Abstract
INTRODUCTION: COVID-19-related mortality varied substantially within and across countries, which may not be fully explained by demographic and clinical differences. Some studies suggest that local governors' ideology has a substantial effect on mortality because of their political stances for and against the stringency of public health interventions. However, recent research indicates that stringency is not consistently related to lower mortality. This study investigated whether regional differences in COVID-19 mortality are attributable to differences in local governance arrangements for collaborative policy responses to pandemic situations in Japan, where local infection control was managed via a decentralized system. METHODS: From December 2020 to November 2021, we conducted a city-level, cross-sectional, ecological study of 20 cities designated by the government ordinance of Japan. COVID-19-related mortality rates were obtained per 3-month period to account for viral variant change. The local deliberative decision to suspend the national health insurance policy that temporarily revokes the benefit eligibility of households because of unpaid premiums was considered an indicator of flexible and collaborative governance, as the decision required unanimous consensus from diverse stakeholders within and across local government institutes. Negative binomial regression was used adjusting for covariates, including population density and emergency care accessibility. RESULTS: During the study, 5,383 COVID-19-related deaths were reported. Of the 20 cities, five had implemented the suspension decision before or during the pandemic. Cities with the suspension policy showed an adjusted mortality relative risk of 0.75 (95% confidence interval: 0.60 to 0.94) compared with cities that retained the temporary revocation policy. Conclusions: The results suggest that local governments with flexible collaborative policymaking were more successful in mitigating the COVID-19 mortality impact in Japan. The findings highlight the potentially important effect of governance arrangements on population health disparities.