How COVID-19 has changed the utilization of different health care services in Poland.

BACKGROUND: The COVID-19 pandemic has affected health care systems in many ways, including access to and the use of non-COVID services. The aim of the study was to assess the impact of the pandemic on the utilization of different public health care services in Poland. METHODS: The aggregated data on health care users and provided services for the years 2015/2016-2021 were used to analyse the changes in health care utilization during the pandemic and deviations from pre-pandemic utilization trends. Quantitative analysis was complemented with qualitative descriptions of the changes in principles of health care provision during the pandemic. RESULTS: The results show a considerable drop in the provision of most health care services in 2020 that in some cases disturbed pre-pandemic utilization trends and was not made up for in 2021. The most significant decrease has been observed in the field of preventive and public health services, as well as rehabilitation. The provision of these services was put on hold during the pandemic. CONCLUSIONS: The accumulated COVID-19-related "health debt" urgently calls for government actions to strengthen disease prevention and health promotion in Poland.

Barriers and Facilitators to Health-Care Provider Payment Reform - A Scoping Literature Review.

Background: Changes to provider payment systems are among the most common reforms in health care. They are important levers for policymakers to influence the health system performance. The aim of this study was to identify, systematize, and map the existing literature on the factors that influence health-care provider payment reforms. Methods: A scoping review was conducted. Literature published in English between 2000 and 2022 was systematically searched in five databases, relevant organizations, and journals. Academic publications and grey literature on health-care provider payment reform and the factors influencing reform were considered. An inductive thematic analysis was applied to map the barriers and facilitators that influence payment reforms. Results: The study included 51 publications. They were divided into four categories: empirical studies (n=17), literature reviews (n=6), discussion/policy papers (n=18), and technical reports/policy briefs (n=9). Most of the studies were conducted in developed economy countries (n=36). The most frequently reformed payment method was fee-for-service (n=37), and the newly implemented methods included bundled payments (n=16), pay-for-performance (n=15), and diagnosis-related groups (n=11). This study identified 43 sub-themes on barriers to provider payment reforms, which were grouped into eight main themes. It identified 51 sub-themes on facilitators, which were grouped into six themes. Barriers include stakeholder opposition, challenges related to reform design, hurdles in implementation structures, insufficient resources, challenges related to market structures, legal barriers, knowledge and information gaps, and negative publicity. Facilitators include stakeholder involvement, complementary reforms/policies, relevant prior experience, good leadership and management of change, sufficient resources, and external pressure to introduce reform. Conclusion: The factors that influence health-care payment reforms are often contextual and interrelated, and encompass a variety of perspectives, including those of patients, providers, insurers, and policymakers. When planning reforms, one should anticipate potential barriers and devise appropriate interventions. Registration: The study was registered with the Open Science Framework.

The Association Between Hospital Financial Performance and the Quality of Care - A Scoping Literature Review.

BACKGROUND: Improving the quality of hospital care is an important policy objective. Hospitals operate under pressure to contain costs and might face challenges related to financial deficits. The objective of this paper was to identify and map the available evidence on the association between hospital financial performance (FP) and quality of care (Q). METHODS: A scoping review was performed. Searches were conducted in 7 databases: Medline via PubMed, EMBASE, Web of Science, Scopus, EconLit, ABI/INFORM, and Business Source Complete. The search strategy combined multiple terms from 3 topics: hospital AND FP AND Q. The collected data were analysed using both quantitative and qualitative methods. RESULTS: 10 503 records were screened and 151 full text papers analysed. A total of 69 papers were included (60 empirical, 2 theoretical, 5 literature reviews, and 2 dissertations). The majority of identified studies were published within the last decade (2010-2021). Most empirical studies had been conducted in the United States (55/60), used cross-sectional approaches (32/60) and applied diverse regression models with FP measures as dependent variables, thus measuring the impact of Q on hospitals FP (34/60). The comparability of the studies' results is limited due to differences in applied methods and settings. Yet, the general overview shows that in almost half of the cases the association between hospital FP and Q was positive, while no study showed a clear negative association. CONCLUSION: This scoping review provides an overview of the available literature on the association between hospital FP and Q. The results highlight numerous research gaps: (1) systematic reviews and meta-analyses of existing studies with similar measures of FP and Q are unavailable, (2) further methodological/conceptual work is needed on the metrics measuring hospital FP and Q, and (3) more empirical studies should analyse the association between FP and Q in non-US healthcare settings.

The National Health Cluster in Yemen: assessing the coordination of health response during humanitarian crises.

Yemen has been facing political, economic and social challenges since 1990. The fragility of Yemen's situation has led to a widespread conflict in 2015, resulting in the world's largest humanitarian crisis. Amid the humanitarian catastrophe and the collapsing health system, a platform for coordinating humanitarian health response, called the National Health Cluster, has expanded its operations across the country. The study aims to evaluate the performance of the National Health Cluster in Yemen between 2015 and 2019. A qualitative research design was employed, and ten semi-structured interviews with key Health Cluster stakeholders were conducted. The study applied the Active Learning Network for Accountability and Performance in Humanitarian Action (ALNAP) guide to evaluating humanitarian action using the Development Assistance Committee (DAC) criteria. Six evaluation criteria were selected: relevance, effectiveness, efficiency, effects, connectedness and participation. Inputs from interviews were manually transcribed and then analysed using NVivo 12 software. The study results indicate that the Health Cluster in Yemen has contributed to saving lives and strengthening the local health capacities in diseases surveillance. In addition, its positive effect was evident in improving the humanitarian health response coordination. Nevertheless, engaging health stakeholders, especially national organisations, was suboptimal. Exit strategies were lacking, while services to address mental health, non-communicable diseases, senior citizens and people with disabilities were not prioritised in the Health Cluster strategic plans and partners' response. To ameliorate Health Cluster performance, revising its objectives and establishing a cluster-specific rapid response funding mechanism are pivotal. Furthermore, preparing the national health system for recovery and actively engaging all stakeholders in the Health Cluster' response and strategic decisions would maximise its positive impact on Yemen's health system and population.

Balancing financial incentives during COVID-19: A comparison of provider payment adjustments across 20 countries.

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries. We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff. We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care.

Czy ludzi stać na płacenie za opiekę zdrowotną? Nowe dowody na temat ochrony finansowej w Polsce: streszczenie

Niniejszy przegląd służy ocenie, w jakim stopniu Polacy ponoszą nadmierne obciążenia finansowe w związku z korzystaniem ze świadczeń opieki zdrowotnej, w tym leków. W analizie wykorzystano dane z corocznych badań budżetów gospodarstw domowych prowadzonych przez Główny Urząd Statystyczny (GUS) za lata 2005 - 2014. Analiza skupia się na dwóch wskaźnikach ochrony finansowej: katastrofalnych wydatkach na opiekę zdrowotną i zubażających wydatkach na opiekę zdrowotną. Uwzględnia również istniejące bariery w dostępie do świadczeń będące przyczyną niezaspokojonych potrzeb z zakresu opieki zdrowotnej.

The association between hospital financial performance and the quality of care-a scoping review protocol.

BACKGROUND: Hospitals operate under constant pressure to contain costs and improve the quality of care. The literature suggests that there is an association between health care providers' financial performance and the quality of care. On the one hand, providers that are financially more stable might have better capacity to maintain reliable systems and resources for quality improvement. On the other hand, providing better quality of care might lead to financial gains in the form of increased revenues or achieved savings and, in consequence, a higher profitability. The general objective of this scoping review is to identify and map the available evidence on the association between hospital financial performance and the quality of care. It aims to (1) provide a broad overview of the topic and (2) indicate a more precise research question for a future systematic review. METHODS: This scoping review will follow five stages: (1) defining the research question; (2) identifying relevant literature; (3) study selection; (4) data extraction; (5) collating, summarizing, and reporting the results; and (6) the consultation process and engagement of knowledge users. The following databases will be searched: MEDLINE via PubMed, (2) EMBASE, (3) Web of Science, (4) Scopus, (5) EconLit, (6) ABI/INFORM, and (7) Business Source Premier. The reference lists of relevant papers will be visually scanned with the aim of identifying further studies of interest. Also, a gray literature search will be conducted by screening the websites of diverse organizations dealing with hospital performance and/or quality of care. The review will not apply a publication date limit and will include both quantitative and qualitative empirical studies as well as theoretical papers, technical reports, books/chapters, and thesis. The reporting will utilize the PRISMA extension for a Scoping Review checklist. DISCUSSION: This scoping review will provide an overview of the existing literature on the association between hospital financial performance and the quality of care. The review process will apply a rigorous methodological approach while broad inclusion criteria should assure comprehensive coverage of the available literature. The main limitation of the review is related to the general limitation of scoping reviews, i.e., the lack of a systematic quality and risk of bias assessment of included studies. In addition, the review will include only publications in English. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework osf.io/z25ag.

Financing Healthcare in Central and Eastern European Countries: How Far Are We from Universal Health Coverage?

After the fall of communism, the healthcare systems of Central and Eastern European countries underwent enormous transformation, resulting in departure from publicly financed healthcare. This had significant adverse effects on equity in healthcare, which are still evident. In this paper, we analyzed the role of government and households in financing healthcare in eight countries (EU-8): Czechia, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia, and Slovenia. A desk research method was applied to collect quantitative data on healthcare expenditures and qualitative data on gaps in universal health coverage. A linear regression analysis was used to analyze a trend in health expenditure over the years 2000-2018. Our results indicate that a high reliance on out-of-pocket payments persists in many EU-8 countries, and only a few countries have shown a significant downward trend over time. The gaps in universal coverage in the EU-8 countries are due to explicit rationing (a limited benefit package, patient cost sharing) and implicit mechanisms (wait times). There is need to increase the role of public financing in CEE countries through budget prioritization, reducing patient co-payments for medical products and medicines, and extending the benefit package for these goods, as well as improving the quality of care.

Mapping variability in allocation of Long-Term Care funds across payer agencies in OECD countries.

INTRODUCTION: Long-term care (LTC) is organized in a fragmented manner. Payer agencies (PA) receive LTC funds from the agency collecting funds, and commission services. Yet, distributional equity (DE) across PAs, a precondition to geographical equity of access to LTC, has received limited attention. We conceptualize that LTC systems promote DE when they are designed to set eligibility criteria nationally (vs. locally); and to distribute funds among PAs based on needs-formula (vs. past-budgets or government decisions). OBJECTIVES: This cross-country study highlights to what extent different LTC systems are designed to promote DE across PAs, and the parameters used in allocation formulae. METHODS: Qualitative data were collected through a questionnaire filled by experts from 17 OECD countries. RESULTS: 11 out of 25 LTC systems analyzed, fully meet DE as we defined. 5 systems which give high autonomy to PAs have designs with low levels of DE; while nine systems partially promote DE. Allocation formulae vary in their complexity as some systems use simple demographic parameters while others apply socio-economic status, disability, and LTC cost variations. DISCUSSION AND CONCLUSIONS: A minority of LTC systems fully meet DE, which is only one of the criteria in allocation of LTC resources. Some systems prefer local priority-setting and governance over DE. Countries that value DE should harmonize the eligibility criteria at the national level and allocate funds according to needs across regions.

Can people afford to pay for health care? New evidence on financial protection in Poland

This review is part of a series of country-based studies generating new evidence on financial protection in European health systems. Financial protection is central to universal health coverage and a core dimension of health system performance. The incidence of catastrophic health spending is high in Poland compared to many European Union countries. It is heavily concentrated among the poorest households, and largely driven by spending on outpatient medicines. Outpatient-prescribed medicines are subject to a complex system of user charges (co-payments), and mechanisms to protect households from co-payments are generally weak, with no exemptions explicitly benefiting low-income people or those with chronic conditions, and no caps on co-payments. Coverage of dental care and medical products is also limited, especially for adults. Efforts to improve financial protection should focus more on low-income people – for example, extending co-payment exemptions to those receiving social benefits. High levels of use of, and out-of-pocket spending on, non-prescribed medicines also warrant attention.

Poland: Health System Review.

This analysis of the Polish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. In late 2017, the Polish government committed to increase the share of public expenditures on health to 6% of GDP by 2024. If the GDP continues to grow in the years to come, this will present an opportunity to tackle mounting health challenges such as socioeconomic inequalities in health, high rates of obesity, rising burden of mental disorders and population ageing that put strain on health care resources. It is also an opportunity to tackle certain longstanding imbalances in the health sector, including overreliance on acute hospital care compared with other types of care, including ambulatory care and long-term care; shortages of human resources; the negligible role of health promotion and disease prevention vis-a-vis curative care; and poor financial situation in the hospital sector. Finally, the additional resources are much needed to implement important ongoing reforms, including the reform of primary care. The resources have to be spent wisely and waste should be minimized. The introduction, in 2016, of a special system (IOWISZ) of assessing investments in the health sector that require public financing (including from the EU funds) as well as the work undertaken by the Polish health technology assessment (HTA) agency (AOTMiT), which evaluates health technologies and publicly-financed health policy programmes as well as sets prices of goods and services, should help ensure that these goals are achieved. Recent reforms, such as the ongoing reform of primary care that seeks to improve coordination of care and the introduction of the hospital network, go in the right direction; however, a number of longstanding unresolved problems, such as hospital indebtedness, need to be tackled.

Poland: health system review

This analysis of the Polish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. In late 2017, the Polish governmentcommitted to increase the share of public expenditures on health to 6% of GDP by 2024. If the GDP continues to grow in the years to come, this will present an opportunity to tackle mounting health challenges such as socioeconomicinequalities in health, high rates of obesity, rising burden of mental disorders and population ageing that put strain on health care resources. It is also an opportunity to tackle certain longstanding imbalances in the health sector, including overreliance on acute hospital care compared with other types of care, including ambulatory care and long-term care; shortages of human resources; the negligible role of health promotion and disease prevention vis-à-vis curative care; and poor financial situation in the hospital sector.Finally, the additional resources are much needed to implement important ongoing reforms, including the reform of primary care. The resources have to be spent wisely and waste should be minimized.The introduction, in 2016, of a special system (IOWISZ) of assessing investments in the health sector that require public financing (including from the EU funds) as well as the work undertaken by the Polish health technology assessment (HTA) agency (AOTMiT), which evaluates health technologies and publicly financed health policy programmes as well as sets prices of goods and services, should help ensure that these goals are achieved. Recent reforms, such as the ongoing reform of primary care that seeks to improvecoordination of care and the introduction of the hospital network, go in the right direction; however, a number of longstanding unresolved problems, such as hospital indebtedness, need to be tackled.

Financial incentives for a healthy life style and disease prevention among older people: a systematic literature review.

BACKGROUND: To motivate people to lead a healthier life and to engage in disease prevention, explicit financial incentives, such as monetary rewards for attaining health-related targets (e.g. smoking cessation, weight loss or increased physical activity) or disincentives for reverting to unhealthy habits, are applied. A review focused on financial incentives for health promotion among older people is lacking. Attention to this group is necessary because older people may respond differently to financial incentives, e.g. because of differences in opportunity costs and health perceptions. To outline how explicit financial incentives for healthy lifestyle and disease prevention work among older persons, this study reviews the recent evidence on this topic. METHODS: We applied the method of systematic literature review and we searched in PUBMED, ECONLIT and COCHRANE LIBRARY for studies focused on explicit financial incentives targeted at older adults to promote health and stimulate primary prevention as well as screening. The publications selected as relevant were analyzed based on directed (relational) content analysis. The results are presented in a narrative manner complemented with an appendix table that describes the study details. We assessed the design of the studies reported in the publications in a qualitative manner. We also checked the quality of our review using the PRISMA 2009 checklist. RESULTS: We identified 15 studies on the role of explicit financial incentives in changing health-related behavior of older people. They include both, quantitative studies on the effectiveness of financial rewards as well as qualitative studies on the acceptability of financial incentives. The quantitative studies are characterized by a great diversity of designs and provide mixed results on the effects of explicit financial incentives. The results of the qualitative studies indicate limited trust of older people in the use of explicit financial incentives for health promotion and prevention. CONCLUSIONS: More research is needed on the effects of explicit financial incentives for prevention and promotion among older people before their broader use can be recommended. Overall, the design of the financial incentive system may be a crucial element in their acceptability.

The use of e-health and m-health tools in health promotion and primary prevention among older adults: a systematic literature review.

BACKGROUND: The use of e-health and m-health technologies in health promotion and primary prevention among older people is largely unexplored. This study provides a systematic review of the evidence on the scope of the use of e-health and m-health tools in health promotion and primary prevention among older adults (age 50+). METHODS: A systematic literature review was conducted in October 2015. The search for relevant publications was done in the search engine PubMed. The key inclusion criteria were: e-health and m-health tools used, participants' age 50+ years, focus on health promotion and primary prevention, published in the past 10 years, in English, and full-paper can be obtained. The text of the publications was analyzed based on two themes: the characteristics of e-health and m-health tools and the determinants of the use of these tools by older adults. The quality of the studies reviewed was also assessed. RESULTS: The initial search resulted in 656 publications. After we applied the inclusion and exclusion criteria, 45 publications were selected for the review. In the publications reviewed, various types of e-health/m-health tools were described, namely apps, websites, devices, video consults and webinars. Most of the publications (60 %) reported studies in the US. In 37 % of the publications, the study population was older adults in general, while the rest of the publications studied a specific group of older adults (e.g. women or those with overweight). The publications indicated various facilitators and barriers. The most commonly mentioned facilitator was the support for the use of the e-health/m-health tools that the older adults received. CONCLUSIONS: E-health and m-health tools are used by older adults in diverse health promotion programs, but also outside formal programs to monitor and improve their health. The latter is hardly studied. The successful use of e-health/m-health tools in health promotion programs for older adults greatly depends on the older adults' motivation and support that older adults receive when using e-health and m-health tools.

A review of health promotion funding for older adults in Europe: a cross-country comparison.

BACKGROUND: Health promotion interventions for older adults are important as they can decrease the onset and evolution of diseases and thus can reduce the medical costs related to those diseases. However, there is no comparative evidence on how those interventions are funded in European countries. The aim of this study is to explore the funding of health promotion interventions in general and health promotion interventions for older adults in particular in European countries. METHOD: We use desk research to identify relevant sources of information such as official national documents, international databases and scientific articles. Fora descriptive overview on how health promotion is funded, we focus on three dimensions: who is funding health promotion, what are the contribution mechanisms and who are the collecting agents. In addition to general information on funding of health promotion, we explore how programs on health promotion for older population groups are funded. RESULTS: There is a great diversity in funding of health promotion in European countries. Although public sources (tax and social health insurance revenues) are still most often used, other mechanisms of funding such as private donations or European funds are also common. Furthermore, there is no clear pattern in the funding of health promotion for different population groups. This is of particular importance for health promotion for older adults where information is limited across European countries. CONCLUSIONS: This study provides an overview of funding of health promotion interventions in European countries. The main obstacles for funding health promotion interventions are lack of information and the fragmentation in the funding of health promotion interventions for older adults.

Towards a stakeholders' consensus on patient payment policy: the views of health-care consumers, providers, insurers and policy makers in six Central and Eastern European countries.

BACKGROUND: Although patient charges for health-care services may contribute to a more sustainable health-care financing, they often raise public opposition, which impedes their introduction. Thus, a consensus among the main stakeholders on the presence and role of patient charges should be worked out to assure their successful implementation. AIM: To analyse the acceptability of formal patient charges for health-care services in a basic package among different health-care system stakeholders in six Central and Eastern European countries (Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine). METHODS: Qualitative data were collected in 2009 via focus group discussions and in-depth interviews with health-care consumers, providers, policy makers and insurers. The same participants were asked to fill in a self-administrative questionnaire. Qualitative and quantitative data are analysed separately to outline similarities and differences in the opinions between the stakeholder groups and across countries. RESULTS: There is a rather weak consensus on patient charges in the countries. Health policy makers and insurers strongly advocate patient charges. Health-care providers overall support charges but their financial profits from the system strongly affects their approval. Consumers are against paying for services, mostly due to poor quality and access to health-care services and inability to pay. CONCLUSIONS: To build consensus on patient charges, the payment policy should be responsive to consumers' needs with regard to quality and equity. Transparency and accountability in the health-care system should be improved to enhance public trust and acceptance of patient payments.

Willingness to pay for publicly financed health care services in Central and Eastern Europe: evidence from six countries based on a contingent valuation method.

The increased interest in patient cost-sharing as a measure for sustainable health care financing calls for evidence to support the development of effective patient payment policies. In this paper, we present an application of a stated willingness-to-pay technique, i.e. contingent valuation method, to investigate the consumer's willingness and ability to pay for publicly financed health care services, specifically hospitalisations and consultations with specialists. Contingent valuation data were collected in nationally representative population-based surveys conducted in 2010 in six Central and Eastern European (CEE) countries (Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine) using an identical survey methodology. The results indicate that the majority of health care consumers in the six CEE countries are willing to pay an official fee for publicly financed health care services that are of good quality and quick access. The consumers' willingness to pay is limited by the lack of financial ability to pay for services, and to a lesser extent by objection to pay. Significant differences across the six countries are observed, though. The results illustrate that the contingent valuation method can provide decision-makers with a broad range of information to facilitate cost-sharing policies. Nevertheless, the intrinsic limitations of the method (i.e. its hypothetical nature) and the context of CEE countries call for caution when applying its results.

The inability to pay for health services in Central and Eastern Europe: evidence from six countries.

BACKGROUND: Out-of-pocket payments for health services constitute a major financial burden for patients in Central and Eastern European (CEE) countries. Individuals who are unable to pay use different coping strategies (e.g. borrowing money or foregoing service utilization), which can have negative consequences on their health and social welfare. This article explores patients' inability to pay for outpatient and hospital services in six CEE countries: Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine. METHODS: The analysis is based on quantitative data collected in 2010 in nationally representative surveys. Two indicators of inability to pay were considered: the need to borrow money or sell assets and foregoing service utilization. Statistical analyses were applied to investigate associations between the indicators of inability to pay and individual characteristics. RESULTS: Patient payments are most common in Bulgaria, Ukraine, Romania and Lithuania and often include informal payments. Romanian and, particularly, Ukrainian patients most often face difficulties to pay for health services (with approximately 40% of Ukrainian payers borrowing money or selling assets to cover hospital payments and approximately 60% of respondents who need care foregoing services). Inability to pay mainly affects those with poor health and low incomes. CONCLUSION: Widespread patient payments constitute a major financial barrier to health service use in CEE. There is a need to formalize them where they are informal and to take measures to protect vulnerable population groups, especially those with limited possibilities to deal with payment difficulties.

The formal-informal patient payment mix in European countries. Governance, economics, culture or all of these?

Cost-sharing for health care is high on the policy agenda in many European countries that struggle with deficits in their public budget. However, such policy often meets with public opposition, which might delay or even prevent its implementation. Increased reliance on patient payments may also have adverse equity effects, especially in countries where informal patient payments are widespread. The factors which might influence the presence of both, formal and informal payments can be found in economic, governance and cultural differences between countries. The aim of this paper is to review the formal-informal payment mix in Europe and to outline factors associated with this mix. We use quantitative analyses of macro-data for 35 European countries and a qualitative description of selected country experiences. The results suggest that the presence of obligatory cost-sharing for health care services is associated with governance factors, while informal patient payments are a multi-cause phenomenon. A consensus-based policy, supported by evidence and stakeholders' engagement, might contribute to a more sustainable patient payment policy. In some European countries, the implementation of cost-sharing requires policy actions to reduce other patient payment obligations, including measures to eliminate informal payments.