title: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom.
authors.forename: John Tayu
authors.initials: JT
authors.lastname: Lee
authors.affiliation: Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom.
authors.forename: Fozia
authors.initials: F
authors.lastname: Hamid
authors.affiliation: Indian Institute of Public Health, Public Health Foundation of India, Bhubaneswar, India.
authors.forename: Sanghamitra
authors.initials: S
authors.lastname: Pati
authors.affiliation: Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, Massachusetts, United States of America.
authors.forename: Rifat
authors.initials: R
authors.lastname: Atun
authors.affiliation: Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom; Public Health Foundation of India, Gurgaon, India.
authors.forename: Christopher
authors.initials: C
authors.lastname: Millett
mesh_terms: D000328:Adult; D015897:Comorbidity; D003430:Cross-Sectional Studies; D003710:Demography; D003906:Developing Countries / Q000191:economics*; D004194:Disease / Q000191:economics*; D005260:Female; D005102:Health Expenditures; D006801:Humans; D007182:Income; D008297:Male; D010045:Outpatients; D010342:Patient Acceptance of Health Care