Impact of Noncommunicable Disease Multimorbidity on Healthcare Utilisation and Out-Of-Pocket Expenditures in Middle-Income Countries: Cross Sectional Analysis

Abstract

Background: The burden of non-communicable disease (NCDs) has grown rapidly in low- and middle-income countries (LMICs), where populations are ageing, with rising prevalence of multimorbidity (more than two co-existing chronic conditions) that will significantly increase pressure on already stretched health systems. We assess the impact of NCD multimorbidity on healthcare utilisation and out-of-pocket expenditures in six middle-income countries: China, Ghana, India, Mexico, Russia and South Africa.

Methods: Secondary analyses of cross-sectional data from adult participants (>18 years) in the WHO Study on Global Ageing and Adult Health (SAGE) 2007-2010. We used multiple logistic regression to determine socio-demographic correlates of multimorbidity. Association between the number of NCDs and healthcare utilisation as well as out-of-pocket spending was assessed using logistic, negative binominal and log-linear models.

Results: The prevalence of multimorbidity in the adult population varied from 3.9% in Ghana to 33.6% in Russia. Number of visits to doctors in primary and secondary care rose substantially for persons with increasing numbers of co-existing NCDs. Multimorbidity was associated with more outpatient visits in China (coefficient for number of NCD = 0.56, 95% CI = 0.46, 0.66), a higher likelihood of being hospitalised in India (AOR = 1.59, 95% CI = 1.45, 1.75), higher out-of-pocket expenditures for outpatient visits in India and China, and higher expenditures for hospital visits in Russia. Medicines constituted the largest proportion of out-of-pocket expenditures in persons with multimorbidity (88.3% for outpatient, 55.9% for inpatient visit in China) in most countries.

Conclusion: Multimorbidity is associated with higher levels of healthcare utilisation and greater financial burden for individuals in middle-income countries. Our study supports the WHO call for universal health insurance and health service coverage in LMICs, particularly for vulnerable groups such as the elderly with multimorbidity.

Fig 1. Prevalence of multimorbidity by age groups in SAGE countries.

Fig 2. Association between number of NCDs and healthcare utilisation- any outpatient utilisation (Fig 2a); Association between number of NCDs and healthcare utilisation- number of outpatient visits (Fig 2b).

Figures in the last column are coefficients and 95% CI for the variable “number of NCD” from regression models adjusting for all covariates. Logistic model is used to estimate any visit for outpatient/inpatient service, and negative binomial model is used for number of visit/ hospitalisation days outcome.

Fig 3. Association between number of NCDs and healthcare utilisation- any inpatient utilisation (Fig 3a); Association between number of NCDs and healthcare utilisation- number of inpatient visits (Fig 3b).

Figures in the last column are coefficients and 95% CI for the variable “number of NCD” from regression models adjusting for all covariates. Logistic model is used to estimate any visit for outpatient/inpatient service, and negative binomial model is used for number of visit/ hospitalisation days outcome.

Fig 4. Proportion of respondents reporting that their last outpatient visit was free of charge (Fig 4a); Proportion of respondents reporting that their last inpatient visit was free of charge (Fig 4b).

Data source World Health Organization (WHO) Study on Global Ageing and Adult Health (SAGE) survey, wave 1.

Fig 5. Percentage of out-of-pocket spending for each type of outpatient service in persons with multimorbidity (Fig 5a); Percentage of out-of-pocket spending for each type of inpatient service in persons with multimorbidity (Fig 5b).

Estimates presented here are based on respondent’s healthcare visit that was not free of charge.