Multimorbidity and Out-of-pocket Expenditure on Medicines: A Systematic Review

Background Multimorbidity, the presence of two or more non-communicable diseases (NCDs), 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. Objective To examine out-of-pocket expenditure on medicines for patients with multimorbidity. Design Systematic Review Data sources Ovid Medline, Embase, EconLit, the Cochrane Library, and the WHO Global Health Library. Eligibility criteria for selecting articles We included primary original articles in English published from the year 2000 to 31 Dec 2016, without any restriction on populations and settings. We defined OOPE as spending on medicines that was not reimbursed. Articles must compare OOPE for medicines for different numbers of multimorbidities, such as reporting OOPE on medicines for zero, one, two, and three or more NCDs. Study quality was assessed using Newcastle-Ottawa Scale. Results 14 articles met inclusion criteria. Findings indicated that multimorbidity was associated with higher OOPE on medicines. When number of NCDs increased from zero to one, two, 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 zero, one, two, ≥2, and ≥3, individuals spent a median of 0.36%, 1.15%, 1.41%, 2.42%, 2.63%, of mean annual household net adjusted disposable income per capita, respectively, on annual OOPE on medicines. More multimorbidities was 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. Non-adherence to medicines was a coping strategy for OOPE on medicines. Key messages: NCD multimorbidity is associated with higher OOPE spending for medication Concerted efforts needed to improve health service coverage and financial protection for patients with multimorbidities, particularly for vulnerable groups such as the elderly.