Universal Health Coverage: Background & Political Commitments (Webinar)
Table of Contents
- Thank you to you ICC for the opportunity to discuss this important topic...
- Governing authority to begin the first step is using data to identify what our...
- Can in fact achieve in a result coverage aligned with the three dimensions as...
- Politicians patients civil society providers and other stakeholders to...
- How can we promote quality to begin with that example again where 700 lives can...
- Right-hand side we see that on the y-axis maternal mortality rate on the x...
00:00
thank you to you ICC for the opportunity
to discuss this important topic
universal health coverage wide matters
to cancer patients providers in our
community to again I have no potential
conflicts of interest to disclose when
we look at the broad landscape of cancer
prevention and control in low and middle
income countries we know that
unfortunately a majority of cancer
patients are not surviving their
diagnosis if we take for example a
sample population of 1 million
individuals on average there will be
00:31
about 3,000 cancer cases each year we
can estimate that only about 700 people
will survive that diagnosis because of
low coverage advanced stage disease and
no quality services but at the same time
money is being spent government's are
paying for cancer services to some
extent communities hospitals and of
course individuals but this is our
starting point we recognize that
governments are financing some cancer
care however we know that is currently
01:02
both inefficient and insufficient to
meet the growing cancer burden and as a
consequence patients are suffering high
out-of-pocket expenditure while
suffering poor outcomes so the question
we have to answer is how can universal
health coverage
improve care promote coverage ensure
financial protection and offer every
cancer patient the best possible outcome
in the next 20 minutes we'll work to
address those questions through these
three specific items to begin with the
01:33
definition of what is universal coverage
then to look at the landscape of what
are the political commitments that
governments have made if the recent UN
high-level meeting on UHC and in other
fora that guide this advancement towards
universal coverage and finally to ask
the question of what can each of us do
as stake holders in the cancer community
to promote universal coverage and its
effective implementation to begin with
the question of what is universal
coverage the w-h-o definition of UHC is
02:04
that all people and communities can use
the promotive preventive curative
rehabilitative and palliative health
services they need
of sufficient quality to be effective
while also ensuring that the use of
these services does not expose the user
to financial hardship it is in short a
principle that maximizes population
coverage of cancer or other health
services that provide value for money
while ensuring that there are accessible
quality and affordable the three simple
02:37
parameters to consider access to quality
care when it is needed and without
suffering financial hardship
often times universal health coverage is
broken down into three dimensions to
help us understand how a specific
program can work towards universal
coverage by asking these questions what
services who will receive those services
and how much will be paid to begin with
the question of what services within the
cancer community the objective is for
all cancer prevention diagnosis
03:08
treatment and palliative care services
to be available to any cancer patient
however recognizing that governments
have limited resources for health what
are the priority interventions that
should be included within a universal
coverage scheme this process of defining
what are the priority interventions is
known as defining the benefit package is
achieved through a three-step process of
informed data to identify health
priorities a broad stakeholder dialogue
and a final decision from an appropriate
03:41
governing authority to begin the first
step is using data to identify what our
health priorities historically the
principle of cost-effectiveness has been
used as the guiding parameter to
identify health priorities in practice
other principles should be used that
include for example fairness and equity
acceptability budget impact and
financial risk protection this process
of using data to inform health
priorities is a process that should be
done with as few conflicts of interest
04:12
as possible because the objective is to
use data across disease groups across
different settings and across different
communities to identify a shared set of
priorities
once these health priorities are
identified a broader stakeholder
dialogue is undertaken to ensure that
the process has legitimacy transparency
and inclusiveness and accountability and
it is in this stakeholder dialogue
process where discussions are had on
what are the specific needs for
vulnerable populations and others who
04:44
may have lacked a voice in the broader
discussion on data and then finally a
decision must be made by an appropriate
governing authority that has a legal
mandate to decide what are the final
interventions that should be included in
a benefit package with the recognition
that this authority should reflect the
citizens voice from the w-h-o
perspective we've started with the
exercise of defining what are some of
the most impactful interventions that
all government should include within
their benefit package a process that has
05:15
been identified and known as the best
buy for tackling in CDs non communicable
diseases this is the beginning of a
broader program of work to define what
are the specific priority interventions
that each country should consider
according to their epidemiologic burden
and their context the next question is
who will receive these services again
the objective is to ensure that everyone
can receive cancer services regardless
of precondition but there are
05:46
considerations that have to be made
regarding capacity that is coverage can
be proportional to the service available
we see in some middle-income countries
that coverage can be scaled up rapidly
this often is the result of investments
in health systems to ensure that there
are enough providers enough hospitals
enough medicines and technologies when
we look at the current landscape however
for cancer in tho and lower
middle-income countries we see that
there remain significant deficits in
06:17
basic availability of services that is
the coverage of key cancer services such
as surgery chemotherapy radiotherapy and
given this context the principle is
coverage is further complicated that
this is only a question of are the
services accessible
it does not consider quality or
financial protection these are covered
in some part to the last dimension which
is how much will be paid and the
objective again is to minimize user fees
06:49
to ensure financial protection the goal
with user fees is to minimize the
financial catastrophe that often occurs
with cancer now how to achieve that
is a point of great discussion it has
been shown that there are diverse
revenue sources that can be considered
to finance healthcare the financing
mechanism is not necessarily the
important output for this dimension what
is critically important is the percent
of people that suffer financial
07:21
catastrophe or financial harm you can
see in the table on the left portion of
the screen a sample of countries that
have reported the number of individuals
who suffer financial harm from the
cancer diagnosis and as you can see the
concerning statistics reflect that many
cancer patients are selling their homes
smelling their personal possessions to
access care this is not consistent with
the principle of Union or self coverage
and an important parameter for us to
consider when developing systems that
07:52
can in fact achieve in a result coverage
aligned with the three dimensions as
presented we can ask ourselves why does
it matter why is universal coverage so
important in cancer there was an
excellent study that was produced in
2016 in The Lancet and demonstrated that
for countries that are that have
achieved universal coverage they in fact
are able to deliver better health
outcomes particularly during economic
downturns that is the most vulnerable
segments of the population can still
08:24
access high-quality cancer care even at
times when resources may be limited this
reinforced the principle that universal
coverage is a cyclical investment it
leads to stronger health systems and in
fact will ultimately achieve better
cancer outcomes as the immediate past
director-general said of the w-h-o dr.
Margaret Chan universal health coverage
is the most powerful
except that public health has to offer
now universal coverage is not a point in
08:55
time when governments can easily raise a
flag and say we have reached the
pinnacle of universal health coverage
when we look at the landscape of high
income countries we see that universal
coverage really is a journey and not an
endpoint in fact in some countries it
took the better part of 50 70 or 100
years to achieve 100% coverage with
financial protection and even when that
is achieved particularly in disease
programs like cancer where there are
rapid discoveries this principle of
09:26
universal coverage will change what in
fact are the services that should be
included for example should some of the
innovative cancer therapies be included
in a benefit package and these are some
of the questions that governments of all
income levels are grappling with as they
try to maintain a universal coverage
scheme for health services so what is it
that governments need to do we know when
we look at four key objectives there are
existing major obstacles that
governments have to consider as a
starting point we know that current
09:58
health expenditure is insufficient
particularly in though unknown countries
the estimated gap is approximately 146
billion dollars per year as the second
point we know that service organization
or service structure often compromise
outcomes for rural populations and those
that are poor because accessing
high-quality Cancer Care is difficult we
know that the set that financial
protection for the set of priority
interventions often leaves people with
out-of-pocket expenditure that forces
10:29
them and their families into poverty
when it is not appropriately compensated
for from public funds and then finally
we know that governments while
increasingly investing in health are
still subjected to significant
inefficiencies the bucho in the past is
estimated that twenty to forty percent
of health spending is wasted so what can
government's do on the screen you can
see that there are some potential
interventions in each of these four
parameters for example promoting Public
Health functions
11:00
investing in prevention to reduce
downscale investments that are may be
needed for treatment and palliative care
we see government's increasing
investments in primary care to
facilitate earlier diagnosis and access
to more advanced therapies for rural
populations we see the principles of
equity and the need for equity to guide
the definition of priority interventions
in a country health technology agencies
increasingly being used to evaluate
priorities and finally for there to be
11:31
stronger data systems to ensure that
programs that are implemented are done
so effectively and while minimizing
inefficiencies and corruption that often
result in wasted healthcare dollars
above all these four guiding principles
we know that political will is needed
now political will is a broad concept
the definition is listed on the screen
but what is most important for the
stakeholders attending the leaders
summit is to recognize we all have a
voice in generating political will
12:00
politicians patients civil society
providers and other stakeholders to
achieve those four parameters there is a
key voice that each of us must
contribute to promote universal coverage
in our countries in our settings so what
is it that governments have committed to
with this increasing recognition that
the political will is being generated at
the global level as some of you may know
just last month governments from around
the world reconvened in New York at the
United Nations to commit themselves to
12:34
universal coverage in what is known as
moving together to build a healthier
world building on commitments that have
been already made in the 2030 agenda for
sustainable development two quotes just
to highlight how important of a meaning
this was the secretary-general of the UN
stated the most that this was the most
comprehensive agreement ever reached on
global health a vision for universal
health coverage by 2030 the director
general of the wao stated that UHC is a
political choice that today's world
13:05
leaders have signaled their readiness to
make that choice and this is now where
we as the cancer community
pick up the ball and ensure that all
cancer patients are covered through a
universal health coverage scheme there
is a long history of UHC in fact it
dates back over five thousand years with
the recognition that governments and
communities have a responsibility to
promote health within their populations
the late 19th and early 20th century was
the beginning of in public health care
13:38
services for broader populations it was
first defined or first recognized as a
formal government system in the 19th
century in Germany and from that process
forward we saw many countries take up
the program of public health care
services then Universal covered freely
found its voice in the 1978 Al Motta
declaration which introduced this
principle of health for all this was the
beginning of universal coverage in the
modern era then four years ago
government's formalized that commitment
14:10
in the sustainable development goals for
which universal health coverage is one
of the health-related targets and since
then we have increasingly seen
governments and regions make this
commitment in a more concrete way in the
progression towards a more formal
universal health coverage scheme and
they're covered in their countries now
what happened one month ago that was
particularly unique as the starting
point some may say well cancer wasn't
highlighted within the political
declaration but in fact that wasn't the
14:41
objective the objective was to highlight
that these are cross-cutting investments
that governments must make to ensure
health for all and it is worthwhile to
notice that non communicable diseases
were broadly mentioned three times in
the political declaration increasingly
highlighting the recognition governments
have that NCDs including cancer are a
reigning public health concern tangibly
government's committed to develop
national targets for universal coverage
by 2020 and to re-emphasize the resolve
15:11
to reach UHC by 2030 as committed in a
sustainable development goal this
included the commitment to cover 1
billion more people by 2023 which aligns
with the w-h-o triple billion target
specifically government's want to focus
in the short term on the rise of
out-of-pocket expenditure a point of
particular relevance in the cancer
community at the same time the UN was
asked to commit to providing coordinated
support across different UN agencies
force the w-h-o will act as the host for
15:44
a multi-agency Network the UN also
committed to host a follow-up meeting at
the UN high-level meeting of 2023 where
UHC will again be presented so what is
it that we can do as a community as we
look forward to the next four years and
towards the 2030 target there are four
specific activities that we can consider
as a community how can we support
defining priority interventions how can
we contribute to expanding coverage how
can we ensure financial protection and
16:14
how can we promote quality to begin with
that example again where 700 lives can
be saved for that 1 million population
as a starting point we as a community
can help governments identify what are
the most impactful interventions to
include in a benefit package recognizing
that some of the commitments and
investments that have been made to date
may not have yielded the return that we
had hoped an example is for example a
targeted therapy without investing in
the pathology to identify who would
16:47
benefit that targeted therapy or
investing in a screening program but not
ensuring that diagnosis and treatment
are available if we in fact take the
money that's currently allocated for
cancer and focus on priority
interventions that are cost-effective
and promote equity we can in fact save
more lives and do so at a lower overall
cost and this dialogue on how to
identify a priority package of services
is an exercise that w-h-o and IARC have
taken on working with other UN agencies
17:18
hub governments in the specific context
understand what are some of the priority
interventions that should be included in
that countries benefit package to give a
brief example of how far we have to go
and some of the challenges we're
currently facing is that we still find
government's are undertaking cancer
programs that are not based on the best
evidence when we look for example at
breast cancer screening
we found that a significant percentage
of countries are screening populations
that are younger than 40 or 50 and we
17:49
know that this is not cost-effective and
yields a significant inefficient
inefficient expenditure in cancer care
these are the types of exercises where
the cancer community must come together
and focus on investing in best practices
in evidence-based policies and programs
to ensure that money that is spent in
cancer is done so effectively second is
the recognition that expanding coverage
is the guiding principle in the most
short term effective way to improve
18:21
population outcomes for cancer if we
were to give two scenarios to help
inform what it means to expand coverage
in scenario number one if the government
has to decide between increasing
participation and cervical cancer
screening or starting a new program for
breast cancer screening which is a more
appropriate investment or a second
scenario if the government must decide
between introducing a new targeted
therapy for lung cancer or increase the
number of women who are receiving trust
souza map which is the better investment
and we know that again by starting with
18:53
priority interventions and promoting
population coverage governments can
ensure that the greatest population
health can be achieved so expanding
coverage is the most important guiding
principle for ensuring cancer services
are optimized at the population level
next is to work together to promote
financial protection we do know that
cancer is an expensive disease but it
does not need to be prohibitively
expensive and one didn't when done well
the financial consequences can in fact
19:25
be low cancer can be seen as an
important Health System investment
rather than an overall cost we know that
countries as you can see in the graph on
the screen right are spending increasing
amounts of cancer even disproportional
to the broader disease burden in the
country but what is important is for us
to develop a consensus as a community as
to how can we ensure that the patients
are not suffering the consequences for
the increased complexity
in costs of Cancer Care one important
19:56
starting parameter is for us to more
accurately monitor out-of-pocket
expenditures for our patients by having
discussions with them and with public
agencies to understand what are the
out-of-pocket cost that cancer patients
may be subject to and how can we as a
community minimize them when in fact
there are a variety of mechanisms to do
so another important parameter for us to
focus on as we progress towards universe
health coverage is to understand the
importance of quality if we look for
example on screen figure on the
20:28
right-hand side we see that on the
y-axis maternal mortality rate on the x
axis institutional birds we would expect
that countries that have a high
proportion of institutional birds that
is women delivering in a hospital should
have the lowest maternal mortality rate
but in fact what we find is that the
correlation is very weak as the
immediate past director general of the
w-h-o has said what good does it do to
offer free maternal care and have a high
proportion of babies delivered in health
facilities and the quality of care is
20:59
substandard or even dangerous for us in
cancer we know this is also a very
relevant question one could does it do
to offer cancer care if a patient
requires a region after initial
operation or if they suffer a
complication from the medicine that was
not handled or administered
appropriately these are the challenges
that each of us as stakeholders in the
communities can focus on how can we
improve quality within our specific
programs and areas of work when we look
at the consequences we see comparing
21:30
outcomes from two countries that stage
specific survival can be as profoundly
different as 10 to 20 percent and these
are countries where the available
treatment is not significantly different
for example the management of cervical
cancer this then raises the question of
quality we can estimate then that
approximately 15 to 25 percent of
survival gaps can be explained by low
quality which translates to one to two
million lines per year this has massive
consequences for outcomes and
22:03
expenditures cancer
why well a discussion on why quality of
cancer care can be low is a complex one
but just to begin workforce capacity
out-of-date practice guidelines and a
failure to coordinate services as three
simple reasons
and finally with that as our guiding
principle universal health coverage what
is it that each of us can do we have the
four guiding principles how does this
then translate to questions or actions
that each of us should take to begin
22:32
defining a package of services we can
ask ourselves as a community what
treatment should be prioritized what
services are truly essential what should
be prioritized in the first phase and
what should be potential opportunities
for scale-up
then what can we do to promote coverage
how can we arrange the vulnerable how we
organize services how we structure the
facilities geographically how we
coordinated care between those
facilities are there interventions that
can increase efficiency for example can
we improve the efficiency of a pathology
23:05
lab by using tele pathology and if so
can we use that as a mechanism to
promote population coverage financial
protection what our patients able to
afford how can we use public funds to
support the gaps that patients are
currently being subjected to paying out
of pocket for cancer services how can we
advocate for our patients and the public
sphere to minimize out-of-pocket
expenditure and then finally what can we
each do to prioritize quality how can we
disseminate best practices what
23:36
contributions can we make to
multidisciplinary care recognizing that
it is beyond just a voice of providers
that is needed in fact is the voice of
patients communities policymakers that
is required for us to develop high
quality cancer programs with that is our
platform we have a unique opportunity as
a community to improve cancer care for
all through the mechanism of universal
coverage we look forward to the
discussions that will take place at the
upcoming world cancer leader summit in
North Sultan and very much appreciate
24:07
the opportunity for you ICC to
facilitate this dialogue at the global
level using the world cancer leader
summit as the forum we look forward to
greeting you there and thank you again
for your
tension and concern