Cancer Care System in Ukraine

White Paper.

Cancer Care System in Ukraine—Current Status, Impact of War, Further Development

September 2022

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1. Executive Summary

The global burden of cancer is growing worldwide, with 12.1 million (mln) new cancer cases and 7.1 mln deaths from cancer in 2020 (Source: GLOBOCAN, 2022). 36% of the new cases and 28 % of the deaths occurred in Europe.

The cancer incidence rate is distributed unevenly among different population categories in Ukraine. Females are more often diagnosed with cancer than males, and morbidity rates of oncological diseases among urban populations prevail over rural ones.

The cancer care system in Ukraine, inseparable from the general health care system, remained virtually unchanged throughout the entire period after gaining independence in 1991. Yet, healthcare financing reform, launched in 2017, brought positive changes that introduced a diagnosis-related groups-based funding system, set up a strategic purchaser and gave hospitals managerial autonomy to cancer care delivery in 2020.

The care provided for patients with oncological diseases requires a multi-dimensional approach, i.e., different means and methods should be applied at both population and individual levels. These levels are applied sequentially, starting from primary prevention, early detection and screening, diagnostic evaluation, primary, neo-adjuvant and adjuvant treatment, follow-up care, treatment of recurrent cancer, and ending with palliative care and end-of-life care, which are often combined in one.

In terms of healthcare infrastructure, more than 900 healthcare facilities (public and private hospitals, pharmacies, laboratories, diagnostic centers, blood banks, etc.) were damaged or destroyed by Russians in Ukraine. Recovery funds (just to rebuild as it was) needed for the Ukrainian healthcare system are estimated at an additional USD 2.4 bn.

As far as further development of the oncology care system is concerned, measures aimed at the further development of the Ukrainian healthcare system would be divided into two subgroups:

• pre-war initiated (obvious and necessary measures to restore the health system, which are proposed in the Recovery Plan proposed by the National Council for the Recovery of Ukraine from the War, clusterization reform, initiation of public-private partnerships),
• initiated during the war (rebuilt or rethink approach based on patient-centric cancer care).

2. Cancer Care System in Ukraine

2.1. Epidemiology

Ukraine's oncological disease burden poses considerable pressure on patients and healthcare facilities to manage early detection, diagnosis, treatment, rehabilitation, and palliative care. The cancer incidence among the 30-69 yo age group in Ukraine is the 2nd highest among other European countries. In the internal structure of morbidity in 2020, the share of neoplasms took 3rd place in Ukraine in the general disease architecture after cardiovascular diseases (CVD) and respiratory system diseases. However, malignant neoplasms constituted the 2nd leading cause of death among Ukrainians in 2020, with a high rate of excess deaths.

The cancer incidence rate is distributed unevenly among different population categories in Ukraine. And females are more often diagnosed with cancer than males, and morbidity rates of oncological diseases among urban populations prevail over rural ones. In turn, the cancer detection rate at the third and fourth stages and the non-detected stage has been growing since 2014, constituting more than 35% of all diagnosed cases. In 2021, patients of all sexes and ages were most often detected with the following types of cancer: breast, non-melanoma skin cancer, lungs, colon, rectum, prostate, uterus, stomach, pancreas, and kidney.

Due to diagnostics discrepancies, mortality rates in Ukraine are relatively high in comparison to other European countries. The mortality rate of oncological diseases, likewise the incidence rate, was severely affected by the Russian invasion (annexation of Crimea, part occupation of Donetsk and Luhansk regions) in 2013-2014 and COVID-19 in 2020-2021. Speaking of localizations, in 2021, deceased oncological patients of all sexes and ages most commonly have cancer localized in the lungs, breast, stomach, colon, rectum, prostate, pancreas, kidney, ovary, and cervix. This rate remains without significant changes compared to the previous years.

2.2. Regulation

The cancer care system in Ukraine, inseparable from the general health care system, remained virtually unchanged throughout the entire period after gaining independence in 1991. The system embraced all key aspects of the Semashko healthcare system—high centralization guided by the strict vertical of power, corruption, and extensive hospital infrastructure. Since then, the system has been decentralized, separated for adult and pediatric oncology, funded by sporadic financial flows, and headed by the lack of strategy from the Ministry of Health of Ukraine, relying on National Cancer Institute (NCI) to bring novelties, manage cancer care hospitals and conduct scientific research.

In 2020, the introduced healthcare financing reform for secondary and tertiary medical care drastically changed the delivery of cancer medical care. The single national payor—National Health Service of Ukraine—elaborated oncology packages, which included all needed interventions to provide qualified medical services and determined a tariff and was authorized to contract hospitals for the medical services delivery. NCI (adult oncology) and Okhmadyt (pediatric oncology) serve as reference centers for complicated cases. State Enterprise “Medical Procurements of Ukraine” (MPU) purchases and delivers essential medicines and medical devices for patients all over Ukraine.

2.3. Evolution of Cancer Care System in Ukraine

Since 2002, four State Programs have aimed to bring change to the cancer care system, enhance patient access to cancer care and increase the therapeutic outcomes of cancer diagnostics and treatment:

1. 2002-2006 Oncology National Program,
2. 2006-2010 Pediatric Oncology State Program,
3. 2010-2016 Oncology National Program,
4. National Cancer Control Strategy 2030 (Strategy-2030),

The first three programs were officially claimed to reach all the expected deliverables yet, in reality, the results of implementation were rather humble, apparent and inferior, especially when talking about the Ukrainian cancer care system. The latest one— National Cancer Control Strategy 2030—was not endorsed by authorities before the full-scale invasion of Ukraine had started. Taking into account the completely changed context, Strategy-2030 (in its initial version) needs drastic rethinking and amendment, allowing the healthcare system, along with the cancer care system, to adapt to the new reality and socio-political landscape.

2.4. Financing

Considering policy-makers roles in financing cancer care, the Ministry of Health elaborates on the political and strategic framework for further development of the healthcare system. This means mentioning priority medical services due to epidemiology rates, the necessary volume of medical services under the national benefits package, and forming and updating the positive lists of drugs and medical devices to provide cancer patients with and estimating the expenses for the following year.

Developed policies are subject to negotiation and alignment with the Ministry of Finance of Ukraine (MFU) and the Ministry of Economic Development of Ukraine as finite resources urge for debate. After the consensus is reached, the MFU elaborates a bill on State Budget for the following year, which the general voting should approve in the Parliament. Based on the future state budget, NHSU and MPU receive funds to fulfill their functions as strategic purchasers of medical services in hospitals, pharmaceuticals, medical devices, and medical equipment from the pharma community.

2.5. Stakeholders

The network of stakeholders involved in cancer care provision is diverse, and it entails a bunch of high public authorities (President, Parliament, Government), healthcare-specific institutions (e.g., MOH, NHSU, MPU, and others), oncology-oriented entities (namely NCI, oncology dispensaries and clinics, medical associations, etc.), PAGs, and private and business entities (manufacturers, wholesalers, pharmacy chains).

Immediately after the Revolution of Dignity in 2014, Ukrainian society has become one of the main drivers of changes in the social and political life of the country. Non-governmental organizations and patient advocacy groups are beginning to mold the tone in the formation of the reform plan and its implementation. In oncology, powerful organizations are emerging that can influence the policy shape and the development of medical care packages, impact a significant increase in the transparency of care providers, and position as change agents in the socio-political landscape. Business entities joining local associations aspire to affect the process of decision-making and make their interests count.

2.6. Cancer Care Drugs Procurement

Cancer patients are entitled to free pharmaceuticals (usually high-priced) within primary and specialized medical care under the national benefits package—Medical Guarantees Program. MOH defines the scope of medicines under the state oncology program for adults and children. Centralized purchases of drugs under these programs are conducted by the single procurement agent in healthcare—State Enterprise “Medical Procurements of Ukraine” (MPU).

Children receive meds free of charge under the “Medicines and Medical Devices for Treatment Children with Cancer and Oncohematological Diseases” program. Adults are provided with necessary treatment via the “Chemotherapy Drugs, Radiopharmaceuticals and Accompanying Drugs for Treatment of Cancer” program. MOH revises the scope of INNs annually under a defined procedure of which all interested stakeholders may become a part.

3. The trajectory of Cancer Care

The care provided for patients with oncological diseases requires a multi-dimensional approach, i.e., different means and methods should be applied at both population and individual levels.

Beginning with the population level, at this stage, cancer-fighting policies are aimed at the general society as such and do not orient much at the individual cases. Primary prevention and early detection represent cancer care at the population level in Ukraine. Primary prevention is done through health counseling, education, environmental controls, and product safety. Early detection strategy implies a broad coverage of patients from the risk groups, which may obtain such services as mammography, cystoscopy, hysteroscopy, bronchoscopy, colonoscopy, and gastroscopy free of charge. Nevertheless, there is underutilization of these services due to the low awareness of them among patients and the relevant physicians.

Proceeding with the individual level, in case of any symptoms, patients refer to the general practitioner, who, in case of suspected cancer, issues referrals for laboratory tests and/or instrumental studies, which could be received for free at the specialized facilities. Further, general practitioner finds an oncological hospital in the National Health Service of Ukraine database, where patients would undergo other diagnostic evaluations if needed and obtain the main course of treatment.

The primary method of cancer treatment remains to be surgical intervention. Also, radiotherapy and chemotherapy are widely used before or after the surgery. Radiotherapy is performed on the machines that are available at the given hospitals. Unfortunately, due to the lack of modern LINACs, many hospitals still use outdated gamma therapy devices.

After undergoing the main course of treatment, physicians elaborate a dynamic observation plan and redirect a patient to other Healthcare facilities to receive medical care for non-cancer conditions, if any. In the case of terminal cancer, patients are entitled to palliative care, which in Ukraine also covers end-of-life care. Palliative care could be provided either at specialized institutions or at outpatient levels by the general practitioner and mobile palliative care brigades at the patient’s home. In both cases, palliative services are reimbursed and cover certain painkillers, lab tests, instrumental examinations, and specialized nutrition.

4. Impact of Russian Invasion on the Ukrainian Cancer Care System

A fundamental analysis of the consequences of the Russian invasion on the Ukrainian healthcare infrastructure is yet to come as the war is expected to flow into 2023 at least.

4.1. On Healthcare Infrastructure

Russia’s invasion of Ukraine has caused USD 108 bn in damage to the country’s infrastructure, according to a study by the KSE released the same day Ukraine’s defense ministry estimated the war had left 3.5 mln people homeless. In terms of healthcare infrastructure, more than 900 healthcare facilities (public and private hospitals, pharmacies, laboratories, diagnostic centers, blood banks, etc.) were damaged or destroyed by Russians in Ukraine. Estimated recovery needs just to rebuild as it was, the Ukrainian healthcare system will require an additional USD 2.4 bn.

Key critical issues of the Ukrainian healthcare infrastructure induced by the Russian invasion:

• Destruction of buildings, incl. electricity, heat, and water supply grids.
• Destruction of or stealing various medical equipment (incl. expensive and complex diagnostic and therapy machines).
• Significant life risk for medical and nursing hospital personnel.
• Loss of patients due to internal and external migration.
• The interruption of necessary treatment for oncology patients, especially radiotherapy that heavily relies on Cobalt-60 machines.
• Premature deaths due to cut access to medical care.
• Distortion or destruction of logistics of medicines to rural areas.

4.2. On Cancer Care Infrastructure

Oncology infrastructure was hit hard in Ukraine since the Russian invasion of Ukraine in 2014 when Russians annexed the Ukrainian Crimea and occupied the Donetsk and Luhansk regions partly. The problem deepened after February 24th, 2022, when invaders occupied oncology medical centers in the newly seized Donetsk (Mariupol COD), Kherson (Kherson ROD), Zaporizhzhia (Melіtopol ROD) regions.

Therefore, the cancer care infrastructure throughout Ukraine transformed during the war. So far, oncology hospitals have faced unprecedented threats to the consistent provision of medical care for patients, life risks for medical staff, and destruction or/and damage threats to buildings. 

4.3. On Patients and Their Families

The full-scale invasion of Ukraine made the treatment of patients, especially children, with oncology within precise timing nearly impossible, challenging families, medical staff, and the healthcare system overall.

More than 2 mln refugees have fled Ukraine since the Russian invasion began on Feb 24, 2022, and over 4 mln people, 10% of the population, are expected to be forcibly displaced as they seek safety, creating a wide-ranging humanitarian crisis. Ukraine has a high cancer burden, with over 160,000 new diagnoses in 2020 alone.

Ukrainian cancer patients faced unseen challenges due to the Russian invasion, including risks of being killed or injured, increased OOP expenditures for much newer generation targeted and immunological cancer treatments, delay in registration in hospitals at the evacuation site due to overcrowding, and significant disorganization in processes.

Furthermore, families of children with cancer had to relocate full (meaning all working family members lost their jobs or income sources). Immediately after the war had started, the SAFER* initiative was organized under the auspices of the USA (ST JUDE GLOBAL SIOP/SIOP-E, CCI/CCI-E) and stakeholders from Ukraine (Tabletochki and Western Ukrainian Specialized Medical Center) and Poland (Herosi and Polish Society of Paediatric Oncology and Haematology). SAFER UKRAINE is a global initiative, which among other things, entails a virtual command center that coordinates and makes possible the evacuation of the ill child to safe places in Ukraine with further travel to the hosting medical center, where the essential therapy within the precise timing may be provided. The team helps find or translate medical records and manages the logistics associated with crossing the border.

The initiative has become a proof-of-concept for global health in terms of taking rapid measures and efforts to react to healthcare challenges and crises.

5. Further Development

Conceptually, measures aimed at further developing the Ukrainian healthcare system would be divided into two subgroups: (A) pre-war initiated, (B) during the war initiated.

Beginning with the pre-war initiatives, even before the war, the Ukrainian Healthcare infrastructure was in urgent need of centralization, optimization, and modernization of medical care delivery. Among others, these problems were planned to be faced by introducing such reforms as healthcare system clusterization and public-private partnerships.

The clusterization of hospital districts reform implies reducing hospital numbers and creating a set of three-leveled hospital districts. Currently, the clusterization reform is not defined by the Government in detail, making it difficult to predict its effectiveness of the latter.

As for the Public-Private Partnerships, this model is planned to be applied while rebuilding the damaged Healthcare infrastructure and improving the working ones. However, before its application, competent specialists should be prepared, and mechanisms for external independent scrutiny must be created.

Proceeding with the Healthcare initiatives proposed during the war, most of them are accumulated into the Recovery Plan proposed by the National Council for the Restoration of Ukraine from the Consequences of the War.

A standalone part of this Recovery Plan is outlined for measures to recover the Ukrainian healthcare system focused on such areas as the restoration of healthcare infrastructure, strengthening of the public health system, developing electronic healthcare, etc.

As for the restoration of the infrastructure, it is essential to remember that it could be made in two ways: rebuilding what was before the war and rethinking or optimizing the system. We believe the second way should be prioritized since the simple rebuilding of the soviet Semashko healthcare model may bring significant challenges to the state economy and public health. Addressing these limitations will require substantial capital investment, but constraints on public finances will reduce the Government’s ability to fund the reconfiguration.