1. 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

2. Contents
1. Demography and Health
2. Strategies
3. Conclusion

3. 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!

4. Demographic Transition
Rate Germany:
Gross brith rate • crude birth rate:
8.8/1000;
5% Gross death rate • crude death rate:
9.2 /1000;
1%
Phase Phase II Phase III Phase IV Phase V time

8. Reason 1: Low Birth Rate
20
18
16
14
12
Life Birth per 1000
10
8
6
4
2
0
1950 1960 1970 1980 1990 1998 1999 2000
Year
Germany Total Old States New States

9. Reason 2: medical progress
Life Expectancy [years]
Women
[years]
Men [years]

10. Consequences: NCDs
susceptibility
NCD
birth 10 20 … 50 60 70 80 time [years]

11. Epidemiological Transition
100
Incidence and prevalence [%]
80
60
40
20
0
0 20 40 60 80 100 120
Time of Epidemiological Transition [year]
Incidence, Infectious diseases Incidence, NCD
Prevalence, infectious diseases Prevalence, NCD

12. Causes of Death (Men 2007)
56947; 1 5%
19067; 5 %
Cardio-­‐Vascular
150472; 3 8% Cancer
21029; 5 % Respiratory
Digestive
30219; 8 %
Accidents
Other
113405; 2 9%
http://de.wikipedia.org/w/index.php?title=Datei:Todesursachen_01.svg&filetimestamp=20100227122441#file

13. 1.2 Aging: a blessing
• 1514: • 2011 :
• 63ys old woman • 77ys old woman

14. „Young old“

15. 1.3 Aging: a curse

16. Health Care Cost and Age

17. 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

18. 1.4 Example: Dementia
• Direct Cost of Dementia in Germany [€ p.c. p.a.]
Medical cost
~15% ca. 1.935 €
Non-medical cost
~85% (accommodation, counselling etc.)
ca. 11.685 €
Source: Schulenburg et al. 1998; Jönsson/ Berr 2005.

19. Prognosis
• Strongly increasing cost in stages
20.000
18.000
Cost p.a. p.c. [€]
16.000
14.000
Kosten [EUR]
12.000
10.000
8.000
6.000
4.000
2.000
0
Moderate (MMSE 11-15)
Mild (MMSE 20-25) Severe (MMSE <= 10)
Severity
Schweregrad
Source: Schulenburg et al. 1998; Quentin et al. 2009.

20. 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

21. 2.1 Deferred Retirement
90
80
70
population Germany [million]
60
50
40
30
20
10
0
Zeit 1960 1970 1980 1990 1995 2000 2010 2020 2030 2040
time [year]
< 20 years 20-<60 years >59 years

22. 70
60
50
working populuation
40
30
20
10
0
2000 2010 2020 2030 2040 2050
time [year]
20-35 years 36-50 years 51-65 years

23. 70
60
50
We must keep our key-
working populuation
40
agent of production in
30 the process – but this
20
requires investments!
10
0
2000 2010 2020 2030 2040 2050
time [year]
20-35 years 36-50 years 51-65 years

24. 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!

25. 2.2 Combat infectious
diseases
• Old people have more infectious diseases
– Sepsis
– Pneumonia
–…
• “Young” old people have new risks:
– HIV and Viagra

26. 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!

27. 2.3 Individualized Medicine
und paradigm shift
• Old patients are multi-morbid
– >65: •average more than 6 drugs, max. 21
But: very, very expensive!
– Side-effects: unpredictable
• Do not use the health care system of
• Treatment depends on many factors: there is no
any other country as blue-print: it is too
“one-fits-all-medicine” anymore!
expensive!
– GenomicsDevelop your own cost-effective basic
– Proteomics
package of treating NCD!
– Metabolomics
Use your ressources as efficient as
–… possible!
• A new mind-set: Chronic-degenerative diseases require a
multi-cause-multi-effect paradigm of medicine!

28. 2.4 Strengthen Prevention
35
Share of prevention budget in total
30
health care budget [%]
25
20
15
10
5
0
0 20 40 60 80 100 120
Time of demographic transition [years]

29. 2.4 Strengthen Prevention
35
Share of prevention budget in total
30
Prevention and Primary
health care budget [%]
25
Care are not the “Medicine
20
15
of the Poor” but a very
10
efficient paradigm for
5
aging societies!
0
0 20 40 60 80 100 120
Time of demographic transition [years]

30. 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!

31. Germany is gaining
experiences with its aging
population and their NCDs –
can we share insights?