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Closing the cancer divide

for women in the Americas:


diagonal health system innovations
Women’s Cancer Prevention and Control in the Americas
Tuesday, 6 February 2018
Pan American Health Organization, Washington D.C.

Dr. Felicia Marie Knaul


UM Institute for Advanced Study of the Americas and Miller School of Medicine,
University of Miami; Tómatelo a Pecho and FUNSALUD, Mexico
January, 2008
June, 2007
Outline
1. Growing equity and
health priority
2. Health systems strengthening through
a diagonal approach
3. Examples from Mexico
4. Evidence to close divides
Women and mothers in LMICs
face many risks through the life cycle
Annual deaths: Women 15-59

-35%
Mortality Breast Cervical
in 30 in
years cancer cancer
childbirth

291,000 195,000 131,000

= 326,000
Source: Estimates based on data from IHME 2016
Leading causes of death among women
15 to 49 years, select LA countries, 2016
Chile Costa Rica México Brasil

Bolivia Ecuador Perú Colombia

Source: IHME. GBD 2016


Mortality: cervix and breast cancer in
Mexican States (1979-2013)
18 Distrito Federal Nuevo León
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. Secretaría de Salud.
“Avoidable” cancer deaths:
Breast and Cervical,
The Americas and LMICs
Breast Cervical

Latin America
and the 57% 64%
Caribbean
Low and middle
75% of breast
income 75% 95%
95% of cervical
countries
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.
Late Detection:
Latin America and USA
Lat
Stage Peru Colom Brazil Mexico Chile Urug´y USA
Am
I 18% 22% 18% 12% 20% 40% 21% 80%
II-III 75% 67% 72% 81% 74% 58% 71% 19%
IV 7% 11% 10% 7% 6% 2% 7% 1%

Sources: Justo, Wilking, Johnsson, Luciani, Cazab, 2014, The Oncologist; and ACS. Facts & figures, 2015-2016.
In LMICs a very large % of Breast Cancer cases
and deaths are in women <55
Latin America High Income

Age at
Diagnosis
33%
62%
15-39

40-54

>55
Age at
Death 34%
61%
Fuente: Estimaciones de los autores basadas en IARC, Globocan 2012
Outline
1. Growing health priority for LAC

2. Health systems
strengthening
through a diagonal
approach
3. Examples from Mexico
4. Evidence-based advocacy
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
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
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
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
‘Diagonalizing’ Cancer Care:
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 primary care platforms,
maternal and child health and anti-poverty programs.
3. Advocacy: integrate advocacy around women´s
cancer to harness & catalyze women´s health and
empowerment, health system reform, & SDGs
4. Pain control and palliative care: reducing barriers to
access for cancer care improves access for all, and
strengthens surgical platforms
Outline
1. Growing health priority for LAC
2. Health systems strengthening through
a diagonal approach

3. Examples from
Mexico
4. Evidence-based advocacy
Juanita:
Advanced metastatic breast
cancer is the result of a series
of missed opportunities
Expansion of Financial Coverage:
Seguro Popular México
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
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
Seguro Popular and breast cancer:
Evidence of impact
Adherence to treatment:
2005: 200/600
2010: 10/900

Human faces of impact:


Guillermina
Abish
Breast cancer: care continuum

Primary Early Palliative


Diagnosis Treatment Survivorship
Prevention Detection 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.
The most insidious injustice: Distributed opioid
the pain divide: morphine-equivalent (and
estimated met need for
http://www.thelancet.com/co palliative care) Morphine in
mg/patient, 2010-2013
mmissions/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:
74 mg (6%) Uganda:
562 mg (36%) 53 mg (11%)
Source: Knaul, Farmer, Krakauer, et al. Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage. The Lancet, 2017.
Access to opioid analgesics in Mexico
• 562 mg morphine-equivalent per
patient with palliative care need
• Unmet need:
– 64% palliative care need
– 95% of all pain control

• Inter-institutional civil society-


led group that advocated for
change
• Results: transition from paper to
electronic presciptions, including
in Seguro Popular
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
Barrier: Low quality primary care
services
½ 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.
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
Diagonalizing delivery:
Inclusion of early detection of breast cancer in
Opportunities program (Today Prospera)

• “Capacitation and orientation guide for beneficiaries of


Oportunidades program” includes information about breast
and cervical cancer
– Inclusion of the vaccination scheme which adds the HPV vaccine
• 3 million copies for promoters and trainers
• Reached 5.8 million families = more than 90% of poor
households in rural areas
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
• Packages of services designed without considering opportunities by level of care
Service
• The basic list of medicines moving away from being essential/basic: should
Delivery 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
Generation of health programs and policies: Mexico falls in between the recommendations for poor
countries and the adoption of recommendations in high-income countries, but we do
not have the evidence we need to solve it.
Outline
1. Growing health priority for LAC
2. Health systems strengthening through
a diagonal approach
3. Examples from Mexico

4. Evidence-based
advocacy to close
divides
Vision:
Improve capacity to respond to the challenge
of women's cancers throughout Latin
America.

Mission:
ULACCAM is a regional, civil society
network dedicated to influencing policy
making on women's cancers and promoting
universal access to information, preventive
services, early detection, effective diagnosis,
and high quality treatment in all stages of
disease.

10 Countries represented by 22 NGO’s


PRESIDENCIA 2016-18
The ULACCAM Regional
Observatory
Is designed to respond to the need for policy and advocacy-oriented
data summarized in an instrument that can be effectively utilized by
civil society.
A series of core, basic indicators - derived from secondary data
sources.
Annual monitoring of progress in the region as a whole, and on how
countries perform relative to each other making it a powerful tool
for national advocacy.
Can be readily transformed into national observatories by and for
local advocacy groups and civil society.
ULACCAM Regional Observatory
scorecard: examples of indicators
Does the country have….
1. A National cancer plan and national women´s cancer plans
2. A national cancer registry including women´s cancer
3. Integration of women´s cancer into women´s health plans
4. An office for women´s cancer in the Ministry of Health
5. Offial “norms” for women´s cancer issued by the MoH, and
updated every 5 years
6. Coverage of primary prevention and early detection programs
(including the HPV vaccine)
7. Inclusion of training on women´s cancer early detection in basic
medical education
8. Number of registered NGOs working on women´s cancer
Has a national cancer plan

Yes

Yes, but not updated

No

Not available
Closing the cancer divide
for women in the Americas:
diagonal health system innovations
Women’s Cancer Prevention and Control in the Americas
Tuesday, 6 February 2018
Pan American Health Organization, Washington D.C.

Dr. Felicia Marie Knaul


UM Institute for Advanced Study of the Americas and Miller School of Medicine,
University of Miami; Tómatelo a Pecho and FUNSALUD, Mexico

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