Germany’s experiences in tackling NCDs in the context

of an aging population

Prof. Dr. Steffen Flessa Department of Health Care Management

University of Greifswald

Contents

1. Demography and Health 2. Strategies 3. Conclusion

1. Demography and Health 1.1 Aging: concept

• Aging: Aging is a multidimensional process of physical, psychological, and social change over time.

aging is not only a question of age – but it has a lot to do with it!

Germany: one of the

oldest populations

in the world!

Demographic Transition

Rate

Phase II Phase III Phase IV Phase

Gross death rate

1 %

Gross brith rate

5 %

Phase V time

Germany: • crude birth rate:

8.8/1000; • crude death rate:

9.2 /1000;

0

2

4

6

8

10

12

14

16

18

20

1950 1960 1970 1980 1990 1998 1999 2000

Life

Birt

h pe

r 100

0

Year

Reason 1: Low Birth Rate

Germany Total Old States New States

Reason 2: medical progress

Women [years]

Men [years]

Life Expectancy [years]

Consequences: NCDs

80 70 60 10 20 50

susceptibility

time [years] … birth

NCD

Epidemiological Transition

0

20

40

60

80

100

0 20 40 60 80 100 120

Incide

nce  an

d  prevalen

ce  [%

]

Time  of  Epidemiological  Transition  [year]

Incidence,  Infectious  diseases Incidence,  NCD

Prevalence,  infectious  diseases Prevalence,  NCD

Causes of Death (Men 2007)

150472;  38%

113405;  29%

30219;  8%

21029;  5%

19067;  5%

56947;  15%

Cardio-­‐Vascular

Cancer

Respiratory

Digestive

Accidents

Other

http://de.wikipedia.org/w/index.php?title=Datei:Todesursachen_01.svg&filetimestamp=20100227122441#file

1.2 Aging: a blessing

• 1514: • 63ys old woman

• 2011 : • 77ys old woman

„Young old“

1.3 Aging: a curse

Health Care Cost and Age

Increase of Demand (Western Pomerania, 2005-2020)

NCD Increase of Demand

Hypertension +6.2%

Diabetes +21.4%

Myocardial infarction +28.3%

Stroke +18.0%

Osteoperosis +19.5%

Dementia +91.1%

Cancer (total +22.6%

Cancer (rectal) +31.0%

Source: Hoffmann 2011

• Direct Cost of Dementia in Germany [€ p.c. p.a.]

Source: Schulenburg et al. 1998; Jönsson/ Berr 2005.

1.4 Example: Dementia

Medical cost

ca. 1.935 €

Non-medical cost

(accommodation, counselling etc.)

ca. 11.685 €

~15%

~85%

• Strongly increasing cost in stages

Source: Schulenburg et al. 1998; Quentin et al. 2009.

Prognosis

Mild (MMSE 20-25)Moderate (MMSE 11-15)

Severe (MMSE <= 10)

02.0004.0006.0008.000

10.00012.00014.00016.00018.00020.000

Schweregrad

Kos

ten

[EU

R]

Cost

p.a

. p.

c. [€]

Severity

2. Strategies

• Overview: – Social Insurance: Long-term Nursing – Training of specialists in geriatrics (doctors, nurses,

etc.) – Homes of the elderly und mobile care – Life-long learning of human workforce – Deferred Retirement – Combat infectious diseases – Individualized Medicine und paradigm shift: Multi-

Cause-Multi-Effect Paradigm – Strengthen Prevention

2.1 Deferred Retirement

0

10

20

30

40

50

60

70

80

90

Zeit 1960 1970 1980 1990 1995 2000 2010 2020 2030 2040

time [year]

popu

latio

n Ge

rman

y [m

illion

]

< 20 years 20-<60 years >59 years

0

10

20

30

40

50

60

70

2000 2010 2020 2030 2040 2050

work

ing

popu

luat

ion

time [year]

20-35 years 36-50 years 51-65 years

0

10

20

30

40

50

60

70

2000 2010 2020 2030 2040 2050

work

ing

popu

luat

ion

time [year]

20-35 years 36-50 years 51-65 years

We must keep our key-agent of production in the process – but this requires investments!

Investments in Health

• Physical – Focus on Prevention – Fostering health promotion

• Mental – Keeping workers creative requires transitional

leadership! • Spiritual

– A sense of meaning, appreciation and contribution! Aging is not simply a medical problem – it requires a new paradigm of leadership!

2.2 Combat infectious diseases

• Old people have more infectious diseases – Sepsis – Pneumonia – …

• “Young” old people have new risks: – HIV and Viagra

2.3 Individualized Medicine und paradigm shift

• Old patients are multi-morbid – >65: average more than 6 drugs, max. 21 – Side-effects: unpredictable

• Treatment depends on many factors: there is no “one-fits-all-medicine” anymore! – Genomics – Proteomics – Metabolomics – …

• A new mind-set: Chronic-degenerative diseases require a multi-cause-multi-effect paradigm of medicine!

2.3 Individualized Medicine und paradigm shift

• Old patients are multi-morbid – >65: average more than 6 drugs, max. 21 – Side-effects: unpredictable

• Treatment depends on many factors: there is no “one-fits-all-medicine” anymore! – Genomics – Proteomics – Metabolomics – …

• A new mind-set: Chronic-degenerative diseases require a multi-cause-multi-effect paradigm of medicine!

• But: very, very expensive! • Do not use the health care system of any other country as blue-print: it is too expensive!

Develop your own cost-effective basic package of treating NCD!

Use your ressources as efficient as possible!

2.4 Strengthen Prevention

0

5

10

15

20

25

30

35

0 20 40 60 80 100 120

Share  of  prevention  bu

dget  in  to

tal  

health  ca

re  bud

get  [%]

Time  of  demographic  transition  [years]

2.4 Strengthen Prevention

0

5

10

15

20

25

30

35

0 20 40 60 80 100 120

Share  of  prevention  bu

dget  in  to

tal  

health  ca

re  bud

get  [%]

Time  of  demographic  transition  [years]

Prevention and Primary Care are not the “Medicine

of the Poor” but a very efficient paradigm for

aging societies!

3. Conclusion

• An aging society will induce a higher share of non-communicable diseases.

• An aging society is a blessing – but it requires wise planning, political commitment, strong leadership, cost-effective interventions.

• Health care financing and social protection are crucial!

Germany is gaining experiences with its aging

population and their NCDs – can we share insights?