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
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?