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Does providing free essential medicines improve treatment adherence?

Canadian healthcare policy experts studied the impact of providing free essential medicines on treatment adherence.

Medicines to treat common health conditions including heart disease and diabetes are often not accessible to patients because of cost. Worldwide estimates of nonadherence to drug treatments for chronic diseases range from 40-60%. Several approaches have been suggested to improve adherence, including providing free essential medicines for some health conditions. The WHO recommends countries develop a list of essential medicines based on their healthcare needs to increase access to care and help achieve universal health coverage.

Treatment nonadherence due to cost can be a problem even in high-income countries. In Canada, physician care and hospitals are all publicly funded, but outpatient medicines are not. Medication funding varies by province but is usually offered for specific groups such as those on social assistance or over-65s. Health policy experts in Canada investigated the effects on providing free essential medicines on treatment adherence. They also conducted comprehensive interviews with policy decision-makers to assess the feasibility of a national essential medicines list in Canada. They recently reported their findings in JAMA Internal Medicine and the Canadian Medical Association Journal.

Treatment nonadherence may be due to cost, even in high-income countries

The researchers developed a list of 128 essential medicines based on the WHO Model list, Canadian clinical practice guidelines and recommendations from doctors and patients. The essential medicines list included antibiotics, pain relievers, antihypertensives, diabetes medications, lipid-lowering agents, antipsychotics, and HIV-AIDS medications.

A total of 786 patients from nine primary care clinics across Ontario who reported cost-related nonadherence to medications were included in the study. Patients were randomly assigned to receive either free essential medicines (intervention group) or their usual access to medications based on current medicine funding policy (control group).

At 12 months into a three-year study, patients in the intervention group had higher adherence than those in the control group (38.2% vs 26.6%; 11.6% difference). In the intervention group, markers of some health conditions had improved compared to the control group – blood sugar control improved in patients with type 1 and 2 diabetes (although this did not reach statistical significance) and blood pressure control improved in patients with high blood pressure. However, blood lipid levels were not significantly improved in patients receiving lipid-lowering drugs in the intervention group compared to the control group.

In a series of structured interviews with key policy decision-makers, there was a consensus on three factors needed to develop an essential medicines list: an independent decision-making body, medicine selection based on best clinical evidence, and clear communication between patients, doctors, and policy makers on the purpose of an essential medicines list.

Free essential medicines improved treatment adherence

The researchers concluded that there was evidence that free essential medicines improved treatment adherence after 12 months. Provisions of free essential medicines also improved certain disease-specific markers, but not others. Whilst there were differing views amongst decision-makers on the suitability of an essential medicines list in Canada, there was general agreement on the policy approach to developing such a list.

“It is sad that in a high-income country like Canada, millions of Canadians cannot afford their prescribed medications – including life-saving medicines such as insulin,” said Dr. Nav Persaud, the lead author of the study. The researchers hope that their findings will help inform policy changes. “This is no longer a question of whether free distribution of medicine can improve health outcomes. It is a question of whether governments will act,” said Dr. Persaud. Following the study, the Canadian Federal Advisory Council on the Implementation of National Pharmacare announced recommendations for universal public pharmacare with coverage for a list of essential medicines.


Written by Julie McShane, MA MB BS



  1. Persaud N, Bedard M, Boozary AS, et al. Effect on treatment adherence of distributing essential medicines at no charge. JAMA Intern Med Published online Oct 7, 2019. Doi:10.1001/jamainternmed.2019.4472
  2. Jarvis J, Murphy A, Perel P, et al. Acceptability and feasibility of a national essential medicines list in Canada: a qualitative study of perceptions of decision-makers and policy stakeholders. CMAJ 2019 October 7;191:E1093-9. Doi:10.1503/cmaj.190567.
  3. St Michael’s Hospital, Press release, 7 Oct 2019. “Distributing essential medicines for free resulted ina 44% increase in adherence.”
  4. Canadian Medical Association Journal, Press release, 7 Oct 2019. “A Canadian essential medicine list must be evidence-based.”

Image by Arek Socha from Pixabay

Julie Mcshane MA MB BS
Julie Mcshane MA MB BS
Julie studied medicine at the Universities of Cambridge and London, UK. Whilst in medical practice, she developed an interest in medical writing and moved to a career in medical communications. She worked with companies in London and Hong Kong on a wide variety of medical education projects. Originally from Ireland, Julie is now based in Dublin, where she is a freelance medical writer. She enjoys contributing to the Medical News Bulletin to help provide a source of accurate and clear information about the latest developments in medical research.


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