State Audit Office, in its audit of the field of oncology, found a number of deficiencies in diagnostics and treatment systems, concluding that the priority in this field is only "on paper": the reality shows not only limited budgetary resources but also a disorderly system in which medicinal products enter the list of reimbursable medicinal products; to whom and by what criteria they are discharged; manufacturers or traders of medicinal products have had too much influence in drawing up the list; on the state's side, there is too little initiative to enter the list for drugs that no longer cost much.
Behind an unaudited list of drugs and obscure criteria are real, living people for whom one entry may turn out to be the price of life.
Mother of three children Inga Mengote was diagnosed with cancer of the lymphatic system several years ago. Chemotherapy and bone marrow transplant followed. After further examinations, the diagnosis has been clarified and a specific immunotherapy preparation is recommended. But it's not state-covered in this particular case. Inga has already repeatedly asked the foundation “Ziedot.lv” for help with cancer treatment.
The treatment previously received with donor support makes her feel better, and the tests have improved. Although limited in movement, she continues to work remotely, pay taxes, and raise three daughters. All requests to find opportunities for the state to pay for the therapy have been rejected. “My treating physician has certainly advised the health service on the need for this medicine specifically in my case. But those refusals are the same: that, in my case, this medicine should not be used. I just don't understand how it comes down to not being used when I'm told after my exams that they are the most appropriate for therapy,” said Inga Mengote.
She reckoned that without this treatment, her own expenses for treatment were already around three thousand euros last year. “I'm trying to hold on because I have kids, they're my motivation. I have also read, for example, the same articles on Stradiņš' website about this illness – that some give up and leave at stage two. I have stage four and keep fighting,” said Inga Mengote.
Viktorija Diļevka, also a mother of three, was advised by doctors to take chemotherapy alongside immunotherapy for breast cancer, which was not paid for by the state. She collected the required 30 thousand with the support of donors. Although the medicinal product in question is on the list of reimbursable medicinal products and also for her diagnosis, her case did not meet the criteria for a prescription – the State pays for it if there are metastases already.
“There was chemotherapy in the basket of options and it was in my case that it was because I just missed some sort of criteria. I understand that with the same diagnosis, other women may also be offered a treatment method with immunotherapy - metastases are needed there. For me, thank God it wasn't the case for that moment, but it was also the reason I wasn't compensated for that medication,” said Viktorija Diļevka.
After this summer's surgery and exams, good news has been received - the tumor has completely disappeared.
62 people have already requested help to pay for the oncology medicine at “Ziedot.lv” this year, and 386 people in the last six years. The average amount a patient has to pay is around €38,000 a year, according to information provided by Ziedot.lv.
What medicines, in what order and under what criteria will patients be paid for? There is a lack of clear rules in this area, the State Audit Office concluded. “We did not find assurance in the audit that those prescription conditions had, even if harsh, but some assessment at the bottom. We think it's all based on how many patients by number, how much we can afford within the budget framework, then what benchmark we could apply to limit their numbers,” said Maija Āboliņa, a State auditor.
The Ministry of Health has asked sectoral organizations to submit proposals by the end of October on what should be improved in the list of reimbursable medicines. Earlier this year, experts from the World Health Organization were also involved in evaluating the reimbursement system for medicinal products and also the list itself. One of the improvements envisaged is to develop criteria according to which priorities are defined for paying for medicines first, if the amount of money is limited.
Currently, the list includes drugs whose prescription conditions haven't changed for as long as a decade.
“I understand that at first the prescription conditions were imposed in order to limit the number of patients, thereby reducing the budgetary impact, let's say so. Right now, the drug already costs 10 times less than when they were included. But the conditions have remained the same, and it unjustifiably discriminates either as part of a diagnosis of some group of patients or, say, has been compensated for early cancer, but has not been compensated for metastatic cancer, there is only first-line therapy, not for everyone in need,” said Alinta Hegmane, an oncologist at the Rīga Eastern Clinical University hospital, Chair of the Board of the Latvian Association of oncologists.
In auditing the system of reimbursable medicinal products in oncology, the State Audit Office refers to the OECD report on the availability of 109 medicinal products for five different malignant tumor treatments, in 22 countries. It is concluded that all 32 medicinal products, which have been recognized as essential by the World Health Organization and which must be available in each country at certain diagnoses, have been registered in Latvia, but a tenth of these medicinal products are not reimbursed. In Lithuania and Estonia, the medicinal products listed in the organization list are available in full.
“I think standard therapy is already on the list of reimbursable drugs and is available. The fact that we are different from Lithuania and Estonia is completely natural because we have about 30% less funding than Lithuania and Estonia,” says Inese Kaupere, director of the Health Ministry's pharmaceutical department.
However, medicines to treat oncological conditions are also cheaper in Lithuania and Estonia.
Data compiled by auditors show that medicine with the active substance needed by Viktorija and Inga would cost EUR 4,041 per month in Latvia, 275 euros cheaper in Estonia, and 141 euros cheaper in Lithuania.
The fact that Latvia has not only a higher VAT and no ceiling for retail markup is particularly seen in expensive medicines. Last year, the concept of reducing drug prices in Latvia was developed and updated this year. It is currently in harmonization, but has not yet been adopted. The basic idea is to ensure that medicines are not more expensive in Latvia than in Lithuania and Estonia.
“We would like a general government statement right now with the conceptual report, and together, yes, we are going in that direction that we do not have higher prices in Latvia than in Lithuania, Estonia. What you say about the ceiling, about the margins - specifically, they are already Cabinet of Ministers regulations in which we would put criteria in order for us to achieve that noble goal that we would label as a top target in the conceptual report, “ said Inese Kaupere.
This year's budget allocated 221 million to reimbursable medicines, but this was not enough to pay for medicines already granted to patients. Another 30 million have been reallocated this year in addition to these targets. In the next year's budget, 71 million were requested for the field of oncology, including the payment of medicinal products.
“We have a lot of medication. And by investing relatively small amounts of money, but probably quite a lot of work, we could make a significant improvement. It would certainly be the first. The second is really for everyone together to agree on priorities so that we look in the same direction and speak the same language and we would have one value - it's an opportunity for oncological patients to survive,“ said Alinta Hegmane.
