The COVID-19 pandemic posed many dilemmas for policymakers, which sometimes resulted in unprecedented decision-making.

BACKGROUND: The COVID-19 pandemic evolved through five phases, beginning with 'the great threat', then moving through 'the emergence of variants', 'vaccines euphoria', and 'the disillusionment', and culminating in 'a disease we can live with'. Each phase required a different governance response. With the progress of the pandemic, data were collected, evidence was created, and health technology was developed and disseminated. Policymaking shifted from protecting the population by limiting infections with non-pharmaceutical interventions to controlling the pandemic by prevention of severe disease with vaccines and drugs for those infected. Once the vaccine became available, the state started devolving the responsibility for the individual's health and behavior. MAIN BODY: Each phase of the pandemic posed new and unique dilemmas for policymakers, which resulted in unprecedented decision-making. Restrictions to individual's rights such as a lockdown or the 'Green Pass policy' were unimaginable before the pandemic. One of the most striking decisions that the Ministry of Health made was approving the third (booster) vaccine dose in Israel, before it was approved by the FDA or any other country. It was possible to make an informed, evidence-based decision due to the availability of reliable and timely data. Transparent communication with the public probably promoted adherence to the booster dose recommendation. The boosters made an important contribution to public health, even though their uptake was less than the uptake for the initial doses. The decision to approve the booster illustrates seven key lessons from the pandemic: health technology is key; leadership is crucial (both political and professional); a single body should coordinate the actions of all stakeholders involved in the response, and these should collaborate closely; policymakers need to engage the public and win their trust and compliance; data are essential to build a suitable response; and nations and international organizations should collaborate in preparing for and responding to pandemics, because viruses travel without borders. CONCLUSION: The COVID-19 pandemic posed many dilemmas for policymakers. The lessons learned from the actions taken to deal with them should be incorporated into preparedness for future challenges.

Coping with COVID-19: the role of hospital care structures and capacity expansion in five countries.

This contribution examines the responses of five health systems in the first wave of the COVID-19 pandemic: Denmark, Germany, Israel, Spain and Sweden. The aim is to understand to what extent this crisis response of these countries was resilient. The study focuses on hospital care structures, considering both existing capacity before the pandemic and the management and expansion of capacity during the crisis. Evaluation criteria include flexibility in the use of existing resources and response planning, as well as the ability to create surge capacity. Data were collected from country experts using a structured questionnaire. Main findings are that not only the total number but also the availability of hospital beds is critical to resilience, as is the ability to mobilise (highly) qualified personnel. Indispensable for rapid capacity adjustment is the availability of data. Countries with more centralised hospital care structures, more sophisticated concepts for providing specialised services and stronger integration of the inpatient and outpatient sectors have clear structural advantages. A solid digital infrastructure is also conducive. Finally, a centralised governance structure is crucial for flexibility and adaptability. In decentralised systems, robust mechanisms to coordinate across levels are important to strengthen health care system resilience in pandemic situations and beyond.

Early health system responses to the COVID-19 pandemic in Mediterranean countries: A tale of successes and challenges.

This paper conducts a comparative review of the (curative) health systems' response taken by Cyprus, Greece, Israel, Italy, Malta, Portugal, and Spain during the first six months of the COVID-19 pandemic. Prior to the COVID-19 pandemic, these Mediterranean countries shared similarities in terms of health system resources, which were low compared to the EU/OECD average. We distill key policy insights regarding the governance tools adopted to manage the pandemic, the means to secure sufficient physical infrastructure and workforce capacity and some financing and coverage aspects. We performed a qualitative analysis of the evidence reported to the 'Health System Response Monitor' platform of the European Observatory by country experts. We found that governance in the early stages of the pandemic was undertaken centrally in all the Mediterranean countries, even in Italy and Spain where regional authorities usually have autonomy over health matters. Stretched public resources prompted countries to deploy "flexible" intensive care unit capacity and health workforce resources as agile solutions. The private sector was also utilized to expand resources and health workforce capacity, through special public-private partnerships. Countries ensured universal coverage for COVID-19-related services, even for groups not usually entitled to free publicly financed health care, such as undocumented migrants. We conclude that flexibility, speed and adaptive management in health policy responses were key to responding to immediate needs during the COVID-19 pandemic. Financial barriers to accessing care as well as potentially higher mortality rates were avoided in most of the countries during the first wave. Yet it is still early to assess to what extent countries were able to maintain essential services without undermining equitable access to high quality care.

Balancing financial incentives during COVID-19: A comparison of provider payment adjustments across 20 countries.

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries. We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff. We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care.

Governing the public-private-partnerships of the future: learnings from the experiences in pandemic times

No-one is safe until everyone is safe. But what can be done when a country fails to take measures to control a pandemic virus? It poses a threat to its own people but also to its neighbours and beyond. Countries do pool sovereignty, working through supra-national structures, such as international agencies, or using processes set out in treaties, recognising the mutual benefits of the international rules-based system. Here we review the ways in which governments have, or have not worked together on other issues that pose a threat to global health and discuss the implications for pandemic responses.

The Israeli Experience with the "Green Pass" Policy Highlights Issues to Be Considered by Policymakers in Other Countries.

In the first half of 2021, Israel had been ahead of other countries concerning the speed of its rollout and coverage of COVID-19 vaccinations. During that time, Israel had implemented a vaccine certificate policy, the "Green Pass Policy" (GPP), to reduce virus spread and to allow the safe relaxation of COVID-19 restrictions in a time of great uncertainty. Based on an analysis of GPP regulations and public statements compiled from the Israeli Ministry of Health website, we describe the design and implementation of the GPP. We also look back and discuss lessons learned for countries that are considering a GPP policy, given the current upsurge of the Delta variant as of summer 2021. To reduce equity concerns when introducing a GPP, all population groups should be eligible for the vaccine (contingent on approval from the manufacturer) and have access to it. Alternatively, health authorities can grant temporary certificates based on a negative test. We also highlight the fact that in practice, there will be gaps between the GPP regulations and implementation. While some places might require a GPP without legal need, others will not implement it despite a legal obligation. The GPP regulations should have standardised epidemiological criteria, be implemented gradually, remain flexible, and change according to the epidemiological risks.

Balancing financial incentives during COVID-19: a comparison of provider payment adjustments across 20 countries

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries. We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff. We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems;(2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care;and (3) periodically evaluating the effects of payment adjustments on access and quality of care.

Governing the public-private-partnerships of the future: learnings from the experiences in pandemic times

No-one is safe until everyone is safe. But what can be done when a country fails to take measures to control a pandemic virus? It poses a threat to its own people but also to its neighbours and beyond. Countries do pool sovereignty, working through supra-national structures, such as international agencies, or using processes set out in treaties, recognising the mutual benefits of the international rules-based system. Here we review the ways in which governments have, or have not worked together on other issues that pose a threat to global health and discuss the implications for pandemic responses.

Addressing vaccine hesitancy and access barriers to achieve persistent progress in Israel's COVID-19 vaccination program.

As of March 31, 2021, Israel had administered 116 doses of vaccine for COVID-19 per 100 population (of any age) - far more than any other OECD country. It was also ahead of other OECD countries in terms of the share of the population that had received at least one vaccination (61%) and the share that had been fully vaccinated (55%). Among Israelis aged 16 and over, the comparable figures were 81 and 74%, respectively. In light of this, the objectives of this article are: 1. To describe and analyze the vaccination uptake through the end of March 2021 2. To identify behavioral and other barriers that likely affected desire or ability to be vaccinated 3. To describe the efforts undertaken to overcome those barriers Israel's vaccination campaign was launched on December 20, and within 2.5 weeks, 20% of Israelis had received their first dose. Afterwards, the pace slowed. It took an additional 4 weeks to increase from 20 to 40% and yet another 6 weeks to increase from 40 to 60%. Initially, uptake was low among young adults, and two religious/cultural minority groups - ultra-Orthodox Jews and Israeli Arabs, but their uptake increased markedly over time.In the first quarter of 2021, Israel had to enhance access to the vaccine, address a moderate amount of vaccine hesitancy in its general population, and also address more intense pockets of vaccine hesitancy among young adults and religious/cultural minority groups. A continued high rate of infection during the months of February and March, despite broad vaccination coverage at the time, created confusion about vaccine effectiveness, which in turn contributed to vaccine hesitancy. Among Israeli Arabs, some residents of smaller villages encountered difficulties in reaching vaccination sites, and that also slowed the rate of vaccination.The challenges were addressed via a mix of messaging, incentives, extensions to the initial vaccine delivery system, and other measures. Many of the measures addressed the general population, while others were targeted at subgroups with below-average vaccination rates. Once the early adopters had been vaccinated, it took hard, creative work to increase population coverage from 40 to 60% and beyond.Significantly, some of the capacities and strategies that helped Israel address vaccine hesitancy and geographic access barriers are different from those that enabled it to procure, distribute and administer the vaccines. Some of these strategies are likely to be relevant to other countries as they progress from the challenges of securing an adequate vaccine supply and streamlining distribution to the challenge of encouraging vaccine uptake.

The Structure and Financing of Health Care Systems Affected How Providers Coped With COVID-19.

Policy Points We compared the structure of health care systems and the financial effects of the COVID-19 pandemic on health care providers in the United States, England, Germany, and Israel: systems incorporating both public and private insurers and providers. The negative financial effects on health care providers have been more severe in the United States than elsewhere, owing to the prevalence of activity-based payment systems, limited direct governmental control over available provider capacity, and the structure of governmental financial relief. In a pandemic, activity-based payment reverses the conventional financial positions of payers and providers and may prevent providers from prioritizing public health because of the desire to avoid revenue loss caused by declines in patient visits.

Israel's rapid rollout of vaccinations for COVID-19.

As of the end of 2020, the State of Israel, with a population of 9.3 million, had administered more COVID-19 vaccine doses than all countries aside from China, the US, and the UK. Moreover, Israel had administered almost 11.0 doses per 100 population, while the next highest rates were 3.5 (in Bahrain) and 1.4 (in the United Kingdom). All other countries had administered less than 1 dose per 100 population.While Israel's rollout of COVID-19 vaccinations was not problem-free, its initial phase had clearly been rapid and effective. A large number of factors contributed to this early success, and they can be divided into three major groups.The first group of factors consists of long-standing characteristics of Israel which are extrinsic to health care. They include: Israel's small size (in terms of both area and population), a relatively young population, relatively warm weather in December 2020, a centralized national system of government, and well-developed infrastructure for implementing prompt responses to large-scale national emergencies.The second group of factors are also long-standing, but they are health-system specific. They include: the organizational, IT and logistical capacities of Israel's community-based health care providers, the availability of a cadre of well-trained, salaried, community-based nurses who are directly employed by those providers, a tradition of effective cooperation between government, health plans, hospitals, and emergency care providers - particularly during national emergencies; and support tools and decisionmaking frameworks to support vaccination campaigns.The third group consists of factors that are more recent and are specific to the COVID-19 vaccination effort. They include: the mobilization of special government funding for vaccine purchase and distribution, timely contracting for a large amount of vaccines relative to Israel's population, the use of simple, clear and easily implementable criteria for determining who had priority for receiving vaccines in the early phases of the distribution process, a creative technical response that addressed the demanding cold storage requirements of the Pfizer-BioNTech COVID-19 vaccine, and well-tailored outreach efforts to encourage Israelis to sign up for vaccinations and then show up to get vaccinated.While many of these facilitating factors are not unique to Israel, part of what made the Israeli rollout successful was its combination of facilitating factors (as opposed to each factor being unique separately) and the synergies it created among them. Moreover, some high-income countries (including the US, the UK, and Canada) are lacking several of these facilitating factors, apparently contributing to the slower pace of the rollout in those countries.

Israel’s response to the COVID-19 pandemic: tailoring measures for vulnerable cultural minority populations

Every country has vulnerable populations that require special attention from policymakers in their response to a pandemic. This is because those populations may have specific characteristics, culture and behaviours that can accelerate the spread of the virus, and they usually have less access to healthcare, particularly in times of crisis. In order to carry out a comprehensive national intervention plan, policy makers should be sensitive to the needs and lifestyles of these groups, while taking into account structural and cultural gaps. In the context of Israel, the two most prominent and well-defined minority groups are the ultra-Orthodox Jewish community and parts of the Arab population. The government was slow to recognize the unique position of these two groups, public pressure eventually led to a response that was tailored to the ultra-Orthodox community and during the month of Ramadan a similar response has been implemented among the Arab community.