Universal Health Coverage and the

Challenge of Responding to Chronic Illness:

a case study of Mexico and breast cancer

Global Health Ethics, Politics, and Economics Yale University Guest Lecture, March 5, 2013
Felicia Marie Knaul, PhD
Harvard Global Equity Initiative, Global Task Force on Expanded Access to Cancer Care and Control in LMICs Tmatelo a Pecho A:C. Mxico Mexican Health Foundation

From anecdote
to evidence

January, 2008 June, 2007

Battling sepsis in the Mdica Sur Hospital. Mexico City. July 2008

Juanita:
Advanced metastatic breast cancer is the result of a series of missed opportunities

Launching a program at the Mexican Health Foundation the day I got sepsis. July 2008.

From anecdote

to evidence

GTF.CCC
Members

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

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

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..

The Cancer Transition

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.

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.

The cancer transition in LMICs: breast and cervical cancer

LMICs account for >90% of cervical cancer deaths and >60% of breast cancer deaths. Both diseases are leading killers especially of young women.
Mortality from breast and cervical cancer in Mxico 1955-2010

16 12 8

Mama
4

Cervix
19 19
19 19 19 19 19 19 19 20 20 20

Mortalidad de cncer de mama y cervical en Mxico 1979-2010

30 25 20 15 10 5 0

Nuevo Len

Cncer de mama Cncer de crvix

Tasa por 100,000 mujeres ajustado por edad

1980 1980

1979

1980 1985

1990 1990

1995 1980

2000 2000

1980 2005

2010 2010

30 25 20 15 10 5 0

Oaxaca

1980 1980

1979

1985 1980

1990

1995 1980

2000 2000

2005 1980

Source: Knaul et al., 2008. Reproductive Health Matters, and updated by Knaul, Arreola-Ornelas and Mndez.

2010 2010

1990

The Cancer Divide: disparities in

outcomes between poor and rich directly related to inequities in access and differences in underlying socio- economic and health conditions.

The divide is the result of concentrating risk factors, preventable disease, suffering, impoverishment from ill health and death among poor populations.
fueled by progress in cutting-edge science and medicine in high-income countries.

The Cancer Divide: An Equity Imperative

Cancer is a disease of both rich and poor; yet it is increasingly the poor who suffer:
1. 2. 3. 4. 5. Exposure to risk factors Preventable cancers (infection) Treatable cancer death and disability Stigma and discrimination Avoidable pain and suffering

Facets

Facet 3: The Opportunity to Survive Should Not, but Is 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%.

Facet 4: Stigma:

Cancer especially in women and children - adds a layer of discrimination onto ethnicity, poverty, and gender.

Facet 5: The most insidious injustice is lack of access to pain control

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

Challenge and disprove the myths about cancer

M1. Unnecessary NECESSARY M2. Unaffordable: .for the poor M3. Inappropriate: either/or Challenging cancer implies taking resources away from other diseases of the poor M4: Impossible

Investing In CCC: We Cannot Afford Not To

Inaction reduces efficacy of health and social investments Total economic cost of cancer, 2010: 2-4% of global GDP Tobacco is a huge economic risk: 3.6% lower 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

The costs to close the cancer divide may be less than many fear:
All but 3 of 29 LMIC priority cancer chemo and hormonal agents are off-patent Cost of drug treatment: cervical cancer + HL + ALL(kids) in LMICs / year of incident cases: $US 280 m Pain medication is cheap Prices drop: HepB and HPV vaccines Delivery & financing innovations are underutilized & undeveloped: purchasing fragmented, procurement unstable

Challenge and disprove the myths about cancer

M1. Unnecessary NECESSARY M2. Unaffordable: .for the poor M3. Inappropriate: either/or Challenging cancer implies taking resources away from other diseases of the poor M4: Impossible

Women and mothers in LMICs face many risks through the life cycle Women 15-59, annual deaths
- 35% in 30 years
Mortality in childbirth Breast cancer Cervical cancer Diabetes

342,900

166,577

142,744

120,889

= 430, 210 deaths

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

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 diseasespecific priorities while addressing systemic gaps and optimize available resources Diagonal strategies: X = > parts
Bridge disease divides: patients suffer over a lifetime, most of it chronic. Generate positive externalities

Diagonal Strategies: Positive Externalities

Promoting prevention and healthy lifestyles: Reduce risk for cancer and many other diseases Reducing stigma around womens cancers: Contributes to reducing gender discrimination Promoting access to education for children w/ cancer Reduces poverty, contributes to social development Pain control and palliation Reducing barriers to access is essential for cancer as well as for for other diseases and for surgery.

Challenge and disprove the myths about cancer

M1. Unnecessary M2. Unaffordable M3. Inappropriate M4: Impossible

Initial views on MDR-TB treatment, c. 1996-97

MDR-TB is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible disease. WHO 1997

Outcomes in MDR-TB patients in Lima, Peru receiving at least four months of therapy
Failed therapy Abandon 8%
therapy 2%
Died 8%

Cured 83%

All patients initiated therapy between Aug 96 and Feb 99

Champions
Drew G. Faust
President of Harvard University 22+ year BC survivor

Nobel Amartya Sen,

Cancer survivor diagnosed in India 50 years ago

Harvard, Breast Cancer in Developing Countries, Nov 4, `09

Rural Rwanda: 0 oncologist

Burkitts lymphoma

Embryonal Rhabdomyosarcoma

Source: Paul Farmer., 2009

St. Judes International Outreach Program

Twinning in 20+ countries
El Salvador: 5-year survival for children with ALL increased from 10% to 60% in five years Cure4Kids/Oncopedia Over 31,000 users in more than 183 countries

Mxico: IT IS POSSIBLE

Diagonalizing Financing:
Integrate cancer care and control into national insurance and social security programs to express previously suppressed demand beginning with cancers of women and children:

Mexico, Colombia, Dom Rep, Peru China, India, Thailand Rwanda, Ghana, South Africa

Universal Health Coverage in Mexico through Seguro Popular

Expanded Benefit Package

Vertical Coverage Diseases and Interventions:

Horizontal Coverage:

> 54.6 million Beneficiaries

Evolution of vertical coverage: cumulative # of covered interventions, 2004-2012

500 450
MING

CAUSES 284 FPCHE 57

131

400

FPCHE EPHS
108 110 49 17 20 49 116

128

128

MING + SP

Number of interventions

350
EPI

300 250 200 150 100 50

6 22 6 63

CBP

49

57

57

FPCHE 57 interventions

CAUSES 91 FPCHE 6
6 83 6 65 8 65 6 65 12 65 12 65 176 184 189 189

198

198

206

Seguro Popular 284 interventions

12 65

12 65

13 65

0
Notes:

2004

2005

2006

2007

2008

2009

2010

2011

2012

SP = Seguro Popular MING = Medical Insurance for a New Generation (Children born after December 1, 2006 and until they are 5 years of age) FPCHE = Fung for Protection against Catastrophic Health Expenditure EPHS =Essential Personal Health Services EPI = Expanded Programme of Immunisations CBP= Community-based package

Seguro Popular:
Cancer and the Fund for Protection from Catastrophic Illness Accelerated, universal, vertical coverage by disease with an effective package of interventions 2004: HIV/AIDS 2005: cervical cancer 2006: ALL in children 2007: All pediatric cancers; Breast cancer 2011: Testicular and Prostate cancer and NHL 2012: Ovarian (colorectal) cancer

Seguro Popular and cancer: Evidence of impact

Access to medicines an anecdote Since the incorporation of childhood cancers into the Seguro Popular
Adherence to treatment: 70% to 95%

Breast cancer adherence to treatment:

2005: 200/600 2010: 10/900

Delivery failure: Breast Cancer

# 2 killer of women 30-54 Only 5-10% of cases in Mexico are detected in Stage 1 or in situ Poor municipalites: 50% Stage 4; 5x rich
% diagnosed in Stage 4 by state

Juanita

Poor/Marginalized

Effective financial coverage: breast cancer in Mexico

Primary prevention Secondary prevention (early detection) Diagnosis Treatment Survivorship care Palliative care

Large and exemplary investment in treatment for women and the health system, yet a low survival rate. By applying a diagonal approach, this can and is being remedied.

Responding to the challenge of chronicity: Health system functions by care continuum

Stage of Chronic Disease Life Cycle /components CCC Health System Functions
Primary Prevention Secondary prevention Survivorship/ Rehabilitation Palliation/ End-of-life care

Diagnosis

Treatment

Stewardship

Financing

Delivery

Resource Generation

Horizontal and vertical financial protection strategies:

Seguro Popular in Mexico

Benefits: covered interventions
ACCELERATED VERTICAL COVERAGE for Catastrophic Illnesses included in the Fund: breast cancer, AIDS Prevention, Early detection

Survivorship

Package of essential personal services

CHILDREN: Health insurance for a New Generation Community and Public Health Services

Poor Beneficiaries

Rich

Solution: Diagonalizing Delivery

Harness platforms by integrating breast and cervical cancer prevention, screening and survivorship care into MCH, SRH, HIV/AIDS, social welfare and anti-poverty programs.

Including breast cancer awareness for early detection in Oportunidades

Gua de orientacin y capacitacin a titulares beneficiarios del programa Oportunidades includes information on breast cancer as of 2009/10 1.5 million copies to promoters Reaches 5.8 million families = more than 90% of poor households

Solution: Diagonalizing Delivery

Harnessing the primary level of care

Results: 000s promoters, nurses, doctors

Survivorship care incipient

Pain and Palliation

Where are the opportunities?

LMICs not months but whole lifetimes to be gained Focus on prevention but do not stop there!
No prevent/treat dichotomization

Do not take prices as fixed or given price permeability Harness global and national health system platforms Innovate in implementation, delivery and financing
Evaluate, replicate and scale up Leapfrog and give forward

Redefine and reformulate health systems to manage chronicity Harness cancer to strengthen health and social systems Recognize LMICs as part of a global solution:

investment in learning, research and human beings

Be an optimist optimalist

Expanding access to cancer care and control in LMICs: Should, Could, and Can be done