LAUSR

Any country thinking of easing COVID-19 lockdowns must be confident that they have a robust system in place to find, test, trace, isolate and support new cases. This is essential if they are to minimise the risks of a second wave going out of control. The theory is simple. Anyone with symptoms is tested and, if positive, their contacts are traced and advised or instructed to isolate. The reality is somewhat different. It requires a complex system with many interlinking components, demanding rapid and effective communication between different organisations, some of which are newly created, while others may be combining their day-to-day work with a major expansion in capacity. Even the best resourced public health system would struggle given the scale of the pandemic. For many, especially those whose capacity has been diminished as a consequence of sustained underinvestment, the challenges are enormous. To help those who are facing these challenges, we have examined what countries across Europe are doing, seeking where possible lessons that can be learned from their experiences. This analysis uses information gathered from the COVID Health System Response Monitor, created by the European Observatory on Health Systems and Policies, the World Health Organisation European Regional Office and the European Commission. A network of national correspondents from 50 countries has prepared a series of structured reports on national responses to the pandemic, regularly updating them as events develop. Conceptually, we can consider a find, test, trace, isolate and support programme as a complex adaptive system, with the individual being tested passing along a non-linear route involving multiple paths, each with feedback loops and with their speed and direction influenced by a multiplicity of factors, many outside their control. Practically, however, if we are to help the busy policymaker, we must simplify this considerably, something that we have done by portraying the main elements of the system as a Snakes and Ladders boardgame (Figure 1). Snakes and Ladders is remarkably well suited to this exercise. To be successful (i.e. to win the game) countries must ensure that those with COVID-19 progress as quickly as possible from the start to the finish. If this does not happen, new cases will appear, and another lockdown will be needed. They can do this most effectively by putting in place measures that enhance their ability to find, test, trace, isolate and support (i.e. landing on ladders) and by avoiding setbacks that occur due to insufficient capacity in the health system and beyond (i.e. avoiding snakes). We now run through the boardgame, pointing out many of the steps that policymakers should be mindful of, highlighting approaches that countries are currently taking to implement a find, test, trace, isolate and support system and thereby ‘win the game’. Before doing so, however, it is important to note an important difference from the real game, in which players land on squares at the throw of a dice. In this case, countries that went into the pandemic with strong public health systems and systems of governance are more likely to land on ladders because the capacity is already in place. The role of the public is also central and unless people are made aware of the symptoms of COVID-19 and the importance of getting tested, it will be difficult to ‘find’ cases in the first place.