Determinants of access to anticancer medicines in South Asia: a multimethod study

OBJECTIVE: South Asia bears a high cancer burden, low universal health coverage and high out-of-pocket expenditure. Access to anticancer medicines is challenging and is influenced by determinants-National Essential Medicines List (NEML), registration and local production-yet these are rarely evaluated. This study evaluates these determinants in eight South Asian countries. DESIGN: Multimethod study using a document analysis phase and semistructured interviews. SETTING: Eight South Asian countries (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka) for document analysis, with stakeholder interviews conducted in six countries, excluding Bhutan and Maldives. PARTICIPANTS: Data were collected from eight regulatory authorities and 30 interviews with drug supply chain stakeholders across six South Asian countries. MAIN OUTCOME MEASURES: The inclusion of 67 anticancer medicines from the 2023 WHO Essential Medicines List (EML) into NEML, their registration and local production, along with macrolevel indicators and stakeholders' perspectives regarding them. RESULTS: The median number of medicines included in NEMLs, registered and locally produced was 23.5, 45 and 6.5, respectively. Local production correlated positively with NEML inclusion (ρ=0.884, p=0.004) and negatively with healthcare expenditure (r = -0.732, p=0.039). Three countries listed >50% of the WHO EML medicines on their NEMLs; six had >50% registered. Local production remained limited, with imports dominating supply. Qualitative analysis identified three key barriers to improving availability: financial constraints, a weak regulatory system and insufficient strategic planning. CONCLUSIONS: Access to anticancer medicines is constrained by systemic misalignment between NEML inclusion, registration and local production, undermined by weak regulatory coordination, limited strategic planning and financial constraints. Strengthening regulatory coordination, improving registration efficiency and supporting regional production strategies aligned with guided WHO guidance may help improve equitable access to cancer medicines in the region.