Background: Population ageing and the growing burden of non-communicable diseases are crucial challenges for low-income and middle-income countries, especially because of their effects on the economy and on development and competitiveness indicators. In 2005, WHO urged countries to establish financing insurance mechanisms ensuring equitable universal health coverage. We assessed health coverage for elderly people with non-communicable diseases.

Methods: We did this cross-sectional analysis of people aged older than 50 years who had non-communicable diseases in six low-income and middle-income countries (China, Ghana, India, Mexico, Russia, and South Africa) from the WHO Study on global AGEing and adult health (SAGE) Wave1 (2007–10). We analysed individual and household data for 17?752 participants with regards to doctor visits, treatment, supervision, effectiveness of care, catastrophic health spending, and equitable distribution of health coverage across socioeconomic groups. We estimated weighted population means, and fitted logistic regression models and standardised concentration curves.

Findings: Effective coverage ranged from 20·7% (95% CI 15·2–27·5) of patients in Mexico to 48·2% (43·9–52·5) in South Africa. Insured patients were significantly more likely to have effective coverage than were uninsured patients in Ghana (odds ratio 1·8, 95% CI 1·4–2·5), India (3·1, 1·9–4·9), and Mexico (3·0, 1·7–5·3). The effect of social determinants on effective coverage varied across countries. Catastrophic health spending ranged from 8·1% (95% CI 5·9–11·2) in South Africa to 45·7% (42·0–49·4) in India, even among people with insurance. Pro-rich inequities existed for effective coverage (except in South Africa) and catastrophic health spending (except in Russia).

Interpretation: Health insurance is associated with health coverage in all the countries studied, but it is insufficient to ensure universal health coverage. Differences in effectiveness and equity within and between low-income and middle-income countries relate to the social circumstances in each country, which determine the challenges of achieving universal health coverage.