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Health Policy 124 (2020) 577–580

Contents lists available at ScienceDirect

Health Policy

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

2 Lessons learned from the management of the coronavirus andemic

ebecca Forman a, Rifat Atun b, Martin McKee c, Elias Mossialos a,d,∗

London School of Economics and Political Science, WC2A 2AE, London, UK Harvard University T.H. Chan School of Public Health, Boston, MA 02115, USA London School of Hygiene and Tropical Medicine, WC1E 7HT, London, UK Imperial College London, SW7 2BU, London, UK

r t i c l e i n f o

rticle history: eceived 30 April 2020 ccepted 5 May 2020

eywords: ovid-19

a b s t r a c t

The Coronavirus SARS-CoV-2 has spread rapidly since the first cases hit Wuhan, China at the end of 2019, and has now landed in almost every part of the world. By mid-February 2020, China, South Korea, Singapore, Taiwan, and – to some extent – Japan began to contain and control the spread of the virus, while conversely, cases increased rapidly in Europe and the United States. In response to the pandemic, many countries have had to introduce drastic legally mandated lockdowns to enforce physical separation, which

andemic olicy responses olicy-making

are ravaging economies worldwide. Although it will be many months or even years before the final verdict can be reached, we believe that it is already possible to identify 12 key lessons that we can learn from to reduce the tremendous economic and social costs of this pandemic and which can inform responses to future crises. These include lessons around the importance of transparency, solidarity, coordination, decisiveness, clarity, accountability and more.

© 2020 The Author(s). Published by Elsevier B.V. This is an open access article under the CC

. Introduction

The Coronavirus SARS-CoV-2 has spread rapidly since the first ases in Wuhan, China at the end of 2019, now reaching almost very part of the world. By mid-February 2020, China, South Korea, ingapore, Taiwan, and – to some extent – Japan began to con- ain and control the spread of the virus, while conversely, cases ncreased rapidly in Europe and the United States. On March 13th, he WHO Director General declared Europe as the epicentre of the andemic “with more reported cases and deaths than the rest of he world” [1], but by the end of the month that label had shifted o New York. Health workers around the world have described ar-like scenes as health systems struggle to gain control over the

irus. In response to the pandemic, many countries have introduced rastic legally mandated lockdowns to enforce physical separation. lthough it will be many months or even years before the final ver- ict can be reached, we believe that it is already possible to identify 2 key lessons that we can learn from to reduce the tremendous

conomic and social costs of this pandemic and which can inform esponses to future crises.

∗ Corresponding author at: London School of Economics and Political Science, oughton Street, WC2A 2AE, London, UK.

E-mail address: [email protected] (E. Mossialos).

ttps://doi.org/10.1016/j.healthpol.2020.05.008 168-8510/© 2020 The Author(s). Published by Elsevier B.V. This is an open access articl .0/).

BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

2. Twelve key lessons

2.1. Transparency is vital

“Pneumonia of an unknown cause” was first reported to the WHO Office in China on 31 December 2019 [2]; yet weeks ear- lier, healthcare professionals had warned Chinese authorities that a SARS-like illness was spreading amongst patients. Instead of noti- fying those higher in the system, Wuhan authorities detained and silenced physician Dr Li Wenliang on a charge of spreading false rumours after he reported a novel illness in his patients in early December [3]. At age 34, Dr Li passed away in February 2020 from COVID-19 infection [3]. This tragedy highlights the critical impor- tance of honesty and transparency. Modelling data suggests that if action had been taken even a few days earlier, the subsequent spread of the virus could have been limited dramatically. How- ever, fears of economic and political repercussions silenced officials who could have sounded alarms, and the virus was able to spread exponentially. Other countries have also struggled to communi- cate the epidemiology of this new infection, sometimes reflecting the challenges of ensuring consistent and coherent messaging in a

fast moving situation, sometimes due to internal disagreements,5

but sometimes, for example in Brazil and the United States, because of blatantly misleading comments [4] by political leaders and the media. These too have consequences. President Trump’s praise for

e under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/

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ydroxychloroquine, despite an absence of evidence of effective- ess in COVID-19, meant that people who did need it, such as hose with lupus, have faced shortages [5]. A lack of transparency round the United Kingdom’s scientific advisory mechanism has ndermined trust [6].

.2. Successful responses hinge on decisive leadership

Recognising its initial response errors, China showed lead- rship in tackling the COVID-19 epidemic within its borders y implementing stringent measures. Through a combination of idespread testing and contact-tracing, legally enforced physical

social) distancing measures, and use of modern technologies such s automated robot cleaners and facial recognition for contact- apping, China has successfully slowed the spread to a halt: on

9 March 2020 – for the first time since the outbreak began in 2019 China reported no locally-transmitted incident cases of COVID- 9 [7]. Other countries, such as South Korea, have followed suit and ave also been relatively successful in controlling spread. Heads of overnment in countries such as New Zealand, Germany, Finland, celand and Taiwan have attracted praise for their decisive action nd ability to communicate the rationale for their policies. As com- entators have noted, they are all women [8].

.3. We need unified responses to pandemics rather than diverse isconnected strategies

So far, there has been little evidence of international co- rdination, worldwide or within regional blocs, as countries close orders and look inwards. WHO has urged countries to implement

comprehensive response to COVID-19 and to “Do it all. . .Find, iso- ate, test and treat every case to break the chains of transmission” 9]. Yet countries have moved at different speeds and intensity, ften without consulting their neighbours. These responses some- imes seem disconnected from the epidemiological evidence; some ountries which have similar disease ‘curves’ are reacting very ifferently. The strict legally backed lockdown measures imple- ented in China and South Korea early in their outbreaks contrast ith the dismissal of the risks of coronavirus, accompanied, at

east initially, by reluctance to impose stringent restrictions by ome politicians in the UK and the US. In places with ‘softer’ ini- ial responses (i.e. France, UK) the rapid increase in cases forced eassessments, with adoption of increasingly severe measures to rotect health systems at risk of collapse.

Today, over half the world’s population faces partial or full lock- own restrictions, and the global economy has taken a devastating it. Coronavirus, like all infectious agents, ignores geopolitical oundaries and attacks people regardless of nationality; we too ust take a unified approach which transcends geopolitical bound-

ries both to tackle the virus and to transition out of market closures nd lockdowns. As countries consider lifting these measures, they ust consult with one another and avoid making decisions in iso-

ation. At the same time, they should also steer away from ‘one fits ll’ solutions, and governments must consider their domestic cul- ures and contexts before ultimately defining a ‘new normal’. The uropean Union has published a roadmap setting out the princi- les that should underpin decisions to open up, noting that health olicy is a national competence, but decisions should be discussed nd communicated with neighbouring member states [10].

.4. Effective communication must occur at the highest political evels

In recent decades, the world’s leading economies have created tructures to allow coordination of policies, including the G7 and 20. There has been a disappointing lack of communication and

y 124 (2020) 577–580

collaboration at the highest political levels. The first virtual G7 and G20 meetings did not occur until mid-March – months after the outbreak began in China. And even when these discussions did take place, consensus lacked on a unified approach to COVID-19. When the G7 met on 25 March, instead of agreeing upon coordinated and collaborative responses to the virus, disputes broke out about who was most to blame for the crisis and a post-meeting joint statement could not be put together [11]. Subsequently, the USA blocked a statement by the G20 re-emphasising the global leadership role of WHO [12]. In this, and in future epidemic and pandemic responses, policymakers at the highest level need to engage with each other early on to develop coherent and unified responses. They must then communicate these to citizens, using every forum available.

2.5. The European Union, and other regional blocs, must assume a greater health role

The current pandemic response has revealed serious obstacles to concerted European Union action. Many European countries responded late to the disease outbreak, and going forward, several changes are needed. With treaties prohibiting ‘interference’ with member States’ autonomy in operation of their own health sys- tems, the crisis has laid bare the limited competencies in health that member States have been willing to give their European institutions [13]. Additionally, the European Centre for Disease Prevention and Control (ECDC) “has limited remit beyond the borders of the Euro- pean Economic Area (EEA)” and there are legal barriers to sharing public health data with countries, such as Switzerland, that have decided to remain outside the EU’s legal framework [13,14]. Going forward, the role of the ECDC must be extended and enhanced with more funding for research and development (R&D) and pre- vention efforts so that it can provide truly European (and not just EEA) coordinated disease responses, working closely with the Euro- pean Regional Office of WHO. COVID-19 will have major impacts on all European economies and the European Central Bank (ECB) will need to play a new role that goes beyond its traditional jurisdiction.

Yet the EU is only one regional bloc. Others, such as ASEAN, CARICOM, and MERCOSUR are, to varying degrees, increasing their role in health. Given the obvious economic impact of a pandemic, this will have to accelerate.

2.6. Global solidarity is the only way to win the war against COVID-19

Every country is making efforts to tackle COVID-19 and its eco- nomic impacts within national borders. However, these efforts are often disparate, and in some instances, even undermine global sol- idarity. For example, early on in the crisis, it was reported that President Trump offered large sums of money to CureVac, a Ger- man firm working on a COVID-19 vaccine, to persuade it to move and give exclusive rights to any vaccine produced to the US [15]. When the outbreak began to ramp up in Europe in March, France and Germany banned the export of protective personal equip- ment (PPE) amidst severe shortages of such equipment elsewhere [13,16]. China, after having weathered the worst of the outbreak, is one of the few countries showing signs of solidarity and providing

support to other countries by donating PPE and lending medical staff, a form of soft power that will not go unnoticed in the future [17]. More of these coordinated responses are the only way to defeat and transition out of a pandemic which cuts across national borders.

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.7. The WHO has done a lot given the resources it has, but there s much room for improvement. It must now focus its activities, xpand its remit and enhance its operational capacity

The WHO has continued to make use of available information hroughout the different stages of the COVID-19 pandemic, but its xperience has highlighted the need for greater focus, a wider remit nd greater operational capacity. Based on what is often inade- uate and uncertain data, the organisation has the difficult task to

nform populations of the spread and severity of SARS-CoV-2, while imultaneously mitigating panic that could send economies into ecession and even depression. Thus far, the WHO has done its best o communicate its messages effectively and has carefully escalated he terminology around SARS-CoV-2 from outbreak, to epidemic, nd to pandemic, based on available evidence. While these efforts re commendable, the pandemic has highlighted the need for some efocusing and increased funding to ensure the WHO is capable of oordinating global responses to major health challenges, includ- ng the capacity to provide even greater operational support where his is needed. However, it now faces enormous challenges as a onsequence of President Trump’s widely condemned decision to efund it [18].

.8. Existing global insurance institutions and policies are nadequate, and these require significant changes and mprovements

While several health security funds exist, these remain disap- ointingly inadequate. In 2016, the World Bank established the andemic Emergency Financing Facility (PEF) to complement the lready-existing UN Central Emergency Relief Fund (CERF) and the HO’s Contingency Fund for Emergencies (CFE). PEF was designed

o release funds to countries and companies responding to pan- emic outbreaks [19]. Yet, in reality, it is underpinned by bonds ith complex terms that are “heavily skewed towards investors”, ith a failure to pay countries affected in a timely fashion (if at all)

19,20]. While the global security space is crowded with insurance chemes, none have proved to be adequate. Any new global insur- nce policy must learn lessons from this experience to allow rapid isbursement of funds to those who actually need them.

.9. Efforts to develop COVID-19 vaccines and treatments are ommendable, but there is still much more to do

Countries and individuals around the globe are working to evelop and manufacture vaccines and treatments for coronavirus

n an unprecedented way. Across government, private and phil- nthropic donor spend, billions of dollars are being put towards fforts to find an effective SARS-CoV-2 vaccine [21,22]. There are ver 115 COVID-19 vaccine candidates in varying stages of R&D, nd the number of clinical trials of potential COVID-19 treatments nd interventions has surpassed 500 [23,24]. While of course, we ommend the commitment shown thus far, the global approach owards how we develop and test these vaccines needs to shift.

e believe the quickest path to successful development will entail ell-organised, mid- to large-size clinical trials rather than the

ushed, small clinical trials that have failed to deliver so far. Furthermore, once a vaccine is developed, the success of any

OVID-19 exit strategy will depend on the distribution of this tech- ology quickly to those most in need. But currently, manufacturing nd distribution channels do not have the capacity to provide access

o the billions of people who will require this vaccine [25]. We herefore suggest that governments jointly purchase the patent ights to these developments which would simultaneously reward evelopers for their innovation, investment, and efforts, while also

y 124 (2020) 577–580 579

allowing countries to rapidly manufacture and equitably distribute the vaccines to all those in need in their populations.

2.10. We need to test the responsiveness and resilience of health systems and make changes and improvements based on the results

Financial institutions are regularly stress tested; a lesson learned after the 2008 economic crisis. Yet while health systems are essential to human wellbeing (as evidenced by the COVID-19 pandemic), the responsiveness and resilience of health systems to epidemics and pandemics are rarely tested. Thus, as SARS-CoV-2 has spread across the world, health systems have been shocked and found underprepared: countries such as the US, which relies on China for the manufacture of over two thirds of the active pharmaceutical ingredients used in the American generics market [26], are highly dependent on well-functioning supply chains and face threats of drug shortages when manufacturers elsewhere are unable to do their jobs because of lockdowns and quarantines. Cru- cially, if systems are tested and weaknesses identified, something must be done. Unfortunately, this often does not occur in practice. For example, after a major exercise in the UK in 2016 exposed a shortage of ventilators, the issue was ignored [27]. Once the cur- rent COVID-19 pandemic is under control, health systems should be tested just like banks are to ensure they are resilient, and that any weaknesses are addressed.

2.11. Accountability is critical for building trust and for sound, inclusive decision making

Those making decisions must be accountable. The data, informa- tion, models and the processes by which the decisions are made, and their rationale should be available for scrutiny. Lack of clarity or purposeful obfuscation leads to confusion and sows mistrust, which undermines the response to an epidemic. Unfortunately, some countries are failing to make their data public, or are not shar- ing the information, models and assumptions on which decisions are made. This ‘perceived secrecy’ has undermined trust in many leaders. For example, in the UK, age and sex disaggregated data on those infected with SARS-CoV-2 or those who have died from COVID-19 have only recently become available, making it difficult to examine the assumptions used to make decisions.

2.12. There are opportunities to introduce novel approaches, such as using robots and artificial intelligence (AI), in this – and in future – pandemic response

The battle against novel diseases, such as COVID-19, may require novel approaches and technology. Robots and Artificial Intelligence (AI) – immune to infection and able to be coated in decontami- nating substances – can play a vital role on the frontlines of this war. Already, we are seeing the deployment of some of these new technologies. For example, in some countries, drones are being used to monitor people in lockdown and to deliver supplies and equipment; in others, robots are screening patients and relieving healthcare workers from some of their duties; furthermore, robots which deliver food and medicines, and even ones that dance, are offering emotional support and interaction for those in isolation; and lastly, robots with UV units are being used to disinfect hospitals and other large buildings [28]. There is a need to look at all options, while ensuring that they are subject to evaluation.

3. Conclusion

Now that SARS-CoV-2 has become a pandemic with close to five million cases and over 300,000 deaths as a result of the virus, the case for investing in health systems, human resources, and health

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[ event of a pandemic. NewStatesman; 2020.

[28] Yang G-Z, Nelson BJ, Murphy RR, Choset H, Christensen H, Collins SH, et al.

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echnologies is clear. It is also easy to see that in the past decade, usterity policies have cut investments in health and these sys- ems have too often been reduced or ignored. While it is essential o cut waste within health systems, this pandemic highlights the eed to have adequate capacity to address and tackle a crisis. It is lso a reminder of the strategic importance of publicly accountable ealth systems, underpinned by investment in people and tech- ologies. We must continue to build upon the lessons learned so

ar from the management of COVID-19 and adjust our approaches o this pandemic, and to other future health and environmental rises, accordingly.

unding

This research did not receive any specific grant from funding gencies in the public, commercial, or not-for-profit sectors.

eclaration of Competing Interest

None.

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