The authors appreciate the financial support of Harvard U, and IDRC Canada Outline 1. UHC and the challenge of chronic conditions 2. Effective Universal Health Coverage 3. Mexico and Seguro Popular Breast Cancer and UHC Pain control and palliative care Huge steps to reform health systems in the quest for UHC in many countries Examples: Brazil Colombia Chile Dominican Republic El Salvador Peru Mexico: Seguro Popular de Salud South Africa China (USA - Affordable Care Act)
Yetoften in the context of rapid, profound, polarized and complex epidemiological transition or battling fragmented health systems 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 disease not 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 ill-health, 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 Source: Cepal, 2012. The epidemiologic profile of Latin America and teh Caribbean: challenges, limits, and actions. 1980 2010 66% 25% 9% 70% 18% 12% Communicable Non- Communicable Injuries
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+ today In a very short time period, the causes of death have reversed In Latin America and the Caribbean, demographic and epidemiologic transitions have been rapid and profound DALYs (%) by cause-group and world region, GBD-IHME, 2010 71 45 45 40 22 19 13 6 21 41 44 48 62 68 71 85 8 15 11 12 16 13 16 9 0% 20% 40% 60% 80% 100% Africa Middle East Southeast Asia World LAC Pacific Europe High Income Countries Injuries non-communicable Communicable, maternal and nutritional Source: Estimates based on Global Burden od Disease Study, 2010. IHME, 2012. 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 have major benefits: X = > parts Bridge disease divides using a life cycle response avoids the false dilemmas between disease silos - CD/NCD- that continue to plague global health Generate positive externalities: e.g. womens cancer programs fight gender discrimination; pain control 4all Disease and health system functions, By integration Diagonal, synergistic: vertical and horizontal integration Disease Specific: vertical integration, horizontal segmentation Generalized: vertical segmentation, horizontal integration Atomized: vertical and horizontal segmentation Stewardship Financing Revenue collection Fund Pooling Purchasing
Provision Revenue generation F U C T I O N S
Adapted from Murray and Frenk; WHO Bulletin 2000 Disease 1 Disease 2 Disease 3 False dichotomies challenge Universal Health Coverage (UHC) Communicable or infection- associated NCD
Chronic HIV/AIDs (KS) Breast cancer
Acute
Diarrhea Respiratory infection
Acute myocardial infarction Acute Lymphoblastic Leukemia Diseases inaccurately labeled chronic or infectious Cervical Cancer (HPV) Long term disability post infection (polio) Chronic w acute episodes: Asma, mental Outline 1. UHC and the challenge of chronic conditions 2. Effective Universal Health Coverage 3. Mexico and Seguro Popular Breast Cancer and UHC Pain control and palliative care Effective Universal Coverage Universal Coverage: quest with 3 stages Legal: affiliation/enrollment Access to a comprehensive package of explicit entitlements with financial protection Effective coverage & effective financial 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 I ntegrated across the life cycle: diseases and people Universal Health Coverage: Population, Diseases, and Interventions Population (Horizontal) Package- Diseases & Interventions (Vertical) 4th dimension: Financing to ensure equity and efficiency with $ protection Source: Modified from the WHO, World Health Report, 2013 andSchreyogg, et al., 2005. An effectiveUHC response to chronic illness must integrate interventions along the Continuum of disease: 1. Primary prevention 2. Early detection 3. Diagnosis 4. Treatment 5. Survivorship 6. Palliative care .As well through each
Health system function 1.Stewardship 2.Financing 3.Delivery 4.Resource generation
Health System Functions Stage of Chronic Disease Life Cycle /components CCC Primary Prevention Secondary prevention Diagnosis Treatment Survivorship/ Rehabilitation Palliation/ End-of-life care Stewardship Financing Delivery Resource Generation eUHC requires an integrated response along the continuum of care and within each core health system function Outline 1. UHC and the challenge of chronic conditions 2. Effective Universal Health Coverage 3. Mexico and Seguro Popular Breast Cancer and UHC Pain control and palliative care Mexico, 2003: Health Reform Almost half of Mexican households lacked health insurance, which limited access to care, reduced opportunities for risk pooling, and generated catastrophic expenditures. Legislative reform introducted Seguro Popular and the System for Social Protection in Health Seguro Popular, Results Lancet 2012 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 Expansion of Coverage: Seguro Popular Horizontal Coverage: Beneficiaries V e r t i c a l
MING FPCHE EPHS EPI CBP # Int. Causes + FPCHE # Int. MING + SP + FPCHE Seguro Popular 284 interventions MING + SP FPCHE 59 interventions CAUSES 91 FPCHE 6 Notes:
SP = Seguro Popular MING = Medical Insurance for a New Generation (Children born after December 1, 2006 and until they are 5 years of age) now XXI Century Medical Insurance FPCHE = Fung for Protection against Catastrophic Health Expenditure EPHS =Essential Personal Health Services EPI = Expanded Programme of Immunisations CBP= Community-based package Evolution of vertical coverage: cumulative # of covered interventions, 2004-2013 Mexico Seguro Popular: financial protection for catastrophic illness Accelerated, universal, vertical coverage by disease with a package of interventions
2004/5: ALL in children, cervical, HIV/AIDS 2006: All pediatric cancers then all children 2007: Breast cancer 2011: Testicular, prostate and NHL 2012: Colorectal cancer Seguro Popular and cancer: Evidence of impact Childhood cancers adherence to treatment: 70% to 95% Breast cancer INCAN 2005: 200/600 2010: 10/900 The human faces: Guillermina Avila Abish Romero The 2003 reform creates a new financial model: Funds of the System of Social Protection in Health * Since Dec 2006. ** Since 2013 Source: Adapted from: Frenk J, Gonzlez-Pier E, Gmez-Dants O, Lezana MA, Knaul FM. Comprehensive reform to improve health system performance in Mexico. Lancet 2006; 368: 1524-34. Public goods Services to people Health goods Funds Stewardship functions Health services to the community Essential services High specialty interventions Budget of the Ministry of Health Federal FASSA-C FASSA-P / CAUSES FPCHE Seguro Popular de Salud MING* / XXI CMI** Level 1 a 3 1 1 y 2 1 y 2 3 Communication between funds and levels is problematic, but the population moves between them B e n e f i t s :
c o v e r e d
i n t e r v e n t i o n s
Delivery and financial protection challenges: Seguro Popular in Mexico ACCELERATED VERTICAL COVERAGE for Catastrophic Illnesses included in the Fund: breast cancer, AIDS Community and Public Health Services Poor Rich CHILDREN: Health insurance for a New Generation / XXI Century Med Ins. Package of essential personal services Beneficiaries Effective financial coverage of a chronic disease: breast cancer Mexico: Large and exemplary investment in financial protection for breast cancer prevention and treatment, yet..a low survival rate. Strengthen early detection, survivorship and palliation Cancer Control-Care continuum Primary Prevention Early Detection Diagnosis Treatment Survivorship Palliation Stage of Chronic Disease Life Cycle /components CCC Finantial protection Primary Prevention Secondary prevention Diagnosis Treatment Survivorship/ Rehabilitation Palliation/ End-of-life care Costa Rica Mxico Partially Partially Colombia Partially Partially Partially Dominican Rep. Partially Peru Coverage of breast cancer in select LAC countries by control-care continuum Outline 1. UHC and the challenge of chronic conditions 2. Effective Universal Health Coverage 3. Mexico and Seguro Popular Breast Cancer and UHC Pain control and palliative care Pain: a global injustice Every year, millions of people suffer unnecessarily from moderate and severe pain, including 5.5 million cancer patients 83% of the worlds population lives in countries with few or no access to pain medicines High-income countries represent less than 15% of the worlds population but more than 94% of total global morphine consumption Even though most pain medicines are off-patent and of low cost, they are expensive in poor countries: Monthly supply of morphine US$1.80 at $5.40 vs US$60 at $180. The most insidious injustice: The pain divide 272,000 mg 2,300 mg 267,000 mg 6,600 mg 37,000 mg Source: 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 mg US/Canada: 270,000 mg Recent major global progress 2014: 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 urges Countries 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 In Mexico Legislative innovative benchmark at a global level: 2009: modification of the General Health Law and Law on Palliative Care 2013: Expansion of the General Health Law on palliative care matter However.. Out of the 83,771 deaths from cancer or HIV/AIDS in 2010, 65,447 patients died in pain Barriers to access palliative care by health system function Health System Functions
Components of the continuum of disease and life cycle Prevention Survivorshi p Palliation, pain control and end-of-life care Stewardship Unifying National Program/Plan lacking Weak, restrictive, and poorly defined regulatory frameworks Absence of an institutional system for monitoring and evaluation Financing
CAUSES and FPCHE: theres no explicit coverage; In Social Security, a whole Delivery Lacking service units Supply and distribution chains incomplete geographically Resource Generation
Scarcity of qualified personnel Fear in the prescription Incorporation of relevant classes in university curricula is missing Absence of published investigations A growing global movement for universal coverage is advocating for the transformation of health care into a universal right, which entails a transition from traditional social insurance as an employment benefit to universal social protection of health, a right of citizenship. Translation of this social right into practice is a quest - it implies a continuous strengthening of health systems to enable them to offer effective universal coverage in the face of chronic illness. Universal Health Coverage and the Rise of Chronic Disease: A Latin American Quest
Felicia Marie Knaul 10th iHEA World Congress
Health Economics in the Age of Longevity:
July 15, 2014 Session: Universal Health Care
The authors appreciate the financial support of Harvard U, and IDRC Canada