Availability, Prices, and Affordability of Immune Checkpoint Inhibitors: A Cross-Sectional Study in Anhui Province,...

Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy, yet their uptake in low- and middle-income areas is hindered by high prices and uneven distribution. Anhui Province, China-characterized by marked urban-rural economic contrasts-offers a critical setting to examine real-world access to these agents. The objective of this study was to assess the availability, price levels, and affordability of ICIs across Anhui Province and to identify policy levers that could narrow observed access gaps.

We applied the World Health Organization/Health Action International (WHO/HAI) standardized survey methodology to evaluate the availability, price differentials, and economic burden of immune checkpoint inhibitors (ICIs) marketed in Anhui Province, China. The survey was conducted in 2025 across 199 public hospitals. Affordability was further assessed using a four-tier framework comprising the WHO/HAI standard indicator (defined as the number of days' wages required to afford 30 days of treatment), adjusted using local urban and rural per capita disposable income to account for China's socioeconomic heterogeneity, and incorporating insurance reimbursement scenarios on the basis of Anhui provincial policy (85% for urban employee insurance and 70% for urban-rural resident insurance) to estimate out-of-pocket expenditure. In addition, catastrophic health expenditure (CHE), defined as household out-of-pocket health spending exceeding 40% of non-food expenditure, was used to capture household-level financial risk beyond individual income-based measures. Availability was defined as the proportion of facilities stocking a medicine on the survey day. Prices were collected at unit level and summarized as medians across facilities, with affordability assessed using the median price ratio (MPR), calculated as median local unit price relative to the international reference price (IRP) from the MSH International Drug Price Indicator Guide, in line with WHO/HAI methodology.

Surveying 199 hospitals, we found that domestic PD-1 inhibitors-sintilimab, camrelizumab, and tislelizumab-were stocked in roughly 4 out of 5 facilities, whereas 11 of the 15 mainly imported ICIs appeared in fewer than 16% of hospitals; although some imported agents had acceptable median-price ratios (0-2), their absolute prices remained several-fold higher than domestic alternatives; thus even after insurance (85% urban, 70% rural), a year's treatment with cadonilimab or durvalumab still exceeded the catastrophic-expenditure threshold by up to 40 times for rural households, while domestic sintilimab or camrelizumab stayed well below that line.

Domestic ICIs are broadly available and relatively affordable, whereas imported brands remain scarce and financially out of reach; boosting reimbursement limits, expanding centralized procurement, and favoring cost-effective domestic options may help reduce Anhui's access gap, although their implementation should take budget constraints and opportunity costs into account.