Effects of economic recession on elderly patients’ perceptions of access to health care and medicines in Portugal
Background In view of the current financial and demographic situation in Portugal, accessibility to health care may be affected, including the ability to adhere to medication. Objective To evaluate the perceived effects of the crisis on elderly patient’s access to medicines and medical care, and its implications on medicine-taking behaviour. Setting Community pharmacy. Method A cross-sectional study was undertaken during April 2013, where elderly patients answered a self-administered questionnaire based on their health-related experiences in the current and previous year. Binary logistic regression was used to ascertain the effects of potential predictors on the likelihood of adherence. Main outcome measures self-reported adherence. Results A total of 1231 questionnaires were collected. 27.3% of patients had stopped using treatments or health services in the previous year for financial motives; mostly private medical appointments, followed by dentist appointments. Almost 30% of patients stopped purchasing prescribed medicines. Over 20% of patients reduced their use of public services. Out-of-pocket expenses with medicines were considered higher in the current year by 40.1% of patients. The most common strategy developed to cope with increasing costs of medicines was generic substitution, but around 15% of patients also stopped taking their medication or started saving by increasing the interdose interval. Conclusion Reports of decreasing costs with medicines was associated with a decreased likelihood of adherence (OR 0.42; 95% CI 0.27–0.65). Lower perceived health status and having 3 or more co-morbidities were associated with lower odds of adhering, whilst less frequent medical appointments was associated with a higher likelihood of exhibiting adherence.
KeywordsAccess to health care Aged Equity Financial Health care rationing Health policy Medication adherence Portugal
Impacts on practice
Cost-containment measures applied to medicines may impact on adherence.
Policy makers should be aware of the long-term consequences of these measures on adherence.
Pharmacists should be conscious of the financial constraints of the elderly to help them develop strategies that do not negatively affect adherence.
New pharmacy services focusing on adherence should be developed and take cost related issues into account
Financial crisis in Europe has led some countries to adopt austerity measures , some focusing on access to health care, and others specifically applicable to the pharmaceutical market. In Portugal, the reduction in healthcare costs was made largely via reduction of public spending on medicines . The measures comprised medicines price cuts, distribution remuneration changes and margins reduction, which result in public expenditure decreases in the short term . However, in the long term, these cost-containment measures may impact on the society’s major health-related outcomes, such as mortality . The crisis has also been referred to as an opportunity for systems’ restructuring . However, some measures may have an additional and less explored consequence, which is the way patients perceive their access to health care, and the way they adapt their chronic medication use.
Equitable access to health care must be a primary concern for government. Access to medication in particular is not easy to ensure, as it may be controlled at several points in the chain, which may be deeply affected in times of economic recession.
One of public health’s main functions is to monitor the impact of economic crisis on the population’s most vulnerable groups and to develop strategies to promote and protect their health . Evidence suggests that vulnerable groups are mostly affected by health outcomes in times of economic recession . Immigrants are often the first to be affected by unemployment, thus affecting the ability to pay for medical care . The elderly are another vulnerable and challenging group. Increasing age leads to health deterioration, higher probability of comorbidities, both of which lead to higher health care utilization [9, 10]. But, ageing itself does not bankrupt the health care systems, rather the increased and badly planned utilization of the system . Population ageing and the global financial crisis led to urgent reorganization of health systems across OECD countries, focusing on elderly assistance policies. The ageing index in Portugal has been increasing and is currently the 4th highest in the EU-27 . As this shift in the demographic pyramid threatens the Social Security, primarily dependent on taxes, retirement age has been postponed . Pensions, mostly attributable to elderly, have been cut-down by austerity .
The Portuguese Health Care System is based mainly on a National Health Service (PNHS) developed from the Beveridge model, being universal in coverage, general in provision and ‘tend to be’ free at the point of use, accordingly to the latest revision of the Constitution . The main sources of the PNHS funding are general taxation, which are compulsory for all citizens, and established according to income. In the last ten years, between 9 and 10% of the GDP is spent on health . Citizens may opt to voluntarily pay for health insurance, which enables them to use additional or alternative services, provided by private contractors. Medicines used in the outpatient sector are covered by the PNHS, but the percentage of co-payment varies according to the pharmacotherapeutic group and depends on their importance for maintaining life, the level of the disease or the economic and social situation of the patients. There are currently four reimbursement strata, where a public co-payment of 15, 37, 69 or 90% is applicable to the general regime, the remaining being paid out-of-pocket by the patient . There are special regimes regulated appropriately for the reimbursement of medicines used in defined pathologies or special groups of patients . Portugal has an additional reimbursement level for pensioners with a low income (earning less than the minimum salary, 485 € at the time of study, and reviewed yearly), where beneficiaries receive a higher co-payment from the PNHS and therefore pay less for their medicines . Pensioners, depending on their income, may also be exempt from user fees. These fees are established according to the type of service being sought, with the higher value established for urgent care (€9.60) . The recession and the following austerity policies adopted in Portugal have worsened self-reported access to health care, most markedly among the individuals that are not exempt from the increase in co-payments. The odds ratio of reporting unmet medical need more than doubled in Portugal in the crisis year, with the greatest impact on employed individuals, followed by the unemployed, retired and other economically disadvantaged groups .
The way people use health care resources may be influenced by socio-economic factors . In dental care, every instance of increasing levels of socioeconomic disadvantage seems associated with worsened oral health and with decreased utilization of services . Medical and dental care seeking in Greece was deeply affected during the financial crisis . The effects of the crisis in the psychological domain are well documented. Increased anxiety and depression symptoms in the elderly have been suggested to result from the economic slowdown . Lifestyle factors, including heavy drinking and smoking, also seem to have a direct link with financial strain among the elderly . There is evidence of worse infectious disease outcomes during recession, often resulting from higher rates of infectious contact under poorer living circumstances, worsened access to therapy, or poorer retention in treatment .
Portugal is mostly affected by non-communicable diseases, with cerebrovascular disease as the main cause of death. Therefore, the impact of financial recession is more relevant on chronic conditions. Adherence to chronic medication has been identified as the most problematic type of medicine taking behaviour. In Portugal primary non-adherence (not purchasing a prescribed medicine) may occur in 25% of pharmacy users, but rising above 50% when looking at secondary non-adherence (not taking a prescribed and purchased medicine) .
Prescribing in Portugal uses the international common denomination and the pharmacist should offer patients a choice of three generics with price set lower than the reference price. The patient may opt for a more expensive medicine (except for specific cases, such as previous adverse drug reactions or medicines with narrow therapeutic margins), paying the difference out-of-pocket . Use of generic medicines has been promoted in the past decade in Portugal, but their market share is still below the set goals  and below the OECD average .
The emergence of the global financial crisis has increased the interest in cost-related medication nonadherence (CRN) worldwide. A US internet survey found that more than 30% of active elderly reported CRN . Disease itself and polypharmacy may increase the likelihood of engaging in non-adherence [32, 33]. The costs of medication, prescription drug coverage, insurance coverage and income have all been reported as predictors of CRN [34, 35]. Low-income patients develop a series of strategies to diminish their expenses with medication, namely delaying a prescription refill, stopping medication all together or not filling a new prescription at all. Conversely, high income patients seem to more frequently split tablets in half or take fewer doses than prescribed . Other strategies reported include choosing some medicines and leaving others .
Aim of the study
To evaluate elderly patient’s perceived effects of the crisis on their accessibility to prescribed medicines and medical care, as well, as the implications on their medicine-taking behaviour.
Ethical approval was not sought as collected information was not personal and did not even include identification or demographic data of patients. The applied questionnaire was anonymous and not relatable. Patients were free to decline participation. As such, the principles of ethical research practices, including confidentiality and anonymity, were followed.
A cross-sectional study was undertaken during April 2013, where patients were approached face-to-face to answer a questionnaire based on their health-related experiences in the current and previous year and their self-reported prescription adherence.
Population and sample
The population of interest were elderly patients (aged ≥ 65). Sample size estimated considered 2 million elderly , prevalence of 50% non-adherence to chronic medication , assumed normal distribution, a 3% error estimate (d) and 95% confidence level and was targeted at 1067 patients.
Inclusion criteria: aged ≥ 65 and taking at least one medicine chronically (for a period longer than 6 months).
Exclusion criteria: patients not purchasing medicines for themselves or unable to communicate in Portuguese (linguistic, or cognitive barriers).
Patients meeting these criteria were invited to participate in the study by the pharmacist and, after being informed about the study objectives, responded to the questionnaire while waiting for their prescription to be filled
A short self-administered questionnaire was developed aiming to obtain answers to the research question. This questionnaire derived from a literature search aimed at identifying the aspects of health care potentially affected by the financial crisis. The items identified were brainstormed among a team of eight health care professionals engaged in aspects of public health and subsequently tested in ten patients, the latter to judge understanding of the wording chosen.
Self-perception of general health status (5-point Likert scale, adopted from the SF-36);
Being diagnosed with a chronic condition;
Taking medicines chronically [a list of the conditions was provided: see appendix]
Frequency of consulting a physician in the current year, compared to the previous;
Having changed co-payment status from special to general regime in 2012 (referencing to 2011), as explained;
Private medicines expenditure in 2012 (the last year), in comparison with 2011 (the previous one);
Not being able to use health care resources for financial reasons (yes/no). If ‘yes’, a list of the possibilities was provided;
Changes in medicines-taking behaviour, evaluated as 3 sub items: lack of persistence (“Did you stop taking medicines?”), engaging into partial adherence (“Did you save medicines by taking less than prescribed?”), and medicines switches (“Did you change your usual medicines to cheaper options?”). In this last subdomain, when answering ‘yes’, the patient was also asked whose initiative was it.
In the present study non-adherence was considered the main variable of interest and defined as those patients stopping their medicines or increasing the inter-dose interval, according to self-reported behaviour.
Data were entered and analysed in IBM SPSS Statistics Software, version 22, resorting to univariate descriptive statistics for sample characterization. The medical conditions being treated with medicines were collected in a dichotomous way following free listing (yes/no); these were then recoded so that the total number of chronic conditions was possible to determine and thereafter treated as a continuous variable. An inferential statistical analysis of the data was carried out, through the application of Chi square test (bivariate analysis) and independent samples t test, at a significance level of 5%. A binary logistic regression (enter method) was performed to ascertain the effects of potential predictors on the likelihood that participants adhere to chronic medication. Predictors tested included perceived health status, number of co-morbidities, reported frequency of medical appointments and reported costs with medicines. The variable co-morbidities was dichotomised for the logistic regression, considering as categories “three or more chronic conditions” versus “two or less conditions”.
Fifty-one pharmacies out of 78 agreed to participate in the study (participation rate = 65.4%). A total of 1231 questionnaires were collected during the study period. The contribution of pharmacies for patient recruitment varied widely (1–186).
Patients simultaneously reporting not to have a chronic illness and not taking medicines daily were excluded (n = 70). Therefore the analysis here reported includes 1161 patients, exceeding the estimated sample size.
The most frequent was for patients to report taking medicines for 3 of the aforementioned conditions [M = 2.8; SD = 1.32; (1–7)], where antihypertensive medicines were the most frequently mentioned (n = 843, 77.1%), followed by lipid lowering medicines (647, 59.2%), musculoskeletal medicines (n = 481, 44.0%) and anxiolytics (n = 371; 33.9%).
Perceived health status
Self-perceived health status was considered reasonable by the majority of participants (n = 637; 55.0%). For purposes of analysis, the categories “Good” and “Excellent” were aggregated (n = 180, 15.5%) and also were the categories “Fair” and “Poor” (n = 341, 29.4%).
Use of health care resources
Private medicines expenses were considered ‘higher’ in the current year by 40.1% of patients (n = 464), ‘the same’ by 42.6% (n = 492) and ‘lower’ only by 197 patients (17.0%). In subsequent analysis, this variable was dichotomized in “spent more” versus “spent the same or less”.
Over two thirds of patients (67.7%, n = 774) mentioned they changed medication to cheaper alternatives (often generics) in the previous year, an attitude stated to be driven by economic factors. A lower but still important and worrisome proportion of patients mentioned they stopped taking their medication (n = 146; 12.8%) or started saving their medication by increasing the inter-dose interval (n = 166; 14.7%).
Relationship between out-of-pocket expenses with medicines and medicines-taking behaviours
Money spent on medicines in 2012, in comparison with 2011
Less or the same
Stopped taking medicines for economic reasons
Increased inter-dose interval to save medicines
Substituted medicines by cheaper options
Mean number of conditions being treated according to forms of non-adherence
Number of medical conditions being treated
Non-adherence (stopped taking medicines for economic reasons) (n = 1132)
Partial non-adherence (increased inter-dose interval to save medicines) (n = 1120)
The mean number of medical conditions reported by patients was higher in those that reported switching to cheaper options compared to the previous year (2.86 (±1.38) vs. 2.28 (±1.40); Student’s t test p < 0.001).
Relationship between the transition from special to general regime and medicines-taking behaviours
Changed co-payment (from special to general regime)a
Spent more on medicines
Stopped using medical resources/treatments
Stopped taking medicines for economic reasons
Increased inter-dose interval to save medicines
Substituted medicines by cheaper options
Self-perceived health status was also associated with medicines-taking behaviours, where patients reporting to have stopped taking medication for economic constraints rated their health status as worse (3.56 (±0.84) vs. 3.17 (±0.81); p < 0.001). A similar tendency was observed for patients reporting to have started increasing the inter-dose interval (3.34 (±1.34) vs. 2.55 (±1.39); p < 0.001).
Results from binary logistic regression using adherence as the dependent variable (n = 1140)
Adjusted odds ratio
95% confidence interval
Perceived health status
Excellent or very good
Fair or poor
Frequency of medical appointments
Costs with medicines
Spent the same
3 or more chronic conditions
Number of observations
LR Chi square (7)
Prob > Chi square
The logistic regression model was statistically significant (χ2(7) = 107.96, p < 0.001), explained 9.1% (R2) of the variance in adherence and correctly classified 78.42% of cases. Results indicate that decreasing costs with medicines was associated with a decreased likelihood of adherence OR 0.42; 95% CI 0.27–0.65). Lower perceived health status was associated with a decrease in the likelihood of exhibiting adherence to chronic medication (OR 0.51; 95% CI 0.29–0.91). Having 3 or more co-morbidities was associated with a decrease in the likelihood of exhibiting adherence to chronic medication (OR 0.48; 95% CI 0.34–0.66). Less frequent medical appointments, in comparison with the previous year, was associated with an increase in the likelihood of adherence (OR 2.17; 95% CI 1.39–3.37), where patients visiting their physician less often were twice as likely to adhere.
The main findings of this study indicate that patients perceive their accessibility to health care to have deteriorated during the economic crisis period in analysis. In fact, around a third stated to have been deprived of health care, with particular effects perceived in private medical care, dental care, eye and ear care.
Socio-economic factors’ influence on ability to pay for medical care have been previously shown , and so have the effects of the economic crisis on access to medical and dental care . Thus, results found are not surprising and suggest patients’ perceptions may quite accurately be used as indicator for access to care.
Public services, considered a basic need, were mentioned by 26.0% of patients refraining from using healthcare for financial reasons, perhaps partly due to increased user fees. This aspect has not been specifically addressed in the present study but could be worth exploring in future research.
Around 30% of patients have reported needing to engage in some form of non-adherence. This study did not explore the strategies adopted for saving medicines, nor did it assess patients’ socio-economic strata. However, we could differentiate between total discontinuation and engaging in some form of partial adherence. Data indicates these occurred evenly. Similar strategies have been reported by low and high-income patients, respectively . Partial adherence includes several strategies, namely delaying filling a prescription, splitting tablets in half or taking fewer doses than prescribed. Research has highlighted another strategy prevalent in in Portugal to be the selective filling of prescription items .
However, the majority of patients reporting financial constraints simply adopted less-costly treatment options, concurring with the European trend of increased generic uptake, which simply indicates a rational economic behaviour. Nonetheless, some reflection is needed on the population group approached in this study and the current legal framework for generic pricing adopted in Portugal, where prices of medicines may change every month and the reference pricing every three months. This policy measure leads patients that need (or want) to save money on medicines to constantly change the generic brand, which may result in confusion and possible duplications, particularly in the very old or in those with cognitive impairment. It should be mentioned that, although statistically insignificant, there was a trend indicating a higher proportion of patients changing to a lower co-payment status have switched to cheaper medicines, which may suggest that higher subsidies for medicines do not induce switching to cheaper options.
Patients with a worse perceived health status, those spending less on medicines and having multi-morbidity less frequently reported adherent behaviours. Conversely, those visiting their physician less often more frequently reported adherent behaviour, perhaps reflecting how much they valued their scarce medical visits. Another hypothesis is, because there is no information on the direction of effect, it might be that they visited their physician less because they were adhering more and hence their conditions were better controlled. Adherence was strongly influenced by self-reported costs of medicines, perceived health status, multi-morbidity and access to medical care, all with similar relative weightings. This finding suggests that some of the cost containment measures taken in the past few years in Portugal, which have resulted in an important proportion of elderly changing their co-payment strata, may have had serious implications on medicines taking behaviours, which may ultimately lead to increased costs caused by health deterioration.
In the light of these results, it seems wise to dedicate additional attention to the potential rise in adherence problems motivated by economical constrains and to deterioration that may consequently develop.
This study has some limitations worth acknowledging. While it was not an aim to measure the true effects of the crisis, but rather obtaining a glimpse of patients’ perceptions of the effects of the economic crisis on their ability to pay for and access medical care, perhaps a longitudinal design would be more robust to minimise recall bias. However, the survey was undertaken at the exact month where Portuguese have to declare their income and money spent for taxing purposes, minimising this bias. Similar methodology has been used elsewhere to explore elderly people’s perceptions on medicines costs . Sociodemographic information of the patients was not collected, and could be presumed important to include in regression modelling. However, age was considered quite homogeneous, and income was assessed by using co-payment regime as a proxy.
Although the patient sample was larger than the estimates, it should be recognized that the sample was obtained from a convenience sample of pharmacists, particularly motivated in research. The implications are that no pre-assumptions should be made on achieving such a high participation rate in future studies. There is no reason to think that the patients recruited by these pharmacists have particular characteristics, other than their geographical location, but the contribution from rural and urban patients was not determined. We can assume that perceptions in rural settings might be worse, as there has been frequent information on decreased accessibility to medical care and medicines in these areas . It should be noted that the contribution of pharmacies varied widely, and therefore one cannot disregard potential bias towards selecting some types of pharmacy customers. Using pharmacies to recruit patients may impact on results, as we fail to capture null compliers, leading to a lower estimate of non-adherence. However, previous studies suggest that often patients engage in partial compliance, choosing among medicines which they can buy . A relationship between the number of medical conditions treated with daily medication and non-adherence was found. It would have been interesting to collect information on the number of medicines taken, as previous research indicates that polypharmacy is also a predictor for non-adherence .
This study shows that patients perceive their access to health care to be affected by the economic crisis. Reported medicines taking behaviours appear changed as a consequence of patients’ perceptions on their ability to pay for treatments.
The authors wish to acknowledge Observatório Português dos Sistemas de Saúde (OPSS) for providing the platform for developing this study and the special contributions of other members of the “medicines subgroup”, namely Sérgio Vilão and Fátima Bragança. We also thank all the community pharmacists who actively engaged in patient recruitment and patients who answered the questionnaire.
The study did not receive any specific funding. Printing costs were supported by OPSS and indirect costs were entirely supported by each of the researchers’ organisations.
Conflicts of interest
The authors declare that they have no financial or other relationships that might lead to a conflict of interest.
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