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How systems respond to policies: intended and unintended consequences of COVID-19 lockdown policies in Thailand

How systems respond to policies: intended and unintended consequences of COVID-19 lockdown... HealthPolicyandPlanning,37,2022,292–293 DOI:https://doi.org/10.1093/heapol/czab103 Advanceaccesspublicationdate:26August2021 Commentary Howsystemsrespondtopolicies: intendedandunintended consequences of COVID-19 lockdown policies in Thailand 1 1 2,3 Borwornsom Leerapan , Phanuwich Kaewkamjornchai , Rifat Atun and 4,5, Mohammad S Jalali FacultyofMedicineRamathibodiHospital,MahidolUniversity,270RamaVIRoad,Ratchathewi,Bangkok,Thailand DepartmentofGlobalHealthandPopulation,HarvardT.H.ChanSchoolofPublicHealth,677HuntingtonAve,Boston,MA02115,USA DepartmentofGlobalHealthandSocialMedicine,HarvardMedicalSchool,641HuntingtonAvenue,Boston,MA02115,USA HarvardMedicalSchool,MGHInstituteforTechnologyAssessment,101MerrimacSt,Boston,MA02114,USA SloanSchoolofManagement,MassachusettsInstituteofTechnology,100MainSt,Cambridge,MA02142,USA *Correspondingauthor.MGHInstituteforTechnologyAssessment,101MerrimacSt,Boston,MA02114,USA. E-mail:msjalali@mgh.harvard.edu Acceptedon13August2021 The coronavirus disease 2019 (COVID-19) pandemic has COVID-19 infections were exported from high-infection revealed the interdependency of health, economic and social conurbation of Bangkok to other parts of the country and systems (Rutter et al., 2020). The COVID-19 lockdown in many of travellers’ destinations reported upticks in COVID- Thailand and its unintended adverse outcomes illustrate this 19 cases in early April—data can be found (Thailand’s complexity, providing valuable lessons regarding the use of Department of Disease Control, 2020a). systems thinking to design successful policies. At the beginning of the pandemic, Thailand implemented Dynamics between policy interventions, a lockdown in its capital city, Bangkok. Ironically, the policy people’s motivations and pandemic outcomes aimed to reduce new infections, but it unintentionally helped spread the disease nationwide. The lockdown prompted the The city lockdown intended to change behaviours and urge rapid movement of economically vulnerable populations and people to stay at home by discouraging travels and family drovethemoutofthecity,especiallylow-incomeandmigrant gatherings. Behavioural change is crucial for improving pan- workers without any welfare support systems. The policy demic outcomes (Michie and West, 2020; West et al., 2020) overlooked the dynamic interactions between people’s moti- andcanbeeffectiveifpoliciesarederivedfromevidence-based vations to mitigate the spread of COVID-19 and their eco- principles of implementation science (Michie and Prestwich, nomic capacity to survive. 2010; Cane et al., 2012; Hirschhorn et al., 2020; Ghaffar From January to March 2020, new COVID-19 cases et al., 2020) and informed by systems thinking (Carey et al., in Thailand were mostly clustered in Bangkok (Thailand’s 2015; Durski et al., 2020a, 2020b). DepartmentofDiseaseControl,2020a),duepartlytothecap- The lockdown in Bangkok may have encouraged people ital’s nature of being a hub of inbound international travel. to stay at home and reduce contact. The causal pathway of Bangkok’s continued tourism and sporting events vastly con- the intended effects is illustrated in Figure 1. However, the tributedtotherapidriseofnewcases. Theincreasingnumber responsetothelockdowndifferedamongpopulations.Work- of cases prompted the government to declare a state of emer- place closures caused financial strain which made it hard to gency on March 26, enforcing strict city lockdowns which stay in Bangkok, so migrant workers chose to return to their closed restaurants, stores and entertainment venues, with hometowns, where the cost of living is much lower, but mass exceptions for essential services (Thailand’s Department of transit was not prepared for the unexpected travel demand. Disease Control, 2020b). Therefore, their inability to survive economically outweighed Many domestic labourers lost their jobs when workplaces their motivations to stay in Bangkok, and their urgency to were forced to close. At least 80 000 people boarded buses travel via underprepared mass transit increased the contact departing from Bangkok over the weekend after the lock- rate from infected travellers to others. The causal pathway of down was announced (Wipatayotin, 2020). The reactionary these unintended, adverse policy consequences can be seen in city departure was sudden and disorganized. Due to the Figure 1. high volume of travellers and lack of public health coordi- Had policy-makers anticipated these patterns of nation, adherence to non-pharmaceutical interventions such behaviours, they could have designed a policy that grants the as physical distancing, face masking and hand washing was working class the motivation and capability to stay safely in low among travellers. With this massive and rapid exeat, thecityandpreparedthetransportationsystem. Forinstance, © The Author(s) 2021. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com Health Policy and Planning, 2022, Vol. 37, No. 2 293 Data statement References to data are reported in the article. No additional data were used in this study. Funding No funding was used to conduct this study. Ethical approval. Ethical approval for this type of study is not required by our institute. Conflict of interest statement. The authors declare that they have no conflict of interest. Figure 1. Causal loops of intentional and adverse effects of the city lockdown policies in Bangkok, Thailand References Cane J, O’Connor D, Michie S. 2012. Validation of the theoretical targeted government subsidy along with phased travel plans domains framework for use in behaviour change and implementa- and mandatory quarantine after travel could have prevented tion research. Implementation Science 7: 37. the spread of COVID-19. Carey G, Malbon E, Carey N et al. 2015. Systems science and systems thinking for public health: a systematic review of the field. BMJ Open 5: e009002. Lessons learned Darabi N, Hosseinichimeh N. 2020. System dynamics modeling in health and medicine: a systematic literature review. System Dynam- Policyinterventionsaimedatcontrollingepidemicshavesoci- ics Review 36: 29–73. etal impacts which may lead to unintended adverse effects on Durski KN, Naidoo D, Singaravelu S et al. 2020a. Systems thinking the targeted population. It is the government’s responsibility for health emergencies: use of process mapping during outbreak todesignawell-roundedpolicypackagethatconsiderspoten- response. BMJ Global Health 5: e003901. tial behavioural responses and incorporates policy instru- Durski KN, Osterholm M, Majumdar SS et al. 2020b. Shifting the ments to prevent unintended, adverse effects. Specifically, paradigm: using disease outbreaks to build resilient health systems. the three essential conditions of human actions—capability, BMJ Global Health. opportunityand motivation—must beexploredbeforeselect- Ghaffar A, Swaminathan S, Sheikh K et al. 2020. Implementa- tion research is crucial to countries’ efforts to strengthen ing appropriately matched portfolios of policy interventions learning health systems. Health Policy and Planning 35: (Michie et al., 2011). If not, measures such as city lock- ii4–ii6. downs can drive unexpected behaviours that lead to deadly Ghaffarzadegan N, Rahmandad H. 2020. Simulation-based estimation consequences. of the early spread of COVID-19 in Iran: actual versus confirmed Sustainable health development is not achieved by aiming cases. System Dynamics Review 36: 101–29. myopically at the best short-term results, but by designing Hirschhorn L, Smith JD, Frisch MF, Binagwaho A. 2020. Integrating policies that create desirable long-term outcomes. A pol- implementation science into COVID-19 response and recovery. The icy that intentionally improves short-term outcomes, such as BMJ 369: m1888. lockdown, can cause long-term harm due to delayed adverse Michie S, Prestwich A. 2010. Are interventions theory-based? Devel- consequences. In contrast, lockdown policies that consider opment of a theory coding scheme. Health Psychology 29: 1–8. behavioural factors increase cost in the short term, but in MichieS,vanStralenMM,WestR.2011.Thebehaviourchangewheel: the long term they may yield satisfactory results: reducing a new method for characterising and designing behaviour change transmission at lower overall cost. interventions. Implementation Science 6: 42. Policy-makers can effectively change people’s behaviours Michie S, West R. 2020. Behavioural, environmental, social, by identifying high-leverage points for effective interventions and systems interventions against COVID-19. The BMJ 370: andbycommunicatingwide-rangingactionsacrossthemulti- m2982. ple sectors whose buy-in is needed to control the epidemic. In Rutter H, Wolpert M, Greenhalgh T. 2020. Managing uncertainty in the early days of the pandemic, when neither empirical data the COVID-19 Era. The BMJ 370: m3349. nor complex epidemiological modelling could rapidly inform Struben J. 2020. The coronavirus disease (COVID-19) pandemic: decision-making, the adverse effects of COVID-19 in Thai- simulation-based assessment of outbreak responses and postpeak strategies. System Dynamics Review 36: 247–93. land and other countries could have been predicted by adopt- Thailand’s Department of Disease Control. 2020a. Covid-19 sit- ing basic principles of systems thinking and implementation uation reports. Nonthaburi, Thailand. https://ddc.moph.go.th/ science. viralpneumonia/eng/situation.php. As the pandemic continues to wreak havoc on health and Thailand’s Department of Disease Control. 2020b. Thailand situation economic systems, ongoing policy can still be favourably update on Coronavirus 2019 Disease (COVID-19). Nonthaburi, shapedbysystemdynamicstoolssuchascausalloopdiagrams Thailand. (Darabi and Hosseinichimeh, 2020) and simulation models WestR,MichieS,JamesRubinG,RichardA.2020.Applyingprinciples (e.g. Ghaffarzadegan and Rahmandad, 2020; Struben, 2020) of behaviour change to reduce SARS-CoV-2 transmission. Nature tounderstandhowelementsofaproblemareinterrelatedand Human Behaviour 4: 451–9. avoid compounding adverse outcomes. WipatayotinA.2020. Cityexodus begins. BangkokPost, March 2020. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health Policy and Planning Oxford University Press

How systems respond to policies: intended and unintended consequences of COVID-19 lockdown policies in Thailand

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Publisher
Oxford University Press
Copyright
© The Author(s) 2021. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
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0268-1080
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1460-2237
DOI
10.1093/heapol/czab103
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Abstract

HealthPolicyandPlanning,37,2022,292–293 DOI:https://doi.org/10.1093/heapol/czab103 Advanceaccesspublicationdate:26August2021 Commentary Howsystemsrespondtopolicies: intendedandunintended consequences of COVID-19 lockdown policies in Thailand 1 1 2,3 Borwornsom Leerapan , Phanuwich Kaewkamjornchai , Rifat Atun and 4,5, Mohammad S Jalali FacultyofMedicineRamathibodiHospital,MahidolUniversity,270RamaVIRoad,Ratchathewi,Bangkok,Thailand DepartmentofGlobalHealthandPopulation,HarvardT.H.ChanSchoolofPublicHealth,677HuntingtonAve,Boston,MA02115,USA DepartmentofGlobalHealthandSocialMedicine,HarvardMedicalSchool,641HuntingtonAvenue,Boston,MA02115,USA HarvardMedicalSchool,MGHInstituteforTechnologyAssessment,101MerrimacSt,Boston,MA02114,USA SloanSchoolofManagement,MassachusettsInstituteofTechnology,100MainSt,Cambridge,MA02142,USA *Correspondingauthor.MGHInstituteforTechnologyAssessment,101MerrimacSt,Boston,MA02114,USA. E-mail:msjalali@mgh.harvard.edu Acceptedon13August2021 The coronavirus disease 2019 (COVID-19) pandemic has COVID-19 infections were exported from high-infection revealed the interdependency of health, economic and social conurbation of Bangkok to other parts of the country and systems (Rutter et al., 2020). The COVID-19 lockdown in many of travellers’ destinations reported upticks in COVID- Thailand and its unintended adverse outcomes illustrate this 19 cases in early April—data can be found (Thailand’s complexity, providing valuable lessons regarding the use of Department of Disease Control, 2020a). systems thinking to design successful policies. At the beginning of the pandemic, Thailand implemented Dynamics between policy interventions, a lockdown in its capital city, Bangkok. Ironically, the policy people’s motivations and pandemic outcomes aimed to reduce new infections, but it unintentionally helped spread the disease nationwide. The lockdown prompted the The city lockdown intended to change behaviours and urge rapid movement of economically vulnerable populations and people to stay at home by discouraging travels and family drovethemoutofthecity,especiallylow-incomeandmigrant gatherings. Behavioural change is crucial for improving pan- workers without any welfare support systems. The policy demic outcomes (Michie and West, 2020; West et al., 2020) overlooked the dynamic interactions between people’s moti- andcanbeeffectiveifpoliciesarederivedfromevidence-based vations to mitigate the spread of COVID-19 and their eco- principles of implementation science (Michie and Prestwich, nomic capacity to survive. 2010; Cane et al., 2012; Hirschhorn et al., 2020; Ghaffar From January to March 2020, new COVID-19 cases et al., 2020) and informed by systems thinking (Carey et al., in Thailand were mostly clustered in Bangkok (Thailand’s 2015; Durski et al., 2020a, 2020b). DepartmentofDiseaseControl,2020a),duepartlytothecap- The lockdown in Bangkok may have encouraged people ital’s nature of being a hub of inbound international travel. to stay at home and reduce contact. The causal pathway of Bangkok’s continued tourism and sporting events vastly con- the intended effects is illustrated in Figure 1. However, the tributedtotherapidriseofnewcases. Theincreasingnumber responsetothelockdowndifferedamongpopulations.Work- of cases prompted the government to declare a state of emer- place closures caused financial strain which made it hard to gency on March 26, enforcing strict city lockdowns which stay in Bangkok, so migrant workers chose to return to their closed restaurants, stores and entertainment venues, with hometowns, where the cost of living is much lower, but mass exceptions for essential services (Thailand’s Department of transit was not prepared for the unexpected travel demand. Disease Control, 2020b). Therefore, their inability to survive economically outweighed Many domestic labourers lost their jobs when workplaces their motivations to stay in Bangkok, and their urgency to were forced to close. At least 80 000 people boarded buses travel via underprepared mass transit increased the contact departing from Bangkok over the weekend after the lock- rate from infected travellers to others. The causal pathway of down was announced (Wipatayotin, 2020). The reactionary these unintended, adverse policy consequences can be seen in city departure was sudden and disorganized. Due to the Figure 1. high volume of travellers and lack of public health coordi- Had policy-makers anticipated these patterns of nation, adherence to non-pharmaceutical interventions such behaviours, they could have designed a policy that grants the as physical distancing, face masking and hand washing was working class the motivation and capability to stay safely in low among travellers. With this massive and rapid exeat, thecityandpreparedthetransportationsystem. Forinstance, © The Author(s) 2021. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com Health Policy and Planning, 2022, Vol. 37, No. 2 293 Data statement References to data are reported in the article. No additional data were used in this study. Funding No funding was used to conduct this study. Ethical approval. Ethical approval for this type of study is not required by our institute. Conflict of interest statement. The authors declare that they have no conflict of interest. Figure 1. Causal loops of intentional and adverse effects of the city lockdown policies in Bangkok, Thailand References Cane J, O’Connor D, Michie S. 2012. Validation of the theoretical targeted government subsidy along with phased travel plans domains framework for use in behaviour change and implementa- and mandatory quarantine after travel could have prevented tion research. Implementation Science 7: 37. the spread of COVID-19. Carey G, Malbon E, Carey N et al. 2015. Systems science and systems thinking for public health: a systematic review of the field. BMJ Open 5: e009002. Lessons learned Darabi N, Hosseinichimeh N. 2020. System dynamics modeling in health and medicine: a systematic literature review. System Dynam- Policyinterventionsaimedatcontrollingepidemicshavesoci- ics Review 36: 29–73. etal impacts which may lead to unintended adverse effects on Durski KN, Naidoo D, Singaravelu S et al. 2020a. Systems thinking the targeted population. It is the government’s responsibility for health emergencies: use of process mapping during outbreak todesignawell-roundedpolicypackagethatconsiderspoten- response. BMJ Global Health 5: e003901. tial behavioural responses and incorporates policy instru- Durski KN, Osterholm M, Majumdar SS et al. 2020b. Shifting the ments to prevent unintended, adverse effects. Specifically, paradigm: using disease outbreaks to build resilient health systems. the three essential conditions of human actions—capability, BMJ Global Health. opportunityand motivation—must beexploredbeforeselect- Ghaffar A, Swaminathan S, Sheikh K et al. 2020. Implementa- tion research is crucial to countries’ efforts to strengthen ing appropriately matched portfolios of policy interventions learning health systems. Health Policy and Planning 35: (Michie et al., 2011). If not, measures such as city lock- ii4–ii6. downs can drive unexpected behaviours that lead to deadly Ghaffarzadegan N, Rahmandad H. 2020. Simulation-based estimation consequences. of the early spread of COVID-19 in Iran: actual versus confirmed Sustainable health development is not achieved by aiming cases. System Dynamics Review 36: 101–29. myopically at the best short-term results, but by designing Hirschhorn L, Smith JD, Frisch MF, Binagwaho A. 2020. Integrating policies that create desirable long-term outcomes. A pol- implementation science into COVID-19 response and recovery. The icy that intentionally improves short-term outcomes, such as BMJ 369: m1888. lockdown, can cause long-term harm due to delayed adverse Michie S, Prestwich A. 2010. Are interventions theory-based? Devel- consequences. In contrast, lockdown policies that consider opment of a theory coding scheme. Health Psychology 29: 1–8. behavioural factors increase cost in the short term, but in MichieS,vanStralenMM,WestR.2011.Thebehaviourchangewheel: the long term they may yield satisfactory results: reducing a new method for characterising and designing behaviour change transmission at lower overall cost. interventions. Implementation Science 6: 42. Policy-makers can effectively change people’s behaviours Michie S, West R. 2020. Behavioural, environmental, social, by identifying high-leverage points for effective interventions and systems interventions against COVID-19. The BMJ 370: andbycommunicatingwide-rangingactionsacrossthemulti- m2982. ple sectors whose buy-in is needed to control the epidemic. In Rutter H, Wolpert M, Greenhalgh T. 2020. Managing uncertainty in the early days of the pandemic, when neither empirical data the COVID-19 Era. The BMJ 370: m3349. nor complex epidemiological modelling could rapidly inform Struben J. 2020. The coronavirus disease (COVID-19) pandemic: decision-making, the adverse effects of COVID-19 in Thai- simulation-based assessment of outbreak responses and postpeak strategies. System Dynamics Review 36: 247–93. land and other countries could have been predicted by adopt- Thailand’s Department of Disease Control. 2020a. Covid-19 sit- ing basic principles of systems thinking and implementation uation reports. Nonthaburi, Thailand. https://ddc.moph.go.th/ science. viralpneumonia/eng/situation.php. As the pandemic continues to wreak havoc on health and Thailand’s Department of Disease Control. 2020b. Thailand situation economic systems, ongoing policy can still be favourably update on Coronavirus 2019 Disease (COVID-19). Nonthaburi, shapedbysystemdynamicstoolssuchascausalloopdiagrams Thailand. (Darabi and Hosseinichimeh, 2020) and simulation models WestR,MichieS,JamesRubinG,RichardA.2020.Applyingprinciples (e.g. Ghaffarzadegan and Rahmandad, 2020; Struben, 2020) of behaviour change to reduce SARS-CoV-2 transmission. Nature tounderstandhowelementsofaproblemareinterrelatedand Human Behaviour 4: 451–9. avoid compounding adverse outcomes. WipatayotinA.2020. Cityexodus begins. BangkokPost, March 2020.

Journal

Health Policy and PlanningOxford University Press

Published: Aug 26, 2021

Keywords: thailand; double effect; covid-19; pandemics

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