Cantonal Level Research Articles

Spreading herbivore manure in livestock farms increases soil carbon content, while granivore manure decreases it

Livestock farming occupies 57% of agricultural area in France and has contrasting impacts on the environment. Studies have analyzed relations between livestock farming and soil organic carbon (SOC) content, but the influence of livestock farming on soils is difficult to perceive at a large scale. The objective of this study was to increase understanding of impacts of livestock farming on soils that receive livestock manure depending on different initial levels of SOC content, at cantonal level. To this end, we used French soil and agricultural databases to analyze relations between livestock farming practices and SOC content. We used statistical data calculated from the French soil test database for the periods 2000–2004 and 2010–2014. For livestock farming practices, we used data from the French agricultural census of 2000 and 2010, and for spreading of livestock manure, data from the French program to control pollution of agricultural origin (2002–2007) and data from the French Livestock Institute. The novelty of our large-scale analysis is to differentiate the origin of livestock manure (herbivore or granivore) and the type of crop on which it was spread (crops or grasslands). Statistical analysis was performed at the cantonal scale for France using the method of generalized least squares. We show for the first time that, at the national scale, spreading of livestock manure influences SOC content and dynamics significantly. Our results also show the importance of the nature of the manure; solid manure increases SOC content, unlike liquid manure. Spreading herbivore manure on crops increases SOC content, but spreading granivore manure may decrease it. Livestock manure spread on grasslands has no significant effect on SOC content, possibly due to under-representation of grassland soils in the soil database. These results demonstrate the importance of the complementary between crop and livestock to maintain soil ecosystem services, including soil fertility.

The construction of a territorial organization of primary care stakeholders facing the covid-19 epidemic: contributions of a case study at the canton level

At the beginning of the Covid-19 epidemic in France, the mobilization of primary care professionals was not driven by the government, which focused its attention on hospitals. As a result of ministerial orders to delay medical consultations as much as possible and to close most of the paramedical practices, one might have expected that primary care activity would be strongly reduced and uncoordinated. However, in some territories, primary care actors consulter each other, adopting a systemic ...

Climate adaptation in practice: How mainstreaming strategies matter for policy integration

AbstractWith some level of climate change now inevitable, climate policy around the world has evolved in recent decades to include adaptation to the impacts of climate change. Most industrialized countries have formulated national adaptation strategies to meet this challenge. However, the implementation of on‐the‐ground measures is lagging. To analyze the implementation process and possible reasons for the implementation gap, we take a closer look at how the integration of adaptation goals into various sectoral policies—often called mainstreaming—has been handled on different administrative levels in Switzerland. Going beyond traditional compilations of barriers to climate change adaptation, we analyze the use of six different mainstreaming strategies across cases and levels and the reasons for their success or lack thereof. We find that different actors at all administrative levels have successfully employed programmatic mainstreaming in combination with inter‐organizational mainstreaming to foster horizontal cooperation. We call this strategy cooperative mainstreaming. Some pioneers even managed to channel their successes into advances in regulatory mainstreaming. However, the lack of systematic regulatory and directed mainstreaming on the national and cantonal levels largely limits adaptation actions on lower levels to those cases where the major impetus derives from extreme events or proactive individuals on the ground. We conclude that the adaptation implementation gap in Switzerland largely stems from the lack of political commitment to promoting local adaptation at the national and cantonal levels.

Identificando clubes de convergencia en Ecuador a nivel cantonal

El estudio tiene por objetivo identificar la existencia de clubes de convergencia a nivel cantonal en Ecuador, establecer los miembros de cada uno y analizar sus tendencias históricas. Los clubes se entienden como una agrupación de cantones que comparten características estructurales económicas intrínsecas y debido a ello convergen a un estado estacionario de largo plazo común según dichas características lo definan. Para lograr los objetivos planteados, se aplica un algoritmo secuencial para datos de panel, comúnmente referido en la literatura como prueba log-t, para el periodo 2007-2018. Los resultados señalan la existencia de cinco clubes de convergencia en Ecuador y una tendencia decreciente a lo largo del tiempo del nivel de productividad per cápita. Además, se evidencia brechas económicas significativas que se han mantenido entre el grupo más rico y los más pobres. El análisis conjunto brinda tres implicaciones de política relacionadas con i) efectos spillover, ii) incentivos económicos a zonas deprimidas y iii) el desarrollo desbalanceado. Con este aporte se contribuye al debate sobre análisis de disparidades territoriales y asimetrías internas.

An Overview of Human Resources and Capacity in Health Care Institutions in the Federation of Bosnia and Herzegovina in the Context of Responding to the COVID 19 Pandemic

Background:The organization of health care system on Cantonal level with the coordination from Federal level represents a real situation with the possibility of decentralization of health care system according to the experiences of developed countries.Objective.To make an overview of the situation at the primary and hospital health care level with the aim of assessing the existing human resources and capacity of health care institutions in FB&H, with which we entered in COVID-19 pandemic.Methods.This retrospective study presents the efficiency of health care in FB&H measured by number of medical doctors, and other medical staff during the time period of five years. Data of the Institute for Public Health FB&H were used. The Institute for Public Health FB&H is authorised by the law to conduct and implement statistical research in the field of health care in line with relevant laws and by-laws. The Institute is obliged to report on organisational structure, human resources and medical equipment.Results.Presented data include the number of health care employees in medical institutions in FB&H in the period 2015-2019 per 100,000 inhabitants and their numbers in primary health care, family medicine, secondary and tertiary level of health care in 2019. The study also presents the number of doctors of medicine, specialists and medical residents in FB&H, the number of nurses of all profiles and levels of education as well as medical staff and other employees in the public health care system in FB&H in 2019.Conclusions.The COVID-19 pandemic in FB&H has confirmed the fact that human resources in health care are insufficient, especially in the field of public health and epidemiology. The availability of these health facilities and human resource is not uniform throughout the FB&H, which may affect the capacity of the health system in some parts of the FB&H to meet the needs of providing services during COVID-19 pandemic.

The Duty to Work as Precondition for Human Dignity

The paradigm of activation and self-responsibility to provide for basic needs has been on top of the political agenda in most Western social welfare states for years. This is true for Switzerland and means-tested ben-efits are no exception to this development. Basic needs are guaranteed on the one hand by a constitutional right to minimum financial means and, on the other hand, through so-called measures of social assistance which include (further) financial support. Switzerland being a federal state, social assistance and the duties for the beneficiaries are regulated in statutes at cantonal level. There is no federal social assistance law. Neither the constitutional right to minimum financial means, nor the right to social assistance are unconditional. Both rights are subsidiary to the individual’s own resources and the obligation to work in the primary labour market. In addition, if the claimant is unemployed, they can be obliged to participate in a work programme offered by the social assistance authorities. Under certain circumstances, participation in such a work programme is not only a behavioural duty of the benefit recipient, which can lead to benefit cuts, but participation can also be an eligibility criterion for the benefits. The authors will focus on these programmes and mechanisms which can lead to questions over eligibility for minimum subsistence rights guaranteed by the constitutional right to financial support when one is in need (Article 12 of the Swiss Constitution).

Analysis of Public Debt at Subnational Government Levels: Evidence from Cantons in the Federation of Bosnia and Herzegovina

Abstract Total public debt of ten cantons in the Federation of Bosnia and Herzegovina (FBiH), one of the two entities in BiH, have substantially increased in recent years. Since it is relatively small in nominal terms, this galloping trend have not attracted enough attention of decision makers. If these developments continue in the future, the public debt at cantonal level in FBiH might create serious fiscal problems and become one of central issues for policy makers. This has motivated our investigation of determinants that caused the increase in public debt over the period 2012-2018. We apply a panel regression analysis and investigate how budget deficit, trade balance, unemployment rate, size of population and institutional changes affect public debt. We find that public debt is positively associated with budget deficit but negatively associated with trade balance, the size of population and institutional changes. These findings motivated policy recommendations presented in the paper.

Effects of a DRG-based hospital reimbursement on the health care utilization and costs in Swiss primary care: A retrospective "quasi-experimental" analysis.

IntroductionIn Switzerland, a nationwide Swiss Diagnosis related Groups (Swiss DRG) system for hospital reimbursement was introduced in 2012. However, the impact of DRG systems on primary care is still unclear with respect to number of consultations and costs. The aim of this study was to investigate the effect of the implementation of DRG on costs and volumes in the primary care sector, on a nationwide basis in Switzerland.MethodsThe study retrospectively analysed yearly data, from 2008 to 2014, of almost 60 Swiss health insurers that covered almost all Swiss general practitioners, with a total number of patients which represented approximately 76% of the Swiss population. GP consultations, total numbers and rates, and the relative costs reimbursed (TARMED tariff values) in the Swiss federal states, cantons, which already introduced a DRG-like system before 2012 (AP-DRG), were compared to the GP consultations and costs reimbursed in the other cantons (DRG-naive). Regression discontinuity design analysis and mixed regression models, at cantonal level, were performed to evaluate the effect of the nationwide implementation of the Swiss DRG on health care demand and costs in the primary care setting. Change in outcome level and yearly trend pattern difference between groups (AP-DRG vs. DRG-naive) were examined.ResultsOverall, the total number of GP consultations and the relative TARMED values increased from 2008 to 2014. In the DRG naive, 15 cantons: in 2008, the number of GP consultations were 13,114,126, with a TARMED value of 1,194,957,157 CHF, and in 2014, the GP consultation were 13,752,511, with a TARMED value of 1,513,861,260 CHF. In the AP-DRG group, 11 cantons, the total number of GP consultations increased from 8,787,646, in 2008, to 9,347,168 in 2014 and the TARMED value increased from 896,673,657 CHF in 2008, to 1,100,203,508 CHF in 2014. The yearly trend pattern of GP consultations and TARMED values, in the AP-DRG group, were not significantly different from the respective trends in the DRG- naive and, overall, no significant change was detected in consultations and costs trends before and after 2012.Discussion/ConclusionThis study found no evidence of any effect of the introduction of the SwissDRG on the yearly trend of primary care consultations and costs. Nevertheless, potential negative impacts on vulnerable patients, as chronically ill patients, could not be excluded and further investigation is required.

Malaria Transmission and Spillover across the Peru-Ecuador Border: A Spatiotemporal Analysis.

Border regions have been implicated as important hot spots of malaria transmission, particularly in Latin America, where free movement rights mean that residents can cross borders using just a national ID. Additionally, rural livelihoods largely depend on short-term migrants traveling across borders via the Amazon’s river networks to work in extractive industries, such as logging. As a result, there is likely considerable spillover across country borders, particularly along the border between Peru and Ecuador. This border region exhibits a steep gradient of transmission intensity, with Peru having a much higher incidence of malaria than Ecuador. In this paper, we integrate 13 years of weekly malaria surveillance data collected at the district level in Peru and the canton level in Ecuador, and leverage hierarchical Bayesian spatiotemporal regression models to identify the degree to which malaria transmission in Ecuador is influenced by transmission in Peru. We find that increased case incidence in Peruvian districts that border the Ecuadorian Amazon is associated with increased incidence in Ecuador. Our results highlight the importance of coordinated malaria control across borders.

Location Decisions of New Manufacturing Firms in Ecuador. Agglomeration Mechanisms

This investigation seeks to explore the importance of agglomeration mechanisms in the location decisions of new manufacturing firms in Ecuador, based on sector and canton level data for the 2000–2010 period. A model is proposed to explore the relative importance of agglomeration mechanisms in location decisions of new manufacturing companies, a regression is performed using instrumental variables, the econometric estimation is developed, and an identification strategy is proposed. The results of the empirical analysis show that the learning mechanism, and history, have a positive and significant impact on the creation of new firms. An increase of 1% in the transfer of knowledge in the industries and cantons of the country is correlated with the increase in the location of new firms in the order of 9.2%. In turn, history has a positive and significant effect on the creation of new firms, in industries and cantons characterized by a past industrial environment. Even when the learning mechanism and history are controlled by provinces, sectors, and cantons, they continue to be the most important determinants of the location of new firms. This evidence could be attributed to the public investment in Ecuadorian industry in recent years. In this sense, the contribution of this work is found in the empirical distinction of the mechanism that favors or inhibits the location decisions of new companies. The analysis was replicated for a three-digit sectorial disaggregation level, to verify whether the agglomeration mechanisms operate differently on a different industrial scale. The results suggested that there were no differences to be considered. When the analysis was done excluding the cantons of Quito, Guayaquil, and Cuenca, given their high representation in terms of the birth of industries and employment, the results were consistent with those previously mentioned. However, it is so only with respect to history, which in this case accounts for 38.8% of the birth of firms; whereas, matching accounts for an order of 38.9% in the period of analysis. This result is explained in the context of the country’s industrial policy.

Community-Based Tourism in Ecuador: Community Ventures of the Provincial and Cantonal Networks

The aim of this work is to identify community the initiatives anchored to community-based tourism (CBT) in Ecuador with the aim of providing an overview of the current reality of community tourism in the country, in addition to publicizing the product lines under development within community initiatives. The methodology used is a descriptive analysis based on the review of secondary sources, which reflect the reality of the different tourism initiatives related to the Plurinational Federation of Community Tourism of Ecuador (FEPTCE) at the level of continental Ecuador. FEPTCE groups indigenous, Afro–Ecuadorian, Montubian and mestizo communities, who depend on their territory and have identified tourism as a mechanism to continue living with dignity within these territories, due to the option of economic diversification that is generated. Within the communities that belong to the FEPTCE, living with dignity implies achieving a good quality of life, which is not based on satisfying a series of basic needs, but implies going further, achieving the idea of “Good Living”, that is to say, reaching an appreciation of well-being, based on the conception of the full set of what culture is, in order to generate comprehensive sustainability of its spaces. Among the main results, the distribution and coverage that the FEPTCE has within continental Ecuador regarding community tourism is shown and analyzed. As a formal network of community-based tourism, it is made up of five networks at the regional level and nine at the provincial or cantonal level, which are analyzed in this study. The consolidation of the initiatives launched has been difficult with only 83 of the initial 121 being active and only 18 registered as community tourist centers. This case study shows that in Ecuador the network approach as the first step in the development of the CBT worked. Therefore, the development of the CBT must be approached from a network approach in which indigenous peoples (indigenous, mestizo, Afro-descendant, etc.) participate, administrations, the private sector, civil society, NGOs and tourist destinations, to which they must to join academic institutions by contributing solid data obtained through research that helps tourism development.

Assessing the impact of non-pharmaceutical interventions on SARS-CoV-2 transmission in Switzerland.

Following the rapid dissemination of COVID-19 cases in Switzerland, large-scale non-pharmaceutical interventions (NPIs) were implemented by the cantons and the federal government between 28 February and 20 March 2020. Estimates of the impact of these interventions on SARS-CoV-2 transmission are critical for decision making in this and future outbreaks. We here aim to assess the impact of these NPIs on disease transmission by estimating changes in the basic reproduction number (R0) at national and cantonal levels in relation to the timing of these NPIs. We estimated the time-varying R0 nationally and in eleven cantons by fitting a stochastic transmission model explicitly simulating within-hospital dynamics. We used individual-level data from more than 1000 hospitalised patients in Switzerland and public daily reports of hospitalisations and deaths. We estimated the national R0 to be 2.8 (95% confidence interval 2.1–3.8) at the beginning of the epidemic. Starting from around 7 March, we found a strong reduction in time-varying R0 with a 86% median decrease (95% quantile range [QR] 79–90%) to a value of 0.40 (95% QR 0.3–0.58) in the period of 29 March to 5 April. At the cantonal level, R0 decreased over the course of the epidemic between 53% and 92%. Reductions in time-varying R0 were synchronous with changes in mobility patterns as estimated through smartphone activity, which started before the official implementation of NPIs. We inferred that most of the reduction of transmission is attributable to behavioural changes as opposed to natural immunity, the latter accounting for only about 4% of the total reduction in effective transmission. As Switzerland considers relaxing some of the restrictions of social mixing, current estimates of time-varying R0 well below one are promising. However, as of 24 April 2020, at least 96% (95% QR 95.7–96.4%) of the Swiss population remains susceptible to SARS-CoV-2. These results warrant a cautious relaxation of social distance practices and close monitoring of changes in both the basic and effective reproduction numbers.

The effect of reduced unemployment duration on the unemployment rate: a Synthetic Control Approach

This paper examines the impact of the fourth partial revision of the law of unemployment insurance (AVIG) on unemployment dynamics in Switzerland at a cantonal level. The authors apply the Synthetic Control Method (SCM), a matching method for comparative case studies. A counterfactual analysis of the cases studied is performed by combining a control group of several untreated units, which provides a better comparison to the treatment group than a single unit. The control unit is designed as a weighted average of the available cantons in the donor pool, taking into account the similarities between the chosen controls and the treated unit. Once policy changes are controlled, the results suggest a significant effect on the unemployment rate at a cantonal level: the reform had a discernible impact on lowering the unemployment rate in the Italian- and French-speaking cantons in Switzerland.

Potential energy of plant biomass: banana, coconut, cacao and corn

In this document, a study was carried out on the energy potential of plant biomass in the Portoviejo canton, since climate change is not a utopia, but the reality. Throughout this study, an overview of the capacity in biomass at the national, provincial and cantonal level (Portoviejo) was presented, a study on the culture of banana, cocoa, coconut, and corn was made since it is important to know if the canton can respond to the biomass demand of the selected plants. Then the socio-economic and environmental impacts were analyzed in a general way.

Women’s Political Participation and Representation in Bosnia and Herzegovina: General Elections 2014 and 2018

This paper aims to introduce readers to the changes and transformations of gender political equality in Bosnia and Herzegovina and their impact on the legal and institutional framework. A brief survey of major changes and transformation will demonstrate to what extent the position of women’s political participation and representation has improved in the past two decades? That is why the goal of this paper is to examine and analyze the participation and election of women to the executive and legislative bodies at the state, entity and cantonal level in the last two parliamentary and presidential elections held in 2014 and 2018 respectively. Then, the comparative analysis of the elections will clearly show statistical gaps between male and female electoral lists nominees and obtained mandates among male and female nominees and mandates across parliamentary, state and entities levels. Thus, the research will analyze gender quotas based on electoral law and obtained mandates among female candidates. Such analysis will demonstrate to what extent female candidates have moved from mere participation in the elections to the level of political representation by obtaining mandates across different governance levels. For testing the main research objectives on the degree of women’s political participation and representation, the researchers used the data from the Central Election Commission of Bosnia and Herzegovina (www. izbori.ba). Both qualitative and quantitative methods were used to present the data regarding women’s political participation and representation in General Elections 2014 and 2018.

MUSLIM COMMUNITY IN THE EDUCATIONAL SPACE OF SWISS CONFEDERATION AT THE TURN OF THE 20ͭth – 21th centuries

The aim of the research is to compare different cantonal models of relations of secular authorities with religious organizations, to study the peculiarities of implementing needs of Muslim students and employees in state schools of Switzerland, to analyze the attempts to implement lessons of Islamic religious education in the cantons of St. Gallen, Lucerne and Thurgau and to assess the federal and cantonal initiatives, aimed at preparation of qualified teachers of Islamic studies, in order to research the perspectives of Islamic religious education development in Switzerland. The research methodology is defined by an interdisciplinary nature of approaches (history, law, Islamic studies). The scientific novelty of the research consists in the fact that it was the first time that on the basis of different groups of sources – regulatory and legislative acts, reports and press organs of organizations and profile commissions, as well as didactic materials for school administration, the place of Islamic community in the educational space of Switzerland was analyzed. The Conclusions . In spite of the fact that according to the Constitution of Swiss Confederation, the issues on education and religion were transferred to the cantonal level, the state, through decisions of the Federal Court of the national level, assisted to protection of religious freedoms of Muslim students (permission for visible religious attributes, special-purpose arrangements for swimming lessons, possible absence at the classes during the biggest religious holidays). It was established that the policy of cantons regarding Muslim community was often defined by external tendencies (the discussion on visible religious attributes and introduction of the course “Religions and Humanitarian Culture” concerned, first of all, French-speaking cantons while the attempts to introduce the system of Islamic religious education concern a range of German-speaking cantons). The pilot projects of IRE in St. Gallen, Lucerne and Thurgau revealed the need in establishing, in Switzerland, the correspondent system for preparing teachers of this direction and elaboration of didactic materials. The Confederation responded to this urgent need with creation, in 2015, of a profile branch by the University of Fribourg – Swiss Centre for Islam and Society. The perspective direction of the research is still the comparison of Swiss, German and Austrian approaches to preparation of IRE teachers and development of didactic materials.

Swiss Сonfedеration experience on reception of migrants

The experience of Swiss Confederation in the field of integration of immigrants – one of the most economically developed countries of the world, occupying the leading position in Europe on the rate of foreign population in general demographic structure, – has been examined in the article. Evolution of the notions of “integration”, “social assimilation”, “acculturation” and others has been considered and different scientific approaches of Western researches to these notions have been adduced. Swiss immigration policy for the past decades has been traced and the modern integration policy of the country in the field of integration of foreign citizens into receiving society has been analyzed. A detailed analysis of the Swiss normative and legal framework in the field of migration, asylum and integration has been made also, and active development of migration laws over the last decade has been noted. Swiss migration politics, like in other developed Western countries-recipients of foreign labor, contains both: immigration policy (control over entry and stay of foreigners in the country) and policy of integration towards foreigners subject to integration processes.The process of integration of a foreign citizen into a new socio-economic, political and cultural environment is a complex, multidimensional phenomenon. There is a developed and scientifically grounded system of reception, accommodation and integration of foreigners and asylum seekers in Switzerland, which is based on constitutional values, respect and mutual tolerance. At the core of this system is a general strategy of integration, which constitutes a country’s core policy of integration and covers various areas: law, politics, labour issues, housing, education, culture and religion. In order to implement the policy of integration, in Switzerland there are being developed and implemented federal and cantonal integration programs. Integration processes management is administered through the developed system of state authorities at federal, cantonal and other levels, with active participation of different public organizations, including migrant organizations. Federal Council publishes reports on development of integration policy in the country, Federal Migration Office issues annual reports, numerous scientific researches on the theme are being conducted. At present each canton has its own Integration program, designed in accordance with the Modal cantonal program, that allows to implement different integration models, depending on regional requirements and priorities.

Assessing the regional governance capacities of spatial planning: the case of the canton of Zurich

ABSTRACT Many countries use spatial planning instruments to coordinate interests in land use and influence land-use change. In Switzerland, the cantonal structure plan (kantonale Richtplan) serves as the main spatial planning instrument at the cantonal level. Coordinating land-use interests and influencing land-use change requires ‘regional governance capacities’. This paper presents an analytical concept of regional governance capacities in spatial planning using the policy arrangement approach and drawing from the spatial planning implementation and evaluation literature. The canton of Zurich, with its embedded cases on the regional and local levels, serves as the case study for testing the analytical concept. Empirical evidence from qualitative interviews, observations and document analyses reveals a coexistence of various regional governance capacities within the canton of Zurich. Whereas regional governance capacities regarding the promotion of inner development in urban areas emerge as high, the results unveil mixed regional governance capacities when it comes to coordinating transport and land-use planning. To make judgements about regional governance capacities in spatial planning, it is essential to observe various spatial challenges, spatial scales and local examples.

The Politics of Renewable Energy Production in a Federal Context: The Deployment of Small Hydropower in the Swiss Cantons

This article explores the factors that hinder and promote the deployment of renewable energy generating infrastructure in/across the Swiss cantons (i.e., the country’s federal units). Using the example of small-scale hydropower, we shed light on how political regulations at the cantonal level interact with national policies and the local political process to affect the deployment of renewable energy production. The analysis demonstrates that political regulations can both foster and hinder the deployment of renewable energy production. While the national feed-in tariff scheme is revealed to be a beneficial framework condition, cantonal regulations hamper, rather than facilitate, the deployment of small-scale hydropower. Moreover, inclusive local processes and the existence of local entrepreneurs seem to act as a trigger for the local acceptance of renewable energy generation infrastructure. More generally, we conclude that, quite independently of whether state structures are decentralized or centralized, subnational and local leeway in the definition and organization of projects can help to prevent or deal with local opposition.

Fixing Federal Faults. Complementary Member State Policies in Swiss Health Care Policy

This article aims to understand what makes member states complement federal healthcare policy beyond the instruments planned by federal policy. We employ a Multiple Streams approach to study how Swiss member states use their discretion in order to complement federal healthcare regulation with the aim of decreasing outpatient healthcare expenditures at the cantonal level. Based on a written survey in the Swiss cantons, we perform a Fuzzy Set Qualitative Comparative Analysis (fsQCA), which places a keen emphasis on complex patterns. The method identifies what combinations of determinants make it particularly likely that a canton opts for complementary policy activity. Several configurations prove to foster such activity. While this is important, it is also important to pay attention to the constellations that precisely do not foster complementary policy activity. Our analysis of the cantonal choices on governing outpatient healthcare reveals that party politics in the executive and/or the public administration play a major role in this task, whereas neither organized interests within the medical profession nor individual policy entrepreneurs are crucial. Federalist systems offer opportunities for policy innovations the federal level ultimately may benefit from.