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Health PolicyCountries and regions have varied in their ability toimplement effective find, test, trace, isolate, and supportsystems. Some locations in Asia, such as South Koreaand Hong Kong, had systems that functioned well at thebeginning of the pandemic, and other countries, such asGermany, were able to redeploy resources, whereas somecountries, such as the UK and Spain, have struggled.Community engagementFor societies to reopen safely, communities should befully engaged and empowered to protect themselvesfrom the virus and the effect of the crisis, especiallythe most vulnerable populations (figure 2). Ideally,authorities should ensure that they fully understand thereality of the situation faced by the people affected bytheir decisions, drawing on principles of coproduction ofpolicy. Advice should also be consistent and credible.Messaging around what is considered a safe physicaldistance between people has been confusing and incon sistent, seemingly drawing on a range of biological andother considerations, such as whether a large distancewould preclude reopening of some facilities. Thus, a 1 mdistance is recommended in Hong Kong, Singapore, andNorway; 1·5 m in Germany and Spain; and 2 m in Japan,South Korea, and, until late June, 2020, England. InEngland, the recommended distance is now at least 1 m,whereas 2 m distance is still recommended in otherparts of the UK.13 In New Zealand, 2 m distance betweenpeople is recommended in public spaces and 1 m isrecommended in schools and workplaces at high alertlevels, but there are no distancing requirements atlevel one. New Zealand also pioneered a social bubblemodel that allows a defined group of people to haveclose physical contact with each other while practisingphysical distancing rules with others outside that group.11According to this approach, what started off as householdbubbles under lockdown were slowly allowed to extendto small and exclusive groups of family and friends, andthen further allowed to expand and merge with otherbubbles. The UK nations have endorsed this idea andstarted a similar support bubble arrangement sinceJune, 2020.14OverallstrategyKnowledge ofinfection statusCommunity engagementPublic-health capacityHealth-system capacityMeasures for border controlHong KongSuppress andlift strategyReal-time Restimated andreported sinceFebruary, 20201 m physical distancing and maskwearing practised; despite seriousmistrust in government,community has shown a highrate of adherence and built theirown collective response to thepandemicDaily PCR-testing capacity beingincreased from 4500 to 10 000;police supercomputer system usedfor contact tracing and electronicwristbands paired with mobilephone apps used to monitorpeople under quarantineSecond-tier isolation beds andcommunity isolation facilitiesadded to public hospitals; safetymeasures have been effective inprotecting health-care workersfrom infectionBorder closed to visitors;all arrivals must submit ahealth declaration formonline, have temperaturescreening and testing onarrival, and serve a 14-dayquarantineJapanTrigger-based One indicator is anapproachincidence rate of 0·5 cumulativeinfections per100 000 people inthe past week2 m physical distancing and maskwearing practised; citizens areencouraged to avoid so-called3Cs (ie, closed spaces, crowdedplaces, and close contact);adherence aided by existingsocial etiquetteDaily PCR-testing capacity is lowbut is being increased from 6000tests per day in May to more than22 000 tests per day; manualtracing done and new mobilephone app introduced inJune, 2020Initially, all patients wereadmitted but, due to lowcapacity, hospitals now focuson caring for people who arevulnerable or have moderate orsevere disease; people with milddisease and people who areasymptomatic supported athome or at lodging facilitiesAll arrivals are subject to14-day quarantine, andtravellers from selectedcountries are denied entry or,if allowed for exceptionalreasons, subject to testingAsia PacificNew Zealand Four-levelalert systemNo publicly specified So-called social bubble approach Testing capacity being increased;manual and app-based tracingindicatorallowed gradual expansion ofsmall and exclusive social groups; being doneno physical distancing required atalert level oneEfforts being made to increasenumber of ICU beds andnumber of staff trained to useICU equipmentBorder closed to most visitors;all arrivals are tested andquarantined for 14 daysSingaporeThree-phaseplanNo publicly specified 1 m physical distancing and faceindicatorcovering required; governmentmessages have consistentlyemphasised individualresponsibility, although policychanges have generated someinitial public confusionMore than 13 000 PCR tests perday done in June, 2020, with plansto increase to 40 000 tests per day;manual and app-based tracingdoneICUs are well under capacity; toreduce pressure on publichospitals, patients with mildsymptoms are transferred toprivate hospitals or communityfacilities for monitoringBorder closed to most visitors;all arrivals must submit ahealth declaration form, servea 14-day Stay Home Notice,and be testedSouth ancingschemeLevel one applies ifnumber of daily newcases is 50,level two for50–100 cases, andlevel three for 100 casesMass testing at a rate of20 000 PCR tests per day, includingat drive-through and walk-throughstations; records from medicalfacilities, global positioningsystem, credit card transactionhistory, and closed-circuittelevision used to supplementmanual contact tracingOn the basis of a triage system,people with mild disease or whoare asymptomatic aremonitored at residentialtreatment centres; people withmoderate or severe disease arecared for at governmentdesignated hospitalsAll arrivals must submit ahealth declaration form,install a mobile phone app,have temperature screening,testing, and 14-dayquarantine2 m physical distancing and maskwearing practised; governmenthas used transparentcommunication methods tosecure public cooperation,including detailed reporting ofnew cases via websites, mobilephone apps, and text alerts(Table continues on next page)www.thelancet.com Published online September 24, 2020 https://doi.org/10.1016/S0140-6736(20)32007-93

Health PolicyOverallstrategyKnowledge ofinfection statusCommunity engagementPublic-health capacityHealth-system capacityMeasures for border controlAt least 1 m physical distancingrequired, and face coveringrequired in many indoor settings;some controversies haveundermined public support for thegovernmentIn theory, capacity exists to do 200 000 PCR tests per day butthere are major logisticalproblems; centralised testing andtracing systems heavily criticisedand local public-health teamstaking over some tracing; initialattempt to develop an app failed;Scotland and Northern Irelandhave implemented their own appsTemporary hospitals onstandby; routine health servicesgradually resuming whilemaintaining capacity forpatients with COVID-19Arrivals from particularcountries must provide theirjourney and contact details,and self-isolate at home for14 days1·5 m physical distancingrequired, and face coveringrequired where safe distancingnot possible; despite initial publicsupport, some fatigue has set in;inconsistent messages andpolicies across different stateshave caused public confusionContinuous scale up of testingcapacity to over 150 000 PCR testsper day; manual tracing done andnew mobile phone app introducedin June, 2020ICUs are under capacity; initially, People entering or returningto Germany from a countrythere was a scarcity ofdesignated as a risk area areprotective equipmentrequired to quarantine1 m physical distancing requiredand masks recommended foradults and young peopletravelling by public transportwhere safe distancing is difficult;citizens have generally compliedwith government advice andrequirements; the call to join thecollective effort has created ateam spirit that is strongWidespread testing not done;testing reserved for people withsymptoms, health-care workers,and vulnerable populations;manual and app-based tracingdoneSpare capacity varies betweenmunicipalities and hospitals,but the country has hadsufficient health-care personnelto manage the local infectionsituationReopened borders to specifiedNordic regions with low ratesof transmission; arrivals fromoutside these regions aresubject to 10-day quarantineAs of April, 2020, PCR-testingcapacity reached 40 000 tests perday, and capacity has continued toincreaseICUs were over their capacities inmany hospitals at the end ofMarch and April, 2020; otherhospital wards and spaces havebeen adapted to accommodatecritically ill patients; healthworkforce has decreased due tohigh infection ratesFully reopened borders to allcountries from July 1, 2020(inbound travellers will not bequarantined)(Continued from previous page)EuropeEnglandThree-phaseplanR estimated andreportedGermanyTrigger-based Uses R and 7-dayapproachincidence rate per100 000 inhabitantsas indicatorsNorwayLong-termtimetablewith sets ofchanges onspecifieddatesR estimated andreportedSpainFour-phaseplanNo publicly specified 1·5 m physical distancingindicatorrequired, and face coveringrequired where safe distancingnot possibleData have been organised according to the four public-health principles developed by Rawaf and colleagues5 and modified to include additional components suggested in this Health Policy paper. Countries aregrouped by region and organised alphabetically. A more detailed table and full data sources are available in the appendix (appendix pp 1–16). ICU intensive care unit. R reproduction number.Table: Overview of approaches to easing COVID-19 restrictions in nine countries and regions as of September, 2020See Online for appendix4An absence of international consensus is especiallyapparent with respect to face coverings. This differencereflects a combination of cultural norms and evolvingevidence for the effectiveness of face coverings, althoughnot helped by scientific inertia in some countries and inWHO. In Hong Kong, Japan, and South Korea, the habitof mask wearing by people with respiratory conditionswas already widespread before the pandemic (ie, mainlyto protect others from seasonal viruses or as a reaction toair pollution). Other countries have been slower to adoptthis practice. After months of counselling the publicagainst wearing face coverings unless they were unwell,Singapore’s Government made it mandatory for everyoneto wear one outside from April, 2020, and providedreusable cloth masks to the entire population.15 Duringthe past 5 months, Germany and Spain have made itcompulsory to wear a face covering where physicaldistancing is not possible, such as on public transport orin shops. In the UK, face coverings are required in manyindoor settings, such as in community centres.16 Norwayhas recommended face coverings for adults and youngpeople travelling by public transport where safe distancingis difficult. New Zealand has not recommended facecoverings for the general public. Mixed messages andpolicy U-turns regarding face coverings have unfor tunately generated public confusion and challenges toadherence in many countries and regions.Various precautionary measures have been suggestedfor schools and workplaces. In all countries and regions,there was, at least initially, a push toward working fromhome as far as possible, while promoting com pliancewith distancing and hygiene rules for workers whoneeded to be physically present. In Singapore andSouth Korea, workplaces must appoint a manager who isresponsible for implementing precautionary measuresand monitoring employees’ health. In Asian countrieswww.thelancet.com Published online September 24, 2020 https://doi.org/10.1016/S0140-6736(20)32007-9

Health Policy2·0 mSafe physical-distancingmeasures1·5 m*1·0 mCommunity engagementand regions, workplaces and schools also practise maskwearing and temperature checking. Schools have largelyfacilitated a staggered return of students, with differentcountries and regions prioritising different groups ofstudents. Singapore, South Korea, and Germany startedwith graduating students attending high schools (eg,aged approximately 15–18 years) to minimise disruptionto education. New Zealand, Norway, and England startedwith younger children, such as children attendingprimary schools (eg, aged approximately 5–12 years).However, it was not always clear whether the primaryfocus was the interests of the child or the desire to enableparents to return to work. Hong Kong and Spain alsostarted with older students, such as students attendinghigher secondary schools (eg, aged approximately15–18 years), as they are presumably better able to followcomplex rules on physical distancing and personalhygiene than are young children. Japan has staggeredattendance, starting with graduating cohorts. Countriesvaried considerably in the extent to which they used thelockdown to prepare schools for reopening and providedresources for online learning.With few exceptions, such as Germany, New Zealand,Norway, Scotland, and South Korea, political leaders havestruggled to secure public trust and thus support forcontinued lifestyle changes. More generally, countrieswith female leaders have done better at securing publicconfidence and adherence to new measures than havecountries with male leaders.17 In England, con troversy sur rounding a trip made during lockdown by a close adviser tothe prime minister has substantially undermined publicconfidence in the government and support for themeasures that it was taking.18 In Hong Kong, continuingpolitical unrest has substantially eroded public trust inthe government, although the community has generallyshown a high level of adherence that could be attributableto lessons learnt from the previous outbreak of SARSin 2003.19 Conversely, the South Korean Government hasadopted a highly transparent communication strategy togain public par ticipation by disclosing detailed infor mationof patients who are infected via government websitesand text alerts, drawing on the country’s past experiencewith MERS.20 The prime minister of New Zealand and thedirector general of health have also won national and inter national praise for communicating firmly yet empa thetically, as shown in formal televised briefings and casuallivestreaming sessions on social media.21COVID-19 has been a reminder of the importance ofprotecting vulnerable populations and addressing healthinequalities, especially in countries that have previouslypaid little attention to these factors. In the UK, as in someother countries, COVID-19 mortality has been dispro portionately high among residents of care homes, Black,Asian, and minority ethnic groups, socioeco nomicallydeprived populations, and workers on low wages.22 Theseinequalities are likely to exist elsewhere, but in manycountries, such as Germany, data are not collected. InIn practice beforeCOVID-19Mask wearing for generalpublicMeasures for reopeningschoolsCountry or regionGermanyHong KongJapanNew ZealandNorwaySingaporeWHO recommends maintaining adistance of at least 1 m (as of April, 2020).However, this recommendation is subjectto interpretation. Countries and regionshave set different standards of what isconsidered a safe distance.Mandated dueto COVID-19Not advised forgeneral public*The purpose of mask wearing differs for two groups of the population:General public and people who cannot physically distance (eg, carers) wearmasks to protect others and prevent asymptomatic spread.Health workers wear masks as part of personal protective equipment forhealth-care service delivery.Starting withyounger childrenStarting witholder studentsStarting withgraduatingcohortsStaggeredattendancestarting withgraduating cohortsSouth KoreaSpainUnited KingdomFigure 2: Key measures in place to allow safe easing of restrictionsDetailed data sources are available in the appendix (appendix pp 1–16). *New Zealand adopts a so-called socialbubble model that allows defined groups of people to have close contact with each other while maintaining safedistancing with other groups.Singapore, migrant workers living in overcrowdeddormitories have constituted almost 95% of close to58 000 confirmed cases.23 In response, the governmenthas improved disinfection regimens, established medicalfacilities onsite, and shielded workers older than 45 yearsby moving them to less dense accommodation than theywere living in.24 All nine countries and regions have alsoheightened practices for infection prevention and controlin care homes, including active testing and isolating ofsymptomatic residents and staff, decreasing or banningvisitors, promoting compliance with hand hygiene, andsupplying protective equipment to these facilities.Economic support to mitigate the effect of the pandemicon communities has been provided by the governmentsof all nine countries and regions, who have announcedsubstantial emergency budgets to help businesses to stayviable, preserve jobs, and alleviate financial burdens onindividuals and households. In the five Asian Pacificcountries and regions, this financial assistance hasincluded one-off cash handouts to the public. Japan, withthe highest emergency spending, amounting to 42% of itsgross domestic product (appendix p 17),25 has handed out 100 000 (approximately US 930) to every resident inthe country. However, unclear legal grounds for payingleave allowance and delayed introduction of the expandedemployment adjustment subsidy scheme have beenheavily criticised. By contrast, the European countrieshave opted for long-term support programmes throughstrengthening their existing social safety nets. In Spain,the COVID-19 crisis has accelerated the approval of ascheme designed to provide a guaranteed minimummonthly income of 462 ( 500) for its poorest citizens.www.thelancet.com Published online September 24, 2020 https://doi.org/10.1016/S0140-6736(20)32007-95

Health PolicyThis scheme is expected to benefit 2·5 million individualsand cost 3 billion annually.26 The UK has also incr

Department of Nursing and Health Sciences, University of South East Norway, Drammen, Norway (E Turk PhD); Medical Faculty, University of Maribor, Maribor, Slovenia (E Turk); College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK (D Sridhar PhD) . identified five prerequisites for easing COVID-19 lock-downs and .