Intended for healthcare professionals

Analysis Looking to Europe

German health care: a bit of Bismarck plus more science

BMJ 2008; 337 doi: (Published 07 November 2008) Cite this as: BMJ 2008;337:a1997
  1. Peter T Sawicki, institute director,
  2. Hilda Bastian, head of health information department
  1. 1German Institute for Quality and Efficiency in Health Care, Dillenburger Strasse 27, Cologne 51105, Germany
  1. Correspondence to: H Bastian hilda.bastian{at}
  • Accepted 26 August 2008

Germany’s health system provides good access to care for all patients. But, as Peter Sawicki and Hilda Bastian explain, it is increasingly turning to science to determine what is good value

Germany was the first country to develop a national system to insure people against medical costs. It was in 1883 that one of the most conservative of politicians, Otto von Bismarck, laid down the first foundation slab for the modern European welfare state. Scientific and medical research was a pillar of Germany’s economic and industrial development strategy from that time as well. These policies and structures helped develop an advanced, highly medicalised, and technological healthcare system. In recent decades, a combination of wealth and strong social welfare infrastructure has insulated Germany from having to ask too many hard questions about the value of one of the world’s most expensive healthcare systems. This article looks at the challenges of maintaining the legacy of access to health care for all, a growing commitment to patient empowerment, and the changing role of evidence in western Europe’s most populous country.

Universal access to all necessary health care

The roots of Germany’s commitment to universal access to health care are deep. It was clear to Bismarck and his contemporaries that the only way to protect individuals from catastrophic health problems was if the whole community shouldered the risk. They could not have foreseen, though, just how expensive health care was going to become 125 years later. Back then, medical insurance was politically the easiest of the social security planks to achieve.1

Fast forward to 2008, and the costs of statutory health insurance are now split roughly 50:50 between employers and employees, with the government paying for coverage of welfare recipients. Statutory insurance covers over 90% of the population. The remainder are covered by private insurance. Cost control in health has …

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