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Health Care Systems in Transition Written by Reinhard Busse Annette Riesberg Germany 2004 The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Offce for Europe, the g overnments of Belgium, Finland, Greece, Norway, Spain and Sweden, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organization and administration GERMANY © World Health Organization 2004, on behalf of the European Observatory on Health Systems and Policies All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. Please address requests about the publications of the European Observatory on Health Systems and Policies to: • by e-mail Contents Foreword ...................................................................................................v Acknowledgements ............................................................................... vii Introduction and historical background ...............................................1 Introductory overview ...........................................................................1 Historical background .........................................................................12 Organizational structure and management ........................................29 Organizational structure of the health care system .............................29 Planning, regulation and management ................................................39 Decentralization of the health care system .........................................54 Health care fnancing and expenditure ................................................57 Main system of fnancing ...................................................................58 Health care benefts and rationing ......................................................67 Complementary sources of fnancing . ................................................72 Health care expenditure ......................................................................81 Health care delivery system ..................................................................91 Public health services ........................................................................91 Primary and secondary ambulatory care ............................................96 Secondary and tertiary hospital care .................................................104 Social care .........................................................................................116 Human resources and training ..........................................................124 Pharmaceuticals ...............................................................................134 Health technology assessment ..........................................................153 Financial resource allocation ..............................................................161 Third-party budget setting and resource allocation...........................161 Payment of hospitals ........................................................................165 Payment of physicians ...................................................................177 Health care reforms .............................................................................185 Objectives of health reforms ............................................................186 Content of reforms and legislation ...................................................189 Conclusions ...........................................................................................207 References .............................................................................................213 List of tables ........................................................................................221 List of fgures ........................................................................................223 Weblinks ...............................................................................................225 Glossary ...............................................................................................227 Germany Foreword he Health Care Systems in Transition (HiT) profles are country-based reports that provide an analytical description of a health care system Tand of reform initiatives in progress or under development. The HiTs are a key element of the work of the European Observatory on Health Systems and Policies. HiTs seek to provide relevant comparative information to support policy- makers and analysts in the development of health care systems in Europe. The HiT profles are building blocks that can be used: • to learn in detail about different approaches to the organization, fnancing and delivery of health services; • to describe the process, content and implementation of health care reform programmes; • to highlight challenges and areas that require more in-depth analysis; and • to provide a tool for the dissemination of information on health care systems and the exchange of experiences of reform strategies between policy-makers and analysts in different countries. The HiT profles are produced by country experts in collaboration with the Observatory’s research directors and staff. In order to facilitate comparisons between countries, the profles are based on a template, which is revised p eriodically. The template provides the detailed guidelines and specific q uestions, defnitions and examples needed to compile a HiT. This guidance is intended to be fexible to allow authors to take account of their national c ontext. Compiling the HiT profles poses a number of methodological problems. In many countries, there is relatively little information available on the health care system and the impact of reforms. Due to the lack of a uniform data Germany vi European Observatory on Health Systems and Policies source, quantitative data on health services are based on a number of different sources, including the WHO Regional Offce for Europe health for all database, O rganisation for Economic Cooperation and Development (OECD) Health Data and data from the World Bank. Data collection methods and defnitions s ometimes vary, but typically are consistent within each separate series. The HiT profles provide a source of descriptive information on health care systems. They can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. They can also be used to inform comparative analysis of health care systems. This series is an ongoing initiative: material is updated at regular intervals. Comments and s uggestions for the further development and improvement of the HiT profles are most welcome and can be sent to Acknowledgements he Health Care Systems in Transition profle on Germany 2004 was written by Reinhard Busse and Annette Riesberg (European Observatory Ton Health Systems and Policies, Technische Universität Berlin). It is based on the HiT profle 2000 which was written by Reinhard Busse (then European Observatory on Health Care Systems, Madrid) in collaboration with Annette Riesberg (Federal Ministry of Health) and edited by Anna Dixon (European Observatory on Health Care Systems, London School of Economics) (1). The European Observatory on Health Systems and Policies is grateful to Martin Schölkopf (Federal Ministry of Health and Social Security) and Markus Wörz (Technische Universität Berlin) for reviewing the report. Thanks are also extended to Helmut Brand (State Public Health Offce, North Rhine-Westphalia), Dorothea Bronner (Offce of the Federal Joint Committee), Eva Susanne Dietrich (Federal Association of Statutory Health Insurance Physicians),1 Christian Gawlik (Federal Insurance Authority), Pekka Helstelä (Federal Association of Regional Sickness Funds), Regina Kunz (Offce of the Federal Joint Committee) and Matthias Perleth (Federal Association of Regional Sickness Funds) who reviewed the HiT profle concerning specifc aspects and provided valuable information. The current series of Health Care Systems in Transition profles has been prepared by the research directors and staff of the European Observatory on Health Systems and Policies. The European Observatory on Health Systems and Policies is a partnership between the WHO Regional Offce for Europe, the governments of Belgium, Finland, Greece, Norway, Spain and Sweden, the European Investment Bank, the Open Society Institute, the World Bank, the 1 For reasons of international comparability and consistency with the former HiT profle (1) the names of institutions used in the following text do not necessarily refect the English names that institutions use themselves (see Glossary). Germany viii European Observatory on Health Systems and Policies London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. The Observatory team working on the HiT profles is led by Josep Figueras, Head of the Secretariat, and research directors Martin McKee, Elias Mossialos and Richard Saltman. Technical coordination, production and copy-editing was led by Susanne Grosse-Tebbe, with the support of Shirley and Johannes Frederiksen (layout) and Thomas Petruso (copy-editor). Administrative support for preparing the HiT on Germany was undertaken by Pieter Herroelen. Special thanks are extended to the WHO Regional Offce for Europe health for all database, from which data on health services were extracted; to the OECD for the data on health services in western Europe; and to the World Bank for the data on health expenditure in central and eastern European countries. Thanks are also due to national statistical offces that have provided data. The HiT refects the state of reform and data in November 2004. Germany Introduction and historical background Introductory overview he Federal Republic of Germany is situated in central Europe and covers an area of about 357 000 km2. The longest distance from north to south Tis 876 km, from west to east 640 km. The country shares borders with (clockwise from the north) Denmark, Poland, the Czech Republic, Austria, Switzerland, France, Luxembourg, Belgium and the Netherlands (Fig. 1). Germany has 82.5 million inhabitants, with 42.2 million women and 40.3 million men. The area of the former German Democratic Republic (GDR) in the eastern part of Germany accounts for 108 000 km2 (30%) of the total land. Its 13.5 million residents represent 16% of the country’s total population (2003 fgures, excluding the eastern part of Berlin with about 1 million inhabitants). The population density is unevenly distributed and varies between 75 inhabitants per km2 in Mecklenburg Western-Pomerania and 3804 inhabitants per km2 in Berlin. Of the 19 cities with more than 300 000 inhabitants only three (including Berlin) are in the eastern part of Germany. The largest city is the capital Berlin, with 3.4 million inhabitants. Other densely populated areas are the Rhine-Ruhr region with about 11 million people and the Rhine-Main area surrounding Frankfurt. Political and economic background Germany is a federal republic consisting of 16 states (Länder)2 (Fig. 2), each of which has a constitution consistent with the republican, democratic and social 2 The new Länder in the area of the former German Democratic Republic (GDR), which accessed the Federal Republic of Germany in 1990, will be called “eastern part” in the ensuing text according to their geographic location in Germany. The old Länder in the area of the former Federal Republic of Germany (FRG) will be termed “western part”. Germany 2 European Observatory on Health Systems and Policies Fig. 1. Map of Germany Denmark Baltic Sea North Kiel Sea Rostock Bremerhaven Lübeck Emden Hamburg Bremen Poland Berlin Hannover Duisburg Magdeburg Essen Kassel Leipzig Düsseldorf Cologne Dresden Bonn Belgium Frankfurt am Main Czech Wiesbaden Republic Mannheim Lux. Stuttgart France Munich Austria Liechtenstein Switzerland Source: The World Factbook, 2004. principles embodied in the national constitution (known as the Basic Law or Grundgesetz). The constitutionally-defned bodies with legislative functions are the Federal Assembly (Bundestag) and the Federal Council (Bundesrat). The Federal Assembly is made up of 603 members, elected every four years. Since 1998, the coalition of Social Democrats and Greens has held the parliamentary majority and formed the government. The main functions of the Federal Assembly are to pass laws, elect the Chancellor and control the government. The Federal Council, which represents the sixteen federal states, does not consist of directly-elected representatives but of three to six members – Germany Netherlands

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