the high satisfaction rate among the respondents, privacy concerns and perceived difficulties in adopting the app were the major challenges of promoting eHealth. Further promotion could be made through doctors and publicity. For future improvement, comprehensive health records and tailored health information should be included. In Hong Kong, a substantial proportion of hospital services is provided by the public sector  and up to 70% of the outpatient services are offered by the private sector . In viewIn stage 2 development, a mobile app, an “eHealth app,” was launched in January 2021 . It faciAcross the world, similar mobile health apps were developed for people to upload and view health records, manage personal health care activities, share clinical information with doctors, and improve public health. Apps such as “Capzule PHR,” “Health and Family,” and “Health Notes” allow patients to view and get access to their medical information and record their data at any time and any place through the internet or by offline access . The govTo further promote quality and efficiency, as well as to recommend the future development of the mobile  app, perceptions and views from users are required to inform a more system-friendly design. The objectives of this project are to evaluate the factors associated with the downloading and utilization of the eHealth app; to examine the awareness, use, and acceptability of the mobile eHealth app; to explore whether eHealth app use may be associated with the joining of the eHRSS; the reasons for nonuse among those who joined the eHRSS; the extent to which the app improves user experience and influences health service utilization; and to recommend a potential room for improvement of the eHealth apps.A self-administered questionnaire was adopted in this study. Prospective study participants were based on a list of patients provided by the HA. A simple random sampling methodology was mainly used. Over 5.5 million existing eHRSS users were included in the population, and computer-generated numbers were listed correspondingly for participant recruitment. An invitational SMS was first sent by the HA to existing eHRSS users. This served to alert the participants that they would receive a subsequent survey invitation by Chinese University of Hong Kong via SMS . Then reSurvey items focused on the awareness, use, and acceptability of the eHealth app; the association between the use of the eHealth app and the joining of the eHRSS; the reasons why some users did not use the eHealth app after joining the eHRSS; the extent to which the eHealth app improved user experience, modified health service access, and health management; and recommendations for possible improvement of the eHealth app. The surveys were designed by an academic physician with relevant experience in projects related to the eHRSS, and extensive expertise in both clinical and public health research studies. The questionnaire draft was face-validated by a panel of epidemiologists, biostatisticians, and professionals in the field of health care policy, public health, and primary care. It was subsequently pilot tested for feasibility and item comprehensiveness among 20 people. The completion rate was 65% (13/20), and the average response time was 7 minutes and 40 seconds .The surveys were available in both Chinese and English versions. All surveys were anonymous, and written consent was provided by the participants at the start of the questionnaire. The study participants were informed that all information presented would be in the form of aggregated data that could not identify any individuals.This study was approved by the Survey and Behavioral Research Ethics Committee of the Chinese University of Hong Kong .P<.20) will be included in a subsequent multivariable regression analysis model. All Pvalues ≤.05 will be considered statistically significant in the multiple logistic regression analysis. Assuming the proportion of the primary outcomes was 50%, which would provide the largest sample size, a total of 2110 surveys would result in precision of approximately 2.2%. In addition, we performed structural equation modeling to identify interactions among the variables.All surveys were checked for their completeness and the presence of participant consent. All data entry and analysis were conducted using SPSS version 26.0 . As part of quality control, at least 20% (422/2110) of all surveys were randomly checked for the validity, quality, and accuracy. All items in the survey were analyzed as stratified according to the status of enrollment. The primary outcome measure was the downloading and acceptance of the eHealth app. We tested for the presence of statistical association by identifying potential associated factors using univariate and multivariate regression analyses. We included age, gender, educational level, job status, monthly household income, the types of mobile phone operating systems currently in use, the eHRSS enrollment status, perceived enablers of acceptance, and perceived barriers of the eHealth app use. Any factors identified as significant in univariate analysis , which was first developed by Fred D Davis, Richard P Bagozzi, and Paul R Warshaw . It is aP values ≤.05 were regarded as statistically significant.Furthermore, we employed the Theory of Planned Behavior (TPB), a commonly used psychological theory that links people’s beliefs and behaviors . The undA total of 2110 completed surveys were collected . OverallParticipants were classified into several groups according to downloading and acceptance of the eHealth app . A totalThe COVID-19 vaccination program , medical doctors , publicity , and friends or family members  were the 4 major sources of information about the eHealth app among respondents . We did In group 1, the majority of participants agreed that the app can show their accurate vaccination records  and other health records . They also expressed that the app provides useful administrative functions, including giving consent to health care providers for sharing their data , easier management of eHealth accounts , and empowerment of their family members and own health . A similar result was also noted in the other 2 groups  and 3.Among the study participants in group 1  and 5, tThe proportion of participants in group 1 who were positive about the downloading and acceptance processes was in general higher than those in group 2. Most respondents in group 1 were satisfied with the downloading processes , appointment records , medication records , allergy records , and health management  were the top 5 useful functions among the users . These pTurning to the perception of the app , a high A high proportion of group 1 respondents, current users, expressed a positive attitude about continuing to adopt  and recommend the app to friends, colleagues, and family members ; had attained secondary educational level ; reported being able to view their accurate health records ; reported being able to show the vaccination records or QR codes ; and reported one’s physician had not joined the eHRSS  and participants who were concerned about personal information and privacy  were significantly less likely to download the eHealth app.Respondents were more likely to download the app when they had joined the eHRSS  were more likely to adopt, whereas individuals with primary educational level or below  and study participants who were uncertain about the benefits of the eHealth app  or perceived the downloading procedures as complicated  were less likely to adopt  and behavioral intention  were determined by perceived ease of use. The behavioral intention strongly predicted the acceptance of the eHealth app . Age  and whether the participant is a student or not  predicted the perceived usefulness. However, perceived usefulness did not significantly predict behavioral intention  and subjective norm  played important roles in determining behavioral intention, which could predict the downloading and acceptance of the eHealth app . The downloading and acceptance of the eHealth app could also be predicted by perceived behavior control . For the 3 core predictors, attitude was predicted by the subjective norm  and perceived behavior control . Subjective norm was predicted by attitude  and perceived behavior control . Perceived behavior control was predicted by attitude  and subjective norm (β=.27; P<.001; Turning to the TPB, attitude (β=.30; Overall, the satisfaction rate among the respondents was high. The satisfaction rate among group 2 respondents was relatively lower, and few of them perceived the downloading process as complicated. The willingness to continue to use and recommend the app was strong among all respondents. The 3 major enablers of adopting the app were the viewing of health records, especially the vaccination record; managing their eHealth accounts and sharing consent; and managing their family members’ and their own health. However, respondents of the 3 groups had different perceived barriers. These include one’s physician had not joined the eHRSS or had not recommended the eHealth app to them, a complicated downloading process, and privacy concerns. Most of the respondents expected to access more health records in the app, such as laboratory results and radiographic images, and have more personalized health information and health tips based on their age groups and health condition.This study has a few limitations. First, the survey was cross sectional, and so only the correlation could be measured instead of the causal relationship with the possibility of reverse causality. To corroborate the enablers and barriers, prospective longitudinal studies are required. In addition, face validity rather than construct validity was applied in the design of the questionnaire. The consistency reliability of the survey measurements has not yet been evaluated. Besides, some variables that could affect the downloading and acceptance of eHealth app may not be discussed in this study. Hence, there was a possibility of residual confounding. Finally, the study focused on acceptance of the app and examined individual factors affecting its use, which was based on a more individual level by using the TAM and TPB models in study design and analysis. Referring to Shachak et al’s  study oneHealth app provides accurate and quick retrieval of clinical details for the citizens, as well as a platform for citizens to record self-monitoring health data. Thus, the app also facilitated the work of health care professionals with the integration and sharing of health records ,7. A medSimilar to our previous studies in 2020, many participants learned about the eHRSS from others, including medical doctors, posters, television, and outdoor advertisement ,21. HoweThe participation of doctors was decisive to encourage the citizens to download and use the eHealth app. Our previous study in 2020 found that the actual use of the eHRSS among patients was also significantly associated with the enrollment among physicians . Giving Privacy was an important perceived barrier to the acceptability of the eHealth app. The respondents in group 3 were worried about their personal information and privacy. As supported by international studies, privacy was a common concern raised by the public about eHealth technologies , especiaMore assistance and support should be provided regarding the perceived difficulties in using mobile apps. To enhance the acceptance rate among people who have not adopted or downloaded the app, the utility and benefit of the app should be emphasized among the public. We suggest further promoting the app through doctors by sharing the benefits of health management in using the app with the citizens. For future development, more sharable scope of the health record, such as laboratory results and radiographic images, and customized health information, including age-specific health care recommendations and tailored health tips, should be included.Regarding the perception of difficulties in using mobile apps, the user interface and user experience should be further enhanced. The acceptance of the eHealth app requires a certain level of technology literacy and a fair understanding of digital technology . To haveRegarding the privacy issue, the security and privacy measures applied to the eHealth app should be reinforced. Further, it is an effective way to ensure widespread participation in the eHealth app by emphasizing the utility and benefits of the app ,32. The In our findings, doctors had an important role in determining people’s acceptance of the app. Doctors could recommend citizens managing the eHealth account and sharing function, which were the top-rated perceived enablers. The app could also improve the workflow of the doctors by allowing them to access patients’ health records that have been shared in the eHRSS. Doctor was an important source for citizens to acknowledge the eHealth app. Therefore, it was also important to introduce the eHealth app to doctors and health care providers, encourage them to manage patients’ health, and facilitate comanagement by patients and their family with the assistance of the eHealth app.For future improvement, personalized and age-specific health care recommendations should be provided to facilitate a more patient-centered eHealth app . Health Overall, the respondents had a high satisfaction rate and a positive attitude toward continuing to adopt and recommend the app. The eHealth app seemed to empower citizens and their family members by enhancing their health information, self-management strategies, and experience with health services. However, privacy concerns and perceived difficulties in adopting were the major challenges of promoting eHealth. More comprehensive health records and tailored health information were recommended to be included for future improvement.


The European Union (EU) labor market needs a better-skilled workforce that can work in any of the Member States. In order to develop the skills and competencies of future competitors in this market, several student mobility programs have been set up in the EU, where they can travel to universities in partner countries to further their studies and enrich their academic performance, culture and knowledge. The best known of these programs is ERASMUS (European Region Action Scheme for the Mobility of University Students). Because Romania also participates in this program in the exchange of university students, the authors wanted, through this study, to highlight the benefits and challenges of participation in the program, to analyze how international mobilities are emotionally perceived by students and what are the behavioral reasons that determine Romanian students to choose a certain university as a study destination abroad. For this purpose, the authors conducted quantitative marketing research among students from the Transilvania University of Brasov who have been abroad with ERASMUS scholarships. The research results show that an important component in choosing a certain university is not the financial expense during the mobility as might have been expected, but rather the initial desire to study abroad. Students also consider the improvement of their academic performance as an equally important reason for embarking on mobility to the social aspect of getting to know other cultures. In recent years, the international mobility of students has become an important goal, whereby learners shape their formation in different environments, in a foreign language and benefit from a cross-cultural experience . Today, The ERASMUS program, established in 1987, represents a part of the European Commission’s initiatives in higher education. The program is partially funded by the European Union and is very popular with university students. The ERASMUS program is based on written collaboration agreements between universities, as stated by Derzsi et al., 2011 .Given that Romania is also part of the ERASMUS student mobility program from the 1998–1999 academic year and that the flow of university students to and from Romania has steadily increased, the authors of this paper are entitled to identify the behavioral perceptions of Romanian students participating in this type of mobility, regarding the reasons why they chose a certain university, what emotional challenges they encountered during the mobility, how they adapted in the country where they left, etc.Improving the mobility process is an important goal of the European Higher Education Area and a priority of the European Union for the modernization of higher education, society, as well as the improvement of educational policies. Mobility is also paramount for the professional development of university students, their academic performance and for enhancing their empathy toward international skills and cooperation.This study analyzes the overall picture of the mobility of higher education students from an academic and socio-economic perspective. The paper focuses, in particular, on the factors that attracted university students to participate in such a program and on identifying the emotional challenges, behavioral problems and necessary resources encountered during mobility, trying to understand the costs of such mobility and how the academic performance in another international university is assessed in comparison to the home university .The authors conducted an opinion poll among students at the Transilvania University of Brasov who benefited from ERASMUS mobilities in universities in the EU. The survey was conducted on the basis of a questionnaire, and a computer-assisted interviewing (CAWI) technique was used to collect the data. This technique implies displaying the questionnaire on a certain website, and, subsequently, respondents complete the answers to the questions in an online manner.The results of the research show that monthly financial expenses during mobility are not an important component when choosing a university for a scholarship abroad. The cost of mobility influences the choice of the host university only in 12.5% of cases. However, a fairly high percentage (90.18%) of respondents stated that they had additional financial resources during their mobility. The main reason why university students choose ERASMUS mobility (regardless of gender and study cycle) is the desire to study abroad. They also opt for the mobility to enhance their academic performance in the same vein as getting to know other cultures. The reputation of the host university ranks significantly higher for Master’s students compared to Bachelor’s students. The major emotional challenge consists in coping with different teaching and examination methods, while the number-one success factor of the mobility (90% of cases) is considering the student–teacher relationship.Cooperation to foster development in the field of university education has become possible on a larger scale with the enlargement of the European Union and the desire to achieve a strong educational area to compete with other regions of the world . The enlThe need and importance of student mobilities arise from the requirements of the labor market toward high-skill jobs, the international competition for talent and the desire to curb youth unemployment. ERASMUS mobilities are perceived to enhance the knowledge, skills and academic performance of university students, thereby raising employability and responsible citizenship. As a consequence, they became one of the central elements of the European Commission’s strategies in the area of education.As observed in the Berlin Communique (2003), student mobilities embrace several different real-life dimensions: political, social, economic, as well as academic and cultural ones .During the years of implementation of the Bologna Process, recent times brought a shift in the way the value of mobility was assessed, with increased attention awarded to the importance of mobility for employability. Thus, it was considered that benefits reach beyond academics and culture to foster positive developments in the European labor market .Indeed, EU officials considered mobility to be a tool for combating youth unemployment, one of the major goals of the Europe 2020 strategy for growth and jobs. A 2014 study demonstrated that the danger of lasting structural unemployment decreased substantially for students who undertook mobility compared to those who did not take the opportunity to study abroad .In the literature, mobilities are classified according to several criteria, as stated by Skribnjek .According to the country where students come from EU universities, there are: vertical mobilities—those mobilities in which university students come from outside the EU for a higher level of education, and horizontal mobilities—intra-European mobilities, between programs of equal value.According to the duration spent abroad, there are: degree mobilities—the duration is until obtaining a university degree, and credit mobilities—the duration is necessary to continue studies, but their completion (obtaining a university degree) is achieved in the country of origin.According to the direction of the flow of university students, there are: incoming mobilities—when foreign students come to a university in a particular country, and outgoing mobilities—referring to students leaving home to go to universities in other countries.Under the current ERASMUS+ program, the term study mobility was meant to describe the mobility of university students, trainees, apprentices, interns, volunteers, youth workers and staff with the aim of learning . Under tThe concept of mobility has always been the essence of the Bologna Process, which started with the Bologna Declaration, signed in 1999. The process has become the most complex European cooperation project in the area of higher education. The best-known program is ERASMUS (European Region Action Scheme for University Student Mobility), which was set up in 1987 and supports student mobility between EU countries.ERASMUS mobilities represent, in fact, a network between higher education institutions, whereas the nodes are the universities and countries involved, and the links are the participating students .Regarding student flows and models involving ERASMUS mobility, Skribnjek  asserts In fact, ERASMUS is the world’s most successful student mobility program, reaching a total number of 4.4 million mobile university students in 2017 .Among the objectives of the ERASMUS program are multilateral cooperation between educational institutions and between them and EU organizations and to increase the transparency and compatibility of the European education system. The ERASMUS program provides university students with grants to cover the additional costs of studying abroad in Europe.As early as 2009, the education ministers of the EU set an ambitious target to be achieved by 2020, namely that a minimum of one-fifth of graduates in the European Higher Education Area should have taken a stage abroad during their study years . To dateNevertheless, the dynamics of mobility have been impressive. In the first year of its existence, 1987–1988, just 3244 students from 11 countries spent a study period abroad on ERASMUS. In 2013–2014, 212,208 students from 34 countries spent study time abroad. Thus, the initial goal of supporting 3 million students to study abroad was reached during the academic year 2012–2013 .The budget of the ERASMUS program increased accordingly. If under the umbrella of the Lifelong Learning Program 2007–2013, ERASMUS had an allocation of almost 7 billion euro, for the new phase, called ERASMUS+, for the period 2014–2020, the budget more than doubled to 14.7 billion euro. The new goal is to reach 3.1 million university students within the ERASMUS program during 2021–2027, with an initial proposal to raise the budget to around 30 billion euro .The ERASMUS program has also led to initiatives to standardize educational policies in the European Union by integrating the curriculum so that the academic achievement of the participating university students is recognized in their home institutions .The mobilities contribute to the personal and professional development of students by enhancing their academic performance and giving them the chance to acquire transferable skills that are well-received by companies/organizations. Students certainly improve foreign language skills and also develop an enhanced cross-cultural empathy. They become quicker to adapt to changes and new environments, overcome emotional challenges, solve problems, participate in teamwork, think in critical terms, be tolerant and communicate better. Mobility boosts job prospects and opens the mind to different cultures ,17.The mobilities are bound to increase the employability of future graduates. As an impact study has revealed, the unemployment rate for ERASMUS participants is 23% lower 5 years after graduation by comparison with non-participating students . MoreoveThe ERASMUS program also brings a number of benefits to universities, such as: gaining international experience and respect, education in an intercultural environment, research contributions and funding sources for projects .University students are motivated to participate in mobility programs, as shown in the literature, by employment and accommodation opportunities, value-addedf student career, social events, the deterring costs involved with international education, to gain international education and life experiences, to develop basic international skills and to improve academic performance and foreign languages ,24,25,26Previous studies show that when students choose a university to attend in the ERASMUS program, they consider professional aspects, personal preferences and financial issues . The choThe most important challenges toward mobilities differ slightly between outgoing and incoming university students. According to an EU-wide survey by the Bologna Follow-Up Group, for outward mobilities, funding is the dominant concern, followed by bureaucratic and organizational difficulties, students’ personal emotional challenges, such as leaving family, friends and workplace, and difficulties of recognition of mobility periods. For incoming mobilities, the lack of support services and accommodation tops the list, followed by funding, curriculum and study organization, a lack of information, behavioral problems, as well as insufficient knowledge of the language ,29,30.The COVID-19 pandemic has changed the dynamics of the whole world, including the higher education area. Students, teachers and administration alike have faced new challenges never seen before. The pandemic has also modified the weight of factors that determine students’ decisions of studying abroad and choosing a respective country . The actThe most severe challenges for ERASMUS students arose from the quarantine measures for getting in and out of a particular country . MoreoveAs stated by Marinoni et al. (2020), due to the COVID-19 pandemic, 60% of universities have adopted virtual mobilities or online learning to substitute for the physical mobilities of students . TeresevHowever, the recent study by Anas et al. (2022) on the effects of the COVID-19 pandemic on students participating in mobilities shows that students lacked the physical environment and social interaction, as well as the competencies and intercultural skills enjoyed in a typical academic framework . BesidesOver 7500 university students from Romania go on ERASMUS mobility every year. At the same time, Romania is chosen as a destination by approximately 3500 students from Europe and the rest of the world. At the Transilvania University of Brasov (UNITBV) and the Faculty of Economic Sciences and Business Administration (SEAA), the flow of students with ERASMUS mobility has evolved, as can be seen in The data show that the number of Romanian university students leaving with ERASMUS mobility varied during this period by around 128 per year, and the number of students from the Faculty of Economic Sciences and Business Administration (the largest faculty) leaving with ERASMUS scholarships varied by around 22 students per year. It can be observed that the number of university students leaving through the ERASMUS mobility program has decreased slightly in the last 3 years (the slump in the last year is explainable due to the pandemic).The destination countries preferred by the students from the Transilvania University of Brasov included in the sample of the research were France, Belgium, Spain and the United Kingdom .The aim of the research was to obtain feedback from university students who participated in the ERASMUS program, to analyze the benefits and challenges of participating in this program and to identify the reasons that led students to choose a particular partner university. The research conducted is a quantitative one of opinion poll type.The statistical population is composed of the 1059 outgoing students from the Transilvania University of Brasov who have benefitted from ERASMUS mobilities during the period 2012–2021 . TransilIdentifying the main reasons that determine Romanian students from Transilvania University to choose a certain partner university;Identifying the countries that Romanian students from Transilvania University choose to carry out their ERASMUS mobility;Determining the main benefits of participating in the ERASMUS program;Determining the main challenges encountered by students from Transilvania University in the ERASMUS program.Given the theme of the paper, the research was based on the following specific objectives:The opinion polling technique was employed by means of a computer-administered questionnaire as a data collection tool, using the method called Computer-Assisted Web Interviewing (CAWI) . Due to The final sample was composed of 112 outgoing students. Generally, the standard error indicates the representativeness of the sample. In the above context, the calculated standard error is 5%, with a confidence level of 95%. Taking into account the statistical population of 1059 persons, the size of the sample should have been larger. However, this is preliminary research. Based on the results obtained from the present research, another grounded, more ample study will be performed in the future, with an extended sample to comprise students from more Romanian and possibly European universities.After collecting the information with the help of the questionnaire, the statistical data were processed with the SPSS system .Given the exploratory nature of the research, the aim was to obtain as many questionnaires as possible completed by students at Transilvania University. The study was conducted on a sample of 112 university students, structured as follows: 76% female, 24% male. Of these, 63% completed mobility during the Bachelor’s cycle, and 37% during the Master’s degree. The age of the respondents is shown in The first part of the study examines the behavioral reasons behind the choice of mobility abroad, such as: the reputation of the university through its teaching and research activities, the attractiveness of that respective country, costs involved, employment opportunities and relatives and friends living in that country; all of them taking into account the funding provided by the ERASMUS program and the additional revenues and resources.To study these reasons, we used the analysis of multiple dichotomous responses. Following the application of this analysis, there were no missing data on the variable providing reasons for participation in ERASMUS and no gender differences in reasons for participation were found.Identifying the key emotional factors that lead university students to choose ERASMUS mobility, as well as improving mobility conditions, is essential for creating educational policies, regulations and guidelines that will attract as many students as possible to such programs. Such experiences are beneficial for society, the economy, professional development, academic performance and improvement of students’ skills and for the development of empathic international behavior, bound to foster cooperation.One of the important aspects to be analyzed inside the topic of international scholarships is the emotional behavior that drives university students to pursue a study period in a foreign country. When investigating the reasons for which students chose to participate in a study mobility abroad, most of the respondents (68.8%), especially Master’s students, indicated the desire to study in another country. The second most important rationale was composed of the characteristics of the host country itself and the educational offer of the host university (58% each).As an interesting finding, the reputation of the host university was deemed two times higher by Master’s students compared to Bachelor’s students, a fact that is related to the higher maturity in their educational career. The study shows that a very small percentage of individual respondents chose to study abroad to be closer to their family and relatives in that country, only 8% .These results are in line with those of other studies ,42, whicNaturally, when embarking on a study period abroad for one semester or two, expectations mount in the minds of the scholarship holders. The most cited desires related to their mobility in a foreign country were to gather useful information and improve academic performance for their future career, as well as visiting new places and getting to know another culture (91.1% of answers in each case). These answers were evenly spread between male and female students.About half of the respondents have also indicated that learning a foreign language and making new friends were among the expectations they had when starting their study mobilities abroad, with a slightly higher frequency for male students . These rIn the process of getting accustomed to studying abroad, students stumble upon various emotional and behavioral challenges during their stay in the foreign country. When asked about what the major challenges they have faced, respondents indicated that they found a major difficulty in adapting to the teaching and examination methods (46.5% of cases), adapting to the work/academic style in the host university (35.4% of cases), insufficient knowledge of the foreign language (23.2% of cases), getting accustomed to the local culture (15.2% of cases), and poor communication with colleagues (13.1% of cases).When comparing the answers on the two levels of study, Master’s students had greater difficulty in communicating with colleagues than their undergraduate colleagues (empathy), while Bachelor’s students found it more difficult to adapt to the university work style ; both categories having approximately the same level of adaptation to the teaching and assessment methodology. However, Bachelor’s students have found it harder to cope with low language skills and empathize with the particular culture when compared to Master’s students .Similar results can be found in the study of Pappa et al., 2013 , which sIn order for the study mobility to be acknowledged as a success by the participant, a group of factors related to the host university needs to be in place and properly addressed. The majority of respondents considered that the educational component itself, the way teaching was done, including the student–teacher relationship, was the most fulfilling aspect of mobility (90.2% of cases). Further, the relationship with academic services (69.6% of cases), the organization of events, shows, fairs by the host university (64.3% of cases), as well as the organization of trips for students (63.4% of cases) were also highly appreciated. Fewer than half of the students have shown positive appraisal for accommodation conditions (43.8% of cases) and the canteen services (40.2% of cases). With a few exceptions, answers did not differ widely between university students from the two academic levels—Bachelor’s and Master’s .As also shown by Endes , universWhen asked about the services related to the host university that caused emotional distress to students undertaking mobilities, two major aspects were revealed. On the one side, Bachelor’s students ranked canteen/food on the first spot of the negative rated aspects with a total of 20% of responses. Master’s students, on the other side, ranked accommodation services in the first place in their negative hierarchy, with a total of 18.8% of responses. Apart from these two components, there were no other notable complaints .An important goal of any student pursuing mobility abroad is the benefit they try to reap for their future career. Taking into consideration that the research was undertaken among graduates, the authors were able to approach the issue of the relationship between the ERASMUS stay abroad and jobs afterward. The result leaves no doubt for interpretation. The vast majority of respondents (89%) have asserted that their mobility in a foreign country has helped them in their future professional careers.There was a significant difference between the observed frequencies and those expected for the participants in the Bachelor’s and Master’s degree cycle and the perception of a benefit as a result of participating in the ERASMUS mobility program. This difference was analyzed by applying the association’s Chi-Square Test (Chi-Square of independence).The Expected Count line features the estimated frequencies. From the summary analysis of the differences between the absolute frequencies (Count) and the estimated ones (Expected Count), particular differences can be identified at the level of all subgroups. The final column in p > 0.05, we can state that there is not enough evidence to reject the null hypothesis of no association between the educational cycle and the benefits of participating in ERASMUS mobility.By applying this test, whose result values are Pearson Chi-Square = 0.647, df(1) and Although one might think that Master’s students are more mature and perceive the benefits that such a scholarship brings in a better way, the results show that this does not happen in real terms.This means that these mobilities need to be continued as part of the educational policies and even extended to facilitate the exchange of information, culture, etc., between university students from different countries. This is also highlighted by Bryla  in his sAccording to Bryla , only 1.Another study  highlighFor a long period of time, university students have complained that the financial grant from the European Union was not enough to cover all necessary costs during their stay abroad so they were determined to find an alternative source of funding. The results of the research confirm this situation, with most of the respondents (90%) stating that they have used a supplementary funding source to manage all the incurred costs during the mobility in another university.Applying the Chi-square test  for the Thus, those who consider that the scholarship covers less than 25% of the monthly expenses are very few, and those who consider that the scholarship covers 51–75% of the monthly expenses are the most.p < 0.001 justify the conclusion that the differences between the five types of responses are significant and are not due to the random variation of sampling.These results correlate with previous studies, which show that for students who go on an ERASMUS scholarship to a foreign university, the main challenge is the amount of the scholarship, which does not fully cover the expenses related to the stay in a foreign country ,29,30. TAs a consequence of not being able to cover all the typical costs that appeared during the ERASMUS stay abroad, most of the respondents (64% of cases) asserted that some supplementary financial benefits related to the scholarship would be really helpful.One of the important features that influences the decision for one destination or another is the way universities promote themselves to future candidates. Promotion takes place by means of a diversity of channels. In the view of former ERASMUS university students, the best method for promotion is to use social media networks (90% of cases) and the own website of the university (87% of cases). Another possibility would be to participate in educational fairs (65% of cases) and much less through the use of leaflets and brochures (24% of cases) or radio channels (18% of cases). There were no significant deviations between the answers of respondents from the two academic levels, with the exception of radio as a means of promotion, which was favored by Master’s students twice as much as by Bachelor’s students. These answers are related to the fact that learners are familiar and make extensive use of social networks and websites, generally online, for information.The ERASMUS program is one of the most important international exchange programs for students. More than three million participants have already enjoyed this experience, with female students being more actively represented compared to male students . ERASMUSThe mobility experience does not only empower people with academic performance but also new skills needed in the labor market  and learning outcomes specific to their field of study . A totalIn the context of the COVID-19 pandemic, due to limited transport possibilities and the closure of some countries, ERASMUS+ mobilities had to be reoriented from the actual mobility  to virtual spaces. In order to take place in a regulated framework and support the move toward the digital transformation of education in Europe, it was necessary to underline more precisely the terms used in relation to the achievement of mobility.Two new forms of mobility have been defined, virtual mobility and combined mobility. Virtual mobility refers to the period in which a participant is in the country of origin and attends online learning activities offered by the institution/organization in the host country. For the “mobility” period in a virtual format, the participant does not receive a subsistence grant or transport from EU ERASMUS+ funds. Blended mobility refers to a learning activity that is achieved by combining a period of “mobility” in virtual format and the period of mobility itself in physical format. The possibility of organizing a combined mobility implies the planning from the very beginning of a period of mobility in virtual format obligatorily correlated with a period of mobility in physical format.The COVID-19 pandemic has shown that when conditions change dramatically, new ways of achieving these mobilities can be found so that student participation is not affected. Besides experimenting now with various forms of mobilities, such as virtual and blended mobilities, the European Union also fights against climate change and strives to reduce the carbon footprint of traditional student mobilities abroad by altering the transportation mode and offering incentives for “green travel” (without using an airplane). However, studies show that although student mobilities have increased over the years, they did not necessarily entail a rise in carbon emissions as the typical pattern leans toward regionalization .The above novelties in the way the ERASMUS program operates are included in a package of priorities. At the core of this package stands an inclusion and diversity strategy, where special attention is provided to students with fewer opportunities, stemming from minorities or low-income families, persons with refugee status, students with disabilities or severe health problems, so as to remove all potential barriers to mobility .In today’s competitive academic environment, the choice of students concerning the future host university where they will spend a study period abroad takes into account various factors. Some interesting findings emerged from the present research, such as the fact that students rank their potential increased academic performance on an equal level with the social aspect of getting to know other cultures. Moreover, emotional challenges differ between Bachelor’s students  and Master’s students . While students generally found it hard to cope with new teaching and examination methods, they ranked the relationship with the teachers as the major success factor of the mobility.The main limit of this research is given by the impossibility of extending the obtained results, a limit imposed by the type of the research method used and its empirical nature. Only the behavioral perceptions of mobile students from a single university from a single country (Romania) were identified and investigated in this research. Despite these limitations, the authors consider that the paper brings valuable empirical contributions to analyzing the most important issues and emotional challenges of student mobilities abroad. It also highlights the areas in which universities can improve the efficiency of mobilities for all participants and apply modern educational measures. Such measures will be stringently needed as competition between universities has intensified due to the COVID-19 pandemic, so higher education institutions search for viable business models to attract foreign students.Starting from these premises, future research can be extended in order to assess the behavioral perceptions of students from other universities in EU member states. This would allow the extension of the findings, paving the way for comparative research across universities in the EU. Given the longstanding cooperation inside the ERASMUS network of the Transilvania University of Brasov and the experience gathered herein, the authors consider teaming up with researchers from partner universities, especially from major student-outbound countries  to test the same approach with multicultural samples and to compare results for a European-wide perspective, in a framework based on the ERASMUS priorities. As such, research on educational mobilities and the emotional traits of participating students would bring significant opportunities on behalf of EU policymakers when designing the educational policies and guidelines for future programs.