Table Of ContentHealth 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
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• 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
