International Health Care Management

Part 2c

Steffen FleßaInstitute of Health Care Management

University of Greifswald

1

Epidemiology of Non-Infectious Diseases

2 Demand for Health Services2.1 Determinants of Demand: Overview2.2 Demographic and Epidemiologic Transition2.3 Epidemiology of Infectious Diseases2.4 Epidemiology of Non-Infectious Diseases

2.4.1 Overview2.4.2 Example: Diabetes Mellitus Type II2.4.3 Example: Cervix Uteri Carcinoma

2.5 Risk Factors2.5.1 Nutrition 2.5.2 Water and Hygiene2.5.3 Smoking, Alcohol and Environmental Influences2.5.4 Pregnancy and Delivery2.5.5 Health Care System in Megacities

2.6 Filter Between Need and Demand

2

Risk Factors

and Develop-

ment

3

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

DEMAND

Want

(Desire for Certain Foods)

Subjective Experience of Deficit (Hunger)

Objective Nutritional Deficiency (Calories, Proteins,

Vitamins…

Supply and Demand for Food

5

DEMAND

Want

(Desire for Certain Foods)

Subjective Experience of Deficit (Hunger)

Objective Nutritional Deficiency (Calories, Proteins,

Vitamins…

Speculation

Want

(i.e. Desire for Biofuels)

Subjective Experience of Deficit (i.e. Mobility)

Alternative Use

6

Supply

Food Production

- Technology

- Forms of

Organization

- Management

Soil - Area - Quality

Labor - Quantity - Quality

Technology - Seeds /… - Machines

Weather - Precipitation - Temperature

Food - Quantity - Quality - Portfolio - Environ-mental Degra-dation / Care

7

State of Health

Food Security

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

Food Price Index and Inflation Rates

Source: FAO9

Malnutrition

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

Malnutrition

11

Africa (4.3)

Other Asia (5.3)India (7.8)

China (1.1)

Latin America &Caribbean (1.2)

Newborns under Malnutrition [Mio/Year]

11

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)

1212

13

Anemia in Pregnant Women(= Iron Deficiency)

13

Obesity

1414

Nairobi 201215

Risk Factor Obesity (Women)

16

Risk Factor Obesity (Men)

17

Obesity

18

1989 1991 1993 1997 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

Diabetes: in Developing Countries as well

Global Prevalence of Diabetes

0

50

100

150

200

250

Africa

America

Europe

Middle East

Asia/A

ustrali

a

Peop

le in

Mill

ions

2000 2030

+62%

+57%

+51% +31% +64%

19

20

Global Mortality of Diabetes in 2000(Age Group 35 to 64 Years)

204.000 231.000 261.000 89.000

977.000

0 200 400 600 800

1.000 1.200

Africa

America

Europe

Middle Ea

st

Asia/A

ustralia

x10

00 P

eopl

e

Diabetes: in Developing Countries as well

20

Nutritional Status of Diabetics in Northern Tanzania (Krawinkel 2008)

BMI>3022%

BMI 18,5-24,937%

BMI<18,53%

BMI 25-2938%

21

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

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

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)

Belg

ium

Germ

any

Eng

land

France

Sw

itze

rland

24

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

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

Millennium Development Goals1. 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 health5. Improve maternal health

– Water and hygiene are basis for maternal health6. Combat HIV/Aids, Malaria and other diseases

– Malaria is a water-related disease7. Ensure environmental sustainability

– Water cycle8. Global partnership for development

27

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

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

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

Water Scarcityhttp://www.savemynature.com/message/13525

31

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

32

The Fight for Water

33

Diarrheal Diseaseshttp://upload.wikimedia.org/wikipedia/commons/e/ef/Choleraverbreitung_%28deutsch%29.PNG

Cases of Cholera worldwide

ReportedSporadically

34

Stool

Flies

Soil (also via pigs, chicken)

Hands, also commodities (especially small chil-

dren)

Drinking Water

Food Mouth

TOILET

INFECTION

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

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

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

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 6th resident of Germany dies due to

consuming tobacco– 86 % of smokers die due to tobacco as estimated by the

Centre for Disease Control

38

Consumption of Tobacco (Proportion of smoking adult males)

http://en.wikipedia.org/wiki/Smoking

39

Risk Factor Tobacco and Poverty(WHO 2007)

40

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. 464-47141

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, CanberraHuans, 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

Prevalence

of Daily Smok

ing (≥18 Years

, 2003-2004)

South

East Asia

Africa

Eastern

Medite

rranean

Weste

rn Pac

ific

America

Europe

0

10

20

30

40

50

60

1. Quintile 5. Quintile

WHO Region

Prev

alen

ce [%

]

43

Model of Smoking

Phase I Phase II Phase III Phase IV

Pro

port

ion

of S

mok

ers

in A

dult

Pop

ulat

ion

[%]

Fat

alit

ies

Due

to S

mok

ing

[%]

Male Smokers

Female Smokers

Fatalities in Male Smokers

Fatalities in Female Smokers

44

Consumption of Alcohol

http://gamapserver.who.int/mapLibrary/Files/Maps/Global_adult_percapita_consumption_2005.png

45

Risk Profile

http://gamapserver.who.int/mapLibrary/Files/Maps/Global_patterns_drinking_score_2005.png

46

Results

http://gamapserver.who.int/mapLibrary/Files/Maps/Global_subregions_dalys_2004_generalized.png

47

Environ-mental

Influences

Economic Growth

Demand Production - CO2 - CFC - CO - N2O - CH4 - H2O

Water Temperature Precipitation

Glaciers Storms Floods Sea

Level

Migra-tion

Agricul-tural Area

Shift in Cli-mate Zones

Forest Decrease

Health Effects

Air Temperature

Dyke Con-struction

Soil Pro-tection

Exploita-

tion

dam Con-

struction

Drought

48

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

Infant and Child Mortality Rates

Source: UN MGD Indicator Data Base

50

Maternal Mortality in Germany 1900-1999

310350

490460

220

8040 15 6

0

100

200

300

400

500

600

MM

R/1

00.0

00 L

B

Maternal Mortality Rate = MMR

Live Birth = LB

51

Maternal Mortality in Comparison

0

100

200

300

400

500

600

700

800

900

1000

1850 1860 1870 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

USA

E&W

SW

Median Poor Countries '93

USA

Sweden

England

52

0

100

200

300

400

500

600

700

800

900

1000

1850 1860 1870 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

USA

E&W

SW

Median Poor Countries '93

USA

Sweden

England

LLDC Average 2000

Maternal Mortality in Comparison

53

Maternal Mortality Worldwide (Fatalities/100.000 Life Births)

54

Müttersterblichkeit weltweit (Todesfälle/100.000 Lebendgeburten)

99% maternal fatalities occurin developing countries!

55

Health and DemographyGermany Tanzania

Child Mortality (<5 years of age)

5/1000 Births 154/1000 Births

Maternal Mortality 0,06/1000 Births

7/1000 Births

Life Expectancy 79 Years 46 Years

Fertility(children per women)

1,3 5,2

Health Expenditure per capita in US$

2412 1256

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

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

• 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

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

Safe Motherhood Actions 1999• Content: Revision of Safe Motherhood Strategy• 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

“ 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

Loss of Effectiveness in Prenatal Care

29,7%

19,0%

14,3%

3,6%2,4%

0%

5%

10%

15%

20%

25%

30%

Pro

po

rtio

n o

f Pre

gn

an

cie

s

From Risk Detection to Adequate Treatment

63

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

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

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

Abortion Laws

68

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

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

2.5.6 Health Care in Megacities

• Reason:– High urbanization in developing countries– Strong attention to rural problems

72

Urbanization in Least Developed Countries

http://esa.un.org/unpd/wpp/index.htmSide Condition: already in 2008 the majority of the world‘s population is living in urban regions!

0

10

20

30

40

50

60

70

80

90

100

0

200000

400000

600000

800000

1000000

1200000

1940 1960 1980 2000 2020 2040 2060

Popu

latio

n [%

]

Popu

latio

n ['0

00]

Time [Years]Population rural (‘000) Population urban(‘000) Population rural [%] Population urban [%]

73

„Urban Penalty“

• Early Industrial Revolution: Life expectancy in cities is significantly lower than in rural areas = urban penalty

• Development: since 20th century non existent

74

Land, Kleinstädte

Großstädte

Life

Expect

ancy

at

Bir

th (

Years

)

Life Expectancy in England and Wales (Szreter 1999) 75

Example: Healthy / Sick Cities

Cities with more than 10 million people

1980 1990 2000

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

Development of Population of Selected Cities, 1950-2005

City Growth Factor

77

Health Promotion: here?

78

or here?

79

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

80

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

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

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

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

Problems in Slums

Environmental Pollution

Low Income

High Density in Population

Missing Social Structures

Hazardous Conditions at Work

Social Inequality

Poor Living Conditions

Low Public Security

Respiratory Diseases, Allergies,

Noise

Violence AIDS

Poor Hygiene

Accidents at Work

Diarrheal Diseases,

Parasitoses

Malaria Obesity, Diabetes

Lack of Physical Ac-tivity

Accidents

Low Quality of Life, High Mortality 85

2.6 Filter Between Desire and Demand

2 Demand for Health Services2.1 Determinants of Demand2.2 Demographic and Epidemiologic Transition2.3 Epidemiology of Infectious Diseases2.4 Epidemiology of Non-Infectious Diseases2.5 Risk Factors2.6. Filter Between Need and Demand2.6.1 Distance and Demand2.6.2 Price Elasticity and Insurance

86

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

Distance-Friction-Effect

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88

Distance-Friction-Effect

Trans-actions

Distance

89

Newton‘s Gravity Formula

d

MMCG 21

• G Gravity within two centers• C Constant

• Mi Mass of center i

• d Distance between two centers• α Friction constant, depending on infrastructure,

mental mobility, relative benefit

Problem: Curative medicine shows small alpha, prevention high alpha 90

Actual Catchment Area

0

2

4

6

8

10

12

14

16

18

20

0 10 20 30 40 50 60 70

Pati

en

ts [%

]

Distance to Masasi Hospital [km]

91

Catchment Area of Minimal Distance

0

2

4

6

8

10

12

14

16

18

20

0 10 20 30 40 50 60 70

Pa

tie

nts

, Po

pu

lati

on

[%

]

Distance to Masasi Hospital [km]

Patients Population 92

0

10

20

30

40

50

60

70

80

90

100

0 0,5 1 1,5 2 3 3,5 4 5 6 8 15

Pro

po

rtio

n o

f P

atie

nts

[%

]

Distance [km]

Catchment Area Kajiado Hospital, Kenya

93

0

10

20

30

40

50

60

70

80

90

100

0 0,5 1 2 3 4 5 7 10 15 20 30 40 50 60 70 100 150

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po

rtio

n o

f P

atie

nts

[%

]

Distance [km]

Catchment Area Thikai Health Centre, Kenya

94

Health Care in Balkh Province, Afghanistan

95

Travel time to Balkh Provincial Hospital

0

0,1

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0,9

1

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trib

ution

func

tion

time [h] 96

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

Occupancy and Fees of 24 Church Hospitals

020406080

100120140160180200

0 20 40 60 80 100

Occ

upan

cy [%

]

Proportion of Fees [%]

98

Demand for Outpatient Services in Mvumi Hospital

02000400060008000

1000012000

1991 1993 1995 1997

Out

patie

nts

Time [Years]

99

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

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%

Immunisation Antenatal Family planning

Delivery

101

Poverty and Human Development Index

• “Multidimensional Poverty”: Proportion of population that are considered poor under various dimensions

102

Human Development Index (2012)

Multidimensional Poverty [% of total population]

Niger 186 92,4Ethiopia 173 87,3Mali 182 86,6Burundi 178 84,5Burkina Faso 183 84Liberia 174 83,9Guinea 178 82,5Somalia .. 81,2Mozambique 185 79,3Sierra Leone 177 77Senegal 154 74,4Congo (Dem. Rep.) 186 74Benin 166 71,8Uganda 161 69,9Rwanda 167 69Timor-Leste 134 68,1Madagascar 151 66,9Malawi 170 66,7Tanzania 152 65,6

https://data.undp.org/dataset/MPI-Headcount-percentage-of-population-in-multidim/ggn4-nphr 103

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

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Consumption per capita in Cambodia (Worldbank

2012)

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Dynamics of Poverty

Poverty-line

time

Wealth

H1 H2 H3 H4 ID 106

Wealth

• Wealth of Assets– Financial Assets– Real Estate Assets

• Wealth of Income Statistics vary significantly!

107

Millionaires Worldwide [in thousands]

http://www.sueddeutsche.de/geld/vermoegen-weltweit-neue-deutsche-millionaere-1.708921

108

http://www.welt.de/finanzen/article117239605/In-Deutschland-leben-erstmals-eine-Million-Millionaere.html109

Poverty in Germany

www.armutsatlas.de

Leader MV: 24,3%

110

Poverty in Germany

www.armutsatlas.de

Leader Vorpommern: 27,0 %

111

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

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