Divided We Survive? Multi-Level Governance during the Covid-19 Pandemic

We compare the intergovernmental health system responses to the first wave of COVID-19 pandemic in Italy and Spain, two countries, healthcare is managed at the regional level, and the impact of the first wave was highly localized. However, whilst in Italy the regional government allowed for a passively accepted central level coordination without restricting autonomy (‘coordinated autonomy’), in Spain, the health care system was de facto centralized under a ‘single command’ (‘hierarchical centralization’). We argue that the latter strategy gave rise to limited incentives for information sharing and regional participation in decision-making. This article documents evidence of important differences in health outcomes (infected cases and deaths) and outputs (regular and emergency hospital admissions) between the two countries, both at the national and at the regional level. We then discuss several potential mechanisms to account for these differences. Given the strong localized impact of the pandemic, allowing more autonomy in Italy compared to a centralised governance in Spain can explain some cross-country differences in outcomes and outputs.