Framing Cancer Within The Universal Health Coverage Framework

By Dr Murallitharan M. |

There is a huge moral and ethical dilemma when it comes to UHC and cancer.

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Universal health coverage (UHC) is one of the most important areas in health today, being one of the World Health Organisation’s key priorities.

Never has there been more focus on UHC than in recent years, with even a UN High Level Meeting held in September 2019 at the UN General Assembly in New York. (1) Heads of state, governments, political and health leaders, policymakers and stakeholders all over the globe are clamouring to get their countries into UHC-ready mode, if they haven’t already.

What is UHC about?

Universal Health coverage is a concept very connected to the idea that health is a human right available for all peoples everywhere. UHC means that anyone, anywhere should be able to access and use any health service; be they promotive, preventive, curative, rehabilitative or palliative.

Universal health coverage is clustered around three dimensions (2);
i) Equitable access – where anyone should be able to access health services irrespective of their socioeconomic status.
ii) Quality of services – where anyone accessing health services should be able to get the services to be of a certain quality.
iii) Protection from financial risk – where anyone accessing health services should be able to get the services without incurring financial risk (i.e. falling into debt or even bankruptcy).

Most countries provide some form of universal health coverage for their citizens; whether through a ‘package of essential services’ or provision of ‘almost free’ services for citizens via a public health care system.

For example, most countries provide vaccinations and maternal and child health services for free widely all across the country to every citizen.

Malaysia, for example, provides access to health for citizens via a largely subsidised public health care system which comprises a whole range of services; from Klinik Desa in the most remote of locations; to Klinik Kesihatan with family medicine specialists, district hospitals, secondary hospital and tertiary centres, including special Centres of Excellence (COEs) focusing on providing sub-specialist care.

Most importantly, Malaysians can access these services at any time, and through the referral system, can receive the appropriate care when they need it, at largely subsidised prices.

UHC and Cancer

Connecting UHC and cancer has been a difficult task. Many countries have chosen to shy away from including cancer into UHC discussions for two simple reasons: Cancer diagnosis and treatment. Both of these aspects of cancer management have been difficult for many countries due to costs which seem to continue escalating astronomically. (3) (4)

Even when diagnosis and treatment are made available to all patients in a country under UHC, quality access to services for cancer patients seems to be a challenge as well. Not all hospitals have the required cancer specialists and sometimes there is a huge gap in geographical availability of services. (3) (4)

Not all treatments such as cancer medications are available to all patients as well. Under a country’s UHC, sometimes basic drugs or radiotherapy are available but not advanced drugs or advanced surgical treatments. (3) (4)

Also, another dimension under UHC is the quality of the services being provided. For example, if breast reconstructive surgery is available to all patients but there is only one surgeon doing this in the whole country, with waiting times of eight to nine months, there are serious questions on whether this treatment modality is realistically something available under UHC. (3) (4)

It must be said though, there is a huge moral and ethical dilemma when it comes to UHC and cancer, and like most things in life, everything is a trade-off. Money allocated for provision of UHC means money for all diseases and the accompanying health infrastructure and human resource.

It may be more cost-effective (i.e. beneficial for a greater number of people) to offer free HPV vaccinations for 10,000 Malaysians, for example, than to make available a multi-million dollar drug used for treating a cancer which may only enable 10 people to use it.

Which do you choose?

Which kind of health service item will you include for Malaysia? Should this new innovative drug treatment be included as part of the UHC package? If so, what are the treatments that I need to take out?

What kind of palliative care services should be included? Will they be available all over the country in equal measure? These are difficult questions… with no correct answers.

Using the UHC Framework for Malaysia

With a range of stakeholders, we mapped the availability of cancer services in Malaysia according to the UHC framework and we prepared a report card of this; available here.

The Report Card summarises the extent of UHC coverage for various aspects of cancer control as well as to identify gaps which can be strengthened to improve the actual on-the-ground UHC coverage at a country level.

Summarising the findings, Malaysia has quite a good number of cancer services within the spectrum covered under the UHC, i.e. available at government hospitals. Sure, there are some shortcomings in terms of accessibility and availability of services, but we are trying our best to cover as much as we can in terms of managing cancer for Malaysians.

Do we pat ourselves on the back as a nation since we have not done so badly at UHC in terms of cancer service? No we don’t.

As many experts acknowledge, a country with an ‘ideal’ UHC means that all treatment and services for all diseases are covered for all patients. This is something not existent in any country in the world today.

Yet it is a goal that all of us, especially cancer advocates, need to work towards, together with other stakeholders in cancer control.

In that, please feel free to utilise the report card to help you, as a present or future cancer advocate, identify area gaps in terms of provision of services to all Malaysians and explore avenues for reducing those gaps.

Working together, all of us hand in hand can truly aid in improving the level of UHC provision in terms of cancer services for Malaysians.

References

  1. World Health Organisation (WHO). UN High-Level Meeting on Universal Health Coverage. Geneva: World Health Organisation; 2019. Available at https://www.who.int/news-room/events/detail/2019/09/23/default-calendar/un-high-level-meeting-on-universal-health-coverage
  2. World Health Organisation (WHO). Universal Health Coverage. Geneva: World Health Organisation; 2019. Available at https://www.who.int/health-topics/universal-health-coverage#tab=tab_1
  3. Akaza H, Kawahara N, Fukuda T, Horie S, Thabrany H, Nozaki S. UICC-ARO Symposium at the UICC 2016 World Cancer Congress How Can We Mobilize Action to Realize UHC in Asia?. Asian Pacific journal of cancer prevention: APJCP. 2017;18(11):2897.
  4. Akaza H, Kawahara N, Nozaki S, Sonoda S, Fukuda T, Cazap E, Trimble EL, Roh JK, Hao X. Roundtable discussion at the UICC World Cancer Congress: looking toward the realization of universal health coverage for cancer in Asia. Asian Pac J Cancer Prev. 2015;16(1):1-8.

Cancer Matters is a column on various issues related to cancer in Malaysia. Dr Murallitharan M. is the Medical Director of the National Cancer Society of Malaysia (NCSM). He can be reached via email at [email protected]

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
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