Closing the cancer divide: Implementing a diagonal approach
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This document discusses expanding access to cancer care and control in low and middle income countries. It argues that expanding access should, could, and can be done. Cancer disproportionately impacts the poor due to greater exposure to risk factors and less access to prevention and treatment. Integrating cancer services into existing health programs through "diagonal" approaches can help address this inequity while strengthening overall health systems. Examples from Mexico integrating breast and cervical cancer screening into primary care and social programs show progress, but more opportunities remain to improve early detection and survival rates.
Closing the cancer divide: Implementing a diagonal approach
- 3. January, 2008 June, 2007
- 4. Juanita: Advanced metastatic breast cancer is the result of a series of missed opportunities
- 6. = global health + cancer care
- 8. 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
- 9. 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
- 10. 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%.
- 11. Cancer – especially in women and children - adds a layer of discrimination onto ethnicity, poverty, and gender.
- 12. 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
- 13. 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 ✓
- 14. ! 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.
- 15. #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
- 16. 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.
- 17. 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
- 18. 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
- 19. 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
- 20. 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
- 21. 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.
- 22. ‘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
- 23. México
- 24. Mexico: Seguro Popular Horizontal Coverage: > 54.6 million Beneficiaries Ver?cal Coverage Diseases and Interven?ons: Expanded Benefit Package
- 25. 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
- 26. 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 ¡
- 27. % 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
- 28. 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
- 29. 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
- 30. 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
- 31. ‘Diagonalizing’ Delivery Results: 000´s promoters, nurses, doctors Harnessing the primary level of care
- 32. 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
- 33. Expanding access to cancer care and control in LMICs: Should, Could, and Can be done