The latest and greatest in global health trends and how GCI fits in.

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How Fragmented Health Systems Hurt Patients

Health system fragmentation is common in low- and middle-income countries. Most countries in Latin America have fragmented health systems with many different health coverage schemes – none of which are universal, and most of which exclude the poorest and most vulnerable patients. The result? A large proportion of patients who need care the most cannot access it, especially for complex chronic diseases like cancer.


What is health system fragmentation?

Health system fragmentation happens when there are many different health “subsystems” that coexist, providing care for different parts of a country’s population. Each of these subsystems has their own way of financing and delivering healthcare, and each provides healthcare to different types of people.  For example, one subsystem will provide coverage for government workers, another will cover formally employed persons, and yet another will attempt to provide basic health benefits for the unemployed, etc.


What is the problem?

The problem is that when these subsystems operate independently from one another, they create major gaps in the provision of health services, often leaving out the poorest patients. Overall, fragmented health systems are less efficient, and provide fewer resources to those who need care the most, leading to great health inequities throughout a country. The issues arising from health system fragmentation are compounded by the fact that many health systems are not well funded by government spending in the first place, especially for chronic diseases like cancer. In fact, while Latin America spends an average of 7.7% of its GDP on cancer care, the U.S. spent nearly 18% of its GDP. Now imagine this small amount of money being used inefficiently and spread over a much larger population. Low- and middle-income countries represent 85% of the world’s population and 61% of new cancer cases globally, but they account for only 6% of global expenditures on cancer care.


A major barrier to accessing care

Fragmented health systems are very difficult for patients to navigate. Trying to move from a primary care center to a more specialized cancer center can be confusing, difficult, or even impossible if a patient doesn’t have proper insurance coverage. Because of this, fragmentation causes delays in diagnosis and initiating treatment, leading to late-stage disease and high mortality rates. Patients throughout Latin America have low screening rates, delayed referrals, and sometimes won’t even seek medical help because of these barriers.


“Catastrophic out-of-pocket expenses”

When health systems are fragmented (and not well-funded to begin with), they require high out-of-pocket expenses from patients at the hospital when they seek health care. Now imagine a family without health insurance, or even an inadequate public health insurance. If a member of that family is diagnosed with cancer, they would face health payments that would drive them into poverty – what we call “catastrophic out-of-pocket expenses.” In 2008, it was estimated that ⅓ of the people in Latin America were considered at high risk for such impoverishment due to catastrophic health expenditures.


Moving toward Universal Health Coverage

The WHO, in partnership with the World Bank, developed an agenda in 2015 to move towards universal health coverage (UHC) worldwide. It is clear that there are major gaps in the provisions of healthcare around the world: over 400 million people do not have access to one or more essential health services. Universal health coverage, in the form of national insurance schemes provided by governments, would not only ensure that basic health care is provided to everyone in that country, but would make the provision of health services more efficient and more equitable.


Importantly, the move toward basic universalism is targeted towards the poorest sectors – the most vulnerable patients with the most barriers to care. Latin American countries have begun to move in this direction by creating special agencies to provide basic care for those who were previously uninsured. Due to this expansion of basic coverage, the proportion of people covered by insurance systems in Latin America grew from 46% to 60% between 2008 and 2013.


How to improve patient care now

The move toward universal health coverage will take time and will be more difficult for some countries than others. However, there are ways we can work within the broken systems that currently exist to help patients access the care they desperately need now. For example, through our Patient Navigation Programs, navigators facilitate patients’ passage through fragmented and complex health systems. They help underserved patients access health resources and overcome barriers they may encounter while trying to get cancer care, like making referral appointments and coordinating insurance paperwork. By providing patients with a knowledgeable resource and support system, navigators can help alleviate some of those systematic barriers to care that would usually stop patients in their tracks when trying to access the care they need.


The information and data in this post are summarized from our Lancet Oncology commissions: Planning Cancer Control in Latin America and the Caribbean and Progress and Remaining Challenges for Cancer Control in Latin America and the Caribbean


Global Tumor Boards Connect Doctors to Improve Patient Care

Jessica St. Louis is the senior program coordinator for GCI and has been with GCI since its inception. Among her many duties, she coordinates Global Tumor Boards: live, online videoconferences that connect doctors from around the world to discuss complex patient cases. Here, Jessica answers some of the most frequently asked questions about these tumor boards and how she works with GCI’s global network to make them happen.


What are tumor boards?

Global Tumor Boards are meetings where a multidisciplinary team of doctors get together to discuss complex patient cases. They are not only valuable for patients, who of course benefit from having multiple doctors reach a consensus on best treatment and care, but they are also an important educational tool. They offer an opportunity for doctors to collaborate and learn from each other – even from different continents.

How exactly do Global Tumor Boards work?

Our tumor boards are online videoconference meetings with the ability to host 15 cameras and unlimited numbers of viewers who can watch the meeting. This is unique in that we can connect and communicate with hundreds of doctors at once in real time from our office in Boston! Doctors can also go on YouTube and watch recordings of our previous tumor boards at any time.

Who are the doctors that join tumor boards? Where do they come from?

Doctors who join our tumor boards are from over 18 countries in Latin America, Eastern Europe, Africa, and Asia. In total, our tumor boards have reached over 350 doctors worldwide. The patient impact of Global Tumor Boards is huge, considering that one doctor typically treats hundreds of patients per day.

What exactly do these doctors talk about during the one-hour meeting?

GCI holds monthly tumor boards on breast and gynecologic cancers. In each meeting, we invite hospitals from low- and middle-income countries (LMICs) to present challenging patient cases to a panel of multidisciplinary experts from prestigious cancer centers in the United States, including Johns Hopkins, Stanford University, MD Anderson, and others. Our panel of experts help the doctors reach a consensus on each patient’s treatment. We find that many doctors have similar challenges when providing cancer care in LMICs with limited resources. We discuss these resource challenges as well as GCI’s research initiatives and interventions to improve access to clinical care.

Why does GCI do tumor boards?

Global Tumor Boards are an effective way to improve patient care through doctors. The doctors in these countries often work in multiple hospitals and see hundreds of patients a day without the guidance of their peers. This burden prevents doctors from keeping up to date on clinical practice guidelines.

They are a great way to engage doctors in patient care discussions with their peers – doctors really enjoy talking about medicine with one another! It creates a “beehive effect” where doctors can learn together and build similar levels of clinical knowledge and styles of practice. We also engage the doctors in discussions about how their patient cases relate to “bigger picture” cancer control issues and public health interventions.

Besides that, it is very comforting for patients to know that their cancer is being watched by a team of doctors who came to a consensus about the best step forward.

What kind of technical capabilities are required to be part of a tumor board?

All that’s needed is a computer with a camera, microphone and an internet connection.

How can I join?

If you are a doctor in a LMIC and would like to join Global Tumor Boards, please contact us at !