Special arrangements for the supply of Pharmaceutical Benefits Scheme (PBS) medicines to patients of eligible Remote Area Aboriginal Health Services (AHSs) were introduced in 1999 under Section 100 of the National Health Act 1953. These patients can obtain PBS medications without charge and without a PBS prescription

Currently 166 remote area AHSs, both community controlled and remote health services operated by the States and Territories, have access to S100 medications through these arrangements.

Numerous evaluations and reports have been performed over the years including a formal evaluation in July 2004 and and a consultants report in 2009.

As well as ensuring supply of pharmaceuticals the S100 program is also supposed to collect data, monitor the program in response to the 2004 evaluation. This “Status Report on action in response to the evaluation” is apparently a living document. It was last updated on 9th October 2007. So the document is dead or they are not really monitoring the program. I’m tempted to believe the latter alternative.

I have placed the document here as a slideshow with a link to the government website and document below.

Over the next few months I will look at some of the activities they are supposed to be reviewing.

Status Report on action in response to the evaluation

In 1986 the 39th World Health Assembly adopted the “Revised Drug Strategy” produced by experts on the rational use of drugs a year earlier. Part of this strategy called on nations to implement a National Medicinal Drug Policy.

A number of policies were developed and implemented culminating in the National Medicine Policy that was launched in 1999.

The aim of the policy is to “improve positive health outcomes for all Australians through their access to and wise use of medicines.”

The National Medicines Policy (NMP) is based on four central objectives:

* Timely access to the medicines that Australians need, at a cost individuals and the community can afford; (an example of this is Australia’s Pharmaceutical Benefits Scheme)

* Medicines meeting appropriate standards of quality, safety and efficacy;

* Quality use of medicines; (National Strategy for Quality Use of Medicines (QUM))

* Maintaining a responsible and viable medicines industry;

The National Medicines Policy is the overarching framework on how we handle medications in Australia. Within this broad and far reaching policy statement is a paragraph focusing on Indigenous Health

In particular, there are substantial access barriers and evidence of under use of medicines by Aboriginal and Torres Strait Islander peoples. Partnership commitments to address the issues (eg Framework Agreements on Aboriginal and Torres Strait Islander health) are required.

In June 2009 the NMP executive and committee hosted the inaugural Partnerships Forum with over 100 invited “stakeholders”. As well as an opportunity for the Executive and Committee to outline priorities and discuss the challenges and opportunities created it also sought stakeholders (I hate that word) input. Outcomes from the forum are to assist the the Executive and the Committee to identify future priorities which are then presented to the Minister for Health and Ageing who I suppose then does something with it.

Peppered throughout the document are references to the importance of access to medicines and the rational use of these medicines. Despite the Section 100 Medicine Supply Arrangements for Remote Area Aboriginal Health Services program allowing free supply of medications to remote communities An Indigenous Australian with a much higher disease burden still only receives 58% of the total PBS benefits paid be other Australian ($168.2 to $288.2)

I’ve been invited to the next forum (30th June 2010 in Sydney) as apparently I know a bit about Indigenous and Remote Health and access to medications. Hopefully I’ll be able to write something about it in July.

In 2004-05 two surveys were undertaken by the Australian Bureau of Statistics to enable comparisons between the health of Indigenous Australians and non-Indigenous Australians.

The survey showed that approximately 6% of indigenous Australians reported either having diabetes or High Sugar Levels (HSL). Indigenous people living in the towns and cities of Australia had close to half the incidence of diabetes or HSL than those indigenous Australians living in remote Australia (5% compared to 9%).

But how does the incidence of diabetes in Aboriginal and Torres Strait Islanders compare to the rest of Australia?

This is not a trick question.

The answer of course is “pretty poorly”. Overall Australia’s Indigenous population was three times more likely to have diabetes than the non-Indigenous population. But it was much worse depending on where you live.

Indigenous people living in remote areas of Australia were more than eight times more likely to report having diabetes or HSL than non-Indigenous people.

In remote areas, Indigenous females were fourteen times as likely to have diabetes or HSL as non-Indigenous females. Indigenous males were nearly six times as likely to have diabetes or HSL as non-Indigenous males living in remote areas.

Diabetes & HSL rates by Indigenous status 2004-05

There is a little, well, rather a big project underway in Australia analysing HbA1c data by postcode for five years.

The “Mapping Glycaemic Control Across Australia Project” will collect, clean and analyse the HbA1c data annually for the next five years. Annual updated summary data will be made available for access through the Changing Diabetes Map providing a framework to track and monitor HbA1c levels.

For the lay person reading this – the HbA1c is a measure of the amount of “sugar” in our red blood cells. As red blood cells last in our our body and are replaced in theory every three months or so it gives us a good picture of the last three months. The project states Australia’s average HbA1c is 7.6%. A well controlled diabetic would aim to have a HbA1c below 7%.

The map searches by postcode. Except for remote areas that is. Then it uses huge geographic regions not allowing us to see HbA1c averages in remote Indigenous areas. It does show the increasing HbA1c levels generally seen in remote and rural areas compared to more urban areas.

A recent news article stated Indigenous Australians have ten times (10x) the incidence of renal disease than other Australians (The same article quoted the figures that Native Americans have double the incidence of end-stage renal disease, and in Canadian Indians the incidence is two and a half times greater, compared with non-indigenous North Americans.)

Now I don’t have a breakdown for renal disease for remote areas compared to non-remote areas as I do for diabetes. But with these much higher levels of disease you would expect healthcare and pharmaceutical costs to be through the roof compared to other Australians.

Sit down for a little surprise.

There is a lovely little report titled ‘Expenditures on health for Aboriginal and Torres Strait Islander peoples 2004-05‘. Note it covers the same period as the ABS diabetes statistics.

Renal disease at ten times the incidence, diabetes (in remote areas) at eight times higher incidence yet the higher spend on healthcare for indigenous Australians was pitiful, especially when you look at the cost of providing healthcare in remote areas.

In 2004-05, $1.17 per person was spent on Aboriginal and Torres Strait Islander health for every $1.00 spent on the health of non-Indigenous Australians. Average total health expenditure per Aboriginal and Torres Strait Islander was $4,718 compared with $4,019 per person estimated for non Indigenous Australians.

The pharmaceutical spend was deplorable. The average expenditure on pharmaceuticals for Australia’s Indigenous population in 2004-05 was 40% of what Australia as a whole spent per individual (PBS subsidy). $140 spent per Indigenous Australian compared with $273 for each non-indigenous Australian.

In remote areas medications are provided by what is called the S100 scheme. This gives us dollar values of what was shipped to remote clinics. Not necessarily what was used by patients. The government figures state that remote Indigenous Australians use $186 of Pharmaceutical Benefit Scheme medications per head. This figure is pathetic considering the incidence of these chronic diseases.

But this Amount of $186 per remote Indigenous person overstates the amount of medications used to treat chronic diseases.

This figure is the value of PBS medications shipped to clinics, not what is used on patients. Some clinics have massive waste due to not having ordering systems in place. And you do need to run with a slight excess and carry some emergency drugs that may go out of date (eg Reteplase at over $1000).

Remote clinics also handle the acute presentations that in urban areas are looked after by hospitals. While these items are not expensive large numbers are used. Benzathine Penicillin, Normal Saline bags for IV use, Ceftriaxone and other parenteral antibiotics in numbers you would not see being dispensed by your normal pharmacy on the PBS. There is no where near $186 dollars per head being spent in providing medications to treat chronic disease in remote Australia.

So what have we got. Massive incidences of chronic diseases in our Indigenous population compared to the rest of us. Despite chronic disease many higher in Indigenous Australians than other Australians there is overall only 17% increased health spending and well under half the usage of medications required to adequately treat these diseases.

Looking at those figures it will come as no surprise that the same report states hospital separations for Indigenous Australians in remote and very remote areas are 820 and 606 per 1000 people respectively.

Is it just me or is there something quite wrong in all this?

If you like this post and what else you see on the blog please subscribe by RSS feed (the orange button) or by email. Visit my subscription page.

Way back in 2003 there was a very contentious article published in the BMJ, “A strategy to reduce cardiovascular disease by more than 80%” along with an editorial “A cure for cardiovascular disease?” The proposed polypill had six ingredients and the editorial claimed that the “combination treatment has enormous potential, especially in developing countries.” It has since been patented.

Since then it has been talked about a lot including an editorial in the Australian Prescriber in 2005 asking whether a polypill would be friend or foe and would a “one size fits all” approach be beneficial to patients. The use of a polypill as primary prevention from cardiovascular death was contentious.

Moving along to the present and a number of polypill trials are commencing or are planned, including in India, and a six country trial including England, NewZealand and Australia.This trial will include people who have a raised risk of heart attack or stroke, but are not on any medication and have no other related health issues.

Several years ago in a discussion with a doctor it was asked why we don’t have a polypill made. With less tablets for our patients to take perhaps it would improve adherence. I could see a lot of problems, particularly testing for stability if we were going to have large amounts produced. It would also be very costly. I asked around and found the Kanyini Vascular Collaboration was in the planning stages. We have been involved with it ever since.

The S100 supply of medications to remote indigenous communities has certainly improved access to drugs but indigenous people experience a greater burden of all disease including heart disease, diabetes and kidney disease than the non-Indigenous population. The study is looking to find out why this occurs and how to improve it.

The study is funded by the National Health and Medical Research Council (NHMRC) and is being run by The Baker Heart Research Institute, Alice Springs and The George Institute for International Health, Sydney.

Aboriginal health services around the country are involved, including city, rural and remote. A map with the participating services can be found here. Ngaanyatjarra Health Service is the only aboriginal health service in Western Australia participating in the trial.

It consists of many parts, some will run concurrently, others staged, over a number of years.

The aim of the Kanyini Vascular Audit

is to quantify the magnitude of evidence-practice gaps in the identification and management of vascular risk among Aboriginal and Torres Strait Islander people.

There is a Qualitative Study involving:

patients at high cardiovascular disease risk, their families and community members, professional health care providers, managers and policy makers in Aboriginal and Torres Strait Islander health to give us greater understanding of the barriers faced and the ways our indigenous population can access best practice chronic disease care and prevention.

There will also be two studies trialling different interventions that will be directed by the results of the research that is currently occurring.

I started off writing about a polypill. There is also a polypill component to this research that we hope to commence this year. There will be two different versions. Other treatments can be added as required. They contain an angiotensin converting enzyme inhibitor, statin, aspirin, Beta blocker or thiazide diuretic.

The logistics of this will be interesting for my mob as they move between three states and may be evacuated to three cities by the RFDS. However I am very excited that the health problems of indigenous Australia have started to be looked at seriously at a policy and practical level rather than just as statistics to bandy around.

“Kanyini” is a word in use in several central Australian aboriginal languages.It is a great word that can be translated as “to have, to hold and to care”.

From the website:

“Kanyini is a verb which reflects a commitment, a full engagement; vitalising again and again all that went before and all that will go after”*

It represents one of the four foundations of Aboriginal life in Central Australia: Tjukurpa (Law, Dreaming); Walytja (Family); Ngurra (Land, Country) and Kanyini. In essence, Kanyini describes the principle and primacy of caring for others – an obligation to nurture, protect and care for other people, family, country and the law.

There is a documentary titled Kanyini. The story guide may be of interest.

Welcome to the first edition of “PBS Remote News”, a newsletter to provide information for remote area Aboriginal and Torres Strait Islander Health Services participating in the special PBS supply arrangements under the provisions of Section 100 of the National Health Act 1953. Participating health services and pharmacists are invited to submit stories or articles that may be of interest to other readers for future newsletters. Any submission, or comment on this edition, should be sent to pbs-indigenous@health.gov.au This edition clarifies the three options for ordering PBS medicines from your supplying pharmacists.

So started the first edition of PBS Remote News in 2004. It was produced by the Pharmaceutical Access and Quality Branch of the Department of Health and Ageing, presumably to show their commitment to remote indigenous health.

There had been no other issues produced. You could see all the editions ever produced (all one of them) here.

But don’t try it. They are updating the website, and to give a positive comment, does seem to be more user friendly which is a strange thing for a government department.

However, I wonder if this newsletter will be resurrected. Particularly as there is an indigenous sub-committee of the PBAC looking at medications required in Indigenous Health. It may have been a nice way to ensure information is passed onto interested parties.

I sent off an email to the S100 area of DoHA yesterday to ask if it will be resurrected. I’ll post if I get a response.