Download - Framing Priorities in Global Health 040411
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Felicia Marie Knaul,Harvard Global Equity Initiative, Harvard Medical School;Global Task Force on Expanded Access to Cancer Careand Control in Developing Countries;
Tomatelo a Pecho; Fundacin Mexicana para la Salud
GLOBAL HEALTHDELIVERY:
Challenges andOpportunities for
AdvancingExcellence and
Equity
Harvard Medical School
April 4th, 2011Boston, MA
Closing the cancer
divide:an equity imperative
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Mandate: Design, develop andimplement global, regional andlocal strategies to improve thefinancing, procurement anddelivery of cancer care,control, treatment and
palliation in a sustainablemanner applying innovativeservice delivery modelsappropriate to health systems
in the developing world.
Convened in Nov 2009
By HSPH, HMS, HGEI, DFCI
Co-Chaired: L Shulman, J Frenk
28 membersrepresenting theglobal health andcancer
communities
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White Paper for policy and strategy &Lancet Commission Report
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Challenge and disprove themyths about cancer/NCD
M1. Unnecessary:
Not a health priority in LMICs/not a problem
of the poorM2. Impossible:
Nothing we can do about it
M3. Unaffordable: .for the poor
M4: Inappropriate: either/or
Challenging cancer implies taking resourcesaway from other diseases of the poor`
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More than 85% of pediatric cancer cases and 95% of deathsoccur in developing countries that use less than 5% of the
world resources.
Level ofIncome
Incidence Mortality Population
Low 21% 27% 20%
Low middle 50% 55% 57%
Upper middle 15% 15% 13%
High 15% 5% 10%
Distribution of childhood cancer globallyby level of income (< 15)
For children & adolescents 5-14 cancer is#2 cause of death in wealthy countries
#3 in upper middle-income#4 in lower middle-income
and # 8 in low-income countries
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The opportunity to survive should not be an accident of geography or definedby income.
Yet it is.But . there is scope for action.
Source: Author estimates based on IARC, Globocan, 2008 and 2010.Quote: HRH Princess Dina Mired
0
0.2
0.4
0.6
0.8
Low incomecountries
Lower middleincome
Upper middleincome
High incomecountries
All cancers, < 15
~casefatality(mo
rtality/inciden
ce)
Leukaemia,
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Cancer is a disease of rich and poor
Yet, transition is polarizing the burden so that itis increasingly the poor who suffer:
Incidence and death: preventable cancers
Death: treatable cancer
Avoidable pain and suffering particularly at end oflife
Financial impoverishment from the costs of care andeffects of the disease
The cancer divide
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IT CAN BE DONE: From evidence to action:
Treating cancer in LMICs usinginnovative delivery and financing: Resourceful tasking Infrastructure shifting Application of technology of
communication Social Protection and health insurance
Models: Low-income: Rwanda-Malawi-Haiti
Lower middle-income: Jordan
Upper middle-income: Mexico
ACCESS
QUALITY
FINANCIAL
PROTECTION
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Rural Rwanda: 0 (zero) oncologists
Source: Paul Farmer., 2009
Burkittslymphoma
EmbryonalRhabdomyosarcoma
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St. Jude International Outreach Program:Global Partnership Innovation Model
Institutional commitment: St. Jude Hospital dedicates a1-3% of their budget to International Outreach Program
Strategy: Partnership and twinning Evaluation and implementation research
15 + countries
El Salvador
5-year survival rate for children with ALL increased from 10%to 60% during the first five years of collaboration
Recife, Brazil
Since 1994, the cure rate for childhood cancers in increasedfrom 29% to 70%
Cure4Kids
Over 24,000 users in more than 175 countres
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Challenge and disprove themyths about cancer/NCD
M1. Unnecessary: NECESSARY
M2. Impossible:POSSIBLE
M3. Unaffordable: .for the poorM4: Inappropriate: either/or
Challenging cancer implies taking resourcesaway from other diseases of the poor`
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`5/80 cancer disequilibrium(Frenk/Lancet 2010)
Almost 80% of the DALYs (disability-adjusted life-years) lost worldwide tocancer are in LMICs, yet these countries
have only a very small share of globalresources for cancer ~ 5% or less.
Worse in certain regions:
Africa: only 02% of global cancer medicalcosts, 1% of global spending on health, 64%of new cancer cases, and 15% of the globalpopulation
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Source: Paul Farmer, 2009
Drug% Decline in price 1997-
9
Amikacin 90%
Ethionamide 84%
Capreomycin 97%
Ofloxacin 98%
Reduced prices of second-line TB drugs
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Key Elements
Mexico 2003 Reform:
1. Access to publicly-funded, heavily subsidized,progressive health insuranceSeguro Popular - forall families excluded from Social Security
2. Separate budgeting and funds for public healthgoods with universal coverage
3. Package of personal health services based on cost-effectiveness and burden of disease expands over
time4. Fund for Catastrophic Illness covering specific
interventions for specific diseases expands overtime
Seguro Popular:
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Seguro Popular:A diagonal approach to financial protection
Horizontal Coverage:Beneficiaries
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Mexico Popular Health Insurance:Fund for catastrophic illness Accelerated universal vertical coverage by
disease with a specified package ofinterventions
2004/5: ALL in children, cervical, HIV/AIDS 2006: all pediatric cancers
2007: breast
2011: testicular and NHL Significant reduction in abandonment of
treatment
Yet, likely variation in outcomes
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Challenge and disprove themyths about cancer/NCD
M1. Unnecessary: NECESSARY
M2. Impossible: POSSIBLE
M3. Unaffordable: .for the poorAFFORDABLEM4: Inappropriate: either/or
Challenging cancer implies taking resourcesaway from other diseases of the poor`
E i ti `C t i d t k f
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Chronic
Acute
Infectiousorigin/communicable
AIDS, Cervical cancer, TB,liver cancer, Chagas,
cardiopathy, rheumatic heartdisease, gastric cancer,
Infectious diarrhealdiseases, respiratory
infections
Non-Communicable
Most cancers, mostCVD, hypertension,diabetes, asthma,
mental illness
Acute myocardialinfarction
Existing `Categories do not work fordeveloping systemic solutions
P l t i k f
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Africa
LMICs
Maternal mortality
207,000
355,000
Breast andcervicalcancer
79,184
87,691
=143,778
772,728
478,640
=1,251,368
People are at risk for manyreasonsvictims of success?
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Vertical programs refer to targeted interventions, proactiveand disease-specific on a massive scale (HIV, maternal andchild health), while horizontal programs refer to moreintegrated health services corresponding to functions of thehealth systems, guided by demand and shared resources.
it has been discussed at length what the mosteffective approach is to deliver health interventions:vertical programs or horizontal programs. This is a falsedilemma, because both interventions need to coexist in
what could be called a diagonal approach
Seplveda et al., Aumento de la sobrevida enmenores de 5 aos: la estrategia diagonal
The diagonal approach tohealth system strengthening
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1. Financial protection/insurance strategies
with horizontal and vertical coverage2. Integrating breast and cervical cancer
screening into MCH, SRH3. Integrating disease prevention and
management into social welfare and anti-poverty programs
4. Catalyzing and employing community healthworkers and expert patients
5. Reducing non-price barriers to pain control6. Developing effective health services
research and monitoring
Diagonal approaches
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Global Health Governance and
Financing for NCDs of the poorest:Lessons from Expanding Access toCancer Care and Control in LMICs
Felicia Marie KnaulDirector, Harvard Global Equity Initiative
Secretariat, Global Task Force on Expanded Access to Cancer Care and Control inDeveloping Countries
Associate Professor, Harvard Medical School
Global Health Governance and Financing forEndemic NCDs
Boston MAMarch 3 2011