Closing the cancer divide: an equity imperative for women and health 071211

8/2/2019 Closing the cancer divide: an equity imperative for women and health 071211

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Felicia Marie Knaul

Harvard Global Equity Initiative,

Mexican Health Foundation

Tmatelo a pecho

World Health Organization

December 6th, 2011

Closing the cancer divide:

an equity imperative

for women and health


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Closing the Cancer Divide:A Blueprint to Expand Access in LMICs

I: Much should be doneII: Much could be done

III: Much can be done

1: Innovative Delivery

2: Access to Affordable Medicines,

Vaccines & Technologies

3: Innovative Financing: Domesticand Global

4: Evidence for Decision-Making

5: Stewardship and Leadership


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Applies a diagonal

approach to avoid

the false dilemmasbetween disease silos

-CD/NCD- thatcontinue to plague

global health

Closing the Cancer Divide:A BLUEPRINT TO EXPAND ACCESS IN LMICs


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Global Task Force on Expanded

Access to Cancer Care and

Control in Developing Countries

= global health + cancer care


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A) Should be done:

B) Could be done:

C) Can be done

Myth 1. Unnecessary

Myth 2. Inappropriate

Myth 3. Unaffordable

Myth 4: Impossible

Expanding access to cancer

care and control in LMICs:


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Cancer is a disease of both rich and poor;

yet it is increasingly the poor who suffer:

1. Exposure to risk factors2. Preventable cancers (infection)

3. Death and disability fromtreatable cancer

4. Stigma and discrimination

5. Avoidable pain and suffering

The Cancer Divide:

An Equity Imperative

Fac

ets


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Risk factor concentration: Obesity

Epidemic in countries such as Mexico

10

60

8

32

57

25

10

2

37

25

36 37

29

2

Malnutrition Adequate

Overweight

Obesity

1988

1999

% women 20-49 years

2006


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Cancer is becoming a leading cause

of childhood death: Epi transition

M. tumorsInf + parasiticRespiratory infs

Source: Estimates based on data from the Ministry of Health, Mexico.

1979

1990

2000

2008

0

10%

20%

30%

40%

1979

1990

2000

2008

1-4 5-14

% of total mortality, Mexico, 1979-2008

Cancer, 5-14: 3rd in upper middle income,

4th in lower middle, 8th in low income countries.


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Mirrors the overall epidemiological

transitionprotracted and polarized*:

LMICs increasingly face both cancersassociated with infection, and all other

cancers.

Cancers that were once considered only ofthe poor, now cease to be the only cancers

of the poor. (e.g. cervical & breast cancer)

The Cancer Transition

* Frenk et al


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MortalityIncidence

Incidence and mortality of cervical cancer(adjusted rate per 100,000 women)


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Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.

The cancer transition in LMICs:

breastand cervicalcancer

53%

20%19%

-31%

0%

LMICs High

income

% Change in # of deaths1980-2010LMICs account for

>90% of cervical

cancer deaths and

>60% of breast

cancer deaths.

Both diseases are

leading killers

especially of young

women.


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The cancer transition within countries:breastand cervicalcancer mortality

Oaxaca

1979-200825

0

8

16 Mexico1955 - 2008

Costa Rica1995 - 2005

0

0

Nuevo Leon1979-200825

0


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Adults

Leukaemia

All cancers

Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.

Children

LOW

INCOME

HIGH

INCOME

Sur

vival

inequa

litygap

LOW

INCOME

HIGH

INCOME

100%

The Opportunity to Survive (M/I)

Should Not Be Defined by Income

In Canada, almost 90% of children with

leukemia survive.

In the poorest countries only 10%.


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Stigma:

Juanita

Cancer, and

especially

reproductive

cancers, adds

a layer ofdiscrimination

onto gender,

ethnicity, andpoverty.

Th t i idi f t


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The most insidious facet:

access to pain control

Non-meth, Morphine-e opioid consumption per death from HIV or cancerUSACanada

Austria

Germany

Denmark

UAE

Norway

KuwaitJapan

050,000

280,000

$0 $40,000 $80,0000

1,000

$0$3,500

Low

Income0

10,000

$0 $14,000

Low

middle

Qatar

Gap in access to pain control: 54 mg per HIV/cancer death in pain in the

poorest decile to >97,000 in the richest decile of the worlds countries.


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A) Should be done:

B) Could be done:

C) Can be done

Myth 1. Unnecessary

Myth 2. Inappropriate


Myth 4: Impossible




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Women and mothers in LMICs

face many risks through the life cycle

Women 15-59, annual deaths

Diabetes

120,889

Breast

cancer

166,577

Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.

Cervical

cancer

142,744

Mortality

in

childbirth

342,900

- 35%in 30

years

= 430, 210 deaths


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The Diagonal Approach to

Health System Strengthening

Rather than focusing on disease-specific vertical

programs or only on horizontal system

constraints, harness synergies that provideopportunities to tackle disease-specific priorities

while addressing systemic gaps.

Optimize available resources so that the whole ismore than the sum of the parts.

Bridge the divide as patients suffer diseases over a

lifetime, most of it chronic.


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Why diagonal?

Shared risk factors

Success and life cycle

Common need for strong healthsystems platforms

Economic developmentSocial justice


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Diagonal Strategies:

Positive Externalities

Promoting prevention and healthy lifestyles:

Reduce risk for cancer and other diseases

Reducing stigma for womens cancers:Contributes to reducing gender discrimination.

Pain control and palliation

Reducing barriers to access is essential forcancer, for other diseases, and for surgery.


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Delivery: Harness platforms byintegrating cancer prevention,

screening and survivorshipsupport into MCH, SRH,

HIV/AIDS, social welfare andanti-poverty programs.

A Diagonal Strategy:

i


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A) Should be done: necessary

and appropriate

B) Could be done:

C) Can be done


Myth 4: Impossible




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Investing In CCC:

We Cannot Afford Not To

Health is an investment, not a cost

Tobacco is a huge economic risk: 3.6% lower GDP

Total economic cost of cancer, 2010: 2-4% of global GDPPrevention and treatment offers potential world savings of

$ US 131-850 billion mostly due to productivity gains and

reducing suffering

1/3-1/2 of cancer deaths are avoidable:

2.4-3.7 million deaths

Of which 80% are in LIMCs

I i I CCC


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Investing In CCC:

The costs to close the cancer divide

may be less than many fear:All but 3 of 29 LMIC priority, candidate cancer chemo

and hormonal agents are off-patent: many < $100 / course

Cost of drug treatment, cervical cancer + HL + ALL(k)in LMICs / year of incident cases: $US 280 m

Pain medication is cheap

Prices drop:HPV 2011 from $US 100 /dose to

GAVI $5

PAHO $14


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A) Should be done: necessary

and appropriateB) Could be done: affordable

C) Can be doneMyth 4: Impossible



Ch i


26/35Harvard Breast Cancer in Develo in Countries Nov 4 `09

ChampionsNobel Amartya Sen,

Cancer survivor diagnosed in India50 years ago

Drew G. Faust

President of Harvard University22+ year BC survivor

S t ti th di


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Successes treating other diseases:MDR-TB treatment

Source: Paul Farmer., 2009

cured

83%

abandon

therapy

2%

failed

therapy

8%

died

8%

Mitnick et al, Community-based therapy for multidrug-resistant

tuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.

Outcomes in MDR-TB patients in Lima,

Peru receiving at least 4 months of therapy

WHO 1997, Multidrug-resistant

tuberculosis is too expensive to treat in

poor countries; it detracts attention and

resources from treating drug-susceptible

disease.

Drug % Decline inprice 1997-9

Amikacin 90%

Ethionamide 84%

Capreomycin 97%

Ofloxacin 98%

Reduced prices of

second-line TB drugs


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Mexico: cervical cancer.

Source: Knaul et al., 2008. Reproductive Health Matters, and updated by Knaul, Arreola-Ornelas and Mndez based on WHO data, WHOSIS (1955-1978), and Ministry of Health in Mexico (1979-2006)

0

4

8

12

16

19551965

1975

1985

1995

2005

Success in treating several cancers.

i i i i


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Financing innovations:

DomesticIntegrate CCC into national insurance programs to

express previously suppressed demand, beginning

with cancers of women and children:Mexico

Colombia

Dominican Republic

Peru

China

India

Rwanda

Taiwan


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Seguro Popular and cancer:

Evidence of impact

Since the incorporation of childhoodcancers into the Seguro Popular

30-month survival: 30% to almost 70%adherence to treatment: 70% to 95%.

Access to medicinesan anecdote

Breast cancer adherence to treatment:2005: 200/600

2010: 10/900

Me ico Seg ro Pop lar:


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Mexico Seguro Popular:

diagonal, financial protection for

catastrophic illness

Accelerated, universal, vertical coverage by disease

with a package of interventions

2004/5: ALL in children, cervical, HIV/AIDS

2006: All pediatric cancers

2007: Breast cancer

2011: Testicular cancer and NHL

Horizontal and vertical financial protection


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Beneficiaries: Population covered

Benefits:coveredi

n

terventions

Horizontal and vertical financial protectionstrategies:

Seguro Popular for Breast Cancer, Mexico

Catastrophic Illness

ACCELERATED VERTICAL COVERAGE: Ex: breast cancer,

Package of essential

personal services

Community Health Services - NUTRITION

Poor Rich

I ti i Fi i


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Innovations in Financing:

Global

Integrated, innovative financingmechanisms that have gone to scale -

Global Fund and GAVI - can be leveragedRMNCH platforms provide models forbroad-based international partnership and

commitment-building for cancer and NCD.Recent, diagonal partnership initiatives arepromising -pink ribbon red ribbon

A i


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Addressing women, health

+and+ NCDs in LMICs:

Shared advocacy to achieve stronger health

systems

Common implementation platformsMulti-stakeholder alliances in-country

Commitment-based funding models

Common, attainable goals

Measurement of progress: evidence and

metrics


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Be an

optimistoptimalist.

Closing the cancer divide: an equity imperative for women and health 071211

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