German Health System Overview
Health System Rankings
Outcomes
Health System Coverage
Costs for Consumers
Health System Expenditures
Germany’s COVID-19 Strategy
Total Health Spending In US$ PPP Per Capita (2020): $6,939
(Note: “Health spending measures the final consumption of health care goods and services (i.e. current health expenditure) including personal health care (curative care, rehabilitative care, long-term care, ancillary services and medical goods) and collective services (prevention and public health services as well as health administration), but excluding spending on investments. Health care is financed through a mix of financing arrangements including government spending and compulsory health insurance (“Government/compulsory”) as well as voluntary health insurance and private funds such as households’ out-of-pocket payments, NGOs and private corporations (“Voluntary”). This indicator is presented as a total and by type of financing (“Government/compulsory”, “Voluntary”, “Out-of-pocket”) and is measured as a share of GDP, as a share of total health spending and in USD per capita (using economy-wide PPPs).”
Source: OECD (2022), Health spending (indicator). doi: 10.1787/8643de7e-en (Accessed on 31 August 2022).
Current Health Expenditure Per Capita In US$ (2019): $5,440
Source: Global Health Observatory. Current health expenditure (CHE) per capita in US$. Geneva: World Health Organization. Last accessed July 26, 2022.
Current Health Expenditure As Percentage Of Gross Domestic Product (2019): 11.7%
Source: Global Health Observatory. Current health expenditure (CHE) as percentage of gross domestic product (GDP) (%). Geneva: World Health Organization. Last accessed July 26, 2022.
Out-Of-Pocket Expenditure As Percentage Of Current Health Expenditure (2019): 12.82%
Source: Global Health Observatory. Out-of-pocket expenditure as percentage of current health expenditure (CHE) (%). Geneva: World Health Organization. Last accessed July 26, 2022.
Out-Of-Pocket Expenditure Per Capita In US$ (2019): $697.2
Source: Global Health Observatory. Out-of-pocket expenditure (OOP) per capita in US$. Geneva: World Health Organization. Last accessed July 26, 2022.
Household out-of-pocket payment in current US$ per capita (2019): $691
Source: Global Health Expenditure Database. Health expenditure series. Geneva: World Health Organization. Last accessed August 31, 2022.
Out-of-Pocket Spending as Share of Final Household Consumption (%) (2019): 2.9%
Source: OECD (2021), Health at a Glance 2021: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/ae3016b9-en.
Remuneration of Doctors, Ratio to Average Wage (2019)
General Practitioners: 4.4
Specialists: 3.4 (Salaried); 5.3 (Self-Employed)
Source: OECD (2021), Health at a Glance 2021: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/ae3016b9-en.
Remuneration of Hospital Nurses, Ratio to Average Wage (2017): 1.1
Remuneration of Hospital Nurses, USD PPP (2019): $58,900
Source: OECD (2021), Health at a Glance 2021: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/ae3016b9-en.
Domestic General Government Health Expenditure as Percentage of General Government Expenditure (%) (2019): 20.1%
Source: World health statistics 2022: monitoring health for the SDGs, sustainable development
goals. Geneva: World Health Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO.
“In 2019, Germany devoted EUR 4,505 per capita (adjusted for differences in purchasing power) to health care – the highest level in the EU and 28 % higher than the EU average (Figure 7). The country also spends the highest share of its GDP on health among EU Member States (11.7 % in 2019, compared to the EU average of 9.9 %).”
Source: OECD/European Observatory on Health Systems and Policies (2021), Germany: Country Health Profile 2021, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.
“Germany spends almost an equal amount on inpatient and outpatient care. At EUR 1,221 per capita for outpatient care and EUR 1,212 for inpatient care in 2019, these figures are above the EU averages (EUR 1,022 for outpatient and EUR 1,010 for inpatient care), as was Germany’s spending across all categories of health care (Figure 8). However, overall spending has increased more slowly than the EU average since 2016, and the distribution of resources across different functions is close to the EU averages at around 27 % each for inpatient and outpatient care (EU: 29.1 % and 29.5 %), 19 % for long-term care (LTC) (EU: 16 %), 19 % for medical goods (EU: 18 %) and 3 % for prevention (EU: 3 %). Over recent years, LTC spending has grown more strongly than other expenditure categories. In 2015, Germany spent EUR 637 per capita on LTC (the health component); this increased to EUR 849 in 2019. The 2017 reform of LTC increased spending as it expanded the benefits package and increased the number of recipients entitled to LTC services.”
Source: OECD/European Observatory on Health Systems and Policies (2021), Germany: Country Health Profile 2021, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.
“Germany spends a substantial amount of its wealth on health. Total expenditure on health amounted to 11.7% of GDP in 2018 according to data of the Federal Statistical Office. According to WHO data, per capita health expenditure more than doubled between 2000 and 2018, from US$ 2687 (adjusted for differences in purchasing power) to US$ 6098, which ranks Germany third in comparison to other WHO Europe countries in 2018 (after Switzerland and Norway) (World Health Organization Regional Office for Europe, 2020) (see Section 3.1 Health expenditure). By OECD data, health expenditure in Germany as a share of GDP was the fourth highest share among OECD countries (after the United States, Switzerland and Norway) and per capita spending was way above the OECD36 average of US$ 3994 in 2018 (OECD, 2019).
“Per capita expenditure on health in Germany rose by an average of 2.5% per annum in real terms between 2013 and 2018 (up from 2.1% p.a. between 2008 and 2013). In comparison to other OECD countries, this was a relatively large increase during this period, and higher than in the Netherlands (0.5%), France (0.8%), Austria (1.0%), Switzerland (2.1%) and the OECD36 average (2.4%). According to OECD calculations, average per capita health expenditure growth is projected at 1.9% a year between 2015 and 2030, which would reflect a moderate increase compared to other OECD countries (OECD, 2019). The pace of health expenditure growth is partly attributable to the comparatively large human, technical and infrastructural resources in the German health care system and a high level of activity (e.g. in terms of consultations, hospital cases, consumption of pharmaceuticals). In addition, the full implementation of reforms to the long-term care insurance (LTCI) scheme, such as the broadening of eligibility criteria and benefits, and a rapidly ageing population, represent additional pressures on the sustainability of financing (see Section 5.8 Long-term care).”
Source: Blümel M, Spranger A, Achstetter K, Maresso A, Busse R. Germany: Health system review. Health Systems in Transition, 2020; 22(6): pp.i–273.
“Cost-sharing and out-of-pocket spending: Out-of-pocket spending accounted for 13.2 percent of total health spending in 2014, mostly on nursing homes, pharmaceuticals, and medical aids.9
“Copayments include EUR5.00 to EUR10.00 (USD6.36 to USD12.72) per outpatient prescription, EUR10.00 per inpatient day for hospital and rehabilitation stays (for the first 28 days per year), and EUR5.00 to EUR10.00 for prescribed medical devices. Sickness funds offer selectable tariffs with a range of deductibles and no-claims bonuses. Preventive services do not count toward the deductible. SHI-contracted physicians are not allowed to charge above the fee schedule for services in the SHI benefit catalogue. However, a list of “individual health services” outside the comprehensive range of SHI coverage may be offered to patients paying out of pocket.
“Safety nets: Children under 18 years of age are exempt from cost-sharing. For adults, there is an annual cap on cost-sharing equal to 2 percent of household income; part of a household’s income is excluded from this calculation for additional family members. About 0.3 million of those insured under SHI exceeded the 2 percent cap in 2014 and were exempted from further cost-sharing. The cap is lowered to 1 percent of annual gross income for qualifying chronically ill people; to qualify, those people have to demonstrate that they attended recommended counseling or screening procedures prior to becoming ill. Nearly 6.3 million people, or around 9 percent of all the SHI-insured, benefited from this regulation in 2014.10 Unemployed people contribute to SHI in proportion to their unemployment entitlements. For the long-term unemployed, government contributes on their behalf.”
Source: Commonwealth Fund. International Health System Profiles: Germany. From the web, last accessed Sept. 30, 2019.
“Allocative efficiency indicates the extent to which an appropriate mix of services or interventions are purchased to maximize population health outcomes. In Germany the allocation of resources at the federal level mostly reflects the bargaining process between corporatist bodies, rather than a restrictive budget plan. Although there are mechanisms in place to secure the (cost-)effectiveness of benefits covered under SHI using tools such as Health Technology Assessment (see Section 2.7 Regulation), there is no priority setting by e.g. formulating goals. Pooled resources are reallocated among the sickness funds according to a morbidity-based risk-adjustment scheme, by which sickness funds have to cover all costs (see Section 3.3 Overview of the statutory financing system). However, the details of care provision and reimbursement are consequently negotiated between corporatist bodies and are not guided by an overarching strategic programme at the national level (instead, budgets are determined by historic spending levels).
“International comparisons of health expenditure by function show that Germany spent 27.2% on curative and rehabilitative care in inpatient and day care settings in 2018, which is higher than in the Netherlands (24.4%), Denmark (25.1%) and Switzerland (25.3%), but lower than the EU average (30%), France (31.5%) and Austria (33.3%) (OECD, 2020b). In more detail, Germany spent € 1169 per inhabitant on hospital care in 2018 (up from € 691 in 2000), € 428 on inpatient long-term care (up from € 211 in 2000) and € 122 on preventive and rehabilitative institutions (up from € 92 in 2000).
“Germany spent considerably less on ambulatory care than other EU countries. For instance, France (27.2%), Austria (29%), the Netherlands (29.2%), Switzerland (33.4%) and Denmark (34.9%) spent a higher share of health expenditure on ambulatory care, and the EU average is 31.4% (OECD, 2020b). In 2018, € 662 was spent per inhabitant for ambulatory care practices (up from € 383 in 2000), € 330 for dental care practices (up from € 227), € 257 for ambulatory long-term care (up from € 83) and € 206 on other allied health professionals (up from € 73).
“Pharmaceuticals and medical devices accounted for another 13.7% of current health expenditures in 2018 (the fourth highest), according to the Federal Statistical Office. OECD data give a higher estimation for this category, with pharmaceuticals and medical devices representing the third highest budget item (19.3%). Under this data source, comparative countries like France (18.4%), Austria (168%), Switzerland (14.8%) and the Netherlands (11.5%) spent less on pharmaceuticals than Germany, while Denmark (10%) recorded almost half of the German costs (OECD, 2020b).”
Source: Blümel M, Spranger A, Achstetter K, Maresso A, Busse R. Germany: Health system review. Health Systems in Transition, 2020; 22(6): pp.i–273.
“A large part of health care expenditure in Germany is derived from the SHI [Statutory Health Insurance] system (see Table 3.2). Contributions to the 105 sickness funds constitute the major system of financing health care. The sickness funds are responsible for collecting contributions, which they transfer to a central reallocation pool known as the Gesundheitsfonds, which is responsible for pooling and reallocating the revenues according to a risk-adjustment mechanism (see Section 3.3.3 Pooling and allocation of funds).
“General tax revenue is also used for various purposes in the health care system. All tax-based budgets, at federal as well as state level, are determined by legislatures acting on proposals from their governments. In addition, the Hospital Financing Act stipulates that investment costs should be paid from state taxes as well as by owners of public, private not-for-profit and private for-profit hospitals, if listed in the state’s hospital requirement plan. Therefore, states receive tax money for investments in their hospitals (see Section 3.7.1 Paying for health services).
“Taxes as a source of health care financing have decreased throughout the last decade, falling from 10.8% of total health expenditure in 1996 to 4.2% in 2018. The most substantial decrease has been observed in spending on long-term care (about 50%), reflecting the unburdening of municipal budgets after the introduction of statutory long-term care insurance (see Section 5.8 Long-term care). Nevertheless, other spending on investments has decreased as well. Altogether, general government and statutory public sources accounted for 73.5% of current expenditure on health. Private sources accounted for a total 26.5% of total current expenditure: this includes direct out-of-pocket payments made by private households (13.6%). Private insurers financed 8.7%, which includes expenditures for substitutive/comprehensive health insurance, complementary health insurance and long-term care insurance.
“It should be noted that the largest tax-financed item – the subsidies for SHI – is not declared as such in the fiscal statistics. Sickness funds receive a fixed amount from the federal budget for several benefits relevant to family policies: maternity benefits, sick-pay for parents caring for sick children, in-vitro fertilization, sterilization for contraceptive purposes, and prescription-only contraception up to the age of 21 and legal abortions. The federal government transfers its subsidy to the central reallocation pool (see Section 3.3.3 Pooling and allocation of funds). In 2012 the federal subsidy was € 14 billion. In order to consolidate the federal budget, the subsidy was temporarily reduced to € 10.5 billion in 2013 and € 11.5 billion in 2015. In 2016 it was again at € 14 billion and from 2017 it has been set at € 14.5 billion annually (Bundesministerium für Gesundheit (BMG), 2020j). Although these funds come from general taxation, these sums are coded as “statutory health insurance” in health expenditure statistics.* Figure 3.4 shows the main financial flows between the population, purchasers and health care providers in the German health care system in 2018 – including public health services and long-term care (except the purchasers and providers mentioned in the footnote).”
Source: Blümel M, Spranger A, Achstetter K, Maresso A, Busse R. Germany: Health system review. Health Systems in Transition, 2020; 22(6): pp.i–273.
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Page last updated Jan. 25, 2023 by Doug McVay, Editor.
