Chapter 2.4 gives an overview of user charges. User charges are out of pocket (OOP) payments made at the point of use for health services. Nearly all countries have some user charges, most commonly for medicines. They are intended to raise revenue and also to reduce the use of unnecessary health care services and products. Key learning includes that

• User charges can generate revenues but have many unintended negative consequences – creating barriers to access, contributing to inequities and increasing the risk of financial hardship for households.

• Health systems can reduce unnecessary or wasteful use of care without user charges by

• – Strengthening prescribing and referral systems to make sure care is appropriate

• – Offering more information to steer patients and providers towards more cost-effective care.

• Supply-side mechanisms that guide providers’ behaviour are more equitable and effective than demand-side mechanisms like user charges and have fewer negative impacts on patients – especially those with chronic or severe conditions or the economically disadvantaged.

• User charges are a suboptimal policy but – if they are to be used – health systems can mitigate the harm they cause and protect health care users through mechanisms such as exemptions, reduced copayments, income-related copayment caps, and to a lesser extent, price control and regulation.