Palliative care began in Kyrgyzstan in 2005 as a pilot home-based care program in Osh Cancer Center and was supported by a small group of nurses and one physician from Scotland. In 2010, the Soros Foundation-Kyrgyzstan and the Open Society Foundation's International Palliative Care Initiative began supporting work on palliative care policy, legislation, essential medicine availability, education, advocacy, and implementation. A Ministry of Health working group was established to lead this initiative, and technical assistance was provided by an international palliative care consultant. Work began with a national needs assessment, which identified the existing barriers to the provision of quality palliative care, and recommendations were made to the working group to address these challenges. Today, palliative care is included in many national health care policies and laws, a national palliative care association has been established, undergraduate medical and nursing education include elements of palliative care, oral morphine and fentanyl patches are now available in parts of the country, inpatient services exist in the National Cancer Center in Osh and Bishkek, two tuberculosis hospitals with multidrug resistant/extensively drug resistant, and home care services in Osh and Bishkek. Public information campaigns and advocacy activities continue to increase public awareness about palliative care and press government action.
Purpose Kyrgyzstan and Tajikistan are Central Asian low-income countries. Breast cancer is the most common cancer in the Kyrgyz Republic and in Tajikistan. Almost 40% of breast cancer cases are detected in advanced stages. The Kyrgyzstan and Tajikistan health care systems do not guarantee equal access to treatment to all people, and patients with breast cancer have to pay out of pocket for the entire course of chemotherapy treatment. Therefore, evaluation of the cost of a chemotherapy regimen represents a first step in the policy discussion and the creation of a government copayment system that would guarantee access to chemotherapy and ensure the effective and sustainable basic-level treatment of most patients. Methods Resource and Policy Exchange, Tajik, and Kyrgyz experts calculated the average drug dose per patient for adriamycin and cyclophosphamide; cyclophosphamide, methotrexate, and fluorouracil; and fluorouracil, adriamycin, and cyclophosphamide regimens recommended by the Breast Health Global Initiative as basic-level therapy and the taxanes average dose—docetaxel and paclitaxel—as enhanced-level therapy. The drug procurement cost per cycle was calculated for each chemotherapy regimen on the basis of on an average dose per patient (standard 1.75 m2), the average number of doses per cycle, and the average list price per milligram. Experts acquired cancer drug price lists from different pharmacies using the lowest generic prices available in Kyrgyzstan and Tajikistan. Results The cost of the basic chemotherapy regimen adriamycin and cyclophosphamide is $249 USD in Kyrgyzstan and $222 USD in Tajikistan. That of the cyclophosphamide, methotrexate, and fluorouracil regimen is $587 USD in Kyrgyzstan and $486 USD in Tajikistan. That of the fluorouracil, adriamycin, and cyclophosphamide regimen is $326 USD in Tajikistan and $526 USD in Kyrgyzstan. However, the cost of the taxanes regimen—enhanced level—is more expensive. The cost of a paclitaxel monotherapy regimen is $4896 USD in Kyrgyzstan and $4,695 USD in Tajikistan, and that of a docetaxel monotherapy regimen $1,411 USD in Kyrgyzstan and $1,086 USD in Tajikistan. Conclusion Chemotherapy regimen cost calculation is an integral part of advocacy and policy work. It helped to negotiate basic-level chemotherapy treatment insurance coverage for women with breast cancer. The cost of a monotherapy taxanes regimen is expensive and requires additional financial resources. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . No COIs from the authors.
Background and context: Breast cancer takes the first place among the cancer diseases in the Kyrgyz Republic. Almost 40% of breast cancer cases are detected in the advanced III and IV stages. Specialized oncology services for cancer patients are available in two oncology centers in the Kyrgyz Republic. One is in Bishkek (capital of the country), and another is in Osh (the second large city). However, medical services provided by the government are limited to the surgery, particularly, with mastectomy. Radiotherapy is not available because of deterioration and breakdown of equipment. Mandatory Health Insurance Fund does not cover chemotherapy cost for cancer patients, and patients pay out of pocket. Kyrgyz National Essential Drug List does not include many vital antineoplastic agents recommended by WHO. The absence of essential antineoplastic agents in National Essential Drug List negatively affects medicine registration and procurement, makes them unavailable, inaccessible and unaffordable in Kyrgyzstan. Advanced breast cancer patients cannot plan their upcoming expenses. Many patients can´t finish the full course of treatment. Ergene is the only organization in Kyrgyzstan that advocates and provides technical assistance to the Oncology Institute and the Ministry of Health to improve access to oncological drugs for the treatment of breast cancer. Aim: Improve access to oncology medicines and treatment of patients with advanced breast cancer. Strategy/Tactics: Ergene team accessed National Essential Drug List (EDL) and selected available oncology drugs. Then the experts compared available oncological drugs from the National EDL and oncology drugs from the WHO list. Together with oncologists, experts analyzed the availability of essential drugs for advanced breast cancer and identified missing drugs to be included in National EDL. These drugs are trastuzumab, anastrozole, paclitaxel, and gemcitabine. Program/Policy process: The team of experts calculated the cost of treatment of breast cancer regimens including therapy with trastuzumab and started negotiations with Mandatory Health Insurance Fund (MHIF) for chemotherapy treatment coverage. The policy makers agreed that the cost of basic chemotherapy regimens is affordable for insurance coverage (adriamycin cyclophosphamide-245 USD, cyclophosphamide methotrexate fluorouracil - 390USD, fluorouracil adriamycin cyclophosphamide -426 USD). However, the cost of monotherapy regimen is more expensive (capecitabine, docetaxel -2400 dollars) and requires additional financial resources. Outcomes: MHIF will include coverage of essential AC, FAC, and CMF regimens for women with breast cancer and will consider partial coverage of trastuzumab and several monotherapy regimens. What was learned: Chemotherapy regimens cost calculation is an integral part of advocacy and policy work. It helped to negotiate chemotherapy treatment insurance coverage for women with breast cancer.
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