NCDs currently pose one of the greatest threats to health and development globally, particularly in the developing world (see section 2.4). Failure to implement proven interventions is a significant missed opportunity to diminish a large, chronic health and cost burden, and continued lack of investment will have steadily increasing health, economic and social consequences.
The broader cost of illness includes indirect social costs, negative impact on national economies and catastrophic expenditures by individuals.
7.1 Background of cancer financing
Effective cancer prevention, screening, diagnosis and treatment will save lives, mainly of adults during their most productive years.
In addition, all cancer services, including palliative care for those who will not survive, create high-quality employment, which adds to GDP. A budget for cancer control services should therefore be regarded not simply as expenditure but as an investment that will result in economic and broader gains (see also section 2.4). The availability of treatment services for an entire population improves uptake of services across the care continuum (1).
Financing of cancer control is part of financing for all health services.
Moving towards UHC, cancer services should expand progressively with appropriately increasing resources. Some extensions will be incremental, and others will require quantum increases in funding.
For example, access to clinical diagnosis and therapy for breast cancer can be increased incrementally to ever larger segments of the population or be extended geographically; however, a radiotherapy unit requires substantial capital expenditure and substantial recurring costs for personnel, supplies and maintenance.
Ensuring equitable access to centralized facilities, such as for radiotherapy, may require funding for travel and accommodation of patients and their families on site.
Appropriate increases in funding for extending cancer services require collaboration among planners and health and finance ministries, guided by understanding of the importance of investing in cancer, the corresponding value proposition and awareness of cost -effectiveness and sustainability.
7.2 Financing cancer services within progressive universal health coverage
Health financing consists of the mobilization, accumulation and allocation of money to cover the health needs of the population, individually and collectively (2). In practice, financing a complex set of services such as those in cancer control requires considerable analysis and contextualization if the objectives of UHC are to be met. How much money should be allocated for cancer within the overall UHC envelope? What benefits accrue from the allocation, and who will benefit from it? These are the questions to be addressed in an investment case (see section 2.4). To date, in many LMIC, funding of services for cancer and other NCDs has been accorded much less priority than funding for other diseases with similar burdens and costs for control.
Health care services are paid from tax revenue, pooled, prepaid funding or out of pocket. Out-of-pocket payments have consistently been shown to be an inefficient, regressive form of health financing (3), as patients have to spend money when they are least capable of doing so. Without price controls, they are often charged higher rates, as their bargaining potential is less than that of pooled purchase. Lower-income groups spend a greater proportion of their income on health care than groups with higher income and often forgo preventive services and potentially curative treatment (4).
Early experience and the broader debate about funding national UHC has resulted in consensus that pooled pre-financed funding, which results in risk pooling, is the preferred approach. Pre-financing may be either public or private, but recent evidence (5) indicates that public, pre-paid compulsory health financing is the most successful strategy for progressing towards UHC. Cancer patients will clearly benefit from pooled pre-financing, without which they are faced with high, often catastrophic, out-of-pocket payments. The lowest-income groups should receive the greatest benefit from pooled pre-financing, which will increase equity in the population and improve access.
Funding for NCDs in LMIC is often expected to come mainly from budgeted domestic funds. Reliance solely on domestic financing would, however, be a major constraint in the extension of cancer services, particularly where the necessary infrastructure and human resources are limited. While little official bilateral or multilateral aid is available for cancer, uncatalogued external support is provided by private cancer centres in HIC and by universities and various professional and advocacy groups. The role of these groups has been mainly to build capacity and infrastructure and to provide expertise, but they also provide and raise funds for these purposes, freeing domestic funding for patient services. Cataloguing such collaborations, including public-private partnerships, could promote dissemination of best
7.3 Current sources of funding for cancer control
practices; their monetary and in-kind contributions have not been estimated systematically nor analysed for integration into NCCPs.
No reliable estimate has been published of how much is spent globally on cancer control, particularly in LMIC. Public spending on all health care worldwide has been increasing consistently since 2000, both as a share of total spending and in absolute terms. Nationally, growth has largely paralleled GDP growth and increased public spending but generally not as increases in the percentage of GDP. An analysis of 40 LMIC showed that expenditure for NCDs accounted for increasingly larger proportions of public funding, estimated to be about 27% in 2016 (6). This may indicate some increase in spending on cancer, but it cannot be quantified or confirmed. National health accounts should report specifically on spending for cancer control.
The main sources of revenue and mechanisms for contribution are shown in Fig. 7.2. The vast majority of official bilateral and multilateral development aid is for infectious diseases programmes, and only about 2% is for NCDs, including cancer (9—11). Additional relevant sources of external funding are the important contributions to cancer control from private cancer centres, universities, global and national professional societies and non-profit organizations working in cancer.
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There is a growing interest in the use of innovative financing to mobilize additional revenue to fund cancer services. Defining innovative financing can be challenging, but it encompasses a wide range of both global and domestic financing instruments, such as solidarity taxes on airline tickets, taxes on tobacco and unhealthy foods and results-based financing models such as development impact bonds. Like more traditional revenue sources, innovative financing instruments should be evaluated in terms of their revenue-generating potential in absolute terms, the associated administrative costs of collecting the revenue and how each instrument will affect the guiding principles of UHC.
Potential innovative revenue sources include:
Fig. 7.1. Main sources of revenue and mechanisms of contribution
•
taxes on tobacco and other unhealthy products (“sin” taxes);•
airline levies;•
independent global financing facilities, such as the International Financing Facility for Immunization;•
development impact bonds;•
corporate social responsibility;•
lotteries;•
private “top ups” from insurance schemes;•
results-based (or performance-based) financing; and•
public—private partnerships Private voluntary insuranceDirect Compulsory pre-payment
(e.g. social health insurance)
Community based HI
Payroll Individual tax
income tax Corporate income tax
Voluntary
Compulsory
Loans Grants In-kind External
Indirect
Value aded
tax (VAT), etc. Excise and sin taxes Domestic
Out-of-pocket
payments Pre-payment
7.4 Spending on cancer control: effectiveness, cost–effectiveness, affordability and feasibility
Countries progressing towards UHC are faced with several important policy decisions. A guiding principle is that progress towards UHC increases the breadth of services in the health benefits