Cancer and children: Strategy in Action NCD Child Conference Oakland CA, March 21st

Felicia Marie Knaul

Harvard 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

From anecdote
to evidence

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:

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

Challenge and disprove the myths about cancer/NCD/Chronic illness

Expanding access to cancer care and control in low and middle income countries: M1. Unnecessary M2. Unaffordable M3. Impossible M4: Inappropriate Should, Could, and Can.. be done

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

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
More than 85% of pediatric cancer cases and 95% of deaths occur in developing countries that use less than 5% of the world resources.

Distribution of mortality, 1-15 years Mexico, 1979-2008

1-4
40%

5-14
40%

30%

30%

20%

20%

Malignant tumors 16%

10%

10%

5% 1979 2008
Injuties Congenital anomalies
0%

1979

Malignant tumors Infectious and parasitic diseases Respiratory infections

2008

0%

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

100%

Children

Adults Survival inequality gap

Leukaemia

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%.

Chronic diseases and Stigma: disability add a layer of discrimination onto ethnicity, poverty, and gender.

The most insidious example of injustice is access to pain control

Non-methadone, Morphine Equivalent opioid consumption per death from HIV or cancer in pain Poorest 10%: 54 mg; Richest 10%: 97,400 mg

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 many other diseases Promoting access to education for children w CI
Reduces poverty, contributes to social development

Introducing child cancer treatment

Improves hygiene and reduce intra-hospital infections

Social insurance for children

Kick-starts broader social insurance for populations

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. We Cannot Afford Not To

Health is an investment, not a cost Tobacco is a huge economic risk:
3.6% lower GDP

Prevention and treatment offers potential world savings of $ US 131-850 billion mostly due to productivity gains and reducing suffering

Avoidable childhood cancer deaths from Leukemia by income region

Income Region Low income Lower middle income Upper middle income High income Lethality 0.73 0.72 0.57 0.18 Avoidable deaths
Social justice/3

0.45 0.38 0.35 0.08

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 chemo ALL(0-14) Afr, LAC, ASIA year of incident cases: $17m, $29m, $63m Pain medication is cheap Prices drop:
HPV 2011: $US 100 /dose to GAVI $5 and PAHO $14

Regional and Global Financing: potential

Leverage integrated, innovative, scalable financing mechanisms - Global Fund and GAVI NRMNCH platforms provide models for
broad-based international partnership Commitment-based funding aggregation

Diagonal partnership initiatives - pink ribbon red ribbon Aggregate purchasing and sustainable procurement through existing funds and platforms
UNICEF PAHO

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:
Nobel Amartya Sen,
Cancer survivor diagnosed in India 50 years ago, age 18

Abish Romeo
Patient, 24 years old
Advocate, Tmatelo a Pecho

CCs child champions:

Successes treating other diseases:

MDR-TB treatment
WHO 1997, Multidrug-resistant tuberculosis is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible disease.
Outcomes in MDR-TB patients in Lima, Peru receiving at least 4 months of therapy
failed therapy died 8% 8%

abandon therapy 2%

cured 83%

Mitnick et al, Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.

Source: Paul Farmer., 2009

Pediatric cancer innovations and lessons

Delivery Severely resource-constrained settings: PIH-DFCI-BWH St Judes IOP Survivorship: Sigamos Aprendiendo en el Hospital Financial protection/insurance: Mexico

Rural Rwanda: 0 oncologist

Burkitts lymphoma

Embryonal Rhabdomyosarcoma

Source: Paul Farmer., 2009

St. Jude International Outreach Program

20 countries including Mexico and Jordan
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 increased from 29% to 70% Cure4Kids Over 24,000 users in more than 175 countres

Survivorship care through education

MOH+MOE 65 Sigamos Aprendiendo classrooms in 23 states the majority of tertiary level hospitals

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, Taiwan Rwanda, Kenya

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 then all children and newborns for almost everything 2007: Breast cancer 2011: Testicular cancer, prostate and NHL

A diagonal approach to social insurance and childhood cancers

Horizontal Coverage: Beneficiaries

Annual spending on children through Seguro Popular

ENROLLMENT
6

RESOURCES INVESTED
5.8
100 Millions of $US Dollars 91.5

102.6

Millions of children enrolled

80.9
75 54.0 50

4.3
4

3.0
2

1.9 0.8

25

12.0 2008 2009 2010 2011

0 2007 2008 2009 2010 2011

2007

Source: Comisin Nacional de Proteccin Social en Salud. Informes de Resultados. Available at: http://www.seguro-popular.gob.mx

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

Cancer: so much can be done for so many.

Making this happen: CHILDREN and Lessons from pediatric cancer can guide work on adult cancer and chronic illness, and on health system strengthening

Be an optimist optimalist.

Horizontal and vertical financial protection strategies: Seguro Popular and SSPH for Children, Mexico
Benefits: covered interventions
Catastrophic Illness ACCELERATED VERTICAL COVERAGE: Ex: childrens cancer, neonatal care, HIV/AIDS

Package of essential personal services

Insurance for a new generation Community Health Services eg nutrition and vaccinations

Poor

Beneficiaries: Population covered

Rich