In Mexico, the overall availability of cancer essential medicines in the public sector was slightly lower than in the private sector. In general, prices in Mexico were lower than international reference prices and lower than other LATAM countries. Only few medicines were considered affordable in both the public and private sectors; affordability of medicines in the public sector (14% of medicines) was slightly better than in the private sector (10% of medicines).
Availability of cancer medicines
The average availability of cancer medicines was lower in the public sector (61.2%) than in the private sector (67.45%), with high variability across individual medicines. The availability of SPS medicines was slightly higher (70.2%), especially for those for breast cancer and leukemia. Greater availability reflects an increased government investment in these two types of cancer treatments. Access to colorectal cancer medicines was lower than breast cancer and leukemia medicines; barriers to access essential medicines for colorectal cancer have been reported [22], despite the fact that colorectal cancer is covered by SPS. Renal cancer medicines for adult patients had the lowest availability of all, likely because they are not covered by SPS and therefore deprioritized [38,39].
Overall, the availability of cancer medicines falls below the World Health Organization’s (WHO) target of 80% for essential medicines to treat major NCDs (which includes cancer) [40–42]. Thus, mechanisms to improve the availability of cancer medicines in Mexico are warranted. Low availability in the private sector could be explained by the fact that specialized medicines are marketed in selected pharmacy chains only. Therefore, patients have a limited choice of pharmacies, restricted to some states and mostly in urban areas.
The availability of cancer medicines in Mexico’s public sector is higher than other LMIC countries from which data were available. For example, studies in Tanzania and Pakistan [12,13] reported 50% availability of cancer medicines in the public sector. In Pakistan, the availability of cancer medicines in the private sector was higher than in the public sector, which is a common trend in LMIC [13]. However, private pharmacies in Pakistan focus more on stocking originator brand cancer medicines, while in Mexico private pharmacies have a better availability of generic cancer medicines [13].
Affordability of cancer medicines
Most cancer medicines are unaffordable for patients, in the private and in three public hospitals where patients paid for cancer medicines. Based on our own definition, only 7 out of 49 cancer medicines were affordable [13,32]. In addition, most cancer treatment regimens require more than one medicine, making the treatment as a whole even less affordable, often leading to catastrophic expenditures and poverty [6,43,44]. The studies from Tanzania and Pakistan also reported that cancer medicines required more than one working day to pay for one day of treatment, therefore considered unaffordable to most patients [12,13]. These results, including Mexico, confirm the LMIC’s general picture of unaffordability of essential cancer medicines. Therefore, more aggressive pricing policies are needed to disrupt this ongoing problem.
We also found that 18 out of 21 of the public hospitals we surveyed reported no additional charges for patients without SPS coverage, as a mechanism to guarantee access to treatment without incurring in health expenditure. For those hospitals that do charge uninsured patients for treatment, these patients must make out-of-pocket payments for (mostly) unaffordable medicines and/or turn to charity organizations [23,45].
Procurement prices and international price comparison
We found that, in general, prices of cancer medicines in the public sector in Mexico were lower than other LATAM countries and international reference prices. The Mexican government has contained procurement prices better in the public sector than other countries in the region, through pooled procurement, price negotiations and using reference pricing for SPS medicines [46–49]. For SPS medicines, most public procurement prices were under the SPS reference prices [47,50], and overall about 20% lower than (MSH) international reference prices. Still, additional efforts are needed to further reduce and monitor prices; in particular for those that are more than twice the reference prices (e.g. docetaxel).
Overall, medicine prices in Mexico’s private sector were lower than retail prices in the regional countries. Yet, current prices, especially for patented medicines, remain unaffordable, warranting the development of comprehensive price regulations schemes, which has not been properly introduced in the country yet [46,51]. High prices of patented cancer medicines seem common in the region, as other LATAM countries, such as Argentina, Chile, Uruguay, Paraguay and Brazil have reported unaffordable prices as well [52]. Such high prices in the private sector usually lead to catastrophic expenditure, in particular for low-income patients who were unable to get their medicines in the public sector [6]. Besides wider national health insurance coverage for public sector medicines, additional pricing policies are necessary to improve access to more affordable cancer medicines in the private sector.
Strengths and Limitations
To our knowledge, this is the first study on the availability, prices, and affordability of cancer medicines using an adapted form of the WHO/HAI methodology. This study collected data from a representative sample of public hospitals and private pharmacies in eight states. Future research should also consider assessing the availability, affordability, and prices of cancer medicines in other insurance schemes (social health insurance institutions) and other geographic regions of Mexico.
This study has some limitations. At the time of data collection, some medicines were reported as “just became out-of-stock”. Thus, our availability data may underestimate the actual availability of cancer medicines on a regular basis [26]. At one surveyed hospital, some medicine prices were restricted, as this information pertained to the state’s MoH database. In addition, our calculations of patient affordability account for single medicine for one day of treatment, which may underestimate the affordability of the treatment as a whole. Furthermore, our affordability assessment in the public sector is limited to the only 3 hospitals that reported patient prices for cancer medicines, which may understate our results on medicine’s affordability in the public sector. However, the current results show that medicines are still unaffordable to patients that receive care at those institutions and pay out of pocket for medicines without coverage.
We only surveyed pharmacies in the private sector because we did not obtain approval from private hospitals to conduct our research. Private hospitals providing cancer care provide chemotherapy at their facilities and care for approximately 19% of cancer cases [53]. Hence, our results do not fully represent the availability, prices, and affordability of cancer medicines in the private sector as a whole. However, the private sector hospitals and clinics represent approximately 2% [54] of the pharmaceutical market. Thus, omitting these data is not likely to have resulted in significant bias in our observations. Additional research is necessary to describe the availability and affordability of cancer medicines in this private subsector.
Practical implications
Medicines in the public sector covered by SPS were the most available, especially for breast cancer and leukemia. These results reflect the additional investment by the government to improve health care access to priority diseases. We recommend periodically revising and updating the SPS’s protocols for “resource appropriate strategies” [2] that guarantee the best level of care with the most efficacious and cost-effective medicines, including innovative medicines. We also recommend the expansion of SPS coverage to improve access to treatment to all types of cancer.
Overall, the Mexican government has kept prices of cancer medicines in the public sector below prices from other LATAM countries. Yet, most medicines remain unaffordable for patients – particularly for innovative medicines under patent. A comprehensive assessment of the government’s budget allocations and the complete calculation of costs of cancer care (i.e. pharmaceutical and non-pharmaceutical) are required.
The high prices and low affordability of cancer medicines in the private sector reflect a lack of pricing policies and pharmaceutical market regulation. Price monitoring, prices transparency for single-source products, and compulsory licensing when all other measured fail to yield affordable medicines, should be implemented to increase affordability for payers (patients and the health system). Mexico should also consider the full range of pricing policies [55] for medicines in the public and private sectors to assure the provision of affordable medicines for all patients.
Further research is needed to assess the affordability of medicines and comprehensive cancer treatments, both from the patient’s and the health system’s perspective. Continuous monitoring of prices and availability of cancer medicines is necessary to monitor their impact on health expenditure and access to cancer care.