Editorial

www.thelancet.com Vol 382 September 21, 2013 999

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-fi nger 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 fi gure 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 superfi cial on health and are almost completely lacking any substantive content on international development and global health. The main diff erences 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

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 diff erent 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 eff ective preventive eff ort 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 fi nancial management, result-driven administration, and strengthening of internal control mechanisms, rather than promising more fi nancial 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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