Closing the cancer divide for women: An opportunity of lifetimes

Womens Cancer Initiative

Pan American Health Organization (PAHO) February 5th, 2013
Felicia Marie Knaul, PhD
Harvard Global Equity Initiative, Global Task Force on Expanded Access to Cancer Care and Control in LMICs Union for International Cancer Control Tmatelo a Pecho A:C. Mxico Mexican Health Foundation

WORLD CANCER DAY Seminar

January, 2007 June, 2008

Breast cancer champions

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

Abish Romeo,
Mxico, patient Seguro Popular

From anecdote

to evidence

GTF.CCC
Members

GTF.CCC: Mission and Vision

design, participate in implementation, and evaluate innovative strategies for expanding access to cancer prevention, detection and care that provide local and cross-country evidence for scaling up access to cancer care and control, and strengthening health systems in LMICs. facilitate action through the production of new knowledge and through multi-stakeholder frameworks and partnerships that demonstrate effective models of care that can be replicated and scaled up in LMICs.

Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries

= global health + cancer care

WHO, 2012

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

Closing the Cancer Divide:

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

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 is an Equity Imperative

Cancer is a disease of both rich and poor but the poor suffer even more:
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 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

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 Double burden for health systems.

Did you know?????

The cancer transition: women LMICs account for >90% of cervical cancer deaths and >60% of breast cancer deaths. Both are leading killers especially of young women.
In LAC, BC is:
The second or third most common cause of death, especially among young women?

Mexico: cervical cancer.

16 12 8 4 0

1955

2010

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.

Investing In CCC: We Cannot Afford Not To

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

1/3-1/2 of cancer deaths are avoidable: 2.4-3.7 million deaths, of which 80% are in LIMCs and women
Prevention and treatment offers potential world savings of $ US 130-940 billion

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: respond to patient needs, lifecycle Generate positive externalities: e.g. womens cancer programs also combat gender discrimination

The costs to close the cancer divide may be less than many fear:
All but 3 of 29 LMIC priority cancer agents are off-patent Pain medication is cheap Prices drop: HepB and HPV vaccines Delivery & financing platforms & innovations are underutilized, undeveloped, purchasing is fragmented, procurement is unstable

Pink Ribbon Red Ribbon: diagonal partnership PAHORibbon Red Ribbon- a diagonal initiative Pink Strategic Fund: includes NCDs, 2012 Global Paediatric Financing Entity

Diagonalizing Domestic 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

Seguro Popular: cancer

Accelerated, universal, vertical coverage by disease

with an effective package of interventions 2005: Cervical cancer

2006: ALL in children 2007: All pediatric cancers; Breast cancer 2011: Testicular and Prostate cancer and NHL 2012: Colorectal cancer

Evidence of impact:
Breast cancer adherence to treatment:
INCAN: 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 requires attention to the chronicity of illness Breast cancer and Seguro Popular
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 low survival. By applying a diagonal approach, this can and is being remedied.

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.
Examples: Integration of breast
Harnessing the primary level of care

and cervical cancer awareness and screening into the national antipoverty program Oportunidades

Results: 000s promoters, nurses, doctors

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 and financing platforms Redefine and reformulate health systems to manage chronicity Innovate in implementation, delivery and financing
Evaluate, replicate and scale up Leapfrog and give forward

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

From anecdote

to evidence