Strengthening health system governance in Germany: looking back, planning ahead

Abstract

Health system governance has been receiving increasing attention in health system research since the 1980s. The contemporary challenges that the German health system is faced with are often closely linked to governance issues. Although Germany has the highest health expenditure as a share of Gross Domestic Product (GDP) in the European Union (EU), the spending on healthcare is out of proportion to the health outcomes of the population. The reason for this lies mainly in the complexity of the German health system which is hard to steer due to several administrative levels in the country and numerous policy actors to whom the decision-making power on healthcare provision is delegated. In this paper, we present the results of focus group discussions on governance and build upon the insights gained through the Neustart project of the Robert Bosch Foundation. Based on an internationally recognised health governance framework from the World Health Organization (WHO), experts who work in, on or for the German health system addressed health governance challenges. They provided evidence-based recommendations for the new legislative period (2021-2025) on transparency, accountability, participation, integrity and capacity of the German health system.

New governance of the digital health agency: a way out of the joint decision trap to implement electronic health records in Germany?

“…Looking at Swiss, French and Swedish experience, it can be argued that the medical profession in general perceives increase in government regulation as a challenge to professional autonomy (Immergut, 1990). Austria and the Netherlands, historically close to Germany's self-governance structure, took different approaches to increase state influence and reduce the competence of self-governing actors: the former centralised and professionalised social insurance, while the latter opted for reduced corporatism and prioritised managed competition (Schmitt et al ., 2023). Such profound changes in the governance of the health system are imperative also in Germany to effectively implement innovations that promote person-centred and preventive care.…”

“…Hence, the preconditions for the problem solving style of decision-making towards implementing ePA can be summarised as follows: on the one hand, the competencies of sickness funds for selective contracting with individual healthcare providers should be strengthened, allowing integrated care to replace the outdated sectoral healthcare provision in standard care (Schmitt et al ., 2023). Parallel to this, in the co-creation of innovations that generate and use health data, patients and healthcare providers as the end users of these technologies (not the administrative bodies supporting fragmented care) should be consulted when making decisions in gematik .…”

<p>Implementing Electronic&nbsp;Health Records in Germany:&nbsp;Lessons (Yet to Be) Learned</p>

“…However, an automated data transfer for the secondary use of ePA data might be politically difficult to introduce in Germany, a country where data security concerns are significant [68]. Indeed, the recommendations of the upper house (Bundesrat) to the Federal Government concerning Germany's positioning on EHDS from September 2022, which included disapproval of some parts of the secondary use of health data in EHDS, indicate a rather cautious approach to data transfer [69].…”