3.15 Access to prescription medicines
Why is it important?
Essential medicines save lives and improve health when they are available, affordable, quality-assured and properly used (WHO 2004b). Affordable access to medicines is important for many acute and chronic illnesses. For chronic illnesses such as diabetes, hypertension, heart disease and renal failure, multiple medications may be required for many years to avoid complications (WHO 2004b). It is important to ensure that Aboriginal and Torres Strait Islander peoples, who experience high rates of acute and chronic illnesses, are able to access appropriate prescription medications when they are required. In Australia, the main mechanism for ensuring reliable, timely and affordable access to a wide range of prescription medications is the Australian Government's Pharmaceutical Benefits Scheme (PBS). In 2013–14, the PBS subsidised the cost of 209.8 million prescriptions, at a cost of approximately $9.15 billion.
In 2010–11, total expenditure on pharmaceuticals per Aboriginal and Torres Strait Islander person was around 44% of the amount spent per non-Indigenous person ($369 compared with $832). In 2010–11, average PBS expenditure per person was $291 for Indigenous Australians and $366 for non-Indigenous Australians. In 2001–02, per person pharmaceuticals expenditure was estimated to be 33% of the amount spent on non-Indigenous people. This suggests that the gap in spending between Indigenous and non-Indigenous Australians is closing. Note that changes over time may partly be explained by methodological changes and increase in Indigenous identification.
Mainstream arrangements account for 66% of payments for Aboriginal and Torres Strait Islander peoples. The remainder are Section 100 and other special supply PBS drugs. The gaps between expenditures for Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians are greatest in non-remote areas. In remote and very remote areas, per person pharmaceutical expenditures for Aboriginal and Torres Strait Islander peoples are higher, largely due to the impact of the special provisions for remote area Aboriginal health services. In 2010–11, pharmaceutical expenditures in these areas were $349 per person for Aboriginal and Torres Strait Islander peoples, compared with $236–$296 in other areas.
In 2012, the number of full-time equivalent pharmacists per 100,000 population declined with remoteness, from 97 per 100,000 in major cities to 60 per 100,000 in remote areas (AIHW 2014aa).
A recent evaluation of use of prescription medicines by Indigenous Australians showed that PBS Co-payment subsidy beneficiaries increased their use of medicines between 2009 and 2012 (KPMG 2014). Aboriginal and Torres Strait Islander peoples aged 0–14 years had a 39% increase in use of PBS medicines in 2012 above the historical trend rates with between 25% and 33% of this increase being attributable to the Indigenous Chronic Disease Package. Similarly, Indigenous Australians aged 15–54 years had a 29% increase in use of PBS medicines above the historical trend rate, with between 13% and 21% of the increase being attributable to the Indigenous Chronic Disease Package.
There is a large gap between PBS pharmaceutical expenditures for Aboriginal and Torres Strait Islander peoples and other Australians, although this gap appears to have reduced between 2001–02 and 2010–11. Estimation of this gap is complicated by the absence of high-quality data sources on Indigenous pharmaceutical usage and expenditures.
Access needs to be addressed at multiple levels. Prescription medicines are prescribed by primary care and specialist practitioners, and barriers to accessing these services in the first place may result in under use of medications. In 2012–13, 14% of Indigenous Australians reported that they needed to see a doctor but did not in the previous 12 months (see measure 3.14). Once a prescription has been issued, access to pharmacies may be limited, particularly in rural and remote areas. Financial barriers, particularly for people on low incomes, can be important, despite safety net schemes. It is estimated that in 2012–13, 34% of Indigenous Australians who did not fill a prescription gave cost as a reason. Ongoing compliance is important for all patients with chronic illnesses.
The following range of programmes and special arrangements allow intervention at multiple levels to improve access to PBS pharmaceuticals for Aboriginal and Torres Strait Islander peoples in both remote and non-remote areas.
Special supply arrangements administered under Section 100 of the National Health Act 1953, allow for PBS medicines to be provided to remote area Aboriginal and Torres Strait Islander primary health care services. The PBS medicines are dispensed to patients of the health care service by a suitably qualified and approved health professional, without the need for a prescription and at no cost. In 2013–14, the Government expenditure for this programme was $43.1 million. This programme has played an important role in addressing medicines access problems in remote areas.
The PBS Co-payment Measure under the Indigenous Chronic Disease Package was introduced on 1 July 2010 to help address the financial barriers Aboriginal and Torres Strait Islander peoples may face in accessing PBS medicines in non-remote locations. These arrangements provide assistance with the cost of PBS medicines for eligible Aboriginal and Torres Strait Islander peoples living with, or at risk of, chronic disease. The identification of Indigenous clients is an important step in reaching the target population. Prior to implementation, it was estimated that over 70,000 people were expected to benefit from the new arrangements by the end of 2012–13. The uptake of the measure has far exceeded this estimate and as of 30 June 2014, approximately 280,885 Aboriginal and Torres Strait Islander patients had accessed the initiative and 8.8 million prescriptions had been dispensed.
Medicines are listed on the PBS on recommendation of the Pharmaceutical Benefits Advisory Committee (PBAC). The expertise on the PBAC is broad and encompasses experts in community settings, including for rural and Indigenous health as well as specialists.
Under the relevant regulations, cost recovery fees for applications to the PBAC may be waived when the application is in respect of medicines for Aboriginal and Torres Strait Islander peoples.
Under the 5th Community Pharmacy Agreement funding is provided to assist pharmacies operating in rural and remote areas through the Rural Pharmacy Maintenance Allowance. Programmes specific to Indigenous health have also been funded including the Quality Use of Medicines Maximised for Aboriginal and Torres Strait Islander People programme. The primary aim of this programme is to improve medication compliance and quality use of medicines and consequently the health outcomes of Aboriginal and Torres Strait Islander peoples that attend participating Aboriginal Community Controlled Health Organisations in rural and urban areas of Australia.
The Pharmaceutical Society of Australia's Guide to providing pharmacy services to Aboriginal and Torres Strait Islander people (PSA 2014) was released in 2014 to assist pharmacists and pharmacy staff to be responsive to health beliefs, practices, culture and linguistic needs of Aboriginal and Torres Strait Islander people, families and communities. The guide encourages increased engagement with Indigenous health services and key Indigenous organisations and includes an overview of Aboriginal and Torres Strait Islander specific medicine programmes and a resource list from which pharmacists can gather more in-depth information.
It is important to develop a better understanding of how the various barriers impact on Indigenous Australians to better target strategies. As data improve, better analysis of gaps in the PBS arrangements will be possible to inform programmes and policies.
Figure 3.15-1 shows the average pharmaceutical expenditure (in dollars) per person for Aboriginal and Torres Strait Islander peoples in 2011 was $274 for Benefit-paid pharmaceuticals and $94 for other pharmacueticals. Average pharmaceutical expenditure per person for non-Indigenous Australians in 2010-11 was $23 for benefit-paid pharmaceuticals and $409 for other pharmacueticals.
Source: AIHW health expenditure database (AIHW 2013c)
Figure 3.15-2 shows Benefits paid through the Pharmaceutical Benefits Scheme were estimated to be 80% of the level of expenditures for non-Indigenous Australians ($291 compared with $366). In 2001–02, per person pharmaceuticals expenditure was estimated to be 33% of the amount spent on non-Indigenous people. This suggests that the gap in spending between Indigenous and non-Indigenous Australians is closing.
Source: AIHW health expenditure database (AIHW 2013c)
Figure 3.15-3 shows The gaps between expenditures for Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians are greatest in non remote areas. In remote and very remote areas, per person pharmaceutical expenditures for Aboriginal and Torres Strait Islander peoples are higher, largely due to the impact of the special provisions for remote area Aboriginal health services. In 2010–11, pharmaceutical expenditures in these areas were $349 per person for Aboriginal and Torres Strait Islander peoples, compared to $236–$296 in other areas.
Source: AIHW health expenditure database (AIHW 2013d)