The dynamic interplay among PHSMs

PHSMs cannot function alone and must be implemented strategically and synergistically to maximise the protection of the health of populations and livelihoods. Synergies across different PHSMs can achieve their intended outcomes and withstand unintended consequences. Three nested interactions that emerged from this study will be discussed.

First, transmission monitoring through testing and contact tracing must be followed by citizens’ compliance with quarantine and isolation to stem community transmission. Ringfencing cases and contacts require alignment with social and economic support measures so that these individuals possess the resources to remain temporarily segregated from the rest of the community.21 This may come in the form of food delivery services as seen performed by village health volunteers in Thailand and allowances or income replacement given to isolated individuals in Singapore. This is especially integral for informal economy workers or daily waged earners, who are disproportionately affected by these quarantine measures, making physical distancing measures difficult to adhere to.22 The need for such support is more evident in low-income and middle-income countries (LMICs), where a large proportion of their population belongs to informal sector and is impoverished.23 24 However, vulnerable groups also exist in upper-middle-income and high-income countries, which are disproportionately affected by COVID-19 who also need government support. This dilemma further adds to the complexities between the protection of the health of the population and livelihoods.

Second, a more complex interaction network between various PHSMs entails interactions between health worker capacity, health infrastructure, border controls, vaccination roll-out and testing requirements, to name a few. To elaborate, human resources are needed to expand health services provision capacities to respond to the pandemic and to maintain other essential routine services at health facilities, which can be accomplished by mobilising military personnel and volunteers to refurbish non-clinical facilities and erect field hospitals and vaccination centres. During vaccination roll-out, human resources are required for inoculation services and facilitation of the cold chain. Private sector providers are commonly engaged to augment government service personnel to conduct laboratory tests, treatment and quarantine services. In Thailand, public and private healthcare providers were contracted on the same terms, conditions and fees, which had to an extent, prevented patient denials by private facilities.25 26 To that end, hotels were also converted into isolation amenities for returning travellers and close contacts during the initial peaks. Closely related are sandbox pilots for travel, where vaccine campaigns were accelerated to reach a certain level of population coverage before reopening of borders, which was determined by the availability of vaccines, manpower capacity to vaccinate and relevant supporting infrastructure.

Third, the availability of PPE, medical supplies and human resources also need to complement one another to maximise their effectiveness. Specifically, in certain countries with initial supply shortfalls, mask coverage for the general population was low during the early stages of the pandemic. These mismatches between PHSM objectives and medically related supplies were alleviated after rapid market approvals were authorised and domestic manufacturing capacities bolstered. Similarly, adequate PPEs for healthcare workers must be preserved to safeguard essential workforces to render COVID-19 related services while maintaining other essential health services. The severe lack of PPEs had endangered the lives of health workers and, in some cases, precipitated into healthcare worker mortality, further straining the countries’ test, trace and test capabilities.27 28

The list of interlinkages, complementation and synergies between different PHSMs are non-exhaustive, as depicted in the framework by the different permutations represented by the intersecting black lines in figure 1. Fundamentally, the mantra that PHSMs do not operate in silos and one PHSM should not substitute but complement another must be amplified at all levels of the health system.29

Key indicators influencing the dynamism of PHSMs

As the pandemic wore on, vaccines became more available and with the emergence of the more virulent strains in 2021, most countries adjusted their PHSM based on these emerging contexts as well as the impact of prolonged PHSMs on the economy. Policies had to balance between the health of the population and livelihoods. In general, the key indicators that govern the scale and duration of PHSMs are similar across the six countries. For example, Vietnam had used five explicit metrics to achieve this. Specifically, during the early stages of vaccination roll-out, a proportion of the population over the age of 50 fully inoculated was the most important indicator, as older persons were more predisposed to severe symptoms and overburden the health system, followed by the percentage of people over 18 who receive at least one vaccine dose. Next, the health system capacity indicator was predicated on the number of oxygen tanks at commune health stations to be used as a precaution for managing milder cases in the community along with the districts’ plan of deploying mobile health stations to provide care for hard-to-reach populations. Another indicator existed during the peak of demand for critical services, where the government earmarked ICU beds for the most severe COVID-19 cases based on an estimation of the percentage of total COVID-19 cases as potential demand. The number of community infections was also incorporated when calibrating the magnitude of PHSMs. Broadly, in all countries reviewed, parameters for decision-making towards scaling up PHSM include: community spread (indicator 1), number of severe cases and mortality (indicator 2) and health system capacity (indicator 3). For most countries, excluding Singapore, decisions were also made at the subnational level, and PHSMs tailored based on subnational key indicators.

n addition, a country’s fiscal capacity (indicator 4) and vaccination coverage (indicator 5) also act as important indicators (25). Countries that depend heavily on tourism, with large informal economies or insufficient budget reserves, might find themselves reopening their economy prematurely.30 Countries such as Thailand whose economy relies on tourism cautiously reopened borders at selected destinations, contingent on high vaccination coverage. Moreover, of the total government debt, 59.5% of GDP in 2022, 98.14% were internal borrows and were used to finance social and economic support and recovery from the pandemic.31 In 2022, vaccine policy changes were influenced by demand for booster doses in the light of waning vaccine immunity, breakthrough infections, new vaccines and existing fiscal space. When Omicron circulated towards the end of 2021, huge waves of infections threatened to overwhelm health systems. As a result, Thailand recommended a fourth dose to health workers, while Singapore mandated a booster dose to be considered fully vaccinated.32 33 However, despite high vaccination rates in countries such as Singapore, increased community transmission resulted in reclosing of borders in December 2021 and January 2022, with the temporary ceasing of VTLs to preserve hospital capacity.34 Concomitantly, these policy decisions and the prolonging of PHSMs require an enlarged fiscal space for health.35

The availability of technology (indicator 6) is a quintessential element to guide the intensity and duration of PHSMs. This is evident in countries such as Indonesia, Thailand, the Philippines and Vietnam, whereby a large proportion of their student population might not have access to the internet for remote online learning. Despite having measures to support students, it is reportedly insufficient to meet the immense demand. The long-term closure of schools and the digital divide threaten the quality of education and exacerbate inequity gaps.36 Access to technology can determine a population’s capacity to maintain physical distancing measures such as WFH arrangements and provision of telehealth services.37 38 Furthermore, leveraging digital technologies such as mobile applications to perform check-ins at locations by scanning QR codes and generating proximity notifications when in close contact to a suspected or positive case using Bluetooth technology in addition to alerting individuals and authorities for contact tracing and follow-up management proved vital to reducing the transmission in countries such as Singapore, South Korea and Thailand.21 39 40

PHSMs centred on equity require governance and community engagement to balance the protection of health of population and livelihoods

The phasing introduction of PHSM, either sequentially or concurrently in a comprehensive manner, synergise and complement each other, reflects the decision-making agility of the government based on evidence from the field of what works and vice versa. The up-scaling and down-scaling of PHSMs are mostly guided by epidemiological evidence, the effectiveness of interventions and unintended consequences of policies, reflecting the governments’ adaptability. Therefore, governance structures need to take into account key indicators to derive a plan of action which involves the evaluation of the effects of PHSMs on health of population vs incomes. On another level, strong and coordinated governance is imperative at subnational levels, where local governments are devolved the authority to make decisions while maintaining a coordinated national response at all levels of government.41 Instrumentally, governments need to emulate transparency and uphold political accountability regarding decision-making processes, which can come in the form of community engagement as populations need to understand the rationale behind PHSMs, their stringency and duration due to PHSMs’ impacts on their health and livelihoods.42 43 Effective and transparent community engagement strategies can help mobilise the general public to action, such as mobilising volunteers to augment the health workforce or to educate and advocate for behavioural changes that promote adherence to PHSMs. This can be achieved through engaging community leaders to promote compliance with physical distancing and mask-wearing measures, leveraging on pre-existing trust fostered within the community.44 This is seen in Vietnam, where community COVID-19 supervision groups comprising village health workers, youth or women union volunteers were responsible for sharing information and promoting compliance to PHSMs.45 In Singapore, the government also launched both WhatsApp and Telegram chat groups to directly engage the public and provide accurate updates on the evolving situation, modifications to regulations and dispel misinformation.46 Notably, there is a need for clear communication channels by the government to clarify vaccine efficacy and safety, and timely management of vaccine misinformation in the Philippines, where vaccine hesitancy was spreading during the initial stages of vaccination roll-out.47 Chiefly, community engagement can strengthen governance by providing feedback channels to understand the local sociocultural context, enabling iterative tailoring and cocreation of PHSMs that fit the needs of the population.48

All PHSMs seek similar objectives of curbing onward transmission, reducing mortality and preserving livelihoods. The unintended consequences of PHSMs can be seen through widening income gaps, increased gender-based violence and forecasted lowering of educational attainment, among other social and health indices.49–51 These inequities and inflictions on population health outcomes will not only impact the present but future health of a population and its national economy. Hence, PHSMs need to place equity at the core at all stages of the pandemic and can only be achieved when governance structures put the most vulnerable first while simultaneously balancing the dichotomous trade-offs between the health of population and livelihoods.52 53

Charting an equitable and resilient recovery

As more variants and subvariants such as Omicron BA.1 and BA.2 continue to emerge, the need for contextually appropriate PHSMs that will augment vaccines due to waning of immunity in the population remains.54–56 Henceforth, governments must remain vigilant and steadfast by executing regular risk assessments through surveillance strategies and reintroducing evidence-based and cost-effective PHSMs.53 Although PHSMs serve to safeguard the lives and livelihoods of all populations, including the vulnerable, governments need to redress the existing vulnerabilities and societal inequities. The pandemic has put a wedge on and expanded the current fissures between the have and have-nots and amplified the inequities in all dimensions, not only in LMICs but in high-income countries as well.57 58 This is observed in countries reviewed, whereby support packages were offered to vulnerable populations such as migrant workers, as most of them are socially marginalised, lack social protection and are more predisposed to getting infected.59 This is also seen in high-income countries such as Singapore, whereby massive outbreaks in crowded foreign worker dormitories led to the implementation of a nationwide Circuit Breaker for 2 months.60 Therefore, countries that do not offer vaccines to migrants and non-residents, might observe a persistence of epidemic waves, dampening the effectiveness of other PHSMs. The instance of such oversight is also reported in other vulnerable groups such as internally displaced people and refugees.61

Essentially, the level of disproportionate impacts on the poor and vulnerable groups is determined by the level of existing structural inequality on the one hand, the size of social capital and resilience on the other hand, calling on national and global solidarity.62 63 In particular, inadequate vaccine coverage and lack of resilient health system pillars can prolong the pandemic as low-income countries continue to fight outbreaks, permitting the emergence of new variants and spread across the world due to international travel.64 Increasingly, as more viable and effective antivirals are developed and authorised for use, their equitable access has also come under scrutiny.65 Therefore, countries need to focus on equitable distribution of vaccines, antivirals and other resources to strengthen health systems globally and narrow the gap between the global North and South.66 67

Lastly, countries must harness this pandemic as an ephemeral window to strengthen health system capacities by investing in three interlocking pillars: (1) capacity to rapidly detect and react to emerging infectious diseases, (2) capacity to absorb infected individuals while maintaining care continuity for routine management of other diseases and (3) foster an enabling climate for the nurturance of healthy lifestyle and behaviours to promote healthier populations resilient towards diseases.68 Only through these steps can populations and health systems become more resilient and steadfast in the face of a prolonged pandemic.

Strengths and limitations

An in-depth analysis of the interlinks and synergies across nine typologies of PHSMs applied by six Asian countries enabled us to rapidly synthesise a framework for PHSMs where key indicators play a significant role in shaping PHSMs as the pandemic unfolds. Importantly, this study confirms a prior study that explores the major negative impacts on social inequity and vulnerability, and that universality principles prevail in the effective containment of the pandemic.69 However, this study captures snapshots of policy responses from January 2020 to January 2022 in the context of data incompleteness. Given the ongoing and rapid changes to contextual environments, it is likely that many of the policies highlighted above may have changed considerably since the time of writing. Certain information on policies might also be unavailable and inaccessible from public domains. It is, however, beyond the scope of this study to assess the full range of PHSMs and ascertain the effectiveness of implementation.