On 13-17 July,
2009 the delegation of the Health Ministry of Ukraine visited the Federal
Republic of Germany on exchange of experience. The delegation included the
Deputy Health Minister of Ukraine V.V. Lazoryshynets, the rector of I.Ya. Horbachevsky Ternopil State
Medical University,
the corresponding member of the Academy of Medical Sciences of Ukraine,
professor - L. Ya. Kovalchuk, the chief
doctor of Ternopil Regional Clinical
Hospital, Honorary doctor of Ukraine - M.Ya. Hirnyak and other rectors of higher
medical establishments of Ukraine.
The Ukrainian Embassy in Berlin hosted the welcoming reception for the Ukrainian delegation. Ambassador plenipotentiary and extraordinary of Ukraine to the Federal Republic of Germany Zarudna Natalya Mykolayvna spoke about the improvement of the working and partner relationships between Ukraine and Germany.
Then the Ukrainian delegation visited the Health Ministry of Ukraine, where the fundamentals of the healthcare in the Federal Republic of Germany, insurance medicine system, medical financing, the leading German hospitals and clinics i.e. Charite hospital in Berlin were discussed and talked about.
University Hospital
Charite (Berlin)
Historical and legal review
The History of Charite
Complying
with an order of King Frederick I
of Prussia from November 14,
1709, it was initially established in 1710 north of the Berlin city walls in
anticipation of an outbreak of bubonic
plague that already had
depopulated East Prussia. After
the plague spared the city it came to be used as a charity hospital for the
poor. On January 9, 1727 Frederick
William I of Prussia gave it the name Charité,
meaning "charity". The construction of an anatomical theatre in 1713 marks the beginning of the
medical school, and then supervised by the collegium
medico-chirurgicum of the Prussian Academy of Sciences. 1795 saw the
establishment of the Pépinière school for the education of military surgeons.
After
the University of
Berlin was founded in
1810, the dean of the medical college Christoph
Wilhelm Hufelandin 1828 integrated the Charité as a teaching hospital. Rudolf Virchow, once student at the Pépinière, worked with
anatomist Robert Froriep as prosector here and in 1856 became director of
the newly created institute of pathology,
where he developed his cell
theory.
After
the partition of Berlin in 1949 the
Charité in Mitte remained the main hospital
of East
Berlin affiliated
with the Humboldt
University, while the
Free University of West Berlin had the Klinikum Steglitz erected in 1968 backed by the US Benjamin
Franklin Foundation of Eleanor Lansing Dulles. In 1986 the
town's Rudolf Virchow Hospital
became the second medical school of the Free University. When after
reunification the City of Berlin
had to deal with three university hospitals, all were finally merged as sites
of the Charité in 2003.
Charite Today
Today, 7,500 students are enrolled at the
Charité. It treats 1,080,000 outpatients and 128,000 inpatients in 3,500 beds annually. 14,400
people are employed at its four locations in Berlin:
§ Charité Campus Mitte (CCM) in Berlin-Mitte
§ Campus Benjamin Franklin (CBF)
in Berlin-Lichterfelde
§ Campus Virchow Klinikum (CVK)
in Berlin-Wedding
§ Campus Berlin Buch (CBB)
in Berlin-Buch
Strictly speaking, the locations in Mitte,
Lichterfelde and Wedding are independent medical
centers, each providing patients with the full range of medical treatments
available in modern medicine. However, affiliated with the Deutsche Forschungsgemeinschaft and the Helmholtz-Gemeinschaft, special research and therapy focuses exist, such as the German Cardiology Center
Berlin at
the Campus Virchow Klinikum, the Center
for Space Medicine at the Campus Benjamin Franklin, the German Rheumatology Research
Center at the Campus Charité Mitte,
and the Center for Molecular and Clinical Cardiology at the Campus Berlin Buch. The DHZB
possesses the largest heart transplantation program in Germany and, after London
and Paris, the
third largest worldwide.
German
hospitals used to exist only as public establishments. Their task was to treat
and to ease people sufferings. Medical care of the patients improved with the
progress of medicine and the technological development. Medical establishments
were supported and financed mainly by church and charitable establishments
(Caritas – the network of European charitable organizations). Later the number
of communal hospitals increased and there were more private hospitals. Nowadays
there is the tendency for private and communal hospitals to unite and a lot of
private hospitals are the part of bigger medical establishments.
Federal law
a) hospital financing
The main law about hospital financing and hospital management has been KHG (Health Financing Act) since 1972. Since then, the hospital
financing is regulated by dual financing. The
distribution of the costs of a healthcare sector (e.g. the inpatient sector) is
subordinated to two different financing organizations,
whereby the Federal States are responsible for financing the
investments and the social services institutions for financing the
services.
b) Social insurance law
Germany has a universal multi-payer system with two main types of health
insurance. Germans are offered three mandatory health benefits, which are
co-financed by employer and employee: health insurance, accident insurance, and
long-term care insurance. Accident insurance is covered by the employer and
basically covers all risks for commuting to work and at the workplace. Long term care is covered
half and half by employer and employee and covers cases in which a person is
not able to manage his or her daily routine (provision of food, cleaning of
apartment, personal hygiene, etc.). It is about 2% of a yearly salaried income
or pension, with employers matching the contribution of the employee.
There are two separate systems of health insurance: public health insurance and private insurance. Both systems
struggle with the increasing cost of medical treatment and the changing
demography.
Federal healthcare legislation (the federal land - Berlin)
The federal lands
are legally regulated by the laws of the federal lands. According to the
federal laws, the federal lands have to compose the hospital plans. The aim of
the hospital plans lies in the ability to provide the population of the federal
lands with the proper medical care in modern hospitals. Only the hospitals
included in the hospital plan of the federal land are financed.
University hospital - it
foremost the hospital which is added to the medical faculty of University. Next
to medical service, it serves for educational aims and researches in industry
of medicine. Hospitals of higher educational establishments, as a rule, are
establishments with the maximal providing. It means- large hospitals with 1000
and more beds, which offer all list of departments and, partly, high-specialized
departments.
In Federal Republic of Germany, the
university hospitals are in the subordination of the corresponding university,
mainly in the form of association, whose council of supervision has representatives
of university and Federal Land . The special place is occupied by the
university hospitals of University of
Bokhum, which do not belong to Federal Land, and the university hospital of
Mangaym, which is under the control of (as the limited liability company) city,
and also the university hospitals of Gisena and Marburga, which are private.
The university hospitals of Germany have the special legal status. Development
and reorganization of higher schools in Federal Republic of Germany is a mutual task of Federation and Federal Lands.
Annually a plan of tasks is made up, which is supported by Federation and Federal Lands. Present volumes of investments
are dependent upon economic position of each separate Land
a) Charite: legal limits in
Berlin
After §69 law on restructuring- Charite
determined as an establishment, common
for Free University of Berlin and the
university of Gumboldta in Berlin. Primary aim of law is restructuring of
medical faculties in the universities of
Federal Land of Berlin. Future leading structures were legally
determined council of supervision, and also
as medical senate – next to
council of faculty and leadership of faculty and clinic.
Legal frameworks for Charite as the sole
system of the university hospitals in Berlin, were determined in 2005. Next to the
law on university medicine, the law of Berlin
on higher schools from 2005 determines the academic tasks of Charite as part of
tasks of higher schools of Berlin.
This law regulates processes in higher schools, rules of examination of
students and defense of the scientific studies. It also determines research
tasks and their implementation. The board of Charite was chosen in 2006. It
regulates a structure and guidance of Charite-centers, specifies the duties of
separate organs of Charite and describes the economic planning and carrying out
of economic policy.
Charite is a public legal subject.
Charite, according to acceding to Federal Land of Berlin, takes rights and
duties of university hospital with membership of schools and educational establishments. For
this purpose Charite and federal land regularly conclude contracts about main
directions of subsequent development of university medicine. Berlin Federal land
and Charite unite the efforts, executing
the task of scientific researches, science and studies, and confirm it by
long-term agreements.
For implementation of these tasks Federal
Land of Berlin executes the state supervision. A task of supervision is executed by council
of supervision, and there are representatives of different senates of Berlin in the council of supervision. The number of
decisions (for example, plans of development, reception of credits, et cetera)
can be accepted only after an agreement with observant council.
c) organization
Annually Charite treats
approximately 625.000 persons. It is 125.000 patients stationary and 500.000
patients ambulatory. The slogan of establishment sounds like: «Research,
studies, treatment, help». Charite is ruled by board. This higher leading organ
carries out strategic decisions. The board consists of chairman of board, dean of
faculty and director of hospital. Dean
carries responsibility for research and studies and simultaneously is on the
top of guidance a faculty. Maintenance of patients is managed by director of hospital. He heads guidance of
hospital. This leading organ is controlled by council of supervision, the
senators of the Berlin federal government, accountable for finances, scientific
activity and research, and also both presidents of university, as well as other
representatives of science, economy and public, belong also to it.. The
presidents of university
of Gumboldta in Berlin and Free University
of Berlin manage a medical senate in turns as chairmen, with a right to
deliberative vote. The medical senate is engaged in admitting to the
educational processes, by intersubject collaboration and other academic
businesses. Guidance of Charite-center adheres to regulation which it is
well-regulated in, who is accountable for organization of main resources of
studies and for co-ordination of the involved clinics and institutes on
questions studies.
Basic principle of health protection
of Germany
is an improvement of grant of medical aid and increase of profitability of
establishments of health protection. In Germany more than 20 thousand of
hospitals (1800 hospitals of acute care, including 32 university clinics). All about 60 thousand of
bed complement. The number of hospitals for the last 10 years grew short on
13%, and number of personnel - on 10%, but here the number of doctors grew on 30%. Hospitals are
both state and church, Red Cross, or
private. For last period of time the number of private hospitals grew, and
state - diminished: 32% the state form,
38% - church and other public, and 30% - private. Private hospitals are rather
small. However in different Federal Lands this correlation can be different.
Financing of hospitals is dual. The current financing takes place through
obligatory insurance in state sick-funds, although there are private
sick-funds. The second source is federal money and money of Federal Lands,
which are used for the improvement of financial condition of buildings and
equipment.
The
current financing is carried out on the basis of the given services of the
insured persons and consists of the medicinal providing, salary of workers,
payment for public utilities and other charges which direct at providing of
patients’ treatment. Standards and terms of treatment are used, swerve from
which are not paid by sick-funds and a calculation is conducted for the money
of hospital. Federal lands invest money in all hospitals. Lately those funds
grew short. However, the Federal Government selects annually on medicine for Federal
Lands the additional centralized
investments in amount of 700 million
euro which enter regions for the subsequent distributing between hospitals (for
comparison: in Ukraine such investments are made by amount of 550 million
euro).
Next day was devoted to visiting of
Grayfsvald (home to some 60,000 people), to the acquaintance with the
university hospital and the medical faculty of university.
The medical faculty is
component part of university and the university hospital on this chart subordinates
under it. About 170 students - future doctors and 40 dentists are admitted as
the first-year students of medical faculty. In addition, the medical faculty
helps other faculties (biologists, psychologists, and other)
The university, as well as
the university hospital, is the property of federal land. The current expenses
of university hospital are executed by medical insurance and maintenance of
buildings - for the money of federal land government and third persons. The
system of financing of university hospitals is difficult enough. A management
is also difficult enough. All clinics in Germany are the property of Federal
Lands (an exception is the university hospital of Marburg
which in 2005 became private). Public looks after with interest how they will
develop. University hospitals form 10%
of all beds and 20% of doctors. From 2007, after reform, exceptionally federal lands
carry responsibility for investments in these hospitals.
By 2019 the Federal Land will be given an investment from
central state funds. By 2014 all hospitals will be given 700 million euro from
central funds annually. What part from those money will be selected for the
university hospital - decide Federal Lands. All depends on that, what place the
university hospital occupies in Federal
Land. In Germany a 10,7%
GDP is given on health protection. It is
4th place after the USA,
Switzerland
and France.
For the last 20 years this number stably was about 11%. Life-span of woman in
Germany – 82 years, and of man – 71 year. A financial crisis did not brush with
health protection. If unemployment will grow, this situation will change in
connection with diminishing of payment to the sick-fund. However, the anti-crisis
program of government sends additional money for health protection.
The necessary laws are improved and issued for the effective work of the
medical establishments in Germany.
There are 180 hospital payment offices, which are mainly state-financed and
highly autonomous. The hospitals do not have the right to determine the number
of beds independently; it is done by the special committees of the federal
ministries. Âîíè ìàþòü âèñîêèé ð³âåíü àâòîíî쳿.
All the hospital payment offices receive 150 billion Euros a year and make an annual financial report concerning all
the expenditures.
Greifswald University Hospital
Greifswald University Hospital in Greifswald, Germany is a teaching
hospital for the University of Greifswald's medical school. Greifswald
University Hospital
is owned and operated by a non-profit Anstalt des
öffentlichen Rechts in cooperation with the university and serves as one of the
primary hospitals in the state Mecklenburg-Vorpommern. It also fills the function of a tertiary
referral hospital for the health care region.
The University of Greifswald's medical
school is the second most requested, the most selective, and among the
best-ranked in Germany. In 2007, Greifswald was ranked
2nd of 34 medical schools in Germany
in terms of popularity with prospective students, out-ranking other popular
universities such as the University of Heidelberg. Degrees are offered in medicine as well as dentistry.
In Germany, places to study medicine and dentistry are usually allocated (by
high school results) on a national level by a country-wide agency. However, a
certain fraction of the places available may be administered by the
universities if they wish so. In the year 2008, there were 2,100 applications
for 95 of those kinds of places for medicine in Greifswald, which equals an admission rate of
only 4.52 percent. In the same year, there were 400 applicants for 29 places in
dentistry, which equals an admission rate of 7.25 percent.
The hospital
is also a scientific centre. The departments in hospital as the departments are
divided into clinics and institutes. Professors, assistants and doctors work at
hospital. A doctor according to the working contract is as well a scientist. He
is obliged to make scientific researches and encourage student studies.
65 professors and 238 scientists (teachers) work at university
hospital. They are paid for medical and scientific-educational activities.
Founded
at the beginning of the 15th century, the alma mater Lipsiensis originally
comprised four faculties: the Faculty of Arts and the three 'higher' faculties,
i.e. Theology, Medicine and Law. That structure based on four large faculties
remained unchanged for some 500 years. Today there are 14 faculties within the University.
With
more than 190 courses our University caters for many different interests in study and research.
With more than 25.000 students Universität Leipzig is Saxony's
second largest university.
The university
hospital in Leipzig.
The university
hospital in Leipzig is organised according to the corporational model.
University
hospital in Leipzig consists of 45 hospitals, institutes and departments, which
are organized in 7 departments. There are 3800 workers in the hospital and 1200
faculty workers (5000 total). There are 1370 beds in the hospital. There are
51000 in-patients and 26000 out-patients (the town has 500 inhabitants). The budget of
hospitals provides 284 million Euro, income
– 9,1 million Euro. Every
year there are negotiations with hospital fund offices. There is a competition between
individual hospitals. The increase in the amount of
patients and pay off by the hospital funds give the possibility to improve the
financial basis and to increase wages.
For the last 10 years federal government
investments provided 380 million and Medical faculty investments provided 120
million (0,5 milliard Euro total). The investments are being directed to the
infrastructure development.
The university hospital has a supervision council (11
persons). Medical faculty is the property of
Saxony, but is integrated in the university. The hospital has the possibility
to organize the subsidiary. The Health Service Ministry doesn’t have the
influence on the university hospital activity. They are going to create the
integration model of the Medical faculty in the university hospital. The
educational process is financed by the agrarian government of Saxony with the
help of the Medical faculty funds and land own funds. As a rule, medical service is not taxed.
They say, that in the nearest future medical services may be taxed too. Funds,
which hospital fund offices receive, are not taxed. Medical faculty is financed
by the Saxony land depending on the level of performed works. The faculty transmits
funds to the hospital administration for the medical and educational work.
According to this, the administration gives wages for the hospital and
university staff. There is a plan of hospitals in Saxony, which doesn’t allow
to open private hospitals out of this plan. There are one university and one
municipal hospitals in Leipzig, which include 1000 beds. The university hospital government elects
supervision council for 5 years. This council consists of 11 persons: 3 persons
from the government, 1 person from the university, 1 person from the dean’s
office, 1 person from the university hospital staff, 2 independent specialists
from the field of medicine, 3 independent business specialists. The university
hospital tries to change the corporation model into the integration model.
The advantages of integration model:
1. To balance doctor and professor staff wages.
2. Better conditions for the university staff to work on their scientific
theses.
3. To use the staff work time more reasonably and with.
The experience, which we obtained while visiting university hospitals in Germany, was very valuable, because it gave us the basis to
create the project of the university hospital in Ternopil. The establishment of
the university hospital in Ternopil depends on time. Without powerful medical
center with maximum supply, Ternopil region will not be ready to the
introduction of the insurance medicine. In such case hospital fund offices will
deal with hospitals from other regions, which have higher medical technologies.
It will contribute to the development of the medical institutions in the
neighbour regions and degradation of our own medicine.
.