COVID-19: Who’s in charge here?

As the novel coronavirus tears through the United States, sending wave after wave of critically ill patients to under-resourced hospitals, state governments are bidding against each other for much-needed medical supplies. The battle among states for critical healthcare resources is the result of poor choices made by leaders at the highest level of government. But, this challenge—along with the rest of the patchwork response to the COVID-19 pandemic—stems from the very nature of US healthcare: a decentralized system in which state and local entities have greater control over decision-making. In more centralized systems, like in China, power over healthcare is concentrated at the national level. So, how do decentralized and centralized healthcare systems compare in handling the worst pandemic in generations?

Although experts say it’s too early to determine what role different systems play in managing the severity of the COVID-19 pandemic, it’s undeniable that each country’s structural organization influences its public health response. In the end, it’s clear that decentralized and centralized healthcare systems have advantages and drawbacks. Analyses of how different institutions shaped this pandemic response could help protect patients, physicians, and hospitals in future outbreaks.

Such analyses are “going to be very important,” Victor Rodwin, PhD, MPH, professor of health policy and management, Wagner School of Public Service, New York University, told MDLinx. “[COVID-19 is] going to take a different toll in different countries depending on the strength of their healthcare systems, the time at which they began to intervene, the cultural issue, and the institutional issues on how they are organized and how they’ve responded.”

Decentralized healthcare system

In recent years, many nations have moved to decentralize their healthcare systems, in different ways and to various degrees. While the United States and Canada differ in who pays for care, for example, each country has a system in which decision-making is relegated, in part, to regional bodies.

In the US’ public health response to the pandemic, states issue stay-at-home orders and clamor for medical equipment. The federal government, meanwhile, works with states and local health agencies through the CDC to understand the spread of the pandemic, and uses its muscle to share guidance, distribute resources from national stockpiles, and provide funding for a range of programs—from local public health efforts to economic relief for residents.

Through the WHO, the United States and other nations have traded a “limited amount of sovereignty,” meaning they surrender some level of decision-making, for evidence-based recommendations that may sway downstream responses, Gregory Marchildon, PhD, MA, JD, a University of Toronto professor who writes extensively on health policy and decentralization, told MDLinx.

Broadly, he explained, the benefits of healthcare decentralization include local decision-making that serves the specific needs of a population, targeted resource allocation, and a feeling of public ownership through a more democratic process. But, there are some drawbacks. The COVID-19 pandemic has underscored some of decentralization’s pitfalls, namely that cross-boundary coordination is voluntary, which can result in a lack of uniformity.

Whether these attributes make a difference in the pandemic, however, might mean less than who’s in charge, according to Dr. Rodwin.

“The relationship between science, policy, and the capacity of leadership to issue a plan, a set of guidelines, and inform people—that’s extraordinarily important,” he said.

That could help explain why the US response has alarmed clinicians, policy experts, and scientists, while the actions taken by Germany—another decentralized healthcare system—have earned praise.

Centralized healthcare system

Like decentralization, healthcare centralization takes on different forms. After taking over most of its hospitals for cost-cutting purposes, Norway has built a notable centralized healthcare system, Dr. Marchildon explained. China, on the other hand, is ruled by one party that dictates much of everything, including healthcare policy, to regional and city governments.

At first, China’s centralized system appeared effective. It enabled the quick mobilization of resources, including the construction of 2 hospitals in as little as 2 weeks, and an airtight lockdown of the region where the novel coronavirus originated. But, the country is also accused of waiting to alert other nations to the virus, using excessive force to impose public health rules, and covering up its number of coronavirus cases.

Whether unilateral decision-making better prepared China for the coronavirus is unclear—and certainly questionable—as another lockdown looms in preparation for a second wave. But, the tactics used by China’s centralized healthcare system would be unacceptable for most people in democratic countries, regardless of their effect on the COVID-19 pandemic.

“If you take the authority away from the existing regional and local governments and you commandeer private companies when this crisis is over or receding, you’re going to have a problem,” Dr. Marchildon said. “I think you won’t have governments acting up to their capacity because they just feel like it’s somebody else making the decisions.”

Florien Kruse, a PhD candidate at Radboud University Medical Center in the Netherlands, who has researched different kinds of European healthcare systems, told MDLinx that the answer might lie in a system with a “centralized core” that keeps care and resource coordination functioning amid a web of decentralized hospitals.

The case for healthcare system scrutiny

While data-driven comparisons of responses to the virus from decentralized and centralized healthcare systems are all but impossible now, the time following the pandemic will bring opportunity for research. Per Kruse, mortality rates are a measure of obvious importance, along with the speed of care coordination, patient transfers, and resource allocation among hospitals. But, it’s uncertain whether the players running any sort of healthcare system will collect or make accessible the data required to scrutinize the institutional response.

It’s even more difficult to speculate how the COVID-19 pandemic might rework the underpinnings of the world’s healthcare systems. In the United States, Dr. Rodwin hopes to see a multidisciplinary scientific panel—comprising epidemiologists, biologists, economists, and more—who plan for and will be able to quickly and effectively respond to similar health crises. In some decentralized systems, Kruse remarked, acute care could receive more public funding, while private providers take over non-acute care. And Dr. Marchildon wants to see decentralized healthcare systems compare their members’ responses to gauge how different actions affected mortality, costs, and beyond.

“The only thing we have control over as human beings largely is our policy interventions, our response,” Dr. Marchildon said. “Otherwise, we just wait and see what happens.”

Importantly, it’s on the governments that maintain these healthcare systems—decentralized and centralized alike—to ensure that tomorrow’s pandemic responses draw lessons from today.