Table 2.

Healthcare financing shocks and the role of purchasers during the COVID-19 pandemic.

Categories	Decision-maker	United Kingdom (England)	Germany	France	Netherlands	Switzerland	Slovakia
Surge in demand for pandemic-related services	Purchaser decision making?	No No role for NHS strategic purchasers (NHSE or CCGs)	No No role for the sickness funds	No No role for health insurance funds	Partial Health insurers contribute to the costs of providing COVID-19 care	Partial Cantons (not insurers) bear the costs for redistribution of essential medical supplies within the canton	No No role for health insurance companies
	Government decision making?	Yes NHS centralized purchasing at the Whitehall level.	Yes Parliament approved the COVID-19 Hospital Relief Act which comprises several measures to guarantee the funding of hospitals and ensure their liquidity. - The Ministry of Health recommended a step-by-step procedure for re-planning hospital bed capacities in Germany.	Yes Ministry of Health activated White Plan containing organizational measures intended to cope with an exceptional increased activity in hospitals	Partial The Ministry of Health agreed with health providers that no health institution might go bankrupt due to the COVID-19 crisis and that the distribution of the cost was a joint responsibility	Partial The Confederation passed the Ordinance on Measures to Combat the Coronavirus (COVID-19 Ordinance 2) which allowed cantons (not insurers) to retain their responsibilities. Cantons were responsible for ensuring sufficient hospital and clinic capacities (Art. 10a).	Yes All funding sources were from the Ministry of Finance
Surge in demand for pandemic-related services (testing, tracking, and tracing)	Purchaser decision making?	No No role for NHS strategic purchasers (NHSE or CCGs)	No No role for the sickness funds	No No role for health insurance funds	No No role for health insurers	Partial Over the course of the pandemic, there was a switch from Cantons and patients bearing the costs of testing (via co-pays) to the confederation assuming all coronavirus testing costs	No No role for health insurance companies
	Government decision making?	Yes Central government departments set up a separate body (NHS Test and Trace)	Yes The federal government secured nine million rapid antigen tests in 2020 via purchase guarantees that the federal states and institutions can officially purchase and distribute according to need	Yes Government installed testing capacity and estimated the number of available tests per day at around 5,000. However, France has developed a dependency on international providers for the reactive of these tests, which limits national autonomy.	Yes Testing and reporting cases is coordinated by the National Institute for Public Health and the Environment (RIVM), while testing and tracking is performed by the public health services.	Yes Over the course of the pandemic, there was a switch from Cantons and patients bearing the costs of testing (via co-pays) to the confederation assuming all coronavirus testing costs	Yes Government secured resources and established testing capacity
Drop in demand for all other healthcare services	Purchaser decision making?	No No role for NHS strategic purchasers (NHSE or CCGs)	Partial The Federal Joint (self-government of physicians, dentists, hospitals, and health insurance funds) announced regulations to implement the ordinance of the federal states to postpone elective procedures within days	No No role for health insurance funds	Partial Stakeholders (providers associations, insurers, and the Dutch Health Care Authority) worked on detailed plans to compensate for revenue losses due to postponed care, as well as new payments for Covid related care, while the Ministry of Health agreed with insurers that no provider should go bankrupt.	Partial FOPH delegated decision-making on drug and lab test reimbursements to health insurers (i.e., reimbursing pharmaceuticals and reviewing conditions)	Partial Health insurance companies covered 75% of average provider income lost
	Government decision making?	Yes Central government put in place a modified national contract to enable use of independent hospital capacity until March 2021	Yes Ministry of Health's ordinance regarding the provision of pharmaceuticals ensured supply of medicinal products to the population during the epidemic and to reduce insured persons’ risk of infection from visiting pharmacies	Yes The White plan resulted in the de-scheduling of all medical procedures and non-emergency surgery to free up a maximum of beds and especially human resources	Partial The Ministry of Health agreed with health providers that no health institution might go bankrupt due to the COVID-19 crisis and that the distribution of the cost was a joint responsibility	Yes Federal Office of Public Health (FOPH) drew up guidelines to ensure that the pricing and cost absorption of inpatient treatment was regulated uniformly throughout Switzerland	Yes Ministry of Finance established laws and economic measures which limited recovery of lost income for purchasers and providers
Change in service modality	Purchaser decision making?	No No role for NHS strategic purchasers (NHSE or CCGs) other than reimbursement	Partial Federal Association of Sickness Funds agreed to extend teleconsultations for physicians and psychotherapists	No No role for health insurance funds other than reimbursement	No No role other than reimbursement	Partial Cantons limited by FOPH rules and mostly focused on reimbursements	No No role for health insurance companies other than enabling increased use of telehealth and email consultations
	Government decision making?	Yes Primary care providers, as well as trusts, could seek reimbursement for the capacity needed to offer remote services	Yes Volume restrictions on physicians providing remote consultations were lifted in Germany. Also, detailed billing schedules have been produced where these did not already exist	Yes Tele-consultations, which were already available (reimbursed) in France and charged the same price as a normal consultation, are highly recommended in the current situation.	Yes Rules were loosened by the Dutch Health Care Authority to enable more remote consultations	Yes FOPH compiled valid rules for billing telehealth consultations and issued recommendations for temporary solutions during COVID-19	Yes Federal government created bonus payment for telehealth services and expanded scope of services that can be done through telehealth tools) was put into effect
Change in provider requirements (equipment, PPE)	Purchaser decision making?	No No role for NHS strategic purchasers (NHSE or CCGs)	No No role for the sickness funds	No No role for health insurance funds	No No role for insurers	Partial Cantons had to reimburse the confederation for medical supplies and PPE	No No role for health insurance companies
	Government decision making?	Yes Commissioned by the government and separate from NHSE or other NHS organizations	Yes The Federal Ministry of Health distributed 290 million masks to nursing professionals and patients and their visitors for the COVID-19 first and second wave	Yes Responsibility of the Ministry of Social Affairs and Health	Partial Responsibility of the providers, with increasing participation in purchasing andwork funding of the Ministry of Health	Partial Costs for the procurement of important medical goods were pre-financed by the Confederation	Yes The government acquired all PPE
Change in provision (vaccines)	Purchaser decision making?	No No role for NHS strategic purchasers (NHSE or CCGs)	No No role for the sickness funds	No No role for health insurance funds	No No role for insurers	No No role for cantons or insurers	No No role for health insurance companies
	Government decision making?	Yes The government secured a spending measure related to vaccines in the 2021 budget: roll-out, clinical trials, increase capacity for vaccine testing, study to test the effectiveness of combinations of different Covid-19 vaccines, and investment in a clinical-scale mRNA manufacturing	Yes In Dec 2020, Prime Health Minister announce a new ordinance regarding the entitlement for vaccination against the coronavirus SARS-CoV-2 -Federal Ministry of Health implemented changes in the ordinance regarding the changes in entitlement for vaccination against the coronavirus SARS-CoV-2	Yes The national health authority secured a vaccine budget for Pfizer and AstraZeneca and started a vaccination campaign.	Yes Ministry of Health procured all COVID-19 vaccines	Yes The federal government procured all COVID-19 vaccines	Yes The government in charge of all vaccine procurement
Change in policy salience and urgency	Purchaser decision making?	No No evidence of population health measures	No No evidence of population health measures	No No evidence of population health measures	No No evidence of population health measures	Partial Limited canton role in national health policy changes	No No role of health insurance companies
	Government decision making?	Yes NHS England in charge of all policy changes	Yes Federal government in charge of all policy changes	Yes Government in charge of all policy changes	Yes Ministry of Health in charge of all policy changes	Yes The Confederation in charge of all policy changes	Yes Federal government in charge of all policy changes

Source: Author's own elaboration