Government can influence the health of their citizens by

Unemployment levels and the number of aid seekers have increased, sometimes dramatically. OECD unemployment is projected to rise to 9. The projections assume that sporadic local outbreaks of the virus will continue, with these being addressed by targeted local interventions rather than national lockdowns; wide availability of a vaccination is not expected until late in OECD, [1].

Given the multi-faceted nature and unprecedented scale of the COVID crisis, comparisons with past crises, including the financial crisis, have significant limitations. COVID is proving unique in its generation of both a supply side and a demand side shock, and its impact on all sectors and regions of the world. The uncertainty is also much higher. Governments face a difficult trade off: managing the economic recovery and mitigating the impact of a second wave of the virus.

The COVID crisis has a strong territorial dimension with significant policy implications for managing its consequences. Two central considerations for policy makers are:.

The regional and local impact of the crisis is highly asymmetric within countries. Some regions, particularly the more vulnerable ones, such as deprived urban areas, have been harder hit than others.

Certain vulnerable populations, too, have been more affected. In economic terms, the impact of the crisis is differing across regions, at least in its initial stages.

Subnational governments — regions and municipalities — are responsible for critical aspects of containment measures, health care, social services, economic development and public investment, putting them at the frontline of crisis management. Because such responsibilities are shared among levels of government, coordinated effort is critical.

The COVID pandemic will have short- medium- and long-term effects on territorial development and subnational government functioning and finance. One risk is that government responses focus only on the short term. Longer-term priorities must be included in the immediate response measures in order to boost the resilience of regional socio-economic systems.

By November , it is clear that the impact of the COVID crisis differs markedly not only across countries, but also across regions and municipalities within countries, both in terms of declared cases and related deaths. In the United States, New York the largest share of federal cases Within-country, COVID deaths per inhabitants can vary greatly, particularly in most hard hit countries.

For example, in Italy, Calabria is the least affected region with 5. Similarly in the United States, Vermont recorded 9. In Brazil, Minas Gerais recorded Regions in South Korea and New Zealand were less affected overall. Sejong recorded 0 deaths per while Daegu recorded 8. For the United States, only the 50 States are considered.

Data were retrieved between 24 October and 2 November. There are a number of factors that contribute to the differentiated impact of COVID, which also may explain the disparities observed in countries as diverse as Canada, Chile, Korea and the UK.

In many instances, large cities, with their dense international links — including international markets, business travel, tourism, etc. Contagion can spread more quickly in large urban areas, due to proximity, if preventive, protective or containment measures are not introduced early enough. However, it is not possible to establish a clear correlation between density and incidence of the disease. Some very densely populated Asian cities, such as Hong Kong 7.

It appears that the problem is more a combination of density plus other factors such as a lack of appropriate measures such as contact tracing, poor housing conditions, or limited access to health care.

Rural regions tend to be equipped with fewer hospital beds. Overall, metropolitan areas and their adjacent regions are better equipped in terms of hospital beds than regions far from metropolitan areas. In , regions close to metropolitan areas had almost twice as many hospital beds per 1 inhabitants than remote regions. While often the virus first took hold in urban areas, over the past few months some countries saw the health impact spread towards less populated regions.

The latter are under strain as daily deaths have continued to increase, reaching 0. Daily deaths rate in metro areas counties of above 1 million people peaked in May at 0. Density per se is not the problem. The problem is density associated with poverty, poor housing conditions and limited access to health care Basset, [32]. Poverty and access to hospitals are more important indicators than density.

Within cities, some neighbourhoods are also more affected. New York City Health Department data indicate that Manhattan, the borough with the highest population density, was not the hardest hit. Deaths are concentrated in the less dense, more diverse boroughs. Factors that do seem to explain clusters of COVID deaths in the US include household crowding, poverty, socio-economic segregation and participation in the work force Basset, [32].

The ONS study underlines that poverty and population density significantly increase the risk of death due to the coronavirus. For example, in Wales, the most disadvantaged areas had registered around 45 COVID deaths per people, while areas with less deprivation have experienced close to 23 COVID deaths per inhabitants Iacobucci, [33] between January and April In France, mortality rates are twice as large in municipalities in the first quartile of the national income distribution than in municipalities in higher quartiles Brandily, [34].

This heterogeneity maybe explained by municipal differences in housing conditions and occupational exposure. While density associated with poor housing conditions plays a role in the spread of the virus, it is worth noting that mortality rates are also determined by the health system capacity, and pre-existing health conditions e.

Not all regions are equally equipped to battle the crisis. Regional disparities in access to health care are quite high in some countries when measured by the number of hospital beds per 1 inhabitants Figure 6. These disparities appear to be regardless of whether health care spending is decentralised. It should be noted, however, that the number of hospital beds alone is a limited measure for real health care capacity and quality. Much depends on health worker density and distribution, and the quality of hospital equipment.

Some research suggests that regional disparities in health outcomes in Spain and Italy have not increased after the decentralisation of health care spending Lopez-Casasnovasa, Costa-Font and Planas, [38] ; Bianco and Bripi, [39]. Furthermore, a recent OECD Fiscal Federalism Network study showed that hospital costs are lower in countries with a higher degree of administrative decentralisation, even after controlling for particular treatments Kalinina et al.

The decentralisation and concentration debates need to be distinguished for the different categories, notably basic health and intensive care. For the most advanced care, there are obvious quality arguments for concentrating although not necessarily centralising services.

In such cases, however, there remains a need to ensure that travel times to care centres do not prevent service use. Since the outbreak of the pandemic in early , regional and local governments have been at the forefront of managing the COVID health crisis and its social and economic consequences. Together with central governments and social security bodies, they have significant responsibilities in the different areas affected by the COVID crisis.

The total of general government spending is non-consolidated. Source: OECD, [41]. In many countries, subnational government are also responsible for welfare services and social transfers. Regional and local governments are managing the closing and re-opening of schools under very strict health measures. Subnational governments are also ensuring the continuity of public services in a crisis context, adapting these as necessary, and protecting their own staff.

Citizens expect seamlessness in essential public services, such as water distribution and sanitation, waste collection and treatment, street cleaning and hygiene, public transport, public order and safety, and basic administrative services, and the proper delivery of many of these are fundamental in managing the pandemic.

In some countries, emergency services and police are managed by state, regions and municipalities, and they have been called upon during confinement periods to ensure control, security and rescue.

Regional and local governments are responding by maintaining essential services, if not at full service-levels then at adjusted ones, and by developing or providing better access to tele-services tele-health consultations, tele-education. Finally, the emergency situation has led many subnational governments to take initiatives in areas outside the scope of their responsibilities, either upon request by the central government or because they decided to do so in response to emergencies that arose.

Many comparisons have been made between the COVID crisis and the global financial crisis, but they differ radically in scope, origin endogenous in versus exogenous in , and consequences. Both crises are also very different in their impact on territories, with the crisis having a more differentiated impact than that of For example, regions with economies that are heavily dependent on tourism will be more affected by the coronavirus than other regions.

Capital regions or other metropolitan regions show a relatively higher risk of job disruption than other regions OECD, [42]. Regions with large shares of non-standard employment can help explain within-country differences arising from the COVID crisis. Evaluating the share of jobs potentially at risk from a lockdown is one way to assess the territorial impact of the COVID crisis.

These shares can be estimated based on the specific sectors of activity considered to be at risk in a region, following an OECD note on the economic impact of containment measures OECD, [44]. Regional disparities in the share of jobs potentially at risk in the short term as a result of confinement measures are stark.

In the short term, tourist destinations and large cities are suffering the most from COVID containment measures. The importance of tourism and of local consumption — including large retailers, general-purpose stores, and businesses in the hospitality industry, such as coffee shops and restaurants — partially explains this.

The extent to which activities have recovered during the high tourist season is an important factor to determine the actual economic decline in tourist destinations. The longer and more stringent the containment measures, the higher the risk for regional economies. In summer , targeted localised lockdowns were adopted in a number of countries to minimise the costs of national lockdowns. In autumn , some countries are going back to national confinement measures to mitigate the impact of a second wave of cases.

Possible stop-and-go measures are expected in the coming months, until a vaccination is available. The full impact for is yet to be calculated. The extent to which occupations can be performed remotely is an important mitigating factor with respect to economic impact and cost of COVID containment measures. Occupations amenable to remote working depend strongly on the nature of the tasks carried out, which can differ significantly even within the same workplace.

For example, academic researchers in universities can often continue working during a lockdown or under social distancing requirements, while canteen staff working in the same university may be forced to cease or strongly reduce their activities.

This work reveals that the potential for remote working is unevenly distributed within countries. Urban areas a nine percentage point higher share of occupations that can be performed remotely than rural areas OECD, [45]. In most cases large cities and capital regions offer highest potential for remote working within countries Figure 9. Such a capacity might contribute to a territorial differentiation in resilience. On average, there is a 15 percentage point difference between the region with the highest and lowest potential for remote working in a given country.

This difference reaches more than 20 percentage points in the Czech Republic, France, Hungary, and the U. It is important to note that these findings hold under the assumption that all workers — regardless of location — have access to an efficient internet connection and to the necessary equipment. As a consequence, differences across space arising from disparities connectivity and available equipment might determine the extent to which the potential to telework translates into an actual opportunity.

Note: The number of jobs in each country or region that can be carried out remotely as the percentage of total jobs. Countries are ranked in descending order by the share of jobs in total employment that can be done remotely at the national level. Source: OECD, [45]. A June-July , a survey jointly conducted by the OECD and the European Committee of the Regions CoR with representatives of regional and local governments in 24 countries of the European Union CoR-OECD, [46] indicates that in the short and medium terms most subnational governments expect the socio-economic crisis linked to COVID to have a negative impact on their finances, with a dangerous "scissors effect" of rising expenditure and falling revenues.

For example, the US National League reports a severe and long-lasting impact on US cities with a loss of own-source revenue reaching The impact of COVID on subnational finance is differentiated among countries, among levels of government, among regions and among municipalities.

The varying effects on subnational finance depend on five main factors, all of which need to be taken into account to analyse and compare the fiscal impact of COVID on regions and municipalities:. It is extremely difficult quantify the impact of the COVID crisis on subnational finance as there are many uncertainties surrounding its severity, duration, variability across territories, and the effectiveness of the support mechanisms introduced by international, national and subnational public authorities.

Moreover, the new waves of infections and new lockdowns may continue to strongly affect subnational government finances. With new waves of infection, the evolution of the crisis reveals itself to be non-linear. Countries must manage combined shocks and their cascading effects in parallel, as well as implement recovery plans.

Many countries have introduced expansionary fiscal measures. Withdrawing them too quickly and introducing tight fiscal consolidation measures is risky as it could result in public investment becoming an adjustment variable.

This happened after , leading to a strong and persistent drop in public investment and hampering growth in many in many OECD countries. The effects on stocks are on the assets owned by subnational governments and on their liabilities. Physical or financial assets and liabilities will likely be affected but this will depend on a variety of factors, such as the evolution of real estate prices, insurance reserves, pension funds, local company values, etc.

For example, in the US, the crisis and the stock market collapse have exposed the fragility of public pension systems, exacerbating the solvency crisis of many pension systems and jeopardising the future retirement benefits of state and local public-sector workers. Public pension plans closed in fiscal year with virtually no change in their average funded ratio despite the high volatility in asset prices in the first half of the year.

However, decreasing state and local governments revenues will hamper their ability to make their required pension contributions in the near term SLGE, [48].

Some categories suffered from the cessation or slowdown of activity, particularly in the tourism, culture, leisure and transport sectors.

Business failures and threats to capitalisation and equity affect subnational governments as shareholders FEPL, [49]. Subnational governments face strong pressure on expenditure and reduced revenue, thus increasing deficits and debt. While the crisis has already put short-term pressure on health and social expenditures and on different categories of revenue, the strongest impact is expected in the medium term.

National governments, associations of local governments, and individual entities have started estimating the short and medium term fiscal impact, in order to prepare and adjust budgets, and to design appropriate support measures Box 1. As already underlined, these estimates are still tenuous and need to be regularly updated, given the context of uncertainty.

This second shock may be stronger for those subnational governments that drained all their fiscal reserves to resist the first shock; while they may still be under the effects of the previous shock. Behind this is a postponement of tax payments, which will result in tax collection being delayed. At the municipal level, it is estimated that the crisis will cost up to EUR 2 billion in because of additional spending needs. In Canada, municipalities may have lost between CAD 10 billion and CAD 15 billion in revenue over the first three quarters of and unanticipated costs including public safety measures and support for vulnerable populations Federation of Canadian Municipalities, [52].

By the end of , it appears that COVID will not reduce municipal tax revenues as sharply as was predicted in the spring. The relatively good development of municipal tax revenues is partly due to the fact that the state increased the share of municipal corporate tax in and as one of its first support measures, particularly benefiting the largest cities.

In Germany , many state governments will see a sharp deterioration in their budgetary performance in , given falling revenues and rising expenditure. Behind this are packages adopted by the regions to support local economies and the wish to maintain, and even increase, public investment.

According to the Association of German municipalities, the municipal share of income tax will also fall by 7. In Iceland, a report released in August estimates that municipal revenues will decrease significantly in due to the COVID crisis, with a total shortfall of over ISK 33 billion, accounting for 8.

Municipal tax revenues, their largest single source of revenue, will shrink significantly. In general, the impact of COVID is the most significant in tourist areas, and in municipalities which assume the most expenditure on social services and financial assistance sectors Ministry of Transport and Local Government, [57].

A low risk scenario with a loss of revenue among municipalities of about EUR 3. This is based on a relatively rapid exit from the emergency beginning in May , where the largest losses would be concentrated on the sectors directly exposed to the crisis, with other sectors recovering relatively quickly in or by A medium risk scenario, with an estimated municipal revenue loss of about EUR 5.

In this scenario, COVID triggers a major and long running national and international economic crisis that causes recovery difficulties for all economic sectors ANCI, [58]. Regional governments also face financial difficulties. To this is added a drop in receipts from the regional tax on productive output IRAP , the regional surtax on the personal income tax and the regional tax on vehicles. In Japan, prefectural spending to contain the novel coronavirus, amounting USD 9.

The drop will continue in as Switzerland's tax collection is spread out over several years. Cantons have also started to support local economies.

In the UK , local government finance is facing a difficult future. Recent analysis estimate that local councils face a 7. In the US , according to a recent study released in July by the Council of State Governments, states face a combined estimated revenue shortfall of between USD billion and USD billion in general fund receipts in fiscal years and as a result of the COVID pandemic and its economic impact. At the local level, recent research estimates a drop in municipal revenue of 5.

These losses could lead to significant cuts in critical public safety services, parks and recreation, and pay and jobs cuts.

All subnational government transactions are likely to be highly affected by the crisis in the short and medium terms.

A detailed analysis of the expected impact on expenditure, revenue, debt management and access to new borrowing permits identifying their contribution to changes in subnational government finance Figure Overall, surveyed regions and municipalities in the European Union expect the crisis to have a slightly larger impact on revenue than on expenditure.

This crisis is calling on regions and cities to increase their expenditure in many areas. The impact of this, however, will vary according to their spending responsibilities.

In many countries, subnational governments are responsible for critical aspects of health care systems, including emergency services and hospitals. In the context of the crisis, subnational governments are confronted with a number of complex and costly tasks. They have first managed the full or partial closure of certain services and facilities and then their reopening while having to ensure the continuity of essential public services, adapt services either physically public transport, collection of waste, cleaning of public spaces or virtually tele-health consultations, remote education arrangement, local tax payments, access to government information, etc.

Finally, in many countries, subnational governments are involved in delivering support policies for SMEs and the self-employed, as well as infrastructure investment. Although some expenditure items are temporarily reduced related to the slowdown of public services, the cancellation of events, and decrease in intermediate consumption, for example petrol or deferred in time, most subnational spending items tend to increase in the short term emergency expenditure , and also in the medium-term in response to exit strategies and recovery programmes.

According to the OCDE-CoR survey, anticipate significant expenditure increases in social services and benefits, support to SMEs and the self-employed, and public health. More moderate expenditure increases are expected in education, information and communication technologies, adapting local public transport, adapting administrative services and public order and safety. Regions in the EU are more likely than municipalities to experience increased spending on health services, support to SMEs and the self-employed, and adaptation of public transport, likely reflecting their broader responsibilities in these areas OECD-CoR, [65].

In a number of OECD countries, states, regions, and municipalities are responsibility for public health services and hospital spending. Subnational governments account for about However, the degree of decentralisation in the health sector varies markedly.

The OECD developed the typology to indicate the level of decentralisation in the health sector in OECD countries Box 2 based on the combination of three subnational expenditure spending ratios: i as a share of total public health expenditure Figure 7 ; ii as a share of total subnational expenditure; iii as a share of GDP.

The practice of public health has been dynamic in India, and has witnessed many hurdles in its attempt to affect the lives of the people of this country. Since independence, major public health problems like malaria, tuberculosis, leprosy, high maternal and child mortality and lately, human immunodeficiency virus HIV have been addressed through a concerted action of the government.

Social development coupled with scientific advances and health care has led to a decrease in the mortality rates and birth rates. The new agenda for Public Health in India includes the epidemiological transition rising burden of chronic non-communicable diseases , demographic transition increasing elderly population and environmental changes.

Mental, neurological and substance use disorders also cause a large burden of disease and disability. The rising toll of road deaths and injuries 2—5 million hospitalizations, over , deaths in makes it next in the list of silent epidemics. Behind these stark figures lies human suffering. Health systems are grappling with the effects of existing communicable and non-communicable diseases and also with the increasing burden of emerging and re-emerging diseases drug-resistant TB, malaria, SARS, avian flu and the current H1N1 pandemic.

Inadequate financial resources for the health sector and inefficient utilization result in inequalities in health. As issues such as Trade-Related aspects of Intellectual Property Rights continue to be debated in international forums, the health systems will face new pressures.

The causes of health inequalities lie in the social, economic and political mechanisms that lead to social stratification according to income, education, occupation, gender and race or ethnicity.

In the era of globalization, numerous political, economic and social events worldwide influence the food and fuel prices of all countries; we are yet to recover from the far-reaching consequences of the global recession of To meet the formidable challenges described earlier, there is an urgent call for revitalizing primary health care based on the principles outlined at Alma-Ata in Universal access and coverage, equity, community participation in defining and implementing health agendas and intersectoral approaches to health.

These principles remain valid, but must be reinterpreted in light of the dramatic changes in the health field during the past 30 years. Public health is concerned with disease prevention and control at the population level, through organized efforts and informed choices of society, organizations, public and private communities and individuals.

However, the role of government is crucial for addressing these challenges and achieving health equity. Contribution to health of a population derives from systems outside the formal health care system, and this potential of intersectoral contributions to the health of communities is increasingly recognized worldwide. Thus, the role of government in influencing population health is not limited within the health sector but also by various sectors outside the health systems.

Important issues that the health systems must confront are lack of financial and material resources, health workforce issues and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment. The Integrated Disease Surveillance Project was set up to establish a dedicated highway of information relating to disease occurrence required for prevention and containment at the community level, but the slow pace of implementation is due to poor efforts in involving critical actors outside the public sector.

Health profiles published by the government should be used to help communities prioritize their health problems and to inform local decision making. Public health laboratories have a good capacity to support the government's diagnostic and research activities on health risks and threats, but are not being utilized efficiently. Mechanisms to monitor epidemiological challenges like mental health, occupational health and other environment risks are yet to be put in place.

There is a need for strengthening research infrastructure in the departments of community medicine in various institutes and to foster their partnerships with state health services.

A good system of regulation is fundamental to successful public health outcomes. It reduces exposure to disease through enforcement of sanitary codes, e. Wide gaps exist in the enforcement, monitoring and evaluation, resulting in a weak public health system. This is partly due to poor financing for public health, lack of leadership and commitment of public health functionaries and lack of community involvement.

Revival of public health regulation through concerted efforts by the government is possible through updation and implementation of public health laws, consulting stakeholders and increasing public awareness of existing laws and their enforcement procedures. These are a few examples of behavior change communication that focus on ways that encourage people to make healthy choices. Development of community-wide education programs and other health promotion activities need to be strengthened.

There are several shortfalls that need to be addressed in the development of human resources for public health services. There is a dire need to establish training facilities for public health specialists along with identifying the scope for their contribution in the field. The Public Health Foundation of India is a positive step to redress the limited institutional capacity in India by strengthening training, research and policy development in public health.

Preservice training is essential to train the medical workforce in public health leadership and to impart skills required for the practice of public health. Changes in the undergraduate curriculum are vital for capacity building in emerging issues like geriatric care, adolescent health and mental health. Early in their development, both Minnesota and the United States recognized the role of the government in protecting the public's health, and each entity makes reference to this in their constitutions as part of a "general welfare" clause.

Public health promotes the welfare of the entire population, ensures its security and protects it from the spread of infectious disease and environmental hazards, and helps to ensure access to safe and quality care to benefit the population. Governmental responsibilities for public health extend beyond voluntary activities and services to include additional authorities such as quarantine, mandatory immunization laws, and regulatory authorities.

The state's partnership functions by encouraging residents to do things that benefit their health e. Minnesota's areas of public health responsibility within the Local Public Health Act follow. They describe what people in Minnesota should expect to receive from their local health department no matter where they live, and are used by community health boards for assessment and planning purposes. The areas of public health responsibility include 1 assuring an adequate local public health infrastructure, 2 promoting healthy communities and healthy behaviors, 3 preventing the spread of communicable disease, 4 protecting against environmental health hazards, 5 preparing for and responding to emergencies, and 6 assuring health services.

You can find more information on public health activities relating to these areas online. Assuring an adequate local public health infrastructure means maintaining the basic capacities foundational to a well-functioning public health system such as data analysis and utilization; health planning; partnership development and community mobilization; policy development, analysis and decision support; communication; and public health research, evaluation and quality improvement.

Promoting healthy communities and healthy behaviors means activities that improve health in a population, such as investing in healthy families; engaging communities to change policy, systems or environments to promote positive health or prevent adverse health; providing information and education about healthy communities or population health status; and addressing issues of health equity, health disparities, and the social determinants of health.

But from the perspective of a single mother a social exclusion can mean lack of access to emergency child care when she has to stay late at her job. For a teenage boy with depression it can mean the one or two people he reaches out to when he feels he has nowhere else to turn.

A neighbour checking in on an elderly woman who cannot leave her house may be the only means of social inclusion she has. Without that neighbour the elderly woman may go days without any other human interaction and, in some cases, personal support care.

The social inclusion processes that make up our lives can have a huge impact on our health outcomes. Education plays an important role in determining health status of an individual, but is more likely to be linked to income, employment, and career success than it is to an individual having a greater store of personal knowledge.

With higher levels of educational attainment, individuals have access to less hazardous jobs, and reduce their risks associated with workplace injuries. In addition, their education attainment proves more access to employment with job security, retirement plans, and health insurance that is not covered by government health programs. In addition, education is also associated with health literacy.

Health literacy is the understandings individuals have about their health and how to access health services and health information. Individuals need to understand the health information they are provided to take control of their health.