Palliative care for cancer patients in resource-limited settings of Kazakhstan: implications for cost-effectiveness and health policy

ABSTRACT
Introduction: About 60 million people need palliative care worldwide, and nearly 80% of them live in low-to middle- income countries (LMICs) where only 12% of patients who require palliative services have access to them. As a Central Asian LMIC with a transitional economy and a reforming healthcare system, Kazakhstan has recently taken on the task of integrating palliative care into the general healthcare system to meet its national needs and international standards. Although palliative care services in Kazakhstan have significantly improved care for persons nearing the end of life, patients needing these services still suffer from pain, lack of access, and high out-of-pocket expenditures. Palliative care in Kazakhstan is provided by hospices, cancer centers, general hospitals, and mobile teams. More than 100,000 people need palliative care in Kazakhstan; however, as one or more family members are usually involved in the care of a terminal patient, more than 200,000 people would benefit from high-quality palliative care services in this country. Considering that cancer is a primary illness necessitating palliative care, there is a need for a comprehensive understanding of how strategies aimed at preventing cancer could reshape the demand and delivery of the spectrum of cancer care
services, including palliative care.
Objectives of this study include:
• Present a detailed analysis of palliative care in Kazakhstan, including funding, policy, workforce, education, infrastructure, etc., providing an evidence base for future assessments and research of palliative care in Kazakhstan and in other LMICs.
• Assess the cost-effectiveness of hospice-based palliative care for cancer patients compared to the current standard of care provided in cancer centers across the country.
• Explore the challenges faced by palliative care stakeholders in resource-limited settings, and to offer evidence-based recommendations for policymakers to facilitate
the advancement of palliative care in Kazakhstan and other LMICs.
• Asses the cost-effectiveness of genetic testing for Lynch syndrome provided to patients newly diagnosed with colorectal cancer, followed by cascade genetic screening of biological relatives from the perspective of the Swiss healthcare system. Methods: The authors assessed the nation's palliative care landscape using data from the Ministry of Health, regional healthcare centers, and NGOs (Study 1). This comprehensive evaluation involved soliciting information through official correspondence and engaging with
key stakeholders.
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For the cost-effectiveness analysis, a total of 182 family caregivers were recruited, 104 from three hospices and 78 from three palliative care units of cancer centers (Study 2). Patients’ state of health and family caregivers’ burden were assessed with the Palliative Outcome Scale (POS) and the Zarit Burden Inventory (ZBI). Direct medical and non-medical costs, and family caregivers’ out-of-pocket expenses associated with palliative care were collected. One-way and probabilistic sensitivity analysis was conducted by generating 1,000 resamples using bootstrapping with Monte-Carlo simulation.
To assess challenges of palliative care stakeholders, we conducted 29 semi-structured interviews with palliative stakeholders (family caregivers n=12, healthcare professionals =12, administrators n= 5) across five regions (Study 3). Verbatim transcripts were analyzed using content analysis to identify challenges of palliative stakeholders in resource-limited settings. Recognizing that these findings mirror the well-documented challenges faced by palliative care stakeholders, we converted these insights into evidence-based recommendations, specifically designed for the resource-constrained contexts of LMICs, and in congruence with the latest body of literature on palliative care and family caregiving.
Additionally, we used decision trees with Markov models to conduct a cost-effectiveness analysis of universal genetic testing for Lynch syndrome of all patients newly diagnosed with colorectal cancer, and compared it with the current tumour-based testing with immunohistochemistry techniques followed by DNA sequencing that examines for germline pathogenic variants associated with Lynch syndrome.
Results: The authors obtained the necessary data through official responses from the Ministry of Health, regional centers of healthcare and NGOs. These responses were accompanied by supplementary materials that fulfilled the authors' requests. Overall, the findings of the assessment provide a thorough understanding of the current state of palliative care in Kazakhstan presented in this study along with areas that require attention for future development.
Cost-effectiveness analysis revealed that after 14 days of inpatient palliative care, patients’ median POS score was 5 points better in the hospice group compared to the cancer center group. Family caregiver burden was also 2.5 points lower in favour of the hospice group. The median cost of palliative care per patient over 14 days was $31 lower for the hospice group. There was a statistically significant correlation between the cost of palliative care and patients’
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quality of life (r = 0.58). Probabilistic sensitivity analysis showed that hospice-based care has better outcomes and lower costs than care provided in cancer centers in 80% of tested scenarios. Discovering the challenges of palliative care stakeholders, our analysis identified seven main themes that were initially brought forward by different groups of stakeholders. The most common challenges highlighted by family caregivers were high out-of-pocket expenditures; the lack of mobile palliative care services; and shortages of opioids to prevent pain suffering. Health professionals highlighted poor palliative care education and lack of medication, especially opioids for pain relief as the major challenges they encounter in their daily practice. Major challenges for administrators included lack of societal awareness about palliative care, and lack of financial support from the State.
Within the analysis of the universal genetinc testing for Lynch syndrome, the incremental cost- effectiveness ratio of this strategy was CHF65,058 per QALY saved, which is cost-effective in the Swiss context. Moreover, the universal testing correctly identifies all colorectal cancer patients with Lynch syndrome, prevents 17 deaths and prevents 19 colorectal cancer cases compared to the currently applied tumor-based testing.
Conclusion: Despite recent progress, Kazakhstan faces ongoing challenges such as restricted opioid availability, insufficient education, and low public awareness about palliative care services. Hospice-based palliative care can be a cost-effective alternative in resource-limited settings of Kazakhstan. Implementation of further national palliative care strategies and policies require a large-scale coordinated involvement of all stakeholders. Family caregivers play a crucial role in providing palliative care, yet, they have been completely unsupported by they system in their tasks. Our recommendations are based on the idea that coordinated targeted and tailored stakeholder engagement is preferred to a one-size-fits-all strategy.
In the Swiss healthcare context, universal genetic testing has demonstrated both cost- effectiveness and significant health advantages. However, the ICER of CHF 65,058 (USD 70,000) surpasses the cost-effectiveness threshold of most low-to middle-income countries, including Kazakhstan where the GDP per capita is USD 11,000. Hence, the authors underline the critical necessity for locally viable, low-cost cancer screening options in resource-restricted settings. The introduction of more affordable cancer preventive measures, such as mammography, Pap smear test, and fecal occult blood test, among others, could be considered as more financially viable options for population-based cancer screening.