5. Provision of services
key feature of the health care delivery system in Germany is the clear institutional separation between (1) public health services, (2) primary and secondary ambulatory care and (3) hospital care, which has traditionally been confined to inpatient care. The early sections are arranged accordingly. Separate sections discuss emergency care, pharmaceutical care, rehabilitative services, nursing and long-term care, palliative care, psychiatric care, dental care, complementary and alternative medicine, and services for people with physical and mental disabilities.
5.1 Public health
While the specific tasks of the public health services and the levels at which they are carried out differ from Land to Land, they generally include activities linked both to the Land’s sovereign rights and the care provided for selected groups, such as:
- surveillance of communicable diseases;
- health reporting;
- supervision of hygiene in hospitals and among hospital staff, and since 2000 of office-based physicians and non-physician health professionals;
- supervision of commercial activities involving food, pharmaceuticals and drugs;
- overseeing certain areas of environmental hygiene;
- physical examinations of schoolchildren and certain other groups;
- diagnostic and – in exceptional circumstances – therapeutic services for people with specific communicable diseases including sexually transmittable diseases and tuberculosis;
- provision of community-oriented psychiatric services;
- health education and promotion; and
- cooperation with and advice to other public agencies.
These services are provided by roughly 350 public health offices across Germany, which vary widely in size, structure and tasks.
In the first decades of the Federal Republic’s history, the Länder defended their responsibility for public health services against several attempts by the federal government to extend its influence in this sector. Originally, immunizations, mass screening for tuberculosis and other diseases, as well as health education and counselling, were in the hands of the public health services. Since the 1970s, however, many of these individual preventive services have been transferred to physicians in private practice, combined with an expansion of the SHI benefits package. Before 1970, only antenatal care was included in the benefits package. Since 1971, however, screening for cancer has become a benefit for women over 20 years and men over 45 years. At the same time, regular check-ups for children under 4 years of age were introduced (and extended to children under 6 years of age in 1989 and to adolescents in 1997). Also in 1989, group dental preventive care for children under 12 years and individual dental preventive care for those aged 12–20 years became SHI benefits; individual preventive care was extended to those aged 6–20 years in 1993. Regular health check-ups, such as screening for cardiovascular and renal diseases and diabetes, for sickness fund members over 35 years were also introduced in 1989.
Primary prevention and health promotion were made mandatory for sickness funds in 1989, eliminated in 1996 and reintroduced in modified form in 2000. With §§ 20 and 20a SGB V, the Act to Strengthen Competition in SHI expanded the scope of the sickness funds’ activities yet further to include occupational health promotion as a standard SHI benefit as of 2007. The sickness funds are given a benchmark of €2.78 per insured individual for primary prevention measures and occupational health promotion. In 2010, the sickness funds spent approximately €300 million on primary prevention and occupational health promotion. Between 2000 and 2010, spending on primary prevention increased from €1.10 to €4.33 per person covered by SHI. In 2010, around 12 million people – many more than in the previous year – received preventive and health promoting activities from their sickness funds. In particular, setting-based measures were expanded. In 2010, more than 30 000 institutions (up from 14 000 in 2007) – especially kindergartens, schools and vocational schools – were supported by targeted activities in the areas of exercise and healthy eating, thereby reaching 9 million people. Individual courses have also been increased; utilization of these increased steadily between 2002 and 2009, with a slight decrease in 2010. With 52%, exercise courses have remained most popular (Medizinischer Dienst des Spitzenverbandes Bund der Krankenkassen, 2012).
Since 2003, the existing cancer-screening benefits covered by SHI (women: cervix/genital, breast, skin, rectum/colon; men: skin, rectum/colon, prostate) have been extended to include colonoscopy (two tests, at the ages of 55 and 65 years) as an alternative to stool testing and a systematic mammography screening programme for women aged 50 to 69 years.
The expansion of the SHI benefits package to include screening and early detection services means that private-practice physicians are obliged to deliver these services as part of the regional budgets negotiated by the regional associations of SHI physicians and the sickness funds. For some other services, such as immunizations, the physicians negotiate with the sickness funds and arrange separate fees that are not part of the regional budgets. Consequently, preventive services are now delivered within the same legal framework as curative services, meaning their exact definition is subject to negotiations at the federal level between the sickness funds and the physicians. The current directive of the Federal Joint Committee on preventive services includes clinical and laboratory services for screening and information about test results and prognosis; health education, however, is still given low priority in the reimbursement and documentation requirements.
Since 2000, the functions of public health services in controlling communicable diseases have been reorganized according to the Infection Protection Act (Infektionsschutzgesetz). The surveillance procedures were streamlined and essentially centralized at the Robert Koch Institute to better evaluate and inform the public about infectious diseases and to cooperate with European disease-control agencies. Besides supervising hygienic standards in hospitals, public health offices also check hygienic standards in practices of ambulatory care physicians, dentists and other health professionals. Hospitals and ambulatory surgery facilities are now required to report nosocomial infections and multiresistant microbes, with recommendations for improving the situation.
Since the introduction of the Infection Protection Act in 2000, well-proved voluntary and educational standards for HIV have been applied to all sexually transmittable diseases, and the former stricter regulations have been abolished. Public health offices have been required to strengthen their counselling services and to provide diagnostic services and treatment in certain cases, including for example non-compliant patients with tuberculosis.
The Federal Centre for Health Education, an agency of the Federal Ministry of Health, is responsible for population-wide campaigns for lifestyle-oriented primary prevention of chronic diseases, including initiatives to prevent HIV; sex education and family planning; and initiatives to prevent addiction, increase exercise, improve nutrition and help people to cope better with stress. It also operates campaigns to encourage organ and tissue donation. The Centre also operates a database on projects that aim at reducing inequalities in health by particularly targeting the socially disadvantaged. Currently, the database provides information on more than 1700 projects directed at improving the health of socially disadvantaged people or groups.
Since there have been occasional measles outbreaks in recent years, many politicians and medical professionals have been calling for mandatory vaccinations against measles (see health policy update published 26/06/2017).
In July 2019, the Federal Government passed a draft law that requires mandatory vaccination against measles for medical staff as well as children, adolescents and staff in community facilities (childcare, schools, asylum seekers' homes).
The law stipulates that non-vaccinated children can be excluded from visiting childcare facilities, but not from school. Non-vaccinated personnel may not take up any activity in community or health facilities. Parents who do not vaccinate their children cared for in community facilities will face a fine of up to € 2,500.
Statutory sickness funds will in future pay for the vaccination against human papillomavirus (HPV) for boys. The Joint Federal Committee decided on 20th September 2018 to include the HPV vaccination for all children between 9 and 14 years in the SHI benefit catalogue. The decision is expected to come into effect in December this year. The decision is based on a recommendation of the Standing Vaccination Commission (STIKO) based at the Robert-Koch-Institute (RKI) for this age group. The vaccine has been recommended for girls to prevent cervical cancer already since 2007. In June 2018, the STIKO decided to recommend vaccination also for boys.
Federal Joint Committee: Schutzimpfungs-Richtlinie: Umsetzung der STIKO-Empfehlung der HPV-Impfung für Jungen im Alter von 9 bis 14 Jahren (20/09/2018); https://www.g-ba.de/informationen/beschluesse/3502/; accessed 18/20/2018
Robert Koch Institute: HPV-Impfempfehlung für Jungen veröffentlicht (28/06/2018); https://www.rki.de/DE/Content/Service/Presse/Pressemitteilungen/2018/07_2018.html; accessed 18/20/2018
Unlike in many other countries, vaccination is not mandatory in Germany. Immunization coverage rates for diphtheria, tetanus toxoid and pertussis among 1-year-olds are close to the EU average. Also measles immunization coverage among 1-year-olds has been at about 97%, which is above EU average. There has been a clear increase in immunization uptake and pediatric immunization rates have been steadily rising over the last decade. However, gaps still persist in childhood vaccinations against pertussis, hepatitis B and the second dose of measles vaccine, mumps and rubella. There have been occasional measles outbreaks in recent years. 2,500 new measles cases occurred in 2015 which corresponds to an incidence of 3.05 per 100,000 population and is five-times higher than in the previous year. Coverage is low among vaccine objectors leading to major concerns among physicians and politicians.
Vaccination policy as part of the Act to Strengthen Health Promotion and Prevention
The Act to Strengthen Health Promotion and Prevention passed parliament in July 2015. It aims to improve prevention and health promotion by regulating vaccination policy through a range of legal measures. Immunization status will be monitored in the course of health check-ups for children and adults. In the future, also company physicians are allowed to conduct general vaccinations. Furthermore, children are only accepted in day-care facilities after the parents have been counselled by a physician about vaccination. Parents who stubbornly refuse the counselling can be fined with up to €2,500. In case of a measles outbreak in a day-care facility or school, the institution is allowed to exclude unvaccinated children from attendance. The recruitment of employees in medical facilities can be made dependent on the vaccination coverage and immunization status.
Paediatricians demand mandatory vaccination against measles
The Physicians' Chambers hold that the legal measures to improve vaccine uptake are not yet sufficient and demand a tougher action against vaccine objectors, in particular as regards measles. The Federal Association of Pediatricians even considers the legal requirement for measles vaccination. The Federal Supreme Court also considers vaccinations for children to be medically appropriate. According to a recently published resolution, family law courts will have to transfer the decision-making authority to the parent "whose solution is better suited to the child's well-being". This means if parents dispute to vaccinate their child, then the vaccination will be carried out. Critics of mandatory vaccination counter that the legal requirement to certain vaccinations rather strengthens the resistance to all voluntary vaccinations. In the EU, 14 countries require vaccination against at least one disease, including France and Italy. Vaccination against measles is mandatory in eight EU countries, all of them are located in Eastern Europe.
Deutsches Ärzteblatt: https://www.aerzteblatt.de/nachrichten/75898/Bundesgerichtshof-Schutzimpfungen-haben-erhebliche-Bedeutung
Deutsches Ärzteblatt: https://www.aerzteblatt.de/nachrichten/74449/Impfpflicht-fuer-Kinder-gefordert
Federal Ministry of Health: https://www.bundesgesundheitsministerium.de/themen/praevention/praeventionsgesetz.html