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Working Paper – 011 Working Paper – 011 Cancer Care under AB PM-JAY Focus on Radiation Specialty Packages Access and Utilization Authors: Sudha Chandrashekar1, Parul Naib1, Shubhashree Patra2, Anmol Mishra2, Sheena Chhabra1 1 World Bank 2 National Health Authority Disclaimer: The main objective of the working paper series of the National Health Authority (NHA) is to help staff, consultants, advisors and partners to speedily share their research findings based on AB PM-JAY experience with professional colleagues and test their research findings at the pre-publication stage. The opinion(s), view(s) and conclusion(s) expressed in the working paper are those of the authors and do not reflect the view of any author’s employer, official policy or position of any agency of the NHA. The AB PM-JAY data used in the analysis should not be utilized/quoted without prior permission of NHA. The papers do not themselves represent policy advice. Acknowledgements: We acknowledge with gratitude the contribution and support provided by all NHA colleagues, especially the Analytics team (Abhay Sharma, Vichitra Kumar), and the Medical Team (Dr Pradeep Maurya) for their feedback and suggestions.; Special thanks to CEO and Deputy CEO at NHA for their overall strategic guidance and facilitating the necessary approvals. 2 ABSTRACT Ayushman Bharat Pradhan Mantri-Jan Arogya Yojana (AB PM-JAY), the world’s largest health assurance scheme fully funded by the Central and State government of India, aims to provide quality secondary and tertiary care to the poor and vulnerable families as identified by SECC 2011 data. With the ongoing demographic and epidemiological transition, cancer is emerging as a major public health concern in India and thus the scheme has included oncology packages in its scope. Studies say that the out of pocket expenditure on cancer treatment is among the highest for any ailment. Utilisation of oncology packages under AB PM-JAY are covered broadly under three categories medical, surgical and radiation oncology. The present paper is an attempt to understand the access to radiation treatment and preliminary trends observed in the utilization of radiation oncology packages by the states under the AB PM-JAY across public and private hospitals. Keywords – Radiation, Oncology, AB PM-JAY, Cancer INRODUCTION & BACKGROUND Cancer is the second leading cause of death globally, and was responsible for an estimated 9.6 million deaths in 2018. Approximately 70% of deaths from cancer occur in low- and middle- income countries and globally about 1 in 6 deaths is due to cancer. It is predicted that the global burden will double to about 29-37 million new cancer cases by 2040 (Figure 1). Tobacco use is the most important risk factor and is responsible for 22% of the cancer deaths. 3 Figure 1 Ranking of premature mortality due to cancer across countries INDIA: CANCER COGNIZANCE With the ongoing demographic and epidemiological transition, cancer is emerging as a major public health concern in India. As per the 2016 WHO Report, the cancer mortality rate in India is 79 per 100,000 deaths and accounts for over 6% of total deaths1. According to the estimates, there are nearly 25 lakh cases in our country and 4 lakh deaths occur annually due to cancer2.According to GLOBOCAN data, in 2018 there were 11,57,294 new cancer cases in India in both men and women, 7,84,821 deaths and 22,58,208 people living with cancer (within 5 years of diagnosis). The top 5 cancers that affect Indian population are Breast, oral, cervical, gastric and lung cancer3. Report of National Cancer Registry Programme, 2020 says that the leading sites of cancer among males are lung, mouth, oesophagus and stomach cancer while breast cancer was the leading site of cancer among females.4 The cancer burden of India is expected to rise by 12% by 2025. Given the high cost of treatment for cancer, being diagnosed with it often leads to catastrophic 1 WHO; NCD Country Profile Geneva: World Health organization;: http://www.who.int/nmh/countries/ind_en.pdf?ua=1 2 Economic burden of cancer in India: Evidence from cross-sectional nationally representative household survey, 2014 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5826535/ 3 http://cancerindia.org.in/common-cancers/ 4 https://www.ncdirindia.org/All_Reports/Report_2020/default.aspx 4 personal health expenditures that possibly affects the well-being of the entire family. As per estimates, treatment for about 40% of cancer hospitalization cases is financed mainly through borrowings, sale of assets and contributions from friends and relatives.5 Earlier hospital-based studies found that, on an average, a household spends about Rs. 36,812 for the entire cancer therapy excluding non-medical costs. It is also noted that out of pocket (OOP) expenditure on cancer hospitalization is about 2.5 times of overall average hospitalization expenditure. These compelling results urge for the need for building a large-scale inclusive health infrastructure specific to cancer care. CURRENT RADIATION FACILITIES IN INDIA National and international guidelines recommend radiotherapy for optimal management of many solid tumours as well as certain haematological malignancies. These are extremely limited in India, where for 1.2 billion people only 559 machines are available, i.e. 1 machine per 2.1 million people as compared to the recommended standard of 1 machine per 120,000 individuals.6 Based on the number of existing installed units in India, this still would mean a shortfall of >4500 machines7. There is also a lack of specialist’s staff in this field and to meet India’s needs, 2756 radiation oncologists, 1533 medical physicists and 4737 radiation therapists need to join the healthcare workforce by 2020. Nevertheless, the acute shortage is startling and with current figures of 198, 150, and 250 graduates of radiation oncology, medical physicist, and radiation therapists available respectively, it would take many more years to reach the required staff8. The supply of oncology facilities is extremely concentrated and skewed with state-of-the-art technology available mostly within the private sector and a few hospitals in the public sector, but 75% of patients in public sector in India do not have access to timely radiotherapy9. This inequity s׳India of most where areas, rural in amplified is sector public the in radiotherapy to access in population is concentrated. A long-term government commitment to purchase of machine and human resource development in the public sector is needed to improve access. 5 Economic burden of cancer in India: Evidence from cross-sectional nationally representative household survey, 2014 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0193320 6 Datta NR,Samiei M,Bodis S:Radiationtherapy infrastructure and human resources in low- and middle- income countries: Present status and projections for 2020. Int J Radiat Oncol Biol Phys 89(3):448-457, 2014 7 http://www.indianjcancer.com/article.asp?issn=0019- 509X;year=2019;volume=56;issue=4;spage=359;epage=363;aulast=Munshi 8 http://www.indianjcancer.com/article.asp?issn=0019- 509X;year=2019;volume=56;issue=4;spage=359;epage=363;aulast=Munshi 9 Radiation Oncology in India: Challenges and Opportunities https://www.researchgate.net/publication/310390860_Radiation_Oncology_in_India_Challenges_and_Opportun ities 5 The radiotherapy centres in India have either teletherapy facilities alone or both teletherapy and brachytherapy facilities (Table 1)8. Table 1: Distribution of radiotherapy machines across geographical regions The conventional radiotherapy treatments use Cobalt 60 technology while three-dimensional conformal radiotherapy (3D CRT), Intensity modulated radiation therapy (IMRT), and Image guided radiation therapy (IGRT) are said to minimize exposure to radiations and increase precision of treatment, restricting the radiations only to malignant cells10. Currently India has approximately 545 teletherapy machines (180 telecobalt units and 365 medical accelerators), 22 advanced therapy machines (7 Gamma knife units, 8 Tomotherapy machines, 7 Cyber-knife machines and 2 intra-operative radiotherapy machines). The number of remote after loading brachytherapy units is estimated at around 2508 (Table 2). Studies have concluded that advanced techniques like IMRT have advantages over conventional treatment techniques in a number of cancer sites11. Thus, widely replacing the classical approach of treatment. IGRT procedure is most utilized package in male. Brachytherapy is used more often in females. Table 2: Brachytherapy facilities 10 https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/radiation/eXternal-beam- radiation-therapy.html 11 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097603/ 6 The latest technologies in radiation therapy include Stereotactic Radio Surgery (SRS). SRS is a non-surgical radiation therapy used to treat functional abnormalities and small tumours of the brain. It can deliver precisely targeted radiation in fewer high-dose treatments than traditional therapy, which can help preserve healthy tissue. The more uniform and frequent availability of high-quality radiotherapy can improve cancer outcomes and may be regarded as a marker of a comprehensive and equitable system of health care delivery.12 FINANCIAL ASSISTANCE FROM GOVERNMENT SCHEMES In India, the Centre along with many State Governments have provided for the access to cancer treatment through social protection schemes for supporting the disadvantaged. Health Minister’s Cancer Patient Fund (HMCPF) – Under
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