Free access to medicines among older adults in primary care: a cross-sectional study

ABSTRACT BACKGROUND: Access to medicines is an important indicator of healthcare system quality and capacity to resolve problems. The healthcare system needs to ensure free access to medicines for elderly people, in order to provide greater effectiveness of disease control, thus reducing morbidity and mortality, and improving health and quality of life. OBJECTIVES: To analyze the frequency of free access to medication among older adults within primary care and determine the factors associated with free access. DESIGN AND SETTING: Cross-sectional study at two primary care units. METHODS: Free access was defined as provision of all medicines through pharmacies within the Brazilian National Health System and through the Brazilian program for free medicines in private pharmacies. We investigated the sociodemographic, clinical, functional and pharmacotherapeutic characteristics of older adults. Multivariate logistic regression was performed to identify factors associated with free access to medicines. RESULTS: This study included 227 older adults, among whom 91 (40.1%) had free full access to prescription drugs. A direct association with age ≤ 70 years and indirect associations with polypharmacy and multimorbidity (P < 0.05) were found. CONCLUSIONS: Age ≤ 70 years increases the likelihood of having free full access to medicines, and older adults with multimorbidity and polypharmacy use have a lower likelihood of access. Identification of factors associated with free access to medicines among elderly people provides elements to guide the Brazilian National Health System in implementing access improvement actions.


INTRODUCTION
The contribution of medicines to better quality of life, recovery of health and increased survival is appreciable. 1 Thus, resolute public healthcare actions to curb morbidity and mortality are strongly influenced by rational access to and use of drugs. [1][2][3][4] Given the increasing burden of chronic noncommunicable diseases around the world, access to medicines encompassing availability and affordability is a significant public health challenge for both developed and developing countries. The global action plan for noncommunicable disease prevention and control coordinated by the World Health Organization recommends that actions to expand access to medicines should be developed. 5,6 In Brazil, through the National Drug Policy, measures have been implemented to ensure and expand the population's access to medicines since 1998. In 2004, actions were scaled up when the National Pharmaceutical Services Policy Guidelines were defined. 4,7 The following stand out among the different strategies for improving access to medicines that are underway in this country: structuring of pharmaceutical services; improvement and innovation of the legal framework for accessing medicines within the Brazilian National Health System; improved organization of financing for public pharmaceutical services; and higher levels of federal resources for procurement of medicines. 4 Brazil has been experiencing aging of the population as a result of the epidemiological and demographic transition that is taking place in this country. This situation greatly affects the planning of social and healthcare policies, given the increased prevalence of older adults with multiple noncommunicable diseases requiring complex multidrug therapy. 1,8,9 The National Survey on Drug Access, Use and Promotion of Rational Use in Brazil found that 75. 7%  two or more chronic drugs. 1 Given this scenario, healthcare systems need to ensure free access to medicines for elderly people, in order to provide greater effectiveness of disease control, thus reducing morbidity and mortality, and improving health and quality of life. [3][4][5][6] Access to medicines is an important indicator of healthcare system quality and capacity to resolve problems and is considered by the United Nations to be an appropriate means for measuring progress towards achievement of healthcare rights. 7,[10][11][12][13] Primary healthcare is provided through an extensive network of services and can solve most of a population's health problems.
Consequently, ensuring free access to medicines for older adults at this level of care should be a priority. 7,9 OBJECTIVE The aims of this study were to analyze the frequency of free access to medication among elderly people attended at two primary healthcare centers and to determine the factors associated with free access.

Study design and participants
This was a cross-sectional study conducted at two primary care units (PCUs) located in the city of Belo Horizonte, Brazil.
The study population consisted of individuals aged 60 years and over (older adults) who received at least one drug from PCU pharmacies between November 2013 and April 2014. The participants were selected non-randomly, and older adults were invited consecutively to participate in the study in PCU pharmacies. The exclusion criterion was the inability to communicate verbally or visually.

Sample
The sample size was calculated from data in the computerized pharmacy system of the PCU. The mean monthly number of visits to these pharmacies by elderly people was 483. Based on the premise that dispensing of chronic care drugs from PCU pharmacies is done monthly, we considered that elderly people who were attended every month were part of the same population.
Thus, by assuming that there was a finite population of 483 older adults, with a prevalence value of 50% for all observed characteristics, and taking a significance level of 5%, confidence interval of 95% and loss or refusal rate of 10%, the sample size was estimated to be 237 older adults. The "Open Epi" version 3.01 software was used for the sample size calculation. 14

Data collection and organization
Data were collected through face-to-face interviews, using a structured questionnaire that was applied by pharmacists and by pharmacy and medical students who had previously received training.
The questions were on sociodemographic, clinical, functional, access-related and medicine-use characteristics. These data were complemented by consulting the medical records. The information on access to medicines covered the period of the last 30 days.  Self-perceived health was measured by asking the patient: "In general, compared with other people of your age, would you say that your health is excellent, very good, good, fair or poor?" A positive assessment would comprise the responses "excellent", "very good" or "good", whereas a negative assessment would include the other answers, namely, "fair" or "poor".

Statistical analysis
Descriptive analysis was performed by determining the relative and absolute frequencies of categorical variables, and the median,

RESULTS
The characteristics of the 227 elderly people who participated in the study are shown in Table 1   The drugs used by the elderly people were predominantly from the following anatomical groups (level 1) of the ATC classification: group C -circulatory system (50.5%); group A -alimentary tract and metabolism (17.4%); and group N -nervous system (12.9%). On the other hand, analysis on drugs that were not included in RENAME and which were accessed through private pharmacies showed that the most frequent ATC groups were the following: group C (41.4%); group N (20.0%); and group B -blood and hematopoietic organs (12.9%) ( Table 2). Univariate analysis on the associations between full access to medicines within the Brazilian National Health System and the independent variables (   Table 3).

DISCUSSION
This study showed that 40% of the older adults surveyed had free full access to prescription drugs within the Brazilian National Health System. Given the greater burden of noncommunicable diseases among elderly people, ensuring access to drugs for this age group in order to provide more effective control of these diseases, thereby contributing towards improving the capacity of actions provided to this population to resolve problems, is a priority. Among the guidelines and constitutional principles of the Brazilian State is that it guarantees comprehensive therapeutic care. Therefore, access to medicines is a citizen's right. 4 The proportion of individuals with free full access to medicines within the Brazilian National Health System has ranged from 45.1% This is a positive aspect of the way in which pharmaceutical services have been organized. It contributes towards implementation of access expansion actions, given that this facilitates the scheduling and dispensing steps. It also contributes towards rational use of drugs, since medicines included in the MEML are generally safe and effective.
A study conducted in primary healthcare centers in Belo Horizonte found a positive association between presence of the drug in the MEML and user access to it in the PCU. 22  Investigations on access to medicines are important because they provide elements for characterizing the healthcare system and for supporting policies and actions aimed at increasing access to priority groups such as older adults. 9

CONCLUSION
Free access to medicines is determined by the demographic, clinical, and pharmacotherapeutic characteristics of elderly people.
Age ≤ 70 years increases the likelihood of free access, and older adults with multimorbidity and polypharmacy use have a lower likelihood of free full access to medicines. Access to medicines within the Brazilian National Health System among the elderly people surveyed here was high, but less than half of them were covered by full free access to prescription drugs. The availability of drugs in the PCUs was insufficient, which thus compromised the provision of drugs to older adults and geographical accessibility. Identification of factors associated with free access to medication among the elderly provides elements for guiding the Brazilian National Health System in implementing actions to improve access, such as the restructuring of pharmaceutical services to meet the specificities of the older adult population.