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Primary school (Grundschule) is compulsory education that begins at age six and goes on for four years. Students who have completed elementary school can choose their future career and school type while attending the fifth and sixth grades.

Secondary school consists of lower, intermediate, and upper secondary school. Lower secondary school (Hauptschule) provides the basic knowledge everyone needs, and about 20% of Grundschule graduates attend this school. After ninth grade, they move on to vocational training (Ausbildung), and while receiving it, they can enter part-time or full-time vocational school.

Intermediate secondary school (Realschule) is a school between Hauptschule and Gymnasium (see below) that prepares students for intermediate-level jobs in economics and administration. It is a six-year program, and after graduating tenth grade, students go on to full-time vocational school (Berufsfachschule) or specialized upper secondary school (Fachoberschule), where they receive upper-level vocational training, or go on to university by transferring to upper Gymnasium level (Gymnasium Oberstufe).

Upper secondary school (Gymnasium) is attended by about 50% of students who complete Grundschule, and it is a traditional academic school for students aiming to go to university. The Gymnasium of the former West Germany had a nine-year program from the fifth to the 13th grade. Moreover, students in 11th to 13th grade, the Gymnasium Oberstufe, mostly select courses that suit their aptitude or interest except for a few required courses. They can select and prepare for the field in which they plan to specialize, which helps them study for their university major in advance. Before graduating Gymnasium, students take the Gymnasium graduation examination to meet university admission requirements, which is called Abitur.

Comprehensive school (Gesamtschule) is a school that combines Hauptschule, Realschule, and Gymnasium, with curricula for the fifth to tenth grades. It was established to solve the problems that may occur when students decide on their career paths when they are too young.

University, which is an institution of higher education, includes General University (Universität), Technical University (Technische Universität), University of Education (Pädagogische Universität), University of Arts (Kunsthochschule), University of Music (Musikhochschule), University of Applied Sciences (Fachhochschule, Hochschule), and Comprehensive University (Gesamthochschule), which combines technical and general university. There are no entrance quota limitations except in a few departments. Before the EU integration, diplomas in Germany were classified into Diploma, Magister, and Doctor, and students could proceed to the Doctor program after completing Diploma or Magister.

The EU countries each had their own unique higher education systems, which was why in 1999 the Ministers of Education gathered and agreed to promote the international exchange of students and researchers by establishing a diploma system used throughout Europe, and to secure qualitative excellence in education. This consensus was classified into six categories, such as reform of the school system, ensuring of the quality of higher education, equal opportunities of higher education, higher education achievement levels and employment, lifelong learning, and international exchange.^[9] Through this consensus, Europe implemented a standard credit scheme through the credit transfer system among universities, and introduced the National Certification System to ensure the quality of university education so that students could get a diploma in any of the countries. Higher education in Europe had a diploma standardization system established through a credit transfer system called the ECTS (European Credit Transfer System).^[10] The ECTS enables students in EU countries to have the credits they earned by one evaluation standard approved by and transferred to the others, thereby promoting the academic exchange of students within Europe. With this agreement, the higher education system in Germany was reformed into three years for Diploma, two years for Magister, and three years for Doctor.

Germany has various vocational education systems, because students can choose their occupations at a very early age compared to Korea. Aside from the traditional dual education system (Duale Ausbildung), there is also vocational education focused on school.^[11] Those receiving vocational training are students who completed the first level of secondary education-adolescents not attending Gymnasium or other educational institutions. There are various types of vocational schools, and those providing vocational education include vocational schools (Berufsbildende Schule), full-time vocational schools (Berufsfachschule), specialized upper secondary schools (Fachoberschule), and vocational upper secondary schools (Berufliches Gymnasium), which have different names depending on the regulations of the education law by the state governments. At vocational schools, students can complete secondary-level programs. Among these schools, the highest percentage of students attend Berufsfachschule. The curricula provided by Berufsfachschule are mostly for occupations defined at the level of each state government, with assistant jobs in various specialized fields. These curricula are for two to three years, and students must have a diploma for first-level secondary education to be admitted by these schools. Here, the two-year curriculum is to obtain the entrance qualifications for technical universities, and the three-year curriculum is a comprehensive program (Fachhochschulreife, Allgemeine Hochschulreife) to obtain the entrance qualifications for both dual vocational training and technical universities (Fachhochschule, Hochschule). In other words, the business commercial management assistant program certified by the government is a full-time program carried out at a full-time vocational school for two years, and students can also obtain the entrance qualifications for general universities in specialized fields or for other technical universities. The key element of vocational training in Germany is the dual educational system and vocational school. The place for vocational training in the dual education system (Duale Ausbildung) is vocational school (Berufschule) and enterprise (Betrieb). The learning spaces in the vocational school are classrooms, workrooms, and laboratories, and in the enterprise it is workplaces, offices, and laboratories, or lectures in a company. Duale Ausbildung is strictly based on industrial cooperation in which the enterprise is in charge of on-the-job vocational training, while vocational schools provide theoretical knowledge related to the major. Students receiving vocational training with Duale Ausbildung receive training at the enterprise three to four days a week, and at the vocational school for one to two days. Enterprises cover the expenses required for training, and pay the training support to fund the trainees according to the wage negotiation rules in each occupational field. This fund is about one-third of the first month’s salary of a specialized profession on average. The graduation examination for Duale Ausbildung is divided into theoretical and practical training. After obtaining the certification, students can build their career in their specialized profession through continuing education, obtain a license as a Meister or business manager through the next-level curriculum in the scope of the national certification system, or seek promotion or a higher position in specialized fields. Dual study (Duale Studium) is a curriculum that includes the training period at the enterprise within the university study plan. Education is provided in two places, just as in Duale Ausbildung: theoretical learning at the university, and practical training at the enterprise. The contents of education are closely linked to each other. Duale Ausbildung does not have formal entrance standards, whereas Duale Studium has university entrance requirements.^[8]

In general, AO is a certification obtained by students who graduated from secondary school, received Duale Ausbildung for two to three years, and took the examinations.^[8,11] Students can receive training only where there are AMs to educate the trainees. For three years, Augenoptikergesellen (journeymen) learn management, communication, the preparation of eyeglasses for vision correction, and the effects and characteristics of optical devices. To participate in the program, students must have qualifications for secondary education and higher (mitterlerer Bildungsabschluss) or full-time vocational school (Fachhochschulreife). In 2017 there were approximately 6,845 Augenoptikergesellen in all education institutions (including the 33 Berufsschulen für Augenoptiker), excluding universities.^[12] They cannot open an optical shop with the certification obtained after the Augenoptikergesellen curriculum, but they can be employed for work. To open an optical shop, they must complete higher education and be registered as AMs.

There are 38 educational institutions, and there is no limit to the number of students enrolled.

The conventional way to enter the optical industry is to become an AM. The AM is generally characterized by three core jobs: a specialist for optometric services, an entrepreneur, and a supervisor of trainees. Basically, Meister is a title earned after successfully completing the AM examination, not a curriculum. Due to the complexity and difficulty of the examination, many institutions provide courses-part-time, full-time, or block instruction-to prepare for the final examination. In general, the courses take about 12-30 months. The contents of education follow the regulations of the AM examination (Augenoptikermeisterverordung), consisting of theoretical and empirical knowledge as well as experience in the fitting of eyeglasses and contact lenses, subjective and objective refraction, and testing and decision-making for vision defects and dysfunctions. In addition, courses in economy, commerce, communication, and pedagogy are also provided. These courses are provided at education centers such as ZVA and the education center of the optometrists’ guild in Hankensbüttel.^[3,14] There are 18 institutions providing these curricula.

Due to the long regional administration and influence of guilds, there is the Staatlich geprüfter AO certification, which is a regional optometrist certification. Courses to become Staatlich geprüfter AOs require, at minimum, a secondary education at a special institution (Fachschulen) for Augenoptikergesellen. The Handicrafts Code was amended in 2004 and this is no longer mandatory, but an additional year of field training is required to enter this curriculum. Four institutions, in Cologne, Munich, Jena, and Diez, provide these courses. The study period is generally two years, complete with a final examination prescribed by the state government and the AM examination. Since education is based on the curriculum controlled by regular performance measurements, the title of Staatlich geprüfter AO has a higher level than traditional AMs. Thus, one might assume that there is a difference in job performance due to the diversity of the training process between the two certifications, but actually there is no difference.

A typical Meister institution has no restrictions on the admission quota. However, Staatlich geprüfter AO schools have a limited admission quota.

There are three ways to earn the title of optometrist. The first is to receive education at an ZVA academy run by AMs and take the examination. Since 2010, ZVA has provided continuing education for Weiterbildungsangebot Optometrists (HWK), targeting Meisters. The second way AMs can obtain the optometrist title is through continuing education at Fachhochschule or Hochschule, or through a university associated with ZVA. The third way is to graduate from the University of Applied Sciences (Fachhochschule or Hochschule) to earn a Bachelor of Sciences in Augenoptik/Optometrie. The bachelor’s degree program generally takes six to seven semesters, including one semester of internship. The bachelor’s degree itself can be considered the certification of optometrists. The curriculum follows that of the ECOO (the European Council of Optometry and Optics)^[15] and ECTS (the European Credit Transfer and Accumulation System).^[10]

Currently there are seven universities of applied sciences providing curricula. These curricula aim for British optometrist and ECOO degrees, including the AM examination and optometry courses. This higher education requires qualifications such as Abitur in addition to perfectly completing the program as an Augenoptikergeselle. ZVA provides bachelor’s degree programs for students who do not have the right qualifications. If students with these bachelor’s degrees join the Handwerkskammer, they have equal rights to the AM designation as craftsmen do. Table 3 shows the baccalaureate institutions of Augenoptik/Optometrie (except for Technische Hochschule Lübeck and Technische Hochschule Brandenburg).

In addition, the European Diploma in Optometry was established in 2000. It is offered by a range of accredited universities and institutions throughout Europe, allowing students to graduate with the European Diploma in Optometry alongside their degree or diploma.

Germany has various training programs to nurture specialists after being qualified as AOs, AMs, or optometrists. The aforementioned optometrist program is a post-graduate program for those with field experience or an AM-level background. This content is expanded beyond the scope of AM examinations, with a focus on courses such as slit lamp examinations, ophthalmoscopes, screening tests, and ocular anatomy and physiology. Moreover, students may also receive more advanced or intensified biomedical education. They also require training as optometrists according to Europe and the World Council of Optometry (WCO).^[16]

Universities in Jena, Aalen, and Berlin are running master’s programs in optometry and vision sciences for students with a bachelor’s degree, which generally take three semesters. They are striving to provide high education quality in cooperation with optometry schools overseas. Candidates with a bachelor’s degree, AO, or AM can participate in seminars and courses provided by ZVA, and can receive advanced education and specialist training in fields such as sports vision, contact lenses, and low vision. Table 4 shows the education flow chart for AO, AM, and optometrist.

As such, this study examined the basic education systems in Germany and the education systems to train specialists in optometry-related occupations. Specialists in optometry can take various curricula with different job scopes, and have opportunities to receive more advanced and higher education. There are more and more education institutions and graduates in optometry due to an increase in the number of people with visual dysfunction and ametropia, which results in regionally even distribution of optometric specialists, optical shops, and clinics. Thus, people can receive eye health services for free in many different regions. Moreover, with the inauguration of the EU, Germany adopted a standardized optometry education system and is striving to train and produce optometrists. Germany also provides standardized university education through continuous education, targeting AOs and AMs, thereby striving to nurture optometrists and expand the job scope.

Currently, ophthalmologists, AMs, and optometrists are the ones providing primary eye health services in Germany. In this system, the AMs and optometrists send the patient to the ophthalmologists if ophthalmological abnormalities are discovered in patients during an eye examination. This system was not established in a short period of time. The prescription rate of eyeglasses for vision correction by AMs in 1972 was only about 5%. However, by 1996 the rate of prescriptions by AMs and optometrists had grown to 45%, and by ophthalmologists to 55%, and by 2016/2017 it had grown to 82% by AMs and optometrists, but only 18% by ophthalmologists.^[16] This change began in 1972 because of the decision to allow AMs and optometrists to perform refractions, internal and external eye examinations, and in 2000, glaucoma and screening tests as well.^[17] These decisions are made to contribute to the improvement of eye health for the people, not for the benefit of a certain organization or group.

Concerning the range of activities performed by AMs and optometrists, it is notable that they offer health services (such as subjective or objective refractions, or screenings for glaucoma) rather than simply handicraft services. However, the allocation to the handicrafts sector restricts the performance of medical activities, such as the diagnosis or treatment of eye diseases. Only the detection of eye health abnormalities is allowed, without medical assessment. This restriction is the main reason for several attempts by the ZVA to release the Augenoptiker profession from the handicraft sector and establish it as a healthcare profession. These tendencies have been accompanied by initiatives to acknowledge the optometric profession officially in the German eyecare system, with an independent law for optometrists.^[18]

Ametropia and glaucoma are classified as diseases in Germany as well. However, at optical shops, many patients receive free examinations such as refraction, examinations for contact lenses, visual function examinations, and screening tests. This is in line with the reform of health insurance in Germany. Financial support for optical devices for vision correction was abolished in 2004 with the reform of health insurance. In general, health insurance does not cover refractions for optical devices for vision correction even when it is prescribed by ophthalmologists.

Both professions perform primary eyecare services to an appreciable extent, and for the patient, there is no formal difference with regard to access to care. Regarding the costs of optometric and ophthalmologic services, in the statutory health insurance (SHI) program, financial support for optical appliances was widely abolished with the healthcare reform of 2004. Consequently, the share of costs borne by the statutory health insurers decreased from 16.4% in 2003 to 1.3% in 2009.^[19] Moreover, since AM is an occupation that follows the Handicrafts Code and there are no laws supporting optometrists, health insurance does not cover overall eye examinations or other services provided by AMs and optometrists.

According to the Korean Ministry of Health and Welfare,^[20] there are 2.1 doctors per thousand of the Korean population, which is half the number (4.4) in Germany. In addition, the annual number of medical checkups by doctors per capita in Korea was 14.9 in 2014, which is the highest level among OECD countries. This is 2.2 times the OECD average (6.8 cases). In 2017, the number of AMs and optometrists in Germany was 48,400,^[16] and the number of ophthalmologists was 7,497,^[21] while the number of optometrists in Korea was 42,398^[22] and the number of ophthalmologists was 3,236.^[23] The ratio of ophthalmologists to population is 9.1 (Germany)/6.3 (Korea) per hundred thousand, and that of optometrists is 59 (Germany)/82 (Korea). As such, Germany has many more ophthalmologists and fewer optometrists per capita than Korea. However, the ratio will be similar if the number of optometry university graduates in Germany is added. In 2014, among adults aged 18 and above in Germany,^[16] the rate of wearing eyeglasses was approximately 50% (excluding age 60 or above), and the rate in Korea was approximately 55.4% in 2015.^[24]

As such, Germany has a lower rate of wearing eyeglasses than Korea but is still producing more ophthalmologists, AMs, and optometrists per capita than Korea. However, Germany is trying to expand the job scope of AMs and create new optometrist jobs. This is due to the change in the social perception of optometric specialists. Recently, in a reliability survey about AMs and optometrists, about 74% of respondents gave them scores of between 8 and 10 (out of 10).^[16] This is direct evidence of the fact that people trust AMs and optometrists. Of course, they have been gaining national trust as craftsmen for a long time, but what is gaining national trust more than anything is the process of expanding the job scope, as well as the changes in practical curricula to provide a greater variety of eye health services for the people, along with social changes. This national trust is increasing the possibility of expanding the job scope of AMs and optometrists by acknowledging them as health personnel instead of craftsmen. In Korea, the ratio of examinations for vision correction instruments is 66.2% for optical shops and 28.3% for ophthalmologists. And according to a survey by the Korean Optometric Association (2017), 46.5% of respondents referred to Korean optometrists as ‘sellers of eyeglasses, sunglasses, and contact lenses’. The reality is that almost half the people perceive optometrists more as vendors than as eye test specialists (26.7%) or eye health specialists (12.5%).^[25] This result is due to the lack of legal and administrative support, which falls behind the trend.