{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,20]],"date-time":"2026-03-20T12:10:05Z","timestamp":1774008605894,"version":"3.50.1"},"reference-count":32,"publisher":"Oxford University Press (OUP)","issue":"Supplement_2","license":[{"start":{"date-parts":[[2026,3,20]],"date-time":"2026-03-20T00:00:00Z","timestamp":1773964800000},"content-version":"vor","delay-in-days":19,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"DG SANTE"},{"name":"Government of the Autonomous Community of Catalonia"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,3,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Global and regional commitments to universal health coverage emphasize reducing financial hardship due to out-of-pocket payments for health care. Despite this, many countries continue to rely on user charges\u2014either to raise revenue or reduce demand\u2014especially under fiscal pressure. We conducted a narrative review of academic literature on the theoretical basis for and empirical effects of user charges in health systems. This was complemented by recent case studies from Slovenia, Estonia, and Cyprus, selected to illustrate diverse approaches to user charge policy under fiscal constraints. Common arguments in favour of user charges are that they can mitigate excess health care consumption and generate revenues. However, evidence suggests they often deter necessary care and lead to financial hardship, especially for low-income groups. Country case studies reveal varied approaches towards user charges in the context of fiscal pressure: Estonia increased co-payments despite prior efforts to improve financial protection; Slovenia eliminated user charges by introducing a flat levy to generate additional revenue; and Cyprus dramatically reduced its reliance on out-of-pocket payments by increasing public spending on health. Growing fiscal pressure may tempt countries to implement or increase user charges. However, doing so without adequate protective mechanisms can increase financial hardship, poverty and unmet health needs. Policymakers should prioritize pre-payment mechanisms and equity-oriented safeguards to ensure sustainable, fair and affordable access to health care. Continuous monitoring of financial hardship remains essential to inform policy decisions.<\/jats:p>","DOI":"10.1093\/eurpub\/ckaf219","type":"journal-article","created":{"date-parts":[[2025,11,18]],"date-time":"2025-11-18T12:51:02Z","timestamp":1763470262000},"page":"ii30-ii35","source":"Crossref","is-referenced-by-count":0,"title":["Poverty and access to health care: the political economy of redesigning user charges in the context of fiscal pressure"],"prefix":"10.1093","volume":"36","author":[{"given":"Jonathan","family":"Cylus","sequence":"first","affiliation":[{"name":"WHO Barcelona Office for Health Systems Financing , Barcelona,","place":["Spain"]},{"name":"European Observatory on Health Systems and Policies , London,","place":["United Kingdom"]},{"name":"London School of Economics and Political Science LSE Health, , London,","place":["United Kingdom"]},{"name":"London School of Hygiene and Tropical Medicine Department of Health Services Research and Policy, , London,","place":["United Kingdom"]},{"name":"Barcelona Institute for Global Health (ISGlobal) , Barcelona,","place":["Spain"]},{"name":"Brown University School of Public Health Center for Health System Sustainability (CHeSS), , Providence,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sarah","family":"Thomson","sequence":"additional","affiliation":[{"name":"WHO Barcelona Office for Health Systems Financing , Barcelona,","place":["Spain"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Triin","family":"Habicht","sequence":"additional","affiliation":[{"name":"WHO Barcelona Office for Health Systems Financing , Barcelona,","place":["Spain"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tam\u00e1s","family":"Evetovits","sequence":"additional","affiliation":[{"name":"WHO Barcelona Office for Health Systems Financing , Barcelona,","place":["Spain"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2026,3,20]]},"reference":[{"key":"2026032006013236300_ckaf219-B1","volume-title":"European Pillar of Social Rights\u2014building a Fairer and More Inclusive European Union","author":"European Commission","year":"2023"},{"key":"2026032006013236300_ckaf219-B2","author":"United Nations","year":"2015"},{"key":"2026032006013236300_ckaf219-B3","author":"World Health Organization","year":"2008"},{"key":"2026032006013236300_ckaf219-B4","doi-asserted-by":"crossref","first-page":"599","DOI":"10.2471\/BLT.18.209031","article-title":"Catastrophic Health Spending in Europe: Equity and Policy Implications of Different Calculation Methods","volume":"96","author":"Cylus","year":"2018","journal-title":"Bull World Health Organ"},{"key":"2026032006013236300_ckaf219-B5","author":"UHC Watch","year":"2025"},{"key":"2026032006013236300_ckaf219-B6","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1093\/heapol\/czj013","article-title":"The Prospects of Creating \u2018fiscal space\u2019 for the Health Sector","volume":"21","author":"Heller","year":"2006","journal-title":"Health Policy Plan"},{"key":"2026032006013236300_ckaf219-B7","volume-title":"How Does Population Ageing Affect Health System Financial Sustainability and Affordable Access to Health Care in Europe?","author":"Cylus","year":"2025"},{"key":"2026032006013236300_ckaf219-B8","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1016\/0022-0531(70)90010-4","article-title":"Medical insurance: a case study of the tradeoff between risk spreading and appropriate incentives","volume":"2","author":"Zeckhauser","year":"1970","journal-title":"J Econ Theory"},{"key":"2026032006013236300_ckaf219-B9","volume-title":"Free for All? Lessons from the RAND Health Experiment","author":"Newhouse","year":"1993"},{"key":"2026032006013236300_ckaf219-B10","first-page":"251","article-title":"Health insurance and the demand for medical care: evidence from a randomized experiment","volume":"77","author":"Manning","year":"1987","journal-title":"Am Econ Rev"},{"key":"2026032006013236300_ckaf219-B11","author":"Gruber","year":"2006"},{"key":"2026032006013236300_ckaf219-B12","doi-asserted-by":"publisher","first-page":"813","DOI":"10.1007\/s10198-013-0526-8","article-title":"How does copayment for health care services affect demand, health and redistribution? a systematic review of the empirical evidence from 1990 TO 2011","volume":"15","author":"Kiil","year":"2014","journal-title":"Eur J Health Econ"},{"key":"2026032006013236300_ckaf219-B13","doi-asserted-by":"crossref","first-page":"515","DOI":"10.1111\/j.1475-6773.2007.00824.x","article-title":"How effective are copayments in reducing expenditures for low-income adult medicaid beneficiaries? 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