Between resources and reforms, results are (also) a management issue

EMMAS 19 and 20’s Study Tour in Germany


Resources” and “reforms” seem to be the most frequently used words in the academic and professional debate when dealing with the sustainability of health protection systems in the medium and long term. Yet these two words alone cannot sum up the dynamics that characterize and will characterize the evolution of the industry.

Let us take two systems as examples: the German and the Italian ones. The differences are well known: Germany adopts the Bismarck model, or “healthcare and social insurance system,” which is funded through mandatory contribution by both employers and employees. Healthcare has a “dedicated” funding channel and does not compete with other sources of spending general taxation funds, as it is in Italy. This may be one of the reasons why public health spending reaches nearly 10% of GDP in Germany, as opposed to 6 % in Italy. As a result, just to mention a few figures, while the number of physicians is roughly the same, in Germany the number of nurses is significantly higher (13 per 1,000 inhabitants versus 5.8 in Italy), as is the number of beds (8 per 1,000 versus 3.2). In addition to that, the German system is highly decentralized, which allows companies greater autonomy in managing their strategic space, on the one hand, but causes fragmentation on the other. The plurality of players requires continuous negotiation among the parties, who are systematically busy balancing mutual interests. These are therefore two very different systems in terms of governance and resources, but they are inspired by the same central principle: universality.

As participants in the 19th and 20th editions of EMMAS - Executive Master in Management of Health and Social Care Organizations came to understand in their International Study Tour module, the challenges facing the German and Italian systems are far more similar than expected: funding mechanisms, governance of the health care system, governance of public healthcare companies, the role of nursing professionals, rehabilitation models, emergency management models.

With local support from Drs. Harald and Evelyn Plamper and guidance of the Program Management Team, EMMAS participants covered three main locations: the University Hospital in Cologne, one of the largest and oldest in Germany; the Dr. Becker rehabilitation clinic, and the Catholic St. Marienhospital, where an innovative model of geriatric care is being pioneered. They were also able to meet numerous stakeholders from the health care and insurance world.

Despite Germany’s significantly higher resources compared to Italy, the German health care system is perceived as “underfunded” by most local experts, as well as heavily affected by a major difficulty in recruiting nurses. Moreover, apart from the current figures, it is also facing a sustainability issue, generated by the reversal of the demographic pyramid. And there are discussions in Germany as in Italy about how to solve the system’s lack of digitization, which is not just a matter of perceptions. Indeed, electronic medical records are struggling to get off the ground there as well, and certainly not because of a lack of resources but because of a high level of management fragmentation that often causes a lack of integration among IT systems.

So, the two systems differ in resources and institutional structure, but the issues they need to address largely overlap. Perhaps we should add another keyword to “resources” and “reforms” if we want to contribute to the medium-to-long-term sustainability of health care systems. The word is “results.” And results are contributed to by innovative management practices, such as those that have led German geriatricians to cooperate with orthopedists in assessing and defining the course of care for an elderly person’s femur fracture so as to intervene with enviable timeliness; or those that have enabled effective prevention of COVID-19 infection among health care workers (keeping the positivity rate below 3%); or the choices that enhance the role of hospital pharmacists in patient care. These innovative practices have also pushed public healthcare companies’ executives to prepare, implement, monitor and maintain medium-to-long-term strategies, even in the midst of extraordinary environmental discontinuities such as the ones generated by the pandemic.

If results are a management issue, managerial skills need to be trained, strengthened and systematically exchanged and compared. Italian healthcare is made up of 21 different regional systems, and the need for comparison and benchmarking among regions is often called for with a view to fostering enrichment and convergence. But the challenge becomes even greater when we scale up to a European context that needs to strengthen (if not find) its identity.

It then appears clear that exchange with other systems is essential today, and even our NHS (which we should perhaps be more proud of) may have something to suggest to others, including from a managerial point of view. For EMMAS, Study Tours are an opportunity to open up to new frontiers and “discover” the strengths of your own organizations at the same time. These are both essential requirements for enabling managers to develop their own strong, conscious and innovative vision.

Francesca Lecci e Lorenzo Fenech

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