Expanding Access to Cancer Care and Control in LMICs: Lessons for Health Systems

Felicia Marie Knaul Harvard Global Equity Initiative, Mexican Health Foundation Tmatelo a pecho World Diabetes Congress 2011 December 5th, 2011 Dubai, United Arab Emirates

Addressing NCDs in LMICs:

Shared risk factors Success and life cycle Common need for strong health systems platforms Social justice

From anecdote
to evidence

January, 2007 June, 2008

Juanita:

br

From anecdote

to evidence

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

= global health + cancer care

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

Closing the Cancer Divide:

A Blueprint to Expand Access in LMICs
I: Much should be done II: Much could be done III: Much can be done
1: Innovative Delivery 2: Access to Affordable Medicines, Vaccines & Technologies 3: Innovative Financing: Domestic and Global 4: Evidence for Decision-Making 5: Stewardship and Leadership

Expanding access to cancer care and control in LMICs:

A) Should be done:
Myth 1. Unnecessary Myth 2. Inappropriate B) Could be done:
Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

The Cancer Transition

Mirrors the overall epidemiological transition protracted and polarized*:
LMICs increasingly face both cancers associated with infection, as well as all other cancers some of which have specific risk factors. Cancers that were once considered only of the poor, now cease to be the only cancers of the poor. (e.g. cervical & breast cancer)
* Frenk et al

Distribution of mortality, 1-15 years Mexico, 1979-2008

40% 40% 30% 30%

20%

20%

10%

10%

0
1979 1980 1985 1990 1995 2000 2005 2008

0
1979 1980 1985 1990 1995 2000 2005 2008

Malignant tumors Infectious and parasitic diseases

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

Respiratory infections

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

100%

Children

Adults Survival inequality gap

Leukaemia

All cancers LOW INCOME HIGH INCOME LOW INCOME 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%. A child with retinoblastoma in a high-income country can hope to preserve vision and life; in LMICs neither.

The most insidious example of injustice is access to pain control

The gap in access to pain control is tremendous: ranging from 54 milligrams per death in pain from HIV/AIDS or cancer in the poorest decile to almost 97,400 in the richest decile of the worlds countries.
Non-methadone opioid consumption (morphine-equivalents) Per death from HIV or cancer in pain by income level
300000 Non-methadone opioid consumption per capita (mg)

CAN
250000

USA

200000

Austria Germany
y = 1.6618x - 5288.3 R = 0.3442

150000

100000

Norway
50000

UAE Kuwait Singapore

GNI per capita (PPP 2008)

QATAR

$0 $10,000$20,000$30,000$40,000$50,000$60,000$70,000$80,000$90,000

Source: Estimates based on GAPRI methodology available at http://www.treatthepain.com/methodology and World Development Indicators of the World Bank.

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

Expanding access to cancer care and control in LMICs:

A) Should be done:
Myth 1. Unnecessary Myth 2. Inappropriate B) Could be done:
Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

Women and mothers in LMICs face many risks through the life cycle Women 15-59, annual deaths
- 35% in 30 years

Mortality in childbirth

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 a Lancet 2011.

The Diagonal Approach to Health System Strengthening

Rather than focusing on disease-specific vertical programs or only on horizontal system constraints, harness synergies that provide opportunities to tackle disease-specific priorities while addressing systemic gaps.
Optimize available resources so that the whole is more than the sum of the parts. Bridge the divide as patients suffer diseases over a lifetime, most of it chronic.

Health Systems Strengthening: Opportunities for Diagonal Strategies

Prevention healthy lifestyles: Nutrition and diet, Tobacco Survivorship care: Reduce stigma: also associated with gender and ethnicity. Pain control and palliation Reducing barriers to access is essential for cancer, for other diseases, and for surgery.

Diagonal Strategies
Delivery: Harness platforms by integrating cancer prevention, screening and survivorship into MCH, SRH, HIV/AIDs, social welfare/anti-poverty programs.

Expanding access to cancer care and control in LMICs:

A) Should be done: necessary and appropriate B) Could be done:
Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

Investing In CCC: We Cannot Afford Not To

Health is an investment, not a cost Tobacco is a huge economic risk: 3.6% lower GPD Total economic cost of cancer, 2010: 2-4% of global GDP Prevention 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 millions deaths, 80% in LIMCs

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 available for under $100 per course Cost of drug treatments for cervical cancer, HL, and ALL in children in LMICs per year of incident cases is $US 280 million Prices drop: HPV 2011: $US 100 per dose to PAHO $14 and GAVI $5 Pain medication is cheap

Expanding access to cancer care and control in LMICs:

A) Should be done: necessary and appropriate B) Could be done: affordable C) Can be done
Myth 4: Impossible

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

Premio Nobel Amartya Sen,

Cancer survivor diagnosed in India 50 years ago

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

Successes treating other diseases:

MDR-TB treatment
WHO 1997, Multidrug-resistant tuberculosis is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible disease.
Outcomes in MDR-TB patients in Lima, Peru receiving at least 4 months of therapy
failed therapy died 8% 8%

abandon therapy 2%

cured 83%

Mitnick et al, Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.

Source: Paul Farmer., 2009

Mexico: cervical cancer.

16

12

1965

1975

1985

1955

1995

2005

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)

Delivery innovations and models: Global Partnership

St. Jude International Outreach Program

Strategy:
ICT for education + teleoncology + twinning

Institutional commitment: 1-3% of budget

15-20 countries

Evaluation and implementation research

El Salvador: 5-year survival rate for ALL increased from 10% to 60% in first five years of collaboration

Delivery innovation:
Harnessing the primary level to improve BC detection and care, Mexico

Financing innovations: Domestic

Several countries have integrated CCC into national insurance programs and are expressing previously suppressed demand:
Mexico Colombia Dominican Republic Peru China India Rwanda Taiwan

Seguro Popular and cancer: Evidence of impact

Since the incorporation of childhood cancers into the Seguro Popular
30-month survival: 30% to almost 70% adherence to treatment: 70% to 95%. Breast cancer adherence to treatment: 2005: 200/600 2010: 10/900

Access to medicines an anecdote

Addressing NCDs in LMICs:

Shared advocacy to achieve stronger health systems Common implementation platforms Multi-stakeholder alliances in-country Commitment-based funding models Common goals Measure progress: evidence and metrics

= social justice + efficiency

Be an optimist optimalist.