Jamaica's experience with drug subsidization : examining access and adherence to prescription medicines through the National Health Fund among adults with diabetes or hypertension

Background: Cardiovascular diseases are responsible for a large proportion of deaths globally and disproportionately affects developing countries. Diabetes and hypertension are major contributors to the burden of cardiovascular diseases worldwide (WHO, 2017; IDF, 2017; WHO, 2013). In Jamaica, the prevalence of diabetes and hypertension was estimated at 12% and 22% respectively, and has been attributed to an ageing population, increased prevalence of obesity, sedentary living and unhealthy diet (MOHW, 2018; WHO, 2018; WHO Global Data Repository). Access and the appropriate use of essential chronic disease medicines is an effective public health strategy against the morbidity and mortality associated with diabetes and hypertension. The consequences of inappropriate drug therapy are poor health outcomes and increased health care costs to individuals and society. The National Health Fund (NHF), which was implemented in 2003, provides financial assistance for medicines to Jamaicans with one or more of 16 specific chronic diseases, including diabetes and hypertension. This benefit is available to all Jamaicans regardless of age, sex or socio-economic status. To be eligible, individuals are required to have their physician sign an enrollment application confirming their diagnosis (es). Although medicines can be accessed with no fee at point of service at public pharmacies, over 80% of the pharmacies in Jamaica are privately run and may be a more convenient and accessible option for many patients (PAHO, 2012). NHF enrollees have the option of accessing their medicines at a subsidized cost through this network of private pharmacies. Affordability of medicines was highlighted as a barrier to accessing chronic disease medicines, with approximately 25% of Jamaicans reporting not taking medicines due to unaffordability (PAHO, 2012). This study included a literature review, which highlighted multiple barriers to accessing medicines in developing countries. The extent, to which these barriers affected access and use of the NHF, was explored in this study. Objective: This study set out to answer three research questions related to access and use of the NHF in Jamaica among adults with diabetes or hypertension: 1) What are the factors predicting enrollment in the National Health Fund? 2) What is the drug utilization patterns and the factors associated with adherence to medicines among NHF enrollees with diabetes or hypertension? 3) What was the effect of a major health policy (the removal of user fees from primary health facilities in 2008) on access and use of the NHF? Design and methods: The study population was community dwelling adults between the ages of 18 and 59 years with diabetes or hypertension. Data were derived from two disparate sources, the Jamaica Health and Lifestyle Survey (2008) and the NHF pharmacy claims data. Multiple quantitative methods were used to analyze the data. Multivariate logistic regression models were used to identify predisposing, enabling, need and contextual factors associated with enrollment in NHF (n=626), and to identify factors predicting adherence among the enrollees (2008, n=20, 264; 2017, n=77, 454). Interrupted Time Series (ITS) models were used to examine the impact of the removal of user fees from public health facilities on access and use of the NHF (n=49,599; n=74,520). Results: Five years following the implementation of the NHF individualized drug benefits, only 25% of adults (18-59 years) with diabetes and/or hypertension were enrolled. Low enrollment was mainly seen among younger adults. While higher enrollment was observed among those with comorbid hypertension and diabetes. Adherence levels among this population of enrollees was also low at just over 50% in 2017, which represents a decline from 2008 (p < 0.001). Multiple factors were found to be predictive of adherence in both years examined. Howvever, out-of-pocket (OOP)/unsubsidized expense had the strongest effect on adherence when compared to the other predictors included in the model, with lower adherence consistenly observed among individuals with the lowest monthly out-of-pocket (OOP)/unsubsidized expense on medicines. Individuals who obtained multiple drug therapies; those with comorbid conditions; those who lived in the Southeast Health Region; females and those less than 45 years old were also significant predictors of medication adherence but with relatively small effects. Using independent sub-group analysis, the study found that the removal of user fees from public health facilities in 2008, increased NHF enrollment among specific sub-groups (females, urban residents, residents within the Southeast health region and adults ages 18 to 39 years and 45 to 54 years). However, the policy was not effective at increasing the rate of NHFCard users each month. Conclusion: The results of this study suggests that adults between the ages of 18 and 59 years, with diabetes or hypertension had suboptimal access to essential chronic disease medicines through the NHF. Additionally, continued access measured by adherence to drug therapy was low and showed indications of geographic and socio-economic differences. The study also found that different factors are associated with different levels of access, for example need and predisposing factors were the primary drivers of NHF enrollment, while enabling factors were primary drivers of medication adherence among those already enrolled. These findings highlight the need for interventions in Jamaica to increase access and use of the NHF. Considering the multiple factors predicting access and the limited effectiveness of the policy to remove user-fees from public health facilities, interventions must take a multidimensional approach and target those most in need.