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Trust, Coordination and Multi-level Arrangements: Lessons for a European Health Union

Published online by Cambridge University Press:  12 November 2020

University of Lausanne, Switzerland; email:


In the wake of the outbreak of the COVID-19 crisis, the Swedish and Swiss governments adopted a similar policy approach. They enacted mostly non-binding measures to contain the epidemic, relying on the high level of interpersonal trust and trust in political institutions that exist in both of these (broadly comparable) countries to ensure compliance. However, unlike Sweden’s strategy, the Swiss policy response evolved during the early weeks of the “first wave”, achieving public health and socioeconomic results that have been considered as satisfactory, notwithstanding the complex institutional setting and policy process, the central location of Switzerland in continental Europe, its openness and its closeness with deeply affected regions in Italy and France. To shed light on this policy response and to draw lessons from it, this paper firstly discusses the role played by the new Swiss Epidemics Act. This law centralises decision-making capacity at the federal level and expands the competences of the central government, while leaving leeway to subnational units for implementation and recognising the need for increased international regulatory cooperation. Secondly, it shows how such a solution – a multi-level arrangement steered from the federal level with quite strong vertical and horizontal coordination mechanisms – could work as a blueprint for a European Health Union.

© The Author(s), 2020. Published by Cambridge University Press

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This paper is an opinion piece based on personal research as well as on research in the framework of the project Trust in Governance and Regulation in Europe (TiGRE), funded by the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 870722.


1 Anthony S. Fauci, member of the US Coronavirus Taskforce, as reported in B Philipp, “The lesson of revised death toll estimates shouldn’t be that distancing was an overreaction”, The Washington Post, 9 April 2020.

2 Federal Councillor Alain Berset, press conference, 16 April 2020. (Original: “Nous souhaitons agir aussi vite que possible, mais aussi lentement que nécessaire”.)

3 A Alemanno, “Taming COVID-19 by Regulation: An Opportunity for Self-Reflection” (2020) 11 European Journal of Risk Regulation 187.

4 K Levin et al, “Overcoming the tragedy of super wicked problems: constraining our future selves to ameliorate global climate change” (2012) 45 Policy Sciences 123.

5 S Flaxman et al, “Estimating the effects of non-pharmaceutical interventions on COVID-19 in Europe” (2020) 584 Nature 257.

6 T Hale et al, “Variation in government responses to COVID-19” (2020) 31 Blavatnik School of Government working paper.

7 G Capano et al, “Mobilizing Policy (in) Capacity to Fight COVID-19: Understanding Variations in State Responses” (2020) Policy and Society 1; D Toshkov, K Yesilkagit and B Carroll, “Government Capacity, Societal Trust or Party Preferences? What Accounts for the Variety of National Policy Responses to the COVID-19 Pandemic in Europe” (2020) Working paper, Institute of Public Administration, Faculty of Governance and Global Affairs, Leiden University, The Netherlands.

8 On policy disproportionality, see M Maor, “Policy overreaction” (2012) 32 Journal of Public Policy 231; M Maor, “Policy persistence, risk estimation and policy underreaction” (2014) 47 Policy Sciences 425; on under-reaction to COVID-19, see R Horton, The COVID-19 Catastrophe: What’s Gone Wrong and How to Stop It Happening Again (Cambridge, Polity Press 2020).

9 As regards Sweden, see, for instance, the WHO meeting, WHO COVID-19 virtual press conference held on 29 April 2020, where Michael J. Ryan, Chief Executive Director of the WHO Emergencies Programme, reported that the Swedish government “really has trusted its own communities to implement that physical distancing”, and the “Strategy in response to the COVID-19 pandemic” released by the Swedish Prime Minister’s Office, stating that: “People in Sweden have a high level of trust in government agencies. This means that a large proportion of people follow government agencies’ advice. In the current situation, people in Sweden are on the whole acting responsibly to reduce the spread of infection by, for example, restricting their social contacts”. For Switzerland, see, for instance, the statement of Federal Councillor Alain Berset in “La Suisse a fait ses preuves”, Le Temps, 13 June 2020: “In accordance with our democratic culture, the Federal Council has opted for collective intelligence and discernment. Forcing people to behave in a certain way does not work. You have to convince. This approach made it possible to avoid extreme measures at a time when other countries were restricting the freedoms of their citizens to a much greater extent. … Mutual respect and trust between the Confederation and the cantons have always been perceptible”, and the interview of the President of the Swiss Confederation, Simonetta Sommaruga, in Le Temps, 17 April 2020, where she said: “We need to restore people’s confidence, while avoiding a rebound in the epidemic. … Asking people to wear a mask outside at all times? It doesn’t work here.” (Translations from French are mine.)

10 Quoted in N Rothschild, “Sweden Is Open for Business During Its Coronavirus Outbreak”, Foreign Policy, 24 March 2020.

11 Press conference of the Swiss Federal Council, 20 March 2020.

12 J Ludvigsson, “The first eight months of Sweden’s COVID-19 strategy and the key actions and actors that were involved” (2020) forthcoming in Acta Paediatrica; see also R Milne, “Swedish expert admits country should have had tighter coronavirus controls”, Financial Times, 3 June 2020.

13 Author’s calculations based on M Roser et al, “Coronavirus Pandemic (COVID-19)” (2020), Published online at <> (last accessed 5 July 2020); MJ Conyon, L He and S Thomsen, “Lockdowns and COVID-19 Deaths in Scandinavia” (2020), available at SSRN 3616969.

14 Data come from OECD.stat, Quarterly National Accounts: “Quarterly growth rates of real GDP, change over previous quarter”.

15 EJW Orlowski and DJA Goldsmith, “Four months into the COVID-19 pandemic, Sweden’s prized herd immunity is nowhere in sight” (2020) 113 Journal of the Royal Society of Medicine 8.

16 J Pierre, “Nudges against pandemics: Sweden’s COVID-19 containment strategy in perspective” (2020) 39 Policy and Society 478; KJ Karlsson, “Sweden’s Failure to Protect Its Elderly Population from Coronavirus Started Long before the Pandemic”, Foreign Policy, 23 June 2020.

17 See notably: the letter entitled “Gefärlichkeit von COVID-19” addressed to Federal Councillor Alain Berset on 25 February 2020 by Christian Althaus and three other professors, and the letter entitled “Offener Brief an den Bundesrat bzgl. Coronavirus” addressed to the Federal Council on 12 March 2020 by Christian Althaus and twenty-three other scientists.

18 Eidgenössisches Departement des Innern EDI, Bundesamt für Gesundheit BAG, “Taskforce 2019-nCoV Protokoll”, Bern, 23 January 2020; Eidgenössisches Departement für Verteidigung, Bevölkerungsschutz und Sport VBS, Bundesamt für Bevölkerungsschutz BABS, Geschäftsstelle BSTB, “Protokoll der a.o. Direktorenkonferenz BSTB vom 24.01.2020 (Informationsveranstaltung)”, Bern, 27 January 2020; Eidgenössisches Departement des Innern. Krisenstab des Bundesrats Corona (KSBC), “1. Sitzung: Kick-off Krisenstab des Bundesrats Corona (KSBC)”, Bern, 25 March 2020.

19 Epitomising – somewhat paradoxically – the primacy of politics.

20 As mentioned by L Wolf, “Les sciences à l’épreuve de la pandémie Dans le processus décisionnel de gestion de la crise liée au Covid-19, quid du rôle des scientifiques?” Domaine Public, 1 July 2020 <>. In that regard, see in particular: C Althaus, “Real-time modeling and projections of the COVID-19 epidemic in Switzerland” (2020) <https://ispmberngithubio/covid-19/swiss-epidemic-model/>; P Karnakov et al, “Data driven inference of the reproduction number (R0) for COVID-19 before and after interventions for 51 European countries” (2020) 150 Swiss Medical Weekly 20313; JC Lemaitre et al, “Assessing the impact of non-pharmaceutical interventions on SARS-CoV-2 transmission in Switzerland” (2020) 150 Swiss Medical Weekly 20395; C Althaus et al, “Time is of the essence: containment of the SARS-CoV-2 epidemic in Switzerland from February to May 2020”, preprint available at <>.

21 Cellule enquête Tamedia, La première vague (Geneva, Éd. Slatkine 2020).

22 M Maggetti and P Trein, “Multilevel governance and problem-solving: Towards a dynamic theory of multilevel policy-making?” 97 Public Administration 355.

23 W Linder, Swiss Democracy: Possible Solutions to Conflict in Multicultural Societies (Basingstoke, Palgrave MacMillan 2010).

24 P Sciarini, M Fischer and D Traber, Political Decision-Making in Switzerland: The Consensus Model under Pressure (Basingstoke, Palgrave MacMillan 2015); Y Papadopoulos and M Maggetti, “Policy Style(s) in Switzerland. Under Stress” in M Howlett and J Tosun (eds), Policy Styles and Policy-Making: Exploring the Linkages (Abingdon, Routledge 2018).

25 The Norwegian approach was comparable in that regard, even if the contextual conditions were quite different. See T Christensen and P Lægreid, “Balancing governance capacity and legitimacy-how the Norwegian government handled the COVID-19 crisis as a high performer” (2020) 80(5) Public Administration Review 774.

26 F Bernard, “La loi sur les épidémies à l’épreuve du nouveau coronavirus” (2020) 30 Jusletter 1.

27 F Bernard, “La répartition des compétences entre la Confédération et les cantons en situation de pandémie” (2020) Revue de droit suisse 55.

28 See G Biaggini. BV Kommentar: Bundesverfassung der Schweizerischen Eidgenossenschaft (Zurich, Orell Füssli 2017), namely BV 118 N 15.

29 EpidA, Art 9.4.

30 Eidgenössisches Departement des Innern. Krisenstab des Bundesrats Corona KSBC, “Rapport final: Etat-major du Conseil fédéral chargé de gérer la crise du coronavirus (EMCC)”, Bern, 19 June 2020.

31 K Füglister, Cantons as Policy Laboratories of the Federal State? The Diffusion of Health Insurance Subsidy Policies among the Swiss Cantons within a Federal State (Zurich, University of Zurich 2011).

32 Y Willi et al, “Responding to the COVID-19 Crisis: Transformative Governance in Switzerland” (2020) 111(3) Tijdschrift voor economische en sociale geografie 302.

33 Swiss Conference of the Cantonal Ministers of Public Health (GDK–CDS), “Nouveau coronavirus. Critères d’application de l’interdiction de manifestations”, press release, 5 March 2020.

34 Swiss Conference of the Cantonal Ministers of Public Health (GDK–CDS), “Nouveau coronavirus: Les directrices et directeurs cantonaux de la santé adhèrent à la décision du Conseil fédéral”, press release, 13 March 2020.

35 Swiss Conference of the Cantonal Ministers of Public Health (GDK–CDS), “Nouveau coronavirus: Obligation du port du masque dans les transports publics: une mesure au niveau national”, press release, 1 July 2020.

36 Press conference of the Swiss Federal Council, 20 March 2020.

37 Bernard, supra, note 27.

38 24heures, “L’obligation de porter un masque convainc”, 30 April 2020.

39 RTS Info, “La grande majorité des Suisses portaient un masque lundi dans les transports publics”, 7 July 2020.

40 See, for instance, Economiesuisse, “Surmonter le choc du COVID: mesures pour favoriser une reprise rapide de l’économie”, press release, 30 April 2020; A Niederer, “Die Corona-Fallzahlen nehmen wieder leicht zu”, Neue Zürcher Zeitung, 17 June 2020.

41 European Parliament, “Parliament wants a European Health Union”, press release, 10 July 2020.