Governance 93

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 COVID19 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

Eurohealth — Vol.26 | No.2 | 2020