Economic burden of multimorbidity in South Africa - findings from the ENHANCE Trial
1
SAMRC/Wits Centre for Health Economics and Decision Science – PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
2
Knowledge Translation Unit, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
3
Biostatistics Research Unit, Medical Research Council, Cape Town, South Africa
4
Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
5
Centre for Research in Health systems, University of KwaZulu-Natal, Durban, South Africa
6
Chronic Disease Initiative for Africa, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
7
Institute of Global Health, University College London, London, United Kingdom
Popul. Med. 2026;8(Supplement Supplement 1):A3002
ABSTRACT
BACKGROUND:
International evidence shows that multimorbidity increases out-of-pocket payments (OOPs), indirect costs such as missed workdays, and risk of catastrophic health expenditure1. In South Africa, despite free primary healthcare and chronic medication in the public sector, individuals face substantial additional cost2. Studies among people living with HIV, diabetes, and hypertension highlight how small but repeated expenses accumulate, leading to treatment interruption, poor adherence, and disengagement from care 3,4. While national efforts toward universal health coverage and integrated chronic disease management are expanding, evidence on the economic burden of multimorbidity in South Africa remains limited.
METHODS:
We conducted a cross-sectional study nested within the ENHANCE type 2 hybrid effectiveness-implementation trial evaluating a health system strengthening intervention for people with multiple long-term conditions (MLTCs) in public primary healthcare facilities in the Western Cape and KwaZulu Natal. We estimated OOPs and productivity losses. We used a generalized linear model to explore predictors of OOP spending.
RESULTS:
Among 1,743 adults with MLTCs (mean age 57.6 years) and 23% employment rate, 66% had two conditions, 27% had three conditions and 8% had four or more conditions. OPP was reported in 61.1% of participants. Mean number of days due to illness was 2.5 (SD 2.92). Average OPP was R 436.86 (SD 426.38) per person in three months. Employment status (OR 2.2, p < 0.001), higher number of chronic conditions (OR 1.22, p < 0.007) and older age (OR 1.20, p< 0.048) had higher odds of incurring OPP. No significant association was found between demographic and socio-economic factors and OPP amount.
CONCLUSIONS:
Older age, number of conditions and employment status were important determinants of OPP. Free care remains insufficient to protect vulnerable populations from catastrophic health expenditure, government needs to consider additional measures that translate into comprehensive financial protection and equitable health access for patients with MLTCs.
International evidence shows that multimorbidity increases out-of-pocket payments (OOPs), indirect costs such as missed workdays, and risk of catastrophic health expenditure1. In South Africa, despite free primary healthcare and chronic medication in the public sector, individuals face substantial additional cost2. Studies among people living with HIV, diabetes, and hypertension highlight how small but repeated expenses accumulate, leading to treatment interruption, poor adherence, and disengagement from care 3,4. While national efforts toward universal health coverage and integrated chronic disease management are expanding, evidence on the economic burden of multimorbidity in South Africa remains limited.
METHODS:
We conducted a cross-sectional study nested within the ENHANCE type 2 hybrid effectiveness-implementation trial evaluating a health system strengthening intervention for people with multiple long-term conditions (MLTCs) in public primary healthcare facilities in the Western Cape and KwaZulu Natal. We estimated OOPs and productivity losses. We used a generalized linear model to explore predictors of OOP spending.
RESULTS:
Among 1,743 adults with MLTCs (mean age 57.6 years) and 23% employment rate, 66% had two conditions, 27% had three conditions and 8% had four or more conditions. OPP was reported in 61.1% of participants. Mean number of days due to illness was 2.5 (SD 2.92). Average OPP was R 436.86 (SD 426.38) per person in three months. Employment status (OR 2.2, p < 0.001), higher number of chronic conditions (OR 1.22, p < 0.007) and older age (OR 1.20, p< 0.048) had higher odds of incurring OPP. No significant association was found between demographic and socio-economic factors and OPP amount.
CONCLUSIONS:
Older age, number of conditions and employment status were important determinants of OPP. Free care remains insufficient to protect vulnerable populations from catastrophic health expenditure, government needs to consider additional measures that translate into comprehensive financial protection and equitable health access for patients with MLTCs.
| eISSN: | 2654-1459 |
We process personal data collected when visiting the website. The function of obtaining information about users and their behavior is carried out by voluntarily entered information in forms and saving cookies in end devices. Data, including cookies, are used to provide services, improve the user experience and to analyze the traffic in accordance with the Privacy policy. Data are also collected and processed by Google Analytics tool (more).
You can change cookies settings in your browser. Restricted use of cookies in the browser configuration may affect some functionalities of the website.
You can change cookies settings in your browser. Restricted use of cookies in the browser configuration may affect some functionalities of the website.
