# Global access and affordability roadmap: essential medicines and generics → biosimilars and frugal trials → reliance, pooling and homegrown innovation

Source: https://onco.cc/roadmaps/global-access-roadmap/  
OnCo record `global-access-roadmap` (Roadmap). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Seven in ten cancer deaths happen in countries with almost no cancer care, and even rich systems cannot afford every new drug. The roadmap is the set of levers that already work, from generics and biosimilars to trials that cut the dose, and the ones being built: regulators trusting each other's reviews, pooled purchasing, and drugs and cell therapies made where patients live.

## Summary

The first levers were policy: the WHO Essential Medicines List, generic manufacturing in India, and compulsory licensing when a patent priced a drug out of reach (Natco v Bayer, 2012). Biosimilars of trastuzumab and rituximab, on the market since 2017, cut the price of HER2 and lymphoma treatment by large fractions, and India's National Cancer Grid showed that pooled procurement across hundreds of hospitals lowers prices further.

The second lever is frugal evidence. Tata Memorial's trials showed that a twentieth of a nivolumab dose added to cheap metronomic chemotherapy improves survival in head and neck cancer, that oral metronomic tablets match intravenous cisplatin, and that a single cheap progesterone injection before breast surgery helps; INTERLACE, PERSEPHONE and FAST-Forward showed that cheaper schedules of existing treatments are as good. India and China now develop their own: India's first CAR-T (NexCAR19) at a fraction of the Western price, an Indian HPV vaccine, and Chinese PD-1 antibodies and ADCs that have gone from domestic approval to beating Western standards head to head.

The next levers are institutional: regulators accepting each other's reviews (Project Orbis, reliance pathways), WHO prequalification and pooled demand for biosimilars, patent pools for essential cancer drugs, public cell-therapy manufacturing, pooled procurement of radiotherapy, and prices anchored to measured clinical benefit. The pace is set by pricing power, regulatory divergence, workforce, and the near-absence of pain relief where most people die of cancer.

## Fields

- Kind: Roadmap
- Last checked: 2026-09-10

## Sources

- OnCo: getting the cost of cancer care down: https://onco.cc/costs/
- WHO Model Lists of Essential Medicines: https://www.who.int/groups/expert-committee-on-selection-and-use-of-essential-medicines/essential-medicines-lists
- Lancet Oncology Commission: cancer care in India (Pramesh et al.): https://doi.org/10.1016/S1470-2045(14)70117-2
- Patil et al., low-dose nivolumab with triple metronomic chemotherapy (JCO 2023): https://doi.org/10.1200/JCO.22.01015

## Connected records

- collections: [CSCO guidelines (China)](https://onco.cc/collections/csco-guidelines/), [ESMO Clinical Practice Guidelines & MCBS](https://onco.cc/collections/esmo-guidelines/), [NICE cancer guidance and technology appraisals (UK)](https://onco.cc/collections/nice-guidance/), [NICE technology appraisals](https://onco.cc/collections/src-nice-ta/)
- key papers: [A National Cancer Grid pooled procurement initiative, India](https://onco.cc/key-papers/paper-pramesh-ncg-pooled-procurement-2023/), [Delivery of affordable and equitable cancer care in India](https://onco.cc/key-papers/paper-pramesh-lancet-oncol/), [Low-dose immunotherapy in head and neck cancer: a randomised study (Tata Memorial)](https://onco.cc/key-papers/paper-patil-low-dose-nivolumab-jco-2023/), [Socioeconomic inequalities in lung cancer treatment: systematic review and meta-analysis](https://onco.cc/key-papers/paper-forrest-socioeconomic-inequalities-lung-cancer-treatment-plos-med-2013/)
- ideas: [90-day reliance approval for cancer drugs cleared by two stringent regulators](https://onco.cc/ideas/idea-reg-reliance-90-day-lmic/), [A Gavi-style pooled purchaser for radiotherapy equipment and service](https://onco.cc/ideas/idea-acc-pooled-procurement-radiotherapy/), [A Global Fund for cancer care in low- and middle-income countries](https://onco.cc/ideas/idea-fund-global-cancer-fund/), [A joint price negotiation bloc for middle-income countries, modelled on Beneluxa](https://onco.cc/ideas/idea-reg-middle-income-negotiation-bloc/), [A non-profit manufacturer for generic cancer drugs in chronic shortage](https://onco.cc/ideas/idea-reg-nonprofit-generic-chemo-manufacturer/), [A platform trial of very-low-cost metronomic chemotherapy in LMIC common cancers](https://onco.cc/ideas/idea-acc-metronomic-lmic-platform-trial/), [A ten-dollar blood test for the five cancers that kill most people in poorer countries](https://onco.cc/ideas/idea-prev-lmic-five-cancer-methylation-test/), [An advance market commitment for PD-1 biosimilars for lower-income countries](https://onco.cc/ideas/idea-reg-pd1-biosimilar-advance-commitment/), [Approve cancer biosimilars on analytics and pharmacokinetics, no efficacy trials](https://onco.cc/ideas/idea-reg-biosimilar-no-efficacy-trial/), [Biosimilar-first defaults and payment parity in every cancer day unit](https://onco.cc/ideas/idea-reg-biosimilar-first-default-switching/), [Burden-matched funding for trials led in low- and middle-income countries](https://onco.cc/ideas/idea-fund-lmic-burden-match/), [Cap public prices for new cancer drugs to tiers of the ESMO and ASCO value scales](https://onco.cc/ideas/idea-reg-price-anchored-to-mcbs/), [Community health workers trained in cancer triage, navigation and home palliative care](https://onco.cc/ideas/idea-acc-community-health-workers-oncology/), [Confirm ultra-low-dose immunotherapy so it can be afforded where most patients live](https://onco.cc/ideas/idea-tr1-low-dose-immunotherapy-for-lmic/), [Fund trials that test shorter courses of the most expensive adjuvant drugs](https://onco.cc/ideas/idea-cost-shorter-course-trials/), [Grant extra exclusivity only in exchange for binding low prices in poorer countries](https://onco.cc/ideas/idea-reg-tiered-pricing-for-exclusivity/), [Hospital-based CAR-T manufacturing at cost through a public network](https://onco.cc/ideas/idea-fund-public-car-t-manufacturing/), [HPV self-testing with same-day treatment as the national cervical programme](https://onco.cc/ideas/idea-acc-hpv-self-sample-same-day-ablation/), [Low-cost cobalt-60 brachytherapy for cervical cancer in every regional centre](https://onco.cc/ideas/idea-acc-frugal-hdr-brachytherapy/), [Make a population cancer registry a condition of every cancer aid programme](https://onco.cc/ideas/idea-acc-registries-as-aid-condition/), [Make one-week radiotherapy the default in overloaded systems](https://onco.cc/ideas/idea-acc-hypofractionation-default-lmic/), [Medicines Patent Pool licences for every patented cancer drug on the WHO list](https://onco.cc/ideas/idea-reg-patent-pool-oncology-eml/), [National opioid quota reform so morphine reaches cancer patients](https://onco.cc/ideas/idea-acc-balanced-opioid-policy-reform/), [Pay a different price for the same cancer drug depending on the indication](https://onco.cc/ideas/idea-reg-indication-specific-pricing/), [Pay for radiotherapy machine uptime, not for the machine](https://onco.cc/ideas/idea-acc-linac-uptime-contracts/), [Pivotal trials include sites in Africa, South Asia and Latin America, sponsor-funded](https://onco.cc/ideas/idea-tr1-lmic-sites-in-pivotal-trials/), [Project ECHO tele-mentoring for district clinicians managing cancer](https://onco.cc/ideas/idea-acc-echo-tele-mentoring-oncology/), [Public-sector CAR-T manufacturing in India, Brazil and South Africa under $50,000](https://onco.cc/ideas/idea-reg-lmic-public-cart-manufacturing/), [Publicly funded trials of lower and less frequent doses of expensive cancer drugs](https://onco.cc/ideas/idea-reg-public-deescalation-trials-for-cost/), [Round-the-clock remote treatment-planning hubs for clinics without physicists](https://onco.cc/ideas/idea-acc-remote-planning-hubs/), [Screen every cancer patient for financial toxicity as a vital sign, with navigation](https://onco.cc/ideas/idea-reg-financial-toxicity-vital-sign/), [Tie WHO essential-medicines listing to a published tiered price and supply pledge](https://onco.cc/ideas/idea-acc-eml-listing-price-commitments/), [Treat the deprivation gradient in lung cancer as a defect in delivery that can be fixed and measured](https://onco.cc/ideas/idea-lung-deprivation-gradient-treated-as-a-defect-in-delivery/), [Turn Project Orbis into a work-sharing review with one shared assessment report](https://onco.cc/ideas/idea-reg-orbis-work-sharing/), [Validate low-cost metronomic oral regimens in phase 3 and carry them into guidelines](https://onco.cc/ideas/idea-reg-metronomic-lmic-phase3-to-label/), [WHO prequalification plus pooled demand to push biosimilar prices below 10% of the originator](https://onco.cc/ideas/idea-acc-biosimilar-prequalification-pool/)
- roadmaps: [Cancer prevention roadmap: tobacco control and vaccines → biomarker-guided chemoprevention → interception in carriers](https://onco.cc/roadmaps/prevention-roadmap/), [Chemotherapy roadmap: mustard gas → curative combinations → the warhead inside smarter drugs](https://onco.cc/roadmaps/chemotherapy-roadmap/), [Radiotherapy roadmap: X-rays → shaped beams → fewer fractions, particles and FLASH](https://onco.cc/roadmaps/radiation-roadmap/), [Trial modernisation roadmap: the randomised trial → platforms and adaptive designs → decentralised, pragmatic and always-on](https://onco.cc/roadmaps/trial-modernisation-roadmap/)
- technologies: [Generic oncology drug supply and shortage mitigation](https://onco.cc/technologies/generic-drug-shortage-response/), [Global oncology and access in low- and middle-income countries](https://onco.cc/technologies/global-oncology-access/), [HPV DNA testing and self-sampling](https://onco.cc/technologies/hpv-testing/), [Oral cancer visual screening](https://onco.cc/technologies/oral-visual-screening/), [Palliative radiotherapy](https://onco.cc/technologies/palliative-radiotherapy/), [Telemedicine, teleoncology, and telepathology](https://onco.cc/technologies/telemedicine-teleoncology/), [Thermal ablation and cryotherapy for cervical precancer](https://onco.cc/technologies/precancer-ablation/)
- drugs: [Camrelizumab](https://onco.cc/drugs/camrelizumab/), [CERVAVAC (quadrivalent HPV vaccine, India)](https://onco.cc/drugs/cervavac/), [Relmacabtagene autoleucel](https://onco.cc/drugs/relmacabtagene-autoleucel/), [Sintilimab](https://onco.cc/drugs/sintilimab/), [Talicabtagene autoleucel](https://onco.cc/drugs/talicabtagene-autoleucel/), [Trastuzumab biosimilars](https://onco.cc/drugs/trastuzumab-biosimilars/), [Trastuzumab rezetecan](https://onco.cc/drugs/trastuzumab-rezetecan/), [Varnimcabtagene autoleucel](https://onco.cc/drugs/varnimcabtagene-autoleucel/)
- companies: [Biocon](https://onco.cc/companies/biocon/), [Biocon Biologics](https://onco.cc/companies/biocon-biologics/), [Cipla](https://onco.cc/companies/cipla/), [Dr. Reddy's Laboratories](https://onco.cc/companies/dr-reddys/), [Immuneel Therapeutics](https://onco.cc/companies/immuneel/), [ImmunoACT](https://onco.cc/companies/immunoact/), [Innovent Biologics](https://onco.cc/companies/innovent/), [Intas Pharmaceuticals (Accord Healthcare)](https://onco.cc/companies/intas/), [Jiangsu Hengrui Pharmaceuticals](https://onco.cc/companies/hengrui/), [Natco Pharma](https://onco.cc/companies/natco/), [Serum Institute of India](https://onco.cc/companies/serum-institute-of-india/), [Shanghai Junshi Biosciences](https://onco.cc/companies/junshi/), [Sun Pharmaceutical Industries](https://onco.cc/companies/sun-pharma/), [Zydus Lifesciences](https://onco.cc/companies/zydus/)
- institutions: [European Medicines Agency](https://onco.cc/institutions/ema/), [FDA Oncology Center of Excellence](https://onco.cc/institutions/fda-oce/), [International Agency for Research on Cancer (IARC / WHO)](https://onco.cc/institutions/iarc/), [National Cancer Grid of India](https://onco.cc/institutions/national-cancer-grid/), [National Healthcare Security Administration](https://onco.cc/institutions/nhsa/), [Tata Memorial Centre](https://onco.cc/institutions/tata-memorial/), [Tata Trusts](https://onco.cc/institutions/tata-trusts/), [Union for International Cancer Control](https://onco.cc/institutions/uicc/), [World Health Organization Cancer Programme](https://onco.cc/institutions/who/)
- terms: [Biosimilar](https://onco.cc/terms/biosimilar/), [Health technology assessment (HTA), reimbursement and QALYs](https://onco.cc/terms/hta/), [Hypofractionation (fewer, larger radiotherapy doses)](https://onco.cc/terms/hypofractionation/), [Project Orbis](https://onco.cc/terms/project-orbis/), [WHO Essential Medicines List for cancer](https://onco.cc/terms/who-essential-medicines/)
- trials: [Elective vs therapeutic neck dissection in node-negative oral cancer (Tata Memorial)](https://onco.cc/trials/elective-neck-dissection-tmh/), [HARMONi-2](https://onco.cc/trials/harmoni-2/), [IARC India HPV vaccine dose study (one, two or three doses)](https://onco.cc/trials/iarc-india-hpv-dose-study/), [IMAGINE (varnimcabtagene autoleucel, Immuneel)](https://onco.cc/trials/imagine-varnimcabtagene/), [INTERLACE](https://onco.cc/trials/interlace/), [KEN SHE (single-dose HPV vaccine)](https://onco.cc/trials/ken-she/), [Kerala oral cancer visual screening trial (Trivandrum)](https://onco.cc/trials/kerala-oral-screening/), [Low-dose nivolumab plus metronomic chemotherapy (Tata Memorial)](https://onco.cc/trials/low-dose-nivolumab-tmh/), [METRO PLUS (Tata Memorial Centre, Varanasi)](https://onco.cc/trials/metro-plus-varanasi/), [Mumbai VIA cervical screening trial (Tata Memorial)](https://onco.cc/trials/mumbai-via-screening/), [Oral metronomic chemotherapy vs intravenous cisplatin (Tata Memorial)](https://onco.cc/trials/metronomic-vs-cisplatin-tmh/), [ORIENT-11](https://onco.cc/trials/orient-11/), [Osmanabad cervical screening trial (HPV testing vs cytology vs VIA)](https://onco.cc/trials/osmanabad-hpv-screening/), [PERSEPHONE](https://onco.cc/trials/persephone/), [RELIANCE](https://onco.cc/trials/reliance/), [Single-injection depot progesterone before breast surgery (Tata Memorial)](https://onco.cc/trials/progesterone-preop-tmh/), [Talicabtagene autoleucel (NexCAR19) phase 1/2](https://onco.cc/trials/talicel-phase-1-2/)
- bottlenecks: [Most of the world has almost no cancer care](https://onco.cc/bottlenecks/b-global-access/), [No incentive to repurpose cheap drugs](https://onco.cc/bottlenecks/b-generic-repurposing/), [Not enough oncologists, nurses, pathologists, physicists](https://onco.cc/bottlenecks/b-workforce/), [Pain relief and palliative care are unavailable to most](https://onco.cc/bottlenecks/b-palliative/), [Prices and value](https://onco.cc/bottlenecks/b-drug-pricing/), [Regulatory divergence between regions](https://onco.cc/bottlenecks/b-regulatory-fragmentation/), [Trials do not represent the people who get cancer](https://onco.cc/bottlenecks/b-trial-diversity/)

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