Global Health Governance and Financing for NCDs of the poorest: Lessons from Expanding Access to Cancer Care

and Control in LMICs

Felicia Marie Knaul
Director, Harvard Global Equity Initiative Secretariat, Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries Associate Professor, Harvard Medical School

Global Health Governance and Financing for Endemic NCDs Boston, MA March 3, 2011

 Mandate: Design, develop and implement global, regional and local strategies to improve the financing, procurement and delivery of cancer care, control, treatment and palliation in a sustainable 27 members manner applying innovative representing the global health and service delivery models appropriate to health systems cancer in the developing world. communities

Convened in Nov 2009 By HSPH, HMS, HGEI, DFCI Co-Chaired: L Shulman, J Frenk

White Paper for policy and strategy & Lancet Commission Report

Challenge and disprove the myths about cancer/NCD

M1. Unnecessary: Not a health priority in LMICs/not a problem of the poor M2. Impossible: Nothing we can do about it M3. Unaffordable: .for the poor M4: Inappropriate: either/or Challenging cancer implies taking resources away from other diseases of the poor`

Distribution of childhood cancer globally by level of income (< 15)

Level of Income Low Low middle Upper middle High Incidence 21% 50% 15% 15% Mortality 27% 55% 15% 5% Population 20% 57% 13% 10%

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

~ case fatality (mortality/incidence)

The opportunity to survive should not be an accident of geography or defined by income. Yet it is. But . there is scope for action.

0.8

73%

Leukaemia, <15

0.6

0.4

All cancers, < 15

18%

Survival inequality gap

0.2

0
Low income countries Lower middle income Upper middle income High income countries

Source: Author estimates based on IARC, Globocan, 2008 and 2010. Quote: HRH Princess Dina Mired

Lethality gap
Cancers that can be prevented (e.g. cervical) Cancers that can be detected early and cured (e.g. breast) Cancers that can be treated successfully (e.g. LLA children, testicular)

The cancer of poverty

Cancer is a disease of rich and poor
Yet, the burden is increasingly of the poor:

Death from preventable and treatable cancer is more exclusive to the poor Avoidable pain and suffering particularly at end of life is only permitted for the poor Financial impoverishment from the costs of care and effects of the disease is concentrated among the poor

Challenge and disprove the myths about cancer/NCD

M1. Unnecessary: NECESSARY M2. Impossible: Nothing we can do about it M3. Unaffordable: .for the poor M4: Inappropriate: either/or Challenging cancer implies taking resources away from other diseases of the poor`

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

In developing countries, people with multidrug-resistant tuberculosis usually die, because effective treatment is often impossible in poor countries. WHO 1996
MDR-TB is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible disease. WHO 1997
failed therapy died 8% 8%

abandon therapy 2%

cured 83%

Peru, Lima: All patients initiated with at least 4 months therapy between Aug 96 and Feb 99

Source: Paul Farmer, 2009

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

IT CAN BE DONE: From evidence to action:

Treating cancer in LMICs using innovative delivery and financing:
Resourceful tasking Infrastructure shifting Application of technology of communication Social Protection and health insurance

Models:
ACCESS QUALITY
FINANCIAL PROTECTION

Low-income: Rwanda-Malawi-Haiti

Lower middle-income: Jordan

Upper middle-income: Mexico

Rural Rwanda: 0 (zero) oncologists

Burkitts lymphoma

Embryonal Rhabdomyosarcoma

Source: Paul Farmer., 2009

St. Jude International Outreach Program: Global Partnership Innovation Model

Institutional commitment: St. Jude Hospital dedicates a 1-3% of their budget to International Outreach Program Strategy: Partnership and twinning Evaluation and implementation research
15 + countries 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

Challenge and disprove the myths about cancer/NCD

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

`5/80 cancer disequilibrium

(Frenk/Lancet 2010)
Almost 80% of the DALYs (disabilityadjusted life-years) lost worldwide to cancer are in LMICs, yet these countries have only a very small share of global resources for cancer ~ 5% or less. Worse in certain regions:
Africa: only 02% of global cancer medical costs, 1% of global spending on health, 64% of new cancer cases, and 15% of the global population

Reduced prices of second-line TB drugs

% Decline in price 19979 90% 84% 97% 98%

Drug Amikacin Ethionamide Capreomycin Ofloxacin

Source: Paul Farmer, 2009

Key Elements Mexico 2003 Reform:

1. Access to publicly-funded, heavily subsidized,
progressive health insurance Seguro Popular - for all families excluded from Social Security

2. Separate budgeting and funds for public health

goods with universal coverage

3. Package of personal health services based on costeffectiveness and burden of disease expands over time

4. Fund for Catastrophic Illness covering specific

interventions for specific diseases expands over time

Seguro Popular: A diagonal approach to financial protection

Horizontal Coverage: Beneficiaries

Mexico Popular Health Insurance: Fund for catastrophic illness

Accelerated universal vertical coverage by disease with a specified package of interventions 2004/5: ALL in children, cervical, HIV/AIDS 2006: all pediatric cancers 2007: breast 2011: testicular and NHL Significant reduction in abandonment of treatment Yet, likely variation in outcomes

Challenge and disprove the myths about cancer/NCD

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

Existing `Categories do not work for developing systemic solutions

Infectious origin/communicable NonCommunicable

Chronic

AIDS, Cervical cancer, TB, liver cancer, Chagas, cardiopathy, rheumatic heart disease, gastric cancer,

Most cancers, most CVD, hypertension, diabetes, asthma, mental illness

Acute

Infectious diarrheal diseases, respiratory infections

Acute myocardial infarction

People are at risk for many reasonsvictims of success?

Maternal mortality Breast and cervical cancer

Africa

207,000

79,184 87,691 =143,778 772,728 478,640 =1,251,368

LMICs

355,000

The diagonal approach to health system strengthening

Vertical programs refer to targeted interventions, proactive and disease-specific on a massive scale (HIV, maternal and child health), while horizontal programs refer to more integrated health services corresponding to functions of the health systems, guided by demand and shared resources. it has been discussed at length what the most

effective approach is to deliver health interventions: vertical programs or horizontal programs. This is a false dilemma, because both interventions need to coexist in what could be called a diagonal approach
Seplveda et al., Aumento de la sobrevida en menores de 5 aos: la estrategia diagonal

Diagonal approaches
1. Financial protection/insurance strategies with horizontal and vertical coverage 2. Integrating breast and cervical cancer screening into MCH, SRH 3. Integrating disease prevention and management into social welfare and antipoverty programs 4. Catalyzing and employing community health workers and expert patients 5. Reducing non-price barriers to pain control 6. Developing effective health services research and monitoring

Global Health Governance and Financing for NCDs of the poorest: Lessons from Expanding Access to Cancer Care and Control in LMICs
Felicia Marie Knaul
Director, Harvard Global Equity Initiative Secretariat, Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries Associate Professor, Harvard Medical School

Global Health Governance and Financing for Endemic NCDs Boston, MA March 3, 2011