Intersectoral governance for health has long been seen as a “nice to have”- a search for useful win-wins between sectors. In the COVID-19 pandemic, it is critical and occurring virtually everywhere in one way or another.
Public health measures and health system operations depend on a high level of coordination at all levels between different organizations that are often poorly linked to health policymakers, such as police and interior ministries. Very strong central coordination is being established in order to change the priorities of pre-existing bureaucracies across the whole of government. Some, but not all countries have formally declared a state of emergency in order to force rapid intersectoral coordination within government. Among those that have taken this approach, there is some variation in the stage of the pandemic when they have declared a state of emergency. The majority have done so early in the crisis at a time with very few actual COVID-19 cases or deaths, with France and Spain as notable exceptions within Europe (Figure 1).
Figure 1. Stage of the pandemic (reported cases and deaths) on the date that a state of emergency was declared
Here we describe in detail some of the main tools countries are using to shift governance towards more centralized levels (see Table 1 for an overview of countries that have enacted emergency plans and legislation based on a desk review and data from the COVID-19 HSRM).
Table 1. Use of emergency plans and legislation by country
Many countries have passed emergency laws
One tool is special legislation to authorize actions pertaining to the COVID19 pandemic. These laws vary considerably, in large part because of differences in countries’ overall legal frameworks. They authorize governments to take specific actions (e.g. in surveillance or economic policy). In the United Kingdom, an emergency law passed on March 25 grants the British government powers related to restricting movement among infected individuals, prohibiting gatherings and increasing capacity in the health workforce. In some cases, these laws reconfigure decision-making within government. In Germany, the “Act for Protecting the Public (Health) in an Epidemic Situation of National Importance” enacted on March 27 grants the Federal Ministry of Health expanded but timely limited powers related to the provision of pharmaceutical and medical devices or the strengthening of the health care workforce. In Spain, a Royal Decree declaring the State of Emergency grants full responsibility to the Spanish government to implement COVID-19 related measures. In non-federal countries, emergency legislation either empowered the Prime Minister (Estonia) or the Minister of Health (Israel, Denmark) to lead the response to the pandemic. In some cases, these laws have justifiably raised serious concerns about their duration and effects on the rule of law. A subset of countries did not issue emergency legislation at the national level, including, Lithuania, the Netherlands, and Serbia. These countries grounded their response to COVID-19 on preexisting pandemic action plans and laws. The pace and timing of these emergency measures varied significantly from a country to another, with a subset of states issuing emergency plans or regulations as early as January (Romania, Georgia, Israel and Kyrgyzstan) while the vast majority of countries enacted emergency legislation in March.
New committees responsible for coordinating governance at a centralized level
A second tool, often found in special COVID-19 legislation or existing law, is the creation of a coordinating committee that enhances intersectoral governance by centralizing authority in a body that represents the key sectors involved in response. Most countries have established or activated such a body, led by top politicians or their delegates. The Russian government established a Coordination Council led by the Prime Minister and the Mayor of Moscow to coordinate all actions at the federal, regional, and municipal levels. Non-federal countries created different types of institutional designs to coordinate the response, such as special government emergency committees (Lithuania, North Macedonia, Ukraine, Finland), an Operational Intersectoral Headquarter (Serbia) or an interagency working group led by the Minister of Social Affairs (Estonia). A subset of countries empowered preexisting entities, such as the Croatian National Civil Protection Authority or the Dutch National Institute for Public Health and the Environment, which became the main coordinating actors in the national response to COVID-19.
Important decisions are being shifted to heads of government
A third tool, still common but often less formal (i.e. without specific legislation), is the centralization of key decisions and priorities in the head of government’s office. All government contains a latent hierarchy that allows different ministries and ministers some latitude in normal times but controls them much more tightly in crises. Heads of government are mostly taking a serious interest in COVID-19 response, and using their power to force intersectoral coordination and reprioritization. In Canada, Estonia, Finland, France, Israel, Serbia and Ukraine, the pandemic response is led by the Prime Minister’s Office. In other countries, such as the Czech Republic, Greece, Lithuania and Slovenia, the Minister of Health is at the forefront of the governmental response to COVID-19. Finally, heads of government work in tandem and share equal responsibility with Ministers of health in a subset of countries, including Estonia, Lithuania, Latvia and Malta.
Where key decisions have been centralized at the highest level of government, several heads of state either involved universities (Finland, Israel) or set up ad-hoc scientific committees (France, Estonia, Ireland, Netherlands, Serbia) that advise them on the public health measures that should be adopted. National public health agencies and ministries of health remain the main sources of scientific decisions in several cases, such as Israel or North Macedonia.
The pace of centralization occurs more slowly in some countries than others
Also of note, some countries more gradually substituted a regionalized approach for a more centralized response to the pandemic. The Dutch authorities coordinated the response at the regional level, but then scaled it up to the national level as the outbreak intensified. Although responses differ at the subnational level in Denmark and Germany, their central governments were granted expanded powers to lead the national response to COVID-19.
Centralization of functions occurs not only across government but also within health systems
Finally, in addition to intersectoral coordination, governments are also centralizing activities within the health system. Spain and Ireland temporarily have assumed control over their private hospitals. France seized all available supplies of face masks. A number of countries approved fast track procedures for the authorization of drugs and medical devices, including Canada, Ukraine and North Macedonia. Others lifted or simplified public procurement rules, such as Latvia, Malta, Poland, Romania and Russia. Italy has a highly decentralized health system. However, there have been rapid changes in health governance with the involvement of the central state and the activation of the Department of Civil Protection (although Italian regions still retain decision-making autonomy regarding the delivery and organization of health services).
Governance changes are happening all over
In addition to these tools operating within individual governments, there are also changes in the relations between governments, as with the relations between central, regional, and local, or between different governments of the same tier (e.g. between regional governments within a country). The coordination and centralization mechanisms that we identify here naturally have spillovers and change the possible problems and solutions in coordination at other levels.
Scott Greer, Holly Jarman, Sarah Rozenblum, Matthias Wismar