Intended for healthcare professionals


Europe’s cost of living crisis jeopardises medication adherence

BMJ 2023; 380 doi: (Published 30 March 2023) Cite this as: BMJ 2023;380:p747
  1. Tamas Agh, research associate professor12,
  2. Job FM van Boven, associate professor3,
  3. Przemyslaw Kardas, professor4
  1. 1Center for Health Technology Assessment and Pharmacoeconomic Research, University of Pecs, Hungary
  2. 2Syreon Research Institute, Hungary
  3. 3Department of Clinical Pharmacy & Pharmacology, Medication Adherence Expertise Center of the northern Netherlands (MAECON), University Medical Center Groningen, University of Groningen, the Netherlands
  4. 4Medication Adherence Research Centre, Department of Family Medicine, Medical University of Lodz, Poland

Care must be taken to ensure that economic hardship doesn’t lead to medication non-adherence and entrench social inequalities, write Tamas Agh and colleagues

Much of Europe is struggling with a weak economy. Annual inflation across the European Union (EU) reached 10.4% in December 2022, compared with just 5.3% a year earlier,1 as the economy went into freefall in the wake of the covid-19 pandemic and the Russia-Ukraine war. Consumers are facing a growing energy crisis and soaring food prices. Policy makers and healthcare professionals should bear in mind that the widespread fall in people’s disposable incomes in real terms will not only affect people’s daily living expenses, but also the affordability of lifesaving medications.

Evidence shows that economic crises adversely affect medication adherence in patients with non-communicable and communicable diseases.234 During the 2010-14 Portuguese financial crisis, almost 15% of older patients started saving money by increasing the inter-dose interval of their medication, and around 13% stopped taking their medication entirely.2 Similarly, during the Greek debt crisis between 2009 and 2017, patients with financial difficulties were less likely to adhere to their medication regimens compared with those who were not experiencing financial hardship. Around 12% of patients reduced the frequency or dose of their medication because of its cost.3

Other research has highlighted how economic downturns can increase the transmission of infectious diseases and reduce treatment adherence. These risks are particularly acute for groups who are already vulnerable, such as people who are homeless, migrants, or on a low income.4 Finally, economic slumps also tend to increase anxiety and depression, which may fuel poor medication adherence and its negative consequences.2 As we grapple with another economic crisis, how can we mitigate these risks?

To start with, healthcare providers and policy makers should be aware of the negative consequences of poor medication adherence. It’s been estimated that every year medication non-adherence in the EU is associated with almost 200 000 deaths and costs between €80–125bn.5 The current economic downturn could exacerbate the damage already caused by non-adherence and increase the pressure on healthcare systems. Medication non-adherence and interruptions to treatment for infectious diseases, such as tuberculosis or HIV, can also increase the risks to the wider public’s health through the spread of infections and worsening of drug resistance.46

Ensuring the rational use of medicines takes on even more importance during periods of economic uncertainty. When selecting and prescribing medications, clinicians should give greater consideration to patients’ ability to pay for any out-of-pocket costs. Governments can also introduce various policies and levers to ease the burden on patients.

Substituting existing medication with a generic option is one strategy that’s been used to reduce drug costs.2 Many European countries have introduced generic reference pricing systems, which establish a reference price for a group of interchangeable generic medicines.7 This caps the amount that patients are reimbursed for a medicine, thereby stimulating price competition between manufacturers, lowering medicine prices, and reducing the budgets of healthcare systems. By clearly illustrating the relative costs of generic medicines, it can also encourage patients to use a cheaper medication option, potentially lowering their copayments or otherwise saving them money.8 It’s worth noting, however, that too frequent switching of generic products may cause confusion and medication errors, especially in older patients using multiple medicines. To prevent this happening, regular monitoring of medication adherence—through analysing pharmacy refill databases, for example—should be part of the care process, especially in this potentially vulnerable patient group.

Medication non-adherence is a problem not only for patients but also for governments, insurance companies, the pharmaceutical industry, and healthcare providers. Close cooperation among these stakeholders can help to facilitate interventions in clinical practice that encourage medication adherence.9 Medication review services or patient education, for example, can encourage the cost effective use of medication, ensuring patients carry on with the treatments they need.

Finally, if we’re to avoid creating or entrenching social inequalities in healthcare then it’s critical to allocate scarce economic resources fairly during economic downturns. This may mean that targeted policy actions are needed—such as not charging certain groups for medication—to ensure equitable access and enable adherence to medicines in people who are likely to be hit hardest by the cost of living crisis.

Additionally, Russia’s invasion of Ukraine has forced millions of people to flee and seek refuge in the EU and other neighbouring countries. To maintain their access to medicines, Ukrainian refugees should be affiliated to the public health insurance system of host countries. Furthermore, international support is needed to provide medicines for patients staying in areas affected by conflict.9

Looking back at the consequences of previous economic crises underlines the increased risk of medication non-adherence that we may be facing in the years ahead. Strong collaboration between stakeholders, targeted policy actions, educational programmes, international bodies such as the European Commission and World Health Organisation taking an active role, and adherence interventions are all needed to prevent future fallout in the healthcare system during this tough economic climate.


  • Competing interests: This article is based upon work from COST Action CA19132 “ENABLE,” supported by the COST (European Cooperation in Science and Technology). JFMvB is the chair, and TA and PK are working group leaders of the European Network to Advance Best practices and technoLogy on medication adherencE (ENABLE) COST Action. Nothing further declared.

  • Provenance and peer review: not commissioned; not externally peer reviewed.