Bringing down the price of cancer
Despite the plethora of life-saving new cancer drugs hitting the market in the last decade, many of them continue to be prohibitively expensive for the patients who need them. At a recent forum at University Malaya Medical Centre (UMMC) titled “Improving Access to Affordable Cancer Treatments in Malaysia”, the issue was discussed by a gathering of panellists from the Ministry of Health (MOH) and pharmaceutical industry representatives.
In a technical report presented to the World Health Organization (WHO) in 2019, it was highlighted that a course of standard treatment for early-stage HER2+ breast cancer would cost approximately 10 year’s average annual wages in India and South Africa, or 4 years’ wages in Malaysia assuming an average Malaysian’s monthly income of RM3,000. [Nature 2018;555(7695):S26-S29]
As a result, many patients find themselves at risk of financial catastrophe. The 2015 ASEAN Costs in Oncology (ACTION) study found that 51.4% of cancer patients experienced financially catastrophic payments for their care at 1 year after diagnosis.
Recognizing this, the WHO has presented six strategic options for UN Member States to reduce cancer drug prices, consisting of: strengthening pricing policies at national and regional level; improving efficiency of cancer medicines expenditure; improving pricing transparency; promoting collaboration on information sharing, regulation and procurement; managing factors influencing medicine demand; and realignment of research and development incentives.
During the recent UMMC panel, Dr Lee Boon Chye, Deputy Health Minister, and Dr Ramli Zainal, MOH Pharmaceutical Services Program (PSP) senior director were questioned by Prof Rosmawati Mohamed, University Malaya Medical Centre consultant hepatologist and cancer survivor, regarding the government’s perspective on the issue. The following is an excerpt from the panel.
Rosmawati (R): What plans does the PSP have to improve medicines access?
Ramli: Most of the six strategies and initiatives that have been laid out by [the WHO] have been implemented in Malaysia. Having said that, there’s a few things to consider when looking at the pharmaceutical landscape as a whole.
First is strengthening the system. We have a good regulatory system with fast-track applications to make the product available as quickly as possible. In a survey done by the Centre of Innovation in Regulatory Sciences that we participated in, in terms of our rate of product approvals, our timeline is just below authorities such as the US FDA, and we make products available faster than any other ASEAN country.
Then there’s the issue of affordability. We have made [the product] available, we have registered it, the question is now whether we can afford to pay a fair price for the product. Not the cheapest price, but a fair price, meaning: is it affordable for the country, and is it sufficient for the industry to remain sustainable in terms of R&D? “Sufficient” doesn’t mean excessive profits.
When we talk about the supply chain, about formulary management; almost all of the drugs in the WHO Essential Medicines List, especially for cancers, are in our formulary. So that is not an issue. When we talk about the supply chain we must also have a reliable procurement system. In the MOH context, we are trying our level best to negotiate a fair price for drugs—the price of certain drugs in the government is currently much cheaper than the private sector.
Then after getting the product into the system, we need to talk about responsible use of medicines. This is where the physician comes in; they have a role to play in making sure medicines are used responsibly.
The final stage is monitoring; we need to have a mechanism in place for us to be able to monitor, to collect data so we can make better informed decisions. This includes adverse drug reactions (ADRs), substandard and falsified medicines.
We have carried out a lot of the [recommended WHO] strategies and initiatives, but this is a work in progress. We are negotiating with pharma, with everybody on how we should have a fair price mechanism. We have already have the Patient Access Scheme (PASc) program, which is also a managed entry program; we have a lot of collaboration between ministries and between ASEAN countries; and we are also working on pooled procurement between three different ministries (Education, Health and Defense).
On the aspect of demand-side factors… we are also working with physicians to try and correct misconceptions about generics and biosimilars.
R: What is the Deputy Health Minister’s perspective on this discussion?
Lee: As a policymaker, I would like to look at ways to reduce the cost of doing business for the pharmaceutical industries. Facilitating the approval process is certainly one of them; the other thing is providing them with up-to-date patient data, which we hope things like electronic medical records and the National Cancer Registry would help to an extent, so that they know how much of the necessary cancer drugs they can import.
But I do hope that industry can also look at other ways of cost-cutting. You [the industry] have probably got to look at your rewarding system for your distribution process. At the moment, the MOH doesn’t come down hard on your mechanism of distribution, how you market, but maybe the industry should look at how much its expenses are in marketing and distribution.
Pooled procurement has already been mentioned but looking at the other aspect of [industry] pricing policy for cancer drugs… if you look at recent years, there’s no doubt we are living in very exciting times, with so many more drugs coming out with fantastic results and outcomes for the patients.
Unfortunately, we’ve also seen the ugly side of capitalism, and we see that [the industry’s] pricing policies are really based on the Michael Porter Policy; “how much the consumer will pay”. The moment they think that [the consumer] can pay more, more will be charged. There’s no longer such a thing, as from older days, where you price based on your investment. As a result, you can see the exorbitant prices being put in.
We see that across the world, in the third world countries, it was always thought that maybe the advanced countries will subsidize the cost. They would pay a higher price compared to lower- and middle-income countries. But unfortunately, we see that some drugs in the private sector are [at prices] comparable or even higher than what can be gotten in advanced countries. So there is some anomaly there.
And I’m not saying—I’m not a socialist. I do recognize that capitalism drives innovation, so we need an appropriate reward system. But unfortunately, the current system of rewarding innovators is all reflected in Wall Street, in balance sheets, bottom lines and profit and loss statements. I think this system should be reviewed. Especially in the medical fraternity—so much of medical innovation in the past occurred because the medical fraternity shared information without expectation of reward. But this part of it is more philosophical.
We probably need to have a more attainable, sustainable pricing system from international pharmaceutical companies… I hope that the WHO and the international community will help look at the pricing issue. We could exercise country rights—for example, as what we did for hepatitis C medicines—but there’s a limited scope to that, even in the case of Hepatitis C where we had very strong grounds to exercise those rights.