Improving Access to Pain Control and Palliative Care Through Global AlliancesUHN Princess Margaret Cancer CentreFriday, July 25, 2014

Closing the Global Divide in Pain and Palliative Care: An equity and health systems perspective Dr. Felicia Marie KnaulHarvard Global Equity Initiative and Harvard Medical SchoolFundacin Mexicana para la Salud and Tmatelo a PechoBoard Member: UICC

The night of my high school prom visiting my father, Sigmund Knaul, at Mount Sinai Hospital, Toronto a few weeks before his death from cancer. May 1984.

OutlineThe divide in access to pain control and palliative careUniversal Health Coverage and the challenge of chronic conditionsEffective universal health coverage and the Diagonal approach Effective Universal Coverage and expanding access to pain control in Mexico

GTF.CCC= global health+ cancer care

Cancer is a disease of both rich and poor; yet it is increasingly the poor who suffer:

Exposure to risk factorsPreventable cancers (infection)Death and disability from treatable cancerStigma and discriminationAvoidable pain and suffering The Cancer Divide: An Equity Imperative

Pain Control and Palliative Care: a global injusticeEvery year, > 100 million require palliative care; < 8% accessOnly 20 countries have integrated palliative care into their health systems. Every year, tens of millions of people suffer unnecessarily from moderate and severe pain; 5.5 million cancer patients83% of the worlds population lives in countries with almost no access to pain medicinesHigh-income countries represent < 15% of the worlds population but > 94% of global morphine consumptionMost pain medicines are off-patent and low cost, yet expensive in poor countries: Monthly supply of morphine US$1.80-$5.40 vs US$60- $180.

The most insidious injustice: the pain divide272,000 mg2,300 mg267,000 mg6,600 mg37,000 mgSource: Based on data from: Treat the pain (http://www.treatthepain.com )Non-methadone, Morphine Equivalent opioid consumption per death from HIV or cancer in pain:Poorest 10%: 54 mg Richest 10%: 97,400 mgUS/Canada: 270,000 mgIndia

Trends in opiate consumption in the Americas 1965 to 2010 LOGARITHMIC SCALEMorphine Equivalence (mg/capital)1000019701980199020002010SOURCE: Pain & Policy Studies Group. Opioid Consumption Motion Chart. University of Wisconsin. (http://ppsg-production.heroku.com/chart )for 2007 (accessed April 22 2011).CanadaUnited States of AmericaArgentinaBrazilChileCosta RicaMexicoColombia

Recent global progress2014: The WHO Executive Board adopted a groundbreaking resolution urging countries to ensure access to pain medicines and palliative care for people with life-threatening illnesses.The resolution urgesCountries to integrate palliative care within their health systems The WHO to increase its technical assistance to member states in the development of palliative care services

Source: Based on WPCA-OMS, 2014, Global Atlas of Palliative Care at the end of life .Level of development of palliative care by country in the world

OutlineThe divide in access to pain control and palliative careUniversal Health Coverage and the challenge of chronic conditionsEffective universal health coverage and the Diagonal approach Effective Universal Coverage and expanding access to pain control in Mexico

Worldwive wave of reforms to achieve UHCUniversal 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, Palliative care and access to pain control have been almost universally ignored in UHC

DALYs (%) by cause-group and world region, GBD-IHME, 2010Source: Estimates based on Global Burden od Disease Study, 2010. IHME, 2012.

Source: Cepal, 2012. The epidemiologic profile of Latin America and teh Caribbean: challenges, limits, and actions. 1980201066%25%9%70%18%12% CommunicableNon-CommunicableInjuries

In just over 40 years, LAC will achieve the aging rates that most European countries took over two centuries to reach.Life expectancy has increased from 30+ in 1920, to 75+ todayIn a very short time period, the causes of death have reversedIn Latin America and the Caribbean, demographic and epidemiologic transitions have been rapid and profound

Universal Health Coverage: Population, Diseases, and Interventions Population(Horizontal)Package- Diseases& Interventions(Vertical) Package- Quality & Interventions (depth)4th dimension: Financing to ensure equity and efficiency with $ protection Source: Modified from the WHO, World Health Report, 2013 andSchreyogg, et al., 2005.

Why have pain control and palliative care been forgotten in the quest for UHC?Not associated with a specific illness;Most patients die advocacy is especially challenging;People who are alive are afraid of death and would rather not discuss it;Burden of Disease and Cost-efectiveness analysis skew priority setting.

False dichotomies challenge Universal Health Coverage (UHC)Tagged diseases: by chronicity and infectionChronic w acute episodes:Asthma, mentalCervical Cancer HPV)Long term disability post infection (polio)

Communicable or infection associatedNCD

ChronicHIV/AIDs (KS)Breast cancer

Acute

Diarrheas Respiratory infection

Acute myocardial infarctionAcute Lymphoblastic Leukemia

OutlineThe divide in access to pain control and palliative careUniversal Health Coverage and the challenge of chronic conditionsEffective universal health coverage and the Diagonal approach Effective Universal Coverage and expanding access to pain control in Mexico

For decades, energy has been spent in disputes opposing disease-specific vertical service delivery models to integrated horizontal models. Delivery science is consolidating evidence on how some countries have solved this dilemma by creating a diagonal approach: deliberately crafting priority disease-specific programs to drive improvement in the wider health system. Weve seen diagonal models succeed in countries as different as Mexico and Rwanda.Jim Yong Kim, World Bank President, World Health Assembly, 2013

The Diagonal Approach to Health System StrengtheningRather 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 resourcesDiagonal 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.

Diagonal Strategies:Positive ExternalitiesPain control and palliative care:Reducing barriers to access is essential for cancer, for other diseases, and for surgery.Diagonalizing: Integrate pain control and palliative care into national health reform, insurance and social security programs

Effective Universal Health Coverage (eUHC)Beneficiaries: Vulnerable groupsBenefits, explicitly defined the package:Complete: Community, public, personal and catastrophicExplicit: interventions, diseases, health conditionsCost-effective: increasing but not exhaustiveProactive to promote equity and rightsHigh qualityFinancial protectionIntegrated across the life cycle: diseases and people

An effective UHC response to chronic illness must integrate interventions along theContinuum of disease:Primary preventionEarly detectionDiagnosisTreatmentSurvivorshipPalliative care.As well as through each

Health system function

StewardshipFinancingDeliveryResource generation

eUHC requires an integrated response along the continuum of care and within each core health system function

Health System FunctionsComponents of the continuum of disease and life cycle Primary PreventionSecondary preventionDiagnosisTreatmentSurvivorship/Rehabilitation Palliation/End-of-life careStewardshipFinancingDeliveryResource Generation

OutlineThe divide in access to pain control and palliative careUniversal Health Coverage and the challenge of chronic conditionsEffective universal health coverage and the Diagonal approach Effective Universal Coverage and expanding access to pain control in Mexico

The Lancet: Universal Health Coverage in Mexico, a global exampleMexico: celebrating universal health coverage. The Lancet, Volume 380, Issue 9842, Page 622, 18 August 2012.Mexico reached a truly immense landmark in its pioneering journey of health reform: achieving UHC for its 100 million citizens.

Affiliation:2004: 6.5 m2013: 55.5 m

Benefit package:2004: 1132013: 284+59 Mexico 2003: major health reform created Seguro Popular

Mexico Seguro Popular: financial protection for catastrophic illnessAccelerated, universal, vertical coverage by disease with a comprehensive package of interventions2004-2013: Cervical, HIV/AIDS,, All pediatric, breast testicular, prostate, NHL, colorectal, ovarian cancers..Pain control and palliative care were not integrated into the benefit package of Seguro Popular except for cancer in hospital settings

In MexicoLegislative innovative benchmark at a global level: 2009: modification to the General Health Law and Law on Palliative Care 2013: Expansion of the General Health Law on palliative care matters However..Out of the 78,719 deaths from cancer or HIV/AIDS in 2012, 62,975 patients died in pain (http://www.treatthepain.org)

01234 513% >5# of clinics by state# Hospitals that provide & stock morphine by stateSource: Dr. Alfonso Petersen Farah, Presentacin: Clnicas del Dolor, Foro Internacional Promoviendo las Oportunidades de los Cuidados Paliativos en Mxico. Octubre 11, 2013N = 30Very few pain control or palliative care centers60% have 0-270% have 0-4

Barriers to access palliative care by health system functionSource: Adapted from Knaul, F. M., Gralow, J. R., Atun, R., & Bhadelia, A. (Eds.). Closing the Cancer Divide. Harvard University Press, 2012.

Health System FunctionsComponents of the continuum of disease and life cycle PreventionSurvivorshipPalliation, pain control and end-of-life careStewardshipUnifying National Program/Plan lackingWeak, restrictive, and poorly defined regulatory frameworksAbsence of an institutional system for monitoring and evaluation FinancingCAUSES and FPCHE: theres no explicit coverage; In Social Security, a wholeDeliveryLacking service unitsSupply and distribution chains incomplete geographicallyResource GenerationScarcity of qualified personnelFear in the prescriptionIncorporation of relevant classes in university curricula is missingAbsence of published investigations

Integrated, systemic solutions applying an all-of-society response

National Plan:Pain Control and Palliative Care2014

Improving Access to Pain Control and Palliative Care Through Global AlliancesUHN Princess Margaret Cancer CentreFriday, July 25, 2014

Closing the Global Divide in Pain and Palliative Care: An equity and health systems perspective Dr. Felicia Marie KnaulHarvard Global Equity Initiative and Harvard Medical SchoolFundacin Mexicana para la Salud and Tmatelo a PechoBoard Member: UICC

UHC requiresa 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).

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