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View from Germany.

Dr Bertram Hdussler, director of the Institute for Health and Social Research describes developments in Germany's health care system since unification and the future of quality assurance. Until October 1990 two German health care systems existed, which differed at least as much as the corresponding economic systems. The eastern system was financed by a relatively low national budget distributed among the health services through several hierarchical levels. All services were provided by the state. Their use was free of charge and the public paid only token social security contributions. Physicians were public employees, like any other member of the national workforce, and were paid an average salary. The German Democratic Republic more or less followed a primary health care model. In urban areas primary and secondary care were organised in polyclinics large units with up to fifty doctors, some hundred other health workers, and other staff. Because of its considerably smaller economic power and the smaller share of the gross national product it allocated to the health care system, the republic had poor facilities compared with those of West Germany. Most hospitals were in poor condition, and technical equipment was either lacking or out of date. Pharmaceutical supplies were restricted to those that could be produced by the domestic sector or eastern bloc and were rarely of international standard. Waiting lists were considerable for scarce health services predominantly distributed to active members of the working force. The health care system of former federal republic has become the uniform system for Germany as a whole. It is funded within a social security system which has remained essentially unaltered for over 100 years. More than 90 per cent of the population pay insurance premiums and employers pay half of the total premium of their employees. The premiums are a fixed percentage of the wages, and family members who are not employed have their insurance covered without extra charge. The use of services is generally free except for some user part charges for example, for medicines outside a list of free medicines. Ambulatory services are generally provided by doctors in private offices. Most doctors are self employed. Patients have free access even to specialists. Ambulatory and hospital care are strictly separated. Physicians in private offices are paid on a fee for service basis whereas those in hospitals are employees. Private offices, particularly those of specialists, are often equipped to a high technological standard. Long waiting lists are widely unknown even in hospitals, and expensive services are widely available, usually soon after their introduction.