Multimorbidity refers to the presence of two or more chronic diseases, and it holds a variety of clinical implications, including a strong mandate for patient-centered care due to the potential for drug interactions necessitating adaptive treatment. For public health authorities to effectively manage high levels of multimorbidity, they need a health system that provides quality primary care, streamlines referrals, and effectively allocates and utilizes drug stockpiles.

Multimorbidity management models operate on multiple levels, performing disease surveillance and detection at the macro level to inform decision-making. At the micro level, multimorbidity management focuses on highquality, integrated care which centers on the patient’s unique clinical needs and makes treatment accessible. In the middle, public health education encourages diseasepreventive behavior and strong patient referral systems and supply chains ensure the delivery of essential medical services and products.

The phenomenon of multimorbidity is growing rapidly in conjunction with an aging population, as seen in Brazil, Colombia, and Uruguay. The World Bank leveraged flexible funding from Access Accelerated to target multimorbidity in these three countries through a phased approach. The first step entails collaboration with national ministries of health to define the characteristics of national population groups with high rates of multimorbidity, including frequent multimorbidity clusters among children, adults, and the elderly. Health system processes, technologies, and service capabilities to treat multimorbidity are referenced against these cases, and opportunities are identified to develop systems that better respond to patients with multiple chronic conditions. These opportunities take the form of best practices and innovations sourced from international literature, assessments of national health systems, and the results of pilot implementation.

In 2023, the Access Accelerated – World Bank partnership supported the design and piloting of alternative models of comprehensive multimorbidity management and care in Brazil, Colombia, and Uruguay. These models of care serve as a capstone to multiple years of productive engagement between World Bank country teams and an array of local counterparts from government, the public and private health sectors, insurers, and advocacy groups representing patients and caregivers. Brazil, Colombia, and Uruguay present strategic opportunities for targeted investment in multimorbidity because of their aging population demographics, high prevalence of NCD risk factors, and the complementary characteristics of their health system structure and the World Bank’s technical capabilities in the LAC region.

A study carried out under this activity found that the Colombian prevalence of multimorbidity to be 19.5% across all ages and genders. Using data from the 2019 Brazilian National Health Survey, a similar study conducted by the World Bank found a 29.5% overall rate of multimorbidity across Brazil, with higher prevalence among women and individuals lacking formal education. The World Bank study in Brazil estimated the costs of multimorbidity to the Brazilian National Health System, finding that the total costs for a patient with multimorbidity were 129% higher on average than a patient with a single chronic disease.

These studies exemplify the World Bank’s commitment in supporting countries in the design of policies and programs for NCD prevention, management, and control. In this case, collaboration with national health stakeholders brought about knowledge products which not only advocate for investment in multimorbidity management, but also provide models of care based on cutting-edge insights from pilot implementation and the global literature.

This suite of policy reports produced multiple key recommendations:

• It is essential to recognize the social determinants of multimorbidity and make a comprehensive assessment of patients and their risk stratification.
• Solutions for multimorbidity are found in the household and in primary health centers, where people perform self-care and access early detection services.
• Preserving continuity of care is essential, and primary health centers must be able to provide patients with a warm handoff to specialists.