International Health Care Management

Part 1a

Steffen FleßaInstitute of Health Care Management

University of Greifswald

1

Structure

1 International Public Health 2 Demand for Health Services 3 Supply of Health Services 4 Health Systems and Reforms

2

Structure

1 International Public Health 1.1 Background1.2 Health and Development1.3 Concepts

2 Demand for Health Services 3 Supply of Health Services 4 Health Systems and Reforms

3

1 International Public Health

1.1 BackgroundSee Book!1.2 Health and Development1.3 Conceptions

4

1.2 Health and Development• Structure:1 International Public Health

1.1 Background1.2 Health and Development

1.2.1 Context 1.2.2 Static Concept of Development1.2.3 Dynamic Concept of Development1.2.4 Health Care in Developing Countries

1.3 Conceptions

5

1.2.1 Context

• Hypothesis: Health and development are correlated

• Approach:– Theoretical concept– Reality for Europe– Reality for developing countries: 1.2.2-1.2.4

6

Solow Theory of Growth

)(hLaKY • Y Gross National Product• a Constant• K Capital Stock• α, β Partial Elasticity of Production• h Health• L Labor

7

Health and Growth

L

L

h

h

K

K

a

a

Y

Y

h

h

Y

Y

8

Vicious Circle or Stairway to Heaven?

+

DEVELOPMENT

+

HEALTH

9

Development Traps

• Poverty Trap: economic growth high birth rate economic burden deterioration in the health situation lower economic growth

• Malthus Trap: economic growth high birth rate increasing demand for food linear increase in agricultural production, population grows exponentially lower economic growth

time

crops

agricultural output

population growth and food needs

10

CAPITAL INVESTMENT

11

CAPITAL INVESTMENT

ECONOMIC GROWTH

K

K

Y

Y

12

CAPITAL INVESTMENT

ECONOMIC GROWTH

EXPONENTIAL GROWTH OF POPULATION

K

K

Y

Y

MALNUTRITION DISEASE

„Malthus Trap“

13

CAPITAL INVESTMENT

ECONOMIC GROWTH

EXPONENTIAL GROWTH OF POPULATION

K

K

Y

Y

ECONOMIC DEPRESSION

MALNUTRITION

h

h

Y

Y

DISEASE

14

CAPITAL INVESTMENT

ECONOMIC GROWTH

EXPONENTIAL GROWTH OF POPULATION

K

K

Y

Y

ECONOMIC DEPRESSION

MALNUTRITION

LINEAR AGRICULTURAL

GROWTH

h

h

Y

Y

CONSTANT HEALTH

RESOURCES

DISEASE

POOR HEALTH

CARE

15

INVESTMENT IN HEALTH ECONOMIC

GROWTH

h

h

Y

Y

h

h

Y

Y

HEALTH

SOCIAL STABILITY;

SATISFACTION OF NEEDS; QUALITY

OF LIFE LOW OR EVEN NEGATIVE EFFECT ON

THE GROWTH OF POPULATION

16

Theory and Reality

• Theory: – development generates health– health generates development– health and development are correlated positively

• Reality:– Europe:

• Comparing countries: poorer countries only• Comparing social groups: applicable

– Developing countries: applicable

17

Data Base

• http://data.worldbank.org/topic/health• http://data.worldbank.org/data-catalog• http://data.euro.who.int/hfadb/

18

Health and Development

30

40

50

60

70

80

90

0 10.000 20.000 30.000 40.000 50.000

Lif

e E

xpec

tan

cy [y

ears

]

Gross National Product [US$ per capita per annum]

Cor=0.57

Source: The World Bank, World Development Indicators 2010. http://data.worldbank.org/data-catalog 19

0

50

100

150

200

250

300

0 10.000 20.000 30.000 40.000 50.000

Ch

ild

Mo

rtal

ity

[per

100

live

bir

ths]

Gross National Product [US$ per capita per annum]

Health and Development

Cor=-0.46

Source: The World Bank, World Development Indicators 2010. http://data.worldbank.org/data-catalog 20

<= 85

<= 81

<= 77

<= 73

<= 69

No data

Min = 65

060101 +Life expectancy at birth, in years

LastAvailable

EUROPE73.91

Europe

21

Upper

4-th

3-rd

2-nd

Lower

No data

Min = 0

080100 +Maternal deaths per 100000 live births

LastAvailable

EUROPE17.49

Europe

22

Cor=0.74

0 10000 20000 30000 40000 5000065

70

75

80

85

EUROPE

Y = 0.0002787X+71.43Y

X

X - 990000 Gross national product, US$ per capita, Last AvailableY - 060101 +Life expectancy at birth, in years, Last Available

GNP and Life Expectancy in Europe

GNP p.c. 23

„The contribution of health to the economy in the European Union“

„…good health promotes earnings and labor supply. Of particular relevance to Europe, with its ageing population, they show how poor health increases the likelihood of early retirement. Taken together, this evidence provides a powerful argument for European governments to invest in the health of their populations, not only because better health is a desirable objective in its own right, but also because it is an important determinant of economic growth and competitiveness.” (Markos Kyprianou, European Commission 2005)

24

Global Health 2035

“There is an enormous payoff from investing in healthThe returns on investing in health are impressive. Reductions in mortality account for about 11% of recent economic growth in low-income and middle-income countries as measured in their national income accounts. […] Between 2000 and 2011, about 24% of the growth in full income in low-income and middle-income countries resulted from VLYs [value of additional life-years] gained. This more comprehensive understanding of the economic value of health improvements provides a strong rationale for improved resource allocation across sectors.” (The Lancet Commission 2035, 2013)

25

Income and Health of Differing Social Groups

Germany Highest Quintile : Lowest Quintile

Risk Heart Attack 1:2.5Risk Diabetes 1:1.85Risk Cancer 1:2.26Risk Obesity (Male) 1:2.26

Risk Obesity (Female) 1:4.18

Life Expectancy 82:72

26

Disease as Cause and Result of Poverty

POVERTY – SOCIAL INEQUALITY

HEALTH INEQUALITIES

POVERTY INDUCED DISEASE

27

POVERTY – SOCIAL INEQUALITY

Unhealthy Environment, Place of Work,

Living Situation, etc.

Ability of Recovering Coping Strategies

Health Care System

Differing Behavior regarding Health Promotion and Prevention

(Nutrition, Smoking, Sport, Alcohol, Compliance)

HEALTH INEQUALITY –

POVERTY INDUCED DISEASE

28

POVERTY – SOCIAL INEQUALITY

Unhealthy Environment

etc.

Ability of Recovering etc.

Health Care System

Differing Behavior EDUCA-

TION

PROFES-

SION

LOW INCOME

HEALTH INEQUALITY – POVERTY INDUCED DISEASE

29

1.2.2 Static Concept of Development

• Static Concept of Development

Level of development based on specific indicators

• Dynamic Concept of Development

Process of development

30

Indicators of the Static Concept of Development

• Per Capita Income • Gini Coefficient for Income Distribution • Illiteracy • Epidemiological Indicators (child mortality,

infant mortality, maternal mortality, life expectancy)

• …

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Inco

me

[%]

Population [%]

31

Gross National Product per capita [US$]

http://www.econguru.com/2007-gdp-nominal-per-capita-world-map-imf/

32

Gini-Index (worldwide)

http://de.wikipedia.org/w/index.php?title=Bild:World_Map_Gini_c

oefficient_2004.png&filetimestamp=20080519153423

33

Country Categories

• Traditional Classification- Developed Countries - Underdeveloped Countries

• Classification according to GNP per capita - Developed Countries - Less Developed Countries (LDC) - Least Developed Countries (LLDC)

34

Least Developed Country: Definition

• Income: the annual per capita income does not exceed $905 in a three-year rolling average

• Economic Vulnerability Index (EVI): describes „the vulnerability of a society“ primarily originating from the dependency on one source of income, i.e. proceeds from export, share of agricultural production, processing industry and services in the gross domestic product

• Human Assets Index (HAI): the HAI provides information on the human capital, i.e. food security, malnutrition, child mortality, school enrollment rate, ability to read in adults 35

Least Developed Countries 2007

Quelle: http://commons.wikimedia.org/wiki/File:Least_Developed_Countries_map_-_2007.png

36

Other Classifications

• Classification according to proportion of market relations: first, second and third world

• Classification according to the Human Development Index – Low-Income Countries – Middle-Income Countries – Severely Indebted Low-Income Countries – Severely Indebted Middle-Income Countries– Most seriously affected countries (MSAC)

37

High, low and middle income countries

Source: The World Bank 2014 38

Annual Loss of Quality of Life per 1000 Inhabitants

0

100

200

300

400

500

600

Africa India AR ME SA China FS DME

Los

s o

f DA

LYs

per

100

0 in

hab

itan

ts

Source: Worldbank 1993, S. 3

developed market economies (DME) former socialist countries (FS) South America (SA)Middle East (ME), Rest of Asia (AR), excluding India

39

Burden of Disease 2007 (WHO 2008)

0

100

200

300

400

500

600

High Income Africa America Eastern Mediterranean

Europe Southeast Asia Western Pacific

Burd

en o

f Dis

ease

[DAL

YS p

. 100

0 In

habi

tant

sp.a

.]

Group I: Communicable diseases, maternal diseases, perinatal complications

Group II: non-communicable diseases

Group III: Accidents

40

1.2.3 Dynamic Concept of Development

• Theory of cultural stages (Hans Bobek)– Hunters and Gatherers– Specialized Fishermen and Hunters – Peasantry Clans– Hierarchical Agricultural Society– Unproductive Capitalism– Productive Capitalism

41

Excursion

• What follows the group of „Productive Capitalism“?– Information Age?

• Limiting factor = information• Better: knowledge

– Restricted to a person– Basics for decision-making– „Wisdom“

• People become scarce factors– Self-realization– Paradigm of Wholeness

42

Dynamic Concept of Development

• Ever since the industrial revolution: development along long waves (Kondratieff Cycles)

1st Kondratieff 2nd Kondratieff 3rd Kondratieff 4th Kondratieff 5th Kondratieff 6th Kondratieff

1800 1850 1900 1950 1990 20xx

Steam Engine, Textile Industry

Railway, Steel

Chemistry, Electrical Engineering

Automobile, Petrochemistry

Information Technology

???

43

Kondratieff-Cycles

• Explanation: Overview– Basic Innovations– Time Preference

44

Explanation I: Basic Innovations

• 1st Kondratieff: – Mechanical and Energetically Innovation (1800-

1850) • Steam Engine: James Watt (*19/1/1736 †19/8/1819;

1769 Invention)

• 2nd Kondratieff: – Steel, Railway (1850-1900)

• 3rd Kondratieff: – Chemistry and Electrical Engineering

(1900-1950) 45

Basic Innovations (cont.)

• 4th Kondratieff: – Petrochemistry and Mobility Engineering (1950-

2000) • 5th Kondratieff:

– Microelectronics und Information Technology (1980-?)

• 6th Kondratieff: – Proposal 1: Nanotechnology (starting 2050?) – Proposal 2: Human Technology / Psychosocial

Health? 46

Basic Innovation in the 6th Kondratieff according to W. E. Baaske: Human Technology

• Social competence as key competence– Competences:

• Expertise• Methodological Competence• Social Competence• Self-Competence

• Personality as the Basis of Authority – Traditional foundations of authority

• Reward• Punishment• Legitimation

– Advanced foundations of authority• Expertise• Personality

Intensification to Self-Competence

47

Human Technology (cont.)

• Spirituality – Content: Unity of body, soul and spirit in all dimensions of life

• Body: Health, Fitness– How can I stay healthy and productive?

• Spirit: Education, Mental Capacity– How can I stay creative and up-to-date?

• Soul: Question of the Meaning and the Being, Reference to Transcendence– Why should I keep engaging?– Which values are valuable?– Which meaning is sensible?– Which life is worth living?– Which work is worth the effort?– Do I leave anything behind?

48

Explanation II of the Kondratieff-Cycles

• Time Preference according to Neumann– Content: Systematic disregard of future benefits– Mathematical instrument: Discount rate– Value and Economical Growth

Economics is part of cultural science even though economists traditionally have a hard time giving cultural explanations for economic phenomenons

49

Explanation II of the Kondratieff-Cycles• The Buddenbrook-Syndrome

– Founding Generation• Luck, Coincidence• Frugality: low time preference• Diligence

– Preserving Generation• Higher propensity to consume: average time preference• Diligence: lower work orientation

– Ruining Generation• High propensity to consume, high time preference• Laziness• Bad luck

50

1.2.4 Health Care in Developing Countries

• Development Goals of the WHO– Life Expectancy > 60 years– Infant Mortality < 50 per 1000 – Child Mortality < 70 per 1000

51

Gross National Product per capita (2007) [US$]

http://www.econguru.com/2007-gdp-nominal-per-capita-world-map-imf/

52

Life Expectancy (2007)

http://commons.wikimedia.org/wiki/File:Life_Expectancy_2007_Estimates_CIA_World_Factbook.PNG

53

Infant Mortality

http://commons.wikimedia.org/wiki/File:Infant_mortality_rate_world_map.PNG

54

Child Mortality (2003)

http://www.who.int/healthinfo/statistics/01.whostat2005map_under5mortality.jpg

55

Causes of Poverty

Physical Disposition Environment Behavior

Individual Behavior Culture Genetic Disposi-tion

Disability

Intelligence

...

Mineral Resources

Flora and Fauna

Climate, Relief, Axes

Access to sea

...

Diligence

Frugality

Risk-Taking

Aggressiveness

…

Religion

Political System

Economic System

Social System

...

Diseases

56

Disease as Cause for Poverty Human Diseases

Animal Origin

Measles Cow (Rinderpest (word like in German))

Tuberculosis Cow (Bovine Tuberculosis) Pox Cow (Bovine Pox) and other

species with related pox viruses Influenza Pig, DuckWhooping Cough

Pig, Dog

Malaria Chicken, Duck, other birdsConstraint: Almost every infectious disease in humans is of animal origin. Transmission only occurred through living closely to domestic animals.

57

Religion as Cause for Poverty

• Max Weber: „Protestant ethics and the spirit of capitalism“

• Examples: – Using resources of animal origin in religion – Role of women and gender competition– Fatalism– Linear versus cyclic development of human beings

58

Nutrition as Cause for Poverty• Centers of Agricultural Origin in Independent Centers

of Civilization:– West Africa – Fertile Crescent

• Domestication of Plants: 8500 AD• Domestication of Animals: 8000 AD

– China – New-Guinea – Eastern USA – Central America– Andes– Potentially Amazon

http://www.pbase.com/daveb/image/4267332059

Nutrition as Cause for Poverty: Domestication

Region Plants Animals Time

Fertile Crescent

Wheat, Peas, Olives

Sheep, Goat 8500 AD

China Rice, millet Pigs, Silk Worm 7500 AD

Central America

Corn, Beans, Pumpkin

Turkey 3500 AD

Andes/Amazon

Potato, Manioc Lama,Guinea Pig

3500 AD

Eastern USA

Sunflower - 2500 AD

Western Africa

Yam, Oil Palm - 3000 AD

New-Guinea

Banana, Sugarcane

- 7000 AD60

Nutrition as Cause for Poverty: Domestication

• Precondition for Domestication of Plants – Annual plants – Plants high in protein – Large seeded plants (Wheat vs. Corn) – Seasonal climate with a distinct phase of ripening – High profitability– Hermaphrodite (Zwitterblütler) self pollinating plants

61

Natural Occurrence of Large Seeded Plants

Region No.Mediterranean Zone in Western Asia, Europe and Northern Africa

33

Eastern Asia 6Sub-Sahara Africa 4North America 4Central America 5South America 2Australia 2 62

Nutrition as Cause for Poverty: Domestication of Animals

Species Time LocationDog 10000 Near East,

China, North America

Sheep 8000 Near EastGoat 8000 Near EastPig 8000 China,

Near East63

Species Time Location

Cow 6000 Near East, India, North Africa

Horse 4000 Central Asia

Donkey 4000 Egypt

Buffalo 4000 China

Lama / Alpaca 3500 Andes

Camel 2500 Central Asia

Dromedary 2500 Arabia

64

Nutrition as Cause for Poverty: Domestication of Animals

• Precondition for Domestication – Efficient, simple nutrition in captivity – High growth rate– No fertility issues in captivity– No unpredictable nature– No tendency to stampede-like escape– High social hierarchy (human beings as herd

leader)

65

Diffusion of Domesticated Plants and Animals

• Starting Situation: Dependency of agriculture on climate (precipitation, temperature, seasons)

• Habitat of same latitude usually show similar conditions in climate, habitat of same longitude show differing ones

• Result: Diffusion on latitude is easier than on longitudeResult: Broader continents have better prospects of diffusion than long continents

66

Continental Axes

67

Causes of Poverty

Physical Disposition Environment Behavior

Individual Behavior Culture Genetic Disposi-tion

Disability

Intelligence

...

Mineral Resources

Flora and Fauna

Climate, Relief, Axes

Access to sea

...

Diligence

Frugality

Risk-Taking

Aggressiveness

…

Religion

Political System

Economic System

Social System

...

Diseases

68

Trends (Example Kenya)

40

60

80

100

120

140

40

60

80

100

120

1990 1994 1998 2002 2006 2010

Ra

te [%

]

Ra

te [‰

]

Time [Years]

Infant Mortality Child Mortality Vaccination Coverage

Attended Births Preparation for Birth 69

Example: Kenya

25

30

35

40

45

50

55

1993 1995 1997 1999 2001 2003

Time [years]

Po

pu

latio

n <

na

tion

al p

ove

rty

leve

l [%

]

.

National Rural Urban w.o. Nairobi Nairobi70

Example: Kenya

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Population [%]

Inc

om

e [

%]

Gini=42.5

20% of population hold 50 % of income

71