Cry no more: Universal access to cancer treatment is possible in a low-income country as we learn from the Uganda experience.
Date of Publication: April 22, 2021
Unaffordable, impoverishing, stressful…are the repeated phrases characterising the road to cancer treatment in low income countries (LICs). However, the government of Uganda, through the Uganda cancer institute has defied the odds as we explore in this blog.
The double burden of disease (communicable and non-communicable), with the associated high cost for prevention and treatment, and the need for sophisticated interventions and service delivery models, are resounding challenges to achieving universal health coverage(UHC) in LICs, Uganda inclusive. Closely related to this is the increasing burden of cancer in Uganda currently accounting for 35,300 deaths and an estimated 30,000 – 50,000 new cases annually, in the face of low government spending on health. The health sector accounted for 8.9% of the national budget (FY 2019/20) against the Abuja commitment of 15%, and has a current percapita expenditure on health of US$39. This falls far below the estimated requirement of $112 per capita for low income countries (LICs) to ensure access to a meaningful package of essential health services (governments are expected to finance at least 80 percent translating into a per capita spending of $90 for LICs from government sources). Turning to cancer treatment, a study undertaken in South Africa estimated the average cost of cancer chemotherapy in the public sector as US$1,100 per patient. In the face of scarce resources and limited fiscal space for health, efficiency gains has been a logical argument whose operationalisation has remained elusive.
Osinde et al narrate the 4 years’ road to increasing access to quality anticancer medicines in Uganda from which I draw major lessons that are beneficial to LICs and thus say …. Cry no more, it is possible. The road is underpinned by what authors refer to as “innovations in increasing access to lifesaving anticancer medicines”. This embodies approaches to improving access, guarding against counterfeit (falsified) medicines and ensuring affordability through effective negotiation with manufactures. A five-step process delivered the much-needed result that is enshrined in the universal health coverage (UHC) concept, that is, universal access to cancer treatment.
Firstly, the Uganda cancer institute (UCI), which is the national referral centre for cancer management in the country, redefined cancer medicines as highly specialized drugs (HSDs). This garnered the required policy makers attention as well as restrictions in acquisition and prescription by specialised public and private facilities given the unique characteristics and thus the need for direct negotiation between the specialists and the manufacturers.
Secondly, the newly enacted law (UCI Act 2016) by the parliament provided a window to streamline the procurement and supply chain system. The UCI directly contracted with manufactures minimising the role of middlemen with associated costs. Further, the timely quantification and forecasting facilitated cost-effective, high volume and timely delivery of high-quality medicines under the right conditions and from authentic suppliers.
Thirdly, the multi stakeholder approach ensured a holistic approach to improving access to anti-cancer medicines. The involvement of the Parliament of Uganda, ministry of health and finance ensured timely availability of funds, the Uganda Revenue Authority effected a tax waiver, National Medical Stores guided on the process while the National Drugs Authority facilitated regulatory compliance.
Fourthly, through the UCI Act 2016, the procurement of anticancer medicines was legalized as highly specialized drugs (HSDs) which mandated the UCI to directly procure anti cancer medicines. Fifthly, the UCI has harnessed opportunities through enrolling in either pricing or donation access initiatives.
Through these initiatives, The UCI has realised a threefold increase in the medicines procured with the same budget allocation and improved availability of medicines throughout the year. In the year 1st July 2019 to 30th June 2020, only one out of 32 anti-cancer essential medicines was out of stock for only 15 days. The prescriptions served at the dispensing window increased four-fold. The UCI laboratory increased the volume of tests undertaken and expanded the range services, including specialised cancer diagnostic services provided free to the patient. The price reductions on many consumables accrued from the novel procurement system resulted in reduced cost per test.
Gross savings have been registered through eliminating the middlemen and directly negotiating with manufactures. In the year 1st July 2018 to 30th June 2019, The UCI realised a saving of about $2,888,966 with a resultant increase in availability of medicine from 29% in the previous year to 86%.
What do we learn from the 4 year’s road undertaken by the UCI? … it is possible, it is not necessarily more money, it takes innovation and commitment and every stakeholder playing their role. More benefits are within reach, the voluntary pooled procurement around Regional Economic blocks offer additional options.
…..I thus conclude that cry no more, it is possible.
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About Juliet Nabyonga-Orem
Health systems Expert, WHO