Strengthening Health Systems:

Learning from Cancer

Hong Kong Academy of Medicine

March 12, 2015
Dr. Julio Frenk
Dra. Felicia Marie Knaul
Harvard School of Public Health Harvard Global Equity Initiative
and Harvard Medical School
Fundacin Mexicana para la Salud y
Tmatelo a Pecho

Duality:
evidence and advocacy
Evidence-based
advocacy

Advocacyinspired evidence

Action:
projects, programs, policies

From anecdote

to evidence

GTF.CCC
=
global health

+
cancer care

Closing the Cancer Divide:

An Equity Imperative
Expanding access to cancer care and control in LMICs:
M1. Unnecessary
M2. Unaffordable
M3: Inappropriate
M4. Impossible

I: Should be done
II: Could be done
III: Can be done

1: Innovative Delivery
2: Access: Affordable Meds, Vaccines & Techs
3: Innovative Financing: Domestic and Global
4: Evidence for Decision-Making
5: Stewardship and Leadership

Closing the Cancer Divide:

A BLUEPRINT TO EXPAND ACCESS IN LMICs

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

Women and mothers in LMICs

face many risks through the life cycle
Women 15-59, annual deaths
- 35%
in 30
years

Mortality
in
childbirth

291,000

Breast
cancer

Cervical
cancer

150,000195,000

105,000131,000

Diabetes

110,000139,000

= 373,000 465,000
Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.

The Cancer Transition

Double burden for health systems
Mirrors the epidemiological transition
LMICs increasingly face both infectionassociated cancers, and all other cancers.
Cancers increasingly only of the poor, are
not the only cancers affecting the poor
LMICs account for >90% of cervical and 70%
of breast cancer deaths. Both are leading killers
especially of young - women.

The Cancer Divide:

An Equity Imperative

Facets

Cancer is a disease of both rich and poor;

yet it is increasingly the poor who suffer:
1.
2.
3.
4.
5.

Preventable cancers (infection)

Exposure to risk factors
Treatable cancer death and disability
Stigma and discrimination
Avoidable pain and suffering

The Opportunity to Survive (M/I)

Should Not Be Defined by Income!
100%

100%

Children
India
China

Breast
Cervix

India

Testis

China

Prostate
Tyroid

20%

Leukaemia

All cancers

LOW
INCOME

Canada
HIGH
INCOME

LOW
INCOME

Canada
HIGH
INCOME

In Canada, almost 90% of children with

leukemia survive.
In the poorest countries only 10% survive.

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

The most insidious injustice: The pain divide

Non-methadone, Morphine Equivalent opioid consumption
per death from HIV or cancer in pain:
Poorest 10%: 179 mg
Richest 10%: 99 mil mg
US/Canad: 344 mil mg
N. America

355,000 mg

Europe China: 1,593 mg

144,000
Malaysia: 6,476
Singapore: 7,292

333,000 mil mg

India:
467

Mexico
3,500

Africa
Latin America

Source: Estimaciones propias Knaul F.M. Arreola H, et.al.,

basado en datos de: Treat the pain and INBC
(http://www.treatthepain.com )

Challenge and disprove the

myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE

The costs to close the cancer divide

are less than many fear:
All but 3 of 29 LMIC priority cancer chemo
and hormonal agents are off-patent
Prices drop: HepB and HPV vaccines
Pain medication is cheap
Delivery & financing innovations can
aggregate & stabalise prices and procurement

The costs of inaction are huge:

Invest IN action
Tobacco is a huge economic risk: 3.6% lower GDP
Total economic cost of cancer, 2010: 2-4% global GDP

1/3-1/2 of cancer deaths are avoidable:

2.4-3.7 million deaths,
of which 80% are in LIMCs

Prevention and treatment offers

potential world savings of
$ US 130-940 billion

Champions the economics of hope:

Drew G. Faust
President of Harvard
University 25+ year BC
survivor

Nobel Amartya Sen,

Cancer survivor diagnosed in
India 60 years ago

Challenge and disprove the

myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE
M3. InappropriateAPPROPRIATE

Worldwive wave of reforms to

achieve UHC
Universal Health Coverage:
all people should obtain needed
health services
prevention, promotion, treatment,
rehabilitation, and palliative care
without risking economic hardship or
impoverishment (WHO, WHR 2013).

An effectiveUHC response to chronic illness

must integrate interventions along the
Continuum of disease:
1.
2.
3.
4.
5.
6.

Primary prevention
Early detection
Diagnosis
Treatment
Survivorship
Palliative care

.As well to each

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

eUHC requires an integrated response along the

continuum of care and within each
core health system function
Stage of Chronic Disease Life Cycle: components of cancer care
Health System
Functions

Stewardship

Financing

Delivery

Resource
Generation

Primary
Prevention

Secondary
prevention

Diagnosis

Treatment

Survivorship/
Rehabilitation

Palliation/
End-of-life care

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

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.

Diagonalizing Cancer Care:

Financing, Delivery & Evidence
1.

2.

3.

Financing: Integrate cancer care into national

social insurance and social security programs
and reforms, e.g. Mexico and China
Delivery: Integrate
cancer
prevention,
survivorship and palliative care into existing
primary care platforms, e.g. Maternal and Child
Health, HIV/AIDS, and anti-poverty programs.
Evidence-building: use an inter-disciplinary
approach to link health systems and global
health experts and palliative care experts

Challenge and disprove the

myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE
M3. Inappropriate APPROPRIATE
M4: Impossible
POSSIBLE

Expansion of Financial Coverage:

Seguro Popular Mxico
Affiliation:

Benefit package:
2004: 113

2014: 285
59 in the
Catastrophic
Illness Fund

Benefits Package

2014: 55.6 m

Vertical Coverage
Diseases and Interventions:

2004: 6.5 m

Horizontal Coverage:

Beneficiaries

Seguro Popular now includes

cancers in the national,
catastrophic illness fund
Universal coverage by disease with an effective
package of interventions
2004/6: HIV/AIDS, cervical, ALL in children
2007: pediatric cancers; breast
2011: Testicular, Prostate and NHL
2013: Ovarian and colorectal

Seguro Popular and breast cancer:

Evidence of impact
National Institute
of Cancer:
treatment
adherence
2005: 200/600
2010: 10/900

The human faces:

Guillermina Avila

Diagonalizing Delivery Innovation 1:

Integration of cervical & breast cancer
education into anti-poverty programs,
Oportunidades
Include information in
manuals for community
workers
1.5 million promoters
> 90% of poor Mexican
households: 5.8 million
families

Diagonalizing Delivery 2:
Training primary care providers in
early detection of breast cancer

(Keating, Knaul et al 2014, The Oncologist)

Significant increase in
knowledge, especially in
clinical breast examination

Health Promoters
Risk Score (0-10)

6
5
4
3
Pre

Post

3-6 month

Breast cancer awareness and

education materials for use in China

Brochure for use

with rural women

Working manual for local

ACWF community outreach
workers

HGEI-Lancet Commission on Global Access to Pain

Control and Palliative Care

=
Global
Health and
Health
Systems

Palliative
care
specialists

Goal:
Alleviate Avoidable
Pain & Suffering
Inaugural meeting of the Commission held September 22-23, 2014, in New York City Lancet Office

Be an
optimist
optimalist