Bridging the gap in access for childhood essential cancer medicines in low- and middle-income countries

Survival rates for children with cancer living in in high-income countries (HICs) can be over 80%; for those living in low- and middle-income countries (LMICs), they can be less than 30. This is one of the most glaring inequities in global health, and among the complex factors that contribute to it is the lack of access to lifesaving medicines.

There are several significant barriers to accessing these medicines, including a lack of data-driven procurement, frequent stockouts, the utilisation of data analytics tools and techniques in the procurement process to make more informed decisions, low supplier incentives to engage in procurement, lack of availability, few health policies specific to childhood cancers and financial and logistical constraints for parents and caregivers [GU1] (such as transportation, time off work, etc) that contribute to delays and discontinued treatment.

A study in Trinidad and Tobago highlights a lack of data-driven procurement as a key issue. The absence of reliable data on the availability and affordability of essential medicines for childhood cancer hampers effective service by healthcare providers.

Another barrier noted by the same study is the low incentive for suppliers to engage in the manufacture of such medicines. Given that these drugs are often expensive, suppliers may deem the financial benefits insufficient, leading to decreased availability.

A survey conducted by the International Society of Pediatric Oncology on access to medicines revealed that the availability in LMICs for top essential cancer medicines for children (EMLc) ranged from 9% to 46%, against 25% to 89% for upper middle-income countries (UMICs), and 67% to 100% for HICs.

The survey also noted that even when medicines are available, the risk of catastrophic expenditure (8%-20% in LMICs, 0%-28% in UMICs, 0% in HICs) often prevents access.

Additionally, an international study focused on East Africa identified frequent stockouts as a significant reason for lack of availability, with many LMICs suffering from weak national supply chains and vulnerable to global market perturbations. The study noted that global, national and regional policy makers need to mobilise and allocate sufficient funding and resources to optimise childhood cancer medicine availability and affordability.

Indeed, addressing these barriers will require a multi-faceted, multisectoral and multilateral approach that includes improving procurement and supply chain processes, increasing supplier incentives, addressing patient-level financial constraints, and developing policies focused on childhood cancers.

The UICC-led Access to Oncology Medicines  Coalition (ATOM Coalition), launched  in May 2022, is such a global health initiative established to reduce the burden of suffering from cancer in low- and lower-middle income countries (LLMICs) by improving patient access to essential cancer diagnostics and cancer medicines, including paediatric cancer medicines.

In its first phase, the ATOM Coalition is focusing efforts on strengthening access to essential cancer medicines in 46 target countries, with countries selected based on a number of criteria, including health systems readiness, diagnostic capability, the number of essential medicines already listed on their national EMLs and the existence of other access programmes in the country

Capacity strengthening initiatives will commence in a subset of these 10 target countries, focused on key areas affecting access, including registration, diagnostic capacity, supply chain management and training on appropriate use.

With guidance from the Medicines Expert Advisory Group, the ATOM Coalition has established a target list of priority generic, biosimilar, and patented medicines currently on the WHO Essential Medicines List, with a focus on cancers with the highest incidence and mortality in LLMICs, including childhood cancers.

As part of the ATOM Coalition’s model to an integrated approach that complement, enhance and amplify existing programmes, the ATOM Coalition is supporting and championing initiatives dedicated to childhood cancer, including the WHO’s Global Initiative for Childhood Cancer, which aims to increase access to quality treatment for children with cancer, as well as the WHO-hosted GAP-f network (Global Accelerator for Paediatric formulations), which works to promote innovation and access to quality, safe, efficacious and affordable medicines for children, including most recently childhood cancer medicines and in which coalition partners, Medicines Patent Pool (MPP) and PATH, are a member of.  

With its 40 partners, the ATOM Coalition is working to increase the supply of essential cancer medicines in these countries, including the availability of generic and biosimilar cancer medicines, which are often more affordable than branded medicines.

As part of these efforts, the ATOM Coalition facilitated the first ever voluntary license agreement for a cancer medicine by two of its partners, MPP and Novartis. Nilotinib is listed on the WHO EML for the treatment of both adults and children over the age of one from chronic myeloid leukaemia. A dedicated working group, led by the ATOM Coalition and MPP, has been set up to create an implementation plan, which will soon begin rollout to the seven target countries.

The implementation strategy of the nilotinib rollout in countries will help inform the future work with regulatory authorities in target countries, with the aim of streamlining the approval process for essential cancer medicines, and improving the quality of cancer medicines available in these countries and by promoting the use of quality-assured generic and biosimilar medicines.

Partners on the ground will also be collaborating with healthcare providers in the target countries to improve the capacity to diagnose and treat cancer, so that the right medicines reach the right patient at the right time. Strengthening healthcare systems is also necessary so that the supply of essential cancer medicines can be effectively managed and is sustainable in the long term.

As concerns for health equity continue to rise, the role of initiatives such as the ATOM Coalition becomes crucial in bridging the gap in access to essential cancer medicines, providing a multi-faceted solution to a complex issue.

Ensuring equitable access to cancer treatment for children is not merely a question of logistics or economics, it's a matter of social justice and human rights.