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Research
Multimorbidity and out-of-pocket expenditure on medicines: a systematic review
  1. Grace Sum1,
  2. Thomas Hone2,
  3. Rifat Atun3,
  4. Christopher Millett2,
  5. Marc Suhrcke4,5,
  6. Ajay Mahal6,
  7. Gerald Choon-Huat Koh1,
  8. John Tayu Lee1,2,6
  1. 1 Saw Swee Hock School of Public Health, National University of Singapore, Singapore
  2. 2 Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
  3. 3 Harvard T.H Chan, School of Public Health, and Harvard Medical School, Harvard University, Boston, Massachusetts, USA
  4. 4 Centre for Health Economics, University of York, England, UK
  5. 5 Luxembourg Institute for Socio-economic Research, Luxembourg, Europe
  6. 6 Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
  1. Correspondence to Dr Grace Sum; gracesum{at}u.nus.edu

Abstract

Background Multimorbidity, the presence of two or more non-communicable diseases (NCD), is a costly and complex challenge for health systems globally. Patients with NCDs incur high levels of out-of-pocket expenditure (OOPE), often on medicines, but the literature on the association between OOPE on medicines and multimorbidity has not been examined systematically.

Methods A systematic review was conducted via searching medical and economics databases including Ovid Medline, EMBASE, EconLit, Cochrane Library and the WHO Global Health Library from year 2000 to 2016. Study quality was assessed using Newcastle-Ottawa Scale. PROSPERO: CRD42016053538.

Findings 14 articles met inclusion criteria. Findings indicated that multimorbidity was associated with higher OOPE on medicines. When number of NCDs increased from 0 to 1, 2 and ≥3, annual OOPE on medicines increased by an average of 2.7 times, 5.2 times and 10.1 times, respectively. When number of NCDs increased from 0 to 1, 2, ≥2 and ≥3, individuals spent a median of 0.36% (IQR 0.15%–0.51%), 1.15% (IQR 0.62%–1.64%), 1.41% (IQR 0.86%–2.15%), 2.42% (IQR 2.05%–2.64%) and 2.63% (IQR 1.56%–4.13%) of mean annual household net adjusted disposable income per capita, respectively, on annual OOPE on medicines. More multimorbidities were associated with higher OOPE on medicines as a proportion of total healthcare expenditures by patients. Some evidence suggested that the elderly and low-income groups were most vulnerable to higher OOPE on medicines. With the same number of NCDs, certain combinations of NCDs yielded higher medicine OOPE. Non-adherence to medicines was a coping strategy for OOPE on medicines.

Conclusion Multimorbidity of NCDs is increasingly costly to healthcare systems and OOPE on medicines can severely compromise financial protection and universal health coverage. It is crucial to recognise the need for better equity and financial protection, and policymakers should consider health system financial options, cost sharing policies and service patterns for those with NCD multimorbidities.

  • public health

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjgh-2017-000505

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    Footnotes

    • Handling editor Seye Abimbola

    • Contributors JTL, CM, and GS contributed to the conception and design of this research. GS performed the literature search and extracted data from individual studies. GS and TH conducted the data analysis and interpreted the data. GS wrote the first draft of the paper. All authors revised the first and subsequent drafts. All authors contributed to the interpretation of the findings and revised the manuscript for important intellectual content.

    • Funding GS is funded by the President’s Graduate Fellowship, National University of Singapore. JTL is funded by the Ministry of Education (MOE) Tier 1 Grant, Singapore. CM is funded by NIHR Research Professorship.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional data are available.

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