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Universal Health

Coverage and the
Rise of Chronic
Disease:
A Latin American
Quest

Felicia Marie Knaul
10th iHEA World Congress

Health Economics in the
Age of Longevity:

July 15, 2014
Session: Universal Health Care


The authors appreciate the financial support of
Harvard U, and IDRC Canada
Outline
1. UHC and the challenge of chronic
conditions
2. Effective Universal Health Coverage
3. Mexico and Seguro Popular
• Breast Cancer and UHC
• Pain control and palliative care
Huge steps to reform health systems in the
quest for UHC in many countries
Examples:
•Brazil
•Colombia
•Chile
•Dominican Republic
•El Salvador
•Peru
•Mexico: Seguro Popular de Salud
•South Africa
•China
•(USA - Affordable Care Act)

Yet…often in the
context of rapid,
profound,
polarized and
complex
epidemiological
transition or
battling
fragmented health
systems
… 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 disease—
not 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. This double
burden requires a double response, a
predicament that places huge responsibilities on
the stewards of national health systems.


JULIO FRENK & RICHARD HORTON
HEALTH REFORM IN MEXICO SERIES; THE LANCET, 2006
Source: Cepal, 2012. The epidemiologic profile of Latin America and teh Caribbean: challenges, limits, and actions.
1980 2010
66%
25%
9%
70%
18%
12%
Communicable
Non-
Communicable
Injuries

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 have
reversed
In Latin America and the Caribbean,
demographic and epidemiologic transitions
have been rapid and profound
DALYs (%) by cause-group and
world region, GBD-IHME, 2010
71
45 45
40
22
19
13
6
21
41
44
48
62 68
71 85
8
15
11
12
16
13
16
9
0%
20%
40%
60%
80%
100%
Africa Middle East Southeast
Asia
World LAC Pacific Europe High
Income
Countries
Injuries non-communicable Communicable, maternal and nutritional
Source: Estimates based on Global Burden od Disease Study, 2010. IHME, 2012.
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 have 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. women’s cancer
programs fight gender discrimination; pain control 4all
Disease and health system functions,
By integration
Diagonal,
synergistic:
vertical
and
horizontal
integration
Disease
Specific:
vertical
integration,
horizontal
segmentation
Generalized:
vertical
segmentation,
horizontal
integration
Atomized:
vertical
and
horizontal
segmentation
Stewardship
Financing
Revenue collection
Fund Pooling
Purchasing

Provision
Revenue
generation
F
U
C
T
I
O
N
S

Adapted from Murray and Frenk; WHO Bulletin 2000
Disease 1
Disease 2
Disease 3
False dichotomies challenge
Universal Health Coverage (UHC)
Communicable or infection-
associated
NCD


Chronic
• HIV/AIDs (KS) • Breast cancer




Acute




• Diarrhea
• Respiratory infection


• Acute myocardial infarction
• Acute Lymphoblastic
Leukemia
Diseases inaccurately “labeled” chronic or infectious
• Cervical Cancer (HPV)
• Long term disability post infection (polio)
• Chronic w acute
episodes: Asma, mental
Outline
1. UHC and the challenge of chronic conditions
2. Effective Universal Health
Coverage
3. Mexico and Seguro Popular
• Breast Cancer and UHC
• Pain control and palliative care
Effective Universal Coverage
• Universal Coverage: “quest” with 3 stages
• Legal: affiliation/enrollment
• Access to a comprehensive package of explicit
entitlements with financial protection
• Effective coverage & effective financial
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
• I ntegrated across the life cycle: diseases
and people
Universal Health Coverage:
Population, Diseases, and Interventions
Population
(Horizontal)
Package-
Diseases
& Interventions
(Vertical)
4th
dimension:
Financing
to ensure
equity and
efficiency
with $
protection
Source: Modified from the WHO, World Health Report, 2013 andSchreyogg, et al., 2005.
An effectiveUHC response to chronic illness
must integrate interventions along the
Continuum of disease:
1. Primary prevention
2. Early detection
3. Diagnosis
4. Treatment
5. Survivorship
6. Palliative care
….As well through each

Health system function
1.Stewardship
2.Financing
3.Delivery
4.Resource generation

Health System
Functions
Stage of Chronic Disease Life Cycle /components CCC
Primary
Prevention
Secondary
prevention
Diagnosis Treatment
Survivorship/
Rehabilitation
Palliation/
End-of-life care
Stewardship
Financing
Delivery
Resource
Generation
eUHC requires an integrated response along the
continuum of care and within each
core health system function
Outline
1. UHC and the challenge of chronic conditions
2. Effective Universal Health Coverage
3. Mexico and Seguro Popular
• Breast Cancer and UHC
• Pain control and palliative care
Mexico, 2003: Health Reform
Almost half of Mexican households
lacked health insurance, which
limited access to care, reduced
opportunities for risk pooling, and
generated catastrophic expenditures.
Legislative reform introducted
Seguro Popular and the System for
Social Protection in Health
Seguro Popular, Results
Lancet 2012
• Increased coverage:
• legal, basic and effective
• Financial protection improved
• The financial disequilibrium between
the insured and the uninsured – now
covered by Seguro popular- has closed
Expansion of Coverage:
Seguro Popular
Horizontal Coverage:
Beneficiaries
V
e
r
t
i
c
a
l

C
o
v
e
r
a
g
e



D
i
s
e
a
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e
s

a
n
d

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:




B
e
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e
f
i
t
s

P
a
c
k
a
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e



Affiliation:
• 2004: 6.5 m
• 2012: 54.6 m

Benefit package:
• 2004: 113
• 2012: 284+57

CAUSES 284
FPCHE 59
63 65 65 65 65 65 65 65 65 65
6
6 8 6
12 12 12 12 13 13
22
83
176
184
189 189
198 198
206 205
6
6
17
20
49 49
49
57
57 59
110
108
116
128
128
131 131
0
50
100
150
200
250
300
350
400
450
500
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
N
o
.

I
n
t
e
r
v
e
n
t
i
o
n
s

MING
FPCHE
EPHS
EPI
CBP
# Int. Causes
+ FPCHE
# Int. MING
+ SP
+ FPCHE
Seguro Popular
284 interventions
MING + SP
FPCHE
59
interventions
CAUSES 91
FPCHE 6
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) 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 ”
Evolution of vertical coverage: cumulative #
of covered interventions, 2004-2013
Mexico Seguro Popular:
financial protection
for catastrophic illness
Accelerated, universal, vertical coverage by disease
with a package of interventions

2004/5: ALL in children, cervical, HIV/AIDS
2006: All pediatric cancers then all children
2007: Breast cancer
2011: Testicular, prostate and NHL
2012: Colorectal cancer
Seguro Popular and cancer:
Evidence of impact
Childhood cancers
adherence to treatment:
70% to 95%
Breast cancer
INCAN
2005: 200/600
2010: 10/900
The human faces:
Guillermina Avila
Abish Romero
The 2003 reform creates a new financial
model:
Funds of the System of Social Protection in Health
* Since Dec 2006.
** Since 2013
Source: Adapted from: Frenk J, González-Pier E, Gómez-Dantés O, Lezana MA, Knaul FM. Comprehensive reform to improve health system
performance in Mexico. Lancet 2006; 368: 1524-34.
Public
goods
Services to
people
Health goods
Funds
Stewardship
functions
Health services to
the community
Essential
services
High specialty
interventions
Budget of the
Ministry of
Health
Federal
FASSA-C
FASSA-P /
CAUSES
FPCHE
Seguro
Popular
de
Salud
MING* / XXI
CMI**
Level
1 a 3
1
1 y 2
1 y 2
3
Communication
between funds
and levels is
problematic, but
the population
moves between
them
B
e
n
e
f
i
t
s
:

c
o
v
e
r
e
d

i
n
t
e
r
v
e
n
t
i
o
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
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
Cancer Control-Care continuum
Primary
Prevention
Early
Detection
Diagnosis Treatment Survivorship Palliation
Stage of Chronic Disease Life Cycle /components CCC
Finantial
protection
Primary
Prevention
Secondary
prevention
Diagnosis Treatment
Survivorship/
Rehabilitation
Palliation/
End-of-life
care
Costa Rica
México Partially Partially
Colombia Partially Partially Partially
Dominican
Rep.
Partially
Peru
Coverage of breast cancer in select LAC
countries by control-care continuum
Outline
1. UHC and the challenge of chronic conditions
2. Effective Universal Health Coverage
3. Mexico and Seguro Popular
• Breast Cancer and UHC
• Pain control and palliative care
Pain: a global injustice
• Every year, millions of people suffer unnecessarily from
moderate and severe pain, including 5.5 million cancer patients
• 83% of the world’s population lives in countries with few or no
access to pain medicines
• High-income countries represent less than 15% of the world’s
population but more than 94% of total global morphine
consumption
• Even though most pain medicines are off-patent and of low
cost, they are expensive in poor countries:
• Monthly supply of morphine US$1.80 at $5.40 vs US$60 at $180.
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
Recent major global
progress
• 2014: The WHO Executive Board adopted a
groundbreaking resolution urging countries to
ensure access to pain medicines and palliative
care for people with life-threatening illnesses.
• The resolution urges
• Countries to integrate palliative care within their health
systems
• The WHO to increase its technical assistance to member
states in the development of palliative care services
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
pain
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
Stewardship
Unifying National Program/Plan lacking
Weak, restrictive, and poorly defined regulatory
frameworks
Absence of an institutional system for monitoring and
evaluation
Financing


CAUSES and FPCHE: there’s no explicit coverage;
In Social Security, “a whole”
Delivery
Lacking service units
Supply and distribution chains incomplete geographically
Resource
Generation

Scarcity of qualified personnel
Fear in the prescription
Incorporation of relevant classes in university curricula is missing
Absence of published investigations
A growing global movement for universal
coverage is advocating for the transformation
of health care into a universal right, which
entails a transition from traditional social
insurance as an employment benefit to
universal social protection of health, a right of
citizenship. Translation of this social right into
practice is a quest - it implies a continuous
strengthening of health systems to enable them
to offer effective universal coverage in the face
of chronic illness.
Universal Health
Coverage and the
Rise of Chronic
Disease:
A Latin American
Quest

Felicia Marie Knaul
10th iHEA World Congress

Health Economics in the
Age of Longevity:

July 15, 2014
Session: Universal Health Care


The authors appreciate the financial support of
Harvard U, and IDRC Canada