As is well documented by now, the COVID-19 pandemic has caused a crisis of unparalleled proportions since its onset in Europe in 2020. While all tiers of government were faced with extraordinary challenges, the heavy reliance by central governments on LRG leadership in providing support to citizens, businesses and communities apace, during an acute health and economic crisis, is undisputed. The pressure exerted by COVID-19 on health systems across the globe has been enormous, and the worsening pandemic was quick to reveal any shortcomings and weaknesses, as well as existing problems in countries’ health systems. In countries all over, wide-ranging reflections are already underway on what can be done to strengthen public health systems and how to better govern-in-partnership, so as to improve preparedness for future crises.   


The following section focuses on whether the introduction of health reforms had any impact on LRG capacity to deal with the COVID-19 pandemic. The section also chronicles the different experiences of LRGs, as recounted by CEMR’s national associations, in managing the crisis. It should be stressed that since the data was primarily collected during the first quarter of 2021, this information represents a snapshot in time. Given the fast-moving pace of managing such events, it is highly likely that the results presented in the following section have since evolved, but what follows seeks to document the ongoing changes faced byLRGsduring the past months.

Impact of health reforms on local and regional governments’ pandemic preparedness

CEMR’s members were asked to share their experiences regarding the degree to which recent health system reforms affected the ability ofLRGsto confront the pandemic. The survey results established that there had been reforms during the period in question in 22 countries,[1] and  associations in five countries[2] believed that the changes to their health systems had improved the ability of local governments to address the COVID-19 pandemic. For associations in eight countries,[3] the view was that health system reforms had had no effect on the ability ofLRGsto address the COVID-19 pandemic.


Slovakian municipalities were obliged to enter into cooperation agreements with non-public sector entities to carry out COVID-19 testing. Municipalities were presented with no other alternatives, and those that had no health competences of their own or insufficient medical staff and/or infrastructures at their disposal found themselves particularly powerless in this regard.


In the eyes of the national associations in Poland and Ukraine,  it was felt that territorial reform changes had in fact worsened the capacity of local government to effectively address the pandemic.


Figure 8 – Impact of health reforms on local and regional governments’ ability to address the COVID-19 pandemic

TERRI Survey 2021 | CEMR


In Finland, it was the onset of the pandemic that triggered important changes in the domain of public health. Although there had been no major shifts in the management of healthcare responsibilities in the ten previous years, this changed with the central government’s proposal for a Health and Social Services reform bill at the end of 2020, which was adopted by the Parliament in June 2021. The acts stemming from this bill have progressively entered into force, with the final provision to take effect in January 2023.[4] For the first time, “wellbeing services counties” are being established, a development that has introduced significant changes to Finnish LRGs’ healthcare roles as the authority responsible for organising health and social services and rescue services, given that these functions are being transitioned away from the local government level (municipalities) to the county government level.[5]


In Sweden, legislation on patient’s choices in outpatient care has made it possible for Swedish residents to opt to be vaccinated in a region other than where they reside. According to the Swedish Association of Local Authorities and Regions (SALAR), other new legislation promoting collaboration at discharge from inpatient care has improved the cooperation between municipalities and regions, and thus led to better care and less contagion, especially among the elderly.


In Norway, a longstanding and systematic cooperation between hospitals (central government responsibility) and municipalities has fostered better understanding and trust between the different tiers, a very good platform for handling the various challenges arising during the crisis.


The health reforms, or the productive collaboration amongst tiers of governance, e.g. in Norway, had an impact on the management of the pandemic. But what was the impact of COVID-19 crisis on local health systems in particular and on governance in general?


Having studied the response data on how the pandemic has been managed overall, the broad consensus is that a successful COVID-19 crisis response requires coordination both between and across governments. The information provided by CEMR’s associations has provided useful insights into the management of powers and responsibilities during this time.


Box 5: Sweden – How COVID-19 accelerated the transition to local healthcare

While healthcare responsibilities generally remained the same, the pandemic exerted substantial additional pressure on existing structures, all while causing the expansion and further development of certain services, e.g. the offering of digital health services.


Excerpt from a Swedish report by SALAR:

 “The provision of healthcare [changed] rapidly so as to be able to care for a large number of contagious and severely ill patients and to contain transmission. The number of intensive care beds [more] than doubled, whilst at the same time planned healthcare decreased sharply, although the regions’ objective had been to maintain this service. In most regions, however, healthcare that could be postponed was moved to later dates; this applied to both operations and clinic visits. Cooperation with municipal healthcare has been developed, and part of the transition in healthcare has led to important advances. The transition to local healthcare has been given momentum. The collaboration between municipal healthcare and regional psychiatric services, in particular, has made important progress. Strategic development of services has had to be deferred to make space for everyday developments driven by the pandemic.” [6] 

[1] Albania, Austria, Cyprus, Czech Republic, Finland, France, Georgia, Germany, Hungary, Italy, Malta, Moldova, Netherlands, Norway, Poland, Portugal, Serbia, Slovakia, Spain, Sweden, Ukraine, United Kingdom

[2] Germany, Norway, Serbia, Spain, United Kingdom (COSLA and LGA)

[3] Austria, France, Hungary, Italy, Moldova, Netherlands, Portugal, Slovakia

[4] services-reform-and-related-legislation-proceeds-to-parliament

[5] For more information on the establishment of the new counties, see Part 1, Box 1

[6] An excerpt from SALAR’s “The Economy Report, October 2020: On Swedish Municipal and Regional Finances”