expanding accessto cancer care and control in lmics: lessons for health systems 051211

8/2/2019 Expanding accessto cancer care and control in LMICs: Lessons for health systems 051211

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From anecdote

to evidence


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January, 2008

June, 2007


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br

Juanita:


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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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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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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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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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Mirrors the overall epidemiological

transitionprotracted and polarized*:

LMICs increasingly face both cancersassociated with infection, as well as all

other cancers some of which have specific

risk factors.

Cancers that were once considered only of

the 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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Distribution of mortality, 1-15 years

Mexico, 1979-2008

Malignant tumors

Infectious and parasitic diseases

Respiratory infections

Source: Estimates based on data from the Ministry of Health, Mexico.

0

10%

20%

30%

40%

1979

1980

1985

1990

1995

2000

2005

2008

0

10%

20%

30%

40%

1979

1980

1985

1990

1995

2000

2005

2008


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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%.

A child with retinoblastoma in a high-income country can

ho e to reserve vision and life; in LMICs neither.


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The most insidious example of

injustice is access to pain controlThe gap in access to

pain control is

tremendous: ranging

from 54 milligrams perdeath in pain from

HIV/AIDS or cancer in

the poorest decile toalmost 97,400 in the

richest decile of the

worlds countries.

y = 1.6618x - 5288.3

R = 0.3442

0

50000

100000

150000

200000

250000

300000

$0 $10,000$20,000$30,000$40,000$50,000$60,000$70,000$80,000$90,000

Non-methado

neopioidconsumptionpercap

ita(mg)

GNI per capita (PPP 2008)

UAE QATAR

USACAN

Non-methadone opioid consumption(morphine-equivalents) Per death from HIV

or cancer in pain by income level

Austria

Germany

Norway

SingaporeKuwait

Source: Estimates based on GAPRI methodology available athttp://www.treatthepain.com/methodology

and World Development Indicators of the World Bank.
http://www.treatthepain.com/methodologyhttp://www.treatthepain.com/methodology


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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


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A) Should be done:

B) Could be done:

C) Can be done

Myth 1. Unnecessary

Myth 2. Inappropriate


Myth 4: Impossible



W d th i LMIC


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Women and mothers in LMICs

face many risks through the life cycle

Women 15-59, annual deaths

Diabetes

120,889

Mortality

in

childbirth

Breast

cancer

342,900 166,577

Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et a Lancet 2011.

Cervical

cancer

142,744

- 35%

in 30

years

= 430, 210 deaths


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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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Health Systems Strengthening:

Opportunities for Diagonal Strategies

Preventionhealthy lifestyles:

Nutrition and diet, Tobacco

Survivorship care:Reduce stigma: also associated with gender

and ethnicity.

Pain control and palliationReducing barriers to access is essential for

cancer, for other diseases, and for surgery.


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Delivery: Harness platforms by

integrating cancer prevention,

screening and survivorship into

MCH, SRH, HIV/AIDs, social

welfare/anti-poverty programs.

Diagonal Strategies

E di


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A) Should be done: necessary

and appropriate

B) Could be done:

C) Can be done


Myth 4: Impossible




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Investing In CCC:

We Cannot Afford Not To

Health is an investment, not a cost

Tobacco is a huge economic risk: 3.6% lower GPD

Total economic cost of cancer, 2010: 2-4% of global GDPPrevention 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 millions deaths,

80% in LIMCs

I ti 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 available for

under $100 per courseCost of drug treatments for cervical cancer, HL, and

ALL in children in LMICs per year ofincident cases

is $US 280 millionPrices drop: HPV 2011: $US 100 per dose to PAHO $14

and GAVI $5

Pain medication is cheap


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A) Should be done: necessary

and appropriateB) Could be done: affordable

C) Can be doneMyth 4: Impossible




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S t ti th di


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Successes treating other diseases:MDR-TB treatment

Source: Paul Farmer. 2009

cured

83%

abandon

therapy

2%

failed

therapy

8%

died

8%

Mitnick et al, Community-based therapy for multidrug-resistant tuberculosis in

Lima, Peru. NEJM 2003; 348(2): 119-28.

Outcomes in MDR-TB patients in Lima,

Peru receiving at least 4 months of therapy

WHO 1997, Multidrug-resistant

tuberculosis is too expensive to treat in poor

countries; it detracts attention and resources

from treating drug-susceptible disease.

M i i l


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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)

Mexico: cervical cancer.

0

4

8

12

16

1955 1965

1975

1985

1995

2005

Delivery innovations and models:


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Delivery innovations and models:

Global PartnershipSt. Jude International Outreach Program

Strategy:

ICT for education + teleoncology + twinning

Institutional commitment: 1-3% of budget15-20 countries

Evaluation and implementation research

El Salvador: 5-year survival rate for ALL

increased from 10% to 60% in first five

years of collaboration


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Delivery innovation:Harnessing the primary level to improve BC

detection and care, Mexico

Fi i i ti


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Financing innovations:

Domestic

Several countries have integrated CCC into

national insurance programs and are expressing

previously suppressed demand:Mexico

Colombia

Dominican Republic

PeruChina

India

Rwanda

Taiwan


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Seguro Popular and cancer:

Evidence of impact

Since the incorporation of childhoodcancers into the Seguro Popular

30-month survival: 30% to almost 70%adherence to treatment: 70% to 95%.

Breast cancer adherence to treatment:

2005: 200/6002010: 10/900

Access to medicinesan anecdote


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Addressing NCDs in LMICs:

Shared advocacy to achieve stronger healthsystems

Common implementation platforms

Multi-stakeholder alliances in-country

Commitment-based funding models

Common goals

Measure progress: evidence and metrics

= social justice + efficiency


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Be an

optimistoptimalist.

expanding accessto cancer care and control in lmics: lessons for health systems 051211

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