During my meeting with Prof. Dr. Manfred Wildner and his colleague Dr. Herbert Zöllner in Munich, Germany, we discussed the comparative advantages and disadvantages of the German, UK, and US public health systems. The systems are strikingly different.
Professor Wildner is Director of the Health Division at the Bayerisches Landesamt für Gesundheit und Lebensmittelsicherheit (Bavarian Health and Food Safety Authority). In close cooperation with the Institute for Medical Information Processing, Biometry and Epidemiology at Ludwig-Maximilians-Universität, an interdisciplinary professorship for Public Health Policy & Administration was created at the Pettenkofer School of Public Health, which is held by Professor Wildner. His current area of research is public health policy and administration. He studied medicine and worked as a doctor in Germany, the UK and in the US for several years. He also holds an MPH from the Harvard School of Public Health.
Dr. Zöllner worked for the World Health Organization from 1971-2002, in a variety of roles. He was Regional Officer for Health Economics at WHO’s Regional Office for Europe in Copenhagen and later member of the executive management team in Strategic Planning and Coordination. He was also a key member of the team developing the “Health for All” policy in Europe, which was adopted by all WHO member states. He has contributed to a wide range of WHO publications. Dr. Zöllner teaches courses on comparative systems and public health management at Ludwig-Maximilians-Universität in Munich and provides advice to Bavarian health authorities on new disease prevention and health promotion initiatives. He has a Ph.D. in Economics from the University of Colorado.
Professor Wildner and Dr. Zöllner are based in Munich, Germany
Q: Professor Wildner, you worked as a doctor in the UK, US and Germany. These are quite different public health systems. How do these systems compare with each other?
Prof. Wildner: This is a sensitive topic. The British are doing extremely well relative to the money they invest in their system. I got my basic medical training in the UK and it was beautiful. It was organized, logical, and you knew what to expect. As a patient, you have to wait – and you have big wards with 10-20 patients to a room. From the government’s perspective, this works very well. From the doctor’s perspective, this also works well, although you have to put in long hours. From the patient’s perspective, while it’s better than most countries in the world, it is not always comfortable.
As for the US, doctors have very good income opportunities and the US has great research facilities. However, I imagine that, for a lot of people, it is not as accessible as it might be, due to the high cost of service. You have the same procedures as elsewhere, but at higher prices; there is no quality difference, but the patient has to pay more for the same thing.
And then, coming back to Germany, it lies in between the UK and the US systems. We are doing fine; we have hardly any waiting lists and are quite responsive to patient needs. It’s not as logical as in the UK. Future improvement could include greater transparency and accountability.
Q: Is there a difference in terms of health care spending?
Dr. Zöllner: A good friend of mine at Princeton University, the late Professor Uwe Reinhardt, who focused his research on health care spending, found that health system accessibility is dependent on prices. This does not show up so much when you just look at the cost of doctors – the average spend in Germany is about the same in this respect as it is in the US. But averages are misleading. There are far fewer doctors per capita in the US versus Germany, so the cost is much higher per doctor. In addition, administrative and insurance expenses also increase US costs.
In terms of spending on public health institutions, while Germany is doing fine, the UK and the US are far better. UK research output at its universities and institutions is fantastic. Their public health service focuses on health promotion and effective centralized management of the whole system.
Prof. Wildner: You are touching on a central point here. The health care system focuses on curing disease and giving you support when you are sick, while the primary task of the public health system is to promote and protect health. These are quite different tasks. You may ask, what promotes health? The first thing that comes to mind is education, followed by professional development, a fair income, safe public spaces and infrastructure.
When it comes to the practice of public health as a science, the UK and the US are doing much more than Germany. However, when it comes to public health outcomes, Germany’s successful educational system is a huge asset. For us, it is important that every student finishes school and almost everyone has a chance to get professional training. This solid educational system compensates for Germany’s lack of scientific edge when it comes to securing favorable public health outcomes.
Q: Would you have any advice for young people interested in pursuing a career in public health?
Dr. Zöllner: You need to get solid training in one of the basic sciences, medicine, etc. Then you have to focus on one area of specialization. It’s such a huge field that no one person can know it all. Consider, for example, the many subject experts who must collaborate within an international organization to make it work.
Prof. Wildner: It’s a beautiful field. I can think of three things to tell you. First, know your talents and then focus your professional career on leveraging those talents. If you aim to make that your contribution in life, then you will be successful. Second, it’s difficult to make plans for the long term, so focus your planning on seven year periods, re-assessing your objectives every seven years. Third, my best advice would be to stay at university and get as much academic training as you can, because once you leave university, it’s difficult to go back. Do as much as possible, get the best training at the best institutions and then, when you are in your 30s, shift to somewhere else. Don’t make it later than that, but also don’t leave any earlier.
If you want to go into administration, it’s probably best to have an M.D. and an MPH. If you don’t have a medical degree, then you should aim to have a PhD.
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