HEADRIK VAN DEN BUSSCHE
Since the unification of Germany in 1990, the educational system, research policy, and administration of health care in the former German Democratic Republic (GDR) have been undergoing dramatic transitions. Most probably, this process will consist of a progressive adaptation to the standards of the former West Germany ( Wissenschaftsrat 1991). As this process is still underway, the data and the analysis in this chapter refer to West Germany only.
Health services in the German Federal Republic (FRG) are delivered within a comprehensive and highly bureaucratic social security system that covers more than 90 percent of the population and provides for direct reimbursement to health care providers. The health services system employs approximately two million people (3.3 percent of the population), consumes more than 10 percent of the GNP, and is still growing, both in budget and work force, in spite of the expenditure containment laws of the last 15 years ( Sass and Massey 1988; Deneke 1988). The FRG is a leader among Western European countries with regard to the accessibility of services and the freedom of their use, acute hospital bed density (72 beds per 10,000 inhabitants), the number of hospital care days/population ( Sachverständigenrat 1987), the availability of sophisticated equipment ( Sachverständigenrat 1988) and the physician: population ratio. For example, the ratio of hospital care days to population is 100 percent higher than in the US and 200 percent higher than in the UK.
The German health care system is a loose aggregation of subsystems. The degree of coordination and cooperation among and within the subsystems (ambulatory care, hospital care, public health care, and rehabilitation) is low and competition is intense, including that among the sick funds (health insurance funds) for new members ( Light et al. 1986). The health care system is dominated by the providers, is disease and cure-oriented, and excels with regard to the