Germany

Klaus D. Plümer

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Rechel B, Maresso A, Sagan A, et al., editors. Organization and financing of public health services in Europe: Country reports [Internet]. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2018. (Health Policy Series, No. 49.)

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Organization and financing of public health services in Europe: Country reports [Internet].

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4Germany

Klaus D. Plümer.

Introduction

In Germany, the “public health service” (Öffentlicher Gesundheitsdienst, ÖGD) is comprised of state and local health departments, certain institutions of veterinary and food inspection, and health authorities at the national, state and municipality levels, including their subordinate bodies. At the heart of the public health service is the local health authority (Gesundheitsamt) or public health department (Fachbereich or Fachdienst Gesundheit) of the municipality of cities and rural district administrations.

Public health services are provided by approximately 400 public health offices across Germany, which vary widely in size, structure and tasks. Germany’s federal structure ensures that some key policy areas, such as health, education and cultural affairs, fall within the responsibility of the federal states (Länder). They outline the general conditions, legal parameters, responsibilities and, to a certain extent, how to set up and run the local public health authorities or departments in cities and rural districts. In the first decades of the Federal Republic’s history, the Länder defended their responsibility for public health services against several attempts by the federal government to extend its influence in this sector. However, at the same time, a growing number of individual preventive services, such as immunizations and health education and counselling, were transferred from the public health service to physicians in private practice (Busse & Blümel, 2014).

In a definition provided by the postgraduate professional training order of the Federal Chamber of Physicians in 2003, public health comprises: “the tasks of monitoring, assessment of and adherence to the health concerns of the population, advising the provider of public duties in health issues, including planning and organisational tasks, health promotion and primary health care, public hygiene, health supervision and the prevention and control of diseases” (Akademie & LGL, 2009).

Historical background

The public health service in Germany has its roots in the darkest era of the country, the Nazi period. After a social hygiene period during the Weimar era (1918–1933), in which the concern of public health was with improving the health of the population through education, the National Socialists created the statutory basis for the public health service in 1934 with the implementation of the “Law on the Unification of Health Services” (Gesetz zur Vereinheitlichung des Gesundheitswesens vom 3. Juli 1934), shifting the emphasis to “racial hygiene” and eugenics. This act, with its three implementing regulations, served as an organizational framework for the structure and areas of responsibility of the public health service until the end of the 20th century; only the racist term “genetic and racial hygiene” was removed. The public health service in Germany was thus originally created as a selection apparatus and enforcement instrument in the context of inhumane biopolitics.

Since the early 1970s a number of attempts have been made to reorganize public health services. For example, in 1972 “Guidelines for federal state law on public health”, developed by the Federal Conference of Health Ministers, were adopted. However, it was not until after German reunification in the 1990s that most federal states began to outline new statutory principles for their public health services with new and upgraded health service acts (Gesundheitsdienstgesetze). In the new eastern states of Germany these were based on the 1990 de Maizière ordinance. Some 20 years earlier Schleswig-Holstein became the first federal state to introduce a New Health Services Act in 1979, which was subsequently updated in 2002; Hesse was the final state to adopt new legislation in 2007. These specific reforms were driven by two administrative reform processes: first, the introduction of new public management (NPM) approaches and, second, further communalization in federal states such as Bavaria and Baden-Wuerttemberg that still had a state-based local public health service.

The 1990s saw constant change within the public health service. In some municipalities this period saw a series of organizational experiments, with local public health offices implementing cost-accounting and contract management as new methods to determine their effectiveness and efficiency and to identify potential areas for restructuring to improve performance. These reforms were part of a wider process of administrative reform in Germany (Grunow & Grunow-Lutter, 2000).

Reforms in the 1990s were dominated by the establishment of health reporting systems, integrating and establishing tools for health assessments of environmental factors, and applying the health promotion approach outlined in the 1986 Ottawa Charter. The main focus was on strengthening the orientation of public health services towards population health against the prevailing patient-oriented individual medical perspective within the health system. As part of the reforms, mission statements were discussed and developed. Furthermore, leadership and management training for different managerial levels was offered to support the process of reorientation within public health services. For example, the Düsseldorf Academy of Public Health ran a specific training programme containing six core modules for the public health workforce on “Leadership in Public Health – New Public Health Management” (Plümer, 2007).

A key driver of reforms was the emergence of the HIV/AIDS pandemic in the 1980s. New measures to combat the spread of the virus were needed, and in 1987 the federal government launched the Immediate Action Programme to Combat HIV/AIDS. This HIV/AIDS prevention programme provided public health services nationwide with around 700 HIV/AIDS professionals, bringing new expertise and knowledge to public health offices and contributing to new structures. New departments on health promotion were established, as well as other new structures within local health authorities, such as specialist teams (Plümer, 2015).

The 1990s were thus a decade of important changes for the public health service. Achievements contributed to the realignment of public health policy at the local level, covering health reporting systems and health promotion. In addition, the implementation of regional and local health conferences and the phasing-in of cost-accounting, including cost-benefit calculation, enabled the measurement of service performance, efficiency and effectiveness. Although the reforms and the implementation of the new public management approach created many challenges for the public health workforce, it also, for the first time, provided data for internal quality assurance, cost awareness and resource utilization. This enabled the use of data for decisions and evaluations and “evidence” became a key term on the public health service agenda.

Organizational structures

The public health service (ÖGD) is part of the public health system. It includes all public sector institutions that are directly responsible for protecting and monitoring the health of the population, including at the federal, state, county and municipal level. The public health service is also responsible for identifying and tackling public health threats, as well as for promoting the health of the overall population, including specific target groups.

Current vision for public health

The current vision for public health in Germany is best described by a public health service that acts as coordinator, moderator and advocate for health. It has the function of a steering committee, with its instrument of health conferences at the local level, supported and guided by a state health conference. This model has, for example, been established in the latest state health services act of Baden-Wuerttemberg in July 2015; municipal health conferences are mandatory and a new standard for 44 local public health service units in urban and rural districts for that federal state (Baden-Wuerttemberg, 2015).

This approach to public health was first created and implemented by the Federal State of North-Rhine Westphalia in the 1990s. It was initiated as a pilot programme called “local coordination” (Orstnahe Koordinierung) and fixed as a duty of local public health services in the new health service act from 1998. Of 54 local health offices, 28 joined the implementation of the programme that was accompanied and evaluated by the Institute of Medical Sociology, Heinrich-Heine University of Dusseldorf, the Faculty of Health Sciences, University of Bielefeld, and the state institute of public health service in North-Rhine Westphalia – lögd (von dem Knesebeck et al., 2001).

Main actors in the public health service

The public health service in Germany is often equated with local health authorities or public health offices or departments. This applies in particular to the operational level of communities and the interface for clients with public health services. However, there are also federal authorities and, in five federal states (Baden-Wuerttemberg, Bavaria, Hesse, North-Rhine-Westphalia and Saxony), state-level authorities, where local public health offices or departments are by definition lower health authorities (Figure 4-1). This might suggest the existence of a top-down hierarchy, but in fact territorial entities (Gebietskörperschaften) represent local self-government and have the right to design administrative tasks autonomously, based on municipal codes decreed by state law. The main impact of the 2006 Federalism Reform was the transfer of responsibilities from the national level via the state level (through concurrent legislation) to the local level (BMG, 2006).

Figure 4-1

Organization of the public health service in Germany. Source: Nagel, 2007

National level

The Federal Ministry of Health is responsible for the control and prevention of infectious diseases, preventive health care, the prevention of addiction to narcotics and other substances, and policies on prevention, rehabilitation and disability. It is also responsible for European and international health policy.

The portfolio of the Federal Ministry of Health contains the following government institutions: the Federal Institute for Drugs and Medical Devices; the Federal Centre for Health Education (Bundeszentrale für gesundheitliche Aufklärung); the German Institute of Medical Documentation and Information; the Paul-Ehrlich-Institute (the Federal Institute for Vaccines and Biomedicines); and the Robert Koch Institute (the Federal Institute for Communicable and Non-Communicable Diseases). The Federal Institute for Drugs and Medical Devices and the Robert Koch Institute were previously (in 1952–1994) part of the Federal Health Office, alongside the Federal Institute for Consumer Health Protection and Veterinary Medicine, which was transferred to the Federal Institute for Risk Assessment in 2002. The Federal Office of Consumer Protection and Food Safety was also part of the Federal Health Office, but is now an authority within the portfolio of the Federal Ministry of Food and Agriculture.

An Advisory Council for the Assessment of Developments in the Health Care System (previously called the Advisory Council for “Concerted Action in Health Care”) provides expertise on the role of public health in strengthening health promotion and disease prevention to reduce the burden of disease and health care expenditure. It argues for treating public health services as a key player and the “third pillar” of the health system, as which it was traditionally described.

High authorities

The Conference of Health Ministers of the Federal States (Gesundheitsministerkonferenz) is the highest-ranking authority in the health sector after the Federal Ministry of Health. It is an important body providing technical and policy advice and coordination of health policy issues and tasks between the country’s federal states, including in the area of health promotion and disease prevention. The Presidency of the conference rotates annually between the federal states.

The annual conference is prepared by the Deputy Ministers Conference, composed of the Secretaries of State for Health and Councils of State for Health of the federal states. Resolutions arising from this conference address priority issues in the health sector, although they are not binding.

The Conference of Health Ministers of the Federal States also hosts bi-annual meetings of the Working Group of the Supreme Health Authorities. Attendees include the directors of health departments of the federal states, the Federal Ministry of Health, and other public health institutions, such as the Robert Koch Institute or the Federal Institute for Drugs and Medical Devices. The Working Group of the Supreme Health Authorities assists the Deputy Ministers Conference and is supported by a number of working groups, including one on infection control and one on the hospital system.

Regional level

The network for the social economy (www.socialnet.de) identifies 15 regional authorities of relevance to public health issues. However, only six of them are public health state offices in the narrow sense of the German public health service: the Bavarian State Office for Health and Food Safety; the State Health Office Brandenburg; the State Health Office Baden-Wuerttemberg in Stuttgart Regional Council; the Lower Saxony State Health Department; the National Centre for Health North Rhine-Westphalia (the former State Institute for the Public Health Service in NRW – lögd); and the State Office for Health and Social Affairs Mecklenburg Western Pomerania.

Local level

In many federal states the public health service is devolved to the municipal level, a diversity characterized by state law. In Baden-Wuerttemberg and Bavaria there are still state health departments, which are also organizationally integrated into the administrative units of district offices (Landratsämter).

In the city states of Hamburg and Berlin a different organizational structure is in operation, with the district health authorities having a specific legal relationship with the state level. In addition, the city state health authority has a stronger position than in area states. In Bavaria, Baden-Wuerttemberg, Hesse, North Rhine-Westphalia and Saxony the tasks of the public health service are also fulfilled at the administrative level between the federal state and the municipality.

Depending on the federal states, there are also various specialized authorities (e.g. forensic services or police medical services) and state agencies (e.g. state health departments, diagnostic laboratories, state examination offices) that are part of the public health service. Occasionally, public health acts also provide opportunities to outsource provision of public health services to third parties.

A positive aspect of the “municipalization” of health authorities has been the creation of better conditions for integrating public health services into the municipal health policy process. Public health services are thus, in theory, able to play a stronger role in designing “Municipal Health Landscapes”, although this opportunity is rarely exploited in practice (Luthe, 2010).

Local health authorities and public health departments share a number of responsibilities, including:

health protection;
prevention, social care and health education; and
health management, quality assurance and communication.

State-specific tasks are also included, in addition to core responsibilities:

youth dental health;
healthy consumer protection; and
trade control (at state level).

According to Article 28 of Germany’s basic law (Grundgesetz), the organization of local living conditions, including the securing of healthy living conditions, falls within the jurisdiction of the municipality. This means that the development of local health policies is one of the tasks of the municipality. Local health authorities or public health departments are therefore not just a special medical service of the municipality, but also have a political responsibility for the health of the population in the community. Indeed, in 1991, the Conference of Health Ministers of the Federal States declared that “the public health service in health promotion, preventive health care and early detection of disease is an important coordinating and management function of community-based measures” (Franzkowiak & Sabo, 1993).

The municipalities are the only actors within the local health sector that have an explicit public welfare obligation and are therefore required to focus on the health of the population. According to state law, the municipalities are responsible for running local health authorities or public health departments, because the federal government has no jurisdiction to assign the tasks directly to municipalities. In fact, the most relevant policy framework for the German public health service is at the urban and rural district level, since local health departments are an organizational part of municipalities. The districts are also responsible for implementing federal and state government tasks that are rooted in European law (e.g. drinking water regulations) in local public health services.

In general, local public health departments do not have an explicit mandate to undertake research. Nevertheless, they can participate in research using their own resources after fulfilling their mandated responsibilities. They must do so in cooperation with local universities as they lack the necessary research skills and facilities. This also applies to the Academy of Public Health in Düsseldorf, as it is not involved in applied research or public health-related research projects, with a few exceptions.

Competencies and capacity to engage in research are further limited by the increasing work-load in local public health departments and the lack of research skills. Research activities are undertaken mainly in classical clinical fields such as infectiology and epidemiology, with research primarily undertaken by federal and regional institutes.

Financing

Detailed information on the financing of the public health service is unavailable, due to its federal structure and a lack of data. The public health service is mainly financed from public budgets and, to a lesser extent, by fees levied for some public health services. The federal states and the municipalities bear the cost of health offices, while the federal government assumes the costs of the successors of the Federal Health Office and other federal public health agencies. The national state also funds research projects in the area of public health. Mixed methods of funding may be in place for public health programmes connected to projects such as “healthy cities” which receive financial support from statutory health insurance. Out-of-pocket payments for public health services are limited and made primarily to obtain health certificates for jobs or businesses.

According to the Federal Statistical Office, expenditure on prevention and public health services as a share of total health expenditure in Germany amounted to 3.27% in 2015, a share that has remained fairly stable in recent years (Table 4-1). Health protection and health promotion were the two main categories of expenditure, followed by the early detection of diseases.

Table 4-1

Share of prevention and public health services as percentage of total health expenditure, 1992–2015.

The flow of financial resources for public health services can be considered as generally stable, although it ultimately depends on political processes and the current budgetary situation in federal states and municipalities. In practice, this means that only short- to mid-term planning is possible and projects usually last two to three years.

The budget of public health services depends on their status as either a state authority or a municipal authority or department. Most of the budget is used to cover staff costs, with a small percentage allocated for material expenses. Local health authorities and public health departments receive their budget from the municipality, district or state to which they belong administratively or as an organizational unit. Annual budgets are negotiated every year with the budget committee of the municipality or the next higher administrative level. These negotiations are based on factors such as budget consolidation and specifications in budget estimates (e.g. job cuts).

The public health service deals with the financial department or city treasurer at the local level. However, local public health service budgets have become more flexible since the shift from the traditional “Cameralism” system of budget management to double-entry book-keeping and modern cost accounting. This means that, in principle, any underspend can be transferred to the next budget year and material expenses can be covered from the staff budget and vice versa. To do so, public health offices must provide product descriptions of the services provided and parameterize them in their product budget plan. This procedure is undertaken with reference to a “Target and Indicator System” for each of the main areas of action of the municipal health service. It also enables implementation of internal contract management with fee-for-services to other municipal departments (e.g. social welfare or the local job centre), as well as outsourcing of tasks to other health care providers or third-party suppliers.

Efforts to pass a national prevention act as a prerequisite for establishing a so-called Health Fund were initiated several years ago. The “Act to Strengthen Health Promotion and Prevention” eventually passed the Lower House of Parliament on 18 June 2015 and the Upper House on 10 July 2015 (BMG, 2015), after multiple unsuccessful attempts, the first in 2004/2005. It now needs to be implemented at regional and local level. Sickness and long-term care funds will invest €500 million annually in the Health Fund for use in local and regional health promotion projects. It is hoped that the public health service can benefit from the new prevention act and play an important role as local health manager, mediator and coordinator, despite the fact that the statutory health insurance funds will take a leading role in developing framework agreements on the objectives and fields of action to be pursued in cooperation with other relevant institutions and organizations (Box 4-1).

There are currently no plans to fund public health services from taxation on tobacco, alcohol or unhealthy foods. The tobacco industry has previously offered financial support for anti-smoking campaigns at schools and in other child and youth facilities, but these offers were rejected in most cases.

Box 4-1

The 2015 Act to Strengthen Health Promotion and Prevention.

Pooling and resource allocation

Pooling agreements exist in some federal states based on a memorandum of understanding, but not as an actionable contract with recoverable claims. In many instances, these pooling arrangements have been unsuccessful due to disagreements on resource allocation. For example, in the 1990s Hamburg established a so-called “Hamburg Pot” with a considerable sum for financial support of local city projects. However, a state health conference of about 130 members failed to agree on how the money should be spent. The instrument was thus not practicable due to failures in the decision-making process, and was consequently abolished.

Decisions on resource allocation were also the biggest obstacle to passing the Prevention Act in the years prior to 2015, as statutory health insurance funds and state health authorities were unable to come to an agreement on who had the final decision-making power on the allocation of funds, although both sides agreed that the focus should be on socially disadvantaged groups in deprived areas and targeted towards specific facilities such as kindergartens and schools in order to reduce health inequalities.

The public health workforce

Data on the public health service workforce are outdated, with the latest available national information from the 1998 health report for Germany covering the year 1995 (Statistisches Bundesamt, 1998). Information on the workforce is based on data collected and published by federal states, although some federal states, such as Hesse, do not publish workforce statistics.

The staffing of local health authorities or public health departments varies significantly in federal states, from below 28.5 per 100 000 population in 1995 in Schleswig-Holstein, North-Rhine-Westphalia, Rhineland-Palatinate, Saarland, Baden-Wuerttemberg and Bavaria to more than 70.8 per 100 000 population in Berlin (Statistisches Bundesamt, 1998). These differences correlate with different interpretations of the roles and responsibilities of the public health service and the different priorities of health authorities.

Wolfgang Müller has calculated the total number of public health professionals at approximately 20 810, based on the 2000 Statistical Yearbook covering 419 local health authorities and public health departments (Müller, 2005). This estimate includes 4200 physicians as the largest professional group, followed by social workers at 3700 (Table 4-2).

Table 4-2

Number of staff in 419 local health authorities and public health departments, 2000.

In 1995, Germany had 495 public health offices, declining to 379 in 2015 (Poppe, Starke & Kuhn, 2016). The Working Group of the Federal State Health Authorities initiated a nationwide workforce survey that was conducted in early 2016 (Kuhn & Trojan, 2015). A questionnaire was distributed to all 379 public health offices, and responses were received from 236 of them (a response rate of 62%). Information from 193 public health offices could be used for an analysis of the public health workforce. According to these questionnaires, 39% of the 193 offices had a workforce under 20 employees (full-time equivalent), 34% had 20–40 employees and 26% had more than 40 employees (Poppe, Starke & Kuhn, 2016), a distribution similar to that found in a 2007 survey (Stockmann, Kuhn & Zirngibl, 2008). In the 2016 survey, 20.1% of all employees (full-time equivalent) were administrators, 18.5% physicians, 18.3% social workers and 10.5% health inspectors (Poppe, Starke & Kuhn, 2016).

The public health service sees itself as a multi-professional unit in the municipality. Occupational groups working for the public health service include physicians, dentists, social workers, health engineers, health inspectors and disinfectors, nurses and sociomedical assistants, administrators and health care assistants. These public health workers have a wide range of disciplinary backgrounds covering medicine, psychology, social sciences, pedagogics, business administration, nursing and midwifery. Some have additional qualifications in public health, social medicine, therapeutic and counselling qualifications, and management. However, a breakdown of different professional categories as a percentage of the total public health workforce cannot be given due to a lack of data. Public health researchers are generally located in state health offices or health authorities at the federal and state level, rather than in local health authorities or public health departments.

Working in the public health service does not require a medical degree, with the exception of medical service units and heads of special services or departments. In fact, the majority of staff in local health authorities or public health departments are non-medically trained professionals. In contrast, physicians have greater decision-making powers than other professional groups. However, this traditional entitlement, combined with a lack of leadership skills, has led to some municipalities using non-medical professionals for staffing the position of medical officers and creating a specific medical service unit. These local health authorities or public health departments are headed by a managing director.

Due to the lack of data it is not possible to provide a demographic profile of the public health workforce in terms of age, gender or ethnicity. However, there has been an increase in the average age of medical specialists in public health, with the ratio of specialists under 50 years of age to those older than 50 years increasing from 1:1.3 in 2000 to 1:4.3 in 2011. According to Ute Teichert, there were only eleven specialists in public health nationwide in 2011 who were younger than 40 years (Teichert, 2014a, 2014b; Rommelfanger, 2014).

Working conditions

Working for the public health service has a number of benefits, including having a permanent job for life, fixed nine-to-five working hours and regular earnings. Many physicians who enter the public health service do so in pursuit of a better work-life balance than can be achieved in a hospital. However, the implementation of the new Tariff for the Civil Service in 2006 led to a downgraded remuneration structure and much lower salaries for public health physicians compared to other specialists. Indeed, the starting salary for public health physicians is now at least one salary level and up to €1000 less per month than that of a physician in a municipal hospital. This has resulted in a recruitment problem and the number of medical specialists in public health offices decreased by 35.7% between 1995 and 2013, from 3780 to 2432 staff (Teichert, 2014a).

In principle, the new Tariff for the Civil Service offers incentives to work in the public sector, but these have to be accepted and implemented based on a collective agreement in a local health office. This creates challenges in the public service, due to the prevailing attitude of treating all staff equally that prevents implementation of a tiered incentive system for different roles. Incentives can thus have a counterproductive effect and do not necessarily improve the working environment.

The public health service does not offer career progression for skilled professionals. As in the wider public service, absenteeism due to illness is much higher than in the private sector, potentially indicating low levels of satisfaction among the workforce in public health offices.

Human resources policies

The annual congress of the German Medical Assembly in 2014 was the first that included an agenda item on the public health service. In its concluding resolution, it asked for appropriate staffing of public health offices and adequate reimbursement of public health physicians (German Medical Association, 2014; Teichert 2014b).

The city state of Berlin has created a so-called model health office based on the updated State Health Service Act of 2008, meant as a portfolio profile for all of Berlin and its city districts. Yet this was not a clear strategy for public health and no efforts have been made to act on its recommendations since publication of the final reports in 2010.

Human resource management

Efforts to introduce human resource management have primarily been undertaken at the level of municipalities, as they are self-governing bodies with autonomy and sovereignty over staffing, organization, planning, financing, local taxation and certain legal affairs. These are new public management issues, which are primarily administrated with support from consultancy agencies (Osnabrück, 2004).

A leadership development programme and several specific management training workshops were offered by the Academy of Public Health in Düsseldorf between 1991 and 2011. The leadership development programme has now been introduced as a specific module of the training course for specialists in public health (Plümer, 2007). Since 2014, the Academy also offers individual coaching for course participants on a voluntary basis. Out of a group of 22 participants in the upgrade training course for specialists in 2014, 14 participants signed up for individual coaching.

Training

Public health as an academic discipline evolved in Germany in the late 1980s and early 1990s. In some federal states, such as North Rhine-Westphalia, it developed alongside broader public health service reforms under the label “ÖGD 2000”. The emergence of academic public health was also stimulated by the WHO strategy “Health for All by the Year 2000” and the joint WHO/ASPHER project to create a common curricular for a European Master of Public Health. The Düsseldorf Academy of Public Health was involved in this project, not as an academic institution but as a governmental institution providing professional training for the public health service workforce.

In this context, the definition of public health was discussed, as the Federal Association of Physicians of the Public Health Service was looking for an appropriate translation of the term “public health” into German. However, although some proposals were made, none was adopted. The universities had little interest in a German translation, instead wanting to keep the English term to maintain a distance from the problematic historical roots of the German public health service in the Nazi period (Maschewsky-Schneider, 2005).

In the 1990s the Federal Chamber of Physicians wanted to replace the Specialist in Public Health training at the Academy of Public Health with the new postgraduate Master of Public Health programme. However, they could not succeed at that time because the Academy of Public Health was the only state-run specialist training school for physicians up to 2005 and had the monopoly on the training of public health officers. This special legal status remained in place until the amendment of the (model) training order by the German Medical Assembly in 2003. This amendment transferred the subject “ÖGW” (Öffentliches Gesundheitswesen; the publicly funded health system) in the health care profession acts of federal states to the federal chambers of physicians; the subject (including public health) became a responsibility of the federal chambers of physicians in the majority of federal states in 2006.

To become a specialist in public health at the Academy for Public Health in Düsseldorf, physicians from local public health services and regional health authorities must complete a 720-hour training course (equivalent to two terms) and pass a specialist examination at the Medical Association. Furthermore, they have to obtain three years of clinical practice and two years of practice in the public health system and the public health service. Specialist training for public health has a total duration of five years (Akademie & LGL, 2009). In Bavaria the training of medical officers has been integrated into a postgraduate course with the degree of “Master of Public Health Administration and Management” at the University of Munich.

Quality assurance and performance measurement

Quality assurance and performance measurement for the public health service became a key focus of reforms in the 1990s. The core element of the administration reform process was to critically review the existing public health service portfolio and to develop strategies and instruments to transform the public health service into a modern outfit focused on citizen orientation, effectiveness, efficiency, sustainability and flexibility. The main instrument to achieve this was the development of product descriptions with key indicators for the main areas of action, which were published in the 1998 report “Objectives, Performance and Management of the Municipal Health Service” of the Municipal Community Office for Public Management (KGSt, 1998). The development of this report was supported by advisory opinions from a project group, which included six directors of city health authorities or public health departments and the director of the Academy of Public Health in Düsseldorf. Representatives from the German Association of Cities and Towns and the German County Association were also involved.

In 2004, in the context of the National Cooperation Network “Equity in Health”, twelve quality criteria were developed and adopted in order to improve, monitor and evaluate the performance of health promotion projects (Kooperationsverbund, 2015). On a voluntary basis, health promoters can now submit their projects for review and assessment, with the incentive that their projects may be published as a so-called “Good Practice Project” on an Internet data base (www.gesundheitliche-chancengleichheit.de/) hosted by the Federal Centre for Health Education (Kooperationsverbund, 2015; Mielck et al., 2016). This quality assurance process is still on-going and in July 2016 the revised, updated and adjusted database contained 2798 projects, of which 119 were recognized as “good practice projects”.

The focus at the moment is still very much on participatory methods and approaches in the context of health promotion and disease prevention projects in order to achieve better outcomes and to gain evidence-based data. In the case of evaluation studies, summative and process-oriented evaluation methods are preferred (Kooperationsverbund, 2015). Based on this inductive bottom-up approach, a set of manuals have been developed and disseminated for free to all health promoters throughout Germany. In addition, training workshops have been offered on topics such as target development, programme development, monitoring and evaluation and how to apply participatory methods.

Although some progress has been made in developing quality assurance processes, many further efforts are needed. For instance, inter- and intra-organizational benchmarking are not on the agenda within local health authorities and public health departments are more interested in how to reach and address a target group than in achieving objectives. There is thus little use of monitoring, benchmarking, evaluation and target-performance comparisons at this level (Plümer, Kennedy & Trojan, 2010). Furthermore, resources are scarce and the specific skills needed for quality assurance and performance measurement are still limited because of a low level of experience and limited interest.

Accreditation and certification

The professional standards, licensing and accreditation systems available in Germany are related to specialist training at the Academy of Public Health in Düsseldorf and other institutions. The universities offer postgraduate programmes with a degree in Master of Public Health or Master in Science and some offer doctoral public health studies.

Local health authorities and public health departments can apply for certificates such as ISO 9001 or to become a “Centre of Excellence”. To achieve this recognition, they have to pass procedures such as an employee survey, a customer survey or an audit by an external agency or consultancy firm.

Universities and universities of applied sciences have an accreditation system offered by the Accreditation Council (the Foundation for the Accreditation of Study Programmes in Germany). There are several institutes that operate under the licence of the German Accreditation Council and are entitled to award its quality seal to study programmes that have successfully undergone accreditation.

Conclusion

The health status of the population in Germany has improved further in recent years, with a steady decline in preventable mortality and an increase in life expectancy. These successes are partially attributable to the public health service undertaking essential functions such as ensuring clean drinking water, monitoring hygiene in public facilities and restaurants, running immunization programmes and developing strategies to counteract risky health behaviours. However, any progress in health promotion is largely ascribed to the wider health system, as the general public in Germany lacks a clear understanding of the institutions involved in the public health service and the overall role of public health.

This lack of awareness is a symptom of the low public profile and reputation of the public health service in Germany. Although a series of reforms in the 1990s was expected to lead to a renaissance of public health, this did not materialize and the public health service as an organizational unit within the municipalities missed many opportunities to realign and reposition itself as a leader within the health system. The public health service remains characterized by a fragmented structure based on an inconsistent legal framework and without any nationally representative body.

Nevertheless, recent years have seen considerable political efforts to improve prevention and health promotion. Most notably, the Act to Strengthen Health Promotion and Prevention was passed by parliament in 2015, with the aim of strengthening prevention and health promotion, inter alia by regulating immunization policies and expanding health check-ups. These activities are being pursued within a settings approach, with health promotion targeted to children’s day-care facilities, schools, the work environment, and long-term care facilities. This initiative will be supported by an annual investment of €500 million from sickness and long-term care funds and represents an important opportunity for public health in Germany. However, the role of the public health service in the implementation of the Act remains unclear, with statutory health insurance funds remaining the key actor and decision-maker with regard to health promotion activities and resource allocation. Enhancing the role of the public health service in the implementation of the Prevention Act thus remains a key challenge for the future.

The public health service also faces difficulties due to staff shortages and insufficient data to inform workforce planning. The introduction of a health information system to capture data on the public health workforce at the national, regional and local level would represent a significant development allowing fundamental improvements in future planning. Furthermore, although physicians account approximately for only a quarter of the workforce in the public health service, they see themselves as key decision-makers and representatives of the system, which undermines the functioning of a multi-disciplinary workforce. Implementation of modern, public health-oriented training of medical officers could contribute to organizational development in the public health service.

Further efforts are also needed to develop quality assurance systems for the public health service. Although twelve quality criteria were developed in 2004, within the context of the National Cooperation Network “Equity in Health”, monitoring and evaluation of health promotion projects remain ad hoc and are conducted on a voluntary basis. Inter- and intra-organizational benchmarking are not on the agenda within local health authorities and public health departments and there is little use of target-performance comparisons. Furthermore, resources are scarce and the specific skills needed for quality assurance and performance measurement are still limited.

Strengthening the capacity of the public health service to develop strategies and programmes is essential for achieving public health goals such as reducing health inequalities and tackling an increasing range of noncommunicable diseases and risky health behaviours. One noteworthy recent initiative is the “Future Forum Public Health”, launched at a Symposium in Berlin in November 2016. The aim was to facilitate various networking activities. The Robert Koch Institute provided start-up financing for an office and the homepage [www.zukunftsforum-public-health.de]. Although the financing of the public health service has remained relatively stable in Germany in recent years, the resources that will be made available to the public health service in the future remain unknown, making long-term planning challenging. It will be important to ensure the adaptability and resilience of the public health service to meet future challenges within a potentially changing macroeconomic and political environment.

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