{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T11:20:09Z","timestamp":1787916009102,"version":"build-2784847793"},"reference-count":58,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T00:00:00Z","timestamp":1787875200000},"content-version":"unspecified","delay-in-days":58,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["bmjph"],"accepted":{"date-parts":[[2026,8,18]]},"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Pakistan has one of South Asia\u2019s highest burdens of out-of-pocket health expenditure. The disaggregated evidence for urban poor populations in major cities remains limited and hidden under the national data. Among the big cities in Pakistan, Karachi\u2019s informal settlements concentrate the country\u2019s most financially vulnerable households where formal health insurance coverage is negligible. This study measured catastrophic health expenditure prevalence among urban poor households in Karachi, determined its socioeconomic distribution and evaluated the financial protective effect of existing health insurance.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A cross-sectional household survey was conducted across six administrative districts of Karachi between March and August 2023, covering informal settlements and low- and middle-income neighbourhoods. Multi-stage stratified cluster probability sampling yielded 1211 households (response rate 94.7%), with household heads or primary economic decision-makers as respondents. Catastrophic health expenditure was assessed at 10%, 25% and 40%\u2009WHO thresholds using standardised methodology. Concentration index analysis quantified socioeconomic distribution of the burden. Multivariate logistic regression identified determinants and assessed insurance effectiveness. Health expenditure-induced impoverishment and financial coping mechanisms were also examined.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Catastrophic health expenditure affected 91.7% (95% CI 90.1% to 93.1%) of households at the 10% threshold, 78.2% (95% CI 75.8% to 80.5%) at 25% and 66.1% (95% CI 63.4% to 68.8%) at 40%. Prevalence was uniformly high across income tertiles (lowest 95.0%, middle 93.8%, highest 86.4%), yielding a near-zero concentration index of \u22120.048 that contradicts the expected pro-poor gradient. Health expenditures impoverished 342 households (28.2%), pushing them below the national poverty line. Hospitalisation (adjusted OR 4.8, 95%\u2009CI 3.2 to 7.1)\u2009and chronic illness (adjusted OR 2.9, 95%\u2009CI 2.1 to 4.0) were the strongest determinants. Insurance coverage, present in only 68 households (5.6%), provided no significant financial protection (adjusted OR 0.82, 95%\u2009CI 0.43 to 1.57, p=0.553).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Near-universal catastrophic burden distributed uniformly across income groups argues against means-tested targeting and supports universal financial protection approaches. Existing insurance provides no meaningful protection, pointing to systemic failure requiring fundamental health financing reform rather than incremental programme expansion.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjph-2026-005170","type":"journal-article","created":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T11:00:16Z","timestamp":1787914816000},"page":"e005170","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Financial protection failure among urban poor populations in Karachi, Pakistan: a cross-sectional household survey of catastrophic health expenditure prevalence, determinants and insurance effectiveness"],"prefix":"10.1136","volume":"4","author":[{"given":"Ahsanullah","family":"Khan","sequence":"first","affiliation":[{"name":"Department of Health Management, Policy & Economics, School of Public Health, International Campus, Tehran University of Medcial Sciences (TUMS), Tehran, Iran"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6026-4997","authenticated-orcid":false,"given":"Shahzad Ali","family":"Khan","sequence":"additional","affiliation":[{"name":"Department of Public Health, Health Services Academy, Islamabad, Pakistan"},{"name":"Vice Chancellor, Health Services Academy, Islamabad, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ali","family":"Akbari-Sari","sequence":"additional","affiliation":[{"name":"Department of Health Management, Policy and EconomicsSchool of Public Health, Tehran University of Medical Sciences (TUMS), Tehran, Iran"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mostafa","family":"Hosseini","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics School of Public Health, Tehran University of Medical Sciences Tehran (TUMS), Tehran, Iran"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7806-5558","authenticated-orcid":false,"given":"Amirhossein","family":"Takian","sequence":"additional","affiliation":[{"name":"Center of excellence for Global Health (CEGH), Department of Global Health, TehranUniversity of Medical Sciences (TUMS), Tehran, Iran"},{"name":"Department of Health Management, Policy & Economics, School of Public Health, Tehran University of Medical Sciences (TUMS), Tehran, Iran"},{"name":"Health Equity Research Center (HERC), Tehran University of Medical Sciences (TUMS), Tehran, Iran"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,8,28]]},"reference":[{"key":"2026082804000765000_4.3.e005170.1","doi-asserted-by":"crossref","first-page":"1250","DOI":"10.1016\/S0140-6736(20)30750-9","article-title":"Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990\u20132019: a systematic analysis for the Global Burden of Disease Study 2019","volume":"396","author":"Lozano","year":"2020","journal-title":"The Lancet"},{"key":"2026082804000765000_4.3.e005170.2","unstructured":"UHC2030 Secretariat . 2024-2027 strategic framework. 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