global health governance and financing for ncds of the poorest 030311

8/2/2019 Global Health Governance and Financing for NCDs of the Poorest 030311

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Global Health Governance and

Financing for NCDs of the poorest:Lessons from Expanding Access toCancer Care and Control in LMICs

Felicia Marie KnaulDirector, Harvard Global Equity Initiative

Secretariat, Global Task Force on Expanded Access to Cancer Care and Control inDeveloping Countries

Associate Professor, Harvard Medical School

Global Health Governance and Financing forEndemic NCDs

Boston, MAMarch 3, 2011


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Mandate: Design, develop andimplement global, regional andlocal strategies to improve thefinancing, procurement anddelivery of cancer care,control, treatment and

palliation in a sustainablemanner applying innovativeservice delivery modelsappropriate to health systems

in the developing world.

Convened in Nov 2009

By HSPH, HMS, HGEI, DFCI

Co-Chaired: L Shulman, J Frenk

27 membersrepresenting theglobal health andcancer

communities


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White Paper for policy and strategy &Lancet Commission Report


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Challenge and disprove themyths about cancer/NCD

M1. Unnecessary:

Not a health priority in LMICs/not a problem

of the poorM2. Impossible:

Nothing we can do about it

M3. Unaffordable: .for the poor

M4: Inappropriate: either/or

Challenging cancer implies taking resourcesaway from other diseases of the poor`


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More than 85% of pediatric cancer cases and 95% of deathsoccur in developing countries that use less than 5% of the

world resources.

Level ofIncome

Incidence Mortality Population

Low 21% 27% 20%

Low middle 50% 55% 57%

Upper middle 15% 15% 13%

High 15% 5% 10%

Distribution of childhood cancer globallyby level of income (< 15)

For children & adolescents 5-14 cancer is#2 cause of death in wealthy countries

#3 in upper middle-income#4 in lower middle-income

and # 8 in low-income countries


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The opportunity to survive should not be an accident of geography or definedby income.

Yet it is.But . there is scope for action.

Source: Author estimates based on IARC, Globocan, 2008 and 2010.Quote: HRH Princess Dina Mired

0

0.2

0.4

0.6

0.8

Low incomecountries

Lower middleincome

Upper middleincome

High incomecountries

All cancers, < 15

~casefatality(mo

rtality/inciden

ce)

Leukaemia,


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Lethality gap

Cancers that can be prevented (e.g. cervical)

Cancers that can be detected early and cured

(e.g. breast) Cancers that can be treated successfully (e.g.

LLA children, testicular)


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Cancer is a disease of rich and poor

Yet, the burden is increasingly of the poor:

Death from preventable and treatable cancer is moreexclusive to the poor

Avoidable pain and suffering particularly at end of lifeis only permitted for the poor

Financial impoverishment from the costs of care andeffects of the disease is concentrated among the poor

The cancer of poverty


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M1. Unnecessary: NECESSARY

M2. Impossible:

Nothing we can do about itM3. Unaffordable: .for the poor

M4: Inappropriate: either/or



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In developing countries, people withmultidrug-resistant tuberculosis usuallydie, becauseeffective treatment is oftenimpossible in poor countries.WHO 1996

MDR-TB is too expensive to treat in poorcountries; it detractsattention and resources fromtreating drug-susceptible disease.WHO 1997

Initial views on MDR-TB treatment, c. 1996-97

Mitnick et al, Community-based therapy for multidrug-resistant

tuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.

cured

83%

abandon

therapy

2%

failed

therapy

8%

died

8%

Peru, Lima: All patients

initiated with at least 4months therapy between Aug

96 and Feb 99

Source: Paul Farmer, 2009


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IT CAN BE DONE: From evidence to action:

Treating cancer in LMICs usinginnovative delivery and financing: Resourceful tasking Infrastructure shifting Application of technology of

communication Social Protection and health insurance

Models: Low-income: Rwanda-Malawi-Haiti

Lower middle-income: Jordan

Upper middle-income: Mexico

ACCESS

QUALITY

FINANCIAL

PROTECTION


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Rural Rwanda: 0 (zero) oncologists

Source: Paul Farmer., 2009

Burkittslymphoma

EmbryonalRhabdomyosarcoma


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St. Jude International Outreach Program:Global Partnership Innovation Model

Institutional commitment: St. Jude Hospital dedicates a1-3% of their budget to International Outreach Program

Strategy: Partnership and twinning Evaluation and implementation research

15 + countries

El Salvador

5-year survival rate for children with ALL increased from 10%to 60% during the first five years of collaboration

Recife, Brazil

Since 1994, the cure rate for childhood cancers in increasedfrom 29% to 70%

Cure4Kids

Over 24,000 users in more than 175 countres


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M2. Impossible:POSSIBLE

M3. Unaffordable: .for the poorM4: Inappropriate: either/or



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`5/80 cancer disequilibrium(Frenk/Lancet 2010)

Almost 80% of the DALYs (disability-adjusted life-years) lost worldwide tocancer are in LMICs, yet these countries

have only a very small share of globalresources for cancer ~ 5% or less.

Worse in certain regions:

Africa: only 02% of global cancer medicalcosts, 1% of global spending on health, 64%of new cancer cases, and 15% of the globalpopulation


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Source: Paul Farmer, 2009

Drug% Decline in price 1997-

9

Amikacin 90%

Ethionamide 84%

Capreomycin 97%

Ofloxacin 98%

Reduced prices of second-line TB drugs


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Key Elements

Mexico 2003 Reform:

1. Access to publicly-funded, heavily subsidized,progressive health insuranceSeguro Popular - forall families excluded from Social Security

2. Separate budgeting and funds for public healthgoods with universal coverage

3. Package of personal health services based on cost-effectiveness and burden of disease expands over

time4. Fund for Catastrophic Illness covering specific

interventions for specific diseases expands overtime

Seguro Popular:


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Seguro Popular:A diagonal approach to financial protection

Horizontal Coverage:Beneficiaries


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Mexico Popular Health Insurance:Fund for catastrophic illness Accelerated universal vertical coverage by

disease with a specified package ofinterventions

2004/5: ALL in children, cervical, HIV/AIDS 2006: all pediatric cancers

2007: breast

2011: testicular and NHL Significant reduction in abandonment of

treatment

Yet, likely variation in outcomes


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M2. Impossible: POSSIBLE

M3. Unaffordable: .for the poorAFFORDABLEM4: Inappropriate: either/or


E i ti `C t i d t k f


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Chronic

Acute

Infectiousorigin/communicable

AIDS, Cervical cancer, TB,liver cancer, Chagas,

cardiopathy, rheumatic heartdisease, gastric cancer,

Infectious diarrhealdiseases, respiratory

infections

Non-Communicable

Most cancers, mostCVD, hypertension,diabetes, asthma,

mental illness

Acute myocardialinfarction

Existing `Categories do not work fordeveloping systemic solutions

P l t i k f


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Africa

LMICs

Maternal mortality

207,000

355,000

Breast andcervicalcancer

79,184

87,691

=143,778

772,728

478,640

=1,251,368

People are at risk for manyreasonsvictims of success?


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Vertical programs refer to targeted interventions, proactiveand disease-specific on a massive scale (HIV, maternal andchild health), while horizontal programs refer to moreintegrated health services corresponding to functions of thehealth systems, guided by demand and shared resources.

it has been discussed at length what the mosteffective approach is to deliver health interventions:vertical programs or horizontal programs. This is a falsedilemma, because both interventions need to coexist in

what could be called a diagonal approach

Seplveda et al., Aumento de la sobrevida enmenores de 5 aos: la estrategia diagonal

The diagonal approach tohealth system strengthening


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1. Financial protection/insurance strategies

with horizontal and vertical coverage2. Integrating breast and cervical cancer

screening into MCH, SRH3. Integrating disease prevention and

management into social welfare and anti-poverty programs

4. Catalyzing and employing community healthworkers and expert patients

5. Reducing non-price barriers to pain control6. Developing effective health services

research and monitoring

Diagonal approaches


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Global Health Governance and

Financing for NCDs of the poorest:Lessons from Expanding Access toCancer Care and Control in LMICs

Felicia Marie KnaulDirector, Harvard Global Equity Initiative

Secretariat, Global Task Force on Expanded Access to Cancer Care and Control inDeveloping Countries

Associate Professor, Harvard Medical School

Global Health Governance and Financing forEndemic NCDs

Boston, MAMarch 3 2011

global health governance and financing for ncds of the poorest 030311

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