Germany scores comparatively well in a study by the ESPN research network.

Dr. WSW/AD – 12/2018

On behalf of the European Commission, the European Social Policy Network (ESPN) carried out a comprehensive study on ‘Inequalities in access to healthcare’. The study is less about objectively measurable health outcomes and more about people’s subjective perception of gaps in healthcare. Within the framework of the European Pillar of Social Rights, progress is measured by the Social Scoreboard indicator of ‘self-reported unmet need for medical care’.

The starting point and benchmark is the right of all people to timely access to affordable, high-quality healthcare. The study found inequalities both between and within the 35 European countries studied. The study concludes that the following areas are particularly problematic: a) underfunding of public healthcare systems, b) out-of-pocket payments, c) waiting lists and their lack of transparency, and d) fragmented formal coverage. The focus was also on difficulties reaching socially vulnerable groups.

Underfunding of the public healthcare system is an issue in at least ten countries. Although Germany is not one of these countries, fixed budgets in Germany were named as a possible source of ‘informal rationing’.

Germany belongs to the comparatively large group of countries in which co-payments have to be made. However, these user charges are capped and have certain social criteria – which is the case in only a few countries.

Paying more to get faster treatment

In the majority of the countries studied, waiting lists were not criticised per se but rather the ability to bypass waiting times by paying for private health insurance. Germany’s system is criticised for allowing private health insurance patients to access services faster than those with social health insurance. In countries without private health insurance, the proportion of under-the-table payments is probably higher.

In terms of waiting times, the report is also openly critical of company medical treatment schemes, such as those that exist in Finland and the Netherlands. They allow easier and quicker access to healthcare, especially for people who are financially better off. Even if this form of insurance is more likely to be the exception in Germany because of its effective statutory accident insurance system, the statements made in this report appear rather out of place.

As is also the case with old-age pensions, occupational insurance schemes are not the cause, but rather the response to gaps in public schemes; furthermore, they also facilitate faster reintegration into the workplace. 

Access rates

In terms of formal access for citizens, Germany scores well with almost 100% coverage, whereas Poland and Greece have substantial gaps in coverage with rates of 90% and 80% respectively.  

First access to medical care, in the sense of a medical examination, has seen a significant decline in unmet need in Germany to 0.3%, whereas in certain other countries it is well above 10%. Economic status plays a decisive role in this. People who are not active in the labour market, especially the unemployed and pensioners, have comparatively greater difficulties accessing healthcare. 


The report recommends that the Member States limit co-payments, especially for vulnerable groups, so that user charges do not impede access to healthcare.

Priority-setting for waiting lists should become more transparent, and doctors should no longer have incentives to prioritise patients who pay more.


Voluntary health insurance systems should not be directly or indirectly subsidised by the state, rather resources should instead be invested in the statutory health system [editorial note: ‘Voluntary health insurance’ as used in the report does not refer to voluntary health insurance within the German statutory health insurance system].