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San Antonio Breast Cancer

Symp, Dec 5, 2017

Health System Responses to


Womens Cancers in the Americas:
Closing Divides to Achieve
Universal Health Coverage
San Antonio Breast Cancer Symposium
December 5, 2017

Dr. Felicia Marie Knaul


Miami Institute for Advanced Study of the Americas and Miller School of Medicine,
University of Miami; Fundacin Mexicana para la Salud; Tmatelo a Pecho
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San Antonio Breast Cancer
Symp, Dec 5, 2017

Closing divides around


womens cancer
is a health, equity & economic imperative;
affordable and achievable through
diagonal approaches.
Synergistic strategies combining
womens rights, health and cancer
platforms need to be
developed & implemented.
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

PAISES SOCIOS

ARGENTINA 3
10 pases BRASIL 3
COSTA RICA 3
22 NGOs 2
COLOMBIA
ECUADOR 1
EL SALVADOR 1
MXICO 4
PER 2
URUGUAY 1
PRESIDENCIA VENEZUELA 2
2016-18
TOTAL 22

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Outline
1. Growing health
priority for LAC
2. Health systems strengthening through
a diagonal approach
3. Examples from Mexico

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Percentage of DALYs by cause


grouped by world region
100%
8 10 9
15 16

80% 21

41 41
60%
62
85
40%
71

20% 45 49

22
0% 6
Africa Middle East Low and LAC High
Middle Income
Income Countries
Countries
Injuries Non-communicable Communicable, maternal and nutritional

Source: Estimates by the LAC Health Observatory based on data from WHO, 2004.
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017
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
European countries 66% 70%
took over two
centuries to reach. Communicable
Life expectancy has Non-
increased from Communicable
approx 30 in 1920,
25% Injuries
to over 75 today
18%
In only a few 12%
decades, causes of 9%
death changed 1980 2010
dramatically.
Source:
This Cepal,is2012.
presentation The epidemiologic
the intellectual profile
property of the of Latin
presenter. America
Contact: and the Caribbean:
fknaul@miami.edu challenges,
for permission limits,
to reprint and
and/or actions.
distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

The cancer transition: by income, region:


breast and cervical cancer,
% change 1980-2010 BC cases (I)
300
264
252
BC deaths (M)
236

CC cases (I)
% Change in incidence

200 177
144
and mortality

CC deaths (M)
115
96
100
68 68
44 42 31 35
19
0

-14 -14
Latin America Low Middle High
Source: Knaul, Arreola, Mendez. estimates based on IHME, 2012. income income income
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Leading causes of death among women


15 to 49 years, select LA countries, 2015
Chile Costa Rica Mxico Brasil

Bolivia Ecuador Per Colombia

Source: IHME. GBD 2015.


This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Mexico: Success reducing cervical cancer


death. Emerging challenge of breast cancer.

16 Trends in mortality from


breast and cervical cancer
( 1955-2014 )
Mortality rate x 100,000

0
1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

2010

2014
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 (1979-2014)

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Mortality: cervix and breast cancer in


Mexican States (1979-2013)
18 Distrito Federal Nuevo Len
18
16 16
14 14
12 12
Mortality per 100,000 women

10 10
8 8
6 6
4 4
2 2
0 0
1979

1985

1990

1995

2000

2005

2013

1979

1985

1990

1995

2000

2005

2012
2013
20 25
18
Puebla Oaxaca
16 20
14
12 15
10
8 10
6
4 5
2
0 0

2013
1979

1985

1990

1995

2000

2005
2011
1979

1985

1990

1995

2000

2005

2013

Source: Estimaciones propias basadas en datos de DGIS. Base de datos de defunciones 1979-2013. SINAIS. Secretara de Salud.
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

In LMICs a very large % of Breast Cancer cases


and deaths are in women <55
Low income Latin America High Income
Diagnosis
Age at

33%
66% 62%
15-39

40-54

>55
Age at
Death

34%
67% 61%
Fuente: Estimaciones de los autores basadas en IARC, Globocan 2012
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Avoidable breast cancer deaths:


by country group, 2016

Country group Breast

Latin America and the 57% (24,500)


Caribbean

75% of breast
LMICs
95% of cervical
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Trends in breast cancer mortality:


USA, Canada, Australia,
Mexico, Colombia
USA
Age-adjusted mortality rate

Canada
Australia

Colombia Mexico

0 2030?
1975 1980 1985 1990 1995 2000 2005 2010 2014
Source: Data extracted from CI5plus.

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Outline
1. Growing health priority for LAC

2. Health systems
strengthening
through a diagonal
approach
3. Examples from Mexico

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Universal Health Coverage


All people must obtain the health services they
require - prevention, promotion, treatment,
rehabilitation and palliative care - without the risk
of impoverishment (WHO)

a wave of global reforms in the tough context


of a complex epidemiological transition, and
with highly fragmented health systems

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

An effective UHC response to chronic illness


must integrate interventions along the
Continuum of disease:
1. Primary prevention
2. Early detection
3. Diagnosis
4. Treatment
.As well through each
5. Survivorship
6. Palliative care Health system function
1. Stewardship
2. Financing
3. Delivery
4. Resource generation
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

The challenge of chronicity: 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 Secondary
Functions Primary prevention/ Survivorship/ Palliation/
Diagnosis Treatment
Prevention early Rehabilitation End-of-life care
detection

Stewardship

Financing

Delivery

Resource
Generation and
evidence
buliding

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Coverage of breast cancer treatment


in Latin America (source ESMO)

Adjuvant Breast: Chemo/Biol Metastatic Breast: New/Biol


Trastuzumab

Cycloph (IV)

Trastuzumab

NAB pacllt.
MTX (tap)
MTX (IV)
Epirub.

Pertuz.

Everol.

Babep.
CarbP.

TDM-1
Dogt
Doxo

Padit

Lapat

BEV.
5FU
Country

Argentina

Brazil

Chile

Colombia

Mexico

Peru

Free Full cost to patient


Partly insured Not avaiable
Source: ESMO International Consortium Study of the Availability of anti-neoplastic medicines.
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Coverage of breast cancer in select LAC


countries by control-care continuum:
complex analysis
Stage of Chronic Disease Life Cycle /components CCC

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

Costa Rica

Mxico Partially Partially

Colombia Partially Partially Partially

Dominican
Rep.

Peru

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

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 add value:
Exploit existing platforms e.g. anti-poverty programs
Compound, which means increase effectiveness at a given cost
Generate positive externalities
Bridge disease divides using a life cycle response
Avoid the false dilemma of disease silos
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer

Diagonalizing Cancer Care:


Symp, Dec 5, 2017

Financing & Delivery


1. Financing: Integrate cancer care into national social
insurance and social security programs and reforms
2. Delivery: Integrate cancer prevention, survivorship
and palliative care into existing primary care
platforms, anti-poverty programs and HIV/AIDs.
3. Pain control and palliative care: reducing barriers to
access for cancer care improves access for all, and
strengthens surgical platforms
4. Advocacy: integrate advocacy around womens
cancer to harness & catalyze womens health and
empowerment, health system reform, & SDGs
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Outline
1. Growing health priority for LAC
2. Health systems strengthening through
a diagonal approach

3. Examples from
Mexico

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Expansion of Financial Coverage:


Seguro Popular Mxico
Affiliation:
2004: 6.5 m

Diseases and Interventions:


2016: 54.9 m

Benefits Package
Vertical Coverage
Benefit package:
2004: 113
2016: 287
61 in the
Catastrophic
Illness Fund Horizontal Coverage:
Beneficiaries
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

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 kids
2007: pediatric cancers; breast cancer
2011: Testicular, Prostate and NHL
2012: Ovarian and colorectal
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017
San Antonio Breast Cancer Symposium, December 5-9, 2017

Seguro Popular and breast cancer:


Evidence of impact
Adherence to treatment:
2005: 200/600
2010: 10/900
Human faces of impact:
Guillermina
Abish

This
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is the is theofintellectual
intellectual property the presenter. property of the presenter.
Contact: fknaul@miami.edu Contact:to fknaul@miami.edu
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San Antonio Breast Cancer
Symp, Dec 5, 2017

Breast cancer: care continuum

Primary Early Palliative


Prevention Detection Diagnosis Treatment Survivorship
Care

Mexico: Exemplary programs for prevention


of risk factors and investment in treatment
but.
late detection, long lag time between
diagnosis and treatment, and little access to
survivorship or palliative care.
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

5-year survival, breast cancer:


USA and Mexico
Survivorship INCAN Mexico City
Stage USA (ACS) (2007+) (1990-99)

I 98% (>80%) 97% (14%) 82% (10%)


II-III 84% 82% (73%) 59% (87%)
IV 27% 36% (13%) 15% (3%)

WITH TIMELY AND


APPROPRIATE TREATMENT
Sources: ACS. Facts & figures, 2015-2016. Reynoso-Noveron, Mohar et al, Journal of Global Oncology, 2017;
Flores Luna et al, 2008
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Breast Cancer early detection:


Delivery failure
2nd cause of death, women 30-54
10-15% of cases detected in Stage I
Poor municipalities: 50% Stage 4; 5x rate for rich
I II
50% III IV

High %
Stage IV

0%
Marginalized High Access
Source: Authors estimates with database from IMSS, 2014
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Barrier: Low quality primary care services


of women diagnosed with breast cancer reported
problems with medical attention in the diagnostic process

Did not receive BCE or information in their


routine annual exam & pap test
Doctors understated the importance of signs
and symptoms manifested by the women,
and sent them home without a diagnosis
NATIONAL QUALITATIVE STUDY Nigenda et al.

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Diagonalizing Delivery: Engage and Train primary care


promoters, nurses and doctors in early detection and
post-treatment management of breast cancer

> 16,000
Health Promoters
8 Risk Score (0-10) Significant increase in knowledge,
7 *
among health promoters,
6
especially
5
in clinical breast examination
4
(Keating, Knaul et al 2014, The Oncologist)
3
Pre Post 3-6 month
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

The most insidious injustice: Distributed opioid


morphine-equivalent (and
the pain divide: estimated met need for
http://www.thelancet.com/commissions palliative care) Morphine in
mg/patient, 2010-2013
/palliative-care Russia:
124 mg (8%)
Canada:
68,194 mg (31 x)
Western Europe:
18,316 mg (8 x) China:
314 mg (16%)
USA:
55,704 mg (31 x)
Haiti:
5.3 mg (0.8%)
India:
43 mg (4%)
Australia:
40,636 mg (19 x)
Mexico: Bolivia:
562 mg (36%) 74 mg (6%)
Uganda:
53 mg (11%)
Source: Knaul, Farmer, Krakauer, et al. Alleviating the access abyss in palliative care and pain reliefan imperative of universal health coverage. The Lancet, 2017.

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Access to DOME in Mexico

562 mg per patient with


palliative care need
(serious health related
suffering)
Unment need:
64% palliative care need
95% of all pain contron

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Coverage of pain control as a component


of palliative care in Mexico
Last 6 months of life for all
In Seguro Popular
- Medicines, primary level of care:
- Acetylsalicylic acid, ibuprofen, morphine, paracetamol,
lidocaine, midazolam, propofol, sevoflurane, vecuronium
- Medicines, second level care:
- Buprenorphine, oxycodone, tramadol + medicines
availabe at primary level
- Medicines for covered cancers, in tertiary hospital
settings:
- All the medicines that are available at secondary level
This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

What is still missing in breast cancer


coverage in Mexico?
Health Components of the continuum of care
System
Primary Secondary Survivorship/ Palliation and End-of-
Functions Prevention Prevention
Diagnosis Treatment
Rehabilitation Life Care

Fourth phase of systemic reform


Stewardship National Cancer Plan
National Cancer Registry

Fragmentation by institution
Financing Rigidity and lack of alignment between the 1st, 2nd, and 3rd levels of care
Inflexible system: Lack of portability
Lack of articulation between the 1st, 2nd, and 3rd levels of care
Service Packages of services designed without considering opportunities by level of care
Delivery The basic list of medicines moving away from being essential/basic: should concentrate on
drugs without patents, except where there are no effective alternatives
Diagnosis, survival and palliative care neglected in 1st and 2nd levels, overloaded in the 3rd level
Under-utilization of human resources in 1st level for detection, survival and palliative care
Resource Lack of research on practices, methods, protocols, and implementation and evaluation of health
programs and policies: Mexico falls in between the recommendations for poor countries and
Generation the adoption of recommendations in high-income countries, but we do not have the evidence
we need to solve it.

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Juanita:
Advanced metastatic breast
cancer is the result of a series
of missed opportunities

This presentation is the intellectual property of the presenter. Contact: fknaul@miami.edu for permission to reprint and/or distribute.
San Antonio Breast Cancer
Symp, Dec 5, 2017

Health System Responses to


Womens Cancers in the Americas:
Closing Divides to Achieve
Universal Health Coverage
San Antonio Breast Cancer Symposium
December 5, 2017

Dr. Felicia Marie Knaul


Miami Institute for Advanced Study of the Americas and Miller School of Medicine,
University of Miami; Fundacin Mexicana para la Salud; Tmatelo a Pecho
This
This presentation presentation
is the is theofintellectual
intellectual property the presenter.property of the presenter.
Contact: fknaul@miami.edu Contact:
for permission to fknaul@miami.edu
reprint and/or distribute. for permission to reprint and/or distribute.

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