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The household economic burden of non-communicable diseases in 18 countries
  1. Adrianna Murphy1,
  2. Benjamin Palafox1,
  3. Marjan Walli-Attaei2,
  4. Timothy Powell-Jackson1,
  5. Sumathy Rangarajan2,
  6. Khalid F Alhabib3,
  7. Alvaro Jr Avezum4,
  8. Kevser Burcu Tumerdem Calik5,
  9. Jephat Chifamba6,
  10. Tarzia Choudhury7,
  11. Gilles Dagenais8,
  12. Antonio L Dans9,
  13. Rajeev Gupta10,
  14. Romaina Iqbal11,
  15. Manmeet Kaur12,
  16. Roya Kelishadi13,
  17. Rasha Khatib14,
  18. Iolanthe Marike Kruger15,
  19. Vellappillil Raman Kutty16,
  20. Scott A Lear17,
  21. Wei Li18,
  22. Patricio Lopez-Jaramillo19,
  23. Viswanathan Mohan20,
  24. Prem K Mony21,
  25. Andres Orlandini22,
  26. Annika Rosengren23,
  27. Ismail Rosnah24,
  28. Pamela Seron25,
  29. Koon Teo2,
  30. Lap Ah Tse26,
  31. Lungiswa Tsolekile27,
  32. Yang Wang28,
  33. Andreas Wielgosz29,
  34. Ruohua Yan28,
  35. Karen E Yeates30,
  36. Khalid Yusoff31,
  37. Katarzyna Zatonska32,
  38. Kara Hanson1,
  39. Salim Yusuf2,
  40. Martin McKee1
  1. 1London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
  2. 2Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
  3. 3Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
  4. 4Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
  5. 5Department of Health Management, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
  6. 6Department of Physiology, University of Zimbabwe, Harare, Zimbabwe
  7. 7Independent University, Dhaka, Bangladesh
  8. 8Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Ontario, Canada
  9. 9Department of Medicine, University of the Philippines Manila, Manila, Philippines
  10. 10Eternal Heart Care Centre and Research Institute, Jaipur, India
  11. 11Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
  12. 12School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
  13. 13Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, the Islamic Republic of Iran
  14. 14Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  15. 15Africa Unit for Transdisciplinary Health Research, North-West University, Potchefstroom, South Africa
  16. 16Health Action by People, Trivandrum, Kerala, India
  17. 17Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
  18. 18State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, University Teknologi MARA, Beijing, China
  19. 19FOSCAL, Medical School, Universidad de Santander (UDES), Bucaramanga, Colombia
  20. 20Dr. Mohan's Diabetes Specialities Centre & Madras Diabetes Research Foundation, Chennai, India
  21. 21St John's Medical College and Research Institute, Bangalore, India
  22. 22ECLA Foundation, Santa Fe, Argentina
  23. 23Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University, Gothenburg, Sweden
  24. 24Community Health Department, Faculty of Medicine, UKM Medical Centre, Kuala Lumpur, Malaysia
  25. 25Facultad de Medicina, Universidad de La Frontera, Temucu, Chile
  26. 26JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
  27. 27School of Public Health, University of the Western Cape, Bellville, Western Cape, South Africa
  28. 28State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
  29. 29Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
  30. 30Department of Medicine, Queen's University, Kingston, New Hampshire, Canada
  31. 31UiTM, Selayang, Selangor and UCSI University, Cheras, Kuala Lumpur, Malaysia
  32. 32Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
  1. Correspondence to Dr Adrianna Murphy; adrianna.murphy{at}


Background Non-communicable diseases (NCDs) are the leading cause of death globally. In 2014, the United Nations committed to reducing premature mortality from NCDs, including by reducing the burden of healthcare costs. Since 2014, the Prospective Urban and Rural Epidemiology (PURE) Study has been collecting health expenditure data from households with NCDs in 18 countries.

Methods Using data from the PURE Study, we estimated risk of catastrophic health spending and impoverishment among households with at least one person with NCDs (cardiovascular disease, diabetes, kidney disease, cancer and respiratory diseases; n=17 435), with hypertension only (a leading risk factor for NCDs; n=11 831) or with neither (n=22 654) by country income group: high-income countries (Canada and Sweden), upper middle income countries (UMICs: Brazil, Chile, Malaysia, Poland, South Africa and Turkey), lower middle income countries (LMICs: the Philippines, Colombia, India, Iran and the Occupied Palestinian Territory) and low-income countries (LICs: Bangladesh, Pakistan, Zimbabwe and Tanzania) and China.

Results The prevalence of catastrophic spending and impoverishment is highest among households with NCDs in LMICs and China. After adjusting for covariates that might drive health expenditure, the absolute risk of catastrophic spending is higher in households with NCDs compared with no NCDs in LMICs (risk difference=1.71%; 95% CI 0.75 to 2.67), UMICs (0.82%; 95% CI 0.37 to 1.27) and China (7.52%; 95% CI 5.88 to 9.16). A similar pattern is observed in UMICs and China for impoverishment. A high proportion of those with NCDs in LICs, especially women (38.7% compared with 12.6% in men), reported not taking medication due to costs.

Conclusions Our findings show that financial protection from healthcare costs for people with NCDs is inadequate, particularly in LMICs and China. While the burden of NCD care may appear greatest in LMICs and China, the burden in LICs may be masked by care foregone due to costs. The high proportion of women reporting foregone care due to cost may in part explain gender inequality in treatment of NCDs.

  • health economics
  • health insurance
  • cardiovascular disease
  • health systems
  • diabetes

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  • Handling editor Lei Si

  • Twitter @adriannakmurphy

  • Contributors All authors contributed to the conception of the study, execution of data collection, data analysis or writing and revision of the paper.

  • Funding AM is funded by a Wellcome Trust Research Fellowship (number 104349/Z/14/Z). BP and MM were supported by a UK Economic and Social Research Council grant (number ES/L014696/1) under its Secondary Data Analysis Initiative scheme. SY is funded by the Marion Burke Chair of the Heart and Stroke Foundation of Canada. KY is supported by a Ministry of Higher Education Malaysia Research Grant (number 600-RMI/LRGS 5/3 [2/2011]). The main Prospective Urban and Rural Epidemiology (PURE) Study and its components are funded by the Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario and through unrestricted grants from several pharmaceutical companies (with major contributions from AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier and GlaxoSmithKline, and additional contributions from Novartis and King Pharma) and various national or local organisations in participating countries. These include: Argentina: Fundacion ECLA; Bangladesh: Independent University, Bangladesh and Mitra and Associates; Brazil: Unilever Health Institute, Brazil; Canada: Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de La Frontera (DI13-PE11); China: National Center for Cardiovascular Diseases; Colombia: Colciencias, grant number 6566-04-18062 and Fundacion Oftalmologica de Santander; India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia, grant number 100-IRDC/BIOTEK 16/6/21 (13/2007), grant number 07–05-IFN-BPH 010, Ministry of Higher Education of Malaysia grant number 600-RMI/LRGS/5/3 (2/2011), Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15–2010); Occupied Palestinian Territory: the UN Relief and Works Agency for Palestine Refugees in the Near East, Occupied Palestinian Territory; International Development Research Centre, Canada; Philippines: Philippine Council for Health Research & Development; Poland: Polish Ministry of Science and Higher Education, grant number 290/W-PURE/2008/0, Wroclaw Medical University; Saudi Arabia: Saudi Heart Association, The Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia (research group number RG-1436–013); South Africa: The North-West University, SA and Netherlands Programme for Alternative Development, National Research Foundation, Medical Research Council of South Africa, the South Africa Department of Science and Technology, The South African Sugar Association, Faculty of Community and Health Sciences; Sweden: AFA Insurance, Swedish Council for Working Life and Social Research, King Gustaf V's and Queen Victoria's Freemasons Foundation, Swedish Heart and Lung Foundation, Swedish Research Council, grant from the Swedish State under (Läkar Utbildnings Avtalet) Agreement, grant from the Västra Götaland Region (FOUU); Turkey: Metabolic Syndrome Society, AstraZeneca (Turkey), Sanofi-Aventis (Turkey); and United Arab Emirates: Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences and Dubai Health Authority, Dubai, United Arab Emirates.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethics committees at each centre approved the protocol, published elsewhere, and all participants provided written informed consent.

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

  • Data availability statement Data may be obtained from a third party and are not publicly available. Participant-level data cannot be publicly deposited because consent to share individuals’ data publicly has not been obtained, and data collection is ongoing. Researchers wishing to access these data should contact the PURE Program Manager, Sumathy Rangarajan at

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