Exploring risk factors associated with catastrophic health expenditure on diarrhea management in Karachi, Pakistan, 2022-2024

Figures
Abstract
Catastrophic health expenditure (CHE) is a situation where a household’s out-of-pocket medical payments are excessively high relative to its income, potentially leading to impoverishment. This study explores the risk factors associated with CHE in the management of diarrhea among children enrolled in Enterics for Global Health (EFGH) facilities in Karachi, Pakistan. We conducted a secondary analysis of data from 1,400 children presenting with diarrhea at Pakistan EFGH facilities. We estimated households’ direct medical and non-medical costs per diarrheal episode. CHE was defined as healthcare expenditures exceeding 10% of total monthly household expenditure. Risk factors for CHE were assessed using univariate and multivariate regression models. CHE was observed in 9 (0.6%) households. Children experiencing severe diarrhea were 9.53 times (95%CI:1.93-46.91, p = 0.006) more likely to incur CHE compared to those with mild cases. Children with Cryptosporidium had a 7.08 times higher risk (95%CI:1.46-34.38, p = 0.015) compared to non- cryptosporidium. Children with moderate or severe wasting were 5.47 and 9.71 times more likely to experience CHE compared to those without wasting (95%CI:1.01-29.69, p = 0.011 and 1.64-57.6, p = 0.012, respectively). Similarly, moderately underweight children were 5.4 times more likely to experience CHE compared to their non-underweight counterparts (95%CI:1.01-29.69, p = 0.043). After adjusting for diarrhea severity, the risk of CHE among households where the father’s education was limited to Quranic schooling was 8.4 times higher compared to no formal education (95%CI:1.13-62.49, p = 0.038). Estimates were based on a small number of CHE events and had wide confidence intervals. Although rare, CHE remains a potential risk for the vulnerable population. While limited statistical power due to small sample sizes warrants cautious interpretation of our risk ratios, our analyses suggest that severe diarrhea, malnutrition, and Cryptosporidium infection are associated with increased risk of CHE. Improving access to affordable healthcare, vaccination and nutritional programs, water, sanitation, and hygiene (WASH) practices, and financial support could reduce the impact of CHE.
Citation: Ahmed N, Yousafzai MT, Rao SI, Means AR, Pavlinac PB, Morozoff C, et al. (2026) Exploring risk factors associated with catastrophic health expenditure on diarrhea management in Karachi, Pakistan, 2022-2024. PLOS Glob Public Health 6(7): e0005391. https://doi.org/10.1371/journal.pgph.0005391
Editor: Md Sabbir Hossain, Shahjalal University of Science and Technology, BANGLADESH
Received: October 17, 2025; Accepted: June 15, 2026; Published: July 15, 2026
Copyright: © 2026 Ahmed et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The deidentified and anonymized EFGH datasets, data dictionaries, statistical analysis plan, CRFs and study protocol are publicly available at the following repository: https://search.vivli.org/doiLanding/studies/PR00011860/isLanding.
Funding: This work was funded by the Gates Foundation (award numbers INV-031791, INV-045988, INV-062665, INV-076498). The funding organization had no role in the study design, data collection, analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Diarrhea is the second leading cause of death among children under five globally, claiming over half a million lives each year, which equates to 1 in 9 child deaths daily [1]. Children living in low- and-middle-income countries (LMICs) are disproportionately affected, with sub-Saharan Africa and South Asia accounting for 90% of these deaths due to inadequate access to water, sanitation, and hygiene (WASH) [2–4]. In Pakistan, almost half a million children aged under 5 die annually from diarrheal diseases, largely due to poor WASH practices and a fragile health system infrastructure [1,5]. Although diarrhea is preventable and treatable with low-cost interventions, it still results in frequent healthcare visits in LMICs [6,7].
There are proven strategies available for the treatment and prevention of childhood diarrhea, including oral rehydration therapy, zinc supplementation, rotavirus vaccine, improvement in WASH practices, emphasis on exclusive breastfeeding, and improving caregiver healthcare-seeking behavior [1,8]. There has been a slight decline in cases of diarrhea with the introduction of the rotavirus vaccine; however, other pathogens continue to cause diarrhea among children [9].
Childhood diarrhea can pose a significant financial burden on families and the healthcare system, particularly in resource-limited settings. In Pakistan and other LMICs, many families incur out-of-pocket (OOP) medical payments when seeking care, which, especially in lower wealth quintiles, can cause financial hardship and could be a barrier to timely access to healthcare seeking [10,11]. The average cost of treating diarrhea varies across countries and visit characteristics, but is generally estimated at approximately $40 per outpatient visit and $160 per inpatient episode in LMICs, when capturing both health system and household costs (costs in 2015 USD) [8]. One study estimated the mean cost per episode of diarrhea incurred by households in Pakistan to be $6.47, with 10% of cases surpassing $10.11 (2011 USD), while another study estimated costs to range from $3.32 to $6.32 (2012 USD) depending on the pathogen [12,13]. In Pakistan and other LMICs, state-provided healthcare services are often insufficient in providing complete coverage of medical fees, leaving families vulnerable to OOP expenditures. In addition, families often incur non-medical costs, such as transportation fees to health facilities. Given the frequency of childhood diarrhea, treatment can become financially burdensome for both families and healthcare systems [11,14,15].
Catastrophic health expenditure (CHE) describes the unfortunate scenario where medical costs are so high that they risk impoverishing a household. CHE is often estimated as OOP expenditure (direct medical and direct non-medical) for a health condition exceeding a certain threshold (generally 10% or 25%) of monthly household expenditure [7,16,17]. CHE disproportionately affects households with lower socioeconomic status (SES) [18–20]. Households with sufficient financial capacity can buffer medical expenses and avoid catastrophic health impacts, while in poorer households, even low levels of health spending can cause devastating financial consequences [21–23]. Despite growing evidence on the economic burden of diarrheal diseases in LMICs, evidence on CHE related to childhood diarrhea in Pakistan remains limited, with few studies assessing its determinants using surveillance data that link clinical information, such as disease severity and pathogens, with household cost data [8,12,13]. Generating such data on CHE due to child diarrhea is important for policymakers’ decisions around prioritizing, upgrading, and introducing new interventions to reduce disease burden. This study aims to estimate CHE among families of children aged under 5 years with medically attended diarrhea enrolled in the EFGH Shigella surveillance study in Karachi, Pakistan.
Methods
Ethics statement
Parent study
The Enterics for Global Health (EFGH) Shigella surveillance study was conducted in seven countries: Bangladesh, Kenya, Malawi, Mali, Pakistan, Peru and The Gambia. The aim of this study was to determine the incidence and consequences of medically attended diarrhea (MAD) among children aged 6–35 months. This was a facility-based MAD hybrid surveillance study conducted at selected health facilities over 24 months. The study enrolled children with diarrhea between August 2022 and August 2024, with a follow-up period of three months. The full study protocol is published elsewhere [24].
Study design
This was a secondary analysis of data obtained from the EFGH study. The aim of this analysis was to explore risk factors associated with CHE on diarrhea management in households of children enrolled in EFGH from the outpatient departments (OPDs) of six health facilities in Karachi, Pakistan. We used case report forms (CRFs) to collect information from study participants across time points. We used CRF data from enrollment, discharge, and week 4 follow-up visits describing caregiver-reported expenses associated with management of the diarrhea episode. Client and visit characteristics were obtained from the data treatment record CRFs (Table 1).
Study setting
Data of children enrolled at six EFGH study health facilities (Abbasi Shaheed Hospital, Khidmat-e-Alam Medical Centre, Sindh Government Hospital Korangi 5, Sindh Government Hospital Ibrahim Hyderi, Ali Akbar Shah, Vital Pakistan Trust (VPT) Center, and Bhains Colony VPT Center (BHC)) situated in Nazimabad and Bin-Qasim town are included in this study. These facilities are a mix of tertiary care public sector hospitals and primary healthcare centers run by non-governmental organizations. All facilities serve the population of low-and middle-income urban slums and provide treatment free of charge, except Khidmat-e-Alam Medical Center, where minimal charges are paid by the caregiver. Description of these health facilities is published elsewhere [25].
Study participants
Children aged 6–35 months who visited OPDs of the EFGH health facilities were eligible for enrollment. Children who presented with the complaint of diarrhea, defined as more than three stools in the last 24 hours, living in the defined catchment area with plans to remain in the catchment area for the next four months, were approached for possible enrollment in the study. Details of the exclusion criteria have been reported elsewhere. [26].
Study outcome
The outcome of this study was the occurrence of catastrophic health expenditure, which was defined using the budget share approach, also called the basic approach used by the World Bank to ascertain CHE [27]. The budget share approach defines CHE as OOP expenditures related to a health condition exceeding a certain proportion of total household income or expenditure within a given period [17]. Specifically, we defined CHE as meeting or exceeding a threshold of 10% of monthly expenditures, which had most commonly been used in the context of low- and middle-income settings [28].
Diarrhea was defined as the passage of three or more loose or liquid stools per day (or more frequent passage than normal for the individual), and MAD was defined as any diarrheal episode for which medical care is sought at an EFGH enrollment site. We also assessed direct medical costs, which encompassed expenses pertaining to the diagnosis and treatment of a child with MAD, either in outpatient or inpatient settings. In our analysis, we included the portion of direct medical costs paid by caregivers, which includes clinical registration fees, lab tests or diagnostics, medications, and other medical supplies purchased in or outside the facility. We also included direct non-medical costs, which included the cost of transportation to reach the healthcare facility, food or accommodation while children were being treated, or other non-medical fees spent related to the visit (e.g., childcare for other children).
Data collection
We primarily utilized data collected through the EFGH study related to child demographic and anthropometry indicators, as well as visit costs. During a child’s enrollment visit at the health facility, a study physician conducted a physical examination, collecting anthropometry measurements including child length, weight, and mid-upper arm circumference. A caregiver interview was first conducted during the child’s enrollment visit to collect information on socio-demographic characteristics, health-seeking behaviors, and the cost to access the healthcare facility and treatment. Caregiver interviews also included a simplified asset questionnaire, adapted from the Demographic Health Survey wealth index form, to estimate the household’s wealth quintile [29]. A stool sample was collected at baseline to test for pathogens. Additional data on direct medical and direct non-medical costs were collected at 4-week follow-up visits to capture new costs incurred after leaving the health facility.
The EFGH study did not collect information on household incomes or expenditures, therefore, we estimated household expenditures from the government of Pakistan’s Household Integrated Economic Survey (HIES) 2018–2019 data, Pakistan Bureau of Statistics [30,31]. Specifically, we extracted monthly household expenditure per wealth quintile from Sindh province.
Statistical analysis
We determined CHE status per child enrolled in the EFGH study. To do so, we first summed caregiver-reported costs to calculate total OOP fees per child visit. Each child visit was also assigned a monthly household expenditure from Pakistan’s HIES, matched based on their wealth quintile (as measured by a wealth index). All costs were collected in Pakistani Rupees, and for comparability, were inflated to 2023 currency using Gross Domestic Product price deflators from the World Bank. Per child-visit, we calculated the proportion of monthly household expenditure spent on OOP expenditure on the management of diarrhea. Cases where OOP was 10% or greater were determined to be CHE.
We considered the following risk factors for CHE: type of health facility, age and sex of the child, caregiver’s age, education status of child’s parents, number of children in the house, healthcare seeking prior to enrollment in EFGH, travel time to clinic, type of pathogen, and diarrhea severity. Descriptive statistics on risk factors are presented using means and standard deviations for continuous variables and counts and proportions for categorical variables. Risk ratios (RR) and 95% confidence intervals (CI) were used to describe the association between risk factors and catastrophic expenditure on diarrhea.
To determine potential predictors of CHE, we constructed a regression model with a generalized estimating equation (GEE) approach and a Poisson distribution with a log link, and clustering per child (to account for children with multiple diarrheal episodes). The binary dependent variable was whether the diarrheal episode resulted in CHE. We first estimated unadjusted models for each predictor, followed by multivariate models adjusting for diarrhea severity. Due to the small number of CHE events, adjustments in the multivariable model were limited to diarrhea severity to avoid unstable estimates.
Sensitivity analyses
We ran sensitivity analyses to test the effect of key analytical decisions on the risk of CHE. To test the effect of the CHE definition on our results, we tested monthly household expenditure spent on the diarrheal episode at 8% and 5% threshold, as opposed to the standard 10% threshold.
Results
Child health, caregiver characteristics, and pathogen distribution
A total of 1,400 children were included in this analysis. Of the total, 646 (46.1%) of children were 12–23 months old, and 53.2% were male. The Shigella isolation rate among enrolled children was 25.3%, followed by Enterotoxigenic Escherichia coli (ETEC) at 12.0%, rotavirus 8.5%, and Cryptosporidium at 4.4%. Approximately one-third of children were stunted, wasted, or underweight at presentation at the health facility. The mean age of the caregivers was 27.12 ± 5.61 years. Households with male children, children with severe diarrhea, and those who presented to primary healthcare facilities were more common in the CHE category (Table 2). CHE was rare, observed in 9 (0.6%) households. The largest medical and non-medical costs incurred on the management of an episode of diarrhea were drugs with a mean cost of 55.9 Pakistani rupee (PKR), followed by the transportation mean cost of 53.6 (PKR) (data not shown).
Factors associated with CHE
In the univariate model we tested 19 risk factors for CHE and found that severe diarrhea, Cryptosporidium pathogen, moderate and severe wasting, and moderate underweight were significantly associated with CHE (Table 3). After adjusting for diarrhea severity in the multivariate model, we found moderate wasting was no longer significantly associated with CHE. Father’s education limited to Quranic school only was significantly associated with CHE in multivariate analysis but not in the univariate model.
Compared to mild diarrhea cases, households with children experiencing severe diarrhea were estimated to be 9.53 times more likely to experience CHE (95% CI: 1.93- 46.91, p = 0.006), while no significant difference was observed between moderate and mild diarrhea. The risk of CHE among children with Cryptosporidium (as compared to non- Cryptosporidium) was estimated to be 7.08 times (95% CI: 1.46-34.38, p = 0.015); and similarly, 6.51 times (95% CI: 1.31-32.43, p = 0.022) more likely after adjusting for diarrhea severity with wide confidence intervals.
Compared to children with no wasting, children with moderate wasting who experienced diarrhea were 5.47 times more likely to experience CHE (95% CI: 1.01-29.69, p = 0.049) and those with severe wasting were 9.71 times more likely to experience CHE (95% CI: 1.64-57.6, p = 0.012). After adjusting for diarrhea severity, the risk of CHE among children with severe wasting decreased slightly to 8.21 (95% CI: 1.3-51.79, p = 0.025) (Table 3). Moderately underweight children who experienced diarrhea were 5.4 times more likely to experience CHE (95% CI: 1.05-27.68, p = 0.043). The results remained similar after adjusting for diarrhea severity 5.66 (95% CI: 1.12-28.68, p = 0.036).
We did not observe meaningful differences in the risk of CHE by mother’s or father’s education in the univariate analysis. However, after adjusting for diarrhea severity, the risk of CHE increased 8.4 times (95% CI: 1.13-62.49, p = 0.038) among fathers whose education was limited to Quranic schooling compared to fathers with no formal education.
Sensitivity analysis of CHE thresholds
When testing the effect of the CHE threshold in sensitivity analyses, we found that 12 households experienced CHE when using a threshold of 8% of monthly household expenditures spent on the diarrheal episode, while 17 households experienced CHE when the threshold was set to 5%. Having severe diarrhea remained significantly associated with CHE when using a 5% and 8% threshold. Households with children positive for the Cryptosporidium pathogen and severe wasting were associated with CHE at the 8% threshold, but not at the 5% threshold. Chronic comorbidity and stunting were significantly associated with CHE at 5% threshold. See S1 Table for further details on sensitivity analysis.
Discussion
This study explored risk factors associated with CHE in the management of diarrhea in EFGH facilities in Karachi, Pakistan. Besides affecting household financial stability, CHE can lead to poorer health outcomes, especially for the poorest, who face both serious health risks and financial hardship [11]. Our study highlighted that CHE is rare and occurred in 0.6% of the households at a threshold of 10%. The risk of CHE increased among households of children with severe diarrhea, cryptosporidium infection, and compromised nutritional status. Antibiotics and transportation were the largest costs of diarrhea management. The EFGH study sites in Pakistan are a mix of public, private, and not-for-profit, therefore, the costs of the treatment may be different between sites. All the patients sought outpatient care, and none sought inpatient care, and a minimal number of patients enrolled with severe disease.
In our study, severe diarrhea and compromised nutritional status were associated with an increased risk of CHE. Both our descriptive statistics and univariate models suggest that a child’s diarrhea severity and their nutritional status at the time of presentation to a health facility may influence CHE risk. These specific risk ratio estimates should be interpreted with caution, given the limited statistical power due to small sample sizes. The vulnerability and associated high cost may be due to the interplay of these factors, as poor nutritional status and underlying health conditions increase susceptibility to diarrheal disease, resulting in more frequent healthcare visits and higher medical costs, leading to CHE. This aligns with findings from Mozambique, where children with diarrhea and additional health impairments, including wasting, experienced prolonged hospital stays leading to higher medical costs [32]. Our findings also align with studies by Sultana R et al. (2021) and Memirie et al. (2017), who reported that higher expenditure on severe diarrhea among children leads to financial catastrophe and instability among households of low-income communities [33,34]. While wasting is partially linked to diarrhea severity and age, it may also independently increase the risk of CHE [32]. Cryptosporidium infection was associated with CHE in our study, although the estimates were based on a small number of cases and showed considerable uncertainty. A study conducted in three developing countries reported higher treatment cost for cryptosporidium infection and a consequent significant cost impact on a household [35].
In our study, even though the risk of CHE was rare, it still occurred in 0.6% of the households that fall in the third quintile of monthly expenditure. A modeling study reported the risk of CHE among households to be 0.1% overall and 0.4% among households at 10% threshold in income quintile one in 34 LMICs [11]. The discordance of CHE risk could be because the services in this modeling study were provided at the primary healthcare level, however, in our study a significant number of children sought care at tertiary care hospitals, indicating a more severe disease. In contrast to our study, a study from Bangladesh involving 899 households reported that 47% incurred CHE at the 10% threshold of household consumption expenditure when seeking care for childhood diarrhea, with 14% spending more than 25% of their monthly resources on treatment [7]. The reason for the higher occurrence of CHE in this study could be because almost 65% of the patients were hospitalized for inpatient care. In comparison, in our study, none of the patients were hospitalized for care. While CHE is rare according to traditional definitions, it’s possible that households face greater financial risk due to the loss of income while caring for their sick child. In the main EFGH study [36], the indirect cost accounted for 18% of the total expenditure on the management of Shigella MAD in EFGH Pakistan sites, indicating a substantial burden on the families and a risk to CHE.
Our study showed a low occurrence of CHE in EFGH sites in Pakistan, however, it could be more common in other areas. This may be because the treatment is provided free of cost in all EFGH study sites in Pakistan, except one. Furthermore, a majority of participants resided in close vicinity with minimal transportation costs to access these facilities. In the main EFGH study [36], Pakistan had the lowest household costs compared to other countries; by contrast, in other EFGH sites, the costs were higher, and transportation was the primary driver of costs when seeking care for Shigella MAD, substantially contributing to financial burden and potentially leading to CHE. Therefore, our study population may not represent the entire population of Pakistan. In Pakistan, the spending on healthcare is mostly through OOP to cover direct medical and non-medical costs [37]. Moreover, the proportion of households experiencing CHE related to any illness in the most deprived quintile (Q1) is reported to have progressed from 8.3% (2007–08) to 13.7% (2018–19) at 10% threshold [37,38]. Therefore, preventing the occurrence of CHE is crucial because it can push families into poverty, force them to cut back on essential needs like food and education, and create long-term financial instability [37].
There are a few important limitations to this study. The EFGH study did not capture actual income or expenditure of the household, therefore, a proxy provincial level data [30] source on household expenditure by wealth quintile was used to document the results. This approach may introduce some measurement uncertainty, as proxy expenditure values may not fully capture individual household conditions, potentially affecting the classification of CHE. The small number of households experiencing CHE in this study limited statistical precision, resulting in imprecise estimates that may affect the ability to reliably assess associated factors and the generalizability of the findings. Further studies with larger sample sizes are needed to generate more precise estimates of which clinical and socioeconomic factors most strongly predict CHE in this setting. However, given that CHE due to diarrhea occurred in an estimated 0.1-0.6% of cases, the substantial sample sizes needed to meaningfully improve the precision of these estimates may be difficult to justify relative to the resources required for primary data collection.
The study used a 10% threshold as the primary definition of CHE, but results from sensitivity analyses applying 8% and 5% thresholds highlighted additional financial risks, particularly among children with chronic health conditions, where repeated clinic visits can increase the risk of ongoing CHE for families. These results indicate that the risk of financial catastrophe is sensitive to how CHE is defined, underscoring the need for policymakers to consider multiple thresholds when designing social protection strategies.
Conclusion
Our study highlights that while CHE is rare within EFGH facilities in Pakistan, it remains a potential risk for vulnerable populations, particularly those with severe diarrhea and poor nutritional status. Among direct medical and direct non-medical costs, antibiotics and transportation were the main drivers of CHE. Strengthening financial risk protection, promoting preventive healthcare, and ensuring equitable access to treatment may help reduce the impact of CHE. Integrating preventive measures such as improved sanitation, nutrition support, and vaccination programs can further mitigate the economic impact of diarrheal diseases in Pakistan and other LMICs.
Supporting information
S1 Table. Sensitivity analysis of factors associated with CHE.
https://doi.org/10.1371/journal.pgph.0005391.s001
(DOCX)
Acknowledgments
The authors thank the children who participated in this study and their families, and the dedicated physicians, nurses, scientists and staff at each study site for their dedication and outstanding performance of clinical and laboratory study activities. The authors also thank Ms. Beth A. Tippett Barr from Nyanja Health Research Institute who facilitated and contributed to the EFGH Manuscript Writing Cohort Program.
References
- 1. WHO. Diarrhoeal disease 2024. https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease
- 2. Kotloff KL, Platts-Mills JA, Nasrin D, Roose A, Blackwelder WC, Levine MM. Global burden of diarrheal diseases among children in developing countries: Incidence, etiology, and insights from new molecular diagnostic techniques. Vaccine. 2017;35(49 Pt A):6783–9. pmid:28765005
- 3. GBD 2016 Diarrhoeal Disease Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis. 2018;18(11):1211–28. pmid:30243583
- 4. GBD Diarrhoeal Diseases Collaborators. Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: A systematic analysis for the Global Burden of Disease Study 2015. Lancet Infect Dis. 2017;17(9):909–48. pmid:28579426
- 5. Rahmat ZS, Zubair A, Abdi I, Humayun N, Arshad F, Essar MY. The rise of diarrheal illnesses in the children of Pakistan amidst COVID-19: A narrative review. Health Sci Rep. 2023;6(1):e1043. pmid:36620511
- 6. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al. Global, regional, and national causes of child mortality in 2008: A systematic analysis. Lancet. 2010;375(9730):1969–87. pmid:20466419
- 7. Hasan MZ, Mehdi GG, De Broucker G, Ahmed S, Ali MW, Martin Del Campo J, et al. The economic burden of diarrhea in children under 5 years in Bangladesh. Int J Infect Dis. 2021;107:37–46. pmid:33864914
- 8. Baral R, Nonvignon J, Debellut F, Agyemang SA, Clark A, Pecenka C. Cost of illness for childhood diarrhea in low- and middle-income countries: A systematic review of evidence and modelled estimates. BMC Public Health. 2020;20(1):619. pmid:32370763
- 9. Praharaj I, Platts-Mills JA, Taneja S, Antony K, Yuhas K, Flores J, et al. Diarrheal etiology and impact of coinfections on rotavirus vaccine efficacy estimates in a clinical trial of a monovalent human-bovine (116E) oral rotavirus Vaccine, Rotavac, India. Clin Infect Dis. 2019;69(2):243–50. pmid:30335135
- 10. Rehman A, Shaikh BT, Ronis KA. Health care seeking patterns and out of pocket payments for children under five years of age living in Katchi Abadis (slums), in Islamabad, Pakistan. Int J Equity Health. 2014;13:30. pmid:24739395
- 11. Bolongaita S, Lee Y, Johansson KA, Haaland ØA, Tolla MT, Lee J, et al. Financial hardship associated with catastrophic out-of-pocket spending tied to primary care services in low- and lower-middle-income countries: Findings from a modeling study. BMC Med. 2023;21(1):356. pmid:37710266
- 12. Rheingans R, Kukla M, Faruque ASG, Sur D, Zaidi AKM, Nasrin D, et al. Determinants of household costs associated with childhood diarrhea in 3 South Asian settings. Clin Infect Dis. 2012;55 Suppl 4(Suppl 4):S327-35. pmid:23169945
- 13. Zimmermann M, Kotloff K, Nasrin D, Roose A, Levine MM, Rheingans R, et al. Household costs of diarrhea by etiology in 7 countries, the global enterics mulitcenter study (GEMS). Open Forum Infect Dis. 2019;6(4):ofz150. pmid:31049364
- 14. Shaikh BT. Universal health coverage in Pakistan: Exploring the landscape of the health system, health seeking behaviours, and utilization of health services. Lancet Reg Health Southeast Asia. 2024;27:100440. pmid:39015938
- 15. Shaikh BT, Ali N. Universal health coverage in Pakistan: Is the health system geared up to take on the challenge?. Globalization and Health. 2023;19(1):4.
- 16. Cylus J, Thomson S, Evetovits T. Catastrophic health spending in Europe: Equity and policy implications of different calculation methods. Bull World Health Organ. 2018;96(9):599–609. pmid:30262941
- 17. Nguyen HA, Ahmed S, Turner HC. Overview of the main methods used for estimating catastrophic health expenditure. Cost Eff Resour Alloc. 2023;21(1):50. pmid:37553675
- 18. Zhao Y, Oldenburg B, Mahal A, Lin Y, Tang S, Liu X. Trends and socio-economic disparities in catastrophic health expenditure and health impoverishment in China: 2010 to 2016. Trop Med Int Health. 2020;25(2):236–47. pmid:31713972
- 19. Mutyambizi C, Pavlova M, Hongoro C, Booysen F, Groot W. Incidence, socio-economic inequalities and determinants of catastrophic health expenditure and impoverishment for diabetes care in South Africa: A study at two public hospitals in Tshwane. Int J Equity Health. 2019;18(1):73. pmid:31118033
- 20. Li Y, Wu Q, Xu L, Legge D, Hao Y, Gao L, et al. Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: Policy implications of universal health insurance. Bull World Health Organ. 2012;90(9):664–71. pmid:22984311
- 21. Hsu J, Flores G, Evans D, Mills A, Hanson K. Measuring financial protection against catastrophic health expenditures: Methodological challenges for global monitoring. Int J Equity Health. 2018;17(1):69. pmid:29855334
- 22. Lee HJ, Lee DW, Choi DW, Oh SS, Kwon J, Park EC. Association between changes in economic activity and catastrophic health expenditure: Findings from the Korea Health Panel Survey, 2014–2016. Cost Effectiveness and Resource Allocation. 2020;18:1–9.
- 23. Ngcamphalala C, Ataguba JE. An assessment of financial catastrophe and impoverishment from out-of-pocket health care payments in Swaziland. Glob Health Action. 2018;11(1):1428473. pmid:29382274
- 24.
Atlas HE, Conteh B, Islam MT, Jere KC, Omore R, Sanogo D. Diarrhea case surveillance in the enterics for global health Shigella surveillance study: epidemiologic methods. Oxford University Press US. 2024.
- 25.
Ahmed N, Yousafzai MT, Naz Qamar F. The enterics for global health (EFGH) Shigella surveillance study in Pakistan. Oxford University Press US. 2024.
- 26. Morozoff C, Ahmed N, Chinkhumba J, Islam MT, Jallow AF, Ogwel B, et al. Quantifying the Cost of Shigella Diarrhea in the Enterics for Global Health (EFGH) shigella surveillance study. Open Forum Infect Dis. 2024;11(Suppl 1):S41–7. pmid:38532961
- 27. Wagstaff A, van Doorslaer E. Catastrophe and impoverishment in paying for health care: With applications to Vietnam 1993-1998. Health Econ. 2003;12(11):921–34. pmid:14601155
- 28. Weraphong J, Pannarunothai S, Luxananun T, Junsri N, Deesawatsripetch S. Catastrophic health expenditure in an urban city: Seven years after universal coverage policy in Thailand. Southeast Asian J Trop Med Public Health. 2013;44(1):124–36. pmid:23682447
- 29. Chakraborty NM, Fry K, Behl R, Longfield K. Simplified asset indices to measure wealth and equity in health programs: A reliability and validity analysis using survey data from 16 countries. Glob Health Sci Pract. 2016;4(1):141–54. pmid:27016550
- 30. Pakistan Bureau of Statistics. Social & Household Integrated Economic Survey. 2019. https://www.pndajk.gov.pk/uploadfiles/downloads/hies_2018-19_writeup.pdf
- 31. The World Bank. GDP deflator. World Bank Open Data. https://data.worldbank.org/country/pakistan?view=chart. 2024. Accessed 2025 March 28.
- 32. Bauhofer AFL, Sambo J, Chilaúle JJ, Conjo C, Munlela B, Chissaque A. Examining comorbidities in children with diarrhea across four provinces of Mozambique: A cross-sectional study (2015 to 2019). PLoS One. 2023;18(9):e0292093.
- 33. Sultana R, Luby SP, Gurley ES, Rimi NA, Swarna ST, Khan JAM, et al. Cost of illness for severe and non-severe diarrhea borne by households in a low-income urban community of Bangladesh: A cross-sectional study. PLoS Negl Trop Dis. 2021;15(6):e0009439. pmid:34115764
- 34. Memirie ST, Metaferia ZS, Norheim OF, Levin CE, Verguet S, Johansson KA. Household expenditures on pneumonia and diarrhoea treatment in Ethiopia: A facility-based study. BMJ Glob Health. 2017;2(1):e000166. pmid:28589003
- 35. Rafferty ER, Schurer JM, Arndt MB, Choy RKM, de Hostos EL, Shoultz D, et al. Pediatric cryptosporidiosis: An evaluation of health care and societal costs in Peru, Bangladesh and Kenya. PLoS One. 2017;12(8):e0182820. pmid:28832624
- 36.
Ahmed N, Sanogo D, Jallow M, Zegarra PLF, Ogwel B, Islam MT, et al. Costs and Cost Drivers Of Shigella Medically Attended Diarrhoea: Results from the Enterics for Global Health (EFGH) Study. 2025.
- 37. Bashir S, Kishwar S. Incidence and determinants of catastrophic health expenditures and impoverishment in Pakistan. Public Health. 2021;197:42–7. pmid:34311430
- 38. Bashir S, Kishwar S, Nasir M, Ali S. Socioeconomic inequalities in out-of-pocket and catastrophic health expenditures in Pakistan. Int J Public Health. 2024;69:1607313. pmid:39600526