Health in Germany: high spending, poor results – a new analysis reveals the problem

Germany is one of the world's strongest economies. The social system is well developed, and per capita health expenditure is the third highest within the Organization for Economic Cooperation and Development (OECD). Nevertheless, the country's health indicators lag behind those of comparable European countries. People are sicker and die earlier. How can that be?

A health policy review published on Monday in the renowned medical journal Lancet Public Health, under the direction of Prof. Dr. Hajo Zeeb of the Leibniz Institute for Prevention Research and Epidemiology - BIPS, comes to a sobering conclusion: Germany has a structural problem in public health care. Instead of preventing disease, the system focuses too much on treating it - and with some inefficient structures.

“A system that manages diseases instead of preventing them”

The scientists see three main problems:

• Lack of central control – Germany has no strong institution to coordinate public health measures. Instead, there is a patchwork of responsibilities between the federal, state and local governments, which leads to poor coordination and inefficient allocation of resources.
• Too little prevention, too much repair medicine – Health insurance companies invest billions in highly specialized treatments, while the financing of prevention and health promotion continues to be neglected.
• Lobbies prevent effective measures – sugar tax? Advertising bans on unhealthy foods? Regulations for tobacco and alcohol? In Germany, these measures have either been weakened or never implemented – often under the influence of economic interests.

“The result is a health system that is extremely expensive but does too little for the long-term health of the population,” says first author Zeeb.

Disadvantages of federal structures

In addition to some advantages, such as the leeway for setting one's own priorities, federal structures in public health care also have disadvantages. Too often, health data is collected in an uncoordinated manner and cannot be linked sufficiently – a problem that became particularly apparent during the Covid 19 pandemic.

“While other countries have developed clear strategies for public health, Germany lacks one,” explains co-author Prof. Dr. Ansgar Gerhardus from the University of Bremen.

Proposed solutions: More courage for public health

The authors of the paper propose four key reforms:

• Develop a strong identity for public health – Germany needs a coherent vision for health policy that prioritizes prevention and health promotion.
• Develop a national public health strategy – Health promotion must no longer remain a patchwork, but must be thought of systematically and across sectors.
• Understand health promotion as a task for society as a whole – In addition to the health care system, education, labor and environmental policy must also be geared more towards preventive action.
• Regulate commercial interests – Politicians must have the courage to push back against harmful commercial interests, whether in nutrition, alcohol or tobacco.

“Germany must rethink”

The scientists emphasize that the status quo is not only a problem for the health of the population, but also for the economic future of the country. The costs for the health care system have been rising for years, while the health insurance companies have to repeatedly announce increases in contributions.

“Germany cannot afford its current system in the long term – neither in terms of health policy nor economically,” says Zeeb. ”We need a reorientation towards more prevention if we want to escape the cost spiral.”

The analysis makes it clear: Germany has the means to build a healthier and more efficient system – but so far there is a lack of political will to tackle the necessary reforms.

Original publication

Zeeb H, Loss J, Starke D, Altgeld T, Moebus S, Geffert K, Gerhardus A. Public health in Germany: Structures, dynamics, and ways forward. The Lancet Public Health. 2025. https://doi.org/10.1016/S2468-2667(25)00033-7

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