India’s Cancer Medicine Crisis
The prognosis could not be worse for India. Saddled with a crumbling public healthcare system, low levels of health spending and a prohibitively expensive private healthcare sector, India already faces formidable challenges in combating communicable diseases and seasonal epidemics. Add to this precarious health system, the burden of painful, expensive and life threatening cancers, as well as other noncommunicable diseases like diabetes and the healthcare needs of the elderly and the situation becomes alarming.
Can India cope with this?
As Indians age, health needs are changing
Not at all, going by current preparedness. An ageing population is more vulnerable to cancers. In 2011, the percentage of India’s population over the age of 65 was 4.8, not high by world standards but as India’s population already well over one billion it represents a huge number of people. India’s National Cancer Registry Programme, recording new cancer cases through its network of cancer registries, estimated almost one million new cancers in 2008 (946,172) and this number is rising rapidly and is expected to hit 1.2 million in 2020.
India is not alone in witnessing the rapid rise of cancers. Changing lifestyles, a toxic environment and a host of other risk factors have seen a dramatic growth in the disease across the world. Dr Siddhartha Mukherjeee, author and cancer specialist, has pointed out the link in India between the prevalence of cancer and its causes like exposure to asbestos, aluminum and other carcinogenic substances. In Punjab, at least, the green revolution with its extensive use of pesticides and artificial fertilizers together with the widespread introduction of new, intensive crops, has contributed to the increasing incidence of many diseases including cancers. In just three decades, the nation’s granary was reduced to an arid desert and it’s once sturdy people rendered sick.
Treatment and care out of reach
The rapid increase in cancers and other noncommunicable diseases coincided with the burgeoning growth in the drug industry in India and a boom in medical education that delivered doctors into the lucrative private healthcare system. As drug firms and medical equipment companies grew and formed cartels, super-specialty hospitals also started appearing across the country. These expensive, private hospitals have become an obstacle in the way of affordable and effective cancer drugs. Without the ability to pay, their care and the promise of effective treatment, remains out of reach of the bulk of India’s patient population.
Screening, diagnosis, treatment and pain relief
In India, the screening, diagnosis, treatment and care for cancer are not yet close to meeting current demand, let alone expected demand in the future. For a country like India, with its myriad health priorities, in any consideration of access to cancer treatments, both the cost as well as the complexity of treatment need to be taken into account. Access to cancer treatment must also include measures to make sure that people have access to early diagnosis as well as low-cost quality drugs for cancer.
The high price of many new cancer drugs is a global challenge for rich and poor alike, with health technology assessment and health insurer clauses often serving to restrict access to new drugs the US and Europe. In India it is literally a matter of life and death. There are proven older treatments as well as more recent products like dasatinib, docetaxel, erlotinib, imatinib, letrozole and trastuzumbab. Of these, only imatinib, used in the treatment of multiple cancers and on the WHO list of essential medicines, is on the National List of Essential Medicines in India. Three of these six medicines, deocetaxel, letrozole and trastuzumab, are for the treatment of breast cancer, the fastest growing cancer in India. Not only is chemotherapy barely accessible for most Indians, essential drugs for pain management are not easily available to cancer patients thanks to archaic rules and byzantine bureaucracy. Without access to morphine, many cancer patients suffer the last days of their lives in excruciating pain.
A national strategy is needed
Given the increasing incidence of cancers, India badly needs a national cancer strategy and a policy for early prevention, early detection and diagnosis as well as treatment and management of the disease. The payment for nursing care is of particular importance as for the majority of Indians, as a cancer diagnosis could well mean a slip into crushing poverty.
According to the Indian Commission on Macroeconomic and Health Financing, up to 70 per cent of payment for healthcare comes from household budgets. Because most Indians are self-financing, a comprehensive cancer prevention strategy has to address the issue of drug pricing. The good news is that increasing access through lowering prices may not be so far away. India has many important domestic pharmaceutical companies which can produce quality low-cost cancer drugs. And to top it all, the prices of cancer drugs may come down in the coming months. The National Pharmaceutical Pricing Authority has begun its review process to bring more drugs within price controls. This is aimed at bringing more drugs under the essential list which is covered by the National List of Essential Medicines.
The pharma companies are not too thrilled by all this. According to DG Shah, the secretary general of the Indian Pharmaceutical Alliance, quoted in the Hindustan Times, “Whatever decision the government will take, it has to consider the interest of both – the patient and the industry.”
Pricing and licensing
A study of drug pricing with improved access to cancer medication for use in a national healthcare system will help create markets for essential cancer products, many of which are not patented in India. India also needs to make use of the waivers introduced in the Doha Declaration regarding the Trade Related Intellectual Property Rights (TRIPS) accord, and frame policies that could encourage access to vital medicines and make universal health care a reality. The formulation of an essential cancer drugs list will also help give direction to India’s IP policies. This will allow its generic pharma companies to engage in forward planning. By tapping into the indigenous industry to produce more drugs and deliver innovations could cut the costs of cancer treatment enormously and also encourage a healthy competition among the traditional medicinal systems. As of now, India has signaled that it is willing to provide compulsory licences for patented cancer drugs. The choice of candidates for compulsory licensing should be based on health needs, which must be spelt out in a national policy. Compulsory licences for the production of generic cancer drugs should also cover export to countries that lack access to these medicines.
Action is needed now
The Indian government really needs to focus on this subject. The figures available at the moment are frightening. Breast cancer is expected to rise from over 95,000 new cases in 2010 to almost 125,000 new cases by 2020. Leukaemias will also increase dramatically with 18,500 new cases of lymphoid leukemia and 35,000 new cases of myeloid leukaemia expected by 2020. And these figures are likely to be gross under-estimates as many cases remain undiagnosed a they fall between the many cracks in the public healthcare system.
All this adds up to a serious challenge to India’s overburdened health care system which is understaffed and underfunded even when it comes to dealing with common ailments.There is a pressing need for education, diagnosis and specialist medical staff and the government health ministry to step up the pace to deliver and implement a national cancer strategy. Resources to support cancer services must be made available to public healthcare and more cancer drugs need to be on the essential drug list. What the future holds for India’s many new cancer patients will depend on the willingness and commitment of central government to act quickly and avert a national cancer catastrophe.
 The Ministry of Statistics and Programme Implementation, Government of India. Estimate for 2020 1,148,758 new cases of cancer.