Yacine Sellam, president of the Algerian Society for Regulatory Affairs & Pharmacoeconomics, outlines the progress made under Algeria’s National Cancer Plan and the steps that still need to be taken to ensure all Algerian cancer patients can receive the care they need.
It is undeniable that tangible progress has been achieved in the framework of Algeria’s 2015-2019 National Cancer Plan
It is undeniable that tangible progress has been achieved in the framework of Algeria’s 2015-2019 National Cancer Plan (NCP), both in terms of cancer treatment infrastructures (41 services and 77 chemotherapy units across the country) and health facilities (53 radiotherapy accelerators, including 10 in the private sector). The category of drugs has not been left behind, since in recent years there has been a more regular availability of chemotherapy products, while the overall bill for their acquisition sharply increased, especially with the entry into service of new anti-cancer centres (four others coming soon in El Oued, Adrar, Béchar and Laghouat). This bill amounted to DZD 63 billion (USD 530 million) in 2018, or 59 percent of the total purchases of the Central Pharmacy Hospital (PCH), according to statistics provided by the Ministry of Health.
In order to rationalize pharmaceutical expenditure, the 2015-2019 NCP advocated the adoption of therapeutic consensus for the most frequent cancers (Axis 8, Objective 1, Action 1.2, Measure 4), as well as the creation of a cancer national committee for periodic updating of the different therapeutic guides and creation of new guides, if necessary (Axis 4, Objective 1, Action 1.1, Measure 6). However, except for the six guides released in February 2016 (breast, colon, rectal, bronchopulmonary, prostate and cervical cancers), which have not yet been updated, no new guide has been developed by experts, even though the introduction of immunotherapy has been announced for 2019 for at least three locations (non small cells bronchopulmonary cancer, melanoma-type skin cancer, and bladder and excretory pathways cancers).
The registration in early 2018 of two immunotherapy drugs (Pembrolizumab and Nivolumab) in Algeria, and their promising results in several types of advanced cancers, have raised new expectations for both oncologists and patients. Nevertheless, these expectations are penalized in view of the very expensive price (DZD 2,700,000 to 13,500,000 (USD 22,700 to 113,700) /patient/year) which reminds the reality of the budgetary constraints and the necessity for supervision of their use. Some would like to expand the prescriptions of these two innovative drugs to all 21 anti-cancer centres in the country. However, immunotherapy is associated with adverse effects of immunological origin, the occurrence of which should make it possible to consider modification, suspension or even the final cessation of treatment. Therefore, only eligible patients should be prescribed these therapies by qualified and experienced oncologists (according to indications approved in Algeria), and should be monitored continuously during treatment and up to five months after the last dose.
Currently, the approach that is making its way is to “provide” immunotherapy at five or six regional centres only (Algiers, Oran and Constantine for the North, El Oued, Adrar and possibly Laghouat for the South), even if there is still the problem of patient transportation and endorsement of the costs of these treatments (institution budget, PCH grant or special funds). In various respects, multidisciplinary consultation meetings could serve as a basis for the prescription of these two innovative drugs, so that this decision is discussed on a case by case basis, but these meetings, yet defended in the 2015-2019 NCP, are slow to see the day. It has been reported that patients were prescribed, in the absence of such multidisciplinary consultation, targeted therapies (of a DZD 29 billion (USD 244 million) total cost in 2018, i.e. 46 percent of expenditures for anticancer drugs) for lesions that were not metastases, based on the report of a radiologist alone.
Unfortunately, the financing of immunotherapy for the benefit of all eligible patients cannot be made possible, given the means already committed in the fight against cancer, without the reduction of inefficient expenditure and waste (example of targeted therapies above). Biosimilars, where they exist, can also allow savings on the costs of targeted therapies that would then be reinvested in immunotherapy. For the same purpose, the savings that can be made in relation to preventable cancers, especially those related to smoking and those that can be prevented by vaccination (cervical cancer), are also necessary for these same purposes. Additional savings on care costs could also be achieved by detecting cancers earlier (lower treatment costs with higher chances of success) through the spread of awareness and organized early detection campaigns throughout the country (in 2019, pilot projects against breast cancer in seven provinces: Biskra, Laghouat, Jijel, Tlemcen, Constantine, Tipasa and Boumerdes, and against colorectal cancer in five provinces: Batna, Annaba, Bejaia, Boumerdès and Sidi Bel Abbès).
Finally, at the core of the topic, and except the “admitted” fact that these therapies should benefit the patients of all 48 provinces in Algeria, the public payers cannot vouch for the payment of expenses generated by the use of immunotherapy without sufficient guarantees of treatment success, knowing their budgetary impact and consequences on the financial equilibrium of the anti-cancer centres and especially the PCH, as well as on the drug import bill (annual treatment costs per patient of at least EUR 20,000 (USD 22,750) with Nivolumab and up to EUR 100,000 (USD 113,750) with Pembrolizumab).
As such, the performance contracts introduced in the 2017 Finance Law (and whose implementation texts are slow to be promulgated) which provide for the back payment by the pharmaceutical companies in the event of therapeutic failure of the amounts covered by the social security for “very expensive” drugs, should immediately be extended, as a mandatory condition, to immunotherapy products which are the first to meet this definition. In fact, unlike drugs dispensed via community pharmacies (which are few in the treatment of cancer), which must first go through the reimbursement approval process, most of the approved anticancer drugs that are acquired via the hospital circuit are automatically converted into PCH purchase orders, as long as there is prescription (even for non-approved indication), without any right to look at the therapeutic results.
Original article (in French) published in El Watan newspaper on February 17th, 2019: https://www.elwatan.com/pages-hebdo/sante/immunotherapie-anticancereuse-entre-progres-therapeutique-et-contraintes-budgetaires-17-02-2019