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The German healthcare system is meaningfully shaped by the principle of self-governance. While in other countries, e.g., Great Britain, healthcare is (centrally) regulated by the state, the German system is based on the self-responsibility of its stakeholders. The state provides the statutory framework. Concrete design and implementation are the responsibility of the stakeholders. Self-governance consists, on the one hand, of insured individuals and contributors, represented by the National Association of Statutory Health Insurance Funds and its member health insurers. on the other hand, the healthcare providers and their organisations are represented by the Federal Association of Statutory Health Insurance Physicians, the Federal Association of Statutory Health Insurance Dentists and the German Hospital Association. These parties, in turn, are organised in the highest decision-making body of self-governance in the healthcare system, the Federal Joint Committee. The Federal Joint Committee determines, in the form of resolutions and guidelines, which medical services can be claimed by insured individuals in Germany and lays down measures to ensure quality in practices and hospitals. The relevant patient organisations are also represented in the Federal Joint Committee. However, they only have the right to petition-, not to vote (Federal Joint Committee 2020).

The details of the remuneration of medical and psychotherapeutic services in the uniform evaluation standard are also the subject of the negotiations of the so-called federal framework agreements between healthcare providerss and health insurers and their associations.

In addition, there are structures in the federal states. The Association of Statuory Health Insurance Physicians (KV) as well as the Chambers of Physicians and the Chambers of Pharmacists are organised by federal state, plus a second structure for the state of North Rhine-Westphalia (e.g., the Association of Statutory Health Insurance Physicians of the North Rhine and the Association of Statutory Health Insurance Physicians of Westphalia-Lippe). There is also a hospital association for each federal state. The Association of Statuory Health Insurance Physicians negotiates the total remuneration for its members (physicians and psychotherapists) for the district of the KV concerned. As a result, the effective levels of flat rates reimbursed for outpatient care can vary from one federal state to another. They have the mandate to ensure nationwide care, regulate on-call duty, and participate in questions of licensing. The above-mentioned chambers decide, on the professional regulations for physicians, which means that, for example, exclusive telemedical treatment is still prohibited under professional law in Brandenburg, while all other chambers have made changes to professional law in other states.

In Germany, it is not a central, state agency that decides on the design of healthcare; instead, the stakeholders—in part at the level of the individual federal states—are responsible for their own actions.