1. International Health Care Management Part 2c Steffen Fleßa Institute of Health Care Management University of Greifswald 1

2. Epidemiology of Non-Infectious Diseases 2 Demand for Health Services 2.1 Determinants of Demand: Overview 2.2 Demographic and Epidemiologic Transition 2.3 Epidemiology of Infectious Diseases 2.4 Epidemiology of Non-Infectious Diseases 2.4.1 Overview 2.4.2 Example: Diabetes Mellitus Type II 2.4.3 Example: Cervix Uteri Carcinoma 2.5 Risk Factors 2.5.1 Nutrition 2.5.2 Water and Hygiene 2.5.3 Smoking, Alcohol and Environmental Influences 2.5.4 Pregnancy and Delivery 2.5.5 Health Care System in Megacities 2.6 Filter Between Need and Demand 2

3. Risk Factors and Develop- ment 3

4. 2.5.1 Health and Nutrition Traditional Notion: – Hunger, Malnutrition Reality: – Wrong Nutrition – Obesity – „Diseases of Civilization“  high complexity of worldwide nutritional situation! Various “worlds of nutrition” within one country 4

5. Supply and Demand for Food 5

6. 6

7. Supply 7

8. State of Health Food Security Capacity for Care Health Care Knowledge, Education, Welfare (i.e. maternity protection) Access to clean drinking water, sanitation and health care facilities Quantity and Quality of Available Resources: human natural economic social and political context Ingestion Access to food as the result of food market (price, quality, quantity, distance, …) Food Security 8

9. Food Price Index and Inflation Rates Source: FAO 9

10. Malnutrition (http://upload.wikimedia.org/wikipedia/commons/7/78/Percentage_population_undernourished_world_map.PNG) 10

11. Malnutrition 11

12. Malnutrition and Wrong Nutrition One deficit does not equal the other Hunger  Global Malnutrition – (formerly: Protein-Energy-Malnutrition) ‚Hidden Hunger‘  Deficit of Micronutrients – Individual nutrients (i.e. vitamin A, iron, iodine) 12

13. 13 Anemia in Pregnant Women (= Iron Deficiency) 13

14. Obesity 14

15. Nairobi 2012 15

16. Risk Factor Obesity (Women) 16

17. Risk Factor Obesity (Men) 17

18. Obesity 18 1989 1991 1993 1997 China is becoming wealthier... Proportion of China‘s population (20-45 years), that gets less than 10% of their energy from fat: Proportion.. more than 30% of energy from fat 18

19. Diabetes: in Developing Countries as well Global Prevalence of Diabetes 0 50 100 150 200 250 Africa America Europe Middle East Asia/Australia People in Millions 20002030 +62% +57% +51% +31%+64% 19

20. 20 Global Mortality of Diabetes in 2000 (Age Group 35 to 64 Years) 204.000231.000261.000 89.000 977.000 0 200 400 600 800 1.000 1.200 Africa America Europe Middle East Asia/Australia x1000 People Diabetes: in Developing Countries as well 20

21. Nutritional Status of Diabetics in Northern Tanzania (Krawinkel 2008) 21

22. Nutrition and Diseases Regulatory Circuit: – Wrong and malnutrition increase susceptibility to disease – Disease results in malnutrition Reason: – Increased need in sickness Calories: up to 100 % additionally Vitamins: up to couple 100% additionally – Diseases specific to the digestive system, i.e. hookworm  Anemia 22

23. 2.5.2 Water and Hygiene Consumption in Germany (44.000 l p.c. p.a.) – Agricultural irrigation (3%) – Consumption in households (personal hygiene): 14% Drinking water: 0,5-2,5 l per day – Industrial consumption (83%) Consumption in Developing Countries (i.e. India: 91.250 l p.c. p.a.): – Predominantly agricultural http://www.hydrologie.uni-oldenburg.de/ein-bit/11686.html 23

24. Consumption of Water per Day http://www.forumla.de/f-politik-gesellschaft-92/ t-wasserknappheit-81294 Comparison – international consumption of water liter/p.c. (as of 2000) BelgiumGermanyEnglandFrance Switzerland 24

25. Hippocrates of Cos (460 BC -370 BC) „Air, Water and Places" – Whoever wishes to investigate medicine properly, should proceed thus: in the first place to consider the seasons of the year, and what effects each of them produces for they are not at all alike, but differ much from themselves. Then the winds, the hot and the cold, especially such as are common to all countries, and then such as are peculiar to each locality. We must also consider the qualities of the waters, for as they differ from one another in taste and weight, so also do they differ much in their qualities. – These things one ought to consider most attentively, and concerning the waters which the inhabitants use, whether they be marshy and soft, or hard, and running from elevated and rocky situations, and then if saltish and unfit for cooking; and the ground, whether it be naked and deficient in water, or wooded and well watered, and whether it lies in a hollow, confined situation, or is elevated and cold; and the mode in which the inhabitants live, and what are their pursuits, whether they are fond of drinking and eating to excess, and given to indolence, or are fond of exercise and labor, and not given to excess in eating and drinking. http://www.paganrod.com/2010/02/hippocrates-on-airs-waters-and-places.html 25

26. Declaration of Alma Ata (1978) Primary health care … includes at least: – education concerning prevailing health problems and the methods of preventing and controlling them; – promotion of food supply and proper nutrition; – an adequate supply of safe water and basic sanitation; – maternal and child health care, including family planning; – immunization against the major infectious diseases; – prevention and control of locally endemic diseases; – appropriate treatment of common diseases and injuries; – and provision of essential drugs; 26

27. Millennium Development Goals 1.Eradicate extreme poverty and hunger until 2015 – Water is the basis for nutrition 2.Achieve universal primary education 3.Promote gender equality and empower women 4.Reduce child mortality – Water and hygiene are basis for child health 5.Improve maternal health – Water and hygiene are basis for maternal health 6.Combat HIV/Aids, Malaria and other diseases – Malaria is a water-related disease 7.Ensure environmental sustainability – Water cycle 8.Global partnership for development 27

28. Water-Related Diseases (Drinking)Water-Transmitted Diseases – Water is medium of transmission – i.e. Cholera, Hepatitis A, Diphtheria, Salmonellae, Polio Water-Washable Diseases – Water is medium of prevention – i.e. Colds and Flues, Worms, Diarrhea, Pox Water-Resistant Diseases – Water is reservoir – i.e. Bilharzias, Malaria, Dengue, River Blindness 28

29. Water and Health 884 million people do not have access to safe water 2.6 billion people do not have safe toilettes 10% of worldwide burden of disease is caused by water and sanitation 30% of child mortality in developing countries is caused by water and sanitation (OECD 2011) 29

30. Example: Rotavirus Most Common Severe Diarrhea Worldwide – 111 million cases annually – 25 million in health care system 35-50% clinical diarrhea 2 million hospital admissions <5 years – 850.000 fatalities annually (predominantly children) Main cause of death: dehydration Transmission: fecal-oral 30

31. Water Scarcity http://www.savemynature.com/message/13525 31

32. Water Scarcity and Population http://www.tor-nach-afrika.de/home/content.cfm?ID=366&nav=Partnerschaften 32

33. The Fight for Water 33

34. Diarrheal Diseases http://upload.wikimedia.org/wikipedia/commons/e/ef/Choleraverbreitung_%28deutsch%29.PNG Cases of Cholera worldwide ReportedSporadically 34

35. Diesfeld et al. (1997): S. 94 35

36. Toilet Systems: Primary Prevention No Toilet – Roadside, bushes, water channels, rice fields… Dry Latrines – Pit with cover, danger of formation of gases, breeding place for flies Ventilated Dry Latrine – Pit is ventilated, fly trap Flush Toilet with Odor Trap – Low water consumption, primarily serves odor/smell reduction via siphon Water Closet – Thorough removal of excrements by use of water pressure and amount 36

37. Water and Hygiene in Health Care Facilities Sample: 66000 health care facilities in 54 low- and middle-income countries “improved water source”: not available in 38% Water and soap for handwashing: not available in 35 % “improved sanitation” (Toilets): not available in 19 %  WASH: water, sanitation and hygiene concept by WHO & UNICEF 37

38. 2.5.3 Smoking, Alcohol and Environmental Influences Tobacco associated fatalities in Germany (incl. Passive smoking) – Cancer: 60.000 – Cardio-Vascular Diseases: 52.000 – Respiratory Diseases: 28.000 – Total: > 140.000 (16 % of total fatalities) – Almost every 6 th resident of Germany dies due to consuming tobacco – 86 % of smokers die due to tobacco as estimated by the Centre for Disease Control 38

39. Consumption of Tobacco (Proportion of smoking adult males) http://en.wikipedia.org/wiki/Smoking 39

40. Risk Factor Tobacco and Poverty (WHO 2007) 40

41. Cost of Smoking (Germany 2003) Average consumption: 16,6 cigarettes per smoker per day Tobacco Tax (2008): 13,6 billion Euro Cost: – Direct Cost: 7,5 billion Euro Outpatient care: 24 % Drugs: 24 % Rehabilitation: 4 % Acute hospital care: 48 % – Indirect Cost: 13,5 billion Euro Mortality: 4,7 billion Euro Morbidity: 8,8 billion Euro Source: Neubauer et al. (2006): Mortality, Morbidity, and Costs attributable to Smoking in Germany. Tobacco Control 15, p. 464-471 41

42. Cost of Smoking (International) Australia (2004/5) – Tobacco Tax: 5,1 billion US$ – Direct Cost: 1,7 billion US$ – Indirect Cost: 3,1 billion US$ Massachusetts (USA) – Direct Cost: 4,3 billion US$ – Indirect Cost: 1,7 billion US$ Taiwan (2001) – Direct Cost: 2,3 billion US$ – Indirect Cost: 2,0 billion US$ Source: Collins, D.J.; Lapsely, H.M. (2008): the costs of tobacco, alcohol and illicit drug abuse to Australian society. Commonwealth of Australia, Canberra Huans, X. et al. (2008): Smoking-attributable mortality and economic costs. Bureau of substance abuse services, Department of Public Health, Mass. Yang, M.C. et al. (2005): Smoking attributable medical expenditures… Tobacco Control 14, 62-70 42

43. Prevalence of Daily Smoking (≥18 Years, 2003-2004) 43

44. Model of Smoking 44

45. Consumption of Alcohol http://gamapserver.who.int/mapLibrary/Files/Maps/Global_adult_percapita_consumption_2005.png 45

46. Risk Profilehttp://gamapserver.who.int/mapLibrary/Files/Maps/Global_patterns_drinking_score_2005.png 46

47. Resultshttp://gamapserver.who.int/mapLibrary/Files/Maps/Global_subregions_dalys_2004_generalized.png 47

48. Environ- mental Influences 48

49. 2.5.4 Pregnancy and Delivery Starting Point: Millennium Development Goals, Goals 3-5 – Promotion of gender equality and empower women – Reduce child mortality Reduce mortality rate of children younger than 5 by 2/3 until 2015 (basis 1990) – Improve maternal health Reduce maternal mortality rates by 3/4 until 2015 (basis 1990) 49

50. Infant and Child Mortality Rates Source: UN MGD Indicator Data Base 50

51. Maternal Mortality in Germany 1900-1999 Maternal Mortality Rate = MMR Live Birth = LB 51

52. Maternal Mortality in ComparisonUSA Sweden England 52

53. USA Sweden England LLDC Average 2000 Maternal Mortality in Comparison 53

54. Maternal Mortality Worldwide (Fatalities/100.000 Life Births) 54

55. Müttersterblichkeit weltweit (Todesfälle/100.000 Lebendgeburten) 99% maternal fatalities occur in developing countries! 55

56. Health and Demography GermanyTanzania Child Mortality (<5 years of age) 5/1000 Births154/1000 Births Maternal Mortality0,06/1000 Births 7/1000 Births Life Expectancy79 Years46 Years Fertility (children per women) 1,35,2 Health Expenditure per capita in US$ 241212 56

57. Maternal Mortality: a Main Problem of Health? Maternal mortality has a significant share of total mortality in women of reproductive age (10-30%) Maternal mortality has a significant share of pregnancy related mortality: 7% of total pregnancy related fatalities involve mothers Proportion of burden of disease (in DALYs) in Africa: – Maternal conditions: 3,2 % – Perinatal:6,5 % 57

58. Mother-Child-Programs (MCH) 1948: Mother-Child-Health (MCH) is one of four priorities in founding the WHO 1978: MCH is an element of PHC - Prenatal care and obstetrics - training MCH health professionals - Focus on survival of children 58

59. 1985: more emphasis on maternal health: “Where is the “M” in MCH?” 1987: Safe Motherhood Initiative: - Concept of risk in prenatal care - Training of traditional midwifes - Obstetrics in in reference hospital (concept of districts) Mother-Child-Programs (MCH) 59

60. International Conference on Population and Development Abbreviation: – ICPD – Cairo 1994 Resolutions: – Prevention and referral – Obstetrics assisted by trained midwives – Preventing over-intervention – Abortion care – Increase quality and effectiveness – Informed decision 60

61. Safe Motherhood Actions 1999 Revision of Safe Motherhood Strategy Content: Revision of Safe Motherhood Strategy Goals: Goals: 1. Advance Safe Motherhood Through Human Rights 2. Empower Women: Ensure Choices 3. Safe Motherhood is a Vital Economic and Social Investment 4. Delay Marriage and First Birth 5. Every Pregnancy Faces Risks (Emergency Care) 6. Ensure Skilled Attendance at Delivery 7. Improve Access to Quality Reproductive Health Services 8. Prevent Unwanted Pregnancy and Address Unsafe Abortion 9. Measure Progress 10.The Power of Partnership 61

62. “ The emphasis is on improving the accessibility, quality and utilisation of Emergency Obstetric Care for women who develop such complications, rather than on having contact with all pregnant women“ (D. Maine 1997) 62

63. Loss of Effectiveness in Prenatal Care 63

64. Medically Defined Risk Groups versus Self Assessment of Mothers (Example Mtwara, Tanzania) Hospital Births: 21% Risk Pregnancies according to catalogue: 29% Risk Pregnancy in Hospital: 6% 64

65. Current Debate Can maternal health be improved without an improvement of overall health care? Is an emphasis on emergency care justified? What role has prenatal care? Maternal versus child health? Improving the legal and social status of women. 65

66. Abortion Est. 35-53 mio. p.a. worldwide 97 countries prohibit abortion (only in case of conflict of life of mother): 39 % of world population 66

67. 67

68. Abortion Laws 68

69. Example Kenya Abortion is illegal (except for conflict of life of mother and after rape) Estimated number of (illegal) abortions: – 300-400.000 p.a. – Predominantly girls < 15 years – Post coital contraception: unknown number High mortality due to illegal abortions – Estimate: 40 % of maternal mortality 69

70. 70

71. Conclusion All previous “magic bullet” concepts failed Actual progress in reducing maternal mortality demands for an overall improvement of health care in addition to specific measures (i.e. training midwives) 71

72. 2.5.6 Health Care in Megacities Reason: – High urbanization in developing countries – Strong attention to rural problems 72

73. Urbanization in Least Developed Countries http://esa.un.org/unpd/wpp/index.htm Side Condition: already in 2008 the majority of the world‘s population is living in urban regions! 73

74. „Urban Penalty“ Early Industrial Revolution: Life expectancy in cities is significantly lower than in rural areas = urban penalty Development: since 20 th century non existent 74

75. Land, Kleinstädte Großstädte Life Expectancy at Birth (Years) Life Expectancy in England and Wales (Szreter 1999) 75

76. Example: Healthy / Sick Cities Cities with more than 10 million people 198019902000 New York, Mexico City, Sao Paulo, Shanghai, Tokyo New York, Mexico City, Sao Paulo, Shanghai, Tokyo, Los Angeles, Buenos Aires, Mumbai, Kalkuta, Peking, Seoul New York, Mexico City, Sao Paulo, Shanghai, Tokyo, Los Angeles, Buenos Aires, Mumbai, Kalkuta, Peking, Seoul, Reio de Janeiro, Lagos, Cairo, Krachi, Delhi, Dhaka, Jakarta, Manila 76

77. Development of Population of Selected Cities, 1950-2005 City Growth Factor 77

78. Health Promotion: here? 78

79. or here? 79

80. http://www.thelancet.com/journals/lancet/article/PIIS0140673613608697/images?imageId=fx1&sectio nType=lightBlue&hasDownloadImagesLink=false 80

81. Diseases of Higher Prevalence in Megacities Diseases of Digestive Organs – High child mortality Diseases of the Lungs, Asthma – Strong pollution Mexico City is considered the “most dirty city” Ozone > WHO standard on more that 300 days / year Hearing Loss – Noise pollution Nervousness, communication disorders, sleep disorder Obesity Allergies Diabetes 81

82. Problems Insecure living situation - physical (i.e. landslides) - legal (missing tenures, especially women) Insecure supply of drinking water; no sanitation High density in population  risk for spread of diseases Work conditions hazardous to health 82

83. Problems (2) Economic growth does not reach everybody to the same extend: social inequality remains Empowerment: health conscious middle class is reached – not so the poor Different priorities: work, tenures, legal status of women … Social structures: no growth / vulnerable to resettlement programs 83

84. Problems (3) Physicians do not show interest in empowerment (questioning their own role) and in prevention (are smoking themselves) Prevention requires investment, i.e. infrastructure for sports (missing especially for women) Treatment of manifested diseases are complex and expensive 84

85. Problems in Slums 85

86. 2.6 Filter Between Desire and Demand 2 Demand for Health Services 2.1 Determinants of Demand 2.2 Demographic and Epidemiologic Transition 2.3 Epidemiology of Infectious Diseases 2.4 Epidemiology of Non-Infectious Diseases 2.5 Risk Factors 2.6. Filter Between Need and Demand 2.6.1 Distance and Demand 2.6.2 Price Elasticity and Insurance 86

87. Importance of Distance to the Health Care System Service Character: – Cannot be stored – Cannot be transported – Requires presence of patient Consequence: Production and sales in unity of place, time and action Consequence: Overcoming distance in the short-term is essential 87

88. Distance-Friction-Effect 88

89. Distance-Friction-Effect Trans- actions Distance 89

90. Newton‘s Gravity Formula GGravity within two centers CConstant M i Mass of center i dDistance between two centers α Friction constant, depending on infrastructure, mental mobility, relative benefit Problem: Curative medicine shows small alpha, prevention high alpha 90

91. Actual Catchment Area 91

92. Catchment Area of Minimal Distance 92

93. Catchment Area Kajiado Hospital, Kenya 93

94. Catchment Area Thikai Health Centre, Kenya 94

95. Health Care in Balkh Province, Afghanistan 95

96. Travel time to Balkh Provincial Hospital 96

97. 2.6.2 Price Elasticity and Insurance Procedure: – Economic basics implied – Here: exceptions To Repeat: Definition of Elasticity – Price Elasticity – Cross-Price Elasticity – Income Elasticity 97

98. Occupancy and Fees of 24 Church Hospitals 98

99. Demand for Outpatient Services in Mvumi Hospital 99

100. Fee Waiver for Poverty Groups Definition of Poverty – absolute poverty (1 US$) – relative poverty: exclusion from “normal” way of life Problems: – Determining criteria Poverty in income? Poverty in assets? (Massai owning 200 cows?) – Side-payments 100

101. Share of Costumers of Health Facilities Having to Pay for Services That Are Free of Charge (Kenya) 45% 55% 60% 54% 0% 10% 20% 30% 40% 50% 60% 70% ImmunisationAntenatalFamily planning Delivery 101

102. Poverty and Human Development Index “Multidimensional Poverty”: Proportion of population that are considered poor under various dimensions 102

103. Human Development Index (2012) Multidimensional Poverty [% of total population] Niger18692,4 Ethiopia17387,3 Mali18286,6 Burundi17884,5 Burkina Faso18384 Liberia17483,9 Guinea17882,5 Somalia..81,2 Mozambique18579,3 Sierra Leone17777 Senegal15474,4 Congo (Dem. Rep.)18674 Benin16671,8 Uganda16169,9 Rwanda16769 Timor-Leste13468,1 Madagascar15166,9 Malawi17066,7 Tanzania15265,6 https://data.undp.org/dataset/MPI-Headcount-percentage-of-population-in-multidim/ggn4-nphr 103

104. Lorenz-Chart of Cambodia (2004) (World Bank 2008)World Bank 2008 104

105. Consumption per capita in Cambodia (Worldbank 2012) 105

106. Dynamics of Poverty 106

107. Wealth Wealth of Assets – Financial Assets – Real Estate Assets Wealth of Income  Statistics vary significantly! 107

108. Millionaires Worldwide [in thousands] http://www.sueddeutsche.de/geld/vermoegen-weltweit-neue-deutsche-millionaere-1.708921 108

109. http://www.welt.de/finanzen/article117239605/In-Deutschland-leben-erstmals-eine-Million-Millionaere.html 109

110. Poverty in Germany www.armutsatlas.de Leader MV: 24,3% 110

111. Poverty in Germany www.armutsatlas.de Leader Vorpommern: 27,0 % 111

112. Consequences Large proportion of the world’s population cannot afford minimal health care Health insurance is a possibility to pool the risk of catastrophic payment A proportion of the German population would also not be able to pay for health care 112

113. Disadvantages of Insurance Standard Knowledge: – Adverse Selection – Moral Hazard – Overhead Expenses – Risk Disadvantages in Countries Poor of Resources: – Need for Catching Up – Problems in Institutions – Ethnological Problems 113