People who live in urban and densely populated areas (approximately 55% of the world population, according to the United Nations), are mostly used to seeing multiple pharmacies, within a reasonable radius, where they can purchase medicines that they require, in the event that the health systems do not provide them directly or in the event of their failure (lack of availability, waiting times, etc.).
This is not necessarily the reality in rural areas, those with less population density, or the poorest, where the proximity of a pharmacy is not necessarily a reality. In many cases, the cost of transportation and the time involved can exceed several times the cost of the required drug, especially if we are talking about widely used and low-cost drugs, mainly for chronic diseases.
This geographical barrier to access to medicines has been found to be quite invisible before the discussion of public policies, which has usually focused on the cost of medicines and the out-of-pocket expense involved versus coverage policies. As can be anticipated, the geographical barriers to access to medicines are, on the one hand, a “tax on rurality or poverty”, that is, an additional cost for the patient or greater out-of-pocket expense, but on the other, a problem of equity in access compared to the reality of urban or wealthier areas.
Now, from the health perspective, this geographical barrier is not indifferent. A 2020 study, carried out in the Liguria region of Italy, which presents important geographical barriers, tries to elucidate the effects of these, for the treatment of cardiovascular diseases in older adults. To do this, the aforementioned study uses, among others, the “Pharmacy Desert Indicator” which assigns the value 1 if the distance to the nearest pharmacy is greater than 1 mile in urban areas, and 10 miles in rural areas, with 0 being the least difficulty in accessing medicines, and 1 being the greatest difficulty in accessing them. In addition, demographic, health, socioeconomic, distance to other health services, etc. variables were considered. With this, they conclude that geographical barriers are associated with a persistent and significant decrease in adherence to therapies among older adults affected by cardiovascular diseases. They also hypothesize that patients replace the lack of adherence with a greater use of hospital services. Likewise, they conclude that the lack of adherence and the excessive use of hospitalizations negatively affect the health of patients by increasing the probability of mortality.
Now, even “drugstore deserts” have been characterized in cities as populous as Chicago and New York. For example, 25% of the census tracts in Los Angeles County are considered “pharmacy deserts.”
Most of the available studies on pharmacy deserts have been carried out in developed countries, especially in the United States of America, so it could be assumed that this situation is even more dramatic in low- and middle-income countries.
Now, regarding solutions for “pharmacy deserts”, home delivery systems or automatic drug dispensers or that the doctor himself can dispense have been proposed and implemented (assuming that there is no geographical barrier to access it). ), however, there is little evidence on how this has contributed to closing the gaps.
An innovative solution that is being implemented in a developing country, such as Chile, is the project called “Comunas sin Farmacia”, promoted by a socially oriented start-up called Fracción, which seeks to bring physical pharmacies to those communes that do not have them. . 50 communes in Chile (close to 15% of the total), which is the country’s smallest administrative division, do not have a pharmacy and it affects close to 300,000 people (approximately 1.5% of the population). The solution has been developed through public-private partnerships, involving local authorities, Chilean Government agencies, as well as various private companies that provide either financing or various assets necessary for the implementation of this project. This solution has proven to be a feasible way to gradually close the gaps caused by geographic access barriers. In any case, it is very likely that if the “pharmacy desert indicator” is applied, the problem in that country is even greater.
As can be seen, the problem of geographical barriers to access to medicines and “pharmacy deserts” is a determining factor that negatively affects adherence to therapies, which results in greater use of various health services, affecting the health of patients and the proper use of health system resources. This is a problem that has been made invisible by public policies and that requires solutions, for which we must learn from models that are already being successfully implemented and that can be applied in various parts of the world, for the benefit of patients. .
*The author is an expert in public health policies, Director of the Chilean Association of Health Law, and has been an academic at various Chilean universities on issues related to health systems.
