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Felicia Marie Knaul, PhD

Harvard Global Equity I nitiative, Global Task Force on Expanded Access to


Cancer Care and Control in LMI Cs
Tmatelo a Pecho A:C. Mxico
Mexican Health Foundation
Womens College Research Institute
Toronto, May 23, 2014
Closing the Cancer Divide:
The case of womens cancers and
Mexicos Seguro Popular
Evidence-based
advocacy
Advocacy-
inspired evidence
Action:
projects, programs, policies
Duality:
evidence and advocacy
From anecdote


to evidence
January, 2008
June, 2007


to evidence
From anecdote




Miembros
GTF.CCC
Global Task Force on
Expanded Access to
Cancer Care and Control
34 members:
Global health + Cancer care
Technical Advisory Committee: 60+
Private Sector Engagement Group
Priority areas and Working groups:
Ped Onc, Pain & Palliation, Womens
cancers, Survivorship, Economics of cancer
Global Task Force on Expanded
Access to Cancer Care and
Control in Developing Countries
= global health + cancer care
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
Closing the Cancer Divide:
An Equity Imperative
I: Should be done
II: Could be done
III: Can be done
M1. Unnecessary
M2. Unaffordable
M3. Impossible
M4: Inappropriate
Expanding access to cancer care and control in LMICs:
1: Innovative Delivery
2: Access: Affordable Meds, Vaccines & Techs
3: Innovative Financing: Domestic and Global
4: Evidence for Decision-Making
5: Stewardship and Leadership
Mirrors the epidemiological transition
LMICs increasingly face both infection-
associated cancers, and all other cancers.

The Cancer Transition
Double burden for health systems

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.



#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 developing countries.
For children & adolescents
5-14 cancer is
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 Cancer Divide:
An Equity Imperative


F
a
c
e
t
s

Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.
Children
LOW
INCOME
HIGH
INCOME
Facet 3: The Opportunity to Survive
(M/I) Should Not Be Defined by Income
In Canada, almost 90% of children with leukemia survive.
In the poorest countries only 10% survive.
Leukaemia
All cancers
100%
Mexico
Canada
LOW
INCOME
HIGH
INCOME
Breast Cervix
Testis Prostate
Non-hodkins Hodkins
Tyroid
Mexico
Canada
S
u
r
v
i
v
a
l

i
n
e
q
u
a
l
i
t
y

g
a
p

Adults
100%
The most insidious injustice:
The pain divide
272,000 mg
2,300 mg
267,000 mg
6,600 mg
37,000 mg
Source: Based on data from: Treat the pain
(http://www.treatthepain.com )
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
India
Challenge and disprove the
myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE
M3. Inappropriate APROPRIATE
M4: Impossible POSSIBLE

`5/80 cancer
disequilibrium
(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 of inaction are huge:
Invest I N action
Tobacco is a huge economic risk: 3.6% lower GDP
Total economic cost of cancer, 2010: 2-4% of global GDP

Prevention and treatment offers
potential world savings of
$ US 130-940 billion
1/3-1/2 of cancer deaths are avoidable:
2.4-3.7 million deaths,
of which 80% are in LIMCs


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 are
underutilized & undeveloped so that purchasing
is fragmented and procurement is unstable

PAHO 2013 Strategic Fund for NCDs
includes key cancer drugs
Challenge and disprove the
myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE
M3. Inappropriate APROPRIATE
M4: Impossible POSSIBLE

What is maternal morality?
Women and mothers in LMICs
face many risks through the life cycle
Diabetes
120,889
Breast
cancer
197,501
Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.
Cervical
cancer
135,164


Mortality
in
childbirth
342,900
-35%
in 30
year
= 453, 554 deaths
Annual deaths, LMI CS,
Women 15-59
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
Bridge disease divides using a life cycle response
avoids the false dilemmas between disease silos -
CD/NCD- that continue to plague global health
Generate positive externalities: e.g. womens cancer
programs fight gender discrimination; pain control 4all
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.
Investing in treatment produces champions
Pain control and palliation
Reducing barriers to access is essential for
cancer, for other diseases, and for surgery.
Diagonalizing Cancer Care:
Financing & Delivery
1. Financing: Integrate cancer care into
national insurance and social security
programs
2. 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 NECESSARY
M2. Unaffordable AFFORDABLE
M3. Inappropriate APROPRIATE
M4: Impossible POSSIBLE

Champions:
Nobel Amartya Sen,
Cancer survivor diagnosed in
India 60 years ago
Drew G. Faust
President of Harvard
University 22+ year BC
survivor
In developing countries,
people with multidrug-
resistant tuberculosis usually
die, because effective treatment
is often impossible in poor
countries. WHO 1996
Examples from other diseases:
MDR-TB treatment, 1996-99
Source: Paul Farmer., 2009
MDR-TB is too expensive to
treat in poor countries; it
detracts attention and resources
from treating drug-susceptible
disease. WHO 1997
Drug
% Decline in
price 1997-9
Amikacin
90%
Ethionamide
84%
Capreomycin
97%
Ofloxacin
98%
with WHO:
Reduced prices of second-
line TB drugs
Mexico: cervical cancer.
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)
0
4
8
12
16
1955
1
9
6
5

1
9
7
5

1
9
8
5

1
9
9
5

2008
Success in treating several cancers.
all 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-health, and injuries.

JULIO FRENK & RICHARD HORTON
HEALTH REFORM IN MEXICO SERIES
THE LANCET, 2006
Huge steps in the transition thru reform toward
Universal Health Coverage 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
Diagonalizing Cancer Care:
Financing & Delivery
1. Financing: Integrate cancer care into
national insurance and social security
programs
2. 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.
Domestic Financing
Innovations
Integrate CCC into national insurance and
social security programs to beginning with
cancers of women and children:

Mexico, Colombia, Dominican
Republic, Peru
China, India, Taiwan
Rwanda, Kenya
Mexico s 2003: major health reform
created Seguro Popular
Horizontal Coverage:
Beneficiaries
V
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c
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l

C
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r
a
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e



D
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:




B
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Affiliation:
2004: 6.5 m
2012: 54.6 m

Benefit package:
2004: 113
2012: 284+57

Evolution of vertical coverage: cumulative #
of covered interventions, 2004-2012
Notes:

SP = Seguro Popular
MING = Medical Insurance for a New Generation (Children born after December 1, 2006 and until they are 5 years of age)
FPCHE = Fung for Protection against Catastrophic Health Expenditure
EPHS =Essential Personal Health Services
EPI = Expanded Programme of Immunisations
CBP= Community-based package
0
50
100
150
200
250
300
350
400
450
500
2004 2005 2006 2007 2008 2009 2010 2011 2012
63 65 65 65 65 65 65 65 65
6 6
8 6 12 12
12
12
13
22
83
176
184
189 189
198 198
206
6
6
17
20
49 49
49
57
57
110
108
116
128
128
131
MING
EPHS
EPI
CBP
FPCHE
N
u
m
b
e
r

o
f

i
n
t
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r
v
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t
i
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n
s

Seguro Popular
284 interventions
MING + SP
FPCHE
57
interventions
CAUSES 91
FPCHE 6
CAUSES 284
FPCHE 57
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
Key aspect of Seguro Popular:
diagonal, financial protection for
catastrophic illness
Seguro Popular and cancer:
Evidence of impact
Breast cancer adherence to treatment:
2005: 200/600
2010: 10/900
Since the incorporation of childhood
cancers into the Seguro Popular
30-month survival: 30% to almost 70%
adherence to treatment: 70% to 95%.
The human faces of
Seguro Popular:
Guillermina Avila
&
Abish Romero
B
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f
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s
:

c
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e
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i
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t
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t
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n
s

Delivery and financial protection challenges:
Seguro Popular in Mexico
ACCELERATED VERTICAL COVERAGE for Catastrophic
Illnesses included in the Fund: breast cancer, AIDS
Community and Public Health Services
Poor Rich
CHILDREN: Health insurance for a New Generation / XXI Century Med Ins.
Package of essential personal
services
Beneficiaries
Health System
Functions
Stage of the Chronic Disease Life Cycle Continuum
Primary
Prevention
Secondary
prevention
Diagnosis Treatment
Survivorship/
Rehabilitation
Palliation/
End-of-life care
Stewardship
Financing
Delivery
Resource
Generation
Responding to the Challenge of Chronicity:
Health System Functions by Care Continuum
Effective financial coverage of a
chronic disease: breast cancer
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:
diagonalize delivery
Cancer Control-Care continuum
Primary
Prevention
Early
Detection
Diagnosis Treatment Survivorship Palliation
Barriers to Access Palliative Care
by Health System Function: Mexico
Source: Adapted from Knaul, F. M., Gralow, J. R., Atun, R., & Bhadelia, A. (Eds.). Closing the Cancer Divide. Harvard University Press, 2012.
Health
System
Function
Components of the Health Care Continuum
Prevention
Survival
Palliative Care, Pain Control and End of Life Care
Regulation
Missing: National Plan / Program
Weak, poorly defined and restrictive regulatory frameworks
Absence evaluation and monitoring
Financing


NO explicit coverage of interventions in either the Comprehensive
Package for Essential Services or the Fund for Protection Against
Catastrophic Expenditure
-Social Security there is an everything and nothing
Delivery
Lacking units and levels for delivery
Supply chain and distribution is sporadic and spotty
Resource
Generation and
Research

Lack of trained personnel
Fear of prescription
Topic not available in medical school curriculum
No published research related to health system
% diagnosed in Stage 4 by state
# 2 killer of
women 30-54
5-10% detected
in Stage 0-1
Poor
municipalites:
50% Stage 4; 5x
the rate for rich
Breast Cancer: Delivery failure
Poor
Rich
Juanita:
Advanced metastatic breast
cancer is the result of a series
of missed opportunities
Diagonalizing Delivery 1:
Integration of cervical & breast cancer
education into anti-poverty programs,
Oportunidades
Include information in
manuales for
community workers
1.5 million promoters
> 90% of poor
Mexican households:
5.8 million families
Diagonalizing Delivery 2:
Training primary care providers
in early detection of breast cancer
Promoters (+4000), Nurses & MDs (+1400)
medical students (+750)
Nuevo Leon, Jalisco, Morelos, Puebla & Mexican Institute
of Social Security (32,000 MDs)
Significant increase in knowledge, especially in CBE
Ongoing research and initiatives

Closing the Pain Divide
Survivorship Brazil and Mexico
Economics of Hope
Financing Platforms PAHO Ped
Onc


Be an
optimist
optimalist

Expanding access to cancer care and control in
LMICs: Should, Could, and Can be done
Felicia Marie Knaul, PhD
Harvard Global Equity I nitiative, Global Task Force on Expanded Access to
Cancer Care and Control in LMI Cs
Tmatelo a Pecho A:C. Mxico
Mexican Health Foundation
Womens College Research Institute
Toronto, May 23, 2014
Closing the Cancer Divide:
The case of womens cancers and
Mexicos Seguro Popular

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