Advantage Federal?

There has been a lot of speculation in the press about why Germany (and to some extent Switzerland) have seen proportionately fewer deaths than other countries during the first wave of the Covid-19 virus (1). While there are undoubtedly many reasons for why this is the case, and we will not understand the full picture until this pandemic is over, many have concluded that it is the sheer extent of the testing in these countries that has been effective in constraining the scale of the outbreak there (2).

One aspect that has gone largely unnoticed, however, is the positive impact of the federal system on shaping both countries’ capabilities.

It is inherent in the nature of federal systems that healthcare facilities are decentralised. Whereas the UK has created major regional centres of specialisation – such as the Liverpool Heart & Chest Hospital, serving everywhere from the Isle of Man and Anglesey in Wales to Liverpool and the northwest of England – in Germany and Switzerland every state (or canton) is expected to be largely self-sufficient. This means that, in contrast to Britain, which started out with just a single, centralised testing unit, Germany was able to immediately replicate testing in numerous centres throughout the country.

In the view of Christian Drosten, the director of the institute of virology at Berlin’s Charité hospital, whose team of researchers developed the first COVID-19 test used in the public domain, this goes to the heart of the matter. He told NPR, the German public radio broadcaster, that Germany’s low fatality rate was the result of his country’s ability to test early and often. 

“We have a culture here in Germany that is actually not supporting a centralized diagnostic system,” said Drosten, “so Germany does not have a public health laboratory that would restrict other labs from doing the tests. So we had an open market from the beginning.”(3)

Germany’s 16 federal states make their own decisions on coronavirus testing because each of them is responsible for their own healthcare system. The same is true in Switzerland, another country with a federal system, which has achieved one of the highest testing rates in the world (4).

But it is not just testing, of course. Another aspect that also came in for scrutiny in the UK at the beginning of this crisis is the number of intensive care beds per a million people. Germany had 292 compared to the UK’s 66 (5). Why the difference? The same answer holds true: in Germany, all 16 states needed to replicate ICU facilities, whereas in the Britain they were heavily centralised. Even if Germany wanted to, the states wouldn’t have allowed it to reduce the number of intensive care beds down to the level seen in Britain.

There is another harsh truth that has little to do with decentralisation: the NHS has been underfunded for a considerable time. Years of austerity have ensured that the UK has inadequate facilities in place to deal with the annual winter flu outbreaks, let alone a virulent pandemic such as Covid-19. In an interview with The Financial Times, Severin Schwan, CEO of Roche, a Swiss based pharmaceutical giant, said that the UK government lagged behind other countries in dealing with the coronavirus crisis because it had not invested enough in healthcare and testing. Speaking from lockdown in Switzerland, Mr Schwan said to the FT, “I am not saying [the decision not to invest] is right or wrong, . . . But don’t wonder [when] a crisis like this comes and you don’t have the infrastructure that you are in a more difficult situation.” In other words, don’t be surprised, Mr Johnson, when the austerity chickens all come home to roost.

So, is there something that other countries can learn from the experience of Germany and Switzerland? Probably. And, to give credit to the UK government, it seems that these lessons have already been learnt to some extent. Since the start of the outbreak the British government has acted quickly to correct the inherent problem of over-centralisation and underinvestment, rapidly equipping seven Nightingale Hospitals, one in each region of England. Others have been added in the other countries of the Union.

Similarly, they have addressed the problems due to over-centralisation of testing. Starting with just a single centre, the UK has now increased the number of testing centres to three, supplementing this by university facilities and numerous drive-through centres. Dozens of mobile units are soon to add to this flexibility. Is this the beginning of a new federalised approach? Could decentralisation and increased investment be the legacy of Covid-19? Let us hope so.

If federal systems are so great, what on earth has happened in the USA? There is an obvious answer; there is another factor at play: a Presidential system headed by President Trump. This has had a major influence on the outcomes there. A moment’s thought, however, shows the federal advantage even in America. New York and California have been able to act as they see fit to deal with the crisis. Though Trump has attempted to interfere on occasion, he has not been able to stop the governors of these states acting in the best interests of their citizens. In short, the death toll might have been a whole lot worse without federal independence of action. This is an independence that has been widely recognised and praised in the US (6).

A note of caution: I don’t want to give the impression that federalism is universally seen as better than a centralised system in every single aspect. The Germans and the Swiss both complain on a regular basis about how slow their decision-making is. Because little can be imposed top-down by the central government, often consensus is arrived at through a long, slow and painful process. “It takes too long to make decisions,” is a complaint heard regularly. On occasion, the citizens of both countries even overcome deep prejudices and look over the fence at more centralised systems, such as that of neighbouring France, with something akin to envy.

At present, however, much of the envy faces in the other direction. And this is despite France having what is widely recognised to be one of the best healthcare systems in the world. To the surprise of many of their citizens, the federal systems of Switzerland and Germany have shown just how fleet of foot they can be during an emergency. Advantage Federal.

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3 thoughts on “Advantage Federal?

  • This is very interesting – I never realised this is how our healthcare system works in the UK – but there must be downsides to decentralisation too? How would hospitals be able to afford the expensive equipment?

    • Very true it would cost more. This is one reason the government has chosen to move to a much more centralised model over the past 20 years – it saves money. We need to find a way to improve financing and to take it out of the control of the Treasury. The UK is currently seventeenth in the world in terms of healthcare expenditure per capita – and it shows in our outcomes. We have relatively low cancer survival compared to our peers, for instance:

  • UPDATE: The Guardian reports that the government has admitted that it cannot manage the testing regime for Care Homes, so is handing this responsibility to the NHS trusts. It repots, “Ministers have asked local directors of public health to take charge of Covid-19 testing in English care homes in what will be seen as a tacit admission that centralised attempts to run the programme have fallen short.” This sadly comes very late in the day.

    The article goes on to say: “The switch is a conspicuous, if belated, vote of confidence in local government’s ability to help get a grip on the Covid crisis. There has been frustration and incomprehension that public health teams have until now been left as bit-players in the testing programme and in tracking and tracing carriers of the virus.”

    “One senior director of public health said: “We’ve been pushing and pushing government to realise that we exist and that we are best placed to organise things like testing, alongside directors of adult social services, because we know our patch.”

    What can one say? For the full article see:

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