Access to and Affordability of World Health Organization Essential Medicines for Cancer in Sub-Saharan Africa: Examples from Kenya, Rwanda, and Uganda

Factors impacting hospitalisation and related health service costs in cancer survivors in Australia: Results from a population data linkage study in Queensland (COS-Q)

BACKGROUND

The global economic cost of cancer and the costs of ongoing care for survivors are increasing. Little is known about factors affecting hospitalisations and related costs for the growing number of cancer survivors. Our aim was to identify associated factors of cancer survivors admitted to hospital in the public system and their costs from a health services perspective.

METHODS

A population-based, retrospective, data linkage study was conducted in Queensland (COS-Q), Australia, including individuals diagnosed with a first primary cancer who incurred healthcare costs between 2013 and 2016. Generalised linear models were fitted to explore associations between socio-demographic (age, sex, country of birth, marital status, occupation, geographic remoteness category and socio-economic index) and clinical (cancer type, year of/time since diagnosis, vital status and care type) factors with mean annual hospital costs and mean episode costs.

RESULTS

Of the cohort (N = 230,380) 48.5% (n = 111,820) incurred hospitalisations in the public system (n = 682,483 admissions). Hospital costs were highest for individuals who died during the costing period (cost ratio 'CR': 1.79, p < 0.001) or living in very remote or remote location (CR: 1.71 and CR: 1.36, p < 0.001) or aged 0-24 years (CR: 1.63, p < 0.001). Episode costs were highest for individuals in rehabilitation or palliative care (CR: 2.94 and CR: 2.34, p < 0.001), or very remote location (CR: 2.10, p < 0.001). Higher contributors to overall hospital costs were 'diseases and disorders of the digestive system' (AU$661 m, 21% of admissions) and 'neoplastic disorders' (AU$554 m, 20% of admissions).

CONCLUSIONS

We identified a range of factors associated with hospitalisation and higher hospital costs for cancer survivors, and our results clearly demonstrate very high public health costs of hospitalisation. There is a lack of obvious means to reduce these costs in the short or medium term which emphasises an increasing economic imperative to improving cancer prevention and investments in home- or community-based patient support services.

Cancer survival in sub-Saharan Africa (SURVCAN-3): a population-based study

BACKGROUND

The Cancer Survival in Africa, Asia, and South America project (SURVCAN-3) of the International Agency for Research on Cancer aims to fill gaps in the availability of population-level cancer survival estimates from countries in these regions. Here, we analysed survival for 18 cancers using data from member registries of the African Cancer Registry Network across 11 countries in sub-Saharan Africa.

METHODS

We included data on patients diagnosed with 18 cancer types between Jan 1, 2005, and Dec 31, 2014, from 13 population-based cancer registries in Cotonou (Benin), Abidjan (CÔte d'Ivoire), Addis Ababa (Ethiopia), Eldoret and Nairobi (Kenya), Bamako (Mali), Mauritius, Namibia, Seychelles, Eastern Cape (South Africa), Kampala (Uganda), and Bulawayo and Harare (Zimbabwe). Patients were followed up until Dec 31, 2018. Patient-level data including cancer topography and morphology, age and date at diagnosis, vital status, and date of death (if applicable) were collected. The follow-up (survival) time was measured from the date of incidence until the date of last contact, the date of death, or until the end of the study, whichever occurred first. We estimated the 1-year, 3-year, and 5-year survival (observed, net, and age-standardised net survival) by sex, cancer type, registry, country, and human development index (HDI). 1-year and 3-year survival data were available for all registries and all cancer sites, whereas availability of 5-year survival data was slightly more variable; thus to provide medium-term survival prospects, we have focused on 3-year survival in the Results section.

FINDINGS

10 500 individuals from 13 population-based cancer registries in 11 countries were included in the survival analyses. 9177 (87·4%) of 10 500 cases were morphologically verified. Survival from cancers with a high burden and amenable to prevention was poor: the 3-year age-standardised net survival was 52·3% (95% CI 49·4-55·0) for cervical cancer, 18·1% (11·5-25·9) for liver cancer, and 32·4% (27·5-37·3) for lung cancer. Less than half of the included patients were alive 3 years after a cancer diagnosis for eight cancer types (oral cavity, oesophagus, stomach, larynx, lung, liver, non-Hodgkin lymphoma, and leukaemia). There were differences in survival for some cancers by sex: survival was longer for females with stomach or lung cancer than males with stomach or lung cancer, and longer for males with non-Hodgkin lymphomas than females with non-Hodgkin lymphomas. Survival did not differ by country-level HDI for cancers of the oral cavity, oesophagus, liver, thyroid, and for Hodgkin lymphoma.

INTERPRETATION

For cancers for which population-level prevention strategies exist, and with relatively poor prognosis, these estimates highlight the urgent need to upscale population-level prevention activities in sub-Saharan Africa. These data are vital for providing the knowledge base for advocacy to improve access to prevention, diagnosis, and care for patients with cancers in sub-Saharan Africa.

FUNDING

Vital Strategies, the Martin-Luther-University Halle-Wittenberg, and the International Agency for Research on Cancer.

TRANSLATIONS

For the French and Portuguese translations of the abstract see Supplementary Materials section.

Overcoming geographical and socioeconomic limitations in colorectal cancer screening

Despite colorectal cancer's (CRC) high global incidence, residents of low- and middle- income countries, as well as low-income minorities in advanced economies have low screening rates. Observational studies demonstrate that in these groups higher incidence of CRC is observed, yet screening rates remain low for consistent reasons. Low income, low educational background, and lack of awareness in combination with inadequate social security of certain population groups impede access and compliance rates to CRC screening. On the other hand, despite the global availability of multiple screening approaches (colonoscopy, sigmoidoscopy, faecal occult blood test, faecal immunochemical test, computed tomography-colonography, etc.) with proven diagnostic validity, many low-income countries still lack established screening programs. The absence of screening guidelines in these countries along with the heterogeneity of guidelines in the rest of the world, demonstrate the need for global measures to tackle this issue comprehensively. An essential step forward is to develop a global approach that will link specific elements of screening with the incidence and available resources in each country, to ensure the achievement of at least a minimum screening program in low-income countries. Utilizing cheaper, cost-effective techniques, which can be carried out by less specialized healthcare providers, might not be equivalent to endoscopy for CRC screening but seems more realistic for areas with fewer resources. Awareness has been highlighted as the most pivotal element for the effective implementation of any screening program concerning CRC. Moreover, multiple studies have demonstrated that outreach strategies and community-based educational programs are associated with encouraging outcomes, yet a centrally coordinated expansion of these programs could provide more consistent results. Additionally, patient navigator programs, wherever implemented, have increased CRC screening and improved follow-up. Therefore, global coordination and patient education seem to be the main areas on which policy making needs to focus.

Colorectal cancer disease profile and treatment patterns at an urban tertiary hospital in Rwanda

Background

The incidence of colorectal cancer (CRC) in sub-Saharan Africa (SSA) is rising, due to improving cancer registration efforts on one hand and an increasing westernisation of diets and lifestyle on the other as well as increasing rates of comorbidities.

Methods

We present data for the clinical characteristics, pathology, treatments received, and survival outcomes of patients diagnosed with CRC at King Faisal Hospital (KFH) between January 2019 and May 2023. KFH is an urban tertiary hospital in Rwanda that provides chemotherapy and surgery to cancer patients. The data were extracted from electronic medical records, imaging and histopathology reports from the patient's time of diagnosis. We plotted Kaplan-Meier estimation of survival, defined as the time from presentation to death, within the study period (2019-2023).

Results

Seventy-four patients diagnosed with CRC with complete information were identified in the KFH oncology records. The mean age at diagnosis was 54.6 years, with ages ranging between 22 and 81 years. At diagnosis, 24 (32.4%) patients were less than 50 years old and 29 (39.2%) were females. The rectum (36.5%) was the most common tumour location, and 58.1 tumours were left-sided. Most patients presented with Stage III (41.9%) or IV (35.1%) disease. Adenocarcinoma was the most common histological type (98.6%) including adenocarcinoma not otherwise specified (NOS) (86.5%), mucinous adenocarcinoma (10.8%), signet ring cell carcinoma (1.4%) and followed by squamous cell carcinoma (1.4%). In terms of treatment, 19 (25.7%) patients received only chemotherapy, 43 (58.1%) patients received neo-adjuvant or adjuvant chemotherapy, 9 (12.2%) of patients received both neo-adjuvant and adjuvant chemotherapy, 49 patients (66.2%) underwent surgery and 17 (23%) patients also received radiation. At the end of the follow up period, 63 (85.1%) patients remained in surveillance, 10 (13.5%) patients died, and 1 (1.3%) patient was lost to follow up. Mean overall survival was 45.5 (SD ± 2.0) months.

Conclusion

CRC patients presented at an advanced stage and required complex treatment regimens at KFH. Further epidemiologic and molecular research is needed to characterise CRC incidence and presentation at a national level in Rwanda as increasing westernisation continues to change the face of CRC in urban areas of SSA.

Cancer medicines: a private vice for public benefit?

Cancer medicines have become one of the most dominant global medical technologies. They generate huge profits for the biopharmaceutical industry as well as fuel the research and advocacy activities of public funders, patient organisations, clinical and scientific communities and entire federal political ecosystems. The mismatch between the price, affordability and value of many cancer medicines and global need has generated significant policy debate, yet we see little change in behaviours from any of the major actors from public research funders through to regulatory authorities. In this policy analysis we examine whether, considering the money and power inherent in this system, any rationale global consensus and policy can be achieved to deliver affordable and equitable cancer medicines that consistently deliver clinically meaningful benefit.

Moving forward through consensus: a national Delphi approach to determine the top research priorities in prostate cancer in Uganda

OBJECTIVE

To identify key areas for research in prostate cancer (PC) in the Ugandan context by establishing the major health system, socioeconomic and clinical barriers to seeking, reaching and receiving high-quality cancer care.

DESIGN

Modified Delphi Technique.

SETTING

Government and private-not-for-profit hospitals.

METHODS

We applied a two-stage modified Delphi technique to identify the consensus view across cancer experts. In round 1, experts received a questionnaire containing 21 statements drawn from a systematic review identifying the reason for the delay in accessing cancer care. Each statement was scored out of 20. Statements scoring ≥15 from over 70% of participants were prioritised for inclusion while statements for which <30% of participants gave a score of ≥15 were excluded. Sixteen statements were included in round 2 as they did not receive consensus for inclusion or exclusion.

RESULTS

We found that the top six research priority areas arise from challenges including: (1) lack of diagnostic services-ultrasound, laboratory tests and biopsy facilities; (2) high costs of services, for example, surgery, radiotherapy, hormone therapy are unaffordable to most patients, (3) lack of essential medicines, (4) limited radiotherapy capacity, (5) lack of awareness of cancer as a disease and low recognition of symptoms, (6) low healthcare literacy. The lack of critical surgical supplies, high diagnostic and treatment costs were ranked highest in order of importance in round 1. Round 2 also revealed lack of diagnostic services, unavailability of critical medicines, lack of radiotherapy options, high costs of treatments and lack of critical surgical supplies as the top priorities.

CONCLUSION

These research priority areas ought to be addressed in future research to improve prompt PC diagnosis and care in Uganda. There is need to improve the supply of high-quality affordable anticancer medicines for PC patients so as to improve the survivorship from the cancer.

Availability and affordability of anticancer medicines at cancer treating hospitals in Rwanda

BACKGROUND

Availability and accessibility of anti-cancer medicines is the pillar of cancer management, and it is one of the main concerns in low-income countries including Rwanda. The objective of this study was to assess the availability and affordability of anticancer medicines at cancer-treating hospitals in Rwanda.

METHODOLOGY

A descriptive cross-sectional study was conducted at 5 cancer-treating hospitals in Rwanda. Quantitative data were collected from stock cards and software that manage medicines and included the availability of anti-cancer medicines at the time of data collection, their stock status within the last two years, and the selling price.

RESULTS

The study found the availability of anti-cancer medicines at 41% in public hospitals at the time of data collection, and 45% within the last two years. We found the availability of anti-cancer medicines at 45% in private hospitals at the time of data collection, and 61% within the last two years. 80% of anti-cancer medicines in private hospitals were unaffordable while 20% were affordable. The public hospital that had most of the anti-cancer medicines in the public sector provided free services to the patients, and no cost was applied to the anti-cancer medicines.

CONCLUSION

The availability of anti-cancer medicines in cancer-treating hospitals is low in Rwanda, and most of them are unaffordable. There is a need to design strategies that can increase the availability and affordability of anti-cancer medicines, for the patients to get recommended cancer treatment options.

Access to essential cancer medicines for children: a comparative mixed-methods analysis of availability, price, and health-system determinants in east Africa

BACKGROUND

Access to essential childhood cancer medicines is a core determinant of childhood cancer outcomes. Available evidence, although scarce, suggests that access to these medicines is highly variable across countries, particularly in low-income and middle-income countries, where the burden of childhood cancer is greatest. To support evidence-informed national and regional policies for improved childhood cancer outcomes, we aimed to analyse access to essential childhood cancer medicines in four east African countries-Kenya, Rwanda, Tanzania, and Uganda-by determining the availability and price of these medicines and the health system determinants of access.

METHODS

In this comparative analysis, we used prospective mixed-method analyses to track and analyse the availability and price of essential childhood cancer medicines, investigate contextual determinants of access to childhood cancer medicines within and across included countries, and assess the potential effects of medicine stockouts on treatment. Eight tertiary care hospitals were included, seven were public sites (Kenyatta National Hospital [KNH; Nairobi, Kenya], Jaramogi Oginga Odinga Referral and Teaching Hospital [JOORTH; Kisumu, Kenya], Moi University Teaching and Referral Hospital [MTRH; Eldoret, Kenya], Bugando Medical Centre [BMC; Mwanza, Tanzania], Muhimbili National Hospital [MNH; Dar es Salaam, Tanzania], Butaro Cancer Centre of Excellence [BCCE; Butaro Sector, Rwanda], and Uganda Cancer Institute [UCI; Kampala, Uganda]) and one was a private site (Aga Khan University Hospital [AKU; Nairobi, Kenya]). We catalogued prices and stockouts for 37 essential drugs from each of the eight study siteson the basis of 52 weeks of prospective data that was collected across sites from May 1, 2020, to Jan 31, 2022. We analysed determinants of medicine access using thematic analysis of academic literature, policy documents, and semi-structured interviews from a purposive sample of health system stakeholders.

FINDINGS

Recurrent stockouts of a wide range of cytotoxic and supportive care medicines were observed across sites, with highest mean unavailability in Kenya (JOORTH; 48·5%), Rwanda (BCCE; 39·0%), and Tanzania (BMC; 32·2%). Drugs that had frequent stockouts across at least four sites included methotrexate, bleomycin, etoposide, ifosfamide, oral morphine, and allopurinol. Average median price ratio of medicines at each site was within WHO's internationally accepted threshold for efficient procurement (median price ratio ≤1·5). The effect of stockouts on treatment was noted across most sites, with the greatest potential for treatment interruptions in patients with Hodgkin lymphoma, retinoblastoma, and acute lymphocytic leukaemia. Policy prioritisation of childhood cancers, health financing and coverage, medicine procurement and supply chain management, and health system infrastructure emerged as four prominent determinants of access when the stratified purposive sample of key informants (n=64) across all four countries (Kenya n=19, Rwanda n=15, Tanzania n=13, and Uganda n=17) was interviewed.

INTERPRETATION

Access to childhood cancer medicines across east Africa is marked by gaps in availability that have implications for effective treatment delivery for a range of childhood cancers. Our findings provide detailed evidence of barriers to access to childhood cancer medicine at multiple points in the pharmaceutical value chain. These data could inform national and regional policy makers to optimise cancer medicine availability and affordability as part of efforts to improve childhood cancer outcomes specific regions and internationally.

FUNDING

American Childhood Cancer Organization, Childhood Cancer International, and the Friends of Cancer Patients Ameera Fund.

Practical notes on the current ESMO consensus guidelines for the management of patients with metastatic colorectal cancer in resource-constrained environments of low- to middle-income countries

Letter (no abstract).

Price, Availability and Affordability of Anti-Cancer Medicines in Addis Ababa, Ethiopia

Introduction

Cytotoxic drugs are essential treatments available for patients with cancer. There are concerns that unavailability and high prices of cancer medicines may limit patient access. Since information on availability, prices and affordability for cancer medicine is lacking for several countries, particularly for lower income countries like Ethiopia, it will be difficult to know the real situation of those medications' access.

Purpose

The purpose of this study was to assess availability, affordability and price of anti-cancer medications, in Addis Ababa, Ethiopia.

Methods

The study was cross-sectional using a modified form of the WHO/HAI methodology of measuring medicine price, availability and affordability in public, private, Kenema municipal and Red Cross Pharmacies found in Addis Ababa, Ethiopia. Data on the availability and price of 47 cytotoxic medications for both lowest priced generics and originator brands were collected in 3 public, 6 private and 2 NGO pharmacies which are expected to dispense cytotoxic medications in Addis Ababa. The data were entered and analyzed using WHO/HAI data entry and analysis form. Results were presented in tables and figures.

Results

The majority of the anti-cancer medications assessed were not available and the few available medicines were unaffordable. The lowest priced generic were relatively more available (34.8%) than the originator brand medications (2.8%) in the public sector. Generally, the availability of anti-cancer medicine differs when comparing the public, private and other sectors. The availability of cytotoxic medications was 18.8%, 5.3% and 8.8% in the public, private and other sectors. The prices of cytotoxic medications available in the private sector were higher than the public and other sectors. All of the medications except for anastrazole were unaffordable.

Conclusion

Medicines for cancer treatment are unavailable and the few available medicines are unaffordable in Addis Ababa, Ethiopia. Different interventions should be done to improve access to cytotoxic medications.