{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,10]],"date-time":"2026-06-10T15:52:12Z","timestamp":1781106732035,"version":"3.54.1"},"reference-count":61,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,1,30]],"date-time":"2026-01-30T00:00:00Z","timestamp":1769731200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>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\u2019 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2025.1622066","type":"journal-article","created":{"date-parts":[[2026,1,30]],"date-time":"2026-01-30T06:42:29Z","timestamp":1769755349000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Local policy governance arrangements and COVID-19-related mortality in municipalities in Japan: a cross-sectional ecological study"],"prefix":"10.3389","volume":"13","author":[{"given":"Yuki","family":"Nakamoto","sequence":"first","affiliation":[{"name":"Department of Health and Social Behavior, School of Public Health, The University of Tokyo","place":["Tokyo, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hideki","family":"Hashimoto","sequence":"additional","affiliation":[{"name":"Department of Health and Social Behavior, School of Public Health, The University of Tokyo","place":["Tokyo, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,1,30]]},"reference":[{"key":"ref1","volume-title":"Closing the gap in a generation: Health equity through action on the social determinants of health (2008)","year":""},{"key":"ref2","doi-asserted-by":"publisher","first-page":"999","DOI":"10.1136\/bmj.312.7037.999","article-title":"Inequality in income and mortality in the United States: analysis of mortality and potential pathways","volume":"312","author":"Kaplan","year":"1996","journal-title":"BMJ"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"853","DOI":"10.1377\/hlthaff.2022.00085","article-title":"The association between COVID-19 mortality and the county-level partisan divide in the United States","volume":"41","author":"Sehgal","year":"2022","journal-title":"Health Aff"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"16","DOI":"10.1136\/bmj.324.7328.16","article-title":"Individual income, income distribution, and self rated health in Japan: cross sectional analysis of nationally representative sample","volume":"324","author":"Shibuya","year":"2002","journal-title":"BMJ"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"1331","DOI":"10.1001\/jama.2022.3785","article-title":"The growing influence of state governments on population health in the United States","volume":"327","author":"Woolf","year":"2022","journal-title":"JAMA"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"115","DOI":"10.1016\/j.amepre.2021.01.034","article-title":"Associations between governor political affiliation and COVID-19 cases, deaths, and testing in the U.S","volume":"61","author":"Neelon","year":"2021","journal-title":"Am J Prev Med"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"433","DOI":"10.1016\/j.amepre.2021.09.003","article-title":"Governor\u2019s party, policies, and COVID-19 outcomes: further evidence of an effect","volume":"62","author":"Shvetsova","year":"2022","journal-title":"Am J Prev Med"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"05049","DOI":"10.7189\/jogh.12.05049","article-title":"Drivers of COVID-19 policy stringency in 175 countries and territories: COVID-19 cases and deaths, gross domestic products per capita, and health expenditures","volume":"12","author":"Jalloh","year":"2022","journal-title":"J Glob Health"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"e38371","DOI":"10.2196\/38371","article-title":"Utility of the comprehensive health and stringency indexes in evaluating government responses for containing the spread of COVID-19 in India: ecological time-series study","volume":"9","author":"Kishore","year":"2023","journal-title":"JMIR Public Health Surveill"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"231","DOI":"10.1002\/epa2.1146","article-title":"The influence of democracy, governance and government policies on the COVID-19 pandemic mortality","volume":"8","author":"Wagschal","year":"2022","journal-title":"Eur Policy Anal"},{"key":"ref11","year":""},{"key":"ref12","doi-asserted-by":"publisher","DOI":"10.50870\/00000357","article-title":"COVID-19 related deaths in Japan","author":"Beppu","year":"2022","journal-title":"IPSS Res Rep"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"e2117060","DOI":"10.1001\/jamanetworkopen.2021.17060","article-title":"Association of socioeconomic characteristics with disparities in COVID-19 outcomes in Japan","volume":"4","author":"Yoshikawa","year":"2021","journal-title":"JAMA Netw Open"},{"key":"ref14","volume-title":"Number of new coronavirus deaths per population by prefecture","year":""},{"key":"ref15","volume-title":"Worst: No. 1 Osaka, no. 2 Kyoto, and Kochi surpass Tokyo; Okinawa surprisingly ranked 41st; COVID-19 mortality in 47 prefectures in Japan (in Japanese)","author":"Yoshizaki","year":"2022"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"292","DOI":"10.20683\/jniph.71.4_292","article-title":"The response of local governments and public health centers to COVID-19: looking for infectious disease control due to the change of trend and mutations of the virus (in Japanese)","volume":"71","author":"Shirai","year":"2022","journal-title":"J Natl Inst Public Health"},{"key":"ref17","volume-title":"Countermeasure for COVID-19 in local governance: Perspectives and issues","year":"2020"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"105234","DOI":"10.1016\/j.worlddev.2020.105234","article-title":"The local governance of COVID-19: disease prevention and social security in rural India","volume":"138","author":"Dutta","year":"2021","journal-title":"World Dev"},{"key":"ref19","volume-title":"Local government in Japan 2020 (2022 revised edition)","year":"2023"},{"key":"ref20","first-page":"21","article-title":"Decentralization in Japan","volume-title":"Japan\u2019s road to pluralism: Transforming local communities in the global era","author":"Furukawa","year":"2003"},{"key":"ref21","doi-asserted-by":"crossref","DOI":"10.1596\/1813-9450-5430","article-title":"The worldwide governance indicators: methodology and analytical issues","author":"Kaufmann","year":"2010"},{"key":"ref22","volume-title":"Worldwide governance indicators","year":""},{"key":"ref23","doi-asserted-by":"publisher","first-page":"1106","DOI":"10.1016\/S0140-6736(11)60828-3","article-title":"Japanese universal health coverage: evolution, achievements, and challenges","volume":"378","author":"Ikegami","year":"2011","journal-title":"Lancet"},{"key":"ref24","year":""},{"key":"ref25","year":""},{"key":"ref26","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1093\/jopart\/mur011","article-title":"An integrative framework for collaborative governance","volume":"22","author":"Emerson","year":"2012","journal-title":"J Public Adm Res Theory"},{"key":"ref27","year":"2021"},{"key":"ref28","volume-title":"Report on the state of national health insurance operations 2020","year":"2022"},{"key":"ref29","volume-title":"Guidelines for the handling of health insurance certificates during visits to medical institutions for diagnosis and testing related to COVID-19 infection","year":"2020"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"33","DOI":"10.24742\/jhep.2013.04","article-title":"The impact of short-term health insurance card and eligibility certification card on health care access in Japan: findings from national health insurance receipt data (in Japanese)","volume":"25","author":"Ohtsu","year":"2013","journal-title":"Jpn J Health Econ Policy"},{"key":"ref31","volume-title":"Governance for health emergency management: Lessons from COVID-19","author":"Shiroyama","year":"2024"},{"key":"ref32","year":""},{"key":"ref33","first-page":"165","article-title":"Reflection","volume-title":"Public management reform: A comparative analysis\u2014Into the age of austerity","author":"Pollitt","year":"2017"},{"key":"ref34","year":""},{"key":"ref35","year":"2022"},{"key":"ref36","year":"2020"},{"key":"ref37","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1002\/jae.3950010104","article-title":"Econometric models based on count data: comparisons and applications of some estimators and tests","volume":"1","author":"Cameron","year":"1986","journal-title":"J Appl Econ"},{"key":"ref38","doi-asserted-by":"publisher","first-page":"344","DOI":"10.1016\/j.jclinepi.2007.11.008","article-title":"The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies","volume":"61","author":"von Elm","year":"2008","journal-title":"J Clin Epidemiol"},{"key":"ref39","year":"2025"},{"key":"ref40","year":"2023"},{"key":"ref41","year":""},{"key":"ref42","year":""},{"key":"ref43","year":"2021"},{"key":"ref44","year":"2021"},{"key":"ref45","year":"2014"},{"key":"ref46","first-page":"75","article-title":"Managing government, governing management","volume":"74","author":"Mintzberg","year":"1996","journal-title":"Harv Bus Rev"},{"key":"ref47","doi-asserted-by":"publisher","first-page":"429","DOI":"10.1111\/faam.12094","article-title":"Managerialism redux?","volume":"32","author":"Pollitt","year":"2016","journal-title":"Fin Acc Manag"},{"key":"ref48","doi-asserted-by":"publisher","first-page":"335","DOI":"10.20683\/jniph.71.4_335","article-title":"Overall picture of the COVID-19 vaccination program in Japan (in Japanese)","volume":"71","author":"Hayashi","year":"2022","journal-title":"J Natl Inst Public Health"},{"key":"ref49","doi-asserted-by":"publisher","first-page":"982","DOI":"10.1111\/ggi.14484","article-title":"Restrictions on visits and outings in geriatric care facilities during the COVID-19 pandemic","volume":"22","author":"Kazawa","year":"2022","journal-title":"Geriatr Gerontol Int"},{"key":"ref50","doi-asserted-by":"publisher","first-page":"e103","DOI":"10.1017\/S095026882100100X","article-title":"Impact of meteorological parameters and population density on variants of SARS-CoV-2 and outcome of COVID-19 pandemic in Japan","volume":"149","author":"Sharif","year":"2021","journal-title":"Epidemiol Infect"},{"key":"ref51","doi-asserted-by":"publisher","first-page":"100365","DOI":"10.1016\/j.lanwpc.2021.100365","article-title":"Comparison of patient characteristics and in-hospital mortality between patients with COVID-19 in 2020 and those with influenza in 2017-2020: a multicenter, retrospective cohort study in Japan","volume":"20","author":"Taniguchi","year":"2022","journal-title":"Lancet Reg Health West Pac"},{"key":"ref52","doi-asserted-by":"publisher","first-page":"916","DOI":"10.1001\/jamainternmed.2023.1154","article-title":"Excess death rates for republican and democratic registered voters in Florida and Ohio during the COVID-19 pandemic","volume":"183","author":"Wallace","year":"2023","journal-title":"JAMA Intern Med"},{"key":"ref53","doi-asserted-by":"publisher","first-page":"1046","DOI":"10.1108\/JHOM-10-2020-0417","article-title":"Overwriting new public management with new public governance in New Zealand\u2019s approach to health system improvement","volume":"35","author":"Tenbensel","year":"2021","journal-title":"J Health Organ Manag"},{"key":"ref54","doi-asserted-by":"publisher","first-page":"324","DOI":"10.20683\/jniph.71.4_324","article-title":"Review and future prospects of the medical system for COVID-19","volume":"71","author":"Anan","year":"2022","journal-title":"J Natl Inst Public Health."},{"key":"ref55","doi-asserted-by":"publisher","first-page":"250","DOI":"10.7416\/ai.2022.2546","article-title":"A new paradigm of hospital care for SARS-COV-2 patients in the post-emergency phase in Italy","volume":"35","author":"Bianchi","year":"2023","journal-title":"Ann Ig"},{"key":"ref56","doi-asserted-by":"publisher","first-page":"2171185","DOI":"10.1080\/21645515.2023.2171185","article-title":"COVID-19 vaccination hesitancy among Italian parents: a systematic review and meta-analysis","volume":"19","author":"Bianchi","year":"2023","journal-title":"Hum Vaccin Immunother"},{"key":"ref57","doi-asserted-by":"publisher","first-page":"e069316","DOI":"10.1136\/bmjopen-2022-069316","article-title":"Vaccine coverage for recommended vaccines among splenectomised patients in Apulia, South Italy: a retrospective cohort study","volume":"13","author":"Bianchi","year":"2023","journal-title":"BMJ Open"},{"key":"ref58","doi-asserted-by":"publisher","first-page":"1072","DOI":"10.1111\/bjh.18731","article-title":"Burden of COVID-19 disease and vaccine coverages in Apulian splenectomized patients: a retrospective observational study","volume":"201","author":"Bianchi","year":"2023","journal-title":"Br J Haematol"},{"key":"ref59","doi-asserted-by":"publisher","first-page":"2450858","DOI":"10.1080\/21645515.2025.2450858","article-title":"Influenza vaccination hesitancy and related factors among pregnant and breastfeeding women: a cross-sectional study","volume":"21","author":"Comparcini","year":"2025","journal-title":"Hum Vaccin Immunother"},{"key":"ref60","doi-asserted-by":"publisher","first-page":"1273853","DOI":"10.3389\/fpubh.2023.1273853","article-title":"Significant burden of post-COVID exertional dyspnoea in a South-Italy region: knowledge of risk factors might prevent further critical overload on the healthcare system","volume":"11","author":"Resta","year":"2023","journal-title":"Front Public Health"},{"key":"ref61","doi-asserted-by":"publisher","first-page":"597","DOI":"10.7416\/ai.2024.2617","article-title":"Low-intensity rehabilitation in persistent post COVID-19 dyspnoea: the value of Spa health resort as appropriate setting","volume":"36","author":"Resta","year":"2024","journal-title":"Ann Ig"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2025.1622066\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,30]],"date-time":"2026-01-30T06:42:35Z","timestamp":1769755355000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2025.1622066\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,30]]},"references-count":61,"alternative-id":["10.3389\/fpubh.2025.1622066"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2025.1622066","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,30]]},"article-number":"1622066"}}