World Health Organization 6 September 2018 Scaling up for treating cancers in LMIC: towards a comprehensive cancer treatment programme Andreas Ullrich MD MPH Geneva Switzerland

Cancer burden by type

Cancer Control Capacity (2011)

World Health Organization Population per Radiotherapy Service http://cancer.iaea.org/agart.asp

Health system for cancer control

The “cancer chapter” of the NCD action plan Every country with a national NCD strategy which includes: Behavioral risk reduction/ HPV/ HBV Cervical cancer screening Cancer registry

Projections NCD avoided Four main non-communicable diseases BAU % Achieving Targets % Deaths avoided Below 70 Beyond 70 All cardiovascular diseases 18 34 11 400 000; 15 900 000 All cancers 3 7 2 400 000; 2 100 000 Chronic respiratory diseases 16 - 24 1 200 000; 2 500 000 Diabetes + 11 - 5 1 100 000; 900 000 Total - 10 - 21 16 100 000; 21 400 000 BAU Business as usual Achieving 6 NCD Targets

What we can learn: Behavioural Risk Reduction alone will not achieve 25x25 Goal Infectious /environmental factors are at the forefront in Low and Middle income Countries Early detection + treatment: key element of additional contribution to 25 x 25 Goal Strengthen health care systems is at stake

Comprehensive approach PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY PREVENTION Comprehensive approach Framework New stakeholders and partners for cervical cancer prevention and control Ministry of health: Immunization, sexual and reproductive health, adolescent health, cancer control, and HIV prevention partners, Ministry of education: school health, Women's groups Community based group to reach girl out of school Interdisciplinary stakeholders and solid in-country coordination needed by MoH

Cancer Screening Cervical cancer Breast Cancer Colorectal cancer Oral cancer

Success criteria • Feasibility in pilot • Governance and leadership. • health system • Validated protocols and guidelines • Quality assurance and information systems • Regular monitoring, • Sufficient organizational and financial

A health system for cancer control Using a building block framework Integration into existing health care systems Medicines Workforce Services Governance

Challenges for service integration Services Challenges for service integration Proposed linkages HIV services Increased access to cancer care Expected outcome Existing services Provincial hospital Almost absent Tertiary care Priority intervention: Prevention / palliative care Community Reproductive Primary Health Care

The cost of cancer Method (1)* : costs of care ( 53%) + care givers (23%) + productivity loss (24%) *: > 1.16 Trillion US $ = 2% GDP Method (2)** statistical life approach + variety of individual costs > 2.5 Trillion (1.7 HIC / 0.8 LMIC) * Beaulieu Economist Intelligence (2010) ** WEF (2011)

Cancer Medicines: Sales & Market Share by region * $ Million

Cost of Cancer Treatment: Breast Cancer

Fundamental tension(s) over how to solve the ‘cost crisis’: multiple lessons…… Human desire for health services Accurately measure costs & link to outcomes, Robert Kaplan & Michael Porter, Sept, 2011 Harvard Business Revew Implement Value Based Pricing Convergence of ‘regulatory- acceptable’ efficacy & effectiveness: greater hurdles for all domains to demonstrate Reduce / stop off label use Mandatory integration of socio- economic studies into clinical research Why do we love medicines so much? EMBO Reports 2010 11: 572-78

The way forward Political: UN NCD review July 2014: the opportunity for the professional cancer organizations to join the debate Normative: Expansion of the WHO model essential medicines list for anti neoplastic medicines Clinical: Collaboration with professional organizations (ESMO ASCO SLACOM): national treatment standards Research: health system for cancer control, analysis of effectiveness /cost –effectiveness of cancer treatment regimens