5.1. Public health

At the national level there are several institutions undertaking public health functions. For instance, the Robert Koch-Institute advises authorities (at state, federal and international level) on measures for the prevention and detection of communicable diseases and the prevention of their spread, and advises the supreme health authorities on measures involving more than one state (pursuant to the Infection Protection Act of 2000, amended in 2020). The Federal Centre for Health Education (Bundeszentrale für gesundheitliche Aufklärung – BZgA) is the key authority for disease prevention and health promotion via the means of mass-media campaigns and projects on health-related behaviour (see section 2.8.1 Patient information). Moreover, the BZgA is commissioned by the Federal Association of Sickness Funds to develop, implement and scientifically evaluate prevention and health promotion programmes.

However, provision of public health is primarily a responsibility of the states; the specific tasks of the public health services and the level at which they are carried out differ from state to state (although a majority is delegated to municipalities). The broad public health responsibilities include activities linked to the states’ sovereign rights as well as the care provided for selected groups, such as:

• prevention, surveillance and containment of communicable diseases;
• health reporting;
• hygiene supervision in hospitals and among hospital staff, office-based physicians, dentists, allied health professionals and LTC facilities;
• supervision of commercial activities involving food, pharmaceuticals and drugs;
• overseeing certain areas of environmental hygiene;
• physical examinations of schoolchildren and certain other groups;
• diagnostic and – in exceptional circumstances – therapeutic services for people with specific communicable diseases, including sexually transmittable diseases and tuberculosis;
• diagnostic and predefined therapeutic services (e.g. vaccinations, diagnostic services) for refugees and asylum seekers, as well as hygiene surveillance of their accommodation;
• provision of community-oriented psychiatric services;
• health education and promotion; and
• cooperation and advice to other public agencies.

These services are provided by 375 public health offices across Germany, which vary widely in size, structure and tasks. In 2019 the total workforce was estimated to be around 17 000 people, including a total of 2561 physicians working in public health offices (Bundesärztekammer, 2019; GBE-Bund, 2020f ). In addition, public health services in Germany are carried out by a multitude of actors operating at municipal, state and federal level (and by private, public and corporatist bodies of the SHI), and often these services are only one out of their many tasks (Robert Koch-Institut (RKI), 2015c).

The Act to Strengthen Health Promotion and Disease Prevention (2015) (Gesetz zur Stärkung der Gesundheitsförderung und der Prävention) mainly aimed at a better coordination of actors and formulating an overarching national prevention strategy (§20d SGB V ). To this end, the National Conference on Prevention (Nationale Präventionskonferenz – NPK) was established and a summarizing report on actors, activities and spending was first published in 2019. According to this report, sickness funds spent a total of €519 million (€7.17 per insured) on public health-related services and private insurers €20.5 million in 2017 (up from €238 million in SHI and €13.5 million in PHI in 2012) (Nationale Präventionskonferenz, 2019). In 2018 the SHI spent €158 million (€2.18 per insured) on primary prevention in e.g. kindergartens and schools; €172 million (€2.37 per insured) for occupational health services; and €214 million for behavioural-related prevention, mostly sport courses or stress management (Bauer et al., 2019).

5.1.1. Primary prevention programmes – screening and early detection services

Gradually, after the Second World War, many preventive services, immunizations, mass screening for tuberculosis and other communicable diseases, as well as health education and counselling, were transferred from public health services to SHI physicians. In 2019 the vast majority of immunizations were carried out by SHI physicians. In addition, the following primary prevention measures are under the sole responsibility of SHI.

• Cancer screening is organized according to gender and age groups. Women over 20 are entitled to an annual cervical screening, breast cancer screening (over 30 years of age) and a systematic mammography every two years (aged 50–69 years). Men are entitled to prostate cancer screening after they reach 45. Both genders are entitled to skin cancer screening at the age of 35 (every two years) and to two screenings, at least 10 years apart, for colon/rectal cancer (for men aged 50; women aged 55; including colonoscopy) (Gemeinsamer Bundesausschuss, 2020f ). From 2020 the colon and cervical cancer screening programmes are organized screenings with sickness funds sending out invitations to participants every five years; they also provide additional information and programme evaluation. Women aged 20–34 are also entitled to an annual cytological diagnostic and an HPV test after the age of 35, every three years (Gemeinsamer Bundesausschuss, 2020d).
• Regular check-ups, such as screening for cardiovascular and renal diseases and diabetes, for adults are covered once for people in the 18–35 age group, and then every three years for those over 35 (including diagnostics such as urine tests). Women over 25 can have a chlamydia trachomatis screening every year. In addition, since 2017 men over 65 have been entitled to screening for abdominal aortic aneurysms (Gemeinsamer Bundesausschuss, 2020g).
• Antenatal care, including up to 14 antenatal appointments and three ultrasound screenings, are provided by a gynaecologist or other SHI-affiliated physician. In addition, further diagnostic tests are covered if deemed necessary, for instance an HIV test (Gemeinsamer Bundesausschuss, 2020h).
• Regular check-ups for children up to the age of 6 and for adolescents (a) between the ages of 12 and 14 and (b) between 16 and 17 years are also available (Gemeinsamer Bundesausschuss, 2017, 2020e). In addition to a general examination and subsequent counselling if necessary (also with regard to the child’s social environment), there are screenings for specific diseases (e.g. pulse oximetry screening, cystic fibrosis) covered by SHI. Immunization status is monitored during the course of health check-ups for children and adults alike.
• Occupational health promotion is also covered by SHI. Since 2019 the sickness funds have been given a benchmark of €3.15 per insured for occupational health promotion measures.

A total of €7.52 is set as a benchmark for all primary prevention measures following an individual setting approach (§20 SGB V). With the SHI Guideline for Prevention, the Federal Association of Sickness Funds, in cooperation with the associations of health insurers at the federal level, defines the content-related fields of action and qualitative criteria for the services provided by the health insurers in primary prevention and workplace health promotion, which are binding for the provision of services on site. Regarding secondary prevention, entitlements to medical and dental early detection examinations are subject to negotiations in the Federal Joint Committee.

5.1.2. Communicable diseases – surveillance, monitoring, immunization

The Infection Protection Act (2000) regulates the surveillance procedures of around 50 communicable diseases (including food poisoning) and essentially centralizes them at the Robert Koch-Institute to better evaluate and inform the public about infectious diseases and to cooperate with international agencies. The Robert Koch-Institute is tasked with compiling disease-specific notifications by public health offices and is the key authority for the surveillance and containment of outbreaks of communicable diseases as well as for informing the public (see also Box5.1). It is supported by 20 national reference centres and 37 consulting laboratories as well as other specialized laboratories for specific agents and diagnostic methods. Since the introduction of the Infection Protection Act in 2000, standards for HIV have been applied to all sexually transmittable diseases. Public health offices have been required to strengthen their counselling services and to provide diagnostic services and treatment in certain cases, including, for example, for non-compliant tuberculosis patients. The Robert Koch-Institute is also responsible for immunization recommendations that are organized according to vaccine-preventable diseases and age (via its Standing Vaccination Commission (Ständige Impfkomission – STIKO)). Currently, vaccination against 15 diseases is recommended (for details see Robert Koch-Institut (RKI) (2019b)). Since early 2020 the Institute has played a key role in Germany’s response to the COVID-19 pandemic (Box5.2).

Box5.1	Box5.2