Closing the cancer divide: an equity imperative

Felicia Marie Knaul, Hctor Arreola-Ornelas, Julio Frenk The Global Task Force for Expanded Access to Cancer Care and Control in Developing Countries

Non-communicable disease transitions: Rich and poor countries

GLOBAL HEALTH METRICS & EVALUATION CONFERENCE: CONTROVERSIES, INNOVATION, ACCOUNTABILITY March 14, 2011

Vignette: a series of Missed Opportunities: Juanita

left breast substantially larger than right; arrived at Morelos Womens Hospital bc she could not move her swollen arm; father of children abandoned household at diagnosis History Part 1:
- Age 42; 5 children aged 7-18; breast fed all - Cartilla de la mujer: regular PAP and clinic visits - Has Oportunidades attends regular community health platicas

History Part 2:
Felt a breast lump 4 years prior fear kept her from saying anything Lump grew last year doctor at local clinic gave anti-b w/out BCE Is entitled to Seguro Popular and free care Cannot travel to Mexico City; seeking care locally; paying out of pocket

br

The cancer divide

Cancer is a disease of rich and poor
Yet, transition is polarizing the burden so that it is increasingly the poor who suffer:
Incidence and death: preventable cancers Death: treatable cancer Avoidable pain and suffering particularly at end of life Financial impoverishment from the costs of care and effects of the disease

Outline
1. Increasing inequity in the global burden of cancer 2. Country-specific evidence: Mexico, breast cancer 3. Opportunities for action: the diagonal approach

Mortality/incidence by cancer type and country income, adults

1.00

Pancreas Non-Hodgkin lymphoma Hodgkin lymphoma

0.80

mortality to incidence

0.60

Survival inequality gap

0.40

Thyroid
0.20

Colorectal Cervix uteri Breast Prostate Testis

0.00

Low income

Lower middle income

Upper middle income

High income

Cervical cancer incidence by income per capita and data source

40

Jamaica
30 Incidence rate (x 1000 miles women)

Sin data incidencia y mortalidad

Solo data incidencia
Lithuania

Zimbadwe Peru
20

South Asia Sub-Saharan Africa East Asia & Pacific

Dem. Rep. Congo

Latin America & Caribbean Eur. East & Central Asia Sola data mortalidad

10

Europe

Middle East & North Afr

Samoa Malta
9 10

North America
Qatar Kuwai t
11 12

Norway

0 4 5 6 7

Con data incidencia y mortalidad

-10

Ln (GDP per capita)

275,000 deaths worldwide; 93% in LMCs

Mortality/Incidence, Breast Cancer; by income per capita and data source

1

0.8

Letalidad (Mortalidad/Incidencia)

Guinea Ecuatorial
0.6

Brunei

Sin data incidencia y mortalidad

Zimbadwe

Solo data incidencia

0.4

Sola data mortalidad

0.2

New Zeland Korea

Con data incidencia y mortalidad
11 12

0 4 5 6 7

Samoa
8 9 Ln (PIB per capita) 10

Mortality/incidence by cancer type and country income, adults

~ case fatality (mortality/incidence)
0.8 73%

Leukaemia, <15

0.6

0.4

All cancers, < 15

18%

Survival inequality gap

0.2

0
Low income countries Lower middle income Upper middle income High income countries

Source: Author estimates based on IARC, Globocan, 2008 and 2010. Quote: HRH Princess Dina Mired

Estimated childhood-cancer 5-year survival by level of government spending on health (Riberio et al)
100

80 Venezuela 60 Ukraine 40 Egyp t Honduras Polond Estonia Slovakia Czech Republic Malta Slovenia 1000 Austria Italy Finland Netherlands UK France Germany USA Sweden Denmark Switzerland Iceland Norway 10000

5 year survival (%)

Morocco

20 Tanzania Bangladesh Vietnam 10 Philippines Senegal 100

Annual govertment spending on health care per capita ($US)

Source: Ribeiro RC, Steliarova-Foucher E, Magrath I, Lemerle J, Eden T, Forget C, et al . Baseline status of paediatric oncology care in ten low-income or mid-income countries receiving My Child Matters support: A descriptive study. Lancet Oncol 2008;9:721-9.

Distribution of childhood cancer globally by level of income (< 15)

LMICS: More than 85% of pediatric cancer cases and 95% of deaths. 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

Outline
1. Increasing inequity in the global burden of cancer 2. Country-specific evidence: Mexico, breast cancer 3. Opportunities for action: the diagonal approach

Breast and cervical cancer mortality, Mexico 1955-2008

16

Age adjusted rate per 100,000 women

12

2006: BC>CC.
For the first time in 5 decades.
Source: Knaul et al, 2008. Reproductive Health Matters. And updated by Knaul, Arreola and Mndez.

2005

1955

1965

1975

1985

1995

La brecha entre la mortalidad por cncer de crvix y mama se est cerrando aunque aun prevalece en los estados pobres en Mxico
16
TM x 100,000 mujeres

Distrito Federal

16 12 8

TM x 100,000 mujeres

Nuevo Len

12

4
0 25 20 15 10

crvix mama
2008 1979 1980 1985 1990 1995 2000 2005 TM x 100,000 mujeres

4 0

1979

1980

1985

1990

1995

2000

2005

Oaxaca

30 25 20 15 10 5

TM x 100,000 mujeres

Tabasco

5
0

1979

2008

1980

1985

1990

1995

2000

2005

1979

1980

1985

1990

1995

2000

2005

Fuente: Lozano, Knaul, Gmez-Dants, Arreola-Ornelas y Mndez, 2008, Tendencias en la mortalidad por cncer de Mama en Mxico, 1979-2008. FUNSALUD, Documento de trabajo. Observatorio de la Salud.

2008

2008

Stage at diagnosis by level of municipal marginacin, Mexico, IMSS 2006

(Mxico, IMSS 2006)
50% 40% Stage 1 30% Stage 2 Stage 3 20% Stage 4 10% % diagnosed in Stage 4 0%
Poor (High) Middle Low Very low

Late detection by state

< low > mid > high

N=221 (3.8%)

N=1737 (30%)

N=2877 (49.8%)

N=946 (16.4%)

Source: Authors estimation based on IMSS data, 2006.

Outline
1. Increasing inequity in the global burden of cancer 2. Country-specific evidence: Mexico, breast cancer 3. Opportunities for action: the diagonal approach

 Latin American nations, much of eastern Europe and

central Asia, China, India, many other parts of south Asia, and even countries in Africa, [are] facing a painful double burden of diseasenot only the persistence of infectious threats, child and maternal mortality, and undernutrition, but also the emergence of new dangers, notably diabetes, obesity, cardiovascular disease, stroke, cancer, mental ill-

This double burden requires a double response, a predicament that places huge responsibilities on the stewards of national health systems.
health, and injuries.
JULIO FRENK & RICHARD HORTON HEALTH REFORM IN MEXICO SERIES; THE LANCET, 2006

The diagonal approach to health system strengthening

it has been discussed at length what the most effective approach is to deliver health interventions: vertical programs or horizontal programs. This is a false dilemma, because both interventions need to coexist in what could be called a diagonal approach

Seplveda et al., Aumento de la sobrevida en menores de 5 aos: la estrategia diagonal

The diagonal approach

Horizontal Coverage: Beneficiaries

Mexico Popular Health Insurance: Fund for catastrophic illness an example of the diagonal approach
Population-based coverage of community and personal health services Accelerated universal vertical coverage by disease with a specified package of interventions
2004/5: ALL in children, cervical, HIV/AIDS 2006: all pediatric cancers 2007: breast 2011: testicular and NHL

Diagonal approaches to expanding access to cancer care and control:

1. Financial protection/insurance strategies with horizontal and vertical coverage 2. Integrating breast and cervical cancer screening into MCH, SRH, HIV/AIDS care and control 3. Integrating disease prevention and management into social welfare and anti-poverty programs 4. Reducing non-price barriers to pain control 5. Developing effective health services research and monitoring by state and non-state actors

`5/80 cancer disequilibrium

(Frenk/Lancet 2010)
Almost 80% of the DALYs (disabilityadjusted life-years) lost worldwide to cancer are in LMICs, yet these countries have only a very small share of global resources for cancer ~ 5% or less.

The cancer divide: an equity imperative

Felicia Marie Knaul, Hctor Arreola-Ornelas, Julio Frenk
Non-communicable disease transitions: Rich and poor countries
GLOBAL HEALTH METRICS & EVALUATION CONFERENCE: CONTROVERSIES, INNOVATION, ACCOUNTABILITY March 14, 2011