Even with centralized decision-making, cantons retained some decision-making capacity: they had the freedom to make their own policies if there was no national ordinance. The resulting, often complex, situation of decentralization can be exemplified by the governing council of the canton Uri, which decided on March 20 to ban people over 65 years old from leaving their houses but on the same day the Federal Council issued a new ordinance rendering the canton's decision invalid and lifting the curfew.
Stepwise re-opening began on 27 April 2020. On 19 June 2020, the situation was de-escalated from the "extraordinary" to "special," returning some autonomy back to the cantons. The opening and de-escalation steps were taken more quickly than expected; cantons criticized the short timeframes between discussion and decision-making, and between communication of the decisions and implementation.
In 2020, the government mobilized 74 billion Swiss Francs (CHF) for combatting the pandemic in the form of loans for companies and social welfare. On 25 June 2020, the Federal Council fully subsidized all tests for symptomatic persons, persons in close contact with the positive cases, and persons that were in quarantine mandated by cantonal authorities.
At the height of the first wave, wearing masks was only recommended for cases, their care takers or risk groups. The public perceived this as a strategic decision due to a shortage of masks, which was disputed by the Federal Office of Public Health (FOPH) as the scientific basis for this mandate was not yet given. A report from 2021 attests that there was a severe shortage of masks by the end of February 2020. Following an increase in cases in July 2020 (Figure 1), the first national mask mandate in public transport was issued. The Swiss NationaL COVID-19 Science Task Force (SN-STF) called for stricter measures (such as a mask mandate in shops). The public discourse was dominated by a sense of uncertainty by the statements of the SN-STF, the diverging actions of the Federal Council, and the cantons' sense of being overburdened and unsupported. At the end of July 2020, the FOPH proposed uniform national rules to avoid confusion among the public.
Spain enacted surveillance and monitoring mechanisms before detecting the first confirmed case on 31 January 2020. The national government activated existing coordination mechanisms for an integrated response across ministries and regions, and created a communication strategy to raise awareness of the transmission risk and preventive measures. However, the false perception of low community transmission risk among the public resulted in low compliance with preventive measures in the initial phases of the pandemic. Eventually when Spain became one of the epicenters of the health crisis in Europe, the public perception changed dramatically.
Despite a rapid increase in the number of cases in February, only on 3 March 2020, community transmission was declared in Madrid, Basque Country and La Rioja, and more restrictive measures (e.g., school closures and congregation restrictions) were introduced. The legal framework of the decentralized governmental system in Spain made it impossible to implement targeted lockdowns in autonomous regions and so the national government had to resort to the declaration of a nationwide lockdown on 14 March 14, 2020.
Initially, PCR tests were reserved for hospitalized patients, health professionals and workers in essential services. After 7 May 2020, testing was extended to all suspected cases and diagnosis, surveillance, and contact tracing were performed by the public health system.
Primary Health Care (PHC) was left outside of COVID-19 pandemic planning and management and the strategic focus on hospital care limited the potential of the PHC system to respond to the pandemic and led to a deficient contact tracing system in some regions. With the increased demand in hospitals and nursing homes, PHC providers were reallocated to provide treatment to COVID-19 patients. With an overstretched PHC system and shortage of personal protective equipment (PPEs) by April 2020, Spain had the highest number of health professionals infected with COVID-19 worldwide.
Years of structural adjustment programs after the 2008 economic crisis in Spain left an under-resourced social and health care system. Although structural and contingency funds were mobilized, and social measures to protect the most vulnerable populations were activated (e.g., guarantee home care for dependent persons), these measures could not fix the existing structural gaps. An under-resourced PHC and failing to monitor the quality of care and social services resulted in almost 20,000 deaths in nursing homes between January and June 2020.
While public acceptance of preventive measures increased due to recognition of the epidemic's gravity, debate over the lockdown measures rose steadily since April 2020. The lockdown in Spain was one of the strictest lockdowns in Europe resulting in negative social and economic impacts. Compared to the more proactive containment strategies (massive testing and contact tracing) taken by countries such as South Korea, in early stages of the pandemic, Spain's approach was criticized in the scientific literature as being unnecessarily restrictive in controlling the spread of the virus. Fear of economic slowdown and political polarization in parliament combined with social opposition to restrictive measures resulted in the loss of parliamentary support for the continued state of alarm. On 21 June 2020, all pandemic response competencies were fully devolved to the autonomous communities and the quick reopening resulted in deficient implementation of tracking and tracing systems, likely hindering the efficiency of the pandemic response.
Iran was among the first countries to face the heavy burden of the COVID-19 outbreak. Immediately after officially detecting the first case of the disease on 19 February 2020, the National COVID-19 Committee (NCC) was established. Among the NCC's immediate decisions (between February 22-26, 2020) were suspending commercial flights from China, issuing health certificates for foreign travelers, closing schools and universities, banning public gatherings, congregation restrictions, and reducing working hours (Table 3).
Although all economies were significantly handicapped by the pandemic, Iran's economy faced a double burden due to pre-existing unilateral economic sanctions; therefore, timeliness and effectiveness of mitigation strategies were overshadowed by low economic resilience. Despite the growing number of cases in February 2020, authorities hesitated to impose more restrictive measures such as national lockdown, which did not come into effect until early March 2020 (Figure 1). The continuous surge in daily reported new cases to over 1000 in March 2020, combined with concerns about the high risks of spread of the virus during the Persian New Year (Nowruz) holidays on 20 March 2020, led to imposing further restrictions, such as fines for travel ban violations.
Eventually economic concerns and frequent changes in the lead policy-makers in the most conflicted provinces led to the premature lifting of COVID-19 restrictions. By 3 April 2020, during the peak of the first wave, businesses, which had been closed since 18 March 2020 due to Nowruz holidays, reopened gradually. Easing the preventive measures continued with the reopening of mosques, allowing religious ceremonies during Ramadan (25 April-24 May 2020), and gatherings during the consecutive holidays of Eid :celebration of the end of the month of Ramadan: which likely instigated the rise of the second wave.
With the unilaterally imposed economic sanctions, adopting a whole of government (WOG) approaches has led to the self-sufficiency of Iran in the face of shortages of the basic prerequisites for managing COVID-19. The strong political support of the Supreme Council for National Security, within the framework of the WOG approach, allowed the government to launch various national campaigns and make use of the resources of the army and many other national organizations for conducting training programs, providing health support packages, monitoring and tracking the disease.
Given the state of the fragile economy, the risk of low compliance from public to restrictive measures at national level and differences in the prevalence of COVID-19 across provinces, the NCC delegated policy-making powers for re-imposing restrictions to the provincial COVID-19 Committees.
Despite the efforts to minimize the economic burden, as a result of COVID-19 restrictions, about 3 million Iranians lost their jobs between March and September 2020 and the government's financial aid to the affected businesses and households was insufficient to protect them from economic hardship.
In response to the shortage of essential medical supplies, particularly at the outset of the pandemic, the government facilitated import, banned exports and incentivized the domestic industry to increase production capacity. The capacity for real-time PCR tests increased from two centers to 190 laboratories by 22 July 2020, led by the Pasteur Institute of Iran, which began coordination on the first week a case was detected. However, only symptomatic individuals were allowed to be tested free of charge and upon a physician's request, perhaps explaining the relationship low testing intensity in the country (Figure 2).
A multi-sectoral response was designed through the creation of the National Coordinating Council (NCC) to manage the epidemic 3 weeks after the first case was detected:the slowest of any of the countries in our analysis.
Pakistan initiated preventive strategies in January 2020. One of the first containment actions taken was contact tracing of international travelers, designating quarantine houses in airports and near borders for individuals entering Pakistan to prevent community transmission; however, the state of the quarantine houses was questionable due to unsanitary conditions.
Pakistan's risk communication strategies included using national television programming, mobile ringtone messaging, the development of a helpline, and daily-televised briefings by the Ministry. However rumors and misinformation from social media, framing the pandemic as a conspiracy theory hindered these efforts and the country faced the challenge of low compliance by the public to the preventive measures.
Implementing restrictive measures such as lockdown requires taking into account the country-specific circumstances such as population structure, health needs and resources. According to Patel et.al. economically disadvantaged people are more vulnerable to COVID-19 due to poor housing conditions, no possibility to work remotely, unstable work conditions and comorbidities. Thus implementing a lockdown policy without a welfare support system in a low income country could increase the unemployment rate and further drive down compliance and increase the spread of the virus. This also accords with the situation in Pakistan when the government announced a national lockdown for 3 weeks starting on 15 March 2020. This decision did not receive public acceptance and was criticized and violated widely due to its economic impacts on a large portion of the population. Inefficiency in implementing the national lockdown resulted in lifting the measures after 2 weeks and introducing a "smart lockdown" strategy by enforcing the lockdown, only in places with higher positivity ratio.
Adopting a whole-of-society approach, the government worked with the existing social safety net "Ehsaas," to alleviate the economic burden associated with the pandemic by providing cash disbursements for daily wage earners starting in April 2020.
Despite the concerns about maintaining social distancing during the prayers at mosques, the mosques were open to the public during the month of Ramadan (23 April-23 May 2020). The support of religious leaders during Ramadan was instrumental in gaining broad compliance in many areas of the country. On 19 May 2020 and right before the religious festival of Eid which ends the month of Ramadan (23-24 May 2020), the Supreme Court decided to ease the measures and opened shopping centers and public transport, resulting in a sharp increase in cases in the following 2 weeks (Figure 1).
The initial shortage of health commodities and medical equipment in April and May 2020 was addressed by the disbursement of more than six billion Pakistani rupees (PKR) (USD 37M) to buy equipment, ventilators and to upgrade hospital facilities. Additionally, state banks provided low-interest loans to hospitals to improve their case management capacity. While diagnostic testing was initially very scarce, Pakistan acquired increased testing capacity in late February 2020 when several testing sites across the country were established by the federal government under the supervision of Pakistan's National Institute of Health (NIH). However, within the 4-country case study presented here, Pakistan observed a relatively low testing intensity (Figure 2), probably representative of the testing capacity of poorer countries around the world.
Our study is subject to a number of limitations. The accuracy of the observed incidence might not be comparable as different countries had different testing and diagnostic policies (Figure 2). There were not enough jurisdictions examined across the 17 indicators to analyze the independent and synergistic effects of each policy in a quantitative manner, and therefore we decided to rely on a structured thematic periodization of the package of interventions. Data from more countries could have also improved the geographic representation of the sample, but as this was a volunteer-based data collection effort, we relied on available and willing colleagues. Despite the collection of 17 indicators for 7 months, the decentralized responses in any one country could not be fully captured, nor could shortcomings with the centralization of decision-making. Moreover, the indicators of the economic impact of lockdowns are not perfectly comparable across countries whose informal employment sector is substantial.
Health systems are complex adaptive systems embedded in a wider ecosystem of economic, social and cultural super-systems that influence each other. Disentangling the effects of this dynamic interaction to capture independent and synergistic effects of policies require both transparencies in publicly available information and a broad collection across jurisdictions of one country or several countries. The results illustrate that the functional boundaries of the health system do not stop at the edges of WHO's six building blocks of the health systems framework.
The policy responses to COVID-19 are largely dependent on the level of decentralization of the system, their social and cultural contexts and the economic forces that define them.
Health systems with chronically under-resourced primary care and public health services, weak governance mechanisms, and substantial fragmentation across services hampered the ability of governments to respond to the health needs of citizens in a timely manner. Primary health care is the first contact point of people with the health system, however during the pandemic it was overshadowed by prioritizing secondary care. An under-resourced primary health care slowed down preventive responses and led to increased transmission.
Overall economic context and the strength of social protection systems played a crucial role in the type of interventions that the different governments put in place. Access to COVID-19 tests and functional health infrastructures allowed Switzerland to take a proactive approach to "flatten the curve" using containment measures such as testing and contact tracing thus avoiding a national lockdown. On the other side of the spectrum, in Iran and Pakistan implementing a partial lockdown was an inevitable choice, not only because of limited access to diagnostic tests but also due to the low coverage of sick or unemployment benefits.
Another major finding was that in all countries compliance to the measures was a concern. This further reinforces the importance of effective communication strategies and the need to galvanize context-driven "trust" dynamics between population and centralized and decentralized governments.