Why is it important?:Essential medicines save lives and improve health when they are available, affordable, quality assured and properly used (WHO 2004). Affordable access 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 2004). 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 2008–09, the scheme subsidised the cost of an estimated 182 million prescriptions, at a cost of $7.7 billion.
Access to pharmacies is particularly problematic for people living in rural and remote Australia, where many Aboriginal and Torres Strait Islander peoples live. Specific provisions under the PBS allow clients of around 167 approved remote-area Aboriginal and Torres Strait Islander primary health care services to receive medicines directly from these services at the time of medical consultation without charge or the need for a normal prescription form.
In 2005, the Expert Advisory Panel on Aboriginal and Torres Strait Islander medicines was formed to advise the Pharmaceutical Benefits Advisory Committee (PBAC) on medicines for the treatment of conditions usually specific to Indigenous Australians. The PBAC recommends medicines for listing on the PBS. To date the panel has assisted with the listing of 19 items which support treatment of conditions common in Indigenous health settings. These medicines have been listed to address the greater burden of disease experienced by Indigenous Australians and morbidity almost exclusively seen in this population.
Findings:In 2006–07, total expenditure on pharmaceuticals per Aboriginal and Torres Strait Islander person was around 40% of the amount spent on non-Indigenous people ($248 compared with $613). Benefits paid through the Pharmaceutical Benefits Scheme were estimated to be 60% of the level of expenditures for non-Indigenous Australians ($175 compared with $290). 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.
Mainstream arrangements account for 69% of payments for Aboriginal and Torres Strait Islander people. The remainder are Section 100 and other special supply PBS drugs. The gaps between expenditures for Aboriginal and Torres Strait Islander peoples 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. Pharmaceutical expenditures in these areas are almost twice the per person expenditures for Aboriginal and Torres Strait Islander peoples in other areas.
Implications:There is a large gap between pharmaceutical expenditures for Aboriginal and Torres Strait Islander peoples and other Australians, although this gap appears to have reduced between 2001–02 and 2006–07. Estimation of this gap is complicated by the absence of high quality data sources on Indigenous pharmaceutical usage and expenditures, the younger age profile for Aboriginal and Torres Strait Islander peoples and the problems in access to prescription medicines faced by all people living in remote and very remote Australia. Improved estimates are now available using the Voluntary Indigenous Identifier (VII) available with Medicare data.
Given the high prevalence of acute and chronic illnesses for Indigenous Australians, low levels of expenditure suggest severe problems in access to medicines. These problems are evident across geographical regions. The special provisions under the Pharmaceutical Benefits Scheme for remote Aboriginal and Torres Strait Islander primary health care services have played an important role in addressing problems in remote areas.
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. Appropriateness of prescribing may also be an issue. 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 nets. It is estimated that in 2001, around 19% of Australians did not fill a prescription because of cost (Blendon et al. 2003). Ongoing compliance is an issue for all patients with chronic illnesses, and these issues may be exacerbated for Indigenous Australians.
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. The new arrangements provide assistance with the cost of PBS medicines for eligible Aboriginal and Torres Strait Islander people living with, or at risk of, chronic disease. Over 70,000 people are expected to benefit from the new arrangements by the end of 2012-13.
Under the 4th Community Pharmacy Agreement funding is provided to assist pharmacies operating and starting up in rural and remote areas. Programs specific to Indigenous health have also been funded including the Quality Use of Medicines Maximised for Aboriginal and Torres Strait Islander People program. The primary aim of this program 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 Services in rural and urban areas of Australia. The program will be extended under the 5th Community Pharmacy Agreement.
It is important to develop a better understanding of how the various barriers impact on Indigenous Australians, in order to better target strategies. As data improve, better analysis of gaps in the PBS arrangements will be possible to inform programs and policies.
Figure 171 – Average pharmaceutical expenditure per person, Australia, 2006–07
Source: AIHW 2009
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Figure 172 – Average health expenditure per person by the Australian Government on the Pharmaceutical Benefits Scheme, constant prices, by Indigenous status, 1998–99, 2001–02, 2004–05 and 2006–07
Source: AIHW 2008
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Figure 173 – Average health expenditure per person by the Australian Government on the Pharmaceutical Benefits Scheme, Indigenous Australians, by remoteness, 2006–07
Source: AIHW 2010d
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