Germany: Social Determinants and Health Equity

Share of Urban Population (%), 2023: 78%
Annual Growth Rate of Urban Population (%), 2020-2030: 0.1%
Net Migration Rate (per 1,000 population), 2023: 7.2
Adolescent Birth Rate (Births Per 1,000 Adolescent Girls and Young Women), 2017-2023:
– Aged 10-14: 0
– Aged 15-19: 6
Share of Household Income, 2015-2023:
– Bottom 40%: 21%
– Top 20%: 40%
– Bottom 20%: 8%
Gini Coefficient, 2015-2023: 32
Palma Index of Income Inequality, 2015-2023: 1.2
Gross Domestic Product (GDP) Per Capita (Current US$), 2015-2023: $52,746

Notes: Adolescent birth rate – Number of births per 1,000 adolescent girls and young women aged 10–14 and 15–19.
Share of household income – Percentage of income received by the 20 per cent of households with the highest income, by the 40 per cent of households with the lowest income and by the 20 per cent of households with the lowest income.
Gini Coefficient – Gini index measures the extent to which the distribution of income (or, in some cases, consumption expenditure) among individuals or households within an economy deviates from a perfectly equal distribution. A Lorenz curve plots the cumulative percentages of total income received against the cumulative number of recipients, starting with the poorest individual or household. The Gini index measures the area between the Lorenz curve and a hypothetical line of absolute equality, expressed as a percentage of the maximum area under the line. Thus a Gini index of 0 represents perfect equality, while an index of 100 implies perfect inequality.
Palma Index of income inequality – Palma index is defined as the ratio of the richest 10% of the population’s share of gross national income divided by the poorest 40%’s share.
GDP per capita (current US$) – GDP per capita is gross domestic product divided by midyear population. GDP is the sum of gross value added by all resident producers in the economy plus any product taxes and minus any subsidies not included in the value of the products. It is calculated without making deductions for depreciation of fabricated assets or for depletion and degradation of natural resources. Data are in current US dollars.

Source: United Nations Children’s Fund, The State of the World’s Children 2024: The Future of Childhood in a Changing World – Statistical Compendium. UNICEF, Nov. 20, 2024.

“Analyses of time trends in health inequalities often refer to self-rated health, an indicator reflecting the subjective dimension of health and well-being. Longitudinal studies have shown self-rated health to be an independent predictor of the uptake of health services and further life expectancy [23, 24]. According to data taken from the SOEP [the German Socio-Economic Panel], between 1994 and 2014 a widening of income inequalities was observed for self-rated health. The proportion of women and men with middle and high incomes who rated their overall health as ‘fair’ or ‘bad’ decreased slightly during this period; however, it increased among women and men with low incomes. A comparison of the figures from the first and last observation period demonstrates that absolute income inequalities in self-rated health widened by 2.4 percentage points among women and by 3.2 percentage points among men (Figure 1).

“Another recent study that focused on the same observation period, but differentiated between population groups with different levels of education among 30- to 49-year-olds, reached a somewhat different conclusion [25]. The study identified pronounced educational inequalities in self-rated general health over the entire observation period. Over time, the extent of these differences varied among both men and women. All in all, however, the results suggest that the inequalities in self-rated general health observed with regard to educational level remained largely consistent over time. This is also in line with the results of the MONICA/KORA study, which focused on 25- to 64-year-olds in the Augsburg region in Germany. In terms of self-rated general health, this study identified marked differences across levels of education and income, which hardly changed from the beginning of the observation period (1984/1985) and over the following 15 years. However, whereas slight increases in both absolute and relative inequalities were observed, they did not reach statistical significance [26].”

Source: Lampert T, Kroll LE, Kuntz B, Hoebel J (2018). Health inequalities in Germany and in international comparison: trends and developments over time. Journal of Health Monitoring 3(S1): 1-24. DOI 10.17886/RKI-GBE-2018-036.

“Every year, a large number of studies demonstrate that substantial social inequalities continue to exist in health and life expectancy in Germany and other countries. Since the data available at the national level has been steadily improving, it is now possible to study time trends in health inequalities in Germany. The studies undertaken so far either suggest that social inequalities in health and life expectancy in Germany have remained relatively constant over the last 20 to 30 years, or that they have increased.

“It is important to note that the results vary according to the respective socioeconomic indicator and health outcome used in each study, and according to the age group examined. Moreover, inconsistent results have sometimes been obtained from the same data. Most of the studies on trends in health inequalities in Germany examined self-rated general health, with a particular focus on SOEP data. The results suggest that although general health has improved over time, this has only been the case among the socially advantaged groups; moreover, strongly pronounced health inequalities tend to have increased further. The majority of these studies compare educational level and income groups. However, one study that compared unemployed people to parttime and full-time employees came to the same conclusions regarding these developments. However, the studies that focused on material deprivation do not quite fit this picture. An increase in inequalities in self-rated general health was reported between 2001 and 2005; however, it was followed by a decrease in the following years.”

“Very few analyses are currently available for Germany when it comes to time trends in social inequalities in chronic diseases. The only available studies focus on diabetes mellitus and cardiovascular diseases. The results indicate that social inequalities remained relatively stable over time. Only one study reported an increase in social inequalities in cardiovascular diseases among men, which was attributed to the observed decline in cardiovascular diseases among men with a high socioeconomic status. In addition, the available studies on chronic pain and physical impairment related to health-related quality of life indicate that pronounced social inequalities continue to exist and have hardly changed over time.

“Health inequalities have also widened in terms of health behaviours and behavioural risk factors. This is particularly clear in relation to sporting activity, as the proportion of women and men who do not engage in any form of sport has clearly declined in the middle and high educational groups, and has remained largely unchanged among the lower educational group. With regard to men’s use of tobacco, positive developments such as the decline in smoking rates observed since the early 2000s have only been found among socially advantaged groups.

“Finally, the few available studies addressing developments in social inequalities in mortality and life expectancy in Germany suggest that health inequalities have widened rather than decreased. This is the case on both the individual and regional level. By the late 1990s, people living in districts that can be considered as socioeconomically advantaged in terms of the labour market, education and income had higher life expectancies at birth than those living in socioeconomically deprived districts. In recent times, these inequalities have increased further.”

“Apart from the Ministry of Health, several federal ministries work on different population health issues. The Ministry of Food and Agriculture initiated a network that brings together programmes to promote healthy nutrition and physical activity among different sectors of the population, for example children, pregnant women and elderly people. Environment-related health is one of the responsibilities of the Ministry for Environment, Nature Conservation, Building, and Nuclear Safety. Several initiatives aim at recognizing adverse environmental effects and to reduce or prevent their formation if possible. With the option of choosing between different sickness funds and tariffs as well as between various service providers, the competition for patients has increased. Therefore, consumer protection has become a health-related topic. Until 2013, health-related consumer protection was linked to the Federal Ministry of Food and Agriculture and is today a department of the Ministry of Justice and Consumer Protection. The Federal Ministry of Labour and Social Affairs (Bundesministerium für Arbeit und Soziales) is responsible for the participation of disabled people and rehabilitation as well as work-related mental health. Although population health issues arise in a number of federal ministries, interactions and collaborations between these sectors and the Ministry of Health are rather small.

“Collaborations between different stakeholders tend to take place at state and corporatist levels and are often associated with public health services (see section 5.1). Some Länder public health services have initiated local committees known as “health conferences”, bringing together a broad variety of providers, payers and self-help groups in order to agree on health targets and to improve coordination of prevention measures. In North Rhine-Westphalia, health conferences have even been established through legislation. Several public health offices have also introduced such conferences at the municipal level. Another forum for improving cooperation among public health services, SHI-accredited physicians, policy-makers and many other stakeholders has been established at the federal level. The German Forum for Prevention and Health Promotion (Deutsches Forum Prävention und Gesundheitsförderung) was founded in July 2002 following stakeholder initiatives at the federal level since 2000 to define health targets and debate ways to strengthen prevention in round-table discussions. The target of the forum’s 71 institutional members (2012) is to actively strengthen prevention and health promotion, to promote the development of broad preventive programmes and information and to establish sustainable organizational structures capable of fund raising. Priority areas of activity are health promotion in preschools, schools and workplaces, prevention in old age and a comprehensive programme to prevent cardiovascular diseases.”

Source: Busse R, Blümel M. Germany: health system review. Health Systems in Transition, 2014, 16(2):1–296.

Germany: Social Determinants and Health Equity - Healthcare - Access, socioeconomic status, income - National Policies - World Health Systems Facts

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Page last updated November 5, 2025 by Doug McVay, Editor.