CANCER CONTROL IN CHILE AN UNDERFUNDED SYSTEM WITH POCKETS OF STRENGTH

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1 HIGHLIGHTS The Economist Intelligence Unit has created a unique scorecard, the Latin America Cancer Control Scorecard (LACCS), which covers policies and programmes designed to reduce inequality in cancer-care access in 12 Latin American countries: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, Mexico, Panama, Paraguay, Peru and Uruguay (the study countries). To do so, it assessed current policy responses and identified opportunities for improvement over time to reduce inequalities. The LACCS tracks six domains: cancer plan; monitoring performance; medicines availability; radiotherapy availability; prevention and early detection; and finance. It was not designed to measure the level of inequality or its impact. Raw scores for each domain have been normalised to a scale of 1-5 to enable comparisons across domains (see chart 1). 1 Without a caveat it might be all too easy to misinterpret the LACCS scores. The exercise is one of benchmarking against others in the region, not against some global ideal. Thus, a score of five in any one domain should be read as a sign that the country performs well compared with its peers, not that it is flawless in this area. Chart 1 The Latin America Cancer Control Scorecard (LACCS), 2017 Plan strategically Monitor performance Medicines availability Radiotherapy availability Prevention and early detection Finance Score Score Score Score Score Score Uruguay Costa Rica Chile Mexico Brazil Colombia Panama Peru Ecuador Argentina Paraguay Bolivia Domain Score (max 60) Country Score (max 30) 1 For a more detailed description of the methodology, see the appendix in The Economist Intelligence Unit, Cancer control, access and inequality in Latin America: A tale of light and shadow, July COMMISSIONED BY Note: Raw scores for each domain have been normalised to a scale of 1-5 (with 1 being the worst and 5 the best) to enable comparisons across domains. The scores have been rounded to the nearest whole number. For example, Argentina's overall score is 14.46, which has been rounded down to 14. Maximum total country score is 30. Maximum total domain score is 60. Source: The Economist Intelligence Unit, The Latin America Cancer Control Scorecard (LACCS), The Economist Intelligence Unit Limited

2 KEY FINDINGS FOR CHILE In the LACCS Chile performs best in the radiotherapy availability domain (5). It also receives a good score for prevention and early detection (4). The country s strategic plan and medicines availability both get moderate scores (3 each). There is significant room for improvement in the monitoring performance and finance domains (2 each). Chile has a radiotherapy coverage of more than 100% (which means that more than the estimated proportion of patients requiring radiotherapy is able to access it). The country has invested in preventive measures such as pap screening tests for women aged every three years and an HPV vaccination programme that operates as part of a routine immunisation programme. It also has a programme to screen those over 40 with a family history of stomach cancer and a current ulcer and is piloting a screening programme for colorectal cancer. The country s Explicit Guarantee System (Acceso Universal con Garantías Explícitas, or AUGE) includes coverage for the country s top ten cancers (except lung cancer). It covers all children as well as preventive measures. However, government spending on health is below the OECD average, and out-of-pocket expenditure is higher than the average for the Americas. Monitoring systems are weaker than other areas of Chile s cancer control, although it has several good cancer registries, including subnational population-based registries with good data quality. 2 International Agency for Research on Cancer (IARC), Global Cancer Observatory, Cancer Today. Available at: M Andia et al, Geographic variation of gallbladder cancer mortality and risk factors in Chile: a population-based ecologic study, International Journal of Cancer, 2008 Sep 15;123(6): C Caglevic, The current situation for gastric cancer in Chile, Ecancermedicalscience, 2016; 10: 707. THE CANCER CHALLENGE IN CHILE With more than 40,000 new cases in 2012, cancer presents a heavy burden to Chile, according to data from the International Agency for Research on Cancer (IARC). The country has an age-standardised rate (ASR) for incidence of per 100,000 people. 2 When it comes to mortality, it has an ASR of 103.0, while five-year prevalence is per 100,000 people. These are among the highest rates in the study countries (see table 1). As in many countries, Chile has high rates of prostate cancer, which is the dominant form among men (with an ASR for incidence of 52.4 per 100,000 in 2012). For women, breast cancer is most common (with an ASR of 34.8 that year), according to IARC data. But while Chile is not unusual in this respect, the country is known for having among the world s highest rates of gallbladder cancer, with an ASR in 2012 of 12.8 for women and 6.3 for men, compared with global average figures of 2.3 and 2.1, respectively. 3 The reasons behind this are unclear. However, it has been suggested that it may be related to genetic factors and poor living conditions. 4 Stomach (or gastric) cancer also presents a major burden, with an ASR of 15.6 per 100,000 people, according to the IARC. More than 3,000 people die every year from this form of cancer, making it the main cause of cancer deaths in Chile. 5 2 The Economist Intelligence Unit Limited 2017

3 Table 1: Cancer incidence, mortality and prevalence in the study countries, 2012 (age-standardised, per 100,000 people) Incidence Mortality Five-Year prevalence Argentina Bolivia Brazil Chile Colombia Costa Rica Ecuador Mexico Panama Paraguay Peru Uruguay Note: All cancers excluding non-melanoma skin cancer. Source: International Agency for Research on Cancer (IARC), Global Cancer Observatory, Cancer Today. Available at: gco.iarc.fr/today. More broadly, socioeconomic divergences also drive varying rates of cancer across the country. People who develop the condition are 26 times more likely to be from the poorer inland region in the south of the country than the coastal north. Meanwhile, poor and urban citizens and ethnic Mapuche all face higher risk. 6 Geographical divides have also been revealed in the data from two well-established population registries, one in the desert north at Antofagasta and the other in the rainforest region of the south, Valdivia. They show very different mixes of cancer types related to environmental risks (sun and arsenic in the north), and poverty and ethnic influence in the south (stomach, gallbladder and lung cancer), explains Jorge Jiménez de la Jara, professor of public health at the Catholic University of Chile and a former minister of health for the country. As in many other countries, cancer in Chile takes an economic as well as a human toll. One estimate found that lost working time due to cancer cost the economy US$3.5bn per year. 7 And with a rapidly ageing population, of which 40% smoke, 67% are overweight and 18% abuse alcohol, the burden of cancer will impose increasing costs on the country s healthcare system. 8 6 Andia et al, Geographic variation of gallbladder cancer mortality and risk factors in Chile: a population-based ecologic study. 7 J Jimenez de la Jara et al, A snapshot of cancer in Chile: analytical frameworks for developing a cancer policy, BioMed Central (BMC), 2015 Jan 26;48:10. 8 The Economist Intelligence Unit Limited

4 AREAS OF ADVANCEMENT Chile s highest score (5) is in the LACCS radiotherapy availability domain. As well as medical equipment, this includes sufficient human resources. In one recent study, Chile and Uruguay were the only countries among 9 N Datta et al, Radiation Therapy Infrastructure and Human Resources in Low- and Middle-Income Countries: Present Status and Projections for 2020, International Journal of Radiation Oncology, Ministerio de Salud, Formulario Nacional de Medicamentos, DTO. N 194 DE Available at: medicines/country_lists/ chl_formulario_2005.pdf 11 Pain & Policy Studies Group, 2015 Global Consumption of Morphine (mg/ capita). Available at: sites/ edu/files/global_morphine. pdf 12 Ministerio de Salud, ESTRATEGIA NACIONAL DE SALUD Para el cumplimiento de los Objetivos Sanitarios de la Década Available at: portal/url/item/c4034eddbc- 96ca6de b8. pdf 13 ICO Information Centre on HPV and Cancer, Chile: Human Papillomavirus and Related Cancers, Fact Sheet Available at: the 12 included in the LACCS to have sufficient numbers of radiation oncologists. 9 Moreover, in terms of treatment availability, Chile is the only country among the 12 countries included in the LACCS that has made three newer drugs dating from the middle of the last decade available, with eight countries having approved none of these. 10 That said, Chile only gets a score of 3 in the medicines availability domain as it lags behind in making both key older drugs and novel treatments available. But positively, morphine consumption in Chile is above the average for the study countries. 11 Meanwhile, Chile scores 3 in the strategic planning domain, with a national health strategy that includes specific targets for reducing cancer mortality. There is no separate cancer plan, but cancer is integrated into its non-communicable diseases plan for , which includes considerable consideration of inequalities, according to research conducted for the LACCS. 12 Chile scores 4 in the prevention and early detection domain. Measures include pap tests for women aged every three years, according to data from the International Agency for Research on Cancer (IARC), with 60% of these women having had the test in the previous three years (2011 data from the Pan American Health Organisation included in the LACCS). To tackle cervical cancer, in 2014 Chile introduced vaccination to protect against the human papilloma virus (HPV, the major cause of cervical cancer) as part of a routine immunisation programme. 13 Chile offers free mammography screening to women aged 50 and older. 14 It also has a programme to screen those over 40 with a family history of stomach cancer and a current ulcer, 15 and is piloting a screening programme for colorectal cancer. 16 OBSTACLES TO PROGRESS Chile s greatest weakness is in monitoring, where it only receives a score of 2 in the LACCS. The country actually has several good individual cancer registries, as highlighted by a high score in the data quality subcategory: assessments from the Globocan Cancer Atlas show high-quality incidence data and medium-quality mortality data in Chile. 17 However, the biggest problem is that Chile s registries cover only a small part of the population. Regardless of how representative the current registries are, because they cover just 7% of the population, national incidence estimates are often based on mortality data instead. 18 Dr Jimenez believes 4 The Economist Intelligence Unit Limited 2017

5 that further improvements in data collection are needed. We know that cancer is growing, but we have many uncertainties in data gathering and reliability. This has an impact on cancer control. We are uncertain where and how to put in effort in planning and providing services. This leads to late diagnosis and ineffective treatment. Chile performs poorly in the LACCS finance domain with a score of 2. In the 1950s the country created a state-run national health system based on the British model, with funding from tax revenue. Public service reforms of the early 2000s led to the creation in 2005 of the Explicit Guarantee System (Acceso Universal con Garantías Explícitas, or AUGE), 19 which ensures diagnosis, treatment and follow-up of 80 prioritised health conditions. 20 Research done for the LACCS revealed that the AUGE system includes coverage for the country s top ten cancers (except lung and ovarian cancer) and covers all children. It also covers extensive preventive interventions. Government spending on health, at 3.9% of GDP in 2014, is below the study country average of 4.6% and well below the OECD average of 7.7%, according to World Bank data. Meanwhile, out-of-pocket expenditure, at 31.5% of total spending on health, is well above the average of 13.7% in the Americas and the global average of 18.2%, according to 2014 data from the World Health Organisation. Although Chile has made efforts to reduce health inequities, these persist. Low-income, high-risk populations are served mainly by the public sector, which is underfunded, and they have limited access to care from private-sector providers K Puschel and B Thompson, Mammogram screening in Chile: Using mixed methods to implement health policy planning at the primary care level, Breast, author manuscript; available in PMC 2012 Apr Y Yuan, A survey and evaluation of populationbased screening for gastric cancer, Cancer Biology and Medicine, M S Sierra et al, Cancer patterns and trends in Central and South America, Cancer Epidemiology, 2016 Sep;44 Suppl 1:S23-S42. THE WAY FORWARD When it comes to deploying limited resources for cancer treatment and care, Dr Jimenez has an extensive list of priorities. The first obvious answer is more prevention, primary and secondary, strong anti-tobacco and pro-healthy lifestyles. However, he also sees a need to focus on the most prevalent cancers in certain groups of the population: childhood cancers, breast, cervix, stomach and lung. Finally, he would like to see the development of a more robust cancer infrastructure. We need to build a network for early cancer detection and referral, with the creation of one centre of excellence for every 5m people. This, he says, would allow Chile to rely more on a wide, systematic approach. 17 IARC, Global Cancer Observatory, Cancer Today. 18 Jimenez de la Jara, et al, A snapshot of cancer in Chile. 19 TJ Bossert, Innovation and Change in the Chilean Health System, New England Journal of Medicine, 2016; 374: The Economist Intelligence Unit, Value-based Healthcare: A Global Assessment. Country snapshot Chile. Available at: vbhcglobalassessment.eiu. com/?country=cl 21 The Economist Intelligence Unit Limited