Divided we survive? Multi-level governance during the COVID-19 pandemic in Italy and Spain

We compare the intergovernmental health system responses to the first wave of the COVID-19 pandemic in Italy and Spain, two countries where healthcare is managed at the regional level and the impact of the first wave was highly localized. However, whereas in Italy the regional government allowed for a passively accepted central level of coordination without restricting autonomy (“descentralised coordinantion”), in Spain, the healthcare system was de facto centralized under a “single command” (“hierarchical centralization”). We argue that the latter strategy crowded out incentives for information sharing, experimentation 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 regional levels. We then discuss several potential mechanisms to account for these differences. We find that given the strong localized impact of the pandemic, allowing more autonomy in Italy (compared to centralized governance in Spain) can explain some cross-country differences in outcomes and outputs.