Cary Adams CEO, Union for International Cancer Control and Rebecca Morton Doherty Advocacy and Programmes Coordination Manager, Union for International Cancer Control
With the expiry date of the Millennium Development Goals fast approaching in 2015, the cancer community has a unique opportunity to influence the framework for the successor development goals, and ensure that cancer prevention and control are no longer sidelined. The adoption of the UN Political Declaration on Non-communicable Diseases in 2011, which recognized NCDs as a global health and development priority, has helped to raise public awareness and created a strong political mandate on which to build future advocacy efforts at the global and regional level and nationally. These efforts must be supported through innovative partnerships within and beyond the cancer and health field; the recently updated World Cancer Declaration provides a shared vision on which to build collaborative partnerships, within the NCD framework, but also for reaching out to new players in the broader health and development community.For PDF click here
From the Millennium Development Goals to a post-2015 agenda
In September 2000, when world leaders came together to adopt the eight Millennium Development Goals (MDGs), which included health goals targeting a reduction in child mortality, combating HIV/AIDS, and improving maternal health by 2015, cancer and other non-communicable diseases (NCDs) were largely absent from the agenda.
This had a negative impact both on the level of global political attention accorded to the prevention and control of NCDs, and on the levels of bilateral and multilateral funding directed to tackling the NCD epidemic in low-income countries. Less than 3% (US$ 503 million out of US$ 22 billion) of overall development assistance for health was allocated to NCDs in 2007.1 Similarly, although the World Health Organization’s (WHO) budget for tackling NCDs has increased three-fold since 2011 (to US$ 318 million in the 2014–2015 WHO Programme budget)2 this remains insufficient for a set of diseases which account for 63% of all deaths annually.3
Today, as discussions around the post-2015 framework gain momentum, the cancer community has a unique opportunity to influence the agenda by feeding into the consultation process led by the United Nations (UN) to define the priority development themes for post-2015. Several expert groups and high-level committees have been established to guide the consultation process, which has included wide-ranging national and regional meetings, online consultations and discussions and generated a series of reports including the Report of the High Level Panel (HLP) of Eminent Persons on the Post-2015 Development Agenda4, and the Report of the Secretary General5 published in July 2013. The Union for International Cancer Control (UICC) has worked closely with its members, partners and the NCD Alliance6 to draw attention to the NCD burden through a series of think-pieces, policy briefing papers and analyses of the various reports highlighting the need for health and NCDs to be integrated across all dimensions of the post-2015 framework.
Whilst these reports acknowledge health as a driver, an outcome and a measurement of development, and recognize NCDs as a social, economic and environmental challenge for the post-2015 agenda – there are still notable weaknesses and omissions in the way that NCDs are defined and addressed. For example, the HLP Report frames cancer and other NCDs as an issue for high-income countries only, failing to recognize that NCDs are a universal issue, with a disproportionate impact on low- and middle-income countries and vulnerable populations. While the HLP Report gives little focus to the common NCD risk factors (tobacco use, harmful use of alcohol, physical inactivity and unhealthy diet), the recommendations of the Sustainable Development Solutions Network7 do not address the need for a health systems response to NCDs, including the critical need for improving access to essential cancer medicines and technologies.8 These omissions serve as a stark reminder that the cancer community still has some way to go to ensure that the full continuum of care for cancer is firmly positioned in the post-2015 agenda.
Making the case for cancer in the post-2015 agenda
A strong political mandate
Since the development of the MDGs, the cancer and NCD community has made history by securing a UN High-Level Meeting which adopted the UN Political Declaration on NCDs in 2011. This Declaration recognizes that “the global burden of and threat of non-communicable diseases constitutes one of the major challenges for development in the twenty-first century, which undermines social and economic development throughout the world, and threatens the achievement of internationally agreed development goals”.9
In May 2012, a global target to reduce premature deaths from NCDs by 25% by 2025 was adopted by Member States at the World Health Assembly. In 2013, the foundations of a new global NCD architecture were put in place with the adoption of a Global Monitoring Framework for NCDs (GMF), a Global NCD Action Plan 2013–2020 (GAP) and a Global Coordination Mechanism for NCDs. UICC, its members and partners, welcomed the inclusion in the GMF and GAP of cancer-specific targets, indicators and actions including in the areas of cancer planning and surveillance, vaccination for HPV and HBV against cervical and liver cancers, early detection and screening for breast, cervical, oral and colorectal cancers linked to timely treatment, access to essential medicines and technologies, and palliative care policies. These new and ambitious commitments to the prevention and control of cancer, particularly in low- and middle-income countries, signal the readiness of governments to prioritize cancer in the global health agenda, and recognition of the intrinsic links between cancer and development.
The economics of cancer
The 13.3 million new cases of cancer in 2010 were estimated to cost US$ 290 billion, and medical costs accounting for the greatest share (US$ 154 billion), with non-medical costs and income losses accounting for US$ 67 billion and US$ 69 billion respectively. The total costs are expected to rise by US$ 458 billion in the year 2030.10 Given that 47% of cancer cases and 55% of cancer deaths occur in low- and middle-income countries, with this percentage set to rise11, a large proportion of these costs will hit the countries that are least equipped to address this challenge. Even so, the staggering risk that cancer poses to economic growth and development is still only just starting to receive recognition through investment in national cancer control plans, despite the fact that we know that this risk can be managed effectively and that a return on investment in health is possible. The World Health Organization estimates that a basic package of cost-effective strategies to address the common cancer risk factors in low- and middle- income countries would require an investment of only US$ 2 billion a year12, and yet less than 3% of overseas development assistance for health is invested in cancer and other NCDs.13
Cancer and the environment
Challenges to sustainable development such as rapid urbanization, climate change and shifting agricultural and resource use patterns impact on nutritional security, and are linked with greater exposure to cancer risk factors including smoking, poor diet and low physical activity.
Additionally, a wide range of environmental causes of cancer, encompassing environmental contaminants or pollutants in air and water, occupation-related exposures such as asbestos and UV-radiation as well as exposure to excessive sunlight and cancer-causing infections, together make a significant contribution to the cancer burden.
Closing the cancer divide
Disparities in cancer outcomes exist between the developed and developing world for most cancers. Patients in lower resource settings whose cancers are potentially curable in the developed world unnecessarily suffer and die due to a lack of awareness and weak health service infrastructure for access to affordable, effective and quality cancer services that enable early diagnosis and appropriate treatment and care.
Cervical cancer is an example of the disproportionate burden borne in the developing world. Over 85% of the 275,000 women who die every year from cervical cancer are from developing countries. If left unchecked, by 2030 cervical cancer will kill as many as 430,000 women, virtually all living in low-income countries.14 The reality of cancer cure rates in children is also reflective of the inexcusable inequities in access to care and essential cancer medicines that occur globally. There are an estimated 160,000 newly diagnosed cases of childhood cancer worldwide each year15 with more than 70% of the world’s children with cancer lacking access to effective treatment. The result is an unacceptably low survival rate of ~10% in some low- and middle-income countries compared to ~80% in some high-income countries.16,17
In many cases the largest and most unacceptable gap in cancer care is the lack of adequate palliative care and access to pain relief for much of the world’s population. The disparities in worldwide use of medical opioids are shocking, with just four countries – United States, Canada, United Kingdom and Australia – using 68% of opioids, while low- and middle-income countries together only account for 7% of global use.18 A short list of medications can control pain for almost 90% of all people with cancer pain including children, yet even where opioids are available, cost to the patient and pervasive overregulation make them virtually inaccessible to millions in need.19,20
The evidence base from diverse countries is growing to dispel the myth that effective, quality care is only achievable for high-income countries, with successful cancer control and care programmes in many low resource settings now in place using locally appropriate solutions across the full cancer care continuum.21
The way forward
Building broad support for solutions for cancer prevention and control that can be implemented in all resource settings and within a global development framework will not be easy. However, by rallying around a defined set of evidence-based targets and actions, and using these to reach out to non-traditional partners beyond the cancer and health fields, the cancer community can create a powerful and united advocacy push to position cancer in the post-2015 agenda.
The World Cancer Declaration 2013
Originally launched in 2008, the World Cancer Declaration has helped to bring the growing cancer crisis to the attention of government leaders and health policy-makers, and to drive new government commitments in the global fight against cancer and other NCDs. In light of these groundbreaking developments in the fight against NCDs, and with the expiration of the MDGs fast approaching, UICC saw a growing need to more closely align the Declaration with the emerging global NCD framework and the dialogue on the post-2015 development agenda. Based on feedback from UICC’s members, partners and the wider health community, an updated Declaration was developed and launched at the World Cancer Leaders’ Summit in Cape Town in November 2013.
The language used in the Declaration has been updated to reflect current discourse in the public health and development arenas. Other specific changes to the Declaration include:
‰ The timeframe for achievement of the Declaration targets has been shifted from 2020 to 2025 to align with the GMF. Governments have already committed to take action to reduce premature deaths from NCDs by 25% by 2025; UICC believes the advocacy and programmatic efforts of the cancer community will be more powerful if we work to and support the same timeline.
‰ The text of the Declaration targets (specifically targets 1 and 7), and list of immediate actions have been enhanced to acknowledge the importance of the quality of cancer care and emphasize the principles of equitable access to effective, safe patient-centred services.
The Declaration provides governments, agencies, civil society, relevant private sector and other key stakeholders with a shared vision on which we can unite to form a collective voice and build collaborative partnerships to address the global cancer burden.
By more closely aligning the updated Declaration with the emerging global NCD framework and post-2015 development discourse, UICC believes that the Declaration targets will resonate more widely, allowing the cancer community to reach out to non-traditional partners in development, disability, education, employment and many other sectors for innovative partnerships.
By connecting the cancer community from the grassroots levels to national and regional cancer societies and networks and joining forces with the larger NCD community through the NCD Alliance, an opportunity has already been created to ensure that all people with cancer have a voice at the highest political levels.
The onus is now on the cancer community to build on this momentum and continue to expand its sphere of influence to push for national accountability for existing commitments within the Political Declaration and the GMF, and to push for cancer to be mainstreamed in the post-2015 development agenda. l
1. Nugent, R. A., & Feigl, A. B. 2010. Where have all the donors gone? Scarce donor funding for non-communicable diseases. Center for Global Development.
2. World Health Organization. 2013. World Health Assembly Resolution WHA66.2 Programme Budget 2014-2015. Geneva: World Health Organization
3. World Health Organization. 2011. Global Status Report on Noncommunicable Diseases 2010. Geneva: World Health Organization
4. United Nations. 2013. A New Global Partnership: Eradicate Poverty and Transform Economies through Sustainable Development, The Report of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda. New York: United Nations.
5. United Nations. 2013. A life of dignity for all: accelerating progress towards the Millennium Development Goals and advancing the United Nations development agenda beyond 2015, Report of the Secretary-General. New York: United Nations.
6. The NCD Alliance was founded by four international NGO federations representing the four main NCDs – cardiovascular disease, diabetes, cancer, and chronic respiratory disease. Together with other major international NGO partners, the NCD Alliance unites a network of over 2,000 civil society organizations in more than 170 countries. The mission of the NCD Alliance is to combat the NCD epidemic by putting health at the centre of all policies.
7. Leadership Council of the Sustainable Development Solutions Network. 2013. An Action Agenda for Sustainable Development, Report for the UN Secretary-General. http://unsdsn.org/files/2013/06/130613-SDSN-An-Action-Agenda-for-Sustainable-Development-FINAL.pdf
8. NCD Alliance. 2013. NCD Alliance Response to the UN-NGLS Consultation on Post-2015 Reports. Available at: http://www.ncdalliance.org/post2015resources
9. United Nations. 2011. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases
10. Bloom, D. E., Cafiero, E. T., Jane-Llopis, E., et al. 2011. The Global Economic Burden of Non-communicable Diseases. Geneva: World Economic Forum. 11. Nugent, R. A., & Feigl, A. B. 2010. Where have all the donors gone? Scarce donor funding for non-communicable diseases. Center for Global Development. 12. World Health Organization. 2011. Scaling up action against noncommunicable diseases: how much will it cost? Geneva: World Health Organization. 13. Nugent, R. A., & Feigl, A. B. 2010. Where have all the donors gone? Scarce donor funding for non-communicable diseases. Center for Global Development. 14. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F.GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. 15. Ribeiro RC, Steliarova-Foucher E, Magrath I, Lemerle J, Eden T, Forget C, Mortara I, Tabah-Fisch I, Divino JJ, Miklavec T, Howard SC, Cavalli F. 2008. Baseline status of paediatric oncology care in ten low-income or mid-income countries receiving My Child Matters support: a descriptive study. Lancet Oncology 2008 Aug;9(8):721-9 16. ibid 17. Pritchard-Jones, K., Pieters R., Reaman, G. H., Hjorth, L., Downie, P., Calaminus, G., Naafs-Wilstra, M. C., Steliarova-Foucher, E., 2013. Sustaining innovation and improvement in the treatment of childhood cancer: lessons from high-income countries. www.thelancetoncology.com Published online Februray 20, 2013
18. Treat the Pain. 2013. Access to Essential Pain Medicines Brief. Available from: http://www.treatthepain.org 19. Cherney, N.I., Baselga, J., de Conno, F., Radbruch, L. 2010. Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Europe: a report from the ESMO/EAPC Opioid Policy Initiative. Annals of Oncology 21: 615–626, 2010 20. Cherny NI, Cleary J, Scholten W et al. The Global Opioid Policy Initiative (GOPI) project to evaluate the availability and accessibility of opioids for the management of cancer pain in Africa, Asia, Latin America and the Caribbean, and the Middle East: introduction and methodology. Ann Oncol 2013; 24 (Supplement 11): xi7–xi13. 21. Knaul, F. M., Frenk, J., & Shulman, L. 2011. Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries. Harvard Global Equity Initiative. Boston: Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries.