World Cancer Leaders’ Summit 2015

Heartfile tackles cancer care in Pakistan

Dr Sania Nishtar - HeartFile, Islamabad, Pakistan

It is great news that you have initiatives concerning cancer care in Pakistan, can you tell me about Heartfile and what it is that’s special that you’re doing?

Heartfile is an NGO and there are two sides to Heartfile. One is a policy think tank which focuses on health systems and advocates for change independently. The second aspect of Heartfile is an access to treatment initiative which provides financial resources for urgently needed medical treatment for very poor patients who would otherwise forego care or would become impoverished in the process of seeking care.

Can you give me an example of the sort of thing you’re able to do, then, as a result of having Heartfile?

On the humanitarian access to treatment initiative an example would be a child who requires a bone marrow transplantation because of a haematological disorder, or a women who requires mitral valve replacement and whose family cannot afford it, or a labourer who has fallen and has broken a leg and cannot afford a nailing and a plating. So these are expensive treatments that patients are unable to afford as a result of which they would forego care.

How do ordinary people in Pakistan take advantage of this, then?

The point of entry is a health facility which is registered with us because normally when poor patients require high cost treatment they usually go to a public health facility which is the entity that we register. So once they are there the doctors are able to ascertain their financial access barrier and then they alert us through an SMS. So the whole programme works on an SMS.

You also have a national action plan in Pakistan for prevention and control of non-communicable diseases, how does your work mesh in with that?

I wear different hats at different times, so this is from my policy advocacy side. In 2003 I was able to forge a collaboration between my NGO, Heartfile, between the Ministry of Health of the government of Pakistan and the World Health Organisation and in 2003 we developed an integrated comprehensive plan of action targeting four non-communicable diseases as well as mental health and injuries. So the premise was that there are these six conditions, four diseases, and you target the four common risk factors and you act through an integrated plan of action. So through one entry point you address all the problems.

How well is it going?

It was initialised in 2003, it was ahead of its time. The government at that time committed to it initially but then they were more focussed on infectious diseases and HIV and maternal and child health issues. We as an organisation continued to carry it at a baseline level but as of recently interest in the plan of action has exponentially increased after the 2011 political declaration on non-communicable diseases and of course our provincial governments are all rallying around the plan and the different elements of implementation that it called for.

In the Pakistan context what are the NCD issues that you face, then?

We’ve got a major burden of cardiovascular disease, so coronary heart disease, high blood pressure, diabetes is a major problem. We harbour a significant cancer burden as well; chronic respiratory disease is very common, as are many other NCDs.

Could you tell me about the main points that you are trying to get over here at this meeting of cancer leaders in Istanbul?

I was asked to talk about conflict of interest at this meeting in my keynote and I was very pleased that they asked me to do that because after the pronouncement of the 2015 sustainable development goals the agenda for implementation is very clear for countries.

What is the conflict of interest that you’re talking about then?

Conflict of interest is when one organisation or an individual has two interests, the primary interest and a secondary interest and there’s a risk that the primary interest, which is the key goal of a professional activity, will be influenced by a person’s secondary interest, which is usually…

And in this context?

In this context it is usually financial in nature. Because the implementation narrative in the 2015 sustainable development agenda is veering very much towards partnerships for achieving the goals and a very salient role of the private sector, conflict of interest considerations have become very important.

Are you saying that in trying to control and care for patients with non-communicable diseases or, indeed, to prevent them conflicts of interest can intervene?

Absolutely and you need to systematically hedge against them because non-communicable diseases, their prevention is not something as simple as a vaccination shot. These require some complicated fiscal and regulatory measures on the part of governments.

So if you’re going to take regulatory measures then these need to be about which targets, do you think? Which are the big issues to take regulatory messages over?

The regulatory messages are around tobacco and, of course, diet as well as the extent of physical activity, but basically diet and tobacco. And of course there’s a huge influence of commercial entities who are often very close to governments. So conflict of interest concerns really need to be managed. The existence of a conflict of interest does not mean that impropriety has occurred, it just denotes that judgement may be compromised and that the conflict needs to be managed.

How easy is it in the context of Pakistan to introduce legislation which can discourage the use of tobacco and perhaps do things like cutting down the sugar content of foods?

The issue in countries like Pakistan is not in the enactment of the legislation, it’s in its implementation. Because we have a lot of nice policies and plans and laws in place but when it comes to implementing them there are systematic barriers to implementation and that’s where the main challenge is.

What messages then, briefly to wrap this up, would you give to health organisers all over the world in trying to get good things implemented? You’re saying rather surprisingly and unpleasantly that getting the laws in place isn’t enough.

The first message is that partnerships are an imperative. In order to get things done there are comparative advantages of different entities, the government, civil society, the private sector, academia, the scientific community. So you really need to join the dots to get things done and that’s message number one. Message number two: we need to be cognizant of conflicts of interest and there need to be systematic approaches, systematic and systemic approaches to hedging against these. But as you say very correctly, the pronouncement of laws and the framing of policies is not enough, governments need to step up their capacity to ensure that those are effectively implemented.