key: cord-1010505-fztg7bjo
authors: Bekker, Marleen; Ivankovic, Damir; Biermann, Olivia
title: Early lessons from COVID-19 response and shifts in authority: public trust, policy legitimacy and political inclusion
date: 2020-10-05
journal: Eur J Public Health
DOI: 10.1093/eurpub/ckaa181
sha: 30514fa034c6b4bae32ce12d2e7076ce6b423360
doc_id: 1010505
cord_uid: fztg7bjo

nan

I n attempts to reverse the spread and prepare the curative care sector, and under huge uncertainties, many governments have responded to the COVID-19 outbreak with either voluntary or mandatory physical isolation and distancing measures. These have put state-society relationships in any political system under great pressure. In addition, many countries have shifted public decision-making authority from the democratic institutions to temporarily concentrated executive arrangements. With specialist expertise involvement, these arrangements enabled quick and invasive regulatory response. 1 To the extent evidence is available, such technocratic crisis administration offers policy rationality. Yet, it also tends to postpone or disregard public value assessments. It thereby increases a perceived contradiction between 'health' and 'the economy' while in fact the two are mutually reinforcing values. As a result, such shifts in decision-making authorities have consequences for public trust. News about unintended socioeconomic consequences affects the 'output legitimacy' of the COVID-19 policies and regulations. 2 Moreover, minority needs and impacts are easily overlooked as democratic policy deliberation (a policy's 'input legitimacy') is temporarily postponed or even shut down altogether. For instance, in an open letter 'A call to defend democracy', published 25th of June in international and national news media, 500 political and civil leaders, Nobel laureates and pro-democracy institutions from around the world observe that, besides the unsurprising repression of critics by authoritarian regimes, 'even some democratically elected governments 

Covid-19 morbidity and mortality should be as low as possible. Epidemiological guidance on how to minimize overall morbidity and mortality shall inform decision-making. Justice

Justice as fairness in the distribution of resources and opportunities reducing health inequalities, secures that everyone receives his or her due, according to health needs, and that no one is discriminated against due to personal characteristics such as gender, socio-economic status or age. Autonomy

People have the right to make their own informed decisions, and are free to act according to these informed norms, wishes and beliefs. Harm Principle

Self-determination is acceptable as long as one does not harm others.

Public institutions informing about, regulating and practicing health policies should be trustworthy, and decide and act according to shared moral and democratic values that are made transparent.

Distribution of benefits and burdens should acknowledge our socio-economic interdependence at different levels (solidarity). Priority should be given to those who face a disproportionate burden in protecting the public good (reciprocity).

To protect the interests of (groups of) people who are especially vulnerable or in some way dependent on the choices and actions of 'others', special responsibilities must be fulfilled by these 'others'.

are fighting the pandemic by amassing emergency powers that restrict human rights and enhance state surveillance without regard to legal constraints, parliamentary oversight or timeframes for the restoration of constitutional order.' 3 In this viewpoint, we address these issues exploring, at the moment of writing the piece (end of June), the latest evidence in the COVID-19 Health Systems Response Monitor on the 'governance theme' country reports. (Belarus, Monaco, USA and Uzbekistan provided no data and were excluded from the analysis, making the total number of countries analysed 48. Except for Israel these all belong to the Eurasian region.) We looked at country similarities and differences in (i) the degree to which pandemic/emergency preparedness plans and laws pre-existed in analysed countries as well as whether and how they were activated and/ or modified; (ii) shifts in decision-making authorities, including which minister(s)/official(s) took the lead and, and centralization trends; (iii) introduction of new regulations/laws and their duration; (iv) introduction/declaration of the national state of emergency or crisis; and (v) using rule by decree as a governance approach.

Given the continuous updates, variety and sometimes underreporting of themes and issues in country reports, we have to be very cautious interpreting these data. Nevertheless, the explorative comparison provides indications of the COVID-19 outbreak governance as the Eurasian region slowly moves from the control stage to the protection stage. Summarized, in the course of a mere 3 months, almost threequarters of all 48 countries activated pandemic plans; shifted governmental decision-making authority to a concentrated group of political officials most often directly advised by biomedical experts, and more than half also centralized decision-making to a higher-level public authority; and introduced new regulations.

Along with the activation of national pandemic plans, a State of Emergency was declared in about half of the assessed countries. Most countries turned to either executive decrees. Others less explicitly concentrated power in a few officials in a tremendous effort to enable a quick response, but without Parliamentary approval. Central lead governmental officials across countries range from the obvious Prime Minister's Office and the Minister of Health and Social Affairs to the Ministers of Defence, Civil Protection and Justice, Internal Affairs, Foreign Affairs and Economic and Financial Affairs. This huge variety cannot be explained by the severity of the outbreak and the state of the disease control system alone. The choice of leading officials may also depend on a country's evolved political system and economy. In times of crisis, political reflex is informed by historical pathways, some paved with unitary centralism or devolved regional administration, some with adversarial or corporatist politics, with military or technocratic dominance, to name a few. An economy that highly depends on import, export or migrant workforce will likely be included in the centralized authority. Pandemic response organized by hierarchical, partisan or technical dominance is more likely to limit or exclude options for public and democratic deliberation. While this could be effective in the narrow achievement of disease control, it raises many questions on the broader functioning of a society.

Apart from manifestations of sheer opposition by more opportunistic groups wishing to destabilize the government, several countries also face a moral call for more public, social scientific and democratic deliberation. Public concern centres around a number of issues. At the time of writing this piece, only half of the expanded government mandates in the assessed countries are reported to be temporary with an end date, introducing public uncertainty about the duration of concentrated power. Also, governments propagate physical distancing as 'the new normal' for at least the coming year, raising concern among specific groups whose quality of life or economy depends heavily on social and physical encounters. Moreover, given the secondary outbreaks in elderly homes, prisons, and migrant workers in the meat processing industry, the initial policy focus on curative services is, unintentionally, disproportionately affecting vulnerable and minority groups in a negative way. In response to these concerns, governments either lift restrictions or re-affirm them with reference to secondary outbreaks. Currently, some governments are also considering (re-)decentralizing mandates for more tailored response to infection rates and trends at regional levels in order to maintain policy support in less affected areas.

How to strengthen future pandemic governance?

There is no uniform governance solution that fits across all these contexts. On the one hand, there are corrective solutions to (perceived) policy failures. In case of gross negligence, the backbone option to protect vulnerable and minority groups, such as those without income and those staying in collective residential facilities (e.g. elderly, people with severe handicaps, youth, criminal offenders, and migrants), is to activate the rule of law. Yet this might lead to public litigation that is costly, polarizing and reactive and contributes to a further deterioration of public trust and policy legitimacy. Another option is the general elections. 'Policies have a major influence on mass publics, generating patterns of behaviour (lock-in effects) and interpretive efforts (attempts to identify policy effects and trace those effects to government decisions) that have significant political repercussions.' (pp. 625-626). 4 The upcoming elections (Several countries North and Southeastern Europe 2020; Netherlands, UK regions, Germany, Russia among others in 2021. https://en.wikipedia.org/wiki/List_of_elections_in_2021) could lead to large scale power shifts, of which the French Green party dominance in municipalities elected last June provides the first indication.

On the other hand, policy mitigating and politically moderating options are available and we name a few here. While scientific evidence contributes to the potential effectiveness of policy measures, generating policy feedback and feedforward from stakeholders and the public in between the 4-year electoral cycle will increase the 'input and output legitimacy' 2 and contribute substantially to the use, feasibility and acceptability of policies in society. Consequently, this may facilitate the actual implementation, organizational compliance and public adherence to regulations. To avoid or mitigate disproportionate impacts for vulnerable and minority groups in future outbreaks, rapid policy response can benefit from organizing quick consultations, rapid appraisals and fast feedback assessments. 5 Finally, besides countryinternal government response structures, all countries are in dire need of legitimated and capacitated intergovernmental infrastructures to adequately, collectively prevent, control and mitigate future pandemics.

Until now, the COVID-19 pandemic has revealed the next level in the scale of globalized interconnectedness in economic and infectious disease trends and the consequences for vulnerable and minority groups as well as society at large. Our explorative assessment shows that there are considerable improvements possible to the organization of inclusive decision-making and joint action to mitigate the short-and long-term socio-economic consequences of the pandemic response. Avoiding legalistic actions and political repercussions that threaten the stable conditions needed for pandemic response.

Conflicts of interest: None declared.

European Observatory on Health Systems and policies. Health System Response Monitor