SKOPJE -- After Filiz Ndochi was diagnosed with cancer in December 2022, she was quickly thrust into a sea of potentially life-changing decisions. Foremost among them was where to seek treatment. Her conclusion, she says, surprised even her.
"I've worked in the health system for 21 years, contributing," she said, "and after 21 years you end up not having confidence to be treated in your own country. This feeling was terrifying for me."
Ndochi, who is head nurse at a state dental clinic in North Macedonia's capital, had heard rumors for years of rampant corruption and abuse involving prescription drugs at the University Clinic of Radiotherapy and Oncology in Skopje, the Balkan country's premier state-run cancer-treatment center.
So, she added up her savings and borrowed money from friends and relatives to undergo an operation and treatment more than 500 kilometers away in Turkey. "The disease couldn't wait for me to confirm the rumors from my colleagues, so I decided to get treated abroad," she told RFE/RL's Balkan Service.
One operation and nine months of treatment later, she says she felt oddly vindicated at news that allegations that life-saving cancer medication from the same clinic was being sold on the black market finally caught the attention of police investigators.
"I had a guilty conscience that I was 'luxuriating' and spending other people's money for treatment abroad," Ndochi said. "But when I found out about [the] Oncology [Clinic scandal], somehow it became easier for me -- I didn't make a mistake by deciding to be treated on the side."
A steady stream of scandals in the ex-Yugoslav republic's health-care sector going back at least a decade has long undermined Macedonians' faith in their state-run system.
But the situation boiled over this month when prosecutors finally took action four months after damning reports of mismanagement and abuse at the Oncology Clinic, including the serial theft of expensive, badly needed cancer drugs for sale on the black market.
North Macedonia's president, Stevo Pendarovski, described the situation as "horrifying" and welcomed the actions of the Prosecutor-General's Office and the Interior Ministry. He added that "the health system has obviously failed, losing trust not only among those patients, but also inviting questions about the quality of treatment for each future patient."
The health minister and other senior officials within Prime Minister Dimitar Kovachevski's Social Democratic Union-led government, which has been in office since early 2022, have acknowledged problems but argue that the current issues stretch back to previous administrations.
In Poor Health
Health-care spending has indeed steadily declined in North Macedonia to one of the lowest levels in Southeastern Europe, according to the European Observatory on Health Systems and Policies, a multinational monitoring and assessment network. Meanwhile, an increasing reliance on out-of-pocket payments has frustrated patients, exacerbated by a shortage of prescription medicines. And experts say an exodus of trained medical professionals has further contributed to the health-care problem.
Mortality rates for noncommunicable diseases, including cancer in particular, have climbed worryingly over the past two decades, along with perceptions that North Macedonia has too many "access barriers" to care, such as a shortage of medicine and staff and inadequate public spending.
The Oncology Clinic has long been regarded as the country's most advanced -- and prestigious -- publicly owned cancer-treatment center.
But the findings at the center of the current uproar, published in a series of investigative articles by Fokus beginning in May, are damning. They paint a picture of a once-prestigious institution run amok, with mismanagement at the Skopje Oncology Clinic creating some 20 million euros ($21.4 million) of debt and employees stealing cytostatics, the costly drugs used to destroy cancer cells by inhibiting cell division, even as patient waiting times ballooned for those and other potentially life-saving drugs.
The Fokus reports quote state auditors in March pointing to failures that include procurement and pricing irregularities, logistical and scheduling chaos, and budget overruns compounded by neglect that left equipment like a multimillion-dollar particle accelerator lying around gathering dust instead of being used for radiation therapies.
'Murderers!'
The announcements by the Prosecutor-General's Office and the Interior Ministry on September 2 of raids on the clinic and other locations sparked a raucous demonstration outside the government headquarters and the Health Ministry in Skopje two days later. Demanding justice for affected patients, the crowd pelted the buildings with eggs, splattered red paint on sidewalks, and accused officials at corrupt institutions of being "murderers" and of "killing oncology."
The same day, Health Minister Fatmir Medjiti had issued assurances that patients at the Skopje clinic were receiving adequate treatment and urged the public to avoid spreading false information.
"I understand the frustration this case has caused our citizens, especially those directly affected by cancer," Medjiti said. "I will do everything in my power to clear up the case of the Oncology Clinic and to determine the responsibility of everyone. I will create conditions so that this never happens again."
He pledged full transparency to ensure a thorough investigation.
Interior Minister Oliver Spasovski issued a harsh statement but also appeared to deflect the political fallout by blaming decades of rot and abuse.
"Such events have been happening for 20 years [and] there have been clues many times before, but now the moment has come to clean up corruption, and for that we are taking all the steps and measures available," Spasovski said. "Everyone who was involved, regardless of the positions they held, will be part of the process and bear responsibility."
He added that unidentified individuals had been placed under special investigative measures and that many people, including journalists, have shared information related to the case with the ministry.
The leading opposition party, the nationalist VMRO-DPMNE, which has been in power for much of the last two decades, has insisted there must be criminal and political consequences for the "monstrous actions" at the center of the oncological scandal. It accuses Kovachevski's government of staying silent despite knowing about the clinic's problems and juxtaposed the current coalition's billboards touting European-level health care with what it described as the reality of "a mafia" in the system.
Medical Disasters
The scandal has also evoked painful memories of past disasters in the health-care sector that went unresolved or resulted in seemingly mild punishments despite public cries for accountability.
Suspended sentences were handed down against two hospital executives in June in connection with a modular hospital -- a medical facility built cheaply and quickly, often with prefabricated materials -- in the northwestern city of Tetovo, where a fire in September 2021 killed 14 people and injured a dozen more. Investigators are said to be still looking into further charges in the case, and appeals are still winding through the courts.
An investigation using German expertise blamed the Tetovo blaze on a short circuit in an extension cord. But sleuths at the Investigative Reporter Laboratory (IRL) claimed in a recent documentary that the construction of the Tetovo facility and other modular COVID-19 sites built during the pandemic crisis was shoddy and skirted fire inspections and other safety controls.
The same year as the Tetovo tragedy, the state auditor concluded that there had been a series of illegalities in public procurement for state hospitals during the pandemic, including secret agreements among administrators and profiteering.
Also in 2021, an investigation by RFE/RL's Balkan Service found that millions of dollars' worth of advanced medical equipment for radiotherapy had been gathering dust in a warehouse since 2013, even as cancer patients nearby were forced to travel to Skopje for similar treatment. For some of the devices, safety certifications had long expired.
More recently, Health Minister Medjiti in July was forced to acknowledge an acute problem acquiring the drug Trikafta, essential for treatment of the 130 patients with cystic fibrosis in North Macedonia, after the government took up the issue under public pressure.
At the same time, some of the country's 150,000 or so sufferers of diabetes protested what they said was a seven-month absence of instruments like test strips and blood-glucose monitors that help them control the disease.
Left To Die
But the revelations of alleged abuse at North Macedonia's foremost treatment center for oncology have hit differently, and the damage is already being felt in the community of patients and their families.
Simona Divanishova's mother, Georgieva, had been undergoing treatment for breast cancer at the Oncology Clinic for two years before her condition worsened earlier this year.
Her doctors ordered tests on April 18 to determine if she was a candidate for treatment with cytostatics.
"Since we knew even then that there was a problem with the supply of this therapy, my mother told the doctor that if it was determined that she needed it, we were ready to pay for it ourselves, just so she could receive it as soon as possible," Divanishova told RFE/RL's Balkan Service. "However, the doctor said that in 10 days she'd have the results and that, if necessary, she would start receiving the therapy immediately."
Four months later, with her condition worsening, they still hadn't received the results and no cytostatics had been prescribed.
Now, mourning the death of her mother and with the Oncology Clinic mired in scandal and disrepute, Divanishova is filled with doubts and regret.
"Our results about whether my mother was suitable for that expensive immunotherapy with cytostatics never came back, and my mother died," Divanishova said. "So the question remains whether my mother should have received that therapy and whether maybe with that therapy her condition might have improved."
