Closing the Cancer Divide: Meeting the challenge of cancer and NCDs in LMICs

8/12/2019 Closing the Cancer Divide: Meeting the challenge of cancer and NCDs in LMICs

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Felicia Marie Knaul, PhDHarvard Global Equi ty I ni tiative, Global Task F orce on Expanded Access to

Cancer Care and Control in LM ICs

Tmatelo a Pecho A:C. Mxico

Mexican Health F oundation

Boston, HST 934 I ntroduction to Global Medicine

Apri l 7th, 2014

Closing the Cancer Divide:

Meeting the challenge of cancer and

NCDs in LMICs


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Evidence-basedAdvocacy

Advocacy-inspired Evidence

Action:

projects, programs, policies

Duality:

evidence and advocacy


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Allan Brandt

Medical Historiannow undergoing second

stem cell transplant

Living

&Learning


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Harvard, Breast Cancer in Developing Countries, Nov 4, `09

Nobel Amartya Sen,Cancer survivor diagnosed in

India 60 years ago

Drew G. FaustPresident of Harvard

University 22+ year BCsurvivor


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January, 2008

June, 2007


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to evidence

From anecdote


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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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Global Task Force on

Expanded Access to

Cancer Care and Control

35 members:

Global health + Cancer care

Technical Advisory Committee: 60+

Private Sector Engagement Group

Priority areas and Working groups: Ped Onc, Pain & Palliation, Womens

cancers, Survivorship, Economics of cancer


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Closing the Cancer Divide:An Equity Imperative

I: Shouldbe done

II: Could be doneIII: Can be done

M1. Unnecessary

M2. Unaffordable

M3. Impossible

M4: Inappropriate

Expanding access to cancer care and control in LMICs:

1: Innovative Delivery

2: Access: Affordable Meds, Vaccines & Techs3: Innovative Financing: Domestic and Global

4: Evidence for Decision-Making

5: Stewardship and Leadership


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#2 cause of death in wealthy countries

#3 in upper middle-income#4 in lower middle-income

and # 8 in low-income countriesMore than 85% of pediatric cancer cases and 95% of

deaths occur in developing countries.

For children & adolescents

5-14 cancer is


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Mirrors the epidemiological transition

LMICs increasingly face both infection-

associated cancers, and all other cancers.

The Cancer TransitionDouble burden for health systems

Cancers increasingly only of the poor, are

not the only cancers affecting the poor

LMICs account for >90% of cervical and 70%

of breast cancer deaths. Both are leading killers

especially of young - women.

C t iti i M i


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Cancer transition in Mexico:

Breastand Cervicalmortality

0

4

8

12

16

1955 1990 2010Mortalityrateadjustedbyage

Oaxaca(Poorest)

Nuevo Len(Wealthiest)

Source: Knaul et al., 2008. Reproductive Health Matters, and updated by Knaul, Arreola-Ornelas and Mndez.

0

10

20

30

1980 20100

10

20

1980 2010


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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 factors

2. 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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Adults

Leukaemia

All

cancers

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

Children

LOW

INCOM

HIGH

INCOME

Sur

vival

inequa

lity

gap

LOW

INCOM

HIGH

INCOME

100%

Facet 3: 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% survive.

Russia


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Non-methadone, Morphine

Equivalent opioid consumption perdeath from HIV or cancer in pain:

Poorest 10%: 54 mg

Richest 10%: 97,400 mg

US/Canada: 270,000 mg

Latin America

N.America

Africa

Asia

injustice:

the pain divide

Data: http://www.treatthepain.com/methodology

Calculations: HGEI/FunsaludKnaul et al. Eds Closing the Cancer Divide.

India
http://www.treatthepain.com/methodologyhttp://www.treatthepain.com/methodology


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Challenge and disprove the

myths about cancer

M1. Unnecessary

M2. UnaffordableM3. Inappropriate

M4: Impossible


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The costs of inaction are huge:

Invest I NactionTobacco is a huge economic risk: 3.6% lower GDP

Total economic cost of cancer, 2010: 2-4% of global GDP

Prevention and treatment offers

potential world savings of

$ US 130-940 billion

1/3-1/2 of cancer deaths are avoidable:2.4-3.7 million deaths,

of which 80% are in LIMCs


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The costs to close the cancer divide

are and may be less than many fear:

All but 3 of 29 LMIC priority cancer chemo and

hormonal agents are off-patent

Pain medication is cheap

Prices drop: HepB and HPV vaccines

Delivery & financing innovations are

underutilized & undeveloped so that purchasing

is fragmented and procurement is unstable

PAHO 2013 Strategic Fund for NCDs

includes key cancer drugs


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myths about cancerM1. Unnecessary

M2. UnaffordableM3. InappropriateM4: Impossible


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Women and mothers in LMICs

face many risks through the life cycle

Women 15-59, annual deathsDiabetes

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

year

= 430, 210 deaths


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The Diagonal Approach to

Health System StrengtheningRather than focusing on either disease-specific vertical orhorizontal-systemic programs, harness synergies that

provide opportunities to tackle disease-specific priorities

while addressing systemic gaps and optimize available

resources

Diagonal strategies major benefits:X = > parts

Bridge disease divides using a life cycle response

avoids the false dilemmas between disease silos -

CD/NCD- that continue to plague global health

Generate positive externalities: e.g. womens cancer

programs fight gender discrimination; pain control 4all


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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.

Investing in treatment produces champions

Pain control and palliationReducing barriers to access is essential for

cancer, for other diseases, and for surgery.


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DiagonalizingCancer Care:

Financing & Delivery1. Financing: Integrate cancer care into

national insurance and social security

programs2. Delivery: Harness platforms by integrating

breast and cervical cancer prevention, screening

and survivorship care into MCH, SRH,HIV/AIDS, social welfare and anti-poverty

programs.


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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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myths about cancer

M1. Unnecessary

M2. UnaffordableM3. Inappropriate

M4: Impossible


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Huge steps in the transition thru reform toward

Universal Health Coverage in many countries

Examples:

Brazil

China

Colombia

Chile

EEUU(Affordable Care Act)

El Salvador

Peru

South Af r ica

Taiwan

Mexico: Seguro Popular de Salud

Yetoften in thecontext of rapid,

profound,

polarized andcomplex

epidemiologicaltransition or

battlingfragmented health

systems

2003 REFORM: ELIMINATE SEGMENTATION IN ACCESS TO


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2003 REFORM: ELIMINATE SEGMENTATION IN ACCESS TO

HEALTH INSURANCE BY GENERATING A SYSTEM FOR SOCIAL

PROTECTION IN HEALTH THAT INCLUDES PUBLICALLY

FUNDED HEALTH INSURANCE FOR FAMILIES EXCLUDED

FROM SOCIAL SECURITY

Social Security

Public and private,Formal sector workers

and their families:

Ministry of Health

with residual funding

Poor, informal sector,non-salaried, rural

areas:~50% ofpopulation

1943

2001/3: Pilot of PHI

2003: Law

Jan. 1, 2004: SSPH

2010: Universalcoverage of PHI

System for SocialProtection in Health

Seguro

Popular

Frenk et al., 2004.


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Mexicos 2003: major health reform

created Seguro Popular

Horizontal Coverage:

Beneficiaries

VerticalCoverage

Diseasesa

ndInterventions:

BenefitsPackage

Affiliation: 2004: 6.5 m

2012: 54.6 m

Benefit package: 2004: 113

2012: 284+57

Evolution of vertical coverage:


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Evolution of vertical coverage:

cumulative # of covered interventions,

2004-2012

Notes:

SP = Seguro Popular

MING = Medical Insurance for a New Generation (Children born after December 1, 2006 and until they are 5 years of age)

FPCHE = Fung for Protection against Catastrophic Health Expenditure

EPHS =Essential Personal Health Services

EPI = Expanded Programme of Immunisations

CBP= Community-based package

0

50

100

150

200

250

300

350

400

450

500

2004 2005 2006 2007 2008 2009 2010 2011 2012

63 65 65 65 65 65 65 65 65

6 6 8 6 12 1212 12 13

22

83

176 184189 189 198 198

206

6

6

1720

49 4949 57

57

110

108 116128

128131

MING

EPHS

EPI

CBP

FPCHE

Numberofinterv

entions

Seguro Popular

284 interventions

MING + SP

FPCHE

57interventions

CAUSES 91

FPCHE 6

CAUSES 284

FPCHE 57


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Accelerated, universal, vertical coverage by disease

with an effective package of interventions

2004/6: HIV/AIDS, cervical cancer, ALL in

children

2007: All pediatric cancers; Breast cancer2011: Testicular and Prostate cancer and NHL

2012: Ovarian (colorectal) cancer

Key aspect of Seguro Popular:

diagonal, financial protection for

catastrophic illness


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Seguro Popular and cancer:

Evidence of impactBreast cancer adherence to treatment:

2005: 200/600

2010: 10/900

Since the incorporation of childhood

cancers into the Seguro Popular30-month survival: 30% to almost 70%

adherence to treatment: 70% to 95%.

The human faces of


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The human faces of

Seguro Popular:

Guillermina Avila

&Abish Romero

Effective financial coverage of a


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Effective financial coverage of a

chronic disease: breast cancer

Mexico: Large and exemplary investment in financialprotection for breast cancer prevention and treatment,

yet..a low survival rate.

Strengthen early detection, survivorship and palliation:

diagonalize delivery

Cancer Control-Care continuum

Primary

Prevention

Early

Detection Diagnosis Treatment Survivorship Palliation

Delivery and financial protection challenges:


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Benefi

ts:coveredin

terventions

Delivery and financial protection challenges:

Seguro Popular in Mexico

ACCELERATED VERTICAL COVERAGE for Catastrophic

Illnesses included in the Fund: breast cancer, AIDS

Community and Public Health Services

Poor Rich

CHILDREN: Health insurance for a New Generation

Package of essential personal

services

Beneficiaries


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Health System

Functions

Stage of the Chronic Disease Life Cycle ContinuumPrimary

Prevention

Secondary

preventionDiagnosis Treatment

Survivorship/

Rehabilitation

Palliation/

End-of-life care

Stewardship

Financing

Delivery

Resource

Generation

Responding to the Challenge of Chronicity:

Health System Functions by Care Continuum

Barriers to Access Palliative Care


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Barriers to Access Palliative Care

by Health System Function: Mexico

Source: Adapted from Knaul, F. M., Gralow, J. R., Atun, R., & Bhadelia, A. (Eds.). Closing the Cancer Divide. Harvard University Press, 2012.

HealthSystem

Function

Components of the Health Care Continuum

Prevention

SurvivalPalliative Care, Pain Control and End of Life Care

Regulation

Missig: National Plan / Program

Weak, poorly defined and restrictive regulatory frameworks

Absence evaluation and monitoring

Financing

NO explicit coverage of interventions in either the Comprehensive

Package for Essential Services or the Fund for Protection Against

Catastrophic Expenditure

-Social Security there is an everything and nothing

DeliveryLacking units and levels for delivery

Supply chain and distribution is sporadic and spotty

Resource

Generation and

Research

Lack of trained personnel

Fear of prescription

Topic not available in medical school curriculum

No published research related to health system


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% diagnosed in Stage 4 by state# 2 killer of

women 30-54

5-10% detected

in Stage 0-1

Poor

municipalites:50% Stage 4; 5x

the rate for r ich

Breast Cancer: Delivery failure

Poor

RIch

J i


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Juanita:Advanced metastatic breast

cancer is the result of a series

of missed opportunities

Di li i D li 1


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Diagonalizing Delivery 1:

Integration of cervical & breast cancer educati

into anti-poverty programs, Oportunidades

Include information in

manuales for communityworkers

1.5 million promoters

> 90% of poor Mexicanhouseholds: 5.8 million

families



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Training primary care providers in

early detection of breast cancerPromoters (+4000), Nurses & MDs (+1400)

medical students (+750)

Nuevo Leon, Jalisco, Morelos, PueblaSignificant increase in knowledge, especially in CBE


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The ?s that keep me up at night

and

worry me throughout the days:

1) Why has/should breast cancer become

such an emblematic and powerfulmessage?

1) Is it right or fair to advocate only on

behalf of ones own disease?


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Be an

optimistoptimalist


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Felicia Marie Knaul, PhDHarvard Global Equi ty I ni tiative, Global Task F orce on Expanded Access to

Cancer Care and Control in LM ICs

Tmatelo a Pecho A:C. Mxico

Global Health Forum on Cancer, Taipei

November 21, 2013

Global responses to the cancer

epidemic:

Scaling up health systemtransformation

Closing the Cancer Divide: Meeting the challenge of cancer and NCDs in LMICs

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