Chemotherapy Medications in Sub-Saharan Africa: Availability, Pricing, Affordability, and Predictors of Quality.

Abstract

We assessed the availability, price, and affordability of commonly used chemotherapy medications in Cameroon, Ethiopia, Kenya, and Malawi. We also examined the characteristics that could predict chemotherapy medication quality. Samples of seven commonly used chemotherapy medications were collected: cisplatin, cyclophosphamide, doxorubicin, ifosfamide, leucovorin, methotrexate, and oxaliplatin. Stockouts and medicine prices were recorded at public national hospitals and community pharmacies. Using the National Comprehensive Cancer Network's harmonized guidelines for sub-Saharan Africa, we estimated the costs of medications to treat early-stage breast cancer, colorectal cancer (CRC), and head and neck cancer. Every sample was tested for quality using high-performance liquid chromatography against USP standards. We ran logistic regressions to assess medicine characteristics that could predict substandard and falsified chemotherapy medications. Stockouts of chemotherapy medications in public hospitals were observed in three of four countries. Other than in Malawi where medications are free when available in the public sector, chemotherapy medications were unaffordable, costing government worker salary equivalents of 47-242 days, 233-869 days, and 22-196 days to treat early-stage breast cancer, CRC, and head and neck cancer, respectively. On average across the population, $36 US dollars (USD) (95% CI, $50 USD to $134 USD, 9%-25% of medication cost) was spent on poor-quality medicines for treatment of breast cancer, $32 USD (95% CI, $6 USD to $214 USD, 0.5%-17%) for CRC, and $15 USD (95% CI, $4 USD to $49 USD, 2%-21%) for head and neck cancer. Price of the medication, public/private source, and medicine registration status were poor predictors of medicine quality. We found that medicines for cancer treatment are unaffordable without government subsidies. Moreover, poor-quality chemotherapy medicines are hard to detect without chemical testing. Government policies and supply chain practice changes are needed to improve the availability, affordability, and quality of chemotherapy medications in sub-Saharan Africa.