A nurse checks womans's blood pressure at community medical center / Photo: World Bank
Addressing the simultaneous presence of two or more chronic diseases in an individual — defined as multimorbidity by the World Health Organization (WHO) — is a global health challenge, and Latin America is at the forefront of this battle. Multimorbidity is a significant contributor to high healthcare costs and a detriment to the quality of life for patients, their families, and caregivers.
Despite the commonality of multimorbidity, healthcare systems often provide fragmented care, focusing on individual conditions rather than the patient as a whole. This disjointed approach can lead to conflicting treatments where medication for one condition adversely affects another, complicating the patient's health even further.
To shift towards a person-centered management of multimorbidity, we must innovate in the design, funding, and organization of health systems. This includes transforming healthcare delivery models, rethinking professional training, and refining clinical practices, especially in prescribing medications. A holistic understanding of the patient and a multi-professional approach are essential for delivering quality care.
This need for innovation motivated the World Bank, with financial support from Access Accelerated, to develop studies on how to improve health service management for patients with multiple chronic diseases in Brazil, Colombia, and Uruguay. These studies had different scopes, exploring innovative care models focused on comprehensive, person-centered care, incorporating timely patient stratification, case management, interdisciplinary care, self-care, patient empowerment, and the active involvement of geriatricians and caregivers.
The Brazilian study advanced in the characterization of the population with multimorbidity. The analysis of the data from the 2019 National Health Survey found that 29.5% of Brazilians have multimorbidity, with a prevalence that: increases with age (over 56% in those over sixty), is higher in women (35.4%) as well as among the less educated (44.8%, compared to with those with completed higher education (25.7%). In Brazil, the chronic diseases with higher prevalence are hypertension (23.9%), chronic back problems (21.6%), high cholesterol (14.6%), and depression (10.2%). Interestingly, prevalence is higher among the less educated. Data from the Unified Health System (SUS) consolidated by the Federal University of Minas Gerais, revealed that between 2000 and 2015, over half of Brazil's public health spending (53%) was on patients with multimorbidity, who also experienced more hospitalizations and medical consultations.
The Uruguayan study focused on:
- Developing a stratification model for the chronic disease population.
- Evaluating existing care models for chronic non-communicable diseases and multimorbidity.
- Proposing optimizations for the current care model.
It advocated for 'person-centered case management' to streamline care, reduce hospital readmissions, and minimize drug interactions. This approach aims to unify care teams to recognize multimorbidity and establish joint care and follow-up criteria at primary and secondary care levels.
The study also highlighted that in Uruguay, patients with five or more pathologies —though only 8% of those with any of 46 chronic diseases patient population—account for 42% of total expenditure and over half of medication spending. Those with multiple hospitalizations in the previous year and on more than five medications, while only 5.6% of patients, represented 83% of total spending and 87.4% of medication costs for this group.
In Colombia, two studies have shed light on the challenges and opportunities in managing multimorbidity. The first study, spanning from 2012 to 2016, revealed a multimorbidity prevalence of 19.5% across all age groups. Notably, it highlighted a surge in healthcare utilization and costs, particularly linked to the aging population and the complexity of managing multiple conditions simultaneously.
The second Colombian study proposed a comprehensive, innovative care model for individuals with multimorbidity and their caregivers, based on an extensive literature review, successful national strategies, and a pilot implementation. This adaptable, person-centered model is designed to fit into the patient's life and environment, starting with risk identification and stratification within a strong primary care system. The model then expands to a multi-tiered healthcare approach, integrating essential elements like physical activity, emotional support, and nutrition, each contributing to a holistic care experience tailored to meet each individual's unique needs.
Multimorbidity is a significant concern in Latin America, where it is prevalent among individuals with chronic conditions and is particularly common in those over sixty. The region faces the dual challenges of a rapidly aging population and a rise in mental health issues, both of which amplify the complexities of managing multimorbidity. Addressing these challenges is becoming increasingly urgent in order to ensure the health and well-being of the population.
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