Community-centred yet little community health: The paradoxes of the German health system

Due to its history of development since the middle of the 19th century, the German health care system is almost exclusively dominated by pathogenesis and the resulting reactive treatment. Insiders dub it “repair medicine”. The situation of community health in Germany is very heterogeneous: On the one hand, the community is referred to as the ‘mother of all settings’. In health services research, it is also referred to as the third pillar of the health care system, alongside inpatient and outpatient care. On the other hand, it cannot and must not be ignored that public budget cuts hit public health structures very hard. Ultimately, the COVID-19 pandemic exposed the deficits caused by thirty years of consistent austerity policies. National surveys shows that the already weak public image of the community health structures has once again suffered a massive loss of confidence among the population during this period. The OECD points out that the health behaviour of the population in Germany deteriorated significantly more during the pandemic than was the case in countries which have had strong health promotion structures for decades. The municipality as the ‘mother of all settings’ could and should have intervened here - but did not. In the context of the ‘Public Health Service Pact’ the German government is currently implementing nationwide so-called ‘health stores’ with a focus on socio-economic hotspots in large cities. Concerned here are low-threshold offerings across the entire spectrum of health promotion and prevention. In this regard, we are also currently involved in an Erasmus KA 203 project with the title ‘Family Health Advisor’. From the German perspective, the project sustainability will depend on the extent to which we manage to transfer the project contents into community health structures, which the ‘Public Health Service Pact’ will bring with it in the next few years.