Closing Divides:

Global Health Challenges and Opportunities

Hong Kong Academy of Science

December 8, 2014
Dra. Felicia Marie Knaul
Harvard Global Equity Initiative and Harvard Medical School
Fundacin Mexicana para la Salud y Tmatelo a Pecho

Duality:
evidence and advocacy
Evidence-based
advocacy

Advocacyinspired evidence

Action:
projects, programs, policies

June, 2007
6 2007

January 2008

 to evidence

From anecdote

GTF.CCC
=
global health

+
cancer care

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

The Opportunity to Survive (M/I)

Should Not Be Defined by Income
100%

Adults

Children

Survival
inequality gap

China
Leukaemia

All cancers

LOW
INCOM

HIGH
INCOME

LOW
INCOM

HIGH
INCOME

In Canada, almost 90% of children with

leukemia survive.
In the poorest countries only 10% survive.

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

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 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.

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 have 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

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.

 2004: 6.5 m

2013: 55.3 m
Benefit package:
2004: 113

2013: 284+59

Benefits Package

Affiliation:

Vertical Coverage
Diseases and Interventions:

Expansion of Coverage:
Seguro Popular Mxico

Horizontal Coverage:

Beneficiaries

Seguro Popular and cancer:

Evidence of impact
Childhood cancers
adherence to treatment:
70% to 95%

Breast cancer
INCAN
2005: 200/600
2010: 10/900

The human faces:

Guillermina Avila
Abish Romero

Diagonalizing Delivery:
Training primary care providers in
early detection of breast cancer

(Keating, Knaul et al 2014,

The Oncologist)

Significant increase in
knowledge, especially in
clinical breast examination

Health Promoters
Risk Score (0-10)

6
5
4

3
Pre

Post

3-6 month

Breast cancer awareness and

education materials for use in China

Brochure for use

with rural women

Working manual for local

ACWF community outreach
workers

Worldwive wave of reforms to

achieve UHC
Universal Health Coverage (UHC): all people should
obtain needed health services prevention, promotion,
treatment, rehabilitation, and palliative care without
risking economic hardship or impoverishment (WHO, WHR
2013).

In the challenging context of rapid and

complex epidemiological transition, and
while battling fragmented health systems,
Palliative care and access to pain control
have been almost universally ignored in
Univeral Health Coverage

The most insidious injustice: The pain divide

Non-methadone, Morphine Equivalent opioid consumption
per death from HIV or cancer in pain:
Poorest 10%: 179 mg
Richest 10%: 99 mil mg
US/Canad: 344 mil mg
N. America

355,000 mg

Europe China: 1,593 mg

144,000
Malaysia: 6,476
Singapore: 7,292

333,000 mil mg

India:
467

Mexico
3,500

Africa
Latin America

Source: Estimaciones propias Knaul F.M. Arreola H, et.al.,

basado en datos de: Treat the pain and INBC
(http://www.treatthepain.com )

Recent global progress

2014: The WHO Executive Board adopted a
groundbreaking resolution urging countries to
ensure access to pain medicines and palliative
care for people with life-threatening illnesses.
The resolution urges
Countries to integrate palliative care within
their health systems
The WHO to increase technical assistance to
member states

HGEI-Lancet Commission on Global

Access to Pain Control and Palliative Care

=
Global
Health and
Health
Systems

+
Palliative
care
specialists

Goal: Alleviate
Avoidable Human
Suffering
Inaugural meeting of the Commission held September 22-23, 2014, in New York City Lancet Office

Be an
optimist
optimalist