An acknowledged global cancer policy expert, Prof Richard Sullivan, Professor, Cancer Policy & Global Health at Kings College London and Director of the New Kings Institute of Cancer Policy has led a number of major studies examining the affordability of cancer in high-income countries, global childhood cancer care and most recently cancer care in Latin America. With research interests spanning the study of national cancer research systems to the relationship between research and cancer outcomes, his talk on delivering affordable cancer care in India” at the upcoming Indo-UK Oncology Summit 2013 scheduled for 6-7 September in Chennai, has immense relevance for the country. As co-lead on a 2014 Lancet series that will examine the state of cancer in India, Viveka Roychowdhury quizzes Prof Sullivan on his suggestions to bridge the affordability and access gaps in cancer care in India.
There is a wide gap between the price of cancer care and its affordability in India. How can this gap be addressed?
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| Prof Richard Sullivan |
We need to recognise that the challenges India face in delivering equitable, quality and affordable cancer care to all is a huge challenge. Firstly India is having to deliver a universal healthcare system in the face of a disease burden that spans across the whole of the spectrum from infectious to chronic affecting all socio-economic classes across the whole age spectrum. No high-income country has had to face such a challenge (see Lancet Oncology Commission Delivering Affordable Cancer Care in High Income Countries) and thus the policy actions for India will, by necessity need to unique. The first major issue is understanding what the country is currently paying for it’s cancer care and how this is linked to good outcomes. The second is the need to properly a public cancer care system (India only spends some 1.2 per cent of GDP on publicly funded healthcare at the moment) that will need to develop both private fiscal models and develop the its social health insurance models, e.g. RSBY. It will be critical for India to develop an evidenced-based system of priority setting for cancer care (including prevention). This is essential for delivering cost effective treatments, including cancer medicines and also cost effective models of care. Furthermore, we know that the only way to deliver affordable care systems is to prevent as much disease as possible. In this regard there are a raft of measures that federal and state will need to drive to reduce the cancer burden, and thus the cost burden on India.
Access to cancer care is also an issue in India. One of your interest areas is the relationship between research and cancer outcomes. Is this a viable solution in India, given the recent outcry against clinical research in India?
Cancer research is absolutely critical for India. India must invest more through both the public and private sectors. Despite the governance issues that have happened research activity and good outcomes are directly correlated, something that we examined in great depth (see Annals Oncology Clinical Research and Healthcare Outcomes: A workshop at the International Agency for Research on Cancer). India needs a broad, high quality research portfolio both to deliver cost effective, evidenced-based interventions fit for its setting and also to compete with the global cancer community to recruit and retain bright scientists, clinicians and other healthcare staff such as nurses who will be the research leaders of today and tomorrow. And the research India is doing and will do can have huge global impact. Without doubt, the presentation by Dr Shastri from Tata Memorial Hospital, Mumbai was one of the highlights of ASCO 2013. The research presented findings from a randomized, controlled trial conducted among 150,000 women in Mumbai slums over a 15-year period that showed biennial screening for cervical cancer by trained non medical personnel using acetic acid reduced cervical cancer mortality by 31 per cent. If implemented in developing countries that have little or no access to pap screening, this easy-to-use procedure could ultimately prevent 22,000 deaths from cervical cancer in India and 72,000 deaths in low-resource countries worldwide each year. The amazing enthusiasm and commitment shown by women from the poorest backgrounds (compliance was almost 90 per cent over the course of the trial) I think demonstrates that the Indian public do believe and will support cancer research that has good governance.
What can India learn from global experience/ examples of delivering affordable cancer care?
I think from high income countries we can serve as a warning that it is easy and dangerous to let costs run out of control. Furthermore high costs do not mean good outcomes. We have also let the issues of cancer medicines and pharmaceutical policy become too dominant in the policy discussion around affordable cancer care. The reality is early detection, coupled to good surgery and radiotherapy are the foundations of good care. Moreover it is often too easy to forget and thus under fund important domains of cancer care such as palliative care in our rush to embrace the latest technologies. Priority setting in the more social minded healthcare systems in high income countries has been a strength and organisations like NICE International have much to teach on the methodologies and options for priority setting and cost effectiveness. There are also major opportunities for mutual learning from countries like Brazil which is going through a similar transition. Looking more broadly, the experience of countries like Cuba in delivering prevention strategies can help formulate local and national plans in India. However, ultimately India will need to forge its own path towards what it judges to be an equitable, universal cancer care system.
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