Table 2 Summary of study themes that describe how the implementation of the standard prescription medicine co-payment may influence equitable access to prescription medicines

The influence of working as community-minded professionals

A sense of community, and the desire to help people provide meaning in the profession of pharmacy

Individuals who practice community pharmacy are committed to ensuring that service users are not negatively affected by standard prescription medicine co-payments

"I believe it should be done on a whanau [family]-centric patient model, obviously, and so reducing costs for them when necessary. As opposed to imposing more costs… I think as a sector, …we need to highlight to the Ministry and the government, that that does not work. Right. Those are what cause inequities in the system. And unless we’re doing things collectively, the same way, it’s never gonna work for anybody..”—Employee, Individual interview

Community pharmacists are often conflicted by the idea that service users require medicines but may not be able to afford them

“So, if people are coming in with a prescription for antibiotics and don’t have the capacity to pay or anything like that, then we would tend to find a solution to support them… Most of the time… I would tend to just issue the whole script and just say ‘Look, when you can, when you can come back and pay for it, then that’s fine.’”—Employee, Individual interview

A profession under strain

The practice of community pharmacy is exposed to demands of a small private business and the associated instability of income, affecting the role of the community pharmacist

Due to the current context of community pharmacy and the perception of increasing demands, community pharmacists feel that the profession is struggling in the environment

“…there are so many demands on pharmacy at the moment. They’ve given us all these extra tasks we can do, and we get paid for them. But it’s always an opportunity cost and if you’re going to … do this or do that, you’ve got your… other work is piling up.”—Employee, Individual interview

“…at the moment, pharmacies are mainly competing in the sector, and how much cheaper they can make their services, rather than how well they provide their services… The services that we don’t get payment for, it’s really difficult to justify from a business perspective…”—Employee, Focus group

Community pharmacies in Aotearoa have been disadvantaged by the introduction of discount pharmacies

“We do everything, we go further, we deliver, we do all those sort of things. We need the $5 currently to afford to do that, if we lose that. It’s a slow, agonising death. And we’ve already seen, in my other role, it’s pharmacies going under, more and more every year, having to close the doors because of this one thing…”—Owner, Focus group

“It should be the same playing fields, everybody, you can’t let some give off, and some can’t. It’s bad management on behalf of the profession, yeah. In my opinion, yep.”—Employee, Individual interview

Some community pharmacists are not willing to discount the standard prescription medicine co-payment when participants cannot pay, meaning that some service users will not access their medicines

“Honestly, sometimes I do tell them to go to Chemist Warehouse [a discount pharmacy], just because like, this, I know they can’t afford it. And I know that Chemist Warehouse does it free for them. And we, because we’re private, we can’t give prescriptions for free and maintain, you know, like a business by just giving medications for free. And I know that Chemist Warehouse can absorb that cost. And some circumstances I do, say like, ‘Hey, Countdown’s down the road, they are free of charge. You can like walk there and try and get your prescription from them instead.’ Because it’s, we’re losing the customer. But if we take the cost, we’re losing actual money. You know, we’re paying that co-payment that the patient should be paying to the government. So, like, it’s a shame, but it is the only real alternative that you can keep, err, without losing money.”—Employee, Focus group

A sector that is committed to delivering an essential health service

The community pharmacy sector perceives itself as part of the health system, believing that they better adhere to the service users’ needs, which may result in a higher standard of care at the banner or independent community pharmacies, compared to discount pharmacies

Some community pharmacists might be providing a higher quality service than discount pharmacies

"… some people may take their medicines really, really, really well. And the fact that and they’re very adherent to the medication regime, but they just can’t afford that cost… conversely, you have other patients… that may not take their medicines well at all, but they will always go to the place that it’s free. And that doesn’t necessarily mean Chemist Warehouse and Countdown [discount pharmacies] provide poor services, it just means that they go there for… free prescriptions, but then mainly, but if Chemist Warehouse and staff are really busy, they may not have the time to fully counsel the patient, you know, for for the medications and the fact that whether they’re taking up properly or not, and that may have some flow-on effects later on. Like they may not, you know, they may be taking the medicines incorrectly for a really long time, but because it’s free, they’re just continuously going back"—Employee, Focus group

Some discount pharmacies are not fulfilling contractual requirements by choosing not to fill all prescription items

“… you’ll find that these discounters will quite often turn people away and say that they can’t do it because they don’t have the raw materials to do it or for whatever reason, and you will end up having a prescription that’s stamped with, you, so you know, that they’ve been elsewhere… it’s, it’s frustrating because they’re not fulfilling their contract with their DHBs… it’s meant to be a one-stop shop.”—Owner, Individual interview

The fairness of co-payments for community pharmacy and service users

The implementation of the government co-payment policy has had unintended consequences, and may undermine original policy goals

There are inconsistencies between government policy intentions of the standard prescription medicine co-payment and implementation

"Once again, and during and around COVID times we’ve seen that things that we’ve constantly asked for, which is a direct payment from Work and Income [social services] to pay for medication need and for medical expenses, which has always been, you know, denied, have been able to be implemented. You’re in COVID with certain groups getting access to directly charge Work and Income for families who cannot afford to get their medication or food. So currently, the system that we have doesn’t really help facilitate any of the issues that we have around co-payment other than those people going outside the regional area to access free scripts…. It’s quite a challenge."—Owner, Individual interview

Community pharmacists are subordinate to the demands the government has in relation to standard prescription medicine co-payments and related requirements

"But yeah, there has to be a cut off somewhere. It won’t go away. I don’t, I don’t think it will, the government will utilise the fact that the pharmacy sector will be allowed to be able to absorb that debt and make it the sector’s problem to deal with it rather than the government’s problem to deal with it."—Owner, Individual interview

Government departments are influencing equitable access to medicines by encouraging service users to collect medicines from discount pharmacies

"…and then the government’s quite happy for us to collect the $5 charge, but they’re now quite happy for, in a number of scenarios to direct patients to the people that give free, don’t charge co-payments…”—Owner, Focus group

Community pharmacists often understand that the standard prescription medicine co-payment system is regressive and inequitable, disproportionately affecting those with co-morbidities and high medicine usage

"…someone that’s, you know, only taking the medications all in the morning or something, they would only pay $5 per month so that’s quite tricky as well because… they can’t kind of control, like, what medications they get put on, and how often they’ll need to take them… So yeah, it’s a bit tricky in that regard as well."—Employee, Individual interview

Community pharmacists’ role as gatekeepers and government policy enforcers

The role of health professionals as gatekeepers and policy enforcers of health entitlements may contribute to inequitable implementation

Some service users may not receive a further subsidy to the standard prescription medicine co-payment because the sole responsibility to check eligibility sits with the community pharmacist

“So quite often, and it happens quite regularly. You’ll, you’ll you’ll charge them… for the scripts, the $5, and then they’ll say, ‘Oh, my wife gets prescriptions at another pharmacy.’ And so we’ve just gotta go backtrack and start all over again and get the right price and do a bit of background work on that. So that’s challenging and takes up time, and resources.”—Owner, Individual interview

The practice of community pharmacy often requires community pharmacists to implement and enforce the government policy of the standard prescription medicine co-payment

"…you notice it more when the pharmacies sort of came out that weren’t charging for scripts. You know, like, you would kind of get questioned a lot like, ‘…why are you charging this to me? And why are they not? And how…’ you know, ‘how can they do it and you can’t?’ Kind of thing. Like, I find it quite tricky to explain it to patients as to why you know, that it’s more like a tax and that kind of thing. And that, you know, if you don’t pay it, then we pay it for you…"—Employee, Individual interview

Power imbalances exist within the professional role

The dynamic of employer and employee, whereby pharmacy owners hold more power, can limit an employee community pharmacist’s ability to support access to medicines when service users cannot pay

Individual community pharmacists do not feel that they have the authority to ensure that service users receive access to medicines if they cannot pay standard prescription medicine co-payments

“So, it can be a barrier for some, but fortunately, for our regular patients, particularly our patients who are on, you know, anywhere between five to 12 medicines, they will typically have an account. So, they can pay that off slowly, which I think makes a huge difference in terms of access, and health outcomes overall. But it is, you know, at the discretion of my boss… and lately, they’re wanting to cut, or stop, any new accounts… So it is, yeah, that’s a business loss in a sense or a business decision that they’ve made in the past for better health outcomes. But yeah, it’s a balancing act.”—Employee, Individual interview

Community pharmacists are aware of the power they hold over service users in accessing medicines equitably

Community pharmacists, like other health professionals, play an influential role in access to medicines

“I’m not ever going to judge where people spend their money. That’s not my job. But if it means that they can’t get their medicines that day because they don’t have any left or they don’t get paid till the next day, then it’s my role to ensure that they have access to medicines”—Employee, Individual interview

Community pharmacists’ unique place in the co-payment process

Health professionals’ position in the health system may influence their perspective and understanding of a patient’s needs

Some health professionals are making assumptions on behalf of service users, influencing patient autonomy by directing service users towards discount pharmacies

“But a lot of people are being led towards them [discount pharmacies] by health professionals that aren’t pharmacists, like when I was working in the hospital… a lot of the time the doctors just send them to a free chemist rather than their regular ones, just because it is a free service. And they think it’s going to benefit them without realising that no, they actually have an existing relationship with … a pharmacy and all this stuff.”

- Employee, Focus group

Community pharmacists recognise that standard prescription medicine co-payments prevent people from accessing prescription medicines

“But for co-payments, I reckon sometimes $5 is a bit too dear for quite a large, you know, particularly in Māori and Pacific or people that are, that just don’t make enough money simply $5, or let’s say you need to be on medications, like a bunch of blood pressure, you know, diabetes meds, or some gout meds or something like that.”—Employee, Focus group

Evidence of value judgements towards service users

Health professionals’ beliefs of individualism and personal responsibility may influence interactions with service users

Community pharmacists sometimes make value judgements about what they believe to be choices that service users make in relation to collecting, or not collecting, prescription medicines

“There is the option to take a copy of the receipt and go to WINZ [Work and Income New Zealand] and get a card allocated to the amount of the prescription, and WINZ will do that. We’ve got a WINZ office pretty much straight across the street. That is an option but it takes time, of course, so they have to swallow their pride sometimes and go and do that. But that is an option…. But as I say, they’ve got to have the will to do it, in the time.”—Owner, Focus group

“…they’re so willing to spend money on everything else to do with their health, but just not, you know, they’ll spend $20 on a vitamin, and then they won’t want to spend $5 on their blood pressure tablets. A lot of people genuinely can’t afford it. But a lot of the time, I feel like there’s no real understanding of like how, you know, the system is actually benefiting them in a lot of ways”—Employee, Focus group

Some community pharmacists believe the moral hazard argument, that if people contribute towards the cost of their healthcare then they value it more

“You’re probably gonna end up with a huge amount of wastage because, people, if they got everything for nothing, they don’t attach any value to it. So, by paying a little bit of the $5 each time, they, they, attach a slight bit of value to it.”—Employee, Individual interview