State Audit Office in a statement to the media about the audit results that early detection of oncological disease is critical to ensuring more successful treatment. However, since 2017, the proportion of oncological diseases detected early has not risen.
The disease can be detected early in healthy people through routine preventive tests with their general practitioner and screening, as well as in patients already with symptoms or health complaints.
However, in the case of minor suspicions, further investigations should be carried out in an expedited manner as part of the “green corridor” and post-screening.
The annual preventive check-up with the general practitioner is the first missed option. A general practitioner has a duty to provide prophylactic testing to adults once a year, which is fully paid for by the state budget.
However, from 2017 to 2021, on average, only 14% of adults have been subjected to such tests and their share is decreasing annually.
This data also shows critically low cooperation with patients in Latvia, State Audit Office points out.
“Unfortunately, currently there are no established procedures in doctors' practices for systematically inviting patients to preventive tests,” explained Maija Āboliņa, a Member of the State Audit Office Board.
State-organized screening for early detection of oncological diseases is another missed opportunity, indicates the auditor. Four types of cancer screening are performed in Latvia – cervical, breast, intestinal, and prostate.
Oncological disease is detected at an early stage in patients who have previously undergone screening, but patient responsiveness is low – it falls significantly short of the indicators planned by the Ministry of Health and recommended in Europe.
Only a small proportion of patients found to have oncological disease have previously undergone screening, with rates varying from 2 percent prostate, 20 percent bowel cancer, 32 percent breast cancer to 40 percent cervical cancer.
One of the causes identified in the audit is the disorderly institutional structure and the share of responsibilities. Latvia only sends out invitation letters for years and collects statistics on citizens who respond to the invitation, but there is no action to improve responsiveness.
According to the auditors, the measures of the Ministry of Health to address target groups are passive and formal.
There is also no uniform order in which patients receive information about screening results in the country, the Audit Office concluded. eporting results has been left to each treatment institution, and while the most assertive patients find out for themselves, the others may be left without answers.
The “green corridor” introduced in 2016 also doesn't work in reality. It aims to allow patients with suspected oncological illness to get state-paid examinations and get a diagnosis on a priority basis - outside the overall queue and at a maximum of 10 working days. But only 25% of patients received services within 10 working days, and the average time from visiting a general practitioner to diagnosis is 195 days instead of the intended 65 days.
One reason is that in the “green corridor,” virtually all patients end up in a single queue again, as 92% of the exams are of patients with an already confirmed oncological diagnosis.
The audit also found that some patients failed to conduct state-paid post-screening examinations when needed. In such cases, the checks carried out during the screening and the resources used for them have been in vain.
Expensive medicines and missing funding
While oncology is one of the priority areas of healthcare, funding from the Ministry of Health for reimbursement of medicines is not planned according to the needs of oncology patients. In addition, neither the health department nor oncology patients can expect stable additional funding in the long term. Additional funding is not always included in the national budget base and as a result is required again in the following year.
The Health Services Improvement Plan for Oncology 2022-2024 is also without full funding. At the same time, prices of reimbursable medicinal products for the treatment of oncological diseases in Latvia are highest in the Baltics.
The audit concluded that, for example, in Latvia, the mark-up of Tafinlar wholesalers and pharmacies together with VAT represents 12% of the final price, while in Estonia and Lithuania respectively 8% and 5%, as a result, the final price of medicinal products in Latvia is 271 euro higher than in Estonia and 529 euro higher than in Lithuania, the State Audit Office noted.
Reimbursement of medicinal products in Latvia is also not based on the needs of patients. Even if the medicinal products are effective and their cost is adequate, they shall be included in the list of reimbursable medicinal products only if additional funding is available.
In addition, the list also includes medicinal products that, in some cases, are not used at all to treat the relevant diagnoses, are no longer used, are outdated, and not in line with international clinical guidelines. The situation therefore arises where some patients with the same diagnosis are able to receive treatment and others are not.
According to the State Audit Office, the decision to include effective medicinal products on the list, if it requires additional funding, should also be tracked and disclosed to the public, as there is no publicly available information on which medicinal products will be included in the list and in what order.
If there is no medicinal product on the list to treat a particular patient's diagnosis, the should be able to claim the necessary reimbursement of the medicinal product on an individual basis even when the medicinal product is not on the list due to lack of funding but is therapeutic and cost-effective.
Although the compensation procedure provides that in such cases the purchase expenses of medicinal products shall be compensated in the amount of 100%, at the same time a restriction has been determined – the purchase of medicinal products for one patient shall be compensated for a maximum of EUR 14,228.72 in a 12-month period.
This limit has not been revised since 2006 and the Ministry of Health does not have the historical data or the considerations on which it is based.
Meanwhile, for oncology patients with a diagnosis for which the drug is listed, it costs an average of €49,560 over a 12-month period.
Not all cancer diagnoses are treated in accordance with international guidelines. Comparing state-paid and international guidance-mandated drug therapies for the treatment of 11 of the most common cancer diagnoses found that in almost all cases, state-funded therapies are incomplete or inadequate and ineffective.
Of the 11 diagnoses included in the audit sample, only ovarian and non-metastatic bowel cancers are treated in Latvia in accordance with the guidelines.
Similarly, 39% are provided with basic therapy in Latvia, 35% with continuity of treatment, while only 27% of diagnoses are fully provided with both basic therapy and continuity of treatment.
Furthermore, there is no rational link between the list and individual reimbursement of medicinal products. For example, if a particular diagnosis includes a medicinal product that is not used at all for treatment or the patient does not qualify for reimbursement of the medicinal product due to restrictions imposed by the National Health Service (NVD), the patient shall also be refused reimbursement of the medicinal product on an individual basis.
“Most likely it's a consequence of limited public funding, but in the auditors' assessment, such conduct is not only unfair, illogical and absurd, but also degrading to oncology patients,” Maija Āboliņa noted.
Prospects for the cancer registry project remain uncertain
In Latvia oncological diseases belong to compulsory-registered diseases – information regarding patients for statistical purposes is accumulated in the patient registry, the operation of which is ensured by the SPKC.
Unfortunately, the registry does not function properly because the data it collects on oncology patients is poor and incomplete.
For example, in June 2023, the most recent available data was published in 2019 and the data remain marked “provisional”.
In order to make more extensive use of oncology patients, a new cancer register started to be established in 2022, with the responsibility of the NVD and SIA “Riga East Clinical University Hospital” (RAKUS) and funding of approximately EUR 1.6 million.
The auditors were unable to receive information on the management plan of the project to establish the new cancer register, and during an audit the Ministry of Health concluded that RAKUS was not at all entitled to ensure the establishment and operation of a national patient register, which resulted in the transfer of responsibility back to the NVD, but the allocated funding was invested in RAKUS's share capital in December 2022, with approximately EUR 900,000 allocated to the budget for the purchase of an unplanned medical device.
Unfortunately, the future outlook for the new cancer registry project remained uncertain during the audit.
State Audit Office has issued six recommendations to the Ministry of Health, the implementation deadlines of which are from 2025 to 2029.