How accessible is herbal medicine in Germany? Jonas Brab explores the regulation and integration of phytotherapy in German healthcare.
Understanding the system
Herbal medicine has a long tradition in Germany, dating back to ancient Roman and Germanic practices and further shaped by mediaeval herbalists. In more modern times, phytotherapy in Germany has been influenced by scientists and physicians who advocated for plant-based treatments grounded in scientific evidence. Though to understand how herbal medicine fits into Germany’s health care system, it is worth taking a look at this first.
No two countries are the same when it comes to how they organise and deliver healthcare to their people, which provides a plethora of different approaches and results regarding the efficacy of their healthcare provision. The healthcare system in Germany is marked by using a decentralised healthcare system model, with governance divided between the federal and state levels, and corporatist bodies of self-governance. Compared to other countries, it has a relatively high spending on healthcare with 11.7% of its GDP, compared to, for example, the UK, spending 10.2% of its GDP on healthcare. Health insurance is compulsory and provided either under the statutory health insurance scheme or through a private health insurance (1).
People living in Germany have higher rates of regular expenditures for their healthcare, through monthly insurance payments, but generally have to pay less money out of pocket than in other countries when accessing comparable services (2). And, while all insurances alike cover the most basic medical needs, there is variability on coverage depending on the insurance type, i.e. private or statutory. Private insurance tends to be more expensive to the individual, but access is provided to better services and is more likely to extend to phytotherapy. Mainstream insurances tend not to cover the use of herbal medicine; however, owing to the growing popularity of phytotherapy, some insurers now offer add-on policies that include alternative treatments such as phytotherapy.
How is herbal medicine regulated in Germany?
Germany has one of the most rigorous regulatory frameworks for herbal medicine worldwide. Perhaps most famous globally is the German Commission E, a scientific advisory board formed in 1978, which evaluated and published monographs on individual herbs, detailing recommended uses, dosages, side effects, and interactions. This monograph system was then used to categorise herbs based on their pharmacological effects, allowing only those that met specific efficacy and safety criteria to receive approval for use as medical treatments. Consequently, Germany became a pioneer in evidence-based herbal medicine, establishing practices and standards that remain influential today.
Although the European Medicines Agency (EMA) now oversees herbal monographs at the EU level, the Commission E still guides many German physicians and pharmacies in their use of herbal medicines. The Federal Institute for Drugs and Medical Devices (BfArM) oversees the approval, classification, and quality control of these products, similar to how it regulates conventional medications, comparable to the HMRA in the UK. Herbal products are classified either into medicinal products or phytopharmaceuticals and traditional herbal medicines. Phytopharmaceuticals are fully licensed medicines that must meet evidence-based standards for efficacy and safety, just like any other drug.
Traditional herbal medicines are subject to a simplified registration process under the Traditional Herbal Medicinal Products Directive (THMPD) if they can demonstrate a history of safe use for at least 30 years (15 years in the EU). Herbal products are also subject to the same Good Manufacturing Practices (GMP) standards as pharmaceuticals, ensuring their purity, potency, and safety.
How people in Germany access herbal medicine
Germany also has the largest herbal medicine market in Europe. The UK on the other hand comes 16th among the 27 countries included in the analysis (3). In Germany, pharmacies are still the greatest provider of herbs and herbal medicine products in Germany, although over-the-counter products can also be found in health food shops and some supermarkets. Around 71% of the sales of phytopharmaceuticals and ‘gesundheitsmittel’ (medical health care products) are through pharmacies (3). In 2023 alone, pharmacies sold 76 million euros worth of homoeopathy and phytotherapy products (4). Some licensed ‘prescription only’ herbal preparations can only be accessed through the pharmacy with a prescription. Since herbal products are mostly bought in pharmacies, pharmacists in Germany are still required to learn about medicinal plants. Pharmacognosy, their use and the pharmacology of their active constituents is a part of academic pharmacy studies and constitutes about 15 % of the entire academic curriculum (3). Some herbal preparations are still produced on site by the pharmacists, usually this is done on an individual basis for patients and is often based on their individual prescriptions.
Herbal medicine products are either available over the counter, or as a prescribed medicine. They can be prescribed either by a heilpraktiker or a medical doctor who has additional training in phytotherapy. Heilpraktiker (healing practitioner) is a practitioner in Germany who is permitted to practise medicine without conventional medical training or teaching, once they have completed a statutory regulated exam specifically designed for heilpraktiker. They are recognised as alternative and complementary healthcare professionals by German law, though while anyone can seek their services, the costs are usually not covered by the standard insurance companies. Interestingly, unlike herbalists in the UK, heilpraktiker or doctors in Germany are not allowed to prescribe their own herbal products, they can only advise on which regulated products or herbs to buy from the pharmacy, or prescribe herbal medicine, which the patient then has to collect from a pharmacy. In the UK, there is limited regulation of herbal practitioners or the herbal medicine products that they supply to patients following a one-to-one consultation. Unlicensed remedies can be made up and supplied by a herbal practitioner to meet the needs of an individual patient following a one-to-one consultation.
Alternatively, to individual GPs who have had further training, or individual heilpraktiker, there are also a number of specialised clinics or hospitals that offer phytotherapy as part of a wider offer. One of these hospitals is Klinik Blankenstein, which can be found in Hattingen, a small town in the northwest of Germany. Klinik Blankenstein has a multidisciplinary team of medical professionals with training in naturopathy, including the use of herbs as well as other therapy forms. The clinic offers naturopathy, including hydrotherapy, movement therapy, phytotherapy and nutritional therapy. In particular, they focus on treating chronic conditions such as chronic fatigue, chronic pain, chronic bronchial conditions, skin conditions, and metabolic issues such as diabetes, hypertension and obesity. Treatments may include anything from the above areas, for example, herbal baths, fomentations, herbal teas or herbal medicine products, any form of physiotherapy, fitness training, and other movement therapies, and nutritional interventions such as fasting. There are a few other hospitals like this around the country.
While services such as GPs or heilpraktiker are available for herbal advice, a study conducted in 2019 found that 92% of those who used herbal medicine in the previous year had done so by self-medicating. And, only 38% of those informed their doctors of the herbs they were taking (5). This study was based on a survey, and provides some further interesting data on how people use herbs. Most participants used herbs to treat chronic conditions, followed by generally promoting health and to prevent illness. The most common conditions they used herbs for were the common cold/flu infection (65.8%), respiratory problems (61.8%), and gastrointestinal diseases (47.8%).
Interestingly, the biggest source of information people used to learn about herbs and how to use them was the internet, 68% of people reported relying on the internet. But only 25% of people stated that they thought the internet was a reliable source of information. Pharmacists were the second source of information, and are trusted much more (68%). The third frequent source of information was family members and only fourth were physicians. The authors also asked questions around self-evaluated knowledge around interactions and side effects of herbal medicines, which participants tended to rate as low. Overall, they also saw an increase of people using herbal medicine when comparing the data to a similar study conducted in 2010, the overall increase being 26.6%, indicating that the use of herbal medicine is on the rise in Germany.
Conclusion
Perhaps Germany has gone further than many other European countries in its attempt to integrate herbal medicine into its modern healthcare system. The use of herbs and the sale of herbal products is strictly regulated, based on scientific evidence, but this has enabled herbs to enter the healthcare system at various levels. While many physicians remain sceptical of the potential benefit of using medicinal herbs, many are also embracing it, and several clinics offer an integrative service. However, it remains a challenge to produce the same body of evidence for medicinal herbs as there is for conventional treatment, and this remains a problem for the access to herbal medicine.
Additionally, one could argue that the way the insurance system is set up, the use of herbs usually requires patients to pay for treatment and any prescribed herbal medicines, meaning that conventional treatment will often be at a much lower cost to individuals. However, herbs are being used at an increasing rate, and more and more insurance policies offer to cover the costs to access these medicines, further bridging the gap between traditional herbal medicine and modern medicine. This integrative approach not only expands therapeutic options for patients but also reflects Germany’s commitment to a holistic and scientifically validated healthcare system. Due to this integration, there is also a strong drive to commit to further the evidence-based use of herbs.
Between 1980 and 1999 more than 300 clinical studies have been carried out in Germany, focusing on standardised phytopharmaceuticals and the amount of those products on the market is increasing further (6). Through ongoing research and collaboration, Germany continues to set an example for how herbal medicine can be effectively integrated into contemporary medical practice. Though perhaps this integration comes at a cost of individual choice and freedom. Many herbalists in the UK are proud to be making their own medicines, supplying their patients with the herbs they have grown, harvested and processed into tinctures or balms.
Certainly, from an experiential point of view, the link between land, plants and people, could be seen as far more interconnected and shared, and through the astringent regulations and need for standardisation humans would lose some of that personal relationship with the healing herbs. The question is, is it possible to keep the best of both worlds?
References
- Blümel M., Spranger A., Achstetter K., Maresso A., Litvinova Y.,Busse R. Germany: health system summary 2022. 2022
- Eric C., Fields K., Williams II R. D. Mirror, Mirror 2021: Reflecting Poorly Health Care in the U.S. Compared to Other High-Income Countries. 2021
- Heinrich M., Sharma S. K., Suetterle U., Bhamra S. K. Herbal medicine use in the UK and Germany and pharmacy practice – A commentary. 2022
- https://de.statista.com/statistik/daten/studie/238427/umfrage/apothekenumsatz-mit-rezeptfreien-homoeopathischen-und-pflanzlichen-arzneimitteln/
- Welz A. N., Emberger-Klein A., Menrad K. The importance of herbal medicine use in the German health-care system: prevalence, usage pattern, and influencing factors. BMC Health Serv Res. 2019
- Wagner H. Phytomedicine research in Germany. Environ Health Perspect. 1999
