Who Counts Where? COVID-19 Surveillance in Federal Countries

Context: While the World Health Organization (WHO) has established guidance on COVID-19 surveillance, little is known about implementation of these guidelines in federations, which frag-ment authority across multiple levels of government. This study examines how subnational gov-ernments in federal democracies collect and report data on COVID-19 cases and mortality asso-ciated with COVID-19. Methods: We collected data from subnational government websites in 15 federal democracies to construct indices of COVID-19 data quality. Using bivariate and multivariate regression, we analyzed the relationship between these indices and indicators of state capacity, the decentral-ization of resources and authority, and the quality of democratic institutions. We supplement these quantitative analyses with qualitative case studies of subnational COVID-19 data in Brazil, Spain, and the United States. Findings: Subnational governments in federations vary in their collection of data on COVID-19 mortality, testing, hospitalization, and demographics. There are statistically significant asso-ciations ( p < 0.05) between subnational data quality and key indicators of public health system capacity, fiscal decentralization, and the quality of democratic institutions. Case studies illustrate the importance of both governmental and civil-society institutions that foster accountability. Conclusions: The quality of subnational COVID-19 surveillance data in federations depends in part on public health system capacity, fiscal decentralization, and the quality of democracy.