Access to pediatric oncology medicine in Iran: a cross-sectional survey in Urmia

Abstract

Background

Cancer stands as a significant cause of mortality among children and adolescents, imposing a considerable burden on global healthcare. The World Health Organization (WHO) reports a stark imbalance in the accessibility of cancer medicines between low-income and high-income countries. Due to high prevalence of cancer in Iran and current barriers to access to oncology medicines, this study aims to scrutinize the landscape of pediatric oncology medicine access, considering unique factors such as sanctions and Iran’s economic context.

Methods

This study was conducted in Urmia (West Azerbaijan, Iran) in 2022. We employed a descriptive cross-sectional design to explore the availability, pricing, and affordability of 21 outpatient medications related to the five most utilized treatment protocols for prevalent pediatric cancers. A systematic survey was carried out using the recognized methodologies of the WHO and Health Action International (HAI). Data extraction was conducted by a trained student using the checklist provided by the WHO. Data analysis was conducted using SPSS software.

Results

Among the 21 medicines analyzed, 14 had accessibility rates that were below 50%, with one entirely unavailable and 10 exhibiting availability below 25%. Dactinomycin highlighted the highest Median Price Ratio at 4.1, closely followed by Asparaginase at 3.9. Conversely, Cytarabine, Cyclophosphamide, and Filgrastim displayed the lowest Median Price Ratios (MPR) values, each recording an MPR of 0.1. In the assessment of affordability, it is observed that insured patients across all income deciles have the financial means to cover the minimum costs of medicines. Intriguingly, among the various income deciles, only individuals in the 10th decile exhibit the financial capacity to acquire medicines associated with the examined treatment regimens without insurance coverage, with the exception of the ALL (Acute Lymphoblastic Leukemia) regimen.

Conclusion

This study illuminates the complex challenges surrounding the availability, cost, and affordability of pediatric cancer medications in Urmia, Iran. It is crucial to develop supportive policies that aim to lower medication expenses for patients and improve their access to cancer treatments. Tackling these challenges necessitates a collaborative effort involving stakeholders, policymakers, and healthcare providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-025-05993-y.

Introduction

Cancer emerges as a predominant contributor to mortality among children and adolescents. The likelihood of survival subsequent to a childhood cancer diagnosis is closely associated with the geographical location of the child. In high-income countries, the cure rate for childhood cancer surpasses 80%, whereas in numerous Low- and Middle-Income Countries (LMICs), the cure rate is below 30% [1, 2]. Barriers related to the availability and affordability of essential cancer medicines may lead to non-standardized or discontinued treatment protocols, resulting in compromised health outcomes and reduced chances of survival [3]. According to the World Health Organization (WHO), only 29% of low-income countries report consistent accessibility of cancer medicines to their populations, a sharp contrast to the significantly higher figure of 96% reported by high-income countries [4]. Consequently, it is unsurprising that the child mortality rate in low- and middle-income countries is four times higher than that in high-income countries [5]. The success of prevention, screening, and treatment programs, particularly in developing countries, is significantly dependent on the availability and consumption of medicines. Various factors, such as elevated prices, irrational utilization, insufficient financing, an unreliable supply system, substandard treatment quality, and non-adherence to clinical guidelines, collectively undermine patients’ access to essential medications [6].

In 2021, Mattila et al. conducted an evaluation of essential medicines for pediatric cancer patients, focusing on access, pricing, and affordability in LMICs. The results indicated significant fluctuations in the pricing and accessibility of anticancer medicines among pharmaceutical brands in LMICs. Moreover, the cost-effectiveness of these medicines posed challenges for patients with lower income levels, occasionally leading to treatment discontinuation, a phenomenon observed across different countries [7]. Another 2021 study in Ghana, conducted the assessment of essential medicines for pediatric cancer and their accessibility. In hospital pharmacies, the mean availability of essential cancer and non-cancer medications was 38% and 27%, respectively, while in private pharmacies, the figures were 84% and 75%, respectively. The researchers concluded that, with a median price ratio of less than 4 among cancer and non-cancer medicines, the mean availability of cancer medicines at public and private drug stores fell below the WHO goal of 80%. However, the cost of medications appears to be unaffordable in the local context [8]. In a 2019 study, Zhu et al. evaluated the accessibility, affordability, and availability of oncology medicines in China. Between 2012 and 2016, a notable decline was observed in the availability of originator brands, dropping from 7.79 to 5.71%, as well as in the availability of lowest-priced generics, decreasing from 36.29 to 32.67%. Additionally, patients in high-income regions experienced greater affordability in accessing oncology medicines compared to those in low-income regions [9].

The prevalence of cancer in Iranian children aged 0 to 14 is 16.80 per 100,000 for boys and 16.56 per 100,000 for girls [10]. Common cancers among Iranian children include hematological, brain, and central nervous system, lymphomas, and renal cancers [11]. A crucial step toward improving access to oncology medicines involves measuring the availability and affordability of essential medications across countries. A study conducted in 2004 assessed the accessibility of primary care medications in the Islamic Republic of Iran [12]. Additionally, another study in 2019 evaluated access to non-communicable disease medicines, excluding oncology medications [13]. However, to date, there has been no study specifically evaluating the availability and affordability of pediatric oncology medicines.

Among the barriers to medicine accessibility in Iran are sanctions. Zartab et al. in 2020, conducted research regarding this topic. Their findings demonstrated how unstable the pharmaceutical market was during the sanction era, and catastrophic waves of drug shortages affected not just the community but even the political establishment [14]. A further analysis conducted in 2020 by Abbasian et al. identified one of the primary risks to the Iranian biopharmaceutical supply chain: the challenges associated with money transfers brought on by the sanctions [15]. Access to pharmaceutical products is also severely restricted by Iran’s rising trend of inflation during recent years, which weakens the purchasing power of the nation’s citizens.

Therefore, our primary objective is to assess the access to pediatric oncology medicines, considering the unique conditions of sanctions and Iran’s economic situation. The overarching goal is to provide policymakers with comparable, evidence-based information to guide decision-making in this crucial realm of healthcare.

Materials and methods

Study setting

The study was conducted in Urmia, the center of a northwestern province of Iran (West Azerbaijan). As of 2022, Urmia is home to more than 800,000 inhabitants, with a population density of approximately 76,000 people per square kilometer [16].

Study design

This study adopted a descriptive cross-sectional design. The data collection period for this study was the first quarter of 2022. Out of 180 active pharmacies, only 5, comprising 3 privately-owned and 2 publicly owned establishments, offered outpatient pediatric oncology medicines. These pharmacies were mainly located in the city center. 21 Medicines related to the 5 most used treatment protocols in prevalent pediatric cancers were selected. These protocols comprise AML (Acute Myeloid Leukemia), ALL (Acute Lymphoblastic Leukemia), LMB (Lymphome Malin de Burkitt) protocol for BL (Burkitt’s lymphoma) and DLCL (Diffuse Large Cell Lymphoma), Brain Tumor, and Wilms Tumor [17].

The method used to assess the pricing, availability, and affordability of pediatric oncology medicines in this study was based on the WHO and Health Action International (HAI), which was also employed by Varmaghani et al. in a similar study [18, 19]. The WHO/HAI methodology’s primary goal is to produce accurate data regarding the availability, price, and affordability of selected essential medications as well as the supply chain’s pricing components. The approach is meant to assist efforts to improve everyone’s access to reasonably priced medications. This approach involves a systematic survey to gather data and information on the pricing, availability, and affordability of pediatric oncology medicines, referencing the Iran Drug List (IDL). Main steps of this approach include:

• Presurvey Planning.

• Preparation.

• Training (supervisors, data collectors, and data entry personnel).

• Field Data Collection.

• Data Entry & Analysis.

• Price Component Measurement.

• International Comparisons.

• Policy Exploration & Reporting [20].

Availability assessment

The availability of the investigated medicines in each sector (public and private) was determined as a percentage of pharmacies where the medicines were consistently in stock over a specified period (the past 3 months). This calculation also encompassed the availability of all medicines related to a treatment protocol for common childhood cancers, including hematological, central nervous system, lymph node, and renal cancers. The related formula is [19]:

Price assessment

The highest and lowest prices of each medicine were collected. These prices were extracted from the pharmacy’s computer based on the IFDA (Iran Food & Drug Administration) online data regarding medicine prices [21]. Using global techniques, the Median Price Ratios (MPR) represent the ratio of local prices to international reference prices, with average prices reported by the Management Sciences for Health (MSH) organization serving as the reference point. MPR is calculated by dividing the local price by the international reference price, expressed in local currency [19, 22]. Furthermore, all costs were stated using the official exchange rate and reported in US dollars (1 USD = 285,000 Rial) [23]. The median Price Ratio can be calculated using the following formulas:

Affordability assessment

Regarding the affordability assessment, the study examined two scenarios from the patient’s perspective in different situations. These scenarios were differentiated based on insurance coverage, specifically in the Social Security Organization (SSO) and non-insured sectors.

Scenario 1: A drug is deemed affordable if its cost is equal to or less than a worker’s minimum daily wage for a month, and unaffordable if it exceeds this amount. The minimum daily wage was determined based on the labor office’s announcement of the minimum wage in Iran [6, 24]. The related formula is mentioned below [19].

Scenario 2: The assessment of the affordability of pediatric oncology medicines is conducted as part of a treatment protocol, assuming the allocation of 20% of the monthly income in different income deciles. In this scenario, treatment protocols are considered affordable if they can be covered by 20% of the average monthly income in different income deciles.

Data collection and interpretation

Data extraction was conducted by a trained student using the checklist provided by the WHO. In addition, various national and international databases were utilized to gather information, as detailed in Additional file 1. Data analysis was conducted using SPSS software. Descriptive statistics, including mean and standard deviation for quantitative variables, and frequency, percentage, mean, and standard deviation for qualitative variables, were employed to characterize the dataset.

Results

Among the 21 medicines assessed, the accessibility of 17 medications fell below the 80% threshold, while four medications demonstrated an availability range of 80–100%. Additional details can be found in Table 1.

Table 1.

Availability of selected pediatric oncology medicines

Availability	Generic name
0%	Amsacrine
20–80%	Daunorubicin – Asparaginase – Cytarabine – Mercaptopurine – Thioguanine - Etoposide – Mitoxantrone – Folinic acid – Procarbazine – Dactinomycin - Cyclophosphamide – Doxorubicin – Temozolomide - Prednisolone – Vincristine – Hydrocortisone sodium succinate - Filgrastim
80–100%	Cisplatin - Methotrexate – Dexamethasone - Paclitaxel

The analysis encompassed an evaluation of medicine availability within each of the five treatment protocols, namely AML, ALL, LMB, Brain tumor, and Wilms tumor, across the selected pharmacies.

Within the ALL protocol, Methotrexate and Dexamethasone exhibited the highest prevalence, each was available in 4 of 5 pharmacies, while approximately half of the remaining medicines were available in 1 of 5 pharmacies. Conversely, in the AML protocol, only 20% of the medicines were accessible in pharmacies, with Amsacrine entirely unavailable. In the LMB regimen, Methotrexate displayed the highest frequency, accessible in 4 of 5 pharmacies, whereas Folinic acid and Cytarabine recorded the lowest frequency, each available in only 1 of 5 pharmacies.

Procarbazine and Etoposide were available in 1 of 5 pharmacies, while Cisplatin emerged as the most commonly accessible medicine in the Brain tumor protocol, available in 4 of 5 pharmacies. In the Wilms tumor regimen, Vincristine held the highest frequency, available in 3 of 5 of pharmacies, whereas Dactinomycin and Etoposide were found in only 1 of 5 pharmacies. Comprehensive data is delineated in Table 2

Table 2.

Available medicines in treatment protocols

Medicine	Availability (%)
ALL protocol
Prednisolone	60
Vincristine	60
Daunorubicin	20
Asparaginase	20
Cytarabine	20
Methotrexate	80
Cyclophosphamide	40
Mercaptopurine	20
Dexamethasone	80
Doxorubicin	40
Thioguanine	20
AML protocol
Etoposide	20
Daunorubicin	20
Amsacrine	0
Mitoxantrone	20
Asparaginase	20
Cytarabine	20
LMB protocol
Prednisolone	60
Cyclophosphamide	40
Vincristine	60
Folinic acid	20
Hydrocortisone sodium succinate	60
Cytarabine	20
Methotrexate	80
Doxorubicin	40
Brain tumor protocol
Procarbazine	20
Prednisolone	60
Cisplatin	80
Temozolomide	40
Cyclophosphamide	40
Vincristine	60
Etoposide	20
Wilms tumor protocol
Dactinomycin	20
Cyclophosphamide	40
Vincristine	60
Etoposide	20
Doxorubicin	40

It was also determined to what extent access to medicine there was in each of the five protocols; the findings are shown in (Fig. 1), where it is evident that the AML protocol had the least availability and the LMB protocol had the most.

Fig. 1.

Total availability of treatment protocols

Regarding the evaluation of pricing, Table 3 presents the global and local prices of the examined medicines, along with the corresponding MPR calculated for each. The outcomes reveal that Dactinomycin exhibited the highest MPR at 4.1, followed by Asparaginase at 3.9. In contrast, the lowest MPR values were associated with Cytarabine, Cyclophosphamide, and Filgrastim, all recording an MPR of 0.1.

Table 3.

Median price ratio (MPR) of investigated medicines

Generic name	Global reference price (22) (US$)	Local price (US$)	Median Price Ratio (MPR)
Asparaginase 10,000 IU/ml	52.88	203.69	3.9
Cisplatin 10 mg/ml	2.75	2.80	1.0
Cyclophosphamide 500 mg	5.23	0.38	0.1
Cytarabine 100 mg	3.47	0.20	0.1
Dactinomycin 500 mcg	8.70	36.00	4.1
Daunorubicin 20 mg	19.32	14.27	0.7
Doxorubicin 10 mg	2.12	2.52	1.2
Filgrastim 300 mcg/ml	40.03	7.78	0.1
Hydrocortisone sodium succinate 100 mg	0.52	0.52	0.9
Mercaptopurine 50 mg	2.23	0.37	0.2
Methotrexate 25 mg/ml	2.22	6.57	2.8
Paclitaxel 100 mg	11.08	15.62	1.4
Prednisolone 50 mg	0.09	0.10	1.1
Temozolomide 100 mg	19.57	5.57	0.5
Vincristine 1 mg	2.54	0.81	0.3

In the context of affordability assessment, the first scenario involved evaluating the capacity to afford pediatric oncology medicines, presuming the allocation of the total daily income of a basic laborer, as per the guidelines set by the WHO. The total daily income of a basic laborer was determined in accordance with the official wage sanctioned by the Iran Ministry of Cooperatives, Labor, and Social Welfare in 2022, amounting to 4.89 US dollars per working day [25]. More details are available in Table 4.

Table 4.

Affordability based on 1 st scenario

Insured	Non-insured
ALL protocol
19.9 $	360 $
24.6%	1.4%
AML protocol
15.9 $	159 $
30.7%	3.1%
LMB protocol
4.12 $	35.90 $
118.7%	13.6%
Brain tumor protocol
1.75 $	13.42 $
279.6%	36.4%
Wilms tumor protocol
3.24 $	78.22 $
151.1%	6.2%

In the second scenario, considering both individuals covered by the SSO and those without insurance, the affordability of pediatric oncology medications was computed. This estimation assumed that the treatment protocol would represent 20% of the monthly income across different household income deciles.

Within the ALL protocol, none of the deciles exhibited the ability to independently cover the expenses. However, under the umbrella of insurance coverage, all deciles demonstrated the capability to meet the costs. The 1 st decile contributed 1.25%, while the 10th decile allocated 12.5% of their monthly income for medicine expenses associated with this protocol over a 30-day period. Similar patterns were evident in the AML protocol, albeit with the noteworthy distinction that only the 10th decile could afford the expenses without insurance coverage.

In the LMB protocol, solely the 1 st decile lacked the capacity to independently cover expenses. Conversely, within the Wilms tumor protocol, deciles one through five were incapable of independently meeting the associated costs. Lastly, in the Brain Tumor protocol, all deciles demonstrated the ability to afford expenses without relying on insurance coverage. More details can be found in Table 5

Table 5.

Affordable treatment protocols based on Iranian household income deciles at 20% monthly income

Income deciles	20% Monthly income (US$)	ALL protocol		AML protocol		LMB protocol		Brain tumor protocol		Wilms tumor protocol
		Insured	Non-insured	Insured	Non-insured	Insured	Non-insured	Insured	Non-insured	Insured	Non-insured
		19.86 $	360.07 $	15.91 $	159.14 $	4.12 $	35.90 $	1.75 $	13.42 $	3.24 $	78.22 $
1 st decile	24.82	1.25	0.07	1.56	0.16	6.03	0.69	14.20	1.85	7.67	0.32
2nd decile	44.54	2.24	0.12	2.80	0.28	10.82	1.24	25.48	3.32	13.76	0.57
3rd decile	56.44	2.84	0.16	3.55	0.35	13.71	1.57	32.28	4.21	17.44	0.72
4th decile	66.65	3.36	0.19	4.19	0.42	16.18	1.86	38.12	4.97	20.60	0.85
5th decile	76.85	3.87	0.21	4.83	0.48	18.66	2.14	43.96	5.73	23.75	0.98
6th decile	87.72	4.42	0.24	5.51	0.55	21.30	2.44	50.17	6.54	27.11	1.12
7th decile	101.77	5.12	0.28	6.40	0.64	24.71	2.84	58.21	7.58	31.45	1.30
8th decile	119.79	6.03	0.33	7.53	0.75	29.09	3.34	68.52	8.93	37.02	1.53
9th decile	149.56	7.53	0.42	9.40	0.94	36.32	4.17	85.54	11.14	46.22	1.91
10th decile	248.32	12.50	0.69	15.60	1.56	60.30	6.92	142.03	18.50	76.74	3.17

Discussion

This study marks the inaugural examination of the affordability, availability, and pricing of pediatric oncology medications within Urmia City, Iran, conducted in 2022. A key result of our study is identifying significant disparities in access to oncology medicines across pharmacies in Urmia. The alarming fact that merely 20% of pharmacies stock these vital medications, falling well below the WHO recommended target of 80% for cancer medications [26], prompts an inquiry into the consistency of access provision. Furthermore, this constrained availability implies potential delays in treatment initiation, presenting substantial challenges in adhering to prescribed treatment protocols. Immediate and deliberate actions are essential to address the gap in drug access, ensuring the continuous availability of vital medicines for pediatric cancer patients. The medicine delivery system in Iran functions similarly in both the public and private sectors. Pharmacies in all sectors obtain medicines from the same distributors. Although there is no specific procurement system for public health facilities, vaccines and rare medications may be exceptions to this general rule. Drug prices are categorized into three levels (pharmacy, distributor, and manufacturer) during the registration process and are updated annually by the FDA of Iran. Treatment costs for patients are consistent in both public and private sectors, as the FDA enforces a public drug policy to encourage the prescription and distribution of generic drugs, along with allowing pharmacists to substitute generics [27].

Availability

In the context of AML treatment, the data reveals a concerning situation, with only 20% of all required medicines accessible from pharmacies and the absence of crucial medications such as Amsacrine, which is entirely unavailable in any pharmacy. Such limitations may pose significant hurdles in adhering to recommended AML treatment protocols. Although circumstances are comparatively better in the ALL protocol, with an 80% availability of Methotrexate, the low availability rate of 45% for other medicines raises concerns regarding the comprehensive implementation of ALL treatment strategies. Analogous patterns emerge in the LMB protocols. However, the restricted availability of Cytarabine and Folinic acid, both found in only 20% of pharmacies, gives rise to apprehensions.

For brain tumor regimens, achieving an 80% accessibility rate for Cisplatin is considered optimal. Conversely, challenges arise with Procarbazine and Etoposide, as they are only available in 20% of pharmacies, posing potential difficulties in treatment adherence. In the context of Wilms tumor protocols, the overall situation appears favorable, with the essential medicine Vincristine accessible in 60% of pharmacies. However, concerns arise due to the constrained availability of Dactinomycin and Etoposide, both found in only 20% of pharmacies. Addressing these limitations is crucial for ensuring comprehensive and effective treatment options for patients undergoing these specific protocols.

A parallel investigation conducted in India by Faruqui et al. reported that the average availability of crucial anti-neoplastic medicines was 70% across surveyed areas, encompassing hospitals and private sector pharmacies. In contrast, non-cancer medicines exhibited complete availability of 100%. Further insights revealed that the average availability of essential anti-neoplastic medicines was 38% in private sector pharmacies, 43% in public hospital pharmacies, and notably higher at 71% in private hospital pharmacies [28]. A comparative analysis between the findings of the current study and the aforementioned research in India underscores a substantial disparity, indicating that India exhibits notably greater accessibility to the medicines under investigation in comparison to Urmia City, Iran.

The 2021 research conducted by Nguyen et al. in Hanam province, Vietnam, revealed that despite the higher cost of medications in private pharmacies, the majority remained affordable in both public and private sectors. However, a notable challenge surfaced in the form of an extremely low mean availability of pediatric essential medications, particularly in rural districts. This scarcity was identified as the primary barrier to access, highlighting the significance of addressing accessibility issues in underserved areas for comprehensive healthcare delivery [29].

Affordability and pricing

In relation to affordability, our research indicates that all insured deciles possess the financial means to afford pediatric oncology medicines through insurance coverage. Notably, only the 10th decile demonstrates the capability to purchase these medications without reliance on insurance. This underscores the critical role of health coverage in ensuring the affordability of pediatric oncology medicines and underscores the potential disparities in access contingent upon one’s insurance status.

In a 2017 study, Goldstein et al. asserted that the affordability of oncology medicines in middle-income countries, such as India, China, and South Africa, is comparatively lower than that in high-income countries like the UK, Australia, and Israel. Furthermore, despite the lower medicine prices in India when compared to the USA, the affordability in the USA was reported to be higher [30]. The findings from a 2023 study in Iran highlighted similar issues, revealing that nearly all patients, especially those lacking insurance coverage, faced challenges in acquiring oncology medications. Additionally, 53.5% of these medicines exhibited very low availability [18]. These observations underscore the complex interplay between medicine affordability, pricing, and accessibility, highlighting the need for targeted interventions to address these issues in diverse healthcare landscapes.

The MPR analysis illuminates the pricing dynamics surrounding certain pediatric oncology medicines. Elevated MPR values, exemplified by Dactinomycin and Asparaginase in our study, underscore potential impediments to cost-effective access. Conversely, the observation of low MPR values for Cytarabine, Cyclophosphamide, and Filgrastim suggests a more favorable pricing scenario. A comprehensive examination of these MPR values, considering the specific factors influencing medicine pricing, is imperative for the formulation of targeted policies aimed at enhancing accessibility for pediatric cancer patients.

In a 2019 study, Heidari et al. investigated the availability, pricing, and affordability of selected medicines for noncommunicable diseases in Iran. Their findings indicated that the procurement cost for the most sold and lowest-priced generic medications in the survey was 1.19 times higher than the global reference price. Moreover, the collective average accessibility of the examined lowest-priced generic medications within public, private, and alternative contexts was reported at 75.5%, 83.3%, and 80.3%, respectively. Notably, the expenses associated with treating prevalent noncommunicable diseases of high burden remained below the equivalent of a single day’s remuneration for the least compensated government employee [13]. These insights shed light on the complexities of medicine availability and pricing dynamics in the context of noncommunicable diseases in Iran.

The findings by Faruqui et al. also highlighted that the lowest-paid government workers in India face challenges in affording chemotherapy medicines, despite the median price ratio compared to worldwide reference prices being less than 4. This observation suggests that, while the cost of medicines in India is relatively lower than in other countries, economic constraints still pose barriers to accessibility for certain segments of the population, emphasizing the nuanced interplay between pricing, affordability, and socioeconomic factors in healthcare access [28].

The 2017 study by Salmasi et al. comparing retail prices of anti-cancer medicines across high-, middle-, and low-income countries in Southeast Asia, Western Pacific, and Eastern Mediterranean regions, highlighted substantial variability in the pricing of these medicines within the mentioned regions. The study also noted a correlation between the price of oncology medicines and the income category of the respective country, with Taiwan having the lowest average unit prices and Oman exhibiting the highest [31]. The findings of the current study align with these investigations, particularly in terms of pricing and affordability considerations.

Policy context

A study by Varmaghani et al. in 2023 identified a contributing factor to the limited accessibility of chemotherapy medicines in Iran. This factor was attributed to the dominance of companies involved in the import and distribution of these medicines, coupled with insufficient and ineffective regulatory measures, as well as inadequate oversight by the IFDA in monitoring the distribution of cancer medicines to pharmacies [18]. This underscores the multifaceted nature of challenges within the pharmaceutical distribution system, calling for comprehensive regulatory and oversight measures to ensure improved accessibility and affordability of crucial medicines.

Sanctions are considered one of the main barriers to accessing medicines. They reduce national income, leading to less affordability, and hinder financial transactions with international suppliers, resulting in decreased availability. This aligns with the research conducted by Zartab et al. and Abbasian et al. in 2020 [14, 15].

Finally, some policy solutions to address these challenges include strengthening insurance funds to lower out-of-pocket payments, fostering local production by providing renovation loans and facilitating technology transfer to ensure a steady supply of medicines, and enhancing foreign relations to neutralize or lift sanctions.

Study limitations

Our research is subject to certain limitations. The first is its cross-sectional design, which hinders the ability to capture the dynamic changes in the accessibility and cost of medicines over time. Future research endeavors should focus on longitudinal studies that clarify the temporal dimensions of these challenges, offering a more sophisticated understanding of the changing landscape. Additionally, considering the study’s impact on treatment adherence, patient outcomes, and the broader structure of healthcare systems presents a promising avenue for further research. Finally, since this study was conducted in one city, the results may not be truly representative of Iran.

Conclusion

This study substantiates the scope and complexity of challenges associated with the availability, cost, and affordability of cancer medications tailored for pediatric patients in Urmia City, Iran.

One key result of our inquiry is the identification of notable differences in the availability of oncology medicines at various pharmacies because of the high cost of these medications. This may cause patients to stop treatment and worsen disparities in healthcare access. Hence, it is crucial to develop supportive policies that aim to lower medication expenses for patients and improve their access to cancer treatments. Tackling these challenges necessitates a collaborative effort involving stakeholders, policymakers, and healthcare providers. As we interpret the complexities of pediatric oncology accessibility, a collective commitment to finding effective solutions becomes imperative for advancing the quality of care for our youngest patients.

Abbreviations

LMICs

Low- and Middle-Income Countries

WHO

World Health Organization

AML

Acute Myeloid Leukemia

ALL

Acute Lymphoblastic Leukemia

LMB

Lymphome Malin de Burkitt

BL

Burkitt's lymphoma

DLCL

Diffuse Large Cell Lymphoma

HAI

Health Action International

IDL

: Iran Drug List

IFDA

Iran Food & Drug Administration

MPR

Median Price Ratios

MSH

Management Sciences for Health

USD

U.S Dollar

SSO

Social Security Organization

Authors’ contributions

Conceptualization: HA, MV Data curation: KB, MN Formal analysis: KB, SN, HA Methodology: HA, MV Supervision: HA Writing – original draft: SN Writing – review & editing: HA All authors read and approved the final manuscript.

Funding

No funding was received.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The study was confirmed by the Ethics Committee of Urmia University of Medical Sciences (UMSU): IR.UMSU.REC.1401.260. Informed consent to participate was obtained from the parents or legal guardians of any participant under the age of 16.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Clinical trial number

Not applicable.