AP’s Cancer Screening Drive Aims To Slash Health Costs, Improve Outcomes

Behind this move is the increasing burden of cancer on the state, evidenced from the growing expenditure on patients seeking cancer treatment through the Dr NTR Vaidya Seva Trust (previously, the Dr YSR Aarogyasri Health Care Trust), the state-sponsored health insurance scheme.

Expenditure on cancer as a proportion of the total state expenditure on health has increased from 12.8% to 18.2% in the last five years, according to the state health department.

Medical oncology has seen the steepest increase, 423%, followed by radiation oncology, at 213% and surgical oncology, at 73%. Over all these three disciplines, the expenditure has increased 264%.

Cancer is one of the most expensive non-communicable diseases to treat, for which--various studies show--between 34% and 84% patients incur catastrophic expenditure rates.

The World Health Organization (WHO) defines catastrophic health spending as out-of-pocket payments that exceed 40% of a household’s capacity to pay for healthcare. The WHO defines capacity to pay for health care as total household consumption minus a standard amount to cover basic needs (food, housing and utilities).

India’s National Health Policy 2017 deems household healthcare expenditure as being catastrophic when it exceeds 10% of the total monthly consumption expenditure or 40% of the monthly non-food consumption expenditure.

Now that this burden is falling on the state, it is prioritising the early diagnosis and treatment of cancer.

“We propose to complete the first round of screening of women for breast, cervical and oral cancer in a year, and make this an annual exercise,” Chevvuru Hari Kiran, commissioner, health and family welfare in the AP government, told IndiaSpend.

A recent study based on the treatment of breast cancer at the Tata Memorial Hospital, Mumbai, found that women with early stage (stage I or II) breast cancer incurred 15% less expenditure on the medical plus non-medical items than patients with an advanced stage (stage III or IV).

Treating breast cancer, cervical cancer and oral cancer in the early stages could reduce the medical cost to a third in the long run, Umesh Mahantshetty, director, Homi Bhabha Cancer Hospital & Research Centre, Visakhapatnam, told IndiaSpend.

“In the first few rounds of screening, we may detect prevailing cancers with advanced disease,” said Mahantshetty. “Subsequent rounds of screening will reveal early stage cancers. Diagnosing and treating early stage cancers will gradually reduce the cost incurred as compared to [what would have been spent on] the multimodality treatment in advanced stages.”

Over a period of time, regular screening may reduce the financial burden to manage cancers in the community, he said.

Essentially, early stage cancer necessitates “less intensive treatment and a shorter treatment duration, and is associated with fewer treatment-related adverse effects”, said P. Nageswara Reddy, consultant, medical oncology, and head, clinical services at the Sri Venkateswara Institute of Cancer Care & Advanced Research, Tirupati.

Further, the early stage diagnosis and treatment of cancer reduces mortality, 20-30% for breast cancer and 50% for cervical cancer, reckoned Reddy, and those saved can go on to make valuable contributions to the economy and society, directly or indirectly.

“Having resourceful people and intact families is the biggest return of state investment in health,” said Mahantshetty.

State-sponsored health insurance: A tale of bad economics vs welfare

To protect people from medical expenditure-induced poverty, the Niti Aayog had recommended moving towards universal health insurance coverage. To this end, the Union government, through the Ayushman Bharat health insurance scheme, Andhra Pradesh through the Dr YSR Aarogyasri Health Care Trust (now renamed the Dr NTR Vaidya Seva Trust), and many other states through similar schemes have sought to pick up the cost of hospitalisation for secondary or tertiary care for the poor.

This move has helped improve access to hospital care and expanded choices for people to seek inpatient care from the public or private sectors, but only as long as the government health scheme covers the treatment.

A child, age 9, died of blood cancer in March 2024 after a three-year fight with the disease. She was treated at the government hospital in Vijayawada, her hometown, and at private hospitals in the city and in Telangana. Despite the cost of bone marrow transplantation being covered by the government-sponsored scheme, Pragati, the child’s mother, needed to take a loan of about Rs 5 lakh to cover a part of the cost.

“I am now struggling to pay back the loan,” Pragati told IndiaSpend.

Reddy pointed out that many drugs have been introduced in oncology in the last decade, including targeted therapy, immunotherapy, antibody-drug conjugates. While these new treatments may improve cure rates and prolong longevity, the benefits they offer are sometimes not proportional to their high costs.

Even when the health insurance scheme covers a disease, it doesn’t always protect against morbidity and mortality.

“When insurance schemes cover only hospitalisations, people are more likely to wait for symptoms to get worse and go to a hospital directly, rather than seek primary care,” Anuska Kalita, health systems specialist at the global health and population department, Harvard University, told IndiaSpend.

Late treatment in a disease like cancer usually means increased mortality. Additionally, the significant increase in government spending on such hospitalisations is of concern.

Public hospitals largely dependent on annual budgets and salaries have no real motivation to prevent disease, Kalita said, while private hospitals which earn revenue through out-of-pocket spending or case-based reimbursements through insurance have a clear incentive to over-provide often unnecessary/irrational care and do no prevention at all. “In time, these also directly lead to increase in prices set by healthcare providers.”

“Such payment models and the incentive structures that they create for the whole health system (providers and patients) become unsustainable, as we have seen even for rich economies like the US,” she added.

This situation is already playing out in AP. The state’s GDP grew 16% in 2022-23, its expenditure on cancer care grew 264% over the last five years.

Earlier this year, the AP Super Speciality Hospital Association threatened to stop providing services if their pending dues totalling Rs 1,500 crore weren’t cleared. They also cited stagnant package rates under the government scheme since 2013 as being a concern.

“Public-funded health insurance schemes work only in the beginning, and as long as the uptake is low,” Indranil Mukhopadhyay, professor, Jindal School of Government and Public Policy told IndiaSpend. “With awareness of the scheme, the uptake increases and eventually the actual expenditure overshoots the allocation. We’ve seen this happen with various schemes in the country including the Chirayu Scheme in Haryana and the Swasthya Sathi Scheme in West Bengal.”

Developing countries such as Thailand, Turkey, Uruguay and Kazakhstan and also developed countries have redesigned their systems to focus on comprehensive primary healthcare, said Kalita. “The rationale is to shift the focus from curative care and hospitalisations to preventing diseases and managing illnesses at an earlier stage, which is more cost effective.”

For every non-communicable disease, this mandates prevention as well as screening.

Prevention is better than cure. Where does that leave hospitals that earn from treating?

Prevention spans primary prevention, preventing the disease from occurring; secondary prevention, managing the disease so that the patient doesn’t need hospitalisation (or the disease doesn’t progress); and tertiary prevention, preventing the disease from progressing to a major event requiring tertiary care or causing permanent disability or death.

Primary prevention cannot just be left to people, emphasised Kalita. “Especially, in the Indian context, with limited and weak primary care that hardly ever focuses on prevention and promotion, where people don’t have providers that are actively working to keep them healthy.”

The key is to make providers--both public and private--accountable for the health outcomes of the population they serve, she said.

“This could involve incentivising providers to align with health goals, and could possibly be implemented through capitated payments, global budgets, and performance-based payments,” Kalita suggested.

The goal is providers that actively work to keep people healthy through identifying those at high risk of developing the disease, and monitoring them through preventative health behaviours and screenings, and continuous management of those with chronic diseases to prevent high-cost hospitalisations.

In the context of cancer in AP, Mahantshetty emphasised the need to focus on primary prevention. “For oral cavity, cancer of the cervix and breast, prevention would entail health awareness, tobacco-control measures, vaccination against HPV [human papillomavirus] and promotion of a healthy lifestyle,” he said.

However, implementing HPV vaccination needs a robust screening programme, monitoring and strong trust-building in the community.

“Without screening you can have no idea of the efficacy of vaccination, and you cannot assume that women who have been vaccinated will be okay,” added Mahantshetty.

AP’s health infra chain has prepared for screening

Screening is not a one-person or one-team job but rather interdepartmental work requiring all the involved stakeholders to be on the same page, said Reddy.

For example, screening for breast cancer on a mass scale will generate a considerable number of women for confirmation of the diagnosis via a mammography, biopsy or fine needle aspiration cytology, and for various treatment modalities. Those departments must be adequately staffed and equipped to avoid excessive waiting and anxiety among patients and their families.

So, Reddy points out that a successful mass screening programme must be preceded by strengthening cancer care facilities, including medical, radiation, and surgical oncology, as well as pathology, radiology, microbiology, nursing and other involved departments.

“Mere screening without expansion of the cancer care infrastructure would disrupt the treatment of patients already diagnosed with cancer and waiting for treatment slots,” he said.

In this context, AP has established a roadmap to scale up its human resources and established a chain of comprehensive cancer care facilities across the state.

“We have established a preventive oncology wing in every medical college, and trained 10 doctors in every tertiary care centre in preventive oncology, with the help of a few not-for-profit partners and the Homi Bhabha Cancer Hospital & Research Centre, Visakhapatnam,” said Hari Kiran. “They are being used as master trainers.”

“Trained mid-level healthcare providers who are stationed in villages will examine the women and refer suspect cases, as needed, to family doctors, primary health centres, community health centres, district hospitals and medical colleges,” he added.

“We have applied to start postgraduate courses in radiation oncology, head & neck surgical oncology and onco-pathology to develop human resources for the state,” added Mahantshetty.

At the outset, a screening programme will increase the number of cancer patients flowing in for treatment, and hence the cost of treatment.

On the basis of the West’s experience of screening, and considering statistics of false positivity rates, Reddy estimated that 10% of eligible women would be waiting for investigations, and the incidence of breast cancer patients would increase significantly.

“As most of these patients would seek treatment under state health schemes, the government should escalate the budget allocation to the health sector to suit the increased needs,” he said.

Subsequent rounds of screening, as we said, will help diagnose patients earlier and gradually reduce the cost incurred on treatment besides delivering social and economic returns.

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