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Integrating Pain Control and Palliative Care into health systems:

Effective Universal Coverage:


Closing the Pain Divide: A diagonal approach to harness health systems
April 16-17, 2014

Dra. Felicia Marie Knaul


Harvard Global Equity Initiative and Medical School Fundacin Mexicana para la Salud and Tmatelo a Pecho

GTF.CCC = global health

+ cancer care

Global Task Force on Expanded Access to Cancer Care and Control


35 members: Global health + Cancer care Technical Advisory Committee: 60+ Private Sector Engagement Group Priority areas and Working groups: Ped Onc, Pain & Palliation, Women's cancers, Survivorship, Economics of cancer

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

= global health + cancer care

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

Facets

The most insidious injustice: The pain divide


Non-methadone, Morphine Equivalent opioid consumption per death from HIV or cancer in pain: Poorest 10%: 54 mg Richest 10%: 97,400 mg US/Canada: 270,000 mg
267,000 mg 37,000 mg

272,000 mg

India

2,300 mg

6,600 mg
Source: Based on data from: Treat the pain (http://www.treatthepain.com )

Closing the Cancer Divide:


A BLUEPRINT TO EXPAND ACCESS IN LMICs

Applies a diagonal approach to avoid the false dilemmas between disease silos -CD vs NCD- that continue to plague global health

Outline
1.The Diagonal Approach
2. Effective Universal Coverage and the challenge of chronic conditions 3. Effective Universal Coverage: Mexico

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 avoids the false dilemmas between disease silos that continue to plague global health Bridge disease divides using a life cycle response Generates positive externalities:

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

For decades, energy has been spent in disputes opposing disease-specific vertical service delivery models to integrated horizontal models. Delivery science is consolidating evidence on how some countries have solved this dilemma by creating a diagonal approach: deliberately crafting priority disease-specific programs to drive improvement in the wider health system. Weve seen diagonal models succeed in countries as different as Mexico and Rwanda.
Jim Yong Kim, World Bank President, World Health Assembly, 2013

Outline
1. The Diagonal Approach

2.Effective Universal Coverage and the challenge of chronic conditions


3. Effective Universal Coverage in Mexico

Universal Health CoverageUHC


All people obtain the health services they need prevention, promotion, treatment, rehabilitation, and palliative care without suffering economic hardship or impoverishment. a strong, efficient, well-run health system; a system for financing health services; access to essential medicines and technologies; a sufficient capacity of well-trained, motivated health workers. (WHO, World Health Report, 2013).

Universal Health Coverage: Population, Diseases, and Interventions

PackageDiseases & Interventions (Vertical)

Population (Horizontal)
Source: Modified from the WHO, World Health Report, 2013 andSchreyogg, et al., 2005.

4th dimension: Financing to ensure equity and efficiency with $ protection

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

Huge steps in the transition thru reform in the quest for UHC in many countries
Examples:
Brazil China Colombia Chile EEUU (Affordable Care Act) El Salvador Peru South Africa Taiwan Mexico: Seguro Popular de Salud

Yetoften in the
context of rapid, profound, polarized and complex epidemiological transition or battling fragmented health systems

Rapid, profound demographic and epidemiologic transitions


In just over 40 years, LAC will achieve the aging rates that most European countries took over two centuries to reach. Life expectancy has increased from 30+ in 1920, to 75+ today In a very short time period, the causes of death inverted

66%

70%

Communicable
NonCommunicable
25%
9%

Injuries
18% 12%

1980

2010

Source: Cepal, 2012. The epidemiologic profile of Latin America and teh Caribbean: challenges, limits, and actions.

False dichotomies challenge Universal Health Coverage (UHC)


Diseases inaccurately labeled chronic or infectious
Communicable or infectionassociated

NCD
Breast cancer

HIV/AIDs (KS)

Chronic Cervical Cancer (HPV) Long term disability post infection (polio) Chronic w acute episodes: Asma, mental

Acute

Diarrhea Respiratory infection

Acute myocardial infarction Acute Lymphoblastic Leukemia

An effectiveUHC 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 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
Health System Functions
Stewardship Financing Delivery Resource Generation Components of the continuum of disease and life cycle
Primary Prevention Secondary prevention

Diagnosis

Treatment

Survivorship/ Rehabilitation

Palliation/ End-of-life care

Not associated with a specific illnesses Most patients lose their lives making advocary especially challenging advocacy People who are alive are afraid of death and would rather not discuss it Measurement based on Burden of Disease and Cost-efectiveness misses the point and skews priority setting

Why have pain control and palliative care been forgotten in the quest for UHC?

Outline
1. The Diagonal Approach 2. Effective Universal Coverage and the challenge of chronic conditions

3.Effective Universal Coverage in Mexico

The Lancet: Universal Health Coverage in Mexico, a global example


Mexico reached a truly immense landmark in its pioneering journey of health reform: achieving UHC for its 100 million citizens Mexico has showed how UHC, as well as being ethically the right thing to do, is the smart thing to do. Health reform, done properly, boosts economic development Lets celebrate success, and hope for a sustained Mexican wave of UHC worldwide
Mexico: celebrating universal health coverage. The Lancet, Volume 380, Issue 9842, Page 622, 18 August 2012.

Dimensions of social protection in health


Protection against health risks

Example: COFEPRIS (Federal


Commission for Protection against Sanitary Risk)

Social Protection in Health

Protection of patients

Example: CONAMED
(National Commission of Medical Arbitration)

Financial protection

Example: Seguro Popular

Mexicos 2003: major health reform created Seguro Popular


2004: 6.5 m Vertical Coverage Diseases and Interventions:

Affiliation:

2012: 54.6 m
Benefit package:
2004: 113

2012: 284+57

Benefits Package

Horizontal Coverage:

Beneficiaries

Evolution of vertical coverage: cumulative # of covered interventions, 2004-2013


500 450 400 350

MING FPCHE EPHS EPI CBP # Int. Causes + FPCHE # Int. MING + SP + FPCHE
17 108 110 49 20 49 49 57 57 116 128 128 131

CAUSES FPCHE

284 59

131

MING + SP

No. Interventions

300 250 200 150 100 50 63 0 2004


Notes:

59

FPCHE 59 interventions

CAUSES 91 FPCHE 6
6 83 6 22 6 6 65 2005 8 65 2006 6 65 2007 176 184

189

189

198

198

206

205 Seguro Popular 284 interventions

12 65 2008

12 65 2009

12 65 2010

12 65 2011

13 65 2012

13 65 2013

SP = Seguro Popular MING = Medical Insurance for a New Generation (Children born after December 1, 2006 and until they are 5 years of age) now XXI Century Medical Insurance FPCHE = Fung for Protection against Catastrophic Health Expenditure EPHS =Essential Personal Health Services EPI = Expanded Programme of Immunisations CBP= Community-based package

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

Out of the 83,771 deaths from cancer or HIV/AIDS in 2010, 65,447 patients died in

Barriers to access palliative care by health system function


Health System Functions

Components of the continuum of disease and life cycle


Prevention Survivorshi p

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

CAUSES and FPCHE: theres no explicit coverage; In Social Security, a whole Lacking service units Supply and distribution chains incomplete geographically Scarcity of qualified personnel Fear in the prescription Incorporation of relevant classes in university curricula is missing Absence of published investigations

Delivery

Resource Generation

Source: Adapted from Knaul, F. M., Gralow, J. R., Atun, R., & Bhadelia, A. (Eds.). Closing the Cancer Divide. Harvard University Press, 2012.

The 2003 reform created a new financial model:


Funds of the System of Social Protection in Health
Health goods Public goods
Stewardship functions Health services to the community Essential services
Federal

Funds

Level

Budget of the 1a3 Ministry of Health

Fund-C

Personal Health Services

High specialty interventions

Seguro Popular de Salud

Fund CAUSES

1y2

1y2
Catastrophic 3 fund

Communication between funds and levels is problematic, yet the population struggles to moves across and between funds

* Since Dec 2006. ** Since 2013 Source: Adapted from: Frenk J, Gonzlez-Pier E, Gmez-Dants O, Lezana MA, Knaul FM. Comprehensive reform to improve health system performance in Mexico. Lancet 2006; 368: 1524-34.

Delivery and financial protection challenges:

Seguro Popular in Mexico


Benefits: covered interventions
ACCELERATED VERTICAL COVERAGE for Catastrophic Illnesses included in the Fund: breast cancer, AIDS

Package of essential personal services


CHILDREN: Health insurance for a New Generation / XXI Century Med Ins. Community and Public Health Services

Poor Beneficiaries

Rich

Integrated and system-wide solutions are needed


EVIDENCE LEGISLATIVE AND NORMATIVE FRAMEWORK REGULATORY FRAMEWORK

PREVENTION AND CONTROL OF ILLICIT DRUG USE

National Plan: Pain Control and Palliative Care

COMPREHENSIVE INSURANCE COVERAGE

AWARENESSPATIENTS CAPACITY BUILDING AND TRAINING

SUPPLY AND DISTRIBUTION OF MEDICATIONS

Integrating Pain Control and Palliative Care into health systems:


Effective Universal Coverage:
Closing the Pain Divide: A diagonal approach to harness health systems
April 16-17, 2014 Dra. Felicia Marie Knaul
Harvard Global Equity Initiative and Medical School Fundacin Mexicana para la Salud and Tmatelo a Pecho

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