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 Eurohealth — Vol.26 | No.2 | 2020 94 Governance 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 Eurohealth — Vol.26 | No.2 | 2020 Governance 95 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