WHO'S IN CHARGE AND WHY? - CENTRALISATION WITHIN AND BETWEEN GOVERNMENTS
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Governance 99
WHO’S IN CHARGE AND WHY?
CENTRALISATION WITHIN AND
BETWEEN GOVERNMENTS
By: Scott L. Greer, Holly Jarman, Sarah Rozenblum and Matthias Wismar
Summary: Successful response to the COVID-19 pandemic requires
coordination within and across governments. Within governments,
heads of governments gathered together power and authority early
in the response, concentrating power and energy at the centre of
government. Across governments, different governments adopted
differing approaches to coordinating pandemic response between
central governments, regions, and local government. In many cases,
policy was temporarily centralised in federations, with the central
government making more policies than usual. In the second wave,
there seems to be less centralisation, particularly in federations, and
regional or local governments are more prominent.
Keywords: Centralisation, Federal countries, Governance, COVID-19, Executives
Cite this as: Eurohealth 2020; 26(2).
Public health planners have long argued government, from a town hall to a country
for a “command and control” approach – gathers together the power normally
to pandemics. 1 Governments almost dispersed across different ministries,
Scott L. Greer is Professor of Health
Management and Policy, Global universally adopted that approach early politicians, and agencies. The other is
Public Health and Political Science in the pandemic. The result was that for a between governments. In this case, power
by courtesy and a member of the few months in 2020, politics looked very that is normally in the hands of one
HMP Governance Lab, University
of Michigan, Ann Arbor, United
different in many countries. Policymaking government, such as a local government,
States and Senior Expert Advisor on became far more centralised and or regional governments such as Italian or
Health Governance to the European hierarchical than usual, with less regional Spanish regions or the states of Austria or
Observatory on Health Systems
and Policies, Brussels, Belgium;
and ministerial autonomy and more Germany, shifts to the central government.
Holly Jarman is John G. Searle empowered heads of government. Normal
Assistant Professor of Health politics is slowly returning, even as the Both kinds of centralisation were at work
Management and Policy and head
pandemic continues. The challenge is to across Europe in spring and summer 2020.
of the HMP Governance Lab,
Sarah Rozenblum is PhD student, learn lessons about ways to coordinate Within government, heads of government
Department of Health Management during and after a health crisis that are centralised power at the expense of
and Policy, and a member of the sensitive to the complexities of politics. ministerial and agency autonomy,
HMP Governance Lab, University of
Michigan, Ann Arbor, United States; whether by running policy directly, by
Matthias Wismar is Programme There are two different kinds of empowering ministers, or by working
Manager, European Observatory centralisation visible in the pandemic so closely with existing agencies. Hands-off
on Health Systems and Policies,
Brussels, Belgium. Email: slgreer@
far. One is within governments. In this approaches were seemingly not politically
umich.edu case, the head of a government – any viable for heads of government. In
Eurohealth — Vol.26 | No.2 | 2020100 Governance
intergovernmental relations, the response intersectoral governance by centralising variation is in how much attention and
in many countries was a degree of authority in a body that represents the respect generalist government gave
centralisation as well as an unusual degree key sectors involved in response. Most them. What kind of status, organisation,
of coordination, but basic constitutional countries have established or activated and strategies led to a prominent place
mechanisms and political incentives are such a body, led by top politicians or for established public health agencies
hard to override for long, and countries their delegates. The Russian Federation and actors in these newly centralised
with problems of intergovernmental government established a Coordination governance approaches? In some cases,
conflict, blame shifting, and poor Council led by the Prime Minister and the the public health agency was firmly in
coordination started to see them re- Mayor of Moscow to coordinate all actions the lead, as in South Korea. In others, it
emerge quickly. at the federal, regional, and municipal was side-lined, firmly subordinated to
levels. Non-federal countries created political leaders, as in France, or even – as
different types of institutional designs to in England – eliminated and folded into a
Centralising within governments:
coordinate the response, such as special new agency with little warning.
taking control of the COVID response
government emergency committees
at the top
(Lithuania, North Macedonia, Ukraine, The most globally visible case to diverge
In early March 2020, COVID-19 moved Finland), an Operational Intersectoral from this pattern was Sweden. Sweden has
from being a public health or health Headquarter (Serbia) or an interagency an unusually high level of legal autonomy
ministry problem to being, in every sense, working group led by the Minister for its government agencies. Legally and
a whole of society problem requiring (at of Social Affairs (Estonia). A subset politically, the Swedish prime minister
least) a whole of government response. of countries empowered pre-existing or health minister have relatively limited
Furthermore, it was clear that citizens entities, such as the Croatian National power over its public health agency, and
were looking to their governments, and Civil Protection Authority or the Dutch only at a high political price could they
that the political stakes of success and National Institute for Public Health and instigate conflict by publicly contradicting
failure were enormous. the Environment, which became the it. This enabled the Swedish public
main coordinating actors in the national health agency, led by its high-profile
In country after country, heads of response to COVID-19. state epidemiologist, to pursue a strategy
government reacted by taking control of unusual in Europe of limited constraint
responses, on their own or with the health on mobility. What is interesting here is
Specialist and generalist government
minister. De facto power moved from whether a country with a less autonomous
have had their objectives aligned
ministries to the head of government, public health agency would have chosen a
often working through a special task We can take away a general point. Most of different route. It is intriguing that in the
force or sub-cabinet. In some countries, government, including health ministries, one high-profile European country where
this meant the health ministry was highly is what Daniel Fox calls “specialist the public health agency was autonomous
visible and important; in others, the head government.” People in it specialise and led the response, the chosen response
of government clearly dominated. At in particular issues and advocate for was so polemical.
least 21 European region countries passed attention to those issues. A smaller and
emergency legislation. more powerful segment of government,
Centralising between governments
typically around the head of government
As the first wave of COVID-19 spread and the finance ministry, is “generalist There are many merits to federalism and
across Europe, the day to day response government.” Generalist government’s key decentralisation. For example, one virtue
was frequently centralised through job is to make the trade-offs between goals is that it means a layer of governments
different tools. As reported in our previous and sectors – between health and education that can take action to compensate for
policy snapshot, 2 in Canada, Estonia, spending, between taxation and spending unconstructive behaviour by the central
Finland, France, Israel, Serbia and levels, or between legislative priorities. As government (as we have seen in a number
Ukraine, the pandemic response was led Fox writes, “Most practitioners of public of the world’s big federations). 4 But
by the Prime Minister’s Office. In other health in government are, by definition, policymaking in a decentralised country
countries, such as the Czech Republic, specialists. To succeed in the politics of is harder, with more need for coordination
Greece, Lithuania and Slovenia, the making and implementing policy they and less unity because governments
Minister of Health was at the forefront of must earn and maintain reciprocal loyalty can be of different political colours. In
the governmental response to COVID-19. with generalists.” 3 some cases, as with the current Scottish
Finally, heads of government work in and Catalan governments, they do not
tandem and share equal responsibility In the case of COVID-19, a public health even agree with the central state on its
with Ministers of health in a subset of issue had the undivided attention of legitimacy. Formally unitary states are
countries, including Estonia, Lithuania, generalist government for a very long time. not exempt from the need to coordinate.
Latvia and Malta. A second tool, often Unsurprisingly, generalist government Local governments are often politically
found in special COVID-19 legislation did not simply delegate management of a important and legitimate and possess
or existing law, is the creation of a worldwide pandemic to health ministries resources that are necessary for public
coordinating committee that enhances or public health agencies. The interesting health and social policy responses.
Eurohealth — Vol.26 | No.2 | 2020Governance 101
Coordinating with them involves a certain Kingdom, Italy, and Canada, where central state. This can be for immediate
amount of inevitable friction and there can substantial health expenditures come out functional reasons, e.g. to acquire
be political incentives to create conflict or of general government budgets and where supplies at a better price and coordinate
try to shift blame. unexpected health challenges can create logistics, or to reduce popular confusion
unexpected problems. about closure and reopening measures.
As reported in our policy snapshot on In Germany, the “Act for protecting the
federal countries, 5 coordination challenges In general, as with much of health politics public health in an epidemic situation
appear in all the major areas of the in federations beneath the confusion there of national importance” granted the
COVID-19 response. Table 1 identifies is a basic rationality at work, with central Ministry of Health (MoH) expanded but
key areas. Governance to decision- governments handling issues that require temporary power. The federal MoH was
making: the general procedures that large risk pools and regional ones issues consequently authorised to take measures
governments within a country use to that handle local knowledge and resources. regarding the provision of pharmaceutical
make and implement decisions. In many Strikingly, we found no case of change in and medical devices and to strengthen the
cases, regional autonomy has been the basic territorial politics of entitlements, medical workforce. These new powers
somewhat curtailed, though many of the which is important. If regional will, however, expire on 1st April 2021.
measures curtailing regional autonomy governments did not take the opportunity In countries with particularly difficult
are temporary. of the crisis to restrict benefits, and instead central-regional politics, the question of
expanded them, that will have good effects whether centralising measures will be
In terms of preventing transmission, on public health, including avoiding temporary or permanent is obviously
which means mechanisms such as avoidable new outbreaks. charged and has not been entirely resolved.
physical distancing and surveillance, In Spain, a Royal Decree declared a
regional autonomy has mostly remained. Given that federations do have clear state of emergency on 14 March and put
This might reflect the fact that regional coordination problems, how do they all publicly funded health authorities
governments often are the ones with deal with them? One way is voluntary under the direct order of the Ministry of
resources such as contact tracing staff cooperation in which regional Health. The Spanish MoH was therefore
or police. Notably, some countries such governments identify and solve shared temporarily entitled to implement
as Spain and Belgium, which have problems among themselves or with COVID-19 related measures across the
complex territorial politics, have at least the central state guidance or control. whole country. In Italy, a country whose
temporarily centralised the acquisition of In Italy, each region adopted its own health care system is highly decentralised,
personal protective equipment (PPE). In approach to testing based on national the MoH issued a series of regulations
ensuring sufficient physical infrastructure and international recommendations but increasing the availability of health
and workforce capacity, insofar as there as testing capacity greatly varied by professionals and requiring all regions
is a pattern it is one of persisting regional regions, national guidelines were issued to increase health care capacity. In most
autonomy or of central governments acting by the central government to outline the cases our data does not show any change
unilaterally (e.g. by easing restrictions on basic criteria for testing. With respect to to the formal role of local government.
professional mobility). In efficient health protective equipment, the German federal Few clearly permanent changes have been
care service provision, likewise, there is government delivered stocks of PPE to made to federal arrangements; this might
a mixture of centralisation and regional the Länder, which were responsible for be a data limitation but, if true, it is an
diversity. In both of these areas, there allocating and distributing the material interesting contrast to the centralisation
is a strong case for regional autonomy to regional health care providers. Though seen in some federations 7 due to the
and regional governments empirically there is in those countries regional global financial crisis of 2008 – 2012.
have resources on the ground, but they budgetary autonomy, investment in public
might lack the ability to coordinate for health infrastructure and new public The third way is continuing regional
efficient patient flows without central health workers positions was coming from diversity and autonomy when there
direction or might not command elements the federal government as it is the case is a case for local implementation
of the legal infrastructure (such as in Germany. As for Spain, the transition and decision-making or when the
professional regulation) necessary to strategy was released in late April and was political situation makes coordination
optimise responses. Finally, and very meant to be coordinated with the Spanish or centralisation unrealistic, resulting
strikingly, we did not find change in health regional authorities. Finally, regarding in a variety of responses. Despite the
financing outside a fairly limited change in inner border closure, the Austrian state increased role of the central government,
Belgium. This might make sense in social governments were in charge of executing Italian regions still retain decision-
insurance systems, where there is often decisions taken at the federal level, but making autonomy regarding the delivery
some distance between social insurance were also free to apply stricter measures, and organisation of health services,
funds and regional governments, but it is such as quarantine for smaller regions such as whether to conduct COVID-19
an area to watch. Broadly, there is more severely hit by the crisis. tests in the entire regional population or
political responsiveness in Berveridgean whether to suspend or maintain medical
national health service (NHS) model The second way is centralisation of services, such as surgical procedures.
systems such as Spain, the United powers and functions 6 in the hands of the In Spain, although all publicly funded
Eurohealth — Vol.26 | No.2 | 2020102 Governance
Table 1: Level of coordination of policy responses
VOLUNTARY POWER REGIONS RETAINING
POLICY RESPONSES ACTIVITIES COORDINATION CENTRALIZATION AUTONOMY
Governance – Belgium Austria Italy
Spain Belgium Spain
Germany Switzerland
Italy
Spain
Switzerland
United Kingdom
Preventing transmission Health communication Canada – Canada
Physical distancing – Italy Belgium
Switzerland Canada
Germany (during the
transition phase)
Isolation and Quarantine – Canada Austria
Canada
Italy
Monitoring and Canada – Austria
Surveillance Canada
Spain
Testing & Contact Tracing Canada Austria Belgium
Germany Canada
Italy Italy
Switzerland
Protective equipment Germany Austria Belgium (during the
(purchasing and Belgium (before the transition phase)
distribution) transition phase) Germany (for the
Germany (for the distribution of PPE)
acquisition of PPE)
Italy
Spain
Ensuring sufficient Physical infrastructure Belgium Austria Canada
physical infrastructure Canada Italy
and workforce capacity
Workforce – Italy Belgium
Spain Canada
Germany
Italy
Providing health Planning services Canada Italy Switzerland
services effectively Germany Spain
Managing cases – Austria Canada
Italy Italy
Maintaining essential – Switzerland Italy
services
Paying for services Health financing – Belgium (for hospitals) Belgium (for nursing
homes and facilities for
people with disabilities)
5
Source: © Copyright European Observatory on Health Systems and Policies
authorities are temporarily supervised were instigated by individual hospitals, their local and regional governments in
by the central government, regional cities or regions, with limited overall the second wave. There is a case for local
and local public health administrations coordination and planning at the and regional pre-eminence in many areas
still retain operational management federal level. since local and regional governments have
of health services. Swiss cantons are resources and knowledge on the ground
free to organise the cantonal response As we might expect, decentralising that central governments often lack, but
to COVID-19, which has led to great between governments is also a tactic that there is also a risk that responsibility and
variation in the organisation of testing and is becoming increasingly prominent. blame are being shifted without resources,
treatment across regions. In Germany, Central governments that centralised money, or power.
measures to expand the workforce in the first wave might choose to share
involved in treating COVID-19 patients more responsibility – and blame – with
Eurohealth — Vol.26 | No.2 | 2020Governance 103
Lessons learned: Centralisation is not likely to fall apart. Generalist government Most crises come and go and the after-
enough, diversity can be an asset will move on – if nothing else, to action report and learning risk being
shaping and responding to the enormous forgotten. COVID-19 is not such a
We should not be surprised to have seen a
effects of COVID-19 on everything crisis. Until there is a safe and widely
high degree of centralisation around heads
from small business to gender equity to distributed vaccine, the need for public
of government. The magnitude of the
housing markets. health response will continue. Political
COVID-19 crisis, and the way it affected
consensus and societal patience might
every dimension of life, meant that it had
Centralisation and coordination problems, not. As a result, it is an opportunity to
to be the focus of the entire government.
in particular within federal countries, learn from the governance experiments
Whole-of-government responses to
are a different kind of issue. COVID-19 so far and build stronger mechanisms that
health problems are famously hard to
did not lead to widespread constitutional can serve in this pandemic and inevitable
achieve, but the pandemic caused them
change. The regional governments of future ones.
nearly everywhere.
Austria, Belgium, Germany, Italy, Spain,
Switzerland, and the UK all remain
We learned that centralisation is not References
powerful and autonomous actors with their
enough. Concentrating power has
own politics, resources, and legitimacy.
1
World Health Organization. Working together
undeniable advantages if we assume that for health: The World Health Report 2006.
That they were willing to tolerate, or
the concentrated power is used effectively. Geneva: WHO, 2006.
unable to prevent, centralisation in
As we have seen, that is not always the
many cases does not mean that authority
2
Greer SL, Jarman H, Rozenblum S, Wismar M.
case. Adopting the wrong decisions, a How are countries centralizing governance and
and power have actually shifted for
lack of political leadership or a lack of at what stage are they doing it? COVID-19 Health
good. Indeed, pandemic response, and
trust on the side of the population may System Response Monitor – Cross-Country Analysis.
the politics of blame, might actually WHO, European Commission, European Observatory
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A dramatic centralisation of power
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within governments was always going
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the challenge crumbles, centralisation is
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