The queues along the corridors leading to the doctors' rooms at Tata Memorial Hospital are long and winding, with patients and families clutching onto their medical reports, and hope.
Hope, that the doctor will allow them to go back home and to life as they knew it, before the illness struck.
And that is exactly what the lady, her head covered in a pink sari, ventures to ask the medical oncologist. Is there a need to start chemotherapy right away? Her husband, convinced that there was the need to start treatment right away progresses to ask the doctor for a reliable hospital closer to home in Rajasthan, to start treatment.
Outside the doctor's room, another patient from the North-East waits to get a letter from the doctor to be able to get the railway concession entitled to a cancer patient.
A regular day at the Tata Memorial Hospital, for cancer.
But not a day goes by without patients asking for medicines that are less expensive, says Dr Kumar Prabhash, a practicing medical oncologist at the hospital for 10 years. “Everyday, day in and day out there are questions from patients,” he says, highlighting the importance of medicine prices in a patient's treatment.
Cancer cases
Last week, when Cipla slashed price by 76 per cent on Sorafenib, an advanced kidney cancer drug, the relief to patients was unmistakable. It had reduced its own price on the drug from Rs 27,950 per month to Rs 6,840. The company also dropped prices on lung cancer drug Gestinib by 60 per cent, besides brain cancer drug Temozolamide.
Sorafenib, though, has a more complicated story. It faces patent-related litigation in the country, and is the drug on which India issued its first ever compulsory license (CL).
The CL allows Natco to make the medicine at a price lower than the innovator of the drug, Bayer — but on payment of royalty to the originator. The medicine is sold by Bayer under the Nexavar brand at Rs 2.8 lakh per month. Natco pegged its price at Rs 8,900.
In a separate but similar case in Delhi, Cipla fights a patent-infringement case on the same drug.
Cipla's latest move to bring down the price on a clutch of cancer drugs may raise other questions on timing and how it was made possible. Meanwhile, in a separate development, Bayer appealed the CL decision at the Intellectual Property Appellate Board.
Another cancer drug, another case — that is the reality for Novartis blood-cancer drug Glivec that awaits final hearing at the Supreme Court.
While these cases take their own course, they are not far removed from our lives, as their outcomes impact the medicines we consume, besides setting precedents for medicines in other therapeutic areas as well.
India-sensitive prices
Though a price-cut brings some relief in an otherwise difficult situation for patients, the grim reality also is: even at Rs 7,000 per month for the rest of their life, the medicine is expensive not just for people from economically weaker backgrounds, but regular salaried people too.
The costs further add up for the patient, as supportive medicines, laboratory tests, doctors fees and hospital costs become part of the medical bill.
The Cancer Patients Aid Association's Mr Y.K. Sapru lauds the issuance of the CL as an excellent tool available with the Government to bring down prices on newer cancer medicines.
Drug-makers counter price arguments with patient-support programmes, where medicines are given free or at a subsidised cost to needy people. While this makes for good social responsibility, it is not a viable business model.
Cancer specialists suggest that companies sport “India-sensitive” prices. If only 1 per cent of the population is able to afford a critical drug, there is an ethical problem. Drug companies need to be flexible and sell their medicines at prices affordable to larger sections of the population. Despite reduced prices, they will get their revenues from increased volumes, they observe.
The pricing ills of cancer medicines are the same as any other medicine, says health expert Dr Anant Phadke of Jan Arogya Abhiyan. Better procurement of medicines is key, he says, as a bulk order can drive a hard bargain.
This is the model followed by multilateral agencies and foreign private foundations that source medicines from Indian companies to supply programmes across the world. There is no reason why a similar procurement model would not be successful if the Indian government procures large volumes of medicines for its citizens.
Drug-makers and hospitals need to work out patient-friendly innovative packages, with subsidised costs that make it attractive for insurance companies to support, observes Mr Gaurav Malhotra, a seasoned hand in healthcare.
In fact, the Centre also needs to be vigilant that hospitals claiming to supply free medicine actually stick to their promise. And patients should be allowed to choose from where they get their medicines — as in cancer, patients often pay a few thousand rupees less when they get the medicine from the stockist, as compared to the hospital or chemist. The price difference contributes favourably to the patient's final medical bill.
The Government can make a difference to medicine prices at various levels by cracking down on trade margins, encouraging industry to develop good medicines and manufacture them locally, besides supporting the setting up of quality hospitals.
But the other key source for new drugs, often over-looked, comes from clinical trials, as explained by oncologist Dr P.P. Bapsy in her book The Dream for Life . When done ethically and with informed consent, clinical trials open a window of hope for patients, when other medicines do not seem to work.
Instead of taking a dark view on research, the Government could possibly start with a handful of good institutions to undertake clinical trials on new cancer drugs, done in a manner transparent to stakeholders. The person in the trial gets the medicine free, but it also gives the Government muscle to bargain for a good price on the drug coming from these trials.
The Government estimates cancer prevalence in the country at 27 lakh people, with the incidence of new cancer cases at 11 lakh annually. It will take several initiatives of good science combined with better procurement and more, to give cancer patients a shot at life.