Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Global	
  Health	
  Ethics,	
  Poli1cs,	
  and	
  Economics	
  
Yale	
  University	
  
Guest	
  Lecture,	
  March	
  5,	
 ...
From anecdote …
… to evidence
January,	
  2008	
  June,	
  2007	
  
Battling sepsis in the
Médica 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 health + cancer care
Challenge and disprove the
myths about cancer
M1. Unnecessary
M2. Unaffordable
M3. Impossible
M4: Inappropriate
• Should,
...
"  Mirrors the epidemiological transition
"   LMICs increasingly face both infection-
associated cancers, and all other ca...
#2 cause of death in wealthy countries
#3 in upper middle-income
#4 in lower middle-income
and # 8 in low-income countries...
The cancer transition in LMICs:
breast and cervical cancer
LMICs account for
>90% of cervical
cancer deaths and
>60% of br...
Mortalidad de cáncer de mama y
cervical en México 1979-2010
0
5
10
15
20
25
30
1979
1980
1985
1990
1995
2000
2005
2010
Oax...
•  The divide is the result of concentrating risk
factors, preventable disease, suffering,
impoverishment from ill health ...
Cancer is a disease of both rich and poor;
yet it is increasingly the poor who suffer:
1.  Exposure to risk factors
2.  Pr...
Adults
Leukaemia
All cancers
Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.
Children
LOW
INCOME
...
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
consumpt...
Challenge and disprove the
myths about cancer
Investing In CCC:
We Cannot Afford Not To
"   Inaction reduces efficacy of health and social investments
"   Total economi...
The costs to close the cancer divide
may be less than many fear:
"   All but 3 of 29 LMIC priority cancer chemo and
hormon...
Challenge and disprove the
myths about cancer
Women and mothers in LMICs
face many risks through the life cycle
Women 15-59, annual deaths
Diabetes
120,889
Breast
cance...
The Diagonal Approach to
Health System Strengthening
"   Rather than focusing on either disease-specific
vertical or horiz...
Diagonal Strategies:
Positive Externalities
"   Promoting prevention and healthy lifestyles:
"   Reduce risk for cancer an...
Challenge and disprove the
myths about cancer
Initial views on MDR-TB
treatment, c. 1996-97
“MDR-TB is too
expensive to treat in
poor countries; it
detracts attention a...
Champions
Nobel Amartya Sen,
Cancer survivor diagnosed in India
50 years ago
Drew G. Faust
President of Harvard University...
Rural Rwanda: 0 oncologist
Source: Paul Farmer., 2009
Burkitt´s
lymphoma
Embryonal
Rhabdomyosarcoma
St. Jude’s International
Outreach Program
•  Twinning in 20+ countries
– El Salvador: 5-year survival for children
with AL...
México: IT IS POSSIBLE
‘Diagonalizing’ Financing:
Integrate cancer care and control into
national insurance and social security
programs to expre...
Universal Health Coverage in Mexico
through Seguro Popular
Horizontal	
  Coverage:	
  	
  
>	
  54.6	
  million	
  Benefici...
Evolution of vertical coverage: cumulative #
of covered interventions, 2004-2012
Notes: 	
   	
   	
   	
   	
   	
   	
  ...
Seguro Popular:
Cancer and the Fund for Protection from
Catastrophic Illness
"   Accelerated, universal, vertical coverage...
Seguro Popular and cancer:
Evidence of impact
"  Access to medicines – an anecdote
"  Since the incorporation of childhood...
% diagnosed in Stage 4 by state
• # 2 killer of women 30-54
• Only 5-10% of cases in Mexico are
detected in Stage 1 or in ...
Effective financial coverage:
breast cancer in Mexico
–  Primary prevention
–  Secondary prevention (early detection)
–  D...
Health System
Functions
Stage of Chronic Disease Life Cycle /components CCC
Primary
Prevention
Secondary
prevention
Diagno...
Benefits:coveredinterventions
Horizontal and vertical financial protection strategies:
Seguro Popular in Mexico
ACCELERATE...
Harness platforms by integrating breast and
cervical cancer prevention, screening and
survivorship care into MCH, SRH, HIV...
Including breast cancer awareness for
early detection in Oportunidades
•  “Guía de orientación y
capacitación a titulares
...
Solution:
‘Diagonalizing’ Delivery
Results: 000´s promoters, nurses, doctors
Harnessing the primary level of care
Survivorship care…
incipient
Pain	
  and	
  Pallia=on	
  
Where are the opportunities?
•  LMICs – not months but whole lifetimes to be gained
•  Focus on prevention but do not stop...
Expanding access to cancer care and control in
LMICs: Should, Could, and Can be done
Universal health coverage and the challenge of responding to chronic illness: a case study of Mexico and breast cancer
Universal health coverage and the challenge of responding to chronic illness: a case study of Mexico and breast cancer
Universal health coverage and the challenge of responding to chronic illness: a case study of Mexico and breast cancer
Universal health coverage and the challenge of responding to chronic illness: a case study of Mexico and breast cancer
Universal health coverage and the challenge of responding to chronic illness: a case study of Mexico and breast cancer
Universal health coverage and the challenge of responding to chronic illness: a case study of Mexico and breast cancer
Upcoming SlideShare
Loading in …5
×

Universal health coverage and the challenge of responding to chronic illness: a case study of Mexico and breast cancer

712 views

Published on

Global Health Ethics, Politics, and Economics. Yale University, Guest Lecture, 5 de marzo de 2013

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Universal health coverage and the challenge of responding to chronic illness: a case study of Mexico and breast cancer

  1. 1. Global  Health  Ethics,  Poli1cs,  and  Economics   Yale  University   Guest  Lecture,  March  5,  2013  
  2. 2. From anecdote … … to evidence
  3. 3. January,  2008  June,  2007  
  4. 4. Battling sepsis in the Médica Sur Hospital. Mexico City. July 2008
  5. 5. Juanita: Advanced metastatic breast cancer is the result of a series of missed opportunities
  6. 6. Launching a program at the Mexican Health Foundation the day I got sepsis. July 2008.
  7. 7. From anecdote … … to evidence
  8. 8. GTF.CCC Members  
  9. 9. = global health + cancer care
  10. 10. Challenge and disprove the myths about cancer M1. Unnecessary M2. Unaffordable M3. Impossible M4: Inappropriate • Should, • Could, and • Can….. ….be Expanding access to cancer care and control in low and middle income countries:
  11. 11. "  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.
  12. 12. #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  
  13. 13. 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  México  1955-­‐2010   0   4   8   12   16   1955   1960   1965   1970   1975   1980   1985   1990   1995   2000   2005   2010   Mama   Cervix  
  14. 14. Mortalidad de cáncer de mama y cervical en México 1979-2010 0 5 10 15 20 25 30 1979 1980 1985 1990 1995 2000 2005 2010 Oaxaca Tasapor100,000mujeresajustadoporedad Nuevo León 0 5 10 15 20 25 30 1979 1980 1985 1990 1995 2000 2005 2010 1980 1990 2000 2010 1980 1980 1980 1980 1990 2000 2010 1980 1980 1980 Source:  Knaul  et  al.,  2008.  Reproduc=ve  Health  MaBers,  and  updated  by  Knaul,  Arreola-­‐Ornelas  and  Méndez.   Cáncer de mama Cáncer de cérvix
  15. 15. •  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.
  16. 16. 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
  17. 17. 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%.
  18. 18. Cancer – especially in women and children - adds a layer of discrimination onto ethnicity, poverty, and gender.
  19. 19. 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
  20. 20. Challenge and disprove the myths about cancer
  21. 21. 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 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 ✓  
  22. 22. 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
  23. 23. Challenge and disprove the myths about cancer
  24. 24. 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
  25. 25. 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
  26. 26. 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 "   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.
  27. 27. Challenge and disprove the myths about cancer
  28. 28. 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 All patients initiated therapy between Aug 96 and Feb 99 Abandon therapy 2% Failed therapy 8% Died 8%
  29. 29. Champions Nobel Amartya Sen, Cancer survivor diagnosed in India 50 years ago Drew G. Faust President of Harvard University 22+ year BC survivor
  30. 30. Rural Rwanda: 0 oncologist Source: Paul Farmer., 2009 Burkitt´s lymphoma Embryonal Rhabdomyosarcoma
  31. 31. St. Jude’s 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
  32. 32. México: IT IS POSSIBLE
  33. 33. ‘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
  34. 34. Universal Health Coverage in Mexico through Seguro Popular Horizontal  Coverage:     >  54.6  million  Beneficiaries   Ver=cal  Coverage       Diseases  and  Interven=ons:      Expanded  Benefit  Package      
  35. 35. Evolution of vertical coverage: cumulative # of covered interventions, 2004-2012 Notes:                 SP  =  Seguro  Popular     MING  =  Medical  Insurance  for  a  New  Genera=on  (Children  born  aWer  December  1,  2006  and  un=l  they  are  5  years  of  age)   FPCHE  =  Fung  for  Protec=on  against  Catastrophic  Health  Expenditure   EPHS  =Essen=al  Personal  Health  Services     EPI  =  Expanded  Programme  of  Immunisa=ons   CBP=  Community-­‐based  package  ”   0 50 100 150 200 250 300 350 400 450 500 2004 2005 2006 2007 2008 2009 2010 2011 2012 63 65 65 65 65 65 65 65 65 6 6 8 6 12 12 12 12 1322 83 176 184 189 189 198 198 206 6 6 17 20 49 49 49 57 57 110 108 116 128 128 131 MING EPHS EPI CBP FPCHE Numberofinterventions Seguro Popular 284 interventions MING + SP FPCHE 57 interventions CAUSES  91   FPCHE              6   CAUSES    284  FPCHE                   57  
  36. 36. 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
  37. 37. 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
  38. 38. % diagnosed in Stage 4 by state • # 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 Delivery failure: Breast Cancer Juanita Poor/Marginalized  
  39. 39. 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.
  40. 40. Health System Functions Stage of Chronic Disease Life Cycle /components CCC Primary Prevention Secondary prevention Diagnosis Treatment Survivorship/ Rehabilitation Palliation/ End-of-life care Stewardship Financing Delivery Resource Generation Responding to the challenge of chronicity: Health system functions by care continuum
  41. 41. Benefits:coveredinterventions Horizontal and vertical financial protection strategies: Seguro Popular in Mexico ACCELERATED  VERTICAL  COVERAGE  for  Catastrophic  Illnesses  included   in  the  Fund:  breast  cancer,    AIDS   Community  and  Public  Health  Services   Poor   Rich   CHILDREN:  Health  insurance  for  a  New  Genera1on   Survivorship   Package  of  essen1al  personal  services   Preven=on,     Early  detec=on   Beneficiaries
  42. 42. 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
  43. 43. 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
  44. 44. Solution: ‘Diagonalizing’ Delivery Results: 000´s promoters, nurses, doctors Harnessing the primary level of care
  45. 45. Survivorship care… incipient
  46. 46. Pain  and  Pallia=on  
  47. 47. 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
  48. 48. Expanding access to cancer care and control in LMICs: Should, Could, and Can be done

×