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Health Systems and the Challenge of Chronic Disease Through the Lens of Breast Cancer March 29, 2014

4 Felicia Marie Knaul

Harvard Global Equity Initiative Harvard Medical School Global Task Force on Expanded Access to Cancer Care and Control Mexican Health Foundation Tmatelo a Pecho Union for International Cancer Control

From anecdote
to evidence

January, 2008 June, 2007

From anecdote

to evidence

global health
cancer care

Challenge and disprove the myths about cancer

M1. Unnecessary
M2. Unaffordable M3. Inappropriate M4: Impossible

The Cancer Divide: An Equity Imperative

Cancer is a disease of both rich and poor; yet it is increasingly the poor who suffer:


1. 2. 3. 4. 5.

Exposure to risk factors Preventable cancers (infection)

Death and disability from treatable cancer Stigma and discrimination Avoidable pain and suffering

The Opportunity to Survive (M/I) Should Not Be Defined by Income 100% 100%
Children China Mexico

Cervix Testis Prostate




All cancers

Mexico China Canada


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 Global Pain divide

Non-methadone, Morphine Equivalent opioid consumption per death from HIV or cancer in pain : Poorest 10%10%: 54 mg Richest 10%10%: 97,400 mg US/Canada: 270,000 mg

267,000 mg

37,000 mg

272,000 mg

China: 1,276

Mexico: 2,300

Latin America

Challenge and disprove the myths about cancer

M1. Unnecessary

M2. Unaffordable
M3. Inappropriate M4: Impossible

The costs of inaction are huge: So we must Invest IN action

Tobacco is a huge economic risk: 3.6% lower GDP


Total economic cost of cancer, 2010: 2-4% of global GDP


avoidable cancer deaths: 1/3-1/2, 2.4-3.7 million; 80% LIMCs 1/3-1/2240 37080% Prevention and treatment offer potential world savings of $ US 130-940 billion 13009400

The costs to close the cancer divide may be less than many fear:

Pain medication is cheap Prices drop: HepB and HPV vaccines

Delivery & financing platforms & innovations are underutilized and undeveloped

Purchasing is fragmented, procurement is unstable

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 15-59

30 35%

-35% in 30 year

Mortality in childbirth

Breast cancer

Cervical cancer






= 430, 210 deaths

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

False dichotomies challenge Universal Health Coverage (UHC) Disease: by chronicity and infection

Communicable or infection associated NCD

HIV/AIDs (KS) Breast cancer

Cervical Cancer HPV)

Long term disability post infection (polio)

Chronic w acute episodes:

Asthma, mental

Diarrheas Respiratory infection

AMI Infant Leukaemia

Responding to the challenge of chronicity: Health system functions by care continuum

Health System Functions

Stage of Chronic Disease Life Cycle /components CCC

Primary Prevention Secondary prevention Diagnosis Treatment Survivorship/ Rehabilitation / Palliation/ End-of-life care /



Delivery Resource Generation

A response to chronic illness requires an approach that integrates interventions along the continuum of disease and life cycle

1. Primary prevention
2. Secondary prevencin (early detection)() 3. Diagnosis 4. Treatment 5. Survivorship

6. Palliative care
EUHC = Effective Coverage + Effective Financial Protection

The Diagonal Approach to Health System Strengthening

Rather than focusing on either disease-specific vertical or horizontalsystemic programs, harness synergies that provide opportunities to tackle disease-specific priorities while addressing systemic gaps and optimize available resources Diagonal strategies: X = > parts Bridge disease divides: life cycle response

Generate positive externalities: e.g. womens cancer programs fight gender discrimination; pain control 4all


Diagonalizing Cancer Care: Financing & Delivery


Financing: Integrate cancer care into national insurance and social security programs
Mexico , China , India


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.

Challenge and disprove the myths about cancer

M1. Unnecessary M2. Unaffordable M3. Inappropriate

M4: Impossible

2003 Mexico Reform Key Financing Elements:

1. Access to publicly-funded, heavily subsidized, progressive
health insurance Seguro Popular - for all families excluded from Social Security -

2. Separate budgeting and funds for public health goods with

universal coverage effectiveness and burden of disease expands over time

3. Package of personal health services based on cost-

4. Fund for catastrophic illness covering specific interventions

for specific diseases expands over time

Mexico 2003 Health reform created Seguro Popular


Vertical Coverage Diseases and Interventions:

2004: 6.5 m 650 2012: 54.6 m 5460

Benefit package : 2004: 113 2012: 284+57

Affiliation :

Benefits Package

Horizontal Coverage:


Mexico 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

Breast cancer adherence to treatment:

Seguro Popular and cancer: Evidence of impact

2005: 200/600 2010: 10/900

Since the incorporation of childhood cancers into the Seguro Popular

30-month survival: 30% to almost 70% 30

30%70% 70%95%

adherence to treatment: 70% to 95%.

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

Breast Cancer: Delivery failure

# 2 killer of women 30-54 5-10% detected in Stage 0-1 % diagnosed in Stage 4 by state



Poor municipalites: 50% Stage 4; 5x the rate for rich

50% 4


Effective Universal Health Coverage (EUHC)

Beneficiaries :
Beginning with Vulnerable groups

Benefits - the package :

Explicit: interventions, diseases, health conditions

Complete: Community, public, personal and catastrophic

Cost-effective: increasing but not exhuastive Proactive: to promote equity and rights High quality

Financial protection

Integrated accross the life cycle

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 cancer prevention and treatment for women, yet a low survival rate. Opportunities to improve delivery

Delivery and financial protection challenges:


Seguro Popular in Mexico


Benefits: covered interventions

included in the Fund: breast cancer,


Package of essential personal services

CHILDREN: Health insurance for a New Generation

Community and Public Health Services




Advanced metastatic breast cancer due to missed opportunities

Including cervical and breast cancer awareness for early detection in Oportunidades

Gua de orientacin y capacitacin a titulares beneficiarios del programa Oportunidades includes information on breast cancer as of 2009/10200910
1.5 million copies to promoter

Reaches 5.8 million families = more than 90% of poor households

580 90%

Training primary care providers in early detection and mangement of breast cancer
Promoters (+4000), Nurses & MDs (+1400), medical students (+750) Nuevo Leon, Jalisco, Morelos, Puebla Significant increase in knowledge, especially in CBE

Diagonalizing Delivery:

Harvard School of Public Health and Harvard Global Equity Initiative are collaborating with the All-China Womens Federation and National Center for Womens and Childrens Health to conduct pilot projects across six counties in China, exploring an evidence-based, diagonal model for breast cancer education and awareness at the primary level of care adapting and extending the Mexico model

Breast Cancer Initiative: Exploring a diagonal approach in China

Be an optimist optimalist

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