In recent years, a series of World Oncology Forums have brought cancer specialists together with global health organisations and national health policy makers from many countries to try to develop a global response that could do for cancer what the Global Fund does for AIDS, tuberculosis and malaria. Anna Wagstaff and Richard Sullivan sketch out how the discussion has gone so far.
CHARACTERS IN ORDER OF APPEARANCE
- Cancer specialists
- Ministers of Health from many low- and middle-income countries
- Global health bodies – (a loose coalition of governmental, non-governmental and charitable bodies involved in health and development policy and practice)
ACT 1: DEFINING THE PROBLEM
The curtain opens on a large table at which all the characters are seated. The walls are empty except for a large clock, which ticks audibly throughout the proceedings.
CANCER SPECIALISTS: Cancer is the fastest growing cause of premature death across the developing world. By 2030 it will account for 13 million deaths every year. Around 70% of cancer deaths occur in in low- and middle-income countries, and that proportion is set to rise. It is estimated to cost more than 1 trillion dollars – that’s 12 zeros – every year in lost output and the cost of care, not to mention the damage it does to families deprived of breadwinners and grandmothers. It plays a role in preventing economic development in the countries that need it most. Guys you need a plan! We can’t believe you’re not taking this more seriously!
HEALTH MINISTERS: Are you kidding? If you haven’t worked out how to prevent it or cure it, how do you expect us to? We have very little money, and we spend it where it has the greatest impact. Cancer is expensive and difficult to treat, we don’t have the expertise, we don’t have the equipment, and even if we did, by the time people make it to an oncologist, they’re usually beyond saving.
GLOBAL HEALTH BODIES: Don’t tell us we’re not taking this seriously. So maybe we were wrong to have left chronic diseases off the Millennium Development Goals, but we’ve made up for it now. Prevention – including vaccination against cancer-causing viruses – and low-tech screening are now key elements of the Sustainable Development Goals. They feature in the Political Declaration from the UN High-Level summit on non-communicable diseases – which, by the way, most of you health ministers signed up to – and they are integral to the WHO Global Action Plan for the prevention and control of non-communicable diseases, within the context of extending universal healthcare coverage. But if you’re asking for a Global Fund just for cancer, frankly we’re not keen on the idea.
CANCER SPECIALISTS: We’re asking for help treating the millions of people in resource-stretched countries who get diagnosed with cancer every year. OK, so cancer does share certain risk factors with diabetes and heart disease, but you know perfectly well that it’s not just another ‘non-communicable disease’. Cancer can strike at any age, it invariably kills if left untreated, and diagnosing and treating cancer needs infrastructure, planning and a mix of expertise that is in no way comparable with managing diabetes or heart disease. “Preventing the preventable” is of course the first line of defence, particularly to prevent smoking- and diet-related cancers. But people will still get cancer, and they will still need it detected in time, diagnosed correctly and treated or palliated. This requires surgeons, radiotherapists, medical oncologists and others with experience, expertise and adequate equipment. Are you really saying that it’s not a global health priority to help governments put that in place?
GLOBAL HEALTH BODIES: Focusing on prevention makes sense for us, because it’s relatively cheap, and where it works it can be very effective. And focusing on infectious diseases makes sense because we know by and large how to do it. And focusing on tobacco makes sense because it is such a major cause of ill health – though it’s fair to say that our impact has been less than we’d hoped. But the problem with cancer, as you say, is that even with the best prevention measures, it will always be with us. With the best will in the world, global aid is not the solution. India alone has a population of more than 1 billion. Pakistan, Nigeria, Myanmar, Congo all have around a million people. It’s up to all you health ministers to develop sustainable services and fund them from public money. And, by the way, we’d like to point out to all you cancer specialists that lobbying for governments to invest in developing ‘vertical’ services for your particular disease, without reference to the many other health problems they need to address, is very unhelpful as it sucks resources away from other urgent needs.
CANCER SPECIALISTS: It’s not “our disease”. It’s the fastest growing health problem across developing countries, and the one that governments are least equipped to deal with, in part because of stigma, fatalism, and misinformation. If we hadn’t spent the last ten years raising awareness about the coming epidemic, no one would be talking about it now. If we hadn’t prepared policies on how to develop national integrated cancer plans, if we hadn’t run pilot schemes, then governments would have no idea how to do it. And yes, cancer plans are indeed ‘vertical programmes’, because there’s no point using primary care resources to ensure people get their cancers detected earlier if they have no access to specialised diagnostics, treatment and care.
GLOBAL HEALTH BODIES: Well we would question the value of building shiny new high-end cancer centres when time and again we’ve seen they are unable to put their capacity to use because by the time patients get there, it’s too late to save them. Getting prevention and early detection – and palliation – has to be the starting point, and that means investing in strong primary care networks. That’s why we want to prioritise ‘horizontal programmes’ in an effort to achieve basic universal health coverage, which the majority of people in LMIC countries still have no access to. If we’re honest, we’ve been pretty disappointed at how little support our efforts have had from you cancer specialists.
CANCER SPECIALISTS: We’d happily play a stronger part in calls for universal health coverage so long as it includes essential cancer services, including treatment and care. Actually some of us have been leading efforts within the Noncommunicable Disease Alliance, but we won’t deny we do worry that if we focus our efforts on what we have in common with heart disease and diabetes, we play to the agenda of those who argue that developing countries should essentially stick to prevention, and limit their treatment ambitions to the more simple conditions. That would mean abandoning millions of men, women and children who will be diagnosed with cancer, and we won’t compromise on that.
HEALTH MINISTERS: Hey guys, guys, if we could get a word in… Look we really appreciate your concern, and we do see that cancer is a big problem in our countries, that it drains our productivity, and it causes grief and hardship in families and communities. In fact many of us have had to send family members abroad for treatment, as it happens, so if there’s a realistic chance of improving options for treatment at home, we’d certainly be interested. The trouble is that we also see how expensive it is to treat. Even your industrialised western economies are struggling with the cost. So it’s all very well to say it’s up to us health ministers “to develop sustainable services and fund them from public money”. How about you tell us exactly how we are meant to find the resources to do that.
ACT 2: IDENTIFYING SOLUTIONS
CANCER SPECIALISTS: Look it’s true that a lot of the stuff used in Western health systems comes with a pretty shocking price tag, but we’re not promoting that. We’re talking about some essential pathology and imaging, a handful of cancer drugs on the – recently updated – WHO essential medicines list, adequate access to opioids, basic radiotherapy capacity, and investing in surgical services, which are highly cost-effective in resource-poor settings. You can’t provide meaningful universal health coverage without a decent surgical service – so why not include some key cancer surgeries? What you health ministers and your governments need to be focusing on is the economic price your countries pay by not investing in cancer services. If you focus on your own cancer priorities, and make sure you get the basics right, it will pay off quite quickly and you’ll reap the rewards year after year.
GLOBAL HEALTH BODIES: We’ll second that. We’ve shown that investing in essential cancer intervention packages – which include potentially curable cancers, such as early breast, cervical and colorectal cancers as well as certain childhood cancers, depending on countries’ own priorities – represent clear value in terms of lives saved and the economic payback. Just search for ‘DCP3’, the disease control priority setting exercise we do in conjunction with the World Bank – it’s all there.
HEALTH MINISTERS: Cost-effective it may be, but that doesn’t mean it is affordable.
CANCER SPECIALISTS: True. A lot of work has been done on this by health economists, and it’s clear that those of you from countries at the more resource-poor end of the LMIC spectrum would need help. The Lancet Commission on Global Surgery 2030 estimates that raising surgical capacity to meet population needs would require countries in the upper-middle income bracket to raise their health spending by around 1%. That shouldn’t be impossible should it? But those of you from lower-middle income and low-income countries would be looking at around 6% and 8% increase respectively, so we get that you would need a bit of help.
GLOBAL HEALTH BODIES: … Well don’t look at us.
CANCER SPECIALISTS: Well actually we are looking at you. A little over 1.5 per cent of total development assistance for health goes to all so-called non-communicable diseases, and cancer gets only a fraction of that. How can you possibly justify that?
GLOBAL HEALTH BODIES: Well perhaps you should be looking at yourselves. Around 25 billion euros a year goes into funding cancer research. Only the tiniest fraction of this goes to help LMIC countries do the research they need to develop their own cancer services. The EU’s innovative medicines initiative, alone, will get a stunning 3.3 billion euros over the period 2014 to 2020. If you truly want to emulate what the global AIDS community achieved, maybe you can start by looking at their spirit of international solidarity, and allocate a decent fraction of that funding where it is needed most.
HEALTH MINISTERS: Ouch! Guys, guys, settle down. We would welcome funding to develop our cancer services from both global health aid and from cancer research funds – I mean 25 billion euros is more than the entire GDP of Paraguay!
GLOBAL HEALTH BODIES AND CANCER RESEARCH EXPERTS: And you health ministers need to look to your own responsibilities. If your governments don’t prioritise spending on health, you can hardly expect us to pick up the tab. Colombia, 7.2 per cent GDP spent on health, Paraguay, 9.8 per cent – that’s the sort of money that will make a sustained difference. But then Nigeria, 3.7 per cent, Sri Lanka, 3.5 per cent, Ghana 3.6 per cent… Seriously? We know that where health spending is below 4–5 per cent of GDP, or 80 to 100 dollars per capita, there’s little point trying to make an integrated cancer plan work, because the health infrastructure is simply too weak to support it.
HEALTH MINISTERS: Well, looking on the bright side, all these budgeting and cost-effectiveness exercises done by DCP3 and the Lancet commission should provide us with useful ammunition to argue for more money from our finance ministers. But we’ll need to convince them that we would be able to spend that money effectively. I’m not going to lie… there’s more than one of us around this table who’ve made some rather regrettable decisions when it comes to investing in cancer care. Raise your hands if you have any linacs sitting idle in a bunker for lack of spare parts or the technical know-how to fix them…
GLOBAL HEALTH BODIES: Well if you’d just listened to us…
HEALTH MINISTERS: Actually, listening to you may have been part of the problem. Aid from you global donors often comes as a take it or leave it package. You fly in for a few weeks or months, chat to the politicians of the day, and then fly out again. And you’re not very good at asking us what our needs and priorities are.
CANCER SPECIALISTS: We agree absolutely. That’s why we always advise that you start by setting up reliable cancer registries so you have good data about the most problematic cancers in your countries. Only one in five countries can report reliable mortality information, and without that, you won’t know what services you need to plan for and where, or whether the services you do provide are having an impact. The WHO’s International Agency for Research on Cancer has a global initiative for cancer registry development and are aiming for regional hubs with consultants who can give technical assistance…
HEALTH MINISTERS: Sounds great. Where do we sign up? Is this the sort of catalytic capacity building research project that we could get help to fund?
CANCER SPECIALISTS: Sadly there’s no funding stream set aside for that work at the moment. In fact IARC is still short of around 15 million dollars to fully fund their own five-year programme.
HEALTH MINISTERS: So no help set aside for the vital first step… And we’re going to need a lot of help with the next bit, where we have to formulate, cost, argue for and then implement national cancer control plans that fit our overall health priorities, address our cancer priorities, and work as a coordinated, accessible, sustainable whole. It’s immensely complicated. Our health departments are not used to dealing with projects this large or complex. We’ll need help, and for more than just a few months. What can you offer us?
GLOBAL HEALTH BODIES: We can help plan things like vaccination pilots, or even cervical screening pilots, but we don’t really advise on integrated planning and implementation of entire cancer plans.
CANCER SPECIALISTS: No we don’t either. A lot of us and our institutions, offer fellowships and exchange programmes to help with particular aspects such as gynae surgery, childhood cancers, or pathology. Some groups help to adapt and pilot treatment strategies for countries with fewer resources, or poorer general health status. The UN International Atomic Energy Agency advises countries on safe and sustainable radiotherapy equipment.
HEALTH MINISTERS: Well come to that, we ourselves share specific areas of healthcare expertise with neighbouring countries. The issue here is how to stop working on isolated fragments, and develop an integrated national plan tailored to our needs and resources. We’ll need to bring on board our clinicians, researchers, policy makers, administrators, accountants, lawyers, health economists, local and regional government… that’s what we need help with.
CANCER SPECIALISTS: Well the Union for International Cancer Control has recently launched a scheme for big cities that could help. They are offering help with the technical, logistical, and economic aspects of pulling together a tailored integrated cancer plan for cities, with a timescale of three years of involvement – none of that fly in and fly out stuff. In return they ask for evidence that all relevant authorities including the national government are serious about investing in cancer for the long term, and are prepared to back it up with sustainable funding, and are open to working with non-governmental players – NGOs, the private sector, civic society, as appropriate.
HEALTH MINISTERS: Well that sounds like it could be an interesting offer. Where do we sign up?
CANCER SPECIALISTS: Well of course it’s only for cities with one million plus populations. Four cities to start with, which have already shown some level of commitment to investing in cancer. And not the poorest. The UICC is a relatively small international advocacy agency – it’s not geared up to providing that level of technical advice and assistance at a global level. But the concept could well help address some of the key challenges you health ministers have raised.
HEALTH MINISTERS: We’ll need to invest in infrastructure – well building stuff is something I think we can all do. We’ll need to invest in equipment – diagnostics, imaging, storage facilities, digital comms systems, operating theatres, radiotherapy equipment, drugs and vaccines, data management systems. Even with the sort of globalised centralised purchasing agreement that helped bring down the cost of AIDS therapies, and even if we can count on reaping the rewards over the coming decades, we are going to need help funding that.
GLOBAL HEALTH BODIES: We may be able to help with ideas about possible funding opportunities. We did mention in the DCP3 report the need for global initiatives to lower the costs of key inputs through large-scale commodity purchases, as well as to expand technical assistance and promote cancer research in countries that need it most. This is something we’ve helped with in other disease areas, and few of them have the sort of multi-billion dollar resources that are available to cancer research.
HEALTH MINISTERS: OK. We appreciate that. But then here’s the real issue. Capacity building. We are talking about a major step change in every aspect of our health professional capacity – at community level, primary care, specialist care, public health, data management, administration and governance. They’d be great jobs, it would help keep talent and ability in the country, it would be a great resource for the future. No question. But it takes time and it takes money. A lot of it.
CANCER SPECIALISTS AND GLOBAL HEALTH BODIES: Yes, we get it.
HEALTH MINISTERS: Good. So can we summarise where we are? Cancer is the fastest growing health threat across the developing world. It’s an economic drain and a humanitarian crisis. And if we take it seriously, make it a priority, plan properly and invest, we can make a sustainable difference that would pay off for future generations. But you’re not in a position to offer us the technical advice we need to develop sustainable, tailored, integrated national cancer plans. You haven’t got in place centralised large-scale commodity purchasing schemes to make key inputs more affordable. And there’s no initiative to help finance the huge up-front investment this is all going to require, particularly for lower-middle-income and lower-income countries. Not exactly cancer’s answer to the Global Fund to fight AIDS, tuberculosis and malaria are you? Guys you need a plan! We can’t believe you’re not taking this more seriously!
ACT 3 GETTING SERIOUS…
…Act 3 is yet to be written. How it plays out will have a dramatic impact on the lives of millions of people across the world. There are grounds for optimism. All the players want to do the right thing; between them they have the knowledge and experience required to build the global capacity to cope with the coming epidemic; they are talking to one another; and to some extent they are also listening and adjusting their perspectives. But it is hard to see the necessary political will and momentum being generated until civic society and patient advocacy add their voices. Will that be enough to galvanise the sort of streamlined global action that we’ve seen with AIDS, malaria and tuberculosis – technical management assistance and help with upfront financing? It’s up to everyone in the cancer community to make sure it is, or this three act drama will end as a tragedy that could have been avoided.
The above script drew on discussions that took place at successive meetings of the World Oncology Forum and in other forums over the past 10-15 years.
The World Oncology Forum, convened by the European School of Oncology, brings leading cancer clinicians and researchers and global health experts together with advocates, NGOs, industry and health ministry officials to develop a coordinated approach to helping resource-poor countries build capacity to mitigate the impact of the rapid rise in the cancer burden (see WOF, at eso.net).
The conclusions of the most recent World Oncology Forum (Lugano, 2017) were published in The Lancet (The global fight against cancer: challenges and opportunities, Franco Cavalli and Rifat Atun, Lancet 2018, 391:412‒3). Video highlights of the 2017 World Oncology Forum, featuring contributions from a wide spectrum of voices, can be found here.