Nearly 8% of households in Portugal experience financial hardship due to out-of-pocket payments for health care – higher than in many European Union countries, according to the first in-depth analysis of affordable access to health care in the country.
“This report tells the story behind the numbers, highlighting the gaps in coverage that undermine patients’ ability to pay for their health care,” said Dr Natasha Azzopardi-Muscat, Director of the Division of Health Systems at WHO/Europe. “It shows that although the government has taken steps to reduce out-of-pocket payments, more needs to be done to ensure people can trust they can access health care without compromising other basic needs.”
The report, “Can people afford to pay for health care? New evidence on financial protection in Portugal”, finds that catastrophic health spending is driven mainly by spending on outpatient medicines (especially in the poorest households), followed by medical products and dental care. People who experience catastrophic health spending may not be able to pay for other basic needs such as food, housing and heating.
For the poorest households, outpatient care replaces dental care as the third driver, which is likely to be due to a high and increasing degree of unmet need for dental care in households with low incomes.
Strengths in coverage policy
WHO/Europe’s report highlights notable strengths in coverage policy in Portugal. For example, entitlement to publicly financed health care is based on residence, the benefits package is relatively comprehensive and refugees, asylum seekers, the children of undocumented migrants and some undocumented migrants are entitled to the same benefits as residents.
The government has also taken steps to reduce user charges, abolishing co-payments for primary care visits and diagnostic tests in 2020 and co-payments for some emergency care in 2022.
Gaps in coverage undermine financial protection
Despite these efforts, gaps in coverage continue to be a challenge, particularly for people with low incomes.
- Outpatient medicines have high percentage-based co-payments (set at 10% to 85% of the price).
- They are also subject to reference pricing (where people pay any difference between the reference price and the pharmacy retail price), leading to “avoidable co-payments” if the lowest-priced medicine is not available in the pharmacy or if a higher-priced alternative is recommended by a doctor.
- Income-based exemptions from co-payments for outpatient prescriptions were only introduced in 2024, apply to a small group of people (those over 65 years of age with low incomes receiving social support) and are not automatic, which limits take-up.
- The coverage of medical products is restricted and covered products often incur substantial percentage co-payments (ranging from 15% to 85% of the price).
- There is no cap on co-payments.
- Publicly financed dental care is limited due to a lack of public facilities and gaps in coverage.
- Long waiting times affect primary care, specialist visits and elective surgery.
“Out-of-pocket payments in Portugal have decreased since 2010, but too many households still face catastrophic health spending and unmet need,” said Pedro Pita Barros, lead author of the report and Professor of Health Economics at the Nova School of Business and Economics. “The policy options we identify in the report aim to address this by making access to outpatient medicines, medical products and dental care more affordable, particularly for people with low incomes.”
Making health care more affordable
Building on recent efforts, the government could consider the following steps to reduce financial hardship and unmet need.
- Reduce co-payments for outpatient prescriptions by replacing percentage co-payments with low fixed co-payments (which are more transparent). Ensure people can access at least 1 of the 3 lowest-priced medicines in each reference group free at the point of use. Extend co-payment exemptions to all people with low incomes, not just pensioners. Introduce a cap on all co-payments, and link the cap to household income. And ensure exemptions and caps are applied automatically, using digital tools.
- Expand access to publicly financed dental care.
- Broaden the coverage of medical products, including corrective lenses.
- Continue to reduce waiting times and improve access to primary care.
- Abolish tax subsidies for out-of-pocket payments and private or voluntary health insurance premiums because they are more likely to benefit richer households and shift public resources away from health needs.
About the report
This review is part of a series of country-based studies generating new evidence on affordable access to health care (financial protection) in health systems in Europe. It assesses the extent to which people in Portugal face financial barriers to access or experience financial hardship when they use health care. It covers the period from 2000 to 2025 using data from household budget surveys carried out between 2000 and 2022 (the latest available year); data on unmet need for health services up to 2024 (the latest available year); and information on coverage policy (population coverage, service coverage and user charges) up to May 2025.
WHO/Europe monitors financial protection through the WHO Barcelona Office for Health Systems Financing, using regional indicators that are sensitive to equity. Financial protection is central to universal health coverage (UHC) and a key dimension of health system performance assessment. It is an indicator of the Sustainable Development Goals, part of the European Pillar of Social Rights and at the heart of the European Programme of Work, WHO/Europe’s strategic framework.
Explore country-level and comparative data and analysis on UHC Watch, an online platform tracking progress on affordable access to health care in Europe and central Asia.