Background Pandemic response is largely also driven by organization and governance of health systems. In countries with social health insurance (SHI) systems, pluralism of actors and decentralisation may represent a particular challenge in crisis times. Objectives We aim to present a comprehensive analysis of the health system responses during the COVID-19 pandemic of eight SHI countries: Austria, Belgium, France, Germany, Luxembourg, the Netherlands, Slovenia and Switzerland. The question at the centre of the analysis is how SHI funds and defining characteristics of SHI systems have shaped pandemic response and which lessons to draw from the experiences of the first wave (spring to autumn 2020). Results Our analysis highlights key characteristics driving pandemic response common across SHI countries, particular the level of (de)centralization of responsibilities and providers and the role of SHI funds (compared to other actors). Five key themes emerged: governance, SHI fund sustainability, the role of GPs, surveillance strategies and (essential) health service provision. We found that SHI funds were not represented in crisis management teams during the pandemic in the majority of countries analysed. Responsibility partly shifted towards central government and away from the SHI funds. Conclusions Decentralization may pose significant challenges among local authorities with regard to the coordination of policies and information system flows. At the same time, decentralized pandemic management may be favourable as it supports bottom-up self-organization of ambulatory care providers. In fact, coordinated ambulatory care often helped avoid overburdening hospitals in the countries analysed.
Social Health Insurance country responses to the COVID-19 pandemic