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July, 2017
Germany and health
“Germany is now a strong contributor to global health. There is great potential for its political commitment to multilateralism, human rights, and solidarity to be turned into concrete actions, and expectations are high.�
A Series by The Lancet
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Germany and health · July 2017
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Comment
Editor Richard Horton Deputy Editor Astrid James
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My Germany in 2017: a resilient country that is taking responsibility
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Together today for a healthy tomorrow—Germany’s role in global health
S Kleinert H Gröhe
Series
Senior Executive Editors Pam Das Sabine Kleinert Stuart Spencer William Summerskill
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Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition
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Germany’s expanding role in global health
R Busse and others
Executive Editors Jocalyn Clark Stephanie Clark Helen Frankish Tamara Lucas Joanna Palmer
I Kickbusch and others
North America Executive Editor Rebecca Cooney (New York) Asia Executive Editor Helena Hui Wang (Beijing) Managing Editors Lucy Banham Hannah Jones Web Editors Gavin Cleaver Richard Lane Naomi Lee Erika Niesner Senior Assistant Web Editor Francesca Towey Senior Editors Philippa Berman Marianne Guenot John Ji Selina Lo Jennifer Sargent Liz Zuccala Senior Deputy Managing Editors Tim Dehnel Laura Pryce Deputy Managing Editors Olaya Astudillo Helen Penny Senior Assistant Editors Helen Brooks Stephanie Clague Nicolas Dolan Mariam Faruqi Emilia Harding Natalie Harrison Richard Henderson Samuel Hinsley Kayleigh Hook Rhiannon Howe Cheryl Lai Zena Nyakoojo Priya Venkatesan Giulia Vivaldi Christina Wayman Luke Worley Assistant Editors Ashley Cooper Jessica Dwyer Phoebe Hall Rachel Hellier Anna Johnson Charlotte Leigh Kate McIntosh Gabriella Merry Sheila Pinion Anya Sharman Paul Kiet Tang Media Relations Manager Seil Collins Press Officer Emily Head Editorial Assistants Jonathan Blott Angela Bonsu Elliot Hurst Anna Kennedy Aine O’Connor Hannah Towfiq
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Comment
My Germany in 2017: a resilient country that is taking responsibility
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the first paper in this Series explains.2 I remember the friendly general practitioner, always the same one, who visited me at home through all my childhood illnesses: measles, mumps, rubella, whooping cough, chickenpox, scarlet fever—vaccines didn’t exist yet then. For my frequent sports injuries in my time as active volleyball player in a regional league, I had immediate access to either an accident and emergency department or a sports injury specialist in an office-based practice. However, medical school was very different to what it is now. Yet the German system has been slow to catch up with other countries to go beyond rote learning of medical facts. Global health did not feature at all in my course and even public health was a somewhat neglected topic. I had to escape to Vienna, Austria, for my first clinical year to get some practical and patientcentred experience. Working as a doctor, which I did for 6 months in Berlin when the wall was still dividing the city, was characterised by a strong adherence to hierarchy with not always the best people in charge. I remember vividly being told to do as asked “because I say so”, when questioning a decision. Softening professional hierarchies and giving women equal chances in high-ranking positions while making family life possible is only slowly changing in Germany, and was
Published Online July 3, 2017 http://dx.doi.org/10.1016/ S0140-6736(17)31658-6 See Online/Comment http://dx.doi.org/10.1016/ S0140-6736(17)31617-3 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(17)31280-1 and http://dx.doi.org/10.1016/ S0140-6736(17)31460
Adam Berry/Stringer/Getty
2017 is a good year to put a spotlight on Germany and health. Germany is leading the forthcoming G20 meeting and has a general election on Sept 24. The political landscape is shifting palpably given President Donald Trump in the White House, the UK’s decision to leave the European Union, and a newly hopeful and energised France under President Emmanuel Macron. After a frustrating G7 meeting in Taormina, Italy, on May 26 and 27, Germany’s Federal Chancellor Angela Merkel stated in an unusually blunt speech that as Europeans “we should really take our fate into our own hands…the times in which we could rely fully on others are somewhat over”.1 Germany clearly is in a new leadership role that it has been reluctant to take in the past. The two papers in this Lancet Series look at the German health system and its remarkable resilience through a very turbulent time over the past 135 years and Germany’s expanding role in global health.2,3 Leading the G20 Summit in Hamburg on July 7 and 8, Germany has taken important and more assertive steps to show leadership in global health by putting health firmly on the G20 agenda and holding the first ever meeting of G20 Health Ministers in Berlin on May 19 and 20. The declaration by the G20 Health Ministers has a strong focus not only on combating antimicrobial resistance, but also on health systems strengthening for universal health coverage, data systems strengthening for health policy, and building and maintaining a skilled and motivated health workforce as an integral part of functioning and resilient health systems.4 My Germany has changed beyond recognition from the place where I grew up in the 1960s, 1970s, and 1980s. It’s a good change, one that I am proud of, especially now that my chosen country frequently refers to me as a non-UK born European migrant and I am still awaiting news on what will happen to me in the future 1 year after the Brexit referendum. I have now lived nearly as long in the UK, working first as a medical doctor in paediatrics and then as a medical editor at The Lancet, as I have in my home country Germany, where I grew up and went to medical school. What has not changed much is the way the German health system works as
German Federal Chancellor Angela Merkel and German Family Affairs Minister Katarina Barley with participants of the Youth 20 Dialogue, in Berlin, June 7, 2017
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one of the main reasons that I decided against Germany as the country for my professional career. I also remember walking through East Berlin where everything seemed grey, subdued, and at an eerie standstill compared with the western part where I lived. Looking at the Gendarmenmarkt area—the heart of former East Berlin—now, this feels like a dream. Surely a city cannot change so quickly? But Berlin did. The whole country did. I remember the day when the Berlin Wall came down, and I think every German remembers that exact moment. I was working as a House Officer in a London neonatal intensive care unit and the nurse in charge excitedly called me to the television screen. It was an amazing and unbelievably moving moment. A country that managed to have a strong resilient health system through two world wars, a division, and reunification, is in an excellent position to talk about resilience—one of the three pillars of Germany’s G20 presidency. Germany’s chosen motto is “shaping an interconnected world” with the three main pillars of resilience, sustainability, and responsibility.5 The latter was perhaps the most difficult aspect for a country that still prefers to talk about partnerships not leadership. Arguably, the refugee crisis in 2015 and 2016, in which Germany has welcomed a large number of people and taken a clear leadership against the prevailing mood of the moment, has been a turning point for Germany. Angela Merkel, often criticised for being too timid and conventional, has shown strength and resolve to do the right thing: “wir schaffen das” (we will succeed).
Similarly, her positive pre-G20 initiative to give young people from more than 30 countries a chance to present their recommendations at a Youth 20 gathering in Berlin on June 1–8 has shown that she is ahead of many leaders with a much needed change in attitudes.6 Listening to the live broadcast when young people presented their urgent topics for the G20 meeting and proposed solutions to Angela Merkel on June 7 inspired hope and optimism for an interconnected world. Looking backwards and inwards and isolating itself from the world is not Germany’s approach. Sabine Kleinert The Lancet, London EC2Y 5AS, UK sabine.kleinert@lancet.com I declare no competing interests. 1
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Süddeutsche Zeitung. Wir Europäer müssen unser Schicksal in unsere eigene Hand nehmen. Süddeutsche Zeitung, May 28, 2017. http://www. sueddeutsche.de/politik/g-krise-wir-europaeer-muessen-unser-schicksalin-unsere-eigene-hand-nehmen-1.3524718 (accessed June 5, 2017). Busse R, Blümel M, Knieps F, Bärnighausen T. Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition. Lancet 2017; published online July 3. http://dx.doi.org/10.1016/S0140-6736(17)31280-1. Kickbusch I, Franz C, Holzscheiter A, et al. Germany’s expanding role in global health. Lancet 2017; published online July 3. http://dx.doi. org/10.1016/S0140-6736(17)31460. G20 Germany 2017. The Berlin Declaration of the G20 Health Ministers Together Today for a Healthy Tomorrow. 2017. https://www. bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/G/ G20-Gesundheitsministertreffen/G20_Health_Ministers_Declaration_ engl.pdf (accessed June 6, 2017). Federal Government of Germany. Germany’s G20 Presidency begins. 2017. https://www.g20.org/Content/EN/Artikel/2016/11_en/2016-11-30-g20kernbotschaften-im-kabinett_en.html (accessed June 6, 2017). Federal Ministry for Family Affairs, Senior Citizens, Women and Youth. About Y20. 2017. https://y20-germany.org/abouty20/ (accessed June 8, 2017).
Together today for a healthy tomorrow—Germany’s role in global health Published Online July 3, 2017 http://dx.doi.org/10.1016/ S0140-6736(17)31617-3 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(17)31280-1 and http://dx.doi.org/10.1016/ S0140-6736(17)31460
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More than 2 years ago, in west Africa, almost 30 000 people contracted the Ebola virus, and over 11 000 people died. Alongside concern for the health of the affected people in Africa, fear swept across Europe and North America that this disease could spread to other parts of the globe. In international health policy, health crises triggered by communicable diseases are centre stage of public attention. Local outbreaks of disease, if uncontrolled, can quickly escalate into regional and global threats. They can abruptly bring public life to a standstill and
have far-reaching consequences for the social and economic development of the countries concerned. The outbreak of Ebola virus disease, the Zika virus epidemic in South America, and recent outbreaks of yellow fever and Ebola in central Africa are all warnings to the international community to improve pandemic preparedness. That is why Federal Chancellor Angela Merkel decided to put global health high on the agenda of the German G20 presidency. At the first ever G20 Health Ministers’ Meeting in May in Berlin, we put international health crisis management to the test and www.thelancet.com
carried out a simulation exercise to check information and decision-making pathways. Larger scale outbreaks of disease reveal the susceptibility and vulnerability of a health-care system. Improving health care, particularly in the poorest countries, is therefore also part of international pandemic preparedness. Only health systems that are resilient can survive a crisis and alleviate human suffering. At the same time, it is one of the basic principles of humanity that everyone should be able to rely on universal health coverage as stated in the 2030 Agenda for Sustainable Development. Germany used its presidency of the G7 and G20 to put global health policy centre stage and to anchor the topics of antimicrobial resistance (AMR) and health crisis management as a separate health track on the international agenda, and adopted an ambitious Declaration1 on Global Health at the G20 Health Ministers’ Meeting in Berlin. In 2015, Chancellor Angela Merkel addressed the World Health Assembly, emphasising that a reformed WHO has a key role in improving global health. Against this backdrop I am particularly pleased that this year, for the first time, the Federal Ministry of Health was able to put in place an adequate budget title containing voluntary funds to support WHO with up to €35 million, thereby increasing the Health Ministry’s voluntary contributions sixfold. To ensure WHO can do justice to our heightened expectations, we advocate adjusting the assessed contributions of WHO member states. Germany has raised its overall annual support for the global healthcare sector to more than €850 million. This support also includes a substantially increased contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and Gavi, the Vaccine Alliance. Most of the funds come from the development sector and serve primarily to support health-care systems, particularly in Africa. All of this support shows that in recent years global health policy has become a hallmark of German policy and an expression of our international responsibility. Germany’s multilateral approach has made our country a reliable partner. As highlighted in this Lancet Series on Germany and health,2,3 Germany, with its social health insurance system that has evolved over more than 125 years, boasts a strong health-care system and far-reaching knowledge in the field of research on www.thelancet.com
BMG/Jochen Zick (action press)
Comment
German Federal Minister of Health Hermann Gröhe
disease control pioneered by Paul Ehrlich, Robert Koch, and Rudolf Virchow. At the Federal Ministry of Health we have developed a Global Health Programme that allows us to rapidly offer other countries medical assistance in the event of disease outbreaks. Our specialist institutes have excellent disease control skills: the Robert Koch Institute in the field of disease surveillance and prevention, the Paul Ehrlich Institute in its capacity as the Federal Institute for Vaccines and Biomedicines, the Federal Institute for Drugs and Medical Devices in the field of drug safety, and the Bernhard Nocht Institute for Tropical Medicine. I intend to build on this expertise with a Strategy for International Health Security to improve situation assessment and early warning, and to contribute our skills during future outbreaks in an enduring, fast, and comprehensive manner on the international stage. At the same time, it is important to share our knowledge through improved networking. As a first step in this direction, I have invited a number of experts to attend the first meeting of the public health and animal health institutes of the G20 on the topic of AMR that will take place in Berlin in the autumn of 2017. Global health requires the involvement of diverse partners. Germany has numerous non-governmental organisations, scientific institutes, and companies that make important contributions to improving global health. Our aim is to draw together this expertise and share it globally. One successful example is the World Health Summit, a Charité initiative, which enjoys
For the 2017 World Health Summit see https://www. worldhealthsummit.org/
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the support of the Federal Ministry of Health. A forum of this kind must be strengthened and perpetuated. That is why I wish to bring together stakeholders from science, research, practice, and political circles and put in place the preconditions for sustainable networking. The pooling of expert knowledge and experience will also be needed when the German Government reviews the strategy “Shaping Global Health—Taking Joint Action—Embracing Responsibility” to respond to global changes and new challenges. I will, therefore, be convening a board of experts to advise me and all responsible parties within the Federal Government on the new direction for this concept. The diverse nature of global health has strengthened cooperation within the German Federal Government beyond departmental responsibilities. The success of projects in this multidisciplinary field is dependent on close collaboration. This applies as much to the improvements to national health care, carried forward around the world by development aid activities, as it does to efforts in cooperation with research and agricultural policy to combat AMR or extensive international research cooperation such as product development partnerships for medicines and vaccines for poverty-driven and neglected diseases and the research network of the Coalition for Epidemic Preparedness Innovations (CEPI) that is developing new vaccines for future pandemics. We wish to continue on this course of close cooperation and promote it through suitable structures.
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I am convinced that any country that wishes to effectively protect its own population cannot work in isolation but must step up international cooperation. That is why Germany expanded global health within the G20 into a separate health track. The European Union can similarly present good examples of effective cooperation, for instance the establishment of the rapid deployment of European Medical Corps. It has already been on a mission, with German participation, to help combat an outbreak of yellow fever in the Democratic Republic of the Congo. Even more can be achieved. Global health should be a fixture on the agenda. Many of my colleagues have a heightened sense of responsibility and a desire to make a proactive contribution. One thing is clear: we can only make things happen together. We have to seize the moment. Germany will be a reliable partner. Hermann Gröhe German Federal Ministry of Health, 53107 Bonn, Germany Hermann.Groehe@bmg.bund.de I am German Federal Minister of Health. I declare no competing interests. 1
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G20 Germany 2017. The Berlin Declaration of the G20 Health Ministers Together Today for a Healthy Tomorrow. 2017. https://www. bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/G/ G20-Gesundheitsministertreffen/G20_Health_Ministers_Declaration_ engl.pdf (accessed June 9, 2017). Busse R, Blümel M, Knieps F, Bärnighausen T. Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition. Lancet 2017; published online July 3. http://dx.doi.org/10.1016/S0140-6736(17)31280-1. Kickbusch I, Franz C, Holzscheiter A, et al. Germany’s expanding role in global health. Lancet 2017; published online July 3. http://dx.doi. org/10.1016/S0140-6736(17)31460.
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Series
Germany and health 1 Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition Reinhard Busse, Miriam Blümel, Franz Knieps, Till Bärnighausen
Bismarck’s Health Insurance Act of 1883 established the first social health insurance system in the world. The German statutory health insurance system was built on the defining principles of solidarity and self-governance, and these principles have remained at the core of its continuous development for 135 years. A gradual expansion of population and benefits coverage has led to what is, in 2017, universal health coverage with a generous benefits package. Selfgovernance was initially applied mainly to the payers (the sickness funds) but was extended in 1913 to cover relations between sickness funds and doctors, which in turn led to the right for insured individuals to freely choose their healthcare providers. In 1993, the freedom to choose one’s sickness fund was formally introduced, and reforms that encourage competition and a strengthened market orientation have gradually gained importance in the past 25 years; these reforms were designed and implemented to protect the principles of solidarity and self-governance. In 2004, self-governance was strengthened through the establishment of the Federal Joint Committee, a major payer–provider structure given the task of defining uniform rules for access to and distribution of health care, benefits coverage, coordination of care across sectors, quality, and efficiency. Under the oversight of the Federal Joint Committee, payer and provider associations have ensured good access to high-quality health care without substantial shortages or waiting times. Self-governance has, however, led to an oversupply of pharmaceutical products, an excess in the number of inpatient cases and hospital stays, and problems with delivering continuity of care across sectoral boundaries. The German health insurance system is not as cost-effective as in some of Germany’s neighbouring countries, which, given present expenditure levels, indicates a need to improve efficiency and value for patients.
Introduction The German statutory health insurance system is recognised as one of the prototypes of modern health system configurations. Since its introduction in 1883 by the German Chancellor Otto von Bismarck, the guiding principle of the German health system has been solidarity among the insured. Solidarity manifests itself both on the income side and the provision side of statutory health insurance: all insured persons, irrespective of health risk, contribute a percentage of their income, and these contributions entitle the individuals to benefits according to health needs— irrespective of their socioeconomic situation, ability to pay, or geographical location. In this pooled-risk system, people with high income support people with low income, young people support elderly people, healthy people support people who are sick, and people without children support people with children.1,2 The Bismarck model is often compared with the Beveridge health system, which underlies a tax-financed national health service, and with health systems that are based on market principles.3,4 This highly stylised differentiation persists even though health systems worldwide have evolved by incorporating elements of each of the three models to meet new challenges, such as an ageing population, new diagnostic and therapeutic technologies, and doubts about quality and costeffectiveness, and to accommodate the advent of new www.thelancet.com
instruments, such as health-technology assessment and diagnosis-related groups. The G20 summit hosted by Germany in July, 2017, and the approaching 135th anniversary of the German statutory health insurance in 2018 provide impetus for taking stock of Germany’s health insurance system and its development, trends, performance, and opportunities for change. In this Series paper, we describe how the German health insurance system expanded both the population coverage and the benefits package while keeping costsharing low, and we explain how the characteristics of the German statutory health insurance were modified to achieve this. We review developments since 1993, with empirical analysis of data to assess the performance. We look at the statutory health insurance system through the prism of its 135 year history, recognising its remarkable resilience: it survived, with key principles intact, different forms of government (an empire, republics, and dictatorships), two world wars, hyperinflation, and the division and subsequent reunification of Germany. We describe the delegated regulation of the health insurance system through self-governance, both within and between associations of providers and payers. Selfgovernance is particularly difficult to appreciate because, on the one hand, payers and providers are jointly mandated to ensure equal access to and provision of health services, contain costs, and maintain quality; on
Published Online July 3, 2017 http://dx.doi.org/10.1016/ S0140-6736(17)31280-1 See Online/Comments http://dx.doi.org/10.1016/ S0140-6736(17)31658-6 and http://dx.doi.org/10.1016/ S0140-6736(17)31617-3 This is the first in a Series of two papers about Germany and health Department of Health Care Management, Berlin University of Technology, Berlin, Germany (Prof R Busse MD, M Blümel); European Observatory on Health Systems and Policies, Brussels, Belgium (Prof R Busse, M Blümel); BKK Dachverband, Berlin, Germany (F Knieps); Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany (Prof T Bärnighausen MD); Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA (Prof T Bärnighausen); and Africa Health Research Institute, KwaZulu-Natal, South Africa (Prof T Bärnighausen) Correspondence to: Miriam Blümel, Department of Health Care Management, Berlin University of Technology, 10623 Berlin, Germany miriam.bluemel@tu-berlin.de
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Key messages • In 1883, Germany became the first country in the world to establish a social health insurance system based on solidarity; continued expansion and improvement over 135 years have shaped a system with universal coverage and a generous benefits package • The key principle of self-governance initially applied only on the payer’s side; a payer–provider joint system of governance was introduced in 1913, and further developments culminated in the founding of the Federal Joint Committee in 2004 • Since the introduction of choice among payers (the sickness funds) in 1993, elements of competition and a market orientation have been gaining momentum but have not threatened the principle of solidarity and the strong degree of self-governance of the system • Joint self-governance has developed alongside competition and has contributed to a system with good access to health care; however, joint self-governance has also jeopardised continuity of care and has led to an oversupply of pharmaceuticals and inpatient care • Since the late 1990s, the German health system has moved towards integrated care and evidence-based health care, with new financial incentive schemes for both sickness funds and providers to improve quality and efficiency of care • The German statutory health insurance system has proven to be remarkably resilient and capable of extensive changes, while modernising gradually rather than through radical reforms; however, today it faces the same challenges as health systems in other developed countries, such as population ageing and increasing chronic disease burdens
the other hand, the same actors are increasingly facing a regulated environment in which they compete for patients and insured individuals (figure 1). Finally, we highlight the specificities of the statutory health insurance’s service provision structure and its separation into two large sectors, one for ambulatory care and one for inpatient care—a side-effect of self-governance that is increasingly seen as the root of problems with care coordination and continuity, although this separation is also seen as an asset in terms of access.
The first 110 years of Germany’s statutory health insurance system (1883–1993)
See Online for appendix
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The statutory health insurance system was established with the Health Insurance Act (Krankenversicherungsgesetz) of 1883. Chancellor Otto von Bismarck had created a welfare state based on solidarity as part of a political response to the emerging workers’ movement.5 The implementation of comprehensive health coverage for workers removed the fertile ground for discontent for the social democrats and the labour unions and supported Bismarck’s idea of German unification, as already pronounced in the Royal Proclamation of Emperor Wilhelm I in 1881 (appendix p 1).6 Although often portrayed as the originator of statutory health insurance, Bismarck built on traditions and preexisting structures, particularly with regard to the five types of solidarity-based relief funds (for journeymen, craftsmen, factory workers, workers or tradespeople, and community funds), which can partly be traced back to the Middle Ages.1 Innumerable reforms took place until and after the German reunification in 1990; however, from a historical
perspective, the statutory health insurance system is characterised by a high degree of structural continuity.7 The 1883 law defined the founding principles of today’s statutory health insurance. First, according to the principle of solidarity, the size of the insurance contributions is based on the ability to pay; in turn, the insured individual is entitled to benefits according to need. Second, statutory health insurance is compulsory insurance in which employers take part in the financing. Finally, statutory health insurance is based on selfgoverning structures, which means that competencies are delegated to membership-based, self-regulated organisations of sickness funds and health-care providers. Germany’s many historical events have shaped its statutory health insurance system. Despite setbacks and interruptions due to political circumstances, the structural continuity of statutory health insurance endured and is one of the key features of the development of Germany’s health system (appendix p 2).
From compulsory workers’ insurance to population health coverage Health insurance coverage was originally limited to blue-collar workers. In 1885, just 10% of the population were insured in one of 18 776 sickness funds. Between 1885 and 1914, the number of contributing members tripled from 4·3 million members to 13·6 million members. Including co-covered dependants, the total number of insured individuals quintupled from 4·8 million to 23 million individuals, which amounted to 37% of the population.7 The reason for this increase was the rapid growth of German industry, which during that time inevitably accompanied the expansion of statutory health insurance. By 1914, statutory health insurance had become mandatory for transport workers, commercial office workers, agricultural and forestry workers, domestic servants, itinerant workers, and white-collar workers (including individuals employed by lawyers, notaries, bailiffs, industrial cooperatives, and insurance funds). The inclusion of these groups of workers had three visible effects. First, they were all given additional rights, such as the right to maintain membership in separate sickness funds; they had a choice between primary (mainly for blue-collar workers) and substitute funds and could opt out of the system entirely if their income was above a certain threshold (such inequities were only abolished 75 years later). Second, a clear distinction could now be made between private and statutory health insurance. People who were not covered by statutory health insurance, such as civil servants, people who were self-employed, teachers, and clerics) could purchase private insurance. Third, the number of people with statutory health insurance became so large that doctors protested in fear for their income, which led to the development of self-governance mechanisms between sickness funds and provider associations. www.thelancet.com
Series
Parliament Legislation
Federal Ministry of Health Supervision
Ambulatory services
Choice
Patient or insured person
Choice
17 regional associations 150 000 ambulatory care doctors and psychotherapists
Choice
Inpatient services
16 regional federations 1950 hospitals
Federal Association of Statutory Health Insurance Physicians Contracts
German Hospital Federation
113 sickness funds Federal Association of Sickness Funds
Contracts
Being represented but also subject to self-regulation (directives) Federal Committee FederalJoint Association of Sickness Funds Institute for Quality and Efficiency in Health Care
Being commissioned by and supporting the work of the Federal Joint Committee
Institute for Quality Assurance and Transparency in Health Care
Statutory health insurance
Figure 1: Central actors in Germany’s statutory health insurance system
Statutory health insurance coverage was gradually expanded further to include unemployed workers by 1918 (after World War 1), non-earning wives and daughters by 1919, all primary dependants by 1930, and people who have retired by 1941.1 Insurance became mandatory for farmers in 1972, for disabled persons and students in 1975, and for artists in 1981. In 1987, statutory health insurance was mandatory for 76% of the population. Slightly more than 10% of the population, mainly selfemployed and white-collar workers earning more than the income threshold, had statutory health insurance on a voluntary basis, which brought the total population coverage up to 88% in 1987.7 The size of the voluntarily insured population is an important litmus test for the sustainability of the statutory health insurance system as most members pay the maximum contribution, based on their high incomes, and have the option to buy private insurance instead.
From cash benefits to services-in-kind Just as the population coverage increased, so did the scope and scale of covered benefits. The Health Insurance Act of 1883 described insured individuals’ entitlements to cash benefits in case of illness (up to 50% of wages for a maximum of 13 weeks), death, and childbirth. The act also granted in-kind services such as medical treatment and drugs. Alternatively, sickness funds could offer their members coverage of inpatient treatment. Individual sickness funds could extend benefits beyond the minimum statutory benefits package for some areas, such as by increasing the amount of cash benefits, extending the maximum duration of sick pay up to 1 year, and offering additional services-in-kind, including what www.thelancet.com
today would be classified as complementary and alternative remedies.7,8 Further extensions of standard benefits followed, including the doubling of the duration of sick pay to 26 weeks in 1903, the introduction of maternity pay in 1919, and allowances for dependants in 1930. Sickness funds became legally obliged to provide coverage for hospital care to both members and their dependants in 1936. Although seemingly major, this change was in fact incremental because most funds already had been providing this benefit on a voluntary basis. In the difficult economic period after World War 2, the length of entitlement to service and the amount of cash benefits were further increased.7 Between 1965 and 1975, development of care structures and improvement of services also led to increased expenditures. In 1969, blue-collar workers were given up to 6 weeks’ full salary when sick (a regulation that had applied to white-collar workers since 1930). In 1970, preventive medical check-ups and paediatric screenings were included in the benefits package. During the same period, the provision of immunisations was shifted from public health offices to office-based doctors (panel 1), especially paediatricians, which further diminished the weak role of the public health sector. The 1973 Act to Improve Services removed the time limit of hospital care and introduced sick pay to compensate for wages lost while caring for a sick child. Furthermore, the act granted a domestic aid during inpatient stays and extended the coverage of rehabilitation services and of dental and orthodontic services. As a result, statutory health insurance expenditures dramatically increased in the following years. As a share of gross domestic product 7
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Panel 1: A short history of public health in Germany The science and practice of public health have important origins in Germany.9 Very early examples of public health systems in Germany include cheap-meat departments (introduced in Augsburg in 1276 to provide rigorous safety testing of meat from sick or injured animals), antenatal care, and professional midwives (introduced in Ulm in 1491).10 The origins of insurance were introduced by Paracelsus (1493–1541), a Swiss-German physician and philosopher who established the field of toxicology and who is accredited with demanding systems of social protection for sick and disabled mine workers, which led to the creation of the early German sickness funds. Johann Peter Frank (1745–1821) wrote System of a Comprehensive Medical Police, a groundbreaking, six volume tractate describing the first comprehensive strategy to improve population health by regulating public life and influencing private life. In 1800, Franz Anton Mai, professor of obstetrics at the University of Heidelberg, followed in Frank’s footsteps and published a detailed policy proposal for what he referred to as medical police, which would address a wide range of public health subfields such as nutrition, antenatal care, epidemic control and hygiene, and health literacy. Rudolf Virchow (1821–1902), a German physician-scientist and politician, and one of the founding fathers of public health, identified social and political factors as both causes of disease and instruments for intervention, stating famously that “[m]edicine is a social science, and politics is nothing else but medicine on a large scale”.11 At the turn of the century, public health in Germany advanced substantially through the work of the doctors and public health researchers, such as Alfred Grotjahn, Adolf Gottstein, and Alfons Fischer.9 Building on Virchow’s work, Alfred Grotjahn championed the idea that public and population health sciences ought to develop a deeper understanding of the health effects of the social conditions in which human beings are born, live, work, enjoy, procreate, and die. With powerful foresight, Grotjahn laid out a vision of public health as an interdisciplinary field integrating methods from medicine, statistics, demography, anthropometry, economics, and sociology to serve as a scientific counter-movement to the increasingly specialised clinical medicine of the day.10 Today, public health sciences are taught at several German universities.12 Within the German health system, the practice of public health is the responsibility of a network of public authorities at the federal, state, and local levels. Seven institutes operate at the federal level; for example, the Robert Koch Institute and the Paul Ehrlich Institute have responsibility for epidemic prevention and control and for vaccines, respectively. Authorities at the local level are in charge of managing the health offices (Gesundheitsämter) with broad public health responsibilities, such as hygiene monitoring, infection prevention and control, child health checks, HIV and pregnancy counselling, and health promotion. The concept of a medical police legitimised by the state was realised by a number of early local public health authorities (Öffentlicher Gesundheitsdienst) and was subverted from its original benevolent purpose to serve nefarious activities. The Öffentlicher Gesundheitsdienst, in its present administrative form, was established under the Nazi regime with the 1934 Law of Standardisation of Public Health Authorities. The Nazi regime nationalised the public health authorities and co-opted their infrastructures and doctors as instruments in the barbaric policy system of racial hygiene. The local health offices were tasked with carrying out the 1934 Compulsory Sterilisation Law, which led to the forced sterilisation of 400 000 individuals and caused an estimated 7000 deaths. The public health authorities also implemented major components of the Nazi regime’s eugenics programme and genocide in eastern Europe. Shamefully, the Nazi period of German public health authorities has only very recently been systematically examined in medical-historical projects (after 2000).
(GDP), the cost of statutory health insurance expenditure increased from 3·5% in 1965 to 5·9% in 1975, with a growth of 2·1 percentage points between 1970 and 1975 8
alone,7 hence the neologism “Kostenexplosion im Gesundheitswesen” (cost explosion in health care).13 The combined effects of the oil crisis and the end of an economic boom in Germany in the post-war years compromised the sustainability of the expanded statutory health insurance benefits package in the following years. In response, the 1977 Cost Containment Act imposed a spending policy based on actual revenues that forced doctors in ambulatory care and sickness funds to negotiate an overall remuneration. Benefits were removed from the insurance package for the first time, drugs for minor ailments were no longer covered, and copayments for medicines were introduced at this time.
Self-governance structures: from appeasement of workers to joint decision-making bodies The shift from cash payments to benefits-in-kind was associated with an increase in the number of health-care professionals.14 Conflicts between the sickness funds and office-based doctors have been particularly important in shaping Germany’s health system, with office-based doctors having had a dominant role in the ambulatory sector and in steering the general direction of developments in the health system from the 1890s.15 The 1883 law had defined in detail that sickness funds had to be governed by administrative boards of representatives elected from both the workers and their employers, in line with their contribution shares. The ratio of workers to employers on these administrative boards was initially 2:1, reflecting the respective contribution shares. The workers were represented by trade unionists, who were thereby given an area to devote their activities to rather than protesting against the government.16 The 1883 law, however, had not addressed the relationship between sickness funds and doctors or the qualifications of health-care professionals, leaving both matters to the discretion of the funds. At first, doctors took little notice of this aspect of the regulation, but in the 1890s they began lobbying and striking for an increase in autonomy and income.15 This change of approach can be attributed to the increasing number of patients with insurance coverage, restrictions on their access to statutory health insurance-accredited doctors, and the dependence of salaried doctors on the workerdominated sickness funds (which, among other things, led to a decline in the social status of this group of doctors). Through its campaign at the national level, in 1900, the medical profession had convinced various rival groups of doctors to unite and make common demands despite internal divisions, such as those between statutory health insurance-accredited doctors who were dependant on the sickness funds and non-statutory health insurance-accredited doctors who were not. When statutory health insurance coverage was extended to white-collar workers, doctors threatened to go on strike www.thelancet.com
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shortly before the law was to take effect in 1914.17 In December, 1913, the government intervened in the conflict between sickness funds and doctors for the first time. The resulting Berlin Convention stipulated that representatives of the doctors and the sickness funds were to form joint commissions to channel their conflict into constructive negotiations; this intervention marked the beginning of a system of joint self-governance within the statutory health insurance scheme. Contracts with doctors had to be agreed to collectively by all sickness funds.7,16 These contracts served as the basis for codifying the right to freely chose one’s doctor and ended the practice of sickness funds allocating their members to particular doctors. Office-based doctors went on a series of strikes when the Berlin Convention expired at the height of the German hyperinflation in 1923. They felt threatened by the broad range of preventive health education and social care services offered by local communities and welfare organisations. The government responded to the strikes by creating a joint body responsible for decisions on benefits and the delivery of ambulatory care. Known as the Imperial Committee of Physicians and Sickness Funds, this new body pacified office-based doctors, but it disconnected ambulatory care (for which the office-based doctors were granted a monopoly) from both populationbased and public health institutions (which were charged with a narrow set of traditional public health functions; panel 1) and from hospitals that had to limit their scope of work to inpatient services. The result was a fragmented provision of care, a situation that endures to this day. From 1931, office-based doctors providing services for individuals who were covered through statutory health insurance were required to hold membership of their respective Regional Association of Statutory Health Insurance Physicians, which was charged with negotiating collective contracts with the sickness funds. The contracts had to be based on the premise of a total payment for all doctor services. It was (and still is) the responsibility of the self-governed doctor associations to choose the approaches and processes by which to distribute the payment to their individual members, the doctors. During the period of National Socialism (1933–45), the fundamental structures of the social insurance system, including those related to health financing and delivery, remained unchanged. Despite this structural continuity, the principles of the social insurance system were grossly violated because the totalitarian Nazi regime did not tolerate self-governance in any social sector (panel 2). The self-governance structure was largely restored after 1945, with only slight modifications in West Germany in 1955 (appendix p 2). Contributions and representation on boards were now shared equally between employees and employers, and joint regional associations of sickness funds and statutory health insurance doctors became the main stakeholders, with www.thelancet.com
Panel 2: The National Socialist period: a period of violated structural continuity18 Access to medical and cash benefits from statutory health insurance, accident insurance, and old-age insurance were restricted or denied to the Jewish population and other stigmatised minorities. This was part and parcel of the Nazis’ racist policies, which began with the exclusion of these and other groups from all social life and ended with detention in concentration camps, torture, mass murder, and genocide. Forced migrant labourers were obliged to contribute to the statutory health insurance system without any guarantee of receiving benefits, and the services they did receive were often substandard. Moreover, members of the medical profession were instrumental in legitimising social selection, cruelty, and murder.19 The organisation of the health-care sector and the balance of power among the main actors were also changed during the Nazi regime. The sickness funds (1934), community health departments (1935), as well as professional associations, medical chambers, and charitable institutions dealing with public welfare or health education (1933–35) were each centralised and placed under the authority of a director nominated by the Nazi party. Members of the self-governing institutions within the system of joint self-government were chosen by the Nazi party rather than elected, and the participation of employers and employees was limited to serving on advisory councils. In 1933, most socialist and Jewish employees working in the administration of the sickness funds—which amounted to a quarter of all employees—were expelled by law. In the same year, a third of doctors working for public health agencies were forced to leave their positions. Subsequent legislation prohibited Jewish doctors from treating patients covered by statutory health insurance by 1933 and, soon after, all non-Jewish patients by 1937. Finally, in 1938, Jewish doctors were banned from practising medicine altogether. As a result, 12% of doctors in Germany—and 60% of doctors practising in Berlin—were prohibited from pursuing their vocation, which greatly restricted access to health care, especially among Jewish patients. Non-Jewish medical professionals were the occupational group with the largest proportion of members in the Nazi party, and most them welcomed the exclusion of Jewish doctors from medical practice. As the influence of the sickness funds was weakened, that of office-based doctors was bolstered. The regional associations of statutory health insurance doctors and the newly founded National Association of Statutory Health Insurance Physicians were established as corporations under public law in 1934 and were entrusted with negotiating collective contracts with the sickness funds, ensuring the availability of emergency services, and supervising individual doctors contracted by the sickness funds. These associations were also granted the right to decide on the registration of office-based doctors without negotiating with the sickness funds. In return, their members were forbidden to strike. Between 1940 and the end of World War 2 in 1945, Nazi Germany occupied the Netherlands. In 1941, Germany enforced the Sickness Fund Decree, which introduced a statutory health insurance system in the Netherlands identical to the German one, with mandatory health insurance for employees under a certain income threshold and voluntary health insurance for employees with earnings above that threshold or who were self-employed.20
the Federal Committee of Physicians and Sickness Funds responsible for defining general rules and regulation. Although the political path was different in East Germany, important features of the statutory health insurance system were kept (panel 3).
The past 25 years (1993–2017) Very soon after the German reunification in 1990, the structures of the West German statutory health insurance system were transferred to the former East Germany.5 In 9
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Panel 3: The health system in the German Democratic Republic In East Germany, the Soviets took an authoritarian approach to controlling infectious diseases and, despite protests from many doctors, gradually moved towards a centralised, state-operated health system in the German Democratic Republic. But despite socialist ideology, the health system kept important features of the Bismarck model. Although the Central Planning Act of 1950 put the system under central state control, the principle of social insurance—with employers and employees sharing the cost of insurance contributions of 60 Marks a month—was maintained by law. Insurance was made universal, and the administration was concentrated in only two large sickness funds: one for workers (89%) and one for other occupational groups, including members of agricultural cooperatives, artists, and people who were self-employed (11%).21 From 1971, the contribution was never increased, which, given the rising costs of health care, led to enormous underfinancing of the system.5 Unlike in the neighbouring Soviet countries, not all health-care institutions in East Germany were formally nationalised. Some doctors continued to provide ambulatory care in single-handed practices, although most worked at community-based or companybased, state-owned polyclinics staffed by a range of medical specialists and other healthcare professionals. Thus, while the structural division between ambulatory and hospital services was preserved, these sectors often collaborated and were often located on the same premises. Independent hospitals continued to exist, albeit under increasingly difficult circumstances. Indeed, between 1960 and 1989, the number of not-for-profit hospitals decreased from 88 to 75, and the number of private hospitals dwindled from 55 to two. Nevertheless, in 1989, about 7% of all hospital beds were still not state-owned, and some doctors had remained in private practice.22 Local communities provided preventive services, including health education, maternity and child health care, and specialist care for people with chronic diseases such as diabetes or psychiatric disorders. In this manner, the German Democratic Republic created what the political left in West Germany and in many other western countries considered to be, at least until the 1960s, a model health system. However, because of insufficient financing and investment as well as shortages of skilled personnel and modern technologies, the health system in East Germany began to lag behind western standards in the 1970s, leading to a visible worsening of care by the late 1980s. The number of hospital admissions per capita was about 25% lower than in West Germany in the 1980s. This lack of modern medical care has been linked to trends in population health. Although other factors must also be taken into account, such as a high burden of disease in the East German population, these findings point to the possible effect of differences in medical care on population health and the widening mortality gap between the two Germanys. This gap began to develop in the mid-1970s after decades of mostly parallel improvements in life expectancy and even a slight advantage for men in East Germany during the 1960s and early 1970s. In November, 1989, shortly after a National Health Conference resolved to introduce fundamental health-care reforms along with an increase in investment, the Berlin Wall fell.
addition to merging the health systems of the west and east, Germany faced the challenge of rising health-care costs due to the ageing population, growing health-care demand, and progress in medical technology. These challenges led to recurrent deficits and increasing debts in the statutory health insurance, even as sickness funds increased their contribution rates. In 1992, €108 billion in statutory health insurance expenditures stood in contrast with €105 billion in revenues.23 Calls for improvements in efficiency and transparency of service provision were made. Some of the reforms that have taken place in the 10
past 25 years marked strategic new directions, whereas others were readjustments of existing trajectories (figure 2). The main thrust of legislation reform after Germany’s reunification was to foster competition, initially with the goal of controlling expenditure and enhancing technical efficiency. Any new initiatives toward that goal were strictly regulated to avoid risk-selection and other adverse effects of competition.24 Rationalisation was given priority over rationing, and only a few items were removed from the statutory health insurance benefits package.25 Many new drugs and technologies were added to the benefits package during this period, and the service profile pivoted towards long-term and palliative care as well as towards prevention. From 2000, the emphasis on cost containment weakened (although the law still includes cost containment as an overall objective), and efficiency and quality—initially considered secondary issues— became core values. The shift in priorities was a response to a growing dissatisfaction among providers with crude cost-containment measures and the recognition of serious quality problems, especially with the coordination of care for patients who are chronically ill.
The attempt to improve a solidarity-based system through competition The first major reform, the Health Care Structure Act, took place in the early 1990s. This politically driven compromise combined seemingly contradictory elements, namely the introduction of fixed budgets or spending caps for most health-care sectors and the introduction of competition between sickness funds to improve efficiency, all under the watchful eye of regulators and while maintaining the principle of solidarity.26 Competition among providers in the statutory health insurance system had been strengthened by granting patients a free choice of office-based doctors and hospitals. However, competition among payers was lacking because people were mostly assigned to a particular sickness fund. Giving insured individuals the option to choose their sickness fund and to change funds on a yearly basis (with 3 months’ notice as of 1996) was the first essential initiative to strengthen competition in the provision of statutory health insurance. The Health Care Structure Act marked the most important paradigm shift in the history of statutory health insurance, since it not only eliminated the century-old occupational classification and the privileges that white-collar workers had compared with blue-collar workers, but also provided a new regulatory basis for competition among sickness funds and contracts between sickness funds and providers.5 With people choosing a sickness fund irrespective of their occupation, the funds had to market themselves to attract new members and retain existing ones, part of which included reducing their contribution rates.27 In response to the new freedom and growing willingness of members to switch between sickness funds, the sickness www.thelancet.com
Series
Year
Reform
Contents and selected measures
Christian Democratic–Liberal coalition (Chancellor: Helmut Kohl, CDU); Health Minister: Horst Seehofer (CSU) 1993
Health Care Structure Act
• Free choice of sickness funds for most members of the statutory health insurance, supported by the introduction of a risk-adjusted compensation scheme to redistribute contributions equitably among sickness funds (as of 1996) • Needs-based health workforce planning for ambulatory care doctors and accreditation requirements for statutory health insurance doctors • Abolition of full-cost cover principle for hospitals • Introduction of legally fixed budgets or spending caps for the major sectors of health care • Increased copayments for pharmaceutical products and differentiation according to price (1993) and pack size (1994) • Introduction of a positive list of pharmaceutical products
1994
Statutory Long-Term Care Insurance Act
• Introduction of statutory long-term care insurance as of 1996 managed by sickness funds or private health insurance companies
1996, Health Insurance 1997 Contribution Rate Exoneration Act; First and Second Statutory Health Insurance Restructuring Acts
• Reduction of all contribution rates by 0·4% percentage points • Reduction of benefits (eg, rehabilitative care, health promotion, dentures for persons born after 1978) • Increased copayments (eg, hospital care, pharmaceutical products, medical aids, ambulance transportation, and dentures) • Introduction of hospice care benefit • Increased possibilities for non-collective contracts between sickness funds and providers
Social Democratic–Green coalition (Chancellor: Gerhard Schröder, SPD); Health Ministers: Andrea Fischer (Greens, 1998–2000), Ursula Schmidt (SPD, 2001–05) 1998
Act to Strengthen Solidarity in Statutory Health Insurance
• Dentures for persons born after 1978 reintroduced • Lowering copayment rates for pharmaceuticals and dentures
2000
Statutory Health Insurance Reform Act of 2000
• Removal of ineffective or disputed technologies and pharmaceuticals from the statutory health insurance benefit package • Option for selective contracting (integrated care) • Separate budgets for general practitioners and specialists in ambulatory care • Mandatory collection of quality indicators for hospitals
2001
Act to Reform the Risk Structure Compensation Scheme in Statutory Health Insurance
• Introduction of disease management programmes and linkage to risk-structure compensation scheme
Hospital Care Financing Reform Act
• Introduction of German-styled diagnosis-related group system for inpatient services
Statutory Health Insurance Modernisation Act
• Exclusion of over-the-counter drugs and prescription eyeglasses from the statutory health insurance benefit package • Transferring financing of family planning and family policy services not related to insurance to the federal budget • Copayment of €10 per quarter for the first doctor or dentist visit (abolished in 2012) and other increases in copayments • Option for supplementary insurance within statutory health insurance (in cooperation with private health insurers) • Shifting the contribution rate towards the insured (by charging them 0·9% extra, thereby moving away from the 50:50 employee-employer split) • Introduction of diagnosis-related group-based payment in hospitals • Creation of the Federal Joint Committee (replacing the Federal Committee of Physicians and Sickness Funds and similar entities) • Founding of the Institute for Quality and Efficiency in Health Care
2004
Grand coalition: Christian Democrats and Social Democrats (Chancellor: Angela Merkel, CDU); Health Minister: Ursula Schmidt (SPD) 2007
Act to Strengthen Competition in Statutory Health Insurance
• Mandatory universal coverage (either through statutory health insurance or in private health insurance) • Introduction of a uniform contribution rate, a central reallocation pool (Gesundheitsfonds), and resource allocation to sickness funds according to a morbidity-based risk structure compensation scheme • Introduction of specialised ambulatory palliative care • Choice of tariffs in statutory health insurance (eg, no-claim bonuses) • Reform of doctor payment in ambulatory care
Christian Democratic–Liberal coalition (Chancellor: Angela Merkel, CDU); Health Ministers: Philipp Rösler (FDP, 2009–11), Daniel Bahr (FDP, 2011–13) 2011
Statutory Health Insurance Care Structures Act
• New regulations for supplementary premiums and introduction of social adjustment in health-care financing • Reduction of the minimum binding period for chosen tariffs • Reform of needs-based health workforce planning for doctors in ambulatory care
Pharmaceutical Market Reform Act
• Regulation of reimbursement for new pharmaceutical products • Introduction of benefit assessment and value-based pricing
Grand coalition: Christian Democrats and Social Democrats (Chancellor: Angela Merkel, CDU); Health Minister: Hermann Gröhe (CDU) 2014
Act to Further Develop the Financial Structures and Quality in Statutory Health Insurance
• New regulations for contribution rates (sickness funds charge an additional rate on top of the uniform rate, to be paid by the policy holder only) • Founding of the Institute for Quality Assurance and Transparency in Health Care
2015
Statutory Health Insurance Care Provision Strengthening Act
• Several measures concerning better access in ambulatory care
2016
Hospital Structure Reform Act
• Institute for Quality Assurance and Transparency in Health Care tasked with developing indicators for (1) quality-based hospital planning, (2) four areas of selective contracts between sickness funds and hospitals, and (3) pay-for-performance in hospitals • Financial support for hospitals to employ more nurses • Improving emergency services by establishing new emergency out-of-hours practices in or near hospitals
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Figure 2: Main health reforms and acts since 1993 A narrative of these developments is provided in the appendix (p 3). CDU=Christian Democratic Union. CSU=Christian Social Union. FDP=Free Democratic Party. SPD=Social Democratic Party.
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funds also began merging, which reduced the number of funds by 70% between 2000 and 2015 (appendix p 5); however, the market share of the three biggest sickness funds did not increase by much, unlike in the Netherlands.28 To be a member once carried a political connotation rooted in the history of statutory health insurance and the workers’ movement, but the option to choose where to make one’s insurance contribution reframed the relationship between insured people and the sickness funds—a member is now more likely to be treated as a customer. This, however, has not led to any legislative changes as far as the make-up of self-governing boards, and customers still vote to select their representatives. As an assurance that all sickness funds would compete on equal grounds, their opening to individuals of all occupations was accompanied by the implementation of a risk-adjustment scheme that was designed to minimise incentives for risk selection and reduce extreme differences in statutory health insurance contributions between the sickness funds.29,30 Previously, because membership in the funds depended on regional and occupational criteria, there were large differences in the contribution rates due to the varying income and risk profiles of the members. For example, the average contribution in 1992 was 12·7% of an individual’s income, but that contribution varied from 11·2% for the group of substitute funds traditionally insuring whitecollar workers to 13·3% for the regional funds insuring mainly blue-collar workers. Even more striking were the differences in contributions between individual sickness funds, which ranged between 9% and 18%. The riskadjustment scheme redistributed fund contributions to ensure that members with low income and high disease risk were as attractive to the sickness funds as people with high income and low disease risk. The scheme underwent several improvements with time; by 2009, it had changed from retrospective redistribution (based only on sex, age, and invalidity status) to using measures of morbidity to capture disease-risk differentials. As a testament to the success of the risk-adjustment scheme, the proportion of individuals paying highly variable rates decreased to 7% in 1999 (in 1994, 27% of all members had paid a contribution differing by more than 1 percentage point from the average).23,31 However, the remaining differences in contribution did not decrease to below 1 percentage point until the introduction of a uniform contribution for all members in 2009 (appendix p 5).32,33 With the implementation of the risk-adjustment scheme, the only leverage the sickness funds had to compete for members was on the basis of changes to the contribution. The decision to incorporate market regulation mechanisms into the statutory health insurance entailed a number of other important reforms. Competition for service provision or benefits was still severely restricted since individual selective contracts 12
between sickness funds and providers, which overruled the existing system of collective agreement, were only possible in exceptional cases. This restriction was removed in 2000, allowing sickness funds and providers to engage in selective contractual arrangements, often in the form of integrated care, which meant that a group of providers could be contracted by a sickness fund to provide services across sectoral boundaries. The step towards integrated care enabled sickness funds to compete over more than price and to differentiate themselves in a competitive environment. Selective contracting was carefully extended in subsequent years after both a broad discussion of the legislative framework and an examination of the share of statutory health insurance expenditures involved in these contracts. By way of comparison, only 0·02% (€31 million) of total expenditures for statutory health insurance services had been linked to selective contracts between sickness funds and providers in 2002, whereas in 2015, this share increased to 1·5%, equalling €3·13 billion (appendix p 6).34 Between 2009 and 2010, as a result of the introduction of family doctor care models in 2009, expenditure for services based on selective contracts increased from 0·75% to 1·61%. Sickness funds are legally obliged to offer their members the option to enrol in such a programme. In doing so, members accept to comply with gate-keeping rules before seeing a specialist and, in return, receive certain privileges such as exemption from copayments or shorter waiting times. In the mid-2000s, sickness funds gained the right to negotiate discounts with pharmaceutical drug manufacturers. The system is mainly used for generics; once such discount agreements have been reached, pharmacies are obliged to dispense the respective products and, because the discounts are confidential, the manufacturer retrospectively re imburses the sickness fund. By 2015, the proportion of total discounts surpassed 10% of total statutory health insurance expenditure on pharmaceutical products and amounted to more than €3 billion (appendix p 6).34 In 2007, sickness funds began offering a choice of tariffs—a feature previously reserved for private health insurance companies. Different benefits packages and pricing allowed the funds to adapt to the individual needs of their members, for example through plans with a higher-than-standard cost-sharing requirement, which makes statutory health insurance more attractive to people with high incomes and low service use. Tiered rates in statutory health insurance can both strengthen competition between sickness funds and prevent the opting out of low-risk members from the solidarity system. In 2015, 3·5% of the 53·7 million statutory health insurance members (about 1·9 million people) claimed at least one such plan—considerably fewer than the number of members who enrolled in disease management programmes. Most people (60%) who chose a tariff opted for monetary reimbursement, which www.thelancet.com
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Hospital expenditure as a percentage of GDP Expenditure per case as percentage of GDP
Doctors per case Nurses per case
Inpatient cases per person Days in hospital per person
Length of stay
Percentage change relative to index year 2003 (%)
10
5
0
–5
–10
–15
–20 2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Year
Figure 3: Expenditures, human resources, and use of hospital care, 2003–1443–45 GDP=gross domestic product.
replaces the traditional benefit-in-kind system. 27% of members chose plans with deductibles, and 20% of members chose no-claim bonuses, which refer to the refunding of contributions in case no service is used (appendix p 6).35–37
From cost containment to quality (and achieving universal coverage along the way) Apart from the increased management of competition among sickness funds, the 1990s and 2000s were times of many cost-containment interventions. Some interventions, such as the exclusion of certain rehabilitative benefits in 1996–97 and, controversially, of dentures for people born after 1978 (denture coverage was reintroduced in 1998), were unpopular. In 2004, a second wave of cost-containment measures removed insurance coverage for drugs sold over the counter and prescription eyeglasses, which reduced statutory health insurance expenditures for pharmacies from €22·9 billion in 2003 to €20·5 billion in 2004.34 Rather than remove benefits, legislators preferred a costcontainment approach that set budgets or spending caps for entire sectors such as hospitals, ambulatory care, and pharmaceutical products. Budgets helped to keep statutory health insurance expenditure slightly above 6% of GDP, whereas overall expenditures increased moderately from 9·0% in 1992 to 10·3% in 2003.18 These crude budgetary restrictions were politically unwise and impractical in the long term, and the government tried to replace them with www.thelancet.com
alternatives that would also tackle some of the weaknesses of the German system. A primary concern was, and still is, the fragmentation of health-care provision, especially between primary and specialised services in the ambulatory care sector and inpatient services in the hospital sector. Fragmentation of care sectors has led to discontinuities in the provision of health services, reduced effectiveness of interventions, and increased costs. To address this reduced cost-effectiveness, sickness funds were given additional autonomy in 2000 to explore new and innovative ways to provide services.38,39 Within this policy context, disease management programmes were introduced for patients with chronic disorders in 2002. The primary policy objective of these programmes was to improve the quality of care by overcoming fragmentation, but the programmes also had a competition-related objective: as patients enrolled in these programmes were factored in separately in the risk-structure compensation scheme of the statutory health insurance, it reduced the chance of adverse selection by the sickness funds.40 Although disease management programmes can be considered a success in terms of securing participation (appendix p 6), the official evaluation of their clinical effectiveness by the Federal Insurance Authority uses a weak intervention-only design, and results of control-group-design studies are inconsistent.41 The political shift away from cost containment to efficiency-enhancing policies was most visible with the introduction of diagnosis-related groups in 2004 as a basis for reimbursing hospitals for inpatient services. As 13
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Panel 4: Long-term care insurance Municipalities have supported the health needs of an ageing population through taxes, and after years of discussion at the political level, the federal government introduced statutory long-term health insurance in 1994. Fully operational in 1996, statutory long-term health insurance closed a gap in the system of social security and is often denoted as its fifth pillar of social security.55 Long-term care insurance is based on the same organisational principles that define German statutory health insurance: insurance is mandatory and usually provided by the same insurer as health insurance, which means that statutory health insurance members and privately insured individuals are both automatically covered by long-term care insurance, comprising a similar public–private insurance mix. Long-term care funds are affiliated with sickness funds, which handle all administrative tasks; however, financing pools and management are strictly separated.56 Like statutory health insurance, long-term care insurance is financed by contributions that are levied on wages up to a certain limit (in 2017, up to €3938 per month). Contributions were initially set to 1·7% of gross wages and shared between employers and employees. Today, the contribution has increased to 2·55% of gross wages. Since 2005, people who are 23 years or older and do not have children must pay a 0·25 percentage point increased contribution.57 By contrast with statutory health insurance, benefits provided through long-term care insurance are only available by application and for persons who have contributed for at least 2 years. Entitlement to benefits is assessed by the Medical Review Board, which can issue a denial or assign the applicant to one of five levels of care. Beneficiaries can choose between in-kind benefits and cash payments; the latter account for about a quarter of all long-term care insurance expenditures. Both home care and institutional care are provided almost exclusively by private, not-for-profit, and for-profit providers.58 The most important difference between statutory health insurance and long-term care insurance is that for long-term care insurance, like in the British model, benefits do not cover the full costs of care, and copayments are standard.59 As benefits usually cover only about 50% of institutional care costs, people are often advised to buy supplementary private long-term care insurance. In 2013, with the aim of encouraging the development of private insurance to close gaps in the financing of social long-term care insurance, the German Government began offering subsidies for the voluntary purchase of qualified, private long-term care insurance. This type of coverage is known as “Pflege-Bahr,” named after the Minister of Health at the time, Daniel Bahr.60 A reform of long-term health insurance was soon needed to redefine the concept of long-term care. The original interpretation of long-term care had been rather narrow and strongly related to somatic illnesses and restrictions of so-called functions; it also excluded dementia and other cognitive impairments, which affected patients who had slight physical impairment.5 The impending underfunding of long-term care insurance was also subject to intense controversy between different stakeholders. As a result, several reforms have been implemented since 2008, particularly between 2013 and 2016.
the relative cost weights for the diagnosis-related groups are based on actual resource use, they served as a benchmark for spurring competition between providers (ie, hospitals) to increase the efficiency of health service provision.42 These incentives were effective: hospitals reacted by adjusting the composition of clinical personnel assigned to inpatient cases—increasing the ratio of doctors to nurses because it was doctors who provide the coding-relevant procedures—and thereby achieved a stable cost-per-inpatient case measured against GDP during a period of considerable technological progress (figure 3). With the introduction of diagnosis-related 14
groups, policy makers had expected that inefficient hospitals would cease to provide such services, or even cease to provide services altogether and close. The reduction in hospital capacities was, however, modest, leaving Germany with a bed capacity of 65% above the average EU15 average. The number of inpatients increased by 17% between 2005 and 2015 and was 50% higher than the EU15 average in 2015.46,47 In other words, beds that had been emptied because of improved efficiency were filled by the increase in patient admissions, resulting in a stable but high mean duration of hospital stay per person (around 1·74 days per person; appendix p 7). By comparison, the mean duration of hospital stay in Denmark was 0·71 days per person in 2014.48 Legislators were not oblivious to the potentially negative effects of diagnosis-related groups on quality that would be caused by the potential underprovision of services to individual patients on the one hand and by the unnecessary admissions leading to an overprovision of care on the other hand. Hospitals are now required to provide annual quality reports documenting structural, process, and outcome indicators at the hospital level and medical department level for 30 tracer diagnoses and procedures, covering 25% of inpatient cases across the country’s 1600 acute care hospitals. 434 process and outcome indicators are collected at present, which include evidence-based care compliance, readmission, infection, and mortality. Increasingly, the reporting outcomes of these indicators must be made public by the hospitals.49,50 The Hospital Structure Reform Act of 2016 defined the next steps for improving quality, which are to select four areas of selective contracting between sickness funds and hospitals and to initiate pay for performance reimbursements for a limited number of indications or disease areas, but the specific indications are yet to be defined by the Federal Joint Committee.51 Ensuring quality in pharmaceutical care was less straightforward. The 1993 Health Care Structures Act announced the creation of a positive list of all pharmaceutical products that would be covered by statutory health insurance, but this regulation was later cancelled. Instead, all prescription drugs remained covered, and pharmaceutical cost-containment policies relied on spending caps, discounts mandated by the government, and reference prices that were set for groups of comparable drugs. This incentive-based system was used for brand-name drugs for which generics were filling a growing market share because of their low prices. These quality and cost-containment incentives in the pharmaceutical sector left the issue of new and often prohibitively expensive and clinically unproven drugs untouched for a long time. Only in 2011, with legislation referred to as the Pharmaceutical Market Reform Act, did the government require that manufacturers of newly licensed pharmaceutical products submit a dossier with sufficient data to assess the drug’s added benefit relative www.thelancet.com
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to existing products. If a drug had no additional benefit, it would be placed in a reference price group and the cost would be reimbursed at the same rate as existing drugs. For drugs with an added benefit, the Federal Association of Sickness Funds would negotiate a reimbursement amount with the manufacturer.52 Until August, 2016, 319 drugs (excluding orphan drugs) had been assessed, 102 (32%) of which were found to have an added benefit.53 A trend that has yet to be publicly acknowledged in the German debate is the increase in consumption of medicines, or defined daily doses, by more than 50% between 2004 and 2015 (appendix p 8).54 This trend should raise concern about potential patterns of overprescribing. In line with the international debate and developments since 2010, the focus of health reforms in Germany has also brought attention to health service access, especially as a function of geography. Various interventions aim to encourage doctors to work in rural areas or in deprived urban neighbourhoods. To meet new needs and to ensure equal access to services on the basis of solidarity, the benefits package was expanded even during phases of cost containment. For example, palliative care and hospice services were included in 2000, at about the same time as integrated care was introduced in an attempt to reduce fragmentation and restrain associated costs. The most important expansion of benefits, however, came with the introduction of long-term care insurance in 1994 (panel 4). Last but not least, population coverage was expanded in 2008–09 to include individuals receiving welfare benefits, thereby transforming what was already near-complete coverage to complete universal health coverage. The original intention was to ensure that nobody would lose their private insurance coverage through no fault of their own, but this only became possible by mandating health insurance for everybody, either through membership in the statutory health insurance scheme or through private health insurance.61
for Health and Care Excellence in England, the Statutory Health Insurance Modernisation Act in 2004 created two new institutions: the Federal Joint Committee, which was merged with the various specialised committees, and the Institute for Quality and Efficiency in Health Care (figure 1; appendix p 9).62,63
The German health insurance system in 2017 Today, Germany offers universal health coverage. Statutory health insurance is provided by 113 competing, not-for-profit, self-governing sickness funds.64 All employed citizens and other groups, such as pensioners and individuals earning less than the opt-out threshold 4 000 000 patient-doctor contacts in ambulatory care
2 300 000 packs of over-the-counter drugs purchased 2 000 000 packs of prescription drugs dispensed
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Self-governance and the Federal Joint Committee The increasing emphasis by legislators on competition, efficiency, quality, and access issues was accompanied by the introduction of joint self-governance, which, at first sight, runs counter to these priorities. In 2000, the Federal Committee of Physicians, Dentists and Sickness Funds was joined by the Committee for Hospital Care, which was entrusted with quality assurance functions and decision-making capacity with regards to benefit exclusions. A coordinating committee was also formed to coordinate the activities of the committees for ambulatory doctor, dental, and hospital care, to develop integrated care guidelines, and, since 2002, to oversee disease management programmes. However, this solution was insufficient, especially as intersectoral issues became increasingly relevant. Inspired by the National Institute www.thelancet.com
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Figure 4: Daily activities within the German health system, estimated for 201543,54,67 The values have been rounded for ease of presentation.
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(€57 600 per year in 2017), have mandatory statutory health insurance, and their non-earning dependants are insured free of charge. Individuals with a gross income that exceeds the threshold and people who are selfemployed can keep statutory health insurance on a voluntary basis or purchase substitutive private health insurance. About 87% of the population receive their primary coverage through statutory health insurance, and 11% of the population are insured through substitutive private health insurance. The rest of the population (eg, soldiers, police officers, and refugees) receive health insurance through specific governmental schemes. Statutory health insurance is mainly financed through a contribution of 14·6% of wage-related income, which is divided equally between the employee and the employer. These contributions are collected in the Central Reallocation Pool (Gesundheitsfonds) and are supplemented with a relatively modest tax subsidy of €14·5 billion (about 7% of the pooled money). The pooled funds are reallocated to the sickness funds according to a morbidity-based risk-adjustment scheme.58,61 Each sickness fund charges an additional contribution fee directly to its members to cover total expenditure; at present, these additional contributions spread around a mean of 1·1% of wage and vary between 0·3% and 1·8%. 200
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Figure 5: Quality of care for patients with chronic and acute illness by country in 2013 (or most recent data)45,61 The data show measures of selected quality indicators defined by the Organisation for Economic Co-operation and Development. The deviation for asthma hospital admission rate in the USA is 356·2%; this outlier is not shown on the graph. COPD=chronic obstructive pulmonary disease.
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Balancing solidarity and competition Germany spends a substantial amount of its wealth on health care. According to the Organisation for Economic Co-operation and Development, total expenditure on health was €333·5 billion in 2015 (11·1% of GDP).45 The German health system has relatively large human, infrastructural, and technological resources for both ambulatory care and hospital care. Ambulatory care, which includes primary care and highly specialised outpatient services such as radiology and laboratory medicine, is provided by about 150 000 doctors and psychotherapists. About 60% of these medical staff work in single-handed offices, 30% work in group offices, and less than 10% work in health centres although this proportion is increasing.65 In 2015, 1956 hospitals, or one hospital per 42 000 inhabitants, provided 6·1 beds per 1000 inhabitants.43 At first glance, the high number of hospitals gives the impression of a needs-based distribution and a low-threshold access to care. However, according to the National Academy of Science,66 an abundance of hospitals results in insufficient concentration of both human and technological resources, which in turn compromises quality of care. The German health system also provides a large number of activities, possibly more than any other system. Each day, an estimated 4 million contacts take place in ambulatory care and 400 000 patients are admitted to hospital (figure 4).67 An assessment of these vast amounts of services and goods with an eye towards technical efficiency (ie, unit costs per service) would yield different conclusions than when considering their allocative efficiency or costeffectiveness. We have already discussed the low and stable expenditure per inpatient case with respect to technical efficiency (figure 3). The result is similar for ambulatory care: every doctor–patient contact in ambulatory care costs on average less than €30—a low cost, given that about half of these contacts are with specialists. The quality of health care provided by the German system can be compared with that of other countries, both in terms of treatment of ambulatory-care sensitive disorders and in terms of process and outcome parameters of inpatient care. Given the large ambulatory care sector, which ought to help patients avoid complications, the high incidences of admissions for chronic obstructive pulmonary disease and diabetes in Germany are concerning (figure 5).45,61 Mortalityassociated inpatient stroke is relatively low (most cases are treated at stroke units within hospitals), but the incidence of acute myocardial infarction (which is not always treated at catheter units) is high (figure 5). An objective assessment of the cost-effectiveness of the health system is difficult. Although the data suggest an overprovision of services (certainly in hospital-based and pharmaceutical care, and possibly also in primary and specialised ambulatory care; figure 4), money is probably www.thelancet.com
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being wasted on unnecessary care, even if service is technically efficient. However, the problem of care overprovision is especially challenging in the context of self-governing actors. Regarding health outcomes as a function of healthsystem performance as a whole, amenable mortality is increasingly used as a valid indicator for quality since it shows the number of deaths related to certain diseases that could have been prevented by accessible, timely, and effective health care.68 This approach provides an opportunity to assess the contribution of health care to population health.69 Although amenable mortality seems to have decreased as total health expenditures have increased, the absolute amenable mortality and the rate by which it has decreased vary between countries (figure 6). Between 2000 and 2014, amenable mortality in Germany decreased by 37%, which is slightly less than in most comparator countries. If the decrease is compared with the increased expenditure in the same period, the incremental cost-effectiveness is 19 fewer deaths per 100 000 population for every additional US$1000 spent—a greater improvement than in France or the Netherlands, but a weaker improvement than in countries with health expenditures that are lower than Germany’s.70 Public opinion is another way to assess the system. Although the population widely supports the underlying four principles of solidarity (between 2001 and 2015, about 80% of respondents in a representative panel agreed that the principles were fair), satisfaction with
health care is much less pronounced.71 In international comparative surveys of health-system satisfaction, such as the Commonwealth Fund’s 2013 survey, Germany ranks relatively low, coming in sixth among seven European countries.72 Survey data from the Gesundheitsmonitor also show the change in the German public’s satisfaction with the health system with time: after a low of about 25% satisfaction between 2002 and 2004, a time of major reform discussions over exclusion of benefits, satisfaction increased to more than 40% in 2014 and 2015.71
Conclusions and recommendations Bismarck’s Health Insurance Act of 1883 established the first social health insurance system in the world. Its distinguishing characteristics and emphasis on solidarity and self-governance are collectively referred to as the Bismarck model—a model that is not well understood because of its incremental and continuous development. Germany’s pragmatic policy-making style, with its limited state control of the health system, means that the legislator is charging the same actors with solving the problems that they created in the first place: that is, with mandating the Federal Joint Committee, the main selfgovernance institution of payers and providers, to define areas for quality improvement by selective contracting and pay-for-performance. Although the population’s increasing satisfaction with the system does not suggest a need for fundamental reform, the practice of setting policy objectives at the federal level and leaving it to self-governing
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Figure 6: Amenable mortality per 100 000 people and changes in total health expenditure in Germany and selected countries, 2000–1470 The graphs show age-standardised changes in amenable mortality and include all persons aged 0–74 years of age.
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actors to work out the specifics might need to be reassessed. Going forward, if self-governing actors are too slow, too unambitious, or simply too divided, the government might need to define quality and efficiency targets in the law and be more vigilant about implementation and enforcement. In addition to quality improvement, we recommend the following key actions: (1) redefine the legal framework for statutory health insurance and private health insurance to address inequities in financial contributions associated with the principle of ability to pay in statutory health insurance and the risk-related premiums in private health insurance, which benefit well earning employees but disadvantage self-employed persons with low incomes; (2) close the gap between ambulatory and inpatient care, with particular attention to issues that fall between the two sectors (eg, emergency care and continuous care for highly specialised cases); (3) reduce total hospital capacity and centralise services in those hospitals that consistently provide high-quality care; (4) reform the payment system for doctors to further address imbalances between regions (eg, rural vs urban, systems with low vs high shares of privately insured persons) and specialties; (5) strengthen primary care vis-a-vis specialists in ambulatory service provision; and (6) explore and test new roles for health professionals such as nurses. As Germany’s health system continues to adapt and modernise—as it did through a period marked by revolutions, wars, economic crises, and the division and reunification of a nation—it must address problems of discontinuous care and oversupply and cope with the important long-term challenges posed by population ageing, increasing chronic disease burdens and multimorbidity, migration, digitalisation, and urban– rural discrepancies. Contributors All authors contributed to the design and the writing of this report. RB and MB were responsible for the calculation of the empirical data. Declaration of interests FK was Head of Department in the German Federal Ministry of Health between 2003 and 2009; since 2013, he has acted as Chief Executive Officer of the BKK Dachverband, the association of company-based sickness funds. TB is a recipient of the Alexander von Humboldt Professor Award, which is awarded by the Alexander von Humboldt Foundation and financed by the German Federal Ministry of Education and Research. RB and MB declare no competing interests. Acknowledgments This work was funded as part of the Berlin Centre for Health Economics Research (BerlinHECOR) by the German Federal Ministry of Education and Research (grant no. 01EH1604A) References 1 Bärnighausen T, Sauerborn R. One hundred and eighteen years of the German health insurance system: are there any lessons for middle- and low-income countries? Soc Sci Med 2002; 54: 1559–87. 2 ter Meulen R. Solidarity, justice and recognition of the other. Theor Med Bioeth 2016; 37: 517–29. 3 Bohm K, Schmid A, Gotze R, Landwehr C, Rothgang H. Five types of OECD healthcare systems: empirical results of a deductive classification. Health Policy 2013; 113: 258–69. 4 Wendt C, Frisina L, Rothgang H. Healthcare system types: a conceptual framework for comparison. Soc Policy Adm 2009; 43: 70–90.
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28 Thomson S, Busse R, Crivelli L, van de Ven W, van de Voorde C. Statutory health insurance competition in Europe: a four-country comparison. Health Policy 2013; 109: 209–25. 29 Knaus T, Nuscheler R. Risk selection in the German public health insurance system. Health Econ 2005; 14: 1253–71. 30 Buchner F, Wasem J. Needs for further improvement: risk adjustment in the German health insurance system. Health Policy 2003; 65: 21–35. 31 Greß S, Groenewegen P, Kerssens J, Braun B, Wasem J. Free choice of sickness funds in regulated competition: evidence from Germany and the Netherlands. Health Policy 2002; 60: 235–54. 32 GKV-Spitzenverband. Krankenkassenliste. Status on Feb 21,2017. https://www.gkv-spitzenverband.de/service/versicherten_service/ krankenkassenliste/krankenkassen.jsp (accessed Feb 21, 2017). 33 Institut Arbeit und Qualifikation der Universität Duisburg-Essen. Beitragssatzentwicklung in der GKV und Anteil der GKV-Ausgaben am BIP 1980–2015. 2016. http://www.sozialpolitik-aktuell.de/tl_files/ sozialpolitik-aktuell/_Politikfelder/Gesundheitswesen/ Datensammlung/PDF-Dateien/abbVI23.pdf (accessed May 18, 2017). 34 Bundesministerium für Gesundheit. Endgültige Rechnungsergebnisse der GKV 2000–2015. 2016. www. bundesgesundheitsministerium.de/themen/krankenversicherung/ zahlen-und-fakten-zur-krankenversicherung/finanzergebnisse.html (accessed Feb 21, 2017). 35 Bundesministerium für Gesundheit. Gesetzliche Krankenversicherung. Mitglieder, mitversicherte Angehörige und Krankenstand. Jahresdurchschnitt 2015. Ergebnisse der KM1/13 Statistik, 2016. https://www.bundesgesundheitsministerium.de/ fileadmin/Dateien/3_Downloads/Statistiken/GKV/Mitglieder_ Versicherte/KM1_JD_2015.pdf (accessed May 28, 2017). 36 Gesundheitsberichterstattung des Bundes. Gesundheit in Deutschland, 2015. https://www.destatis.de/DE/Publikationen/ Thematisch/Gesundheit/Gesundheitszustand/ GesundheitInDeutschlandPublikation.pdf?__blob=publicationFile (accessed 28 May, 2017). 37 Bundesversicherungsamt. Zulassung der strukturierten Behandlungsprogramme (Disease Management Programme— DMP) durch das Bundesversicherungsamt. Berlin, 2015. www. bundesversicherungsamt.de/weiteres/disease-managementprogramme/zulassung-disease-management-programme-dmp. html (accessed Feb 21, 2017). 38 Nolte E, Knai C, Hofmarcher M, et al. Overcoming fragmentation in health care: chronic care in Austria, Germany and the Netherlands. Health Econ Policy Law 2012; 7: 125–46. 39 Stock S. Integrated ambulatory specialist care—Germany’s new health care sector. N Engl J Med 2015; 372: 1781–85. 40 Busse R. Disease management programs in Germany’s statutory health insurance system—a Gordian solution to the adverse selection of chronically ill in competitive markets? Health Aff 2004; 23: 56–67. 41 Fuchs S, Henschke C, Blümel M, Busse R. Disease management programs for type 2 diabetes in Germany—a systematic literature review evaluating effectiveness. Dtsch Arztebl 2014; 111: 453–63. 42 Geissler A, Scheller-Kreinsen D, Quentin W, Busse R. Germany: understanding G-DRGs. In: Busse R, Geissler, A, Quentin W, Wiley M, eds. Diagnosis-related groups in Europe—moving towards transparency, efficiency and quality in hospitals. Maidenhead: Open University Press, 2011: 243–71. 43 Statistisches Bundesamt. Fallpauschalenbezogene Krankenhausstatistik (DRG-Statistik) 2015. Wiesbaden, 2016. https://www.destatis.de/DE/Publikationen/Thematisch/ Gesundheit/Krankenhaeuser/FallpauschalenKrankenhaus.html (accessed Feb 21, 2017). 44 Statistisches Bundesamt. Gesundheitsausgaben 1995–2015. Fachserie 12 Reihe 7.1.2. Wiesbaden, 2017. https://www.destatis.de/ DE/ZahlenFakten/GesellschaftStaat/Gesundheit/ Gesundheitsausgaben/Gesundheitsausgaben.html (accessed May 28, 2017). 45 Organisation for Economic Co-operation and Development. OECD Health Statistics 2016. http://www.oecd.org/els/health-systems/ health-data.htm (accessed Feb 21, 2017). 46 WHO Regional Office for Europe. European health for all database (HFA-DB). http://data.euro.who.int/hfadb/ (accessed Feb 21, 2017). 47 Statistisches Bundesamt. Grunddaten der Krankenhäuser 2015. Wiesbaden, 2016. https://www.destatis.de/DE/Publikationen/ Thematisch/Gesundheit/Krankenhaeuser/ GrunddatenKrankenhaeuser.html (accessed Feb 21, 2017). www.thelancet.com
48 Danish Ministry of Health. Healthcare in Denmark—an overview. Copenhagen, 2016. http://www.sum.dk/Aktuelt/Publikationer/ Healthcare-in-Denmark-dec-2016.aspx (accessed Feb 21, 2017). 49 Busse R, Nimptsch U, Mansky T. Measuring, monitoring, and managing quality in Germany’s hospitals. Health Aff 2009; 28: w294–w304. 50 Pross C, Geissler A, Busse R. Measuring, reporting, and rewarding quality of care in five nations: five policy levers to enhance hospital quality accountability. Milbank Q 2017; 95: 136–83. 51 Deutscher Bundestag. Gesetz zur Reform der Strukturen der Krankenhausversorgung. Krankenhausstrukturgesetz - KHSG, 2015. http://dipbt.bundestag.de/extrakt/ba/WP18/673/67390.html (accessed Feb 21, 2017). 52 Deutscher Bundestag. Gesetz zur Neuordnung des Arzneimittelmarktes in der gesetzlichen Krankenversicherung. Arzneimittelneuordnungsgesetz—AMNOG. 2010. http://dipbt. bundestag.de/extrakt/ba/WP17/288/28830.html (accessed Feb 21, 2017). 53 von Stackelberg JM, Haas A, Tebinka-Olbrich A, Zentner A. Ergebnisse des AMNOG-Erstattungsbetragsverfahrens. In: Schwabe U, Paffrath D, eds. Arzneiverordnungs-Report 2016. Berlin: Spinger-Verlag, 2016: 159–79. 54 Schwabe U, Paffrath D. Arzneiverordnungen 2015 im Überblick. In: Schwabe U, Paffrath D, eds. Arzneiverordnungs-Report 2016. Berlin, Heidelberg: Spinger-Verlag, 2016: 3–27. 55 Evers A. Social care services for children and older people in Germany: distinct and separate histories. In: Anttonen A, Baldock, J, Sipilä J, ed. The young, the old and the state: social care systems in five industrial nations. Chaltenham: Elgar, 2003: 55–79. 56 Campbell JC, Ikegami N, Gibson MJ. Lessons from public long-term care insurance in Germany and Japan. Health Aff 2010; 29: 87–95. 57 Bundesministerium für Gesundheit. Zahlen und Fakten zur Pflegeversicherung, 2017. https://www. bundesgesundheitsministerium.de/fileadmin/Dateien/3_ Downloads/Statistiken/Pflegeversicherung/Zahlen_und_Fakten/ Zahlen_und_Fakten.pdf (accessed Feb 21, 2017). 58 Blümel M, Busse R. The German health care system, 2015. In: Mossialos E, Wenzl M, Osborn R, Sarnak D, eds. International profiles of health care systems, 2015. Washington, DC: The Commonwealth Fund, 2016: 69–76. http://www. commonwealthfund.org/~/media/files/publications/fundreport/2016/jan/1857_mossialos_intl_profiles_2015_v7.pdf (accessed May 28, 2017). 59 Auth D. Ökonomisierung von Pflege in Großbritannien, Schweden und Deutschland. Z Gerontol Geriatr 2012; 45: 618–23. 60 Nadash P, Cuellar AE. The emerging market for supplemental long term care insurance in Germany in the context of the 2013 Pflege-Bahr Reform. Health Policy 2017; 121: 588–93. 61 Busse R, Blümel M, Spranger A. Das deutsche Gesundheitssystem. Akteure, Daten, Analysen. Berlin: Medizinisch Wissenschaftliche Verlagsgesellschaft, 2017. 62 Deutscher Bundestag. Gesetz zur Modernisierung der gesetzlichen Krankenversicherung. GKV Modernisierungsgesetz—GMG, 2003. http://dip.bundestag.de/extrakt/15/019/15019248.html (accessed Feb 21, 2017). 63 Beerheide R. Ringen um die Gestaltungsmacht. Dtsch Arztebl 2017; 114: A58–60. 64 GKV-Spitzenverband. Anzahl der Krankenkassen. Stichtag: 1 Jaunuar, 2017. https://www.gkv-spitzenverband.de/ krankenversicherung/kv_grundprinzipien/alle_gesetzlichen_ krankenkassen/alle_gesetzlichen_krankenkassen.jsp (accessed Feb 21, 2017). 65 Kassenärztliche Bundesvereinigung. Statistische Informationen aus dem Bundesarztregister. http://gesundheitsdaten.kbv.de/cms/ html/17019.php (accessed Feb 21, 2017). 66 Busse R, Ganten D, Huster S, Reinhardt ER, Suttorp N, Wiesing U. Zum Verhältnis von Medizin und Ökonomie im deutschen Gesundheitssystem. 8 Thesen zur Weiterentwicklung zum Wohle der Patienten und der Gesellschaft. Halle (Saale), 2016. https:// www.leopoldina.org/de/publikationen/detailansicht/publication/ zum-verhaeltnis-von-medizin-und-oekonomie-im-deutschengesundheitssystem-2016/ (accessed Feb 21, 2017).
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67 Riens B, Erhard M, Mangiapane S. Arztkontakte im Jahr 2007. Berlin, 2012. http://www.versorgungsatlas.de/fileadmin/ziva_ docs/14/Arztkontakte_Bericht_Langversion.pdf (accessed Feb 21, 2017). 68 Nolte E, McKee M. Does health care save lives? Avoidable mortality revisited. London: Nuffield Trust, 2004. 69 Nolte E, McKee M. In amenable mortality—deaths avoidable through health care—progress in the US lags that of three European countries. Health Aff 2012; 31: 2114–22. 70 European Observatory on Health Systems and Policies. Trends in amenable mortality for selected countries 2000–2014, 2016. http://www.euro.who.int/en/about-us/partners/observatory (accessed Feb 21, 2017).
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71 Marstedt G, Reiners H. Das deutsche Gesundheitswesen 2001 bis 2015 aus der Versichertenperspektive. In: Böcken J, Braun B, Meierjürgen R, ed. Gesundheitsmonitor 2016. Bürgerorientierung im Gesundheitswesen. Gütersloh: Verlag Bertelsmannstiftung, 2016: 15–39. 72 Osborn R, Schoen C. The Commonwealth Fund 2013 international health policy survey in eleven countries, 2013. http://www. commonwealthfund.org/~/media/files/publications/in-theliterature/2013/nov/pdf_schoen_2013_ihp_survey_chartpack_final. pdf (accessed Feb 21, 2017).
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Germany and health 2 Germany’s expanding role in global health Ilona Kickbusch, Christian Franz, Anna Holzscheiter, Iris Hunger, Albrecht Jahn, Carsten Köhler, Oliver Razum, Jean-Olivier Schmidt
Germany has become a visible actor in global health in the past 10 years. In this Series paper, we describe how this development complements a broad change in perspective in German foreign policy. Catalysts for this shift have been strong governmental leadership, opportunities through G7 and G20 presidencies, and Germany’s involvement in managing the Ebola virus disease outbreak. German global health engagement has four main characteristics that are congruent with the health agenda of the Sustainable Development Goals; it is rooted in human rights, multilateralism, the Bismarck model of social protection, and a link between development and investment on the basis of its own development trajectory after World War 2. The combination of momentum and specific characteristics makes Germany well equipped to become a leader in global health, yet the country needs to accept additional financial responsibility for global health, expand its domestic global health competencies, reduce fragmentation of global health policy making, and solve major incoherencies in its policies both nationally and internationally.
A new context The 2017 G20 Summit hosted by Germany is over shadowed by discussions about global uncertainty and protectionism. Many indications suggest that the USA is no longer willing to support an agenda that upholds multilateralism, globalisation, and free trade and will possibly reduce its foreign aid contributions radically. At the Munich Security Conference in February, 2017, in anticipation of those developments, international security policy decision makers gave a clear signal that Europe will need to take on more global responsibility and that Germany in particular is challenged to act.1,2 This general trend also applies to global health. Concern is mounting over the possible end to a golden era of global health, globalisation, and interconnectedness.3 Financial contributions are stagnating, and the largest global health funders—the USA and the UK—might not retain their political and financial commitments due to pressures to invest nationally.4,5 Many countries now look to Germany, which has recently taken on a political leadership role through its presidencies of the G7 and G20 and in the context of WHO. In this new political environment, Germany’s global health responsibilities, both political and financial, are expected to grow in both the multilateral and the bilateral arena. Germany is one of the few countries still determined to expand its global engagement and increase funding for development and global initiatives, as confirmed by the most recent budget announcements for 2018.6 This strong political statement gives some hope to global health advocates, but although Germany has almost doubled its global health spending in the past 10 years and has contributed substantially to humanitarian health responses, it is still far from contributing the target of 0·1% of gross national income (GNI) towards official development assistance (ODA) for health, as recommended by WHO. The priorities Germany will set for global health cooperation will be just as crucial as the funding commitments. How will these commitments www.thelancet.com
Key messages • Germany entered the global health debate later than other G7 countries, but the visible expansion of the country’s financial and political engagement in the past decade has been complemented by a shift in foreign policy and propelled by strong governmental leadership and influential health security engagement during the Ebola virus disease outbreak • Germany’s global health agenda is congruent with that of the Sustainable Development Goals; it is rooted in human rights, multilateralism, the Bismarck model of social protection, and a link between development and investment on the basis of its own development trajectory after World War 2 • Germany’s foreign policy orientation towards soft power approaches makes it likely that global health engagement will continue to be a priority, but to claim leadership in global health Germany must increase its financial commitments to contribute 0·1% of gross national income towards official development assistance for health • Incoherencies in domestic policies (eg, health-care services for refugees and migrants) and international policies (eg, international tobacco regulation) must be resolved to align with Germany’s values in global health policy • Germany’s expertise in global health is still limited and must be strengthened to effectively build partnerships and alliances across sectors and to integrate global health consistently in its foreign policy strategy • Germany’s strong capacities in health research are underutilised in cooperation with developing countries; institutionalised funding for African–German health research and education partnerships to tackle poverty-related diseases would strongly support Germany’s role in global health and in achieving the Sustainable Development Goals
Published Online July 3, 2017 http://dx.doi.org/10.1016/ S0140-6736(17)31460 See Online/Comments http://dx.doi.org/10.1016/ S0140-6736(17)31658-6 and http://dx.doi.org/10.1016/ S0140-6736(17)31617-3 This the second in a Series of two papers about Germany and health Graduate Institute of International and Development Studies, Geneva, Switzerland (Prof I Kickbusch PhD); CPC Analytics, Berlin, Germany (C Franz MPP); Department of Political and Social Sciences, Freie Universität Berlin, Berlin, Germany (Prof A Holzscheiter PhD); WZB Berlin Social Science Center, Berlin, Germany (Prof A Holzscheiter); Robert Koch Institute, Berlin, Germany (I Hunger PhD); Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany (Prof A Jahn PhD); Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Tübingen, Germany (C Köhler PhD); School of Public Health, Bielefeld University, Bielefeld, Germany (Prof O Razum MD); and Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Eschborn, Germany (J-O Schmidt MSc) Correspondence to: Prof Ilona Kickbusch, Graduate Institute of International and Development Studies, 1202 Geneva, Switzerland ilona.kickbusch@ graduateinstitute.ch
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support the Sustainable Development Goals and the UN? How will the EU move forward with its global health strategy? What alliances will emerge with other countries and stakeholders? To all effects, Germany’s diplomatic representations in Geneva and New York today are more active in global health diplomacy than ever before. Germany has long been a reliable, yet rather silent actor in development cooperation, providing continued support to strengthen health systems. Only recently has it become a prominent voice in promoting global collective responsibility in health. This became evident as it prioritised health during the German G7 presidency in 2015 and followed through with the 2017 G20 agenda “Shaping an interconnected world”.7 Berlin has become a hub for global health conferences, which—for the first time in the G20 context—culminated in a meeting of G20 health ministers in May, 2017. The ministers focused their discussions on strengthening health systems and on two cross-border health issues: antimicrobial resistance and mechanisms to prevent pandemics.7 Their recom mendations will go to the heads of government in Hamburg in July, 2017. In view of the high relevance of health to the economy, security, and wellbeing of countries, Germany will want to achieve continuity for the health debate within G20 and establish a permanent global health group. Global health is defined as “those health issues that transcend national boundaries and governments and call for actions on the global forces that determine the health of people”.8 As the German G20 agenda links health to interconnectedness, it follows an understanding of global health that is broader than development cooperation. It is not easy to track the origins of this shift in mindset because, with few exceptions, not much literature or analysis of Germany’s role in global health exists.9 As is the case for many countries, describing Germany’s role in development cooperation for health and its contribution to international organisations is easier than exploring the full scope of its global health actions, which would include the impact of determinants of health and activities in sectors other than health, particularly areas such as equitable trade and finance, austerity, and migration policies. These contributions are made complex because they are also negotiated within an EU context. The German Government’s new prioritisation of global health has, in principle, been met with broad approval. However, influential non-governmental organisations and leading global health academics are still concerned that Germany’s long-term commitment to strengthening health systems might weaken and investments might shift towards a narrow focus on health security.10 Outside observers of governmental action in global health have therefore called for assurance that the German commitment to protection of human rights and sexual and reproductive health will remain strong, as will the commitment to poverty reduction and multilateralism.9 22
Civil society networks like the German Platform for Global Health continue to urge for a strengthened strategic approach to coping with health inequalities within Germany, in Europe, and worldwide and are highly critical of the Germany-led policies on austerity, refugees, and migration within the EU.11 Another concern is that other G20 ministerial meetings will adopt statements that could have a negative effect on health, especially in low-income and middle-income countries.11 The growing civil society activism on issues of global health expects the German Government to address these issues in the next phase of German global health activities as they argue for a broad agenda on global health that goes beyond biomedical and health-security perspectives and addresses the broad range of social, cultural, economic, and political determinants of global health.
Why Germany is a latecomer to the international global health debate Germany was a latecomer to the international global health debate for various reasons. First, for a long time, the EU prioritised health cooperation much stronger than the German Ministry of Health did, and ministers were not interested in or encouraged to engage in international health; consequently, the Ministry of Health had a very weak office of international health and no budget for activities in this field. Second, budgets for international health development resided with German development assistance, and little, if any, cooperation took place with other ministries and agencies. Third, the vertical global health approach underpinning the Millennium Development Goals did not align with the German health systems-oriented approach and its prioritisation of WHO. Fourth, global health had no strong academic research base. Fifth, the global issues that were given priority by the Ministry of Foreign Affairs did not include health; instead, the highpriority issues were initially focused on global environmental policies. Finally, Germany’s unique geopolitical position required direct support and investments to central and eastern European countries and cooperation within the EU. Germany’s global role is very new and cannot be understood without reference to its history and to foreign policy developments after World War 2. Its development as a nation-state is defined by contradictions, disruptions, and great crimes against humanity. It is often difficult for other countries to fully comprehend the extent to which the historical burden of the Nazi regime is present in the German political debate and still defines German actions. The former German Minister of Foreign Affairs and current President of Germany, Frank-Walter Steinmeier, reiterated this position in a statement published in Foreign Affairs: “Our historical experience has destroyed any belief in national exceptionalism—for any nation”.12 Any claim for a political leadership role is rapidly www.thelancet.com
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challenged both from within and outside of Germany. Even decades after World War 2, Germany did not actively seek a role as a global leader but chose a discrete path, preferably within the multilateral system and, whenever possible, alongside other countries, especially as an EU member state. The historical steps towards the expansion of its international role can be roughly analysed in 20 year periods: the post-war focus of foreign policy was to be a reliable partner in the Western Alliance and to construct and strengthen European cooperation. In 1969, a groundbreaking shift led to the normalisation of relations between West Germany, East Germany, and eastern Europe, called Ostpolitik. Another major reorientation came with the fall of the Berlin Wall in 1989 and German reunification, which led to Germany’s new, yet not always welcome, strength within the EU, especially since the 1992 Maastricht Treaty. The country’s role was to be a regional power constrained by and within the EU. It was only under the leadership of Minister Joschka Fischer (1998–2005) that the German Foreign Office began to engage prominently in global issues. In the global political arena, Germany became a determined leader on environmental issues—not global health. Questions about environmental protection gained increasing relevance in domestic politics, and Germany established a Ministry for the Environment after the Chernobyl disaster in 1986. It soon engaged forcefully in that new global policy arena, which provided space for pioneer countries and was populated by few other established actors.13 Germany was able to bring domestic environmental innovations and intellectual resources to the global level, it gained the directorships of UN’s Environment Programme from 1998 to 2016, and made important contributions to international agreements including the Earth Summit in Rio de Janeiro in 1992, and the Paris Agreements on climate change in 2015.14 A global role and a more assertive German foreign policy became apparent with Germany’s refusal, as chair of the UN Security Council in 2003, to agree to the invasion of Iraq. During the 2007–08 financial crisis and the 2015 refugee crisis, Germany’s new strong role in Europe and beyond became increasingly evident, a development that “attracts praise and criticism in equal measure”.12 German political leaders like to present this shift as a force of circumstance, rather than an expression of Germany seeking a new role, but its strong exportoriented economy relies on a high degree of free trade and close communication with countries in Europe and across the world.15 The approach was to develop a new foreign policy orientation through various government white papers.16 The new direction was expressed forcefully to an international audience by the former German President Gauck during his opening statement at the 50th Munich Security Conference in 2014: “Germany must be prepared to do more”.17 The Government identified two priority areas for expansion www.thelancet.com
that were termed the two dimensions of security: defence and development aid spending.18 The most recent budget plan for 2018 reflects this increase in spending for both development and defence (appendix p 1).6
See Online for appendix
Catalysts of German global health engagement About 10 years ago, Germany began systematically increasing its activities to shape the global health agenda, engage in the governance of global health organisations, and create and support new initiatives. Financial commitments to both funds for global health and total ODA spending were extended (figure 1). The increase in German ODA spending is remarkable, given that other G7 countries—except for the UK, which has enshrined the 0·7% goal by law—did not increase their overall ODA budget in real terms during this period (appendix p 3). ODA for health was increased substantially in Germany (by 94%, from US$578 million to $1·1 billion), the UK (by 136%, from $1·2 billion to $2·8 billion), and the USA (by 97%, $4·4 billion to $8·6 billion), whereas the change in ODA was much smaller in the other G7 countries, and even decreased in Italy. For Germany, taking the step from development cooperation for health to broader global health action was linked to three exceptional factors: the personal commitment of the German Chancellor Angela Merkel, unique political opportunities for leadership in the G7 and G20 arenas, and Germany’s role in health security engagement during the disastrous outbreak of the Ebola virus disease in west Africa.
The German Chancellor Merkel as a leader in health Chancellor Merkel’s personal drive and interest in health is a unique feature of Germany’s involvement in global health,19 especially since the 2007 G8 Summit in Heiligendamm. The key motivation for this involvement is not that different from the motivation that led to Germany’s leadership on environmental issues: recognising the importance of interconnectedness in the era of globalisation. The aims of global health activities, as the German Government approached them in the recent G7 and G20 context, are to reduce the health risks that come with global interdependence for people living in Germany and to ensure healthy lives for populations elsewhere. In her speech at the 51st Munich Security Conference in 2015, Chancellor Merkel described the threat posed by the Ebola virus along the same lines as global issues such as terrorism and forced migration, and she spoke about “the extent to which foreign and security policy impacts matters concerning the internal politics of our societies”.20 Global health is linked to priorities in domestic policy (eg, antimicrobial resistance), is an area in which Germany can share successful experiences, especially in social health protection, and is an attractive policy field that aligns with German foreign policy principles. Involvement in global health policy allows Germany to demonstrate soft 23
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and it was able to ensure continuity of the global health agenda in the 2017 meeting of G20 health ministers.
200
The 2014–15 Ebola virus disease outbreak 150
Change in total ODA (%)
100
Germany
50
UK
Canada 0 France
Italy
–100 –100
Japan USA
–50
–50
0
50 100 Change in ODA for health (%)
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Figure 1: Growth of ODA for health vs growth as percentage of total ODA, 2005–15 Bubbles size indicates ODA for health volume in 2015 (constant 2014 prices). The dashed line indicates equal growth of ODA for health and total ODA. ODA=official assistance development. Source: Organisation for Economic Co-operation and Development DAC and CRE database (Feb 18, 2017).
For the Global Health Security Initiative see http://www.ghsi.ca For the Global Health Security Agenda see https://www. ghsagenda.org/members
power, collaborate with other key players beyond traditional alliances, and contribute to building a global consensus and global solutions. This is why, following the Ebola virus disease outbreak, Germany championed not only national health security but helped to strengthen WHO and improve coordination between UN organisations.21,22
The G7 and G20 presidencies
For further details about VENRO see http://venro.org/ themen/themen-gesundheit/
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Germany’s presidency of G7 and G20 created an exceptional window of opportunity to put health high on the political agenda.23 Before the German G7 presidency in 2015, the German Government had ensured that issues of antimicrobial resistance, health systems strengthening, and neglected tropical diseases were on the G7 agenda. In 2015, Germany also spearheaded a highly successful financial replenishment of Gavi, the Vaccine Alliance. When the seriousness of the Ebola virus disease outbreak in 2014–15 became evident, Germany took the opportunity to champion global health security with the strong personal involvement of Chancellor Merkel. The German Government has also worked with Japan during its G7 presidency in 2016 to promote the integration of the universal health coverage and the health security agenda,
During the Ebola virus disease outbreak, global health security became an issue of national concern for the German Government and an entry point for broader German commitment to global health and health systems strengthening. Like other countries, Germany responded to the outbreak very late but then took an active role in supporting the affected countries under the leadership of the Ministry of Foreign Affairs, which appointed a special ambassador to coordinate the German Government’s response to the Ebola virus disease outbreak. Despite a long-standing, but not prominent, commitment to both the Global Health Security Initiative, which was established in 2001 to strengthen health preparedness and the global response to threats of biological, chemical, or radio-nuclear terrorism and pandemic influenza, and the 2014 Global Health Security Agenda, which has the aim to strengthen both the global capacity and nations’ capacity to prevent, detect, and respond to infectious diseases threats, Germany still has to agree on an integrated policy approach to global health security. The list of Germany’s international activities and contributions to health security is extensive and encompasses a range of ministries; most of these activities and contributions were made after the Ebola crisis. They include support to the UN High-Level Panel on Global Response to Health Crises and the UN Global Health Crises Task Force,24 contributions to the WHO Contingency Fund for Emergencies,25 and pledges to fund the early phase of the Pandemic Emergency Financing Facility.26 In early 2017, Germany joined Japan, Norway, and the Wellcome Trust in contributing to the 5 year budget for the research and development initiative of the Coalition for Epidemic Preparedness Innovations (CEPI), which will focus on research and stockpiling of vaccines.27,28 Health security and the protection of health facilities and health workers are now part of the Munich Security Conference agenda.29 A widespread concern is that health security could be prioritised nationally and internationally at the expense of investments in universal health coverage. In a 2017 advocacy paper, the Verband Entwicklungspolitik Deutscher Nichtregierungsorganisationen (VENRO) and Médecins Sans Frontières argued that the G20 needs to regard health not just as an outcome of human development, but also as a precondition, stressing that “[h]ealth is more than crisis management: Every person has a right to health”.10
The roots of German health engagement Germany’s increased engagement in global health since the early 2000s is built on many years of experience as a reliable partner in bilateral and www.thelancet.com
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multilateral activities in health that are based on four main strategic pillars: (1) a commitment to human rights; (2) long-standing involvement in health systems strengthening in developing countries, led by the Ministry for Economic Cooperation and Development; (3) dependable support to the UN and WHO, led by the Ministry of Health; and (4) a preference for building alliances and collaboration. A strong set of identifying features form the basis of these strategic orientations and have ensured their continuity (figure 2).
Fall of the Berlin Wall: 1989 Bioterrorist attack in the USA: 2001
Severe acute respiratory syndrome (SARS) outbreak: 2002–03
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2003 Germany ratifies the WHO Framework Convention on Tobacco Control After a long period of hesitation and intense lobbying from tobacco industry associations, the German parliament ratifies the Framework Convention on Tobacco Control.
2007 Germany hosts the Global Fund replenishment meeting In Berlin, 29 public donors alongside the Bill & Melinda Gates Foundation and private sector donors pledge $9·7 billion for the second replenishment of the Fund (2008–10).
Germany is member of the WHO Executive Board: 2009–12
2009 First World Health Summit in Berlin Under the patronage of the German Chancellor, Angela Merkel, and the French President, Nicolas Sarkozy, the first World Health Summit establishes an annual meeting for global health experts and policy makers. 2013 For the first time global health is included in a Coalition Treaty of a German Government The agreement between the conservative Union parties, the Christian Democratic Union and the Christian Social Union and the Social Democrats explicitly highlights the importance of the Global Fund, research on neglected tropical diseases, assistance in setting up fundamental social security systems, and the establishment of functional and equitable tax systems.
Ebola outbreak and aftermath: 2014–15
2013 Germany’s first strategy paper on global health The strategy outlines the focus on cross-border health threats, strengthening health systems, intersectoral cooperations, research and development partnerships with the industry, and strengthening of the global health architecture. 2015 Gavi, the Vaccine Alliance replenishment conference Hosted in Germany during the G7 presidency, the replenishment conference secures pledges worth $7·5 billion. Germany pledges $720 million for the years 2016–20.
Continuity of German development cooperation and its unique institutional setup Germany’s contribution to international development began in 1952 in the context of the UN’s Development Programme. In 1961, the Ministry of Economic Co operation was established, which, like in other countries, was initially oriented towards Cold War foreign policy goals but changed its orientation (and name) after the German reunification.15 As an independent ministry, it has been able to invest in longterm strategies and approaches that are based on human rights principles, driven by technical expertise, and built on country partnerships. The ministry can depend on two very strong implementing institutions: the Gesellschaft für Internationale Zusammenarbeit (GIZ), a development agency that is focused on the technical implementation of cooperation projects with about 17 000 employees; and the Kreditanstalt für Wiederaufbau (KfW), a government-owned financing institution that was initiated with funds from the postWorld War 2 Marshall Plan and now supports financial
2001 Establishment of Global Health Security Initiative Germany is a cofounding country of the Global Health Security Initiative that aims to improving reaction to threats of pandemics and biological, chemical, and radio-nuclear terrorism.
2007 G8 Summit in Heiligendamm Germany pledges €4 billion to global health topics (HIV/AIDS, malaria, tuberculosis, and health systems strengthening). By 2013, €4·3 billion were disbursed. In total, the G8 governments pledged US$60 billion to global health causes.
Continuity in the focus on systematic social protection The Bismarck model of social protection and social health insurance, as described by Busse and colleagues in this Series,30 lies at the core of German domestic and international health policy. Despite major historical upheavals, Germany has maintained continuity of a broad social protection system based on human rights and a social health insurance system based on solidarity and redistribution. These values and approaches have shaped Germany’s foreign and development policy and partly explain Germany’s systems-oriented positions in health and why it has been engaged in efforts towards health systems strengthening for decades. Germany also supports the Social Protection Floor Initiative,31 which is a commitment to the human right to social security for all, and it has pushed for intersectoral cooperation between WHO and the International Labour Organization on the links between social protection and health. German non-governmental organisations argue that, on the basis of its historical trajectory, Germany should be at the forefront of proposing a new global social contract that provides a safety net beyond national borders.11
1961 Establishment of Ministry of Development West Germany establishes the Ministry of Development, which will be renamed in 1993 to Ministry of Econonomic Cooperation and Development.
Refugee migration: 2015–
2015 Launch of the Healthy Systems, Healty Lives Initiative Germany co-initiates the Health Systems, Health Lives Initiative at a side event of the UN Summit on the adoption of the Sustainable Development Goals in September, 2015. The initiative aims at improving the coordination of key actors and programmes on health systems strengthening. 2017 G20 Summit in Hamburg Under German G20 presidency the summit includes a meeting of health ministers for the first time.
Figure 2: Stylised timeline of global health developments in Germany Key events that have had an effect on global health and selected German Government initiatives in global health.
cooperation with developing countries. German foreign aid has never been as politically controversial as in other countries, and it does not need to secure rapid foreign policy wins or abide by constant domestic pressures to achieve value for money. 25
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Continuous commitment to the post-World War 2 development trajectory Germany’s own post-World War 2 development trajectory remains a guiding principle of its development cooperation. On the basis of initial support through the Marshall Plan, the country combined extraordinary economic growth with the expansion of universal social protection. The German development approach has always been to combine economic investment with development aid, which is reflected in the name of the responsible ministry—the Ministry for Economic Cooperation and Development. This approach is documented in many joint initiatives between the ministry and German businesses, and it lies at the core of the newly proposed strategy for cooperation with Africa, the Marshall Plan with Africa.32 The conflicts that can arise between public and private sector goals, both in Germany and in partner countries, is beyond the scope of this report.
Continuous commitment to the principle of multilateral engagement German foreign policy considers multilateral engagement to be the “most important principle for international order”.33 Unlike other European donors such as the UK and France, Germany’s geopolitical focus on development engagement is not determined by colonial history.34 The African continent has emerged as a clear focus only within the past few years, as a consequence of increasing migration. Multilateralism is understood by Germany as a commitment to international cooperation and to working in and through international organisations and rule-based systems, while adhering to fundamental norms of the international community such as rule of law, human rights, peace, and prosperity.12,35 In global health, this approach is especially evident in the support to WHO, which Chancellor Merkel has described as the “only international organisation that enjoys universal political legitimacy on global health matters”.36 These features are reinforced through Germany’s G20 agenda, with which the government wishes to set “a course diametrically opposed to isolationism and any return to nationalism”.7 This course includes the reform of the UN and explains why Germany engaged so deeply in the WHO reform process, beginning with its membership of the WHO Executive Board between 2009 and 2012, and following on with its commitment to increase the assessed contributions that countries pay to be a member of WHO.37 This move by the German Government is particularly notable in view of how assessed contributions have been falling in real terms in the past decade,38,39 and it is a very important indicator of Germany’s goal to strengthen the autonomy of WHO and its room for manoeuvre. Germany’s reliance on the multilateral approach to global health can to some extent also be seen in ODA spending. Data of bilateral health spending and imputed 26
multilateral ODA spending on health from the Organisation for Economic Co-operation and Development (OECD) Development Assistance Committee show that, on average, 54% of health-related ODA between 2005 and 2015 was channeled through multilateral institutions, equal to that of other European countries such as France and Italy. Except in 2015, the multilateral share by Germany has always remained greater than 50%. Between 2005 and 2015, the USA and the UK, on the other hand, channelled only 17% and 36%, respectively, of health-related ODA through multilateral institutions. The multilateral and partnership-based approach is also reflected in the launch of joint initiatives with other global health actors and national partners; some examples are the Providing for Health Initiative (P4H), International Health Partnership (IHP), and IHP+. During the Sustainable Development Goals process, the German Government advocated for the inclusion of universal health coverage with special reference to sexual and reproductive health and rights.40 The German Government is now promoting the evolution of IHP+ into a new Universal Health Coverage Alliance (UHC Alliance). Germany has now become a partner in most large global health alliances and is a major donor to the Global Fund to Fight AIDS, Tuberculosis and Malaria and to Gavi, the Vaccine Alliance. Although Germany has taken important steps in stating commitment to multilateralism and international organisations with concrete actions, most notably in the way of active involvement in governance and increasing financial contributions, the country will now have to show its consistent and sustained support on different levels of interaction. The German commitment to multilateralism and to working with others will need to become apparent in the ways in which it funds global public goods for global health, such as the creation of joint systems for monitoring and evaluation or data sharing platforms, and it will need to continue supporting an increase in assessed contributions to WHO. Germany will also need to bolster its efforts to increase the number of German professionals, including secondments, working for international organisations such as WHO and the Global Fund.
Aiming for policy coherence and stakeholder involvement in global health Important steps have been taken towards anchoring global health within the German Government (panel 1), yet much remains to be done, and Germany’s record is not entirely positive. Several major conflicts of objectives have become obvious in past policy decisions and remain unresolved. One example is the Framework Convention on Tobacco Control; Germany’s role in drafting the convention in 2003 was ambivalent, if not obstructive. Germany finally agreed to sign the convention, but the delegation still voiced its reservations against the www.thelancet.com
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convention and its alleged negative economic consequences.43 The convention eventually entered into force in 2005,44 but tobacco advertising in cinemas and on building façades is still not banned,45 and implementation of the convention is based on the implementation of European Commission directives rather than WHO rulings.46 Germany will need to show greater commitment to norm-setting activities and consistency in its positions and values across multilateral institutions. Despite increasing efforts in coordination, the multiplicity of actors still leads to fragmented engagement and weakens the overall effect of German contributions to global health, financially and otherwise. The German Parliament does not have a broad awareness of global health issues. Although the parliament has debated specific topics related to global health (WHO reform,47 tobacco framework negotiations,43,48,49 antimicrobial resistance,50 and the Ebola crisis51), and some parliamentarians show a strong engagement with health development (for example, some members of parliament were awarded the Memento Award for their support of the fight against neglected diseases), global health challenges have been of limited importance to the work of the committee on development policy, notwithstanding their very intersectoral nature. Germany has centres of excellence in research, professional associations, science associations, an active civil society, and an innovative health industry, but these are not strong global health actors. Germany hosts many global health meetings and conferences, including the annual World Health Summit in Berlin since 2009, yet it does not have a well organised and articulate global health community with prominent leaders; although the voices in the development policy arena are strong, the global health advocacy lobby is not as well organised as in many other countries. In particular, the relative weakness of German public health institutions, public health academic teaching, and publich health research institutions must be mentioned—this too can be traced to policies of the Nazi regime and its abuse of public health and medicine, especially through the concept of racial hygiene.52,53 Nevertheless, some important developments towards improved policy coherence and stakeholder involvement have been achieved. A notable step towards a more strategic and coherent approach to global health was achieved with the adoption in 2013 of Germany’s first global health strategy, Shaping Global Health—Taking Joint Action—Embracing Responsibility,54 by the German cabinet after a 2 year consultation process. With this concept, the German Government approaches global health in 14 intersecting policy sectors, most importantly development, security, trade, economy, human rights, education.54 Having recognised health as a cross-sectional and multilevel governance policy area, the government has begun the step-wise establishment of positions and structures for interministerial collaboration and www.thelancet.com
Panel 1: The structure of global health policy in Germany The responsibility of German global health policy lies with the Ministry of Health, which represents Germany at WHO. The Ministry for Economic Cooperation and Development41 has the responsibility for cooperation with the World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria, UNICEF, and the United Nations Population Fund. The Federal Foreign Office is responsible for humanitarian assistance and was the coordinating body for all the activities of the German Government in its response to the Ebola crisis. Research and development activities on neglected tropical diseases and poverty-related diseases are distributed across the Ministry of Education and Research, the Ministry for Economic Cooperation and Development, and the Ministry of Health (and its associated institutes such as the Robert Koch Institute).42 International activities related to sexual and reproductive health are conducted by the Ministry for Family Affairs, Senior Citizens, Women and Youth. The Ministry for Economic Affairs and Energy promotes the activities of German health and technology companies abroad.
coordination on matters of global health. For example, the position of a Coordinator for the Foreign Policy Dimension of Global Health Issues in the Ministry of Foreign Affairs was created in response to the Ebola crisis.55 Improved cooperation between the ministries and agencies was reinforced through the role of the chancellery in relation to the global health activities of the G7 and the G20 process. The government has also increased its outreach to non-governmental organisations, the private sector, and academia, all of which are highly involved in the various G20 global health activities working groups with representatives from business (B20), think tanks (T20), and civil society (C20). Despite the increased political prioritisation of health, financial commitment is still not high enough, and Germany has not reached the target of disbursing 0·1% of GNI for global health.56 Data from the OECD indicate that 0·03% of GNI was spent on global health in 2015. Thus, although the 94% growth of German ODA for health in the past 10 years indicates strong willingness of engagement, a gap between political commitments and disbursed funds remains (figure 3).57 Between 2005 and 2015, Germany has only contributed 5·8% of overall ODA spending to global health, with no strong upwards trend. In their 2016 analysis of ODA, the German Institute for Development Evaluation concluded that “German health ODA in 2002–2013 has not reflected the level of priority recommended by WHO”.57 A global health leader will need to make additional funding available and aim to spend 0·1% of GNI on global health in the near future. At the same time, to be strategic in the transformative era of the Sustainable Development Goals, it will be crucial to gain a reliable overview of all German contributions to global health and its determinants based on a broader
For the Memento Award see http://www.memento-preis.de/ der-memento-preis
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definition of contributions, not only as ODA and not only focused on narrowly defined health investments. Civil society is becoming more vocal in global health. German development cooperation is characterised by a very active and immensely heterogeneous set of civil society organisations, which have only recently moved into the global health agenda. These organisations have had an important role in pushing the German Government to support WHO and to continue its commitment towards universal health coverage, sexual and reproductive health and rights, and HIV/AIDS. Now the organisations are striving to broaden Germany’s global health agenda, strengthening its links more strongly with issues of social justice, addressing exclusion and discrimination, and human rights. The Catholic and Protestant Churches, which both have a development organisation (Misereor and Brot für die Welt), have an important part. Global health concerns were first voiced by the HIV/AIDS lobby, the activists who cooperate in particular in the Action against AIDS Germany, which has successfully lobbied German policy makers for a more prominent role in and commitment to the Global Fund to Fight AIDS, Tuberculosis and Malaria.42 An important step was taken when VENRO, the umbrella association of 120 developmentrelated non-governmental organisations, initiated a working group on global health in 2010 that has contributed to German global health debates and was involved in the preparations of G7 and G20 meetings as well as the C20 civil society working group meeting in 2017. Political foundations such as the Heinrich-Böll-Foundation, which is linked to the Green Party, have also been vocal about global health.58 The German Platform for Global Health is an innovative new civil society actor that was founded in 2012 as an association that brings together national welfare organisations, trade unions, and non-governmental organisations that are active in both global and national health policy, with a strong focus on equity.59 The German health industry has only recently begun to engage in global health. Germany has a very large
USA
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Figure 3: Official development assistance for health in the G7 countries GNI=gross national income. Source: OECD DAC and CRE database (Feb 18, 2017). Change between 2005 and 2015 is calculated using constant US$ (2014). Share of official development assisstance for health in GNI based on current US$.
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health-care market (€328 billion total health-care industry in 2014, with an 11·2% share of gross domestic product (GDP))60 and a prominent and innovative health industry, which includes large global players that are complemented by many medium-sized companies. Yet, there is still strong potential for the German private sector to become a lead contributor to global health and innovation and to act responsibly to improve the health of the poorest people, especially through research and development and in pricing of medicines.61 Nevertheless, there are forums for co operation and dialogue: the German Healthcare Partnership is a new strategic alliance that was established in 2010 jointly by the Ministry for Economic Cooperation and Development and the Federation of German Industries. As part of the G20 process, the B20 working group started a global health initiative that contributed with policy recommendations and events to the debate.62 A new feature is the involvement of non-health private sector companies like Munich Re and SAP (with the Global Fund to Fight AIDS, Tuberculosis and Malaria) and DHL (eg, with GAVI, the Vaccine Alliance) providing support through their core business expertise and technology. Within Germany, companies and scientific research facilities collaborate closely, and the new German Network against Neglected Tropical Diseases (DNTDs) brings together partners from academia, civil society, and industry. Despite these activities, non-governmental stakeholders in academia, civil society, and the private sector are still weak compared with those in some other G7 countries. In an analysis of education and training on global health issues in German universities, Kaffes and colleagues63 paint a rather sober picture of future professionals and the knowledge and skills they are being equipped with to address global health issues, particularly when it comes to broader, interdisciplinary education and training, with “only one-third of medical schools and less than a third of all health-related degree programs in Germany offering some kind of education in Global Health”.63 Thus, although Germany has been tremendously eager to become more visible across core institutions of global health governance, the low prioritisation of global health in its universities’ curricula reflects a gap that needs to be filled as Germany aims to adequately staff its contribution to global health. Compared with North America and the UK, Germany is simply outstripped in its global health education activities, both in the number and degree options as well as in research on global health education.63 The Ministry of Education and Research has created some incentives for German universities and researchers to become more interdisciplinary in their research of global health issues (eg, in neglected tropical diseases),64 but there needs to be a strongerr emphasis on global health education and training at the level of federal ministries, state ministries, and individual universities. This gap is www.thelancet.com
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also an indication of weak professional and scientific organisations whose lobby power is not forceful enough. Some mechanisms can help bring the many global health stakeholders together, such as the World Health Summit in Berlin, meetings hosted by non-governmental organisations and academics, and an annual meeting organised by the Ministry of Health. One new such initiative is the Zukunftsforum Public Health (Forum Future Public Health),65 which is facilitated by the Robert Koch Institute; its working group on global public health stresses the need for more collaborative research on global health, increased funding for such research, and more global health teaching in Germany and abroad. Nevertheless, these initiatives are not sufficient to create a strong and vibrant global health community in Germany. None of the large German foundations have prioritised global health leadership. The gap has partly been filled by the world’s largest global health philanthropy, the Bill & Melinda Gates Foundation, which has increased its cooperation with German partners substantially; for example, a memorandum of understanding between the Bill & Melinda Gates Foundation and the Ministry for Economic Cooperation and Development was signed in February, 2017, and several of the G20 preparatory meetings have been supported by the foundation.66 The influential role of the foundation in global health policy in general, and in Germany in particular,67 has been criticised, but why German foundations have not ventured into the field of global health remains a topic for further research. Only recently have foundations on global health issues (eg, Volkswagenstiftung)68 and other institutions, such as the German Institute of Development, the German Institute for International and Security Affairs, and the WZB Berlin Social Science Center (a non-university research institute), shown first indications of greater engagement.
The global health research and development gap Germany boasts strong research organisations such as the German Research Foundation, the Max Planck Society, the Helmholtz Society, the Leibniz-Association, the German Centers for Health Research, and the Fraunhofer Society. In a ranking of all scientific citations from 1999–2009 by Thomson Reuters, the Max Planck Society ranked second in the world, just after Harvard University.69 The Robert Koch Institute is the government’s central scientific institution in biomedicine research and one of the most important bodies for the safeguarding of public health in Germany. The Paul Ehrlich Institute is the Federal Institute for Vaccines and Biomedicines. It is a senior federal authority of medicinal products, providing services in public health. The German Center for Infection Research, with thematic units for research of malaria, tuberculosis, AIDS, and emerging infections, and additional infrastructure units, was established in 2012 to align translational infection research with the www.thelancet.com
Panel 2: Germany’s research tradition in global health Rudolf Virchow is probably the name that is most frequently mentioned when calling for a more thorough social and political understanding of global public health. The extent to which the rich tradition of German universities, with the unity of teaching and research, contributed to the scientific progress of high relevance to public health and tropical medicine is less remembered. Pioneers include Robert Koch, Paul Ehrlich, Bernhard Nocht, and Theodor Bilharz. German companies were leaders in vaccine and drug development; for example, IG Farben first produced chloroquine, the most successful antimalarial drug for decades. The early discoveries led to the synthesis of anti-infective drugs and important contributions to immunology, medical technology, and infectious disease research. Many of the individuals who were involved in this work contributed to the health programmes of the League of Nations and helped build institutions in developing countries. This leadership in so many fields was destroyed through the atrocities of the Nazi regime and the Holocaust (IG Farben, for example, was the producer of Zyklon B).
development of new diagnostic, preventive, and therapeutic methods. Despite the historically large research output with relevance to global health (panel 2), the translation of those findings from research to political action has remained less pronounced in Germany than in many other countries including the USA, UK, or France. Activities often remain uncoordinated, and no reliable overview of all research activities exists. Germany invests 3% of its gross national product on research and development70 and has a rich research and development tradition in health, but it lags behind in contributions to research of poverty-related diseases. In 2010, the government’s Health Research Framework Programme made the funding of research and development on neglected and poverty-related diseases a priority area.71–73 Germany has since increased its funding for neglected diseases, albeit from a low starting point of $11 million in 2007, to $51 million (0·0015% of GDP) in 2015, making it the fifth largest funder of research of neglected diseases after other G7 countries such as USA (0·0077%), UK (0·0036%), and France (0·0025%).74,75 To address coordination and policy coherence, in 2014, the Ministry of Education and Research presented a list of measures for how to improve cooperation with African countries in health research and education, in particular with higher education institutes and in the professional and advanced vocational training.76 In December, 2015, the Ministry of Education and Research published the strategy for promoting health research in the relevant fields, especially of neglected tropical diseases, until 2020. Programmes aim to pool the activities in infection research and to create research capacities that meet international standards, to promote Germany as a high29
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ranking scientific location that will be attractive to young scientists from around the world, and to support product development partnerships for prevention, diagnosis, or treatment of neglected tropical diseases or diseases that primarily affect children in the poorest regions. In the second round of funding, the financial support to those partnerships increased by €50 million until 2020 (between 2011 and 2015, the government had already invested €22 million).73 Germany does not yet live up to the target 3b commitment of the Sustainable Development Goals, which calls for support towards research and development of diseases affecting predominantly developing countries, prioritising public health needs over intellectual property rights by respecting the Doha Declaration, and making use of the flexibilities within the Agreement on Trade-Related Aspects of Intellectual Property Rights. German nongovernmental organisations underline that access to medicines is a core obligation of the right to health and an essential part of universal health care.10 The German Government has not been very active in this domain. In particular, recommendations of the WHO Commission on Public Health, Innovation and Intellectual Property Rights in 2003 and the Consultative Expert Working Group in 2013 to establish a global health research and development fund were rejected by the German Government. Moreover, the government has yet to respond to the 2016 UN HighLevel Report on Access to Medicines.
The next turning point: refugee migration The influx of 1·2 million refugees in 2015 and 2016 was a turning point in how German policy makers regard foreign affairs, development policies, and the inter connectedness of global and local challenges. As in health security, the distinction between domestic and foreign policy is becoming ever more fluid in relation to refugee and migrant health. During the general debate about the budget in 2016, Chancellor Merkel raised this point and added that the security, welfare, and prosperity of German citizens depends on how Germany acts internationally.77 The Chancellor was highly praised internationally for her initial humanitarian response to the crisis but has faced increasing opposition within Germany and Europe from all sides of the political spectrum. So far, Germany has failed to live up to its aspirations as an innovator and global health leader in relation to migration and refugee health. Germany delayed addressing migrant health in policy-making efforts for a long time. Consequently, Germany ranks only 22 out of 38 countries in the MIPEX health score (a summary indicator for entitlement and access to health services),78 below average when compared with countries with comparable migrant populations and GDP, making the country “just halfway favourable from an integration perspective”. A political response has been to increase investment in the countries of origin, which makes Africa a pivotal 30
strategic focus of a new global development policy.79 The Ministry for Economic Cooperation and Development’s new strategy for cooperation with Africa, the Marshall Plan with Africa, highlights the role of social protection and investment in health. The ministry also invests in rebuilding health infrastructure in northern Iraq and Syria. The German Minister of Health has explicitly mentioned weak health systems as a reason for people to leave their country and to seek a better life in Europe,22 but actions at the political level, such as the EU refugee agreement with Turkey, which Germany had a major negotiating role in, have been heavily criticised for their disregard of health.80 In this context, the Ministry for Economic Cooperation and Development’s overall budget increased from €6·5 billion in 2015 to €7·4 billion in 2016. In November, 2016, the German Parliament approved another increase in the ministry’s budget by €1·1 billion, thereby reaching a total budget of €8·5 billion for 2017.81 The most recent budget plans by the Ministry of Finance indicate an additional small increase in budget of €200 million for 2018.6 The priorities behind this increase in budget include “above all, efforts to address the refugee crisis within and around Syria and to give young people in Africa a better future”.81 Persisting language and cultural access barriers to health services for migrants in Germany, as well as entitlement restrictions for asylum seekers during the first 15 months of their stay, stand in contrast to Germany’s advocacy efforts for universal health coverage internationally.82 German non-governmental organisations have repeatedly called on the German Government to uphold and implement the human right to health within Germany in the same way it is expressed in its development policies.83,84 They call for the current contradiction between universal health coverage and entitlement restrictions for asylum seekers to be resolved and for access barriers for all migrants be removed. This also applies to Germany’s role within the EU. If Germany strives to be a reliable backbone of global health efforts, it needs to be more consistent in its compliance with human rights standards and universal access to health coverage.
Recommendations Germany is now a strong contributor to global health. There is great potential for its political commitment to multilateralism, human rights, and solidarity to be turned into concrete action, and expectations are high. But to have a decisive and sustained effect on global health, Germany will have to strengthen its attention to structural issues that drive health development. This is reinforced by the call in the Sustainable Development Goals for approaches that reflect the interface of domestic challenges with global responsibilities and the need to act beyond just the health sector. Germany has underlined that the world needs strong multilateral institutions to resolve global health issues. As a strong advocate for multilateralism, Germany should www.thelancet.com
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also demand increased innovation, policy coherence, and accountability from the multilateral system—and it should be prepared to show how such coherence can be assured in its own actions inside and across international institutions. The prominent role of the German Government in supporting WHO and the UN must be continued and strengthened. Germany should contribute to productive and pluralist dialogue on what constitutes global health, global public goods, and global health governance. Germany must be better prepared for challenges in global health that are related to other big shifts, including reform of multilateralism, new financing mechanisms, and the transformative strategies of the Sustainable Development Goals. Germany should position itself as committed to innovative and multisectoral global health partnerships based on the transformative thinking associated with implementation of the Sustainable Development Goals. Global positioning will include innovative proposals and the forging of new health alliances, not only in the usual group of donors among high-income countries but with new partners in Africa, Asia, and with China, in particular, which is emerging as a key global health player.85 2017 is an election year in Germany. In preparation for the election, all political parties should be challenged by the major stakeholders to present their global health positions. In October, 2017, the successful political parties will begin negotiating a coalition agreement that will be decisive for the next 4 years. Here, we outline our recommendations for specific priority actions and strategic orientation.
Assign clear responsibilities and accountability
Update the German global health strategy
Make poverty-related diseases and neglected tropical diseases a priority area
The new German Government should make it a priority to update the German global health strategy and transform it into a determined strategic commitment for its period of office, adopted by the cabinet and with the personal commitment of the Chancellor. This strategy should be based on a broad consultation process.
Increase Germany’s global health funding At the core of such a renewed strategy lies the commitment by Germany to continue on its path to increase its global health funding—the new government should set the goal of contributing 0·1% of GNI towards global health funding by the end of its term in the autumn of 2021. Germany’s call during the 68th World Health Assembly for increasing assessed contributions to WHO by 10% needs to be repeated tenaciously—a call that is strongly supported by the C20 civil society working group.86 This call is all the more important as the extent to which the USA will support multilateralism and UN organisations, such as WHO, and will continue to finance large global health programmes is uncertain. www.thelancet.com
The renewed global health strategy would assign clear responsibilities and accountability, and it would include transparency of all funding streams that contribute to Germany’s global health activities. The strategy should ensure policy coherence and not shy away from controversial policy areas, and it should support the establishment of a stable base of institutions, expertise, and advocacy outside of government. A parliamentary committee on global health should follow up on the government’s global health strategy, monitor its implementation, bring new proposals into parliament, and ensure accountability of the government.
Reinforce Germany’s long-standing commitment to health systems strengthening The strategy would reinforce Germany’s long-standing commitment to health systems strengthening, which is essential for the implementation of the universal healthcoverage agenda. The strategy would also ensure that Germany’s commitment is fully reflected in its approaches to preparedness for and response to health crises and antimicrobial resistance. German initiatives such as Healthy Systems, Healthy Lives Initiative have potential to catalyse universal health-coverage innovation and should be taken forward with substantial investment.87 This investment should include support for improved monitoring and analysis of health systems strengthening activities nationally and globally88 and support for interdisciplinary approaches to health that broaden the perspective towards economic, social, cultural, and political determinants of global health in this context.
Poverty-related diseases and neglected tropical diseases should be an obvious priority for the German Government’s new strategy of cooperation with Africa (Marshall Plan with Africa) alongside existing areas of German global health focus. By improving research, development, and innovation in this area, the German Government can reach the poorest groups within African societies and build lasting health research and education infrastructure. Institutional support for research and education centres in Africa are an important element of creating research capacities within Africa that meet international standards and become high-ranking scientific locations that will be attractive to young talent. Germany can build on existing cooperations between African partners and institutions such as the African Partner Sites and related German institutions within the German Center for Infection Research. To achieve a viable solution in the long term, coordination and cooperation must be strengthened between the three leading German ministries engaged in development policy on neglected tropical diseases and poverty-related 31
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diseases (Ministry of Education and Research, Ministry for Economic Cooperation and Development, and Ministry of Health). An institutionalised working group could address short-term and long-term needs for comprehensive control and elimination of neglected tropical diseases.
Include migrant and refugee health in a revised global health strategy By including migrant and refugee health in a revised global health strategy, Germany could make a determined contribution to global health by applying the concepts of “globalisation within”89 or “global health starts at home”,9 with the appreciation that immigration is an organic component of the spatial unit of a social “one world”.90 Fully involving migrant non-governmental organisations in strategy development efforts, rather than the development of policies about migrants, would be a clear step towards recognising migrant health as an inherent part of global health.91
Initiate an update of the EU’s global health strategy The European Commission’s 2010 Communication about global health outlines the EU’s vision in various aspects of global health such as governance, access to health services, the policy-making process, and health research.92 A substantial number of events have since moved the global health agenda and the EU’s role forward, for example in the area of health security. This includes the German–French initiative in 2016 to establish the European Medical Corps to improve the EU’s ability to respond to health crises.93 Action is needed in many different areas of the European Commission’s work, especially in development, research and innovation, health, policy coherence, and determinants of health (ie, EU trade policies). Germany could take an important role in moving this forward; it can also engage more actively in European initiatives such as the European and Developing Countries Clinical Trials Partnership.
Invest domestically Germany cannot strengthen its position in the global health architecture without being prepared to invest domestically. Both the central government and science funding bodies and foundations need to strengthen national institutions (such as universities) and domestic mechanisms to enhance the country’s capacities and expertise on matters of global health. A form of a national Global Health Initiative was proposed by the Leopoldina, the German Academy of Sciences, in 2015.52 Such an initiative must include the broadening of education, training, and research in global health, which pays heed to social and cultural sciences and encourages interdisciplinary exchange between the life sciences and the social sciences.59 German foundations should enter 32
this arena, especially for policy and social science research. They could also support an enabling network or platform to build synergies between the many institutions, create a global health institute or think tank, establish a Global Health Society or a Berlin Global Health Hub, and commission a regular global health report of German activities and contributions. Cooperation with leading institutions in other countries—including developing countries—should be encouraged, and knowledge exchange and global networking platforms, such as the World Health Summit but also other formats should be strengthened.
Address the determinants of health and ensure global public goods As a major economic powerhouse, Germany must give more priority to addressing the determinants of health and ensuring global public goods. The German Platform for Global Health, for example, calls for a broad global health agenda that emphasises health as a social or sociopolitical issue. Germany has in the past repeatedly argued for a financial transaction tax but has not been successful in gaining political support from other key countries. Since many of these issues relate to policies that also reside with the EU, Germany has to link its global health priorities with positions on EU policies. Germany must take on the challenge to become a leader on migrant and refugee health by developing innovative multisectoral approaches both for migrants and refugees in Germany and in other countries.
Becoming a leader The German elections in September, 2017, will be pivotal. The continuity of Germany’s trajectory in global health as an important field of multilateral cooperation and development policy will hopefully be ensured and leadership and investment expanded, even if a new coalition and new individuals come to power. 10 years of activity in global health have created expertise and commitment in many different ministries, at various levels of government, and with other actors and stakeholders. The first health ministers meeting during Germany’s G20 presidency in May, 2017, led to a flurry of global health activities by many different stakeholders.94 This bodes well for continuation. It will be imperative to ensure that a new government keeps and strengthens the global health commitment. Indeed, Germany will be called on to be a strong global health leader by cause of circumstance—politically, conceptually, and financially. By stepping up, Germany will make a substantial contribution to the implementation of the Sustainable Development Goals. Contributors The early drafts of this paper were written by IK with the support of CF on the basis of intensive discussions with and input from all authors. Approach, structure, and key messages were agreed to during two author meetings. All authors commented extensively on each subsequent draft
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and redrafted specific sections. AH, AJ, and OR provided input on the overall analysis, IH on health security, CK on research and neglected tropical diseases, J-OS on development, and OR on migration and on education for global health. Declaration of interests IK declares that the German Government has involved her in G7 and G20 preparations and meetings as a moderator, speaker, and conference participant; she is the Chair of the Council of the World Health Summit, Berlin, and provides strategic advice to the German Network against Neglected Tropical Diseases. CF provides strategic advice to the German Network against Neglected Tropical Diseases. CK is Chairman of the German Society for Tropical Medicine and International Health and is a member of the Board of the German Network against Neglected Tropical Diseases. AJ, AH, IH, OR, and J-OS declare no competing interests. References 1 Pence, M. Remarks by the Vice President at the Munich Security Conference. February 18, 2017. https://www.whitehouse.gov/thepress-office/2017/02/18/remarks-vice-president-munich-securityconference (accessed May 20, 2016). 2 Ischinger W. Big league—more Europe, not less. March 27, 2017. https://www.securityconference.de/en/discussion/monthly-mind/ single-view/article/monthly-mind-march-2017-big-league-moreeurope-not-less/ (accessed March 30, 2017). 3 Morrison SJ. The end of the era of global health? Global Forecast 2012. Washington, DC: Center for Strategic and International Studies, 2012: 82–83. 4 Garret L. Trump 2018 budget proposal: what we know (and don’t know). The Internationalist (blog). Council on Foreign Relations. 2017. http://blogs.cfr.org/patrick/2017/03/20/trump-2018-budgetproposal-what-we-know-and-dont-know/ (accessed March 20, 2017). 5 Garret L. Brexit is a global health risk. Foreign Affairs 2016. http://foreignpolicy.com/2016/07/13/brexit-is-a-global-health-riskglobalization-britain/ (accessed March 15, 2017). 6 Bundesfinanzministerium. Bundeskabinett beschließt Eckwerte für Haushalt 2018 und Finanzplan bis 2021. March 15, 2017. http://www.bundesfinanzministerium.de/Content/DE/ Pressemitteilungen/Finanzpolitik/2017/03/2017-03-15-pmeckwertebeschluss.html (accessed March 15, 2017). 7 Federal Government of Germany. Germany’s G20 presidency begins [G20 agenda presented to Cabinet]. Nov 30, 2016. https://www.g20. org/Content/EN/Artikel/2016/11_en/2016-11-30-g20kernbotschaften-im-kabinett_en.html (accessed Dec 14, 2016). 8 Kickbusch I. The need for a European strategy on global health. Scand J Public Health 2006; 34: 561–65. 9 Bozorgmehr K, Bruchhausen W, Hein W, et al. The global health concept of the German government: strengths, weaknesses, and opportunities. Glob Health Action 2014; 7: 23445. 10 VENRO, MSF. G20 and global health. A global responsibility to implement the Sustainable Development Goals. Berlin: Medecins Sans Frontieres, VENRO, 2017. http://venro.org/uploads/tx_ igpublikationen/Venro-MSF_G20_Positionpaper-final.pdf (accessed Feb 17, 2017). 11 Gebauer T. Das Konzept der sozialen Determinanten von Gesundheit – Wo ist der Aktionsplan für die deutsche Innen- und Außenpolitik? Documentation of the conference of the Deutsche Platform für Globale Gesundheit. Sep 26, 2014. https://www.ippnw. de/commonFiles/pdfs/Soziale_Verantwortung/fachtagung-globalegesundheit.pdf (accessed March 15, 2017). 12 Steinmeier FW. Germany’s new global role. Berlin steps up. Foreign Affairs 2016; (July/August). https://www.foreignaffairs.com/ articles/europe/2016-06-13/germany-s-new-global-role (accessed Dec 1, 2016). 13 Huber J. Pioneer countries and the global diffusion of environmental innovations: theses from the viewpoint of ecological modernization theory. Glob Environ Change 2008; 18: 360–67. 14 Dröge S. The Paris Agreement 2015. Turning point for the international climate regime. SWP Research Paper 2016; RP 4. https://www.swp-berlin.org/fileadmin/contents/products/research_ papers/2016RP04_dge.pdf (accessed March 15, 2017). 15 Schmidt S. Development cooperation as a strategic field of German foreign policy. Aus Politik Und Zeitgeschichte 2015; 65: 29–35.
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