The population perspective in assessing the performance of Germany's health care system: Results of a cross-sectional survey among members of a statutory health insurance

Introduction: Since the World Health Report in 2000, Health System Performance Assessment (HSPA) has been established as a tool for the evaluation and evidence-informed governance of health systems. So far, the population perspective has not been integrated into HSPA in a systematic manner, although people's experiences and expectations are of great importance to improve health systems and especially to strengthen patient-centered care. Therefore, this study aims to conduct an HSPA of Germany's health system from the population's perspective covering all eight goals of WHO's Health Systems Framework, and to identify strengths and needs for improvement. Methods: In 2018, 32,000 people insured with the German sickness fund 'AOK Nordost' were invited by mail to participate in the survey. The questionnaire contained a total of 43 items covering the eight goals of WHO's Health Systems Framework (e. g., access, quality, safety) plus socioeconomics and other characteristics of the insured persons. The data on the health system goals were analyzed descriptively and by subgroups (age, sex, income, chronic conditions, health literacy). Results: The sample (n =1,481; response rate 4.6 %) was 54.8 % female and had a mean age of 59.1 years (+/- 18.5). Altogether, the participants saw several needs for improvement within the German health system. For instance, 60.0 % found quality differences between hospitals to be big, and between 3.9 % and 8.5 % reported mistakes related to their treatment or prescription medication in the previous two years. A big need for reform was especially seen regarding out-of-pocket payments (51.5 %) and the coordination of ambulatory care physicians among each other (44.2 %) and with hospitals (41.9 %). In addition, big subgroup differences were seen, especially for income and health literacy. Of the participants in the lower income group, 37.2 % reported a (very) strong financial burden due to out-of-pocket payments (vs. 20.7 %). People with limited health literacy (52.1 %) assessed the access to care generally as not being good, and they perceived greater quality differences and needs for reform, compared to their counterparts. For instance, 36.6 % had experienced discrimination in the previous year (vs. 19.9 %). Discussion: The survey results provide a comprehensive picture of Germany's health system from the population perspective. In some areas, previous findings were confirmed (e. g., a lack of coordination between providers). Other results expand existing knowledge (e.g., the role of health literacy in health care provision) or raise new questions (e. g., the difference between the subjectively assessed burden from out-of-pocket payments and the objective measures currently used). The great differences between subgroups are a call to action on the level of both politics and practice to better consider the individual's needs in order to make health better for everyone. Further research could provide deeper insights in this regard. Conclusion: Strengthening the population perspective in HSPA allows for a better understanding and evaluation of health systems and, in particular, helps to identify areas for improvement in patientcentered care.