‘A war of a different kind’: local municipalities’ experiences in managing the COVID-19 pandemic in Israel–a qualitative study

Abstract

Objectives

In Israel, in 2020, 57/257 local municipalities were part of the Healthy Cities Network (HCN). HCN municipalities have a strong political commitment to health promotion and reducing health inequalities. This research aimed to (1) explore local municipalities’ management of the pandemic and (2) assess whether belonging to the HCN impacted this management.

Design, setting and participants

Fourteen municipalities were chosen—seven HCN municipalities, matched to seven non-HCN municipalities. In each municipality, semistructured telephone interviews were conducted with three to four officials. Interviews were recorded, transcribed and analysed using inductive thematic coding, both in general and specifically to compare HCN and non-HCN municipalities.

Results

Forty-two interviews were conducted, with five main themes: (1) relationship with the government; with the transference of information to the local municipalities found to be challenging and a strong need for more independence at the local level; (2) contact with residents which was divided into several actions, such as mapping the city population, supporting vulnerable populations and managing volunteers; (3) relationships within the municipality which included a sense of collaboration and community but also a feeling of wear out; (4) difference between the first lockdown compared with following lockdowns; within these themes, no significant differences were found between HCN municipalities and non-HCN municipalities and (5) the role of the Healthy City (HC) coordinator which was critical in several municipalities. They served as brokers, had a pre-existing intersectoral network and held a broader vision of health.

Conclusions

Local municipalities in Israel played an important role in the pandemic response. Municipalities requested a central information source and more independence at the local level. Challenges and responses were similar across municipalities and residents, regardless of their HCN status. However, in some municipalities, the role of the HC coordinator was crucial for the pandemic response due to pre-existing interprofessional and intersectoral networks.

Strengths and limitations of this study.

• Interviews were conducted with a variety of officials from 14 different local municipalities, which gave rich insight into participants’ experiences.

• Matching between municipalities that belonged to the Healthy Cities Network and those that did not belong to the network, allowing for assessing the impact of belonging to the Healthy Cities Network.

• There was a long timeframe from the beginning of the pandemic until data collection, which might have impacted results and differences between municipalities that could have been more evident at the beginning of the pandemic.

• Public-elected officials might present their actions more positively than in reality.

Introduction

Many countries, including Israel, have used social distancing and movement restrictions to mitigate the COVID-19 pandemic.1 2 While governments are responsible for managing the national COVID-19 crisis, local municipalities are responsible for implementing day-to-day containment measures and ensuring healthcare and social services. Local municipalities have played a central role in managing the COVID-19 pandemic and the mitigation of its grave health, economic and social consequences.3–5

It is well known that the built environment influences residents’ health status and health behaviours.6 7 During COVID-19, this association was also apparent regarding the risk of virus transmission (ie, in regard to crowding, poverty, air quality and circulation) and the pandemic social consequences (eg, access to parks and green areas). A liveable city is not just a safe, healthy, sustainable city, with healthy urban planning, but also a city that is resilient.8 A resilient city is a city that supports its residents and their daily activities in an active, safe and healthy approach and can handle rapid changes.8

The Israeli Healthy City Network (HCN) is part of the European Healthy Cities Network, led by the WHO.9 HCN municipalities are strongly committed to health promotion, sustainability and reducing health inequalities. Interdisciplinary and intersectoral activities are carried out to achieve these goals. HCN municipalities appoint a Healthy City coordinator (HC coordinator) who is responsible for promoting health issues in daily routine. In Israel, at the time of the study, 57 municipalities (out of 257), covering ~60% of all Israeli residents, were part of the HCN. HCN municipalities have a pre-existing network structure of collaborations and an array of intersectoral collaborations due to their involvement in the network itself. For example, representatives of the Health Maintenance Organisations (HMOs) and the Ministry of Health are partners in these authorities’ steering committees and in the day-to-day activities.10 This network structure has been developed for different purposes than the management of a pandemic, yet we assume that such regular preparation and previously established ties may help in times of crisis. As the literature on interorganisational and interprofessional collaboration show, these ties are essential for sharing information, data or best practices.11 12 The role of the HC coordinator as a broker and building professional and personal bridges13 may be helpful as a part of the pandemic management. Therefore, one might assume that local municipalities that are part of the HCN may have managed the pandemic differently, or even better, than local municipalities that are not part of the HCN.

At the time of the data collection for this study (October 2020–February 2021), Israel experienced three national lockdowns due to COVID-19. The first lockdown, which was the strictest, began on 11 March 2020 and lasted about 2 months. It included a ban on leaving the house more than 100 m away except for essentials, closure of schools and non-essential businesses and reducing the workforce capacity within essential business by at least 30%, including at the local municipality. Nonetheless, HC coordinators who were responsible also for health during emergencies continued to work, operated in coordination with the Ministry of Health and HMOs and were involved in the local municipality pandemic response. The following two lockdowns had similar, yet not as strict restrictions (eg, residents were allowed to leave their houses for outdoor activities).

This study aims to (1) explore Israeli local municipalities’ management of the COVID-19 pandemic and (2) assess whether belonging to the Israeli HCN impacted this management.

Methods

Sample

Fourteen municipalities were chosen—seven HCN municipalities where the HC coordinator was also responsible for health during emergencies matched to seven non-HCN municipalities. Matching was based on: (1) ethnicity (predominantly Jewish, Arabic or mixed), (2) settlement type (city, local council, regional council), (3) socioeconomic index (ranging from 1 to 10, according to data from the Israeli Central Bureau of Statistics), (4) geographical location (either North, Haifa, Central, South, Tel-Aviv or Judea and Samaria districts) and (5) population size (in thousands, categorised as small (≤30 000), medium (30 000–100 000) and large municipalities (>100 000)). From each municipality, three to four officials were approached—the mayor or chief executive officer (CEO), HC coordinator and/or the person responsible for health during emergency situations (in non-HCN municipalities) and the Head of the Department of Social Services. A more detailed description of the local municipalities characteristics is presented in table 1.

Table 1.

Characteristics of the 14 HCN and non-HCN local municipalities

Pairs of municipalities	HCN status	Population ethnicity	Settlement type	Socioeconomic index	Geographical district	Population size (in 1000)
1	HCN	Arab	City	3	Haifa	29.0
	Non-HCN	Arab	City	3	Central	42.4
2	HCN	Mixed	City	5	North	21.3
	Non-HCN	Mixed	City	5	North	40.6
3	HCN	Jewish	Regional council	7	South	10.0
	Non-HCN	Jewish	Regional council	7	South	8.0
4	HCN	Jewish	Local council	7	Central	23.5
	Non-HCN	Jewish	Local council	7	Central	27.5
5	HCN	Jewish	City	8	Central	100.0
	Non-HCN	Jewish	City	7	Central	138.4
6	HCN	Jewish	City	8	Tel-Aviv	94.0
	Non-HCN	Jewish	City	8	Tel-Aviv	59.5
7	HCN	Jewish	City	6	Judea and Samaria	37.8
	Non-HCN	Jewish	City	6	Judea and Samaria	19.6

HCN, Healthy Cities Network.

Research team

The study team included four researchers—one medical anthropologist and one sociologist, both hold a doctorate degree and are highly experienced in qualitative research (HN and HB) but had not done any prior work regarding local municipalities or the HCN, and two public health physicians and researchers (MD and YB-Z). MD serves in a voluntary role as the chair of the Israeli HCN, and YB-Z has previously worked as the scientific coordinator of the Israeli HCN.

Procedure

A letter was sent by email from the Federation of Local Authorities in Israel to all mayors and CEOs of the 14 local authorities chosen for the study, requesting their participation, followed by direct contact via email and/or phone. Those who agreed were emailed an informed consent form for them to review and sign. After gaining consent, interviews were conducted via phone, audio-recorded and transcribed by a professional transcribing service. Interviews were conducted by the first author (HN) using a semistructured interview guide (online supplemental file 1). All interviews were conducted in Hebrew, and quotes were translated verbatim into English. Interviews lasted on average 46 min (range 21.6–84.0). In some municipalities, the mayor/CEO referred to other officials for the interview. Furthermore, in some municipalities, stakeholders changed during the pandemic, thus, more than one person could have been interviewed for each role. Except for one participant, all of the interviews were conducted when the participant was alone at their office or home.

Analysis

All the interviews’ recordings and transcripts were shared and read by the entire research team. Interviews were coded using a general thematic analysis.14 Initially, a subset of the data (six interviews, three from HCN municipalities and three from non-HCN municipalities) was independently coded by two research team members (HN and HB), and a coding manual was developed, identifying concepts and clusters of concepts.15 Analysis and coding were conducted according to research questions: (1) themes related to the management of the pandemic in general and (2) comparison between HCN and non-HCN municipalities, and specifically in relation to the HC coordinators’ role. The coding manual was discussed by the entire research team and then used by one researcher (HB) to code the remaining transcripts. Considerations in selecting the themes included a wealth of evidence and the extent to which they illuminated various aspects of the narrative, reflecting statements that were raised by most of the interviewees. If new subthemes were found, they were discussed and agreed on with the second coder. In cases of disagreement, further reading of the data was made and further discussions were held until an agreement was reached. The triangulation strategy enhanced our understanding of the phenomena while simultaneously increasing the validity, quality and trustworthiness of data.16 The study combined insights from researchers from different disciplines (medical professionals and social sciences professionals)—interdisciplinary triangulation, and participants from different roles and positions—participants triangulation. This generated more comprehensive knowledge related to the topic of study and gave a broad picture of the state of affairs.16 17

Patient and public involvement

Patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.

Results

Forty-two interviews were conducted from 13 municipalities (in 1 non-HCN municipality no interviews were scheduled despite repeated attempts)—23 officials from HCN municipalities and 19 officials from non-HCN municipalities. Participants included 18 men and 24 women; 7 CEOs (3 HCN municipalities, 4 non-HCN municipalities); 2 mayors (1 HCN municipality and 1 non-HCN municipality) and 4 other officials on behalf of the mayor or CEO from HCN municipalities (Director of the Security Department and Municipal COVID-19 Supervisor, Director of the Strategic Planning and Cooperation Division, Deputy Director General and Acting Mayor); 15 Heads of the Department of Social Services (8 from HCN municipalities and 7 from non-HCN municipality); 7 HC coordinators and 7 people who were responsible for health in emergencies, 6 of these were from non-HCN municipalities, and 1 was from a HC municipality where he worked alongside the HC coordinator.

Five major themes were identified, while some of them included two to five subthemes. Online supplemental file 2 provides illustrative quotes for each theme and subtheme. Across the first four themes, no differences were found between HCN and non-HCN municipalities and therefore results are presented together for all participants. For the last theme (The role of the HC coordinator), notable differences were found and are presented according to HCN status.

Relationship with the government

Transference of information from the government to local municipalities

Transference of information from the government to the local municipalities level was a significant challenge, particularly during the pandemic’s early stages. It was manifested on the one hand in the flood of information, both in terms of the amount and details and in terms of the many sources of information. While officials initially tried to find their way between the massive amount of information and guidelines, they later used their own common sense and focused on one source of information that was perceived as trustworthy. In addition, limited and delayed sharing of morbidity data, and specifically the identity of positive-confirmed patients with COVID-19 from the local municipality (to maintain privacy at the early stages of the pandemic) hindered local municipalities’ ability to respond promptly to break the chain of infections. In later stages, data were exposed to a limited number of officials, allowing local municipalities to conduct epidemiological investigations.

Desire for more independence

Most participants expressed a desire for more independence and control at the local level, stating the differences between the municipalities in terms of size, geographic location, population density and citizens’ heterogeneity or homogeneity. Participants also claimed that local municipalities know their residents better than the government. Therefore, they should have had more autonomy in making local decisions, for example, how to manage the local education system and schools, what kind of enforcement practices to apply, etc. Some stated that they had too many guidelines with not enough power to act on them.

Contact with residents

Mapping the city population

Among the first challenges local municipalities faced was the shortcomings in attaining updated data on residents. In particular, people who were not already part of the ‘system’ (ie, received prior assistance from the department of social services) but needed assistance due to the lockdowns, such as the elderly and people with disabilities over the age of 21. Municipalities worked intensively to update residents’ details. This was done by purchasing or creating new software and by using online surveys. Data management evolved quickly and became advanced and digitalised. Some officials discovered new, meaningful information about the city’s characteristics; for example, a CEO from HCN municipality no. 7 shared that he was surprised to discover a large community of immigrants from the former USSR who do not speak Hebrew in his city.

Vulnerable populations

The elderly population was the focus of the municipalities’ attention, and extensive food operations worked throughout the country—initially in the supply of hot meals for elderly households and later by supplying dry food baskets. Medicines were also provided for those unable to venture out to pharmacies. As the pandemic progressed, municipalities realised that other issues, such as citizens’ emotional well-being (eg, loneliness) were more pressing and their attention was directed in this direction.

Throughout the lockdowns, municipalities did their best to open social clubs as fast as they could for people with special needs and for the elderly to sustain continuous activity. Representatives remained in touch with the elderly who needed assistance and made weekly individual phone calls. Special activities to reduce loneliness were formed while still adhering to restrictions. Local municipalities also assisted people with disabilities, special education students and at-risk youth. In addition, there was an increase in the number of residents who suffered financial strain due to the COVID-19 pandemic (ie, job loss, business closure or reduction in revenue) and required assistance from the department of social services.

Unique activities

The actions taken by local municipalities were characterised by proactivity, which included reaching out to specific populations, and by great creativity to combat loneliness, exhilarate frustrated parents and children and sustain a sense of active, normal life during lockdowns. Such activities included material assistance (food, medicines, computer equipment). educational activities (development and adaptation of content for remote learning), maintaining high morale (live shows to watch from within the vehicle, music trucks around town, recreational kits for children and youth, public singing in open spaces), alternative celebration of ceremonies and events (Holocaust and Remembrance Day ceremonies broadcasting live online, organising small weddings in the municipality building, arranging suitable open places for prayer), online or phone psychological assistance and guidance, online lecturers on resilience and parenthood, aid to local businesses (eg, local business preference policy, local produce fair) and more.

Communicating information and guidelines

Extensive efforts, time and resources were given to the issue of communicating and interpreting medical data about COVID-19 and the rules and instructions expected from citizens. The aims were to encourage compliance with regulations and testing, strengthen contact with residents and create higher levels of trust. The methods were diverse and included formal and informal communication with residents, such as the production of broadcast contents on local TV channels; use of key figures in the city, such as the mayor and religious figures, to explain and encourage citizens to follow restrictions and use of social media (live online broadcasting on Facebook, group messages on WhatsApp) alongside educational campaigns in traditional media. In some small municipalities, the mayor himself called each positive-confirmed patient with COVID-19 for encouragement and emphasis on guidelines. The aim was to produce a uniform language and explicit messages to reach every resident.

Volunteers as an asset

A significant part of the municipality’s activity was credited to volunteers who acted both on their own initiatives and through organised activity by the local municipalities. Officials were surprised by the increase in volunteers, and some operated an array of hundreds of volunteers. Volunteers were crucial contributors to reaching a vast number of residents: they did phone calls to isolated people and the elderly population, fulfilled logistical roles such as transporting and distributing various supplies to those in need and helping with taking out the trash or walking the dogs for vulnerable citizens. In some cases, volunteers served in crucial positions—doctors or people from the Israel Defense Forces with experience in emergencies who were residents of the city. Volunteers were seen as an essential asset, which many municipalities wish to preserve for the future. However, it should be noted some of the activities performed by the volunteers could have been done by paid workers who were sent on a leave of absence to reduce viral transmission.

Relationships within the municipality

The workforce problem

The first challenge rose from the initial lockdown restrictions imposed by the government, who required a reduction of staff (to mitigate viral spread), sending all others on paid vacations or a leave of absence. The workers from the department of social services were exempted from these restrictions in only some of the municipalities. However, they were recognised as essential at a later stage, allowing them to return to a full-time job. The local municipality workforce also suffered from COVID-19 infections, requirements for isolation due to close contact exposures, difficulties to work as a result of needing to be with young children at home due to school closures or belonging to a high-risk population. As a result, local municipalities faced limited staff availability. Since COVID-19 was a national and global challenge, it was not possible to enlist the help of human resources from other municipalities as could be done in other local events.

Collaboration and a sense of community

Collaboration between the municipalities’ departments took place in most municipalities, whether in regular work meetings, daily consultations and transference of employees between departments as needed. The interlocutors were very proud of their municipality’s performance. They spoke highly about the collaboration of the mayor, the CEO and other key public servants in reaching out to residents and in participating in ‘low-ranked’ jobs (such as packing food baskets), which inspired municipalities’ workers. However, officials also expressed a feeling of wear out and tiredness. Department of Social Services’ officials stated the long hours and countless responsibilities they had during the outbreak, with almost no holiday breaks of rest. Participants compared security emergencies (such as missile attacks) that they were accustomed to dealing with, but were usually short-lived, with the pandemic, where the end was not in sight, requiring ongoing management. Workers who had organised days of a break or fun activities sponsored by the municipality reported these activities lifted their spirits and motivation and made them feel appreciated.

Difference between the first lockdown and following lockdowns

The challenges of the municipalities changed with the different stages of the pandemic. Despite the surprise and anxiety that accompanied the first lockdown, and perhaps precisely because of them, the residents’ compliance with the rules and restrictions was very high, and the public cooperated extensively. As time went on, and the pandemic progressed, the residents’ patience shortened and there was an erosion in their resilience. The length of the pandemic taught the local municipalities that the COVID-19 routine requires continuous thinking and assessing the situation, unlike other emergencies that the Israeli society is more accustomed to.

Role of the HC coordinator

The HC coordinator played a key role in the pandemic management in most municipalities. The responsibilities of the HC coordinators during the pandemic were adjusted and shaped according to the needs of the local municipality. On periods of outbreaks in certain areas, they were required to focus their efforts on stopping the infection chain and addressing health issues. During a lockdown, they were required to continuously monitor morbidity rates and address issues within the municipality. The HC coordinator had access to ongoing updated information and to continuous peer consultation through the HC network and updates. They also assisted in response to public perceptions, worries, concerns, rumours and mixed messages. The HC network also served as a source for professional learning from other municipalities’ mistakes and successes. As part of promoting activities for the benefit of the municipalities’ residents, the HC coordinators were involved in increasing the accessibility of information about the pandemic (eg, inviting professionals—epidemiologists and HMO managers who explained the risks and prevention possibilities); they arranged educational lecturers regarding nutrition and physical activity during the lockdowns; raised awareness about consequences of the pandemic such as obesity, depression, anxiety, domestic violence and more. In some municipalities, the personal contact details of the HC coordinator were publicised. The HC coordinators felt that this was essential to raising the residents’ sense of security and trust in the municipality. Other officials, such as the mayor and CEO, also emphasised the importance of the HC coordinator.

A notable difference between HCN municipalities and non-HCN municipalities was HCN municipalities’ interorganisational collaborations, particularly with the Ministry of Health and HMOs. HC coordinators had an existing network of collaborations and interfacing with both organisations before the COVID-19 pandemic, which was very helpful during the pandemic. The interfaces were two-way: HC coordinators received information/assistance and gave information to the Ministry of Health and the HMOs. For some, these connections were based on years of working together and building trust and appreciation. Others gathered all relevant officials to prepare for emergencies prior to the pandemic, as part of their role.

In non-HCN municipalities that did not have a HC coordinator, other personnel, usually high in the hierarchy, filled out this role, which put an additional toll. In the cities where there was no health coordinator, it took longer to establish a relationship with the Ministry of Health. This required a function that understands health. For example, two of the seven non-HCN municipalities recruited volunteer health professionals to provide guidance, and while one did not think a specific role in routine is needed, the other worked to set up a unique municipal health unit.

Another notable difference is emphasising health issues as part of the routine for HCN municipalities. Since some have been working on programmes to increase health among city residents, they adapted it to the COVID-19 context (such as making online videos about physical activity and healthy nutrition during quarantine). The HC coordinators emphasised the need to keep working on health issues for the long term, regardless of the COVID-19 pandemic. While all officials interviewed established conclusions from the pandemic, HCN municipalities focused more on health issues as an integral part of their daily matters for the future.

Discussion

This study aimed to explore local municipalities’ management of the pandemic and to assess whether belonging to the HCN impacted this management. Local municipalities in Israel had an essential role in the pandemic response, adapting their actions as the pandemic and governmental measures unfolded. The role of the HC coordinator was meaningful in facilitating collaborations between groups and relying on a priori professional network. The HC coordinator’s role included a broader action and vision of health issues beyond the COVID-19 pandemic. The themes that were found were similar across municipalities and residents, regardless of their HCN status. We believe that this is due to the long timeframe from the beginning of the pandemic until data collection. During that time, all Israeli authorities had established a person responsible for health and/or for the COVID-19 pandemic. Online conferences of learning from municipalities’ successes were convened, and news articles about local authorities’ significance were published. Local municipalities concluded, learnt from their and others’ mistakes and improved their actions.

It was evident that the disorderliness and uncoordinated data coming from different government ministries posed a great challenge for local authorities. Research shows that among European countries, lack of coordination mechanisms between the different levels of subnational government (regional and local governments, vertical and horizontal) with other levels of government are among the biggest challenges they face in managing a health crisis.18 This emphasises the need for one governmental contact to coordinate all information and directions. The desire for more independence from the government rises as a central theme not only in this research but also as discussed in Israeli public discourse and elaborated in national reports (eg, 2021 State Comptroller Report on local municipalities during COVID-19; Israeli Democracy Index 2021).19 20 It might have resulted from the centralised policy of the Israeli government: according to the World Bank research that ranked countries on political, fiscal and administrative dimensions of decentralisation and localisation, Israel is ranked 94th out of 182 countries in the world in the decentralisation of power to local municipalities, and of all OECD countries, Israel is ranked the lowest.21 Studies show that fiscal decentralisation is one of the key factors influencing the behaviour of local government leaders during the COVID-19 pandemic.22 In Norway, for example, the unique relations between national and local measures that included continuous monitoring of the infection rate and a combination of advice and legislation led to a productive balance between national and local methods in managing the COVID-19 pandemic.23 The pandemic underscored the centralisation policy’s disadvantages and the need for a change in the power allocated to local municipalities. This was evident from the residents’ perspectives as well; findings from the Israeli Democracy Index 2021 indicate that 67% of Israelis want to transfer more power from the government to the local municipalities.20 While some steps for reform in Israel were made in 2020, it is still in its infancy and has already met with strong opposition.24 A recent report based on a mixed-methods study of 15 local municipalities in Israel explored municipalities that presumably dealt with the COVID-19 pandemic in an optimal way (ie, were able to limit the spread of the virus and encourage vaccination). The report warns that such strive for independence may harm good governance, since some local municipalities interpreted orders according to their own understanding.25

Mapping the city population also posed a challenge, taking a lot of workforce, time and effort from municipalities’ employees and forcing local municipalities to create new technologies to manage and update data of city residents. In European regional and local governments, a lack of technical means and equipment also posed a challenge in managing the pandemic.18

Local municipalities’ focus on the elderly and vulnerable populations is in line with research on other emergencies and past disaster responses around the world,26 as well as with findings regarding the increase in loneliness and decrease in the quality of life among these populations during the pandemic.27 It also concurs with other countries’ successful management of the COVID-19 pandemic.28 Municipalities were also correct to create unique activities and to ensure a sense of community, manifested in the social and educational activities for citizens as ways to lift the spirit of the people, as studies show that social support and perceived belongingness to a community were mediators for psychological needs and distress during the COVID-19 pandemic.29 Incorporating volunteers in response efforts was historically used in other epidemic outbursts worldwide.26 Engaging community members in promoting individual and community health has proven to be a powerful tool and a valuable asset for local municipalities in fighting the pandemic in various constellations.26 30 However, studies show that protecting volunteers’ safety and ethical participation is essential, ensuring that volunteers are informed of the potential disease-related risks.31 Most municipalities seemed to succeed in creating a sense of collaboration, unity and community within their organisation. This was suggested to be a major factor in municipal success in fighting the pandemic.25 However, the workforce problems, particularly in the early stages of the pandemic and months of hard work with almost no break, took their toll. Municipalities that organised and funded out-of-office activities and acknowledged their employee’s prolonged hard work were very appreciated.

Overall, local municipalities in this study showed leadership, creativity and proactivity and responded flexibly to manage the new situation. Many of their activities are in agreement with a model for increased trust in public health officials that stresses being proactive, collaborating with various stakeholders; consistency in messages and actions, and providing education of both stakeholders and the public.31 Leadership assessment may situate Israeli municipalities’ strategies as ‘municipal activism’, which emphasises their initiative and action-taking while considering local conditions and citizens’ preferences.22

The differences between the first and following lockdown suggest essential points for future lengthy emergencies. The first lockdown dealt primarily with basic emergency needs such as food and medicine. It focused on high-risk populations. During the second lockdown and onwards, the main challenges were the morbidity within the educational system, enforcement, reducing loneliness and maintaining morale. Towards the third lockdown, enforcement and its challenges were perceived as even more critical.

Municipalities gained much professional information, guidance and assistance with interpretation from HC coordinators. The HC coordinator functioned as brokers, facilitating collaborations, supporting and controlling transfer of specialised knowledge between groups,13 such as between municipality officials and Ministry of Health professionals, HMOs, and between the different municipalities. As studies on interprofessional and intersectoral collaboration in healthcare show,10–12 18 this improved efficiency and increased cooperation by introducing ideas and transferring knowledge more smoothly and quickly.13 Such interorganisational data sharing and success in making operational decisions jointly have been shown as key policy responses in a crisis.11 In HCN municipalities, almost all HC coordinators reported a sense of achievement, gaining support from the HCN peer learning10 and increased appreciation of their role from their superiors and peers. Most mayors/CEOs also appreciated the HC coordinator’s specific role and hard work. However, findings also show that the success of HC coordinators depended on the personal contacts each HC coordinator achieved during their work. Furthermore, when non-HCN officials were asked about the necessity of such a role (a person in the municipality who is formally responsible for health), they were not unanimously convinced of such a need. This means that some officials did not see the need for such a specific position during the COVID-19 pandemic and were content with allocating this role to other officials in the municipality (eg, allocating health authorities and duties to the security department’s manager). However, even these municipalities used other health professionals to help them with decision-making, interpreting medical information and other health-related issues. Recommendations from Beeri et al study of Israeli municipalities’ successes during COVID-19 support our findings.25 They found that an integrative management network contributed to the optimal management of the COVID-19 pandemic in Israel.25 Beeri et al advises examining the possibility of adding a health department in the local authority that will centralise the field of public health in each local authority and facilitate a professional relationship between the officials at the local level and the national health system.25 This, in a nutshell, is part of the HC coordinator’s role in HCN municipalities.

Strengths and limitations of research

One main limitation of this research was the long timeframe from the beginning of the pandemic until data collection. This means that first, participants answered the interview at various levels of morbidity, and second, during the time since the first closure, the authorities had ‘toed the line’. They concluded and learnt from the success stories of other municipalities and adjusted. Therefore, this may have affected our ability to assess any differences between HCN and non-HCN municipalities that might have been more evident at the beginning of the pandemic. Furthermore, the number of Arab municipalities was too small, thus a profound comparison and in-depth discussion about differences from Jewish municipalities were unattainable.

Another limitation is in officials’ appearance management: it is reasonable that public-elected officials, particularly in a higher rank hierarchy, want to appear as performing excellently at their job during the pandemic. Thus, when asked directly about the need for a specific role for a health coordinator, it is hard to establish whether answers are due to officials’ wish to present themselves positively, rationalising their decisions or an outcome of thorough introspection and lessons learnt.

An issue worth discussing is that, like all Israeli citizens, the authors were influenced by municipal-level and state-level decisions. To enhance awareness that the researchers as individuals bring to the inquiry of their own background and set of values,15 the authors shared and discussed these influences and preconceptions with each other. For instance, the first author was hospitalised in a ward for pregnancy at risk, and her partner had to care for their older son alone since the closure did not allow day care. Yet, since none of the authors had a personal connection to stakeholders on the municipal level, the interest in the latter’s stories and viewpoints grew. It was fascinating and understandable, for instance, that municipal stakeholders were frustrated themselves by the fact they could not open daycare on their own decision-making.

The strengths of this study were that a variety of officials from each municipality was interviewed and that a diverse sample of municipalities was included. The diverse data obtained from many stakeholders from each municipality gave rich insight into participants’ experiences and challenges. Furthermore, matching between municipalities in factors of (1) ethnicity, (2) settlement type (city, local council, regional council), (3) socioeconomic index, (4) geographical location and (5) population size, allowing for assessing the impact of belonging to the HCN.

With our focus on the HC coordinator’s role, we intentionally explored events that could shed light on these aspects. Future research should explore each participant role’s unique challenges within the municipality during the pandemic.

Implication for policy and future research

Some pragmatic implications for future emergency events can be concluded from this research. Local municipalities need one central governmental contact in times of a health emergency. Attaining cohesive and accurate directions and data from governmental instructions was repeatedly emphasised as a major challenge. Local municipalities expressed a desire for more independence and control at the local level. Such power allocation would allow local municipalities to make the most of their local knowledge, acquaintance with their citizens, and financial and geographic resources. Lastly, as this research and another recent Israeli study found25 a specific role dedicated to health issues during emergency and routine times should be considered within local municipalities.

Conclusion

Local municipalities in Israel played an important role during the pandemic, facing various challenges, including data management, lack of a central information contact and lack of control and independence. Municipalities relied heavily on volunteers and shifted their management of the pandemic as time and needs changed. Responses of municipalities that were part of the HCN were similar to non-HCN municipalities. Nonetheless, the HC coordinator played a central role in the pandemic response in several HCN municipalities by using their previously established professional networks and focusing on a broader action and vision of health for the municipality.

Data availability statement

Data are available on reasonable request.

Ethics approval

This study involves human participants and received ethical approval from the Hebrew University, Faculty of Medicine, Ethics Committee (no: 16082020). Participants gave informed consent to participate in the study before taking part.