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

Boston, HST 934 Introduction to Global Medicine April 7th, 2014

Felicia Marie Knaul, PhD
Harvard Global Equity Initiative, Global Task Force on Expanded Access to Cancer Care and Control in LMICs Tmatelo a Pecho A:C. Mxico Mexican Health Foundation

Duality: evidence and advocacy

Evidence-based Advocacy Advocacyinspired Evidence

Action: projects, programs, policies

Living & Learning

Allan Brandt Medical Historian
now undergoing second stem cell transplant

Drew G. Faust
President of Harvard University 22+ year BC survivor

Nobel Amartya Sen,

Cancer survivor diagnosed in India 60 years ago

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

January, 2008 June, 2007

From anecdote

to evidence

Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries

= global health + cancer care

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

Closing the Cancer Divide:

An Equity Imperative
Expanding access to cancer care and control in LMICs:
M1. Unnecessary M2. Unaffordable M3. Impossible M4: Inappropriate

I: Should be done II: Could be done III: Can be done

1: Innovative Delivery 2: Access: Affordable Meds, Vaccines & Techs 3: Innovative Financing: Domestic and Global 4: Evidence for Decision-Making 5: Stewardship and Leadership

For children & adolescents 5-14 cancer is

#2 cause of death in wealthy countries #3 in upper middle-income #4 in lower middle-income and # 8 in low-income countries
More than 85% of pediatric cancer cases and 95% of deaths occur in developing countries.

The Cancer Transition

Double burden for health systems
Mirrors the epidemiological transition LMICs increasingly face both infectionassociated cancers, and all other cancers. 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.

Cancer transition in Mexico: Breast and Cervical mortality

Mortality rate adjusted by age

16 12 8 4 0

30

1955

1990
20

2010

Nuevo Len
20

Oaxaca
(Poorest)
10

(Wealthiest)

10

1980

2010

1980

2010

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

The Cancer Divide: An Equity Imperative

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 from treatable cancer 4. Stigma and discrimination 5. Avoidable pain and suffering

Facets

Facet 3: The Opportunity to Survive (M/I) Should Not Be Defined by Income

100%
Children Adults Survival inequality gap

Leukaemia

Russia

All cancers
LOW INCOM HIGH INCOME LOW INCOM HIGH INCOME

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

In Canada, almost 90% of children with leukemia survive. In the poorest countries only 10% survive.

Facet 5: The most insidious injustice: the pain divide Non-methadone, Morphine
N. America
Equivalent opioid consumption per death from HIV or cancer in pain: Poorest 10%: 54 mg Richest 10%: 97,400 mg US/Canada: 270,000 mg

Asia

India

Africa
Data: http://www.treatthepain.com/methodology Calculations: HGEI/Funsalud Knaul et al. Eds Closing the Cancer Divide.

Latin America

Challenge and disprove the myths about cancer

M1. Unnecessary

M2. Unaffordable
M3. Inappropriate M4: Impossible

The costs of inaction are huge: Invest IN action

Tobacco is a huge economic risk: 3.6% lower GDP Total economic cost of cancer, 2010: 2-4% of global GDP

1/3-1/2 of cancer deaths are avoidable: 2.4-3.7 million deaths, of which 80% are in LIMCs

Prevention and treatment offers potential world savings of $ US 130-940 billion

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

Challenge and disprove the myths about cancer

M1. Unnecessary M2. Unaffordable

M3. Inappropriate
M4: Impossible

Women and mothers in LMICs face many risks through the life cycle
Women 15-59, annual deaths
Mortality in childbirth

-35% in 30 year

Breast cancer

Cervical cancer

Diabetes

342,900

166,577

142,744

120,889

= 430, 210 deaths

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

The Diagonal Approach to Health System Strengthening

Rather than focusing on either disease-specific vertical or horizontal-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

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

Diagonalizing Cancer Care: Financing & Delivery

1. Financing: Integrate cancer care into national insurance and social security programs
2. 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.

Closing the Cancer Divide:

A BLUEPRINT TO EXPAND ACCESS IN LMICs

Applies a diagonal approach to avoid the false dilemmas between disease silos -CD/NCD- that continue to plague global health

Challenge and disprove the myths about cancer

M1. Unnecessary M2. Unaffordable M3. Inappropriate

M4: Impossible

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 Africa Taiwan Mexico: Seguro Popular de Salud

Yetoften in the
context of rapid, profound, polarized and complex epidemiological transition or battling fragmented health systems

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

1943

Social Security

Ministry of Health with residual funding

Public and private, Formal sector workers and their families:

Poor, informal sector, non-salaried, rural areas: ~50% of population

2001/3: Pilot of PHI 2003: Law Jan. 1, 2004: SSPH 2010: Universal coverage of PHI
Frenk et al., 2004.

System for Social Protection in Health

Seguro
Popular

Mexicos 2003: major health reform created Seguro Popular

Benefits Package
2004: 6.5 m Vertical Coverage Diseases and Interventions:

Affiliation:

2012: 54.6 m
Benefit package:
2004: 113

2012: 284+57

Horizontal Coverage:

Beneficiaries

500 450

Evolution of vertical coverage: cumulative # of covered interventions, 2004-2012 CAUSES 284

FPCHE
MING
131

57

400

FPCHE EPHS
108 110 49 17 20 49 116

128

128

MING + SP

Number of interventions

350
EPI

300 250 200 150 100 50

6 22 6 63

CBP

49

57

57

FPCHE 57 interventions

CAUSES 91 FPCHE 6
6 83 6 65 8 65 6 65 12 65 12 65 176 184 189 189

198

198

206

Seguro Popular 284 interventions

12 65

12 65

13 65

2004

2005

2006

2007

2008

2009

2010

2011

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

Key aspect of Seguro Popular: diagonal, financial protection for catastrophic illness
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 cancer 2011: Testicular and Prostate cancer and NHL 2012: Ovarian (colorectal) cancer

Seguro Popular and cancer: Evidence of impact

Breast cancer adherence to treatment:
2005: 200/600 2010: 10/900

Since the incorporation of childhood cancers into the Seguro Popular

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

The human faces of Seguro Popular: Guillermina Avila & Abish Romero

Effective financial coverage of a chronic disease: breast cancer

Cancer Control-Care continuum
Primary Prevention Early Detection

Diagnosis

Treatment

Survivorship

Palliation

Mexico: Large and exemplary investment in financial protection for breast cancer prevention and treatment, yet..a low survival rate. Strengthen early detection, survivorship and palliation: diagonalize delivery

Delivery and financial protection challenges:

Seguro Popular in Mexico

Benefits: covered interventions
ACCELERATED VERTICAL COVERAGE for Catastrophic

Illnesses included in the Fund: breast cancer,

AIDS

Package of essential personal services

CHILDREN: Health insurance for a New Generation Community and Public Health Services

Poor Beneficiaries

Rich

Responding to the Challenge of Chronicity: Health System Functions by Care Continuum

Stage of the Chronic Disease Life Cycle Continuum
Health System Functions
Primary Prevention Secondary prevention Diagnosis Treatment Survivorship/ Rehabilitation Palliation/ End-of-life care

Stewardship

Financing

Delivery Resource Generation

Barriers to Access Palliative Care by Health System Function: Mexico

Health System Function

Components of the Health Care Continuum

Prevention Survival

Palliative Care, Pain Control and End of Life Care

Missig: National Plan / Program Weak, poorly defined and restrictive regulatory frameworks Absence evaluation and monitoring
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

Regulation

Financing

Delivery

Lacking units and levels for delivery Supply chain and distribution is sporadic and spotty
Lack of trained personnel Fear of prescription Topic not available in medical school curriculum No published research related to health system

Resource Generation and Research

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

Breast Cancer: Delivery failure

# 2 killer of women 30-54 5-10% detected in Stage 0-1 Poor municipalites: 50% Stage 4; 5x the rate for rich
% diagnosed in Stage 4 by state

RIch

Poor

Juanita:
Advanced metastatic breast cancer is the result of a series of missed opportunities

Diagonalizing Delivery 1: Integration of cervical & breast cancer educatio into anti-poverty programs, Oportunidades
Include information in manuales for community workers 1.5 million promoters > 90% of poor Mexican households: 5.8 million families

Diagonalizing Delivery 2: Training primary care providers in early detection of breast cancer
Promoters (+4000), Nurses & MDs (+1400) medical students (+750)
Nuevo Leon, Jalisco, Morelos, Puebla

Significant increase in knowledge, especially in CBE

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 powerful message?

1) Is it right or fair to advocate only on behalf of ones own disease?

Be an optimist optimalist

Global responses to the cancer epidemic: Scaling up health system transformation

Global Health Forum on Cancer, Taipei November 21, 2013 Felicia Marie Knaul, PhD
Harvard Global Equity Initiative, Global Task Force on Expanded Access to Cancer Care and Control in LMICs Tmatelo a Pecho A:C. Mxico Mexican Health Foundation