The ACCESS EA study revealed variable patterns of cytotoxic and supportive care medicine availability between May 1, 2020, and Jan 31, 2022. Stockouts were evident at both urban and rural sites, academic and community hospitals, and public and private institutions. The mean proportion of cytotoxic medicines that were unavailable across facilities ranged from 15% (lowest mean stockouts) at Aga Khan University Hospital (Kenya) to 48.5% (highest mean stockouts) at Jaramogi Oginga Odinga Hospital (Kenya) (Fig. 1) [4]. Specific medicines—including cyclophosphamide (oral and intravenous), cytarabine, dacarbazine, doxorubicin, methotrexate (oral), paclitaxel, and vinblastine—appeared more susceptible to price variation and inefficient procurement, defined as a median price ratio < 1.5 when comparing domestic and international reference prices, per WHO standards (Fig. 2) [4]. In Uganda, although procurement for cancer and supportive care medicines are institutionally centralized, the presence of selecting inefficiently procured medicines—such as vinblastine, vincristine, cyclophosphamide, etoposide, and doxorubicin—reveal opportunities for further price reductions via regional procurement mechanisms.

Fig. 1

Availability of cytotoxic medicines by site. AKU: Aga Khan University Hospital. BCCE = Butaro Cancer Centre of Excellence. BMC = Bugando Medical Centre. JOORTH = Jaramogi Oginga Odinga Referral and Teaching Hospital. KNH = Kenyatta National Hospital. MNH = Muhimbili National Hospital. MTRH = Moi University Teaching and Referral Hospital. UCI = Uganda Cancer Institute. *Drug not stocked

Fig. 2

Median price ratio of each cytotoxic drug by site. The dashed line represents the accepted threshold for efficient procurement by WHO standard (median price ratio ≤ 1.5). No datapoints are provided for arsenic trioxide, tioguanine, or pegaspargase as they were not available at any point during the study period and so no data were available to calculate median price ratio. AKU: Aga Khan University Hospital. BCCE = Butaro Cancer Centre of Excellence. BMC = Bugando Medical Centre. JOORTH = Jaramogi Oginga Odinga Referral and Teaching Hospital. KNH = Kenyatta National Hospital. MNH = Muhimbili National Hospital. MTRH = Moi University Teaching and Referral Hospital. UCI = Uganda Cancer Institute

These findings underscore the presence of prominent but remediable procurement challenges in the East African region. These challenges principally relate to fractured, uncoordinated, and demand-insensitive approaches to procurement, premised on weak data and institutionally isolated strategies. The result is small, fragmented, and unpredictable markets for childhood cancer medicines, resulting in weak manufacturer incentives for market entry, barriers to sustained supply, and erratic inventory. To overcome these barriers, this policy option focuses on strategies to support efficient and sustained procurement of childhood cancer medicines through regional pooled procurement.

Pooled procurement is a component of supply chain management that is guided by collaboration among buyers, which motivates competition between vendors. Efforts to strengthen centralized procurement regionally can serve as an opportunity for countries to increase their bargaining power, thus reducing costs, and achieving greater predictability in their supply of essential medicines. The ACCESS EA study highlighted the significant role that pooled procurement could play in helping to secure the availability of cancer medicines for children. To guide regional pooled procurement, it is recommended that:

i.

Strong political will guide alignment of shared national/regional values around transparency and data sharing to enable productive collaboration [5];

ii.

Governments align policy reform for tendering and negotiation with reform for centralization of medicine tracking and regional pooled procurement [5];

iii.

Sustainable and predictable financing investment is committed for a capitalization fund to support efforts for pooled procurement [6].

iv.

Investment in human resource technical capacity is prioritized at the level of the buyer and pooled procurement organizing body [6].

v.

Sufficient supply-side competition is pursued via the presence of multiple buyers willing to participate in the tender.