The Health and Social System in Germany – An Overview for Study and Practice

PART 1 – Participation instead of welfare: concepts and core idea

More than treatment: what rehabilitation and participation are about

People who are chronically ill, have had an accident or live with a long-term impairment often need more than medical treatment. The aim is to take part in society again, or for the first time: in work and vocational training, in education, in community and everyday life. This very goal is at the heart of Book Nine of the Social Code, entitled ‘Rehabilitation and Participation of Persons with Disabilities’ (SGB IX). For you as a manager, practitioner or student, this means a change of perspective: the yardstick is not the administration of deficits but the question of what support a person needs in order to pursue their own goals.

In Module 1 you got to know the insurance, welfare and provision (Versorgung) principles as a classification scheme. Participation law cuts across this scheme: the rehabilitation providers include statutory health, pension and accident insurance as well as the Federal Employment Agency (Bundesagentur für Arbeit) and the providers of social compensation (Soziale Entschädigung), public youth welfare and Eingliederungshilfe (integration assistance for persons with disabilities) (section 6(1) SGB IX). The Act therefore bundles benefits that stem from very different system logics under one common goal. That this bundling does not happen by itself in everyday practice is the subject of Parts 3 and 5.

Figure 1 gives you an overview in advance: at the centre is participation, grouped around it are five building blocks – the definition of disability, the benefit groups, the rehabilitation providers, the clarification of responsibility and the Federal Participation Act with the supplementary participation counselling. Feel free to return to this graphic if you lose the thread in the following parts.

The definition of disability under section 2 SGB IX

Before benefits can be discussed, it must be clear who is meant in the first place. The Act defines in section 2(1) SGB IX: persons with disabilities are persons with physical, mental, intellectual or sensory impairments which, in interaction with attitudinal and environmental barriers, can, with a high level of probability, prevent them from participating equally in society for more than six months. An impairment exists if the physical and health condition deviates from the condition typical for the person’s age.

The definition contains several building blocks that you should distinguish in counselling. First, the impairment itself: a deviation of the physical and health condition from the condition typical for the person’s age. Second, the barriers: attitudes, spaces, communication channels, forms or procedures that make participation more difficult. Third, the duration: what is meant is a limitation that will, with a high level of probability, last longer than six months. Disability within the meaning of the Act therefore only arises from the interplay of these elements – not from the diagnosis alone.

In professional discussion, this understanding is often contrasted with a purely medical view that describes disability primarily as a characteristic of a person. The statutory wording opens up the view to the environment: where barriers exist, disability arises; where they are removed, participation can succeed. For managers, this leads to an uncomfortable but productive question: what barriers does your own organisation create – for example through forms that are hard to understand, a lack of sign language or Easy Read (Leichte Sprache) services, opening hours or premises? It should be noted critically that the concept requires a prognosis (‘with a high level of probability’) and therefore leaves room for judgement in individual cases. Moreover, a legal concept says nothing about how people describe themselves. Use labels, therefore, only to the extent that access to benefits requires it.

Severe disability: a narrower concept

Severe disability must be distinguished from the general concept of disability. A person is severely disabled within the meaning of Part 3 of SGB IX if they have a degree of disability (Grad der Behinderung, GdB) of at least 50 and meet the statutory residence or employment requirements (section 2(2) SGB IX). The value of 50 thus belongs to the definition of severe disability and not to the general definition. The question of which specific benefit a provider grants depends in each case on the requirements of the individual benefit; providers and advice centres clarify this in each individual case. In conversations with people seeking advice, a simple rule helps: neither the diagnosis nor the degree of disability alone answers the question of which service is suitable – what matters is which participation needs the person names themselves.

PART 2 – Legal framework: benefit groups, rehabilitation providers and the Federal Participation Act

The five benefit groups under section 5 SGB IX

SGB IX organises support not by provider but by the purpose of the benefit. Section 5 SGB IX names five benefit groups for participation in life in society: first, benefits for medical rehabilitation; second, benefits for participation in working life; third, maintenance and other supplementary benefits; fourth, benefits for participation in education; and fifth, benefits for social participation. This order is also the numbering to which section 6(1) SGB IX refers in relation to the providers. Table 1 presents the groups with examples and shows which providers can in principle deliver them under section 6.

The fact that the groups stand side by side has a practical consequence: a single person rarely has only one need. Someone who is retrained after an accident (group 2) usually also needs financial security during the measure (group 3) and perhaps support in everyday life (group 5). Good counselling therefore thinks in bundles of needs, not in individual applications.

Rehabilitation providers under section 6 SGB IX: who can deliver which benefits?

Which bodies can act as rehabilitation providers is governed by section 6(1) SGB IX; you already know the list of providers from Module 3. What matters here is that the Act assigns certain benefit groups to each provider. This interplay is confusing when read as continuous text. Figure 2 therefore translates the provision into a matrix: the rows show the providers, the columns the five benefit groups, and a tick indicates that the provider can in principle deliver the group.

How to read the matrix: row by row, you see the profile of a provider. The providers of social compensation and soldiers’ compensation (Soldatenentschädigung) are named in all five columns, whereas the health insurance funds appear only for medical rehabilitation and maintenance benefits. Column by column, you see how many bodies are possible for a group: for medical rehabilitation it is almost all the providers listed, for participation in education only three (plus, as a special case, accident insurance for insured persons under section 2(1) no. 8 SGB VII, such as pupils and students). Support for education and everyday life therefore comes mainly from social compensation, youth welfare and Eingliederungshilfe; maintenance benefits are not named for youth welfare and Eingliederungshilfe in this list. Bear in mind, however: the matrix only shows what a provider can deliver in principle. Whether there is an entitlement in an individual case depends on the requirements of the relevant benefit laws.

A brief look back is worthwhile: in Module 2 you got to know statutory accident insurance with its tasks of prevention, restoration of health and compensation (section 1 of Social Code Book VII, SGB VII). Its broad involvement in the benefit groups in the matrix is the logical continuation: anyone tasked with restoring health must also consider work and everyday life. How applications arrive at the ‘first point of contact’ and are forwarded was covered in Module 3; Part 3 of this module explores the rehabilitation-law part of this route in more depth.

The Federal Participation Act: from welfare to participation law

The Federal Participation Act (BTHG) has fundamentally reshaped participation law. According to information from the Federal Ministry of Labour and Social Affairs (Bundesministerium für Arbeit und Soziales, BMAS, n.d.), it came into force in four staggered reform stages up to 2023. Three innovations are particularly significant for your work. First, Eingliederungshilfe is no longer part of social assistance (Sozialhilfe), i.e. the welfare system, but part of participation law in Part 2 of SGB IX (BMAS, n.d.). The providers of Eingliederungshilfe are therefore rehabilitation providers under section 6(1) no. 7 SGB IX. Second, specialist support services (Fachleistungen) are financed separately from benefits for living costs: the actual support for participation and the securing of living costs follow different rules. How living costs are secured is the subject of Module 7. Third, benefits are based on individual need rather than on the type of housing – this is what is meant by ‘person-centredness’ (BMAS, n.d.).

For everyday life in organisations, the third point in particular has far-reaching consequences. If the type of housing no longer sets the framework, the focus shifts to what the person wants to achieve and what support they need for this. This requires conversations on an equal footing, joint planning and a willingness on the part of organisations to design services flexibly. Figure 3 contrasts the two ways of thinking, which often operate side by side in practice.

This comparison is a didactic simplification. It helps you understand the direction of the reform but does not reflect every rule. In the spirit of multiple perspectives, you should be aware of two readings: from one point of view, moving Eingliederungshilfe into SGB IX is a consistent step because it no longer treats persons with disabilities as welfare recipients. From the other point of view, separating specialist support services from living costs requires additional coordination between bodies, which can overwhelm people seeking advice. Both views are plausible; which carries more weight depends on local conditions and cannot be decided on the basis of the sources available here.

PART 3 – The route to the benefit: responsibility, time limits and counselling

The structured system as an everyday experience

Depending on the cause and the aim of a benefit, a different provider is responsible – you got to know this in Module 3 as a feature of the structured (multi-branch) system. This applies with particular force to rehabilitation, because the same benefit group can be delivered by several providers (Figure 2). A person after an accident at work, a person with a chronic illness and a young person with support needs at school may therefore end up with quite different bodies, even though they are all seeking participation. For those affected, this is hard to see through; for practitioners, knowledge of where to refer becomes a core competence.

The legislator recognised this problem and provided a procedure in SGB IX intended to prevent applications from being left lying between providers. Its core is section 14 SGB IX on the lead rehabilitation provider (leistender Rehabilitationsträger).

Lead rehabilitation provider and time limits under section 14 SGB IX

You got to know the time limits of section 14 SGB IX in Module 3: two weeks to determine responsibility (subsection 1), three weeks for the decision if the application is not forwarded and no expert report is required (subsection 2). For rehabilitation, one concept is particularly important: the provider with which the application was first received and which does not forward it thereby becomes the ‘lead’ rehabilitation provider. Figure 4 shows the procedure step by step.

Three rules of action follow from this for practice. First: the date of receipt counts. Record when and where an application was made, and ask for confirmation of receipt. Second: a ‘wrong’ application is not a lost application. Anyone who is unsure about responsibility should submit the application early rather than spend a long time researching; clarification is the providers’ task. Third: following up pays off. If the time limits mentioned have passed without any notification, it is appropriate to make an enquiry with the provider. Do not confuse the provisions here: section 14 SGB I governs the right to counselling, section 14 SGB IX the clarification of responsibility by the rehabilitation providers. Always state the relevant code book in letters and documentation.

Counselling before and alongside the application

Anyone who wants to apply for benefits first has a right to counselling from the competent benefit provider (section 14 SGB I) and can obtain information under section 15 SGB I; you are familiar with both from Modules 3 and 4, and Module 8 explores them in more depth. In the field of rehabilitation there is, in addition, a separate service that deliberately stands outside the benefit providers.

Section 32 SGB IX provides for supplementary independent participation counselling (ergänzende unabhängige Teilhabeberatung, EUTB). The Federal Ministry of Labour and Social Affairs funds counselling services that are independent of benefit providers and service providers and serve to strengthen the self-determination of persons with disabilities or at risk of disability. The counselling is available even before specific benefits are applied for and exists alongside the right to counselling from the rehabilitation providers; in funding decisions, peer counselling by and for people affected is to be given particular consideration (section 32(1) and (3) SGB IX). For practice, independence is the decisive point: anyone who doubts whether a provider or a service provider sufficiently has their interests in mind can turn to a body that neither grants nor delivers benefits. For organisations that offer benefits themselves, this is both a relief and a challenge: they may refer people to this counselling but must accept that people seeking advice will also learn about alternatives there.

PART 4 – Practice: sorting needs and planning participation together

Eingliederungshilfe in figures

Before we turn to methods, it is worth looking at the scale of Eingliederungshilfe. According to the statistics of the Federal Statistical Office (Statistisches Bundesamt, Destatis), around 1,056,000 people received Eingliederungshilfe benefits in the reporting year 2025; that was 2.6% more than in the previous year (Destatis, 2026). Net expenditure amounted to EUR 31.5 billion, an increase of 10.0% (Destatis, 2026; cash-based accounting). In each case, people were counted over the course of the year. Figure 5 shows two subgroups: the number of recipients of benefits for social participation and the number of people employed in recognised sheltered workshops for people with disabilities (Werkstätten), which are counted as participation in working life.

In summary: in 2025, 806,215 people received benefits for social participation and 273,250 people were employed in recognised workshops (Destatis, 2026). Both figures come from the same count; their sum would be greater than the total number of recipients. From this it can be concluded that the groups overlap and the figures must not be added together. This is an interpretation that follows from the figures – the statistics themselves give no reasons here. Likewise: the fact that expenditure rose by 10.0% and the number of recipients by 2.6% is a finding. Why expenditure grew more strongly is not apparent from the available data, and no conclusions about the quality of support can be drawn from the statistics alone.

Worked example: assigning needs after a stroke

Complex responsibilities are best learned by working through a case step by step. The following example shows a five-step working method; afterwards, you apply it in an exercise of your own.

Note what the example shows: the matrix only provides a framework; the narrowing down only comes about through the questions about cause, insurance status and age. In addition, needs are recorded in full, even if they turn out not to be current – this prevents the mistake of seeing only what your own organisation offers.

Exercise: assigning needs to benefit groups and providers

Planning participation together: what management can contribute

The best assignment is of little use if the person is not involved in shaping it. The guiding principle of the BTHG is person-centredness: not the organisation but the person with their wishes and goals is at the centre (BMAS, n.d.). In practice, this means planning participation together: the person formulates goals, the practitioner assigns support needs, relatives or trusted persons are involved if the person so wishes, and the providers are informed at an early stage. Procedural rules on planning are not explored in depth in this module; what matters is the attitude: practitioners support, the person decides.

Managers shape the framework conditions for this. These include time for conversations, clear responsibilities within the team for knowledge of where to refer, simple documentation of application receipts and enquiries, understandable information in plain language and a culture in which employees and service users are allowed to report barriers. In addition, teams should know when they need to refer to advice centres, to the providers or – for employment law questions concerning their own employees – to the legal department and employee representation body.

PART 5 – Critical analysis: limits, areas of tension and consequences

Complexity as a barrier to access

The strength of SGB IX – bundling the benefits of different providers under one roof – is at the same time its weakness: the matrix in Figure 2 shows that several providers come into consideration for many benefit groups. The procedure under section 14 SGB IX, with its time limits, is intended to absorb this complexity by ensuring that applicants do not have to find out for themselves who is responsible. In practice, however, a knowledge gap remains: practitioners and providers know the system, people seeking advice usually do not. Anyone who experiences language, administrative procedures or digital applications as an obstacle finds it harder to obtain their rights. This obstacle can be reduced above all through counselling, simple information and coordinated cooperation between bodies.

A further critical question is how closely aspiration and reality match. The Act sets out time limits and procedures; whether they are complied with in everyday practice cannot be judged from the sources used here, and statements on this would be speculation. If you experience delays in your region, it is worth documenting them objectively and discussing them with the providers or the participation counselling service.

Areas of tension: self-determination, protection and resources

Person-centredness requires negotiation. An area of tension can arise between a person’s wishes and what providers grant. Practitioners move between advocacy for the person, loyalty to their own organisation and the responsibility not to promise anything they cannot decide. Honest conversation names these roles: ‘I will support you in describing your needs clearly; whether and to what extent a benefit is granted is decided by the provider.’

A second area of tension concerns the separation of specialist support services from basic income support. It strengthens the clarity of responsibilities but can create additional interfaces (see Module 7 on basic income support). Whether the advantages outweigh the disadvantages remains open in professional debate; here you can only take away the question of where interfaces arise in your field of work and who coordinates them. A third area is the data situation: figures such as those on Eingliederungshilfe (Destatis, 2026) describe scale and costs but say nothing about satisfaction or participation achieved. Statements on the effectiveness of the reform are therefore not possible on this basis.

Consequences for practice, study and management

Four consequences for practice can be derived from this. First: participation asks about goals, not diagnoses. Second: needs are recorded in full and assigned to the five benefit groups. Third: procedures such as section 14 SGB IX and section 16 SGB I are tools with which practitioners secure access without giving legal advice. Fourth: the link to counselling remains central, whether through the benefit providers themselves, through independent participation counselling or through your own team. How this navigator role is designed systematically is the subject of Module 8. For your studies, the following structure lends itself to a term paper: provision – responsibility – benefit – access barrier – action step.

Self-reflection – 5 questions

Voluntary · not graded – your answers are not saved and are not evaluated by anyone. Click an answer; the explanation helps you assess your own understanding.