Webinar on Quality of Cancer Care in Ukraine with MArS

Eirhub partner, Yevgen Brovko, took part in the MAP Podcast episode organized by MArS Market Access & Pricing Strategy GmbH.

Yevgen was invited to uncover the challenges and peculiarities of the Ukrainian #Cancer Care System during the war, followed by the market access expert Stefan Dr. Walzer put the current environment into perspective.

The podcast is available at the link.

You may also be interested in a comprehensive white paper, "Cancer Care System in Ukraine: Current Status, Impact of War, Further Development."

Some excerpts from the webinar are given below. 

1. In a nutshell, could you summarize cancer care in Ukraine until the end of 2021?

As with anywhere in Europe, oncological diseases significantly burden the Ukrainian healthcare system. Moreover, the cancer incidence among the 30-69 yo age group in Ukraine is the 2nd highest among the other European countries.

Due to such a burden, cancer care was among the priority areas within the Ukrainian Healthcare System. More specifically, the oncology benefit packages were introduced with the HC financing reform for secondary and tertiary medical care in 2020. They covered all needed interventions for qualified cancer care, such as screening services, chemotherapy, radiotherapy, and pharmaceuticals. Compared to other areas of healthcare, oncology was well financed.

Nevertheless, until the end of 2021, the cancer care system still faced severe challenges, such as a lack of modern medical equipment, an excessive number of hospitals, and insufficient competence of physicians. Although, until the end of 2021, the cancer care system in Ukraine was in the process of active development, and notably, the Strategy for improving cancer care was under development.

2. What has changed since the attack in 2014 and finally in 2022 in terms of cancer care?

2.1. Audiotrack

After the Revolution of Dignity and subsequent change in the Government, the Ukrainian healthcare system (including its oncology segment) faced significant changes. Before that time, the cancer care system was embraced by the post-Soviet model of vertical delivery of medical care headed by the post of the so-called "Chief Oncologist of Ukraine." The system was managed by the principles of obsolete clinical protocols, old and morally outdated medical equipment, high OOP payments, and exclusive access to medical care only to specific categories of people with "connections" among authorities, physicians, decision-makers, etc.

In 2020, the introduced HC financing reform for secondary and tertiary medical care drastically changed cancer care delivery. Notably, the National Health Service of Ukraine elaborates on oncology packages with all needed interventions for qualified cancer care. It also determines a tariff for a child or adult care paid to a provider.

Currently, the "Medical Procurements of Ukraine" State Enterprise (this is a relatively new state agency responsible for public procurements in healthcare at the central level for state funds) procures medicines under the benefits package. At the end of 2021, the packages and list of the medicines publicly procured were significantly widened.

2.2. Audiotrack

After the full-scale Russian invasion of Ukraine, additional changes in the Ukrainian HC system were introduced. 

The most significant change for patients is the following. For example, before 2022, patients could obtain specialized oncology services only with the referral of a GP. The procedure has been simplified today, and patients may refer directly to the oncological hospital.

The main change for hospitals is around the clusterization reform. According to the new approach, the network of healthcare facilities in the region, united into one hospital district, will be further divided into hospital clusters considering such factors as:

• borders of administrative and territorial units;
• geographical features of the region and the condition of highways;
• current and projected demographic indicators of the population, the structure of morbidity and mortality;
• optimal clinical routes of patients for timely access to medical and rehabilitation care based on the principles of evidence-based medicine;
• burden on medical workers and rehabilitation specialists.

According to the types of medical care provided in the healthcare facilities of the hospital cluster, the network of healthcare facilities will be divided further into supercluster, cluster, and general hospitals.

As you can see, the reform is hugely about infrastructural and conceptual optimization.

And what are the changes for businesses? The Government simplified the procedure of Marketing Authorization, extended the validity of MA Certificates, and simplified the public procurement procedure. 

3. Can you elaborate on the patient pathway of cancer patients in Ukraine?

3.1. Audiotrack

Generally, the patient's first entry point is a general practitioner. Therefore, if a person has symptoms of oncology or is suspected of an oncological condition, one needs to contact a GP to clarify the possible diagnosis and receive a referral to an oncologist.

When a patient accesses the oncology hospital, the attending oncologist or a council of physicians works jointly to confirm or refute cancer, diagnose cancer, assess the clinical picture, conduct risk-benefit analysis, and elaborate a complex medical care interventions plan, such as radiotherapy, chemotherapy, and surgery.

Although while treatment risks outweigh the patient's benefits, palliative care is usually prescribed. Such care could be provided either at the hospital or at home. In hospitals, palliative patients could obtain painkillers, psychological care, round-the-clock nursing care, lab tests, instrumental examination, specialized nutrition, and intensive care.

At home, the services are relevantly similar and could be provided by the GP and mobile palliative care brigades; a nurse or relatives perform round-the-clock care after the training.

4. How can new therapies be launched and made available in Ukraine? (Managed Entry Agreement made in the last few days…)

4.1. Audiotrack

There are several such options. Some of them, like regular hospital procurement, centralized procurement by MPU, and cumulative procurement by the MPU, are time-consuming and require inclusion either in various lists of drugs with approved effectiveness. Although there are faster options, like decentralized hospital procurement, Managed Entry Agreements and Compassionate use programs.

Starting with the decentralized hospital procurement, cancer drugs must only undergo marketing authorization to be procured under this channel. That is irregular procurement, which is performed only when HC facilities 100% fulfilled their needs in drugs listed in the National Essential Medicines List. Some regional programs may cover the costs for such medicines under the local budgets.

Proceeding with Managed Entry-Agreements, drugs must undergo marketing authorization and HTA procedures to be eligible for such an option.

After that, MAH negotiates with the MOH and the MPU on the procurement conditions.

For example, MOH concluded such a contract concerning the drugs against spinal muscular atrophy - Risdiplam. Additionally, some oncology drugs are being procured in the recent future under negotiation procedure, namely: Alectinib, Gemtuzumab, Venetoclax, Lanreotide, Obinutuzumab, Cabozantinib, Pembrolizumab, Brentuximab Vedotin.

Now about the Compassionate use. This option was introduced in 2022 and involved providing severely ill patients with drugs at the stage of clinical trials, free of charge. Under the program, patients are entitled to free access to medication that is approved for use according to the relevant indications or for which at least the II phase of clinical trials has been started in USA, EEA, AUS, CAN, JPN, GBR, and for which there is sufficient safety and efficacy information to assess the benefit/risk ratio. As of now, this option was not applied in Ukraine.