#1 Social Value and Economic Evaluation of Healthcare
(Angelique LEWIS, Daisuke KATO, Access to Health, Sustainability, Astellas Pharma Inc.)

#2 Financial Toxicity of Cancer in Low- and Middle-Income Countries
(Nirmala BHOO PATHY, Dept. of Social and Preventive Medicine, Universiti Malaya)

- Profile -

Angelique LEWIS is a leader with extensive experience in driving global health initiatives and sustainability efforts. As the Head of Access to Health, Sustainability at Astellas, she leads the company's global strategy to ensure equitable philanthropic access to healthcare, while championing sustainability initiatives that address the evolving needs of communities worldwide. Additionally, she serves as the President and Board Member of the Astellas Global Health Foundation, where she oversees efforts to improve health outcomes and create lasting change in underserved populations, in countries where the company does not have a presence. With a deep commitment to social impact, she has dedicated her career to addressing healthcare disparities and advancing sustainable practices within the global healthcare landscape. She works to bridge the gap between innovation and accessibility, collaborating with public and private stakeholders to maximize the impact of Astellas' initiatives. She joined Astellas in 2018 as Associate Director, Corporate Citizenship. She has nearly 20 years of Sustainability/Social Impact/CSR experience in healthcare, previously at Baxter International Inc.

- Profile -

Daisuke KATO holds a Master's degree in Biotechnology from Osaka University. He began his career at Astellas Pharma, initially working in a department focused on investigating the efficacy and safety of post-marketed pharmaceutical products. He then transitioned to the Marketing Division, where he was responsible for developing market strategies for urology products. Following this, in the Medical Affairs Division, he formulated post-marketing information creation strategies for urology products. During this time, he also led numerous research initiatives, including Phase 4 studies, Post Marketing Surveillances, and database researches, presenting his findings in academic papers and conferences. Subsequently, he moved to the Corporate Strategy Division, gaining experience in corporate governance, including involvement with the Executive Committee and Board of Directors. Currently, he leads a corporate value visualization project within the Sustainability Division. His recent achievements, particularly in monetizing previously unquantifiable non-financial initiatives and demonstrating the correlation between financial and non-financial performance, have been featured in publications like Harvard Business Review and Nikkei BP.

- Profile -

Nirmala Bhoo-Pathy is a public health physician and epidemiologist with a distinguished career dedicated to advancing cancer care systems and improving life after cancer. Her research and policy advocacy support evidence-based strategies to bridge critical gaps in cancer care, particularly across low- and middle-income countries, where her work has driven meaningful change. In addition to her impactful research, Professor Nirmala is deeply committed to medical education. As an educator, she inspires undergraduate medical students and postgraduate students to view public health as a transformative discipline that extends beyond illness, fostering solutions that enhance the health and well-being of entire populations. She serves as the Coordinator of the Master of Public Health program at Universiti Malaya, shaping the next generation of public health leaders. Her leadership also led to the development and successful implementation of the Master of Epidemiology program in Universiti Malaya, further demonstrating her dedication to capacity-building in the field.

(1) Introduction to the lecture

Norie KAWAHARA, lecture series moderator, noted that in the past lectures of the series students had explored the theme: What does well-being mean in the context of Asia? They had looked closely at the challenges Japan has faced—especially those related to an aging population and cancer care—and how these experiences can offer insights for other Asian countries that will soon face similar issues. Students had also considered how Japan’s journey might contribute to the field of global health. 

Prof. Kawahara noted that from the fourth lecture, the focus will shift to more practical and solution-oriented initiatives that go beyond supporting only the most vulnerable populations. Students would look at how to build a more sustainable society through inclusive health programs that also support the middle class and working populations.

The fourth lecture begins with a case study from Malaysia—the BEAUTY & Health project, supported by Astellas Pharma. While more information about the BEUTY & Health project would be provided in a subsequent lecture, the lecture today focuses on the social significance of this project and how we can visualize and measure the social value it creates.

Prof. Kawahara introduced the three speakers, Ms. Angelique Lewis, Head of Access to Health and Sustainability at Astellas Pharma; Mr. Daisuke Kato, also from Astellas, Sustainability, who has been working on the quantification of the social impact generated by the BEAUTY & Health project; and Professor Nirmala Bhoo-Pathy from the Dept. of Social and Preventive Medicine, Universiti Malaya, who will be speaking from the perspective of patients and families, focusing on the issue of financial toxicity—the economic hardship that often accompanies a cancer diagnosis.

It was noted that Prof. Bhoo-Pathy would provide a further lecture on June 3.

(2) Social Value and Economic Evaluation of Healthcare: Evaluation of Social Impact for Access to Health

Angelique Lewis noted that she would be explaining the work of Access to Health, Sustainability at Astellas, where her team looks at Access to Health and all the other activities that Astellas does as a company from a sustainability perspective. The work of assessing the activities of Astellas was implemented in 2022 and shared for the first time with shareholders in February of 2023 (Fig. 1). These metrics continue to be developed and expanded and shared annually.

Fig.1 Access to Health Metrics

In terms of Access to Health at Astellas, at the highest level, the company focuses on access to treatment through the products that we sell, through our prescription drugs (Rx) and Rx+ businesses and looks at expanding access to treatment. There are various types of access mechanisms in place across the company, as well as some sustainability initiatives, which is looking to provide philanthropic access to our products in countries where Astellas does not sell them.

The Astellas Sustainability team is also engaged in awareness, education, diagnosis, and linkage to quality care. Through this type of support, we work with organizations like the Asia Cancer Forum, Japan and National Cancer Society, Malaysia. It is through such efforts that Astellas has been involved in the BEAUTY and Health project. 

In addition to individual projects, the team focuses on global health and social impact, with four priority areas: improving access to treatment; diagnosis and linkage to quality care; awareness and education; and community engagement. We have various types of programs with various partners that we implement in countries where the company operates.

The BEAUTY and Health project, which is the focus for this lecture, aligns with the diagnosis and linkage to quality care pillar. Astellas collaborates with partners to support increased diagnosis and quality care, aiming to improve access to health in countries where we have a commercial presence. These initiatives are designed to strengthen community-based healthcare systems, such as increasing community health workers and screenings, enabling mobile health units to deliver care in remote communities and using technology to connect patients. It is from this perspective that we see the BEAUTY and Health project as a very important partnership for Astellas.

In terms of diagnosis, Astellas considers programs such as BEAUTY as helping to strengthen healthcare systems strengthening, and we provide healthcare to make a meaningful difference in the lives of patients, caregivers, and local communities. We collaborate with charitable organizations, so that is how we came to work with the National Cancer Society, Malaysia, and the Asia Cancer Forum of Japan. We are the funding entity in the case of the BEAUTY and Health project, but we do join in on the ground and go and see the work in person. We look to remove barriers to healthcare and strengthen health systems worldwide. We believe access to health goes beyond simply providing treatments. Our medicines treat the various types of programs that we support through our access to health work. We focus on improving health literacy, preventative care, screenings and therapy, all of which contribute to better health outcomes.

In addition to the BEAUTY and Health project, we have other projects in different countries that we support, including in Peru, Mexico, and Vietnam. While some of these programs may be very therapeutic area specific, others are typically more general and so they may focus in different oncology areas.

(3) About the BEAUTY and Health project

The original BEAUTY and Health project was a three year project in collaboration between the Asia Cancer Forum, Japan and National Cancer Society of Malaysia that we supported with a US$1 million contribution. The primary focus of the initial project was to develop a digital cancer library,  create a cancer screening registry portal, and initiate an intervention program (Fig. 2).

Fig. 2 Outline of the BEAUTY Project 2022-24

Under the project 300,000 people have been registered with the national cancer screening registry system. This is a major accomplishment in the country and something that Astellas is very proud to have been able to support in a meaningful way. There have been more than 16 million individuals that have been impacted through this project. Impact in this context means the number of people who have heard about the project in some way or another.

Astellas has also supported the expansion of the expansion of the project, which focuses on a community-based, digitally driven intervention and uses the assets that were created as part of the original project. BEAUTY in the community will be implemented through beauty salons and barber shops, which was one of the best pieces of the original project. The next part of the project will go into the workplace to provide information and screening at work, which will help the National Cancer Screening Registry to further expand.

(4) Assessing social impact of Astellas programs

Mr. Daisuke KATO, from the Sustainability Dept. at Astellas Pharma Inc. began by noting that great attention today is placed on social impact of sustainability programs and the methods employed to evaluate social impact are therefore of ever-increasing importance. 

  In terms of the definition of social impact, it is the “social and environmental outcomes resulting from the project or activities including both short and long-term challenges and the term social impact is characterized by the following these four key points.

1) Changes occur not only as a result of long term outcomes, but also in the short term.
2) It includes not only those resulting from large scale initiatives, but also small scale ones and the psychological changes in the single person.
3) It can be represented by qualitative information as well as numerical (quantified) information.
4) It includes positive and positive as well as negative changes. 

In terms of why social impact assessment is necessary according to the Access to Health Framework Implementation Guidebook(*1), real time measurement and evaluation during the implementation of the Access to Health program allows a program team to: 1) gauge progress, 2) identify program in implementation and or data correction, and 3) to adapt or improve the program implementation plans. 

In addition, longer term evaluation helps program implementation teams in four ways. First to determine the effectiveness and the importance of the program, second to explore reasons for successes and disappointments, third to determine whether or not the program is effective enough for scale up, and finally to identify adaptations that may be needed to ensure scalability and sustainability.

It is therefore important to visualize and verify the social impact of projects and activities. The Access to Health framework can be used to support different types of evaluation, including needs assessment, process evaluation, and outcome evaluation. 

Very often evaluation plans are set against a project framework or roadmaps, such outlying goals, activities, and measurement opportunities in the logical way. One example of a framework to guide program measurement and evaluation is the Donabedian Healthcare Quality Evaluation Model. Another example is the Logic Model for Monitoring and Evaluation (*2), which ranks program outcomes with output activities and inputs and is commonly used for program monitoring and operation (Fig. 3). This  framework is used relatively frequently because each step can be clarified.

Fig. 3 Logic Model for Monitoring and Evaluation

It is important to note the difference between outcome and impact. Outcomes are the changes that an intervention or program targets, such as changes in knowledge, scale, behavior, or policies. On the other hand, impact refers to the long-term results of an intervention such as population-level changes in health status or quality of life. Impact can be positive or negative, primary and secondary long-term effects produced by an intervention directly or indirectly, intended or unintended.

The difference between outcomes and impact can be tricky to discern, and is not always black and white. One key difference is the time frame of measurement. Outcomes objectives should be realistic given the program goals and should be achievable within the relevant time frame. The objectives can be divided into short-term, medium-term, and long-term outcomes.

Another way to think about outcome and impact is to sit situate then on a causal pathway. Activities lead to short term outcomes, which led to midterm outcomes, which in turn lead to long-term impact.

(5) Evaluating the impact of the BEAUTY and Health program in Malaysia

Astellas selected the BEAUTY and Health program in Malaysia for an impact assessment due to the fact that it has a large volume of epidemiological and treatment data available. 

  In Malaysia more than 60% of cancer patients are diagnosed at a later stage of cancer. This is due to the low level of health education and health literacy levels. The BEAUTY and Health program established a cancer patient registry and promoted this awareness and education among Malaysian people through the medium of beauty salons and barber shops. 

  The logic model for evaluating the social impact of the BEAUTY and Health program is shown in Fig. 4. It was conducted by the Asia Cancer Forum (ACF) and National Cancer Society Malaysia (NCSM).

Fig. 4 Logic model for evaluating the social impact of the BEAUTY & Health program

As a result of these activities, it is expected that cancer will be diagnosed at an earlier stage, treated earlier, and have a better prognosis. Astellas converted the social impact of this outcome into a monetary value. In this study, we limited the impact on colorectal cancer patients due to data availability. 

Impact was assessed by categorizing it into five value categories: 1) medical 2) psychological, 3) economic, 4) scientific, and 5) environmental value.

 In this study we made several assumptions. One is the stage at which cancer is diagnosed. Currently 75% of the patients are detected at stage 3/4, and it is assumed that after the implementation of BEAUTY and Health Program, this ratio can be lowered to 55%. 

In converting social impact into monetary value, Astellas has exactly identified impact valuation items on two axes. The first axis is the area of impact and the second axis is the target benefited from impact (Fig. 5).

Fig. 5 Impact valuation for the BEAUTY and Health Program

For example, in terms of primary impact of “increased access to optimal treatment” above, cancer can be detected and treated at an earlier stage, resulting in better treatment and longer survival. 

Another example as shown in the figure above is “patient’s work productivity,” whereby patients are able to earn more during and after treatment as a result of improved cure rates due to earlier cancer treatment. 

  Following the methodology laid out above, the total social impact of the BEAUTY and Health Program was calculated as being approximately US$4.6 million, of which the primary impact accounted for approximately US$2.8 million. 

  Converting this large figure into the impact per individual cancer patient results in an impact of approximately US$30,000 per person. 

  From the investor’s perspective, from an investment of US$1 million, a return of approximately US$4.6 million could be realized. This demonstrated that the BEAUTY and Health program is highly effective and should be continued. 

Summarizing his lecture, Mr. Kato noted that in terms of social impact, a framework was proposed to evaluate the result of Access to Health initiative in terms of social impact. The evaluation requires monitoring and evaluating inputs, processes, outputs, outcomes, and impacts using a logic model. 

In the case of the BEAUTY and Health program, individual cancer patients could receive a social impact of approximately US$30,000 (4.4 million yen), and from an investor’s perspective, investment in the BEAUTY and Health program will yield a 4.6-fold return.

(6) Assignment to students

Mr. Kato set the following assignment to students: “How can you effectively link a company’s core business with solutions to social issues?” 

Often when companies work on social program or social issues, it can feel disconnected from their core business. Mr. Kato asked students think about the optimal ways of integrating the two aspects of core business and social issues.

Prof. Nirmala BHOO-PATHY began by noting that financial toxicity at present does not have a standard definition. It has been worded in literature as a possible outcome of perceived “subjective financial distress,” which results from objective financial burden. Basically, financial toxicity reflects the detrimental effects of direct and indirect cause of cancer. 

The components of financial toxicity are: objective financial burden, or active financial spending; material response, such as changes in income, finding second jobs, selling property, borrowing money, using savings, or missing bill payments; psychosocial impact, including changes in motivation or changes in productivity; support seeking from others; altering care plans or “coping care”; and changes in one's lifestyle or “coping lifestyle,” including a reduction in leisure activities. 

Financial toxicity does not mean that every component stated above must all be present. It can be one or a combination of one or more components. 

The ACTION Study was conducted in Southeast Asia a decade ago. It was a longitudinal cohort study of close to 10,000 newly diagnosed adult cancer patients who were recruited between 2012 to 2014. Eight member countries of the Association of Southeast Asian Nations (ASEAN) participated. Patients were recruited from 47 public and private hospitals and cancer centers across Southeast Asia, and we followed up the participants throughout the first year after their cancer diagnosis at three time points. The study tools that were used were interviewer administered questionnaires as well as cost diaries, which were used to record out-of-pocket (OOP) expenditure over 12 months (Fig. 6).

Fig. 6 Overview of the ACTION Study

The ACTION study looked at catastrophic expenditures, which is defined as when a family has to spend more than 30% of their total annual household income on cancer-related costs. When we looked at the incidence of catastrophic expenditures in the various ASEAN countries, it was found that patients in Malaysia experienced catastrophic expenditures at a greater level than in Thailand, which has a lower per capita income than Malaysia. These outcomes raised questions about the way healthcare is funded in Malaysia.

One of the components that explained a great deal of catastrophic expenditures was the lateness of diagnosis and late stage at which cancers are diagnosed. This speaks to the importance of implementing initiatives to improve early detection of cancer.

In terms of the healthcare system in Malaysia, there is a dual system in place, comprising the public and private sectors. The public healthcare sector is funded by taxation and the self-pay portion for care is extremely small. Conversely, the private sector is funded by OOP insurance premiums, which people buy voluntarily or through an employer insurance plan. 

Based on the Malaysia data from the ACTION Study a further study was conducted to examine the cost drivers of catastrophic expenditures in Malaysia (Fig. 7)

Fig. 7 Cost drivers of catastrophic expenditures in Malaysia

As can be seen from the above figure, in the public sector, the great majority of the cost drivers for catastrophic expenditures are “all payments (non-medical) related to illness” rather than medical care or traditional medicine. This demonstrates that in the public sector it is non-medical expenses (travel, accommodation, childcare, etc.) that are driving economic catastrophe. 

 The above study was conducted a decade ago, so in terms of what is happening in Malaysia in a more recent post-COVID context, it is the case that COVID had a further exacerbating effect on indirect costs of cancer. A new cohort study implemented form April 2021 to March 2022 sought to assess the prevalence of financial toxicity (FT) in patients with cancer across Malaysia in the years following the pandemic, and identify factors associated with FT, with a specific focus on assessing geographical, gender and ethnic disparities. The participating institutions for the study were from across Malaysia, including East Malaysia, and the study population was approximately 1200 patients with stage I to stage IV cancer (Fig. 8) Data collection was conducted using face-to-face interviews, and the Comprehensive Score for Financial Toxicity (COST) questionnaire. In addition, extensive data on employment and private health insurance ownership was also collected.

Fig. 8 Demographic characteristics of the COST questionnaire

In this study it was found that about 22% of the entire study population reported severe financial toxicity, whereas another 33% had moderate financial toxicity. The median cost score was 24. In the COST questionnaire a higher score indicates a lower level of FT, meaning low scores are bad. Whereas the median COST score was 25, in East Malaysia it was 19, indicating greater prevalence of FT in East Malaysia. The study suggests FT of 16.3% in West Malaysia, vs. 36.3% in East Malaysia. FT was also found to be greater in males than females, in both East and West Malaysia. There was also difference in FT among ethnic groups. Another interesting outcome of the study was that there was severe FT among middle and high income families, which merits further investigation. 

In terms of the predictors of FT, in West Malaysia predictors include age (with younger people reporting greater FT), ethnicity (Indians suffer FT more than Chinese groups), low income, employment, and cancer staging. In East Malaysia, age, gender, income, and employment again emerged as predictors of FT. 

In summary, from this post-COVID study, one-fifth of Malaysians seem to experience severe financial toxicity following cancer, with higher financial vulnerabilities observed in the rural regions. Comprehensive patient-centered interventions that screen for and address not only the medical costs, but also the non-medical costs, as well as the income loss, can be implemented to complement systemic reforms focusing on health financing mechanisms.

Translating evidence to action is the next challenge. When a person receives a cancer diagnosis this comes with a variety of unmet financial needs. Early interventions will really help families to alleviate the financial hardship. This, in turn, will promote equitable access to quality care throughout Malaysia.

  One of the patient-centered interventions that is being implemented is financial navigation, with services being very focused on addressing financial needs of patients.

Tony HILL, project researcher at the Asia Cancer Forum (ACF) noted that the presentations from Astellas had covered the broader “macro” picture, whereas Prof. Bhoo-Pathy had focused on the more “micro” aspects of financial toxicity. One common thread to both of the presentations is the importance of early intervention and early detection and the BEAUTY and Health project is one such initiative that seeks to improve early diagnoses among cancer patients. Where does Astellas think is the potential impact of the BEAUTY project now that it is set to become BEAUTY+ and expand to include workplaces and companies in Malaysia? 

Ms. Lewis responded that Astellas’ hope for all of our projects and programs that we support is that they have long-term impact in communities and long-term impact. This could involve the government stepping in to help support the program or it becoming a part of the health system. Astellas is not looking to be a sole funder or the only funder—our hope is that in the longer term there is the ability for others to step in.

When asked about her knowledge of the BEAUTY and Health program, which approaches people through beauty salons and barbershops, Prof. Bhoo-Pathy noted that she had been very interested to hear about it as a novel and different approach to the “one-size-fits-all” approach to cancer campaigns. She noted that although the project was initially targeted at the lower income stratum of society in Malaysia, perhaps the group that actually falls through the net is the middle-income group. There are a lot of projects and interventions that have been geared up for people from the low income population, but the middle income population are “too rich to be poor and too poor to be rich” and therefore they fall through the net. So these are the kind of people who will benefit immensely if we have these kinds of novel interventions targeted to them.

With regard to the projected impact of the BEAUTY and Health program, which has demonstrated a 4.6-fold return on investment of US$1 million, Mr. Kato noted that that the figures presented are based on various assumptions, but it is important to present these figures to investors from a corporate management aspect. 

A student asked about the assumption that the proportion of diagnoses of stage III-IV cancers could be brought down from 75% to 55%, to which Mr. Kato responded that the data is from the targets of the National Cancer Society Malaysia, but based on realistic assumptions. Prof. Bhoo-Pathy noted that the target sounds logical and it could be useful to include upper and lower thresholds in the calculations.

A student asked about other projects that have been completed that show the impacts of FT. Prof. Bhoo-Pathy responded that in Malaysia efforts are being focused on patient navigation, which involves encouraging people with symptoms to go to hospital to be checked and diagnosed. Financial navigation is a form of patient navigation, but it is more focused on addressing costs. There are several financial navigation services that could potentially be incorporated in the ongoing patient navigation services in Malaysia, but rather than implement a top-down process, work is ongoing through qualitative inquiries to identify three or four financial navigation services that could prove a best fit. One such service would help patients understand their medical bills and calculate how much money would they need to prepare.

  A further service that is in the process of being developed is a resource directory, and another is a service that assists patients in filing the paperwork related to claims for financial assistance.

  Other areas for study include the burden of travel and time toxicity. These are areas where further study is needed as a means of persuading government to establish more cancer centers around the country.

In closing, Dr. Kawahara thanked all lecturers for their insightful comments, noting that all of the aspects covered are important parts of building, building a sustainable society. She noted that Prof. Bhoo-Pathy would again be joining the next lecture, and would guide students in exploring today's themes more deeply, particularly focusing on the kind of policies that are needed to create a more equitable and sustainable future.