India has a huge burden of cancer with 1.45 million new cases reported in 2016, a number expected to grow at a rate of 4-5 percent annually. Approximately 70 percent of cases are reported at a late stage of disease. There is suboptimal access to quality cancer care in India, with the majority of cancer patients traveling long distances to be treated in centers of excellence.
In Tata Memorial Centre, Mumbai, Maharashtra, the majority of cancer patients were from other states of India. This leads to high out-of-pocket expenses for patients and their caregivers due to travel costs, which in turn translates to high drop-out rates before completion of treatment. A study in 2015 found that 42.6 percent of all patients that dropped out did so due to financial or logistical reasons.
Low levels of public health care expenditure, approximately 1.4 percent of gross domestic product, and lack of insurance coverage are major factors that result in high health care costs for individuals and their families. Health insurance penetration levels in India stand at an abysmally low rate of 27 percent as against 100 percent coverage insured under publicly financed health care systems in developed economies such as the United Kingdom. The current public insurance scheme of central government in India has been unsuccessful in enrolling households and has hardly had any effects on financial protection.
Decentralize health care facilities
In order to change the current cancer care landscape in India, the Tata Trusts — one of India’s oldest, nonsectarian philanthropic organizations, which deploys funds towards a whole range of community development programs across — is working in partnership with multiple state governments and central government to roll out a step-down, distributed cancer-care model.
The first state to reach implementation stage is Assam, where the program is jointly funded by the government of Assam and Tata Trusts. A similar model of funding and partnership will be followed for the other states. The aim of the program is to create patient-centric cancer institutions across India, to deliver uniform, high quality and affordable care closer to patients’ homes.
“The aim of the [Tata Trusts Cancer Care] program is to create patient-centric cancer institutions across India, to deliver uniform, high quality, accessible and affordable care closer to patients’ homes.”—
In this model, smaller centers interlinked with the apex centers through a technology backbone, will handle diagnosis and care delivery. A common hospital information management system will be deployed across the centers that will feed data into a central command center to direct patient flow depending upon the proximity of the patient to the center and utilization of hospital assets. Telepathology and teleradiology systems will be used for remote diagnosis. This will result in shifting the load away from apex hospitals, providing quality cancer care closer to home, thereby reducing out-of-pocket expenses for cancer patients.
The infrastructure development is being underpinned by major programs in health promotion, cancer awareness, prevention, screening, and early detection, thereby shifting the stage of first presentation of the disease from late stage to early-stage cancer. This will result in reduction of mortality, and cost savings for the health care system that can then be passed on to the patients in terms of lower insurance premium or lower cost of procedures for the uninsured.
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Furthermore, the private health insurance industry in India is at a nascent stage, with a penetration level of 5 percent, which is nearly half of the 11 percent in the U.K., where health care is publicly financed. As a result of poor penetration of the public insurance schemes, in 2013-14, household health expenditure in India was estimated at 2.72 percent of GDP and accounted for 67.74 percent of total health expenditure.
Increase access to affordable cancer medication
A significant part of cancer patient’s expenditure is medicines. A study of cancer drug prices in seven countries found the lowest drug prices were in India and South Africa. But after calculating price as a percentage of wealth adjusted for the cost of living, cancer drugs appeared to be least affordable in India and China.
In terms of ability to pay, the study found cancer drugs to be most affordable in Australia, where generic drugs were priced at 3 percent of “domestic product per capita at purchasing power parity,” while patented drugs were 71 percent. In India, the cost of generics was 33 percent of that measure, while patented drugs were 313 percent.
A recent exercise in price comparison of drugs was conducted in four hospitals in India. The analysis revealed that not only are there interhospital price variations for the same product — molecule, dosage, presentation — but there are also peculiarities in variations in intrahospital prices. Based on this piece of work a “price discovery cell” has been set up between the Tata Trusts and the National Cancer Grid, a partnership of 140 cancer institutions and stakeholders. Its aim is to first, promote informed buying by hospitals by sharing drug price information across all members; and secondly, consolidate buying by pooling demand across the hospitals, leading to economies of scale.
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Although the government has regulated pricing policy of drugs in India, loopholes are yet to be addressed. The Drugs Price Control Order is issued by the National Pharmaceutical Pricing Authority to declare a ceiling price for essential and lifesaving medicines, to ensure that these medicines are available at a reasonable price to the general public.
A study by NPPA found that manufacturers introduced variants of essential drugs under the National List of Essential Medicines, with slight modifications, and new names to avoid being under price control. Stricter control over pricing and changing the rationale of pricing from average of existing maximum retail price of various brands to cost-plus model for essential drugs would be an ideal strategy, especially in the largely uninformed and fragmented health care market in India.
Cut inefficiencies to improve supply chain
Another factor adding to the cost of drugs and consumables in India is the fragmented and inefficient supply chain, where a drug generally goes through a multilayered combination of central warehouses, clearing and forwarding agents, distributors, stockists, wholesalers, pharmacies, and hospitals, before reaching the patient.
As a percentage of cost of goods sold, the average supply chain cost of the pharma industry in India is 25 percent and the “best-in-class” pharma in India has a cost of 18 percent as compared to 10 percent for both best-in-class pharma and best-in-class fast-moving consumer goods, globally. Hence, pharma companies in India need to establish centralized distribution systems to cut out the inefficiencies, ensure on-time delivery, and improve access as a whole for their drugs to penetrate the Indian market.
Look to future research
Importantly, research is an integral part of clinical care across the patient pathway. Cancer Research UK and the Indian government’s Department of Biotechnology plan to launch a five-year bilateral research initiative in late 2018, which will focus on affordable approaches to cancer. This seeks to address the growing global challenges related to affordability of cancer prevention and care, and will encompass research areas across the cancer pathway, including innovative approaches to identifying risk factors, early detection and diagnosis, and treatment options.
Given the high incidence of cancer, the inadequate number of cancer treatment centers and the high treatment cost, it is imperative that development organizations integrate their efforts in cancer control with the public health care system. As the incidence of cancer patients increases, the need to bring cancer care closer to patients becomes essential.
Cancer care needs to be embedded in the community through a distributed care delivery system, thereby rendering long periods of hospitalization unnecessary. In order to achieve these goals, innovation in a model of distributed cancer care, intensive efforts towards cancer prevention and early detection, and radical new policies on procurement and pricing of medical consumables and drugs are just a few measures that are necessary to make cancer care accessible and affordable in India and other LMICs.
Editor’s note: This guest column has been co-authored by A. Purushotham (Tata Trusts Cancer Care Program and King’s College London); S. Sarvesh, R. Kanodia, R. Venkataramanan, and O. Kunal (Tata Trusts Cancer Care Program); and C.S. Pramesh (Tata Memorial Hospital).
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