Knaul Felicia, Horton Susan, Yerramilli Pooja, Gelband Hellen, Atun Rifat
Cancer accounts for a rapidly growing health and economic burden in low- and middle-income countries (LMICs) (Knaul and others 2014). The long-term nature of chronic and noncommunicable diseases that characterizes many cancers inflicts repeated financial onslaughts on families, intensifying the poverty-illness cycle. Inadequately treated illnesses deepen poverty, leading to a cycle of loss of health, lack of treatment, higher morbidity, lost income, and deeper impoverishment (Atun and Knaul 2012). Many LMICs are working to achieve greater, and even universal, financial protection in health care, with funding from domestic sources that combines public insurance and prepayment. Establishing universal entitlement to key services through guaranteed benefits packages is a cornerstone of these efforts. These countries face challenges as they strive to include cancer and other chronic and noncommunicable diseases in the package of covered services. The inclusion of cancer interventions poses a specific set of challenges because of the chronic nature of the illness and the high costs of treatment. An effective response to cancer requires strengthening all health system functions—stewardship, financing, service provision and delivery, and resource generation—along the entire, six-component, care-control continuum—primary and secondary prevention, diagnosis, treatment, survivorship, rehabilitation, and palliative care and pain control (Hewitt, Greenfield, and Stovall 2005; Knaul, Alleyne, and others 2012). The failure to adequately manage one of the components can jeopardize the entire response, resulting in premature deaths, unnecessary pain, and wasted resources. Although responding to all facets of the continuum is a daunting task, several countries have included cancer care in recent reforms designed to achieve universal health coverage (UHC); these reforms provide useful lessons for other countries. This chapter analyzes one health system function—financing—in relation to cancer, focusing on treatment. The analysis draws on experiences from several middle-income countries (MICs) in which domestic finance is used and efforts are underway to achieve universal coverage. We draw lessons for other components of cancer care and control and highlight the importance of developing strategies for financing that consider all aspects of the care continuum and strengthening of health systems. Our analysis focuses on how domestic sources of funding are deployed to finance cancer care; we leave for later work the issues of how these funds are sourced and collected. Domestic funding in the vast majority of LMICs does, and will inevitably continue to, pay for the bulk of cancer care. We do not focus on global and regional financing and platforms; this is a topic for future research. These platforms are especially important sources of finance for the poorest countries, for catalyzing discovery and innovation and for aggregating demand to reduce the costs of medicines and vaccines.
在低收入和中等收入国家（LMICs），癌症造成的健康和经济负担正在迅速加重（克瑙尔等人，2014年）。许多癌症所具有的慢性和非传染性疾病的长期特性，给家庭带来了反复的经济冲击，加剧了贫困与疾病的恶性循环。治疗不充分会使贫困加剧，导致健康受损、缺乏治疗、发病率上升、收入损失和贫困加剧的恶性循环（阿通和克瑙尔，2012年）。许多低收入和中等收入国家正利用国内资金，通过结合公共保险和预付款的方式，努力在医疗保健方面实现更大范围甚至全民的财务保护。通过有保障的福利套餐确立对关键服务的全民权利，是这些努力的基石。这些国家在努力将癌症及其他慢性和非传染性疾病纳入涵盖服务套餐时面临挑战。由于癌症的慢性性质和治疗成本高昂，将癌症干预措施纳入套餐带来了一系列特殊挑战。有效应对癌症需要在整个六部分的护理 - 控制连续统一体（初级和二级预防、诊断、治疗、生存、康复、姑息治疗和疼痛控制）中加强所有卫生系统功能——管理、融资、服务提供与交付以及资源生成（休伊特、格林菲尔德和斯托瓦尔，2005年；克瑙尔、阿利恩等人，2012年）。对其中一个组成部分管理不善可能危及整个应对措施，导致过早死亡、不必要的痛苦和资源浪费。尽管应对连续统一体的所有方面是一项艰巨任务，但一些国家在近期旨在实现全民健康覆盖（UHC）的改革中纳入了癌症护理；这些改革为其他国家提供了有益经验。本章分析了与癌症相关的一项卫生系统功能——融资，重点是治疗。该分析借鉴了几个使用国内资金并正在努力实现全民覆盖的中等收入国家（MICs）的经验。我们为癌症护理和控制的其他组成部分吸取经验教训，并强调制定考虑护理连续统一体所有方面的融资战略以及加强卫生系统的重要性。我们的分析重点是国内资金如何用于为癌症护理融资；我们将这些资金的来源和筹集问题留待以后研究。绝大多数低收入和中等收入国家的国内资金确实并将不可避免地继续支付大部分癌症护理费用。我们不关注全球和区域融资及平台；这是未来研究的主题。这些平台对于最贫穷国家来说是特别重要的融资来源，有助于促进发现和创新，并汇总需求以降低药品和疫苗成本。
