Suppressing the COVID‑19 pandemic and achieving SDG3 (Good Health and Well‑Being)

Part 2

SDG 3 (Good Health and Well-Being) calls on countries to strengthen access to health care and improve its quality, to assure universal health coverage, and to promote mental health and well-being. Before the COVID-19 crisis, little attention was paid to the SDG framework in relation to health and well-being policies in European countries, and more specifically to those of the EU. Firstly, because European and especially EU institutions have limited competences in the field of public health. Secondly, because European countries were considered to have among the best health-care systems in the world and hence to have achieved (or almost achieved) SDG 3. The targets and objectives included in SDG 3 were thought to be most relevant to developing countries. The COVID-19 crisis has undoubtedly changed the terms of the debate, both in terms of the sharing of competences but also the assessment of the performance of European health systems to respond effectively to such public health crisis.

To inform policies and develop better measures of government preparedness and responses to public health crisis, it is crucial we understand the key success factors in reducing and eventually suppressing the transmission of a new virus such as COVID‑19. SDG Target 3.d calls on all countries to strengthen their capacity “for early warning, risk reduction and management of national and global health risks.”

The number one priority for European countries and the EU should remain the suppression of the pandemic, within and outside Europe. There cannot be sustained socio‑economic recovery while a pandemic is raging. There are three possible ways to suppress a virus: (1) herd immunity; (2) effective use of non‑pharmaceutical interventions (NPIs); (3) development of vaccines and widespread vaccination.

The first option (herd immunity) is not viable, as the mortality consequences would be too high. Infection fatality rate estimates for COVID‑19 have ranged from 0.17% to 1.7% (Meyerowitz‑Katz and Merone, 2020), while herd immunity for COVID‑19 is estimated to require infection of 50–67% of a population (Omer et al, 2020).

Assuming herd immunity at 50% and an infection fatality rate of 1%, herd immunity would come at the price of more than 2.2 million deaths at the level of the European Union, or 2.6 million deaths across the European Economic Area (EU, EEA and UK). This is approximately 8 times the actual number of COVID‑19 deaths in the region as of 30 November 2020. This is unacceptably high, as would be the additional strain on health systems.

While countries are waiting with great hope for vaccines to become available, in the interim the only way that the COVID‑19 epidemic can be suppressed is through mobilising all available NPIs, to reduce transmission of the virus as quickly as possible.

This short section, drafted at the end of November 2020, provides some evidence on policies that have worked – and not worked – in suppressing the virus. It focuses primarily on the EU and its Member States, but also includes comparisons with other countries outside Europe that have done better or worse in controlling the pandemic. It builds extensively on the work of the Lancet Commission on COVID‑19. It is divided into three parts.

First, it provides a snapshot of countries’ performance, in terms of effectiveness and efficiency in controlling the spread of the virus, in Europe and in other OECD and G20 countries. The efficient management of a pandemic caused by a virus like the new COVID‑19 means limiting negative health outcomes (number of cases and deaths) while also mitigating economic impacts.

Second, it provides a list of key NPIs and emphasises their role in controlling the spread of the virus in the absence of a vaccine. We tentatively explore the role of three drivers of successful implementation of NPIs (government action and leadership, population compliance, and demographic/geographic factors).

Third, we discuss some priorities and lessons learned for Europe, on NPIs and vaccines, but also more broadly in terms of crisis preparedness, resilience and disease prevention, that matter for the achievement of SDG 3 (Good Health and Well‑Being) and other SDGs.

2.1 An international perspective on COVID‑19 transmission, deaths and economic impacts

Compared with countries in the Asia‑Pacific region, most European countries have recorded high case rates and death rates from COVID‑19, and the economic impacts of measures taken to control the pandemic have also been greater.

Virus transmission

As of this writing at the end of November 2020, no European country has successfully suppressed the transmission of the virus. In Table 2.1, we consider virus transmission to be suppressed if the rate of daily new infections over the past 30 days is below 5 new cases per million population. Between the end of October and the end of November, new cases have sharply increased in Europe. The average number of new cases per day ranges from 53 per million population over the past 30 days in Finland to 60–100 per million in Iceland, Ireland and Norway, to 600 or more in Austria, Croatia, the Czech Republic, Luxembourg, Slovenia and Switzerland. Some countries that managed to avoid the first wave of the virus in the 2020 European spring were very significantly impacted in September–November (including Central and Eastern European countries).

This is in sharp contrast with many countries in Asia‑Pacific – including Australia, China, New Zealand, South Korea and Taiwan (Province of China) – where fewer than 5 cases per million population were reported over the same 30‑day period, and for several weeks in a row.

COVID‑19 deaths

The number of COVID‑19 deaths in Europe is very high and still rising. We use in this analysis COVID‑19 death rates, but excess mortality is sometimes also used.1 Overall, COVID‑19 deaths per million population were higher in Europe in the spring, summer and autumn of 2020 than in countries in the Asia‑Pacific. Excess mortality has also been higher on average in Europe than in the Asia‑Pacific.

It should be noted, though, that some countries are more susceptible to higher death rates due to COVID‑19 because of inherent factors that go beyond policy responses to the virus – such as having older populations or a higher prevalence of risk factors like obesity or diabetes. Furthermore, those countries first hit by the epidemic – including Italy – had less time to implement comprehensive policy responses than did others. Data on cases, deaths, and tests may not always be perfectly comparable across countries due to under‑testing and under-reporting, different and changing definitions of COVID‑19 deaths, and other reasons (The Lancet COVID‑19 Commissioners et al., 2020).

Table 2.1 | COVID‑19 transmission status and deaths (European, OECD, G20 countries and other selected countries)

Figure 2.1 | COVID‑19 transmission status and deaths (European, OECD, G20 countries and other selected countries)

Source: Authors’ calculations. Based on Our World in Data. As of 29 November.

Efficiency in managing the pandemic

There is really no choice between prioritising health or the economy, since economic activity cannot be sustained when a pandemic is raging. The only viable option is to control the spread of the virus as efficiently as possible. This requires relying on NPIs, including effective test‑trace‑isolate policies and widespread use of masks and other PPEs, to avoid shutting down completely the economy through restrictive lockdowns. Early and targeted containment measures have much more limited economic and fiscal costs (Gaspar and Gopinath, 2020).

Many European countries were hit severely both by the health crisis and the economic crisis. The Autumn 2020 Economic Forecast projects that the European Union will contract by 7.4% in 2020, with substantial negative impact on jobs (European Commission, 2020h). This is driven by a significant contraction of the economy in the first half of the year due to lockdowns. Economic activity rebounded strongly in the third quarter as containment measures were gradually lifted and also thanks to the stimulus, but most European countries are heading towards a double‑dip recession in the fourth quarter of 2020 and first quarter of 2021 due to the surge of COVID‑19 cases in September–November and the re‑introduction of mobility restrictions (albeit generally less strict than during the spring).

A comparison between GDP in the third quarter (Q3) of 2020 and GDP in Q3 of 2019 (the latest available data as of this writing) alongside COVID‑19 deaths per million population provides two meaningful insights. Firstly, it emphasises the relatively good performance of South Korea so far compared with European countries in mitigating both the health and the economic consequences of the COVID‑19 pandemic. This was a key message of the Sustainable Development Report 2020 (Sachs et al., 2020a). China also had relatively low COVID‑19 deaths per capita and positive GDP growth in Q3 2020. In Europe, countries less affected by the first wave in the spring, such as Finland, Norway, Latvia, and the Slovak Republic, managed to better mitigate the health impacts (with fewer than 150 COVID‑19 deaths per million population) and the economic impacts (with a contraction in Q3 2020 of 3% or less compared to Q3 2019). By contrast, Belgium, Spain and the United Kingdom have experienced the largest health and economic impacts from the pandemic.

Figure 2.1 | COVID‑19 deaths and GDP growth

Figure 2.1 | COVID‑19 deaths and GDP growth

Source: Authors’ calculations. Based on Eurostat, OECD and Our World in Data.

Secondly, countries that opted for a more liberal rhetoric to manage the pandemic, such as Sweden and the United States, have not performed particularly well economically and have had among the highest death rates from COVID‑19 so far. The contraction in Sweden in Q3 2020 (compared with Q3 2019) was larger than in Norway, and comparable with Denmark and Finland. But as of November 29, the number of COVID‑19 deaths per capita in Sweden was 4.6 times that of Denmark, 9 times that of Finland and 11 times that of Norway. The Swedish authorities admitted that their approach during the first wave, based on developing some level of herd immunity, did not help much in containing the pandemic in autumn 2020, and new cases continue to soar (Colson, 2020). These substantial GDP contractions even in those countries that imposed less restrictive containment measures might be explained through endogenous reactions from households and businesses – which, even if not constrained, might consume, hire and invest less in times of pandemic, due to high uncertainty about the future.

2.2 The key role of non‑pharmaceutical interventions

Categories of NPIs

In the absence of vaccines, the effective implementation and enforcement of non‑pharmaceutical interventions (NPIs) is the only available policy response to contain virus transmission. A checklist of possible NPIs is shown in Box 2.

Box 2. Key non‑pharmaceutical intervention checklist

Social distancing measures and special protection

• Physical distancing recommendations in public spaces (i.e., spacing)
• Teleworking
• Banning large public events (e.g., sports, concerts)
• Strictly limiting capacities of public indoor places (e.g., restaurants, cafés and bars, gyms, religious settings, theatres and cinemas)
• Special protection of vulnerable populations (e.g., older people and people with pre‑existing chronic conditions)
• Special protection of populations who are socially vulnerable (e.g., children, the poor, people with disabilities, refugees, minorities, indigenous peoples)
• Safe international travel (i.e., bans and quarantines)
• Public awareness, trust and appropriate risk communication

Improved personal and environmental hygiene

• Face masks
• Personal hygiene (e.g., handwashing, covering sneezes and coughs)
• Special protection of congregate settings (e.g., care centres for older people, nursing homes, prisons, worker hostels, refugee camps)
• Safe schooling
• Safe workplaces
• Safe public transport

Testing, tracing and isolation of infected individuals

• Testing (i.e., rapid, comprehensive and free, with follow‑ups including tracing and isolation)
• Quarantine and isolation at home when that environment is safe and in public facilities when the home environment is inadequate
• Social support for those in isolation

Source: Adapted from the Lancet COVID‑19 Commissioners et al., 2020

NPIs can be grouped into three broad categories (OECD/EU, 2020):

1. Social distancing measures – closing workplaces and non‑essential services, school closures, banning mass gatherings, imposing travel restrictions and even full social lockdowns;

2. Improved personal and environmental hygiene, including the use of personal protective equipment such as face masks; and

3. Testing, tracking and tracing of infected individuals, along with the confinement of affected persons. This may be targeted or geared towards large‑scale testing and quarantine policies.

A strict and large‑scale lockdown is the costliest form of NPI.

Countries that were better prepared and acted quickly to reduce the spread of the virus through rapid scaling‑up of NPIs (including testing, tracking, tracing strategies) have been able to avoid much of the most stringent and costly containment and mitigation measures. This was the case for many countries in the Asia‑Pacific region that had recent experience with pandemics, including South Korea. In fact, pre‑COVID‑19 assessments of government preparedness to face pandemics turned out to be poor predictors of effective early response to COVID‑19 as they did not take into account important governance issues (Lafortune, 2020).

Although cases in Europe have soared since September, NPIs have been instrumental in reducing the rate of transmission overall. The effective reproduction rate (ERR) measures the average number of infections resulting from an infectious case. When ERR is less than 1, the number of active cases in a population declines. When ERR is greater than 1, the number of active cases rises. On a conceptual level, suppression of the epidemic requires keeping the ERR below 1 on a sustained basis.

The ERR in most European countries was much lower in October 2020 than it had been in March, the two periods in which many European countries introduced, or reintroduced, lockdown measures (Figure 2.2). This is especially the case in countries hit hardest by the first wave – including France, Germany, Italy and Spain. In Germany, for instance, each person who tested positive to the virus in March 2020 was contaminating on average almost 2.5 people, a rate that had dropped to an average of 1.4 people by October. The central role of NPIs in reducing the ERR is confirmed by other studies using multivariate analyses (Li et al., 2020).

Figure 2.2 | COVID‑19 effective reproduction rate (ERR) in selected European countries, February to November 2020

Figure 2.2 | COVID‑19 effective reproduction rate (ERR) in selected European countries, February to November 2020

Source: Arroyo‑Marioli et al, 2020

Yet, because the ERR remained above 1 for several months during the second wave (starting in June or July 2020), the number of confirmed cases during the second wave in many European countries has been higher than during the first wave. This can also be at least partly attributed to higher testing capacities. This indicates that many European countries were too slow to take decisive action to reduce the ERR to below 1 in autumn 2020, for various reasons. Early evidence suggests that contaminations tend to occur most frequently in indoor locations such as restaurants, gyms, cafés and bars, and in places of worship or during religious ceremonies (Chang et al., 2020)

Understanding success factors in controlling virus transmission in autumn 2020

Success factors in controlling the virus’ transmission early in the crisis – in March and April 2020 – might be different than those later in the year. Success in controlling the virus in Europe’s spring might have had much to do with country preparedness and government reactivity, the timing of the first confirmed case and, possibly, differences in testing capacities. In Asia‑Pacific countries, more recent experiences in managing epidemics have also played a role in the quick and effective implementation of testing and isolation policies and the use of masks and other PPEs.

Yet many European countries had managed between June and July 2020 to bring new cases significantly down, thanks in most cases to strict lockdown measures initiated in spring. Most European countries had by summer also addressed their equipment shortages (of tests kits, PPEs etc.), which was an issue in the early phase of the crisis. Many European countries failed to implement a gradual easing of lockdowns following the first wave and to set up effective early warning mechanisms and testing‑tracing‑quarantining policies.

Interestingly, no European country really managed to contain the spread of the virus better in the second wave compared to the first. In Table 2.2, we compare average daily new cases in European countries over three 3‑month periods: spring 2020 (March to May), summer 2020 (June to August) and autumn 2020 (September to November). Only two European countries – Finland and Norway – managed to keep new cases below 50 per million in all three periods (although as of this writing, new cases per million population have been increasing rapidly between the end of October and the end of November 2020 in these countries as well). All other countries experienced high or very high virus transmission during the second wave. The Baltic States (Estonia, Latvia and Lithuania) and Eastern European countries (Bulgaria, Hungary, the Slovak Republic, Poland and Slovenia) initially maintained low virus transmission but were significantly hit by the second wave in autumn. The management and treatment of patients improved, but the capacity of European countries to contain the spread of the virus remained relatively low compared with several countries in the Asia‑Pacific region.

Table 2.2 | Virus transmission across European countries in the spring, summer and autumn of 2020

Figure 2.2 | Virus transmission across European countries in the spring, summer and autumn of 2020

Note: Ordered by average number of daily new cases per million population, during period 3 (September 1 to November 29). 1=Virus suppressed; 2=Low transmission; 3=Moderate transmission; 4=High transmission; 5=Very high transmission

Source: Authors’ calculations, based on Our World in Data.

Success in containing the spread of the virus in autumn 2020 might have more to do with the effective enforcement of NPIs, including effective test‑trace‑isolate policies and continued compliance with government recommendations, travel bans and rules on social distancing, personal protection and other NPIs. Higher testing capacities in late 2020 might also have contributed in part to the increased number of reported cases, but rising positivity rates also explain the increase to a large extent.

It remains difficult to demonstrate empirically the contribution of specific NPIs to the success in controlling virus transmission in Europe in autumn 2020. This is due to the fact that it is most likely a combination of NPI measures that drives success, and the overall effect of all measures taken together is greater than each one taken separately. This is an important research agenda and part of the Lancet Commission on COVID‑19. High‑quality international measures are lacking that would enable development of robust estimates of the following factors:

1. Delays in obtaining COVID‑19 test results (crucial for isolating confirmed cases and reducing transmission)

2. Number of contacts traced per positive COVID‑19 test

3. Staff dedicated to contact tracing

4. Financial support and specific policies to ensure effective isolation and quarantining

5. Data on the use of protective personal equipment (including face masks and hand sanitisers) disaggregated by population groups, including age groups and vulnerable groups,

6. Average number of contacts per person per day during the pandemic

Some policy measures and behavioural factors appear to have been decisive in reducing virus transmission (Table 2.3, online). These include rapid closures of borders and travel bans, prolonged and widespread use of face masks, as well as people’s fear of the virus and their recent experiences with virus outbreak – which might be a proxy for a drastic reduction in social interactions. As suggested in Table 2.3 (online), there does not seem to be one unique approach that has worked across all countries and contexts.

Despite these limitations, an early review of best practices and the literature suggests that differences across countries in successfully implementing NPIs in the European autumn of September–November 2020 can be attributed to a combination of “technical” and “soft” factors, related to people’s behaviour and compliance with rules and recommendations. We tentatively group these into three categories:

1. Government policies and leadership: recommendations, timing, coordination, monitoring and control systems, and communications about NPIs to promote compliance.

2. Compliance of the population: with government recommendations and rules relating to social distancing, personal protection, and other NPIs.

3. Other demographic and cultural factors: population density, average household size, general community behaviours regarding social interactions, attitudes towards new rules, historical factors.

On (1), several countries in the Asia‑Pacific region put in place effective NPI policies more quickly, including test‑trace‑isolate policies, supported by functional surveillance systems and clear communications. These efforts were also maintained over time. South Korea is so far among the best examples (Box 3). In particular, the Korean Center for Disease Control and Prevention (KCDC) played a central role in rapidly coordinating the country’s response to the pandemic, including through effective early warning systems. Most of the population in Korea rated very positively the government response to the first wave of the pandemic.

Box 3. South Korea’s “TRUST” strategy for dealing with COVID‑19

South Korea’s early and prolonged success in dealing with COVID‑19 is commonly attributed to the acronym “TRUST”, which stands for Transparency, Robust screening and quarantine, Unique but universally applicable testing, Strict control, and Treatment.”

South Korea’s response to COVID‑19 stands out because it flattened the epidemic curve quickly without closing businesses, issuing stay‑at‑home orders, or implementing many of the stricter measures adopted by other high‑income countries. The country has shown early success across three phases of the epidemic preparedness and response framework: detection, containment and treatment. From the outset, decision‑making in South Korea has been a collaboration between the government and the scientific community.

Detection: South Korea built hundreds of innovative, high‑capacity screening clinics and worked closely with the private sector to ensure an adequate supply of tests. As the outbreak escalated, approximately 600 testing centres were established to screen people efficiently outside of the health system, with capacity reaching 15,000 to 20,000 tests per day.

Containment: South Korea isolated infected patients, supported those in quarantine to increase compliance and, most importantly, traced contacts with unusual thoroughness. A workforce of hundreds of epidemiological intelligence officers was deployed for these tracing efforts and empowered to use a wide variety of data sources, including credit‑card transactions and closed‑captioned television footage.

Treatment: The health system surged to meet demand, especially in Daegu, the site of a large cluster of infections. An additional 2,400 health workers were recruited in Daegu alone. Across the country, the government built temporary hospitals to increase capacity and addressed shortages of personal protective equipment (PPE) through centralised government purchasing.

South Korea’s strongly enabling environment positioned the government to act quickly and effectively. After its flawed response to an outbreak of Middle East respiratory syndrome (MERS) in 2015, the government made several reforms to the health system to boost preparedness. In addition, a well‑functioning national health insurance system, ample human resources and infrastructure, and constructive relationships with key institutions such as the president’s office, the Ministry of Health, and the Korea Disease Control and Prevention Agency, allowed for an extraordinarily decisive response to the pandemic.

The recent experience of South Korea with MERS probably helped. Besides the population’s greater familiarity with NPIs, the government also made sure that it did not repeat errors of the past, including in terms of transparency. The South Korean government upgraded the KCDC to a deputy‑ministerial‑level agency, the Korea Disease Control and Prevention Agency (KDCA), and strengthened its autonomy and professional specialties by increasing the number of epidemiological surveyors (Ministry of Health and Welfare, 2016)

Source: Our World in Data (Roser at al, 2020) and authors.

By contrast, a June 2020 survey of public perceptions of government responses to the pandemic, carried out in 19 countries (including 7 European countries), highlights that citizens in European countries rated fairly poorly the performance of their governments in managing the crisis (with the exception of Germany), especially in relation to testing and public communication (Figure 2.3).

Figure 2.3 | Public perception of government responses to COVID‑19, June 2020

Figure 2.3 | Public perception of government responses to COVID‑19, June 2020

Note: Data collected between 16 and 20 June. Data available for 19 countries: Brazil, Canada, China, Ecuador, France, Germany, India, Italy, Mexico, Nigeria, Poland, Russia, Singapore, South Africa, South Korea, Spain, Sweden, United Kingdom, United States

Source: Lazarus et al., 2020

The management of the crisis in the EU might have also been too national or even regional/ local, with limited EU‑wide coordination on intra‑ regional travel, nor to foster economies of scale in testing, tracing, and PPE (Jordana and Triviño‑Salazar, 2020).

On (2), the success of NPI policies depends to a large extent on the compliance of the population and their acceptance of these measures. Several factors might play a role in driving adhesion and compliance, such as confidence in public authorities, the scope and breadth of social‑protection systems, housing quality, the level of fear of the virus among the population, and other general population characteristics and behavioural factors. Anti‑mask demonstrations have taken place in several countries in Europe including Belgium, France, Germany, Italy and Spain. Interestingly, some of the countries that have proven best able to mitigate the spread of the virus in Europe so far tend to have higher levels of confidence in public authorities (Denmark, Finland and Norway: see Figure 2.4). By contrast, confidence in the national government was below 40% in Belgium, France, Italy, Spain and the United Kingdom. For countries that had not experienced major virus outbreaks in recent years, confidence in national authorities might have played a role in explaining compliance or non‑compliance with official recommendations (Han et al., 2020; Lalot et al., 2020). We note that confidence in the national government in Australia and New Zealand was also higher in 2019 than in most European countries that were particularly affected by the pandemic.

Figure 2.4 | Confidence in national government, selected European countries, 2015–2019

Figure 2.4 | Confidence in national government, selected European countries, 2015–2019

Note: Percentage of people who answered “yes” to the question: “In this country, do you have confidence in each of the following, or not? How about national government?”.

Source: Gallup World Poll

On (3), other demographic, geographic and historical factors have also played a role in explaining virus transmission in Europe during the first and second waves. To some extent, those countries that have been most successful in controlling the spread of the virus so far tend to have lower population densities (Figure 2.5). The population per square kilometre is less than 20 in Finland and Norway, whereas it is 200 or more in Belgium, Germany, Italy, the Netherlands and the United Kingdom. Yet, overall population density at the country level is a proxy of the proximity of people and does not take into account the fact that in most countries, virus transmission was particularly rapid in cities. So what probably matters even more is the average population density of urban settlements. The average size of each household is also very relevant as the virus often spread across all the people living in the same household. For example, the average household size in Finland is among the smallest in Europe (Eurostat, 2020), which may have helped to control better virus transmission. Cultural factors might also play a role, such as the average number of daily physical contacts and interactions among a population. Finally, historical factors probably also explain the degree of preparedness to face public health emergencies. For instance, due to a long history of tensions with Russia, Finland has a national Health Protection Act (since 1994), which was complemented by an Emergency Powers Act (2011) and a Communicable Diseases Act (2016) to promote preparedness to pandemics and other threats to public health. This notion of collective emergency action to respond to sudden crises is not only enshrined in the law, but also in people’s attitudes and adherence to rules introduced in times of emergency (Nuorti, 2020; Milne, 2020).

Figure 2.5 | Correlation between population density and virus transmission in European countries, September to November 2020.

Figure 2.5 | Correlation between population density and virus transmission in European countries, September to November 2020.

Note: Excludes European countries with a population of less than one million people.

Source: Authors. Based on Our World in Data and National sources.

2.3 Outlook: Public health priorities and strengthening resilience in Europe

Short‑term priorities: suppress the virus and mitigate health, economic and social impacts

To suppress the virus there are two major priorities: (1) stronger implementation of NPIs and (2) development and distribution of effective and safe vaccines. As described in the previous section, success to date in suppressing the epidemic has been achieved through a combination of NPIs aimed at keeping infected individuals from spreading the virus (including face masks, personal hygiene, physical distancing, banning large public events, safe workplaces, and testing, tracing and isolating). So far, several countries in the Asia‑Pacific have been most successful in mitigating the health and economic impacts of the pandemic. In Europe, Nordic countries – especially Finland and Norway, but with the exception of Sweden – have so far been more successful than Western and Southern European countries.

At the end of November 2020, many European countries are again loosening lockdowns. To avoid a “Stop & Go” situation, which may be particularly damaging for economic, social and cultural activities, it will be important to open up gradually and in a more organised manner than we saw following the initial series of lockdowns in Europe. Effective NPI policies and substantial monitoring and communication will be needed, even after the vaccines become available by the end of 2020 or early in 2021. A particular focus on safe buildings and workplaces might be required in Europe, and on strengthening compliance with NPIs among both the young (18–35 years old), who are more likely to spread the virus, and among older people (people over 60), who are at a higher risk of severe illness from COVID‑19. Learning from countries in the Asia‑Pacific, especially South Korea and Taiwan, digital technologies could be further leveraged for effective testing, contact tracing and isolation of infected people as lockdown measures are gradually eased.

Besides efforts to suppress the pandemic, there is also a need to strengthen the provision of care for people ill with COVID‑19 and those suffering from other health conditions. Studies are beginning to show the extent to which delays in cancer diagnoses and treatment are likely to impact survival rates. In England, it has been estimated that delays in diagnoses during the first wave will increase cancer deaths over the next five years by about 16% for colorectal cancer, 9% for breast cancer, 6% for oesophageal cancer, and 5% for lung cancer (Maringe et al., 2020). In France, studies suggest that delayed cancer diagnoses could lead to an excess mortality of 10% to 15% per month of delay (Santi and Pineau, 2020). Responding to rising mental distress is also key (The LancetCOVID‑19 Commissioners et al., 2020). Further investments in public health are likely to be needed to respond to the indirect effect of the COVID‑19 pandemic.

On the economic side, many European countries are facing a “double dip” recession, with negative GDP growth expected in Q4 of 2020 and Q1 of 2021. In the short run, it will be important to maintain the exceptional fiscal measures introduced in European countries to support jobs and wages. With many workers at risk of losing their jobs and businesses at risk of going bankrupt, it is too early for most European governments to withdraw this vital fiscal support, including the extension of unemployment benefits and wage subsidies, and subsidies and loans to businesses.

The medium‑term recovery will likely follow a “K” shape, with sectors following divergent paths. The crisis is accelerating the digital transformation. Tech companies have increased their market shares, and this will continue. In this context, a careful assessment of balance sheets is needed to identify “zombie” (non‑viable) firms and target effective support programmes. Accelerating the transition to a green and digital Europe and adapting safety nets and training policies will be crucial for the recovery in 2021 and beyond. Sections 3 and 4 discuss the key transformations that are needed to support a sustainable, inclusive and resilient EU.

The virus must be controlled globally. The health, economic and social consequences have to be addressed in all countries, including in low‑ income countries and emerging markets that might often have less fiscal space and less access to international markets to finance their response and recovery. To meet some of these challenges, “Team Europe” was launched in June to support EU partner countries in the fight against the COVID‑19 pandemic and its consequences: 36 billion euros have now been mobilised and will be used to address the devastating effects of the COVID‑19 crisis in partner countries and regions. Lasting solutions, including access to new vaccines and effective treatments, will need close and continued international collaboration. Rethinking the global tax system, including the taxation of tech companies, will be needed to mobilise additional financing. The OECD initiatives on digital taxation and Inclusive Framework on Base‑Erosion and Profit‑Shifting (BEPS) are particularly relevant and important.

The EU should also be very active and vocal in ensuring fair access to new vaccines globally, including in low‑income countries, when they become available. Finally, effective public communication campaigns and pedagogy will be needed to address distrust of vaccines in some countries in Europe and elsewhere. An estimated 4 in 10 French people would be reluctant to be vaccinated against COVID‑19 (Lazarus et al., 2020b).

Long‑term priorities: Strengthen health coordination, preparedness, resilience and prevention

This crisis has revealed the crucial need for partnerships and coordination within the European Union and globally. The EU’s mandate when it comes to public health is traditionally limited. The EU cannot impose public health measures on Member States, including quarantine policies or the shutdown of public spaces. Yet Article 168 of the Treaty (TFEU) provides room for EU‑wide coordination and actions to complement national policies in times of pandemic, and in “combatting serious cross‑border threats to health”.

Early evidence suggests that EU‑wide coordination was slow to pick up, with limited coordinated action to restrict intra‑regional travels or generate economies of scale in testing, tracing and other NPIs in the early phases of the pandemic. Member States’ policies and strategic orientations were primarily driven by their national scientific committees, characterised by the relatively minor role played during the early days of the crisis by the European Centre for Disease Control (ECDC) (Jordana and Triviño‑Salazar, 2020). Joint procurement and other EU‑level actions did reduce strains on global supply chains and helped address shortages in PPE in some Member States in March 2020. The transfer of patients in March and April from overburdened hospitals in the East of France to Austria, Germany, Luxembourg and Switzerland also showed the benefits of inter‑country support.

EU commitments in early November 2020 to strengthen the mandate and role of the ECDC and the European Medicines Agency (EMA), and to establish a new institution modelled on the US Biomedical Advanced Research and Development Authority (BARDA), are positive developments that should favour a more coordinated and integrated response to global health risks in the future. The immediate provision of €220 million to fund cross‑border transfers of COVID‑19 patients in the EU will also help reduce the burden on hospitals in areas particularly affected.

The crisis has highlighted the need not only to strengthen the resilience of health systems, but also more broadly to strengthen economic, climate, digital and other forms of resilience. The likelihood of a pandemic such as COVID‑19 has been stressed by scientists for many years, but, despite its inclusion in SDG target 3.d, few governments were effectively prepared to face this eventuality. COVID‑19 should not be seen as a single threat, but as one extreme event within a larger continuum of possible crises that pose long‑term threats to human health, prosperity and environmental stability (ESIR, 2020). Scientists are now warning policy makers of potentially critical climate events and massive digital security issues. Our experiences with the pandemic should encourage the European Commission and Member States to develop better strategic foresight and agile institutions (and to integrate foresight into the policymaking process), to beef up their capacity to absorb shocks and adapt to change (Lafortune and Schmidt‑Traub, 2020). The resilience dashboards recently proposed in the first annual European Commission Strategic Foresight Report (2020b)are a step in the right direction. These must inform forthcoming discussions regarding the European Semester and assessments of recovery and resilience facility plans (RRF). The proposed EU4Health Programme 2021–2027 (Box 4) emphasizes issues around public health crisis preparedness and resilience.

Resilience requires tackling a number of environmental issues that can have substantial impact on population health:

1. Increasing the resilience of care systems to extreme weather events linked to climate change

2. Accelerating the decarbonization and circularity of the health‑care sector through R&D and investments

3. Building capacity to address key environmental health issues, such as pollution and noise, to prevent respiratory diseases, cardiovascular diseases and other important diseases

4. Guaranteeing access to green and blue spaces to promote physical and mental health as well as Europe’s biodiversity strategy.

Health expenditure is growing faster than the rest of the economy in European and most OECD countries. In such a context, strengthening primary care and community health services, prevention programmes and digitizing health services, are key to generating efficiency gains and improving access to and quality of health services. COVID‑19 and an ageing population will require sustained investment in health promotion and health care throughout the EU. This crisis has also emphasised the need to strengthen disease‑prevention programmes, which currently represent only 3% of health expenditure in EU countries (OECD Health Statistics and Eurostat Database, 2019). Greater investments are needed to prevent and treat mental disorders such as depression and anxiety, which affect more than one in six EU citizens. Poor mental health was already estimated to cost Europe over €600 billion a year, or more than 4% of its GDP: of which a third is in direct health‑care spending (OECD/EU, 2018).

Box 4. EU4Health programme 2021–2027

Under the EU4Health programme, the Commission proposes to invest €5.1 billion over the 2021‑2027 period to strengthen health systems, representing a 10‑fold increase in funding compared to the previous proposal under the European Social Fund of €413 million. This increase has three key objectives:

1. Protecting people in the EU from serious cross‑border health threats and improving crisis‑management capacity.

2. Making medicines, medical devices and other crisis‑relevant products available and affordable, and supporting innovation.

3. Strengthening health systems and the health‑care workforce, including by investing in public health (for example, through health‑promotion and disease‑prevention programmes and by improving access to health care).

Beyond crisis preparedness and response, the EU4Health Programme will address other important long‑term challenges for health systems, in particular:

1. Inequalities in health status across countries, regions and population groups, and in access to affordable, preventive and curative health care of good quality.

2. Burdens from non‑communicable diseases (in particular cancer), mental health disorders, and rare diseases, and risk factors of health determinants.

3. Uneven distribution of health‑care system capacity.

4. Obstacles to the wide uptake and best use of digital innovations, and to their scaling‑up.

5. Growing health burdens of environmental degradation and pollution, in particular air, water and soil quality, and also from demographic changes.

Source: European Commission (2020e)