In many developing and emerging countries, health systems are not yet efficient enough. Large sections of the population – especially poor people and people in rural regions – are not provided with adequate medical care. Most health services are located in cities. In rural areas, basic care is often even lacking. More than 7.5 million infants still die every year from diseases that could largely be avoided.

Improving health systems is one of the priorities of German development cooperation in the health sector. The German government has set itself the goal of improving the population’s access to health services, health-related information and healthy living conditions in its partner countries. Particular attention is paid to the provision of health services to poor and disadvantaged population groups.

Appropriate health services

A core element of human development and poverty reduction is access to appropriate health services for poor population groups. This also includes protecting them against the financial, health and social risks of disease. A country’s health system serves to promote the health of the entire population and to provide appropriate and effective treatment for diseases and injuries. It includes all persons and institutions dedicated to these tasks.

Governments of developing countries have a duty to respect, protect and ensure the right to health. They must ensure health care that meets today’s general quality standards. Germany supports its partner countries intensively in fulfilling this obligation.

A country’s health system is designed to ensure that the population is protected from disease and well cared for in the event of illness. This objective applies especially to the poor. In most developing countries and many emerging markets, however, the majority of people do not have sufficient access to adequate health care.

On the one hand, health services are often concentrated in cities, while in rural areas even basic care is often lacking, while on the other hand the quality of treatment is usually completely inadequate. This is mainly due to a lack of competent personnel, poor infrastructure, missing or non-functioning equipment, inadequate supply of medicines and poorly organised processes.

Public health budgets are usually tight and often only reach the health facilities with a delay.

Centrally organised systems and weak management capacities often prevent health care from being geared to the needs of the population. Ensuring the health of people in developing countries is the task of local health, economic and social policy. Germany supports its partner countries in this endeavour and works with them to develop concepts for strengthening their health systems.

Principles of the German health system, such as solidarity and self-government, therefore play an important role in advising partner countries. Cooperation in the development of health systems focuses on the following topics:

  • Supporting partner countries in the development of health policy strategies that fit the economic and social conditions of the country.
  • Support for the development of personnel development and development plans, the adaptation of framework conditions and the promotion of education and training.
  • Strengthening the management skills of employees to improve the quality of the health care system.
  • Involving the population in health and social policy decisions.
  • Support in ensuring access to and provision of adequate, high-quality services.
  • Development of social security systems (e.g. social health insurance).


To understand why it is so complex to reform the German healthcare system, it helps to look at its history. Many things have grown historically, some of them dating back over 100 years. Since that time, structures have grown and habitual demands in the population have become entrenched. Nevertheless, demographic change makes reform unavoidable in order to cope with rising costs.


The German health care system is one of the oldest in the world: in the Middle Ages there was already health insurance through the joint funds of the guilds, then insurance through factory workers’ unions and in 1883 the first health insurance was finally introduced under Bismarck1. All insured persons were legally entitled to free medical treatment and medication as well as sickness and death benefits. At that time, however, only 10 percent of the population had health insurance; today the figure is about 97 percent2. A short time later, unemployment, pension, accident and, last but not least, long-term care insurance followed. Hardly any other country can look back on such a long tradition of social insurance.


The German health care system is decentralized, self-governing, with many different actors. The main actors include the associations and interest groups of the various occupational groups, health insurance companies, quality assurance institutions, the Ministry of Health and patient organisations. In each federal state, for example, there is a state chamber of physicians which is responsible for all professional concerns of physicians, e.g. their admission and further training.

The health care system in Germany is based on four basic principles:

Compulsory insurance

All citizens are basically obliged to insure themselves in a statutory health insurance fund (GKV). Those who earn more than a basic amount can insure themselves in a private health insurance (PKV). This is what 11 percent of citizens3 currently do.

Contribution financing

Health care is mainly financed by contributions from all insured persons and employers. Subsidies from tax revenues are added. By way of comparison, public health systems such as those in Great Britain and Sweden operate with tax revenues. In market-oriented systems such as the USA, citizens must pay for treatment costs and loss of earnings themselves or insure themselves privately.

Principle of solidarity

All legally insured persons in Germany share the risk of loss of earnings and the costs of medical care in the event of illness. Every legally insured person has the same entitlement to benefits. In this way, all citizens are mutually responsible for each other.

Principle of self-administration

The state decides on the essential framework conditions for medical care. However, the concrete design, organisation and financing of the individual medical services is the task of the institutions of self-administration in health care. It is carried out jointly and autonomously by the representatives of doctors and dentists, psychotherapists, hospitals, health insurance funds and insured persons. The supreme body of self-administration at federal level within the framework of statutory health insurance is the Joint Federal Committee,

Establishing an efficient system requires time, flexibility and professional advice. Success depends heavily on a country’s political culture, the rule of law and respect for human rights.

Within the framework of its development cooperation, Germany always pursues the goal of motivating partner countries to pursue fair, responsible policies geared to social peace.

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