Effect of multimorbidity on utilisation and out-of-pocket expenditure in Indonesia: quantile regression analysis

Anindya K., Ng N., Atun R., Marthias T., Zhao Y., McPake B., van Heusden A., Pan T., Lee J.T.

The Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia; School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, The University of Gothenburg, Gothenburg, Sweden; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States; Department of Public Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia; The George Institute for Global Health at Peking University Health Science Center, Beijing, China; WHO Collaborating Centre on Implementation Research for Prevention and Control of Noncommunicable Diseases, Melbourne, VIC, Australia; Centre for Health Policy, School of Population and Global Health, The University of Melbourne, Melbourne, Australia; Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom


Background: Multimorbidity (the presence of two or more non-communicable diseases) is a major growing challenge for many low-income and middle-income countries (LMICs). Yet, its effects on health care costs and financial burden for patients have not been adequately studied. This study investigates the effect of multimorbidity across the different percentiles of healthcare utilisation and out-of-pocket expenditure (OOPE). Methods: We conducted a secondary data analysis of the 2014/2015 Indonesian Family Life Survey (IFLS-5), which included 13,798 respondents aged ≥40 years. Poisson regression was used to assess the association between sociodemographic characteristics and the total number of non-communicable diseases (NCDs), while multivariate logistic regression and quantile regression analysis was used to estimate the associations between multimorbidity, health service use and OOPE. Results: Overall, 20.8% of total participants had two or more NCDs in 2014/2015. The number of NCDs was associated with higher healthcare utilisation (coefficient 0.11, 95% CI 0.07–0.14 for outpatient care and coefficient 0.09 (95% CI 0.02–0.16 for inpatient care) and higher four-weekly OOPE (coefficient 27.0, 95% CI 11.4–42.7). The quantile regression results indicated that the marginal effect of having three or more NCDs on the absolute amount of four-weekly OOPE was smaller for the lower percentiles (at the 25th percentile, coefficient 1.0, 95% CI 0.5–1.5) but more pronounced for the higher percentile of out-of-pocket spending distribution (at the 90th percentile, coefficient 31.0, 95% CI 15.9–46.2). Conclusion: Multimorbidity is positively correlated with health service utilisation and OOPE and has a significant effect, especially among those in the upper tail of the utilisation/costs distribution. Health financing strategies are urgently required to meet the needs of patients with multimorbidity, particularly for vulnerable groups that have a higher level of health care utilisation. © 2021, The Author(s).

Health service use; Indonesia; Multimorbidity; Non-communicable diseases; Out-of-pocket expenditure


BMC Health Services Research

Publisher: BioMed Central Ltd

Volume 21, Issue 1, Art No 427, Page – , Page Count

Journal Link: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85105379005&doi=10.1186%2fs12913-021-06446-9&partnerID=40&md5=59d667ea8b915905b2c3e7059325df55

doi: 10.1186/s12913-021-06446-9

Issn: 14726963

Type: All Open Access, Gold, Green


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