key: cord-0750622-xkkuhr6s
authors: Connelly, Luke B.; Birch, Stephen
title: Answers in search of questions: what does the comparison of COVID19 data among regions in Northern Italy tell us?
date: 2020-09-04
journal: Health economics, policy, and law
DOI: 10.1017/s1744133120000377
sha: 8d179c1ca3f75dade683ed93a2ac8ec7f963a04b
doc_id: 750622
cord_uid: xkkuhr6s

Since the outbreak of the COVID-19 pandemic, discussions about the capabilities of health and social systems to control and contain infectious diseases have been reignited. In Resilient Managed Competition During Pandemics: Lessons from the Italian Experience, Costa-Font, Turatti and Levaggi ask whether or not institutional differences between the managed competition (MC) systems in three of Italy's regions may have affected their performance – and hence, population health outcomes – during the pandemic. Fuchs (2000) previously argued that institutional arrangements not only ‘matter’, but also sometimes ‘matter a great deal’ (p. 149, emphasis in original) and this may be particularly true in emergencies.

erroneously been thought to be contained to China (Winfield, 2020) . Consequently high levels of undetected community transmission are expected to have occurred prior to the identification of the first case on 20 February (Odone et al., 2020) . Subsequently, high infection rates overwhelmed hospitals in the region, contributing to the high case-fatality rate that Costa-Font et al. report in Table 1 of their article. Contact tracing started on 21 February; although 'patient zero' was not identified, a cluster in Codogno was, and within 1 week there were 530 confirmed cases in the region (Cereda et al., 2020) .

The growth of cases in Lombardy was immediate, rapid and exponential: by 8 March, 5830 cases had been detected (Cereda et al., 2020) . Odone et al. (2020) argue that these factors, along with a 'possibly delayed public health response' (p. e310), render the case-fatality rates of little epidemiological value. We are inclined to agree, mainly for the reasons Odone et al. (2020) outline, but also because of differences in the rates of testing between the regions (leading to different reported numbers of cases and case rates) and the possibility of confirmation bias during a pandemic leading doctors to over-code deaths as due to COVID-19, that may have been due to other causes with similar presentations. Had another (more integrated) region experienced the 'initial conditions' that Lombardy experienced, would the results have been much different? It is difficult to isolate integration as a driver of the deaths data presented in Table 1 .

Interestingly, and with the caveats they make clear, Odone et al. (2020) conducted an exercise in which they computed the CFRs for a 30-day period, from the onset of the first confirmed case, for a number of regions internationally and compared them with Lombardy's CFR. Their comparison shows that the CFRs for New York, USA and Madrid Comunidad, Spain were 81.2 and 77.1 per 100,000 cases, respectively, compared to Lombardy's CFR of 41.4, notwithstanding its first-mover, informational, disadvantage. The rates they computed for two other outbreaks in Europe in Île-de-France, France and the Greater City of London, UK, were 26.9 and 23.0, respectively.

Finally, we note that there has been widespread reporting of mishandling of the crisis both in integrated and non-integrated payer-provider health systems. In the UK, there has been heavy criticism of the handling of the virus including, but certainly not limited to, the devastating outbreaks in aged care facilities (The Guardian, 2020). In Australia, which has a high degree of integration of funding and provision, but also a fairly large private sector, similar criticisms have been levelled at the public health response, especially with respect to outbreaks connected with arriving cruise-ships (see, e.g. Baxendale, 2020), hotel quarantine for returning international travellers (see, e.g. Bashan, 2020) and aged care facilities (see, e.g. Moore, 2020) .

We agree that structural issues in the health sector may well have been critical to aspects of the (mis)management of the COVID-19 pandemic; however, it seems 'heroic' to measure system performance and attribute performance differences by region exclusively to structural, or principal-agent problems in the health sector, based on non-controlled comparisons of epidemiological data between regions.

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