Determinants of access to childhood cancer medicines: a comparative, mixed-methods analysis of four Caribbean countries,The Lancet Global Health

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Determinants of access to childhood cancer medicines: a comparative, mixed-methods analysis of four Caribbean countries
The Lancet Global Health ( IF 34.3 ) Pub Date : 2021-08-17 , DOI: 10.1016/s2214-109x(21)00287-4
Rhonda Boateng ₁ , Kadia Petricca ₂ , Brandon Tang ₃ , Supriya Parikh ₄ , Corrine SinQuee-Brown ₅ , Cheryl Alexis ₆ , Chantelle Browne-Farmer ₆ , Michelle Reece-Mills ₇ , Sharon McLean Salmon ₈ , Curt Bodkyn ₉ , Sumit Gupta ₁₀ , Bryan Maguire ₄ , Avram E Denburg ₁₀

Affiliation

The SickKids-Caribbean Initiative, Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Toronto, ON, Canada.
Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Toronto, ON, Canada.
Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
Biostatistics, Design, and Analysis, Hospital for Sick Children, Toronto, ON, Canada.
Princess Margaret Hospital, University of the West Indies School of Clinical Medicine and Research, The Bahamas.
Queen Elizabeth Hospital, Bridgetown, Barbados.
University of the West Indies Hospital, University of the West Indies, Kingston, Jamaica.
Bustamante Hospital for Children, Kingston, Jamaica.
Child Health Unit, Faculty of Medical Sciences, University of the West Indies, St Augustine, Trinidad and Tobago.
Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Toronto, ON, Canada; Division of Haematology/Oncology, Department of Paediatrics, Hospital for Sick Children, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.

Background

Equitable access to essential medicines is a key facet of childhood cancer care, recognised by WHO as vital to improved childhood cancer outcomes globally. In the Caribbean, childhood cancer outcomes are poorer than those in most high-income countries. We aimed to generate in-depth comparative evidence of the current challenges and opportunities related to access to childhood cancer medicines in the Caribbean to identify context-sensitive health systems strategies to improve drug access and inform evidence-based paediatric cancer policies in the region.

Methods

In this convergent, parallel, mixed-methods study, we mapped and analysed the determinants of access to childhood cancer medicines in four Caribbean countries (The Bahamas, Barbados, Jamaica, and Trinidad and Tobago). We analysed contextual determinants of access to medicines within and across study site jurisdictions, alignment of childhood cancer medicine inclusion between each country's national essential medicines list (NEML) and WHO's 2017 Essential Medicines List for Children, and availability and cost of chemotherapeutic agents at five tertiary care hospitals. We used a mixed-effects logistic regression model to analyse the association of medicine price, procurement efficiency (via median price ratio [MPR]), and site with drug availability. The fixed effect evaluated the effect of site and MPR on the probability of stockout in a given month. We assessed determinants of medicine access via thematic analysis of semi-structured qualitative interviews, literature, and policy documents.

Findings

We collected and analysed data for 28 childhood cancer medicines from Barbados, 32 from The Bahamas, 30 from Trinidad and Tobago, and 31 from Jamaica. Despite stepwise inclusion of childhood cancer medicines in NEMLs, all four countries had frequent and recurrent stockouts for many cytotoxic medicines, showing no consistent relationship between NEML inclusion and availability. A mean MPR of greater than 3·0 in Trinidad and Tobago, The Bahamas, and Barbados suggests uniformly high procurement inefficiency, resulting in significant effects on drug stockout days. For each one unit increase in MPR the adjusted odds ratio (OR) of stockout increased by 10% (adjusted OR 1·10, 95% CI 1·04–1·16; p<0·01). These challenges in access to childhood cancer medicines stem from health system and policy dynamics at institutional, national, and supranational levels that cause price volatility and erratic medicine availability. Key challenges include disparate policy commitments (eg, among sites), inefficient procurement and supply chain management practices, and local effects of international market pressures.

Interpretation

The Caribbean region exemplifies deficiencies in access to childhood cancer medicines that might be overcome by improved regional harmonisation of drug registration, pharmacovigilance, and procurement alongside national forecasting to strengthen global pharmaceutical planning and prioritisation. Focused political attention to address these challenges is required to ensure efficient, reliable, and sustained availability of cancer mediciness.

Funding

The SickKids-Caribbean Initiative.

中文翻译：

获得儿童癌症药物的决定因素：对四个加勒比国家的比较、混合方法分析

背景

公平获得基本药物是儿童癌症护理的一个关键方面，世卫组织认为这对改善全球儿童癌症结果至关重要。在加勒比地区，儿童癌症的结果比大多数高收入国家要差。我们旨在为加勒比地区当前与儿童癌症药物获取相关的挑战和机遇提供深入的比较证据，以确定环境敏感的卫生系统战略，以改善药物获取并为该地区基于证据的儿科癌症政策提供信息。

方法

在这项聚合、平行、混合方法研究中，我们绘制并分析了四个加勒比国家（巴哈马、巴巴多斯、牙买加以及特立尼达和多巴哥）获得儿童癌症药物的决定因素。我们分析了在研究地点管辖范围内和跨研究区域获得药物的背景决定因素、每个国家的国家基本药物清单 (NEML) 与世卫组织 2017 年儿童基本药物清单之间儿童癌症药物纳入的一致性，以及五个三级机构的化疗药物的可用性和成本。护理医院。我们使用混合效应逻辑回归模型来分析药品价格、采购效率（通过中位数价格比 [MPR]）和地点与药品可用性之间的关联。固定效应评估了站点和 MPR 对给定月份缺货概率的影响。我们通过对半结构化定性访谈、文献和政策文件的主题分析来评估药物获取的决定因素。

发现

我们收集并分析了巴巴多斯 28 种儿童癌症药物、巴哈马 32 种、特立尼达和多巴哥 30 种以及牙买加 31 种儿童癌症药物的数据。尽管在 NEML 中逐步纳入了儿童癌症药物，但所有四个国家的许多细胞毒性药物都经常出现缺货现象，表明 NEML 的纳入与可用性之间没有一致的关系。特立尼达和多巴哥、巴哈马和巴巴多斯的平均 MPR 大于 3·0 表明采购效率普遍低下，从而对药物缺货天数产生显着影响。MPR 每增加 1 个单位，缺货的调整优势比 (OR) 就会增加 10%（调整后的 OR 1·10，95% CI 1·04–1·16；p<0·01）。这些在获得儿童癌症药物方面的挑战源于机构、国家和地区的卫生系统和政策动态。导致价格波动和药品供应不稳定的超国家水平。主要挑战包括不同的政策承诺（例如，站点之间）、低效的采购和供应链管理实践以及国际市场压力的本地影响。