Improving Access to Pain Control and Palliative Care

Through Global Alliances

UHN Princess Margaret Cancer Centre
Friday, July 25, 2014


Closing the Global Divide
in Pain and Palliative Care:
An equity and health systems perspective
Dr. Felicia Marie Knaul
Harvard Global Equity I nitiative and Harvard Medical School
Fundacin Mexicana para la Salud and Tmatelo a Pecho
Board Member: UI CC
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.
Outline
1. The divide in access to pain control
and palliative care
2. Universal Health Coverage and the challenge
of chronic conditions
3. Effective universal health coverage and the
Diagonal approach
4. 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:
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 Cancer Divide:
An Equity Imperative
Pain Control and Palliative Care:
a global injustice
Every year, > 100 million require palliative care; < 8% access
Only 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 patients
83% of the worlds population lives in countries with almost
no access to pain medicines
High-income countries represent < 15% of the worlds
population but > 94% of global morphine consumption
Most 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 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
India
Trends in opiate consumption in the
Americas 1965 to 2010
LOGARITHMIC SCALE
M
o
r
p
h
i
n
e

E
q
u
i
v
a
l
e
n
c
e

(
m
g
/
c
a
p
i
t
a
l
)

1000
0
1970 1980 1990 2000 2010
SOURCE: Pain & Policy Studies Group. Opioid Consumption Motion Chart. University of Wisconsin. (http://ppsg-production.heroku.com/chart )for 2007 (accessed April 22 2011).
Canada
United States
of America
Argentina
Brazil
Chile
Costa Rica
Mexico
Colombia
Recent 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
Source: Based on WPCA-OMS, 2014, Global Atlas of Palliative Care at the end of life .
Unknown capacity
Building capacity
Isolated provision
Generalized provision
Preliminary integration
Advanced integration

Level of development of palliative care
by country in the world
Outline
1. The divide in access to pain control and
palliative care
2. Universal Health Coverage and
the challenge of chronic conditions
3. Effective universal health coverage and the
Diagonal approach
4. Effective Universal Coverage and expanding
access to pain control 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,
Palliative care and access to pain control
have been almost universally ignored in
UHC
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
Source: Estimates based on Global Burden od Disease Study, 2010. IHME, 2012.
Injuries Non-communicable
Communicable, maternal
and nutritional
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
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.
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)
Communicable or infection
associated
NCD


Chronic
HIV/AIDs (KS) Breast cancer




Acute




Diarrheas
Respiratory infection


Acute myocardial infarction
Acute Lymphoblastic
Leukemia
Tagged diseases: by chronicity and infection
Chronic w acute episodes:
Asthma, mental
Cervical Cancer HPV)
Long term disability post infection (polio)
Outline
1. The divide in access to pain control and
palliative care
2. Universal Health Coverage and the challenge
of chronic conditions
3. Effective universal health
coverage and the Diagonal
approach
4. 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 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.
Diagonal Strategies:
Positive Externalities
Pain 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 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
An effective UHC 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 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
Health
System
Functions
Components of the continuum of disease and life cycle
Primary
Prevention
Secondary
prevention
Diagnosis Treatment
Survivorship/
Rehabilitation
Palliation/
End-of-life
care
Stewardship
Financing
Delivery
Resource
Generation
Outline
1. The divide in access to pain control and
palliative care
2. Universal Health Coverage and the challenge
of chronic conditions
3. Effective universal health coverage and the
Diagonal approach
4. Effective Universal Coverage and
expanding access to pain control
in Mexico
The Lancet: Universal Health
Coverage in Mexico, a global example
Mexico: 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 m
2013: 55.5 m

Benefit package:
2004: 113
2013: 284+59

Mexico 2003: major health reform
created Seguro Popular
Horizontal Coverage:
Beneficiaries
V
e
r
t
i
c
a
l

C
o
v
e
r
a
g
e



D
i
s
e
a
s
e
s

a
n
d

I
n
t
e
r
v
e
n
t
i
o
n
s
:




B
e
n
e
f
i
t
s

P
a
c
k
a
g
e



Mexico Seguro Popular:
financial protection
for catastrophic illness
Accelerated, universal, vertical coverage by disease
with a comprehensive package of interventions
2004-2013: 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 Mexico
Legislative 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)
0
1
2
3
4
5
13%
>5
# of clinics by state
# Hospitals that provide & stock
morphine by state
0
1
2
3
4
10% 5
10% >5
10%
NA
Source: Dr. Alfonso Petersen Farah, Presentacin: Clnicas del Dolor, Foro Internacional
Promoviendo las Oportunidades de los Cuidados Paliativos en Mxico. Octubre 11, 2013
N = 30
Very few pain control or
palliative care centers
60% have 0-2
70% have 0-4
Barriers to access palliative care by
health system function
Source: Adapted from Knaul, F. M., Gralow, J. R., Atun, R., & Bhadelia, A. (Eds.). Closing the Cancer Divide. Harvard University Press, 2012.
Health
System
Functions

Components of the continuum of disease and life cycle
Prevention
Survivorship
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
Integrated, systemic solutions
applying an all-of-society response



LEGISLATIVE
AND
NORMATIVE
FRAMEWORK REGULATORY
FRAMEWORK
COMPREHENSIVE
INSURANCE
COVERAGE
SUPPLY AND
DISTRIBUTION
OF
MEDICATIONS
CAPACITY
BUILDING
AND
TRAINING
AWARENESS-
PATIENTS
PREVENTION
AND CONTROL
OF ILLICIT DRUG
USE
EVIDENCE
National Plan:
Pain Control
and
Palliative Care
2014
Improving Access to Pain Control and Palliative Care
Through Global Alliances
UHN Princess Margaret Cancer Centre
Friday, July 25, 2014


Closing the Global Divide
in Pain and Palliative Care:
An equity and health systems perspective
Dr. Felicia Marie Knaul
Harvard Global Equity I nitiative and Harvard Medical School
Fundacin Mexicana para la Salud and Tmatelo a Pecho
Board Member: UI CC
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).