Expanding Access to Cancer Care and Control: A global challenge

Felicia Marie Knaul Harvard Global Equity Initiative Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries Mexican Health Foundation Tmatelo a pecho MAC Forum, Moscow, Russia, Moscow, Russia, February 2, 2012

From anecdote
to evidence

January, 2007 June, 2008

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

= global health + cancer care

Closing the Cancer Divide:

A Blueprint to Expand Access in LMICs I: Much should be done II: Much could be done III: Much can be done
1: Innovative Delivery 2: Access to Affordable Medicines, Vaccines & Technologies 3: Innovative Financing: Domestic and Global 4: Evidence for Decision-Making 5: Stewardship and Leadership

Closing the Cancer Divide: Divide:

A BLUEPRINT TO EXPAND ACCESS IN LMICs

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

Expanding access to cancer care and control in LMICs:

A) Should be done:
Myth 1. Unnecessary Myth 2. Inappropriate B) Could be done:
Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

The Cancer Transition

Mirrors the overall epidemiological transition protracted and polarized*:
LMICs increasingly face both cancers associated with infection, and all other cancers. Cancers that were once considered only of the poor, now cease to be the only cancers of the poor. (e.g. cervical & breast cancer)
* Frenk et al

The cancer transition in LMICs: breast and cervical cancer

LMICs account for >90% of cervical cancer deaths and >60% of breast cancer deaths. Both diseases are leading killers especially of young women.
% Change in # of deaths 1980-2010
53%

19%

20%

0%

LMICs

High income
-31%

Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.

The cancer transition within countries:

breast and cervical cancer mortality
16

Mexico
1955 - 2008

0 25

Oaxaca
1979-2008

25

Nuevo Leon
1979-2008

300

Breast and cervical cancer Incidence & mortality, % change 1980-2010

Cases Cases deaths deaths

200

100

0 Europe, Central Europe, Eastem

Russia

Upper Middle Income

Developing

-50 -100

Europe, Westem

High Income

Global

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 Opportunity to Survive (M/I) Should Not Be Defined by Income

100%

Children

Adults Survival inequality gap

Leukaemia

Russia

All cancers LOW INCOME HIGH INCOME LOW INCOME HIGH INCOME

Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.

In Canada, almost 90% of children with leukemia survive. In the poorest countries only 10% survive.

Stigma: Juanita

Cancer, and especially reproductive cancers, adds a layer of discrimination onto gender, ethnicity, and poverty.

The most insidious example of injustice is access to pain control

Non-methadone, Morphine Eq opioid consumption per death from HIV or cancer in pain, mg

Russia: 937 All Developed countries: 57,041

Expanding access to cancer care and control in LMICs:

A) Should be done:
Myth 1. Unnecessary Myth 2. Inappropriate B) Could be done:
Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

The Diagonal Approach to Health System Strengthening

Rather than focusing on disease-specific vertical programs or only on horizontal system constraints, harness synergies that provide opportunities to tackle disease-specific priorities while addressing systemic gaps. Optimize available resources so that the whole is more than the sum of the parts. Bridge the divide as patients suffer diseases over a lifetime, most of it chronic.

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.

Expanding access to cancer care and control in LMICs: A) Should be done: necessary and appropriate B) Could be done:
Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

Investing In CCC: We Cannot Afford Not To

Health is an investment, not a cost 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 131-850 billion mostly due to productivity gains and reducing suffering

1/3-1/2 of cancer deaths are avoidable: 2.4-3.7 million deaths Of which 80% are in LIMCs

Investing In CCC: The costs to close the cancer divide may be less than many fear:
All but 3 of 29 LMIC priority, candidate cancer chemo and hormonal agents are off-patent: many < $100 / course Cost of drug treatment, cervical cancer + HL + ALL(k) in LMICs / year of incident cases: $US 280 m Pain medication is cheap

Prices drop:
HPV 2011 from $US 100 /dose to GAVI $5 PAHO $14

Expanding access to cancer care and control in LMICs: A) Should be done: necessary and appropriate B) Could be done: affordable C) Can be done
Myth 4: Impossible

Champions
Drew G. Faust
President of Harvard University 22+ year BC survivor

Nobel Amartya Sen,

Cancer survivor diagnosed in India 50 years ago

Harvard, Breast Cancer in Developing Countries, Nov 4, `09

Success in treating several cancers Mexico: cervical cancer.

16

12

0 1965 1975 1985 1995

1955

2005

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)

Financing innovations: Domestic

Integrate CCC into national insurance programs to express previously suppressed demand, beginning with cancers of women and children:
Mexico Colombia Dominican Republic Peru China India Rwanda Taiwan

Mexico Seguro Popular: diagonal, 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

2007: Breast cancer

2011: Testicular cancer and NHL

Horizontal and vertical financial protection strategies:

Seguro Popular for Breast Cancer, Mexico Benefits: covered interventions
Catastrophic Illness ACCELERATED VERTICAL COVERAGE: Ex: breast cancer,

Package of essential personal services

Community Health Services - NUTRITION

Poor Beneficiaries: Population covered

Rich

Seguro Popular and cancer: Evidence of impact

Since the incorporation of childhood cancers into the Seguro Popular
30-month survival: 30% to almost 70% adherence to treatment: 70% to 95%.

Access to medicines an anecdote Breast cancer adherence to treatment:

2005: 200/600 2010: 10/900

Addressing cancer +and+ chronic illness + NCDs in LMICs:

Research to build evidence for global and national policy making and advocacy Shared advocacy for stronger health systems around common implementation platforms Multi-stakeholder alliances: global and national Focus global institutions on producing and disseminating global public goods Promote innovations in use of physical, human and technological resources Strengthen national health systems especially stewardship and leadership

Addressing cancer +and+ chronic illness + NCDs in LMICs:

Establish common, attainable goals and measures of progress for accountability (UN Declaration Strengthen the evidence base + better registries Integration models (women and health, HIV/AIDS) Interdisciplinary partnerships
Implementation and evaluation research in country

Be an optimist optimalist. optimalist.

Closing the Cancer Divide:

A Blueprint to Expand Access in LMICs A Repot of the Global Task Force on Expanded Access to Cancer Care and Control (GTF.CCC)
available in:

gtfccc.harvard.edu