Germany: Employment opportunities for people with chronic diseases

  • Observatory: EurWORK
  • Topic:
  • Labour market policies,
  • Pracovní doba,
  • Health and well-being at work,
  • Working conditions,
  • Published on: 14 Listopad 2014


Disclaimer: This information is made available as a service to the public but has not been edited by the European Foundation for the Improvement of Living and Working Conditions. The content is the responsibility of the authors.

In 2009–2010, around 35% of male and 42% of female respondents in a survey carried out by the Robert Koch Institute stated that they had experienced chronic diseases. Besides statistics of this nature, little representative data is available on the working situation of people affected by such diseases. Since 2004, establishments have been obliged by law to offer company integration management for workers falling repeatedly ill or being ill for more than six weeks within one year. Data from the IW Human Resource Panel shows that over 30% of the companies surveyed had such a management in place. Other studies come to a similar figure.

Block 1: Concept, definitions, sources of information and methodological issues on chronic diseases and work from the national perspective

1.1. National definition of chronic disease

There is no standard definition of chronic diseases in Germany. However, in 2004 the Federal Joint Committee (Gemeinsamer Bundesausschuss) published a guideline on defining chronic disease. The committee brings together the national associations of physicians, dentists, hospitals and health insurance funds, which together form the largely self-governing statutory health system in Germany. One of its major tasks is to decide which services are to be paid for by the statutory health insurance funds. To this end, the body publishes directives affecting more than 70 million insured members.

According to the committee’s guidelines, an illness is defined as chronic if it requires treatment at least once every quarter over a minimum period of one year. In addition, for the illness to be defined as chronic, one of the following additional criteria must apply:

  • The affected person has very high or extremely high care needs – i.e. care levels II or III respectively as defined in Social Security Code XI.
  • The illness results in a disability of at least 60% or the persons’ employability is diminished by at least 60%.
  • Continuous medical care is essential to prevent the illness becoming life-threatening, shortening life-expectancy or worsening quality of life.

1.2. Information on national sources of statistical information dealing with the issue of chronic diseases and their relation to employment and working conditions

To our knowledge, there is no single statistical source on chronic diseases. However, parts of the phenomenon as defined in section 1.1 can be tracked in official datasets. This is the case for the numbers of people registered as requiring care levels II and III. Every second year, the Federal Statistical Office (destatis) publishes its “Care Statistics”. As destatis states, the statistics are collected to obtain more information on supply and demand in care services. It uses two information sources:

  • Survey of in- and outpatient service providers
  • Data on recipients of statutory care insurance benefits

The latest data from this source is presented in the table below.

Developments in care: Number of care level II and III recipients (2001-2011)








Recipients of care level II







Recipients of care level III







Notes: Reporting date: 15 December of each year.

Source: destatis, Care Statistics 2011

Block 2: Prevalence, recent evolution and effects of the problem of chronic diseases among workers and companies

2.1. People affected by chronic diseases and employment

Data is available from the Robert Koch Institute (RKI), which conducts a representative (telephone) survey on health issues – including chronic diseases. Data from the 2012 survey has not yet been released. The latest data available is for 2010. For this survey 22,050 interviews were conducted between September 2009 and July 2010 amongst the German-speaking adult population with a landline telephone connection. The proportion of females reporting chronic diseases remained stable at around 42% between 2003 and 2010. The proportion of males who were sufferers was lower.

Prevalence of chronic disease and the commonest types





Female respondents




Male respondents

34.7 %

35.8 %


Diabetes (lifetime prevalence)

6.8 (female)

5.4 (male)

9.3 (female)

8.2 (male)

8.8 (female)

8.5 (male)

Coronary heart disease (lifetime prevalence)

6.9 (female)

7.7 (male)

6.5 (female)

9.2 (male)

6.7 (female)

9.9 (male)

Arthrosis (lifetime prevalence)

23.2 (female)

15.9 (male)

26.6 (female)

17.3 (male)

27.1 (female)

17.9 (male)

Asthma (lifetime prevalence)

6.0 (female)

5.2 (male)

10.1 (female)

8.3 (male)

9.6 (female)

7.9 (male)

Bronchitis (lifetime prevalence)

10.1 (female)

6.9 (male)

10.3 (female)

7.5 (male)

10.4 (female)

7.5 (male)

Source: RKI, 2012

  • What is the employment situation of people with chronic diseases in your country (% of people in employment/unemployment/inactivity that are affected by chronic diseases)?

No data available.

  • Are certain chronic diseases associated to or more prevalent in certain economic sectors/occupations?

No comparative sectoral or occupational data.

  • What are the typical employment trajectories of workers affected by chronic diseases? (entry/exit patterns)

No data available.

  • What are the main difficulties/problems for people with chronic diseases to access or stay in the labour market?

There is no representative data available.

  • What are the main difficulties/problems for enterprises with workers affected by chronic diseases? What solutions do enterprises adopt to deal with these workers affected by chronic diseases?

In 2004, Social Security Code IX was amended. The amendment introduced mandatory company integration management (betriebliches Eingliederungsmanagement, BEM). Since 2004, all companies must establish measures for workers with recurrent illness or illnesses lasting for more than six weeks within one year. The employer must approach the person affected and discuss BEM with them. Only if he or she consents to BEM can further steps be taken.

The discussion covers the measures or services which can be provided to promote the employee’s recuperation, prevent future illness and safeguard the job (para. 84, SGB IX). The overall aim of BEM is not only to prevent new cases of illness, but also to avoid an illness becoming chronic or disabling. If those affected agree, works councils or other employee representation bodies must be involved in the procedure. The employer is usually represented by the human resources department. Rehabilitation and integration offices (e.g. for severely disabled workers) can assist companies and employees in setting up suitable measures. The works doctor can also be useful to support and make suggestions.

Several studies have looked into the prevalence of BEM at the company level. Niehaus et al. (2008), for example, reported that 87% of large, 68% of medium-sized and 28% of small companies knew what BEM was. However, only 68%, 38% and 28% of large, medium-sized and small companies respectively had implemented BEM. Their results are based on a study undertaken by the University of Cologne in 2007. 630 employer representatives, works doctors, employee representatives and disability managers took part in a survey on BEM. In addition, 474 persons (mostly representatives of disabled workers) filled in a questionnaire on the same topic published in the magazine “Disabled persons at work” in June 2007.

Similar results are known from other studies. The IW Human Resource Panel, a representative survey amongst 1,000 to 2,000 personnel managers (conducted three times a year since 2010), shows that over 30% of companies surveyed have BEM in place.

As Vater and Niehaus (2013) stress, several factors facilitate the implementation of BEM. These include:

  • The pre-existence at the company/establishment of a structure for health or active ageing or the presence of a contact person for these issues.
  • The presence of a works doctor or representative for disabled workers.
  • A corporate culture characterised by trust. Senior executives’ attitudes towards health issues are important. A cooperative management style is particularly conducive to the implementation of BEM.

Cooperation agreements between the company and works doctors and/or other rehabilitation service providers can help in preserving the employability of affected workers.

Little data is available on the success of BEM. However, the study by Niehaus et al. shows that around half of all BEM cases led to the participants being successfully reintegrated into their work. Larger companies showed higher success rates. Further notable effects were: decreasing sickness figures (reported by 36%), increasing motivation amongst employees (reported by 30%), an improved working climate (reported by 32%) and fewer dismissals due to illness (reported by 18%).

  • Are there differences in the previously mentioned patterns by types of chronic diseases or groups of pathologies? are there differences according to age or gender

There is no representative data available.

  • Is it possible to identify some changes in the previously mentioned patterns in recent years?, reasons for this and possible specific effects of the economic crisis

As the above data shows, the proportions of those reporting diabetes (both sexes), coronary heart disease (male), arthrosis (female), asthma (both sexes) have risen significantly in the last decade. The RKI report only looks into general health contributors (such as weight, tobacco and alcohol consumption, engaging in sport activities), but not specifically into work-related stressors.

2.2. Working conditions of employed people affected by chronic diseases

  • Health and well-being: Are certain occupations/jobs/sectors associated to certain chronic diseases? Possible relation between occupations and chronic diseases; what are the factors behind this (exposure to risks and hazards, job intensity, type of work, etc.); are special H&S measures implemented at workplace level to avoid/palliate this?

A study by Michelis (2008) looks into the health situation of truck and bus drivers in Germany. Based on an extensive literature research, the analysis finds the following health problems to be significantly more prevalent among drivers:

  • Diseases affecting the circulatory system (heart attack, ischemic heart diseases, high blood pressure and strokes)
  • Diseases affecting the respiratory system (higher risk of Chronic obstructive pulmonary diseases, COPD)
  • Diseases affecting the musculoskeletal system (back pain, herniated disks, etc.)
  • Higher risk of chronic liver diseases and obesity.

However, in some cases, it is hard to distinguish between occupational and life-style factors leading to chronic diseases. As a study by Eckardt et al. (2013) concludes, many chronic diseases are caused by individual habits, such as smoking, unhealthy diets or overweight.

  • Reconciliation of working and non-working life: are people with chronic diseases allowed special conditions in terms of work-life balance, flexibility at work to cope with the diseases/attend treatment, ability to set their own working time arrangements, etc.?

There is no general rule for this. Measures are decided on an individual basis, e.g. as part of BEM. A study by Knoche and Sochert (2013) describes the outline of a typical BEM in seven steps:

  1. Company analyses sickness leave data on a regular basis and can therefore determine which employees have been ill for longer than six weeks.
  2. Workers who might profit from BEM can be contacted by the employer (e.g. a representative of the human resources department), a member of employee representation or a member of the integration team). The goal is to inform the worker of the possibilities of BEM and offer an initial meeting on the topic. If the worker agrees to such a meeting, further steps are taken. Otherwise BEM comes to a close at this stage.
  3. First talk with affected worker: Full information on BEM, measures and possibilities. If consent is reached, a statement of agreement is signed.
  4. Follow-up meeting to discuss details of the case: Employer usually decides who attends this meeting, e.g. works council representatives, representatives for disabled persons or the works doctor. The affected employee is invited to this meeting, but does not have to attend. The goal is to collect all data on the case and formulate a strategy for integration.
  5. Detailed measures or measurement packages are set up for the individual case.
  6. Implementation of measures.
  7. Evaluation of implemented measures.
  • Career and employment security: to which extent and how is the employment status of people with chronic diseases affected by their health situation?; is there an impact in their remuneration levels/conditions?; in what measure is there a repercussion on their employment security and working career?; are they allowed/forced to changes in their jobs?

Measures (which may include changes to their working time or work routines) can be discussed as part of BEM. BEM’s overall goal is to safeguard the employability of affected workers and their jobs.

Block 3: Policies and measures adopted by public and private agents to favour the employment situation and working conditions of people with chronic diseases

3.1. Description of main policy measures/initiatives developed by public authorities or social partners

REHADAT is an information system supporting the vocational integration of disabled persons and occupational inclusion. Commissioned by the Federal Ministry for Health (BMG), it was established by the Cologne Institute for Economic Research (IW) in 1988. REHADAT is supported by a steering committee made up of a multitude of organisations and institutions concerned with social security/care in Germany, including the Federal Ministry for Labour and Social Security (BMAS), the Federal Employment Agency (BA), the Confederation of German Trade Unions (DGB) and the German Confederation of Employers’ Associations (BDA).

REHADAT currently contains about 86,000 documents and 20,000 pictures that are permanently updated.

Detailed information about various aspects of vocational rehabilitation is available from eight databases, five of which can be searched in English. They are designed for use by disabled people as well as professionals involved in rehabilitation.

  • The “Technical Aids Database” provides detailed product descriptions and information about the manufacturers, distributors and prices of all kinds of assistive devices available in Germany.
  • The “Case Studies Database” provides examples of successful vocational integration, in particular, with details of the technical, ergonomic and organisational layout of the workplaces concerned.
  • The “Literature Database” contains articles, research reports, etc.
  • The “Research Database” presents research projects on the vocational rehabilitation of disabled persons.
  • The “Addresses Database” records addresses covering all aspects of rehabilitation (organisations, civil services, self-help groups, etc.).
  • Data and information on “Law”, “Workshops” and “Seminars” are only available in German.

Access to REHADAT is available free of charge on the Internet ( Case studies on BEM are also available.

3.2. Examples of enterprises and/or collective agreements implementing initiatives or establishing clauses to support people with chronic diseases

The information platform REHADAT (see Section 3.1 above) provides examples of best practice. Two are presented in this section:

  • BEM at DHL for an employee affected by cancer: a dispatcher working at the Neubrandenburg office of DHL, a German mail and logistics company, contracted cancer. Due to her illness, her right arm swelled, impairing her body strength and gripping power and making paperwork impossible.

The employee was reintegrated into working life at DHL during a seven-week-long integration phase, during which the work volume and hours were gradually increased until previous levels were reached. To allow her to continue working, an armrest was installed at her workplace to relieve her arm when working at computer screens or the working station keyboard. DHL cooperated with their employee’s pension provider, which paid for the new workplace design in full.

  • BEM at a soil removal and disposal company: The company established a new workplace for a surveyor in the cartographic department. The employee, part of whose job involved work outdoors, was affected by asthma and limited mobility at the knee. Due to his impairment, the employee had to avoid carrying heavy loads, standing and walking for a long time or any static postures. His physical health was also affected by changes in the weather.

At the new workplace, the employee could switch between standing, sitting and walking positions while recording the surveying data. In addition, the company issued him with a GPS system. This reduced physical strain, because he no longer had to manually transport heavy equipment. Appropriate clothing and an air conditioning system for his car helped with the changes in weather. The integration office refunded 50% of the employer’s costs for the necessary adjustments in equipment.


As shown above, little representative national data is available on the sectoral prevalence of chronic diseases. Case studies show that the implementation of company integration management (introduced by law in 2004) can improve the employability of workers in individual cases. As in many similar instances, the data also show that larger companies more often implement BEM whereas small and micro-companies need further support and encouragement to do so.


Badura, B. / Schellschmidt H. / Vetter, C. (ed.), 2007, Fehlzeiten-Report 2006. Zahlen, Daten, Analysen aus allen Branchen der Wirtschaft. Chronische Krankheiten. Betriebliche Strategien zur Gesundheitsförderung und Wiedereingliederung, Heidelberg

Eckardt, R. / Martin, K. / Steinhagen-Thiessen, E., 2012, Rückenschmerzen, Adipositas und Nikotinabusus. Die RAN-Studie als betriebliche Präventionsstrategie, URL: [2014-02-25]

Knoche, Karsten / Sochert, Reinhold, 2013, Einführung, In: Betriebliches Eingliederungsmanagement in Deutschland – eine Bestandsaufnahme, ed. by Karsten Knoche and Reinhold Sochert, iga.Report 24, Berlin/Essen, pp. 6-11

Michaelis, M., 2008, Gesundheitsschutz und Gesundheitsförderung von Berufskraftfahrern, URL: [2014-02-28]

Niehaus, M. / Magin, J. / Marfeld, B. / Vater, E.G. / Werkstetter, E., 2008, Betriebliches Eingliederungsmanagement. Studie zur Umsetzung des Betrieblichen Eingliederungsmanagements nach § 84 Abs. 2 SGB IX, Köln, URL:;jsessionid=5BB5E8F83AC00B75A22AA34CE3FDDB0A?__blob=publicationFile [2014-02-28]

Niehaus, Mathilde / Vater, Gudrun, 2013, Das Betriebliche Eingliederungsmanagement: Umsetzung und Wirksamkeit aus wissenschaftlicher Perspektive, In: Betriebliches Eingliederungsmanagement in Deutschland – eine Bestandsaufnahme, ed. by Karsten Knoche and Reinhold Sochert, iga.Report 24, Berlin/Essen, pp. 13-19

Robert Koch Institute (ed.), 2012, Beiträge zur Gesundheitsberichterstattung des Bundes. Daten und Fakten: Ergebnisse der Studie »Gesundheit in Deutschland aktuell 2010«, URL: [2014-03-07]

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