Large scale public health system transformation: Germany

Abstract The COVID-19 pandemic was a stress test for public health services in Germany. Decision making was complex (party lengthy and inconsistent) due to the divided responsibilities within the federal system. Some improvements on the public health system were already enacted during the pandemic. A “pandemic radar” was established to bundle up relevant infectious disease indicators with indicators of health services use. The national electronic notification and information system for infectious diseases was extended. Digital improvements were made in the public health offices. Laboratory capacity was strengthened, so was inter-science modelling to forecast pathogen spread. A nation-wide collaborative mechanism, the cloverleaf system, was introduced between regions to avoid the overburdening of hospitals. It is now established for times of excess need for inpatient services. In 2020, a 4 billion euros investment program, the “Pact of Public Health Services”, was adopted to strengthen and modernize the German public health service institutions. The pact is implemented until 2026. The human resources component is the largest. Further priorities include digitalization, improvement of the infrastructure (of designated ports and airports) for the implementation of the International Health Regulations, research and the creation of agile and resilient public health structures. Outputs so far include the establishment of more than 4800 new public health positions, the appointment of new professorships for public health services, the initiation of several research projects, and the roll-out of more than 300 digitalization projects. A new federal institute for prevention is planned. It aims to foster networking between public health services, strengthen health communication, data use, and evidence for public health services. In this process, WHO advised the federal ministry e.g. on behavioral insights; heat health action; prevention on noncommunicable diseases and others. Many public health actors have provided opinions. However, consensus building on how Germany can overcome fragmentation in public health is ongoing.