Financing Strategies to Facilitate Access to High-Cost Anticancer Drugs: A Systematic Review of the Literature

Document Type : Review Article


1 Department of Social and Administrative Pharmacy, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand

2 Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Landmark Center, Boston, MA, USA


Each country manages access to anticancer drugs differently due to variations in the structure and financing of the health system, but a summary of the various strategies used is absent. This study aimed to review and summarize financing strategies implemented across countries to facilitate access to high-cost anticancer drugs.
We conducted a systematic review of articles referenced in PubMed, Embase, and Web of Science through May 12, 2021. Articles published in the English language from 2000 that describe strategies implemented in different countries to facilitate access to high-cost anticancer drugs were included. Letters, news articles, and proposed strategies were excluded. Quality assessment was not performed as we aimed to summarize the strategies. Data were analyzed by thematic analysis. A review protocol was registered at PROSPERO (CRD42018068616).

The review included 204 studies from 176 countries. Three themes of financing strategies were identified: (1) Basic pharmaceutical reimbursement and pricing policies, (2) Alternative funding strategies specific to high-cost drugs, and (3) Financial assistance for individual patients. Access in most countries depends mainly on basic pharmaceutical reimbursement policies (165 of 176 countries). Apart from that, high-income countries (HICs) tended to use funding strategies targeting high-cost drugs (72% of HICs vs 0%-24% of the rest), such as managed entry agreements (MEAs) or dedicated funds for high-cost drugs. In contrast, lower-income countries tended to implement financial assistance programs for cancer patients as a tool to increase access (32% of HICs vs 62%-79% of the rest).

Many countries have implemented a combination of strategies to increase access to high-cost anticancer drugs. Most low- and middle-income countries utilized placement of anticancer drugs on a national list of essential medicines and patient assistance programs (PAPs) to facilitate access, while many HICs implemented a broader range of strategies.


  1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394-424. doi:3322/caac.21492
  2. Ruiz R, Strasser-Weippl K, Touya D, et al. Improving access to high-cost cancer drugs in Latin America: much to be done. Cancer. 2017;123(8):1313-1323. doi:1002/cncr.30549
  3. Meropol NJ, Schrag D, Smith TJ, et al. American Society of Clinical Oncology guidance statement: the cost of cancer care. J Clin Oncol. 2009;27(23):3868-3874. doi:1200/jco.2009.23.1183
  4. Leighl NB, Nirmalakumar S, Ezeife DA, Gyawali B. An arm and a leg: the rising cost of cancer drugs and impact on access. Am Soc Clin Oncol Educ Book. 2021;41:1-12. doi:1200/edbk_100028
  5. de Lima Lopes G Jr, de Souza JA, Barrios C. Access to cancer medications in low- and middle-income countries. Nat Rev Clin Oncol. 2013;10(6):314-322. doi:1038/nrclinonc.2013.55
  6. Patikorn C, Taychakhoonavudh S, Thathong T, Anantachoti P. Patient access to anticancer medicines under public health insurance schemes in Thailand: a mixed methods study. Thai J Pharm Sci. 2019;43(3):168-178.
  7. Ghinea N, Little M, Lipworth W. Access to high cost cancer medicines through the lens of an Australian senate inquiry-defining the "goods" at stake. J Bioeth Inq. 2017;14(3):401-410. doi:1007/s11673-017-9800-2
  8. Faden RR, Chalkidou K, Appleby J, Waters HR, Leider JP. Expensive cancer drugs: a comparison between the United States and the United Kingdom. Milbank Q. 2009;87(4):789-819. doi:1111/j.1468-0009.2009.00579.x
  9. Sruamsiri R, Ross-Degnan D, Lu CY, Chaiyakunapruk N, Wagner AK. Policies and programs to facilitate access to targeted cancer therapies in Thailand. PLoS One. 2015;10(3):e0119945. doi:1371/journal.pone.0119945
  10. Pauwels K, Huys I, Casteels M, De Nys K, Simoens S. Market access of cancer drugs in European countries: improving resource allocation. Target Oncol. 2014;9(2):95-110. doi:1007/s11523-013-0301-x
  11. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:1136/bmj.n71
  12. World Bank. World Bank Country and Lending Groups. 2021; Accessed May 27, 2021.
  13. Cherny N, Sullivan R, Torode J, Saar M, Eniu A. ESMO European Consortium Study on the availability, out-of-pocket costs and accessibility of antineoplastic medicines in Europe. Ann Oncol. 2016;27(8):1423-1443. doi:1093/annonc/mdw213
  14. Cherny NI, Sullivan R, Torode J, Saar M, Eniu A. ESMO International Consortium Study on the availability, out-of-pocket costs and accessibility of antineoplastic medicines in countries outside of Europe. Ann Oncol. 2017;28(11):2633-2647. doi:1093/annonc/mdx521
  15. Cuomo RE, Mackey TK. The availability of essential cancer medication: an analysis of national formularies. J Cancer Policy. 2017;12:49-54. doi:1016/j.jcpo.2017.03.010
  16. Shafie AA, Chandriah H. Access to cancer drugs: are we meeting the needs of Malaysian? J Cancer Policy. 2017;13:30-32. doi:1016/j.jcpo.2017.07.003
  17. Milliken D, Venkatesh J, Yu R, Su Z, Thompson M, Eurich D. Comparison of drug coverage in Canada before and after the establishment of the pan-Canadian Pharmaceutical Alliance. BMJ Open. 2015;5(9):e008100. doi:1136/bmjopen-2015-008100
  18. Goss PE, Strasser-Weippl K, Lee-Bychkovsky BL, et al. Challenges to effective cancer control in China, India, and Russia. Lancet Oncol. 2014;15(5):489-538. doi:1016/s1470-2045(14)70029-4
  19. Menon D, Stafinski T, Stuart G. Access to drugs for cancer: does where you live matter? Can J Public Health. 2005;96(6):454-458. doi:1007/bf03405189
  20. World Health Organization (WHO). WHO Model List of Essential Medicines, 20th list (March 2017, Amended August 2017). WHO; 2017.
  21. Neumann PJ, Bliss SK, Chambers JD. Therapies for advanced cancers pose a special challenge for health technology assessment organizations in many countries. Health Aff (Millwood). 2012;31(4):700-708. doi:1377/hlthaff.2011.1309
  22. Karikios DJ, Chim L, Martin A, et al. Is it all about price? why requests for government subsidy of anticancer drugs were rejected in Australia. Intern Med J. 2017;47(4):400-407. doi:1111/imj.13350
  23. Kim ES, Kim JA, Lee EK. National reimbursement listing determinants of new cancer drugs: a retrospective analysis of 58 cancer treatment appraisals in 2007-2016 in South Korea. Expert Rev Pharmacoecon Outcomes Res. 2017;17(4):401-409. doi:1080/14737167.2017.1276828
  24. Ferrario A. Time to entry for new cancer medicines: from European Union-wide marketing authorization to patient Access in Belgium, Estonia, Scotland, and Sweden. Value Health. 2018;21(7):809-821. doi:1016/j.jval.2018.01.003
  25. McGuire A, Drummond M, Martin M, Justo N. End of life or end of the road? are rising cancer costs sustainable? is it time to consider alternative incentive and funding schemes? Expert Rev Pharmacoecon Outcomes Res. 2015;15(4):599-605. doi:1586/14737167.2015.1039518
  26. Russo P, Mennini FS, Siviero PD, Rasi G. Time to market and patient access to new oncology products in Italy: a multistep pathway from European context to regional health care providers. Ann Oncol. 2010;21(10):2081-2087. doi:1093/annonc/mdq097
  27. Pauwels K, Huys I, Vogler S, Casteels M, Simoens S. Managed entry agreements for oncology drugs: lessons from the european experience to inform the future. Front Pharmacol. 2017;8:171. doi:3389/fphar.2017.00171
  28. Cohen J, Malins A, Shahpurwala Z. Compared to US practice, evidence-based reviews in Europe appear to lead to lower prices for some drugs. Health Aff (Millwood). 2013;32(4):762-770. doi:1377/hlthaff.2012.0707
  29. Mihajlović J, Dolk C, Tolley K, Simoens S, Postma MJ. Reimbursement of targeted cancer therapies within 3 different European health care systems. Clin Ther. 2015;37(2):474-480. doi:1016/j.clinthera.2014.12.005
  30. Ferrario A, Arāja D, Bochenek T, et al. The implementation of managed entry agreements in Central and Eastern Europe: Findings and Implications. Pharmacoeconomics. 2017;35(12):1271-1285. doi:1007/s40273-017-0559-4
  31. Grover P, Babar ZU, Oehmen R, Vitry A. Medicines access programs to cancer medicines in Australia and New Zealand: an exploratory study. Health Policy. 2018;122(3):243-249. doi:1016/j.healthpol.2017.12.004
  32. Blommestein HM, Franken MG, Verelst SG, van Agthoven M, Huijgens PC, Uyl-de Groot CA. Access to expensive cancer drugs in Dutch daily practice: should we be concerned? Neth J Med. 2014;72(4):235-241.
  33. Pace J, Ghinea N, Kerridge I, Lipworth W. Demands for access to new therapies: are there alternatives to accelerated access? BMJ. 2017;359:j4494. doi:1136/bmj.j4494
  34. Zhang Y, Hueser HC, Hernandez I. Comparing the approval and coverage decisions of new oncology drugs in the United States and other selected countries. J Manag Care Spec Pharm. 2017;23(2):247-254. doi:18553/jmcp.2017.23.2.247
  35. Morrell L, Wordsworth S, Fu H, Rees S, Barker R. Cancer drug funding decisions in Scotland: impact of new end-of-life, orphan and ultra-orphan processes. BMC Health Serv Res. 2017;17(1):613. doi:1186/s12913-017-2561-0
  36. Löblová O, Csanádi M, Ozierański P, Kaló Z, King L, McKee M. Patterns of alternative access: unpacking the Slovak extraordinary drug reimbursement regime 2012-2016. Health Policy. 2019;123(8):713-720. doi:1016/j.healthpol.2019.05.021
  37. den Exter A. Fighting excessive pharmaceutical prices: evaluating the options. Eur J Health Law. 2020;28(1):68-80. doi:1163/15718093-bja10004
  38. Haitsma G, Patel H, Gurumurthy P, Postma MJ. Access to anti-cancer drugs in India: is there a need to revise reimbursement policies? Expert Rev Pharmacoecon Outcomes Res. 2018;18(3):289-296. doi:1080/14737167.2018.1444479
  39. Dusetzina SB, Keating NL. Mind the gap: why closing the doughnut hole is insufficient for increasing Medicare beneficiary access to oral chemotherapy. J Clin Oncol. 2016;34(4):375-380. doi:1200/jco.2015.63.7736
  40. Lassarat S, Jootar S. Ongoing challenges of a global international patient assistance program. Ann Oncol. 2006;17 Suppl 8:viii43-viii46. doi:10.1093/annonc/mdl987
  41. Umeh CA, Garcia-Gonzalez P, Tremblay D, Laing R. The survival of patients enrolled in a global direct-to-patient cancer medicine donation program: The Glivec International Patient Assistance Program (GIPAP). EClinicalMedicine. 2020;19:100257. doi:1016/j.eclinm.2020.100257
  42. Lee AW, Sze H, Lam KO, Chen X. A tale of two cities in China: Hong Kong and Shenzhen. Int J Radiat Oncol Biol Phys. 2014;89(4):704-708. doi:1016/j.ijrobp.2013.12.053
  43. Egerton NJ. In-office dispensing of oral oncolytics: a continuity of care and cost mitigation model for cancer patients. Am J Manag Care. 2016;22(4 Suppl):S99-S103.
  44. Mitchell A, Muluneh B, Patel R, Basch E. Pharmaceutical assistance programs for cancer patients in the era of orally administered chemotherapeutics. J Oncol Pharm Pract. 2018;24(6):424-432. doi:1177/1078155217719585
  45. Lakdawalla DN, Doshi JA, Garrison LP Jr, Phelps CE, Basu A, Danzon PM. Defining elements of value in health care-a health economics approach: an ISPOR Special Task Force report [3]. Value Health. 2018;21(2):131-139. doi:1016/j.jval.2017.12.007
Volume 11, Issue 9
September 2022
Pages 1625-1634
  • Receive Date: 05 October 2020
  • Revise Date: 19 September 2021
  • Accept Date: 21 September 2021
  • First Publish Date: 22 September 2021