Centralization and integration of public health systems: Perspectives of public health leaders on factors facilitating and impeding COVID-19 responses in three Canadian provinces.

The extent to which power, resources, and responsibilities for public health are centralized or decentralized within a jurisdiction and how public health functions are integrated or coordinated with health care services may shape pandemic responses. However, little is known about the impacts of centralization and integration on public health system responses to the COVID-19 pandemic. We examine how public health leaders perceive centralization and integration facilitated and impeded effective COVID-19 responses in three Canadian provinces. We conducted a comparative case study involving semi-structured interviews with 58 public health system leaders in three Canadian provinces with varying degrees of centralization and integration. Greater public health system centralization and integration was seen by public health leaders to facilitate more rapidly initiated and well-coordinated provincial COVID-19 responses. Decentralization may have enabled locally tailored responses in the context of limited provincial leadership. Opacity in provincial decision-making processes, jurisdictional ambiguity impacting Indigenous communities, and ineffectual public health investments were impediments across jurisdictions and thus appear to be less impacted by centralization and integration. Our study generates novel insights about potential structural facilitators and impediments of effective COVID-19 pandemic responses during the second year of the pandemic. Findings highlight key areas for future research to inform system design that support leaders to manage large-scale public health emergencies.

How does policy learning take place across a multilevel governance architecture during crises?

Policy learning plays a significant role in shaping policy during crises. While scholarship has explored many of the mechanisms and outcomes of such learning, little is known about how policy learning takes place across different levels of a multilevel governance architecture. This is despite their prevalence and influence on crisis responses. Using a case of the Belgian COVID-19 policy response, we explore how policy learning takes place across different levels of multilevel governance within creeping crises, focusing on epistemic policy learning (learning from experts) as one of the most pronounced learning types within such contexts. By means of document analysis, supplemented by primary source data from expert and senior official interviews, we offer an exploratory account of how learning took place at the national and subnational levels. Our findings reveal how the inherent features of the COVID-19 crisis, and the existing multilevel governance architecture broke the policy learning process into smaller heterogenous learning processes at different levels. We find that decentralised approaches to learning provided the space for customised, yet often fragmented policy responses. We also find that institutional legacies, varying degrees of policymaker control over learning, and absence of common approaches to structuring and designing learning processes led policymakers in different jurisdictions to engage in varying policy learning processes. We take stock of these different learning processes and highlight their key features. We conclude by highlighting the implications of these findings for policy learning theory and practice.

Subnational government responses to the Covid-19 pandemic: Expectations, realities and lessons for the future

Although national government and international actor responses to the Covid-19 pandemic have been very much in the public eye, the subnational government role has received less attention. Certain pandemic impacts were universal, but the mix and relative severity differed across countries, The actions taken had to reflect these variations, as well as to reflect country socio-economic, fiscal, institutional and political context. Diversity across areas within countries also required differentiated action. This article provides an overview of the potential subnational government role in pandemic response, summarizes what is known about what actually occurred, and raises the prospect that what was learned in the pandemic might help policymakers and managers both to identify ways to better respond in future crises and to create awareness of and opportunities for needed reforms in intergovernmental systems. This background sets the stage for other articles in this issue that focus on selected countries. Their experiences reinforce lessons from global experience and also provide insights from deeper analysis of specific cases. © 2023 John Wiley & Sons Ltd.

"Local cooperation has been the cornerstone": facilitators and barriers to resilience in a decentralized health system during COVID-19 in Finland.

PURPOSE: The purpose of this study was to elucidate facilitators and barriers to health system resilience and resilient responses at local and regional levels during the first year of the COVID-19 pandemic in Finland. DESIGN/METHODOLOGY/APPROACH: The authors utilized a qualitative research approach and conducted semi-structured interviews (n = 32) with study participants representing five different regions in Finland. Study participants were recruited using purposive and snowball sampling. All study participants had been in management and civil servant positions during the first year of the pandemic, representing municipalities, municipalities' social and healthcare services, hospital districts and regional state administrative agencies. All interviews were completed remotely from April to December 2021 and the recordings transcribed verbatim. The authors coded the transcripts in ATLAS.ti 9.1 using directed content analysis. FINDINGS: The findings highlighted a wide range of localized responses to the pandemic in Finland. Facilitators to health system resilience included active networks of cooperation, crisis anticipation, transitioning into crisis leadership mode, learning how to incorporate new modes of operation, as well as relying on the competencies and motivation of health workforce. The authors found several barriers to health system resilience, including fragmented organization and management particularly in settings where integrated health care systems were not in place, insufficient preparedness to a prolonged crisis, lack of reliable information regarding COVID-19, not having plans in place for crisis communication, pandemic fatigue, and outflux of health workforce to other positions with better compensation and working conditions. ORIGINALITY/VALUE: Factors affecting health system resilience are often studied at the aggregate level of a nation. This study offers insights into what resilient responses look like from the perspective of local and regional actors in a decentralized health system. The results highlight that local capacities and context matter greatly for resilience. The authors call for more nuanced analyses on health systems and health system resilience at the sub-national level.