Comment Assessing national performance in response to COVID-19 Before the advent of the COVID-19 pandemic, several recorded are dependent on a country’s testing strategy Published Online countries participated in an exercise to assess their and capacity and the extent to which individuals go July 15, 2020 https://doi.org/10.1016/ preparedness for pandemics through an assessment of for testing. Furthermore, case numbers do not reflect S0140-6736(20)31601-9 their Global Health Security Index (GHSI).1 The USA and the performance of systems for containing clusters or the UK were identified as two countries most prepared. suppressing virus transmission. These systems, and the Experiences with COVID-19 have shown that in- potential for their performance to change over time, must depth assessments of outbreak preparedness need be factored into any choices made during the COVID-19 to go beyond publicised plans. Prior assessments of response. countries such as Vietnam (ranked 50th on the GHSI) Communities want to assess whether the response and New Zealand (35th on the GHSI)1 are inconsistent systems are contributing to the best possible outcomes with actual performance.2 In practice, it is better to and expect government decisions to make this happen. benchmark countries during a pandemic in ways that The most frequently used outcome measure is the allow information on outcomes and performance to be number of COVID-19 deaths. It is hard to conceal fatalities, obtained, analysed, reported, and used in real time. although methods for counting COVID-19 deaths vary Assessment of the performance of COVID-19 response between, and even within, countries. Other outcomes systems is key to easing lockdowns and opening that could be tracked in the future will include long- borders between and within nations. It requires an term COVID-19 sequelae, including pulmonary, cardiac, understanding of public health capacities, government neurological, and other complications.5,6 Assessments of actions, and community behaviours, recognising that national performance must include one or more of these people, communities, and nations everywhere are outcome measures obtained consistently over time. learning to live with COVID-19. Making decisions about Success in reducing deaths or long-term sequelae border closures or lockdown status without such an requires a well organised and resilient hospital system, assessment gives insufficient attention to the extent including emergency departments, general wards, and to which communities are capable of living with the intensive care units, that is capable of surging in response virus; simply put, actions are taken without some of the to increased patient demand. Such a resilient hospital essential factors being considered. To try to keep cases of system calls for effective organisation, well trained staff COVID-19 sustained at zero while waiting for a vaccine with adequate personal protective equipment, and to become available is a naive option and will result access to necessary medications, oxygen supplies, and in enormous social and economic harm and isolation ventilators. These elements are important contributors to for an indefinite period. There are no guarantees systems performance. that an effective vaccine will be available soon and Performance assessments should also take into account have high community uptake. The other extreme of hospital and other health-care providers’ abilities to accepting uncontrolled transmission leads to excess all- maintain clinical activities unrelated to the pandemic. cause mortality and overwhelmed health systems. As Tagging certain medical and surgical procedures, such people everywhere make sense of the threats posed by as routine vaccination and health screening for cancers COVID-19, they expect decision makers to help them and other chronic conditions, as elective is incorrect if limit both risks to their health and any restrictions on their postponement will lead to avoidable morbidity and their lifestyles and livelihoods. mortality.7,8 Some disturbance to routine health services Trends in the numbers of COVID-19 cases are being is inevitable given that some of the health-care workforce used to judge the performance of national responses to will be assigned to outbreak management. People may be COVID-19. But case numbers are unreliable as indicators deterred from using routine health services unless they of the performance of response systems.3 Serological are confident that effective action is being taken to reduce investigations suggest that case numbers are a small nosocomial infections.9 Such challenges can be mitigated fraction of the total number of people who have been through the use of telemedicine and the ring-fencing of infected.4 Additionally, the actual numbers of cases selected hospitals for non-COVID-19 procedures. www.thelancet.com Published online July 15, 2020 https://doi.org/10.1016/S0140-6736(20)31601-9 1 Comment Efforts to reduce numbers of COVID-19 cases, deaths, need the capacity for isolating individuals with COVID-19 and sequelae require organised capacities within and keeping contacts in quarantine. This function works commu nities that support people as they adapt their best if it is implemented rigorously, with people’s full lifestyles to live with COVID-19 as a constant threat. cooperation, under public health supervision. Third is the Four key capacities are needed. First, communities must capacity for rapid and thorough tracing of the contacts of have the capacity to detect cases early and interrupt cases. Such tracing must also be capable of surging in the transmission chains. This capacity requires a strong face of increased demand. Fourth, public health laws need community-based public health system that adjusts to be in place, understood, and accepted by the public to its functioning according to locally disaggregated data reinforce behaviours that are necessary for community about the whereabouts of the virus and the effectiveness wellbeing.10 of the response. All response elements must be locally In addition to these capacities within communities, coordinated and the entire response system must have income security is crucial to ensure socioeconomic predictable capacity to surge if needed. Virus testing stability and confidence in a national strategy. Many jobs needs to be easily available and free of charge for all. have been, and will be, lost and companies and businesses Useful metrics generated by this capacity include the may be unable to function efficiently due to sickness, percentage of positive test results and numbers of tests isolation, quarantine, and various non-pharmaceutical per million population. The implementation of policies community interventions including business closure, as to who may be tested and the turnaround time for working from home, and physical distancing.11,12 testing can also be quantified. Second, communities Provision of socioeconomic support is needed to remove possible disincentives and facilitate individual and Panel: Proposed performance indicators to assess national public compliance with COVID-19 response measures. performance in response to COVID-19 Furthermore, community confidence and compliance Ability to detect and break transmission chains are more likely if there is reassurance that supply chains • Percentage of cases found by contact tracing of food and medicines are resilient and that access is • Compliance of the community to governmental health maintained for all. directives Protection and support for vulnerable populations • Testing; percentage positive, capacity per million population, policy, turnaround time are also crucial. Many outbreaks are occurring in socioeconomically disadvantaged groups—eg, residents Ability to minimise deaths and severe complications of nursing homes, migrant workers, refugees, prisoners, • Deaths per million population • Ventilator capacity per million population and those living and working in dense settings—that are susceptible to infection and severe disease.13,14 Such Minimise hospital-acquired COVID-19 • Personal protective equipment availability individuals are often poorly paid, work in the informal • Health-care-associated infections economy, or on daily wages and may not be able to reduce their risk given the conditions under which they Fiscal support for individuals and companies • Programmes functioning for those in isolation or work and live. National governments are responsible for quarantine ensuring these groups are protected and supported. • Programmes functioning for those threatened by social Communication and leadership are other important restrictions elements of national responses. COVID-19 is a new Maintenance of food and medicine supply chains disease threat and people everywhere expect their leaders • Demonstrable actions in place to help them make sense of this threat and live with it. Protection and support for vulnerable and neglected They want consistent, honest, and accurate two-way populations in the community communication. Strategies to communicate are vital • Recent clusters in vulnerable groups and need to use every modality to reach all language and • Demonstrable actions in place cultural groups and all educational levels of the target Maintenance of usual health services community. All leaders need to work together for best • Essential services are never reduced results: the virus thrives when decisions are inconsistent • Non-essential services are restored promptly or non-transparent. Leadership for the