Availability of surveyed medicines
The study evaluated the availability, price and affordability of 32 anticancer medicines in Hubei Province by using the WHO and HAI standard methodology. After investigating 13 tertiary hospitals and 15 secondary hospitals, we found that nine LPGs out of the surveyed medicines met the fairly high level of availability in tertiary hospitals, and four LPGs were in the high level availability in the secondary hospitals. Overall, the average availability of OB medicines was lower than that of LPG medicines (Figure1-2). The findings are consistent with prior surveys in developing countries [14, 20, 21]. They found that most of the OB medicines were produced by large international manufacturers. Due to the lack of effective external supervision and approval for the OB medicines, price leading and brand premiums led to the confusingly higher price.
Compared with secondary hospitals, the availability of surveyed medicines were higher in tertiary hospitals. Since radiotherapy and chemotherapy of tumor are very professional and expensive, they are mostly concentrated in large specialized hospitals or departments of tertiary hospitals, which contributed to the higher availability .
In general, the price of the OBs was high because of its core patent right, as well as their high quality and stability were unique advantage [1, 23]. However, LPG can be used as a competitive product to make up for its lack of accessibility . Especially in low and middle-income countries, hospitals will take into account the actual purchasing power of patients, and appropriately reduce the inventory proportion of OBs in hospitals [17, 25]. The findings of our study showed that the availability of some medicines was relatively high, including Gemcitabine, Etoposide, Oxaliplatin, Cyclophosphamide, Tamoxifen, etc. the underlying reason may be that these medicines have a comparatively low toxicity and high effectiveness , and they are widely used in the treatment of some high incidence and mortality cancers, such as lung cancer, gastric cancer, colon cancer in China .
As presented in Figure 3, most of the LPGs for anticancer could be acquired with acceptable price. Meanwhile, for OBs, the MPR value of Cytarabine, Oxaliplatin and Paclitaxel were much higher than the international reference price from MSH. Compared with LPGs, the relatively retail prices for OBs were much higher. This may be explained by the large patient’s rigid demand for the above three categories of medicines. In addition, the particularity of pharmaceutical production technical and core-patient barriers made it difficult for many domestic generic drugs to reach the ideal level and curative effect of the originator brand drugs . Therefore, the mentioned factors above contributed to the high price of OBs in China.
The government has been very concerned about the field of medicine prices. In recent years, it has also issued relevant policies to curb the disordered competition in pharmaceutical market. Launching the new direction of "purchasing with quantity, linking quantity with price and combining bidding and purchasing" has pushed the price of national essential drugs back to a reasonable level [8, 29]. Especially, after the conformity evaluation, generic drugs gradually occupy the share of originator brand drugs and expand the OBs’ substitution in favour of lowering public health expenditure in hospitals . Diversified and fair competitions between OBs and LPGs may bring more preferential benefits to patients.
For the patients from low-income families in Hubei Province, they are still unable to afford course of treatment. Economic burden of disease becomes the major barrier that affects their access to effective targeted anticancer medicines. In this study, the measurement affordability based on the total cost of treatment and the estimation of household income. The top five medicines with poor affordability were: Irinotecan, Oxaliplatin, Bicalutamide and Mycophenolate Mofetil, Methylprednisolone, which were more than 6 times of the 20% minimal monthly household income. The heavy payment burden may be caused by different dosages of 30 day treatment course and the unit price of each medicine. Hence, the government should establish special funds to support low-income household, and use improve the efficiency of national medical insurance . Potential strategies worth consideration include: simplifing the approval process of new drugs at home and abroad, improving their access to the market, reducing the innovation cost, and attracking more high-quality anti-cancer generic drugs to enter the market . Importantly, in terms of the bidding and procurement process, National Health-care Security Administration negotiates with pharmaceutical manufacturers for reducing the OBs price and ensuring that the patients can afford the essential anticancer medicines .
In this survey, private hospitals and pharmacies were not included in the survey because they did not have the right to prescribe anti-cancer drugs. Therefore, the results may not represent the availability of anticancer medicines in all types of hospitals in Hubei Province. Second, during data collection, some “out-of-stock” medicines were not included in the calculation. Thus, the findings may not be generalizable to the whole availability of anticancer medicines. Lastly, for the convenience in comparing the affordability indicators, all medicines charges were calculated according to the course of 30 days. In fact, the patient's condition and tumor disease are different, which could lead to some biases in the accuracy of affordability.