Country Profile

Germany is a classical example of the continental welfare state, based on the Bismarckian system of social insurance. As the system is quite redistributive, the value of the Gini coefficient is 0.283 where 0=perfect equality and 1=perfect inequality (United Nations Human Development Report, 2004).

The provision of welfare services, such as healthcare, education and social services is highly sectoralised due to the federalist system. Germany has 16 federal states or ‘Länder’. Therefore it is difficult to talk about policies to tackle health inequalities at solely the national level. While health care legislation and the health insurance system are a federal (national) competency, health promotion and public health actions aimed at tackling health inequalities take place on the regional level (please see below for examples of national and regional policies). However, some action has been taken on the national level and there is currently legislation being discussed in the Parliament. These actions are based on the new structural developments in Germany in the field of prevention and health promotion.

Since 2000, in the framework of the German health care reform, a range of initiatives were undertaken by the Federal Ministry of Health and Social Security together with all relevant actors of the health system. They were created in order to establish prevention as the 4th pillar of the health system in addition to therapy, rehabilitation and care. These initiatives encompass the following activities:

• The German legislative initiative on prevention. This initiative aims to create a basis for concepts, responsibilities, institutional structures and finances for prevention in Germany. The establishment of a German Foundation for prevention is being discussed, and will probably be implemented with the design of strengthening and financing prevention and health promotion activities. The law is currently in a preparatory stage in the legislative process.
• The discussion and process of agreeing on national health targets. These are disease-related targets including depression, diabetes, breast cancer (screening programmes), behaviour related targets (reducing tobacco consumption), health promotion and related targets (growing up healthy: nutrition, physical activity, coping with stress), the establishment of disease management programmes and strengthening health competences of patients.
• The establishment of the “Deutsches Forum Prävention und Gesundheitsförderung” (German Forum on Prevention and Health Promotion). This is an initiative where all relevant stakeholders of the German public health system discuss the priorities of German health policy in terms of prevention and health promotion.

All these mechanisms are legally focused on tackling health inequalities and encourage streamlining activities primarily for the work with socially disadvantaged people. The activities were connected, and should pave a comprehensive, effective approach to prevention. Hopefully, these mechanisms lead to an innovative and effective support for health promotion and primary prevention programmes in Germany.Moreover some other activities with national impact are taking place, such as the annual national congress on poverty and health with many participants from practice, science and politics.

The background information to this entry was collected by the German project partner - Simone Weyers of the German Federal Centre for Health Education (BzgA).

The following persons also contributed either by participating in the roundtable discussion or by providing their comments independently:

• Thomas Altgeld: chief executive of the health association of Lower Saxony
• Andreas Mielck is a research expert in health inequalities at the GSF Institute of Health Economics and Health Care Management Neuherberg
• Helene Luig-Arlt represents the practitioner side, responsible for coordinating activities in the frame of the Soziale Stadt and E&C in Flensburg
• Monika Hommes is the head of unit 'General Questions on Prevention and Health Promotion' of the Federal Ministry for Health and Social Security

Documents and Publications

This section provides the key documents on health inequalities published on a national level in Germany in the  past decade.

Key Actors

In this section key actors that are in a position to have an impact on health inequalities policies, such as ministries, state agencies, universities and/or independent institutes are listed.

Key Policy Tools

In this section main tools used to implement and monitor national policies in the field of health inequalities are listed.

National database of good practice

Please click here to learn about the databases where you can find a collection of good practices aiming at reducing health inequalities collected in Germany.

Strategic Initiatives

In the course of Closing the Gap, participating institutes have developed Strategic Initiatives outlining further steps that can realistically be taken to tackle health inequalities.