“case study: strategy in action; mexico, universal health coverage; and what’s posible!”
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Cancer and children:
Strategy in Action
NCD Child Conference
Oakland CA, March 21st
Felicia Marie KnaulHarvard Global Equity Initiative,
Global Task Force on Expanded Access to Cancer Care and
Control in Low and Middle Income Countries
Mexican Health Foundation
Tmatelo a pecho
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From anecdote
to evidence
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Global Task Force on Expanded
Access to Cancer Care and
Control in Developing Countries
= global health + cancer care
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Closing the Cancer Divide:A Blueprint to Expand Access in LMICs
I: Much should be doneII: Much could be done
III: Much can be done
1: Innovative Delivery
2: Access to Affordable Medicines,
Vaccines & Technologies
3: Innovative Financing: Domesticand Global
4: Evidence for Decision-Making
5: Stewardship and Leadership
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Applies a diagonal
approach to avoid
the false dilemmasbetween disease silos
-CD/NCD- thatcontinue to plague
global health
Closing the Cancer Divide:A BLUEPRINT TO EXPAND ACCESS IN LMICs
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Challenge and disprove the
myths about
cancer/NCD/Chronic illness
M1. Unnecessary
M2. Unaffordable
M3. Impossible
M4: Inappropriate
Should,
Could, and
Can..
be done
Expanding access to cancer care and control in
low and middle income countries:
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Mirrors the overall epidemiological
transitionprotracted and polarized*:
LMICs increasingly face both cancersassociated with infection, and all other
cancers.
Cancers that were once considered only ofthe poor, now cease to be the only cancers
of the poor. (e.g. cervical & breast cancer)
The Cancer Transition
* Frenk et al
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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 fromtreatable cancer
4. Stigma and discrimination
5. Avoidable pain and suffering
The Cancer Divide:
An Equity Imperative
Fac
ets
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Top 10 causes of Mortality in children
under 15 years by income regions
Communicable, maternal, perinatal and nutritional conditions
Noncommunicable diseases
InjuriesSource: Own estimates based on data from WHO, Global Health observatory.
Low Lower middle Upper middleInfectious and parasitic dis. Perinatal conditions Perinatal conditions
Perinatal conditions Infectious and parasitic dis. Infectious and parasitic dis.Respiratory infections Unintentional injuries Congenital anomaliesUnintentional injuries Respiratory infections Unintentional injuriesCongenital anomalies Congenital anomalies Respiratory infections
Nutritional deficiencies Digestive dis. Malignant neoplasmCardiovascular dis. Nutritional deficiencies Respiratory dis.
Digestive dis. Cardiovascular dis. Nutritional deficienciesNeuropsychiatric
conditionsMalignant neoplasm Neuropsychiatric conditions
Malignant neoplasm Endocrine disorders Cardiovascular dis.
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Distribution of mortality, 1-15
years Mexico, 1979-2008
Malignant tumors
Respiratory infections
Infectious and parasitic diseases
Injuties
Congenital anomalies
0%
10%
20%
30%
40%
1979
2008
1-4
0%
10%
20%
30%
40%
1979
2008
5-14
Malignant tumors
5%
16%
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Adults
Leukaemia
All cancers
Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.
Children
LOW
INCOME
HIGH
INCOME
Sur
vival
inequa
litygap
LOW
INCOME
HIGH
INCOME
100%
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%.
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Stigma:Chronic diseases and
disability add a layer of
discrimination onto ethnicity,
poverty, and gender.
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The most insidious example of
injustice is access to pain controlNon-methadone, Morphine
Equivalent opioid consumption per
death from HIV or cancer in pain
Poorest 10%: 54 mg;
Richest 10%: 97,400 mg
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A) Should be done:
B) Could be done:
C) Can be done
Myth 1. Unnecessary
Myth 2. Inappropriate
Myth 3. Unaffordable
Myth 4: Impossible
Expanding access to cancer
care and control in LMICs:
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The Diagonal Approach to
Health System Strengthening
Rather than focusing on disease-specific vertical
programs or only on horizontal system
constraints, harness synergies that provideopportunities to tackle disease-specific priorities
while addressing systemic gaps.
Optimize available resources so that the whole ismore than the sum of the parts.
Bridge the divide as patients suffer diseases over a
lifetime, most of it chronic.
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Diagonal Strategies:
Positive ExternalitiesPromoting prevention and healthy lifestyles:
Reduce risk for cancer and many other diseases
Promoting access to education for children w CI
Reduces poverty, contributes to social developmentIntroducing child cancer treatment
Improves hygiene and reduce intra-hospital infections
Social insurance for childrenKick-starts broader social insurance for populations
Pain control and palliation
Reducing barriers to access is essential for cancer, for
other diseases, and for surgery.
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A) Should be done: necessary
and appropriate
B) Could be done:
C) Can be done
Myth 3. Unaffordable
Myth 4: Impossible
Expanding access to cancer
care and control in LMICs:
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Investing in.
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
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Avoidable childhood cancer deaths
from Leukemia by income region
Income Region LethalityAvoidable deaths
Social justice/3
Low income 0.73 0.45
Lower middleincome
0.72 0.38
Upper middle
income0.57 0.35
High income 0.18 0.08
1/3-1/2 of cancer deaths are avoidable:
2.4-3.7 million deaths
Of which 80% are in LIMCs
I i I CCC
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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