Positioning Comprehensive Cancer Control in the Sustainable Developmental Goals for India

In 2015, the 2030 Agenda for Sustainable Development Goals was adopted by the member states of the United Nations. Its defining principle was “Leave no one behind.” It is a holistic model of development that encompasses economic, social, and environmental aspects, with the universal call for action towards ending poverty, protecting the planet, and ensuring that all people experience peace and prosperity by 2030. The agenda’s 17 core goals are broken down into 169 associated targets to direct global development strategy until 2030.[1] Target 3.4 is meant to reduce by one-third, the premature mortality from non-communicable diseases (NCDs) through prevention and treatment by 2030. It is central towards achieving comprehensive cancer control, set within the broader SGD Goal 3 which is “to ensure healthy lives and promote well-being for all at all ages.” Year 2023 marked the midpoint of the 2030 Agenda for Sustainable Development. The Sustainable Developmental Goal (SDG) Report 2023 depicts a concerning global picture of SDG progress at the midpoint with only 15% on track for achieving the goals, including NCDs. The same report puts India on a Moderately Improving track to achieve SDG 3—Good Health and Well being with an overall performance and country ranking of 112 out of 166 and a country score of 63.4 with a regional average of 67.2.[1] It is important to highlight at this stage that the estimated age-standardized incidence rates (ASR) as reported by GLOBOCAN 2020 for all cancers, both sexes and all ages, for India stands at 97.1 per 100,000 against that of some high-income countries of USA (362.2), Australia (452.4), and France (341.9) with very high ASR for all cancers.[2] This lends itself to the investigation of the protective factors for cancer in the country as well as investigating mitigation of the risk factors for prevention and control measures for nationwide adoption. Health systems of many of the lower middle-income countries have failed to effectively respond to address the rising burden of cancer and effectively deploy existing evidence-based low-cost effective cancer prevention interventions for their populations. With respect to the current cancer burden in India, the majority of cases are still diagnosed in advanced stages. The mortality-to-incidence ratio is 0.68 in India, which is far higher than that in developed countries (approximately 0.38).[3] Regarding our country’s strategy in health, through the National Health Policy 2017, it is focused on providing essential services to the entire population, by universalizing primary health care with a special emphasis on the poor and vulnerable population. India has a mixed Health Care System with both Public and Private Health Care available to people. However, cancer health care remains highly privatized, with more than 80% of outpatient care and 40% of inpatient care provided by the private sector. Roughly 71.7% of health care gets financed through out-of-pocket payments. Cancer remains one of the most expensive NCDs facing health care systems.[3,4] Positioning Comprehensive Cancer Control within SDG 3 and target 3.4, in practical terms, has to translate into five critical actionable activities, as follows. (1) Primary Cancer Prevention, by adopting optimal strategies for preventable risk factors for cancer such as measures to reduce tobacco use, reduce the harmful use of alcohol, increasing taxes on alcohol, tobacco, unhealthy processed food, public awareness through mass media to promote physical activity and reduce physical inactivity. addressing multiple risk factors can reduce the overall non-communicable disease burden and premature mortality. Selecting the most feasible and cost-effective intervention strategies can achieve these goals. Strengthening of National Hepatitis B Virus and Human Papillomavirus Virus vaccination programs will further consolidate the primary prevention measures. (2) Cancer screenings for breast, cervical, and oral cancers, for early detection with proven cost-effective interventions need to consolidate and scale up within the current NCD program, which currently has sub-optimal coverage and poor linkages with cancer care centers.[5,6] To accelerate the program implementation, an inclusive and coordinated approach by creating and building synergies with other health programs or platforms needs to be assessed. Also identifying partners and networks that harness the potential capabilities of the stakeholders from civil society, professional associations and societies, philanthropic institutions, private sector to create synergies, and reach scale and magnitude to attain the targeted SDG goals. (3) Education and training of health care personnel, and building human resources across the cancer care spectrum are equally crucial to deliver cancer care across the cancer continuum. Manpower and training have not been able to keep pace with the rapidly increasing number of cancer cases which currently is heavily skewed towards the private sector and urban areas of the country. Considerable variations and disparities that exist across the country over the standard of care in the practice and delivery of cancer diagnosis and treatment need to be addressed coherently. The highly specialized nature of cancer treatment plans and protocols mandates the development of country-specific management guidelines and linking them to the government insurance reimbursements. This will assure compliance to deliver evidence-based care.[7] (4) Strengthening of cancer surveillance to be done by generating good quality data through the implementation and expansion of the cancer registry will help prioritize policies at a national level.[5] Access to cancer care and quality essential health care services has to be improved with affordable radiation, drugs, and supportive palliative care. (5) To support the provision of cancer, enhanced health financing and financial risk protection for reducing inequalities should be the central points of action within the health system. National Insurance schemes such as Ayushman Bharat, Pradhan Mantri Jan Arogya Yojana (PM-JAY),[8] a flagship scheme of the Government of India, recommended by the National Health Policy 2017, with its focus on the Comprehensive Primary Health Care system and to achieve the vision of Universal Health Coverage has been designed to meet the SDGs and its underlining commitment, which is to “leave no one behind.” PM-JAY is the world’s largest health insurance/ assurance scheme fully financed by the government that provides a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization across public and private empaneled hospitals in India. Optimal financing of the public health system with improved access, availability, and quality of care will help reduce the current huge disparities in cancer care with the most disadvantaged population with low education, income and geography of residence facing the highest cancer mortality rates along with the largest proportion of out-of-pocket expenditure and the greatest risk of catastrophic health spending. India is witnessing a demographic and epidemiological transition with a definitive shift from high-prevalence infectious diseases to an increasing burden of NCDs in adults. Therefore, the discourse around achieving NCD targets depends on the interlinkages and interdependencies between the targets to be achieved by other SDGs. Achievements of the targets overlap with several other SDG goals and also reinforce the targets of one or several other SDGs.[5,6] Thus, it is likely that for implementing the 2030 Agenda, programs and national policies need to bring about and identify synergies that will contribute towards progress in other goals. While laying emphasizing on the above action points for Comprehensive Cancer Control within SDG 3, Health in general and Cancer Control in particular will not be achieved without positioning Comprehensive Cancer Control with other SDGs. Hence, achievements for target 3.4 under SDG 3 are closely interconnected and interrelated with many other goals that aim toward ending poverty in all its forms everywhere (goal 1), aiming for zero hunger to ensure healthy lives (goal 2), promoting quality education (goal 4), gender equality (goal 5), access to clean water and sanitation (goal 6), and system efforts to reduce inequality (goal 10) will go a long way in achieving the comprehensive goals. Some of the country’s national development goals are mirrored in those that aim to achieve the SDG target 3.4. Economic growth (SDG 8), for example, can be considered as a process that will have a positive effect on outcomes such as the quality of education (SDG 4) and health (SDG 3). Thus, while targeting economic growth, infrastructure development and industrialization, the country’s Government interventions and targeted achievements in the interconnected SDGs will extend the benefits of those investments towards SDG target 3.4 and beyond. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.