Global Health Challenges

Shifting Horizons,
Princess Margaret Cancer Centre:
1995-2015-2035
Toronto ON,
December 1, 2015

Dr. Felicia Marie Knaul

Miami Institute for the Americas and Miller School of Medicine,
University of Miami

We have come a long way

& we now face tougher
health challenges.
Yet, with new resources at
our disposal
if we are open to
innovation and hope

Outline

1. The promise of progress:

health at the forefront
2. Victims of our success
3. New horizons
1. Healthy economies
2. Women and health: motor of the future
3. Effective Universal Health Coverage (eUHC)

4. What can global health do for CCC?

5. What can cancer and CCC do for global health?

Improvements in global health

have redefined our world
Imagine
A world without insulin
A world with polio.

Polio: vaccine 1953

Global poliovirus cases, 1985 through 2014.

Under 5 mortality
1950: 28/100
1990: <10/100,
2011: 5/100

Stephen L. Cochi et al. J Infect Dis. 2014;210:S1-S4

Published by Oxford University Press on behalf of the Infectious Diseases Society of America
2014. This work is written by (a) US Government employee(s) and is in the public domain in the
US

Life expectancy and income per

capita for select countries period
Life expectancy (years)

80

70

60

50

40

30

5000

10000
15000
20000
Income per capita
(1991 international dollars)

25000

Longest female life expectancy at birth (years)

Female life expectancy at birth for selected

countries compared with the frontier

1990 to 2010:
maternal deaths fell
546 000 to 287 000
Year

The frontier line indicates female life expectancy in the best-performing country in that year, which has been Japan for the past 20
years. Data from references 36 and 37 and Vallin J, Institut national dtudes dmographiques, personal communication.

Outline
1. The promise of progress: health at the forefront

2. Victims of our success

3. New horizons
1.
2.
3.
4.

Healthy economies
Women and health: motor of the future
Effective Universal Health Coverage (eUHC)
Measurement and transparency

4. What can global health do for CCC?

5. What can cancer do for global health?

Chronic & NCD dominate the disease burden

DALYs (%), women 15+, by cause-group and region

100%
80%

6%

9%

65%

64%

6%

4%

6%

32%

60%

% DALYs

6%

80%

71%
90%

40%
62%
20%

29%

27%

0%

Injuries

Non-communicable

Source: Estimates based on Global Burden od Disease Study, 2013. IHME, 2015.

14%

23%
6%

Communicable, maternal
and nutritional

Leading causes of death among women

aged 15 to 49 years, select LAC, 2010
Chile

Costa Rica

Mxico

Brasil

Haiti

Bolivia

Per

Panam

Fuente: Global Burden of Disease Study 2010. IHME, 2012.

What is maternal mortality for global health now?

competing risk 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.

 Latin American nations, much of eastern

Europe and central Asia, China, India, many
other parts of south Asia, and even countries in
Africa, [are] facing a painful double burden of
diseasenot only the persistence of infectious
threats, child and maternal mortality, and
undernutrition, but also the emergence of new
dangers, notably diabetes, obesity,
cardiovascular disease, stroke, cancer, mental illhealth, and injuries. This double burden requires
a double response, a predicament that places
huge responsibilities on the stewards of national
health systems.
JULIO FRENK & RICHARD HORTON
HEALTH REFORM IN MEXICO SERIES; THE LANCET, 2006

NCDs: Risk for global economy

World Economic Forum ( WEF ) classifies
NCDs (representing 2/3 of deaths
worldwide) one of the biggest risks for
global economic welfare.

Outline
1. The promise of progress: health at the forefront
2. Victims of success

3. New horizons
1. Healthy economies
2. Women and health: motor of the future
3. Effective Universal Health Coverage (eUHC)

4. What can global health do for CCC?

5. What can cancer do for global health?

Health is
an investment.
Not a cost

Macroeconomic
Impact of Health
Improvements in health and nutrition =
30% of GDP growth in UK from 1780-1979
1 year of LE = 1-4% of GDP growth
Reductions in adult mortality=11% of
economic growth in LMICs 19702000
24% of the increase in full income 19902011 was from years of life gained

The most efficient health systems are not

necessarily the most costly (OECD, 2007)

a
n
d
a
a
n
Ca
Jap

Life expectancy years

85

80

USA

75

70

65
0

1000

2000

3000

4000

Health spending PPP$

Fuente: Estimaciones propias con datos de OECD Health data 2005 para 2001.

5000

Women's Contributions
to Health and the Economy - the choice:
Do we aspire to a Virtuous or a Vicious Cycle?
Virtuous Cycle
Healthy women
invest time
effectively in
producing health
and preventing
disease
Healthy and more
education
women women
produce more
health care
More economic
growth means
more money to
invest in health
and human
development

More health is
produced for men,
women and children

Vicious Cycle
Unhealthy women
invest time ineffectively
in an attempt to prevent
disease and loss of life

Unhealthy, poor,
More equal
disenfranchised
opportunitie
women produce
s
Children learn
less health care
better and adults
are more
productive

More health and

education mean
more economic
growth

Less
health for
men,
women
and
children

Unhealthy children
learn less and
adults are less
productive
Suboptimal
development
of human
capital
Inequality of
opportunities

More
poverty

Less money to
invest in health
and human
development

Poor health and

less education
means reduced
economic growth

Outline
1. The promise of progress: health at the forefront
2. Victims of success

3. New horizons
1. Healthy economies

2. Women and health: motor of the future

3. Effective Universal Health Coverage (eUHC)

4. What can global health do for CCC?

5. What can cancer do for global health?

Average Years of Schooling for Women

0
Estonia

Ireland

UK

Germany

Hungary

Norway

Poland

Bulgaria

Netherlands

France

Romania

Spain

Greece

1950

Canada
Czech Republic

Source: Barro & Lee, 2014 (http://www.barrolee.com/data/yrsch.htm).

Cuba

South Africa

Argentina

Panama

Italy

Mexico

14

Peru

Uruguay

Portugal

China

Nicaragua

Turkey

India

Pakistan

Benin

Increased years of schooling for women

Ave years of education, Women 15 years+
2010

12

10

Economically Active Population growth rate in the period

0

Panama

Jamaica

Ecuador

United States

Argentina

Uruguay

Guyana

Canada

Men

Dominican Rep.

Source: ILO, 2013. ( http://www.ilo.org/ilostat/faces/home/statisticaldata/data_by_subject )

Paraguay

Trinidad & T.
El Salvador

Nicaragua

Colombia

300

Peru

Costa Rica

Guatemala

Honduras

Venezuela

Brazil

Mexico

Increased labor participation of women

(1970 - 2010)
Women
Average LAC

200

100

Medicine; a global phenomenon

Women as % of all physicians 1980-2012, select countries
50
Australia

40

Canada
Czech
Republi
c
Denmark

30

Israel

20

Portugal

United
Kingdom
United States

2012

2010

2005

2000

1995

Source: OECD Statistics.

1990

1985

10

1980

Women physicians as % of total physicians

60

Total value of women's

contributions to the health sector:
TOTAL:
US$ 3.1 TRILLION
4.8% Global GDP

PAID:
51.2%
UNPAID:
48.8%

2.4 times contribution of men (Men: 2%)

Each and every woman contributes
$1,200 to health annually
Exceeds total US+UK health budget

Yet, recognition and opportunities

for progress continue to be limited
Nobel Prizes Awarded to Women 1901 - 2014
Women (4.9%)
47

922

women/t
otal

Women

Men

No.

No.

1901 - 1920

101

4%

1921 - 1940

99

5%

1941 - 1960

113

4%

1961 - 1980

176

3%

1981 - 2000

11

286

4%

2001 - 2014

17

147

10%

Period

Mexico: the workweek

Men and women, based on a 168 hour week
Care giving

MEN

Work outside
of the home

20

R&R

WOMEN

Domestic work

12
hours/da
y
Source: Own estimates based on INEGI 2012 and CEPAL..

56

r?

&
t
s
e
R 6 /da
s
r
u
o
y
h

41

41

42

Women are
the motors of economic growth
and
produce the majority of health care
- paid & unpaid
Yet, health systems are disabling
instead of enabling to women

Outline
1. The promise of progress: health at the forefront
2. Victims of success

3. New horizons
1. Healthy economies
2. Women and health: motor of the future

3. Effective Universal Health Coverage

(eUHC)
4. What can global health do for CCC?
5. What can cancer do for global health?

Worldwive wave of reforms to

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

complex epidemiological transition, and

while battling fragmented health systems,

UHC requires
a strong, efficient, well-run health
system;
a system for financing health
services;
access to essential medicines and
technologies;
sufficient supply of well-trained,
motivated health workers.
(WHO, World Health Report, 2013).

An effective UHC 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 as through 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 CCC
Health System
Functions

Stewardship

Financing

Delivery
Resource
Generation and
evidence
buliding

Primary
Prevention

Secondary
prevention/
early
detection

Diagnosis

Treatment

Survivorship/
Rehabilitation

Palliation/
End-of-life care

Outline
1. The promise of progress: health at the forefront
2. Victims of success
3. New horizons
1. Healthy economies
2. Women and health: motor of the future
3. Effective Universal Health Coverage (eUHC)

4. What can global health do for cancer

care and control?
5. What can cancer and CCC do for global
health

Global Health Public Goods:

Lancet Global health 2035
Population, Policy, and Implementation Research
strengthen primary care services for delivery of
interventions
task shifting, family care, and self-care;
e-health prevention and treatment;
the use of health technology assessment and audit
Global metrics for transparency, monitoring and
evaluation
the evaluation of the health effects of public policies

Innovative intervention ideas: progressive

universalist pathway towards UHC

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 major benefits: X => parts
Avoid the false dilemmas between disease silos
that continue to plague global health;
Bridge disease divides using a life cycle response;
Generate positive externalities.

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 palliative care:
Reducing barriers to access is essential for
cancer, for other diseases, and for surgery.

Diagonalizing:
Implementation
Harness anti-poverty, maternal and
child health, SRH, HIV and other large
programs for cancer education,
prevention, treatment & survivorship
Integrate cancer care and control and
pain control and palliative care into
UHC national health reform, insurance
and social security programs

Outline
1. The promise of progress: health at the forefront
2. Victims of success
3. New horizons
1. Healthy economies
2. Women and health: motor of the future
3. Effective Universal Health Coverage (eUHC)

4. What can global health do for CCC?

5. What can cancer and CCC do for global health?

Apply a diagonal
approach to avoid
the false dilemmas
between disease
silos that continue
to plague global
health

Champions
the economics of hope:
Drew G. Faust
President of Harvard U
25+ year BC survivor

Nobel
Amartya
Sen,
Cancer
survivor
diagnosed
and treated
in India 65
years ago
Harvard, Breast Cancer in Developing Countries,
10 `09

Global Task Force on CCC

The costs of inaction are huge:
Invest IN action

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

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

Prevention and treatment offer

potential world savings of
$ US 130-940 billion

Global Task Force on RT for CC

Lancet Oncology, 2015
Results provide compelling evidence that
investment in RT not only enables treatment
of large numbers of cancer cases to save
lives, but also brings positive economic
benefits.
The returns conservative estimate: to $169
billion in 201535
$14.9 billion in low-income countries;
$18.7 billion in lower-middle-income countries,
$50.5 billion in upper-middle-income countries.

The Opportunity to Survive

Mortality/Incidence
is largely defined by income
100%

Children
Zimbawe

India

Leukaemia

Testis

Zimbawe
India

China

Canada

LOW
INCOME

Breast
Cervix

Adults

HIGH
INCOME

LOW
INCOME

China

Prostat
e
Tyroid

Canada

HIGH
INCOME

Almost 90% of Canadian

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

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

Survival inequality gap

100% die

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
355 mil mg

India: 467 mg

333 mil mg
Africa

Mexico:3
,500 mg

Jordan: 14,000 mg
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 )

Cancer transition in Mexico

Trends in mortality: breast and cervical cancer

16

Cervical cancer
Source: Estimaciones propias basada en 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 (1979-2012)
Source: Data extracted from CI5plus.

2012

2005

0
1985

1955

Rate per 100,000 women

age adjusted mortality rate

Mexico

Breast cancer

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

Be an
optimist
optimalist

Global Health Challenges

Shifting Horizons,
Princess Margaret Cancer Centre:
1995-2015-2035
Toronto ON,
December 1, 2015

Dr. Felicia Marie Knaul

Miami Institute for the Americas and Miller School of Medicine,
University of Miami