Cancer Medicine PricesIN LOW- AND MIDDLE- INCOME COUNTRIES

Global Task Force on Expanded Access to Cancer Care and Controlin Developing Countries (GTF.CCC)

Harvard Global Equity Initiative, Secretariat651 Huntington Avenue

FXB Building, Room 632Boston, MA 02115

gtfccc.harvard.edu gtfccc@harvard.edu

About Management Sciences for Health Management Sciences for Health (MSH) is a global nonprofit health organization, using proven approaches developed over four decades to help leaders, health managers, and communities in developing nations build stronger health systems for greater health impact. We work to save lives by closing the gap between knowledge and action in public health Most of the leading causes of death and disability in developing countries can be prevented or treated with cost-effective medicines. Despite this fact, hundreds of millions of people do not have access to these medicines. Improving the way medicines are accessed and used is a powerful opportunity to create stronger health systems and achieve greater health impact. Management Sciences for Health’s Center for Pharmaceutical Management develops the capacity of both the public and private sectors to select, procure, and distribute quality medicines and health supplies and helps to ensure their proper dispensing and use–all in a cost-effective way.

About The Global Task Force on Expanded Accessto Cancer Care and Control in Developing Countries

The mandate of The Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries (GTF.CCC) is to design, implement and evaluate innovative, multi-stakeholder strategies for expanding access to cancer prevention, detection and care. Through local partners, the GTF.CCC supports implementation of innovative service in delivery models that can provide evidence for scaling up access to cancer care and control, and strengthening health systems in developing countries.

Cancer Medicine Prices in Low- and MiddLe-inCoMe Countries

Rising BuRden of CanCeR and TReaTmenT needs

According to the World Health Organization (WHO), cancer is one of the leading causes of death worldwide; in 2008, it accounted for approximately 7.6 million deaths (13 percent of all causes of death).1 More than 70 percent of all cancer deaths occurred in low- and middle-income countries (LMICs). While it is estimated that more than 30 percent of deaths can be prevented through early detection and modifying or avoiding key risk factors, the demand for cancer treatment, especially in low-income countries, is not being adequately met. High cost and poor availability of cancer treatment are significant barriers to access in many LMICs. In Pakistan, which has a per capita income of 2,860 US dollars (USD), the cost of treating leukemia with chemotherapy and associated transfusion requirements is USD 20,000.2 Although the cost of medicines for palliative care at the supplier level does not represent a substantial barrier to access, retail prices can be a major deterrent to access as they can be prohibitive.3

Ensuring affordable access to quality cancer medicines, vaccines, and related health techno-logies depends not only on wise selection by national authorities, but also on price reduction and procurement strategies appropriate to each type of product. If essential medicines for cancer are listed in a country’s national essential medicines list (NEML) and linked to standard treatment guidelines, selection and procurement become easier and can contribute to lower prices. For example, antihypertensive medicines are cheaper in the public sector when listed in an NEML.4

Procurement officers often do not have easy access to available pricing information to make the best purchase decisions for public health programs. Transparent, web-based exchange of information on prices and sources of cancer medicines and vaccines should be expanded. Such information can achieve dramatic price reductions –especially on off-patent products– when used in competitively pooled procurement by reliable global, regional, or national procurement and supply organizations. For example, price information transparency for antiretrovirals through initiatives by Médecins Sans Frontières and WHO’s Global Price Reporting Mechanism contribute to informed purchasing decisions for HIV/AIDS programs. Likewise, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) requires that principal recipients submit prices paid for a range of procured medicines for AIDS, tuberculosis, and malaria that are then publicly posted through its Price and Quality Reporting System with country and region specific analyses.

WoRld maRkeT PRiCes of essenTial CanCeR mediCines and agenTs

The table below lists antineoplastic, immunosuppressives, and medicines used in palliative care sourced from the WHO’s 17th edition of Model Essential Medicines List. Also listed are several chemotherapeutic agents deemed essential based on recommendations in the essential package of cancer services from the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries’ report, “Closing the Cancer Divide: The Global Equity Imperative of Expanding Access in Low and Middle Income Countries” (http://gtfccc.harvard.edu/icb/icb.do).

The pricing information for these chemotherapeutic agents is from the 2010 edition of the International Drug Price Indicator Guide (http://erc.msh.org/priceguide) published by Mana-gement Sciences for Health (MSH) and WHO. Pricing data are indicative of buyer prices – usually government agency international competitive bidding, or tender, prices from public sector sources. All prices from the MSH Drug Price Indicator Guide are from reputable suppliers who meet quality standards established by MSH and WHO.5

1

Ind

icat

ive

pric

es o

f es

sent

ial

canc

er m

edic

ines

and

age

nts

use

d i

n p

alli

ativ

e ca

re

from

the

MSH

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nter

nat

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al D

rug

Pri

ce I

ndic

ator

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ide

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g (i

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rnat

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al

non

pro

pri

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ames

)

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g P

rice

in

dic

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ide

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dit

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stre

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ge f

orm

un

it p

rice

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est

(us$

)M

edia

n

(us$

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igh

est

(us$

)n

o. o

f p

rice

sH

igh

/Low

r

atio

IMM

UN

OSU

PP

RE

SIV

E M

ED

ICIN

ES

Aza

thio

pri

ne

50

mg

tab-

cap

per

tab

0.09

0.15

0.25

5 2

.83

Cic

losp

orin

25 m

gta

b-ca

pp

er t

ab0.

450.

480.

973

2.17

CY

TO

TO

XIC

AN

D A

DJU

VA

NT

ME

DIC

INE

S

All

opu

rin

ol10

0 m

gta

b-ca

pp

er t

ab0.

020.

020.

064

3.5

Asp

arag

inas

e10

,00

0 IU

/ml

1 vi

al (

1 m

l)p

er v

ial

43.1

563

.73

84.3

22

1.95

Ble

omyc

in15

mg

vial

per

via

l12

.16

15.6

646

.75

93.

84

Cal

ciu

m F

olin

ate

15 m

g ta

b-ca

pp

er t

ab0.

211.

44

2.07

49.

7

Car

bopl

atin

150

mg

vial

per

via

l13

.09

14.0

618

.04

41.

39

Ch

lora

mbu

cil

2 m

gta

b-ca

pp

er t

ab0.

460.

962.

065

4.47

Cyc

loph

osph

amid

e50

0 m

g1

vial

per

via

l3.

686.

719.

904

2.69

50 m

gta

b-ca

pp

er t

ab0.

200.

220.

465

2.23

Cyt

arab

ine

100

mg

vial

per

via

l1.

753.

633.

834

2.19

Dac

tin

omyc

in0.

5 m

g1

vial

per

via

l11

.00

24.6

027

.68

32.

52

Dau

nor

ubi

cin

20 m

g1

vial

per

via

l5.

846.

00

92.0

53

15.7

7

Doc

etax

el80

mg

1 vi

alp

er v

ial

4211

3.51

346.

164

8.24

Dox

oru

bici

n50

mg

1 vi

alp

er v

ial

8.89

12.4

517

.93

62.

02

Eto

pos

ide

20 m

g/m

lvi

alp

er v

ial

0.49

0.84

1.48

63

Flu

orou

raci

l50

mg/

ml

vial

per

ml

0.17

0.19

0.22

31.

34

Hyd

rox

ycar

bam

ide

500

mg

tab-

cap

per

tab

0.08

0.31

0.50

46.

07

Ifos

fam

ide

1 gm

vial

per

via

l10

.36

14.7

446

.86

44.

52

Mer

cap

top

uri

ne

50 m

gta

b-ca

pp

er t

ab0.

581.

832.

744

4.69

Mes

na

100

mg/

ml

Am

pou

le (4

ml)

per

ml

0.37

0.72

1.08

22.

93

Met

hot

rexa

te25

mg/

ml

vial

per

ml

0.55

1.03

1.33

42.

41

2.5

mg

Tab-

cap

per

tab

0.05

0.10

0.15

63.

11

Pac

lita

xel

6 m

g/m

l1

vial

per

ml

1.88

2.61

8.48

54.

51

Th

iogu

anin

e40

mg

tab-

cap

per

tab

3.92

4.62

5.32

21.

36

Vin

blas

tin

e10

mg

1 vi

alp

er v

ial

7.94

14.7

517

.14

52.

16

Vin

cris

tin

e1

mg

1 vi

alp

er v

ial

1.09

2.33

2.69

42.

46

AD

DIT

ION

AL

ESS

EN

TIA

L A

GE

NT

S

An

astr

ozol

e1

mg

Tab-

cap

p

er t

ab0.

471.

012.

264

4.79

Cis

plat

in

1 m

g/m

lvi

alp

er m

l0.

160.

200.

252

1.6

Mel

phal

an2

mg

tab-

cap

per

tab

0.90

1.41

2.0

03

2.23

Rit

uxi

mab

10 m

g/m

lA

mp

oule

per

ml

35.6

341

.35

47.0

82

1.32

HO

RM

ON

ES

AN

D A

NT

I-H

OR

MO

NE

S

Dex

amet

has

one

4 m

g/m

lA

mp

oule

(1

ml)

per

ml

0.02

0.13

0.4

48

22.0

1

Hyd

roco

rtis

one

100

mg

vial

per

via

l0.

180.

291.

719

9.35

Met

hyl

pre

dn

isol

one

40 m

g/m

lvi

alp

er v

ial

1.65

2.47

3.30

22.

01

Pre

dn

isol

one

5 m

g/5

ml

oral

liqu

idp

er m

l0.

020.

050.

073

2.68

5 m

gta

b-ca

pp

er t

ab0.

005

0.01

0.08

916

.88

Tam

oxif

en20

mg

tab-

cap

per

tab

0.01

0.09

0.20

622

.67

ME

DIC

INE

S U

SED

IN

PA

LL

IAT

IVE

CA

RE

Am

itri

pty

lin

e10

mg

tab-

cap

per

tab

0.01

0.01

0.02

31.

9

25 m

gta

b-ca

pp

er t

ab0.

00

40.

010.

067

15.1

3

Dia

zep

am5

mg/

ml

vial

per

ml

0.0

40.

080.

258

6.77

10 m

gta

b-ca

pp

er t

ab0.

010.

020.

353

24.5

1

Flu

oxet

ine

20 m

gta

b-ca

pp

er t

ab0.

010.

020.

04

72.

79

Ibup

rofe

n10

0 m

g/5

ml

oral

liqu

idp

er m

l0.

003

0.01

0.01

54

200

mg

tab-

cap

per

tab

0.0

030.

010.

015

3.21

Lac

tulo

se3.

35 g

/5 m

lor

al li

quid

per

ml

0.01

0.02

0.02

21.

71

Mid

azol

am5

mg/

ml

amp

oule

per

ml

0.17

0.23

1.32

77.

75

Mor

phin

e10

mg/

ml

amp

oule

per

ml

0.16

0.37

1.90

512

.11

30 m

gSR

tab

-cap

per

tab

0.62

0.97

3.66

45.

93

On

dan

setr

on2

mg/

ml

amp

oule

per

ml

0.11

0.26

1.65

415

.33

4 m

gta

b-ca

pp

er t

ab0.

020.

190.

953

51.1

2

2

Not

es:

1. P

rici

ng

dat

a n

ot a

vail

able

for

th

e fo

llow

ing

med

icin

es/a

gen

ts -

cycl

izin

e, d

ocu

sate

sod

ium

, hyo

scin

e h

ydro

brom

ide

and

sen

na.

2. O

nly

on

e p

rice

in

form

atio

n s

ourc

e w

as a

vail

able

for

dac

arb

azin

e, p

roca

rbaz

ine,

im

atin

ib a

nd

tra

stu

zum

ab -

so t

hes

e ar

e n

ot i

ncl

ud

ed i

n t

his

tab

le.

dru

g (i

nte

rnat

ion

al

non

pro

pri

etar

y n

ames

)

MsH

dru

g P

rice

in

dic

ator

Gu

ide

- 201

0 e

dit

ion

stre

ngt

hd

osa

ge f

orm

un

it p

rice

Low

est

(us$

)M

edia

n

(us$

)H

igh

est

(us$

)n

o. o

f p

rice

sH

igh

/Low

r

atio

IMM

UN

OSU

PP

RE

SIV

E M

ED

ICIN

ES

Aza

thio

pri

ne

50

mg

tab-

cap

per

tab

0.09

0.15

0.25

5 2

.83

Cic

losp

orin

25 m

gta

b-ca

pp

er t

ab0.

450.

480.

973

2.17

CY

TO

TO

XIC

AN

D A

DJU

VA

NT

ME

DIC

INE

S

All

opu

rin

ol10

0 m

gta

b-ca

pp

er t

ab0.

020.

020.

064

3.5

Asp

arag

inas

e10

,00

0 IU

/ml

1 vi

al (

1 m

l)p

er v

ial

43.1

563

.73

84.3

22

1.95

Ble

omyc

in15

mg

vial

per

via

l12

.16

15.6

646

.75

93.

84

Cal

ciu

m F

olin

ate

15 m

g ta

b-ca

pp

er t

ab0.

211.

44

2.07

49.

7

Car

bopl

atin

150

mg

vial

per

via

l13

.09

14.0

618

.04

41.

39

Ch

lora

mbu

cil

2 m

gta

b-ca

pp

er t

ab0.

460.

962.

065

4.47

Cyc

loph

osph

amid

e50

0 m

g1

vial

per

via

l3.

686.

719.

904

2.69

50 m

gta

b-ca

pp

er t

ab0.

200.

220.

465

2.23

Cyt

arab

ine

100

mg

vial

per

via

l1.

753.

633.

834

2.19

Dac

tin

omyc

in0.

5 m

g1

vial

per

via

l11

.00

24.6

027

.68

32.

52

Dau

nor

ubi

cin

20 m

g1

vial

per

via

l5.

846.

00

92.0

53

15.7

7

Doc

etax

el80

mg

1 vi

alp

er v

ial

4211

3.51

346.

164

8.24

Dox

oru

bici

n50

mg

1 vi

alp

er v

ial

8.89

12.4

517

.93

62.

02

Eto

pos

ide

20 m

g/m

lvi

alp

er v

ial

0.49

0.84

1.48

63

Flu

orou

raci

l50

mg/

ml

vial

per

ml

0.17

0.19

0.22

31.

34

Hyd

rox

ycar

bam

ide

500

mg

tab-

cap

per

tab

0.08

0.31

0.50

46.

07

Ifos

fam

ide

1 gm

vial

per

via

l10

.36

14.7

446

.86

44.

52

Mer

cap

top

uri

ne

50 m

gta

b-ca

pp

er t

ab0.

581.

832.

744

4.69

Mes

na

100

mg/

ml

Am

pou

le (4

ml)

per

ml

0.37

0.72

1.08

22.

93

Met

hot

rexa

te25

mg/

ml

vial

per

ml

0.55

1.03

1.33

42.

41

2.5

mg

Tab-

cap

per

tab

0.05

0.10

0.15

63.

11

Pac

lita

xel

6 m

g/m

l1

vial

per

ml

1.88

2.61

8.48

54.

51

Th

iogu

anin

e40

mg

tab-

cap

per

tab

3.92

4.62

5.32

21.

36

Vin

blas

tin

e10

mg

1 vi

alp

er v

ial

7.94

14.7

517

.14

52.

16

Vin

cris

tin

e1

mg

1 vi

alp

er v

ial

1.09

2.33

2.69

42.

46

AD

DIT

ION

AL

ESS

EN

TIA

L A

GE

NT

S

An

astr

ozol

e1

mg

Tab-

cap

p

er t

ab0.

471.

012.

264

4.79

Cis

plat

in

1 m

g/m

lvi

alp

er m

l0.

160.

200.

252

1.6

Mel

phal

an2

mg

tab-

cap

per

tab

0.90

1.41

2.0

03

2.23

Rit

uxi

mab

10 m

g/m

lA

mp

oule

per

ml

35.6

341

.35

47.0

82

1.32

HO

RM

ON

ES

AN

D A

NT

I-H

OR

MO

NE

S

Dex

amet

has

one

4 m

g/m

lA

mp

oule

(1

ml)

per

ml

0.02

0.13

0.4

48

22.0

1

Hyd

roco

rtis

one

100

mg

vial

per

via

l0.

180.

291.

719

9.35

Met

hyl

pre

dn

isol

one

40 m

g/m

lvi

alp

er v

ial

1.65

2.47

3.30

22.

01

Pre

dn

isol

one

5 m

g/5

ml

oral

liqu

idp

er m

l0.

020.

050.

073

2.68

5 m

gta

b-ca

pp

er t

ab0.

005

0.01

0.08

916

.88

Tam

oxif

en20

mg

tab-

cap

per

tab

0.01

0.09

0.20

622

.67

ME

DIC

INE

S U

SED

IN

PA

LL

IAT

IVE

CA

RE

Am

itri

pty

lin

e10

mg

tab-

cap

per

tab

0.01

0.01

0.02

31.

9

25 m

gta

b-ca

pp

er t

ab0.

00

40.

010.

067

15.1

3

Dia

zep

am5

mg/

ml

vial

per

ml

0.0

40.

080.

258

6.77

10 m

gta

b-ca

pp

er t

ab0.

010.

020.

353

24.5

1

Flu

oxet

ine

20 m

gta

b-ca

pp

er t

ab0.

010.

020.

04

72.

79

Ibup

rofe

n10

0 m

g/5

ml

oral

liqu

idp

er m

l0.

003

0.01

0.01

54

200

mg

tab-

cap

per

tab

0.0

030.

010.

015

3.21

Lac

tulo

se3.

35 g

/5 m

lor

al li

quid

per

ml

0.01

0.02

0.02

21.

71

Mid

azol

am5

mg/

ml

amp

oule

per

ml

0.17

0.23

1.32

77.

75

Mor

phin

e10

mg/

ml

amp

oule

per

ml

0.16

0.37

1.90

512

.11

30 m

gSR

tab

-cap

per

tab

0.62

0.97

3.66

45.

93

On

dan

setr

on2

mg/

ml

amp

oule

per

ml

0.11

0.26

1.65

415

.33

4 m

gta

b-ca

pp

er t

ab0.

020.

190.

953

51.1

2

3

All prices are expressed in unit cost such as per tablet or per millileter. The high/low ratio compares the highest unit price with the lowest. For example, a high/low ratio of 6 means that the highest unit price is six times greater than the lowest unit price. Of the 42 agents listed in the table, 10 medicines have extreme price variations (high/low ratio) of over 10. For example, the highest unit price for dexamethasone is 22 times the lowest price. Seven medicines have a high/low ratio of over 5 but below 10. A large high/low ratio can indicate an opportunity for cost savings. If buyer A can see he is paying eight times as much for the same product as buyer B, he can use that information to negotiate for a lower price or find another source from which to purchase.

The inTeRnaTional dRug PRiCe indiCaToR guide

The International Drug Price Indicator Guide provides what the name implies – an indication of medicine prices on the international market. The Guide has been published by MSH since 1986, and in collaboration with WHO since 2000. It provides a spectrum of prices from nonprofit drug suppliers and commercial procurement agencies, based on their current catalogs or price lists. It also contains prices obtained from international development agencies and government agencies. MSH and WHO are working with partners to make existing medicine price information more widely available to improve procuring medicines of assured quality for the lowest possible price. This will contribute to equitable access to health services and commodities necessary for the prevention and treatment of prevalent diseases.

Because the cost of providing a full range of treatments for common diseases could potentially be high, prices and financing are inescapable factors in determining access to essential medicines. When price ranges can be reviewed and compared, lower prices can be obtained through bulk purchasing, competition, skillful negotiation, and sound supply management. Such information helps in price negotiations, in locating new supply sources, and in assessing the efficiency of local procurement systems.

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The International Drug Price Indicator Guide helps supply officers determine the probable cost of pharmaceutical pro-ducts for their programs. It can be used as a reference list to compare current prices paid to prices for products available on the international market; it can also be used to assess the potential financial impact of changes to a pharmaceu-ticals list. The Guide is intended as a comparative reference only; it is not suitable for actually ordering products. Prices from buyers are listed for comparison purposes only. The 2010 edition includes more than 1,100 items and has prices from 26 sources.

RefeRenCes

1. World Health Organization. 2011. Fact Sheet No. 297 on Cancer. Geneva: WHO. http://www.who.int/mediacentre/factsheets/fs297/en/index.html accessed 17 October, 2011.

2. Aziz, Z. 2008. Across generations: cancer treatment in developing coun-tries. Journal of Clinical Oncology 26:4990-91.

3. Milani, B. and W. Scholten. 2011. Access to Controlled Medicines. The World Medicines Situation. Geneva: WHO.

4. Twagirumukiza, M., L. Annemans, J. G. Kips, et al. 2010 JG, 2010. Prices of antihypertensive medicines in sub-Saharan Africa and alignment to WHO’s model list of essential medicines. Tropical Medicine & Interna-tional Health 15:350-61.

5. Management Sciences for Health. 2010. International Drug Price Indi-cator Guide. Quality Standards. http://erc.msh.org/mainpage.cfm?file=2.4.cfm&id=5541&temptitle=Quality%20standards&module =DMP&language=English. accessed 17 October, 2011.

Cancer Medicine PricesIN LOW- AND MIDDLE- INCOME COUNTRIES

Global Task Force on Expanded Access to Cancer Care and Controlin Developing Countries (GTF.CCC)

Harvard Global Equity Initiative, Secretariat651 Huntington Avenue

FXB Building, Room 632Boston, MA 02115

gtfccc.harvard.edu gtfccc@harvard.edu

About Management Sciences for Health Management Sciences for Health (MSH) is a global nonprofit health organization, using proven approaches developed over four decades to help leaders, health managers, and communities in developing nations build stronger health systems for greater health impact. We work to save lives by closing the gap between knowledge and action in public health Most of the leading causes of death and disability in developing countries can be prevented or treated with cost-effective medicines. Despite this fact, hundreds of millions of people do not have access to these medicines. Improving the way medicines are accessed and used is a powerful opportunity to create stronger health systems and achieve greater health impact. Management Sciences for Health’s Center for Pharmaceutical Management develops the capacity of both the public and private sectors to select, procure, and distribute quality medicines and health supplies and helps to ensure their proper dispensing and use–all in a cost-effective way.

About The Global Task Force on Expanded Accessto Cancer Care and Control in Developing Countries

The mandate of The Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries (GTF.CCC) is to design, implement and evaluate innovative, multi-stakeholder strategies for expanding access to cancer prevention, detection and care. Through local partners, the GTF.CCC supports implementation of innovative service in delivery models that can provide evidence for scaling up access to cancer care and control, and strengthening health systems in developing countries.