Germany's e-health card: 15 years, €606m of agency spending, almost no working uses

Germany wrote the electronic health card (eGK) into law in the GKV Modernisation Act of 14 November 2003. In 2005 it handed the project to gematik, a company owned jointly by the health system's self-governing bodies - insurers, doctors, dentists, hospitals and pharmacies - and froze the technical architecture in statute: a card-based system on a two-key principle, untouched since 2005, as the Federal Court of Audit (BRH) later noted.

Delivery stalled behind governance. An EU-wide tender in 2013 ended with single suppliers; certified connectors came only in November 2017. By October 2018 about 30,000 of 170,000 practices were connected; no hospital or pharmacy was. Beyond insurance master data, the card offered nothing. Sanctions - a 1% fee cut due January 2019 - were postponed repeatedly. Financing quarrels went to arbitration, and the government conceded it could not quantify what the programme had cost. gematik's own spending reached €606m by 2017.

In a report to the Bundestag budget committee on 18 January 2019, the BRH found the card gave 'no concrete added value for providers and insured', blamed the shareholders' conflicting interests for serial delay, and recommended breaking gematik's all-purpose mandate in favour of top-down decisions by the health ministry. gematik publicly rejected the charge that it was the brake, pointing to specifications delivered on time.

gematik alone spent €606m to 2017 and Berlin could not total the bill; by Oct 2018 only 30,000 of 170,000 practices were connected and no online application was live

The 2005 structure gave every interest group a veto and no one ownership; the law's own justification admitted that the multiplicity of players and the unanimity rule had blocked decisions.

The architecture was frozen in statute - card-based, two-key - leaving no room to adopt cheaper or newer technology as the project aged.

After the 2013 EU tender, gematik depended on single suppliers for connectors; certification dragged to November 2017 and hospital high-speed connectors failed requirements outright.

Spending had no owner: costs sat with insurers, providers and the ministry, financing terms went to arbitration, and nobody in government could state the total programme cost.

Consensus governance is a schedule bomb: one project run by every interest group, with unanimity and no single owner, buys deadlock. Someone must be able to decide - and answer for it.

The audit office's recommendation pointed to exactly the governance change critics had demanded. The electronic patient record (ePA) eventually launched on 1 January 2021 as a voluntary offer for 74 million statutorily insured, with functions to follow step by step; uptake stayed weak, and by end-2022 a relaunch with more functions was planned for 2023. gematik remained the system's specification authority.