Federalism is the kind of unavoidable reality that shapes every element of public health policy and politics in federal countries.
Federal countries have large, general-purpose, elected governments with legislative capacity and, for our purposes, a significant role in health care or public health. That means Austria, Belgium, Canada, Germany, Italy, Spain, Switzerland, and the United Kingdom, for example, are clearly federal even if lawyers might disagree.
We reviewed the federations included in the COVID-19 Health Systems Response Monitor (HSRM) monitor to understand the particular challenges, and responses, of federal countries.
Federal countries face distinctive coordinating challenges. Elected governments of different regions, and often different parties, can have different priorities and ideas, might not appreciate coordination, and might compete for resources and try to blame other governments for apparent problems. Intergovernmental coordination is a constant focus of policy and politics in any federation, but the scale of this crisis creates novel problems, e.g. of who decides whether people can travel across regional borders within countries, or who decides how to respond to regionalized outbreaks as countries reopen. Policy diversity is often a strength of federal systems, permitting adaptation to local circumstances, defusing conflict, and allowing learning and experimentation, but that diversity still leaves significant coordination challenges if health policies and the body politic are not to be harmed. How have federations dealt with, and changed, in the COVID-19 crisis?
Federations face particular challenges
Coordination challenges appear in all of the major areas of COVID-19 response. Table 1 identifies key areas. Governance refers to decision-making: the general procedures that governments within a country use to make and implement decisions. In many cases, regional autonomy has been somewhat curtailed, though many of the measures curtailing regional autonomy are temporary. In terms of preventing transmission, which means mechanisms such as physical distancing and surveillance, regional autonomy has mostly remained. This might reflect the fact that regional governments often are the ones with resources such as contact tracing staff or police. Notably, some countries such as Spain and Belgium, which have complex territorial politics, have at least temporarily centralized the acquisition of personal protective equipment (PPE). In ensuring sufficient physical infrastructure and workforce capacity, insofar as there is a pattern it is one of persisting regional autonomy or of central governments acting unilaterally (e.g. by easing restrictions on professional mobility). In efficient health care service provision, likewise, there is a mixture of centralization and regional diversity. In both of these areas, there is a strong case for regional autonomy and regional governments empirically have resources on the ground, but they might lack the ability to coordinate for efficient patient flows without central direction or might not command elements of the legal infrastructure (such as professional regulation) necessary to optimize responses. Finally, and very strikingly, we did not find change in health financing outside a fairly limited change in Belgium. This might make sense in social insurance systems, where there is often some distance between social insurance funds and regional governments, but it is an area to watch. In general, there is more political responsiveness in Berveridgean national health service (NHS) model systems such as Spain, the United Kingdom, Italy, and Canada, where substantial health expenditures come out of general government budgets and where unexpected health challenges can create unexpected problems. In general, as with much of health politics in federations (open access PDF) beneath the confusion there is a basic rationality at work, with central governments handling issues that require large risk pools and regional ones issues that handle local knowledge and resources. Strikingly, we found no case of change in the basic territorial politics of entitlements, which is important. If regional governments did not take the opportunity of the crisis to restrict benefits, and instead expanded them, that will have good effects on public health, including avoiding avoidable new outbreaks.
Most governments, regional or central have centralized internally (within governments, e.g. in task forces and the head of government’s office, at the expense of ministerial autonomy). The picture is considerably more mixed with regards to federations and whether there is a pattern of cooperation and coordination between regional governments (in some cases orchestrated by the central government), centralization of power in the central government, or continued regional diversity, which will be discussed below. These three broad trends occur in different combinations, in different countries and policy areas.
Coordination matters a great deal in federations
Given that federations do have clear coordination problems, how do they deal with them? One way is voluntary cooperation in which regional governments identify and solve shared problems among themselves or with the central state guidance or control. In Italy, each region adopted its own approach to testing based on national and international recommendations but as testing capacity greatly varied by regions, national guidelines were issued by the central government to outline the basic criteria for testing. With respect to protective equipment, the German federal government delivered stocks of PPE to the Länder, which were responsible for allocating and distributing the material to regional health care providers. As for Spain, the transition strategy was released in late April and was meant to be coordinated with the Spanish regional authorities. Finally, regarding inner border closure, the Austrian state governments were in charge of executing decisions taken at the federal level, but were also free to apply stricter measures, such as quarantine for smaller regions severely hit by the crisis.
The second way is centralization of powers and functions in the hands of the central state. This can be for immediate functional reasons, e.g. to acquire supplies at a better price and coordinate logistics, or to reduce popular confusion about closure and reopening measures. In Germany, the “Act for protecting the public health in an epidemic situation of national importance” granted the Ministry of Health (MoH) expanded but temporary power. The federal MoH was consequently authorized to take measures regarding the provision of pharmaceutical and medical devices and to strengthen the medical workforce. These new powers will, however, expire on 1st April 2021. In countries with particularly difficult central-regional politics, the question of whether centralizing measures will be temporary or permanent is obviously charged and has not been entirely resolved. In Spain, a Royal Decree declared a state of emergency on 14 March and put all publicly funded health authorities under the direct order of the Ministry of Health. The Spanish MoH was therefore temporarily entitled to implement COVID-19 related measures across the whole country. In Italy, a country whose health care system is highly decentralized, the MoH issued a series of regulations increasing the availability of health professionals and requiring all regions to increase health care capacity. In most cases our data does not show any change to the formal role of local government. Few clearly permanent changes have been made to federal arrangements; this might be a data limitation but, if true, it is an interesting contrast to the centralization seen in some federations due to the global financial crisis of 2008-2012.
The third way is continuing regional diversity and autonomy when there is a case for local implementation and decision-making or when the political situation makes coordination or centralization unrealistic, resulting in a variety of responses. Despite the increased role of the central government, Italian regions still retain decision-making autonomy regarding the delivery and organization of health services, such as whether to conduct COVID-19 tests in the entire regional population or whether to suspend or maintain medical services, such as surgical procedures. In Spain, although all publicly funded authorities are temporarily supervised by the central government, regional and local public health administrations still retain operational management of health services. Swiss cantons are free to organize the cantonal response to COVID-19, which has led to great variation in the organization of testing and treatment across regions. In Germany, measures to expand the workforce involved in treating COVID-19 patients were instigated by individual hospitals, cities or regions, with limited overall coordination and planning at the federal level.
What can help improve coordination in politically diverse systems?
Determining which approach is most helpful in solving a particular problem can be difficult and there will inevitably be recriminations, credit-claiming and blame games later. Scholarship on intergovernmental relations generally suggests that transparency about decisions, informal conversation and coordination between officials and ministers, and reliable data all make accidents less likely and enable effective coordination and alignment even in countries where relations between governments are usually highly conflictual. It further suggests that aligning powers and responsibilities produces better outcomes, and that there are actually not that many distinctive ways to operate a sustainable federation. Finally, it suggests that while crises can create both unusual conflict and cooperation, political incentives shape the extent to which any given mechanism can work. This most often means political party systems, which can incentivize cooperation between politicians in different governments, or can equally make coordination hard and blame more likely.
Scott Greer, Sarah Rozenblum, Matthias Wismar, Holly Jarman