Editorial
A new German Government: leadership for health?
On Sept 22, 61·8 million German citizens are eligible
to vote for a new or old German Government. The
predictions are that Chancellor Angela Merkel’s party, the
Christian Democrats (CDU), together with its Bavarian
sister party, the Christian Social Union (CSU), will get
about 40% of votes—a clear lead over the prediction of
26% for the next strongest party, the centre-left main
opposition Social Democratic Party (SPD). And Merkel is
by far the preferred candidate for Chancellor according to
surveys, even before the SPD candidate Peer Steinbrück
was depicted on the front cover of the Süddeutsche Zeitung
news magazine giving a rude middle-finger gesture.
These predictions were so clear-cut and stable that some
branded the forthcoming election as uninspiring and
boring. “Stick with Mutti” (mummy), so recommends the
Economist last week—the nickname given to Merkel for her
no-nonsense and yet homely style of politics. However, it
is far from clear whether the current government coalition
between the Free Democrats (FDP, the current market-
oriented junior partner) will continue. The FDP, who
achieved about 14·6% of votes in the 2009 elections, are
only predicted to achieve 5·5% to 6·0% this time round—a
figure too close for comfort to the 5% threshold required
to enter German Parliament. The options of a so-called
grand coalition between the two main parties CDU/CSU
and SPD, last seen from 2005 to 2009, is again a real
possibility.
So what does this all mean for health and international
development? Both ministries, the Ministry of Health
and the interestingly named Ministry for Economic
Cooperation and Development, are led by FDP politicians,
Daniel Bahr and Dirk Niebel, respectively. Even if the
current coalition continues, the FDP is unlikely to retain as
many ministries as it holds now. Both these ministries are
predicted to change leadership. The election manifestos of
all parties are surprisingly sparse and superficial on health
and are almost completely lacking any substantive content
on international development and global health. The main
differences centre on the nature of provision of health
insurance, whether the private options and statutory
insurance provisions continue as now or whether a more
equitable citizen’s insurance will be introduced for all (the
SPD’s choice). Germany’s health system performs well in
international comparisons. There are almost no waiting
lists, there is free choice of doctors and hospitals, and the
www.thelancet.com Vol 382 September 21, 2013
health insurers now have a surplus of almost €28·3 billion
after the health reform in 2010. However, Germany’s
ageing demographic structure will be a real challenge for
a system that readily allows overdiagnosis, overtreatment,
overpriced drugs, and wasteful multiple visits to different
Ludovic Maisant/Hemis/Corbis
doctors. Comprehensive preventive strategies, although
mentioned by all parties, are still only a pipedream,
especially in a country that struggles to implement the
single most effective preventive effort of tobacco control.
Germany’s role in international development and
global health is in its infancy. It is perhaps therefore not
surprising that the government’s concept note for global
health politics Globale Gesundheitspolitik gestalten—
gemeinsam handeln—Verantwortung wahrnehmen (to
shape global health politics—to act together—to take
responsibility), introduced by Bahr in July, was hardly
noted by anyone. The document outlines three themes:
comprehensive health protection of the German people;
taking global responsibility by providing experience,
expertise, and means; and strengthening international
institutions for global health. The fact that the German
Government is thinking about such a concept note at all
is encouraging and commendable. The note itself is a mix
of self-interest, basic explanations, and a list of current
activities and achievements with an unhealthy emphasis
on bilateral agreements. Some examples are curious, such
as the provision of mammography equipment to China.
The theme on strengthening international institutions
focuses on recommendations for WHO, such as better
financial management, result-driven administration, and
strengthening of internal control mechanisms, rather
than promising more financial support. Germany, you
can do better!
As a leading economy in the European Union and
a large, successful, and prosperous country, Germany
has to step out of its self-imposed introspective role in
health. 4 years of World Health Summits held in Berlin
annually under the patronage of Angela Merkel have
only tentatively raised German awareness and have
contributed modestly beyond a general gathering and
talks among the converted. It has taken some time for
Germany to take its leadership in European politics
and on the world stage, for perhaps understandable
historical reasons. Now, Angela, is the time to show
some leadership for global health as well. „ The Lancet
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