Closing the cancer divide: Implementing a diagonal approach

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Reunión anual de la American Association for Cancer Research, 9 de abril de 2013

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Closing the cancer divide: Implementing a diagonal approach

  1. 1. January,  2008  June,  2007  
  2. 2. Juanita: Advanced metastatic breast cancer is the result of a series of missed opportunities
  3. 3. = global health + cancer care
  4. 4. Challenge and disprove the myths about cancer Expanding access to cancer care and control in low and middle income countries: I: Should be done II: Could be done III: Can be done M1. Unnecessary M2. Unaffordable M3. Impossible M4: Inappropriate
  5. 5. 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.  Treatable cancer death and disability 4.  Stigma and discrimination 5.  Avoidable pain and suffering The Cancer Divide: An Equity Imperative Facets
  6. 6. Adults Leukaemia All cancers Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010. Children LOW INCOME HIGH INCOME Survival inequalitygap LOW INCOME HIGH INCOME 100% Facet 3: The Opportunity to Survive Should Not, but Is Defined by Income In Canada, almost 90% of children with leukemia survive. In the poorest countries only 10%.
  7. 7. Cancer – especially in women and children - adds a layer of discrimination onto ethnicity, poverty, and gender.
  8. 8. 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
  9. 9. Investing In CCC: We Cannot Afford Not To !   Tobacco is a huge economic risk: 3.6% lower GDP !   Total economic cost of cancer, 2010: 2-4% of global GDP !   Inaction reduces efficacy of health and social investments Prevention and treatment offers potential world savings of $ US 130-940 billion 1/3-1/2 of cancer deaths are “avoidable”: 2.4-3.7 million deaths, of which 80% are in LIMCs ✓  
  10. 10. !  Mirrors the epidemiological transition !   LMICs increasingly face both infection- associated cancers, and all other cancers. The Cancer Transition !   Cancers increasingly only of the poor, are not the only cancers affecting the poor.
  11. 11. #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. For children & adolescents 5-14 cancer is  
  12. 12. Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011. The cancer transition in LMICs: breast and cervical cancer 53% 20%19% -31% 0% LMIC’s High income % Change in # of deaths 1980-2010LMICs account for >90% of cervical cancer deaths and >60% of breast cancer deaths. Both diseases are leading killers – especially of young women.
  13. 13. Cancer transition in Mexico: Breast and Cervical mortality México 0 4 8 12 161955 1960 1970 1980 1990 2000 2010 Mortality  rate  adjusted  by  age   Oaxaca (Poorest) Nuevo León (Wealthiest) Source:  Knaul  et  al.,  2008.  Reproduc?ve  Health  MaCers,  and  updated  by  Knaul,  Arreola-­‐Ornelas  and  Méndez.   0 10 20 30 1980 1990 2000 2010 0 10 20 30 1980 1990 2000 2010
  14. 14. Trends in the difference between mortality rate from cervical and breast cancer Mexico, by level of state marginality, (1979 -2010) -­‐10 -­‐5 0 5 10 15 1979 1980 1985 1990 1995 2000 2005 2010 Difference  in  mortality  rate    (Per  100,000  women  age-­‐adjusted) Very  Poor Poor Average Wealthy Very  Wealthy
  15. 15. Women and mothers in LMICs face many risks through the life cycle Women 15-59, annual deaths Diabetes 120,889 Breast cancer 166,577 Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011. Cervical cancer 142,744 Mortality in childbirth 342,900 - 35% in 30 years = 430, 210 deaths
  16. 16. 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:  X = > Σ parts !   Bridge disease divides: patients suffer over a lifetime, most of it chronic. !   Generate positive externalities
  17. 17. Diagonal Strategies: Positive Externalities !   Promoting prevention and healthy lifestyles: !   Reduce risk for cancer and many other diseases !   Reducing stigma around women’s cancers: !   Contributes to reducing gender discrimination !   Pain control and palliation !   Reducing barriers to access is essential for cancer as well as for for other diseases and for surgery.
  18. 18. ‘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
  19. 19. México
  20. 20. Mexico: Seguro Popular Horizontal  Coverage:     >  54.6  million  Beneficiaries   Ver?cal  Coverage       Diseases  and  Interven?ons:      Expanded  Benefit  Package      
  21. 21. 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
  22. 22. Seguro Popular and cancer: Evidence of impact !  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 ¡
  23. 23. % diagnosed in Stage 4 by state • # 2 killer of women 30-54 • Only 5-10% detected in Stage 0-1 • Poor municipalites: 50% Stage 4; 5x rich Delivery failure: Breast Cancer Juanita Poor/Marginalized  
  24. 24. Effective financial coverage of breast cancer in Mexico –  Primary prevention –  Secondary prevention (early detection) –  Diagnosis –  Treatment –  Survivorship care –  Palliative care Large and exemplary investment in cancer treatment for women, yet a low survival rate. Opportunities to diagonalize delivery
  25. 25. Harness platforms by integrating breast and cervical cancer prevention, screening and survivorship care into MCH, SRH, HIV/AIDS, social welfare and anti-poverty programs. Solution: ‘Diagonalizing’ Delivery
  26. 26. Including breast cancer awareness for early detection in Oportunidades •  “Guía de orientación y capacitación 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
  27. 27. ‘Diagonalizing’ Delivery Results: 000´s promoters, nurses, doctors Harnessing the primary level of care
  28. 28. Where are the opportunities? •  LMICs: the potential to reduce DALYs lost is huge •  Focus on prevention but do not stop there! –  No prevent/treat dichotomization •  Do not take prices as fixed or given – price permeability •  Innovate in implementation, delivery and financing –  Evaluate, replicate and scale up –  Leapfrog and give forward •  Harness global and national health system platforms •  Harness cancer to strengthen health and social systems •  Recognize LMICs as part of a global solution:  investment in learning, research and human beings
  29. 29. Expanding access to cancer care and control in LMICs: Should, Could, and Can be done

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