Financial Burden of Prescribed Medicines Included in Outpatient Benefits Package Schemes: Comparative Analysis of Co-Payments for Reimbursable Medicines in European Countries

  • Sabine VoglerEmail author
  • Guillaume Dedet
  • Hanne Bak Pedersen
Original Research Article



The study aimed to analyse the financial burden that co-payments for prescribed and reimbursed medicines pose on patients in European countries.


Five medicines used in acute conditions (antibiotic, analgesic) and in chronic care (hypertension, asthma, diabetes) were selected. Co-payments (standard and five defined population groups, e.g. low-income people, patients with high consumption) were surveyed based on information retrieved from national price lists (September 2017) and co-payment regulation in nine countries (Albania, Austria, England, France, Germany, Greece, Hungary, Kyrgyzstan and Sweden). The financial burden of the selected medicines (originator and lowest-priced generic) was described as the percentage of patients’ payments for 1 month’s therapy or treatment of one episode in comparison to the national minimum monthly wage.


The study showed large variation in co-payments between the countries. Financial burden resulting from co-payments for reimbursed medicines tended to be higher in lower-income countries (Kyrgyzstan: 9% of minimum monthly wage for generic amlodipine; 2–4% for generic and originator salbutamol; Albania: approximately 3% for originator amoxicillin/clavulanic acid and metformin). Most studied countries applied reduction or exemption mechanisms (children were exempt in five countries, no or lower co-payments for low-income people in five countries, exemptions from co-payments upon reaching a threshold of expenses in six countries).


Co-payments for prescribed medicines can pose a substantial financial burden for outpatients, particularly in lower-income countries. The price of a medicine, availability of lower-priced medicines and the design of co-payments, including exemptions and reductions for specific groups, can considerably impact patients’ expenses for medicines.



We sincerely thank the following experts for validating the financial burden analysis for their country: Sarah Mörtenhuber, Main Association of Social Security Institutions (Austria), Dimitra Panteli, Berlin University of Technology (Germany), Chara Kani, EOPYY – National Organization for Healthcare Service Provision (Greece), Gergely Németh, Institute of Health Insurance Fund Management (Hungary), Saltanat Moldoisaeva, WHO Country Office (Kyrgyzstan), Gunilla Rönnholm, Dental and Pharmaceutical Benefits Agency (Sweden) and Stephen Lock, Department of Health and Social Care (United Kingdom). In addition, our thanks go to Peter Schneider of Gesundheit Österreich GmbH (Austrian Public Health Institute), who surveyed the medicine prices for the included EU Member States through the Pharma Price Information (PPI) service and to Manuel Alexander Haasis of Gesundheit Österreich GmbH (Austrian Public Health Institute), who was involved in surveying the co-payment regulations in European countries.

Compliance with Ethical Standards


The study was funded by the WHO Regional Office for Europe’s Health Technologies and Pharmaceuticals programme. No funding was received for the writing of the manuscript.

Conflict of interest

SV, GD and HBP have no conflicts of interest to declare. All authors submitted a signed Conflict of Interest disclosure form.

Author contributions

All authors fulfil the authorship criteria. All authors are aware of the submission and are in agreement with the manuscript. SV developed the methodology, in collaboration with GD and HBP. Data analysis was mainly done by SV, supported by GD, and SV and GD collaborated on the presentation and interpretation of the data. SV had the lead in drafting and revising the manuscript, upon comments by GD and HBP. This article reflects GD’s views and not those of the OECD. After submission of the article, HBP transferred to UNICEF.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Data availability statement

All data generated or analysed during this study are included in this published article (and its Electronic Supplementary Materials files, see in particular files S3–S5).

Supplementary material

40258_2019_509_MOESM1_ESM.docx (24 kb)
Supplementary material 1 (docx 25 kb)
40258_2019_509_MOESM2_ESM.docx (29 kb)
Supplementary material 2 (docx 29 kb)
40258_2019_509_MOESM3_ESM.docx (98 kb)
Supplementary material 3 (docx 98 kb)
40258_2019_509_MOESM4_ESM.docx (155 kb)
Supplementary material 4 (docx 156 kb)
40258_2019_509_MOESM5_ESM.docx (160 kb)
Supplementary material 5 (docx 161 kb)


  1. 1.
    Wettstein DJ, Boes S. Effectiveness of national pricing policies for patent-protected pharmaceuticals in the OECD: a systematic literature review. Appl Health Econ Health Policy. 2018;17:143–62.Google Scholar
  2. 2.
    Dylst P, Vulto A, Godman B, Simoens S. Generic medicines: solutions for a sustainable drug market? Appl Health Econ Health Policy. 2013;11(5):1–7.Google Scholar
  3. 3.
    Vogler S, Paris V, Ferrario A, Wirtz VJ, de Joncheere K, Schneider P, et al. How can pricing and reimbursement policies improve affordable access to medicines? Lessons learned from European countries. Appl Health Econ Health Policy. 2017;15(3):1–15.Google Scholar
  4. 4.
    WHO Regional Office for Europe. Access to new medicines in Europe: technical review of policy initiatives and opportunities for collaboration and research. Copenhagen: 2015.Google Scholar
  5. 5.
    Austvoll-Dahlgren A, Aaserud M, Vist G, Ramsay C, Oxman AD, Sturm H, et al. Pharmaceutical policies: effects of cap and co-payment on rational drug use. Cochrane Database Syst Rev. 2008;1.Google Scholar
  6. 6.
    Gemmill MC, Thomson S, Mossialos E. What impact do prescription drug charges have on efficiency and equity? Evidence from high-income countries. Int J Equity Health. 2008;7:12.Google Scholar
  7. 7.
    Schafheutle EI, Hassell K, Noyce PR, Weiss MC. Access to medicines: cost as an influence on the views and behaviour of patients. Health Soc Care Commun. 2002;10(3):187–95.Google Scholar
  8. 8.
    Wladysiuk M, Araszkiewicz A, Godman B, Szabert K, Barbui C, Haycox A. Influence of patient co-payments on atypical antipsychotic choice in Poland. Appl Health Econ Health Policy. 2011;9(2):101–10.Google Scholar
  9. 9.
    Schokkaert E, Steel J, Van de Voorde C. Out-of-pocket payments and subjective unmet need of healthcare. Appl Health Econ Health Policy. 2017;15(5):545–55.Google Scholar
  10. 10.
    Perumal-Pillay V, Shiraz AR, Suleman F. The perceptions of patient copayment on the reported adherence to prescription medication. Global J Health Sci. 2018;10(11):105–12.Google Scholar
  11. 11.
    Cameron A, Ewen M, Auton M, Abegunde D. The world medicines situation 2011. Medicines prices, availability and affordability. Geneva: World Health Organization; 2011. p. 2011.Google Scholar
  12. 12.
    Ewen M, Zweekhorst M, Regeer B, Laing R. Baseline assessment of WHO’s target for both availability and affordability of essential medicines to treat non-communicable diseases. PLoS ONE. 2017;12(2):e0171284.Google Scholar
  13. 13.
    Niëns LM, Cameron A, Van de Poel E, Ewen M, Brouwer WB, Laing R. Quantifying the impoverishing effects of purchasing medicines: a cross-country comparison of the affordability of medicines in the developing world. PLoS Med. 2010;7(8):1056.Google Scholar
  14. 14.
    Vellopoulou K, Bakakos P, Loukides S, Maniadakis N, Kourlaba G. The economic burden of asthma in Greece: A cross-sectional study. Applied Health Economics and Health Policy. 2019;First Online: 17 April 2019.Google Scholar
  15. 15.
    Arsenijevic J, Pavlova M, Rechel B, Groot W. Catastrophic health care expenditure among older people with chronic diseases in 15 European countries. PLoS ONE. 2016;11(7):e0157765.Google Scholar
  16. 16.
    Thomson S, Cylus J, Evetovits T. Can people afford to pay for health care? New evidence on financial protection in Europe. Copenhagen: WHO Regional Office for Europe; 2019.Google Scholar
  17. 17.
    Qosaj FA, Froeschl G, Berisha M, Bellaqa B, Holle R. Catastrophic expenditures and impoverishment due to out-of-pocket health payments in Kosovo. Cost Effect Resour Alloc. 2018;16(1):26.Google Scholar
  18. 18.
    Tomini SM, Packard TG, Tomini F. Catastrophic and impoverishing effects of out-of-pocket payments for health care in Albania: evidence from Albania Living Standards Measurement Surveys 2002, 2005 and 2008. Health Policy Plan. 2013;28(4):419–28.Google Scholar
  19. 19.
    Łuczak J, García-Gómez P. Financial burden of drug expenditures in Poland. Health Policy. 2012;105(2):256–64.Google Scholar
  20. 20.
    Kronenberg C, Barros PP. Catastrophic healthcare expenditure—drivers and protection: the Portuguese case. Health Policy. 2014;115(1):44–51.Google Scholar
  21. 21.
    Krůtilová V, Yaya S. Unexpected impact of changes in out-of-pocket payments for health care on Czech household budgets. Health Policy. 2012;107(2):276–88.Google Scholar
  22. 22.
    Arsenijevic J, Pavlova M, Groot W. Out-of-pocket payments for health care in Serbia. Health Policy. 2015;119(10):1366–74.Google Scholar
  23. 23.
    WHO Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies. Glossary of pharmaceutical terms. Update 2018. Vienna: 2018. Accessed 3 Feb 2019.
  24. 24.
    Hossein Z, Gerard A. Trends in cost sharing among selected high income countries—2000–2010. Health Policy (Amsterdam, Netherlands). 2013;112(1):35–44.Google Scholar
  25. 25.
    Drummond M, Towse A. Is it time to reconsider the role of patient co-payments for pharmaceuticals in Europe? Eur J Health Econ. 2012;13(1):1–5.Google Scholar
  26. 26.
    Arrow KJ. Uncertainty and the welfare economics of medical care. Am Econ Rev. 1963;53(5):941–73.Google Scholar
  27. 27.
    Pauly MV. The economics of moral hazard: comment. Am Econ Rev. 1968;58(3):531–7.Google Scholar
  28. 28.
    Pauly MV. Medicare drug coverage and moral hazard. Health Aff. 2004;23(1):113–22.Google Scholar
  29. 29.
    Atella V, Schafheutle E, Noyce P, Hassell K. Affordability of medicines and patients’ cost-reducing behaviour: empirical evidence based on SUR estimates from Italy and the UK. Appl Health Econ Health Policy. 2005;4(1):23–35.Google Scholar
  30. 30.
    James CD, Hanson K, McPake B, Balabanova D, Gwatkin D, Hopwood I, et al. To retain or remove user fees? Appl Health Econ Health Policy. 2006;5(3):137–53.Google Scholar
  31. 31.
    Luiza VL, Chaves LA, Silva RM, Emmerick ICM, Chaves GC, de Araújo SCF, et al. Pharmaceutical policies: effects of cap and co‐payment on rational use of medicines. Cochrane Database Syst Rev. 2015(5).Google Scholar
  32. 32.
    Kolasa K, Kowalczyk M. The effects of payments for pharmaceuticals: a systematic literature review. Health Econ, Policy Law. 2017;14(3):337–54.Google Scholar
  33. 33.
    Lexchin J, Grootendorst P. Effects of prescription drug user fees on drug and health services use and on health status in vulnerable populations: a systematic review of the evidence. Int J Health Serv. 2004;34(1):101–22.Google Scholar
  34. 34.
    Gibson TB, Mark TL, Axelsen K, Baser O, Rublee DA, McGuigan KA. Impact of statin copayments on adherence and medical care utilization and expenditure. Am J Manag Care. 2006;12.Google Scholar
  35. 35.
    Gibson TB, Ozminkowski RJ, Goetzel RZ. The effects of prescription drug cost sharing: a review of the evidence. Am J Manag Care. 2005;11(11):730–40.Google Scholar
  36. 36.
    Eaddy MT, Cook CL, O’Day K, Burch SP, Cantrell CR. How patient cost-sharing trends affect adherence and outcomes: a literature review. P & T Peer-Rev J Form Manag. 2012;37(1):45–55.Google Scholar
  37. 37.
    Grootendorst PV. Health care policy evaluation using longitudinal insurance claims data: an application of the panel Tobit estimator. Health Econ. 1997;6(4):365–82.Google Scholar
  38. 38.
    Lu CY, Ross-Degnan D, Soumerai SB, Pearson S-A. Interventions designed to improve the quality and efficiency of medication use in managed care: a critical review of the literature–2001–2007. BMC Health Serv Res. 2008;8(1):75.Google Scholar
  39. 39.
    Fairman KA, Motheral BR, Henderson RR. Retrospective, long-term follow-up study of the effect of a three-tier prescription drug copayment system on pharmaceutical and other medical utilization and costs. Clin Ther. 2003;25(12):3147–61.Google Scholar
  40. 40.
    Teutsch SM, Berger ML. Impact of 3-tier pharmacy benefit design and increased consumer cost-sharing on drug utilization. Am J Manag Care. 2005;11(10):621–8.Google Scholar
  41. 41.
    Fiorio CV, Siciliani L. Co-payments and the demand for pharmaceuticals: evidence from Italy. Econ Model. 2010;27:835–41.Google Scholar
  42. 42.
    Puig-Junoy J, Rodríguez-Feijoó S, Lopez-Valcarcel BG. Paying for formerly free medicines in Spain after 1 year of co-payment: changes in the number of dispensed prescriptions. App Health Econ Health Policy. 2014;12(3):279–87.Google Scholar
  43. 43.
    Sinnott SJ, Normand C, Byrne S, Woods N, Whelton H. Copayments for prescription medicines on a public health insurance scheme in Ireland. Pharmacoepidemiol Drug Saf. 2016;25(6):695–704.Google Scholar
  44. 44.
    Schneeweiss S, Patrick AR, Maclure M, Dormuth CR, Glynn RJ. Adherence to beta-blocker therapy under drug cost-sharing in patients with and without acute myocardial infarction. Am J Manag Care. 2007;13(8):445–52.Google Scholar
  45. 45.
    Damiani G, Federico B, Anselmi A, Bianchi CBNA, Silvestrini G, Iodice L, et al. The impact of Regional co-payment and National reimbursement criteria on statins use in Italy: an interrupted time-series analysis. BMC Health Serv Res. 2014;14(1):1–8.Google Scholar
  46. 46.
    Maciejewski ML, Farley JF, Parker J, Wansink D. Copayment reductions generate greater medication adherence in targeted patients. Health Aff. 2010;29(11):2002–8.Google Scholar
  47. 47.
    Chernew ME, Shah MR, Wegh A, Rosenberg SN, Juster IA, Rosen AB, et al. Impact of decreasing copayments on medication adherence within a disease management environment. Health Aff. 2008;27(1):103–12.Google Scholar
  48. 48.
    Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. JAMA. 2007;298(1):61–9.Google Scholar
  49. 49.
    Wang PS, Patrick AR, Dormuth C, Maclure M, Avorn J, Canning CF, et al. Impact of drug cost sharing on service use and adverse clinical outcomes in elderly receiving antidepressants. J Mental Health Policy Econ. 2010;13(1):37–44.Google Scholar
  50. 50.
    Ong M, Catalano R, Hartig T. A time-series analysis of the effect of increased copayments on the prescription of antidepressants, anxiolytics, and sedatives in Sweden from 1990 to 1999. Clin Ther. 2003;25(4):1262–75.Google Scholar
  51. 51.
    Andersson K, Petzold MG, Sonesson C, Lönnroth K, Carlsten A. Do policy changes in the pharmaceutical reimbursement schedule affect drug expenditures?: Interrupted time series analysis of cost, volume and cost per volume trends in Sweden 1986–2002. Health Policy. 2006;79(2):231–43.Google Scholar
  52. 52.
    Klepser DG, Huether JR, Handke LJ, Williams CE. Effect on drug utilization and expenditures of a cost-share change from copayment to coinsurance. J Manag Care Pharm. 2007;13(9):765–77.Google Scholar
  53. 53.
    Schneeweiss S. Reference drug programs: effectiveness and policy implications. Health Policy. 2007;81(1):17–28.Google Scholar
  54. 54.
    Kaplan WA, Wirtz V, Nguyen A, Ewen M, Vogler S, Laing R. Policy options for promoting the use of generic medicines in low- and middle-income countries. Health Action International (HAI), 2016. Accessed 23 Jul 2019.
  55. 55.
    WHO, HAI. Measuring medicine prices, availability, affordability and price components. 2nd Edition. Geneva: World Health Organization, Health Action International, 2008.Google Scholar
  56. 56.
    Cameron A, Ewen M, Ross-Degnan D, Ball D, Laing R. Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis. Lancet. 2009;373(9659):240–9.Google Scholar
  57. 57.
    Mendis S, Fukino K, Cameron A, Laing R, Filipe A Jr, Khatib O, et al. The availability and affordability of selected essential medicines for chronic diseases in six low-and middle-income countries. Bull World Health Organ. 2007;85(4):279–88.Google Scholar
  58. 58.
    Working Group ‘Promoting good governance for non-prescription medicines’. Report of the Working Group on Promoting Good Governance of non-prescription drugs in Europe. 2013.Google Scholar
  59. 59.
    Greer SL. Devolution and health in the UK: policy and its lessons since 1998. Br Med Bull. 2016;118(1):16–24.Google Scholar
  60. 60.
    Vogler S, Österle A, Mayer S. Inequalities in medicine use in Central Eastern Europe: an empirical investigation of socioeconomic determinants in eight countries. Int J Equity Health. 2015;14(1):124.Google Scholar
  61. 61.
    Vogler S, Schneider P, Zimmermann N. Preparing price studies—key methodological decisions. In: Vogler S, editor. Medicine price surveys, analyses and comparisons. London: Elsevier; 2019.Google Scholar
  62. 62.
    Vogler S, Leopold C, Zimmermann N, Habl C, de Joncheere K. The pharmaceutical pricing and reimbursement information (PPRI) initiative–experiences from engaging with pharmaceutical policy makers. Health Policy Technol. 2014;3(2):139–48.Google Scholar
  63. 63.
    Vogler S, Schneider P. Medicine price data sources. In: Vogler S, editor. Medicine price surveys, analyses and comparisons. London: Elsevier; 2019.Google Scholar
  64. 64.
    Eurostat. National minimum wages in the EU. Monthly minimum wages below €500 in east and well above €1000 in northwest. News Release 25/2017. 10 February 2017. Accessed 5 Sep 2017.
  65. 65.
    Die Presse. Sozialpartner einigen sich auf Mindestlohn. 30. 6. 2017. Accessed 5 Sep 2017.
  66. 66.
    Check in Price. Average and Minimum Salary in Stockholm, Sweden. 17 August 2017. Accessed 5 Sep 2017.
  67. 67.
    Jakab M, Akkazieva B, Habicht J. Can people afford to pay for health care? New evidence on financial protection in Kyrgyzstan. Copenhagen: WHO Regional Office for Europe, WHO Barcelona Office for Health Systems Strengthening, 2018.Google Scholar
  68. 68.
    OECD. Social Protection System Review of Kyrgyzstan, OECD Development Pathways. Paris: OECD Publishing, 2018.Google Scholar
  69. 69.
    Jakab M, Akkazieva B, Kutzin J. Can reductions in informal payments be sustained? Evidence from Kyrgyzstan, 2001–2013. Copenhagen: World Health Organization, WHO Barcelona Office for Health Systems Strengthening; 2016.Google Scholar
  70. 70.
    Falkingham J, Akkazieva B, Baschieri A. Trends in out-of-pocket payments for health care in Kyrgyzstan, 2001–2007. Health Policy Plan. 2010;25(5):427–36.Google Scholar
  71. 71.
    Schneider P, Vogler S. Pharmaceutical pricing and reimbursement reform in Kyrgyzstan. WHO Regional Office for Europe, 2016.Google Scholar
  72. 72.
    Ball D. The Regulation of mark-ups in the pharmaceutical supply chain. Working paper 3, WHO/HAI Project on Medicine Prices and Availability: World Health Organization and Health Action International, 2011.Google Scholar
  73. 73.
    World Health Organization. WHO Guideline on Country Pharmaceutical Pricing Policies. Geneva: 2013.Google Scholar
  74. 74.
    Xu K, Evans DB, Carrin G, Aguilar-Rivera AM. Designing health financing systems to reduce catastrophic health expenditure. Geneva: World Health Organization; 2005.Google Scholar
  75. 75.
    Acosta A, Ciapponi A, Aaserud M, Vietto V, Austvoll-Dahlgren A, Kösters JP, et al. Pharmaceutical policies: effects of reference pricing, other pricing, and purchasing policies. Cochrane Database Syst Rev. 2014;10(10).Google Scholar
  76. 76.
    Brekke KR, Grasdal AL, Holmås TH. Regulation and pricing of pharmaceuticals: reference pricing or price cap regulation? Eur Econ Rev. 2009;53(2):170–85.Google Scholar
  77. 77.
    Casanova-Juanes J, Mestre-Ferrandiz J, Espín-Balbino J. Competition in the off-patent medicine market in Spain: The national reference pricing system versus the regional system of tendering for outpatient prescription medicines in Andalusia. Health Policy. 2018.Google Scholar
  78. 78.
    Dylst P, Vulto A, Simoens S. The impact of reference-pricing systems in Europe: a literature review and case studies. Expert Rev Pharmacoecon Outcomes Res. 2011;11(6):729–37.Google Scholar
  79. 79.
    Kaló Z, Muszbek N, Bodrogi J, Bidló J. Does therapeutic reference pricing always result in cost-containment?: The Hungarian evidence. Health Policy. 2007;80(3):402–12.Google Scholar
  80. 80.
    Koskinen H, Ahola E, Saastamoinen LK, Mikkola H, Martikainen JE. The impact of reference pricing and extension of generic substitution on the daily cost of antipsychotic medication in Finland. Health Econ Rev. 2014;4(1):9.Google Scholar
  81. 81.
    Marđetko N, Kos M. Influence of generic reference pricing on medicine cost in Slovenia: a retrospective study. Croat Med J. 2018;59(2):79.Google Scholar
  82. 82.
    Puig-Junoy J. The impact of generic reference pricing interventions in the statin market. Health Policy. 2007;84(1):14–29.Google Scholar
  83. 83.
    Galizzi MM, Ghislandi S, Miraldo M. Effects of reference pricing in pharmaceutical markets. Pharmacoeconomics. 2011;29(1):17–33.Google Scholar
  84. 84.
    Heinze G, Hronsky M, Reichardt B, Baumgärtel C, Müllner M, Bucsics A, et al. Potential savings in prescription drug costs for hypertension, hyperlipidemia, and diabetes mellitus by equivalent drug substitution in Austria: a nationwide cohort study. Appl Health Econ Health Policy. 2014;13(2):1–13.Google Scholar
  85. 85.
    Cameron A, Mantel-Teeuwisse AK, Leufkens HGM, Laing RO. Switching from originator brand medicines to generic equivalents in selected developing countries: how much could be saved? Val Health. 2012;15(5):664–73.Google Scholar
  86. 86.
    Godman B, Persson M, Miranda J, Skiöld P, Wettermark B, Barbui C, et al. Changes in the utilization of venlafaxine after the introduction of generics in Sweden. Appl Health Econ Health Policy. 2013;11(4):383–93.Google Scholar
  87. 87.
    Dylst P, Vulto A, Simoens S. Demand-side policies to encourage the use of generic medicines: an overview. Expert Rev Pharmacoecon Outcomes Res. 2013;13(1):59–72.Google Scholar
  88. 88.
    Granlund D. Price and welfare effects of a pharmaceutical substitution reform. J Health Econ. 2010;29(6):856–65.Google Scholar
  89. 89.
    Hassali MA, Alrasheedy AA, McLachlan A, Nguyen TA, AL-Tamimi SK, Ibrahim MIM, et al. The experiences of implementing generic medicine policy in eight countries: a review and recommendations for a successful promotion of generic medicine use. Saudi Pharmaceutical Journal. 2014.Google Scholar
  90. 90.
    Kontodimopoulos N, Kastanioti C, Thireos E, Karanikas H, Polyzos N. The contribution of generic substitution to rationalizing pharmaceutical expenditure in Greek public hospitals under recent economic crisis. J Pharm Health Serv Res. 2013;4(4):211–6.Google Scholar
  91. 91.
    Seeley E, Kanavos P. Generic medicines from a societal perspective: savings for health care systems. Eurohealth. 2008;14(2):18–22.Google Scholar
  92. 92.
    Simoens S. Sustainable provision of generic medicines in Europe. Leuven: KU Leuven; 2013.Google Scholar
  93. 93.
    Timonen J, Heikkilä R, Ahonen R. Generic substitution in Finland: lessons learned during 2003–2008. J Pharm Health Serv Res. 2013;4(3):165–72.Google Scholar
  94. 94.
    Olesen C, Harbig P, Barat I, Damsgaard EM. Generic substitution does not seem to affect adherence negatively in elderly polypharmacy patients. Pharmacoepidemiol Drug Saf. 2013;22(10):1093–8.Google Scholar
  95. 95.
    Van Wijk BL, Klungel OH, Heerdink ER, de Boer A. Generic substitution of antihypertensive drugs: does it affect adherence? Ann Pharmacother. 2006;40(1):15–20.Google Scholar
  96. 96.
    Ude M, Schuessel K, Quinzler R, Leuner K, Müller WE, Schulz M. Generic switch after ramipril patent expiry is not associated with decreased pharmacy refill compliance: a retrospective study using the DAPI database. J Hypertens. 2011;29(9):1837–45.Google Scholar
  97. 97.
    Lewis M. Informal payments and the financing of health care in developing and transition countries. Health Aff. 2007;26(4):984–97.Google Scholar
  98. 98.
    Tipirneni R, Politi MC, Kullgren JT, Kieffer EC, Goold SD, Scherer AM. Association between health insurance literacy and avoidance of health care services owing to cost. JAMA Netw Open. 2018;1(7):e184796.Google Scholar
  99. 99.
    Weiss MC, Hassell K, Schafheutle EI, Noyce PR. Strategies used by general practitioners to minimise the impact of the prescription charge. Eur J Gen Pract. 2001;7(1):23–6.Google Scholar
  100. 100.
    Piette JD, Heisler M, Wagner TH. Problems paying out-of-pocket medication costs among older adults with diabetes. Diabetes Care. 2004;27(2):384–91.Google Scholar
  101. 101.
    Kullman D. PHIS Pharma profile United Kingdom. Vienna: Pharmaceutical Health Information System (PHIS); 2011.Google Scholar
  102. 102.
    Begho D. Time for change: Impact of prescription charges on people with asthma in England: Prescription Charges Coalition; 2018. Accessed 4 Jan 2019.
  103. 103.
    Asthma UK. End unfair prescription charges. Accessed 4 Jan 2019.
  104. 104.
    Prescription Charges Coalition. Accessed 9 Mar 2019.
  105. 105.
    Thomson S, Cylus J, Evetovits T. Can people afford to pay for health care? New evidence on financial protection in Europe. Presentation. Ljubljana: 11th European Public Health Conference, 2018.Google Scholar
  106. 106.
    Falkingham J. Poverty, out-of-pocket payments and access to health care: evidence from Tajikistan. Soc Sci Med. 2004;58(2):247–58.Google Scholar
  107. 107.
    Vogler S, Habl C, Leopold C, Rosian-Schikuta I, de Joncheere K, Lyager Thomsen T. PPRI report. Vienna: Pharmaceutical Pricing and Reimbursement Information; 2008.Google Scholar
  108. 108.
    Lillard LA, Rogowski J, Kington R. Insurance coverage for prescription drugs: effects on use and expenditures in the Medicare population. Medical Care. 1999:926-36.Google Scholar
  109. 109.
    Huh S, Rice T, Ettner SL. Prescription drug coverage and effects on drug expenditures among elderly Medicare beneficiaries. Health Serv Res. 2008;43(3):810–32.Google Scholar
  110. 110.
    Poisal JA, Murray L. Growing differences between Medicare beneficiaries with and without drug coverage. Health Aff. 2001;20(2):74–85.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.WHO Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies, Pharmacoeconomics DepartmentGesundheit Österreich GmbH (Austrian Public Health Institute)ViennaAustria
  2. 2.Health DivisionOrganisation for Economic Co-operation and Development (OECD)ParisFrance
  3. 3.World Health Organization (WHO) Regional Office for EuropeCopenhagenDenmark

Personalised recommendations