Determinants of access to childhood cancer medicines: a comparative, mixed-methods analysis of four Caribbean countries

Abstract

Background Equitable access to essential medicines is a key facet of childhood cancer care, recognised by WHO as vital to improved childhood cancer outcomes globally. In the Caribbean, childhood cancer outcomes are poorer than those in most high-income countries. We aimed to generate in-depth comparative evidence of the current challenges and opportunities related to access to childhood cancer medicines in the Caribbean to identify contextsensitive health systems strategies to improve drug access and inform evidence-based paediatric cancer policies in the region.Methods In this convergent, parallel, mixed-methods study, we mapped and analysed the determinants of access to childhood cancer medicines in four Caribbean countries (The Bahamas, Barbados, Jamaica, and Trinidad and Tobago). We analysed contextual determinants of access to medicines within and across study site jurisdictions, alignment of childhood cancer medicine inclusion between each country's national essential medicines list (NEML) and WHO's 2017 Essential Medicines List for Children, and availability and cost of chemotherapeutic agents at five tertiary care hospitals. We used a mixed-effects logistic regression model to analyse the association of medicine price, procurement efficiency (via median price ratio [MPR]), and site with drug availability. The fixed effect evaluated the effect of site and MPR on the probability of stockout in a given month. We assessed determinants of medicine access via thematic analysis of semi-structured qualitative interviews, literature, and policy documents.Findings We collected and analysed data for 28 childhood cancer medicines from Barbados, 32 from The Bahamas, 30 from Trinidad and Tobago, and 31 from Jamaica. Despite stepwise inclusion of childhood cancer medicines in NEMLs, all four countries had frequent and recurrent stockouts for many cytotoxic medicines, showing no consistent relationship between NEML inclusion and availability. A mean MPR of greater than 3•0 in Trinidad and Tobago, The Bahamas, and Barbados suggests uniformly high procurement inefficiency, resulting in significant effects on drug stockout days. For each one unit increase in MPR the adjusted odds ratio (OR) of stockout increased by 10% (adjusted OR 1•10, 95% CI 1•04-1•16; p<0•01). These challenges in access to childhood cancer medicines stem from health system and policy dynamics at institutional, national, and supranational levels that cause price volatility and erratic medicine availability. Key challenges include disparate policy commitments (eg, among sites), inefficient procurement and supply chain management practices, and local effects of international market pressures. Interpretation The Caribbean region exemplifies deficiencies in access to childhood cancer medicines that might be overcome by improved regional harmonisation of drug registration, pharmacovigilance, and procurement alongside national forecasting to strengthen global pharmaceutical planning and prioritisation. Focused political attention to address these challenges is...

Defining Essential Childhood Cancer Medicines to Inform Prioritization and Access: Results From an International, Cross-Sectional Survey

“…Such efforts have begun; these studies demonstrate both access barriers common to adult cancer medicines and unique to childhood cancer populations. [15][16][17] Ongoing expansion of this research to a broader range of countries and regions representing different health system organizations and macroeconomic realities is essential to developing impactful global and national policies to improve medicines access for children with cancer.…”

“…Challenges with efficient procurement and supply management, fair pricing, quality assurance, and public health system financing routinely affect cancer medicine access for children. [15][16][17][18] Fragmented markets, failed tenders, erratic stocks, production bottlenecks in the context of sole-source provision, fragile supply chains, and price inflation all constitute recurrent, fundamental challenges in access to quality-assured cancer medicines. [19][20][21][22] Many health care systems lack mechanisms to assess the value of new and existing medicines, such as health technology assessment, that would facilitate medicine policy priority setting and context-sensitive pricing negotiations.…”

“…24,25 Strategies including evidence-based forecasting of need and cost, pooled procurement, international reference pricing with appropriate comparator markets, competitive tendering from quality-assured suppliers, innovative financing mechanisms, and ring-fenced inventory for pediatric use may contribute to sustained supply of cancer medicines for children. 4,[15][16][17] The recent establishment of a Global Platform for Access to Childhood Cancer Medicines, through joint efforts by St Jude Children's Research Hospital and the WHO, constitutes a landmark development in global policy on cancer medicines for children. In addition to galvanizing attention and funding for this critical global health issue, it has the potential to strengthen mechanisms for forecasting and bulk procurement of quality-assured medicines at competitive prices to enhance access for children with cancer internationally.…”

Alignment in the registration, selection, procurement and reimbursement of essential medicines for childhood cancers in South Africa

“…The novelty and significance of this study lie in the scope of pharmaceutical processes studied. Where previous studies in other countries have compared national EMLs with the WHO model list [33][34][35] or with national drug registries, 11 this study is the first to include data on procurement and potential reimbursement in addition to (international) selection and registration. By studying these steps together, a more comprehensive picture of potential gaps was obtained and specific bottlenecks could be identified.…”

Developing a partnership to improve health care delivery to children <18 years with cancer and blood disorders in the English-speaking Caribbean: lessons from the SickKids-Caribbean Initiative (SCI)

“… 3 , 4 , 5 Constraints to equitable health care include inadequate funding; shortages in appropriately trained healthcare professionals to identify and treat such diseases; limited and/or unreliable access to specialised testing and essential medicines; and lack of registries and case tracking to facilitate appropriate resource planning and policy generation. 2 , 6 , 7 , 8 …”