When most people think of health in low- and middle-income countries (LMICs), they think of infectious disease. Infectious disease has, after all, been the most pressing health concern for the less developed regions of the world, and it oftentimes commands the attention of both media and global health philanthropy worldwide. However, what most people don’t realize is that non-communicable diseases, such as cancer, are overtaking infectious disease as the leading healthcare threat in these LMICs. And when the health system needs to divide its attention between what we are now calling the “double burden” of communicable and non-communicable diseases, it can get overwhelmed.
It is easy for public health officials to wave off the more gradual growth of non-communicable diseases in these countries, especially when patients are suffering from acute infectious illnesses that seem to demand more immediate attention. But as cancer incidence in LMICs rises due, among other factors, to aging, Western lifestyles, cancer-causing infections, and carcinogenic environmental factors, governments and health ministries cannot stand idly by. The burden of cancer in LMICs is now greater than that in more developed countries, as more and more patients are dying of advanced stage disease.
It is time to take action in LMICs to prevent, detect, and treat cancer as early and effectively as possible, and this is accomplished through national cancer control plans (NCCPs).
According to the World Health Organization, an NCCP is defined as “a public health program designed to reduce cancer incidence and mortality and to improve the quality of life of cancer patients, through the systematic and equitable implementation of evidence-based strategies for prevention, early detection, diagnosis, treatment and palliation, making the best use of available resources.” That’s a hefty definition, but essentially NCCPs lower the number of new cancer cases a country sees each year and improve the quality of care cancer patients receive by following a comprehensive national plan.
National cancer control plans are so important for countries that need to address the growing global cancer burden. Establishing an effective NCCP integrates existing health systems in a country and coordinates efforts to address the complexities of cancer care and treatment. However, many LMICs do not have one of these plans and are even struggling to adopt one in the face of competing health priorities, inadequate resources, and lack of expertise.
Latin America is one example of a region that exhibits a great need for national cancer control plans, but countries throughout the region are struggling to design and implement them. One big hurdle they face? Lack of adequate cancer registries.
Cancer registries are a fundamental requirement for the successful implementation of NCCPs. Why? Because you need to know the problem before you can implement a plan to fix that problem. Cancer registries collect highly valuable epidemiologic data on the state of cancer in a country – which cancers are most common, which areas have the highest cancer burden, who is most affected by cancer, etc. The data collected in cancer registries is essential for health officials to know the who, what, when, where, and why of their national cancer control plans. Armed with the knowledge of the local needs and current deficiencies in cancer care, a country can develop an evidence-based and forward-looking NCCP.
Fortunately, the percentage of Latin American and Caribbean countries that reported having a population-based cancer registry increased from 21% to 67% between 2011 and 2014. However, there is still a long way to go, as the proportion of the population that is actually covered by these registries is still quite low compared to developed countries. As the quality and quantity of data collected in Latin America grows, health authorities can begin to establish specific public health strategies to address the growing burden of cancer throughout the region.
Peru is a great example of a country in Latin America that has created, adopted, and implemented a national cancer control plan, which they have named “Plan Esperanza.” Plan Esperanza was created by a multidisciplinary team, including policy makers, that brought together different constituents to put forth comprehensive cancer control policies. The plan now impressively includes ten neoplastic diseases. Since the adoption of their NCCP, the following amazing things have happened in Peru:
- The proportion of patients included in the universal healthcare system increased from 17% to 64%
- The proportion of patients who paid out-of-pocket expenses for cancer treatment decreased from 59% to 7%
- 16 million people have received preventive interventions, such as educational sessions and counselling
- 2.5 million people have been screened for cervical, breast, gastric, colon, or prostate cancer – or a combination of these diseases
National cancer control plans like Peru’s are so important that coordinated international efforts – spearheaded by big organizations like the WHO – have been cropping up over the past few years. For example, the WHO endorsed the Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013-2020, which aims to achieve a 25% reduction in premature mortality from NCDs by 2025. WHO and PAHO (the Pan American Health Organization) launched the Women’s Cancer Initiative to bring together partners to set up action plans for the prevention and control of cervical and breast cancer in Latin America. Finally, the International Cancer Control Planning Partnership (ICCPP) was launched due to the combined forces of the Center for Global Health and the National Institutes of Health in the United States, the Latin America and Caribbean Society of Medical Oncology, PAHO, and the Union for International Cancer Control. The goal of the ICCPP is to implement and assess national cancer control plans with a worldwide framework and international support.
Undoubtedly, there is an urgent need to plan, develop, and better implement national cancer strategies, as low- and middle-income countries continue to bear more and more of the global cancer burden. What other countries or international organizations have been particularly successful at designing and implementing NCCPs? What more is needed from the international community to make these important goals a reality? Join the conversation and comment below!
Information in this post is summarized from our Lancet Oncology Commissions on Planning Cancer Control in Latin America and the Caribbean and Progress and remaining challenges for cancer control in Latin America and the Caribbean.
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