Closing divides:

systemic responses to the challenges of

Chronic Disease
Miller School of Medicine, University of Miami
April 23, 2015
Felicia Marie Knaul, PhD
Harvard Medical School
Harvard Global Equity Initiative
Tmatelo a Pecho A.C. Mxico
& Mexican Health Foundation

Outline
1. The Cancer Divide
2. The Complexities of the Health Transition
3. Effective Universal Health Coverage (eUHC)
and the Diagonal Approach
4. Opportunities for action
a) Seguro Popular Mxico - Financing
b) Human resource generation
c) Access to Pain control and palliative care

Duality:
evidence and advocacy
Evidence-based
advocacy

Advocacyinspired evidence

Action:
projects, programs, policies

January,
2008
June, 2007

From anecdote

to evidence

Outline
1. The Cancer Divide
2. The Complexities of the Health Transition
3. Effective Universal Health Coverage (eUHC)
and the Diagonal Approach
4. Opportunities for action
a) Seguro Popular Mxico - Financing
b) Human resource generation
c) Access to Pain control and palliative care

Global Task Force on Expanded

Access to Cancer Care and Control
in Developing Countries

= 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

For kids 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 LMICs.

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 & Costa Rica

Trends in mortality from breast and cervical
cancer
Costa
Rica

16
40

20

Cervical cancer

Breast cancer

Source: Estimaciones propias basada en 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 (1979-2012)
Source: Data extracted from CI5plus.

2002

2000

1990

1980

2012

2005

0
1985

1955

Rate per 100,000 women

age adjusted mortality rate

Mexico

Mortality: cervix and breast cancer in

Mexican States (1979-2012)
Distrito Federal

16

14

14

12

12

10

10

4
2

Oaxaca

20
15
10

Source: Estimaciones propias basadas en datos de DGIS. Base de datos de defunciones 1979-2012. SINAIS. Secretara de Salud.

2012

2005

2000

1995

1990

1985

5
1979

2005

2000

1995

2012

25

Puebla

2012

20
18
16
14
12
10
8
6
4
2
0

1990

0
1985

Nuevo Len

18

16

1979

Mortality per 100,000 women

18

Evolution of the difference between the death rate

from cervical and breast cancer in Mexico by
levels of marginalization (municipalities, 1979 -2011)
Muy alta
Alta
Media
Baja

Mortality
Cervix-Breast

15

10

-5

High income
-10

Ao
Source: Estimaciones propias basadas en datos de la DGIS. Base de datos de defunciones 1979-2011 y ndice de Marginacin
Estatal y Municipal 2010.

The Cancer Divide:

An Equity Imperative

Facets

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

The Opportunity to Survive (M/I)

Should Not Be Defined by Income
Breast

100%

Cervix

India

Testis
Prostat
e
Non- Hodkins

China
Zimbawe

Hodkins

India

Tyrod

China

Canada

Canada

Leukaemia

All cancers
LOW
INCOME

HIGH
INCOME

LOW
INCOME

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.

Survival inequality gap

Children

100%

The most insidious injustice:

he pain divide
Non-methadone, Morphine Equivalent
N. America

355,000 mg

opioid consumption per death from HIV

or cancer in pain:
Poorest 10%: 179 mg
Richest 10%: 99,000 mg
US/Canada: 344,000 mg
Europe
144,000

333,000 mil mg

China: 1,593 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 )

`5/80 cancer disequilibrium

(Frenk/Lancet 2010)
Almost 80% of the DALYs
(disability-adjusted 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 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 can
aggregate purchasing and stabalise
procurement

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

Champions
the economics of hope:
Drew G. Faust
President of Harvard U
25+ year BC survivor

Nobel
Amartya
Sen,
Cancer
survivor
diagnosed
and treated
in India 65
years ago

Harvard, Breast Cancer in

Outline
1. The Cancer Divide

2. The Complexities of the Health

Transition
3. Effective Universal Health Coverage (eUHC)
and the Diagonal Approach
4. Opportunities for action
a) Seguro Popular Mxico - Financing
b) Human resource generation
c) Access to Pain control and palliative care

DALYs (%) by cause-group and world

region, GBD-IHME, 2010
100%
80%

11

12

41

44

48

16

13

62

68

22

19

16

21

60%
40%

15

71

85

71
45

20%

45

40

0%

Injuries

Non-communicable

Source: Estimates based on Global Burden od Disease Study, 2010. IHME, 2012.

13

Communicable, maternal
and nutritional

In Latin America and the Caribbean,

demographic and epidemiologic transitions
have been rapid and profound
In just over 40
years, LAC will
achieve the aging
rates that most
70%
66%
European countries
Communicable
took over two
centuries to reach.
NonLife expectancy has
Communicable
increased from 30+
Injuries
in 1920, to 75+
25%
18%
today
12%
In a very short time
9%
period, the causes
1980
2010
of death have
reversed
Source: Cepal, 2012. The epidemiologic profile of Latin America and teh Caribbean: challenges, limits, and actions.

Leading causes of death among women

aged 15 to 49 years, select LAC, 2010
Chile

Costa Rica

Mxico

Brasil

Haiti

Bolivia

Per

Panam

Fuente: Global Burden of Disease Study 2010. IHME, 2012.

Women and mothers in LMICs

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

Mortality
in
childbirth

291,000

Breast
cancer

Cervical
cancer

150,000195,000

105,000131,000

Diabetes

110,000139,000

= 373,000 465,000
Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.

Outline
1. The Cancer Divide
2. The Complexities of the Health Transition

3. Effective Universal Health Coverage

(eUHC) and the Diagonal Approach
4. Opportunities for action
a) Seguro Popular Mxico - Financing
b) Human resource generation
c) Access to Pain control and palliative care

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,

UHC requires
a strong, efficient, well-run health
system;
a system for financing health
services;
access to essential medicines and
technologies;
sufficient supply of well-trained,
motivated health workers.
(WHO, World Health Report, 2013).

Effective Universal Health

Coverage (eUHC)
Beneficiaries: Vulnerable groups
Benefits, explicitly defined the package:
Complete: Community, public, personal and
catastrophic
Explicit: interventions, diseases, health conditions
Cost-effective: increasing but not exhaustive
Proactive to promote equity and rights
High quality

Financial protection
Integrated across the life cycle: diseases
and people

An effective UHC response to chronic illness

must integrate interventions along the
Continuum of disease:
1.
2.
3.
4.
5.
6.

Primary prevention
Early detection
Diagnosis
Treatment
Survivorship
Palliative care

.As well as through each Health system function

1.Stewardship
2.Financing
3.Delivery
4.Resource generatioN

eUHC requires an integrated response along

the continuum of care and within each
core health system function
Stage of Chronic Disease Life Cycle /components CCC
Health System
Functions

Stewardship

Financing

Delivery
Resource
Generation and
evidence
buliding

Primary
Prevention

Secondary
prevention/
early
detection

Diagnosis

Treatment

Survivorship/
Rehabilitation

Palliation/
End-of-life care

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
Avoid the false dilemmas between disease silos
that continue to plague global health;
Bridge disease divides using a life cycle response;
Generate positive externalities.

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.

Diagonal Strategies:
Positive Externalities
Pain control and palliative care:
Reducing barriers to access is essential for
cancer, for other diseases, and for surgery.

Diagonalizing:
Integrate pain control and palliative care
into national health reform, insurance and
social security programs

Outline
1. The Cancer Divide
2. The Complexities of the Health Transition
3. Effective Universal Health Coverage (eUHC)
and the Diagonal Approach

4. Opportunities for action

a) Seguro Popular Mxico - Financing
b) Human resource generation
c) Access to Pain control and palliative care

Problem: before 2004

Almost half of Mexican
households lacked health
insurance, which limited access
to care, reduced opportunities
for risk pooling, and generated
catastrophic expenditures.

Catastrophe (30%) and Impoverishment

from health spending, 2000
Catastrophic, 30%: 3.4%
Impoverishment ($US1): 3.8%
Catastrophic and/or impoverishment: 6.3 %
Insured: 2.2%
Uninsured: 9.6%
Poorest quintile: 19.6%
Quintiles 2-5: 3.1%
=1.5 million families per trimester
=~?? 4 million per year ??
Source: authors own estimations based on data from the ENIGH 2000

2003 REFORM: ELIMINATE SEGMENTATION IN ACCESS TO

HEALTH INSURANCE BY GENERATING A SYSTEM FOR SOCIAL
PROTECTION IN HEALTH THAT INCLUDES POPULAR HEALTH
INSURANCE FOR FAMILIES EXCLUDED FROM SOCIAL
SECURITY

1943

Social Security

Public and private,

Formal sector workers
and their families:
~50% of population

2001/3: Pilot of PHI

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

Ministry of Health
with residual
funding
Poor, informal sector,
non-salaried, rural
areas:
~50%
of population

System for Social

Protection in Health

Seguro
Popular

Horizontal and vertical financial protection strategies:

Benefits: covered interventions

Seguro Popular in Mexico

Catastrophic Illness
ACCELERATED VERTICAL COVERAGE: Ex: breast cancer, AIDS

Early detection

Palliative care
Survivorship

Package of essential personal

services
CHILDREN: Health insurance for a New Generation
Community Health Services: prevention+promotion

Poor
Rich
Covered population: 54.6 million Beneficiaries

Results
Increased coverage:
legal, basic and effective
Financial protection improved
The financial disequilibrium between
the insured and the uninsured now
covered by Seguro popular- has closed
Despite major challenges and crises:
economic, H1N1, violence

Evolution of Seguro Popular

enrollment, Mexico 2004-2014
300

55.5
51.8
50
226

52.9
271

$ US279

247

245

55.6

250

43.5

213
200

40
185
173

31.1

155

30

150

27.2
21.9

$134
20

100

15.7
11.4
10

50

5.3
0

0
1

10

2014.0

Public health expenditure per head of population

without social security (USD 2013)

Accumulated affiliation (Population in millons)

60

Expansion of Financial Coverage:

Seguro Popular Mxico
Affiliation:

Benefit package:
2004: 113

2014: 285
59 in the
Catastrophic
Illness Fund

Benefits Package

2014: 55.6 m

Vertical Coverage
Diseases and Interventions:

2004: 6.5 m

Horizontal Coverage:

Beneficiaries

Trends in catastrophic and impoverishing

health expenditure in Mexico, 1992-2012*
Catastrophic

% of households

Impoverishing
Catastrophic and/or
impoverishing

1.3
4

2.7

2.7
2

2.3

2.2

0.7
0

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

Catastrophic and/or impovershing health expenditure:

2002=4.3%, 2004=3.6%, 2012=2.7%

Determinants: HH catastrophic or impoverishing

health expenditure (Mexico, 1992-2012)
marginal effect; bold=significance<10%
Control for wealth, SP coverage in the state of residence,
HH size, sex and education of HH head.

Household insurance (instruments: other

insurance, has bank account)
Social Security
Seguro Popular

Catastrophic expenditure
k=30%
1992-2012

-0.749
-0.118

Composition of Household
With >65 years
With <5 years
With <5 and >65 years
Residence rural=1
Household receives remittances
n

0.625
0.799
0.879
0.645
0.182
171,190

The incidence of catastrophic spending decreased by >20% among HH w/ Seguro

Popular; also overall out of pocket spending especially among the poorest. HHs.
King, Gakidou et al. Lancet 2006.

Progress in closing the gaps between

population groups, health conditions,
and financial protection
Financial Protection

Social Security

Non-social
security*

Out-of-pocket heath expenditure by households as a proportion

of total income(%)

-14.2

-27.6

Out-of-pocket health expenditure by households as a

proportion of disposable income (%)

-10.8

-21.9

% households with catastrophic health expenditures

-10.0
.2 to.1

-20.6

% households with impoverishing health expenditures

Percentage change
2006-2010

Non-social security refers to the population without access to health care through social security institutions, that is the previously uninsured population targeted by SP.

2.1-1.6

Outline
1. The Cancer Divide
2. The Complexities of the Health Transition
3. Effective Universal Health Coverage (eUHC)
and the Diagonal Approach
4. Opportunities for action
a) Seguro Popular Mxico - Financing

b) Human resource generation

c) Access to Pain control and palliative care

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

Seguro Popular now includes

cancers in the national,
catastrophic illness fund
Universal coverage by disease with an
effective package of interventions
2004/6: HIV/AIDS, cervical, ALL in
children
2007: pediatric cancers; breast
2011: Testicular, Prostate and NHL
2013: Ovarian and colorectal

Seguro Popular and breast cancer:

Evidence of impact
National Institute
of Cancer:
treatment
adherence
2005: 200/600
2010: 10/900

The human faces:

Guillermina Avila

Breast Cancer detection:

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

Diagonalizing Delivery:
Training primary care providers in early
detection of breast cancer
Total > 16,000
Health promoters
Nurses
Physicians
8

Health Promoters
Risk Score (0-10)

6
5
4

Significant increase in
knowledge, especially among
health promoters and in clinical
breast examination
(Keating, Knaul et al 2014, The Oncologist)

3
Pre

Post

3-6 month

Preliminary training results: 10,000 primary

care physicians and nurses, 2014

Calificacin
(% de puntos logrados por score)

90

Nurses
N=2,243

Physicians
N=4,872

Signs and symptoms

85

Risk Factors

Global

80

CBE and BSE

Survivorship ??

75
PRE

POST

PRE

POST

Lasting survivorship challenges

for young women:
Qualitative research in Mexico, Brazil and India:

1.
2.
3.
4.
5.

Fear/uncertainty surrounding fertility

Body image perception challenges
Employment discrimination and its impact
Loss of social networks
Unmet primary and psych care needs
Employment discrimination

a
a person
person with
with cancer,
cancer, no
no one
one wants
wants to
to employ
employ them.
them. Because
Because we
we are
are no
no longer
longer useful.
useful.
I
I like
like to
to speak
speak the
the truth
truth when
when II go
go to
to ask
ask for
for aa job.
job. II tell
tell them,
them, II had
had cancer
cancer and
and II have
have to
to go
go
to
to appointments,
appointments, they
they tell
tell me,
me, we
we dont
dont allow
allow absences,
absences, Thanks,
Thanks, see
see you
you later.
later.

Findings and recommendations

Survivorship care is absent in LMICs, yet context-specific
In LMICs survivorship care will become increasing needed
as epidemiological transition proceeds and reform
increases health care coverage and access.
Survivorship care must be integrated into UHC and each
health system function (stewardship, financing, delivery, capacity building)
Educate policy-makers about long-term care and
quality-of-life issues including legal protection
Capacity building for physicians, nurses, other
health care providers and promoters at the
primary level

Outline
1. The Cancer Divide
2. The Complexities of the Health Transition
3. Effective Universal Health Coverage (eUHC)
and the Diagonal Approach
4. Opportunities for action
a) Seguro Popular Mxico - Financing
b) Human resource generation

c) Access to Pain control and palliative care

Pain Control and Palliative Care:

a global injustice

Every year, > 100 million require palliative care; < 8% access
Every year, tens of millions of people suffer unnecessarily from
moderate and severe pain; 5.5 million cancer patients
High-income countries represent < 15% of the worlds population
but > 94% of global morphine consumption
Only 20 countries have integrated palliative care into their
health systems.
83% of the worlds population lives in countries with almost
no access to pain medicines
Most pain medicines are off-patent and low cost, yet
expensive in poor countries:
Monthly supply of morphine US$1.80-$5.40 vs US$60- $180.

1000

Trends in opiate consumption in the

Americas 1965 to 2010
LOGARITHMIC SCALE Canada

Morphine Equivalence (mg/capital)

United States
of America

Argentina
Brazil
Chile
Costa Rica
Mexico
Colombia

1970

1980

1990

2000

2010

SOURCE: Pain & Policy Studies Group. Opioid Consumption Motion Chart. University of Wisconsin. (http://ppsg-production.heroku.com/chart )for 2007 (accessed April 22 2011).

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 its technical
assistance to member states in the
development of palliative care services

HGEI-Lancet Commission on
Global Access to Pain Control and Palliative Care
33
Members

=
Global
Health
and
Health
Systems

Palliative

Background slide from Sept NYC mtg:

HGEI-Lancet Commission Objectives
Contribute to global discussions on UHC and SDGs as
well as momentum at country level in LMICs
Develop core instruments for expanding priority setting:
Include freedom from avoidable pain and suffering
Enable policy makers to incorporate palliative care
Identify opportunities to incorporate PCPC in health
reform to strengthen health systems and achieve
effective UHC
Provide recommendations for innovative health
strategies that harness national and global platforms

Working Groups
Models and Innovations (countries)
Co-Chairs: L de Lima, EKrakauer, M R Rajagopal

Economic Evaluation and Metrics

Chair: Dean Jamison

Palliative Care and Universal Health Coverage

Chair: Rifat Atun

Work streams:
Definition
Humanitarian Emergencies and Disasters

Innovations in Measurement
Determine key components, relevant terminologies,
and complex contextual factors relevant to defining
the parameters of pain control and palliative care
Identify types of distress (physical, psychological,
social, spiritual) and measure access related to
chronic/acute illness by treatment modality
Re-evaluate existing utility-based economic
frameworks that aim to extend life or increase
productivity
Expand existing/introduce new measurement
frameworks
Design and cost packages - essential and
augmented
Extended cost-effectiveness analysis
Develop a new measure to incorporate all

Models and Innovations

Proposed Case Countries
Africa
Malawi
Rwanda
Uganda

East Asia
China
Vietnam
Mongolia

Eastern Europe
Romania
Albania

Latin America
& Caribbean
Costa Rica
Colombia
El Salvador
Jamaica
Mexico

Middle East &

North Africa
Jordan
Lebanon

South Asia
India
Bangladesh
Nepal
Pakistan

High Income as comparison/benchmark cases: Australia (+); United States (-)

Morphine Equivalent Consumption

in LAC
ME with methadone (Mg per capita)

5.5

ME w/o methadone (Mg per capita)

Media AL = 5.8

Media AL = 4.5

Mxico

Mxico

2.4

ME with methadone (by cancer or HIV/AIDS death )

ME w/o methadone (Mg by cancer or HIV/AIDS death)

7523

Media AL = 3,824

Media AL = 5,180

Mxico

Mxico

3202

In Mexico
Legislative innovative benchmark at a
global level:
2009: modification to the General Health
Law and Law on Palliative Care
2013: Expansion of the General Health
Law on palliative care matters
However..

Barriers to access palliative care by

health system function
Health
System
Functions

Components of the continuum of disease and life cycle

Prevention

Survivorship

Palliation, pain control and

end-of-life care
Unifying National Program/Plan lacking

Stewardship

Weak, restrictive, and poorly defined regulatory

frameworks
Absence of an institutional system for monitoring and
evaluation

Financing

Delivery

Resource
Generation

Almost no financial coverage in Seguro Popular;

In Social Security, a whole (nothing)
Lacking service units
Supply and distribution chains incomplete
Scarcity of qualified personnel
Fear of prescription
University curricula: missing
Absence of publications and research

Outcomes to date
Stewardship:
Inter-Agency, Civil Society led Technical
Committee
New area in the Ministry of Health
Publication of Official Standards for Mexico (NOM)
and an Agreement by General Health Council
The Federal Commission for the Prevention of
Health Risks is changing regulation and access
codes.

Financing: pressure for expansion of

coverage in all Seguro Popular funds and
increased access in Social Security
HR: A new virtual curriculum for primary care

A growing global movement for universal

coverage is advocating for the transformation
of health care into a universal right, which
entails a transition from traditional social
insurance as an employment benefit to
universal social protection of health, a right
of citizenship. Translation of this social right
into practice is a quest - it implies a
continuous strengthening of health systems to
enable them to offer effective universal
coverage in the face of chronic illness.

Be an
optimist
optimalist

Closing divides:
systemic responses to the challenges of NCDs
Miller School of Medicine, University of Miami
April 23, 2015
Felicia Marie Knaul, PhD
Harvard Medical School
Harvard Global Equity Initiative
Tmatelo a Pecho A.C. Mxico
& Mexican Health Foundation