So I think there have been a few sessions looking at the issue of access to medicines and what the challenges are. The focus of this session was to have an interactive discussion with a group of panellists who are experts, who are really doing things and initiatives to improve access to medicines. A lot of the session was focusing on understanding what the landscape of solutions are, what the challenges are with the specific solutions that are in place, what have been the successes, and thinking about ways to scale it up and make the model more sustainable. We talked a little bit about differentiating between types of sustainability, but it was an exciting session overall.

What are the challenges to increasing access to quality assured and affordable essential medicines for cancer care in LMICs?

That issue is complex, and I think when we think about access, a lot of people tend to think about availability and prices of the medicines, and this came up in our session as well. But when you think about access, there’s a whole supply chain of access that affects where the drugs are being manufactured. So even before that, you think about access in terms of equity to clinical trials, like what is the data that is actually informing the approval of these drugs? Where are these drugs manufactured? How do these drugs get to the patients in low resource settings? And so thinking about that, the whole supply chain mechanisms, how governments and individuals procure these medicines, how patients pay for these medicines. So in a lot of low- and middle-income countries cancer medicines are out of pocket, which is not sustainable. 

So there’s the issue of financial toxicity, but sometimes when these medicines are available, there are actual social determinants of health as well that affect access. So are patients able to travel the distance to a healthcare facility to get the medicines? Are they able to afford, even when the medicines are free, are they able to afford transportation, childcare, so they can make it to the appointment? And then someone actually brought up the big issue of stigma. You know, there are institutional stigmas, internalised stigma and societal stigma as well. So even when the medicines are available, are patients comfortable enough disclosing their cancer diagnosis so that they can access the medicines? So thinking about access in a multidimensional way is important because it then behoves us to identify different challenges that happen across the continuum of supply chain and access to medicines, and try to identify how we address each of these individually. 

How can these challenges be overcome?

It sounds daunting at first, when you think about access to cancer medicines. A lot of the information I’m borrowing from our session because these are the issues we talk about, and these are the issues on the forefront of a lot of minds, of ministries of health, NGOs, and other programmes that are in the space. So I will just highlight the four initiatives that we talked about. 

So we think about sustainable models for delivering cancer medicines and one of those is actually empowering ministries of health to include access to cancer medicines as part of universal healthcare coverage within ministries of health. We had the head of the NCCP, so the National Cancer Control Plan, in Kenya talk about processes that they have in place to put together a national cancer control plan that is informed by data in the country. Then that allows them to be able to forecast what the financial resources are needed and then also healthcare infrastructure is needed to implement this. So I think that is a sustainable model because ultimately you want governments to be able to assume ownership of these models. 

For different countries, that’s going to take a long time, so this is short term for some countries that are on the verge of coming up with their own NCCPs; for other countries it’s going to be a model that takes a longer time. But one of the points that was highlighted in the session is that a lot of it also comes down to political will. Yes, governments have competing needs of the population, so there’s infectious diseases, there are other issues with maternal foetal mortality, but it really comes down to political will. Are we prioritising cancer? Is it a priority for the government? Because when we prioritise it we can invest in it. So I think there’s thinking about that as well. 

We had a talk about procurement through transnational procurement, so pooled procurement. One of the issues that we identified which I didn’t actually mention was the issue that in a lot of these Sub-Saharan African countries, or low- and middle-income countries, the volumes of medicines being procured is really small, so there’s really no incentive for a lot of suppliers to meet those small demands, they’re really looking for the huge purchases. So the way in which you can shift that power dynamic, which was mentioned, is really thinking about pooled procurement where they have pooled procurement from 35 different entities, transnational entities, and by doing that you leverage economies of scale. So I think pooled procurement is something that a lot of people have thrown around, even for thinking about access to medicines in the Sub-Saharan African region. There’s also voluntary licensing, which MPP, Medicine Patent Pool, talked about. They’ve done a lot of work in the HIV setting, and in making hepatitis C drugs available, and that has been a model that we’re thinking we can translate into cancer care. Obviously cancer care is a little bit different, but I was energised by the conversations around how this can really expand access to affordable medicines, and really see price drops in drugs that patients can actually afford. 

The last one I wanted to talk about is bridging mechanisms, so thinking about newer innovative medicines that are super-expensive, they’re hundreds of thousands of dollars expensive, that patients need now. So patients might not be able to wait for that NCCP model and pooled procurement and all those logistics of voluntary licensing to be implemented. But what’s important is that organisations like the Max Foundation bridge that gap. By bridging that gap I mean they look at medicines that have high efficacy now that there is some need in the lower resource setting. So thinking about the patient who needs the drug right now, who has an indication for the drug, who could benefit from the drug, how do we make it available to them now? So I think donor programmes, a lot of people frown upon donor programmes as not being sustainable, I think it’s an important bridge mechanism because the patients that they’ve helped because these donor programmes existed. Thinking about that as a way to transition, as a model that eventually transitions into government ownership, is a way to think about where they fit into that fabric of sustainable solutions to expanding cancer medicines access.

What has been done so far regarding this matter?

I think one of the big mechanisms that I didn’t talk about is collaborations with ministries of health to facilitate some of this procurement with suppliers. So I know organisations like the American Cancer Society in collaboration with the Clinton Health Access Initiative are looking at pooled procurement, whereby they work with pharmaceutical companies to set a ceiling in terms of how much they can charge low resource settings, and then guarantee that a certain amount of drugs will be purchased for these medicines. So the different initiatives feels a little bit like patchwork now, but given the complexity of cancer medicines and given the fact that the models that apply for generic and biosimilar medicines might not apply to medicines that are expensive, there’s really a need for multilevel and multidimensional approaches to improving access. So these are some of the initiatives that are currently working, have been implemented now. I think there will be more along the way but it’s really energising and promising to see that some of the data show that these have already been successful in improving access.

What does the future look like?

I feel optimistic because throughout the congress I’ve been going around and there’s a lot of sessions on access to cancer medicines, and so, sort of going back to the whole issue of political will, I think there’s now a global political will. WHO has launched an initiative with St Jude’s to expand access to childhood cancer medicines.WHO is also focusing on expansion of access to I want to say vaccines for cervical cancer but then there’s also the Breast Global Initiative as well. So having that global will to improve access to cancer medicines is a good start, because a lot of people rely on the WHO for leadership, and so having the global parity that cancer is no longer too complex to tackle but it’s an important problem that we need to address now, is really a good call to action. So I’m optimistic that a lot of programmes that we’ve talked about, in a few years from now would be expanded and we’ll be telling success stories about “do you remember when cancer medicine was so expensive and now patients can afford it because ministries of health procure it?” 

I’m an oncologist so I have to be optimistic, but I think the landscape is going to change and I think it’s starting now. Some of the dialogues that we’re having were conversations that we didn’t have ten years ago because people thought cancer was just too complex to treat in low resource settings. So I think the future looks good.