European Quarterly of the European Observatory on Health Systems and Policies EUROHEALTHon Health Systems and Policies RESEARCH • DEBATE • POLICY • NEWS COVID-19 Health System Response

• The Health System Response Monitor • Supporting health workers

› 2020 Health system during COVID-19 • Health systems resilience |

• How to protect care homes responses to • The economic and health financing crisis • Compensating health care

COVID-19 professionals for income losses Number 2

• Evidence-informed policymaking | • In and out of lockdowns • Successful find-test-trace-isolate- support systems • Centralisation within and

between governments :: Special Issue :: Volume 26 EUROHEALTH

Quarterly of the European Observatory on Health Systems and Policies Eurostation (Office 07C020) Place Victor Horta / Victor Hortaplein, 40 / 10 1060 , T: +32 2 524 9240 F: +32 2 525 0936 Email: [email protected] http://www.healthobservatory.eu

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LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, https://www.lse.ac.uk/lse-health

EDITORIAL ADVISORY BOARD Paul Belcher, Reinhard Busse, Josep Figueras, Julian Le Grand, Willy Palm, Suszy Lessof, Martin McKee, Elias Mossialos, Richard B. Saltman, Sarah Thomson

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Back issues of Eurohealth are available at: https://www.lse.ac.uk/lse-health Contents 1

Covid-19 Special Issue Preventing transmission

EDITORIAL – Hans Kluge, SUCCESSFUL FIND-TEST-TRACE- 3 Sandra Gallina and Josep Figueras 34 ISOLATE-SUPPORT SYSTEMS: HOW TO WIN AT SNAKES AND LADDERS – Selina Rajan, Jonathan Cylus and Perspectives on COVID-19 Martin McKee

LESSONS FROM THE FIRST EFFECTIVE CONTACT TRACING 5 WAVE: THE COVID-19 HEALTH 40 AND THE ROLE OF APPS: LESSONS SYSTEM RESPONSE MONITOR FROM EUROPE – Cristina Hernández- (HSPM) AN EVIDENCE RESOURCE Quevedo, Giada Scarpetti, Erin Webb, AND A SOURCE OF ANALYSIS – Sherry Nathan Shuftan, Gemma A. Williams, Merkur, Anna Maresso, Jonathan Cylus, Hans Okkels Birk, Signe Smith Ewout van Ginneken and Suszy Lessof Jervelund, Allan Krasnik and Karsten Vrangbæk COVID-19: REFLECTING ON 13 EXPERIENCE AND ANTICIPATING HOW COMPARABLE IS COVID-19 THE NEXT STEPS – Hans Henri 45 MORTALITY ACROSS COUNTRIES? P. Kluge, Dorit Nitzan and Natasha – Marina Karanikolos and Martin McKee Azzopardi-Muscat

EUROPEAN SOLIDARITY DURING Ensuring sufficient workforce 16 THE COVID-19 CRISIS – Isabel de la Mata capacity

COVID-19 AND HEALTH SYSTEMS WHAT STRATEGIES ARE RESILIENCE: LESSONS GOING 51 COUNTRIES USING TO

CONTENTS 20 FORWARDS – Anna Sagan, Steve EXPAND HEALTH WORKFORCE Thomas, Martin McKee, Marina SURGE CAPACITY DURING Karanikolos, Natasha Azzopardi- THE COVID-19 ? – Gemma Muscat, Isabel de la Mata and A. Williams, Claudia B. Maier, Giada Josep Figueras Scarpetti, Antonio Giulio de Belvis, Giovanni Fattore, Alisha Morsella, HOW TO RESPOND TO THE COVID-19 Gabriele Pastorino, Andrea Poscia, 25 ECONOMIC AND HEALTH Walter Ricciardi and Andrea Silenzi FINANCING CRISIS? – Jonathan Cylus and Ewout van Ginneken HOW ARE COUNTRIES SUPPORTING 58 THEIR HEALTH WORKERS DURING TRANSLATING EVIDENCE INTO COVID-19? – Gemma A. Williams, 29 POLICY DURING THE COVID-19 Giada Scarpetti, Alexia Bezzina, PANDEMIC: BRIDGING SCIENCE AND Karen Vincenti, Kenneth Grech, POLICY (AND POLITICS) – Gemma Iwona Kowalska-Bobko, Christoph A. Williams, Sara M. Ulla Díez, Josep Sowada, Maciej Furman, Małgorzata Figueras and Suszy Lessof Gałązka-Sobotka and Claudia B. Maier

European Quarterly of the European Observatory on Health Systems and Policies EUROHEALTHon Health Systems and Policies RESEARCH • DEBATE • POLICY • NEWS COVID-19 Health System Response

› • The Health System Response Monitor • Supporting health workers Health system during COVID-19 2020 • Health systems resilience | • How to protect care homes responses to • The economic and health fi nancing crisis • Compensating health care COVID-19 professionals for income losses Number 2

• Evidence-informed policymaking | • In and out of lockdowns • Successful fi nd-test-trace-isolate- support systems • Centralisation within and

between governments :: Special Issue :: Volume 26 © Photo © Miriam – Doerr (dreamstime.com)

Eurohealth — Vol.26 | No.2 | 2020 2 Contents

Providing health service Paying for services

effectively COMPENSATING HEALTHCARE 83 PROFESSIONALS FOR MANAGING HEALTH SYSTEMS ON INCOME LOSSES AND EXTRA 63 A SEESAW: BALANCING THE EXPENSES DURING COVID-19 – DELIVERY OF ESSENTIAL HEALTH Ruth Waitzberg, Dalhia Aissat, SERVICES WHILST RESPONDING Triin Habicht, Cristina Hernandez- TO COVID-19 – Melitta Jakab, Naomi Quevedo, Marina Karanikolos, Limaro Nathan, Gabriele Pastorino, Madelon Kroneman, Sherry Merkur, Tamás Evetovits, Sarah Garner, Wilm Quentin, Giada Scarpetti, Margrieta Langins, Cris Scotter and Erin Webb, Gemma A. Williams, Natasha Azzopardi-Muscat Juliane Winkelmann and Ewout van Ginneken RESTARTING MORE ROUTINE 68 HOSPITAL ACTIVITIES DURING ADJUSTING HOSPITAL INPATIENT COVID-19: APPROACHES FROM 88 PAYMENT SYSTEMS FOR SIX COUNTRIES – Erin Webb, COVID-19 – Wilm Quentin, Tit Albreht, Cristina Hernández-Quevedo, Giada Alexia Bezzina, Lucie Bryndova, Scarpetti, Nigel Edwards, Sarah Antoniya Dimova, Sophie Gerkens, Reed, Coralie Gandré, Zeynep Or, Iwona Kowalska-Bobko, Sarah Fidelia Cascini, Juliane Winkelmann, Mantwill, Zeynep Or, Selina Rajan, Madelon Kroneman, Judith de Jong, Mamas Theodorou, Liina-Kaisa Enrique Bernal-Delgado, Ester Angulo- Tynkkynen, Ruth Waitzberg and Pueyo, Francisco Estupiñán-Romero, Juliane Winkelmann Selina Rajan and Sujay Chandran

KEEPING WHAT WORKS: REMOTE Governance 73 CONSULTATIONS DURING THE COVID-19 PANDEMIC – IN AND OUT OF LOCKDOWNS, AND Erica Richardson, Dalhia Aissat, 93 WHAT IS A LOCKDOWN ANYWAY? Gemma A. Williams and Nick Fahy POLICY ISSUES IN TRANSITIONS – Holly Jarman, Scott L. Greer, Sarah THE COVID-19 PANDEMIC AND Rozenblum and Matthias Wismar 77 LONG-TERM CARE: WHAT CAN WE LEARN FROM THE FIRST WHO’S IN CHARGE AND WHY? WAVE ABOUT HOW TO PROTECT 99 CENTRALISATION WITHIN AND CARE HOMES? – Margrieta Langins, BETWEEN GOVERNMENTS – Natasha Curry, Klara Lorenz- Scott L. Greer, Holly Jarman, Sarah Dant, Adelina Comas-Herrera and Rozenblum and Matthias Wismar Selina Rajan NATIONAL, EUROPEAN, AND 104 GLOBAL SOLIDARITY: COVID-19, PUBLIC HEALTH, AND VACCINES – Scott L. Greer EDITORIAL

Eurohealth — Vol.26 | No.2 | 2020 Editorial 3

EDITORIAL

As this Eurohealth goes to press many countries across the European region and beyond face a steep surge in transmissions and a renewed challenge from COVID-19.

As we head into winter, health care systems are management of complications; the development again coming under significant pressure. There of new drugs; and the ‘new’ use of existing drugs is still a window of opportunity, albeit one that is such as , have reduced case fatality closing rapidly, to avert the kinds of problems seen ratios. Yet, the pace of implementation, particularly in the Spring. There is also a chance, although again of prevention measures, needs to pick up sharply a slim one, for Europe to use this crisis to tackle in many Member States if we are to succeed in the profound underlying problems that beset our . health systems. Countries are equipped with better evidence but also This special issue of Eurohealth, with its focus, on with examples of how others have tackled the issues. health system responses to COVID-19 is particularly We have seen a burst of innovation and transformation timely. It reviews some of the innovative practices in many countries and the papers here attest to the across our region and outlines policy lessons for the dynamism and ingenuity of many health systems. future. All the papers draw on the COVID-19 Health The fast track introduction of digital and telemedicine System Response Monitor (HSRM) platform, a tools (developments which had been in the pipeline major initiative led by the WHO Regional Office for for years); the rapid mobilisation of additional human Europe, the European Commission and the European resources via recruitment and training of volunteers Observatory on Health Systems and Policies. Neither and through health professionals adapting roles and the HSRM nor this special issue would be possible taking on new skills; the shift to multidisciplinary without an exceptional network of experts and centres team work, have all shown what is possible. Similarly, of excellence. The Observatory’s Health Systems the transformation of hospital and primary care Policy Monitor (HSPM) network which includes the delivery with new care pathways and more flexible whole , the WHO country offices organisational arrangements, supported by new and other experts have together managed to cover purchasing arrangements and payment systems almost every country in the European region. A huge demonstrate how health systems are able to re- debt of gratitude is owed to them. Thanks are due engineer in the face of crisis. Importantly too, the also to the Observatory staff who have been running experience shows how strong a commitment our this initiative and who have pulled together such an health systems can count on: from a dedicated effective platform. The HSRM and the articles that workforce and from the community and NGOs. follow demonstrate how much countries have learned. Overall, the analysis of COVID-19 responses Collectively we are armed with much better evidence. collected in this issue, constitutes a powerful Lessons on preventing transmission are being acted testimony to efforts across Europe. It is also a stark on through improved testing and tracing and through reminder of the many unresolved structural problems progressive scaling of physical distancing measures in our health systems. This pandemic has been a tailored to epidemiological surveillance. Flexibility particularly dramatic health systems shock, and (as in care pathways and the embedding of digital with all shocks) it uncovers and highlights the chronic technology point the way to more effective health existing weaknesses of the system. The observed care delivery. There have also been rapid advances failures in some systems to protect vulnerable and in clinical protocols and treatments. Progress in the underprivileged populations are a strong reminder of best use of intensive care therapies and the early the failings of the past decade, for example in dealing EDITORIAL

Eurohealth — Vol.26 | No.2 | 2020 4 Editorial

with the economic and refugee crises. Shortcomings what works (better and worse) in different settings. It in preventing transmission or in addressing the recognises that transparency and sharing are the best mortality crisis in nursing homes are simply a way to learn and strengthen our individual efforts and reflection of the low priority given to public health to achieve common goals. It also models collaborative and long-term care over the years – and of our failure and cooperative ways of working that bode well for to invest. The pandemic then throws a spotlight on governance in the future, although there is much more the well understood realities and the governance to be done to instil collaborative approaches. shortcomings of health systems. Secondly, you should ‘never let a good crisis go to The central challenge for policy makers now, as a waste’. All too often challenges to health systems second wave takes shape, must of course be dealing have been met with commitments to improve and with the immediate consequences using the evidence collaborate that melt away as soon as the crisis and experience of recent months, but this cannot be subsides. There are both real and fundamental entirely separated out from what this implies for the challenges to health systems and real hope for future of Europe’s health systems. Policy makers need sustainability. This Eurohealth flags some of the to both harness and sustain stakeholders’ commitment very clear lessons from COVID-19 on how we might – not least to new practices; gear up innovations that move forward. We hope therefore that this crisis will work, and, perhaps most importantly, strengthen be different and that out of the pandemic will come governance mechanisms to support the degree of tangible progress – in innovation, in agility, and transformation required. This is key to our ability to in governance and transformation – so that a more cope – as Sagan and colleagues argue in the paper transparent, more collective and more international on resilient health systems, good governance is the approach to health and health systems emerges. “mortar binding everything else together” and crucial for an effective response. It is also key in the longer term. Other papers in this issue pick up on governance Hans Kluge, Sandra Gallina practices that enable appropriate implementation, and Josep Figueras including the piece by Williams et al. on the role of multidisciplinary advisory groups in translating Cite this as: Eurohealth 2020; 26(2). evidence to policy. It clearly flags the challenges around independence and transparency as we try to bridge the science-policy (and politics) gap. Clearly, transparency in communicating the evidence (even when it is equivocal) and in political decision-making is crucial and perhaps the single most powerful tool for generating trust (and compliance) in the population. Again, the lessons for the second wave resonate with the long term challenges.

It is too easy to fall back on clichés in times of crisis but there are two somewhat hackneyed concepts that really are pertinent here. Firstly, ‘we are stronger’ together. In the first stage of the crisis, in many countries, collaboration and solidarity across borders took second place in the rush to protect national citizens and health systems but countries have quickly realised the importance of working together to tackle this pandemic. The WHO and the European Commission have put together a large set of interventions to support Member States and strengthen coordination between them. In many of these they are working closely together, for example on access to vaccines (Greer et al.) or in surveillance, together with the ECDC. The HSRM has been a truly joint undertaking, again between WHO, the European Commission and countries – but this time with the Observatory as the enabler, to share evidence and to understand what countries are doing in practice and

Eurohealth — Vol.26 | No.2 | 2020 Perspectives on COVID-19 5

LESSONS FROM THE FIRST WAVE: THE COVID-19 HEALTH SYSTEM RESPONSE MONITOR (HSPM) AN EVIDENCE RESOURCE AND A SOURCE OF ANALYSIS

By: Sherry Merkur, Anna Maresso, Jonathan Cylus, Ewout van Ginneken and Suszy Lessof

Summary: COVID-19 has posed huge challenges for Europe’s health systems but also for European solidarity. The WHO Regional Office for Europe and the European Commission have worked to maintain an international perspective and, as part of their efforts, called on the European Observatory on Health Systems and Policies. Its response was the HSRM platform. HSRM helps countries systematically capture how they are tackling COVID. It allows policy makers to see immediately how others are ‘governing’ transmission, resources and service delivery. They can identify common issues and share practice. HSRM has also provided the raw material for cross-cutting analysis of key policy questions. This combination of information and analysis has generated learning. What’s more, it has helped assert the importance of countries coming together in the face of an international

Cite this as: Eurohealth 2020; 26(2). health emergency.

Keywords: Health Systems, Country Monitoring, Cross-Country Analysis, Sherry Merkur is Research Fellow, Jonathan Cylus is London Pandemic Response, COVID-19 Hub Coordinator, European Observatory on Health Systems and Policies, London School of Economics and Political Science, The HSRM platform is an information collapse, and cope with economic UK; Anna Maresso is Country tool that has also helped bring shutdown. It has also proved hugely Monitoring Coordinator, Ewout van countries together challenging for international solidarity. Ginneken is Berlin Hub Coordinator, European Observatory on Health COVID-19 was declared a pandemic Countries across the European Region Systems and Policies, Technical on 11 March 2020. 1 It has posed huge University of Berlin, ; mounted complex and aggressive challenges for countries, who have Suszy Lessof is Coordinator, responses to the virus which extended European Observatory on Health struggled to contain the spread of the to closing borders and competing for Systems and Policies, Brussels, disease, protect health systems from Belgium. masks and ventilators. The World Health Email: [email protected] Organization Regional Office for Europe

Eurohealth — Vol.26 | No.2 | 2020 6 Perspectives on COVID-19

(EURO) and the European Commission (EC) have sought both to support countries Box 1: What is HSRM? and to foster the ties between them.

The COVID-19 Health System Response Monitor platform is a publicly available The European Observatory on Health online resource (www.covid19healthsystem.org) that collects and organises Systems and Policies (Observatory) was information on how health systems are responding to COVID-19 across Europe asked to provide help by establishing a and beyond. It is structured and updated to help policy makers review what is monitoring tool to equip policy makers happening country by country and issue by issue. It offers links to core sources of across the Region with a systematic data and delivers cross-cutting analysis of key challenges and how they are being picture of how every country was handled and enables countries to learn from each other. responding. The Observatory is a WHO hosted partnership of governments, Although the focus is primarily on health systems, HSRM also captures wider international organisations, academic public health initiatives on preventing transmission as well as relevant responses and other institutions. It generates in other sectors. It gathers reliable evidence (via publicly available information) evidence for decision-making and is used through a network of country experts from academia and WHO Country Offices. to working with others and responding The network taps into vast national knowledge and links to multiple, complimentary rapidly to policy demands. It built the international networks. Observatory analysts work with the country experts to HSRM initiative (see Box 1) on the back check and cross-reference, edit and update posts. of the Health Systems and Policy Monitor (HSPM) model but convened an even broader network of country collaborators and informants to track the constantly that had sat at the sub-national level (in The structure helps policy makers to changing situation. A mix of leading Länder, provinces or cantons) were being navigate through the different blocks of academics, WHO Country Office teams, centralised in some cases while in others information (on paying for services or policy makers and researchers have local authorities were taking on tasks that on providing them) and to drill down combined forces to record how health had previously been organised at national into the detail (to explore infrastructure system responses have evolved and to level. The Observatory wanted to facilitate or workforce, entitlement or regulation). detail emerging initiatives. The EURO comparison but understood that a clearly It also highlights the latest updates Emergencies team shared data; the structured, clearly signposted description and provides links to contextualise the Division of Country Health Policies and of national experience was not just central health system responses (to international Systems and its public health and health to making comparisons, but useful in and data sources and to the HiT 2 – the systems specialists sought synergies of itself. standard health system description for with other initiatives, and its Country ‘normal’ times). Offices worked directly with ministries It developed a template – a series of to understand the reality for Member headings and questions – to guide how It has proved really useful to country States. DG SANTE was also on hand with country experts should describe what policy makers in practice as they try to information and insights into Commission was happening. The template looks at take stock of their own efforts and to and country actions. key health system functions related to the reflect on how the different strands of their pandemic and the context in which these national responses fit together. functions operate, including prevention measures and the actions of other sectors. HSRM lets countries compare their It is detailed in Table 1 (see overpage) and own approach with other countries’ seeks to reflect the multifaceted ways efforts generates countries have responded to COVID-19 and to be sufficiently flexible to Policy makers have found it just as useful evidence for incorporate emerging issues. to be able to set their own actions in the wider European context. Although it is decision-making The template and the platform itself too early still to be clear on best practices cover 52 countries. Figure 1 shows the and, although context is always different HSRM helps countries to reflect on country page for Slovenia but the model and always important, ministries of health their own performance ‘works’ from Albania to Uzbekistan and want to know how key challenges are from San Marino to the Russia Federation, being tackled elsewhere. The platform was set up as the first and to Finland. It can be used wave of the pandemic rolled across the however big or small, densely or sparsely They have asked WHO and the European Region.‘‘ It recognised that populated a country is and whether the Observatory for examples and news and countries were acting at a remarkable pace system is largely tax or insurance based, the HSRM has helped to provide that and across sectors, health system ‘building well-resourced or underfunded. information. Users of the site can simply blocks’ and authorities. Responsibilities go to the compare country function

Eurohealth — Vol.26 | No.2 | 2020 Perspectives on COVID-19 7

Figure 1: Slovenia’s country page captures core information and gives immediate (see Figure 2) select the countries and the access to the latest updates issues they are interested in and generate a pdf that contains all the relevant sections and updates, and thousands have done just that. Wanting to know what similar (or contrasting) health systems are doing is not the same as expressing solidarity with them but it has helped reassert the importance of sharing information and sharing learning.

HSRM’s cross-country analysis builds on basic comparisons to generate policy relevant insights The platform compares country evidence to analyse key themes (https://analysis. covid19healthsystem.org/) and offer concise comparative ‘policy snapshots’. These are developed in response to policy makers’ questions from countries, WHO and the EC and address the topical, the important and the interesting. Policy snapshots look at context and pull out

Source: 3 narrative threads so that the analysis is useful. They also pick up on patterns and trends and explore emerging Figure 2: Users can easily pull together the information on the countries and the health issues, offering examples of innovative system responses that are most relevant to them or promising practices. Again, the Observatory recognises how many others are working in the area and provides links to key references and linked articles.

The cross-country analysis tool responds to real decision-makers and new snapshots are developed as policy and practice in countries evolves, assessing the ways countries are responding and setting their policy initiatives in context. The initial snapshots have been expanded and updated for this special issue of Eurohealth. The articles that follow offer more in-depth reflections on what Europe has learned so far from COVID-19.

HSRM reflections on the first wave can help inform responses to the second wave New challenges are emerging but reviewing experience to date will stand countries in good stead as they ready themselves for winter.

Preventing transmission, for example, is again at the forefront of thinking. The snapshots developed as lockdown Source: 4 restrictions were first eased, give some

Eurohealth — Vol.26 | No.2 | 2020 8 Perspectives on COVID-19

useful insights for the next wave. The There are also abiding lessons on as well as a mix of modifications to notion that progress (in testing, contact providing health services including current payment systems all of which may tracing, and isolating) is fraught with on how to effectively adopt a dual track prove useful to other policy makers trying complexity is captured by the ‘snakes system that manages the COVID-19 to protect their health institutions from and ladders’ analogy used by Rajan and response in parallel to the delivery of financial collapse. colleagues. They show that policy makers essential and routine health services. taking steps forward – implementing Jakab et al. look at the health system The governance aspects of all the above public health measures and enhancing enablers needed to ensure a well-resourced are captured in the platform but this capacity (climbing the ladders) – must also and functioning system. Webb and Eurohealth focuses in particular on the proactively guard against the bottlenecks colleagues explain how hospital services leadership and governance dimensions and setbacks (avoiding the snakes) that have been restarted as lockdowns were around managing lockdown and reopening can so rapidly undo the progress made. eased, so that patients can access non- economies. The resonances of this are The way over 30 countries have chosen urgent treatment. They flag lessons on more than evident. Hardman et al. flag to manage the ‘find, test, trace, isolate, adapting ways of working to limit the the different demands of transitioning support’ process has been mapped by spread of infection while Richardson between stages including the data and Hernández-Quevedo et al. They drill et al. explain how some countries indicators for decision-making, involving down into contact tracing and identify have kept services going by offering key stakeholders, and communicating whether it is being led by one national remote consultations. The uptake of decisions, not least the communications agency or at a more local level as well teleconsultations has not just increased but strategies for explaining guidance to as flagging where contact tracing apps appears to have established that this is an populations. They find that pinpointing are being used. It is too early to draw important delivery mode going forwards. the level of decision-making, whether conclusions about how the different levels There are also clearly, lessons for the centralised or decentralised, and of success across countries relates to their future to be derived from the suffering in understanding intersectoral collaboration, different approaches, but decision-makers long-term care settings and Langins et al. helps explain the different way countries are looking across at countries like their identify the measures taken to protect care have responded. As countries across own in considering their options. In the homes and the opportunities to strengthen Europe impose new local lockdowns to same way policy makers are interested in systems and protect vulnerable people. protect populations, there are a range of how their mortality rates compare with lessons from past practice. others. Karanikolos and McKee consider differences in mortality recording across Finally an article from Greer addresses Europe and over time, to help countries perhaps the ‘final’ challenge of the assess whether the data are meaningful COVID-crisis – developing and for them and explore whether counting recording policy ensuring access to a vaccine. It looks at COVID-related mortality or alternative European and global solidarity in vaccine metrics, such as excess deaths, is a more makers’ choices development and suggests that even appropriate tool for country comparisons. when a safe and effective vaccine has as the situation been developed, challenges will continue Initiatives on health workforce are with risks of vaccine hesitancy and captured in articles drawn from the evolves public backlash. infrastructure and workforce capacity section of HSRM and of this Eurohealth. There is a dynamic relationship between HSRM tracking of country responses Williams and colleagues report on service provision and paying for services will help policy makers to continue how 45 countries have sought to increase but many (unsalaried) health professionals learning the surge capacity and flexibility of health lost income in the‘‘ early stages of the professionals so that they can sustain pandemic (with decreased demand). In advance of any vaccine many European the COVID-19 response. They look at Waitzberg and colleagues show how countries face increases in infections and the immense challenges of looking after countries have compensated providers hospital admissions. Their experience severely ill COVID patients while meeting through special health sector measures so far and the lessons generated will be requirements for personal protection, or through general support for the self- important in informing responses. and lockdown. A employed and have encouraged tele/ further article describes in detail the e-health solutions to mitigate shortfalls. It is just as important to go on recording range of interventions – from provision of Payment for hospital inpatient services policy makers’ choices as the situation childcare, free accommodation, has also been disrupted and Quentin and evolves. HSRM will monitor how they or parking to financial rewards, as well colleagues detail how countries have tried tackle transmission, the provision of as the support for mental health and to cover the costs of COVID-19 and /or COVID care and essential services and wellbeing – which will all be applicable compensate for revenue shortfalls. They will capture their strategies to protect again as cases continue to rise. capture entirely new payments (in the workforce, providers and people over the form of fees, per diems or cash advances) coming months. It will support WHO,

Eurohealth — Vol.26 | No.2 | 2020 Perspectives on COVID-19 9

the EC and countries with evidence and References 3 Albreht T, Winkelmann J, Scarpetti G. Slovenia page. COVID-19 Health System Response Monitor. country trends whether on expanded 1 WHO. WHO Director-General’s opening remarks WHO, European Commission, European Observatory testing, contact tracing, localised at the media briefing on COVID-19, 11 March 2020. on Health Systems and Policies, 2 October 2020. Available at: https://www.who.int/dg/speeches/ outbreaks in workplace settings, digital Available at: https://www.covid19healthsystem.org/ detail/who-director-general-s-opening-remarks-at- health or resilience. countries/slovenia/countrypage.aspx the-media-briefing-on-covid-19—-11-march-2020 4 Compare countries page. COVID-19 Health System 2 Full list of country HiTs. European Observatory The platform matters because health Response Monitor web site. Available at: https:// on Health System and Policies web site. Available at: systems decision-making is better when it www.covid19healthsystem.org/searchandcompare. https://www.euro.who.int/en/about-us/partners/ has the evidence to draw on. It also matters aspx observatory/publications/health-system-reviews- that countries acknowledge that they have hits/full-list-of-country-hits much to learn from each other. Sharing information and experience reinforces European solidarity and reminds us all of the value of a region wide response to a truly global challenge.

Table 1: HSRM guides users through the evidence so they can review their own situation and garner insights from other countries

Section Core information Sub-sections Aims Preventing transmission • Key public health measures • Health communication To share how countries are preventing the spread of the disease • Measures in place to test and • Physical distancing including by offering details of how identify cases, trace contacts, and • Isolation and quarantine they are advising the general public monitor the scale of the outbreak and people who (might) have • Monitoring and surveillance the disease. • Testing Ensuring sufficient physical • Physical infrastructure • Physical infrastructure To detail the practices developed in infrastructure and workforce countries to fill infrastructure gaps • Measures to address shortages • Workforce capacity and they ways they are trying to • Steps to maintain or enhance protect and support health workers. workforce capacity • Workforce skill-mix and responsibilities • Training and HR initiatives Providing health services • Planning and patient pathways • Planning services To explain approaches to service effectively for COVID-19 cases delivery and explore how countries • Managing cases are balancing COVID and non- • Maintaining essential services • Maintaining essential services COVID care. Paying for services • How countries are paying for • Health financing To explore the different challenges COVID-19 services of paying for care in insurance, • Entitlement and coverage tax-based and mixed systems. Governance • Pandemic response plans – To understand how governance seeks to ensure the continued • Steering of the health system functioning of health systems • Emergency response mechanisms and how information is being communicated to that end. • Regulation of health service provision to affected patients Measures in other sectors • Actions taken and advice provided • Border restrictions To set health system responses in in sectors beyond the health the wider policy environment. • Transport advice system • The economy • State aid • Civil protection • Cross-border collaboration

Source: Authors’ own

Eurohealth — Vol.26 | No.2 | 2020 The COVID-19 Health System Response Monitor (HSRM) is led by the technical expertise of the following country contributors

Albania Canada Gazmend Bejtja, WHO Regional Office for Sara Allin, North American Observatory Triin Habicht, WHO Barcelona Office for Peter Gaal, Semmelweis University, Health Europe, Country Office on Health Systems and Policies; University Health Systems Strengthening Services Management Training Centre of Toronto Bettina Menne, WHO Regional Office for Kristiina Kahur, Private consultant Viktoria Szerencses, Semmelweis Europe, Country Office Tiffany Fitzpatrick, University of Toronto University, Health Services Management Kaija Kasekamp, Ministry of Social Affairs Training Centre Adrian Xinxo, WHO Regional Office for Michel Grignon, McMaster University Kristina Köhler, WHO Regional Office for Europe, Country Office Zita Velkey, Semmelweis University, Nessika Karsenti, Schulich School of Europe Health Services Management Training Medicine, Western University Armenia Marge Reinap, WHO Regional Office for Centre Madeline King, North American Europe, Copenhagen WHO Regional Office for Europe, Observatory on Health Systems and Andres Vork, University of Tartu, Johan Country Office Policies; Telfer School of Management, Skytte Institute of Political Studies University of Ottawa Sigurbjörg Sigurgeirsdóttir, University of Iceland Austria Anna Kurdina, University of Toronto Finland Florian Bachner, National Public Health Greg Marchildon, North American Salla Atkins, University of Tampere Ireland Institute Observatory on Health Systems and Policies; University of Toronto Vesa Jormanainen, Finnish Institute for Sarah Barry, The Centre for Health Policy Katharina Habimana, National Public Health and (THL) and Management, School of Medicine, Health Institute Monika Roerig, North American Trinity College Dublin Observatory on Health Systems and Ilmo Keskimäki, Finnish Institute for Anita Haindl, National Public Health Policies; University of Toronto Health and Welfare (THL) Sara Burke, The Centre for Health Policy Institute and Management, School of Medicine, Sterling Stutz, University of Toronto Meri Koivusalo, University of Tampere Sonja Neubauer, National Public Health Trinity College Dublin Institute Pauli Rautiainen, Finnish Institute for Rikke Siersbaek, The Centre for Health Health and Welfare (THL) Andrea Schmidt, National Public Health Policy and Management, School of Institute Maja Banadinovic, School of Public Health Eeva Reissell, Finnish Institute for Health Medicine, Trinity College Dublin Andrija Štampar, University of Zagreb and Welfare (THL) Malgorzata Stach, The Centre for Health Azerbaijan Aleksandar Dzakula, School of Public Markku Satokangas, Finnish Institute for Policy and Management, School of Health Andrija Štampar, University of Health and Welfare (THL) Medicine, Trinity College Dublin WHO Health Emergencies Programme Zagreb Liina-Kaisa Tynkkynen, University of Steve Thomas, The Centre for Health Belarus Iva Miloš, School of Public Health Andrija Tampere Policy and Management, School of Štampar, University of Zagreb Medicine, Trinity College Dublin Marjaana Viita-aho, University of Tampere Batyr Berdyklychev, WHO Regional Office Maja Vajagic´, School of Public Health for Europe, Country Office Andrija Štampar, University of Zagreb Israel Andrei Famenka, WHO Regional Office for Sterling Stutz, University of Toronto Shuli Brammli-Greenberg, Braun School Europe, Country Office Coralie Gandré, The Institute for Research of public health, the Hebrew University and Information in Health Economics Viatcheslav Grankov, WHO Regional Office of Jerusalem and Myers-JDC-Brookdale (IRDES) for Europe, Country Office Institute Chrystalla Charalampous, Zeynep Or, The Institute for Research and Amit Meshulam, Myers-JDC-Brookdale European University Information in Health Economics (IRDES) Belgium Institute Elena Gabriel, Ministry of Health Sophie Gerkens, Belgian Health Care Georgia Gideon Leibner, The Hebrew University of Knowledge Centre Marios Kantaris, Centre for Health Jerusalem Research & Policy Silviu Domente, WHO Regional Office for Karin Rondia, Belgian Health Care Nadav Penn, Myers-JDC-Brookdale Europe, Country Office Knowledge Centre Mamas Theodorou, Open University Institute Tamila Zardiashvili, WHO Regional Office Ruth Waitzberg, Myers-JDC-Brookdale for Europe, Country Office Bosnia and Herzegovina Institute, Ben Gurion University of the Negev, Israel; Technical University of Mirza Palo, WHO Regional Office for Lucie Bryndová, Institute of Economic Germany Berlin, Germany Europe, Country Office Studies, Charles University Juliane Winkelmann, University of Boris Rebac, WHO Regional Office for Adam Polocˇek, Charles University, Technology Berlin/European Observatory Italy Europe, Country Office Czech Republic on Health Systems and Policies Giovanni Fattore, Bocconi University Tomáš Roubal, WHO Regional Office for Cristoph Reichebner, University of Europe, Country Office Antonio Giulio de Belvis, Università Technology Berlin Cattolica del Sacro Cuore Maria Rohova, Medical University of Varna Jana Votápková, Institute of Economic Studies, Charles University Alisha Morsella, Università Cattolica del Antoniya Dimova, Medical University of Sacro Cuore Varna Jan Žiacˇik, Charles University Charalampos Economou, Panteion Gabriele Pastorino, WHO Regional Office Mincho Minev, Medical University of Varna University of Social and Political Sciences for Europe Daphne Kaitelidou, National and Andrea Poscia, Università Cattolica del Allan Krasnik, University of Copenhagen Kapodistrian University of Athens Sacro Cuore Hans Okkels Birk, University of Olympia Konstantakopoulos, National and Andrea Silenzi, Università Cattolica del Copenhagen Kapodistrian University of Athens Sacro Cuore Signe Smith Jervelund, University of Lilian Venetia Vildiridi, Ministry of Health Walter Ricciardi, Fondazione Policlinico Copenhagen Universitario A. Gemelli Karsten Vrangbaek, University of Copenhagen

Eurohealth — Vol.26 | No.2 | 2020 Perspectives on COVID-19 11

Kazakhstan Monaco Sweden Dana Abeldinova, WHO Regional Office for Delphine Lanzara, Ministry of Health Ines Fronteira, Institute of Hygiene & John-Erik Bergkvist, Swedish Europe, Country Office Tropical Medicine, Nova University Lisbon Agency for Health and Care Services Julie Malherbe, Ministry of Health Analysis (Vårdanalys) Serzhan Aidossov, WHO Regional Office Gonçalo Figueiredo Augusto, Institute for Europe, Country Office Montenegro of Hygiene & Tropical Medicine, Nova Kerstin Gunnarsson, Swedish University Lisbon Agency for Health and Care Services Nadira Yessimova, WHO Regional Office Senad Begic´, WHO Regional Office for Analysis (Vårdanalys) for Europe, Country Office Europe, Country Office Alexander Hedlund Kancans, Swedish Mina Brajovic´, WHO Regional Office for Agency for Health and Care Services Kyrgyzstan Silvia Gabriela Scintee, National School of Europe, Country Office Analysis (Vårdanalys) Public Health Aliina Altymysheva, WHO Regional Office Nemanja Radojevic´, WHO Regional Office Nils Janlöv, Swedish Agency for Health for Europe, Country Office Dana Farcasanu, Centre for Health Policy for Europe, Country Office and Care Services Analysis (Vårdanalys) and Services Nazira Artykova, WHO Regional Office for Batric´ Vukcˇevic´, WHO Regional Office for Simon Jehrlander, Swedish Agency Europe, Country Office Europe, Country Office Russian Federation for Health and Care Services Tasnim Atatrah, WHO Regional Office for Analysis (Vårdanalys) Europe, Country Office The Aleksandr Goliusov, WHO Regional Office for Europe, Country Office Akbar Esengulov, WHO Regional Office for Switzerland Peter Groenewegen, NIVEL – Netherlands Europe, Country Office Amélie Schmitt, WHO Regional Office for Institute for Health Services Research Stefan Boes, University of Lucerne Europe, Country Office Kaliya Kasymbekova, WHO Regional Judith de Jong, NIVEL – Netherlands Sarah Mantwill, University of Lucerne Office for Europe, Country Office Melita Vujnovic, WHO Regional Office for Institute for Health Services Research Europe, Country Office Tanya Kasper Wicki, University of Lucerne Monolbaev Kuban, WHO Regional Office Madelon Kroneman, NIVEL – Netherlands for Europe, Country Office Elena Dmitrievna Yurasova, WHO Institute for Health Services Research Regional Office for Europe, Country Office Turkey Moldoisaeva Saltanat, WHO Regional John Paget, NIVEL – Netherlands Institute Office for Europe, Country Office Çetin Dikmen, WHO Regional Office for for Health Services Research San Marino Europe, Country Office Salieva Saltanat, WHO Regional Office for Europe, Country Office North Macedonia Alessandra Melini, State Authority for Toker Erguder, WHO Regional Office for Health and Social Security Europe, Country Office Aigul Sydykova, WHO Regional Office for Simona Atanasova, WHO Regional Office Europe, Country Office Gabriele Rinaldi, State Authority for Berk Geroglu, WHO Regional Office for for Europe, Country Office Health and Social Security Europe, Country Office Nurshaim Tilenbaeva, WHO Regional Margarita Spasenovska, WHO Regional Office for Europe, Country Office Tufan Nayir, WHO Regional Office for Office for Europe, Country Office Serbia Europe, Country Office Jihane Tawilah, WHO Regional Office for Aleksandar Bojovic, WHO Regional Office Irshad A. Shaikhi, WHO Regional Office for Europe, Country Office for Europe, Country Office Europe, Country Office Daiga Behmane, Riga Stradins University Miljan Rancic, WHO Regional Office for Pavel Ursu, WHO Regional Office for Ja¯nis Misinš, Riga Stradins University Norway ‚ Europe, Country Office Europe, Country Office Haldor Byrkjeflot, University of Oslo Ivan Zivanov, WHO Regional Office for Vegard Skau Ilseth, Norwegian Directorate Europe, Country Office Ukraine Laura Mišcˇikiene˙, Lithuanian University of of Health Jarno Habicht, WHO Regional Office for Health Sciences Anne Karin Lindahl, University of Oslo Europe, Country Office Agne˙ Slapšinskaite˙, Lithuanian University Ingrid Sperre Saunes, Norwegian Institute Martin Smatana, Private consultant Nataliia Piven, WHO Regional Office for of Health Sciences of Public Health (formerly Ministry of Health) Europe, Country Office Mindaugas Šteleme˙kas, Lithuanian University of Health Sciences Slovenia United Kingdom Katarzyna Badora-Musiał, Institute of Tit Albreht, National Institute of Public Natasha Curry, The Nuffield Trust Public Health, Jagiellonian University Health Selina Rajan, London School of Hygiene Juliane Winkelmann, University of Krakow and Tropical Medicine Technology Berlin/European Observatory Maciej Furman, Institute of Public Health, Spain on Health Systems and Policies Jagiellonian University Krakow Ester Angulo-Pueyo, Health Services and USA Małgorzata Gała˛zka-Sobotka, Lazarski Policy Research Unit. Institute for Health Malta Matthew Alexander, Virginia University Sciences in Aragon (IACS) Commonwealth University School of Malta Public Health COVID-19 Response Rafał Halik, National Institute of Public Enrique Bernal-Delgado, Health Services Medicine Team, University of Malta and Ministry Health and Policy Research Unit. Institute for of Health Andriy Koval, Department of Health Health Sciences in Aragon (IACS) Iwona Kowalska-Bobko, Institute of Public Management and Informatics, University of Republic of Moldova Health, Jagiellonian University Krakow Francisco Estupiñán-Romero, Central Florida Health Services and Policy Research Magdalena Kozela, National Institute of Lynn Unruh, Department of Health Oxana Domenti, WHO Regional Office for Unit. Institute for Health Sciences Public Health Management and Informatics, University of Europe, Country Office in Aragon (IACS) Central Florida Kamila Parzonka, National Institute of Iuliana Garam, WHO Regional Office for Public Health Europe, Country Office Uzbekistan Christoph Sowada, Institute of Public Stela Gheorgita, WHO Regional Office for Health, Jagiellonian University Krakow WHO Health Emergencies Programme Europe, Country Office Marzena Tambor, Institute of Public Igor Pokanevych, WHO Regional Office for Health, Jagiellonian University Krakow Europe, Country Office

Eurohealth — Vol.26 | No.2 | 2020 HSRM Country Editors

Country editors Editorial assistance and uploading

Miriam Blümel, Berlin Hub and University of Technology Kerry Brown, The London School of Hygiene and Berlin Tropical Medicine Cristina Hernandez-Quevedo, European Observatory on Nathan Shuftan, University of Technology Berlin Health Systems and Policies, London Hub Marina Karanikolos, European Observatory on Health Systems and Policies, London Hub Platform design, content coordination Anna Maresso, European Observatory on Health Systems and technical implementation and Policies, Berlin Hub Sherry Merkur, European Observatory on Health Systems Jonathan Cylus, European Observatory on Health Systems and Policies, London Hub and Policies, London Hub Wilm Quentin, European Observatory on Health Systems Suszy Lessof, European Observatory on Health Systems and Policies, Berlin Hub and University of Technology and Policies, Brussels Secretariat Berlin Anna Maresso, European Observatory on Health Systems Bernd Rechel, European Observatory on Health Systems and Policies, Berlin Hub and Policies, London Hub Sherry Merkur, European Observatory on Health Systems Erica Richardson, European Observatory on Health and Policies, London Hub Systems and Policies, London Hub Ewout van Ginneken, European Observatory on Health Susannah Robinson, WHO Regional Office for Europe Systems and Policies, Berlin Hub and University of Technology Berlin Anna Sagan, European Observatory on Health Systems and Policies, London Hub Maurizio Uddo, European Observatory on Health Systems and Policies, Brussels Secretariat Giada Scarpetti, European Observatory on Health Systems and Policies, Berlin Hub and University of Technology Berlin Anne Spranger, European Observatory on Health Systems and Policies, Berlin Hub and University of Technology Berlin Ewout van Ginneken, European Observatory on Health Systems and Policies, Berlin Hub and University of Technology Berlin Ruth Waitzberg, European Observatory on Health Systems and Policies, Berlin Hub and University of Technology Berlin Erin Webb, European Observatory on Health Systems and Policies, Berlin Hub and University of Technology Berlin Gemma A. Williams, European Observatory on Health Systems and Policies, London Hub Juliane Winkelmann, European Observatory on Health Systems and Policies, Berlin Hub and University of Technology Berlin

Eurohealth — Vol.26 | No.2 | 2020 Perspectives on COVID-19 13

COVID-19: REFLECTING ON EXPERIENCE AND ANTICIPATING THE NEXT STEPS

A perspective from the WHO Regional Office for Europe

By: Hans Henri P. Kluge, Dorit Nitzan and Natasha Azzopardi-Muscat

Cite this as: Eurohealth 2020; 26(2). Hans Henri P. Kluge is Regional Director, Dorit Nitzan is Regional Emergency Director, Natasha Azzopardi Muscat is Director, Country Health Policies and Systems; World Health Organization (WHO) Regional Office for Europe, Copenhagen, Denmark.

Nine months into the COVID-19 Health Systems Response Monitor which forced our health systems to adjust with pandemic, devastation and disruption was established at the request of the unprecedented speed. Central to these across much of the European Region WHO Regional Office for Europe in the efforts was our health workforce. We continues unabated. A sharp and sustained early days of the pandemic, has provided must first and foremost prioritise their increase in cases is forcing governments invaluable experience in a timely fashion. well-being including providing adequate to navigate complex response tactics as This has allowed policy considerations mental, physical and financial support, they seek to control disease transmission, and technical /operational guidance to be and continuous training and education. If while also seeking to avoid the negative developed in a rapid response manner. we do not care for them, we will have no consequences associated with lockdowns. health system to depend on. In our view, there are three key lessons At this juncture we are dealing both that should form the foundation of the Health care systems need to operate a with the aftermath of the initial stages evolving COVID-19 response and long- dual track service delivery. Disruption to of the pandemic while grappling with a term recovery efforts: essential health services in the European growing and concerning surge in cases, Region is having a significant impact 1. Even the best health systems were not all the while in the midst of a looming in terms of delayed (missed) preventive sufficiently prepared: building resilient economic recession. The WHO Regional measures, like vaccination and diagnoses health systems Office for Europe has been working on and lack of services provision. The the ground within countries to support 2. There is not a competition between duration of the pandemic is storing up policy makers and health authorities to health and the economy: moving health problems for the future both as increase response effectiveness, save towards an economy of well-being a result of pent up demand as well as lives and protect livelihoods, while also due to increased diseases, e.g. mental 3. We will only get out of this if we work strengthening health systems to improve illness. Primary health care services are together: solidarity, innovation and a their preparedness for the challenges instrumental in enabling this dual track multisectoral response. that lie ahead. At the Regional level, response where routine health services we have tried to synthesise the lessons need to be provided in parallel to services learned and build policy considerations Resilient health systems focused on the pandemic response as well to support countries as they move along as providing aftercare to those persons COVID-19 has ‘unmasked’ critical the various scenarios of the pandemic. who are suffering from the ‘long COVID’ health system gaps and deficiencies. This is in spite of the rapidly evolving syndrome. Public health services need to Health workforce shortages, broken situation and the emergent, incomplete be better equipped and capable of timely supply chains, fragmented services and scientific knowledge, which are both detect, isolate, test, trace and quarantine. silo information systems are a few of hallmarks of navigating in unchartered the problems that hindered the response and uncertain territory. The COVID-19 in the early days. The pandemic has

Eurohealth — Vol.26 | No.2 | 2020 14 Perspectives on COVID-19

For us to enable health systems to respond pandemic has shown us once again that It is vital that we continue to explore in the way we need, we must also take investing in health and preparedness yield all possible response mechanisms, advantage of alternative service delivery above and beyond the input. Investing in particularly ones that bring together platforms. The new frontier of digital the economy of well-being would help sectors and technical expertise to and remote services should be scaled up reduce lives lost, morbidity and stress help us move beyond the biomedical to reduce barriers to seeking care and among the population as well as promote (including through behavioural insights) complement the efforts of the scarce economic growth. The COVID-19 to build health system resilience while human resources for health. pandemic has also illustrated the impact also tackling persistent inequalities in of political decision-making on health our communities. As we explore new frontiers, we must also services in a way that is immediate and double down on responding to persistent highly visible. Frameworks for the future challenges that have been exacerbated by the crisis. We need greater investment It is patently clear that keeping COVID-19 To facilitate the utilisation of lessons in mental health care, care for older under control is necessary for a solid and learned so far from COVID-19, WHO people, and a renewed commitment to sustained economic recovery. The mantra, Europe has developed several frameworks immunisation programmes including there is no wealth without health, has been and tools: efforts to tackle vaccine hesitancy. amply demonstrated in a harsh way. 1. An evolving lessons learned catalogue: 1 Although it is too soon for Here it is important to learn lessons a comprehensive and critical evaluation from the financial and economic crisis this document provides a starting point of the previous decade. In order to avoid for regional discussions on how to accentuating catastrophic expenditure on improve preparedness for and response health, it will be necessary to find ways to investing in to future events, and “build back better.” sustain health spending within a situation health and where fiscal space is limited. Cognisant 2. Transition Framework: 2 key of the necessity to think up solutions that considerations for Member States to preparedness may be well outside of the tried and tested help them to decide on the modulation ground, WHO Regional Office for Europe of large-scale restrictive public health yield above and has set up the Pan European Commission measures, while at the same time on Health and Sustainable development strengthening core public health service beyond the input chaired by Mario Monti. This Commission capacities together with personal has the remit to: protective measures. Overall, the pandemic has only • Rethink policy priorities in the light 3. Framework for the reopening of strengthened for us what we already ‘‘ of drawing lessons from schools: 3 guidance to ensure the knew, which is that health systems are the ways in which different countries’ safety and well-being of children, their central to the well-being of people and health systems have responded to the families and communities as schools their communities. For these systems COVID-19 pandemic are reopened. The framework is guided to be resilient to shocks they must have by the best interests of the child and strong governance structures driven by • Make recommendations on overall public health considerations, adequate and effective leadership that investments and reforms to improve informed by cross-sectoral and context- engages with the communities, listens and the resilience and further integration specific evidence. adjusts to their needs. These structures of health and social care systems will support health system preparedness in 4. A framework for responding to • Build consensus on these the face of rapidly changing scenarios and : 4 key considerations recommendations and bringing them population needs. for the planning and implementation to the attention of the highest political of national and subnational strategies level within the government The need for an economy of to maintain and reinvigorate public well-being • Make health and social care as political support to prevent COVID-19. priorities in governments’ political The COVID-19 pandemic has illustrated and fiscal agendas. We are at a pivotal point in the biggest the futility of the debate between life public health crisis of our lifetimes and livelihood; without health, there New approaches to persistent and can be no economy or social cohesion. growing challenges There is an opportunity to take the set Health is an important determinant for of lessons that had to be learned with development, and yet investment decisions COVID-19 has shown us that we need an unprecedented speed and reduce the that are concerned with health system integrated, cross-sectoral approach if we burden this pandemic continues to have on strengthening have been considered as a are going to achieve the structural change communities. Responses must be nuanced cost and a burden on society. However, the needed to protect communities. to meet the specific needs of every

Eurohealth — Vol.26 | No.2 | 2020 Perspectives on COVID-19 15

population group from older people in 4 WHO/EURO. Pandemic fatigue – Reinvigorating care homes to young people at universities the public to prevent COVID-19, September 2020. and in schools. Targeted responses must Available at: https://www.euro.who.int/en/health- topics/health-emergencies/coronavirus-covid-19/ also be designed to cope with the new publications-and-technical-guidance/2020/ challenges brought by the winter months. pandemic-fatigue-reinvigorating-the-public-to- Policy considerations to for an prevent-covid-19,-september-2020-produced-by- autumn /winter season where COVID-19, whoeurope influenza and influenza-like respiratory 5 WHO/EURO. Health system considerations: when illnesses coincide have been prepared. 5 influenza meets COVID-19. Preparedness and response measures when COVID-19, influenza and acute Going forward we must examine the respiratory infections coincide in the WHO European Region, October 2020. Available at: https://www. impact of COVID-19 on our ability to euro.who.int/en/health-topics/health-emergencies/ make significant progress towards the coronavirus-covid-19/publications-and-technical- Sustainable Development Goals. Whilst it guidance/2020/health-system-considerations-when- is clear that progress will be hindered as influenza-meets-covid-19,-october-2020-produced- a result of this pandemic, setbacks should by-whoeurope only serve to sharpen our appetites to achieve our ambitions.

A multi-sectoral approach is paramount, but the true way through this crisis is through bridging the divide between policy makers and the public. Solutions need to be created together, the input of communities needs to rapidly be elevated.

Despite its hardships, COVID-19 is offering an opportunity to rapidly create societal and policy changes on scale that has not been done before. Necessity, courage, innovation and collaboration are the attributes needed to see us through.

References

1 WHO/Europe. The COVID-19 pandemic: lessons learned for the WHO Europe Region, 2020. Available at: https://www.euro.who.int/en/health-topics/ health-emergencies/coronavirus-covid-19/ publications-and-technical-guidance/strategic- documents/the-covid-19-pandemic-lessons-learned- for-the-who-european-region

2 WHO/Europe. Strengthening and adjusting public health measures throughout the COVID-19 transition phases, 24 April 2020. Available at: https://www. euro.who.int/__data/assets/pdf_file/0018/440037/ Strength-AdjustingMeasuresCOVID19-transition- phases.pdf?ua=1

3 WHO. Schooling in the time of COVID-19, 2020. Available at: https://www.euro.who.int/__data/ assets/pdf_file/0011/463817/COVID-19-schooling- virtual-folder.pdf

Eurohealth — Vol.26 | No.2 | 2020 16 Perspectives on COVID-19

EUROPEAN SOLIDARITY DURING THE COVID-19 CRISIS

A perspective from the European Commission

By: Isabel de la Mata

Cite this as: Eurohealth 2020; 26(2). Isabel de la Mata is Principal Adviser for Health and Crisis Management, European Commission, Belgium.

The pandemic shows how closely European Centre for Disease prevention developed in Germany, Ireland and health is linked to the economy, and Control (ECDC) and the European Italy are the first to be linked through employment and wider issues. The Medicines Agency (EMA) through close the European interoperability gateway. EU works across all these areas and coordination and cooperation with MS, Contact tracing is also facilitated by the has tried to respond accordingly through the Health Security Committee Early Warning and Response System, and other coordination bodies. which enables direct communication In just a few months, COVID-19 has between MS and relevant EC services. fundamentally changed our world. It has triggered a public health, economic, The European Commission (EC) The Commission is also working with and social crisis on an unprecedented works in close coordination among MS and across Directorates to arrest scale. 6.3 million Europeans have all different services to align health the increase in local transmission and been diagnosed with the virus, more and other perspectives: testing and sub-optimal adherence to the non- than 200,000 have lost their lives and no distancing measures are a case pharmaceutical measures. Its July country has been spared. in point Communication on Early Detection, Rapid As cases again increase rapidly, MS are Response & Protection of Vulnerable At the onset of the crisis, countries taking steps to scale-up national test Groups, 2 aimed to address the risk of new rushed to protect their citizens. Vital and trace capabilities – measures that waves of the disease. On 24 September, medicines and medical equipment ran are pivotal to reducing the spread of the ECDC published further guidance short and supply chains broke down. The COVID-19. They are also re-implementing reinforcing these essential measures. 3 pandemic also demonstrated the huge stringent non-pharmaceutical interventions impact health has on European life in its (physical distancing, mask wearing, hand No one in the Commission has any widest sense and on national economies. hygiene, limiting social contacts) and doubt – these measures are disruptive It took time and immense multilevel revisiting travel restrictions. to the general well-being of people, efforts for European countries to begin the functioning of society, and the to support each other and work together. The Commission has agreed a economy. They are being encouraged The European Union (EU) has been an Recommendation on COVID-19 nevertheless as key to halting further important part of rebuilding this solidarity testing strategies, 1 including the use widespread transmission and more, which is so critical to Europe’s response. of rapid antigen tests, that sets out key generalised lockdowns. considerations for national, regional or The EU mobilised all means at its disposal local testing strategies including scope, The EU has also worked with MS and to help Member States (MS) tackle the priority groups, and issues around other European agencies to facilitate a pandemic and mitigate the socio-economic testing capacity and resources. The EC coordinated approach to travel measures impact. It has implemented measures is also seeking to support improved by developing a common framework for to support employment, businesses and contact tracing, working with MS to mapping COVID-19 risk across countries society. In the specific area of health, ensure the tracing apps being launched (see Box 1). it is helping strengthen national health by several EU countries are interoperable system responses, in collaboration with the on a cross border level. National apps

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The EC is also leveraging its ties to other European agencies to accelerate work on new treatments and Box 1: Travel is just one area where the EU has used its position to support therapeutics cross-sectoral efforts The EC has worked very closely with Sector specific containment measures have been implemented, including in the ECDC and the EMA to ensure a transport. At the beginning of the outbreak, most countries restricted travel and coordinated response across Europe and in some cases closed borders. As travel in the EU restarted, the Commission and to accelerate work on new treatments relevant agencies have offered technical guidance.. and therapeutics for COVID-19. Together • Aviation Health Safety Protocol: The European Aviation Safety Agency they seek to tackle bottlenecks, to better and the ECDC worked together on the production of measures that can be anticipate future shortages, and to assist implemented by airlines and airports to protect passengers and crew. Similar in adaptating of production. guidance has been produced for other sectors.

• Lifting travel restrictions: MS discuss constantly, at the Council level, the In response to national lockdowns, epidemiological indicators and update the list of third countries for which travel the EC exploited pre-existing Trans- restrictions should be lifted. European Transport Network crossings to introduce “Green lanes”. These facilitate • The Council Recommendation adopted by Ministers on 13 October the uninterrupted flow of goods across established common criteria and a common framework on travel measures in borders. The Commission has also worked response to COVID-19. This is a step towards a more coordinated, predictable with non-European countries to address and transparent MS approach to travel restrictions. It is crucial to safely re- export bans and to ensure the continued building the EU economy and creating the clarity and predictability needed for supply of vital pharmaceuticals. the smooth functioning of the internal market, while protecting citizens’ health.

No specific treatment for COVID-19 exists yet and the development of anti- across Europe. This was a major area of so far and four framework contracts in viral treatments is typically lengthy and concern for the * which place, allowing MS to place orders and complex. The EMA and EC have put tasked the Commission with providing purchase goods. mechanisms in place to support the rapid an overview of stocks, production and development, assessment and authorisation imports and accelerating efforts to ensure There is also the Emergency Support of new medicines and vaccines. These medical equipment was available. A Instrument (ESI) – a financing instrument, accelerate the mandatory steps that number of initiatives have been launched which the EC has used to buy 10 million determine whether and how fast one can in response. masks for health care workers, 34 000 move forward, while making sure that courses of remdesivir, rapid tests and efficacy and safety is assessed using The Commission established the rescEU disinfection robots. The ESI has also sufficiently robust data. medical equipment reserve. The reserve enabled transport of medical supplies, is hosted by several MS (currently patients and medical teams – as well as The Commission is also fostering the Denmark, Germany, Greece, Hungary, covering training for health professionals exploration of different approaches Romania and Sweden) which are on intensive care skills, increase in MS to therapeutics, such as repurposing responsible for procuring and stockpiling testing capacities. existing, approved medicinal products; common European stocks of vital using antibody-rich blood plasma; and medical equipment for distribution during The ESI has also been used to ensure developing completely novel treatments. emergencies. The initiative, including the production and supply of vaccines in EMA has also provided scientific advice transport and storage, is financed by the the EU. In August, a first agreement was for more than 40 developers of potential EC, with the distribution of equipment reached with the pharmaceutical company treatments. Once new therapies have been organised by the Emergency Response AstraZeneca to purchase 300 million established, the next challenges will be Coordination Centre. doses of a potential coronavirus vaccine manufacturing capacity, production and (with the option for 100 million more), large-scale procurement. The EC plays a coordinating role in with provision to donate or re-direct terms of Joint Procurement initiatives, vaccines to other European or low and The EC has used its position to launching Joint Procurement procedures middle-income countries. Two more foster joint procurement initiatives for Medical Countermeasures including agreements with Sanofi-GSK and Johnson which have proved vital in enabling for masks, gloves and gowns, as well as for and Johnson were signed in September MS to access Personal Protective laboratory equipment and ventilators, and and October. In addition, the Commission Equipment, ventilators and intensive care unit (ICU) medicines and confirmed its participation in the COVAX laboratory supplies remdesivir. These initiatives have proved Facility contributing €400 million to successful, with 36 countries participating support equitable access to affordable The March 2020 peak in the pandemic saw COVID-19 vaccines everywhere, for a massive surge in demand for medical * Video conference of the members of the European Council: everyone who needs them. The EU’s supplies and vital equipment and shortages 10 March 2020, 17 March 2020 and 26 March 2020.

Eurohealth — Vol.26 | No.2 | 2020 18 Perspectives on COVID-19

work in the area of COVID-19 vaccines Table 1: The Clearing House: mission, clusters and key EC collaborators is explored further in the article by Greer, later in this issue. The Clearing house aims to: • Give an overview of MS essential needs for medical equipment The Commission has established a • Facilitate the matching of supply and demand for medical equipment at EU level Clearing House for medical equipment • Support MS, companies and other stakeholders in managing information flows and possible to facilitate timely availability of blocks to the supply chain medical supplies • Help provide information on the Emergency Support Instrument selection actions and In addition to the efforts above, the their implications Commission has set up a COVID • Contribute to Commission thinking on possible revision in Export Authorisation Regulations Clearing House for medical equipment • Encourage the exchange of best practices among MS (see Table 1). It gathers information on It has 5 product-related clusters: supply and monitors how supply matches 1. Personal protective equipment (PPE) demand from MS. The Clearing House 2. Medical devices (including ventilators) serves as a platform for MS dialogue and 3. Other hospital supplies information sharing and is a means to 4. Tests overcome shortages and build capacity, 5. Medicines (including ICU therapeutics and vaccines) complementing EC work on joint procurement and stockpiling of medical It brings together expertise and those fighting COVID-19 from across the EC: equipment via rescEU. • SANTE • GROW It works closely with national authorities • JRC across the EU, the European Economic • TRADE Area (EEA), Switzerland and the • ECHO United Kingdom. It also encourages continuous dialogue with manufacturers and other stakeholders both at the level to calls from EU citizens to have a more will allow MS to mitigate the economic of industry associations and individual active role in health. It was intended to and social impact of the crisis and companies. This exchange of information address the COVID-19 pandemic and its frontload reforms and investment around is essential for a better understanding economic consequences, to tackle many employment policies, skills development of the challenges faced by industry; to of the challenges the pandemic uncovered and social inclusion. It also has monitoring potential shortages of medical and to be future-proof. Negotiations €47.5 billion for 2020/21 under REACT- equipment; and to facilitate the matching with the Council and the Parliament are EU which can support youth employment of supply and demand. The Clearing ongoing. Key initiatives are on: and social cohesion. House has provided legal, technical and • Health crisis readiness and cross-border regulatory support to industry, especially threats The EU will continue to promote to new actors with no previous exposure solidarity and unity across MS and to such a regulated area and has helped • Cancer beyond to meet the challenges posed manage technical and regulatory obstacles • Health systems strengthening, including by COVID-19 and to future-proof our and potential bottlenecks. health workforce training health systems The Clearing House also monitors • A European Health Data Space and Epidemiological trends are worrying imports, export restrictions put in place digital improvements, and and there is already tangible evidence by third countries, production capacity, of infection rates spiralling out of • European Reference Networks and supply chains, including transport and control. EC actions so far have increased logistics bottlenecks. short term preparedness, 2 but many In addition to developing the challenges remain including the threat EU4HealthProgramme, the European of a double epidemic (“twindemic”) of An ambitious new EU4Health Council took bold action in July, reaching COVID-19 and influenza which would programme has been proposed a landmark political agreement on a €1.82 challenge health care providers even to respond to COVID-19 and help trillion package for a sustainable and green further. The EC is encouraging risk build resilient and sustainable recovery. The Next Generation EU and reduction including through promoting health systems the Multiannual Financial Framework seasonal flu vaccination and is of course will address the dramatic costs of the The Commission proposed the EU4Health working for cooperation on potential pandemic, whilst making Europe greener, Programme (2021– 2027) as part of an COVID-19 vaccinations. more digital and more resilient. The ambitious package in May. This new, package includes €672.5 billion for the stand-alone Health Programme responds Recovery and Resilience Facility that

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It is also using the crisis to learn more References widely and to lever attention to improve 1 European Commission. EU Health preparedness: crisis preparedness and to manage cross- Recommendations for a common EU testing approach border threats more effectively at both EU for COVID-19. Agreed by the Health Security and MS level. The EU will continue to Committee on 17 September 2020. DG SANTE, address the pandemic with extreme care 2020. Available at: https://ec.europa.eu/health/ sites/health/files/preparedness_response/docs/ and responsibility, with a view to: common_testingapproach_covid-19_en.pdf

• Making sure health is a central part 2 European Commission. Communication from the of Europe’s path to recovery: The Commission to the , the Council, forward-looking EU4Health programme the European Economic and Social Committee is a clear signal that the health of and the Committee of the Regions. Short-term EU health preparedness for COVID-19 outbreaks EU citizens is a priority. It reflects (COM/2020/318), 2020. Available at: https:// aspirations for a real step forward in ec.europa.eu/info/sites/info/files/communication_-_ how the EU deals with health. The short-term_eu_health_preparedness.pdf

Commission has the potential to help 3 ECDC. Guidelines for the implementation of MS make their health systems more non-pharmaceutical interventions against COVID-19. resilient so that high-quality health care Technical Report, 2020. Available at: https://www. is available to all. ecdc.europa.eu/en/publications-data/covid-19- guidelines-non-pharmaceutical-interventions • Future proofing health systems and programmes and making the recovery agenda health-proof: The EC will propose a stronger health threats framework and strive to reinforce and empower the EMA and ECDC – Europe’s centre for disease prevention and control – so that the EU is prepared for new health threats. • Promoting unity amongst citizens, MS and across agencies: Continuing engagement and communication with citizens is ever more important as “isolation fatigue” threatens adherence to containment measures. People’s behaviour remains key in controlling the pandemic and the EC will endeavour to foster a sense of mutual commitment and unity. It will also work with MS to foster collective and collaborative responses. It will also align its Directorates and agencies and continue to work with the World Health Organization because the fragmentation of efforts makes all of Europe more vulnerable.

Eurohealth — Vol.26 | No.2 | 2020 20 Perspectives on COVID-19

COVID-19 AND HEALTH SYSTEMS RESILIENCE: LESSONS GOING FORWARDS

By: Anna Sagan, Steve Thomas, Martin McKee, Marina Karanikolos, Natasha Azzopardi-Muscat, Isabel de la Mata and Josep Figueras

Summary: From the early days of the pandemic policy analysts have been trying to understand what constitutes a resilient health systems response. This article takes stock of the national responses over the past ten months and distils strategies and general lessons for enhancing health systems resilience. Among health systems functions, effective governance, while not easy to pinpoint or secure, has been key to a resilient response, constituting a mortar binding everything

Cite this as: Eurohealth 2020; 26(2). else together. The pandemic has also highlighted the importance of solidarity, both within and between countries – bringing us to a

Anna Sagan is Research Fellow, realisation that we cannot be truly safe until everybody is safe. Over European Observatory on Health Systems and Policies, London the course of the pandemic, the focus in studying resilience has School of Economics and Political Science, and Honorary broadened towards a more holistic recovery that extends beyond Research Fellow, London School of Hygiene and Tropical the health system. Medicine, UK; Steve Thomas is the Edward Kennedy Chair of Health Policy and Management, Keywords: Health Systems Resilience, Preparedness, COVID-19 Trinity College Dublin and a Health Research Board Research Leader; Marina Karanikolos is Research Fellow, European Observatory on Health Systems and Policies, Introduction Six months later, the accumulating social, London School of Hygiene and economic and health consequences of On 23 January, the Chinese government Tropical Medicine, UK; Martin prolonged lockdowns have compelled McKee is Co-Director, European imposed a lockdown on the city of Wuhan governments to find ways in which Observatory on Health Systems and other cities in Hubei province in an and Policies and Professor of they can release some of the restrictions unprecedented effort to halt the spread European Health Policy, London without allowing infections to resume School of Hygiene and Tropical of COVID-19. By the time the World their initial exponential growth. And so, Medicine, UK; Natasha Azzopardi- Health Organization (WHO) declared the we have been learning to live with the Muscat is Director, Country Health novel coronavirus outbreak a pandemic Policies and Systems, World Health virus as initial public health measures have on 11 March, Italy was already in a Organization (WHO) Regional been relaxed, and countries try to contain Office for Europe, Copenhagen, national lockdown and many more the virus with NPIs that are sustainable, Denmark; Isabel de la Mata is countries in Europe and beyond quickly Principal Advisor for Health and watching the movements of the epidemic followed suit, imposing wide ranging Crisis Management, European curve and implementing matching Commission; Josep Figueras is measures to break the transmission of responses to tackle any outbreaks. At the Director, European Observatory infection. These have been termed non- on Health Systems and Policies, same time, countries have been trying pharmaceutical interventions (NPIs). Brussels, Belgium. Email: to restore health services for those with [email protected] non-COVID-19 related conditions as

Eurohealth — Vol.26 | No.2 | 2020 Perspectives on COVID-19 21

well as preventive services (including vaccinations) that, in many countries, have Box 1: Understanding the four stages of the shock cycle been severely affected.

The response to a shock can be seen as a cycle consisting of the following While we wait for an effective vaccine (or four stages: cure) to become widely available, policy analysts have been trying to draw lessons • Stage 1 Preparedness is related to how vulnerable a system is to various from national responses so far, identifying disturbances (limiting exposure) and how ready it is for when a shock hits (e.g. those that appear to have been the most by having practiced and resourced systems of response). effective, and in what circumstances, at • In Stage 2 Shock onset and alert, the focus is on timely identification of the containing transmission and allowing onset and type of the shock. socioeconomic activity to recover as much as possible. 1 • During Stage 3 Shock impact and management the system absorbs the shock and, where necessary, adapts and transforms to ensure that health system goals are still achieved. • Finally, in Stage 4 Recovery and learning there is a return to some kind of normality but there may still be changes as a legacy of the shock. In this stage, governance is it is important to recognise what these legacy components are and how they will key to a resilient continue to impact on the system and on its performance. response Stage 1 Preparedness This article and the accompanying of health systems European Observatory on Health to shocks Systems and Policies’ policy brief on COVID-19 and resilience contributes to these efforts by seeking to understand the characteristics‘‘ of responses that can enhance resilience of health systems in the Stage 4 Stage 2 face of the coronavirus pandemic. In doing Recovery Shock onset so, we draw heavily on our conceptual and learning policy brief on resilience ‘Strengthening and alert health systems resilience: Key concepts and strategies’ 2 and the evidence collected through the COVID-19 Health Systems Response Monitor (HSRM). Stage 3 Shock impact What do we mean by health and systems resilience ? management Resilience is commonly understood to be the capacity to recover quickly from Source: 2 a shock or, in reference to materials, the ability of an object to bounce back into shape (elasticity). This concept has adapt, and transform to cope with new resilience as the health system’s ability been applied in many different fields circumstances. However, as the literature to prepare, manage (absorb, adapt and, especially over the past 20 years, in on health systems resilience has evolved, and transform) and learn from shocks, relation to major societal shocks, including definitions have expanded to also consider whereby we understand shocks to be those causing health emergencies. how to minimise exposure to shocks sudden and extreme disturbances, such (i.e. managing risks) and to identify as epidemics, natural and other disasters, Most definitions of health systems measures that address more predictable and financial crises. We think of a shock resilience in the literature focus on and enduring system strains or stresses, in a dynamic way – a cycle that consists of health system preparedness and the such as population ageing. four stages (see Box 1), with interlinkages ability to respond to a severe and acute between the recovery from a shock and shock. Efforts to understand resilience For this work, we have adopted a narrower preparedness for the next shock cycle, as looked at how the system can absorb, definition, defining health system we go through the loop again. Following

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this definition, and from the perspective index*. Countries with much less technical essential workers), garment factories, of health system performance, resilience capacity, but with leaders who listened to agricultural workers, etc.), homeless goes beyond how a system bounces back the science and acted fast, have been much people, people in institutions (e.g. in care to what it was before, but also addresses more successful in containing the virus homes or prisons, migrants in reception its ability to transform and evolve – ideally and saving lives. Governance has also centres, etc.), were at higher risk of into something better, i.e. how it improves been identified as ‘the mortar that binds infection. 10 Population groups with higher its performance. It has to be noted here all other components together’, rather than prevalence of non-communicable diseases that an experience of a shock is not a a standalone function. It creates trust in (NCDs) (which are socioeconomically necessary precondition for a health system the system. As such, it enables the other patterned) have had higher hospitalisation to be judged as resilient: a resilient health functions to work properly and contributes and death rates. 11 Countries with strong system may be one that is prepared for the to the strengthening of the system as social safety nets, such as in Scandinavia, occurrence of a shock, but this shock may a whole. 6 have generally fared better. The pandemic not necessarily happen. has shown that we are not safe until Some of the worst hit countries were those everybody is safe. Identifying key strategies for that had populist leaders, where there was enhancing resilience: what have a difficult political environment, where Although the pandemic has shown we learned from responses to the there was state-sponsored disinformation that some degree of self-sufficiency is pandemic so far? or where there was secrecy and censorship desirable, e.g. having national stocks of such as silencing of scientific and medical medical supplies and production capacity, Based on country experiences so far, we professionals. 7 Going forward, there will ultimately, countries need to cooperate have distilled a list of responses to the be no easy or quick fixes to these problems to ensure resilience in the face of global pandemic that enhance health system and there may be no way, at least in the shocks such as COVID-19. European resilience. These strategies and the short term, to avoid poor leadership. Given Union (EU) Member States have benefited associated examples of best practice will the risk that will be posed to others by from common surveillance systems, joint be described in detail in the forthcoming countries that fail to combat the pandemic, procurement initiatives, and targeted policy brief. Table 1 gives a first look at the there is likely to be a debate about the funding, among others. We can all benefit key strategies and their elements, grouping role of the international community, from better global surveillance and them according to the relevant health perhaps drawing on existing principles notification systems; more cooperation system function: governance, financing, of humanitarian intervention or the in procurement; stronger cooperation in resources and service delivery. However, Responsibility to Protect. This has led to medical research (for example vaccine we recognise that such distinctions are not calls to rethink the role of WHO, including development and treatment, including clear-cut and there are inevitable overlaps. its organisation and financing. 8 But there ensuring that as many patients as possible are things that we can do more easily to are entered into clinical trials coordinated General lessons emerging from the strengthen governance now. For example, across Europe); sharing best practice (with national responses to the pandemic within the health system, coordination European professional societies and the channels could be put in place and plans WHO having a role); and better global Governance is key to a resilient drawn (and kept up to date) to ensure an governance. A resilient response thus response, but it is not something that is effective response. Beyond the health means ‘leaving no country behind’ and easy to achieve systems, meaningful relationships between ensuring that vulnerable and worst hit communities and providers should be countries get the support they need. No The key aspects of resilient responses nurtured to ensure sustainable and country is safe until all countries are safe. to COVID-19 are (simplistically) inclusive participation. 9 twofold: 1) having appropriate and effective governance and 2) having Conclusions A chain is as strong as its weakest link, technical capacity to respond. Of the i.e. leave no one and no country behind From the onset of the pandemic, policy two, governance dominates and is the analysts have been trying to understand necessary condition for any effective The pandemic has exposed national how a country develops resilience. 12 response. Given the complexity of the differences in vulnerability to COVID-19, The focus of these efforts has evolved COVID-19 shock and the complexity with the most disadvantaged groups over time from how to best manage the of the response it necessitates, we mean bearing the greatest health, social, and pandemic in the short to medium term to here governance in the broader sense, economic burden. Vulnerable population what constitutes a resilient response in i.e. going beyond the governance of the groups, such as workers without access to the longer term, in line with the notion health system alone. While undeniably paid sick leave or in facilities with poor of ‘building back better’ so that we important, technical capacity has proven working conditions (e.g. slaughterhouses emerge from the pandemic stronger and not to be enough, which became apparent and meat-packing plants (now seen as better prepared in future. 13 The notion from the poor performance of countries of a resilient recovery underpins many that topped the global health security * The global health security index (https://www.ghsindex. org/) gives a sense of countries’ technical capacity to fight national and international recovery plans health threats such as pandemics.

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Table 1: Resilient strategies in response to the COVID-19 pandemic and relevant elements

Strategy Elements Governance (1) Adequate and effective Having a clear vision; Reliance on best available evidence but adopting the precautionary principle where evidence leadership is uncertain; Culture of learning; Ability to act fast; Effective and transparent communication (esp. about uncertainty); Community participation; Participation in the international community (e.g. joint procurement, clinical networks, etc.) (2) Effective coordination Presence of a clear and widely understood strategy; Coordination within government (horizontal and vertical); Coordination between the government and key stakeholders including civil society; Measures taken at the appropriate organisational tier, balancing local knowledge with economies of scale; Coordination with international partners and supranational bodies (3) Effective communication Having (or establishing) well-functioning communication channels linked to lines of accountability, incl. hard and systems and flows soft infrastructure (4) Surveillance enabling timely Having effective and well-integrated surveillance systems (see under ‘Resources’ below); Surveillance systems detection of shocks and that follow a ‘one health’ approach and generate timely and accurate data their impact Financing (5) Ensuring sufficient monetary Ability to increase and deploy monetary resources quickly and where needed, subject to safeguards to prevent resources in the system and fraud and corruption flexibility to reallocate and inject extra funds into the system (6) Purchasing flexibility and Ability to quickly adapt procurement and payment systems while maintaining transparency, timeliness, and reallocation of funding within the quality, including measures to prevent corruption 3 system to meet changing needs (7) Comprehensive health Having a comprehensive and evidence-based package of services that is properly resourced, organised and coverage with effective access distributed; Monitoring changes in access to services and eliminating financial and other (e.g. technological, physical) barriers to access; Identifying vulnerable population groups (ensuring that appropriate data are collected) 4 and ensuring adequate access to services Resources (8) Appropriate level and Having strong (or strengthening) public health capacity (with a system to Find, Test, Trace, Isolate, and Support 5 ); distribution of human and physical Having strong (or strengthening) primary health care (key role in maintaining non-COVID essential services to resources populations); Ensuring adequate hospital capacity, including intensive care units and step down facilities (and contingency plans to increase them); Ensuring sufficient supply of personal protective equipment (9) Motivated and well-supported Ensuring mental health (e.g. psychological counselling), family (e.g. childcare), physical (e.g. respite breaks) and workforce financial support for health care workers (10) Ability to quickly increase Ability to increase physical capacity if needed (e.g. via repurposing of wards, reallocating patients to lower levels capacity to cope with a sudden of care (as appropriate), developing new wards or hospitals, using all available capacity irrespective of ownership, surge in demand etc.); Ability to mobilise additional human resources including via training of existing workforce or adapting their roles, recruiting and training volunteers (e.g. to take samples) Service delivery (11) Alternative and flexible Flexibility to implement new care pathways across the health systems and within facilities; Using digital approaches to deliver care technologies to deliver health services safely; Ensuring support systems for vulnerable people especially those in isolation (12) Ability to deliver services Mechanisms in place to ensure effective implementation of infection prevention and control in health care settings safely (13) Ability to share best practice Two-way sharing of best practice: from policymakers to clinicians and from clinicians to policymakers

Source: Authors drawing on the COVID-19 resilience policy brief (forthcoming) to be published at: https://www.euro.who.int/en/about-us/partners/observatory/publications/policy-briefs-and-summaries and instruments (e.g. the Recovery and WHO Regional Office for Europe. 16 These digitalisation. This holistic approach is Resilience Facility, REACT-EU and efforts take a holistic approach, going important as the world is a collection of other EU instruments), 14 and is being beyond strengthening health systems and complex interconnected systems, of which investigated through undertakings such as incorporating social, economic, green the health system is just one. Strategies the Lancet COVID-19 Commission 15 and and other dimensions as well as ongoing to enhance health systems resilience the Pan-European Commission on Health major trends, some of which have been therefore need to be part of such broader, and Sustainable Development initiated by accelerated by the pandemic, such as multi-sectorial approaches.

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We have long known about the risk of 3 McKee M. England’s PPE procurement failures 11 Penkler M, Müller R, Kenney M, Hanson M. epidemics from zoonotic viruses, yet must never happen again. British Medical Journal Back to normal? Building community resilience we were ill prepared for a pandemic like 2020;370:m2858. after COVID-19. Lancet Diabetes Endocrinol. 2020;8(8):664 – 5. COVID-19. Now, retrospectively, we are 4 Patel P, Hiam L, Sowemimo A, Devakumar D, trying to learn from what has happened McKee M. Ethnicity and covid-19. British Medical 12 Legido-Quigley H, Asgari N, Teo YY, et al. to prepare for the next pandemic. Journal 2020;369:m2282. Are high-performing health systems resilient against the COVID-19 epidemic? The Lancet 5 Rajan S, Cylus JD, McKee M. What do countries There are other risks that we know 2020;395(10227):848 – 50. (the ‘known knowns’ in the words of need to do to implement effective ‘find, test, trace, 13 Donald Rumsfeld), such as antimicrobial isolate and support’ systems? Journal of the Royal OECD. Building back better: A sustainable, Society of Medicine 2020;113(7):245 – 50. https://doi. resilient recovery after COVID-19 2020. Available resistance, but we seem to wait for them org/10.1177/0141076820939395 at: https://www.oecd.org/coronavirus/policy- 17 to come to fruition before we act. This responses/building-back-better-a-sustainable- 6 Palagyi A, Marais BJ, Abimbola S, Topp SM, is clearly not enough. To be truly resilient, resilient-recovery-after-covid-19-52b869f5/ McBryde ES, Negin J. Health system preparedness beyond looking back for lessons learned for emerging infectious diseases: A synthesis of the 14 McKee M. A European roadmap out of the covid-19 we also need to look forwards, with literature. Global Public Health 2019;14(12):1847 – 68. pandemic. British Medical Journal 2020;369:m1556. foresight, and do more to address the 7 McKee M, Gugushvili A, Koltai J, Stuckler D. 15 Sachs JD, Horton R, Bagenal J, Ben Amor Y, known risks. Are Populist Leaders Creating the Conditions for the Karadag Caman O, Lafortune G. COVID-19 Spread of COVID-19? Int J Health Policy Manag. 2020. Commission. The Lancet 2020;396(10249):454 – 5.

References 8 Nay O, Kieny M-P, Marmora L, Kazatchkine M. 16 WHO EURO. Inaugural meeting of Pan-European The WHO we want. The Lancet 2020;395(10240): Commission on Health and Sustainable Development 1 Han E, Tan MMJ, Turk E, et al. Lessons learnt 1818 – 20. takes place 2020. Available at: https://www. from easing COVID-19 restrictions: an analysis of euro.who.int/en/about-us/regional-director/ countries and regions in Asia Pacific and Europe. 9 Marston C, Renedo A, Miles S. Community news/news/2020/08/inaugural-meeting-of-pan- The Lancet 2020; https://doi.org/10.1016/S0140- participation is crucial in a pandemic. The Lancet european-commission-on-health-and-sustainable- 6736(20)32007-9 2020;395(10238):1676 – 8. development-takes-place 2 Thomas S, Sagan A, Larkin J, Cylus J, Figueras J, 10 Nestle M. A call for food system change. 17 The Lancet Planetary Health. Walking forwards, Karanikolos M. Strengthening health systems The Lancet 2020;395(10238):1685 – 6. looking backwards. The Lancet Planetary Health resilience: key concepts and strategies. Policy 2020;4(9):e371. Brief 26. Copenhagen: European Observatory on Health Systems and Policies, 2020.

Strengthening health systems While policymakers are often consumed by the urgent day- to-day stresses of running a health system, the COVID-19 resilience: Key concepts and pandemic has reminded everyone of the importance of strategies longer-term planning and preparedness. With this awareness comes the need By: S Thomas, A Sagan, J Larkin, J Cylus, J Figueras, to better understand health M Karanikolos systems’ strengths and Copenhagen: World Health Organization 2020 (acting as vulnerabilities and how the host organization for, and secretariat of, the European to respond resiliently to Observatory on Health Systems and Policies) the outbreak.

Observatory Policy Brief 36 The authors reviewed the literature on strategies for Number of pages: 33; ISSN: 1997-8073 strengthening health system Freely available for download: https://apps.who.int/iris/ resilience and for responding bitstream/handle/10665/332441/Policy-brief%2036-1997- to system shocks, as well 8073-eng.pdf as emerging evidence from national responses to Why have some health systems coped better than others the COVID-19 pandemic. during the COVID-19 pandemic? Some answers might become They mapped those clear if we could assess how resilient health systems are in strategies to the key health response to crises or shocks, such as the current pandemic system functions: governance, financing, and other emergencies, including financial ones, or how well resources and service delivery. They also indicated in which health systems were prepared for such events in the first place. stages of a shock cycle these resilience-enhancing strategies This new policy brief includes a framework to help policymakers are likely to be the most effective. Which strategies should be understand health system resilience and how to strengthen it. It pursued depends on the type of shock (e.g. financial crash, highlights the key features of resilience and provides examples pandemic, climate event), its severity, the stage in the shock of strategies which have been applied in different countries. cycle, and the specific country context.

Eurohealth — Vol.26 | No.2 | 2020 Perspectives on COVID-19 25

HOW TO RESPOND TO THE COVID-19 ECONOMIC AND HEALTH FINANCING CRISIS?

By: Jonathan Cylus and Ewout van Ginneken

Summary: While the initial response to the COVID-19 pandemic was focused on preventing and mitigating a public health crisis, it has rapidly spiraled in many countries into a full blown economic and public finance crisis. We describe this evolution and consider how health financing, as well as population health, are likely to be affected by the economic crisis. We find that countries have applied a variety of measures which include making extra financial allocations available to the health sector, supporting workers experiencing job loss, and compensating health professionals for lost income and extra expenses.

Keywords: Health Financing, Economy, Public Finance, , COVID-19

Background The economic impact of the crisis becomes clear In response to the COVID-19 pandemic, the majority of countries around the The magnitude of the economic impact world were forced to “lockdown” in an varies substantially across countries and ultimate effort to reduce exponential within countries across sectors. Hospitality growth in transmission rates. Among other and tourism have been devastated as one actions, this has involved closing schools, might expect, but even the broader health businesses with perceived high risk of care sector has faced huge losses in many transmissions (restaurants, retail, shopping countries as non-COVID patients reduce centres, hairdressers), sports activities, their use of services, both due to facilities large social gatherings (churches, concerts, being reserved for COVID patients or conferences) and travel routes, effectively otherwise closed, 1 and due to fears of shutting down entire societies. These becoming infected by other patients. Cite this as: Eurohealth 2020; 26(2). interventions have proven effective at ‘flattening the curve’ and preventing Figure 1 gives a sense of the magnitude of health systems from becoming overloaded the economic impact in European Union Jonathan Cylus is London Hub 2 Coordinator, London School of by COVID-19 patients. However, they (EU) countries. Across the EU-27 in Economics and Political Science have caused a number of unintended Q4 2019, (GDP) & London School of Hygiene and consequences; among others, they have per person in nominal terms grew by 0.1% Tropical Medicine, UK; Ewout van Ginneken is Berlin Hub Coordinator, led to many people forgoing much needed compared to the previous quarter. By Q2 European Observatory on Health care and, as we focus primarily on in of 2020, it fell by 11.4% compared to the Systems and Policies, Technical this article, they have resulted in a severe previous quarter, an annualized decline University of Berlin, Germany. Email: [email protected] global economic slowdown. of 38.4%. The largest Q1 to Q2 declines in GDP have occurred in the United

Eurohealth — Vol.26 | No.2 | 2020 26 Perspectives on COVID-19

Figure 1: Quarterly growth in GDP per capital, selected EU counties, June 2019 to June 2020

5

0

-5

Sweden -10 Czechia European Union – 27 countries Italy -15 Greece

Spain -20 United Kingdom

-25 2019Q2 2019Q3 2019Q4 2020Q1 2020Q2

Source: 2

Kingdom (20.4%), Spain (18.5%), Croatia What are the consequences for exception rather than the norm and may be (14.9%), and Hungary (14.5%) with every health financing? insufficient to deal with a prolonged crisis EU country experiencing a contraction. of this magnitude. The lockdown and the subsequent Unemployment rates have increased as economic crisis have implications across well, rising by a half a percentage point But even in systems that depend more society, including potentially major effects overall in EU-27 countries between heavily on general tax revenues to finance on health financing flows. Here we briefly June 2019 and June 2020, with the health care, there are likely to be shortfalls describe these. largest increases in the EU over that time that will result in reductions in health period in Estonia (3.3%), Sweden (2.7%), expenditure (due to either maintaining the Lower revenues for health systems Lithuania (2.6%) and Latvia (2.5%); priority given to health within a shrinking some of these figures may even appear Most health expenditure in Europe budget or prioritising other sectors above worse were it not for job support schemes emanates from government or compulsory health) or will require borrowing to fill in place. sources that can be highly susceptible budgetary gaps and maintain or increase to economic fluctuations since they are expenditure levels. Precisely how this Although many analysts had hoped for a funded primarily through taxes and/ decreased revenue and budgetary choices quick return to normal levels of economic or social (e.g. employer /employee) will affect health system allocations and activity after lifting lockdowns (referred contributions. During the economic consequently expenditures are subject to a to as a V shaped recovery) there is little crisis, the slowdowns in consumption great deal of uncertainty at this stage. evidence that this is occurring. Some expenditure, increases in unemployment forecasts suggest economies in Europe and reductions in salaries each put Lower revenues for some providers will not return to pre-COVID levels significant downwards pressure on these Very few people would expect in the for many years to come. 3 This is due funding sources. In health systems that first instance that a global pandemic in part to continued travel restrictions depend heavily on social contributions could be bad for business in the health and social distancing guidance affecting from the labour market, the revenue sector. However, the pandemic and the many sectors but is also a consequence of shortfalls have occurred almost overnight lockdown in response has led to massive, peoples’ safety concerns about being in as the labour market dried up. practically instantaneous shifts in patterns public places. In fact, some economists are of care with many patients forgoing beginning to refer to a K shaped recovery While countries such as Lithuania have care and capacity being reserved for to reflect the uneven nature of the post- had counter-cyclical systems in place that COVID patients. This has had important COVID economy going forward, as some provide general revenues to substitute for implications for health provider finances sectors (like e-commerce) are expected lost contributions due to unemployment and sustainability. It also has led to to thrive while others (like aviation and and other countries like Estonia and unforeseen expenses because providers retail) are decimated. 4 Regardless, it the Netherlands have built up or were had to reshape their premises to implement is clear that the economic implications legally required to build up financial new distancing measures, hygiene and of COVID-19 will be with us for the reserves, these practices are generally the safety regulations and purchase personal foreseeable future.

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protective equipment (PPE), in addition to deaths due to reduced travel, something €750 billion recovery fund composed of a expensive new equipment like ventilators which is likely to have been magnified mix of grants and loans was agreed at the and intensive care unit (ICU) beds. during the current crisis as people were end of July to support Member States. 8 required to spend most of their time Some of the most significant effects are at home. Regarding health sector revenues, some among providers who have had to shut countries have taken steps to make extra during the pandemic, generally to reserve How have countries responded to allocations available to the health sector, PPE for hospital use, including dentists, these challenges? but it may take months to figure out the ophthalmologists, but also outpatient actual costs and how to divide the bill health professionals (general practitioners, The decline in economic activity naturally between the different payers and (local) allied health professionals, etc.); hospitals leads to reductions in tax collection, governments and ultimately the public (via and care homes were also severely affected which has serious implications for the higher contributions and or taxes). Austria, (see the articles by Langins et al. on sustainability of public finances. At Croatia, Czechia, and Estonia, for example protecting care homes and by Webb et al. the same time, many countries have among many other countries, have injected on restarting routine hospital activities in put in place costly measures to support additional financing into their social health this issue). The crisis made it clear that households and businesses to try to limit insurance funds. health professionals and providers that are the economic fallout, which also has come not paid on the basis of activity, i.e. based with high costs leading to increases in Additionally, countries have supported on (predominantly) capitation or a salary, public debt. Briefly we discuss three types their economy through measures that are less vulnerable to this type of shock of policy responses countries are taking support workers experiencing job loss than those that are largely paid based on including: changes in public sector revenue during the crisis. For example, furlough activity, i.e. through fee-for-service (FFS) raising, public sector efforts to support schemes have been put in place in many or pay-for-performance (P4P) or diagnosis- the economy, and efforts to support health countries including the UK (Coronavirus related groups (DRGs). For those who rely financing flows. Job Retention Scheme), Germany on volume-based payments, the crisis has (Kurzarbeit) and France (Chomage severely disrupted income flows. Partial), among others, to cover lost wages for a period of time. These types of What will the economic crisis mean there initiatives are not only important for the for population health? economy but are also likely to mitigate are likely to be the health effects of the economic crisis In addition to the impact of the economic itself. Evidence from the United States crisis on health financing, there are likely health effects of , for example, suggests that generous to be health effects of the economic unemployment benefit programmes have crisis. These come on top of the negative the economic the potential to reduce suicides during effects on population health caused by times of high unemployment and improve the virus itself and the detrimental effects crisis mental health. 9 Labour market measures on population health of those that have in also are likely to have implications for great numbers been forgoing vaccination, Some countries may opt to alter the health financing where there is a high screening and treatment services. mix of taxes in an effort to ensure more reliance on contributions from employers Disentangling these factors may prove sufficient and stable public revenues. A and employees. challenging but it is safe to say that each few countries‘‘ have considered changing factor contributes substantially. the structure of taxes in response to Countries have also used different changes in economic activity. For example, mechanisms to compensate providers Evidence from the financial crisis that in Latvia there have been discussions and health professionals for their losses began in 2008 in Europe shows that there to reduce the reliance on labour market in income or revenue and extra expenses are links between economic downturns taxation in favour of more consumption due to COVID-19. Essentially, these and declines in mental health, including taxes. 6 Likewise, prior to the crisis, Poland consist of mitigation of losses (e.g. a shift increases in suicides and alcohol-related had planned to reduce the value added towards more payments for eHealth), deaths. 5 The effects have been shown to be tax (VAT) rate but has now delayed this compensation of revenue losses (e.g. predominantly, though not entirely, among change until the economy stabilises. 7 In higher FFS, capitations, DRGS, per the unemployed. Of course, the lockdown countries where altering tax collection diems, shift to global budgets) and itself and the associated loneliness that may not be feasible, some countries have generously reimbursing extra expenses comes with decreased social contacts either increased their borrowing, taking for needed renovations and purchasing have their own effects on mental health on public debt, or sought emergency of equipment. For example, Hungary has independent of the economic pathways. At financing from international lenders to shifted from case-based payments for the same time, economic crises have been meet urgent needs. 8 Within the EU, a hospitals back to global budgets during associated with reductions in road traffic the crisis to maintain hospital financial

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flows. Other countries, like Belgium References 6 XinhuaNET. Crisis right time to cut Latvian labor taxes: central bank official. 25 July 2020. Available and Croatia, have transferred additional 1 Panteli D. How are countries reorganizing non- at: http://www.xinhuanet.com/english/2020- funds directly to hospitals. Two articles in COVID-19 health care service delivery? Health System 07/25/c_139238419.htm this Eurohealth edition detail the various Response Monitor – Cross-Country Analysis. WHO, options for compensating professionals European Commission, European Observatory on 7 Bloomberg Tax. Poland to Delay Lowering VAT and hospitals (see Waitzberg et al. on Health Systems and Policies, 6 May 2020. Available Rates Until Economy Stabilizes. 26 August 2020. at: https://analysis.covid19healthsystem.org/index. Available at: https://news.bloombergtax.com/daily- compensating health care professionals php/2020/05/06/how-are-countries-reorganizing- tax-report-international/poland-to-delay-lowering- and Quentin et al. on adjusting hospital non-covid-19-health-care-service-delivery/ vat-rates-until-economy-stabilizes inpatient payment systems in this issue). 2 Eurostat data. Available at: https://ec.europa. 8 IMF. COVID-19 Financial Assistance and Debt eu/eurostat/web/covid-19/data (accessed Service Relief. Washington, DC: International Conclusion 21 September 2020). Monetary Fund, September 2020. Available at: https://www.imf.org/en/Topics/imf-and-covid19/ 3 OECD. Economic Outlook, Volume 1. Paris: COVID-Lending-Tracker#EUR Health and the economy are inextricably OECD, June 2020. Available at: https://www. linked and so it is natural to expect that a -ilibrary.org/economics/oecd-economic- 9 Cylus J, Glymour MM, Avendano M. Do Generous pandemic and the accompanying policy outlook/volume-2020/issue-1_34ffc900- Unemployment Benefit Programs Reduce Suicide responses will have consequences for en;jsessionid=8lAuDfYp_Sxy01wkduJNpaM7. Rates? A State Fixed-Effect Analysis Covering the economy, and ultimately for health ip-10-240-5-42 1968–2008. American Journal of Epidemiology 2014;180(1):45 – 52. financing. Countries have largely been 4 Sky News. COVID job losses. Available at: https:// proactive in their attempts to mitigate news.sky.com/story/coronavirus-crisis-where-jobs- the economic and health financing have-been-lost-across-the-uk-12029604 (accessed 24 September 2020). implications; however, a major challenge will be adjusting these responses during 5 Karanikolos M, Mladovsky P, Cylus J, et al. the full length of the crisis and whether Financial crisis, austerity, and health in Europe. The Lancet 2013;381(9874):1323 – 31. https://doi. positive responses can be maintained. org/10.1016/S0140-6736(13)60102-6

The Changing Role of the care, review best practice from different Hospital in European Health countries and give Systems pointers to the future. This study looks at Edited by: M McKee, S Merkur, N Edwards, E Nolte many developments that challenge traditional Published by: Cambridge University Press 2020 ideas of the role of the Number of pages: xxii + 306; ISSN: ISBN: 978 1 108 79005 5 hospital. They include: changes in technology Freely available for download at: https://www.euro.who. for diagnostics and int/__data/assets/pdf_file/0010/448048/Changing-role-of- treatments; changes hospitals-eng.pdf in patients, who have This new study provides a timely analysis of the changing role become older, frailer of the hospital across Europe. The hospital is one of the most and often more socially isolated; changes in models of care, recognisable and central parts of a health system. Yet, its involving multidisciplinary teams, networks and integrated care fundamental design has changed little in decades, even though pathways; changes in staffing and concepts of specialists the burden of diseases it must respond to is constantly evolving and generalists. – most recently with the emergence of COVID-19 and, less Written by and for clinicians, hospital managers and those who dramatically, with the growth of multimorbidity and frailty. Also design and operate hospitals, this study argues that hospitals evolving are the things that can be done in hospital, or in some need to change as the patients they treat change and as cases, things that would once have been done there but are the technology to treat them advances. They also show why now better done elsewhere. For these reasons it is time to look hospitals need to be planned as part of the wider system in again at the role of the modern hospital, not as a building filled which they sit, with specialists developing new collaborative with beds but rather as a concept, as a care deliverer and as ways of working with primary care. a workplace. It seeks to challenge existing models of hospital

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TRANSLATING EVIDENCE INTO POLICY DURING THE COVID-19 PANDEMIC: BRIDGING SCIENCE AND POLICY (AND POLITICS)

By: Gemma A. Williams, Sara M. Ulla Díez, Josep Figueras and Suszy Lessof

Summary: Effective responses to public health emergencies should rely on translating rapidly emerging research into timely, evidence- informed policy and practice. The case of COVID-19 demonstrates that doing so in practice is far from straightforward. Evidence uncertainty; the “infodemic”; the blurring of boundaries between science, policy and politics; and the competition between health and economic objectives, all make policy making for COVID-19 immensely complex. This article reviews these challenges and some of the tools countries have used to translate evidence into public health policy, not least multidisciplinary scientific advisory groups, which have often proved pivotal in informing government decision-making. Despite their emphasis on science and objectivity, however, they have posed questions about independence and transparency. This article explores what this means for the way decision-makers use evidence now and in the long-term, and for the role of neutral “knowledge brokers”.

Keywords: Evidence Translation, Evidence-informed Policies, Policy Makers, Knowledge Brokering, COVID-19 Cite this as: Eurohealth 2020; 26(2).

Introduction: The pandemic flags up looked to the science to shape prevention Gemma A. Williams is Research Fellow, European Observatory the wider challenges of evidence- and treatment actions and their wider on Health Systems and Policies, informed policy responses beyond the health sector. London School of Economics However, getting evidence into practice and Political Science, UK; Governments across Europe have become has proved to be challenging, with Josep Figueras is Director and increasingly aware of and committed to Suszy Lessof is Coordinator, questions raised both about the evidence using evidence to inform public policy European Observatory on Health and how it is used. These questions touch over recent decades. The COVID-19 Systems and Policies, Belgium; on longstanding issues: around the quality Sara M. Ulla Díez is Program pandemic is, in some ways, an ‘ideal and independence of evidence; of how Coordinator, Ministry of Health, opportunity’ to build on this and mobilise Spain. decision-makers access and understand scientific knowledge to inform decision- Email: [email protected] it; around public understanding and making. Almost all governments have

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acceptance of expert opinion; and of how differing views on their value and policies Putting aside the validity of the views society manages the contradictions and in countries are still very mixed. Some shared or the motivation behind sharing trade-offs between different objectives. mandate facemask use even outside (e.g. them, there are very significant challenges COVID-19 has not created these issues, France, Italy, Serbia, Spain, Turkey), while that derive simply from the volume of but it has thrown them into sharp relief. others are not prescribing their use in any information available. Members of the The pandemic also creates an opportunity settings (e.g. Belarus, Iceland, Norway and public (like policy makers) have access to assess the kinds of intermediaries Sweden). 2 to an “overabundance” of competing that can help translate evidence into information, what has been termed an practice and to review how independent The sheer volume of data and analysis, “infodemic”. 4 The volume of this and “knowledge brokers” can support the uncertainty around the science and its heterogeneity makes it difficult for evidence-informed policy in the future. the rapid evolution of knowledge mean people to identify which information and that policy makers need help both to guidance on COVID-19 is trustworthy The sheer volume of evidence capture and understand information and to and evidence-based. It also complicates emerging during COVID-19 and interpret its strength and validity. their responses to the inevitable changes the speed at which it evolves poses and uncertainties in ‘official’ sources a challenge for policy makers Public perceptions also affect policy of evidence. This in turn makes it more makers – uncertainty and the difficult for policy makers trying to secure Little was known about COVID-19 at the “infodemic” make it ever harder public cooperation and for the scientists beginning of the pandemic, with evidence for them to convince people to trying to bring evidence into practice. on how it was transmitted, disease ‘follow’ the evidence severity, mortality rates, populations at- Evidence alone cannot resolve the risk and potentially effective preventative The facemasks example also highlights complex trade-offs between policy (and treatment) measures all unclear. the importance of public opinion, which is areas or the complexity of A proliferation of global research from all too often increasingly divided. There implementing policy choices different disciplines has rapidly emerged are vocal minorities in several countries to try and address these questions. Just (e.g. Greece, Ireland, the United Kingdom, Translating evidence into timely policy a few months after the first SARS- the United States) opposing facemask action has been further complicated by CoV-2 case, hundreds of systematic use on the grounds of personal freedom. the fact that while COVID-19 is a public reviews and meta-analysis are available While concerns about civil liberties are health challenge, the policies that address and epidemiologists, economists, social to be expected when governments take it have enormous impacts on society and scientists and data analysts from other measures on the scale of the COVID-19 the economy. Public health objectives fields are providing up-to-date analysis responses, the issues have been amplified may conflict with other government in a myriad of open data web pages and by social media. The pandemic emerged at commitments. Implementing a strict applications. This has huge potential a time when social media had already been lockdown for example, may prevent benefits, but can equally be overwhelming implicated in disseminating inaccurate, transmission, but is at odds with the for decision-makers. sometimes harmful information on need to keep workplaces and schools health. Misleading advice on COVID-19, open to protect people’s livelihoods and What is more, early evidence on the virus has been spread online, often rapidly children’s education. Policy makers are has been surrounded by uncertainty and and widely, and threatens adherence to therefore having to make judgements on new and emerging evidence has not always specific public health measures (including policy measures that balance different been definitive. There has been little time on physical distancing). Beyond this, it objectives, in areas where evidence cannot to replicate research, and in some cases triggers a wider mistrust of scientists provide a straightforward answer and findings published in high profile journals and experts and can encourage people where the differing priorities of different were later retracted due to concerns over to ignore or oppose broad public health stakeholders are often legitimate. data veracity. 1 Uncertain, conflicting measures, again undermining COVID-19 and ‘shifting’ evidence has been a responses. Misleading advice may not In these judgements, decisions are considerable challenge for policy makers. be intentionally malicious, but can be informed not only by the evidence, but It has generated significant debate and damaging nonetheless. 4 also the prevailing values and ethics of contributed to divergent policy responses ruling parties and of the societies they being adopted in different countries, and However, in some cases “fake news” can govern. Right-wing governments may even prompted occasional U-turns. Rules be spread intentionally by organisations be more inclined to protect the free- on physical distancing are a case in point, or individuals, often to promote their market economy than to impose stringent with countries implementing measures political, economic or ideological agendas. lockdowns, which may well reflect the ranging from 1, through 1.5 to 2 metres. 2 Populist politicians, in particular, have views of their electorate. Similarly, the Facemask use is similarly contested. While sought to politicise COVID-19 and have political right may have a different take on evidence in favour of the efficacy of seized on the crisis as an opportunity to the trade-offs between protecting health public use in preventing transmission mobilise their voting base. 5 and respecting individual freedoms than has emerged gradually, 3 scientists hold the left. Some parts of European societies

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Table 1: Approaches to bringing evidence into policy responses to COVID-19

Model Country examples Roles Characteristics Pre-existing expert Belgium, Cyprus, Slovenia, UK Review the available evidence and Contains scientific experts from advisory groups provide directions and communicate multiple disciplines; Convened by advice on appropriate health system governments and embedded in the measures to policy makers and political process; Chaired either by the public Chief Scientific or Medical Officers, public health experts or government actors; Comprised of independent experts Pre-existing institutions Slovenia Review evidence and communicate Usually universities or national advising governments advice on public health measures to institutes of public health policy makers and the public Newly established expert Belgium, Bosnia and Herzegovina, Review the available evidence and Contains scientific experts from advisory groups Canada, Estonia, France, Ireland, provide directions and communicate multiple disciplines; Convened by Italy, Luxembourg, the advice on appropriate health system governments; Chaired either by Netherlands, Spain measures to policy makers and Chief Scientific or Medical Officers, the public public health experts or government actors; Comprised of independent experts Task forces to advise on Estonia, Finland, Ireland To advise governments on social Contains scientific experts from economic recovery and economic impacts of COVID-19 multiple disciplines; Convened and to aid an inclusive recovery by governments Experts acting independently of UK Working independently of Contains scientific experts from official government channels government to develop policy multiple disciplines; Acting recommendations based on independently of government; available evidence that are Release minutes and data behind communicated directly and decisions publicly for transparency transparently to the public

Note: this is not an exhaustive list of institutions advising governments during COVID-19, but are illustrative examples taken from the HSRM.

Source: 2 may also have a liberal aversion to an scale of unintended social or economic use of clinical evidence for treatments expanded role of the state and these beliefs consequences are all part of the review or protocols. While exact models are may make it more difficult to implement of trade-offs and will often modulate culturally and contextually determined, policies that interfere with personal choice. political decisions. The feasibility of a a common approach has seen countries They may also affect the extent to which recommended measure in a given context activate pre-existing expert scientific the population adheres to the measures will also have real impact. If the legislative advisory groups. There have also been that are implemented. base, the infrastructure or the funding to new advisory groups established to guide implement a policy are not available, the health responses and in some cases task Cultural values, traditions of solidarity and decision to do so becomes meaningless. forces have been set up specifically to the societal context influence decision- advise on economic responses both during making and will influence the way Countries have called on re-purposed the crisis and the recession that is expected evidence is understood, believed and acted and ‘new’ expert groups to help them to follow. Examples of these groups and on. Furthermore, policy makers have – as translate evidence for policy their key characteristics are shown in we all do –a set of cognitive biases that Table 1. make it more likely that they will act on Clearly, the route from scientific evidence the evidence that reinforces their own pre- to policy is not straightforward but Examples of established scientific existing (political and ideological) views. different governments have accepted and expert advisory groups that have that the pandemic is a reason to build informed policy decisions during Even in cases where robust and abundant on the progress towards evidence-based previous public health crises include evidence is communicated effectively, policy making and not an excuse to the Risk Assessment Group (RAG) in there are still roadblocks to overcome jettison it. The Health System Response Belgium, comprised of epidemiologists, before it is actually transformed into Monitor (HSRM) throws up some scientists and representatives of health political decisions. The probability useful examples of how countries are authorities and the Scientific Advisory of success in the real-world, the facilitating the translation of evidence Committee in Cyprus consisting of extent to which a given measure will into policy. 2 Here, the focus is solely on independent academics and members of undermine competing initiatives, the public health policy measures and not the the Unit of Surveillance and Control of

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Communicable Diseases. In the UK, the to COVID-19, evidence on (in)effective (e.g. NPHET in Ireland, SAGE UK) scientific advisory group for emergencies actions from past pandemics and have publicly released minutes of all (SAGE) was activated to provide international guidelines and using meetings to allow the public to understand consensus advice on key issues (use of this to provide scientific and technical why certain advice was given. In the facemasks, school closures, lockdown guidance to policy makers on public Netherlands, the National Institute for measures), based on available scientific health measures, re-organising health Public Health and the Environment evidence and includes a wide-range of systems and potential treatment options (RIVM) has published all codes, data experts from public health, medicine, for COVID-19 patients. and assumptions informing models and mathematics and the social sciences. shown how results inform conclusions. Scientific advisory groups have been National institutes of public health in Newly established, multidisciplinary multidisciplinary and “embedded” Albania, Croatia and Serbia, and experts special advisory committees or working in the policy process in Belgium, Cyprus, Germany and the groups, have also been central to UK from various advisory and working government policy making during the The scientific advisory groups and tasks groups have also participated in public crisis in many countries (see Table 1). forces highlighted have a number of briefings alongside government officials Spain, for instance, established a Scientific common features. First, they have been or appeared on various news or current Advisory Committee for COVID-19 made up of established experts, allowing affairs programmes to explain the latest composed of six prestigious researchers governments to tap into existing expertise developments to the general public. to advise the government in relation to the and to derive some credibility from the By sharing the evidence behind policy response. A specific group of experts was skills and experience of the personnel decisions and being transparent and open also set up to advise on the de-escalation assembled. The downside of this is that the about uncertainty, these experts can help of confinement, in the economic, social choice of experts can be questioned and build trust and compliance with public and international spheres. Sectoral the independence of those involved may health measures. Moreover, openness groups have also been formed, such as be compromised by the very act of their can help generate discussion of decisions the Multidisciplinary Working Group accepting an advisory role. among the wider scientific community, that supports the Ministry of Science and potentially resulting in new insights and Innovation in scientific matters related to Secondly, the experts mobilised have solutions to outstanding concerns. It is COVID-19 and its future consequences. come from multiple disciplines. This difficult to argue that transparency is not Belgium meanwhile has established a wide-ranging expertise is fundamental to a good thing, but it can be challenging for multidisciplinary Group of Experts in delivering an effective response. Insights governments and the fact that changes in charge of the Exit Strategy (GEES) to from a mix of disciplines beyond public advice are debated publicly may cause advise the National Security Council on health, such as behavioural sciences, confusion amongst a lay audience. relaxing lockdown measures. economics, sociology and anthropology help improve the effectiveness of public Many scientific advisory groups have Some countries have also established an health interventions. Additionally, also been embedded within the political economic task force to guide the economic measures to prevent the spread of the processes, particularly (but not always) response during the crisis and through the virus are impacting on whole societies when groups have been established by expected economic downturn (see Table 1). and making it important that the full governments seeking evidence-based Ireland has formed a Stakeholder Forum consequences of any policy measures are guidance and recommendations. This chaired by the Department of the understood. There is though, a potential closeness to the policy process involves a Taoiseach (Prime Minister), comprised downside of multidisciplinary advisory direct relationship with policy makers and of 20 organisations across multiple sectors groups, in that there can be difficulty in makes it easier to understand the policy to support public health measures and ensuring public health advice is heard and process, to build trust with decision- inform the government on emerging favoured over other expertise. In the UK makers, and to learn how to give advice downstream social and economic impacts for instance, concerns have been raised and guidance effectively. However, it of COVID-19. In Finland, the government that SAGE contains too many clinical also raises questions over independence has set-up a working group of independent experts and not enough epidemiologists, and objectivity, with a real risk that economic experts and academics to immunologists, public health experts advisors are, or are seen to be, co-opted develop an economic strategy for dealing or social scientists, thus potentially or compromised by government. The with the impact of coronavirus crisis. overlooking perspectives that could be scientific advisory groups explored in critical in developing effective public this article have taken some steps to avoid The exact remit of these advisory health responses. political interference in the evidence committees varies between countries provided and to signal their autonomy and has evolved as the pandemic has Thirdly, most advisory groups have taken from government decision-makers. progressed. Nevertheless, they are steps to increase transparency and In most groups, the remit explicitly primarily tasked with monitoring and to effectively communicate evidence emphasises their independence and reviewing national and international both to policy makers and the public. objectivity. Membership is primarily research and developments in relation For example, some advisory groups of independent academic experts or

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scientific advisors only, with politicians chance of informing policy in practice. Yet and the policy making communities and not generally able to attend meetings. In being close to government may undermine reduces their ability to feed into fast those cases where government advisors public perceptions of and confidence in moving decisions. Ultimately, it may be have been allowed to attend, concerns their independence and trustworthiness. impossible to truly separate scientific have been voiced over the independence Other scientists, the public and opposition advice from politics, but knowledge of the scientific deliberations. There have politicians may challenge the validity of brokering may be an effective tool for also been questions about who chairs these their recommendations and from there the linking the different constituencies. It can groups. Some are facilitated by public value of their expertise simply because ensure that there is appropriate separation health or other academics, but most are it is a government advisory group. An and that communications across the chaired by government Chief Medical advisory group provides guidance, in science-politics divide are informed by or Scientific advisors, who are typically doing so it is implicated in the politics of an understanding of: context and bias; the government employees, and some are even the policy process. role of different disciplines; and how to chaired by politicians, again raising doubts communicate effectively with different about autonomy. Other approaches to the transfer of stakeholders. Above all it may be a way knowledge to policy makers have of insisting that the inherent tensions Concerns over the transparency of placed more emphasis on neutrality and between evidence-informed public health decision-making and the validity of independence. These models depend policy and the politics of evidence- guidance has been such that in some on fully independent intermediaries or informed policy making (and practice) are countries, scientists have formed wholly “knowledge brokers” positioned between handled with the transparency needed to independent advisory groups without policy makers and researchers. 6 7 They create trust. government inputs. These review the aim to facilitate the exchange of evidence available evidence and provide advice and knowledge across the ‘gap’ that then References through public engagements and continues to separate both sets of actors media appearances. protecting the integrity of the evidence. 1 Mehra MR, Desai SS, Ruschitzka F, Patel AN. Knowledge brokers are defined as RETRACTED: Hydroxychloroquine or chloroquine with or without a macrolide for treatment of individuals, institutions or structures that Policy implications: The lessons COVID-19: a multinational registry analysis. Lancet from embedding evidence in policy “cross boundaries” between academia, 2020 May 22:S0140-6736(20)31180-6. Epub ahead policy and practice. 6 7 Knowledge of print. Retraction in: Lancet 2020 Jun 5. Erratum in: processes suggest a role for Lancet 2020 May 30. independent knowledge brokering brokering involves skills in reviewing and integrating evidence from different 2 WHO Regional Office for Europe, the European Scientists and experts have taken centre disciplines; in distilling key messages; Commission, and the European Observatory on stage during the COVID-19 response in understanding the policy context; Health Systems and Policies. The COVID-19 Health in many countries. They have played a and in communicating effectively Systems Response Monitor (HSRM), 2020. Available at: https://www.covid19healthsystem.org/mainpage. critical role in keeping the policy makers with policy makers (and practitioners aspx and the public abreast of the most useful or the public when appropriate). 3 and most relevant emerging research and Perhaps most importantly the notion Greenhalgh T. Face coverings for the public: Laying straw men to rest. Journal of Evaluation in have shared information in a timely and of knowledge brokering is bound up Clinical Practice 2020. Available at: https://doi. credible way. with ideas of neutrality, of presenting org/10.1111/jep.13415 evidence-informed options rather than 4 World Health Organization. Immunizing the public This transfer of knowledge has not though recommendations and of the non- against misinformation. Feature stories, 25 August been without cost. Using respected normative. 2020. Available at: https://www.who.int/news-room/ scientists and experts has helped identify feature-stories/detail/immunizing-the-public- the ‘right’ evidence and in many cases The COVID-19 pandemic has both lessons against-misinformation has contributed to it being translated into and challenges for bringing evidence 5 McKee M, Gugushvili A, Koltai J, Stuckler D. appropriate public health policy measures, into policy. It highlights the difficulty Are Populist Leaders Creating the Conditions for but it has sometimes pushed researchers of researchers and analysts maintaining the Spread of COVID-19? Comment on “A Scoping into uncomfortable compromises. Expert distance and independence in the long- Review of Populist Radical Right Parties’ Influence on Welfare Policy and its Implications for Population groups have helped build public trust in term. It also flags their own cognitive Health in Europe”. International Journal of Health government guidance and encouraged biases, their personal stake in ‘their’ Policy and Management, 2020 adherence to recommendations. interpretation of the evidence, and their 6 Jessani N, Kennedy C, Bennett S. The Human Their closeness to policy makers has vulnerability to becoming politically Capital of Knowledge Brokers: An analysis of nevertheless raised questions over the ‘implicated’. At the same time, it calls into attributes, capacities and skills of academic transparency, rigor, objectivity and questions whether the idea of a credible, teaching and research faculty at Kenyan schools of independence of their analysis. trustworthy and independent ‘knowledge public health. Health Research Policy and Systems broker’ can be the effective bridge 2016;14(58). There is a genuine dilemma. Advisory between evidence and policy in times of 7 Ward V, House A, Hamer S. Knowledge Brokering: groups created directly by governments crisis. Their very ‘neutrality’ keeps them The missing link in the evidence to action chain? to support decision-making have the best at an arm’s length from both the scientific Evidence & Policy 2009;5(3):267 – 79.

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SUCCESSFUL FIND-TEST-TRACE- ISOLATE-SUPPORT SYSTEMS: HOW TO WIN AT SNAKES AND LADDERS

By: Selina Rajan, Jonathan Cylus and Martin McKee

Summary: In order to ease lockdown restrictions and prevent a second wave of infections, countries must be able to find, test, trace, isolate and support new COVID-19 cases. The simplicity of the ‘test, trace, isolate’ mantra dramatically understates the multitude of time- dependent processes that must occur seamlessly for the strategy to work effectively. We reconceptualise the way out of lockdown as a Cite this as: Eurohealth 2020; 26(2). Snakes and Ladders boardgame. To succeed, countries must ensure that people with COVID-19 progress through the board as quickly as Acknowledgements: This article provides an update possible by putting in place measures that enhance their public health to an article originally published as ‘Rajan S, Cylus JD, McKee M. capacity (i.e. landing on ladders) and prevent setbacks caused by What do countries need to do to implement effective ‘find, test, having insufficient capacity (i.e. avoiding snakes). trace, isolate and support’ systems? Journal of the Royal Society of Medicine 2020;113(7):245–50. https://doi. Keywords: Test, Trace, Isolate, Preventing Transmission, COVID-19 org/10.1177/0141076820939395’. It has been re-published under the conditions of a Creative Commons license. Introduction major expansion in capacity. Even the best resourced public health system would Any country thinking of easing struggle given the scale of the pandemic. COVID-19 lockdowns must be confident For many, especially those whose capacity Selina Rajan is Specialist Public that they have a robust system in place has been diminished as a consequence of Health Registrar and Research to find, test, trace, isolate, and support Fellow, Department of Health sustained underinvestment, the challenges (FTTIS) new cases. This is essential Services Research and Policy, are enormous. To help those who are London School of Hygiene if they are to minimise the risks of a facing these challenges, we have examined and Tropical Medicine, UK; second wave going out of control. The Jonathan Cylus is London Hub what countries across Europe are doing, theory is simple. Anyone with symptoms Coordinator, European Observatory seeking where possible lessons that can be is tested and, if positive, their contacts on Health Systems and Policies, learned from their experiences. London School of Economics and are traced and advised or instructed to Political Science & London School isolate. The reality is somewhat different. of Hygiene and Tropical Medicine, This analysis uses information gathered It requires a complex system with many UK; Martin McKee is Co-Director, from the COVID-19 Health System European Observatory on Health interlinking components, demanding rapid Response Monitor (HSRM), created by the Systems and Policies and Professor and effective communication between of European Health Policy, London European Observatory on Health Systems different organisations, some of which School of Hygiene and Tropical and Policies. 1 A network of national Medicine, UK. Email: selina.rajan@ are newly created, while others may be correspondents from over 50 countries lshtm.ac.uk combining their day to day work with a

Eurohealth — Vol.26 | No.2 | 2020 Preventing transmission 35

has prepared a series of structured reports are also used to test for other infections creates a snake because testing sites on national responses to the pandemic, but, during a pandemic, countries face cannot administer tests without the right regularly updating them as events develop. supply constraints, a ‘snake’ that inhibits supplies. Countries offering home testing FTTIS before it has a chance to get started. faced logistic challenges, especially as Conceptually, we can consider a FTTIS postal services were often weakened programme as a complex adaptive system, because of staff shortages and working with the individual being tested passing with social distancing. Some countries along a non-linear route involving multiple also faced particular early challenges in paths, each with feedback loops and with getting tests to certain high risk settings, their speed and direction influenced by a a complex such as care homes, as in the UK. 4 A multiplicity of factors, many outside their failure to distribute test kits to individuals control. Practically, however, if we are system with or test sites where they are most needed to help the busy policymaker, we must will delay access to testing, thus enabling simplify this considerably, something many interlinking new cases to remain undetected and that we have done by portraying the main transmission to continue. elements of the system as a Snakes and components Ladders boardgame (image). Snakes and Developing sufficient skills and Ladders is remarkably well suited to this Equipped with the genetic sequence from facilities to meet testing needs exercise. To be successful (i.e. to win the China, Germany and the United Kingdom game) countries must ensure that those managed to manufacture some of the While few countries were conducting tests with COVID-19 progress as quickly as earliest COVID-19‘‘ tests outside Asia and outside of hospitals early in the pandemic, possible from the start to the finish. If this Germany quickly purchased millions of most now do so, for example by building does not happen, new cases will appear, them. Germany also published a blueprint drive-through or mobile testing units, with and another lockdown will be needed. that the WHO could share with other many others, including Austria, the UK, They can do this most effectively by countries to support their use of the newly and Estonia also starting home testing. putting in place measures that enhance developed test. However, large scale Some governments have outsourced their ability to find, test, trace, isolate, testing is only possible if laboratories some components of this work to private and support (i.e. landing on ladders) and have all of the items required, from companies, for example in Finland, by avoiding setbacks that occur due to glassware to PCR machines. This requires Estonia, and the UK, although with insufficient capacity in the health system very well-functioning procurement and varying degrees of success. and beyond (i.e. avoiding snakes). We distribution systems, something that many now run through the boardgame, pointing countries have struggled to achieve, and Although these measures can increase out many of the steps that policymakers even Germany, widely praised for its the volume of testing they also present should be mindful of, highlighting ability to scale up testing capacity rapidly, enormous logistical challenges as testing approaches that countries are currently has experienced periods when demand supplies must be distributed to a large taking to implement a FTTIS system and has exceeded supply. Countries that do number of testing sites, while testing on a thereby “win the game”. Before doing not manufacture these items themselves large scale depends on recruitment of staff so, however, it is important to note an initially struggled to obtain them in a who are unlikely to have experience in important difference from the real game, global market where they were competing taking samples. Taking a nasopharyngeal in which players land on squares at the against others with greater purchasing swab does require some degree of throw of a dice. In this case, countries that power. Some countries such as Norway, training about how and (critically) when went into the pandemic with strong public have developed and manufactured their to test to reduce the risk of false negative health systems and systems of governance own tests 3 to minimise dependence on results. 5 Without proper training, tests will are more likely to land on ladders because those produced elsewhere. Rather like be wasted and need to be repeated, which the capacity is already in place. printers, where cartridges are specific to in turn erodes limited capacity (another particular brands, PCR machines are often snake). Recent advances have shown Producing and procuring enough licensed for use with specific reagents, great promise for the use of saliva tests, testing materials with global stocks of many of them which can avoid this trade-off between rapidly depleted in the early stage of the availability of trained staff and quality The game starts with procurement, with pandemic. In response, some countries, assurance. a focus on molecular testing supplies for including Belgium, the UK, and Canada nose and throat RT-PCR swabs, the gold eased regulations to enable more flexible After taking a swab, samples should reach standard test recommended 2 by the World use of reagents, drawing on South Korea’s the laboratory rapidly. Otherwise they Health Organization (WHO) to identify earlier response to MERS. may have to be discarded and repeated. COVID-19 cases. Testing requires reliable Thus, it is important to ensure that there supplies of a range of materials, including Once procured and warehoused, supplies is a well-coordinated system to ensure swabs, transport media, reagents, primers, need to be distributed to testing sites and transport of samples from test sites to assays, and PCR machines. Many of these laboratories. Failure to do so effectively laboratories. Ideally, testing sites and

Eurohealth — Vol.26 | No.2 | 2020 36 Preventing transmission

Figure 1: Win the game

Source: Authors’ compilation

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laboratories would be co-located, as in Any mass testing in high risk settings include accelerated training of laboratory hospitals and in some South Korean drive- must also be done under the strictest of technicians, as in Israel, or use of robots, through testing sites. This is a ladder, infection control precautions to prevent as in Denmark. although one that is rare in community cross contamination, which can lead to testing sites in Europe. The ultimate goal falsely positive results. A second type While there is widespread agreement that is to develop a test that does not require of pooling is surveillance sampling of tests should be conducted within a country, a laboratory, using a point of care test wastewater, which has also been shown where possible, debate continues as to the that can produce immediate results, to be a useful early warning system to other approaches. Countries adopting the particularly for those without symptoms, monitor outbreaks 12 and the utility of first one do generally appear to have been but those that have been developed so this approach is now being studied by the successful and although Germany has far have not performed sufficiently well European Commission in a number of struggled to meet demand more recently to depend on at population scale. This European countries. rationalising its testing programme of all approach also removes the need for incoming travellers to those from high laboratories, which are a critical rate Strengthening lab capacity to rapidly risk countries, demand for tests in the limiting step in any pathway at population analyse samples and immediately UK is reported to be many times capacity scale. So far, cases that are confirmed report the results as laboratories have struggled to keep through rapid testing usually have to be pace, with the Prime Minister calling on verified through PCR swab testing and The ability to scale up testing will university laboratories to redeploy staff to so this approach is still only likely to be be easier in countries that have the lighthouse laboratories once again, and feasible at a low prevalence. Estonia has had sustained investment in health resorting to sending more samples abroad. also offered an innovative approach, using infrastructure, including laboratory drones to deliver some samples directly to equipment, technicians, logistics laboratories. In the UK, most testing takes systems, and information technology. place in just seven commercial mega- Germany 13 entered the pandemic with a contact laboratories, creating transport bottlenecks strong diagnostics and chemicals industry, and reports of discarded samples. which allowed it to implement large scale tracing is a core testing rapidly. 14 In contrast, the UK did Given the evidence that symptomatic not. Thus, a lack of sufficient laboratory component of testing alone is likely to miss a large capacity is another snake that will create proportion of infectious presymptomatic severe delays in processing tests, possibly public health and asymptomatic cases, 6 7 there has requiring substantial re-testing which also been a move more recently towards exacerbates an already difficult situation. Once samples are processed, automated regular mass testing in high risk settings reporting can create a ladder, helping to such as in health and social care settings Where laboratory capacity is insufficient, deliver results quickly to cases and contact and areas of increased transmission in three types of response can be seen. One tracers who will be able to initiate tracing Lithuania and England. It remains unclear involves expanding existing medical sooner. There are numerous examples how regular such testing needs to be to laboratories or repurposing others, such as of‘‘ countries where this is working, be effective but some studies suggest an those involved in veterinary surveillance including Belgium, Estonia, Iceland, interval of two days is required, 8 which in universities, as in Croatia, Cyprus, Turkey and Lithuania. Rapid initiation is likely unfeasible for RT-PCR testing. Estonia, France, Germany, Lithuania, and of contact tracing will reduce the risk of Others, including Estonia, France, Iceland Norway, among others. Thus, Germany 13 further transmission. It also increases the and Germany have also instituted testing rapidly commissioned testing in 300 local likelihood that suspected cases will agree for incoming travellers, although their laboratories and Sweden also used existing to isolate while they wait for their results. testing policies and capacity differ. A laboratories in all but 2 of its 21 regions. Without an automated system, results have secondary but important concern for A second involves creation of a few to be telephoned individually to cases, asymptomatic screening is that it does centralised mega-laboratories. In the UK, which is resource intensive and can delay not help to identify which of the cases outsourcing companies, many with little notification and isolation. Some countries will be most likely to transmit the virus or no experience of running laboratories, such as the UK are also planning to to others, given that very few cases seem were contracted to construct a few large implement mass point of care testing and to be responsible for a large proportion lighthouse laboratories, creating a highly it is unclear how this critical component of of transmission, otherwise known as centralised system. A third approach, seen automating results will be factored in. clustering 9 and that RT-PCR can pick in Ireland and Finland, involved samples up both infectious and non-infectious being sent abroad for testing, although Self-evidently, there must be a system to cases. Germany and Portugal are also as the UK has found, if samples are sent monitor test performance to ensure false now testing samples in batches, so called abroad at the wrong temperature they positives and negatives are minimised. pooled sampling, 10 taking lessons from cannot be processed and will be voided. This may create logistic challenges the population screening programme in Other measures that also contribute for quality assurance where new or Wuhan and from HIV testing strategies. 11 repurposed laboratories have come on

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stream, although there are examples, such were able to meet this target in mid-May support necessary upgrades in hardware as those in Italy and Ireland, that can offer and it is unclear what proportion will and software and France has also invested lessons. Further guidance is now required be experienced contact tracers. There in improved contact tracing software. on how to standardise laboratory testing are various ways to boost the contact In contrast, 16,000 cases were recently in different labs using different assays and tracing workforce. They include inviting missed in the UK because of a reliance machines. Quality assurance is critical experienced environmental health officers, on outdated Microsoft Excel templates and mechanisms to monitor this were sexual health specialists, and retired to transfer data. In many countries, implemented in Italy and Ireland. doctors and nurses, as the UK has done (including Austria, Belgium, Croatia, (although uptake is unknown and in Estonia, France, Greece and Ukraine) Building a large, well-trained reality this kind of redeployment can only primary care services are also involved workforce to conduct contact tracing ever be temporary to avoid neglecting in the test, trace, isolate process and (even in countries using digital other serious health problems). Others can monitor and support cases more technologies) have recruited military personnel (as in effectively. Germany and Israel) and medical students Despite renewed attention, contact (as in Finland), or recruited volunteers (as Supporting people in isolation (unless tracing is a core component of public in Cyprus). However, in all cases, there you want to start the game again) health departments, which have long can be challenges in ensuring that they are experience in preventing transmission all adequately trained. Isolation is arguably the most important of other communicable diseases such part of the test, trace isolate process as tuberculosis, hepatitis, and sexually according to recent evidence. 18 A team of transmitted infections. Contact tracing community volunteer contact tracers in requires a well-resourced existing public digital the UK published data 19 from a pilot in health infrastructure, with a trained which it took approximately 80 minutes workforce that is well connected with solutions do not to manage each case, with many contacts local services. Such a system will enable were unwilling to isolate. Cross- clusters and complex outbreaks to be offer a panacea sectional data from May also suggested detected early. This is an important ladder that only 25% of those with household that will help to strengthen the FTTI There has been considerable attention symptoms of COVID-19 in the UK process and is crucial for any containment on digital technology, specifically actually adhered to isolation guidance. 20 or mitigation strategy. Various strategies apps as a potential ladder, given their Measures to support isolation are therefore have been used to trace contacts, outlined potential to identify and notify contacts an important ladder and in Denmark, elsewhere 15 (also see the article by quickly. Countries where they have Finland and Lithuania, people who cannot Hernández-Quevedo, et al. in this issue) been implemented include Austria, isolate are accommodated elsewhere but each case must be interviewed to Belgium, Bulgaria, Canada (Alberta), (albeit for a fee in Finland). The same ensure that they isolate, identify, and risk Denmark,‘‘ Finland, France, Georgia, approach has also been used successfully assess their contacts, providing sufficient Iceland, Ireland, Italy and Germany, to prevent outbreaks in care homes information to locate and engage with where the Corona-Warn-App has been in South Korea. Without facilities to them. An inadequate number of contact downloaded 18 million times since support vulnerable individuals to isolate, tracers creates a snake as manual contact mid-June. England have had to redesign and especially to minimise any loss of tracing is time consuming, demanding its app over the summer, following a income, it is likely that transmission will a large workforce. Any delays will lead pilot in the Isle of Wight and launched rise, another snake that could set back to increased transmission. Modelling in late September, 4 months after it was the entire process. Enforcing isolation is suggests that around 80% of non- anticipated and 2 months after the launch also critical 15 and many countries, such household contacts would have to be in Northern Ireland. However, while as Lithuania and the UK, impose fines traced and isolated within 48 hours of the apps may deliver speed, there is little but this risks penalising marginalized first person experiencing symptoms, with evidence they are effective; 17 coverage populations disproportionately. strict adherence to self-isolation and there and compliance are not guaranteed, Some countries, including Hungary, are few examples of countries in Europe and only 3% of the population have Iceland, Italy, Lithuania, Norway and where this is happening systematically. 16 downloaded it in France, compared to 30% Ukraine 15 use geolocation data to monitor in Finland. This means that considerable the movements of cases, but such efforts To avoid this snake, several countries have time is still required to manually trace still require a dedicated workforce to recruited paid contact tracers to work in all contacts. Recognising that digital enforce it. This requires resources and call centres, including France (> 8,000), solutions do not offer a panacea, Belgium connections to local service providers the UK (18,000) and Germany (up to five and France opted for manual contact who know the local populations. Some contact tracers per 20,000 inhabitants), tracing initially. To support the required groups 21 have suggested that community although an early survey in Germany increase in capacity, the German Ministry health workers could be trained for showed that only 24% of departments of Health committed €50 million to this purpose.

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Successful ‘test, trace, isolate’ 7 Cheng HY, Jian SW, Liu DP, Ng TC, Huang WT, 19 Wight J, Czauderna J, Heller T, et al. Sheffield depends on having adequate capacity Lin HH. Contact Tracing Assessment of COVID-19 community contact tracers: training community in many areas of the public Transmission Dynamics in Taiwan and Risk at volunteers to undertake contact tracing for COVID-19. Different Exposure Periods before and after Symptom BMJ 2020. Available at: https://blogs.bmj.com/ health system Onset. JAMA Intern Med. 2020;180(9):1156–63. bmj/2020/05/29/sheffield-community-contact- tracers-training-community-volunteers-to-undertake- The resources required to successfully 8 Paltiel AD, Zheng A, Walensky RP. Assessment of contact-tracing-for-covid-19/ find, test, trace, isolate and support cannot SARS-CoV-2 Screening Strategies to Permit the Safe be underestimated. Each step requires Reopening of College Campuses in the United States. 20 Smith LE, Amlot R, Lambert H, et al. Factors complex management and logistics JAMA Netw open. 2020;3(7):e2016818. associated with adherence to self-isolation and lockdown measures in the UK: a cross-sectional 9 Adam DC, Wu P, Wong JY, et al. Clustering and and a well-resourced public health survey. Public Health. 2020;187:41–52. infrastructure and workforce. Setbacks superspreading potential of SARS-CoV-2 infections in 21 can be encountered at any stage, but Hong Kong. Nat Med. 2020;17:1–6. Haines A, de Barros EF, Berlin A, Heymann DL, Harris MJ. National UK programme of community 10 Majid F, Omer SB, Khwaja AI. Optimising SARS- many can be anticipated. Many countries health workers for COVID-19 response. The Lancet CoV-2 pooled testing for low-resource settings. have developed innovative measures that 2020;395:1173–5. can boost capacity rapidly. However, it The Lancet Microbe. 2020;1(3):e101–2. is important to focus on the outcome of 11 Sullivan TJ, Patel P, Hutchinson A, Ethridge FTTIS rather than the amount of activity. SF, Parker MM. Evaluation of pooling strategies Increasing the number of tests, will have for acute HIV-1 infection screening using nucleic acid amplification testing. J Clin Microbiol. limited value without a well-resourced 2011;49(10):3667–8. system to trace and isolate cases. In 12 addition to scale, speed is essential. Delays Peccia J, Zulli A, Brackney DE, Grubaugh ND, et al. Measurement of SARS-CoV-2 RNA in wastewater at any stage will allow more cases to tracks community infection dynamics. Nat Biotechnol. remain under the radar, silently spreading 2020;18:1–4. the infection to others. Ultimately, the 13 Labmate. How Germany Has Led the Way on success of FTTI is to get countries out of COVID-19 Testing Labmate Online, 2020. Available at: lockdown. This will depend critically on https://www.labmate-online.com/news/laboratory- their ability to be co-ordinated, flexible, products/3/breaking-news/how-germany-has-led- and prepared. the-way-on-covid-19-testing/52141 14 Buranyi S. Inside Germany’s Covid-19 testing masterclass. Prospect Magazine, 1 May 2020. References Available at: https://www.prospectmagazine.co.uk/ 1 WHO, European Commission, European magazine/germany-covid-19-masterclass-testing- Observatory on Health Systems and Policies. tracing-uk COVID-19 Health System Response Monitor 15 Scarpetti G, Webb E, Hernandez-Quevedo C. platfrom, 2020. Available at: https://www. How do measures for isolation, quarantine, and covid19healthsystem.org/mainpage.aspx contact tracing differ among countries? Health 2 World Health Organization. Advice on the use of System Response Monitor – Cross-Country Analysis. point-of-care immunodiagnostic tests for COVID-19, WHO, European Commission, European Observatory 2020. Available at: https://www.who.int/news-room/ on Health Systems and Policies, 19 May 2020. commentaries/detail/advice-on-the-use-of-point-of- Available at: https://analysis.covid19healthsystem. care-immunodiagnostic-tests-for-covid-19 org/index.php/2020/05/19/how-do-measures-for- isolation-quarantine-and-contact-tracing-differ- 3 O’Shea D. Norway rolls out new COVID-19 test. among-countries/ Univadis, 2020. Available at: https://www.univadis. 16 co.uk/viewarticle/norway-rolls-out-new-covid-19- Hellewell J, Abbott S, Phd J, et al. Feasibility of test-718259 controlling COVID-19 outbreaks by isolation of cases and contacts. Artic Lancet Glob Heal. 2020;8:488–96. 4 Booth R. Testing for coronavirus in UK care 17 homes a ‘complete system failure’. The Guardian, Braithwaite I, Callender T, Bullock M, Aldridge RW. 12 May 2020. Available at: https://www.theguardian. Automated and partly automated contact tracing: a com/society/2020/may/12/testing-coronavirus-uk- systematic review to inform the control of COVID-19. care-homes-complete-system-failure Lancet Digit Heal. 2020.

18 5 Kucirka LM, Lauer SA, Laeyendecker O, Boon D, Kucharski AJ, Klepac P, Conlan AJK, et al. Lessler J. Variation in False-Negative Rate of Effectiveness of isolation, testing, contact tracing Reverse Transcriptase Polymerase Chain Reaction – and physical distancing on reducing transmission Based SARS-CoV-2 Tests by Time Since Exposure. of SARS-CoV-2 in different settings: a mathematical Ann Intern Med. 2020;18;173(4):262–7. modelling study, 2020. Available at: https://cmmid. github.io/topics/covid19/reports/bbc_contact_ 6 Lavezzo E, Franchin E, Ciavarella C, et al. tracing.pdf Suppression of a SARS-CoV-2 outbreak in the Italian municipality of Vo’. Nature 2020;30:1–1.

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EFFECTIVE CONTACT TRACING AND THE ROLE OF APPS: LESSONS FROM EUROPE

By: Cristina Hernández-Quevedo, Giada Scarpetti, Erin Webb, Nathan Shuftan, Gemma A. Williams, Hans Okkels Birk, Signe Smith Jervelund, Allan Krasnik and Karsten Vrangbæk

Summary: Contact tracing is an essential tool to support the transition back to normal life during the COVID-19 pandemic. This article explores how 31 countries operate contact tracing, using data extracted from the COVID-19 Health Systems Response Monitor (HSRM). Two main approaches emerge: centralised (led by one national agency) and decentralised (at regional/district level). In most cases, trained staff conduct phone interviews, and many countries have moved to strengthen the capacity of tracing teams. Further, contact tracing apps are being developed and implemented, although some difficulties related to privacy concerns have arisen, necessitating more transparency on how data are collected.

Keywords: Contact Tracing, Digital Apps, Public Health Capacity, COVID-19

Cite this as: Eurohealth 2020; 26(2). Introduction logistics support to contact tracing teams; and a system to collate, compile, and Contact tracing remains an essential Cristina Hernández-Quevedo analyse data in real-time. 1 is Research Fellow, Gemma A. tool for societies to transition back to as Williams is Research Fellow, near-normal life as possible during the In this article, we present a review of European Observatory on COVID-19 pandemic. The World Health Health Systems and Policies, how 31 countries in the WHO European Organization (WHO) has highlighted the London School of Economics Region structure their contact tracing and Political Science, London, importance of testing, contact tracing operations, based on evidence available in UK; Giada Scarpetti is Research and isolation in order to stem the spread the COVID-19 Health Systems Response Fellow, Erin Webb is Research of COVID-19 and has defined contact Fellow, Nathan Shuftan is Research Monitor (HSRM). We also assess the tracing as “the process of identifying, Assistant, Technical University of features of different apps introduced in Berlin and European Observatory assessing and managing people who have the region to support contact tracing, on Health Systems and Policies, been exposed to a disease to prevent Berlin, Germany; Hans Okkels Birk and conclude with some lessons and onward transmission”. 1 According to is part-time Lecturer, Signe Smith recommendations for the future. Jervelund is Associate Professor, the WHO, critical elements of contact Allan Krasnik is Professor, tracing include: community engagement Karsten Vrangbæk is Professor, Department of Public Health and and public support; careful planning Who performs contact tracing? Department of Political Science, and consideration of local contexts, In the majority of countries, trained University of Copenhagen, communities, and cultures; a workforce Denmark. Email: C.Hernandez- staff, which may include doctors, nurses, of trained contact tracers and supervisors; [email protected] pharmacists, newly qualified doctors

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Figure 1: The main approaches to contact tracing and veterans but also public health Figure 1: The main approach to contact tracing professionals and/or volunteers, conduct phone interviews to identify everyone who has been in contact with infected or Ministry of Health suspected cases. Although contact tracing has been around for decades, the increased demand due to COVID-19 has led to an immediate and substantial need for trained Regional/ workers (who do not necessarily need a National Public District offices background in public health). Contact Health Agency tracing could also be supported by the use of apps (see below). In our analysis, we identified two main approaches by which countries structure their contact tracing Contact tracing teams operations: centralised and decentralised (GPs or public health offices) (see Figure 1).

Countries using a centralised Centralised approach: mandate comes from the Ministry of Health (MoH) and approach for contact tracing have contact tracing is organised by National Public Health agencies, which then one agency to lead operations collect information from contact tracers to feed back to the MoH A range of countries implement centralised Decentralised approach: mandate comes from the MoH to regional/district offices contact tracing at the national level (e.g. which then collect information from contact tracers to feed back to the MoH Belarus, Cyprus, Israel, Kyrgyzstan, Latvia, Lithuania, Luxemburg, Malta, Source: Authors’ compilation Poland, Portugal, Republic of Moldova, Russian Federation). Often, the Ministry Romania, Serbia, Slovenia, Spain). For some countries using a of Health or a subordinate agency For example, in Romania, dedicated staff decentralised approach, general leads these operations. For example, in in the 42 district public health authorities practitioners are part of contact Portugal, contact tracing is coordinated are in charge of calling all the contacts tracing © European Observatory on Health Systems and Policies by the Directorate-General of Health; in of those infected with COVID-19 (e.g. Poland, the National Sanitary Inspection In some countries, general practitioners from home, work and other activities) is in charge. (GPs) play a key role in contact tracing. For and asking specific questions (e.g. date of example, in Serbia, the physician attending the most recent contact, duration of their a possible or probable COVID-19 case interaction, etc.) to investigate which ones is responsible for recording the patient’s are close contacts, in order to establish close contacts after the onset of symptoms isolation measures or offer testing, if they of COVID-19, and then sending it to have symptoms. In Spain, contact tracers the epidemiologist of the territory’s transparency at the regional level track down people public health institute. Afterwards, the who were closer than two meters to either epidemiologist contacts all the people on regarding how suspected or confirmed cases for more the list and requests that they self-isolate than 15 minutes in the two days before the for 14 days. the information is onset of symptoms or a positive test. In England, NHS Test and Trace operates as In Norway, GPs in the municipalities are gathered and for a partnership between the national level, responsible for tracing contacts for all where contact tracers interview cases and patients with confirmed COVID-19, in what purpose identify contacts for non-complex cases, cooperation with the Norwegian Institute and the local level, where contact tracers of Public Health. Decentralised contact tracing puts the from local Public Health England Health responsibility on‘‘ regions or districts Protection Teams deal with more complex cases (e.g. in schools, workplaces, prisons Many countries are making more A number of countries use a more or care homes). 2 Contact tracing strategies, funding and employment decentralised approach by implementing however, differ across England, Scotland, opportunities available for contact contact tracing at regional/district Wales and Northern Ireland. tracing teams level (e.g. Albania, Belgium, Bosnia and Herzegovina, Bulgaria, Estonia, Most countries have invested in additional Finland, Germany, Italy, the Netherlands, human resources in public health to North Macedonia, Norway, Slovenia, strengthen their tracing teams. This

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is the case in Romania, where several measures have been taken to increase Box 1: Germany: the main features of a successful contact tracing strategy the availability of human resources, not only to increase the number of health Run primarily at the local level, contact tracing is organised by 375 public health professionals dealing with COVID-19 offices across the country that have been monitoring cases, tracing outbreaks and outbreaks (including hospital staff and providing counselling. Contact tracing teams in the country have been built using public health workers tackling contact existing resources and officials from the public health offices. Medical students, tracing), but also to retain existing health armed forces members and civil servants were all brought in to help, and primarily workers. In Serbia, the Minister of Health work through daily phone and house calls. The federal and state governments stated that 4,500 health workers were agreed on 25 March that public health offices must have at least one contact employed during the state of emergency tracing team of five people per 20,000 inhabitants. 3 The Robert Koch Institute (RKI) period, including 1,800 doctors, with recruited and trained “containment scouts” to help build these teams. A survey of newly employed staff being trained the public health offices made public on 14 May found that 67% did not reach their on basic aspects of coping with the targets until mid-May, so 105 mobile contact tracing teams were also created as an COVID-19 outbreak, including using RKI program financed by the Ministry of Health. 4 contact tracing tools. In England, 18,000 contact tracers were initially recruited The RKI launched the “Corona-Warn-App” on 16 June. Using decentralised and and started work at the end of May. Of anonymous software, the app exchanges temporary encrypted IDs with other these, 3000 had a medical or public app users via Bluetooth. It notifies them if they have been in the vicinity of an health background and were responsible infected person for a period of at least 15 minutes within the last 14 days. 5 By for initial interviews with cases and mid-September the app had been downloaded 18 million times. 6 Furthermore, as identifying contacts. These contact tracers Schengen internal borders slowly re-open and commuters and tourists return, the were supported by 15,000 individuals, RKI has made the app available for international download. most with no experience in health care, who followed-up to provide advice to named individuals. 2 In Germany, the if a user has been at least 15 minutes and are able to voluntarily install it on their Health Ministry provided public health within 2 meters with another person that phones. At the end of June, the app offices at the local level with €50 million is using the app. If a person on that history had about 4 million downloads. 12 In to digitise and speed-up tracing operations list self-reports to have tested positive for Ireland, a COVID-19 Tracker App was as well as hire additional tracers COVID-19, those logged contacts would launched on 7 July 2020. The app utilises (see Box 1). be notified and can take measures to a decentralised model, with information self-isolate (see Box 2). Contact tracing exchanged between close contacts using Contact tracing apps are being apps which monitor the movement of anonymous codes. To demonstrate developed and used to help contain COVID-19 patients based on geolocation the openness and transparency of the spread of the virus can take the form of monitoring bracelets the technology behind the app, the (Russian Federation), or they could be Data Privacy Impact Assessment and Several countries have identified apps mobile apps downloaded to phones. source code was published prior to as a supportive measure to telephone However, apps using geolocation raise launch. Within 36 hours, the voluntary contact tracing with the potential to trace privacy concerns as they use location data app had one million downloads contacts of infected persons that they may from telecommunications providers. (approximately 20% of Ireland’s not know personally but have been in population). close proximity to (e.g. Austria, Belgium, Most apps developed so far can be Bulgaria, Denmark, Finland, France, downloaded voluntarily, and how much Georgia, Germany, Iceland, Ireland, Governments grapple with the difficult they allow users to opt-in on different Russian Federation, Spain, Ukraine, balance between effectively tracing features (e.g. geolocation, data sharing) and the UK). The specific technical contacts and ensuring data privacy varies. For example, Denmark has details and capabilities of the apps can developed an app, which tracks citizens Several countries explicitly mention that vary substantially, which affects how who voluntarily decide to use the app. privacy concerns, data storage, governance individuals use them and what data are If a citizen using the app is diagnosed considerations, and partnerships with collected. This article specifically focuses with COVID-19, all citizens who have private industry players impact the speed on apps designed for contact tracing, while downloaded the app who have been close of adoption of these apps (Belgium, apps used for self-diagnosis, monitoring to the person will be informed that they France, the Netherlands, Spain), as active cases and communications are may have been exposed to COVID-19, governments weigh these implications. outside of this review. but the identity of the patient will not be For example, while Norway launched an revealed to them (see Box 2). app on 16 April, concerns about privacy Contact tracing apps employed in the issues, including from the Norwegian surveyed countries can either rely on On 31 May, Italy launched the Immuni Data Protection Agency, due to the use Bluetooth or geolocation services. Contact app on Apple and Android. Citizens of GPS-tracking, as well as a fall in the tracing apps based on Bluetooth detect

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We have also found that most countries tend to implement a decentralised Box 2: The Smitte|stop app in Denmark approach for contact tracing through regional/district public health services. The single Danish contact tracing app – ‘Smitte|stop’ (‘Contagion|stop’) – was This approach facilitates closeness to the developed as a public-private innovation initiative, involving the Ministry of Health, population and its needs, but may result in the Danish Patient Safety Authority, the Danish Health Authority, the Agency for uneven contact tracing across the country Digitization, the Statens Serum Institut and a private company, Netcompany. 7 if there is a geographical imbalance On 15 May, a large majority in the Danish Parliament agreed to develop the app, in public health capacity. Additional and it was implemented in 18 June. 8 coordination at national level may avoid Using the app is voluntary, and it may be downloaded for free. The app relies on an unequal implementation of contact Bluetooth technology and Google’s and Apple’s technology for decentralised tracing within countries, and promote the tracing of contacts (, ENF). The app logs every device for fluid coordination between the testing and everyone who has downloaded the app and whose Bluetooth connection has tracing systems. been nearby. This data is stored on the mobile device; it is not reported to other databases. 9 This is particularly relevant for the use of apps. We found that some countries A person who wants to self-report that they are COVID-19-positive must log-in have developed different contact on the app by way of ‘NemID’, a Danish common secure login on the Internet, 10 tracing apps to broaden their ability to whereupon the diagnosis is validated in the National Patient Registry. If the person undertake early detection of potential new is registered with a diagnosis of COVID-19, the patient will be asked whether he/ COVID-19 infections. However, there she has symptoms of COVID-19, when the symptoms started, and whether the is heterogeneity in the characteristics of patient wants to share the information. 9 these apps: some apps are voluntary (e.g. If so, devices which have been closer than one meter to the device, for more Denmark) while others are compulsory than 15 minutes within the latest 14 days are notified. Neither the patient, nor (e.g. Russian Federation); some countries the citizens, receive information about each other’s identity. 9 By 8 July, the app have introduced legislation to allow access had been downloaded 745,000 times (12.8% of the population, assuming each to private data (e.g. Spain) while others user was unique), and 112 persons had registered themselves as infected with only use anonymised data (e.g. Belgium). COVID-19 using the app. 11 Independently of their characteristics, there should be transparency regarding how the information is gathered and for what purpose, with data number of active users, led to it being were largely assuaged by including input privacy prioritised. discontinued on 15 June; all data collected from cybersecurity experts at German were deleted. In Spain there is an order research institutes. that regulates the use of anonymised and aggregated data provided by Some lessons and recommendations limited mobile operators in order to analyse the for the future population movements prior and during the lockdown, with a view to identify Contact tracing has been identified as uptake by hotspots and improve the management a key element to control the spread of and coordination of health care resources. COVID-19. In our analysis we have found citizens means The app will be fully available for those that some countries had contact tracing autonomous communities that so wish by strategies in place, but dedicated resources that apps should September 15th, although some regions were initially insufficient at the onset of could have a first functional version by the health crisis. As the COVID-19 crisis not be the only mid-August, if needed. The use of the developed, countries invested additional app as well as communicating a possible resources into contact tracing, such as solution contagion would be voluntary. The hiring new personnel and/or developing Further, while some think that the use of technology for the app in Belgium has apps that could help support the re- apps can help make the contact tracing to be open source, use only anonymised opening of the economy. However, even if ‘‘ operation faster and more effective and data, and rely on Bluetooth technology countries have the appropriate resources engage citizens in the process, a limited as opposed to geolocation technologies. to perform contact tracing, ensuring the uptake by citizens mean that apps should Moreover, Belgium has specified that if system can identify possible cases quickly, not be the only solution. In fact, few different regions use different applications, as well as having adequate supervision countries get above 1 in 5 residents to they should be compatible with each other and management of contact tracers in download the contact tracing app. and with the federal eHealth platform. The place are key elements for the success of German app was developed by SAP and contact tracing. Deutsche Telekom and privacy concerns

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To conclude, we understand that the 3 Tagesschau.de. Corona Monitoring: Many 8 Nemid. Press release in Danish from the Ministry success of a solid contact tracing strategy Offices Remain Behind Guidelines. Hamburg: NDR/ of Health, “Now the app smitte|stop is ready for the is very much intertwined with other tagesschau.de, 2020. Available at: https://www. Danes”, 2020. Available at: https://www.nemid.nu/ tagesschau.de/investigativ/ndr-wdr/corona- dk-en/about_nemid/introduktion_til_nemid/index. strategies. These include the reinforcement gesundheitsaemter-103.html html of early detection of infection in primary 4 9 care (by PCR or any other equivalent Aerzteblatt.de. 496 Containment Scouts needed Smittestop. Q&A on Smitte|stop. Homepage in for Contact Tracing. Berlin: Deutsches Ärzteblatt, Danish, 2020 Available at: https://smittestop.dk/ test), closer coordination with the 2020a. Available at: https://www.aerzteblatt.de/ spoergsmaal-og-svar/ epidemiological surveillance services, nachrichten/112459/Fuer-Kontaktverfolgung- 10 Nemid. Homepage on NemID, 2020. Available and compliance with isolation measures. werden-496-Containment-Scouts-benoetigt at: https://www.nemid.nu/dk-en/about_nemid/ Further analysis across these may reveal 5 DW. German COVID-19 warning app wins on user introduktion_til_nemid/index.html relevant lessons for future health crises. privacy. Bonn: Deutsche Welle, 2020. Available at: 11 TV 2. News report from TV 2, a Danish https://www.dw.com/en/german-covid-19-warning- government-owned subscription television app-wins-on-user-privacy/a-53808888 References station, 2020. Available at: https://nyheder.tv2. 6 Independent. Germany coronavirus tracing dk/tech/2020-07-10-danmarks-smitteapp-hentet- 1 World Health Organization. Contact tracing in app transmits 1.2 million test results in 100 days. 745000-gange-men-vi-er-ikke-helt-i-maal-siger- the context of Covid-19 (Interim guidance), 2020. Available at: https://www.independent.co.uk/news/ professor Geneva: World Health Organization. Available at: world/europe/germany-coronavirus-track-and-trace- 12 agi.it. Immuni reaches 4 million downloads. https://www.who.int/publications/i/item/contact- test-app-cases-b550059.html tracing-in-the-context-of-covid-19 Pisano: Technically the app works well, 2020. 7 Ministry of Health. Press release in Danish of Available at: https://www.agi.it/economia/ 2 Department of Health and Social Care. NHS Test May 15 2020 from the Ministry of Health, “Political news/2020-06-27/immuni-download-pisano- and Trace: How it works. Guidance. 2020. Avaliable agreement on voluntary contact tracing app for bending-spoon-9005501/ (accessed on at: https://www.gov.uk/guidance/nhs-test-and-trace- COVID-19”, 2020. Available at: https://sum.dk/ July 14 2020). how-it-works Aktuelt/Nyheder/Coronavirus/2020/Maj/Politisk- aftale-om-frivillig-smittesporingsapp-for-covid-19. aspx

Achieving Person-Centred design and implementation of person-centred health systems but will also be an excellent resource for academics and Health Systems: Evidence, graduate students researching health systems in Europe. Strategies and Challenges Contents: Forewords; Acknowledgements; The person at the centre of health systems: an introduction; Person- Edited by: E Nolte, S Merkur & A Anell centredness: exploring its evolution and meaning in the health system context; Person-centred health Published by: Cambridge University Press, 2020 systems: strategies, Number of pages: xxiv + 398 pages drivers and impacts; Achieving person- ISBN: 978 1 108 79006 2 centred health systems: Freely available for download: https://www.euro.who. levers and strategies; int/__data/assets/pdf_file/0010/455986/person-centred- Community participation health-systems.pdf in health system development; Patient The idea of person-centred health systems is widely and public involvement advocated in political and policy declarations to better in research; Listening address health system challenges. A person-centred to people: measuring approach is advocated on political, ethical and instrumental views, experiences and grounds and believed to benefit service users, health perceptions; Choosing professionals and the health system more broadly. However, providers; Choosing there is continuing debate about the strategies that are payers: can insurance available and effective to promote and implement ‘person- competition strengthen centred’ approaches. person-centred care?; The This new study brings together the world’s leading experts service user as manager in the field to present the evidence base and analyse current of care: the role of direct challenges and issues. It examines ‘person-centredness’ from payments and personal budgets; Choosing treatments and the different roles people take in health systems, as individual the role of shared decision-making; The person at the centre? service users, care managers, taxpayers or active citizens. The role of self-management and self-management support; The evidence presented will not only provide invaluable policy Patients’ rights: from recognition to implementation; Index. advice to practitioners and policy makers working on the

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HOW COMPARABLE IS COVID-19 MORTALITY ACROSS COUNTRIES?

By: Marina Karanikolos and Martin McKee

Summary: Surveillance and monitoring systems are central to governments’ responses to the COVID-19 pandemic. This article focuses on assessing differences in mortality recording across countries and over time, to inform country comparisons. We show that variations in definitions, testing policies and changes over time affect international and intra-country comparability. Estimating excess deaths is therefore increasingly used to monitor the impact of COVID-19, with early evidence showing a major increase in excess mortality in countries most affected. Enhanced monitoring of the impact of COVID-19 on mortality using multiple data sources, with data published in a timely and accessible manner, is thus important.

Keywords: Mortality, Excess Deaths, COVID-19

Introduction comparisons, they must first understand how each country conducts surveillance The COVID-19 pandemic has created a and monitoring of deaths. This article, revolution in health data. Once, anyone based on the information collected from wanting to discover how a country was the COVID-19 Health Systems Response doing in terms of improving the health Monitor (HSRM) network, explores of its population would have to wait for how COVID-19 mortality is recorded in months or, in many cases, years to find countries in Europe and North America. out. No more. Now they can consult online dashboards such as those published online by the World Health Organization How are COVID-19 deaths defined? (WHO), Johns Hopkins University, and Headline figures for COVID-19 (those Cite this as: Eurohealth 2020; 26(2). Worldometer, among others, and find reported daily by official Government daily numbers and rates of COVID-19 sources for the current or previous day) of cases and deaths. But can they rely on cases and deaths have the benefit of being Marina Karanikolos is Research what they see? These dashboards rely real-time or near real-time. However, Fellow, European Observatory on summary data mostly supplied by on Health Systems and Policies, in many cases they have been gathered national governments. Yet, even in a London School of Hygiene and using systems set up specially to track the Tropical Medicine, UK; Martin single country, figures for COVID-19 pandemic, for example by gathering data McKee is Co-Director, European related deaths can vary among different Observatory on Health Systems and from hospitals or long-term care homes. sources and there are large variations in Policies and Professor of European It is therefore important to distinguish the proportion of additional deaths that Health Policy, London School of the resulting figures from those reported Hygiene and Tropical Medicine, UK. countries list as due to COVID-19 since by national statistical offices (or other Email: marina.karanikolos@lshtm. the onset of the pandemic. If those using ac.uk agencies/authorities) that use data from the dashboards are to make meaningful

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Table 1: Definition of COVID-19 deaths in headline figures

Diagnosis- Country Test-based Other issues affecting comparisons based Belgium ✔ – Only lab-confirmed deaths (largely in hospital) reported until 31st March Bulgaria ✔ – All reported deaths had +ve test result Canada ✔ – Figures include deaths from other causes “with” COVID Croatia ✔ – Those ‘probable’ can only be included if test +ve Cyprus ✔ ✔ Test result has to be recent Estonia ✔ – – France ✔ – – Germany ✔ – Figures include deaths “with” COVID Greece ✔ ✔ – Only lab-confirmed deaths were reported until 21st April, but all subsequent figures also Ireland ✔ – include probable deaths from the start of the pandemic Israel ✔ – – Latvia ✔ – All reported deaths had +ve test result Lithuania ✔ – – Malta ✔ – Those ‘probable’ can only be included if test +ve Poland ✔ – – Portugal ✔ – Probable deaths are tested for COVID-19 Romania ✔ ✔ – Serbia ✔ ✔ – USA ✔ – Only lab-confirmed deaths reported until mid-April Austria – ✔ – Bosnia and Herzegovina – ✔ – Hungary – ✔ – Iceland – ✔ – – due to +ve test requirement most are hospital deaths; Italy – ✔ – likely underestimate as alternative sources (e.g. statistical office) report higher numbers – due to +ve test requirement most are hospital deaths; Netherlands – ✔ – likely underestimate as alternative sources (e.g. statistical office) report higher numbers Norway – ✔ – – widespread testing performed with all patients with moderate/severe respiratory Slovenia – ✔ symptoms hospitalised and tested – due to +ve test requirement most are hospital deaths; Spain – ✔ – likely underestimate as alternative sources (e.g. statistical office) report higher numbers Sweden – ✔ – – may differ from data reported by cantons, where deaths also include those Switzerland – ✔ clinically diagnosed – until 29th April only hospital deaths were included for England; United Kingdom – ✔ – likely underestimate as alternative sources (Office for National Statistics, which publishes weekly data) report higher numbers

Note: Diagnosis-based definition is that based on clinical diagnosis of cause of death, both confirmed and probable; test-based definition is that where positive COVID-19 test is the required for death to be attributed to COVID-19. This information is based on country expert opinion collated within HSRM initiative as of June 2020. These are also based on publicly available information and may be subject to change.

the normal death registers, but take Table 1 shows the two main ways in COVID-19 cases that have died (e.g. longer to be processed. For a number of which COVID-19 deaths are reported Belgium, Canada, France, Germany) and reasons (see below), deaths reported daily in headline figures. The first, based on are not dependant on the availability of in headline figures may not be entirely clinical diagnosis of the cause of death, laboratory tests. The second, in contrast, is comparable across countries. counts clinically confirmed or probable reliant primarily on a positive laboratory

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test (e.g. Austria, Italy, the Netherlands, basis for many national diagnosis-based Where the clinical diagnosis-based Spain, the United Kingdom). However, the definitions (Column 2 in Table 1), although definition is used, it is more likely that distinction is not always clear cut. Some there may be variable delays in reporting a greater share of COVID-19-associated countries include probable COVID-19 due to the length of death certification deaths will be captured, unlike in deaths in the definition but still, in process. The June update added the last countries relying solely on positive tests – practice, require laboratory confirmation sentence to the above mentioned definition for reasons mentioned above. However, (e.g. Cyprus, Greece, Romania, Serbia), to ensure that all deaths due to COVID-19 there are further caveats: recording of while there are also countries that in all countries are identified, including cause of death on the death certificates can primarily use clinical diagnosis of cause in countries that may not follow WHO vary due to differences in implementation of death, but also include any death among guidance for death certification. of international and national guidelines, positive cases (e.g. Canada). Occasionally, as well as death certification and coding countries distinguish deaths with The other definition relies on a positive practices. For example, some countries COVID-19 and deaths from COVID-19 in test, and as a consequence, on rigorous using the clinical diagnosis-based the headline figures (e.g. Lithuania). testing policies and availability of accurate definition still require a positive test result tests. As a result, the following issues must (e.g. Greece), while others (e.g. Canada) be considered: include any death in a person with COVID-19, even if it was not triggered • Testing policies vary widely across by the virus (e.g. trauma). There may countries; moreover, they have evolved also be changes in guidelines over time, over the course of the pandemic. 2 Once which is particularly relevant during this resulting in community spread began, population pandemic, as it involves the emergence on groups in some countries with limited a novel cause of death. The complexity of many years of life testing capacity eligibility for tests was tracking COVID-19 mortality, accounting restricted (e.g. to people with severe for changing definitions and different expectancy symptoms). This resulted in limiting sources of data, especially where there are reporting mainly to hospital deaths (e.g. differences among sub-national units, can being wiped out Italy, the Netherlands, Spain, the United be seen in the United Kingdom (see Box 1). Kingdom (England)) as those attributed The international standard for the to COVID-19. At the same time, definition of COVID-19 death based deaths in long-term care institutions Monitoring excess deaths can more on clinical diagnosis was published by and residential setting have often accurately highlight the scale of WHO on 16th April 2020 and updated been underreported. 3 COVID-19 impact ‘‘ 1 guidelines on 7th June. According to these guidelines, death due to COVID-19 • In addition to absolute number of The issues discussed above limit is defined as: deaths, the case-fatality ratio for comparability of the headline COVID-19 COVID-19 is also affected by testing. mortality figures among countries. “a death resulting from a clinically Countries with very narrow testing Therefore, both WHO and the European compatible illness, in a probable or criteria, for example those only testing Centre for Disease Prevention and Control confirmed COVID-19 case, unless there severe cases that present in hospital, are (ECDC) recommend European countries is a clear alternative cause of death that likely to have comparatively high case- monitor total, as well as excess mortality cannot be related to COVID disease fatality rates as a result of the smaller (compared with what would be expected (e.g. trauma). There should be no period volume of tests. at that time of year) by age at least on a of complete recovery from COVID-19 weekly basis. 8 Tracking all deaths has between illness and death. A death due In terms of testing accuracy, PCR several advantages. Most importantly, it to COVID-19 may not be attributed to (polymerise chain reaction) test sensitivity includes deaths among those who probably another disease (e.g. cancer) and should can be as low as 54%, 4 with results also had COVID-19. It also provides a more be counted independently of pre-existing depending on the timeliness and expertise comprehensive picture of the scale of conditions that are suspected of triggering of sample collection. This means that a mortality during the crisis and facilitates a severe course of COVID-19. Deaths due number of cases were not detected due to comparisons across countries. Excess to COVID-19 are the ones that are counted false negatives. However false positives deaths would include all causes, and in cause of death data collection (for the are extremely rare. therefore include any increase in mortality purposes of COVID-19 death reporting)”. from other conditions, including those where people were not able to access Following from this, diagnosis- or Implications for interpreting the timely care (but would also be reduced cause-based approach requires reported headline COVID-19 mortality figures where deaths fell, for example from fewer COVID-19 deaths to be identified on Given the variation in defining COVID-19 road traffic injuries when people were a death certificate by a clinician as an deaths in the headline figures, caution under lockdown). underlying cause where the disease is needed when making comparisons of caused, or is assumed to have caused, COVID-19 mortality across countries. or contributed to death. It served as a

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Box 1: Counting COVID-19 deaths – an example from The impact of differences in assessing the impact of COVID-19 the United Kingdom mortality can be illustrated using the figures from England and Wales, as reported by the ONS for 2020. 6 From the week Challenges in maintaining coherent mortality dataset can ending 13th March to week ending 17th July, a total of 245,007 be illustrated by looking at the UK, which has undergone deaths were registered. Of these, a quarter (57,886) were several iterations in definition of COVID-19 deaths, coupled excess deaths (those above the average of corresponding with variations across the UK countries of England, Northern weeks for the preceding 5 years). The number of deaths where Ireland, Scotland and Wales (Table 2). First, until 29th April, the COVID-19 was mentioned on a death certificate (i.e. probable, official daily COVID-19 death count for England only included suspected or confirmed) amounted to 50,800. These, however, deaths in hospitals, but not in any other settings. Second, may be an underestimate, as in England doctors were not the breadth of definition across countries still varies. Third, required to mention COVID-19 on the death certificate. 7 the Office of National Statistics (ONS) reports a parallel set of Deaths with a COVID-19 positive lab test represent an even figures for England and Wales, using the definition based on smaller number, about 42,000, suggesting a further degree of clinical diagnosis. Fourth, in July it transpired that for England underestimation, despite the possibility of inclusion of some figures include deaths from causes not related to COVID-19 if deaths from other causes while a person also tested positive a person ever tested positive for COVID-19. This led to change for COVID-19. in definition in August and recalculation of deaths reported in the headline figures. 5

Table 2: Definitions of death from COVID-19 in the UK’s headline figures

Country Source Definition of COVID-19 death UK UK Government (Gov.uk) Figures are the total of COVID-19 deaths reported by the four devolved administration. England Public Health England (PHE) From 12/08/2020: Deaths are only included if the deceased had had a positive test for COVID-19 and died within 28 days of the first positive test. From 29/04/2020 to 12/08/2020: deaths of people who have had a diagnosis of COVID-19 confirmed by a PHE or NHS laboratory. Before 29/04/2020: deaths in NHS-commissioned services (e.g. hospitals) of patients who have tested positively for COVID-19. Wales Public Health Wales From 12/08/2020: deaths of hospitalised patients in Welsh Hospitals or care home residents where COVID-19 has been confirmed with a positive laboratory test and the clinician suspects this was a causative factor in the death. The majority of deaths included occur within 28 days of a positive test result. Before 12/08/2020: A death in a hospitalised patient or care home resident where COVID-19 has been confirmed with a positive test and the clinician suspects this was a causative factor in death (does not include deaths in other settings). Scotland Scottish Government (Gov.scot) A confirmed COVID-19 death of an individual who dies within 28 days of their first positive COVID-19 laboratory report. Northern Department of Health Northern Ireland Deaths reported to the Public Health Agency where the deceased has had a positive test Ireland for COVID-19 and died within 28 days, whether or not COVID-19 was the cause of death.

A number of initiatives to facilitate important to bear in mind that there is groups are essentially invisible in the international comparisons using excess variation by age group, deprivation level, statistics. 10 Weekly figures reported deaths have been developed. The Financial sex and ethnicity, with higher mortality by the Economist 11 suggest that there Times has been an especially valuable rates in men compared to women and were weeks in the spring of 2020 where source. Its analysis, on 13th July 2020, in older age groups. Evidence from the mortality exceeded historical levels in reports an increase in mortality in UK and USA also shows that death Belgium, France, Italy, Netherlands, comparison to levels of previous years of rates are also disproportionately higher Spain, Sweden, Switzerland and over 40% in several countries (e.g. in Italy, among people with Black and some the United Kingdom. Spain, Belgium, the United Kingdom). 9 Asian ethnic backgrounds; however, very However, the situation varied markedly few other countries in Europe record Excess mortality not only makes it among regions within countries. It is also information on ethnicity, meaning these possible to better understand the overall

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impact of COVID-19 on population Figure 1: Excess mortality in the peak of the COVID-19 pandemic in Europe health, it also facilitates tracking the impact of the pandemic in real time, if reported with a minimal delay and at least on a weekly basis. This shows the important role of Statistical Offices or equivalent agencies in timely collection and publication of all-cause mortality data. As an analysis by the UK’s Health Foundation shows, during the peak of the pandemic, the number of deaths in Spain, Italy and the United Kingdom has more than doubled in comparison to the average figure for the corresponding week in the preceding 5 years. 12 A recent study from Sweden shows that from the first week of April onwards the country experienced an increase in excess mortality among people over 60 years of age, with those over 80 being particularly affected with a 75% increase in mortality in men and 50% in women. 13 That study also finds that this is leading to a rapid drop in life expectancy at age 50 – by 3 years in men and 2 years in women. Unfortunately, however, these crucial data are not routinely reported or tracked via dashboards in the same way as COVID-19 headline figures in most countries, even within the European Union.

The exception is a subset of countries (18 European Union / (EU/EEA) countries, Berlin region of Germany and the 4 countries of the United Kingdom) whose agencies contribute to the EuroMOMO project. 14 Despite the approximately 4 weeks delay in publishing Note: Figure shows excess deaths in Week 15 (beginning of April) 2020. a complete dataset and the scale of excess deaths for individual countries or regions Source: Data from Euromomo being expressed as a z score (with each z unit being one standard deviation) Conclusions reporting of COVID-19 mortality. In rather than the more intuitive figure of contrast, figures that are based on death In summary, national definitions of the percentage of excess mortality (or certificates are widely recognised as more COVID-19 deaths fall broadly into ideally, the actual figures to allow for reliable, but take longer to be reported, two groups: clinical diagnosis-based more detailed inspection), it still shows and therefore are subject to varying, but (confirmed and probable) and test-based. that in spring 2020 mortality in Belgium, often considerable delays. In addition, This may result in a substantial lack France, Ireland, Italy, the Netherlands, accuracy may vary depending on the of comparability of COVID-19 related Portugal, Spain, Sweden, Switzerland and implementation of international guidelines mortality across countries. In addition, the 4 countries of the United Kingdom and recording practices within countries. issues such as testing policies, places of was significantly higher than the levels death included, changes over time, and seen between 2015 and 2019 for all ages Estimations of excess deaths are regional variations in practices can further (see Figure 1). The highest increases in increasingly used to monitor the true scale complicate mortality monitoring. deaths were seen in people over 65 years of the impact of the COVID-19 pandemic of age, but high excesses (z > 10) were also with minimal time lag. Early evidence Where headline figures are subject to seen in France, Spain and particularly in already shows close to two-fold increase laboratory test confirmation, there often England among younger age groups. in excess mortality in countries most is evidence from statistical offices or affected, resulting in many years of life research agencies of substantial under-

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expectancy being wiped out. However, it 3 Health Foundation. Care homes have seen the 8 European Centre for Disease Prevention and seems remarkable that there are so many biggest increase in deaths since the start of the Control. Rapid Risk Assessment: Coronavirus disease difficulties in obtaining comparable and outbreak. 2020. Available at: https://www.health.org. 2019 (COVID-19) in the EU/EEA and the UK – ninth uk/news-and-comment/charts-and-infographics/ update. 2020. Available at: https://www.ecdc.europa. timely data on the deaths of the people of deaths-from-any-cause-in-care-homes-have- eu/en/publications-data/rapid-risk-assessment- Europe. The current pandemic must lead increased coronavirus-disease-2019-covid-19-pandemic-ninth- national governments to place a higher update 4 European Commission. Current performance of priority on timely collection, analysis, and COVID-19 test methods and devices and proposed 9 Financial Times. Coronavirus tracked: the latest reporting of mortality in the future. For performance criteria – Working document of figures as countries reopen. 2020. Available at: now, however, they should concentrate Commission services. 2020. Available at: https:// https://www.ft.com/content/a2901ce8-5eb7-4633- on ensuring that we can see the impact of ec.europa.eu/docsroom/documents/40805 b89c-cbdf5b386938 COVID-19 on mortality using a variety 5 PHE (12/08/2020) PHE data series on deaths in 10 Pan D, Sze S, Minhas J, et al. The impact of of data sources, published in a timely and people with COVID-19: technical summary. Available ethnicity on clinical outcomes in COVID-19: A accessible manner. at: https://www.gov.uk/government/publications/ systematic review. The Lancet. 2020;23:1004040. phe-data-series-on-deaths-in-people-with-covid-19- DOI https://doi.org/10.1016/j.eclinm.2020.100404 technical-summary 11 The Economist. Tracking covid-19 excess deaths References 6 Office for National Statistics (ONS). across countries. 2020. Available at: https://www. 1 World Health Organization. Medical certification, Deaths registered weekly in England and Wales, economist.com/graphic-detail/2020/07/15/tracking- ICD mortality coding, and reporting mortality provisional. 2020. Available at: https://www. covid-19-excess-deaths-across-countries associated with COVID-19. 2020. Available at: https:// ons.gov.uk/peoplepopulationandcommunity/ 12 Health Foundation. Understanding excess www.who.int/publications/i/item/WHO-2019-nCoV- birthsdeathsandmarriages/deaths/datasets/weeklyp mortality. 2020. Available at: https://www.health.org. mortality-reporting-2020-1 rovisionalfiguresondeathsregisteredinenglandandwal uk/news-and-comment/charts-and-infographics/ es 2 Karanikolos M, Rajan S, Rechel B. How do understanding-excess-mortality-the-fairest-way-to- 7 COVID-19 testing criteria differ across countries? Dyer C. Covid-19: Trust withdraws guidance that make-international-comparisons Health Systems Response Monitor (HSRM). 2020. doctors need not put “covid-19” on death certificates 13 Modig K, Ebeling M. Excess mortality from Available at: https://analysis.covid19healthsystem. British Medical Journal 2020; 369 :m1641. COVID-19. Weekly excess rate deaths by age and org/index.php/2020/04/16/how-do-covid-19- sex for Sweden. MedRxiv preprint. DOI: https://doi. testing-criteria-differ-across-countries/ org/10.1101/2020.05.10.20096909

14 Euromomo. European mortality monitoring activity. 2020. Retrieved from: https://www.euromomo.eu/ graphs-and-maps/

includingCover_PB_Building preventive on value-based healthcare.qxp_Cover_policy_brief services 02/10/2020 10:59 Page 1 Building on value-based World Health Organization Regional Office for Europe and other publicUN City, Marmorvej 51, health functions. DK-2100 Copenhagen Ø, Denmark Tel.: +45 39 17 17 17 They then Fax:define +45 39 17 18 18 value to be the health care: Towards a health E-mail: [email protected] web site: www.euro.who.int system perspective contribution of the health system HEALTH SYSTEMS AND POLICY ANALYSIS to societal wellbeing. The European Observatory on Health Syst partnership that supports and promotes evidenc ems and Policies is a policy-making through comprehensive and rigor e-based health health systems in the European Region. It brings POLICY BRIEF 37 range of policy-makers, academics and pr ous analysis of together a wide trends in health reform, drawing on experactitioners to analyse HEAL By: PC Smith, A Sagan, L Siciliani, D Panteli, M McKee, The authorsEurope to illuminatefind policy that issues. The Observatory’ any ience from across are available on its web site (http://www.healthobservatory.eu). TH s products CARE A Soucat & J Figueras meaningful formulation of the Building on value-based health care concept of wellbeing includes Copenhagen: World Health Organization 2020 (acting as Towards a health system perspective health, and by extension health Peter C Smith Anna Sagan the host organization for, and secretariat of, the European Luigi Siciliani systems, as an important Dimitra Panteli Observatory on Health Systems and Policies) HEAMartin McKeeLT H Agnès Soucat contributor to wellbeing. Health Josep Figueras Observatory Policy Brief 37 improvement, responsiveness, SYSTEM financial protection, efficiency Number of pages: 31; ISSN: 1997-8073 Print ISSN and equity are widely 1997-8065 Web ISSN Freely available for download at: https://apps.who.int/iris/ accepted as health systems’ 1997-8073 bitstream/handle/10665/336134/policy-brief-37-1997-8073- core contributions to eng.pdf?sequence=1&isAllowed=y wellbeing. Health systems can also contribute to wellbeing indirectly through Preoccupation with the value created by health systems the spillover effects that its actions have on other sectors. has been longstanding, and will likely only intensify given the ongoing health systems strains and shocks such as the Moreover, effective governance of the whole health system COVID-19 pandemic. But the focus so far has usually been is needed to ensure that stakeholder perspectives and policy limited to value as seen from the perspectives of certain actors levers are aligned to promote a common concept of health in the health system and/or to certain dimensions of value. system value and, ultimately, of societal wellbeing. There are governance tools, such as the TAPIC framework, that can In this policy brief, the authors call for a shared understanding help achieve this. of value that embraces the health system in its entirety,

Eurohealth — Vol.26 | No.2 | 2020 Ensuring sufficient workforce capacity 51

WHAT STRATEGIES ARE COUNTRIES USING TO EXPAND HEALTH WORKFORCE SURGE CAPACITY DURING THE COVID-19 PANDEMIC?

By: Gemma A. Williams, Claudia B. Maier, Giada Scarpetti, Antonio Giulio de Belvis, Giovanni Fattore, Alisha Morsella, Gabriele Pastorino, Andrea Poscia, Walter Ricciardi and Andrea Silenzi

Summary: Finding ways to increase the surge capacity and flexibility Cite this as: Eurohealth 2020; 26(2). of the health workforce has been fundamental to delivering an effective COVID-19 response. This article explores the strategies Gemma A. Williams is Research Fellow, European Observatory that 44 countries in Europe plus Canada have taken to maintain on Health Systems and Policies, London School of Economics and increase the availability of health workers using data from the and Political Science, London, UK; Claudia B. Maier is Senior COVID-19 Health System and Response Monitor. We show that all Researcher; Giada Scarpetti countries have used a variety of strategies to repurpose and mobilise is Research Fellow, Technical University of Berlin and European the existing health workforce, while some have also augmented Observatory on Health Systems and Policies, Berlin, Germany; capacity by utilising foreign-trained or previously retired or inactive Antonio Giulio de Belvis is Researcher, Institute of Public health professionals, medical and nursing students and volunteers. Health, Section of Hygiene, Catholic University of the Sacred Heart, Rome, Italy; Giovanni Fattore is Full Professor, Department Keywords: Health Workforce, Surge Capacity, Planning, Implementation, COVID-19 of Policy Analysis and Public Management, Bocconi University, Milan, Italy; Alisha Morsella is Research Assistant, Institute of Introduction infected by COVID-19. Monitoring and Special Medical Pathology and surveillance data show, for example, Health systems globally have taken steps Medical Semeiotics, Catholic that out of all persons infected with to maintain and enhance the capacity University of the Sacred Heart, COVID-19, health care workers made Rome, Italy; Gabriele Pastorino of the health workforce during the up 7% of the total in Germany, 10% in is Technical Officer, Division of COVID-19 crisis. This surge planning was Country Health Policy and Systems, North Macedonia, 14% in the United required not just to meet an anticipated World Health Organization Regional Kingdom, and almost 20% in Cyprus and Office for Europe, Copenhagen, rise in demand for health care in acute Lithuania. 1 Moreover, many countries Denmark; Andrea Poscia is Doctor, and emergency care settings, but to Walter Ricciardi is Full Professor, entered the crisis with pre-existing increase testing and monitoring and Institute of Public Health, Section workforce shortages and/or geographical of Hygiene, Catholic University surveillance capacity and to ensure that imbalances in the distribution of health of the Sacred Heart, Rome, Italy; essential services across all settings Andrea Silenzi is Doctor of Public care professionals. 2 3 Health, Center for Research and could be maintained. Ensuring the availability of health workers has been Studies on Leadership in Medicine, As noted in the World Health Catholic University of the Sacred complicated by workforce depletion Organization’s (WHO) technical Heart, Rome, Italy. as health care workers themselves Email: [email protected] guidance on ‘Strengthening the Health comprised a substantial share of those System Response to COVID-19’,

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Table 1: Country strategies for maintaining or scaling up health workforce capacity

Among Medical /nursing Retired Inactive Foreign-trained Other existing health Volunteers students HP HP HP measures + workforce ° Albania ✔ ✔ ✔ – – – – Armenia ✔ ✔ – – – – ✔ (abroad) Austria ✔ ✔ – – ✔ – ✔ (military) Azerbaijan – ✔ – – – ✔ – Belgium ✔ ✔ ✔ – – ✔ – Bosnia and ✔ ✔ ✔ – – – – Herzegovina Bulgaria ✔ ✔ ✔ – – ✔ – Canada ✔ ✔ ✔ ✔ – – ✔ (military) Croatia ✔ – – – – – – Cyprus ✔ ✔ – – – ✔ ✔ (private) Czech Republic ✔ ✔ – – ✔ ✔ – Denmark ✔ ✔ – ✔ – – ✔ (military) Estonia ✔ – – ✔ – ✔ ✔ (military) Finland ✔ – – – – – – France – – – – – ✔ – Germany ✔ ✔ ✔ – ✔ ✔ – Greece ✔ – – – – ✔ – Hungary ✔ ✔ – – – – ✔ (private) Iceland ✔ ✔ ✔ – – – – Ireland ✔ ✔ ✔ ✔ – ✔ ✔ (private) Italy ✔ ✔ ✔ – ✔ ✔ ✔ (military Israel ✔ ✔ – – – – – Kyrgyzstan – ✔ – – – ✔ – Latvia ✔ ✔ – – – – – Lithuania ✔ ✔ ✔ – – ✔ – Luxembourg ✔ ✔ ✔ ✔ – – – Malta ✔ ✔ – ✔ – ✔ – Monaco ✔ – – – – – – Montenegro ✔ ✔ – – – – – Netherlands ✔ ✔ ✔ ✔ – – ✔ North Macedonia ✔ – – – – – ✔ (private) Norway ✔ ✔ – – – – – Poland ✔ ✔ – – – – ✔ (military) Portugal ✔ ✔ – – – – – Romania ✔ ✔ – – – – – Russian – ✔ – – – – ✔ (military) Federation San Marino ✔ – – – – – – ✔ (military Serbia – ✔ – – – – abroad) Slovenia ✔ ✔ – – – – – Spain ✔ ✔ ✔ ✔ ✔ – – Sweden ✔ ✔ – – – – – Switzerland ✔ ✔ – – – – ✔ (military)

Eurohealth — Vol.26 | No.2 | 2020 Ensuring sufficient workforce capacity 53

Among Medical /nursing Retired Inactive Foreign-trained Other existing health Volunteers students HP HP HP measures + workforce ° Turkey ✔ – – – – – – Ukraine ✔ ✔ – – – – – ✔ (military, United Kingdom ✔ ✔ ✔ ✔ ✔ ✔ private)

Notes: HP = Health professionals, MoH = Ministry of Health

° examples include extra hours, part-time to full-time, cancelling leave

+ examples include redeploying armed forces personnel or private sector health professionals to the public sector

Source: Authors’ analysis, based on 1

surge capacity can be enhanced Multiple strategies have been additional training, such as in use of through a variety of measures, implemented to expand the capacity personal protective equipment (PPE) or including repurposing and mobilising of the existing workforce, often in the management of patients with acute the existing workforce, changing underpinned by emergency legislation respiratory failure. In many countries, working patterns, bringing inactive older health professionals at greater Table 1 shows that the majority of or retired health professionals back to risk of severe illness from COVID-19 countries have implemented a range the workforce, calling on volunteers, were moved away from face-to-face of policy measures to maintain to the and mobilising nongovernmental and consultations to answer helplines or to capacity of the existing professional private sector workforce capacity. 4 provide teleconsultations (e.g. Spain, health workforce. The most common In this article we explore which of these Poland and the UK). strategies (reported by 21 countries) strategies 44 countries in the European include: asking health professionals to region plus Canada have adopted to Additionally, some countries have work extra hours, including moving from expand workforce surge capacity during redeployed private sector staff into the part-time to full-time work or allowing the first wave of the COVID-19 pandemic public sector (e.g. Cyprus, England, extra overtime (e.g. Croatia, Finland, using data extracted from the COVID-19 Ireland, Malta, Montenegro, North Germany, Norway, Ireland, Italy, Latvia, Health System and Response Monitor Macedonia). For example, in England, Poland, Spain, Sweden); modifying (HSPM). 1 We also consider whether any an agreement has been brokered for the work schedules (e.g. Canada, Croatia); new strategies have been utilised and government to take over private hospitals suspending ongoing or scheduled external the tools that have been used to facilitate and their staff for the duration of the crisis, rotations for residents in training (e.g. implementation in practice. We should resulting in tens of thousands of clinical Spain, Romania); suspending exemptions note that while supporting health workers staff moving to the public sector. after night shifts or on-call activities in practical terms and protecting their (e.g. Poland, Spain, Switzerland); and mental health and well-being are important Implementation of many of these reforms cancelling leaves of absence or foreign- measures to maintain health workforce has necessitated adoption of emergency travel (e.g. Canada, Czech Republic, capacity, strategies targeting these legislation or suspension of existing Greece, Israel, Luxembourg, Norway, issues are discussed in the next article in legislation. Examples include a decree Spain). Four countries (Austria, Hungary, this special issue and are therefore not enacted in Finland requiring all staff The Netherlands and the UK) have also addressed here. between the age of 18 and 68 working temporarily changed or postponed re- in both private and public health care registration and revalidation obligations Our findings show that of the measures to work to tackle the crisis as needed. for physicians. outlined in the WHO technical guidance, Greece meanwhile has officially revoked most have been adopted to increase surge leave of absences for public sector staff, Many countries have also redeployed capacity in the European region and while Israel has prohibited health care health workers to work in different settings Canada, with most countries adopting at workers from leaving the country. In (e.g. in hospitals instead of the community least two or more measures in combination Canada, the provinces of Ontario and or rotating between different facilities), to (see Table 1). Quebec announced regional legislation regions or cities with greater care needs, to redeploy health and social care or to different disciplines, most notably professionals to different units /facilities to assist in intensive care units (ICUs), based on needs and to cancel vacations emergency departments or provision of and modify work schedules. In Germany, telehealth services in primary care. These directives on minimum nurse staffing health workers have generally received

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Box 1: Measures towards maintaining or increasing health premium of €200 for each day of work, paid by the Department workforce capacity in Italy of Civil Protection. Hosting regions were responsible for reimbursing transfer and accommodation. Italy has adopted several measures to increase the availability These measures have enabled several regions to rapidly of health workers, facilitated by the implementation of two increase their workforce capacity. In absolute numbers, Decrees (n. 14 of 9/03/2020 and n. 18 of 17/03/2020), and by 8th May, Lombardy had hired 589 additional doctors underpinned by additional funding of €660 million. These (+ 3.8%) and 1,016 nurses (+ 2.6%) whereas Emilia Romagna measures have included the government approving the hired 421 doctors (+ 4.7%) and 1032 nurses (+ 4.0%). The permanent hiring of 20,000 health care professionals, allocating biggest effort was made by Marche, which increased its €250 million for staff overtime, authorising health care facilities capacity of clinicians by 15.8% and of nurses by 7.3%. to retain staff eligible above the age of retirement, offering retired doctors and nurses the opportunity to volunteer to A number of other countries have also sent volunteer teams practice and requesting temporary enrolment of doctors to Italy as acts of solidarity. For example, Ukraine sent and nurses from the armed forces. In addition, freelance over 16 doctors and 4 nurses in support of the Marche region, and temporary contracts for nurses and doctors have been while Albania sent a team of specialised physicians and nurses permitted, also for those who are not yet listed as specialist to Lombardy. Moreover, teams of doctors and nurses from, in the Medical Registers (i.e. resident doctors) and temporary Tunisia, China, Cuba, Poland and Russia have come to serve practice in Italy has been allowed for those who have been in the most affected areas of Lombardy such as Bergamo, practising abroad under European Union (EU) directives. Brescia and Cremona. A team of 19 physicians from Norway and another team of 11 doctors and four nurses from Romania On the 20th and 28th March 2020, the Department of were also deployed to Lombardy through the European Civil Civil Protection issued two Ordinances (N° 654 and 656, Protection Mechanism. This mechanism has been set up by respectively) to establish a Specialist Medical Unit and a the EU to enable a prompt sharing of resources among all Technical-Nursing Unit, with doctors and nurses recruited Member States to respond effectively to emergencies that through online calls. Almost 7,000 doctors and 10,000 occur inside or outside the EU. It facilitates cooperation and nurses applied as candidates, with 300 physicians and 500 coordination to foster prevention, preparedness and response nurses (from the National Health Service, private clinics and to disasters. When, as in the case of COVID-19, an emergency freelancers) later recruited by the Head of the Department requires a stronger effort than a country by itself can handle, of Civil Protection on the basis of specific requirements. the European Commission coordinates the Mechanism and Participation was voluntary and volunteers were sent to areas contributes to at least 75% of the transport and/or operational most affected by the COVID-19 emergency. In addition to their costs of deployments. normal salary, each professional received a flat-rate solidarity

levels in hospitals and the professional assisting with contact tracing (e.g. Bosnia and online portals (e.g. Ontario, Canada nurse /nursing assistant ratios in nursing and Herzegovina, Malta, Montenegro, and Bavaria, Germany) that match demand homes and ambulatory nursing practices Serbia, Slovenia). from health facilities in need, with supply. were suspended. Italy enacted a number of Decrees to increase the availability of Campaigns were launched to bring Efforts to encourage non-registered health health workers (see Box 1). retired or inactive health professionals to return to work have also professionals back to the workforce been taken at the local level. Hospitals Most countries have called upon in some countries (e.g. the Netherlands, medical and nursing students to work In Belgium, Bosnia and Herzegovina, Bosnia and Herzegovina and Germany) in clinical practice Denmark, Germany, Iceland, Ireland, Italy, have, for example, asked inactive or retired Malta, The Netherlands, Norway, Poland, health professionals to return to work, In 36 countries, provisions were made the UK, and the provinces of Ontario and often through social media campaigns and to recruit medical and nursing students Quebec in Canada, national or regional with the offer of additional, short-term to support health professionals, for campaigns have been launched asking trainings for returnees. instance by allowing final year students retired and /or other previously registered to graduate early and join the workforce health professionals to join the COVID-19 These measures have resulted in a or by offering a gap semester to support response. These measures have been large number of health professionals health professionals (see Table 1). Students supported by the creation of temporary volunteering to return to work, although that were not necessarily in their final year registers, underpinned by emergency less have been recruited in clinical have also assisted in operating COVID-19 legislation to simplify re-registration practice. In Ireland, 72,000 people signed hotlines in a number of countries or by procedures (e.g. Poland, Spain, the UK) up to ‘Be on call for Ireland’, with 260 nurses and 63 doctors hired by mid-

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the pandemic were transferred to Austria, Germany, Luxembourg and Switzerland Box 2: Various initiatives have been taken in Germany to enable foreign-trained for treatment. High-level diplomacy professionals to support the response between governments and coordination across sectors such as transport, the Germany has taken steps to enable physicians trained outside the EU and not yet military and health care played a key role licenced to practice in Germany to assist the response. Before the pandemic, there in facilitating these arrangements. 5 were an estimated 14,000 foreign-trained physicians in Germany waiting for their medical qualifications to be recognised, many of whom arrived as refugees in 2015. To enable these professionals to support the response, a number of initiatives were Volunteers have also been enlisted to launched at the State and local level. In Saxony, for example, the state medical support the COVID-19 response in association launched a Facebook appeal asking for German-speaking, foreign- selected countries trained doctors living in the state but without a license to practice, to volunteer In France, the “medical care reserve” by working as medical assistants. By the end of March, almost 300 doctors had was mobilised to allow for volunteers, signed-up to help. In Bavaria, foreign-trained doctors in the process of having mostly with health education such as qualifications recognised but without a medical license were granted permission retired nurses and physicians or students, to work as medical assistants for a year. In North Rhine-Westphalia, foreign- to be deployed by the government. trained doctors in particular those working in anaesthetics, ENT and general Similarly, in Belgium, a list of reserves internal medicine, were able to obtain an expedited professional permit to practice with medical experience was organised at (under supervision) provided they passed a simplified language exam and already the level of federated entities to provide had a contract with a health facility. In addition, professional permits of health assistance with health services under their professionals already working in the State were automatically extended beyond competencies where required. In addition, the usual two-year limit. Red Cross volunteers have set up medical orientation posts at 20 hospital sites. In Greece, more than 8,000 volunteers April. In the UK, over 10,000 health asylum seekers with medical qualifications applied to support the COVID-19 response professionals registered to return to work, were able to work in support roles such as through the digital platform (https:// with close to 5,000 hired and redeployed health care assistants, while registration ethelontes.gov.gr), created by the Ministry by mid-April. fees for foreign-trained doctors have of Health. been waived. Foreign-trained doctors, Countries have also implemented nurses and already working Other countries (including Cyprus, emergency recruitment procedures in the UK, but with visas due to expire by Estonia, Germany, Greece, Italy, Malta, to hire new health workers October 2020 have had them automatically Poland and the UK) have also asked renewed for a year. In Austria, 24-hour for volunteers with little or no prior Emergency procedures to hire new health carers from Eastern European countries experience to help, often in basic support workers have been launched in a number were allowed to continue to enter the roles such as manning helplines or of countries. In Portugal, hiring of health country to ensure that people with live-in delivering medication and food to the most care workers was facilitated through an carers continue to receive care. vulnerable, such as those self-isolating exceptional procedure, with 137 doctors or shielding. and 1,100 nurses hired by the end of In eleven countries medical and support July. In Serbia, 4,500 health workers were personnel from the army were also To date, there is limited information employed during the state of emergency recruited to help with the pandemic on how volunteers will be or have been period, while Romania has created 2,000 in health or long-term care settings deployed in practice and how safety temporary jobs (6 months). (see Table 1). standards have been adapted and ensured.

Other recruitment strategies have In an act of solidarity, some European Policy lessons and implications targeted migrant health workers, countries have also sent health workers health professionals from the private to countries in need. For example, teams Evidence from the COVID-19 Health sector or armed forces of physicians from France, Lithuania and Systems and Response Monitor shows Italy were sent to Armenia to provide care that a range of policy options at different Belgium, Czech Republic, Ireland, Italy, to COVID-19 patients, while teams from levels (national, regional and local) were Luxembourg, Spain, the UK and several various countries have assisted in Italy used by countries to enhance the surge regions in Germany (see Box 2) have (see Box 1). In Serbia, an NGO invited capacity of the health workforce to meet developed strategies to bring foreign- Serbian physicians abroad to temporarily unprecedented demand and /or to support trained health professionals – in the return. In addition, patients from some re-organisation of health services during process of registration – into the workforce European countries including France, Italy the COVID-19 pandemic. The strategies temporarily or to speed up recognition and the Netherlands that were in danger of and tools used to support implementation procedures. In Ireland, refugees and running out of ICU capacity at the start of are outlined in Table 2. The most common

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Table 2: Strategies adopted to maintain and enhance surge capacity and tools used to facilitate implementation

Strategy Implementation tools Repurpose and redeploy the existing health workforce Modify existing work • Suspend existing regulations or contractual arrangements to modify work schedules, increase practices working hours, change night shift working or relax minimum staffing requirements • Emergency legislation to cancel leaves of absences or change registration requirements • Coordination between professional associations and national or regional health authorities • Contractual arrangements to modify work schedules, increase working hours, change night shift working or relax minimum staffing requirements Redeploy health workers • Centralised or regional online portals to match supply with demand to disciplines, facilities, • Extra funding and temporary contract changes regions or cities with greater need • Additional training in person or online for health professionals to facilitate expanded scope of practice or greater task sharing • Mandate health workers at risk of severe consequences from COVID-19 to work in non-patient facing roles Redeploy private sector • Emergency legislation for public sector actors to take over private sector hospitals and staff workers to work in the • Coordination between private and public sector representatives public sector • Government funding to pay wages or compensation to private sector workers Mobilising and recruiting additional health workers, students and volunteers Recruit (final year) medical • Medical and nursing schools approve early graduation and nursing students • Allow early graduates to apply for provisional registration • Relevant bodies to develop and offer temporary recruitment contracts • Allow students that do not want to take early provisional registration to work in support roles Bring inactive or retired • National or regional recruitment campaigns using traditional and social media health professionals back • Creation of temporary registers to the workforce • Relevant professional associations or health authorities to develop and offer temporary recruitment contracts • Professional bodies directly contacting potential returnees • Individual health facilities appealing to past employees to return • Refresher training and training on COVID-19 treatment, management and safety measures, either online or in person • Online portals to match supply with demand Recruit new health • Coordination between health facilities and regional or national government to report and assess demand and supply professionals • Additional funding • Emergency legislation to launch exceptional recruitment procedures Bringing foreign-trained • Reduce language requirements and waive fees for conversion exams health professionals into • Emergency legislation to allow foreign-trained doctors to work in support roles the workforce • Automatically extend work visas for foreign-trained professionals • Allow health and care workers to continue to cross borders to work, even if borders are otherwise closed • Remove working hour restrictions for medical and nursing students on visas Utilising military medical • Cross-sectoral coordination capacity • Emergency legislation allowing military health workers to work in civilian settings Requesting assistance • High-level diplomacy at Ministerial level from other countries or • Cross-sectoral working to transport health workers across borders international organisations • Mutual recognition of qualifications across the EU Recruit volunteers for • National or regional recruitment campaigns using traditional and social media non-medical or basic • Appropriate training medical tasks • Digital tools to match supply with demand

Source: Authors’ own

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measures utilised include strategies to References enhance the capacity of the existing 1 World Health Organization, European workforce, combined with recruiting Commission, European Observatory on Health (final year) medical and nursing students. Systems and Policies. COVID-19 Health System Some countries also took measures to Response Monitor platform, 2020. Available at: bring retired or inactive or foreign-trained https://www.covid19healthsystem.org/mainpage. aspx but unregistered health professionals into to the workforce, redeployed private 2 World Health Organization. Global strategy on sector workers into the public sector or human resources for health: workforce 2030. Geneva: WHO, 2016. Available at: https://www.who.int/hrh/ asked volunteers to support the response. resources/pub_globstrathrh-2030/en/ Most countries adopted at least two 3 measures to increase surge capacity, European Commission. State of Health in the EU Companion Report. Luxembourg: Publications with countries most affected by the Office of the European Union, 2019. Available at: pandemic implementing a broader range https://ec.europa.eu/health/sites/health/files/state/ of measures. docs/2019_companion_en.pdf

4 World Health Organization. Strengthening the The implementation of many of these health system response to COVID-19: Maintaining changes has necessitated rapid adoption the delivery of essential health care services while of emergency legislation to give planners, mobilizing the health workforce for the COVID-19 providers and commissioners of health response. Technical working guidance #1. Copenhagen: WHO Regional Office for Europe, 2020. services temporary new powers related Available at: https://apps.who.int/iris/bitstream/ to changing recruitment, planning and handle/10665/332559/WHO-EURO-2020-669- integration of these new workers in 40404-54161-eng.pdf?sequence=1&isAllowed=y clinical practice. Additionally, online 5 Winkelmann J, Scarpetti G, Hernandez- portals have been critical to enable Quevedo C, van Ginneken E. How do the worst-hit current or inactive health care workers to regions manage COVID-19 patients when they have register interest in joining the response, no spare capacity left? Health System Response to facilitate temporary registration where Monitor – Cross-Country Analysis. WHO, European Commission, European Observatory on Health required and to match workforce shortages Systems and Policies, 24 April 2020. Available at: with supply. Additional training to enable https://analysis.covid19healthsystem.org/index. health professionals to work in different php/2020/04/24/how-do-the-worst-hit-regions- health care settings and roles or to allow manage-covid-19-patients-when-they-have-no- volunteers to join the response was also spare-capacity-left/ needed. In many cases, new funding was required to facilitate the hiring of new workers on a temporary or permanent basis, to support training and the re- deployment of workers to different health care facilities or regions.

There is little information on how these strategies have played out in practice and the impact they have had on workforce expansion, workflows, skill-mix and quality of care. Evaluations of the different workforce strategies that have been employed ad-hoc in the various countries would be beneficial to learn from the crisis and inform contingency plans in the event of future waves and to re-consider health workforce options for the future.

Eurohealth — Vol.26 | No.2 | 2020 58 Ensuring sufficient workforce capacity

HOW ARE COUNTRIES SUPPORTING THEIR HEALTH WORKERS DURING COVID-19?

By: Gemma A. Williams, Giada Scarpetti, Alexia Bezzina, Karen Vincenti, Kenneth Grech, Iwona Kowalska-Bobko, Christoph Sowada, Maciej Furman, Małgorzata Gałązka-Sobotka and Claudia B. Maier

Summary: Health workers have been at the forefront of treating and caring for patients with COVID-19. They were often under immense pressure to care for severely ill patients with a new disease, under strict hygiene conditions and with lockdown measures creating practical barriers to working. In this article we consider measures that countries have put in place to support health workers and enable Cite this as: Eurohealth 2020; 26(2). them to do their job. We show that countries have implemented a range of measures, from mental health support, financial bonuses Gemma A. Williams is Research Fellow, European Observatory and practical support such as free accommodation and transport. The on Health Systems and Policies, London School of Economics and effectiveness of these initiatives should be evaluated to inform future Political Science, UK; Claudia B. Maier is Senior Researcher, crisis responses and strategies for health workforce development. Giada Scarpetti is Research Fellow, Technical University of Berlin and European Observatory Keywords: Health Workforce, Mental Health and Well-being, Childcare, on Health Systems and Policies, Financial Support, COVID-19 Germany; Alexia Bezzina is Resident Specialist in Public Health Medicine, Department for Policy in Health, Ministry of Health, Malta; Karen Vincenti is Introduction symptoms of depression, 19.8% symptoms Consultant Public Health Medicine, of anxiety, 8.27% insomnia and 21.9% An effective COVID-19 response includes Department for Policy in Health, high perceived stress. 2 This mental health Ministry for Health, Malta and implementing strategies that can support burden may lead to burnout and force staff WHO National Counterpart for health workers to provide high-quality Malta; Kenneth Grech is Resident to take sick leave or leave their profession care, while maximising their protection. Academic, University of Malta; altogether. Moreover, many countries have Iwona Kowalska-Bobko is Health workers treating COVID-19 been in lockdown with schools closed Professor, Jagiellonian University patients have been shown to be at high and transport reduced, which has created Medical College, Faculty of Health risk not only of becoming infected Science, Institute of Public Health, practical barriers for health workers to by the virus themselves, but also of Poland; Christoph Sowada is work. A survey by the Irish Nursing and Professor, Jagiellonian University experiencing anxiety, stress, trauma and Midwife Organisation, for example, has Medical College, Faculty of other mental health conditions. An early Health Science, Institute of Public found that 62% of nurses and midwives study from Wuhan, China for instance Health, Poland; Maciej Furman is with childcare needs in Ireland have had Assistant, Jagiellonian University found that 13.5% of health professionals to take annual leave to care for children Medical College, Faculty of Health treating COVID-19 patients showed signs Science, Institute of Public Health, during the pandemic. 3 Poland; Małgorzata Gała˛zka- of depressive disorder, 24.1% showed signs Sobotka is PhD student, Lazarski of anxiety disorder, and 29.8% showed In this article we explore the range of University, Institute of Health signs of stress. 1 Similarly, 49.3% of health mental health, financial and other practical Care Management, Poland. Email: workers in Italy reported experiencing [email protected] support measures that 36 countries in post-traumatic stress symptoms, 24.7% Europe and Canada have put in place

Eurohealth — Vol.26 | No.2 | 2020 Ensuring sufficient workforce capacity 59

Table 1: Measures taken to support health workers during the COVID-19 outbreak outside of clinical settings

Mental health Childcare Financial + Other ++

Albania – – ✔ –

Armenia – – ✔ –

Austria – ✔ – –

Belarus – – ✔ –

Belgium ✔ ✔ – –

Bosnia and Herzegovina – – ✔ –

Bulgaria ✔ – ✔ –

Canada ✔ – ✔ –

Croatia ✔ – – –

Czech Republic ✔ ✔ – –

Denmark ✔ ✔ – –

Estonia – – ✔ –

Finland ✔ – – ✔

France ✔ ✔ ✔ –

Germany ✔ ✔ ✔ –

Greece – – ✔ –

Hungary ✔ – ✔ ✔

Ireland ✔ ✔ – –

Israel ✔ ✔ – –

Italy ✔ – ✔ ✔

Kyrgyzstan ✔ – ✔ ✔

Latvia ✔ – ✔ –

Lithuania ✔ ✔ ✔ ✔

Malta ✔ ✔ – ✔

Monaco – ✔ – –

Montenegro – – ✔ –

Netherlands – ✔ – –

Norway ✔ ✔ – ✔

Poland ✔ – ✔ ✔

Portugal – ✔ – –

Romania ✔ ✔ ✔ ✔

Russian Federation ✔ – ✔ –

San Marino ✔ – – –

Sweden ✔ ✔ – –

Turkey ✔ – – ✔

United Kingdom ✔ ✔ – ✔

Source: Authors’ compilation from 3

Notes: + These include financial measures beyond usual payments or salaries for health workers, including bonuses and pay rises for COVID-19 related work; ++ These include practical measures such as provision of free accommodation, transport or parking.

Eurohealth — Vol.26 | No.2 | 2020 60 Ensuring sufficient workforce capacity

Box 1: Support for health workers in Malta The guidance recommends resting and eating well, noticing and trying to help colleagues who may be struggling with their Malta has provided a wide range of support to health workers mental health and making supervisors or colleagues aware of during the COVID-19 crisis. their own mental health needs where necessary.

Mental health support Financial support

Mental health support provided by psychiatrists and Health care workers who were required to stay at home on psychologists has been organised in Malta for public health Preventive Quarantine under the Protection of Vulnerable staff and also for medical staff working on the frontline. Where Persons Order (LN 111 of 2020) still received their basic pay requested, in-house psychologists are providing outreach and class /grade allowances. in various front-line workplaces, giving short interactive Other practical support sessions on basic self-care skills and resilience. Mindfulness sessions have also been offered to hospital workers together Measures to ensure continuity of parental care of children with targeted video clips on how to increase resilience. at home due to school closures include the facilitation of Several mental health NGOs and institutions have developed complementary shift work, support of telework by the parent/ agreements with government to provide mental health support guardian staying at home to look after children, or financial to the public by means of a freephone helpline run by mental support in terms of paid leave where this is not possible. health professionals and volunteers, including fast track referral In addition, a free childcare centre was opened by the pathways to those requiring psychological and psychiatric care. government to care for children of health care professionals and members of the disciplined corps. A confidential Employee Support Programme (ESP) that was established prior to the pandemic continues to offer free A number of initiatives delivered through the main hospital confidential support to public service employees including (Mater Dei Hospital), the main professional associations for health care workers. Employees are able to use ESP services health care workers and also through the Ministry for Health during their working hours if they take vacation leave or request sought to facilitate and fund accommodation for front-line a temporary absence with the approval of their supervisor. workers who needed to leave their residence to reduce the risk The Medical Council has also issued guidelines for doctors, of transmission to family members. encouraging safe practice, the use of telephone and virtual By: Alexia Bezzina, Karen Vincenti, Kenneth Grech consultation and safe online prescribing, and self-care.

to support health workers, using data workers can call to access psychological are often in addition to more general extracted from the COVID-19 Health support from trained professionals and/ guidelines for mental health support that Systems Response Monitor (HSRM). or to receive referrals to additional mental were available pre-crisis. We only consider initiatives implemented health services. These helplines are outside of clinical settings where sometimes organised at the national level Remote counselling sessions with COVID-19 patients are treated, and (e.g. Bulgaria, Czech Republic, France, psychiatrists or psychologists are provided therefore exclude workplace provisions Israel, Malta, Romania, San Marino, in some countries (e.g. Denmark, Finland, such as availability of personal protective United Kingdom) at the regional level Italy, Lithuania, Malta, Kyrgyzstan, equipment, working time limits or (e.g. Belgium and Denmark) and /or by Poland, Russian Federation and the UK) mandatory rest periods. professional associations for specific for COVID-19-related stress management, professions (e.g. France, Ireland, Latvia, burnout prevention and other mental health Most countries have put in place Poland, Turkey, UK). In Hungary and support. Norway has also established special measures to support the Croatia, helplines are run by universities a buddy-system whereby health mental health of health workers, and schools of public health. Apps and professionals can talk to a matched peer. often through helplines and online services are also available in some In Malta, a range of mental health support remote counselling countries (e.g. Belgium, Finland, Ireland, has been offered, including mindfulness Norway, Romania, UK). sessions for hospital workers and sessions Table 1 shows that 25 countries have on resilience for the public health response adopted special measures to support the In Germany, Ireland, Norway and the UK, team (see Box 1). mental health of health and social care guidelines or other forms of guidance for workers during the COVID-19 crisis. promoting mental health and well-being In Stockholm, Sweden the rules for have been issued, targeting both health accessing 24-hour mental health support In many countries, this support is provided workers themselves and employers. These have been relaxed for the duration of the through newly established helplines that health and oftentimes social care

Eurohealth — Vol.26 | No.2 | 2020 Ensuring sufficient workforce capacity 61

Box 2: Support for health workers in Poland Compensation will be maintained for medical personnel who will not be able to work in other locations. Poland has implemented a number of initiatives to support Some hospitals have supplemented the salaries of their health workers during the COVID-19 crisis. employees with an allowance to compensate them for being Mental health support exposed to patients with COVID-19. For example, employees of hospitals in Gdan´sk receive an additional 20% of their basic In terms of psychological support for medical staff and other salary (as specified in the employment contract) and 20% employees working during the pandemic, the Supreme Medical of the hourly rate (as per the contract); and in Wroclaw an Chamber created a database of mental health specialists who additional PLN 30 (€6.82) (gross) per hour of work is offered as are willing to offer their services to doctors, nurses, paramedics compensation. The director of the University Hospital in Krakow and other medical free of charge, either online or by phone. In has also committed to paying supplements to personnel addition, the state insurance state company (PZU Life) has set working in the infectious disease ward and in the hospital’s up a helpline (tel. number 22 505 11 77) offering psychological emergency department. support to health care workers. The helpline is open every day from 8am until 8pm. Other support for health workers

Financial compensation Various citizens’ initiatives were launched during COVID-19 to support health workers in terms of providing childcare. The From 29 April 2020 to 27 July 2020, health care employees in best known are the “Medical students” and “The crown won’t Poland who were in contact with COVID-19 patients (or persons fall off” initiatives. Volunteers are trained by action coordinators, with a suspected coronavirus infection) were prohibited from together with a group of educators from “Villages” – an initiative working in more than one place. To compensate them for that aims to educate and support teachers, families and local the lost income due to this restriction, the Minister of Health communities in creating and running educational environments instructed the National Health Fund (NHF) to provide them with for young children. monthly cash benefits, which were financed from the Ministry of Health budget. The benefits were set at a maximum of Because medical personnel working in hospitals are at higher PLN 10,000 (€2,270) per month and were calculated as 80% of risk of contracting coronavirus, in order to protect their families the remuneration received at the place of work where, after the some hotels are providing accommodation to such medical introduction of the restriction, the employee no longer works, personnel. Voivodeship branches of the National Health Fund or, at a minimum, at 50% of remuneration received at the place are responsible for securing and paying for accommodation for where the employee chose to work after the restriction was the staff of hospitals treating patients with COVID-19. introduced. It is estimated the bonus was on average PLN 6500 The staff of the emergency department of the University (€1,480) for physicians and PLN 3000 (€682) for nurses. Hospital in Zielona Góra together with the Polish Radio West The compensation also covered the costs of social security prepared a spot as part of the #wspierajmedyka (‘support the contributions payable by the employer. medic’) campaign, which aims to draw attention to the problem On 27 July 2020, the obligation for medical professionals of discriminatory treatment that some health care workers have to work in one facility was relaxed. This is now decided by experienced during the COVID-19 pandemic (e.g. not being directors of medical facilities, who may release employees allowed into shops out of fear that they are infectious). from the obligation to work in only one entity. An employee By Iwona Kowalska-Bobko, Christoph Sowada, Maciej Furman, may be denied this if the exemption would result in the facility Małgorzata Gała˛zka-Sobotka having difficulties in providing care to COVID-19 patients.

crisis, such that health workers are able to (Austria, Belgium, Czech Republic, Israel, some hospitals and universities access help directly without a referral from Denmark, France, Germany, Monaco, independently organised childcare (for their manager. Netherlands, Norway, Portugal and children aged 3+ years) for their workers. UK), the provinces of British Columbia, Childcare facilities were provided for Ontario, and Quebec in Canada and One-time bonuses or other forms of health care workers in several Vilnius Municipality, Lithuania. Romania financial compensation have been countries where schools were closed meanwhile paid allowances to cover for awarded to health workers in childcare costs during the crisis in the case many countries During the peak of the COVID-19 where a health worker’s partner could not pandemic, childcare facilities and schools take paid leave. Nineteen countries reported providing remained open to provide childcare for additional financial support and health workers where these institutions In the absence of a national childcare compensation above normal salaries were otherwise closed in several countries scheme for health care workers in to health care workers involved in the

Eurohealth — Vol.26 | No.2 | 2020 62 Ensuring sufficient workforce capacity

COVID-19 response. This generally took (BVAP). Some German states (e.g. Policy lessons and implications the form of one-time bonus payments Bavaria) have also given health workers Countries have introduced a variety of (Bosnia and Herzegovina, Estonia, a bonus in addition to that provided by measures outside of clinical settings to France, Greece, Germany, Hungary, Italy, the central government. support and value health workers and Kyrgyzstan, Romania, Russian Federation, enable them to do their job during the Ukraine) or monthly bonus payments for Health care professionals working with COVID-19 pandemic. These range from the duration of the crisis (Albania, Latvia) COVID-19 patients have been granted mental health and well-being support from the central government. In Bulgaria, a temporary salary increase in Belarus, initiatives, to providing bonuses and a monthly premium of BGN 1,000 (€511) Lithuania and Montenegro for the duration temporary salary increases. Practical for medical and non-medical professionals of the crisis, set as a percentage of usual measures such as childcare provision and treating coronavirus patients has been monthly salaries. In Canada, the federal free transport and accommodation have announced, to be paid until the end of government, provinces and territories also been implemented to ensure health the year. have agreed to share wage top-ups for workers can get to their workplace and essential workers. have their children looked after. Other In Kyrgyzstan the bonus amount was initiatives such as offering continuing reported to vary according to profession, Beyond bonuses and salary rises, some professional development credits for with doctors paid the highest amount. countries (e.g. Denmark, Lithuania and knowledge learnt during the crisis were In Greece, Latvia and the Russian Spain) have recognised COVID-19 as also offered in some countries, albeit Federation, the bonus amount was set as a work-related injury for health care less frequently. a proportion (50%, and between 20 – 50%, staff, enabling them to access associated and 20 –100% respectively) of the regular benefits. Further, in Kyrgyzstan, While a large number of initiatives monthly wage. In Lithuania, salaries Lithuania, Romania, Spain and the UK, have been introduced, often as ad-hoc of health care professionals at medical health workers’ families will receive a measures, their effectiveness in helping institutions treating COVID-19 patients lump sum payment if a health care worker staff is unknown in most countries. It and those carrying out prevention working with COVID-19 patients dies due is important that countries evaluate the activities were to increase by 60 –100% to COVID-19 infection. In Spain, Social impact of these initiatives to inform during the pandemic; the exact amount at Security will consider COVID-19 as the strategies for delivering an effective crisis public providers is to be determined by cause of death if the fatality occurs within response in the future. In addition, the the head of institution, depending on the five years after the onset of the infection. mental health and well-being of health type and place of work, and the associated workers should be routinely assessed risks of contracting the disease. In France, Other support measures such as both during the crisis and after. Beyond financial bonuses have been offered free transport, accommodation, and the crisis period, providing appropriate to all staff working in public hospitals continuing education credits have long-term mental health support, adequate irrespective of their occupation and been put in place salaries and other compensation should position, as well as staff working in private be measures for further evaluation as core hospitals that deal with COVID-19 patients Some countries have introduced other components of developing a sustainable and those working in nursing homes. The practical support measures for health health workforce. bonus for health workers ranged from workers. For example, Poland, Romania, €1,500 for those in the most affected Malta and some provinces in Turkey have regions to €500 for those in less affected offered free accommodation for health References € regions, and from 1,500 for nursing home workers isolating from their families 1 Zhu Z, Xu S, Wang H, et al. COVID-19 in staff if they worked in a badly affected during the pandemic. In Hungary and Wuhan: Sociodemographic characteristics and region to €1,000 if they worked in a less some parts of the UK, health workers hospital support measures associated with the affected region. In Poland, health workers have been given free access to public immediate psychological impact on healthcare received financial compensation and transport, while NHS workers in London workers. EClinicalMedicine, published by the Lancet 2020;100443. bonuses for being exposed to COVID-19 can hire bikes for free from a city-wide patients and having restrictions placed on cycle scheme. In Helsinki, Finland health 2 Rossi R, Socci V, Pacitti F, et al. Mental health where they can work (see Box 2). It should, workers have been granted free parking outcomes among frontline and second-line health care workers during the Coronavirus disease 2019 however, be noted that in some countries, near health facilities. A hospital in Poland (COVID-19) pandemic in Italy. JAMA Netw Open. bonuses promised by central governments has launched a campaign to reduce 2020;3(5):e2010185. have yet to be received by health workers. discrimination against health workers 3 Irish Nursing and Midwife Organisation (INMO). see Box 2 ( ). In Italy, doctors, dentists, Nurses using up annual leave to provide childcare – In Armenia and Estonia, bonus payments nurses and pharmacists who continued INMO survey, 2020. Available at: https://inmo.ie/ for staff have been paid by individual working during the COVID-19 pandemic Home/Index/217/13596 hospitals. In Germany, long-term care have been awarded 50 Continuing Medical workers were paid a bonus by the labour Education (CME) credits for the year 2020. union ver.di and the Federal Association of Employers in the Care Industry

Eurohealth — Vol.26 | No.2 | 2020 Providing health services effectively 63

MANAGING HEALTH SYSTEMS ON A SEESAW: BALANCING THE DELIVERY OF ESSENTIAL HEALTH SERVICES WHILST RESPONDING TO COVID-19

By: Melitta Jakab, Naomi Limaro Nathan, Gabriele Pastorino, Tamás Evetovits, Sarah Garner, Margrieta Langins, Cris Scotter and Natasha Azzopardi-Muscat

Summary: The COVID-19 pandemic has put health systems and their ability to deliver health care services under strain. During the pandemic, health policymakers and health managers have learned to operate within a so-called “new normal” carefully balancing the response to COVID-19 with ensuring continuity of essential health services. Depending on the phase of the epidemic, the focus of service delivery needs to change requiring rapid shifts in priorities and allocation of resources while maintaining a baseline functionality for both. This dual-track approach presents an extreme challenge for policymakers and health facility mangers in agility and rapid alignment of key health system functions to accommodate increased demand for health services. Cite this as: Eurohealth 2020; 26(2).

Keywords: Health Systems, Dual Track, Transition, Essential Health Services, Service Melitta Jakab is Head of Office, Delivery, COVID-19 WHO European Centre for Primary Health Care, Naomi Limaro Nathan is Consultant, Division of Country Policies and Systems, Gabriele Introduction – Increasing demand for the likely long-lasting consequences of Pastorino is Technical Officer, health services amidst growing fiscal COVID-19. This dynamic preparedness Division of Country Policies and Systems, Tamás Evetovits is Head constraints in a dynamic context is the “new normal” and some of the key challenges policy makers have to consider of Office, WHO Barcelona Office The COVID-19 pandemic has revealed for Health Systems Strengthening, when managing responses have been weaknesses in health systems’ Sarah Garner is Coordinator, addressed in the document published by Cris Scotter is Consultant, and preparedness and responses across the the WHO Regional Office for Europe Natasha Azzopardi-Muscat is European region. This has compelled Director, Division of Country on “Strengthening and adjusting public countries to rapidly adjust their public Policies and Systems, Margrieta health measures throughout the COVID-19 Langins is Advisor, World Health health measures, reconfigure their health transition phases”. 1 Organization Regional Office for systems 1 and remain prepared to continue Europe, Copenhagen, Denmark. Email: [email protected] to deliver a dynamic response, in view of

Eurohealth — Vol.26 | No.2 | 2020 64 Providing health services effectively

Figure 1: Dynamic change in demand for health services during the COVID-19 pandemic

COVID-19 outbreak peaks

Health system capacity (max surge) Accumulated demand for essential services

Health system capacity (basic)

Demand for health services for health Demand Temporary crowd-out of essential services Demand for more services due to economic crisis Time

Source: Authors’ own

The “new normal” implies that health It is therefore essential to consider lessons (iv) family planning and contraception systems will have to operate in a learnt in order not to repeat mistakes and (disrupted in 74% of surveyed challenging context – navigating both the adequately balance efficiency and equity countries); and, increasing demand for health services considerations going forward, while (v) outreach services for routine (discussed below) and the resource maintaining health as a priority of public immunisations (disrupted in 63% of constraints within new norms, standards policy and spending. Without adequately surveyed countries). and restrictions introduced as infection resourced health systems, economic and prevention and control measures. It also social recovery will not be possible. In addition, complete disruption of routine requires countries to recalibrate and outreach for immunisation, facility- reinforce their targets on progressing The impact of COVID-19 responses on based immunisation and rehabilitation towards Universal Health Coverage (UHC) essential health service delivery services has been reported by nearly to ensure that populations have access to a fifth the WHO European region’s quality health services during and after the So far, maintaining a balance between countries. 5 Not surprisingly, the three least pandemic, without experiencing any form COVID and non-COVID service delivery affected services have been urgent blood of financial hardship. 2 tracks and implementing dynamic shifts transfusion services, inpatient critical between service provision modalities care services and emergency surgery Countries are witnessing an increasing has been a challenge across the WHO since these all have a time-critical period demand for health services, arising European region. for intervention. from (i) COVID-19 cases, (ii) the pent- up demand for regular health services During pandemic peaks, many countries Explanatory factors for service delivery that are delayed during epidemic peaks, have reported severe disruptions in disruptions and reduced utilisation (iii) the physical and mental health impact regular service delivery, including in patterns include supply-side, demand-side of physical distancing measures and essential health services. 5 The five most and wider community factors. Essential isolation; (iv) continued need of care and significantly disrupted services from a list health services supply declined due to rehabilitation for long-COVID cases, and of 25 services surveyed were: 5 policies to accommodate surge capacity (v) the long-term impacts of the economic (i) rehabilitation services (disrupted in 91% for COVID-19 care such as reducing downturn (see Figure 1). of surveyed countries); health workers at primary health care level to expand surge capacity for the acute Meeting this increasing demand takes (ii) dental services (disrupted in 91% of COVID-19 response, instructing facilities place at a time of tightening resource surveyed countries); to shut down due to lack of guidelines, constraints due to the economic (iii) non communicable disease (NCD) operating standards and infection implications of the pandemic despite diagnosis and treatment (disrupted prevention and control mechanisms. historical fiscal measures. 3 The tightening in 76% of countries); Demand was affected by several factors, fiscal environment will echo experiences including explicit instructions to minimise from the financial crisis a decade ago. 4 face-to-face care seeking for non-

Eurohealth — Vol.26 | No.2 | 2020 Providing health services effectively 65

Figure 2: Overview of the dual track health system

Safety first: rethink patient flows for IPC at system and facility level (WG1)

Strengthen surveillance and create public health Strengthen and resource primary health care surge capacity to prevent peaks to respond to pent-up and new demand Recovery of health services

Elasticity in acute and intensive care Enhance and resource optimized platforms of

to remain prepared service delivery (video, phone, internet) (WG2)

Mechanism and system to deliver best clinical Restore confidence in safety of health care seeking

COVID-19 (WG1) knowledge to the frontline

Identify vulnerabilities and reconfigure regular care Protect older people in long-term care facilities for shielded people

Human resources for health: physical, psychological, social (WG3) Ensuring access to essential medicines and health technologies (WG4) Health financing implications: budgets, contracts, coverage (WG5) Governance of a dual system (based on dual dashboard) (WG6)

Note: IPC = Infection prevention and control Source: Authors’ own

COVID conditions, and due to the fear capacity for public health and laboratory 2. Essential health services track: This of exposure to the virus in health care services for testing, contact tracing and track calls for improving availability settings. In addition, wider community isolation. It also entails that countries and access to essential health services factors, such as barriers to physical access remain prepared for further outbreak with due considerations for patient and (e.g. public transport lockdowns) affected peaks and responding rapidly when health worker safety. 7 This requires utilisation patterns. they occur. Specifically, there are four identifying and addressing the root important policy areas to operationalise causes of disruptions in essential Dynamically changing dual track this track: health services during pandemic peaks. Specifically, there are four important health system - Strengthen surveillance and create policy areas to operationalise this track: public health surge capacity to prevent Going forward and expecting further further epidemic peaks; - Strengthen and resource primary shifts in the dynamic of the pandemic, it health care (PHC) to enable meeting is important to balance the response to - Remain prepared for further peaks by increased roles and functions of COVID-19 with those to other sources of estimating the needed surge capacity PHC during the pandemic such as morbidity and mortality. The continuous for hospitalised treatment of COVID-19 providing surge capacity to acute care monitoring of the range of services needed cases under different scenarios, 6 response for COVID-19, participating to prevent, diagnose, and treat COVID-19 monitor saturation of hospitals, and in public health action such as contact patients while restoring and maintaining create a step-wise elastic plan of tracing, “catching-up” delayed and the operation of essential health services is expanding and retracting hospital postponed delivery of essential health therefore key as countries enter different capacity for COVID-19 cases as the services (e.g. immunisation, screening, stages of the pandemic. country moves between different stages chronic condition management, etc.); of the epidemic; responding to new demand such as In order to meet these objectives health - Develop mechanisms to deliver rapidly increased chronic and mental health systems could adopt a dual track dynamic changing clinical knowledge about the conditions due to economic and social approach (see Figure 2) that allows for the delivery of COVID services; and problems associated with the pandemic, COVID-19 response and the delivery of and rehabilitation (e.g. for “long- essential health services to be managed in - Protect vulnerable populations and COVID” cases); one parallel system: marginalised groups, especially older people by tailoring both public health - Enhance and optimise service 1. COVID-19 track: This track entails and health service delivery approaches delivery platforms (e.g. by video, creating a blended public health strategy to their needs. phone, Internet) while analysing their with a mix of physical distancing impact and limitations; measures and rapid expansion of surge

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- Restore confidence in the safety of health care facilities by introducing Box 1: Ukraine – Psychosocial support for health workers strong infection control measures and communicating this clearly to the The Public Health Center of the Ministry of Health of Ukraine developed training for population; and health care staff working in emergencies and the COVID-19 pandemic response. - Identify vulnerabilities and The course aims to improve the ability of health care workers in providing reconfigure regular care for vulnerable psychosocial support to the population, as well as mastering the skills of stress patients (e.g. older people, immune- management at the workplace and protecting their own well-being. The training compromised people, etc.), to minimise course was based on the latest recommendations of the United Nations Inter- their physical attendance at health Agency Standing Committee, and WHO, as well as other best practices in mental facilities with greater risk of infection. health and psychosocial support (MHPSS).

Enablers for operationalising the dual track health system Box 2: Italy – Hotel facility close to the hospital in Puglia used to ensure rest The ability to operate the dual track and safety of workforce system is dependent on the activation of cross-cutting enablers in the health The Bari Policlinico General Hospital was designated a COVID-19 network hospital. system. These enablers include governance 656 health care workers were assigned to 300 COVID-19 beds. These workers of the dual track system, health workforce, were housed in a nearby hotel. In order to ensure there was no contact with public financing and access to medicines areas and hotel staff, the entrances, exits and lifts were defined as dedicated ‘dirty and technologies. paths’, along with the implementation of a range of other measures and protocols (electronic check-in, separate waste removal, etc). The initiative served both Governing the dual track system hospital and patient needs, and was also good for the health workers themselves, as they were given the opportunity to rest, protect their families and in tandem The organisation and management of it mitigated community spread (workers were not going home to their families or the dual track system requires utilising moving around the community). This example shows that with careful planning existing governance arrangements in an and excellent staff cooperation, health care workers can be hosted safely in hotel environment of increased complexity. facilities during the COVID-19 pandemic or similar emergencies. To ensure that both tracks are effectively governed, it is important to establish agile consultation mechanisms to facilitate dialogue between key stakeholders, The health workforce plays a key role and the article by Williams et al. on including patient, community and health supporting health workers) should be The health workforce is the backbone of worker representatives, and policymakers provided to avoid burnout and stress. the dual track system. It plays a key role and to ensure that decisions are taken in ensuring that both tracks are well- - The pandemic also provides urgent rapidly and are as participative and as balanced and can maintain the delivery of impetus to improving long-due labour transparent as possible. This requires health services in the “new normal”. This market policies to safeguard health bridging the governance and management is an extremely challenging task placing workers and enable their retention in the of the emergency response with that of the the health workforce under unprecedented health sector. health service delivery system. strain. Some potential mitigation measures include: Financing the dual track system Robust monitoring systems need to build a “dual dashboard of indicators” that tracks - The mobilisation of additional Evidence from previous economic shocks indicators and trends on COVID-19 in workforce – by hiring unemployed indicates that countries need to balance parallel to indicators and trends on the health workers, providing financial efficiency and equity considerations in delivery of essential health services. A incentives to attract recent leavers the health and social protection areas dual dashboard with a governance bridge or recruit health workers from other during economic downturns. Applying built between the management of the sectors (see the article by Williams severe austerity measures to health and emergency and that of service delivery et al. in this issue on health workforce social protection policies were counter- will allow countries to better manage surge capacity). productive during previous economic simultaneously their COVID-19 response crises, exacerbated the economic response - Addressing the working conditions, and the delivery of essential health in the long-run and created a political safety and mental health of health services. Finally, clear communication backlash. 4 8 9 workers. A conducive working to the public will be key to reassure environment with adequate rotation health service users that it is safe to To maintain health spending, with rest and recuperation periods and access facilities. countercyclical mechanisms – public psycho-social support (see Box 1, Box 2 spending that increases as the economy

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declines, could be used to ensure stability - Monitoring availability of medicines 4 Thomson S, Figueras J, Evetovits T, et al. in funding flows; these include drawing and health products that may be affected Economic Crisis, Health Systems and Health in on reserves; introducing formulas to by shortages. Europe Impact and implications for policy. Policy Summary. Copenhagen: World Health Organization determine the level of government budget - Ensuring that products for sale and (acting as the host organization for, and secretariat transfers to the health system; abolishing distribution meet regulatory standards of, the European Observatory on Health Systems and ceilings on contributions; and broadening Policies), 2014. Available at: https://www.euro.who. for safety, quality and effectiveness. the tax base from wages to all forms int/__data/assets/pdf_file/0008/257579/Economic- of income. crisis-health-systems-Europe-impact-implications- Conclusions policy.pdf

The pandemic with the tightening fiscal 5 The COVID-19 pandemic has put a strain WHO. Pulse survey on continuity of essential constraint together can further catalyse on health systems’ ability to respond health services during the COVID-19 pandemic: policies to enhance health system interim report. Geneva: World Health Organization, and deliver care, often at the expense of efficiency towards ensuring the effective 27 August 2020. Available at: https://www.who. the most vulnerable population groups. use scarce resources. Countries can: int/publications/i/item/WHO-2019-nCoV-EHS_ Countries have an opportunity to learn continuity-survey-2020.1 (European data separately • Review priority setting mechanisms to from the experiences, success stories and analysed and not yet published) ensure that public health and primary mistakes made during the first months of 6 For surge calculators developed by WHO to health care are adequately resourced; their response to tackle the continued need expand acute care capacity including human to strengthen their health systems. resources, see https://www.euro.who.int/en/health- • Review coverage and purchasing topics/Health-systems/pages/strengthening-the- mechanisms including for high-cost health-system-response-to-covid-19/surge-planning- In order to deliver essential health services services and medicines to ensure tools while responding to COVID-19, health coverage and spending reaches the most 7 systems will have to allocate a realistic WHO. Maintaining essential health services: cost-effective services; operational guidance for the COVID-19 context. amount of financial and human resources Geneva: World Health Organization, 1 June 2020. • Review service delivery master plans to address peaks and pent-up demand, Available at: https://www.who.int/publications/i/ and investment to ensure that the while ensuring health care workers’ safety item/WHO-2019-nCoV-essential-health- network is fit for purpose; and mental wellbeing. The systems should services-2020.1 be prepared to be as adaptable as possible 8 • Review coverage policies to ensure all Hou X, Velényi EV, Yazbeck AS, Iunes RF, Smith O. and ready to surge capacity by optimising Learning from Economic Downturns: How to Better have access to essential health services delivery platforms and enhancing the Assess, Track, and Mitigate the Impact on the Health without facing financial hardship to role of primary health care as needed. Sector. Washington, DC: The World Bank, 2013. ensure timely cost-effective health Continued access to medicines and 9 Velényi E, Smitz M. Cyclical Patterns in care access. health products and a robust governance Government Health Expenditures between 1995 and mechanism to plan, manage and monitor 2010: Are Countries Graduating from the Procyclical Access to Medicines and Technologies Trap or Falling Back? Health, Nutrition, and Population the response will be key to ensure a (HNP) Discussion Paper. Washington, DC: Sustainable and continued access to sustained response in the months to come. The World Bank, 2014. medicines and health products is essential for implementing and operationalising the References dual track system. Countries have faced challenges in the supply of medicines 1 WHO. Strengthening and adjusting public health and health products. In order to ensure measures throughout the COVID-19 transition phases. Policy considerations for the WHO uninterrupted access to medicines European Region. Copenhagen: World Health and supplies, countries need to adopt Organization, 24 April 2020. Available at: https:// measures, policies, and regulations that apps.who.int/iris/bitstream/handle/10665/332467/ are evidence-informed and supported by WHO-EURO-2020-690-40425-54211-eng. adequate and sustainable financing. pdf?sequence=1&isAllowed=y 2 WHO. Strengthening the health financing Some of these measures could include: response to COVID-19 in Europe. Copenhagen: World Health Organization, 22 April 2020. Available - Centralised procurement and forecasting at: https://www.euro.who.int/__data/assets/ to avoid competition amongst health pdf_file/0003/439617/COVID-19-health-financing- providers and prioritisation of products response-Europe.pdf necessary for the population health; 3 IMF. A Crisis Like No Other, An Uncertain Recovery. World Economic Outlook Update. Washington, DC: - Increasing local production, if possible, International Monetary Fund, June 2020. Available at: or repurposing to meet the needs of https://www.imf.org/en/Publications/WEO/ the health system (e.g. this occurred in Issues/2020/06/24/WEOUpdateJune2020 Germany, the Russian Federation and the United Kingdom), and

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RESTARTING MORE ROUTINE HOSPITAL ACTIVITIES DURING COVID-19: APPROACHES FROM SIX COUNTRIES

By: Erin Webb, Cristina Hernández-Quevedo, Giada Scarpetti, Nigel Edwards, Sarah Reed, Coralie Gandré, Zeynep Or, Fidelia Cascini, Juliane Winkelmann, Madelon Kroneman, Judith de Jong, Enrique Bernal-Delgado, Ester Angulo-Pueyo, Francisco Estupiñán-Romero, Selina Rajan and Sujay Chandran

Summary: During the COVID-19 pandemic, hospitals face the concurrent challenges of maintaining routine services while attending to COVID-19 patients. This article shares approaches taken in six countries to resume hospital care after the first wave of the pandemic by surveying country experts and using data extracted from the

Cite this as: Eurohealth 2020; 26(2). COVID-19 Health Systems Response Monitor (HSRM). Four strategies were observed in all six countries: prioritisation or rationing of

Erin Webb, Giada Scarpetti and treatments, converting clinical spaces to separate patients, using Juliane Winkelmann, Technical University of Berlin and European virtual treatments, and implementing COVID-19 free hospitals or Observatory on Health Systems and Policies, Berlin, Germany; floors. Clear guidance about how to prioritise activities would Cristina Hernández-Quevedo, European Observatory on Health support hospitals in the next phases of the pandemic. Systems and Policies, London, UK; Nigel Edwards and Sarah Reed, Nuffield Trust, London, UK; Keywords: Hospitals, Essential Services, Prioritisation of Care, COVID-19 Coralie Gandré and Zeynep Or, the Institute for Research and Information in Health Economics (IRDES), Paris, France; Fidelia Cascini, Department of Life Introduction The decrease in hospital services during Sciences and Public Health, the first months of the pandemic was often As the COVID-19 pandemic unravelled, Università Cattolica del Sacro substantial: data from five hospitals in Cuore, Rome, Italy; Madelon hospitals had to deal with the often Italy showed a 73 – 83% drop in paediatric Kroneman and Judith de Jong, overwhelming need to treat patients NIVEL, Utrecht, the Netherlands; emergency department visits, 2 while exposed to the virus. To minimise Enrique Bernal-Delgado, a study in Spain on the impact of the Ester Angulo-Pueyo and exposure and maximise health workforce COVID-19 on interventional cardiology Francisco Estupiñán-Romero, Unit capacity, many hospitals postponed activity showed a 56% decrease in the of Data Science in Health Services elective procedures and non-essential and Policy Research, Institute for number of diagnostic procedures and 81% services. 1 As a number of countries in Health Sciences in Aragon (IACS), reduction in structural interventions. 3 Zaragoza, Spain; Selina Rajan, Europe have begun to carefully resume The World Health Organization (WHO) Faculty of Public Health and Policy, services that were limited or suspended The London School of Hygiene and has released operational guidance on during the first wave of the pandemic, Tropical Medicine, London, UK; maintaining essential health services, and Sujay Chandran, Western Sussex this article looks at how six countries highlighted the need to limit non-essential Hospitals NHS Foundation Trust, (England, France, Germany, Italy, Spain, West Sussex, UK. facility-based encounters at hospitals for the Netherlands) have restarted more Email: [email protected] safety and capacity reasons. 4 In addition routine hospital care services.

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Table 1: Changes in hospitals to resume routine hospital activities after the first wave of COVID-19

Is this change expected in your country? (✔ = yes) Lower volume of activities in hospitals Prioritization or rationing of treatments Increase testing of staff Convert clinical spaces to separate patients Investment in facilities Investment in PPE Investment in staff Use of private sector capacity Emergency departments manage the inflow of patients differently Use of digital or phone and non-face-to-face modes continue and grow Use Covid-19-free hospitals or floors

France – ✔ ✔ ✔ ✔ ✔ ✔ – – ✔ ✔ Germany ✔ ✔ ✔ ✔ ✔ ✔ – – ✔ ✔ ✔ Italy ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Spain ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ The Netherlands ✔ ✔ – ✔ – – – – – ✔ ✔ England ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Source: Authors’ own to the impact on patient access, the requirements. The German Hospital also supported by the new Decree of reduction in routine hospital activities Federation does not expect a return to the Ministry of Health named “August also influenced hospital budgets in many routine activities until late 2021. 6 The Decree”. 11 countries, as the health financing system Netherlands reported an increase in often relies on activity-based payments. waiting times for some non-acute and Several countries have prioritised or Several countries in Europe have planned care such as in orthopaedics, rationed treatments, often using a already adjusted their hospital payment dermatology, gynaecology, ENT, and phased approach mechanisms as a result of altered activity. 5 ophthalmology; however, the waiting times in other specialties, including cardiology, In most countries, health systems are We designed a survey based on initial paediatrics and internal medicine, appear prioritising not only emergency care but findings from England on the necessary to have fallen. As of July 1, the number of also urgent care for which timeliness of and expected changes in the hospital referrals from general practitioners (GPs) intervention is crucial such as cancer setting for them to resume normal to hospital care has resumed to 80% of the services. In France, this is the key criteria activities. We collected responses from pre-pandemic volume in that country. In for resuming care, with a focus on national experts in six countries within England, targets have been set for the NHS vulnerable individuals including those the COVID-19 Health System Response to return to near-normal levels activity living with a chronic disorder. Further, Monitor (HSRM initiative) as of 1st in the period before winter, including hospitals are cautious to ensure intensive September 2020. An overview of the restoring full operation of cancer services, care unit (ICU) beds and rehabilitation survey and responses is presented in and 80% – 100% of elective capacity capacities remain available in case of Table 1 below. Some shared approaches (depending on the procedure). 7 However, another COVID-19 wave. By the end of for resuming routine hospital activities there are concerns from doctors on the August 2020, the number of available among the selected countries is illustrated feasibility of these targets and how well resuscitation beds was about twice in Figure 1. they can be sustained. A survey from the bed capacity before the first wave the Royal College of Physicians suggests (12,000 against 5,000). This caution is that it will take up to two years to recover also observed in other countries. Elective Health care systems expect a lower 8 volume of hospital activities in the the backlog from COVID-19. In Spain, procedures in England are expected to foreseeable future the number of organ transplants has resume to 80% of last year’s activity plummeted by 87% from 16.1 per day with full restoration of cancer services It is expected that hospitals will run at a to 2.1 per day. 9 In Italy, the situation by September. In Germany, at the end of reduced rate of occupancy for a prolonged became critical after the two-month April, hospitals were asked to keep 25% period of time, especially given the highly lockdown (which ended on May 4): the of all ICU beds available for COVID-19 volatile epidemiological context. For demand for health care was high and patients, down from a previous target example, in Germany, hospital rooms the waiting lists were very long, 10 even of 50%. Due to the federal structure with multiple beds may not reach their for ambulatory services. However, since of the hospital system in Germany, the occupancy due to physical distancing August, waiting lists have shortened federal states (Länder) developed their

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Figure 1: Common approaches to resuming routing hospital activities with country examples

The Netherlands and Germany England has red, amber have created lists of and green wards based on procedures to pending and actual prioritise. Separate COVID-19 status. Prioritise/ration clinical spaces treatments for patients

Increase use Implement of virtual COVID-19-free Until December 2020, treatments spaces Hospitals in the SHI fund will cover Spain and Italy set 100% of tele-consultation up COVID-19-speci c costs in France. ­oors and departments.

Source: Authors’ own Note: SHI = Statutory Health Insurance

own regional concepts, which allow created a list of diseases that may always outbreak, and preparations are being made the individual state to ensure 25% ICU require urgent surgery, such as hernias to test all staff routinely in the event of a capacity throughout the whole state with incarceration, gastrointestinal second wave. instead of in each hospital. In other bleeding, organ transplants, and more. words, a state can choose to have all these Clinical spaces that do not allow ICU beds in one hospital for COVID-19 Testing health care personnel will patients to be physically separated patients and other hospitals without continue towards supporting the safe may require reorganisation COVID-19 wards, as long as they meet provision of care the 25% ICU capacity overall. From All countries surveyed reported the need early May, hospitals were able to conduct In the absence of a vaccine, regular testing to create additional capacity and cohort elective surgeries again, following a of health care personnel is a key measure patients by repurposing other clinical reopening phase based on a stepwise implemented by countries to contain spaces. German hospitals are advised to approach, coupled with a frequent re- the spread of the virus and protect staff have separate units for new patients with evaluation of ICU bed capacity. and patients, which has implications in suspected COVID-19 infection, as well terms of cost and time. France reported as quarantine and isolation rooms for Spain has adopted different criteria systematically testing all health workers patients who tested positive for COVID-19. to prioritise surgery in five potential after the end of the lockdown in the In Spain, surgical recovery units were scenarios, ranging from a quasi-normal country. In Germany, to avoid or stop adapted to function as secondary ICU, situation (1st scenario, COVID-19 patients outbreaks of the virus, the testing and specific minor procedure rooms were < 5% of admissions) to an emergency strategy of the Robert Koch Institute set as COVID-19-specific. In England situation (5th scenario, COVID-19 patients foresees an increase in testing patients there are red, amber and green wards > 75% of admissions), depending on and staff in hospitals and other residential based on pending and actual COVID-19 the epidemiological situation. 12 In the facilities. In Spain, testing of healthcare patients’ status to try and separate Netherlands, a multi-stakeholder process personnel is prioritised and regular patients effectively. Wherever possible, drafted, commented on and validated (as testing is recommended for personnel patients with confirmed or suspected advice) an ‘urgency list’ of procedures of nursing homes and assisted-living COVID-19 are placed in cohorts with to prioritise when scaling up regular facilities (at least once each 15 days), as designated staff in self-contained areas to hospital care. 13 The German Association well as testing employees returning from prevent transmission. for General and Visceral Surgery created leave or vacation and new employees a list of prioritised elective interventions, before joining. In England, staff who are Some countries have introduced with surgeries of patients with rapidly experiencing symptoms (or have been ‘COVID-19 free’ hospitals or floors to progressing diseases and manageable exposed to someone who has) are tested. further reduce the rate of infection. In comorbidities preferred, however the Asymptomatic staff are tested routinely England, urgent and emergency surgery individual physician still makes the in places with high prevalence or a known was performed in ‘COVID-19-free’ treatment decisions. The association also private hospitals. In the Netherlands,

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some hospitals with multiple buildings Continuing investments in facilities, where safe and appropriate to do so, created COVID-19 hospitals and non- PPE and staff will be required building from efforts started before the COVID-19 hospitals, and some have pandemic to make digitally-enabled care In most cases, additional waiting rooms separate spaces for those with and without the mainstream across the NHS. Care and space to maintain physical distancing symptoms. Similarly, hospitals in Spain models like ‘virtual wards’ – where and keep infected and non-infected set up COVID-19-specific floors and patients who had been admitted and patients separate are paramount to prepare departments. In Italy, COVID-19 dedicated treated for COVID-19 in hospitals are sent hospitals for a potential increase of hospitals and wards were selected, and home for ongoing management remotely – COVID-19 cases, along with an adequate different intra-hospital patient flows were may become the norm to free up capacity supply of personal protective equipment designed to separate COVID-19 hospital and avoid further transmission. In Italy, (PPE). Further, the pandemic exacerbated admissions and also diagnostic and there was an important increase of health the health workforce shortage in some therapeutic activities from other patients. care providers initiatives concerning countries, which will need to be addressed In France patients are isolated, as much as telemedicine, especially teleconsultation. (for example, in England, by retaining possible, in dedicated wards. Among these, 29% were for COVID-19 staff who returned to work during the patients and 71% for non-COVID patients pandemic). Italy reported substantial (i.e. diabetology, cardiology, oncology). 14 Emergency departments in some investments to increase the number of In Spain, consultations before and after countries have changed their triage contracts for physicians and nurses. Other surgery are recommended to be conducted systems to adapt to the challenges support services, such as mental health via telephone. of the pandemic support services available in Spain, France and England, will continue while the Even before COVID-19, many emergency COVID-19 pandemic persists. departments were operating at capacity, with a configuration that did not some necessarily allow for physical distancing. The private sector can provide Several countries have changed the additional capacity in some countries countries have way that patients interact with the In those health systems with both public emergency department as a result of the and private provision of health care, introduced COVID-19 pandemic. increased utilisation of private health care providers can support overflowing demand ‘COVID-19 free’ Generally, patients with COVID-19 in the public system. This was the case symptoms are advised not to go to in some Italian regions (red zones in the hospitals or emergency departments (e.g. France), northern part of Italy) and in towns with while other countries separate the inflow high-density populations. Spain expects floors of patients with suspected COVID-19 an increase in public-private partnerships infections or respiratory symptoms from to reduce waiting lists, and England plans Conclusions and Policy Implications all other patients (e.g. in Germany), to continue the use of private hospitals to ‘‘ or conduct triage in the emergency Returning to providing routine services support NHS services into 2021. department to identify patients with after they were suspended or postponed respiratory symptoms who will be isolated is a challenging task for many hospitals. (e.g. Spain and England). COVID-19 As countries grapple with how to As a result of the necessary conversion patients in Italy followed a different keep patients and staff safe, the use of clinical spaces in response to the pathway for COVID-19 hospital admission of phone or video consultations is COVID-19 emergency, hospitals will after GP /helpline indications. In England projected to increase have less capacity for routine activities. and Spain, patients attending accident Hence, waiting times are expected to The use of non-face-to-face consultation and emergency (A&E) departments are further increase. Also, some patients may modes has substantially increased, similarly triaged into separate pathways, choose to forgo elective treatments, at least and is expected to grow further in all and are tested and assessed for severity until the COVID-19 pandemic subsides. six countries. In the case of France, and managed accordingly. Patients are While this might reduce unnecessary 100% of teleconsultation costs are instructed to contact designated hotlines treatments or minimise induced health covered by the social health insurance with suspected symptoms before attending system demand, many patients could (SHI) fund until December 2020, and the hospital to help determine severity experience unmet need for medical care teleconsultations are strongly encouraged and the appropriate care pathway, with potentially negative impacts on their in all areas, including psychiatric care. which also occurs in Germany. In the health. In addition, there may be additional However, the use of teleconsultation in Netherlands, emergency departments are ongoing treatment needs for COVID-19 hospitals remains rare. Not only do these only accessible by ambulance or by GP / patients that will require rehabilitation digital tools reduce potential infections, helpline referral, which was already the and long-term follow up. For example, the they also allow for at-risk health workers case before COVID-19. Netherlands will reimburse rehabilitative to still provide care safely. In England, care for COVID-19 patients, even though digital consultations are to be maintained

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the care has not been scientifically proven care services, especially for testing, is key 6 DKG. “DKG zur aktuellen DKI-Blitzumfrage zur as effective, due to the extraordinary to reduce waiting lists within hospitals as COVID-19-Pandemie: Krankenhäuser für mögliche situation. 15 well as restructuring emergency services zweite Pandemiewelle gut gerüstet” [DKG on the current DKI quick survey on the COVID-19 to avoid unnecessary collapse from pandemic: Hospitals well equipped for second wave 18 The impact of the COVID-19 pandemic on COVID-19 patients. of pandemic]. 7 July 2020. https://www.dkgev. health professionals also affects the ability de/fileadmin/default/Mediapool/1_DKG/1.7_ of hospitals to return to more routine Nonetheless, countries may have Presse/1.7.1_Pressemitteilungen/2020/2020-07-07_ activities. Health workforce shortages will to reassess how they evaluate the PM-DKG_zu_DKI-Umfrage_Corona.pdf have an impact on overall productivity, performance of hospitals in this new 7 Letter from NHS CEO and COO. Important – for and at-risk health professionals may context, which now operates with dual action – third phase of NHS response to COVID-19. have to be moved to providing remote goals of limiting the spread of the 31 July 2020. Available at: https://www.england. nhs.uk/coronavirus/wp-content/uploads/ consultations. Even when care is provided coronavirus while maintaining routine sites/52/2020/07/Phase-3-letter-July-31-2020.pdf in person, health care professionals services. Clear guidelines on how to 8 may find it more difficult to establish prioritise routine care with various Domínguez-Gil B, Coll E, Fernández-Ruiz M, et al. COVID-19 in Spain: Transplantation in the midst of the relationships with their patients due to COVID-19 scenarios should be available, pandemic. 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16 Bielicki JA, Duval X, Gobat N, et al. Monitoring KEEPING WHAT approaches for health-care workers during the COVID-19 pandemic. Lancet Infectious Diseases, 2020. https://doi.org/10.1016/S1473- 3099(20)30458-8 WORKS: REMOTE

17 Kalenzi C. Telemedicine can be a COVID-19 game-changer. Here’s how. World Economic Forum. 13 May 2020. Available at: https://www.weforum. CONSULTATIONS org/agenda/2020/05/telemedicine-covid-19-game- changer/

18 WHO/Europe. Strengthening the health DURING THE system response to COVID-19: Adapting primary health care services to more effectively address COVID-19. Technical working guidance #5. COVID-19 PANDEMIC Copenhagen: WHO Regional Office for Europe, 2020. Available at: https://apps.who.int/iris/bitstream/ handle/10665/332783/WHO-EURO-2020-727- 40462-54321-eng.pdf?sequence=1&isAllowed=y

By: Erica Richardson, Dalhia Aissat, Gemma A. Williams and Nick Fahy

Summary: The COVID-19 pandemic saw a rapid rise in the use of remote consultations by telephone and video link. Remote consultations proved important as a way of supporting non- severe COVID-19 patients, reducing pressure on inpatient care, and maintaining access to routine services. Although remote consultations cannot fully replace face-to-face consultations, it is a cost effective and efficient way of enabling access to care that was being promoted long before the current pandemic but with relatively low uptake in most systems. Further development of remote consultation infrastructure would build greater surge capacity into systems to help protect from future shocks while also ensuring platforms are designed to protect patient confidentiality.

Cite this as: Eurohealth 2020; 26(2). Keywords: Remote Consultations, Digital Health, Access to Care, COVID-19

Erica Richardson is Technical Officer, European Observatory Introduction or mental health problems. 1 Evidence on Health Systems and Policies, has also shown that remote consultations London School of Hygiene and A remote consultation between doctors Tropical Medicine, London, UK; can be cost-effective compared to routine or between doctors and patients can use a Dalhia Aissat is Policy Officer, care, particularly for routine treatment the French National Health video link (a teleconsultation) or take place for people with chronic conditions and Insurance Fund (Caisse nationale over the telephone, and it can occur at all those living in remote areas, while being de l’Assurance Maladie – CNAM), levels of the system. Remote consultations Paris, France; Gemma A. Williams safe, effective and achieving equivalent predate the COVID-19 pandemic, and the is Research Fellow, European patient outcomes and improved patient Observatory on Health Systems potential for digital tools to improve access satisfaction. 2 3 4 However, before the and Policies, London School of to services has long been recognised, Economics and Political Science, COVID-19 pandemic, technological particularly as a means of overcoming London, UK; Nick Fahy is challenges, professional scepticism and Senior Researcher, University of health workforce shortages in remote and ethical, financial, administrative and Oxford, Oxford, UK. Email: Erica. rural areas and to improve convenience for [email protected] legal barriers had limited the uptake and patients that work, have reduced mobility use of remote consultations, ensuring

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Figure 1: Number of teleconsultations in France, 2020 (Week 1 to Week 23)

1,000,000 900,000 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 2020.01 2020.02 2020.03 2020.04 2020.05 2020.06 2020.07 2020.08 2020.09 2020.10 2020.11 2020.12 2020.13 2020.14 2020.15 2020.16 2020.17 2020.18 2020.19 2020.20 2020.21 2020.22 2020.23

Lockdown: week 12 to week 19 week 1 to week 23

Source: CNAM

they accounted for a limited proportion six months of the COVID-19 pandemic In France, in February 2020, more than of patient consultations. 2 5 Moreover, and the enabling factors that have 3000 doctors provided teleconsultations less progress was made than either the facilitated rapid implementation and use. and approximately 40,000 were technology or the regulations allowed reimbursed. Teleconsultation was for. For example, remote consultations The use of remote consultations in established as a mode of service delivery often used telephone links rather than Europe has increased substantially in 2018 but eligibility conditions were video or other platforms that would enable during the COVID-19 pandemic loosened at the height of the COVID-19 the simultaneous sharing of test results, crisis; between March and April 2020, diagnostic images or other files. 1 Remote consultations in primary 5.5 million teleconsultations were care were scaled up rapidly in many provided by 36,000 physicians in The COVID-19 pandemic has been countries (e.g. Croatia, Malta, Poland, March and up to 56,000 physicians in a stimulus to make progress in the Sweden, the United Kingdom), and were April. At their highest level, on average implementation of telehealth and to also used more intensively in others teleconsultations accounted for up to 27% overcome these longstanding challenges. (e.g. Austria, Belgium, Denmark, Estonia, of all consultations – about 1 million per Remote consultations were actively France, Germany, Italy, Luxembourg, week. Since the end of the lockdown in encouraged during the pandemic – Switzerland). To ensure the quality France (on 11 May 2020), there has been particularly for patients with COVID-19 of remote consultations, professional a slowdown of teleconsultations, but symptoms, to provide medical support guidelines on safe use of remote the number remains higher than before, and triage without increasing the risk of consultations and e-prescribing have been stabilising at 150,000 per week. During transmission. Remote consultations have developed in some countries (e.g. Malta), the first week of June, about 400,000 also been promoted to ensure access and and training on remote consultation teleconsultations were provided continuity of care for non-COVID-19 has also been provided in others (see Figure 1). patients while supporting physical (e.g. UK, Sweden). distancing and shielding where necessary. Notably, before the lockdown in This has led to a rapid expansion in the General Practitioner (GP) data for England France, younger patients (under 50 use of various digital tools for remote shows a rapid increase in telephone years of age) were more likely to use consultations, both between professionals consultations relative to face-to-face teleconsultations; for those over the age and between professionals and patients consultations – telephone consultations of 50, teleconsultation use decreased in many countries in Europe. In this already being a well-established mode of sharply with age. However, during the article, using data extracted from the service delivery. The number of telephone lockdown the balance shifted as more COVID-19 Health Systems and Response consultations in England increased older patients (over 70 years of age) moved Monitor and input from European from 856,631 to 2,022,798 per week online – this group accounted for 8% of all Observatory on Health Systems and between 2 March and 18 May 2020, while teleconsultations before lockdown but 20% Policies’ partners including the French the number of video consultations was during. Moreover, this trend appears to National Health Insurance Fund (CNAM), higher in March than in April or May have continued after lockdown, as older we assess how the use of remote when it was around 10,000 per week. 6 patients represent about one-fifth of consultations has changed during the first all teleconsultations.

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The shift to teleconsultations has also considered offering video consultation in Austria, Greece, Ireland), or allowed been embraced in Denmark, where there near future; about 80% of psychotherapists remote certification of sickness absence were 71,508 consultations via video offer video consultation. 8 from work. link (population 5.4 million) during the COVID-19 crisis. In the future, hospital Germany’s largest doctor-patient portal In some systems, changes to the way treatment, health checks, rehabilitation, (“jameda”) has had a huge increase services are paid for needed to be made doctor visits and psychiatric consultations in demand for video consultations – before remote consultations could be will continue to take place at home. This increasing by more than 1,000% in March reimbursed. In England’s National fits with the country’s digitisation strategy compared with February 2020 – and the Health Service (NHS), providers were and is to be maintained and expanded. number of doctors and psychotherapists reimbursed from the central budget for Similarly, in Germany, since the partial using the portal to provide services additional capital expenditure needed loosening of lockdown in May 2020 has quadrupled. 9 10 Similarly, a to scale-up IT capabilities to facilitate made it easier to conduct face-to-face private company providing a platform remote consultations and smarter working consultations, data from Doctolib (the that offers online service of medical (see the article by Waitzberg et al. on digital appointment management service consultations 24/7 through an app in Spain compensating health care professionals in for doctors) shows a sustained interest (“MEDIQUO”) was established around this issue). In countries with Social Health in online consultations: in April, there two years ago. In February 2020 it has Insurance financing, detailed billing were 4,133 Doctolib video consultations, around 70 self-employed doctors working schedules have been produced where in May this increased to 4,870 on it and around 700,000 users. By mid- these did not already exist (e.g. Germany, teleconsultations. 7 March this had increased 153% compared Belgium, Switzerland). In France, all to the previous month – many of these remote consultations with physicians were 11 12 Who is providing consultations were COVID-19 related. covered as were follow-up consultations remote consultations? by nurses but other practitioners were Regulatory and financing changes also authorised to provide remote In France, the vast majority of to support remote consultations consultations – physiotherapists, teleconsultations were, as previously, psychomotor specialists, occupational invoiced by private practitioners One of the key barriers to the wider use therapists, speech therapists and midwives (96%) and of these, GPs billed 80% of remote consultations was the need to for antenatal care. of all teleconsultations, followed by change existing restrictions to allow such psychiatrists (6%), paediatricians (2%), services to expand. Restrictions had to In the Netherlands, there was also a gynaecologists (1.3%), dermatologists be relaxed rapidly with the demands of new expansion of teleconsultations, (1.1%) and endocrinologists (1.1%). Of providing care during the COVID-19 with 72% of surveyed GPs saying they the total number of teleconsultations crisis. In France, teleconsultations have had started using video consultations invoiced, before the lockdown 23% were been reimbursed since September 2018, with patients in 2020. Moreover, 28% of for pre-existing chronic disease patients but were restricted to physicians only and GPs indicated they would continue using but this share increased to 28% after. On only with established patients (i.e. had at video consultations more intensively average, 80% of teleconsultations were least one face-to-face consultation before after the crisis. 13 However, it is not clear between patients and doctors who already a teleconsultation). Remote consultations that the shift to online consultations will had a face-to-face consultation in the also had to be by video link not over the be sustained after the COVID-19 crisis previous year. telephone and use professional software everywhere in Europe. In Luxembourg, to ensure data protection and privacy. easing lockdown has seen the volume of In Germany, the Federal Association of The restrictions were dramatically teleconsultations plummet; Esanté Agency Statutory Health Insurance Physicians simplified at the beginning of March 2020. (backed by Luxembourg’s National Health (KVB) reported on first quarter (Q1) It was possible for doctors to see new Fund – CNS) has seen the weekly volume of 2020 and about 19,500 teleconsultations patients remotely and some remote of teleconsultations fall from 1,000 during were performed in March 2020, consultations by telephone were allowed. lockdown to around 100 in the weeks compared to 1,700 teleconsultations in In addition, the use of all technological following. 14 January and February 2020 (an increase means available for video transmission of 1,047%). By the end of April, KVB (including Skype, Whatsapp, Facetime, Challenges in rapid expansion of data shows 25,000 medical practices etc.) was authorised alongside other remote consultations offered video consultations, up from 1,700 solutions specifically developed for in January, which is one in four GP or teleconsultations. Volume restrictions on Rapidly expanding access to remote psychotherapist practices. According to physicians providing remote consultations consultations by telephone and video a May 2020 survey of 2,240 physicians were lifted in Germany and Sweden. Many link enabled health systems in Europe to and psychotherapists in Germany, 52.3% countries have also relaxed regulations better cope with COVID-19. They served offered video consultation and 10% around the use of e-prescriptions (e.g. to reduce pressure on inpatient care, helped reduce transmission of the virus by reducing contacts and allowed people

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with COVID-19 to be supported remotely Looking to the future 7 Ehealthcom. Terminbuchungen für Online- in their own home. Remote consultations Konsultationen bei Doctolib auf stabilem Niveau. As discussed, remote consultations also enabled people with other care needs (Appointments for online consultations at Doctolib proved important as a way of supporting at a stable level), 9 June 2020. Available at: to continue seeking care, in particular non-severe COVID-19 patients, reducing https://e-health-com.de/details-unternehmensnews/ those with concerns about COVID-19 pressure on inpatient care as well as terminbuchungen-fuer-online-konsultationen-bei- infection through face-to-face contact. doctolib-auf-stabilem-niveau/ enabling access to routine care for non- While remote consultations were already 8 COVID patients. Although telehealth Obermann K, Brendt I, Hagen J, et al. Ärztliche in place in many countries, the pandemic cannot fully replace face-to-face Arbeit und Nutzung von Videosprechstunden während provided the impetus for swift and der Covid-19 Pandemie. (Medical work and use consultations, it is a cost effective and widespread scaling up, with rapid changes of video consultation hours during the Covid-19 efficient way of enabling access to care. to regulatory frameworks and financing pandemic.) Available at: https://www.stiftung- Countries can build greater surge capacity gesundheit.de/pdf/studien/aerzte-im-zukunftsmarkt- mechanisms to enable this expansion. into their system to help protect it from gesundheit_2020.pdf future shocks by further developing the 9 Initial adaptations to allow this appear to Jameda Pressemitteilungen. Covid-19 führt zu quality and infrastructure around remote steigender Nachfrage nach Videosprechstunde. have been relatively narrowly focused. consultations. However, policymakers (Covid-19 leads to increasing demand At system level, this has primarily need to ensure that equity in access to for video consultations), 30 March 2020. concerned lifting previous restrictions and Available at: https://www.jameda.de/presse/ services is not compromised. ensuring financial coverage for remote pressemeldungen/?meldung=270 consultations. However, capitalising on 10 It is imperative that doctors have access to Saarbrucker Zeitungsaarb. Telemedizin derzeit the progress made will require greater unbegrenzt möglich. (Unlimited telemedicine is secure platforms for remote consultations attention to quality and underpinning currently possible), 20 April 2020. Available at: to protect patient confidentiality because infrastructure. Training and support https://www.saarbruecker-zeitung.de/sz-spezial/ not all commercial platforms are fit for internet/antraege-fuer-videosprechstunden-nehmen- for health professionals to use this such potentially sensitive communications. in-zeiten-von-corona-stark-zu_aid-50146651 technology appropriately and to build Going forward it will be important to 11 rapport with patients remotely is an ConSalud.ed. El uso de la telemedicina en España conduct a rapid evaluation of the current aumenta un 153%. (The use of telemedicine in Spain important component. expansion to help guide the best future increases 153%), 6 May 2020. Available at: https:// use of remote consultations and identify www.consalud.es/tecnologia/tecnologia-sanitaria/ Evaluation of the strengths and limitations telemedicina-espana-aumenta-153_78862_102.html their limits. of remote consultations is also urgently 12 Gispert B. Mediquo, atención médica needed, and the current unprecedented en remote. (Doctor, remote medical usage provides an opportunity to do so. References care.) La Vanguardia, 28 January 2020. Available at: https://www.lavanguardia.com/ For example, while remote consultations 1 Donaghy E, Atherton H, Hammersley V, economia/20200128/473184295173/atencion- have improved access to care during the et al. Acceptability, benefits, and challenges medica-remoto-mediquo.html COVID-19 pandemic and can continue to of video consulting: a qualitative study in support the delivery of care afterwards, primary care. British Journal of General Practice 13 Tuyl LHD van, Batenburg R, Keuper JJ, Meurs M, they may not be appropriate for care 2020;69(686):e586 – 94. Friele R. Gebruik van e-health in de huisartsenpraktijk tijdens de COVID-19-pandemie. (Use of e-health in 2 Greenhalgh T, Shaw S, Wherton J, et al. to patients with complex or sensitive general practice during the COVID-19 pandemic). Real-World Implementation of Video Outpatient health or social care needs and patients Utrecht: Nivel, 2020. Available at: https://nivel.nl/ Consultations at Macro, Meso, and Micro Levels: may first need to access in-person sites/default/files/bestanden/1003743.pdf Mixed-Method Study. Journal of Medical Internet consultations to build trust with their Research 2018;20(4):e150. 14 Obert M. Online medical appointments plummet 15 provider. Some types of remote care after lockdown easing. Delano, 25 June 2020. 3 Buvik A, Bergmo TS, Bugge E, et al. Cost- may be much improved if accompanied Available at: https://delano.lu/d/detail/news/online- Effectiveness of Telemedicine in Remote Orthopedic medical-appointments-plummet-after-lockdown- by supporting devices, such as oximeters, Consultations: Randomized Controlled Trial. Journal easing/210870 that patients can use at home and which of Medical Internet Research 2019;21(2):e11330. can provide additional information for 15 Horton T, Jones B. Three key quality 4 Levin K. Telemedicine diabetes consultations considerations for remote consultations. London: care. Emphasising digital solutions such are cost-effective, and effects on essential diabetes Health Foundation, 4 June 2020. Available at: https:// as video links also has the potential for treatment parameters are similar to conventional www.health.org.uk/news-and-comment/blogs/three- treatment: 7-year results from the Svendborg widening the ‘digital divide’ in countries key-quality-considerations-for-remote-consultations where not all households are online, Telemedicine Diabetes Project. Journal of Diabetes especially those living in deprived areas Science and Technology 2013;7(3):587 – 95. or in older age groups. While social or 5 Chakrabarti S. Usefulness of telepsychiatry: economic policy solutions to ensure a critical evaluation of videoconferencing- equitable access to the Internet would based approaches. World Journal of Psychiatry 2015;5(3):286 – 304. address this, in their absence ensuring equity in access to in-person consultations 6 NHS Digital. Appointments in General Practice must be assured. data, 4 June 2020. Available at: https://digital.nhs. uk/data-and-information/publications/statistical/ appointments-in-general-practice—weekly-mi/ current

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THE COVID-19 PANDEMIC AND LONG-TERM CARE: WHAT CAN WE LEARN FROM THE FIRST WAVE ABOUT HOW TO PROTECT CARE HOMES?

By: Margrieta Langins, Natasha Curry, Klara Lorenz-Dant, Adelina Comas-Herrera and Selina Rajan

Summary: The COVID-19 pandemic has highlighted and exacerbated pre-existing problems in the long-term care sector. Based on examples collected from the COVID-19 Health System Response Monitor (HSRM) and the International Long-term care Policy Network (LTCcovid), this article aims to take stock of what countries have done to support care homes in response to COVID-19. By learning from the measures taken during the first wave, governments and the sector itself have an opportunity to put the sector on a stronger footing from which to strengthen long-term care systems.

Keywords: Long-term Care, Care Homes, Integrated Health Care Systems, Workforce, COVID-19 Cite this as: Eurohealth 2020; 26(2).

Introduction losses were avoidable. This article aims Margrieta Langins is Advisor, to take stock of what countries have World Heath Organization, Regional Long before COVID-19, care homes Office for Europe, Copenhagen, done within care homes in response to across the World Health Organization Denmark; Natasha Curry is Deputy COVID-19 in order to place the sector Director of Policy, Nuffield Trust, (WHO) European Region were facing on a stronger footing from which to face London, UK; Klara Lorenz-Dant is several challenges. 1 For staff, families and Research Officer, Care Policy and future outbreaks. It also reflects on the residents of care home these challenges Evaluation Centre, Department of importance of underlying structures and and gaps in the system have been all Health Policy, London School of features in different countries and how Economics and Political Science, too obvious. The long-term care (LTC) the context into which a similar set of UK; Adelina Comas-Herrera is sector was already a myriad of financial, Assistant Professorial research measures are introduced are likely to staffing and operational difficulties in fellow, Care Policy and Evaluation impact on how effective they are. Centre, Department of Health Policy, most countries before the pandemic, London School of Economics and and it has been hit badly, with as many Political Science, UK; Selina Rajan is Specialist Public Health Registrar as 47% of all COVID-19 related deaths Key challenges predating COVID-19 and Research Fellow, London happening among care home residents. 2 Although every country’s LTC system School of Hygiene and Tropical However, the impact has not been uniform Medicine, UK. Email: langinsm@ is different, there are a number of within or between countries, which raises who.int common challenges across the WHO the question of whether some of these

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European Region that has meant the often without pay. 6 As absences increased, to report COVID-19 outbreaks to the sector’s response to COVID-19 was staff in care homes were more stretched Health Information and Quality Authority. particularly complex. than ever. In some European countries, Similarly, in Germany, teams from the migrant care workers make up a large Robert Koch Institute were deployed A lack of coordination between health proportion of the LTC workforce 7 and the to support outbreak containment in and LTC services closure of borders also had a impact on these facilities. these workers. Organisation and governance of LTC The Czech Republic, Denmark, Estonia, services is often separate to that of health Systems rely heavily on unpaid carers, Finland, Germany, Greece, Malta and the services 1 and countries frequently even in care homes Netherlands centralised the management distribute responsibility for LTC across and /or procurement of PPE supplies for the national, regional and local actors. Family carers provide an important share care sector. In Spain, regional authorities In many countries, an absence of of LTC across countries, both through have had to provide bi-weekly information coordination between the two services, direct care, and by coordinating and on the number of infections, deaths, etc. each with a diversity of actors, means complementing formal services. 8 Even in care homes to the national Ministry of that there are parallel but not always when people with care needs move to Health. In a small number of countries aligned systems for oversight, financing, a care home, many family members examined (notably Hungary and Ireland), staffing, and collection/management continue to be involved by providing care homes have been required to appoint of data. 1 This underlying complexity emotional stimulation, activities, a COVID lead in order to define clear (sometimes resulting in fragmentation) bedding and even food. This has become accountability in the event of an outbreak. was brought to the fore during COVID-19 increasingly important in the context of in many countries, where this lack of staff shortages. As visits to care homes clear accountability for LTC services were restricted during COVID-19, this and underdeveloped information systems source of support for residents (and staff) created complexities and delays in the disappeared. COVID-19 response. 1 countries largely What measures were taken to protect Care systems have suffered significant care homes during the first wave of implemented a underfunding the COVID-19 crisis? In many countries, LTC services have Although data are still emerging, a scan similar set of been poorly resourced, particularly when of the region shows that countries largely compared to health spending. This historic implemented a similar set of measures measures underfunding results in a high degree of which were focused on providing rationing of publicly funded services and There has also been a trend towards guidance, strengthening medical support, affects the quality of provision. 3 As the centrally-produced guidance and preventing the spread of the virus and pandemic hit, the sector was in an already regulation in an attempt to put in place minimising infection, and supporting the weakened position and not well-equipped support structures for the sector. In sector by boosting staffing and funding. ‘‘ to implement rigorous infection prevention many countries, this has taken the form The examples cited in the following and control measures nor absorb additional of guidance and training around the section have been documented and can costs arising from personal protective use and wearing of PPE and infection be read about in two key resources: the equipment (PPE) needs, training needs control but monitoring and enforcement COVID-19 Health System Response and staff sickness. has varied between countries. For Monitor (HSRM) and the International instance, in Austria, responsibility for the Long-term care policy network Workforce shortages are widespread development of guidance in LTC settings, (LTCcovid). (see Figure 1). their implementation and monitoring has Severe staffing shortages, fuelled by been given to newly established national poor working conditions, low pay and Increasing oversight of LTC services task forces. In Italy, the guidelines for a perception of low skill meant that the A number of countries sought to increase nursing homes published by the Ministry sector struggled during the pandemic. oversight of LTC services, strengthening of Health require providers to ensure the As a low-paid, predominantly female central accountability and certain COVID-related training of care workers. workforce, 4 many of whom work on functions. This took a variety of forms. In Ireland, a new Infection Prevention flexible contracts with little or no sick pay, For instance, Austria, Greece, Hungary, and Control Hub offers residential LTC their exposure to the virus was high. It is Iceland, Israel and Germany established settings guidance for outbreak preparation not uncommon for care workers to work national LTC task forces. In Ireland, and management, information on infection across multiple facilities, adding to the national and regional outbreak teams prevention and control, and support risk of spread of the virus. 5 As testing in have been set up to oversee, prevent and with applying national advice. Some many countries was slow to roll out, in the tackle COVID-19 clusters in residential of this support is provided via tele- early phases of the pandemic care staff LTC settings. Care home providers started mentoring interventions and webinars for were faced with self-isolating for 14 days

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Figure 1: Measures taken in countries to protect care homes during COVID-19

Strengthening Reducing and medical support managing visitors to prevent infection Establishing Devising creative ways long-term for enabling visits care task forces with relatives

Providing Minimising infection guidance through workforce management

Risks: • Vulnerable residents • Confined spaces Providing financial Boosting staffing levels support through recruitment and retention

Repeat testing Centralising for staff procurement of equipment Planning for isolation Expanding testing and quarantine for residents

© European Observatory on Health Systems and Policies

Source: 13 nursing homes. In addition, the national has been provided in some countries. In LTC insurance. In contrast, in England and membership organisation of home care Ireland, some of this was given directly Sweden, additional money flowed to local providers has developed a COVID-19- to care homes which were able to receive authorities which had autonomy to allocate specific National Action Plan. immediate temporary assistance payment it according to their own priorities and this to respond to a COVID-19 outbreak. led to variation between local areas in how Funding for care homes has increased The regional Dutch LTC offices gave much was spent on LTC and, in England, in several countries LTC providers extra funding if they some claims that additional funding was faced additional costs due to COVID-19. not reaching providers. In recognition that care homes are facing Similarly, in Germany, institutions that increased costs (e.g. from extra PPE, staff incurred additional costs or loss of revenue In some countries, the extra money was sickness) and /or revenue losses (e.g. from due to COVID-19 were reimbursed by the earmarked for specific purposes; e.g. reduction in occupancy), financial support

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in Austria, some of the €100 million impact of the relaxation of usual rules and Efforts to prevent and manage allocated to support the LTC sector was requirements on standards and quality or outbreaks within care homes earmarked for expanding residential the spread of infection is not yet known. A big challenge during COVID-19 has care bed capacity for people who could been preventing infections entering not be cared for sufficiently in their own Efforts have also been made to retain care homes and managing outbreaks. home because of the complexities of the existing workforce. In the United Bans on visits to care homes have been delivering home care during the pandemic. Kingdom, Scotland and Wales have implemented in most countries. However, In Denmark, Parliament provided raised wages and offered special one-off as the crisis has continued, it has become DKK 100 million (about €13.4 million) to payments to incentivise staff. Austria clear that physical distancing for people municipalities to support people in receipt has awarded one-off payments of €500 in LTC facilities can be detrimental to of residential and community LTC with to migrant care workers who have their wellbeing and therefore guidance and the intention of developing solutions to remained in the country to provide care. rules have since been amended to allow maintain social relations, quality of life In Germany, there are plans to raise the some contact with families and friends. In and to prevent loneliness, including the minimum wage for care workers and Germany and the Netherlands, care homes use of digital technologies, reconfiguring all people employed in care homes will have created ways for residents to see and spaces to enable limited visits and receive a one-off bonus payment of up to speak with relatives by using virus-proof dedicated staff. In May, the English €1,000 (increased to €1,500 in four states). containers, garden sheds, telephone boxes government allocated £600 million or other solutions. (about €660 million) for infection control Health care provision within care homes in care homes. has been strengthened Testing programmes in care homes The lack of health care provision within expanded as the crisis unfolded but many care homes 9 has created particular countries have struggled with either difficulties in places where transfer to logistical or capacity issues (or both) and hospital has been explicitly discouraged, so rolling out testing has been slow in because hospitals were both overstretched many places. Several countries began preventing and a potential source of COVID with a relatively focused approach, only transmission (e.g. England, France, Italy, testing those with symptoms or, those with infections the Netherlands, Norway,). Support has symptoms and underlying conditions, or been deployed to LTC homes in some those who had been in close contact with entering care countries to avoid admission to hospital: people who tested positive. Over time, Italy and Luxembourg have required care efforts have been made to expand testing homes and homes to have a 24 /7 medical presence to including for those in homes without follow up unwell residents and France, by symptoms. Denmark began testing managing May, was encouraging physician visits and all residents, regardless of symptoms. offering greater remuneration after having In the Czech Republic and, from mid-April outbreaks told homes to minimise such visits in the in England, all new residents have been ‘‘ early months of the pandemic. Austria required to be tested before moving into A focus on recruitment and retention requires its hospitals to offer support homes. Prior to this, in England, people of staff to care homes in the form of personnel, were being discharged from hospital In the face of widespread staff shortages, expertise and equipment. In Ireland, there into care homes after testing positive for many countries have made efforts to boost has also been an agreement that enables COVID-19 or while awaiting a test, then staffing levels in care homes through the Health Services Executive (HSE) to from 3rd April care homes were advised measures to increase recruitment and redeploy HSE staff to private nursing to quarantine those individuals but retention. England and Ireland launched homes on a voluntary basis. In Slovenia, many homes struggled to do so because recruitment campaigns to attract medical teams are deployed to a residential of limited space or staffing. In most newcomers and former staff to the sector. care setting if the regular staff becomes countries, guidance has been issued for In Finland, retired staff and students that exhausted or overwhelmed. In Israel, the discharge of patients from hospitals did not fall into risk group have been the Ministry of Health as made a special to different care settings and since recruited to maintain staffing levels. team available for period of 7 to 14 days mid-April, most have required testing Similarly, in Spain care workers without to support residential care settings that before discharge. the required training certificates could are acutely short staffed and a 24h call be legally employed and the Netherlands centre has been established to support Like testing for residents, the policy on enabled nursing homes to recruit care LTC facility managers with medical and staff testing has evolved during the crisis workers more widely (e.g. medical management advice. period and varies between countries. students). Germany relaxed some staffing The Czech Republic and Denmark have rules and operational frameworks to stressed the need for repeat testing with relieve pressure on the workforce. The asymptomatic staff, or those with a negative test, being retested at regular

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Box 1: The Impacts of Policies on Care Home Providers in England

In England, 26,500 excess deaths have been reported in LTC (until 7th August) and yet many of the policies recommended in WHO guidance 11 were theoretically in place, leading many to question what went wrong. Survey responses from LTC operators across England 12 at the end of May and early June show how implementation of some of the key policies was ineffective and delayed, with considerable variation between areas. We report some examples in the table below:

Policy area Policy actions Providers reported Infection February – June: Guidance published for LTC settings; • Guidance changed frequently and contradicted Control government provision of PPE and infection control itself, causing confusion and loss of confidence training • Government provision only included emergency PPE, leaving providers to pay inflated prices for PPE without national quality control

• Providers needed more funding and PPE rather than training Surge March: NHS and social care advised to share • Negligible perceived support to manage workforce workforce workforces shortages

April: Government announced a recruitment campaign for social care and future plans to redeploy staff from the NHS to social care, which are still awaited Coordinated March: NHS and local authorities advised to provide • Inflexible systems prevented effective collaboration services mutual aid to LTC between the NHS and social care, with only a few successful examples May: Improved clinical support promised to LTC • Variable support from local authorities nationwide Testing April: Tests offered to asymptomatic staff, residents • Less than half of providers accessed tests by the and patients discharged from hospital end of May, when 90% of outbreaks had already happened July: Repeated whole home testing announced • Hospital discharges were not universally tested on discharge, despite government guidance Funding March – April: £3.2 billion (about €3.5 billion) • Prior to the infection control grant, access to to support local government services funding varied considerably between areas and was often conditional upon the number of publicly May: £600 million (about €660 million) paid to funded residents, with differences reported in LTC providers to support infection control what funds could be used for

Source: Authors’ own

intervals (7 – 14 days). In Ireland, staff Similarly, where a positive case arises Conclusions have been screened for symptoms twice in care homes in Slovenia, people living Our analysis has revealed that the a day since early April. The European in nursing homes have been moved to countries for which information was Centre for Disease Prevention and other facilities and Israel and Ireland available took a similar set of measures Control suggest testing priorities should have worked with hotels to accommodate to protect care homes during the first be linked to local levels of community people either with symptoms or awaiting wave of the pandemic. At the time of transmission. 10 transfer. Care homes in Israel have been writing, it is not clear the extent to which required to establish COVID care units single measures have been effective at Guidance on managing outbreaks within and in the Czech Republic, LTC facilities protecting care homes and more research care homes largely focused on isolating have been required to reserve 10% of their is needed to establish this. What is clear or transferring residents. In Turkey, capacity to accommodate suspected or is that the impact of COVID-19 has not the health of residents was monitored infected cases. been uniform between (and sometimes and those with a suspected COVID-19 within) countries. 2 9 Some differences infection were immediately isolated in how countries implemented measures and transferred to a pandemic hospital. could account for some of the differing

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impact. The speed of response differed systems and their inherent inequalities and 9 Hirdes JP, Declerq A, Finne-Soveri H, et al. between countries as did the extent weaknesses. If anything positive can come The Long-term Care Pandemic: International to which approaches sought to clarify out of this period of history it will be a Perspectives on COVID-19 and the Future of Nursing Homes. July 2020. https://www. accountability. The level of centralisation proactive effort to put in place financially balsillieschool.ca/the-long-term-care-pandemic- of response has also varied between and politically sustainable systems that international-perspectives-on-covid-19-and-the- countries with some favouring a more enable the most vulnerable among us to future-of-nursing-homes/

locally-determined or state-level response. live as independent and fulfilling lives 10 ECDC. Technical Report: Surveillance of COVID-19 This largely reflects the individual as possible. at long-term care facilities in the EU/EEA. 2020. country’s governing structures and Available at: https://www.ecdc.europa.eu/sites/ default/files/documents/covid-19-long-term-care- LTC organisation. It is likely that the References effectiveness of measures will be affected facilities-surveillance-guidance.pdf 1 by how they are implemented and the WHO/Europe. Country assessment framework 11 WHO/Europe. Preventing and managing context within which they are enforced. for the integrated delivery of long-term care. the COVID-19 pandemic across long-term care Ageing, 2019. Available at: http://www.euro.who. Box 1 on England demonstrates the same services in the WHO European Region, 2020. int/en/health-topics/Life-stages/healthy-ageing/ Available at: https://apps.who.int/iris/bitstream/ set of measures can impact LTC providers publications/2019/country-assessment-framework- handle/10665/333067/WHO-EURO-2020-804- in different ways depending on how they for-the-integrated-delivery-of-long-term-care-2019 40539-54460-eng.pdf?sequence=1&isAllowed=y

are implemented. It is crucial, as countries 2 Comas-Herrera A, Zalakaín J, Litwin C, et al. 12 Rajan S, Mckee M. Learning from the impacts face future waves, that consideration is Mortality associated with COVID-19 outbreaks in care of COVID-19 on care homes in England: A Pilot taken not just about the effectiveness of homes: early international evidence. LTCcovid.org, Survey – Resources to support community and measures but their appropriateness in a International Long-Term Care Policy Network, CPEC- institutional Long-Term Care responses to COVID-19. particular context and how they will be LSE, 26 June 2020. Available at: https://ltccovid.org/ LTCcovid.org, International Long-Term Care Policy wp-content/uploads/2020/06/Mortality-associated- implemented and enforced. Network, CPEC-LSE, 10 June 2020. Available from: with-COVID-among-people-who-use-long-term-care- https://ltccovid.org/2020/06/09/learning-from-the- 26-June.pdf impacts-of-covid-19-on-care-homes-in-england-a- pilot-survey/ 3 Coste S, Ces S. Mapping long-term care quality assurance practices in the EU Summary Report. 13 Curry N, Langins M. What measures have been European Commission, 2019. Available at: https:// taken to protect care homes during the COVID-19 www.google.com/url?sa=t&rct=j&q=&esrc=s&sou crisis? COVID-19 Health System Response COVID-19 has rce=web&cd=&ved=2ahUKEwiG9vKunarrAhW8VBUI Monitor – Cross-Country Analysis. WHO, European HfF6DC4QFjABegQIBxAB&url=https%3A%2F%2Fec. Commission, European Observatory on Health disproportionately europa.eu%2Fsocial%2FBlobServlet%3FdocId%3D2 Systems and Policies, 18 June 2020. Available at: 2303%26langId%3Den&usg=AOvVaw0c414B6Cb1O https://analysis.covid19healthsystem.org/index. g1E0OxiHaFC php/2020/06/08/what-measures-have-been-taken-

affected the 4 to-protect-care-homes-during-the-covid-19-crisis/ OECD. Who cares? Attracting and retaining care workers for the elderly. Health Policy Studies. Paris: most vulnerable OECD publishing, 2020. Available at: https://doi. org/10.1787/92c0ef68-en

in society 5 OECD. Workforce and safety in long-term care during the COVID-19 pandemic. Paris: OECD COVID-19 has disproportionately affected publishing, 2020. Available at: https://www.oecd. the most vulnerable in society across org/coronavirus/policy-responses/workforce- ‘‘ and-safety-in-long-term-care-during-the-covid-19- the world. Countries will be measured pandemic-43fc5d50/#biblio-d1e220 by how well they protected their most vulnerable during this pandemic. 6 OECD. Paid sick leave to protect income health Following the first wave of infection, and jobs through the COVID-19 crisis. Paris: OECD publishing, 2020. Available at: http://www.oecd.org/ there is an urgent need to learn lessons coronavirus/policy-responses/paid-sick-leave-to- from each other about what worked and protect-income-health-and-jobs-through-the-covid- what didn’t work in order to ensure care 19-crisis-a9e1a154/

homes are put on a stronger footing ahead 7 Rodrigues R, Huber M, Lamura G. Facts and of any future waves. But there is also an Figures on Healthy Ageing and Long-term Care. opportunity to make more fundamental Europe and North America Occasional Reports changes to care systems, the weaknesses Series 8, 2012. Vienna: European Centre. of which undoubtedly exacerbated and 8 OECD. Informal carers. Paris: OECD publishing, dampened the effect of some of the 2019. Available at: https://www.oecd-ilibrary.org/ measures intended to protect it. These sites/4dd50c09-en/1/2/11/8/index.html?itemId=/ opportunities have been identified in content/publication/4dd50c09-en&mimeType=text/ html&_csp_=82587932df7c06a6a3f9dab95304095d the WHO European Region’s Technical &itemIGO=oecd&itemContentType=book Guidance outlining 10 policy objectives for improving long-term care. 11 This crisis has laid bare the inadequacies of care

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COMPENSATING HEALTHCARE PROFESSIONALS FOR INCOME LOSSES AND EXTRA EXPENSES DURING COVID-19

By: Ruth Waitzberg, Dalhia Aissat, Triin Habicht, Cristina Hernandez-Quevedo, Marina Karanikolos, Madelon Kroneman, Sherry Merkur, Wilm Quentin, Giada Scarpetti, Erin Webb, Gemma A. Williams, Juliane Winkelmann and Ewout van Ginneken

Summary: COVID-19 has affected the incomes of some health Cite this as: Eurohealth 2020; 26(2). professionals by reducing demand for care and increasing expenditures for treatment preparedness. In a survey of 14 European Ruth Waitzberg is Research Scholar, Myers-JDC-Brookdale countries, we found that most countries have incentivised substitutive Institute, Jerusalem, Israel, Ben Gurion University of the Negev, e-health services to avoid loss of income. Health professionals have Beer Sheva, Israel and Minerva Stiftung fellow Technical University also received financial compensation for loss of income either through of Berlin (TUB), Berlin, Germany; Dalhia Aissat is Policy Officer, initiatives specifically designed for the health sector or general self- Strategic research department, French Statutory Health Insurance employment schemes, and have either been reimbursed for extra (Caisse nationale de l’Assurance Maladie – CNAM); Triin Habicht COVID-19-related expenditures such as personal protective equipment is Senior Health Economist, WHO Barcelona Office for Health Systems (PPE) or had these provided in kind. Compensation is generally funded Strengthening, Barcelona, Spain; Cristina Hernandez-Quevedo is from health budgets, complemented by emergency funding from Research Fellow, Sherry Merkur is Research Fellow, Gemma A. government revenue. Williams is Research Fellow, European Observatory on Health Systems and Policies, London Keywords: Financial Compensation, Payment Mechanisms, Incentives, Health School of Economics and Political Science, UK; Marina Karanikolos Professionals, COVID-19 is Research Fellow, European Observatory on Health Systems and Policies, London School of Introduction services were postponed due to restricted Hygiene and Tropical Medicine, capacities in hospitals and patients not UK; Madelon Kroneman is Senior The COVID-19 pandemic has affected Researcher, Netherlands Institute going to clinics for elective care out of the incomes of ambulatory health for Health Services Research fear of being infected by COVID-19. 1 2 (NIVEL), Utrecht, The Netherlands; professionals in hospitals and in the Second, many health professionals faced Wilm Quentin is Senior Researcher, community in two main ways. First, Giada Scarpetti is Research additional expenditures for COVID-19 many health professionals have faced Fellow, Erin Webb is Research treatment preparedness such as reshaping Fellow, Juliane Winkelmann is a substantial loss of income due to a clinics, securing necessary supplies and Research Fellow, TUB and European reduced demand for care. While some personal protective equipment (PPE), for Observatory on Health Systems and have had their elective work reduced, Policies, Berlin, Germany; Ewout which prices have increased substantially. 3 others have seen patients forgo services. van Ginneken is Coordinator, Berlin Countries have used various strategies Hub of the European Observatory For example, American radiologists to mitigate against the loss of income on Health Systems and Policies, faced reduced demand of services due TUB, Berlin, Germany. Email: ewout. and compensate health professionals for to reduced traffic injuries during the [email protected] forgone revenue and additional spending. lockdown, and neurologists reported that

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This article aims to support policymakers across countries in tailoring policies to Box 1: Introduction and incentives to use e-health consultations in Estonia tackle health providers’ loss of income during the COVID-19 pandemic. In March 2020, the Estonian Health Insurance Fund (EHIF) reacted immediately to the suspension of elective care by introducing a fee for remote outpatient specialist consultations to provide an alternative for office visits. The EHIF defined a list of services that could be conducted remotely, with minimum standards of quality and monitoring requirements. The fees for remote services were equal to those for on- incentivising the site consultations/office visits. In addition, hospitals were eligible to apply for a one- time compensation to scale up their capacity for remote outpatient consultations. use of alternative The compensation was equivalent to 1.5% of the amount of their annual outpatient elective care contract. Hospitals could apply for this payment if at least 20% e-health care of visits (compared to the number of visits during the same period of time last year) were conducted remotely and if at least 20% of these remote visits were performed as video consultations. During the emergency situation, about one-third Data were collected from the COVID-19 of consultations were conducted remotely, including more than three-quarters of Health System Response Monitor (HSRM) consultations in psychiatric care. The preliminary results of a survey among 183 (up to 10 July 2020) as well as a survey of patients suggest that more than 80% were satisfied with remote consultations country experts that were asked questions and would use them again. 5 The EHIF continues to finance remote consultations. on how countries have been compensating However, the service standards and criteria are being reviewed and tightened. health professionals‘‘ for income losses and increased expenditures. The paper focuses on 14 countries including the Czech Republic, Denmark, England, Estonia, France, Germany, Israel, Italy, Lithuania, Box 2: Compensatory payments in The Netherlands Luxembourg, the Netherlands, Spain, Dutch GPs are paid primarily through a combination of (passive) capitation and Sweden and Switzerland. FFS for each visit (about 75% of their income), with some P4P-like components (the other 25%). In March 2020, GPs, health insurers and the Dutch Healthcare The payment method of health Authority agreed upon compensation for GPs during the pandemic: (1) GPs professionals impacts their potential received a one-time extra flat rate capitation payment (for each registered patient loss of income in their practice), regardless of the COVID-19 morbidity rate among their patients; (2) GPs can charge a higher fee for home visits to COVID-19 patients; (3) GPs In several countries, certain groups can negotiate additional financial support to avoid bankruptcy with the “preferred” of health professionals, particularly health insurer that covers most of their patients. primary care providers (PCPs), are paid prospectively or without a link to their Health insurers compensate for 60 – 85% of the shares of allied health professionals’ activity, i.e. they are paid (predominantly) turnover to cover fixed costs. Health care providers may be subject to paying back on a capitation basis or as salaried some of the compensation if they manage to limit financial losses during the rest of employees. In these countries, including the year. If this compensation is not sufficient, these health professionals may apply the Czech Republic, Estonia, Israel, Italy, for the general support for businesses. Spain and Sweden, income losses were relatively small, and there was no pressing need for extensive compensation schedules at the time of this review. However, A widely used strategy to facilitate health professionals to keep providing health professionals who are largely access to care, that also helps mitigate services and for patients to receive the paid retrospectively based on activity income losses, has been incentivising necessary care, thereby also securing such as fee-for-service (FFS) or pay-for- the use of alternative e-health care. 4 revenue flow for providers to some extent. performance (P4P) have proven vulnerable Countries have loosened restrictions on to reduced demand for services and have digital or phone consultations (the Czech Countries employ various strategies suffered a substantial loss of income, Republic, Germany, Luxembourg, the to offset the income losses of health e.g. general practitioners (GPs) in France. Netherlands, Sweden, Switzerland), and professionals due to decreased have paid for remote health services at demand for health services Countries are incentivising e-health the same or higher fees as for face-to- and remote services to facilitate face consultations (Denmark, Estonia – Table 1 shows that countries have used access to care, which also helps see Box 1, France). In England, GPs different mechanisms to offset the to reduce income losses could get reimbursement for setting up or income losses for health professionals. enhancing their information technology First, health professionals can get non- (IT) capacity and equipment. This allowed health care specific COVID-19-related

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Table 1: How are countries compensating health professionals for income losses due to COVID-19?

Non-health sector Country Health sector specific specific COVID-19-related Flat compensation Compensation based Temporarily Subsidies to cover compensation to any e.g. extra capitation on previous year suspending FFS or fixed costs such as self-employed or temporarily higher turnover up to a fixed P4P while increasing rent and employees professional or fees percentage the share of fixed business payment Czech Republic Self-employed health PCPs that perform All providers (under – Dentists and private professionals tests at the end of discussion) health care providers quarantine of patients; Dentists Denmark – – GPs – – England – – – GPs – Estonia Non-EHIF contracted – EHIF contracted – EHIF contracted physicians providers providers France – GPs All health professionals – All health professionals Germany Solo ambulatory Physicians, Physicians, – – practices considered psychotherapists and psychotherapists, all as entrepreneurs all allied health allied health professionals professionals Israel Outpatient self- – Inpatient professionals – – employed specialists infected or quarantined Italy – GPs and paediatricians – – – working after hours Lithuania – – Physicians – – Luxembourg – GPs and specialists – – – treating COVID-19 patients The Netherlands Allied health GPs Allied health – GPs professionals professionals Spain – PCPs treating – – – COVID-19 patients Switzerland Self-employed – – – Self-employed outpatient outpatient professionals professionals

Notes: PCP = primary care providers; GPs = general practitioners; FFS = fee-for-service; P4P = pay-for-performance; CCG = Clinical Commissioning Groups; EHIF = Estonian Health Insurance Fund; PPE = personal protective equipment. compensation, which are available compensate certain groups of health practices will temporarily not be linked to all self-employed professionals or professionals through payments based on to performance to compensate for the loss businesses in some countries (the Czech the previous year’s turnover. In Lithuania of income due to scaled-back services; Republic, Estonia, Germany, Israel, the primary care institutions continued to GPs will instead receive payments at rates Netherlands, Switzerland). In Estonia receive the planned monthly income that assume they would have continued and the Netherlands, this mechanism is of one-twelfth of the annual contract to perform activities at the same levels mainly intended for those cases where with the National Health Insurance as before the outbreak. Fifth, several the COVID-19-related compensation Fund (NHIF). Other examples include countries are providing payments to cover payments were not sufficient, whereas, compensating income if it falls by more fixed costs such as for rent and employees in Israel and Switzerland it is the main than 10% in Germany (for physicians, (the Czech Republic, Estonia, France, mechanism. Second, some countries psychotherapists, allied health the Netherlands, Switzerland). Finally, at provide flat compensations for lost professionals) or 30% in Denmark (for least in the Netherlands, there are plans to revenue, e.g. extra/higher capitation GPs). In the Netherlands, allied health recoup some of the additional payments or temporarily higher fees (the Czech professionals can receive compensation after the crisis, e.g. through lower future Republic, Estonia, Germany, Italy, expressed as a set percentage of annual reimbursement levels. Luxembourg, the Netherlands). Third, turnover (see Box 2). Fourth, as is the case some countries have chosen to broadly in England, payments for primary care

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Figure 1: What can countries do to offset income losses and extra expenses due to COVID-19?

How are countries tackling loss of income and extra expenditures due to COVID-19?

Avoid income loss: Compensate for loss Compensate for COVID-19 incentives for of income extra expenditures substitutive e-Health

Flat compensations In kind provision of Higher fees (higher FFS or capitation) materials (hygiene, PPE)

Loosening restrictions Compensations based on Additional fees for services on digital or phone previous year turnover for COVID-19 patients consultations

Temporarily suspending Additional reimbursements Reimburse extra spending activity-based payment for e-Health investments (adapting clinics) (FFS/P4P)

Source: Authors’ compilation

Countries used different ways to pay COVID-19 preparedness, i.e. redesigning paying for them. Where it is not provided professionals for increased COVID-19- clinics and waiting rooms, and treatment in kind, there seems to be a lack of clarity related expenditures equipment such as PPE and hygiene regarding funding or compensation for products were provided in kind in the additional expenses. Some health professionals have faced Czech Republic, Germany, Israel, Italy extra expenses related to the COVID-19 or were reimbursed by the government Some countries also provided additional outbreak, for example because they had in Estonia, France, the Netherlands, Spain, fees for services for (suspected) COVID-19 to reshape clinics to implement physical Switzerland. In kind provision and funding patients (e.g. Germany, the Netherlands for distancing measures, hygiene and safety may not always be sufficient, meaning GPs) or have reimbursed extra spending regulations or to purchase PPE. However, that health professionals in these countries such as to improve e-health platforms compensation for this additional spending may still be searching for equipment and (e.g. Spain, England). The Czech Republic varied substantially across countries. implemented new fees for antibody tests, the Netherlands and France set incentives Box 3: French statutory health insurance (CNAM) compensatory payments for GPs to treat COVID-19 patients with to health professionals a higher tariff for visits (see Box 3). Germany set higher tariffs for GPs treating In France, community health care professionals are self-employed and payed on patients in long-term care institutions and a FFS basis. During the lockdown (March – April, 2020), their activity (and income) German hospital professionals received has dramatically dropped. Teleconsultations were encouraged and paid at the bonuses for treating COVID-19 patients same price as face-to-face consultations. The French statutory health insurance that varied according to the prevalence of (CNAM) also attempted to support health professionals to keep providing care by the disease in their region. helping them to cover fixed expenditures such as rent, staff costs, social security contributions and taxes. It is the first time that such a support system has been Compensation schemes are often implemented. CNAM also introduced higher fees for consultations: one for the funded from health budgets and management of COVID patients (i.e. reporting the case and providing contact complemented by ‘emergency’ funds details), and another fee to handle chronic diseases patients (i.e. for a medical check-up and follow-up). Finally, CNAM is negotiating with health professionals There are several ways in which national over providing compensation to cover costs of increased hygiene measures. health systems fund the revenue losses and additional spending due to the

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COVID-19 pandemic, reflecting country- based payments due to providing fewer specific contexts including payer mix, services, extra or higher compensation payment method, fiscal space and health (e.g. through FFS, capitation), suspending insurance fund reserves. In some cases, activity-based payment, or subsidies funds were allocated directly to providers, to cover fixed expenses such as rent particularly if they are self-employed or or salaries for employees, are viable paid via FFS. When professionals are options. Third, if not eligible for the salaried employees or paid on a capitation aforementioned support, self-employed basis, these funds are typically allocated health professionals could be included to payer agencies, such as municipalities, in non-health care specific COVID-19- Clinical Commissioning Groups and related compensation schemes which are health insurers. In other cases, health available to all self-employed professionals insurers have reserves, either because or businesses. Other compensations for of legal obligations, from past years COVID-19 related expenses have been or from services forgone during the given by providing centrally procured pandemic, and these are being used to pay PPE and hygiene products in kind, which for extra COVID-19-related expenses. may also prevent competition among Finally, countries may increase insurance professionals for PPE and lower unit contributions/premiums or taxes in the cost. Further options include providing near future to cover COVID-19-related additional fees for COVID-19-related extra expenses. services and reimbursing any expenses related to reshaping clinics to comply with physical distancing, hygiene and safety regulations and developing variety e-health services.

of strategies to References financially 1 Arnaout O, Patel A, Carter B, Chiocca A. Letter: Adaptation Under Fire: Two Harvard Neurosurgical Services During the COVID-19 Pandemic. support health Neurosurgery 2007;87(2):EE173 – 7. care providers 2 Cavallo J, Forman H. The economic impact of the COVID-19 pandemic on radiology practices. Radiology 2020, 201495.

Policy lessons 3 Carroll N, Smith D. Financial Implications of the COVID-19 Epidemic for Hospitals: A Case This article has shown that countries have Study. Journal of Health Care Finance 2020; 46(4). implemented a variety of strategies to ‘‘ 4 Rockwell K, Gilroy A. Incorporating financially support health care providers telemedicine as part of COVID-19 outbreak in the ambulatory sector during the response systems. American Journal of Managed pandemic to mitigate their loss of income Care 2020;26(4):147 – 8. Lounaeestlane.ee. and to help relieve financial pressures Haigekassa: Kaugvastuvõtte jätkatakse ka peale due to additional expenses. Overall, three eriolukorda [EHIF: Remote reception will continue broad strategies to compensate ambulatory even after an emergency], 2020. Available at: https:// lounaeestlane.ee/haigekassa-kaugvastuvotte- health care professionals can be identified jatkatakse-ka-peale-eriolukorda/ (see Figure 1). First, countries attempt to mitigate reduced demand for elective (non-COVID-19) health care services by increasing the availability of e-health and remote consultations through looser restrictions or higher reimbursement. This has the additional benefit that it may prevent patients from forgoing necessary care and allows the providers to deliver real services instead of simply handing out money that may have to be recouped later. Second, in those countries where professionals lost income from activity-

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ADJUSTING HOSPITAL INPATIENT PAYMENT SYSTEMS FOR COVID-19

By: Wilm Quentin, Tit Albreht, Alexia Bezzina, Lucie Bryndova, Antoniya Dimova, Sophie Gerkens, Iwona Kowalska-Bobko, Sarah Mantwill, Zeynep Or, Selina Rajan, Mamas Theodorou, Liina-Kaisa Tynkkynen, Ruth Waitzberg and Juliane Winkelmann

Cite this as: Eurohealth 2020; 26(2).

Wilm Quentin is Senior Research Fellow, Department of Health Care Management, Technical University Summary: All countries in Europe will have to find solutions to protect Berlin and European Observatory on Health Systems and Policies, Berlin, hospitals from revenue shortfalls and to adequately reimburse for Germany; Tit Albreht is Senior Researcher at the National Institute COVID-19-related costs of care. This article reports on changes to of Public Health of Slovenia; Alexia Bezzina is Resident hospital payment systems in Belgium, Bulgaria, the Czech Republic, Specialist, Department for Policy in Health, Malta; Lucie Bryndova Finland, France, Germany, Israel, Poland, Romania, Switzerland, and is Adjunct Lecturer, Institute of Economic Studies, Faculty of Social the United Kingdom (England). Hospitals in these countries are paid Sciences, Charles University, Prague, Czech Republic; Antoniya for treating COVID-19 patients using the usual system, modified Dimova is Professor of Healthcare management, Medical University of Diagnosis Related Groups or new mechanisms. In many countries, Varna, Bulgaria; Sophie Gerkens is Expert in Health Economics, Belgian hospitals receive their usual budgets or new money to compensate Health Care Knowledge Centre (KCE), Brussels, Belgium; Iwona for revenue shortfalls. Only a few countries are paying non-contracted Kowalska-Bobko is Professor at providers. Jagiellonian University Medical College, Faculty of Health Science, Institute of Public Health, Poland; Sarah Mantwill is Postdoctoral Keywords: Financing, Payment Mechanisms, Hospitals, COVID-19 Researcher, Universität Luzern, Lucerne, Switzerland; Zeynep Or is Research Director, Institute for Introduction to hospital payments patients can be substantial and these costs Research and Information in Health Economics (IRDES), Paris, France; and COVID-19 could not be anticipated at the time when Selina Rajan is Specialist Public hospital budgets or hospital payments were Since the emergence of COVID-19, health Health Registrar and Research determined. In addition, hospitals have Fellow, London School of Hygiene systems worldwide have had to respond had to invest in purchasing new ventilators and Tropical Medicine (LSHTM), to a range of different challenges. 1 With London, UK; Mamas Theodorou or protective personal equipment (PPE) a considerable proportion of COVID-19 is Professor of Health Policy, to prepare for COVID-19 patients. patients requiring hospitalisation, 2 Open University of Cyprus, Latsia, Second, in many countries with activity- Cyprus; Liina-Kaisa Tynkkynen hospitals were at the forefront of the based payment systems, hospitals have is Assistant Professor, Tampere pandemic in many countries. Hospitals University, Faculty of Social experienced revenue shortfalls because have had to cope with the influx Sciences, Tampere, Finland; Ruth they had to cancel elective procedures or Waitzberg is Research scholar, of COVID-19 patients, or with the because patients avoided being admitted Myers-JDC-Brookdale Institute, consequences of preparing hospitals for Jerusalem, Israel, and PhD student to hospitals. Third, non-contracted acute an anticipated influx. Hospital services at Ben Gurion University of the care facilities (including private hospitals) Negev, Beer Sheva, Israel and have been restructured, intensive care have been used in some countries to Minerva Stiftung fellow at Technical unit (ICU) capacity expanded, 3 elective University Berlin, Germany; Juliane provide care (both for COVID-19 and admissions cancelled, and patient Winkelmann is Research Fellow, other patients), and they have had to be Technical University Berlin, Berlin, pathways reorganised. Germany. Email: wilm.quentin@ compensated for the services provided. tu-berlin.de All of these challenges have had This article aims to support policymakers implications for hospital financing. First, across countries who have to respond the costs of care related to COVID-19

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to these challenges by taking decisions Figure 1: Hospital payment approaches in response to COVID-19 about the payment of hospitals: Should payment be adjusted to reflect the costs of COVID-19? Should payment be kept Covering costs the same irrespective of activity to of COVID-19 compensate for revenue shortfalls? What mechanisms can be used to channel financial resources to non-contracted • New fees (Belgium, Poland) New providers? We identified hospital payment • Cost reimbursement (England, Finland) system adjustments in countries reporting • New per diem codes (Belgium, Israel) • New budgets (Belgium) to the COVID-19 Health System Response Monitor (HSRM), then checked with national experts about further changes (up • DRG + €50 add-on per case (Germany) Modified until the end of July 2020) to understand • Usual budget + new per diem (Czechia) • Modified DRG (France, Romania, Switzerland) whether and how countries have changed their hospital payment systems in response to COVID-19. The paper focuses on a As usual selection of countries including: Belgium, • Usual case payment + per diem (Bulgaria) Bulgaria, the Czech Republic, Finland, France, Germany, Israel, Poland, Romania, Switzerland, and the United Kingdom Usual budget level (England) but also draws on examples from Cyprus, Malta, Slovakia, and Slovenia, where relevant.

• New per diem for empty beds New In many countries, hospitals receive (€560 in Germany) their usual budgets or new money to • New cash advance (€1bn in Belgium) compensate for revenue shortfalls • New budget (Belgium)

In many countries, compensating • Replacing DRG-based payment with Modified revenue shortfalls resulting from the global budget (England) interruption of usual activities has been a • Compensating COVID-19 related loss more important problem than paying for of revenue (Belgium, Finland, France) COVID-19 patients. Figure 1 shows that numerous countries have responded to • Usual budget despite lower activity (Belgium, As usual these revenue shortfalls through a range Czechia, Poland, Slovenia) of approaches, which differ considerably, • 95% of target budget as income guarantee (Israel) depending on the pre-existing payment system, amongst other factors.

In Poland, where most hospitals receive Compensating a Diagnosis-related group (DRG)-based revenue shortfalls budget (determined by the previous year’s activity), hospitals in the public hospital network continue to receive their usual Note: DRG = Diagnosis-related group. monthly instalments despite considerably Source: Authors’ own compilation reduced activity. Hospitals outside of the network can apply to receive monthly instalments for contracted services under However, in Czechia, a new regulation provided beyond the 79 – 82%. In Slovenia, the assumption that these will be provided has specified that hospitals can keep a decision has not yet been taken on the later during the year. Similarly, in the the full budget as long as their 2020 settlement of the annual bill. In Israel, Czech Republic and Slovenia, hospitals activity is between 79% and 82% of where hospitals are mostly paid based continue to receive their regular monthly their 2018 activity (depending on the on a mix of DRG-like payments and per instalments of a DRG-based budget number of COVID-19 patients treated). diems, hospitals always have a guaranteed despite a substantial decrease of activity. If hospitals stay below this level, their minimum income of 95% of the previous Under normal circumstances, this would monthly instalments in 2021 will be year’s income, which protects them affect the settlement of the annual bill at adjusted accordingly, while they may from income loss – also in the case of the end of the year. receive additional payments for services COVID-19.

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Box 1: Substantial support for hospitals: To fund increased treatment capacities, hospitals receive Germany’s Hospital Relief Act a one-time payment of €50,000 for each additional ICU bed with ventilation capabilities that they set up in the period In March 2020, the German government passed the between 1 April and 30 September. In addition, Länder Hospital Relief Act to provide financial support for hospitals governments often top-up this payment to cover the full costs with the aims to: (1) compensate revenue shortfalls due to of creating a new ICU bed. decreased admissions; (2) fund increased treatment capacities; To cover additional expenditures related to COVID-19 hospitals (3) cover additional expenditure related to COVID-19; and receive a top-up payment of €50 for every patient who is (4) provide hospitals with financial leeway. admitted during the period between 1 April and 30 June The most important financial support for hospitals is to cover for the increased costs for PPE. Since 1st July, compensation for revenue shortfalls related to postponement of this amount has been increased to €100 and prolonged non-essential surgery and treatments. Until September 2020, until 30th September. hospitals receive a per diem payment of €560 per day for every Hospitals receive a higher daily nursing fee (an additional €38 empty bed. In practice, hospitals receive a per diem-based per patient per day) to allow them to schedule for an increased lump sum, which is calculated by determining the difference level of nursing care. between the number of patients currently being treated per day and the average number of patients treated in the previous These support measures are accompanied by several financial year. A revision of the Act on 1st July, which introduced a and administrative relief measures that aim to further secure system of tiered per diems (ranging between €360 and €760), the liquidity of hospitals. These include a reduced payment where the amount depends on the hospital’s case mix index, periods for Social Health Insurance funds, fewer billing the average length of stay in 2019 and the reporting of ICU audits, temporary audit exemptions for hospital treatments capacities to the intensive care register. of COVID-19 patients and a new additional fee to finance COVID-19 tests performed in hospitals.

In England, where hospitals are usually new law was approved at the end of March and 80% of the difference between the paid on the basis of a DRG-like payment guaranteeing that hospitals will receive per current salary and the normal salary of system with certain adjustments based on diem payments (€560 per day) for every their employees will be covered by the quality of care (P4Q – Pay for Quality), a empty bed until the end of September 2020 government. radical decision was taken at the beginning (see also Box 1). In Belgium, the federal of the pandemic that the normal payment authorities created a short-term cash € Hospitals are paid for treating system would be discontinued between advance to hospitals (of 1 billion), to COVID-19 patients using the usual April and July 2020. Instead, all hospitals compensate for revenue losses – and also system, modified DRGs or new have received a global budget based on to cover the extra costs of COVID-19 mechanisms the previous year’s average monthly patients. However, a proposal currently expenditures plus an increase to account suggests that the cash advance will be Figure 1 also provides an overview for inflation. The UK government has counted towards any further COVID- of payment systems used by different also taken a decision during COVID-19 to 19-related hospital payment adjustments countries to pay for COVID-19 patients. write-off £13.4 billion (about €14.9 billion) (e.g. an income guarantee, a budget for Several countries have – at least initially – of historic debt of NHS trusts in England. capacity expansion, and per diems for used their regular hospital payment In France, where the DRG-based payment hospitalisations). system. In Bulgaria, hospitals are paid system has remained in place, a guarantee using a mix of case payment (based on was issued by the Ministry of Health in In Switzerland, financial compensation an existing general case definition), per March 2020 that hospitals would receive for the lost revenue resulting from the diems (for every day a patient is treated additional payments to compensate cancellation of elective admissions has on an ICU). In Israel, hospitals were any income loss when compared to depended on cantonal decisions, and some initially paid based on existing per diem their usual revenues. In Finland, the cantons were quicker to react and provided codes for internal medicine wards and national government has made available more generous compensation than others. ICUs. However, since mid-April new €200 million, and (public) hospital owners In general, hospitals – in particular private per diem codes have been created for can apply for funding to compensate for ones – could apply for bridging credits patients treated on dedicated COVID-19 COVID-19 related deficits. and short-time work compensation just as wards of geriatric and general hospitals any other business entity in the country for moderately/severely ill COVID-19 Other countries have made substantial making a loss and being at risk of job patients (including with ventilation). These resources available to hospitals through losses. If hospitals apply for short-time payments are excluded from the usual new payment approaches. In Germany, a work, they can reduce their salary costs, budget cap.

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Box 2: Poland: Channelling new funding to hospitals, to provide transport. This list has been extended to 33 items, while protecting them from revenue loss with some items split into more detailed procedures. Hospitals exclusively treating COVID-19 patients receive a lump sum and The central government is responsible for financing COVID-19- payment for each COVID-19 service provided, as well as funds related hospital services. Funds are transferred (based on a for readiness to provide services. monthly report) to the National Health Fund (NHF), which in turn Additional funds for health care services have been released uses them to pay for health services. The payments are made by the NHF to cover extra costs without reducing regular based on reports and bills submitted by providers to the NHF payments to hospitals due to the cancellation of services not outside the usual contracts for providing health care services. related to COVID-19. During the first months of the pandemic, Only providers included in the list of providers dedicated to hospitals in the public hospital network continued to receive performing services related to COVID-19, are entitled to receive their ‘usual’ monthly instalments, which had been increased these dedicated funds. by 5% at the beginning of the year. In addition, they received In order to pay for COVID-19 related services, the NHF has payments for services related to COVID-19, which could add up established a new reimbursement catalogue with prices. to substantial amounts if they treated many patients. For these According to the catalogue, providers are paid lump sums hospitals, the regular lump sum payments have now been for assuring readiness to provide services and FFS for the reduced. Hospitals outside the network could apply to receive actual provision of services. Over time, the catalogue has payments for contracted services (in monthly instalments) been updated to reflect the changing needs of the population. under the assumption that they would provide these services Originally, it included six items such as hospitalisation, later in the year. To secure financial liquidity of hospitals, hospitalisation in an ICU, isolation in a designated facility, payments are made faster and more frequently. transport, readiness to provide hospitalisation, and readiness

In France, Germany, Romania and services. In Poland, the National Health hospitals were allowed to make capital Switzerland, where hospitals are paid Fund has established a reimbursement list, investments of up to £250,000 (€278,000) using DRG-based payment systems, which includes fees for hospitalisation, without requiring national pre-approval. these systems had to be slightly hospitalisation in an ICU, isolation in modified to enable payment for patients a designated facility, and lump sums Only a few countries are paying with COVID-19. For example, coding for readiness to provide hospitalisation. non-contracted providers guidelines for diagnoses and procedures Over time, the list has been extended were adjusted to enable hospitals to code to include 30 COVID-19-related fees Only relatively few countries seem to for isolation treatment for patients with for inpatient and outpatient care (see have put in place specific rules to pay confirmed coronavirus. In addition, also Box 2). In England, providers were for services provided by non-contracted hospitals in Germany receive a top-up given the possibility to claim additional (public and private) providers, either to payment for every hospital case (including reasonable expenditures related to increase capacity for treating COVID-19 for non-COVID-19 patients) treated COVID-19, if the new global budgets did patients or to compensate for reduced between 1 April and 30 September to not equal actual costs (e.g. if additional capacity in public hospitals, which are cover the additional costs of PPE; and the staff had to be employed). Similarly, in busy taking care of COVID-19 patients. average daily nursing fee was increased Finland, the central government will For example, in England, the NHS made by €38 (see Box 1). In the Czech Republic, compensate hospital districts (i.e. hospital a block contract with the vast majority of hospitals receive a new per-diem for owners) for additional costs related to the private hospitals to make their capacity COVID-19 positive patients (€2,237 per care of patients with COVID-19. available for NHS patients, while being day for treatment in an ICU and €88 per reimbursed for services provided based on day on other ward) in addition to their Concerning necessary investments, the full costs of care. Similar agreements usual monthly instalments. In addition, governments in several countries (e.g. with the private sector were also concluded the usual monthly instalments have been the Czech Republic, England, Israel, in Malta. In Cyprus, patients who could increased by about 1% in order to account Malta, Slovakia, Slovenia) have directly not be treated in public hospitals due for the additional costs of PPE. purchased ventilators, beds, and/or PPE to the closure of departments could be and distributed these to hospitals – at least treated by private providers, and costs of In Belgium, where hospitals are usually during the early stages of the pandemic. care were reimbursed by the Ministry of paid based on a mix of global budgets, In Germany, hospitals received a lump Health through FFS payments at a slightly DRGs, and fee-for-service (FFS), new FFS sum payment of €50,000 for every reduced rate (20% below usual private billing codes have been created, e.g. for new ICU bed set up to prepare for the sector prices). physicians treating COVID-19 patients, expected influx of patients. In England, as well as for ICU care and for specialist between 3 April and 19 May, NHS

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find that has taken the dramatic decision to References discontinue its normal (DRG-based) 1 WHO. Strengthening the health system response to solutions to payment system (at least during the COVID-19: Recommendations for the WHO European pandemic) in favour of global budget Region. Policy brief. Copenhagen: WHO Regional protect hospitals allocations and cost-based reimbursement. Office for Europe, 2020. Available at: https://apps. who.int/iris/bitstream/handle/10665/333072/ WHO-EURO-2020-806-40541-54465-eng. from revenue In view of the ongoing challenges of pdf?sequence=1&isAllowed=y COVID-19, all countries in Europe will 2 shortfalls and to have to find solutions to protect hospitals MIG. Data on Covid-19 hospitalisations / ICU treatments across European countries from revenue shortfalls and to adequately with data available. Fachgebiet Management im adequately reimburse for COVID-19-related costs Gesundheitswesen (MIG) /Department of Health of care. A top priority should be for Care Management. Berlin: TUB, 2020. Available at: reimburse for policymakers to minimise the impact of https://www.mig.tu-berlin.de/fileadmin/a38331600/ COVID-19 on regular service provision, sonstiges/COVID-19-STATS_0408_2340.pdf ‘‘ 3 COVID-19- e.g. by concentrating care for these Phua J, Weng Li, Ling L, et al. Intensive patients at dedicated wards of designated care management of coronavirus disease 2019 related costs providers. This may allow other hospitals (COVID-19): challenges and recommendations. Lancet Respiratory Medicine 2020;8(5):506-17. to continue normal operations, thus of care avoiding the need to compensate revenue 4 Khullar D, Bond AM, Schpero WL. COVID-19 shortfalls. Of course, the easiest (short- and the Financial Health of US Hospitals. JAMA 2020;323(21):2127-8. doi:10.1001/jama.2020.6269. In Switzerland, hospitals that provide term) solution to avoid revenue shortfalls acute care but are not included in cantonal is keeping existing hospital budgets intact. hospital plans, could be mandated by However, this also reduces the incentive cantons to provide care for designated for hospitals to restructure service delivery groups of patients during the crisis. In this in line with new provision needs during case, they were paid by DRG using the the pandemic. same tariff as for other general hospitals in the canton. In addition, in order to expand Concerning the reimbursement of COVID- ICU capacities, the Swiss government 19-related costs, all countries will likely allowed hospitals to bill ICU related DRGs need to adjust their hospital payment for all patients treated in non-certified systems, e.g. by modifying DRG-based ICUs. payments, increasing per diem rates, or adding additional fees to FFS systems. Conclusion However, these payment adjustments would ideally accompany and support In addition to clinical and organisational the concentration of care, e.g. by making challenges, COVID-19 has placed the designation as a COVID-19 centre a significant burden on hospital a prerequisite for receiving COVID- finances. 4 Although a complete overview 19-related payments like in Israel or of all countries currently remains Poland. In addition, given the risk of unavailable, all of the countries included future pandemics, processes need to be in this article have responded relatively put in place to rapidly adjust payment quickly to find pragmatic solutions systems to meet new challenges where and to evolving challenges. However, the when needed. adopted approaches differ considerably across countries. Germany stands out as having made substantial additional resources available to hospitals, both to pay for COVID-19 and to compensate for revenue shortfalls (see Box 1). Belgium has also responded very quickly to mobilise substantial additional resources for hospitals. Other countries, such as the Czech Republic and Poland continue to pay the usual monthly instalments to hospitals, which effectively compensates for revenue shortfalls in the short-term. England also stands out as a country

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IN AND OUT OF LOCKDOWNS, AND WHAT IS A LOCKDOWN ANYWAY? POLICY ISSUES IN TRANSITIONS

By: Holly Jarman, Scott L. Greer, Sarah Rozenblum and Matthias Wismar

Summary: In the absence of effective treatments or a vaccine, governments depend on public policy to respond to COVID-19. This article reviews key issues surrounding transitions – the “closing” and “reopening” of economies during the pandemic. It identifies a number of key issues such as the use of data to inform decisions and the localisation of lockdowns, as well as key questions about how decisions are made and implemented. Identifying leadership, financing, key stakeholders, data, and communications strategies for different issues has proven crucial to managing transitions.

Keywords: Transition, COVID-19, Social Policy, Leadership, Governance

Cite this as: Eurohealth 2020; 26(2). Introduction This article synthesises many of the issues that were found in the course of a series As there are currently few effective of cross-cutting analyses on transition Holly Jarman is John G. Searle treatments and no vaccinations for decision-making 1 2 3 based on evidence Assistant Professor of Health COVID-19, physical distancing Management and Policy and head available from the COVID-19 Health requirements remain among the most of the HMP Governance Lab, Systems Response Monitor (HSRM). Sarah Rozenblum is PhD student, effective means of controlling the spread Department of Health Management of the disease and reducing morbidity and Policy, and a member of the We can understand governments’ and mortality. Nevertheless, physical HMP Governance Lab, University transition planning in terms of six distancing and other public health of Michigan, Ann Arbor, United categories. First, policy capacity, meaning States; Scott L. Greer is Professor requirements need to be aligned with a government’s core capacity to make of Health Management and Policy, measures that support economic activity. Global Public Health and Political and implement COVID-19 related policy Most countries in the World Health Science by courtesy and a member decisions. Second, policy measures of the HMP Governance Lab, Organization (WHO) European region are addressing geographic variation in University of Michigan, Ann Arbor, making and implementing strategic plans United States and Senior Expert COVID-19 spread, prevalence and impact. to manage the transition away from tough Advisor on Health Governance to Third, policies addressing specific the European Observatory on Health COVID-19 controls as well as developing sectoral risks such as those posed by Systems and Policies, Brussels, and implementing plans to reimpose Belgium; Matthias Wismar is school systems, higher educational controls during surges. There are a number Programme Manager, European institutions or sectors with many high- Observatory on Health Systems and of common elements to this transition density workplaces. Fourth, operational Policies, Brussels, Belgium. Email: planning, described below. [email protected] guidance issued by governments, such

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as rules on how to sanitise or change distancing, personal hygiene and the • total number of new cases (interpreted the layout of businesses. Fifth, policies relevant symptoms one must experience to in light of testing rules and rates, which to ensure adequate capacity in health warrant testing. can produce undercounts) and public health systems. Finally, many • excess mortality (which shows the governments introduced or modified Table 1 elaborates upon these categories number of deaths above what we would social policy stabilizers with the aim of and domains, providing a conceptual have been expected under ‘normal’ limiting the impact of the pandemic on matrix that can be used to identify the conditions. It is arguably a useful people and businesses. priorities and decisions being taken in measure for understanding policy any given jurisdiction in light of the effects, since it is not dependent on approaches and issues elsewhere. The next testing, but there is often a time lag in section identifies in more detail the kinds the data being reported) the total of challenges that countries are facing as they make transition decisions. • hospital capacity forecasts (availability number of cases of intensive care beds and normal beds) Policy capacity: Policymakers are • the testing rate (daily tests only makes taking advice, considering data, per 1,000 people) making plans and using metrics sense when • the test positivity rate (those that Most countries have established task test positive for coronavirus which balanced against forces with executive authority, advisory is an indirect indicator of whether groups, or groups that mix the two. In enough testing is being done. A high testing rates and Belgium, a “Group of Experts in charge of test positivity rate, above 3% or 5%, the Exit Strategy” (GEES) was set up on suggests that there is inadequate testing test positivity April 6th to advise the National Security and unmonitored spread) Council in defining the national transition ‘‘ • measures of adherence to policy Across each of these categories, strategy. For this, the GEES relied on requirements such as physical governments face challenges that fall indicators such as the decrease in the distancing. within five domains: leadership, financing, number of daily hospitalisations and the stakeholders, data, and communications. flattening of the curve of deaths linked These metrics and measures should The first domain is leadership, where to the virus. The transition phase out of be adapted to or complemented with challenges include basic questions of who lockdown began on May 4th, then the measures to identify vulnerable has authority in a given area (the head reintroduction of more stringent controls populations and people at different levels of government, regional governments, began in late July. of vulnerability to complications (e.g. co- an autonomous agency, a professional morbidities) in order to identify particular organisation, etc.) as well as challenges The expertise that seems to be consistently risks. All of them, and possibly others, are arising from the process of decision- useful includes epidemiology, population necessary to inform an effective response. making. The second domain is financing, health expertise, expertise in health The total number of cases only makes where challenges arise because many care and public health infrastructure, sense when balanced against testing rates of these measures directly cost money and expertise in logistics and business and test positivity, for example. Age- and it comes from somewhere. The third sectors. Behavioural and social sciences’ stratified excess mortality takes time and domain involves challenges in managing appearance, and the decision as to who effort to calculate, but it is a more reliable key stakeholders and the extent to which represents those fields, is less consistent. measure of the severity of the pandemic they are involved in informing decisions, Governments also tend to identify clear and its impact across the population than a for example the extent to which guidelines and useful measures and metrics to straight count of COVID-attributed deaths. on issues such as hygiene in service understand when it is safe to open and establishments are written with or by when lockdown needs to remain or be re- Clarity about government intentions, trade associations. The fourth domain imposed. Metrics and measures that have processes and decisions is a common involves the data deemed necessary been deemed to be of value include: objective and can be fulfilled through to make decisions (e.g. what indicators • R0 (pronounced “R naught” which a published plan that is used or revised of COVID-19’s spread are being used, estimates how many people each person in transparent ways. Most countries and on what level of aggregation, from with COVID-19 is infecting. However, are transitioning away from controls in local to national). The fifth domain is this is a dangerous statistic on its own multiple stages that account for different communications, with challenges relating since it is an estimate, with potential levels of risk across activities, sectors or to the level of publicity and transparency error, and is also unrevealing when geographic areas. France used a “traffic- for the scientific advice being given transmission is concentrated in specific light” system in which regions labelled to governments or the approach to settings such a prisons or abattoirs) “green” eased restrictions faster than communicating guidance on physical “red” regions where the virus was still active. Several countries are using targeted

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Table 1: Checklist to help policymakers systematically approach transition decisions

1. Leadership (who has authority) 2. Financing 3. Key stakeholders 4. Necessary data 5. Communications 6. Other 1. POLICY CAPACITY Establish task force / advisory group ● Epidemiologists ● Population health experts ● Health care and public health infrastructure experts ● Economics, business, logistics experts Identify key measures and metrics, e.g., ● R0 ● Cases ● Excess mortality ● Hospital capacity ● Testing rate ● Test positive rate ● Measures of adherence to policy requirements ● Risks and spread among specified vulnerable individuals / populations Create transition plan ● Description of multiple phases with measures at each phase ● Plan for geographic variation (localized variation + national borders) ● Assessment of sectoral risks (spread of disease + economic vulnerability) ● Operational guidance ● Plan to measure and assess systemic capacity ● Details of social policy stabilizers ● Metrics for decision-making Communications strategy, e.g., ● Targeted at individuals ● Targeted at high risk populations ● Targeted at employers ● Targeted at potential social policy beneficiaries ● Publish transition plan, rationale and metrics ● Acknowledge potential to increase lockdown measures ● Communicate criteria for increasing lockdown measures 2. GEOGRAPHIC VARIATION ● Is transition plan regionalized? Y/N ● close off regional borders (at which phases?) ● close off national borders (at which phases?) ● quarantine measures for international travellers ● pause or change immigration policies / procedures 3. SECTORAL RISKS ● Primary and secondary education ● Higher education ● Childcare (institutional, e.g., nurseries) ● sports (outdoor activity) ● sports (professional) ● High touch retail ❚ Essential retail ❚ Small retail ❚ Large retail ❚ Shopping centers ● High touch services ❚ Restaurants ❚ Hotels ❚ Hair salons, etc. ❚ Cinemas and large venues ❚ Childcare (individual) ● Construction ● Health sector ● Social care sector ● Prisons ● Transportation ● Science, e.g., laboratories ● Food system ● Manufacturing ● Export sectors

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1. Leadership (who has authority) 2. Financing 3. Key stakeholders 4. Necessary data 5. Communications 6. Other 4. OPERATIONAL GUIDANCE ● Capacity (how many people can be in enclosed space) ● Physical distancing (how far apart, under what circumstances) ● Masks (when required) ● Hygiene (institutional, e.g., how should restaurants be cleaned) ● Hygiene (personal, e.g., all employees should wash their hands) ● Workforce protections (necessary equipment, environment, procedures, contracting) 5. SYSTEMIC CAPACITY ● Testing supplies and sites ● Contact tracing system, workforce, technology ● PPE acquisition and distribution ● Research funding and prioritization ● Regulation of private companies, e.g., test manufacturers ● Routine health system capacity, e.g., workforce, beds, routine treatment / prevention ● Crisis health system capacity, e.g., field hospitals ● Community triage (which care takes place where) ● Dissemination of innovation (technology + practice) 6. SOCIAL POLICY STABILIZERS ● Vulnerable populations, definition, support ● Unemployment insurance ● Income protection, including for precarious / independent workers ● Short-time work ● Health care access ● Labour market policies ● Food support ● Housing 7. OTHER

Source: Authors’ own

local lockdowns, as with Leicester in Finally, a clear and coherent acknowledge the potential of increased England or Guterslöh in Germany. communications strategy is a priority lockdown measures and the criteria for Some subnational governments, such as for governments, even if not all of deciding to lock down an area or sector. Saxony, have produced their own regional them succeed consistently. Most See also the policy snapshot looking at plans with detailed criteria governing communications strategies have health communication channels across future lockdowns. dimensions targeted at individuals European countries. 4 (e.g. with regard to physical distancing A plan that explains the measures and or personal hygiene), plans for Geographic variation: There are metrics being used as governments add communicating with particular geographic regional differences in lockdown or reduce restrictions can, it seems, aid areas and local leaders (including during requirements and the loosening planning and public communications. It local lockdowns), high risk populations of restrictions can include an explanation of the core such as diabetics, hypertensives, people criteria and thresholds for making a over 60 or people in jobs that put them In many countries, the risks and the decision, plans for handling geographic at increased risk; communications to burden of COVID-19 vary considerably, variation (e.g. whether border controls employers about the procedures, costs, and not just between urban and rural can be imposed within a country or at and benefits of opening at a given time; areas, but often within them in a pattern international frontiers, why, and when), and communications to social policy that is often not clearly understood. how policymakers assess sectoral risks beneficiaries of the available support, Most countries are adopting regional (e.g. of opening schools or universities), in part to discourage vulnerable people lockdowns, with some areas under looser operational guidance, transparency exposing themselves when they need controls than others, including France, about the measurement of health system not. The strategy can include publication Spain, and Greece. Many governments are capacity, or clarity about social policy of the transition plan, its rationale, and making clear their criteria and decision stabilizers such as unemployment benefits. metrics, and in order to prepare for what processes for closing down particular areas might be a long struggle it should clearly or loosening restrictions, and whether

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they will police movement internally. restaurants, concert venues and haircutting increase in on-site work, as opposed This might have benefits for transparency are all subject to different risk assessments to remote work. Businesses are being and adherence. in different governments. Explaining the encouraged to utilise outdoor spaces where policies to the public and the decisions possible to supplement capacity. Some The possibility of international travel underlying them might have value, given governments are putting in place measures is likewise going to vary. On the one the high public visibility of these issues to support the use of outdoor space, such hand, explaining the logic of quarantine and the challenges of re-establishing high- as pedestrianising urban spaces (which decisions for international travellers, and touch services, leisure travel and tourism. can then be used by restaurants, which policies for issues such as people transiting might enable reopening at reduced risk at airports, will aid a resumption of safe Some countries have specific policies of transmission). Other regions and travel. There is also a tendency to loosen addressed at enclosed populations such municipalities, including Berlin, London 5 controls at borders with countries at a as care homes (see the article in this issue and Paris, are expanding bicycle lanes to similar level of perceived risk (e.g. Austria, by Langins et al.) or prisons, as well as reduce the use of public transportation. Germany, and Switzerland). There was a the employees in them who can rapidly time when Estonians, for example, were carry an outbreak in one of them into Systemic capacity: Countries are allowed to travel to Latvia, Lithuania, and a surrounding community. Prisons and working to secure systemic capacity Finland providing that they did not exhibit detention centres in England, for example, requirements in health care, public symptoms and had not travelled abroad are expected to follow guidance for health and research within two weeks. Many strategies and isolating infected prisoners or admitting plans try to make clear the criteria for such them to hospital as well as ensuring staff It seems that most governments view decisions. Coordination procedures would are physically distancing where possible transition planning as more likely to help ease decision-making in this regard and able to access appropriate personal work when supported by adequate and would support planning if measures protective equipment (PPE). Likewise, capacity in essential systems such as have to be temporarily reversed. certain undeniably important industries health care, public health and research. such as abattoirs and social care (e.g. Countries are addressing capacity Sectoral risks: Sector specific residential nursing care or care workers requirements by securing testing supplies, guidance allows for different levels who travel from house to house) bring recruiting or reassigning contact tracers, of activity depending on the particular risks and can benefit from commissioning technological solutions associated risk specific guidance. In late June, over 1,500 to contact tracing, and acquiring and people tested positive for the virus after an distributing PPE. Germany, for instance, Many countries have issued sector outbreak at a meat-processing facility in emphasised contact tracing and sought specific guidance that takes into account Gütersloh, in the north west of Germany. to establish a five-person team for the different levels of risk inherent in every 20,000 individuals (see the article different activities. The potential impact Operational guidance: Governments in this issue by Hernandez-Quevedo et al. of school closures is a key issue given are setting operational guidance in on contact tracing operations and the the uncertainty about their contribution collaboration with industry role of apps). Many countries use an app to disease spread. This sector presents that records proximity using Bluetooth complex problems since childcare and Across many of these sectors, countries technology. If the app’s user comes into schools are crucial to parents’ participation are issuing guidance with some common contact with someone who then reports in labour markets and the reopening of elements. In order to maintain physical that they are infected with COVID-19, the the economy. distancing to the greatest extent possible, app notifies the user and instructs them countries are setting limits on the enclosed to self-isolate. Some countries are also In other cases, our review of plans physical capacity of locations including prioritising research on relevant measures suggests that decisions on sectoral shops, restaurants and public transport. In including improving on the validity of guidance depend on assessing risk and Malta and Cyprus, the government issued antibody testing and vaccine development. balancing it, in some cases, against the mandatory conditions and guidelines for Monitoring health system capacity and its economic importance of the sector (e.g. businesses, services and public transport changes on a day to day basis matters here, manufacturing and export sectors). The to follow when reopening. Some countries in order to understand the level of risk benefits of outdoor exercise and risks of are promoting guidance on institutional being taken at any given time. individual sports are also much debated hygiene measures, and personal hygiene due to their overall positive contribution measures including the use of masks, or In terms of health care systems, countries to health and wellbeing. Likewise, policies working in more or less formal partnership are addressing capacity requirements by regarding retail tend to distinguish with trade associations. Most countries issuing guidance to hospitals about routine small and large retail (measured by size are working with relevant stakeholders treatment and prevention activities, by of business or number of people on the to ensure greater compliance with safety setting up field hospitals and by overseeing premises) as well as essential retail of any measures. The Danish government community triage efforts. In Polish size, and shopping centres. In this concern discussed with unions and industry regions where there are two designated with risk, “high touch” activities such as representatives to initiate a gradual single-infection (COVID-19) hospitals,

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one of them resumed their former activity every resident, while Austria provided References

on June 1st. Should incidence rates additional financial assistance to particular 1 Jarman H, Rozenblum S, Greer SL, Wismar M. increase or a second wave of infections categories of people, including students What do governments need to consider as they materialise, the hospitals will be able to and older people. implement transition plans? Health System Response revert to single-infection units dedicated to Monitor – Cross-Country Analysis. WHO, European COVID-19 patients. Some are also actively Transition planners in practice consider Commission, European Observatory on Health Systems and Policies, 7 May 2020. Available at: working to disseminate innovation, both the extent to which social policy measures https://analysis.covid19healthsystem.org/index. technology and good practice in a way that are or are not supportive of public health php/2020/05/07/what-do-governments-need-to- supports spreading clinical knowledge. measures, and enter into discussions on consider-as-they-implement-transition-plans/

that basis, including by making the case 2 Jarman H, Rozenblum S, Greer SL, Wismar M. that measures which predictably kick in How will governments know when to lift and upon renewal of a lockdown will limit the impose restrictions? Health System Response no damage and improve adherence to public Monitor – Cross-Country Analysis. WHO, European health measures. Social policy measures Commission, European Observatory on Health Systems and Policies, 7 May 2020. Available at: clear path to that stabilize economies and enable https://analysis.covid19healthsystem.org/index. public health policies can include special php/2020/05/07/how-will-governments-know- take, with measures for vulnerable populations (e.g. when-to-lift-and-impose-restrictions/ the homeless), unemployment insurance, 3 Jarman H, Rozenblum S, Greer SL, Wismar M. uncertain and income protection measures, including for How are countries getting out of lockdown? Health precarious or independent workers (e.g. in System Response Monitor – Cross-Country Analysis. rapidly the arts) and even basic income schemes, WHO, European Commission, European Observatory short-time work (kurzarbeit), measures to on Health Systems and Policies, 7 May 2020. Available at: https://analysis.covid19healthsystem. developing ensure health care access, labour market org/index.php/2020/05/07/how-are-countries- policies such as special support for high- getting-out-of-lockdown/

science risk workers to stay home, food support 4 Weitzel T, Middleton J, ASPHER COVID-19 for people cast into food insecurity, and ‘‘ Taskforce. What channels are countries using to Social policy stabilizers: Supporting housing support. communicate with the public and at what frequency? transitions through social policy Health System Response Monitor – Cross- Country Analysis. WHO, European Commission, Conclusion Governments are also using social policies European Observatory on Health Systems and Policies, 3 July 2020. Available at: https://analysis. to support transitions. There are three There is a great deal of variation in how covid19healthsystem.org/index.php/2020/07/03/ key issues for social policy. First, there countries are approaching transitions. what-channels-are-countries-using-to-communicate- is variation in the extent to which social In many cases there is no clear path with-the-public-and-at-what-frequency/

policy cushions economies against the to take, with uncertain and rapidly 5 Warren H. How London Transport Is Preparing ongoing enormous demand shock of the developing science and difficulties in for Life After Lockdown. Bloomberg, 10 June 2020. pandemic. Restrictions on business hurt adapting general scientific findings to Available at: https://www.bloomberg.com/ businesses and can hurt employment as particular circumstances. Thus, countries graphics/2020-london-cycling-streetspace/ well as government tax revenue. This are defining vulnerable populations in creates pressure on policymakers to different ways, while others have paid less reopen. Second, there is variation in the attention to some vulnerable populations, extent to which it enables people to survive e.g. migrants, or were slow to include data, lockdown. If people’s basic ability to e.g. care homes; likewise, there is huge survive depends on violating public health variation in the definition and handling of orders, many of them will violate public high-touch activities like hairdressers or health orders. Supportive social policy the arts. The extent to which compliance enables people to adhere to public health will continue also relies on public trust, rules. Third, there is variation in the extent public messaging and law enforcement to which social policy supports public actions, all of which will be tricky for health. Measures that protect income, governments to balance. housing, and similar necessities can increase adherence to lockdown measures Table 1 provides a checklist, informed by since it means people are not forced out our rapid review of the decisions, for topics to work when it is unsafe to do so. In this that analysts and policymakers should regard, France, Germany, Italy, Malta and consider as they develop, implement, and the United Kingdom all implemented some fine-tune transitions strategies for what unprecedented measures. The approaches might be a very long period of crisis. to social support are diverse: for example, Spain provided masks at no cost to

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WHO’S IN CHARGE AND WHY? CENTRALISATION WITHIN AND BETWEEN GOVERNMENTS

By: Scott L. Greer, Holly Jarman, Sarah Rozenblum and Matthias Wismar

Summary: Successful response to the COVID-19 pandemic requires coordination within and across governments. Within governments, heads of governments gathered together power and authority early in the response, concentrating power and energy at the centre of government. Across governments, different governments adopted differing approaches to coordinating pandemic response between central governments, regions, and local government. In many cases, policy was temporarily centralised in federations, with the central government making more policies than usual. In the second wave, there seems to be less centralisation, particularly in federations, and regional or local governments are more prominent.

Keywords: Centralisation, Federal countries, Governance, COVID-19, Executives

Cite this as: Eurohealth 2020; 26(2). Public health planners have long argued government, from a town hall to a country for a “command and control” approach – gathers together the power normally to pandemics. 1 Governments almost dispersed across different ministries, Scott L. Greer is Professor of Health Management and Policy, Global universally adopted that approach early politicians, and agencies. The other is Public Health and Political Science in the pandemic. The result was that for a between governments. In this case, power by courtesy and a member of the few months in 2020, politics looked very that is normally in the hands of one HMP Governance Lab, University of Michigan, Ann Arbor, United different in many countries. Policymaking government, such as a local government, States and Senior Expert Advisor on became far more centralised and or regional governments such as Italian or Health Governance to the European hierarchical than usual, with less regional Spanish regions or the states of Austria or Observatory on Health Systems and Policies, Brussels, Belgium; and ministerial autonomy and more Germany, shifts to the central government. Holly Jarman is John G. Searle empowered heads of government. Normal Assistant Professor of Health politics is slowly returning, even as the Both kinds of centralisation were at work Management and Policy and head pandemic continues. The challenge is to across Europe in spring and summer 2020. of the HMP Governance Lab, Sarah Rozenblum is PhD student, learn lessons about ways to coordinate Within government, heads of government Department of Health Management during and after a health crisis that are centralised power at the expense of and Policy, and a member of the sensitive to the complexities of politics. ministerial and agency autonomy, HMP Governance Lab, University of Michigan, Ann Arbor, United States; whether by running policy directly, by Matthias Wismar is Programme There are two different kinds of empowering ministers, or by working Manager, European Observatory centralisation visible in the pandemic so closely with existing agencies. Hands-off on Health Systems and Policies, Brussels, Belgium. Email: slgreer@ far. One is within governments. In this approaches were seemingly not politically umich.edu case, the head of a government – any viable for heads of government. In

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intergovernmental relations, the response intersectoral governance by centralising variation is in how much attention and in many countries was a degree of authority in a body that represents the respect generalist government gave centralisation as well as an unusual degree key sectors involved in response. Most them. What kind of status, organisation, of coordination, but basic constitutional countries have established or activated and strategies led to a prominent place mechanisms and political incentives are such a body, led by top politicians or for established public health agencies hard to override for long, and countries their delegates. The Russian Federation and actors in these newly centralised with problems of intergovernmental government established a Coordination governance approaches? In some cases, conflict, blame shifting, and poor Council led by the Prime Minister and the the public health agency was firmly in coordination started to see them re- Mayor of Moscow to coordinate all actions the lead, as in South Korea. In others, it emerge quickly. at the federal, regional, and municipal was side-lined, firmly subordinated to levels. Non-federal countries created political leaders, as in France, or even – as Centralising within governments: different types of institutional designs to in England – eliminated and folded into a taking control of the COVID response coordinate the response, such as special new agency with little warning. at the top government emergency committees (Lithuania, North Macedonia, Ukraine, The most globally visible case to diverge In early March 2020, COVID-19 moved Finland), an Operational Intersectoral from this pattern was Sweden. Sweden has from being a public health or health Headquarter (Serbia) or an interagency an unusually high level of legal autonomy ministry problem to being, in every sense, working group led by the Minister for its government agencies. Legally and a whole of society problem requiring (at of Social Affairs (Estonia). A subset politically, the Swedish prime minister least) a whole of government response. of countries empowered pre-existing or have relatively limited Furthermore, it was clear that citizens entities, such as the Croatian National power over its public health agency, and were looking to their governments, and Civil Protection Authority or the Dutch only at a high political price could they that the political stakes of success and National Institute for Public Health and instigate conflict by publicly contradicting failure were enormous. the Environment, which became the it. This enabled the Swedish public main coordinating actors in the national health agency, led by its high-profile In country after country, heads of response to COVID-19. state epidemiologist, to pursue a strategy government reacted by taking control of unusual in Europe of limited constraint responses, on their own or with the health Specialist and generalist government on mobility. What is interesting here is minister. De facto power moved from have had their objectives aligned whether a country with a less autonomous ministries to the head of government, public health agency would have chosen a often working through a special task We can take away a general point. Most of different route. It is intriguing that in the force or sub-cabinet. In some countries, government, including health ministries, one high-profile European country where this meant the health ministry was highly is what Daniel Fox calls “specialist the public health agency was autonomous visible and important; in others, the head government.” People in it specialise and led the response, the chosen response of government clearly dominated. At in particular issues and advocate for was so polemical. least 21 European region countries passed attention to those issues. A smaller and emergency legislation. more powerful segment of government, Centralising between governments typically around the head of government As the first wave of COVID-19 spread and the finance ministry, is “generalist There are many merits to federalism and across Europe, the day to day response government.” Generalist government’s key decentralisation. For example, one virtue was frequently centralised through job is to make the trade-offs between goals is that it means a layer of governments different tools. As reported in our previous and sectors – between health and education that can take action to compensate for policy snapshot, 2 in Canada, Estonia, spending, between taxation and spending unconstructive behaviour by the central Finland, France, Israel, Serbia and levels, or between legislative priorities. As government (as we have seen in a number Ukraine, the pandemic response was led Fox writes, “Most practitioners of public of the world’s big federations). 4 But by the Prime Minister’s Office. In other health in government are, by definition, policymaking in a decentralised country countries, such as the Czech Republic, specialists. To succeed in the politics of is harder, with more need for coordination Greece, Lithuania and Slovenia, the making and implementing policy they and less unity because governments Minister of Health was at the forefront of must earn and maintain reciprocal loyalty can be of different political colours. In the governmental response to COVID-19. with generalists.” 3 some cases, as with the current Scottish Finally, heads of government work in and Catalan governments, they do not tandem and share equal responsibility In the case of COVID-19, a public health even agree with the central state on its with Ministers of health in a subset of issue had the undivided attention of legitimacy. Formally unitary states are countries, including Estonia, Lithuania, generalist government for a very long time. not exempt from the need to coordinate. Latvia and Malta. A second tool, often Unsurprisingly, generalist government Local governments are often politically found in special COVID-19 legislation did not simply delegate management of a important and legitimate and possess or existing law, is the creation of a worldwide pandemic to health ministries resources that are necessary for public coordinating committee that enhances or public health agencies. The interesting health and social policy responses.

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Coordinating with them involves a certain Kingdom, Italy, and Canada, where central state. This can be for immediate amount of inevitable friction and there can substantial health expenditures come out functional reasons, e.g. to acquire be political incentives to create conflict or of general government budgets and where supplies at a better price and coordinate try to shift blame. unexpected health challenges can create logistics, or to reduce popular confusion unexpected problems. about closure and reopening measures. As reported in our policy snapshot on In Germany, the “Act for protecting the federal countries, 5 coordination challenges In general, as with much of health politics public health in an epidemic situation appear in all the major areas of the in federations beneath the confusion there of national importance” granted the COVID-19 response. Table 1 identifies is a basic rationality at work, with central Ministry of Health (MoH) expanded but key areas. Governance to decision- governments handling issues that require temporary power. The federal MoH was making: the general procedures that large risk pools and regional ones issues consequently authorised to take measures governments within a country use to that handle local knowledge and resources. regarding the provision of pharmaceutical make and implement decisions. In many Strikingly, we found no case of change in and medical devices and to strengthen the cases, regional autonomy has been the basic territorial politics of entitlements, medical workforce. These new powers somewhat curtailed, though many of the which is important. If regional will, however, expire on 1st April 2021. measures curtailing regional autonomy governments did not take the opportunity In countries with particularly difficult are temporary. of the crisis to restrict benefits, and instead central-regional politics, the question of expanded them, that will have good effects whether centralising measures will be In terms of preventing transmission, on public health, including avoiding temporary or permanent is obviously which means mechanisms such as avoidable new outbreaks. charged and has not been entirely resolved. physical distancing and surveillance, In Spain, a Royal Decree declared a regional autonomy has mostly remained. Given that federations do have clear state of emergency on 14 March and put This might reflect the fact that regional coordination problems, how do they all publicly funded health authorities governments often are the ones with deal with them? One way is voluntary under the direct order of the Ministry of resources such as contact tracing staff cooperation in which regional Health. The Spanish MoH was therefore or police. Notably, some countries such governments identify and solve shared temporarily entitled to implement as Spain and Belgium, which have problems among themselves or with COVID-19 related measures across the complex territorial politics, have at least the central state guidance or control. whole country. In Italy, a country whose temporarily centralised the acquisition of In Italy, each region adopted its own health care system is highly decentralised, personal protective equipment (PPE). In approach to testing based on national the MoH issued a series of regulations ensuring sufficient physical infrastructure and international recommendations but increasing the availability of health and workforce capacity, insofar as there as testing capacity greatly varied by professionals and requiring all regions is a pattern it is one of persisting regional regions, national guidelines were issued to increase health care capacity. In most autonomy or of central governments acting by the central government to outline the cases our data does not show any change unilaterally (e.g. by easing restrictions on basic criteria for testing. With respect to to the formal role of local government. professional mobility). In efficient health protective equipment, the German federal Few clearly permanent changes have been care service provision, likewise, there is government delivered stocks of PPE to made to federal arrangements; this might a mixture of centralisation and regional the Länder, which were responsible for be a data limitation but, if true, it is an diversity. In both of these areas, there allocating and distributing the material interesting contrast to the centralisation is a strong case for regional autonomy to regional health care providers. Though seen in some federations 7 due to the and regional governments empirically there is in those countries regional global financial crisis of 2008 – 2012. have resources on the ground, but they budgetary autonomy, investment in public might lack the ability to coordinate for health infrastructure and new public The third way is continuing regional efficient patient flows without central health workers positions was coming from diversity and autonomy when there direction or might not command elements the federal government as it is the case is a case for local implementation of the legal infrastructure (such as in Germany. As for Spain, the transition and decision-making or when the professional regulation) necessary to strategy was released in late April and was political situation makes coordination optimise responses. Finally, and very meant to be coordinated with the Spanish or centralisation unrealistic, resulting strikingly, we did not find change in health regional authorities. Finally, regarding in a variety of responses. Despite the financing outside a fairly limited change in inner border closure, the Austrian state increased role of the central government, Belgium. This might make sense in social governments were in charge of executing Italian regions still retain decision- insurance systems, where there is often decisions taken at the federal level, but making autonomy regarding the delivery some distance between social insurance were also free to apply stricter measures, and organisation of health services, funds and regional governments, but it is such as quarantine for smaller regions such as whether to conduct COVID-19 an area to watch. Broadly, there is more severely hit by the crisis. tests in the entire regional population or political responsiveness in Berveridgean whether to suspend or maintain medical national health service (NHS) model The second way is centralisation of services, such as surgical procedures. systems such as Spain, the United powers and functions 6 in the hands of the In Spain, although all publicly funded

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Table 1: Level of coordination of policy responses

VOLUNTARY POWER REGIONS RETAINING POLICY RESPONSES ACTIVITIES COORDINATION CENTRALIZATION AUTONOMY Governance – Belgium Austria Italy Spain Belgium Spain Germany Switzerland Italy Spain Switzerland United Kingdom Preventing transmission Health communication Canada – Canada Physical distancing – Italy Belgium Switzerland Canada Germany (during the transition phase) Isolation and Quarantine – Canada Austria Canada Italy Monitoring and Canada – Austria Surveillance Canada Spain Testing & Contact Tracing Canada Austria Belgium Germany Canada Italy Italy Switzerland Protective equipment Germany Austria Belgium (during the (purchasing and Belgium (before the transition phase) distribution) transition phase) Germany (for the Germany (for the distribution of PPE) acquisition of PPE) Italy Spain Ensuring sufficient Physical infrastructure Belgium Austria Canada physical infrastructure Canada Italy and workforce capacity Workforce – Italy Belgium Spain Canada Germany Italy Providing health Planning services Canada Italy Switzerland services effectively Germany Spain Managing cases – Austria Canada Italy Italy Maintaining essential – Switzerland Italy services Paying for services Health financing – Belgium (for hospitals) Belgium (for nursing homes and facilities for people with disabilities)

Source: © Copyright European Observatory on Health Systems and Policies 5

authorities are temporarily supervised were instigated by individual hospitals, their local and regional governments in by the central government, regional cities or regions, with limited overall the second wave. There is a case for local and local public health administrations coordination and planning at the and regional pre-eminence in many areas still retain operational management federal level. since local and regional governments have of health services. Swiss cantons are resources and knowledge on the ground free to organise the cantonal response As we might expect, decentralising that central governments often lack, but to COVID-19, which has led to great between governments is also a tactic that there is also a risk that responsibility and variation in the organisation of testing and is becoming increasingly prominent. blame are being shifted without resources, treatment across regions. In Germany, Central governments that centralised money, or power. measures to expand the workforce in the first wave might choose to share involved in treating COVID-19 patients more responsibility – and blame – with

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Lessons learned: Centralisation is not likely to fall apart. Generalist government Most crises come and go and the after- enough, diversity can be an asset will move on – if nothing else, to action report and learning risk being shaping and responding to the enormous forgotten. COVID-19 is not such a We should not be surprised to have seen a effects of COVID-19 on everything crisis. Until there is a safe and widely high degree of centralisation around heads from small business to gender equity to distributed vaccine, the need for public of government. The magnitude of the housing markets. health response will continue. Political COVID-19 crisis, and the way it affected consensus and societal patience might every dimension of life, meant that it had Centralisation and coordination problems, not. As a result, it is an opportunity to to be the focus of the entire government. in particular within federal countries, learn from the governance experiments Whole-of-government responses to are a different kind of issue. COVID-19 so far and build stronger mechanisms that health problems are famously hard to did not lead to widespread constitutional can serve in this pandemic and inevitable achieve, but the pandemic caused them change. The regional governments of future ones. nearly everywhere. Austria, Belgium, Germany, Italy, Spain, Switzerland, and the UK all remain We learned that centralisation is not References powerful and autonomous actors with their enough. Concentrating power has 1 own politics, resources, and legitimacy. World Health Organization. Working together undeniable advantages if we assume that That they were willing to tolerate, or for health: The World Health Report 2006. the concentrated power is used effectively. Geneva: WHO, 2006. unable to prevent, centralisation in As we have seen, that is not always the 2 many cases does not mean that authority Greer SL, Jarman H, Rozenblum S, Wismar M. case. Adopting the wrong decisions, a and power have actually shifted for How are countries centralizing governance and lack of political leadership or a lack of at what stage are they doing it? COVID-19 Health good. Indeed, pandemic response, and trust on the side of the population may System Response Monitor – Cross-Country Analysis. the politics of blame, might actually render centralisation of power ineffective. WHO, European Commission, European Observatory make intergovernmental relations more on Health Systems and Policies, 19 April 2020. Decentralisation produces coordination difficult in the near future. We already Available at: https://analysis.covid19healthsystem. problems but diversity can be an asset if see public arguments between major org/index.php/2020/04/19/how-are-countries- it reduces the effect of any one mistaken, centralizing-governance-and-at-what-stage-are-they- regions and their central governments delayed, or ineffective policy. doing-it/ in cases as different as Scotland and the 3 Madrid region of Spain. This trend may Fox DM. Toward a public health politics of In addition, not all kinds of centralisation consequence: An autobiographical reflection. be reinforced by the dwindling financial are the same. In some cases, individual American journal of public health 2017;107(10):1604. base of public health and health care, due regional or local governments were 4 to falling tax revenues and falling social Greer SL, King EJ, da Fonseca EM, Peralta- more or less rigorous than their state Santos A. The comparative politics of COVID-19: insurance contributions. Very quickly, governments would have chosen. Simply The need to understand government responses. conflicts around the sustainability of taking away their powers might be Global Public Health 2020;1 – 4. DOI:10.1080/1744169 health finance may arise, replacing the 2.2020.1783340 unwise as well as unconstitutional, but investment policies of today with by 5 conditional support for them in managing Greer SL, Rozenblum S, Wismar M, Jarman H. austerity like measures. their problems (e.g. construction or How have federal countries organized their COVID-19 response? COVID-19 Health System Response improvement of state-wide surveillance Monitor – Cross-Country Analysis. WHO, European systems) might shape their behaviour. Conclusion Commission, European Observatory on Health Systems and Policies, 16 July 2020. Available at: Policymakers should not be too impressed https://analysis.covid19healthsystem.org/index. The return of normal politics by some of the short-term centralisation php/2020/07/16/how-have-federal-countries- we saw in federations. Normal politics organized-their-covid-19-response/ A dramatic centralisation of power is coming back, and will assert itself 6 within governments was always going Bekker M, Ivankovic C, Biermann O. Early lessons in COVID-19 response and recovery to be largely temporary, outside cases from COVID-19 response and shifts in authority: as well as all the other issues. It would public trust, policy legitimacy and political inclusion. of democratic backsliding. As the probably be wise to draw lessons about European Journal of Public Health 2020;30(5): 854–5. literature on Health in All Policies shows, better coordination and alignment that Available at: https://doi.org/10.1093/eurpub/ckaa181 there are powerful fissiparous forces can work outside the kind of rush we saw 7 Greer SL, Elliott H. (eds.) Federalism and Social within government that mean agencies in early 2020, since many countries are Policy: Patterns of Redistribution in 11 Democracies, as different as the police, health care showing far less unity as they enter the 2019. DOI: 10.3998/mpub.9993201 providers, and schools, for example, will second wave of COVID-19. More robust 8 Greer SL, Vasev N, Wismar M. Fences and have distinct interests and be hard to coordination mechanisms, grounded in ambulances: Intersectoral governance for health. coordinate. 8 9 Controlling them takes clear law and political agreements, are Health Policy 2017;121(11):1101 – 4. not just impressive energy and focus hard to build but the pandemic might offer 9 Greer SL, Lillvis DF. Beyond leadership: political at the centre of government, but also an opportunity to build them since nobody strategies for coordination in health policies. a shared sense of crisis and mission can rely forever on the ability of elected Health Policy 2014;116(1):12 – 7. that inevitably abates. As soon as the central, regional, and local governments to perceived importance and consensus on get along. the challenge crumbles, centralisation is

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NATIONAL, EUROPEAN, AND GLOBAL SOLIDARITY: COVID-19, PUBLIC HEALTH, AND VACCINES

By: Scott L. Greer

Summary: Developing, procuring, and distributing vaccines for COVID-19 could have very good or bad outcomes for solidarity, public health, and science. The European Union (EU), whose public health role advanced greatly in 2020, has a Vaccines Strategy that goes far beyond earlier EU procurement strategies. The World Health Organization’s COVAX partnership pursues a global strategy of vaccines procurement and distribution. Governments are maximising their chances of access to vaccines for their own citizens with various combinations of national deals and international collaboration. There are powerful reasons to expect national egotism. The question is when the chosen case for collaboration makes solidarity the rational approach.

Keywords: Vaccines, Solidarity, COVAX, European Union, COVID-19

Introduction in terms of a basic idea: Solidarity is a question of the head more than the Every health crisis leads to claims that heart. 1 In particular, it focuses on the there will be big changes in public next point of crisis: the development of, health governance. This time, there and access to, vaccines. A vaccine will might actually be. COVID-19 shone an be attractive to all countries, especially unforgiving light on political systems of the ones that have not successfully all kinds but also created the impetus for contained COVID-19. Vaccine politics are Cite this as: Eurohealth 2020; 26(2). the kinds of dramatic reforms we rarely nevertheless very high-risk. There is the see in global health governance. Both the risk of fierce competition over vaccines; European Union (EU) and international a risk of vaccines that prove ineffective or Scott L. Greer is Professor of Health organisations such as the World Health dangerous; and a risk of vaccine hesitancy Management and Policy, Global Organization (WHO) have absorbed Public Health and Political Science or rejection. All three could combine criticism, but they are also both being by courtesy and a member of the in particular places to produce a public HMP Governance Lab, University given new tasks and challenges that health disaster. of Michigan, Ann Arbor, United might help us control the pandemic while States and Senior Expert Advisor on changing health governance for good. Health Governance to the European Focusing on solidarity focuses our Observatory on Health Systems and attention on the mechanisms that lead to Policies, Brussels, Belgium. Email: This commentary frames the development better outcomes for different groups of [email protected] of EU and WHO responses to COVID-19 people and governments. Whether voters in 2020, and potential future directions,

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Box 1: EU Vaccine Strategy • Sanofi-GSK to purchase up to 300 million doses. Member States may donate reserved doses to lower- and middle- A safe and effective vaccine, accessible to all in Europe and income countries. around the globe, is the really lasting exit strategy from the • Janssen Pharmaceutica NV, one of the Janssen pandemic. No region of the world is safe until we are all safe. Pharmaceutical Companies of Johnson & Johnson. As time is of essence – we are in a situation of a public health Once the vaccine has proven to be safe and effective emergency – we have to invest up-front in vaccine development against COVID-19, the contract allows Member States to ensure that successful vaccines are being produced at the to purchase vaccines for 200 million people. They will scale required as early as possible. This is why the Commission also have the possibility to purchase vaccines for an has adopted an EU Strategy for COVID-19 vaccines, setting additional 200 million people. out a common EU approach to securing vaccine supplies for Exploratory talks have been concluded – and contractual Member States and their citizens. frameworks are in negotiations – with: On 17 June, the European Commission presented a European • CureVac for the purchase of 225 million doses strategy to accelerate the development, manufacturing and deployment of vaccines against COVID-19. An effective and • Moderna for an initial purchase of 80 million doses and safe vaccine against the virus is our best bet to achieve a the option to purchase 80 million more permanent solution to the pandemic. Time is of the essence. • BioNTech-Pfizer for the initial purchase of 200 million doses Every month gained in finding such a vaccine saves lives, and the option to purchase a further 100 million more. livelihoods and billions of . Global cooperation € 2.1 billion under the European Support Instrument have been used to secure the production of vaccines in the EU and On 18 September, the European Commission confirmed its sufficient supplies for its Member States through Advance participation in the COVAX Facility for equitable access to Purchase Agreements with vaccine producers. This is part affordable COVID-19 vaccines, following its announcement of of the European Commission’s vaccine strategy. a contribution of € 400 million. On 21 September, the European Commission joined the statement by Friends of the COVAX To date, the European Commission reached agreements with Facility to strongly support vaccine multilateralism and the goal three pharmaceutical companies for the purchase of a potential of ensuring affordable, fair and equitable access to safe and vaccine against COVID-19 once the vaccine has proven to be effective COVID-19 vaccines for all. The European Commission safe and effective: and the 27 EU Member States, Team Europe will initially • AstraZeneca to purchase 300 million doses, with an option contribute with € 230 million. A contribution of € 230 million to purchase 100 million more; as well as to donate or is equivalent to reserves or options to buy 88 million doses re-direct vaccines to other European or other lower and and the EU would transfer these to eligible Advanced Market middle-income countries. Commitment countries. This contribution is complemented with €170 million in financial guarantees from the EU budget.

By: European Commission

or elites in different countries feel kindly with a Directorate General and a not help that some EU governments used towards one another is a less important Commissioner with a mandate letter COVID-19 measures to speed up their question than whether they recognise that substantially more ambitious than that of democratic backsliding and paid no price. in a pandemic their fates are linked. The her predecessor. 2 key question is: with whom there will be Such national egotism was no surprise. what kind of solidarity of the head? Who In spring 2020, one might have been In the panicky atmosphere of March, few will they see as sharing their fates, and – excused for forgetting that there was an politicians felt that they could be generous. a very different question – who will they EU health policy. 3 Member States were They were all, after all, learning that they trust to pursue their interests? slow to help each other through even were ill-prepared for the pandemic that obvious moves such as the activation of so many had warned them about. The European solidarity of the head: RescEU, the centrepiece of the EU’s civil breakdown nonetheless seemed to pose The shared problem of COVID-19 protection strategy. Closure of borders to a real threat to the EU. goods as well as people meant disorder. In late 2019, EU health policy advocates, Member States ignored their mutual ties By autumn 2020, things were very officials, and experts involved in EU of solidarity and instead rushed to keep different. What is surprising about the health policies were letting themselves out foreigners and hoard supplies, creating EU’s case is how rapidly it made progress sigh with relief: at least there would a bad impression at a crucial time. It did that would have been unimaginable in continue to be a clear EU health policy,

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late 2019, a process that Eleanor Brooks, will be just in time for the next challenges especially vulnerable populations. The Anniek de Ruijter, Sarah Rozenblum and of COVID-19 and the inevitable next key moral commitment is to bring every I have explored. 4 - 7 public health emergency. participating country to 20% vaccination before releasing supplies for any country By July, the Member States saw a case European and global solidarity to go above 20%. for solidarity. At a 17 – 21 July Council in vaccines meeting they agreed a €1.7 billion In the specific case of vaccines, COVAX “EU4Health” programme for 2021 – 2027, The EU also decided an EU is also an appeal to solidarity of the and in the same deal RescEU also received Vaccines Strategy and a forthcoming head because the alternative, a thicket of a large budget increase of €1.9 billion. Pharmaceutical Strategy (see Box 1). advance purchase agreements, will be That number was a disappointment relative The objective of the Vaccines Strategy inequitable, slow eventual control of the to the original €9.6 billion proposal from is to be distributing an effective vaccine virus, and create the risks for governments the Commission, but it is far larger than within 18 months. The EU will sign that they sign advance purchase the previous Health Programme budget Advance Purchase Agreements with agreements on vaccines that turn out to not of around €450 million, and it remains a pharmaceutical companies on behalf of work well and then find they lack access to freestanding fund rather than being rolled the Member States and coordinate the ones that do. 9 into the European Social Fund as was distribution of the vaccine. This is far planned before the pandemic. EU4Health more centralised, and uses the size of the For those who do not see a globally has three priorities: cross-border threats, EU market more effectively, than the 2014 equitable distribution of vaccines as clearly availability of medicines, and, more of a Joint Procurement Agreement. As with the desirable, the additional carrot is that the novelty, health systems strengthening. EU development of RescEU, Member States size of the scheme makes it possible to Member States have understandably been have agreed to much more centralised place more bets on particular vaccines very reluctant to spend on health systems EU action, and as we might expect they and production sites, giving humanity in other Member States, but COVID-19 took it in areas where European states more chances to get good vaccines, more might have reduced that reluctance by, are too integrated to separate and too opportunity to produce on a massive scale, however temporarily, showing them the small to manage international markets on and a more resilient supply. extent to which health is a shared problem their own. rather than a domestic concern. Solidarity with whom? COVAX is the WHO’s scheme for the Solidarity in practice has not always global identification, production, and A policy maker in a large, rich, European lived up to the greatest ambitions. For a distribution of effective COVID-19 country had three options: a purely particularly clear example: enforcement vaccines (see Box 2). If the EU’s model is national one of buying vaccines, including of the travel rules in and out of Schengen solidarity of the head among the tightly through advance purchase agreements; that are agreed by the Justice and Home connected Member States, the WHO’s is European Union collaboration through the Affairs Council is up to Member States, of a global solidarity of the head. COVAX Vaccines Strategy; and COVAX. Outside and their border guards might not do quite makes the rational case for a collective Europe, the main options are purely what is mapped out in Brussels. benefit and builds on the WHO’s strengths national and COVAX. Smaller countries as the necessary, central, global player (even if rich) and poorer countries (even In anything to do with pharmaceuticals in health as well as the increasingly if big) lack the option to go it alone and purchasing in Europe, such as joint cooperative infrastructure of public- are likely to benefit from multilateral procurement or pricing transparency, private partnerships that actors such as the approaches. “Safety in numbers” is always Member States frequently pursue opaque Gates Foundation and key donor countries a good strategy for smaller countries – and zero-sum twin-track policies of have built to flank WHO in specific areas. if they can commit to their own solidarity. collective and individual action. We can It is a solidarity of the head because we all expect this to continue with COVID-19 know how hard it is for countries to thrive Despite efforts to make COVAX more vaccines and therapeutics. 2 while isolating themselves and because attractive to rich countries, they are so far we all know how damaging endemic reluctant to entrust their vaccines demands Nonetheless, the EU has had a good crisis COVID-19 could be for world order and to it. 10 If nothing else, it would not so far. Jean Monnet famously said that the global economy. guarantee them vaccines for more than a “L’Europe se fera dans les crises et elle fifth of their citizens until a fifth of people sera la somme des solutions apportées COVAX is an alliance of Gavi, CEPI in every country had vaccines. Australia, à ces crises.” [Europe will be forged in (the Coalition for Epidemic Preparedness Canada, Japan, the United Kingdom, and crises, and will be the sum of the solutions Innovations), and the WHO to orchestrate the United States have thus opted to sign adopted for those crises.] 8 The solutions the identification, production, and bilateral purchase agreements. 11 to some crises, for examine the 2010 debt distribution of effective COVID-19 crisis, have left the EU worse off. This one vaccines. It has worked to develop a While EU Member States can donate to looks different: it precipitated genuine EU scheme for globally equitable distribution COVAX, they cannot participate in both action for health to an extent we could not of the vaccines, emphasising early the EU Vaccines strategy and COVAX. have imagined a year ago, and one that vaccination of health care workers and This pits COVAX against the EU model.

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Box 2: WHO’s role in COVAX and COVID-19 vaccine vaccines to its prioritised population groups, when a safe development and deployment and effective vaccine is available. While the vaccine-characteristics of COVID-19 vaccines Effective vaccines against COVID-19 will play a significant role remain to be ascertained, WHO Europe has geared up its in protecting populations and restarting economies. Within support to its Member States with “strategic decision-making the overarching concept of “No-one is safe until everyone is considerations” for COVID-19 vaccine deployment and safe”, through the launch of Access to COVID-19 Tools (ACT) vaccination. Through a regional coordination mechanism, Accelerator, WHO has facilitated a ground-breaking global WHO Europe has convened representatives of the European collaboration to accelerate development, production, and Commission, European Centre for Disease Prevention equitable access to COVID-19 tests, treatments, and vaccines. and Control (ECDC), US Centers for Disease Control and Through a combined effort of Gavi, CEPI (the Coalition for Prevention (CDC), UNICEF and Gavi to monitor the country Epidemic Preparedness Innovations) and WHO, the COVID-19 preparedness, COVID-19 vaccine deployment and vaccination Vaccines Global Access (COVAX) Facility has provided a in the WHO European Region. platform for countries to benefit from a portfolio of safe and effective vaccines so that their populations can have access Solidarity is key not only to ensure access to COVID-19 to effective vaccines. vaccine, but also to ensure that countries support each other in sharing best practices and experiences both before and Within the ACT-Accelerator, WHO has played a critical role in during the vaccination implementation. The role of WHO policy formulation, defining the product allocation framework, and other global and regional partners will be key to identify norms, standards, ensuring safety and regulatory standards, areas that need specific technical assistance and provide the and country support. The convening role of WHO in each of required support; and this can only be achieved if Member the above areas along with research communities, industry States, WHO and other partners work in tandem – “solidarity representatives, international organisations and donors, and being at the heart of the response”. regulators has consolidated the global fight on the COVID-19 pandemic. WHO is working closely with global and regional By: Dr Siddhartha Sankar Datta, Vaccine-preventable Diseases partners to ensure country preparedness to equitably deliver & Immunization Programme, World Health Organization Regional Office for Europe

EU Member States have responded by has tried to imagine ways to avoid such There is also the problem that even choosing the EU approach to procure their a result, 14 but it is not clear that it will politicians whose intentions are good will own vaccines, donating to COVAX as a be avoided. not think that other politicians’ intentions contribution to global health rather than are good. A reasonable politician might their own public health. 10 Even if the United States resumes indeed think it unwise to trust the good constructive engagement in the world intentions and competence of major EU Member States appear to be treating in 2021, there is a strong chance that powers, or international coalitions such COVAX as a problem of international investment in the global public good of as COVAX. The desire not to be taken health and development assistance rather mass COVID-19 vaccination will be a advantage of means that politicians with than their own countries’ route to safety – plaything of great power politics, with multiple options will not place a single bet a life preserver that they can toss to the rich countries looking after their own or be too impressed by calls to collective less fortunate, rather than a lifeboat for all citizens, middle-income powers often action. And all politicians, no matter their of us. 12 This helps to explain why COVAX trying to develop their own industries country, have options if they choose to is nowhere near the funding it requires and geopolitical strategies as well as use them. to carry out its full strategy. 13 Promises public health, 15 and the smaller and to donate unused vaccines (some states poorer countries trying to use whatever Risks include vaccine hesitancy and seem to have ordered far more doses than combination of bilateral and multilateral public backlash they could use *) bring back memories of strategies they can. Forceful exercises of the H1N1 vaccines problems in 2009 – 10. state power and huge expenditures among To add to the difficulty, identifying In that pandemic, countries that bought the rich countries; foreign aid and Gates vaccines and determining their safety is too many vaccines during the crisis tried support for the poor. On the bright side, going to put every pharmaceuticals market to sell or give ageing vaccines to poorer with 170 countries having sent expressions access regime to the test. There is a high states amidst recrimination. Much of of interest, and impressive early action by risk of vaccine hesitancy and a backlash the thinking about vaccines since then COVAX members, it is likely that COVAX even against a very safe and effective will work even if without some very large vaccine. For example, there is no good

* It appears that between them the US and UK have and rich countries. Complete failure of reason to expect that citizens will trust a committed to purchase 600 million doses of vaccine: https:// global solidarity is unlikely. vaccine based on synthetic biology, or that www.statnews.com/2020/08/28/plan-to-expand-global- access-to-covid-19-vaccines-nears-fish-or-cut-bait-moment/

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populations who have been reminded by and one of its richest citizens. Rising 5 Greer SL, de Ruijter A, Brooks E. The COVID-19 the pandemic why they do not trust their international actors have shown no greater pandemic: Failing forward in public health. In: government will rush to trust its vaccine. global solidarity than the older powers, Riddervold M, Trondal J, Newsome A (eds) Palgrave Handbook of EU Crises, forthcoming 2021. even if their mere presence affords A rushed vaccine that produces significant poorer countries a useful increase in their 6 Greer SL, de Ruijter A. EU health law and policy negative side effects could be a catastrophe strategic options. 19 We already have seen in and after the COVID-19 crisis. European Journal of Public Health 2020;30:623 – 4. for both COVID-19 control and the spectacularly egotistical and sometimes credibility of vaccines in general. Global criminal behaviour in the rush to acquire 7 Brooks E, de Ruijter A, Greer SL. COVID-19 and geopolitical competition and domestic equipment earlier in the pandemic 20 and European Union health policy: From crisis to collective action. Social Policy in the European Union: State of politics are already leading countries to there is no reason to imagine a vaccine Play, 2020. Brussels: European Social Observatory overplay their achievements and start will be different. International politics is (OSE)/ European Trades Union Institute, 2020. administering vaccines in contexts that an unforgiving arena. 8 Monnet J. Mémoires. Paris: Fayard, 1976. can only with far too much charity be called clinical trials. To have an apparently The situation is nonetheless not as bleak 9 Phelan AL, Eccleston-Turner M, Rourke M, desirable vaccine will be a coup for any as it could be – or as bleak as it would Maleche A, Wang C. Legal agreements: barriers and enablers to global equitable COVID-19 vaccine government, and many governments have have been had the world approached access. The Lancet 2020;396:800 – 2. incentive to claim it even if their vaccine COVID-19 with the governance and policy 10 is not safe or effective enough to pass approaches of a decade ago. COVAX has Reuters. Exclusive: WHO sweetens terms to join struggling global COVAX vaccine facility – disinterested scrutiny. already spread vaccine development and documents. Available at: https://www.reuters.com/ preparation, and is likely to be helpful article/us-health-coronavirus-who-offer-exclusiv- Likewise, pharmaceuticals regulators to many poorer countries. The European idUSKBN25O1L5

proud of their hard-won autonomy from Union is finally developing both a health 11 Branswell H. Plan to expand global access politics are coming under tremendous policy and a vaccines policy to match to Covid-19 nears fish or cut-bait moment. political pressure, and it is not clear that its longstanding integration. There Statnews. Available at: https://www.statnews. all of them will emerge with the autonomy are daunting challenges ahead, since com/2020/08/28/plan-to-expand-global-access-to- and credibility intact. The wish for a identifying and administering a safe and covid-19-vaccines-nears-fish-or-cut-bait-moment/ New reckoning for WHO vaccine plan as governments vaccine, particularly among countries effective vaccine to the world will put go it alone. whose nonpharmaceutical interventions every country’s governance and every 12 have failed to control the outbreak, is international organisation to the test. Kelland K, Guarascio F, Nebehay S. New reckoning for WHO vaccine plan as governments go likely to lead to the triumph of availability Very bad outcomes are possible. But in it alone. Reuters, 2020. Available at: https://www. over safety or effectiveness in some cases. Europe and in the world, there is still a reuters.com/article/us-health-coronavirus-who- A grim but plausible scenario unites strong chance that we will come to see the vaccines/new-reckoning-for-who-vaccine-plan-as- these different forms of international response as an ultimate success. governments-go-it-alone-idUSKBN25O0L6 dysfunction in the form of intense conflict 13 Gavi. COVAX explained. 2020. Available at: over access to vaccines that are not safe, References https://www.gavi.org/vaccineswork/covax-explained effective, or accepted by the population. 14 de Ruijter A. EU Health Law & Policy: The 1 WHO. Statement and Speeches. Statement by Expansion of EU Power in Public Health and Health Dr Hans Henri P. Kluge, WHO Regional Director for Care. Oxford University Press, 2019 Solidarity of the head in practice Europe, to the 70th session of the WHO Regional Committee for Europe, 2020. https://www.euro. 15 da Fonseca EM. How can a policy foster local This is probably a suboptimal outcome for who.int/en/about-us/regional-director/statements- pharmaceutical production and still protect public all of us, even if it could be worse in the and-speeches/2020/statement-by-dr-hans-henri- health? Lessons from the health – industry complex absence of COVAX. As WHO Director- p.-kluge,-who-regional-director-for-europe,-70th- in Brazil. Global Public Health 2018;13:489 – 502. session-of-the-who-regional-committee-for-europe General, Ghebreyesus, 16 WHO. WHO Director-General’s opening remarks put it in August, “Vaccine nationalism 2 Greer SL, Fahy N, Rozenblum S, et al. Everything at the media briefing on COVID-19, 16 March 2020. only helps the virus.” 16 you always wanted to know about European Union Available at: https://www.who.int/dg/speeches/ health policy but were afraid to ask. Second, revised detail/who-director-general-s-opening-remarks-at- edition. Brussels: European Observatory on Health the-media-briefing-on-covid-19—-24-august-2020 Avoiding such an outcome is going to Systems and Policies; 2019. nonetheless be difficult. Rich countries 17 Chorev N. The World Health Organization between 3 have well-documented ways to shift Herszenhorn DM, Wheaton S. How Europe failed North and South. Cornell University Press, 2012. the coronavirus test. Politico.EU, 2020. Available at: 18 Babb S. Behind the Development Banks: agendas and forums in order to maintain https://www.politico.eu/article/coronavirus-europe- Washington Politics, the Wealth of Nations, and World their dominance in international failed-the-test/ politics. 17 18 The rise of independent Poverty. Chicago: University of Chicago Press, 2009. 4 Brooks E, de Ruijter A, Greer SL. The European 19 Benabdallah L. Shaping the Future of Power: wealthy donors such as the Gates Union confronts COVID-19: Another European rescue Knowledge Production and Network-Building in Foundation, which revolutionised global of the nation-state? In: Greer SL, King E, Peralta A, China – Africa Relations. University of Michigan Press, health, does not change the centre- Massard E (eds) Coronavirus Politics: The politics and 2020. periphery dynamics. One could arguably policy of COVID-19. Ann Arbor: University of Michigan model many current developments in Press, forthcoming 2021. 20 Kavanagh MM, Erondu NA, Tomori O, et al. Access global health governance as an argument to lifesaving medical resources for African countries: COVID-19 testing and response, ethics, and politics. between the United States government The Lancet 2020;395:1735 – 8.

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