All of CEMR’s national associations indicated that they performed, to a greater or lesser degree, an intermediary function in supporting the effective management of their public health systems.


The survey responses highlighted their active role in discussions and negotiations with the central government and other tiers of government. The Association of Netherlands Municipalities (VNG) represents all Dutch municipalities in negotiations with the national ministries with powers over social and health services provided by municipalities to their residents even if, in terms of delivery, many of these services are delivered by private or semi-private companies. The system in the Netherlands is known to be quite unique. In Hungary, the Hungarian National Association of Local Authorities (TÖOSZ) takes part in discussions with the government on all issues that concern the day-to-day operations of local governments in the area of healthcare. This is also the case in Malta where the national association, the Local Councils’ Association (LCA), performs a facilitator role between the central and local governments, similar to the role of the National Association of the Units of Local Self-Government of the Republic of North Macedonia (ZELS), which too acts as a coordinator between the central and local governments.


In Spain, the Spanish Federation of Municipalities and Provinces (FEMP) created a network of “healthy cities”, which federates more than 250 local governments, supports the exchange of good practices and prepares guides and manuals. Working with the Ministry for Health, this network promotes citizens’ well-being and a safe local health system.


In Kosovo, the Association of Kosovo Municipalities (AKM) has been granted an exclusive mandate to represent municipalities in dialogues with the central government and, through its executive board, it has become directly involved in developing the national health system. In Norway, the Norwegian Association of Local and Regional Authorities (KS) acts as a contact point and coordinator for the entire local government sector, the parliament, the government, and the directorates. As a result, it has become a one-stop shop providing expert knowledge and information on critical aspects relating to local health services and local social contexts (in each municipality), as well as a source for shared digital tools (contact tracing, etc.).


The national associations in countries operating under a federal system also play a key role in negotiations relating to public health matters between the central and regional tiers. In Germany, the national associations are consulted and active in the national legislative consultation process and this involvement extends to legislation concerning the health sector as well. Furthermore, they act as a liaison between the municipal and the federal tiers. In Belgium, the associations ofLRGsadvocate for their members’ interests in discussions with the other tiers of government on public health matters.


In Latvia, the national associationLALRGperforms a key service by preventing health service delivery from being overly concentrated at one tier of government. Since 1997, regional governments have had wide-ranging responsibilities for the financing and organisation of primary and secondary health care; whereas for local governments, the ability to ensure accessibility to health care services and health promotion is highly dependent on questions of budget and local priorities.


In Bulgaria, representatives of the National Association of Municipalities in the Republic of Bulgaria (NAMRB) participate in national councils, working groups and other bodies tasked with preparing regulatory amendments for the healthcare sector. Bulgaria’s central government is authorised to provide subsidies to hospital care institutions established by municipalities, for their activities in difficult to access and/or remote areas. What’s more, these subsidies are ultimately determined based on proposals put forth by NAMRB.


In Serbia, the Standing Conference of Towns and Municipalities (SCTM)’s work has led to the signing of a co-operation agreement between the Ministry of Health and public health institutes.SCTMwas also able to take part in the drafting of the Law on Public Health and the National Public Health Strategy. In Slovenia, the national association has been active in monitoring health legislation in view of shaping future legislative changes through its proposals.


National associations have also proven to be vital actors when it comes to negotiating the overall healthcare budget, but also in securing extra funding when needed due to emergencies, as has been the case with the COVID-19 crisis.


Every year, Local Government Denmark (LGDK), representing the municipal tier and Danish Regions (KL – representing the regional one) negotiate the complete economic framework for both the local and regional sectors with the central government. In addition, bothLGDKandKLalso act as the employer organisations for each of their respective tiers in collective agreements.


In Finland, the Association of Finnish Local and Regional Authorities (AFLRA), which represents local and regional governments, advocates for local self-government and the modernisation of municipal services on behalf of all Finnish municipalities. During COVID-19,AFLRAensured that municipalities received extra funding for the additional work caused by the pandemic.


The Local Government Association (LGA) in England has long supported and collaborated with the councils (local tier) to help their citizens achieve the best possible outcomes across health and social care. This work has been achieved alongside partners in health and social care, including the National Health Service. During the pandemic, support was offered to Directors of Public Health and their teams, with a focus on testing, contact tracing and outbreak management.


A number of CEMR’s associations highlighted their role in supporting exchanges of information, knowledge and practice amongst their members. In Estonia, the national Association of Estonian Cities and Municipalities (ELVL) has no direct role in the healthcare system but works to collect information and mediate between its members and interested parties. Support for capacity-building efforts was also underlined as a valuable contribution of national associations to boosting national health systems. In Sweden, the Swedish Association of Local Authorities and Regions (SALAR) is not involved in the daily operations concerning the financing and provision of health services, but it actively assists its members, functions as a platform for cooperation between regional and local authorities and runs various types of quality improvement projects.


In Turkey, the Union of Municipalities of Turkey (UMT) does not have a defined role in the area of health; it does however work to support municipalities indirectly in this domain through capacity-building projects and also assists the national government by supporting national campaigns.