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
Type: All Open Access, Gold, Green
(2018) Noncommunicable diseases country profiles 2018, , World Health Organization, Geneva; Barnett, K., Mercer, S.W., Norbury, M., Watt, G., Wyke, S., Guthrie, B., Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study (2012) Lancet, 380 (9836), pp. 37-43; Hussain, M.A., Huxley, R.R., Al, M.A., Multimorbidity prevalence and pattern in Indonesian adults: an exploratory study using national survey data (2015) BMJ Open, 5 (12); Berita resmi statistik: Hasil sensus penduduk 2020 (2021) Jakarta; United Nations, Department of Economic and Social Affairs PD (2019) World Population Prospects 2019, Online Edition, , https://population.un.org/wpp/Download/Standard/Population/(), Rev. 1; Xu, K., Evans, D.B., Carrin, G., Aguilar-Rivera, A.M., Musgrove, P., Evans, T., Protecting households from catastrophic health spending (2007) Health Aff, 26 (4), pp. 972-983; Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K.A., EL Suparmi, A., Universal health coverage in Indonesia: concept, progress, and challenges (2019) Lancet, 393 (10166), pp. 75-102; (2020) Indonesia health profile 2019, , Ministry of Health of the Republic of Indonesia, Jakarta; Chang, A.Y., Cowling, K., Micah, A.E., Chapin, A., Chen, C.S., Ikilezi, G., Sadat, N., Dieleman, J.L., Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995–2050 (2019) Lancet, 393 (10187), pp. 2233-2260; Jaspers, L., Colpani, V., Chaker, L., van der Lee, S.J., Muka, T., Imo, D., The global impact of non-communicable diseases on households and impoverishment: a systematic review (2014) Eur J Epidemiol, 30, pp. 163-188; Marmot, M., Social determinants of health inequalities (2005) Lancet, 365 (9464), pp. 1099-1104; Khan, J.A.M., Ahmed, S., Evans, T.G., Catastrophic healthcare expenditure and poverty related to out-of-pocket payments for healthcare in Bangladesh—an estimation of financial risk protection of universal health coverage (2017) Health Policy Plan, 32 (8), pp. 1102-1110; Boutayeb, A., Boutayeb, S., Boutayeb, W., Multi-morbidity of non communicable diseases and equity in WHO eastern Mediterranean countries (2013) Int J Equity Health, 12 (1), p. 60; Sum, G., Hone, T., Atun, R., Millett, C., Suhrcke, M., Mahal, A., Koh, G.C.H., Lee, J.T., Multimorbidity and out-of-pocket expenditure on medicines: a systematic review (2018) BMJ Glob Health, 3 (1); Wang, L., Si, L., Cocker, F., Palmer, A.J., Sanderson, K., A systematic review of cost-of-illness studies of multimorbidity (2018) Appl Health Econ Health Policy, 16 (1), pp. 15-29; Finkelstein, E.A., Chay, J., Bajpai, S., The economic burden of self-reported and undiagnosed cardiovascular diseases and diabetes on Indonesian households (2014) PLoS One, 9 (6); Mahwati, Y., Determinants of multimorbidity among the elderly population in Indonesia (2014) Kesmas Natl Public Heal J, 9 (2), p. 187; Sum, G., Salisbury, C., Koh, G.C.H., Atun, R., Oldenburg, B., Mcpake, B., Implications of multimorbidity patterns on health care utilisation and quality of life in middleincome countries: cross-sectional analysis (2019) J Glob Health, 9 (2); Pati, S., Agrawal, S., Swain, S., Lee, J.T., Vellakkal, S., Hussain, M.A., Millett, C., Non communicable disease multimorbidity and associated health care utilization and expenditures in India: cross-sectional study (2014) BMC Health Serv Res, 14 (1), p. 451; Strauss, J., Witoelar, F., Sikoki, B., (2016) The Fifth Wave of Indonesia Famiy Life Survey: Overview and Field Report, , Santa Monica; Strauss, J., Witoelar, F., Sikoki, B., User’s guide for the Indonesia family life survey, wave 5 (2016) Santa Monica, , https://doi.org/10.7249/WR1143.2; von Elm, E., Altman, D.G., Egger, M., Pocock, S.J., Gøtzsche, P.C., Vandenbroucke, J.P., The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies (2007) Lancet, 370 (9596), pp. 1453-1457; Chobanian, A.V., Bakris, G.L., Black, H.R., Cushman, W.C., Green, L.A., Izzo, J.L., The seventh report of the joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report (2003) J Am Med Assoc, 289 (19), pp. 2560-2572; Organisation for Economic Co-operation and Development (OECD Purchasing Power Parities (PPP) (Indicator)., , https://data.oecd.org/conversion/purchasing-power-parities-ppp.htm, accessed September 10, 2020; Barros, A.J.D., Hirakata, V.N., Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio (2003) BMC Med Res Methodol, 3 (1), pp. 1-13; Fan, G., Deng, Z., Wu, X., Wang, Y., Medical insurance and health equity in health service utilization among the middle-aged and older adults in China: a quantile regression approach (2020) BMC Health Serv Res, 20 (1), p. 553; Teni, F.S., Gebresillassie, B.M., Birru, E.M., Belachew, S.A., Tefera, Y.G., Wubishet, B.L., Tekleyes, B.H., Yimer, B.T., Costs incurred by outpatients at a university hospital in northwestern Ethiopia: A cross-sectional study (2018) BMC Health Serv Res, 18 (1); de Souza, A.S.S., Braga, J.U., Trends in the use of health services and their relationship with multimorbidity in Brazil, 1998–2013 (2020) BMC Health Serv Res, 20 (1), p. 1080; Sum, G., Koh, G., Atun, R., Oldenburg, B., Lee, J., Vellakkal, S., Multimorbidity patterns and implications for healthcare utilisation and quality of life in six LMICs (2018) Eur J Pub Health, 28; Picco, L., Achilla, E., Abdin, E., Chong, S.A., Vaingankar, J.A., McCrone, P., Chua, H.C., Subramaniam, M., Economic burden of multimorbidity among older adults: impact on healthcare and societal costs (2016) BMC Health Serv Res, 16 (1), p. 173; Marthias, T., Anindya, K., Ng, N., Mcpake, B., Atun, R., Arfyanto, H., Impact of non-communicable disease multimorbidity on health service use, catastrophic health expenditure and productivity loss in Indonesia: a population-based panel data analysis study (2021) BMJ Open, 11, p. 41870; Basic health research 2018 (2018) Jakarta; Lu, C., Chin, B., Li, G., Murray, C.J.L., Limitations of methods for measuring out-of-pocket and catastrophic private health expenditures (2009) Bull World Health Organ, 87 (3), pp. 238-244; D’Hoore, W., Bouckaert, A., Tilquin, C., Practical considerations on the use of the Charlson comorbidity index with administrative data bases (1996) J Clin Epidemiol, 49 (12), pp. 1429-1433; Husnayain, A., Ekadinata, N., Sulistiawan, D., Su, E.C.Y., Multimorbidity patterns of chronic diseases among indonesians: insights from indonesian national health insurance (INHI) sample data (2020) Int J Environ Res Public Health, 17, pp. 1-12; Hidayat, B., Němec, J., Viktoria, R., Rozanna, C.S., Spatz, J., (2015) Out-of-pocket payments in the National Health Insurance of Indonesia: a first year review policy brief, , Indonesian-German Social Protection Programme, Jakarta; Duy Kien, V., Van Minh, H., Giang, K.B., Dao, A., Tuan, L.T., Ng, N., Socioeconomic inequalities in catastrophic health expenditure and impoverishment associated with non-communicable diseases in urban Hanoi, Vietnam (2016) Int J Equity Health, 15 (1), p. 169; Nugraheni, W., Mubasyiroh, R., Kusuma, R., (2019) The Role of National Health Insurance (JKN) in Reducing the Financial Burden of Childbirth, , Jakarta; Mboi, N., Murty Surbakti, I., Trihandini, I., Elyazar, I., Houston Smith, K., Bahjuri Ali, P., Kosen, S., Hay, S.I., On the road to universal health care in Indonesia, 1990–2016: a systematic analysis for the global burden of disease study 2016 (2018) Lancet, 392 (10147), pp. 581-591; Pothuraju, R., Krishn, S.R., Gautam, S.K., Pai, P., Ganguly, K., Chaudhary, S., Mechanistic and functional shades of Mucins and associated Glycans in Colon Cancer (2020) Cancers (Basel), 12 (3); Stenberg, K., Hanssen, O., Bertram, M., Brindley, C., Meshreky, A., Barkley, S., Tan-Torres Edejer, T., (2019); Bhat, R., Holtz, J., Avila, C., Reaching the missing middle: ensuring health coverage for India’s urban poor (2018) Heal Syst Reform, 4 (2), pp. 125-135; Duy Kien, V., Van Minh, H., Giang, K.B., Ng, N., Nguyen, V., Tuan, L.T., Views by health professionals on the responsiveness of commune health stations regarding non-communicable diseases in urban Hanoi, Vietnam: a qualitative study (2018) BMC Health Serv Res, 18, p. 392; Schröders, J., Wall, S., Hakimi, M., Dewi, F.S.T., Weinehall, L., Nichter, M., How is Indonesia coping with its epidemic of chronic noncommunicable diseases? A systematic review with meta-analysis (2017) PLoS One, 12; Seiglie, J.A., Marcus, M.E., Ebert, C., Prodromidis, N., Geldsetzer, P., Theilmann, M., Agoudavi, K., Manne-Goehler, J., Diabetes prevalence and its relationship with education, wealth, and BMI in 29 low- and middle-income countries (2020) Diabetes Care, 43 (4), pp. 767-775; Bischops, A.C., Manne-Goehler, J., Jaacks, L.M., Awasthi, A., Theilmann, M., Davies, J.I., Atun, R., Geldsetzer, P., The prevalence of concurrently raised blood glucose and blood pressure in India (2019) J Hypertens, 37 (9), pp. 1822-1831; Manne-Goehler, J., Atun, R., Stokes, A., Goehler, A., Houinato, D., Houehanou, C., Hambou, M.M.S., Bärnighausen, T., Diabetes diagnosis and care in sub-Saharan Africa: pooled analysis of individual data from 12 countries (2016) Lancet Diabetes Endocrinol, 4 (11), pp. 903-912; Prenissl, J., Manne-Goehler, J., Jaacks, L.M., Prabhakaran, D., Awasthi, A., Bischops, A.C., Atun, R., Geldsetzer, P., Hypertension screening, awareness, treatment, and control in India: a nationally representative cross-sectional study among individuals aged 15 to 49 years (2019) PLoS Med, 16 (5); Geldsetzer, P., Manne-Goehler, J., Theilmann, M., Davies, J.I., Awasthi, A., Vollmer, S., Jaacks, L.M., Atun, R., Diabetes and hypertension in India a nationally representative study of 1.3 million adults (2018) JAMA Intern Med, 178 (3), pp. 363-372; Hidayat, B., Provider choice for outpatient health care services in Indonesia: the role of health insurance (2009) Bul Penelit Kesehat, 12, pp. 217-226; Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., The Republic of Indonesia Health System Review. Asia Pacific Observatory on Health Systems and Policies (2017) Health Syst Transit, 7, p. 66
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