Women's cancer transition: Challenge

for global health and health systems

Women and gender Colloquium
September 25, 2015
Womens and Gender Studies
University of Miami

Dra. Felicia Marie Knaul

Miami Institute for the Americas, University of Miami
Fundacin Mexicana para la Salud y Tmatelo a Pecho

Duality:
evidence and advocacy
Evidence-based
advocacy

Advocacyinspired
evidence

Action:
projects, programs, policies

Outline
1. From anecdote... to evidence
2. Great transitions: Health, employment, education and
women in the world
3. Women's cancer transition: Challenge for global health
and health systems
4. Answers of health systems. The Seguro Popular
5. Specific experiences: The breast cancer in Mexico

Enero,
Junio,2008
2007

From evidence

to action

Comisin Global para Ampliar el

Acceso a la Atencin del Cncer en los
Pases en Desarrollo

=
Salud global + atencin del cncer

Outline
1. From anecdote... to evidence

2. Great transitions: Health, employment,

education and women in the world
3. Women's cancer transition: Challenge for global health
and health systems
4. Answers of health systems. The Seguro Popular
5. Specific experiences: The breast cancer in Mexico

In Latin America and the Caribbean,

demographic and epidemiologic transitions
have been rapid and profound
In just over 40
years, LAC will
achieve the aging
rates that most
70%
66%
European countries
Communicable
took over two
centuries to reach.
NonLife expectancy has
Communicable
increased from 30+
Injuries
in 1920, to 75+
25%
18%
today
12%
In a very short time
9%
period, the causes
1980
2010
of death have
reversed
Source: Cepal, 2012. The epidemiologic profile of Latin America and teh Caribbean: challenges, limits, and actions.

DALYs (%) by cause-group and world

region, GBD-IHME, 2010
100%
80%

11

12

41

44

48

16

13

62

68

22

19

16

21

60%
40%

15

71

85

71
45

20%

45

40

0%

Injuries

Non-communicable

Source: Estimates based on Global Burden od Disease Study, 2010. IHME, 2012.

13

Communicable, maternal
and nutritional

 Latin American nations, much of eastern

Europe and central Asia, China, India, many
other parts of south Asia, and even countries in
Africa, [are] facing a painful double burden of
diseasenot only the persistence of infectious
threats, child and maternal mortality, and
undernutrition, but also the emergence of new
dangers, notably diabetes, obesity,
cardiovascular disease, stroke, cancer, mental illhealth, and injuries. This double burden requires
a double response, a predicament that places
huge responsibilities on the stewards of national
health systems.
JULIO FRENK & RICHARD HORTON
HEALTH REFORM IN MEXICO SERIES; THE LANCET, 2006

Average Years of Schooling for Women

0
Estonia

Ireland

UK

Germany

Hungary

Norway

Poland

Bulgaria

Netherlands

France

Romania

Spain

Greece

1950

Canada
Czech Republic

Source: Barro & Lee, 2014 (http://www.barrolee.com/data/yrsch.htm).

Cuba

South Africa

Argentina

Panama

Italy

Mexico

14

Peru

Uruguay

Portugal

China

Nicaragua

Turkey

India

Pakistan

Benin

Increased years of schooling for women

(Women 15 years or older)
2010

12

10

Labor force participation of women has also

increased substantially
Labour Participaton of Women (%)

(1970 2014 in Select Countries)

1970

2014

60
50
40
30
20
10
0
Nicaragua South Cuba Mexico Turkey
Africa

India

LMIC
Source: ILO, 2014. ( http://www.ilo.org/ilostat/faces/home/statisticaldata/data_by_subject )

Norway United Spain Greece

Kingdo
m

High Income

Labor participation of women has increased

substantially; much more than among men
Men

500

Women

400
300
200

Low & Middle Income Countries

United
Kingdom
Sweeden

Germany

Italy

Greece

Netherlands

Ireland

Portual

Spain

Norway

Poland

Turkey

Hungary

India

Argentina

South Africa

Mexico

Panama

Cuba

100
Nicaragua

Growth rate of economically active

population in the period

(1970 2014 in Select Countries)

High Income

Source: ILO, 2014. ( http://www.ilo.org/ilostat/faces/home/statisticaldata/data_by_subject )

60

Australia

50

Canada
Czech
Republi
c
Denmark

40

Israel
Portugal

30

United
Kingdom
United States

20

2012

2010

2005

2000

1995

Source: OECD Statistics.

1990

1985

10

1980

Women physicians as % of total physicians

Women as % of total physicians

1980-2012, select countries

Increased proportion of professional

women working

1990

60

2000

2011

40

20

Engineers
,

Architects

Lawyers

Source: Estimaciones propias con base en la ENEU, segundo trimestre, 1990 y 2000 y ENOE 2011.

Physicians

Nobel Prizes Awarded to Women

1901 - 2014
Women (4.9%)

Men

No.

No.

1901 - 1920

101

4%

1921 - 1940

99

5%

1941 - 1960

113

4%

1961 - 1980

176

3%

1981 - 2000

11

286

4%

2001 - 2014

17

147

10%

Period

47

922

women/t
otal

Women

Outline
1. From anecdote... to evidence
2. Great transitions: Health, employment, education and
women in the world

3. Women's cancer transition: Challenge for

global health and health systems
4. Answers of health systems. The Seguro Popular
5. Specific experiences: The breast cancer in Mexico

The Cancer Transition

Double burden for health systems
Mirrors the epidemiological transition
LMICs increasingly face both infectionassociated cancers, and all other cancers.
Cancers increasingly only of the poor, are
not the only cancers affecting the poor
LMICs account for >90% of cervical and 70%
of breast cancer deaths. Both are leading killers
especially of young - women.

Survival
inequality gap

The Opportunity to Survive

Mortality/Incidence
is but should not be defined by income
5
0
4
0

48%
40%

2
0

38%
24%

Low
Income

High
Income

Almost 90% of Canadian childhood leukemia patients survive

the
only 10% survive.
Source: Knaul, Arreola, Mendez.In
estimates
based poorest
on IARC, Globocan,countries
2010.

Cancer transition in Mexico & Costa Rica

Trends in mortality from breast and cervical
cancer
Costa Rica

16
40

20

Cervical cancer

Breast cancer

Source: Estimaciones propias basada en Knaul et al., 2008. Reproductive Health Matters, and updated by Knaul, Arreola-Ornelas and
Mndez based on WHO data, WHOSIS (1955-1978), and Ministry of Health in Mexico (1979-2012)
Source: Data extracted from CI5plus.

2002

2000

1990

1980

2012

2005

0
1985

1955

Rate per 100,000 women

age adjusted mortality rate

Mexico

Mortality: cervix and breast cancer in

Mexican States (1979-2012)
Distrito Federal

16

14

14

12

12

10

10

4
2

Oaxaca

20
15
10

Source: Estimaciones propias basadas en datos de DGIS. Base de datos de defunciones 1979-2012. SINAIS. Secretara de Salud.

2012

2005

2000

1995

1990

1985

5
1979

2005

2000

1995

2012

25

Puebla

2012

20
18
16
14
12
10
8
6
4
2
0

1990

0
1985

Nuevo Len

18

16

1979

Mortality per 100,000 women

18

The Cancer Divide:

An Equity Imperative

Facets

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. Death and disability from
treatable cancer
4. Stigma and discrimination
5. Avoidable pain and suffering

The most insidious injustice:

the pain divide
N. America

355,000 mg

Non-methadone, Morphine
Equivalent opioid consumption per
death from HIV or cancer in pain:
Poorest 10%: 179 mg
Richest 10%: 99,000 mg
US/Canada: 344,000 mg
Europe
China: 1,593 mg
144,000

333,000 mil mg

India:
467

Mexico
3,500

Africa
Latin America

Source: Estimaciones propias Knaul F.M. Arreola H, et.al.,

basado en datos de: Treat the pain and INBC
(http://www.treatthepain.com )

`5/80 cancer disequilibrium

(Frenk/Lancet 2010)
Almost 80% of the DALYs
(disability-adjusted life-years) lost
worldwide to cancer are in LMICs,
yet these countries have only a very
small share of global resources for
cancer ~ 5% or less.

The costs to close the cancer divide are

and may be less than many fear:
All but 3 of 29 LMIC priority cancer
chemo and hormonal agents are off-patent
Pain medication is cheap
Prices drop: HepB and HPV vaccines
Delivery & financing innovations can
aggregate purchasing and stabalise
procurement

The costs of inaction are huge:

Invest IN action
Tobacco is a huge economic risk: 3.6% lower GDP
Total economic cost of cancer, 2010: 2-4% of global GDP

1/3-1/2 of cancer deaths are avoidable:

2.4-3.7 million deaths,
of which 80% are in LIMCs

Prevention and treatment offers

potential world savings of
$ US 130-940 billion

Qu esmortalidad materna?
Las mujeres y las madres en los pases de ingresos
bajos y medios enfrentan muchos riesgos a travs
del ciclo de vida

-35% en
30 aos

Mortalidad
materna

Cncer de
mama

Cncer de
cervix

Diabetes

291,000

150,000195,000

105,000131,000

110,000139,000

Muertes anuales en los pases

de ingresos bajos y medios de
las mujeres de 15-59 aos

= 373, 000-465,000

Fuentee: Estimaciones propias basadas en datos del Institute for Health Metrics and Evaluation (http://www.healthdata.org/gbd/data ) .

False dichotomies challenge

Universal Health Coverage (UHC)
Diseases inaccurately labeled chronic or infectious
Communicable or infectionassociated

HIV/AIDs (KS)

NCD
Breast cancer

Chronic Cervical Cancer (HPV)

Long term disability post infection (polio)
Chronic w acute
episodes: Asma, mental

Acute

Diarrhea
Respiratory infection

Acute myocardial infarction

Acute Lymphoblastic
Leukemia

Outline
1. From anecdote... to evidence
2. Great transitions: Health, employment, education and
women in the world
3. Women's cancer transition: Challenge for global health
and health systems
4.

Answers of health systems.

The Seguro Popular

5. Specific experiences: The breast cancer in Mexico

Worldwive wave of reforms to

achieve UHC
Universal Health Coverage (UHC): all people
should obtain needed health services prevention,
promotion, treatment, rehabilitation, and palliative
care without risking economic hardship or
impoverishment (WHO, WHR 2013).

In the challenging context of rapid and

complex epidemiological transition, and

while battling fragmented health systems,

Effective Universal Health

Coverage (eUHC)
Universal Coverage: quest with 3
stages
(Legal) affiliation
Access to a comprehensive package of explicit
entitlements with financial protection
Effective coverage and financial protection:
quality and highest level of health outcomes

Universal Health Coverage:

Population, Diseases, and Interventions

Pa
Q ck

Population
(Horizontal)

In ual ag
(d te ity eep rv
th e n &
)
tio
ns

PackageDiseases
& Interventions
(Vertical)

Source: Modified from the WHO, World Health Report, 2013 andSchreyogg, et al., 2005.

4th
dimension:
Financing
to ensure
equity and
efficiency
with $
protection

Effective Universal Health

Coverage (eUHC)
Beneficiaries: Vulnerable groups
Benefits, explicitly defined the package:

Complete: Community, public, personal and

catastrophic
Explicit: interventions, diseases, health conditions
Cost-effective: increasing but not exhaustive
Proactive to promote equity and rights
High quality

Financial protection
Integrated across the life cycle: diseases
and people

UHC requires
a strong, efficient, well-run health
system;
a system for financing health
services;
access to essential medicines and
technologies;
sufficient supply of well-trained,
motivated health workers.
(WHO, World Health Report, 2013).

An effective UHC response to chronic illness

must integrate interventions along the
Continuum of disease:
1.
2.
3.
4.
5.
6.

Primary prevention
Early detection
Diagnosis
Treatment
Survivorship
Palliative care

.As well as through each Health system function

1.Stewardship
2.Financing
3.Delivery
4.Resource generatioN

eUHC requires an integrated response along

the continuum of care and within each
core health system function
Stage of Chronic Disease Life Cycle /components CCC
Health System
Functions

Stewardship

Financing

Delivery
Resource
Generation and
evidence
buliding

Primary
Prevention

Secondary
prevention/
early
detection

Diagnosis

Treatment

Survivorship/
Rehabilitation

Palliation/
End-of-life care

FUCTIONS

Disease and health system functions,

By
integration
Atomized:
Diagona
Disease

Steward
ship
Financin
g

l,
synergi
stic:vert
ical
and
horizont
al
integrat
ion

Specific:
vertical
integratio
n,
horizontal
segmenta
tion

Generalize
d:
vertical
segmentati
on,
horizontal
integration

vertical
and
horizontal
segmenta
tion

Revenue
collection
Fund Pooling
Purchasing

Provision
Revenue
generati
on
Adapted from Murray and Frenk; WHO Bulletin 2000

Disease
1
Disease
2
Disease

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 major benefits: X => parts
Avoid the false dilemmas between disease silos
that continue to plague global health;
Bridge disease divides using a life cycle response;
Generate positive externalities.

A diagonal approach
Delivery: Harness platforms by integrating breast
and cervical cancer prevention, screening and
survivorship care into MCH, SRH, HIV/AIDS,
social welfare and anti-poverty programs.
Examples:
Integration of breast and

Harnessing the primary level of care

cervical cancer awareness

and screening into the
national anti-poverty
program Oportunidades
Results: 000s promoters, nurses, doctors

Universal Health Coverage in Mexico

a globally example
The Lancet
Mexico reached a truly immense landmark in its
pioneering journey of health reform
"Mexico has showed how UHC, as well as being
ethically the right thing to do, is the smart thing to
do. Health reform, done properly, boosts economic
development
let us celebrate success, and hope for a sustained
Mexican wave of UHC worldwide
Mexico: celebrating universal health coverage.
The Lancet, Volume 380, Issue 9842, Page 622, 18 August 2012.

Problem: before 2004

Almost half of Mexican
households lacked health
insurance, which limited access
to care, reduced opportunities
for risk pooling, and generated
catastrophic expenditures.

2003 REFORM: ELIMINATE SEGMENTATION IN ACCESS TO

HEALTH INSURANCE BY GENERATING A SYSTEM FOR SOCIAL
PROTECTION IN HEALTH THAT INCLUDES POPULAR HEALTH
INSURANCE FOR FAMILIES EXCLUDED FROM SOCIAL
SECURITY

1943

Social Security

Public and private,

Formal sector workers
and their families:
~50% of population

2001/3: Pilot of PHI

2003: Law
Jan. 1, 2004: SSPH
2010: Universal
coverage of PHI
Frenk et al., 2004.

Ministry of Health
with residual
funding
Poor, informal sector,
non-salaried, rural
areas:
~50%
of population

System for Social

Protection in Health

Seguro
Popular

Expansion of Financial Coverage:

Seguro Popular Mxico
Affiliation:

Benefit package:
2004: 113

2014: 285
59 in the
Catastrophic
Illness Fund

Benefits Package

2014: 55.6 m

Vertical Coverage
Diseases and Interventions:

2004: 6.5 m

Horizontal Coverage:

Beneficiaries

Horizontal and vertical financial protection strategies:

Benefits: covered interventions

Seguro Popular in Mexico

Catastrophic Illness
ACCELERATED VERTICAL COVERAGE: Ex: breast cancer, AIDS

Early detection

Palliative care
Survivorship

Package of essential personal

services
CHILDREN: Health insurance for a New Generation
Community Health Services: prevention+promotion

Poor
Rich
Covered population: 54.6 million Beneficiaries

Seguro Popular: Results

Increased coverage:
legal, basic and effective
Financial protection improved
The financial disequilibrium between
the insured and the uninsured now
covered by Seguro popular- has closed
Despite major challenges and crises:
economic, H1N1, violence

Outline
1. From anecdote... to evidence
2. Great transitions: Health, employment, education and
women in the world
3. Women's cancer transition: Challenge for global health
and health systems
4. Answers of health systems. The Seguro Popular

5. Specific experiences:
The breast cancer in Mexico

Seguro Popular now includes

cancers in the national,
catastrophic illness fund
Universal coverage by disease with an
effective package of interventions
2004/6: HIV/AIDS, cervical, ALL in
children
2007: pediatric cancers; breast
2011: Testicular, Prostate and NHL
2013: Ovarian and colorectal

Seguro Popular and breast cancer:

Evidence of impact
National Institute
of Cancer:
treatment
adherence
2005: 200/600
2010: 10/900

The human faces:

Guillermina Avila

Breast Cancer detection:

Delivery failure
# 2 killer of
women 30-54
5-10% detected
in Stage 0-1
Poor
municipalites:
50% Stage 4; 5x
the rate for rich

% diagnosed in Stage 4 by state

RIch

Poor

Juanita:
Cncer de mama
avanzado y metastsico
como resultado de una
br
serie de oportunidades
perdidas

Diagonalizing Delivery:
Training primary care providers in early
detection of breast cancer
Total > 16,000
Health promoters
Nurses
Physicians
8

Health Promoters
Risk Score (0-10)

6
5
4

Significant increase in
knowledge, especially among
health promoters and in clinical
breast examination
(Keating, Knaul et al 2014, The Oncologist)

3
Pre

Post

3-6 month

Preliminary training results: 10,000

primary care physicians and nurses, 2014

Calificacin
(% de puntos logrados por score)

90

Nurses
N=2,243

Physicians
N=4,872

Signs and symptoms

85

Risk Factors

Global

80

CBE and BSE

Survivorship ??

75

PRE

POST

PRE

POST

eUHC requires an integrated response along

the continuum of care and within each
core health system function
Stage of Chronic Disease Life Cycle /components CCC
Health System
Functions

Stewardship

Financing

Delivery
Resource
Generation and
evidence
buliding

Primary
Prevention

Secondary
prevention/
early
detection

Diagnosis

Treatment

Survivorship/
Rehabilitation

Palliation/
End-of-life care

Be an
optimist
optimalist

Women's cancer transition: Challenge

for global health and health systems
Women and gender Colloquium
September 25, 2015
Womens and Gender Studies
University of Miami

Dra. Felicia Marie Knaul

Miami Institute for the Americas, University of Miami
Fundacin Mexicana para la Salud y Tmatelo a Pecho