This document discusses strategies for expanding access to cancer care and control in low- and middle-income countries. It proposes a "diagonal approach" that harnesses synergies between disease-specific and health system strengthening programs. Examples of diagonal strategies include integrating cancer screening and treatment into existing maternal and child health programs. The document argues that closing the cancer divide is an equity imperative and that innovative delivery models, affordable drugs and technologies, and evidence-based decision making can help expand access to cancer care in LMICs.

2. January,
2008
June,
2007

4. From anecdote …
… to evidence

5. GTF.CCC
Members

6. 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.

7. = global health + cancer care

8. Abish Romeo,
México
Drew G. Faust
President of Harvard University
22+ year BC survivor

10. Closing the Cancer Divide:
An Equity Imperative
I: Should be done
II: Could be done
III: Can be done
M1. Unnecessary
M2. Unaffordable
M3. Impossible
M4: Inappropriate
Expanding access to cancer care and control in LMICs:
1: Innovative Delivery
2: Access: Affordable Med’s, Vaccines & Tech’s
3: Innovative Financing: Domestic and Global
4: Evidence for Decision-Making
5: Stewardship and Leadership

11. Cancer is a disease of both rich and poor but
the poor suffer even more:
1. Exposure to risk factors
2. Preventable cancers (infection)
3. Treatable cancer death and disability
4. Stigma and discrimination
5. Avoidable pain and suffering
Closing the Cancer Divide
is an Equity Imperative
Facets

12. 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%.

13. 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

14. " Mirrors the overall 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.

15. LMICs account for
>90% of cervical
cancer deaths and
>60% of breast
cancer deaths. Both
are leading killers –
especially of young
women.
Did you know?????
The second or third most common
cause of death, especially among
young women?
In LAC, BC is:
The cancer transition:
women
0
4
8
12
16
2010
1955
Mexico: cervical cancer.

16. 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

17. 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
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 and women
✓

18. 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: e.g. women’s cancer
programs also combat gender discrimination; access to pain
control supports surgery platforms

19. 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-­‐
a
diagonal
ini3a3ve
Global
Paediatric
Financing
En3ty
PAHO
Strategic
Fund:
includes
NCDs,
2012
Pink
Ribbon
Red
Ribbon:
diagonal
partnership

20. ‘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

21. Universal Health Coverage in Mexico
through Seguro Popular
Horizontal
Coverage:
>
54.6
million
Beneficiaries
Ver3cal
Coverage
Diseases
and
Interven3ons:
Expanded
Benefit
Package

22. 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

23. % 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

24. 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

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
Examples:
• Integration of breast and
cervical cancer awareness
and screening into the
national anti-poverty
program Oportunidades
Results: 000´s promoters, nurses, doctors
Harnessing the primary level of care

26. 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
• 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

27. Expanding access to cancer care and control in
LMICs: Should, Could, and Can be done

28. From anecdote …
… to evidence