Background: Decentralization in health systems enhances responsiveness and equity but is often accompanied by uneven implementation and resource disparities. Greece' health system has undergone successive phases of decentralization, culminating in a transformation in 2015 when regional health authorities (RHAs) assumed operational responsibility for public primary healthcare (PHC). This study presents the first comprehensive assessment of this transition, examining funding adequacy and resource allocation across RHAs. Methods: Financial and operational analyses were performed to assess disparities among RHAs and between RHAs and hospitals. Data were drawn from publicly available sources, including financial statements, reports from the Ministry of Health, and national statistics. The analysis examined patient visits, staffing levels, infrastructure, funding, labor productivity, and efficiency across health regions. Results: Between 2018 and 2023, patient visits declined at most RHAs. Staffing composition shifted toward nursing personnel, while medical staff numbers declined. Substantial intraregional and interregional disparities were observed in service utilization, staffing, infrastructure, funding, labor productivity, and efficiency. Hospitals continued to absorb a large share of PHC demand and funding, whereas RHA units held markedly fewer assets and received lower financial support. Funding imbalances among RHAs were evident, and the overall negative return on assets indicated systemic underfunding of public PHC. Conclusion: The ongoing decentralization of Greece's health system faces structural challenges, including overlapping territorial jurisdictions and uneven, occasionally insufficient, resource allocation. These challenges hinder progress toward health equity. Policy interventions should prioritize evidence-based resource allocation, standardized financing frameworks, and strengthened PHC integration to promote equitable and sustainable healthcare delivery under decentralized governance.
Pakistan confronts a severe mental health crisis that compels urgent action. Mental disorders constitute a burgeoning global burden, with depression alone accounting for a staggering 4.4% of worldwide Disability-Adjusted Life Years (DALYs) [1]. A stark inequity persists, with over 90% in low-and middle-income nations lacking access to mental health treatment, compared to over 50% receiving care in high-income countries [2]. These disparities emanate from a chronic underinvestment, with lowincome nations allocating a mere fraction, less than 1% of health budgets, to mental health [3].Pakistan mirrors these global inequities. With a paucity of just 0.19 psychiatrists per 100,000 people [4], and an underwhelming allocation of only 0.4% of the health budget for mental health [5], Pakistan grapples to meet the needs of an estimated 24 million individuals requiring mental health services [6]. Depressive, anxiety, and schizophrenia disorders are the most prevalent [7]. Stigma surrounding mental illness remains an entrenched societal challenge [8].Currently, Pakistan's mental health system operates primarily through tertiary care hospitals in major cities, with minimal integration into primary healthcare. Mental health services are largely concentrated in psychiatric departments of teaching hospitals, creating geographic and economic barriers for rural populations. The existing system relies heavily on psychiatrists and clinical psychologists, with limited involvement of general physicians, community health workers, or other non-specialist providers. Mental health education is notably absent from school curricula, and workplace mental health programs are virtually non-existent. Digital mental health solutions remain unexplored within the public sector, while community-based mental health services are severely limited. The proposed transformations would mark significant departures from this status quo through: task-sharing with non-specialist providers instead of exclusive specialist care; integration of services into primary healthcare facilities rather than tertiary hospitals alone; establishment of community clinics in place of centralized urban facilities; leveraging digital technology where traditional in-person care is the norm; and engaging community partners versus the current isolated clinical approach.To expand access, the WHO recommends strategies such as task-sharing care to nonspecialist providers, integrating services into primary care and educational institutions, developing community clinics, leveraging digital technology, and engaging community partners [9]. Pakistan could adapt approaches like training primary care workers in mental health protocols, building teacher capacity for school-based services, deploying lay counselors with specialist supervision, offering telemental health services, and engaging community health workers in outreach efforts [10].[Figure 1] telepsychiatry and digital tools, and address social determinants through campaigns on gender equity [11]. Organizations like Pakistan Institute of Living and Learning (PILL) advocate for policies, build workforce capacity, and scale up culturallyadapted interventions [12]. Digital startups like Sehat Kahani use telepsychiatry and mobile applications to bridge the workforce gap [13].A critical component in addressing Pakistan's mental health crisis is the implementation of comprehensive anti-stigma campaigns [14]. These initiatives should operate at multiple levels based on established evidence [15]:A. Community-level interventions [14,15] To comprehensively address the crisis, Pakistan must invest in scaling up its mental health workforce through training more specialists and task-sharing to non-specialists [3,16]. Integrating services into primary care and establishing community mental health centers is crucial for decentralizing access [9,10]. Increasing public mental health spending, developing sustainable financing mechanisms, and strengthening governance and policies are imperative [5,16]. Research on effective, contextuallyappropriate interventions should guide investments [14]. Developing quality monitoring mechanisms is key to ensuring standards of care [9].Addressing social determinants through multi-sectoral coordination and whole-ofsociety approaches involving government, private sector, and civil society is vital [14].Sustained political commitment and strategic investments enabling universally accessible, community-based mental healthcare are crucial for realizing wellbeing for all Pakistanis [15,16].In essence, Pakistan confronts a formidable treatment gap with escalating rates of mental illness amid extreme limitations in mental health system capacity.Comprehensive strategies are necessitated, spanning workforce expansion, service integration into communities, increased financing, anti-stigma efforts, school interventions, research, quality assurance, and multi-sectoral coordination. While challenges are immense, prioritizing community-driven, decentralized mental health systems can ensure no individual is left behind on the path to greater wellbeing.
Giovanni Guarducci, Gabriele Messina, Simona Carbone, Nicola Nante
BACKGROUND: In a Beveridgean decentralized healthcare system, like the Italian one, where regions are responsible for their own health planning and financing, the analysis of patients' mobility appears very interesting as it has economic and social implications. The study aims to analyze both patients' mobility for hospital rehabilitation and if the beds endowment is a driver for these flows; Methods: From 2011 to 2019, admissions data were collected from the Hospital Discharge Cards database of the Italian Ministry of Health, population data from the Italian National Institute of Statistics and data on beds endowment from the Italian Ministry of Health website. To evaluate patients' mobility, we used Gandy's Nomogram, while to assess if beds endowments are mobility drivers, we created two matrices, one with attraction indexes (AI) and one with escape indexes (EI). The beds endowment, for each Italian region, was correlated with AI and EI. Spearman's test was carried out through STATA software; Results: Gandy's Nomogram showed that only some northern regions had good hospital planning for rehabilitation. A statistically significant correlation between beds endowment and AI was found for four regions and with EI for eight regions; Conclusions: Only some northern regions appear able to satisfy the care needs of their residents, with a positive attractions minus escapes epidemiological balance. The beds endowment seems to be a driver of patients' mobility, mainly for escapes. Certainly, the search for mobility drivers needs further investigation given the situation in Molise and Basilicata.
Climate change will widen health inequities; action on the social determinants of health is essential In a conversation recently, a former senior public servant suggested to me that the social determinants of health are too theoretical. It is true that there are a number of theoretical perspectives associated with social determinants. A key one, from Nobel Laureate Amartya Sen,1 highlights the importance of having the freedoms and capabilities to lead a flourishing life. According to theory, these are shaped by the conditions in which people are born, live, work and age, which are unequally distributed.2 There is, however, nothing theoretical about the manifestation of social inequities and their impact on peoples’ health. Every day, people living in Australia embody stark inequities in income, working conditions, lived environment, and access to quality health and social care. For example, before the coronavirus disease 2019 (COVID-19) pandemic, Australians in the top 20% income bracket received six times more money than the lowest 20%.3 Three million Australians were estimated to be living below the poverty line in 2017, including 18% of all children.3 Before the pandemic, more than a million people were in rental stress, and waiting lists for social housing were into the hundreds of thousands.4 Within the first few months of 2020, 880 000 Australians lost their jobs, with women, young people, and those in precarious employment disproportionally affected.3 Workers in casual employment accounted for 63% of job losses between February and May 2020.3 Since the COVID-19 pandemic began, Australia’s 31 billionaires have increased their wealth by $85 billion.5 People embody these inequities,6 which makes them sick and contributes to high levels of premature death. In 2017, 17% of Victorians reported high psychological distress. In 2020, that rose to 44% and to 60% among those who lost their jobs.7 Across Australia, people living in the lowest socio-economic quintile had mortality rates twice as high as those in the highest quintile, and these inequities widened between 2011 and 2016.8 Despite narrowing, the gap in life expectancy between Indigenous and non-Indigenous Australians remains high.9 What do social determinants have to do with climate change and planetary health? The fires, hail, floods and droughts that Australia has endured in recent years10 affect everyone, but not everyone experiences them equally.11 Affluent people can afford to live in insulated buildings with air conditioning and air purifiers, or add flood proofing and extra drainage. Meanwhile, people who are poor, older individuals, people with disabilities, and those who are socially marginalised are the least able to adapt to the changing climate, unable to escape the fires and heat, and live in dwellings and environments that amplify its effects.11 As has happened in other countries experiencing similar impacts from climate change, having lost homes and livelihoods, and fearful for the future, some people may leave their communities and perhaps the country.12 This will exacerbate inequities, with those who have more financial and social capital having more options — wealthy Australians are already buying land in Tasmania to escape the worst ravages of climate change.13 For people living in caravan parks in Lismore, New South Wales, having insurance is a stretch.13 Moving is not an option. This climate change-exacerbated social inequity adds to existing inequities in disease burdens and premature mortality — this is climate change interacting with the social determinants of health inequities.11 Planetary health inequity is a concept that recognises the impact of climate change on social and health inequities. It also recognises the importance for health equity of considering planetary systems — if we do not have a functioning Earth system, we have social disruption and risk to human survival. Planetary health inequity therefore embodies the common drivers of climate change and health inequity. These common drivers comprise major structural forces. Power asymmetries between actors, institutions and ideas, a neoliberal fetishism of market forces and individualism, hyperglobalisation, and the associated norms and values that permeate institutions and communities affect policy decisions that structure society and differentially affect daily living conditions and, ultimately, health.14-18 These structural social determinants of health inequity overlap substantially with the drivers of climate change and can be described collectively as the global “consumptogenic system”. The consumptogenic system is characterised by institutions, policies, business practices, and social norms that embed and entrench principles of extractive capitalism and colonialism.19 Such a system encourages and rewards excessive production and hyperconsumerism of fossil fuel-reliant goods and services that are unhealthy and inequitably valued and distributed.20 If left on the current trajectory, the consumptogenic system will amplify potentially irreversible consequences for environmental degradation, inequalities and poor health. Governments have the chance to advance planetary health equity goals by addressing the consumptogenic system and inequitable distribution of resources that create negative health outcomes and climate change. The issue is not that it is too theoretical, the issue is the often lack of political will to address inequality, adopt a social model of health, and tackle climate change. In the May 2022 federal election, the Australian electorate demanded change. Encouragingly, the new Labor government promised to do better by the people and, although not in the language of the social determinants, their proposed action plan21 will go some of the way to advance planetary health equity goals. But it must go further. Achieving the transformative goal of planetary health equity requires a “social vaccine”22 (Box), the targets of which are the conditions underpinning four basic requirements for health and equity to flourish: a life with security, opportunities that are fair, a planet that is habitable by humans and supports biodiversity, and governance that is just. Achieving these conditions requires the ambition, design and implementation of policies that ensure a fair social foundation and economic environment operating within the ecological ceiling.23 In Australia, as elsewhere, we have long needed policy that helps with adaptation to the damage already done by climate change. Good social and planning policy that ensures access to safe, stable and affordable housing, decent working conditions for all, income support levels that enable living with dignity, and inclusive infrastructure development is good climate adaptation policy. They are also good health equity policies. Adaptation is essential. So too is mitigation. The Climate Change Bill 2022 commits Australia to a greenhouse gas emissions reduction target of a 43% reduction from 2005 levels by 2030. This target should be considered only a starting point. A roadmap to net zero and an empowered secure Climate Change Authority is essential. Adequate climate change mitigation and planetary health equity will not be achieved unless there is ambitious and immediate action that disrupts the consumptogenic system. The targets should be the institutions, actors, structures and discourses that embed, facilitate and normalise the global dominance of a consumptogenic system addicted to growth regardless of the environmental, social and health costs. At the very least, any new fossil fuel project must be assessed for potential damage to species and environments through its impacts on climate change. Fundamentally, however, disruption of this system requires Australia and the rest of the world to stop extracting, burning and investing in oil, coal, gas and other fossil fuels, with government vetoing all new fossil fuel developments. The absence of an overarching framework guiding the actions of all Australian Government departments in a mission towards planetary health equity is problematic. This lack of authorising environment enables at best an ineffective siloed, scattergun approach; at worst policy silence. Implementing a national strategy that brings together climate change, inequality and health, such as the proposed Climate and Health Alliance’s Healthy, Regenerative and Just framework, is essential.24 An engaged strong civil society is key to the delivery of a social vaccine. Implementing a progressive policy framework will confront stubborn resistance and challenge the power of dominant vested interests. Public-interest coalitions can support governments to act, as well as hold them to account.25 Climate change and health alliances are essential — doctors and other health professionals have knowledge, opportunity and political leverage that can help ensure actions are taken.24 This article has laid out ways of advancing planetary health equity goals. To help achieve these, the health community must advocate for and engage in intersectoral policy discussions relating to the social determinants and the structural consumptogenic system. Acting immediately on these issues is critically important if we are to avert a planetary health inequity crisis. No relevant disclosures. Commissioned; externally peer reviewed. Open access publishing facilitated by Australian National University, as part of the Wiley - Australian National University agreement via the Council of Australian University Librarians.
The COVID-19 pandemic has provided an ultimate testing ground for evaluating the resilience and effectiveness of federal and decentralized systems. The article analyses how the Spanish asymmetrical system of decentralization has responded to the pandemic, focusing on the management developed by the sub-central governments (Autonomous Communities) during the first two waves of the pandemic in 2020. The research, which is both quantitative and qualitative, employs multidisciplinary tools and information sources, analyzing and linking fiscal and budgetary sources with the available statistics and information on health. Although the health, economic and social crisis caused by COVID-19 has highlighted appreciable shortcomings related to the decentralized model of territorial organization - in questions of both regional financing and health management - the research concludes that decentralization has not per se been a handicap when confronting the pandemic in Spain.
This introductory article to the European Policy Analysis special issue on “Public Policy Responses to COVID-19 in Europe” proceeds through four parts. Part I presents an abbreviated timeline of how the COVID-19 pandemic first emerged in China in late 2019, its recorded arrival in Europe in February, and the lockdown measures and public policy responses which followed during the first six months of 2020. Part II briefly reviews some of the contributions that an analysis of the public policy responses to COVID-19 in Europe might make to the debates in the social sciences. Part III briefly presents potential areas for future research that lie beyond the limited scope of this issue. Part IV introduces each of the fifteen contributions that follow. On 31 December 2019, the Wuhan Municipal Health Commission in Wuhan City, Hubei province, China, reported a cluster of 27 cases of pneumonia which were said to be linked to a wholesale fish and live animal market in the city. The first recorded cases of what would become known as coronavirus disease (COVID-19) and the virus that causes it (the severe acute respiratory syndrome coronavirus 2 -SARS-CoV-21) was confirmed in China in early January. The genetic sequence of the virus was shared publicly on 11–12 January shortly after the first death had been recorded in China—that of a 61-year-old man with underlying health conditions. By 13 January Thailand had recorded its first case—the first outside of China—and by 20 January human-to-human transmission of the disease was confirmed by the Lancet medical journal (Chan et al., 2020). The first cases of COVID-19 in Europe were recorded in France and Germany on 24 and 28 January 2020, respectively. In each case, infections related to persons who had recently traveled from China. On 26 January, the Stockholm-based European Centre for Disease Prevention and Control (ECDC)—an independent EU agency responsible for strengthening Europe's defenses and preparedness against infectious diseases—reported that there was “a high likelihood” of cases being imported into those European countries with the greatest volume of people traveling to and from Wuhan and Central China (ECDC, 2020) and on 30 January the World Health Organisation (WHO) designated the outbreak of novel coronavirus a Public Health Emergency of International Concern (PHEIC) (WHO, 2020a). Over the coming weeks, several European countries implemented screening measures for travelers arriving from China and many airlines suspended flights to and from the region altogether in a bid to limit the spread of infection. On 04 February, a first major outbreak of COVID-19 was recorded outside of China on board the Diamond Princess, a British-registered cruise ship. The ship, along with its passengers and crew, was quarantined for almost a month in the Port of Yokohama in Japan. By mid-March, more than 700 of the 3,711 on board had tested positive for COVID-19, accounting for more than half of the recorded infections outside of China, and at least seven passengers died with the illness in the following month (Mallaparty, 2020). By mid-February, amid increasing cases of human-to-human transmission around the globe, the ECDC considered the risk for capacity in European healthcare systems to be overwhelmed by any outbreaks of COVID-19 at the peak of the influenza season (typically between November and April in the northern hemisphere, which includes Europe) to be “low to moderate,” while the risk to the health of visitors and residents in areas with elevated rates of infection to be high. On 22 February, in what was the first major case of community transmission in Europe—that is, where infection was not associated with travel to an infected region—Italian authorities reported clusters of COVID-19 across northern Italy in the regions of Lombardy, Piedmont, and Veneto. In a bid to better understand the nature of the virus, including its symptoms and methods of transmission, and the potential for prevention and containment, ECDC and WHO began a joint twelve-day mission to the region on 24 February. By the start of March, ECDC had identified the risk associated with COVID-19 infection in Europe to be moderate to high, based on the probability of transmission and the impact of the disease. On 08 March, the Italian government became the first in Europe to introduce restrictions on movement and to impose social distancing requirements in the country's most affected regions. The measures were extended to cover the whole country on 11 March as the reproductive rate of the virus increased—the same day the WHO declared the COVID-19 outbreak to be a global pandemic (WHO, 2020b). In the weeks that followed, most other European countries introduced similar public health measures in a bid to combat the spread of the virus. The suite of COVID-19 responses introduced by policy-makers across Europe was broadly similar, involving restrictions on economic activity, the promotion of social distancing, and the interdiction of large gatherings, and typically included the closure of schools, universities, and businesses that were deemed non-essential. While broadly similar in nature and design, the modalities, specificities, and duration of restrictive measures differed markedly, as did the timing of their introduction. Most European governments introduced legislative measures to underpin the measures by mid-March, including in France, Germany, and Spain, while a handful of governments opted not to, aiming instead to promote voluntary practices to halt the spread of the disease and to reach for “herd immunity,” whereby society would gain immunity through widespread exposure, as occurred in Sweden and the United Kingdom (see Petridou, 2020; Colfer, 2020a. It is now clear that the introduction of lockdown measures across Europe early-on in the pandemic saved millions of lives (NIHR, 2020). Meanwhile, as the pandemic took hold, economic activity fell, supply chains seized up, and tax revenues dwindled. European and US stock markets reported historic losses throughout the first half of the year as the IMF predicted a deep recession in 2020 and a slow recovery in 2021, with global output projected to decline by almost 5% (Gopinath, 2020). At the same time, government expenditure on healthcare and social protection rose dramatically, as unemployment in the EU rose to 7.4% in August (Eurostat, 2020) and many workers were temporarily laid off. In what may be one of the most enduring structural changes brought about by the pandemic, up to 40% of the European workforce began working from home, at least in part, while many frontline workers in healthcare, transport, and delivery services were unable to do so (Ahrendt et al., 2020). At the time of writing (October 2020), there have been over 34 million recorded cases of COVID-19 and over 1 million deaths associated with the disease globally, of which more than 5 million cases of infection and more than 200,000 deaths have been in Europe. Over only a few weeks, the pandemic introduced fundamentally new economic, political and social realities across the globe. Government responses, and the nature of their implementation, present important questions and lessons for the practice and study of public policy. This episode has also laid bare the capacity, preparedness, and willingness of policy-makers in Europe and elsewhere to respond to an unanticipated crisis as it develops. In particular, differing levels of capacity in healthcare and social protection systems became apparent as the crisis unfolded. The analysis of the onset of COVID-19, and the public policy measures mobilized in Europe in response to it, contribute to a range of related and overlapping debates in the social sciences. This includes as regards: the role of the state; how policy-makers respond to crises; the nature of political behavior; the legitimacy of public policy; and the future of the EU, to give only a few examples. COVID-19 has ushered in a new era of state-sponsored and state-directed activity around the globe, and the crisis has seen a changing and increasing role for public policy in the day-to-day lives of most Europeans. Arguably this episode provides an opportunity to assess the role and functioning of state institutions and programs in people's lives—and even to reimagine what the fundamental role of the state can be in the 21st century. The capacity of states to manage and oversee lockdowns, including by meeting the surge in demand for intensive care beds and personal protective equipment (PPE) in hospitals and care settings, as well as the enormous social protection costs associated with supporting citizens experiencing a sudden loss of income, was exposed during the initial months of the pandemic (Hassenteufel, 2020). This gave rise to debates about the prospect of fiscal burden-sharing between member states in the EU, as we shall see (Camous & Claeys, 2020; van Overbeke & Stadig, 2020). The early stages of the pandemic also tested the resilience of state institutions and their ability to function without permanent or stable governments following inconclusive elections, as was the case in both Belgium and Ireland. The pandemic in Europe also provided a number of examples of multicentric (Neuvonen, 2020) and multi-level governance in action as some states tailored responses to the specific needs and interests of different communities, regions, and devolved authorities, as was the case for example in Italy and the UK (see Colfer, 2020b; Malandrino & Demichelis, 2020). Building on this, an analysis of public policy responses to COVID-19 in Europe can contribute to the crisis management literature (Boin et al., 2017; Brändström & Kuipers, 2003; Drennan et al., 2014). For example, COVID-19 shows how a similar set of circumstances—in this instance, the onset of a global health crisis—can be managed and framed differently across various polities and political contexts. For example, 't Hart (2014) argues that crises may be best understood as situational in nature, involving events and forces that are largely exogenous and temporary, or institutional in nature, involving factors that are more fundamental, intrinsic and deep-seated, and it is possible that a situational crisis could evolve into or merge with an institutional one. For example, in the case of Cyprus, lesson-learning from the early Chinese experience of COVID-19 is said to have allowed that country to prevent a situational crisis from morphing into an institutional disaster as the country's policy response prevented public services from becoming overwhelmed (Petridou et al., 2020). Relatedly, an analysis of public policy responses to COVID-19 can reveal much about political behavior, and how leaders deal with uncertainty, risk, and expertise. and are an of and risk and the is to what governments do Colfer, et al., during the functioning of institutions is tested and policy-makers make with uncertainty, time and levels of & Demichelis, 2020; with a crisis COVID-19, governments could a to an issue and to or or a for and political The pandemic presents to understand how and governments to or by on questions of and COVID-19 et al., 2020). The pandemic also questions about the role of in public policy. is between and public health and economic realities during a that on the of (see also and and van and that can present for policy-makers to in the and of a The to which public policy responses to COVID-19 were based on or economic and the to which or were to the in political across Europe and had a major on the nature and timing of COVID-19 can also reveal about how citizens respond to restrictive public policy and crisis are as or can become COVID-19, in some cases at it was clear with a initial restrictions were with by a of citizens and a the was recorded which & as the initial of the crisis gave to new and as states of for on economic and social activity began to in some et al., 2020). This was framed in by the to which are seen as & and the experience of the into the political by political and public risk over time, people can their first their of being infected (see 2020; et al., 2020). The public policy responses to the pandemic and fundamental in the of public in some to of the lockdown measures have been be it against or restrictions on public gatherings, for example, in Germany (see et al., 2020) or from for a different between economic and social as has been seen in (see & 2020). there is the of restrictions being to this an important for and (see 2020; 2020). COVID-19 as the EU had its of following the from the economic and social the crisis on many of Europe's and the of the UK to a few of the most the from the public health and social protection the pandemic it is clear that the introduction of measures at any time a of and of the prospect of and political in some of Europe's more (see 2020; 2020). the onset of COVID-19 has the role of and on the of workers to many including and 2020). the impact of COVID-19, the of the market and the of the was by the pandemic (Camous & Claeys, 2020). this, the EU to in the of to the regions affected by the crisis through the recovery from several northern member with The being the most the be from on markets by the Commission on of the EU and a fiscal at EU one of the most important in EU in a 2020b; 2020). This in to the and around the at a response to the and crises over the and an important for research and of the in this many more and in the contributions in this special issue. are many more debates and that a analysis of this deal that the contributions in this issue on public policy responses to COVID-19 in Europe in the first six months of 2020. we that this issue can a on which future research can be research with a may on a range of and of for public policy that are not in in this issue. In the the impact of the pandemic on the and health of the and on the social that the of public policy as the impact of COVID-19 on the market and the future of The for this is by the role by frontline workers in society functioning throughout the pandemic and the increasing for many et al., 2020). to promote the health and of frontline workers and how to and an workforce be of The the pandemic changes how we and and how and are COVID-19 policy of as of personal are in new for example, with and The delivery of a one be one of the greatest in and future research how supply chains be to the needs of the COVID-19 Relatedly, restrictions on the prospect of the for and the potential to supply may new policy and that research might the impact of the pandemic has been differently across the are with the greatest social and health of COVID-19, while people and market deal with the recession in a and the prospect of economic and social and policy This special issue reviews public policy responses to COVID-19 in more than European countries in the first months of the coronavirus crisis from January to 2020. This includes the the WHO declared a pandemic on 11 March 2020, most European countries first introduced on social and economic activity that were to halt the spread of the virus, and governments began to restrictions from While in this issue presents a of how the initial stages of the COVID-19 crisis were by policy-makers across a range of different European countries and including Cyprus, France, Germany, Spain, the United and the as well as in China and at the of the reviews the public policy responses in countries and to the by policy-makers their and settings, and to to debates in the social sciences. The to this issue from a range of and including from political and public and are based in more than across Europe and The issue on a at the for European at in and most of the were at during the The of this briefly reviews each of the contributions that make up this special issue. Italy was one of the countries most affected by the outbreak of COVID-19, and became the first European country to both a and lockdown in the of the health Malandrino and how the response to the public health brought with it a high of the of along the government and the of by public The article shows how this and the and in this, the first the of between and authorities the of by The based on both political and public the of policy and case and for an of the Italian response to the crisis as a case in which the of institutional uncertainty, which in affected and how the COVID-19 crisis was in France by policy changes and in the public health argues that the response is at least by the of a health that of in which was as a and which to the of the agency to to and This health authorities were for the as by the of and intensive care beds the pandemic as well as by the large number of infections and in the The a that public policy responses in France, the of political and in the as the of and of for which did to The also the of the impact of COVID-19 on future health in France, and on the role of in the of health policy & 2020). the case of Spain, one of the countries affected by the pandemic in of rates of infection and The article the of the crisis for and the to the pandemic by on the political and structural factors that a more and response in that the public policy responses to COVID-19 in and the United their countries took different in the early stages of the The government to introduce restrictions on movement and social activity and introduced a lockdown on March in with most of the of Europe. Meanwhile, after a slow initial response with for the United Kingdom restrictions only on 20 March and became a in cases of analysis of cases different of the role of and how risk is by policy-makers that the to the Meanwhile, as the pandemic the responses to the pandemic in different of the UK as the leaders of the devolved governments different political on to introduce or This questions about the of in the and the and the public policy response to the pandemic in what see as in that country's crisis occurred elsewhere in the government to introduce measures to limit the infection rate and to while the on health and outside the and the country's lockdown the shows clear of as the to the lockdown was by economic following by interests in the most by for The that in institutional even by a state of as COVID-19 Europe with an While the virus to be in nature, not of government responses were largely governments in multi-level policy at the and In their Overbeke and at the crisis response in the and the to understand the impact of that on the political The that multi-level policy in both countries has up against the of to political In slow between the and governments the into while in the the of European institutions with fiscal policy has the of the EU fiscal in public The response to COVID-19 was to “herd without the of restrictive measures on economic and social not only from other European also from other countries that are and The that from an analysis of the case the the country to a response to the onset of the pandemic with most of the of Europe. the response to the pandemic in Sweden as the which to through an analysis of the of in the of public and the devolved governance that on public and public The that the between and in Sweden in an initial set of responses that was The response in with high political the and was to, than restrictive The with a that the response in for how initial policy response to COVID-19 the of with legislative by the The article first the between and the of the in the of COVID-19 policy. The analysis shows how during the state of about to and the of public This case is considered in the of multicentric and the for by government a in the in the conditions. 't (2014) of et the public policy response to a situational the authorities lessons from the Chinese experience to prevent the onset of the virus from into a institutional The between situational and institutional 't Hart is that the events that are largely considered exogenous temporary, while institutional crises more intrinsic institutional and a that is brought into during a The lessons the authorities from the Chinese experience of COVID-19 the impact of the of and the of in the response The article with on what this might for public et at the cases of and and how leaders and policy-makers may to or in of uncertainty, and political a by and it with from Brändström and the article the factors the of of and the of public policy responses to the COVID-19 crisis in The the in the political and with for political as leaders to public political and public health during the Meanwhile, on that in the early of the more governments were better to than their the lockdown measures are to and economic and social activity is more at a and this might be in a global pandemic that public and In and across the pandemic a in The by governments to a is to introduce fiscal policy policy to be limited to a of market a of willingness by governments to be exposed to market fiscal policy this This occurred in the of the public policy response to COVID-19 not government that fundamental and EU governments have as travel and to citizens from Central and European countries could not COVID-19 in this European and the between and in those a on the case of and with to and the the and that policy and argues that systems a role in policy as for policy and as for from one occurred to a country's the economic and political of the COVID-19 crisis for the states of the on and and this article how factors the sudden in brought about by the the of of and the of fiscal to from the EU, and other of and in the early months of the an of the between government and EU in the this article argues that while in the in the fiscal risk state and the on et at the of assess public for COVID-19 in The first the during the first weeks of restrictions and on from the how public for the most important has been In so the article on the of the social and political of the on the article the to which the measures were seen as or not by a of this is important for policy-makers as the to which a policy is seen as people that policy. The analysis shows following initial widespread for the lockdown measures in March, for on economic and social activity The onset of COVID-19 many of the and economic the and the measures by the European institutions in the initial stages of the pandemic and were to the of the economic crises as The article first reviews how institutions the European Central its programs and the European to member This and political which the for a and institutional a first a fiscal with between countries and This to be for This article this issue by on what this might for the future of Europe.
This empirical study addresses the role of economic and institutional determinants on population health, estimated by life expectancy and accessibility to good quality medical services. Several national health systems are described descriptively and analytically. The practical application considers 30 European countries for which data on all necessary variables are available. The data are provided by international institutions such as the World Bank, Insurance Europe, Global Health Security and national institutions from the sampled countries. The results of the OLS cross-country regressions clearly demonstrate the positive role of health financing and the decentralization of the national health system. Instead, the role of private health insurance remains debatable, as does its complementarity or substitutability in relation to public funding. Based on the main results, recommendations are formulated regarding possible adjustments for an increased efficiency of the medical system and possible future research directions, especially regarding the role of the financing structure and the type of decentralization of the medical services.
Chrissa McFarlane, Marquesa Finch, Tiffany Gray, Jonathan M. Fuchs · 6 authors
There are growing initiatives and calls for focusing greater attention to social determinants of health and their impact on population health [1]. Several emerging strategies are being used to begin to address social determinants, such as the use of health impact assessments and applying health in all policies (HiAP). These strategies and tools are being implemented in an effort to review existing and needed policies, as well as propose new policies to lessen health disparities [2]. Efforts to further integrate social determinants of health through the use of health information technology and other emerging technologies, such as distributed ledger technology both in and outside of existing health care systems are also increasing [2]. Understanding and addressing the social determinants of health through both traditional and non-traditional sectors is key to further reducing health disparities [1, 3-4]. Through exploration of the current state of social determinants of health in the healthcare industry, an analysis of blockchain technology will render the acceleration and adoption of social determinants of health to effectively provide improved health outcomes.
The 2001 World Health Report made plain the global challenge posed by poor mental health. Worldwide, 20% of individuals may experience mental health problems during their lifetime, and such disorders account for approximately a third of all years lived with a disability 1. The consequences of poor mental health range far and wide, of course; they are associated with higher rates of non-mental health-related comorbidity and premature mortality. Some mental health problems are also associated with poor employment experiences, poor personal relationships, strain on families, and a higher-than-average risk of homelessness and contact with the criminal justice system. The 2001 report helped to raise awareness of the importance of mental health. The need to promote and maintain good mental health and well-being as integral elements of health policy is now quite widely recognised in high-income countries. For instance, the European Commission published in 2005 a Green Paper on mental health 2 and all 52 Member States in the European Region of the World Health Organization (WHO) endorsed a Declaration and Action Plan at Helsinki earlier that same year 3,4. In the United States, a Presidential Commission called for investment in actions to ensure that mental health receives the same level of attention as physical health problems, specifically recommending actions to tackle suicide and reduce stigma, as well as interventions to promote child mental health 5. Positive actions can also be seen in the Pacific region, where, for instance, New Zealand has a ten-year national mental health strategy 6, with implementation monitored by a separate Mental Health Commission. The picture in many other parts of the world is much less encouraging. Although there has been some recent focus on the need to tackle the mental health consequences of major disasters such as the Asian Tsunami 7, policy attention and resources in many low- and middle-income countries are still directed largely at communicable diseases. The purpose of this paper is to reflect on some of the challenges faced in low- and middle-income countries and the role that economic evidence could play in strengthening the policy case for investment in mental health. There is obviously a need to improve our understanding of the cost-effectiveness of specific interventions within the health care system. But there is also a pressing need to expand the role of economic analysis in looking at non-health sector interventions that can have a direct impact on mental health or can indirectly help with the uptake and maintenance of treatment. The ways in which services are delivered are of critical importance and also need evaluation. In particular, we shall argue that non-governmental organizations (NGOs) can be key players in the funding, coordination and delivery of services. The burden of mental illness is predicted to increase from its current level of 12% of global disease burden to approximately 15% by 2020; much of this additional burden is projected to occur in low-income countries 8. The consequences of poor mental health in low-income countries may be even worse than in high-income ones, because of the absence of social protection safety nets, compounded by the high levels of stigma and superstition 9. The cycle between poor mental health and poverty in low-income countries has been observed in several studies 10–12. Poor maternal mental health also has long-term adverse consequences for infants in low- and middle-income countries, limiting their own lifetime opportunities 13. Communicable diseases, the focus of much health policy in poorer countries, are also inextricably linked and exacerbated by poor mental health; interventions to prevent and treat mental health problems could help in the management of these conditions, as for instance in the case of HIV/AIDS 14,15. The economic costs of poor mental health are well documented in high-income countries, conservatively estimated to account for between 3% and 4% of gross domestic product (GDP). Few estimates have been made outside the developed world. One exception is a study in Kenya 16 that estimated that the total costs per patient for 5,678 individuals with mental health problems hospitalised in 1999 were US$ 2,351. This included out of pocket costs to family members of US$ 51 and productivity losses of US$ 453. Total economic costs for this group alone were more than US$ 13.3 million, equivalent to 10% of the Ministry of Health's budget; yet these figures would have been substantially larger if costs had also been included for those individuals who were not institutionalised or were treated by traditional healers. To put this in context, the average income per head of the population in Kenya is just US$ 580 per annum, and more than half the population live on less than US$ 1 per day 17. Other examples can be found in India, where the overall costs for outpatients with schizophrenia have been found to be similar to those of people living with another long-term condition, diabetes; a key difference between them, however, is the much greater contribution of indirect costs to overall costs (63% versus 29%) in the case of schizophrenia. This included not only the costs of lost opportunities to work for the individuals with the illness and their families, but also the loans taken out to meet the costs of treatment and money spent on repairing damage to property. In total the annual cost per outpatient treated for schizophrenia was estimated to be US$ 274 18. Another Indian study where free access to essential drugs was provided as part of community outreach services for people with schizophrenia reported that these led to a number of improvements in quality of life over an 18-month period. The impact on cost was modest, with the investment in community outreach services partly offset by a reduced need for caring by family members 19. This impact on family caregivers can be considerable. In Ethiopia, Shibre et al 20 looked at the impact of schizophrenia on 300 family caregivers in traditional rural communities. Relatives experienced financial difficulties, constraints on their social life, reduced opportunities to work and strained family relationships. These problems were particularly challenging for female caregivers. Similarly, a study of 66 caregivers in Zimbabwe reported that two-thirds experienced financial difficulties, especially as food consumption by their relative increased 21. Some people have argued a moral case for greater investment in mental health, given the high number of individuals affected and the ensuing profound consequences 22. Such a case obviously needs substantiating with evidence that targeting more investment on mental health will be effective in preventing or treating mental disorders, and that it represents a cost-effective use of a country's scarce resources. In turn, this generates a need for economic analyses to support clinical and strategic decision-making. Of course, decisions should never be made on the basis of cost or cost-effectiveness alone, and other factors such as fairness, human rights and ethics are usually highly relevant. There has been significant growth in the evidence base on the effectiveness and cost-effectiveness of interventions aimed at treating the consequences of poor mental health (particularly drug therapies) 23–26. Increasingly, economic analyses are being undertaken in low- and middle-income countries 27–31, but the overwhelming majority of studies are from high-income countries. This is not surprising: between 1992 and 2001 only 4% of articles in journals on the ISI Web of Science databases were on mental health issues; of these a mere 6% were from low- and middle-income countries 32. Similarly, Patel and Kim 33 found, from their review of publications between 2002 and 2004 in six leading journals, that only 3.7% of papers were from low-income countries. Unfortunately, economic evaluation findings do not transfer easily between countries, because infrastructures, resources, incentives and cultures can be very different. There is therefore a need to develop the evidence base on the effectiveness and cost-effectiveness of interventions in low- and middle-income countries through additional empirical studies. Practically, however, even with a substantial injection of funding, this evidence base will take some time to emerge, given the human and infrastructure capacity constraints within countries 34. In the meantime, how can economics best be used to inform policy making? In the absence of empirical evidence, careful use of economic “models” which seek to adapt evidence on effect to take account of different local circumstances and cost structures can play a role. The most significant such endeavour is the ongoing work of the WHO CHOICE (Choosing Interventions that are Cost Effective) Programme. CHOICE aims to assess the cost-effectiveness of a wide range of interventions for conditions that make significant contributions to the burden of disease in a range of epidemiological and geographical settings. The core aim is to feed information into the policy process 35. Thus far, the CHOICE programme has looked at schizophrenia, bipolar disorder, depression and panic disorder. It has estimated, for example, that cost-effective interventions can be provided for US$ 3–4 per capita in low-income settings of Sub-Saharan Africa and South East Asia, or around US$ 10 in middle-income regions such as Eastern Europe. These are typically a combination of older off-patent antipsychotic or mood stabilising drugs plus psychosocial therapy. It has also been estimated that, globally, between 300 and 500 million healthy years of life could be gained for each additional US$ 1 million invested. Around one third of the gains would be for severe mental disorders, schizophrenia and bipolar disorder, with the most cost-effective interventions being for depression and panic disorder 36. Welcome though the CHOICE programme is, it has largely on health care interventions to improve mental health there is in high-income countries a of evidence to the role of employment and living There is an need to assess the cost-effectiveness of and many of which outside the health for in the or There is also very evidence from low- and middle-income countries on how poverty and factors impact on the of mental health policy and these have an to mental health policy the substantial adverse impact of poor mental health and the evidence base on the of cost-effective there many in to ensure that mental health receives a level of investment in low- and middle-income countries and that, services are there is access to mental health may have to be a for national policy and of this was the that the World World Report that poor mental health was a major to the global burden of but its essential services for health services not seek to mental disorders, even though their overall burden was that of and HIV/AIDS This some and was in a of the it the case that in low- and middle-income countries the focus of much health policy has been communicable that to premature most and have been such as the by aimed at greater access to drug for The the contribution of good health economic and several health-related yet mental health is by its the of papers for the Commission which the between of economic growth and poor mental health This is exacerbated by This has to a of attention from policy and the in leading to a of resources, poor of information and if greater to mental health, a key on the of services and their as to meet needs is the of epidemiological This is not to low-income one recent review could not on mental disorders in of the European Member States Unfortunately, the infrastructure to such information is not in the of needs it is not to on epidemiological The of all need to be yet it for people with mental health problems and their to have an to in or inform the policy a there is a that policy to that can some of the of mental disorders, such as lost opportunities to work or to in There is also the risk that policy to the challenges of on the health care may the to mental health in may be not in many low-income countries One study from Zimbabwe that over of health care in the and of treatment for depression of health care may be compounded by the of mental with some studies that many that such conditions do not or be treated also that only physical or conditions are than the for more than 2 of the population less than of their total sector health care on mental health The majority of countries in Africa are in this of the world population in low-income countries have access to community care services on of mental health services is but at of people with severe mental health problems do not treatment within in some low-income countries One recent in found that only of people with disorders some of treatment for mental health problems during a In where the overwhelming majority of people with schizophrenia are by the it has been estimated that over still do not make use of services where there is a to mental health, the level of resources will be on the of the even if more than of the total health is to mental health, this will not to much in of overall resources if the overall level of national income is The need to or to make also that services have to be mental health services may be particularly in such to drug the WHO found that, by 20% of all countries were not at one one antipsychotic and one This is to be helped by the of World this can of drugs and the of drugs be by the there are some to these for national and which are life there are for mental In a number of free have been between the and some countries. These can be even than for instance the of protection There are also human especially health have to with the of high countries that can and conditions to these but challenges the middle-income countries of the a major to be the high rates of suicide and disorders, which may partly from economic and social mental health services are being put as resources for health the health by many people to in health care typically do not for long-term mental health The for mental health in many low- and middle-income countries that access to many services is on at the of Around of low-income countries reported to be the for mental health with only 3% of high-income countries this of is as it not take account of costs through with traditional healers. This on is and as it of services by those with which is especially given the between poverty and poor mental health for services may to poverty or if from at very to reduce some of the associated with poor mental health are number of challenges in use of resources have been out on by et al these may also be to health they are to be more to in mental health their impact may be in low- and middle-income countries, where human and financial resources are scarce and where there are many on resources. of these have been the of information on effectiveness and and the level of resources to mental health treatment and Another key is the poor of resources, which are in The to be to a mental health can be in one Indian study a key for the of use of antipsychotic was the need for individuals to have to more than 10 to their outreach 19. In some rural of South Africa there is only one per million population particularly from rural to can also as a to treatment. in is with the of that million people for may also be different disorders or for example, depression has been as a to schizophrenia within the health of countries There is also the that resources are used to support services that do not epidemiological needs or the of or the evidence base on effectiveness and The WHO has the of mental health where mental health is into the health countries which to on care are to be an of services. is a it may to and resources as best to meet population Health may be highly with for or local management of In countries where most resources are within a highly as in the it can be to resources from to The uptake of community outreach services also be poor because of the problems of food of and financial resources. To ensure a of treatment is may with food one in Zimbabwe that more than 10% of family could not to for the additional food for with mental health problems 21. It is therefore to ensure that resources are not and for to not only clinical but also some of the factors that the use of services. there is as in India, local structures need to have the to ensure that are to mental health. may also be by a number of different not only health, but also employment and social Poor coordination and between and local and can the of services. In for example, the of and community services for mental health was to a of coordination also need to be that of services or greater investment not that there will be improvements in mental health in may take several years to in of treatment and policy may therefore be to on of the health where more and can be even if the need for is is the need to ensure that there is a long-term to as to support individuals over time within their communities. one need is to improve access to information on effectiveness and cost-effectiveness of interventions to treat mental health understanding of population needs is also Other information that need to be and cost-effective ways to mental health to care and other and awareness and to tackle some of the consequences of the information and more use of scarce resources would some to strengthening the for mental health. a understanding of how resources are to mental health and other health would also be In many where national health are there is high on of for health Some into the ways that and organizations are in in health and other would help if a case is to be for more investment in mental health. opportunities for mental health and other to in the of would also be particularly as many of these papers to focus on physical health. that have helped the of physical and mental health in different settings also help the case for greater resources for mental health in mental health can also physical health. with that focus on physical health help their in mental health and psychosocial One review of that many they not have the to mental health needs and were in of greater with that in the mental health It is also to expand the role of economic analysis to at the cost-effectiveness of to tackle risk factors for poor mental health, such as poor living conditions, financial economic and levels of For instance, to mental health be through the of in low-income the of such will not be to mental health alone, that a all health would be The in which effective interventions are delivered to mental health-related is also of One is the and of health There is a substantial of in looking at to the of delivery and the need to services different be from care to In the to additional will be as to to services community services are developed and which seek to ensure have to be as to also mental health care as with the in may also The high on is a major to access to and countries should be health on or social major however, is that the structures for do not in low-income countries such as very local community a also need Although the CHOICE programme take into account the of uptake of economic in low- and middle-income countries have this are the to such as of it be to tackle these and if services are delivered by but there is a of information on the effectiveness or cost-effectiveness of the services they as it has been in high-income countries, services that can meet the needs of local in ways that services do with and their with local through the of greater uptake and use of services with To and how are These are key to which we now countries report that they have some in the of mental health. health services were of care in many countries, more or have also to play significant These organizations may be or support from local or other Some may also play significant in and policy it is to that specifically focus on mental health. One recent looked at that mental health services disasters as well as services. Of organizations on the United only reported being in mental health of these had in at one long-term but only were to mental health There are the mental health and the Mental Such organizations may not only raise and for mental health, but also help to services. Another is which in with health to help mental health services at care level in several programme countries in Africa and India, and can some of the to the of mental health policy and for by to raise awareness of the importance of mental health and by for access to services in low-income communities. community or which within local with key and their families, is used because of the challenges in at a high level into on the The community that can help on social in to support the work of health and health can be of to ensure use of and as well as and can also as between traditional and For example, has with traditional as one of their in where some of these have to some people with mental health problems to health services Such between the and the opportunities for health especially to their access to can help in a understanding of how to meet mental health needs in community a greater level of contact with people with mental health problems within local health care local health may make at or levels for drugs and other services to meet these local with can also be for the of mental health services. can as to to for greater In one where for example, the was that a mental health and programme would help to mental health the This has very to a of million US$ for mental health in and a World of Health developed with in to develop community in the and Mental health problems are a major to the global disease they are associated with premature and profound on and they substantial costs to the the of cost-effective interventions in high-income countries and some more but evidence in low- and middle-income countries, mental health and care have been widely with levels of investment in interventions for health where is access to and of services may be even if are of course, they are combination of some to mental health, has to these of within a highly of human rights and to of resources have a in which the to prevent and mental health problems has far largely been these challenges a analysis of the cost-effectiveness of interventions can play a role in this Such analysis needs to interventions that the of mental disorders a understanding is also of the health and the and in which interventions are to be analysis is also of more to risk factors for poor mental health, such as of access to and will have that mental health, and with other are such as those with communicable diseases. of the implementation process is In countries where health are and where mental health is a can play some of the of with can be more this help the case for investment in mental health. have with some in the of HIV/AIDS and maternal and child health. is more or different in looking at mental health problems in the same and in the same The experience from such as that even can have some which in that the of people with poor mental health in low-income countries is not as as is at the policy the key difference between mental disorders and other health is that the are more as a because they are as less mental health only to the attention of local policy a global such as the Asian Tsunami or a high local such as the in The in the of people who had been within a Commission provided the for mental health policy and by and and even the of But as these from it is for mental health to and for the that investment in mental health can economic as well as quality of life is to its on the for economic This is to effective mental health care with in the
Open access
Mental Health Treatment and Access
Health disparities and outcomes
Child and Adolescent Psychosocial and Emotional Development
This thesis examines the Brazilian municipalism after the Constitution of 1988. It verifies the municipalities performance in the provision of local health services vis--vis the decentralization of this policy due to the creation of the SUS (Unified Health System). It argues that the process of health services decentralization developed during the 90's presented two different steps: the step of autonomist decentralization, between 1990 and 1998, when the municipalities were totally free to choose their own local health policies; and the step of the driven decentralization, after the creation of the Basic Assistance Floor -PAB, when the municipalities started receiving targeted incomes, which could be used exclusively for specific health programs, determined by the Health Department. However, as we demonstrate, the both steps were incapable to decrease the extant regional inequalities in what regards the supply, the access and the financing of municipal health services. To summarize, we demonstrate that the inequalities in health produced by our federalism were not balanced through the outline of policies that municipalized the health services.
One of the limitations of cross-country health expenditure analysis refers to the fact that the financing, the internal organization and political restraints of health care decision-making are country-specific and heterogeneous. Yet, a way through is to examine the influence of such effects in those countries that have undertaken decentralization processes. In such a setting, it is possible to examine potential expenditure spillovers across the geography of a country as well as the influence of the political ideology of regional incumbents and institutional factors on public health expenditure. This paper examines the determinants of public health expenditure within Spanish region-states (Autonomous Communities, ACs), most of them subject to similar financing structures although exhibiting significant heterogeneity as a result of the increasing decentralization, region-specific political factors along with different use of health care inputs, economic dimension and spatial interactions.
The frail elderly have special multidimensional housing needs beyond affordability, including shelter that is more adaptive to reduced function and offers supportive services. Suitable housing for this population comprises three policy areas—housing, health care, and social services. In a federal system, development and implementation of policies in these areas involves participation of several levels of government and the nongovernmental sector. This paper uses federalism as a conceptual framework to examine and compare these policy areas in Canada and the United States. In both countries, general national housing policies—relying heavily on the nongovernmental sector and characterized by joint federal‐provincial programs in Canada and by important local government roles and age‐specific programs in the United States‐have benefited the elderly. The effects of such policies on the frail elderly, however, have been less positive because of the general lack of essential human services and, to a lesser degree, health care that enables them to live outside institutions. This is especially true in the United States, where health care policy is fragmented and is dominated by a private insurance system, partial federal financing of health insurance for the elderly, and tense federal‐state relations in financing health care for the poor. Although Canadian policies and programs operate autonomously and more uniformly within a national health plan, neither country has a universal, comprehensive long‐term care system. Geographically diverse patterns of social services, funded by grants to states and provinces and the nonprofit sector, are common to both countries. However, the United States has inadequately funded age‐specific programs and has relied on a growing commercial service provision. Housing outcomes for frail elders are moving in the right direction in both countries; however, Canada seems to be better positioned, largely because of its health care system. As increased decentralization continues to characterize the three policy areas that affect suitable housing for frail elders, the United States can learn from Canada's negotiated federalism approach to more uniform solutions to merging housing and long‐term care.