pISSN 2210-9099 eISSN 2233-6052

https://doi.org/10.24171/j.phrp.2021.0068
Osong Public Health Res Perspect [Epub ahead of print]

Review Article

Scrutiny of COVID-19 response strategies among

severely affected European nations
Shine Stephen1 , Alwin Issac1 , Rakesh Vadakkethil Radhakrishnan1 , Jaison Jacob1 ,
VR Vijay1 , Sam Jose1 , SM Azhar1 , Anoop S. Nair1 , Nadiya Krishnan1 , Rakesh Sharma2 ,
Manju Dhandapani3
1
College of Nursing, All India Institute of Medical Sciences, Bhubaneswar, India
2
College of Nursing, All India Institute of Medical Sciences, Rishikesh, India
3
National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

ABSTRACT

Although the health care systems in Europe are considered the global benchmark, European
nations were severely affected by the coronavirus disease 2019 (COVID-19) pandemic. This
manuscript aimed to examine the strategies implemented to combat the COVID-19 pandemic
by France, the United Kingdom, Spain, Italy, Germany, and Russia and their outcomes in terms
of the number of cases, testing, and deaths. This is the first review of its kind that extensively
analyzes the preparedness, mitigation, and response strategies against the COVID-19
pandemic adopted by these nations. This paper further suggests a strategic preparedness
model for future pandemics. From the analysis, we found that a decentralized approach,
prompt decision-making and timely execution, coordination between local health authorities,
and public participation in the implementation of strategies could substantially reduce the
case fatality rate. Nations with a high percentage of gross domestic product invested in the
health sector, as well as more nurses, physicians, hospital beds, intensive care unit beds, and
ventilators, better managed the pandemic. Instead, nations that postponed their pandemic
response by delaying tracking, tracing, testing, quarantine, and lockdown were badly affected.
The lessons learned from the present pandemic could be used as a guide to prepare for further
pandemics.

Received: May 17, 2021

Keywords: Coronavirus; COVID-19; Europe; Health policy; Pandemics
Revised: June 23, 2021
Accepted: June 24, 2021

Corresponding author:
Shine Stephen Introduction
Department of Nursing,
College of Nursing, All India On December 31, 2019, health authorities from Wuhan, China informed the World Health
Institute of Medical Sciences,
Organization (WHO) about an increase in pneumonia cases of unknown origin. On January 7,
Bhubaneswar, 751019, India
E-mail: shinestephentn@ 2020, Chinese health authorities detected the novel coronavirus as the causative agent of the
gmail.com pneumonia cases, and the virus was initially named “2019-nCoV,” which was later renamed

© 2021 Korea Disease Control and Prevention Agency.

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

https://ophrp.org 1
 COVID-19 response strategies in European countries

as severe acute respiratory syndrome coronavirus 2 of human resources, personnel protective equipment
(SARS-CoV-2) and the disease as coronavirus disease 2019 arranged, number of hospital beds including critical care
(COVID-19). Owing to the virulence and the contagious beds with facilities for mechanical ventilation and other
nature of the virus, the WHO declared the novel coronavirus strategies) and response (screening and isolation facilities,
outbreak a public health emergency of international implementation of lockdown, public relations, and restricted
concern on January 30, 2020 [1,2]. With the steep rise in travel). Since mortality is a precise appraisal of the progression
infections outside China, the WHO declared the outbreak to and outcome of a pandemic [7], with which the management
be a pandemic on March 11, 2020 [3]. strategy of a nation can be evaluated, the death rate (per million
On January 24, 2020, France was the initial country in population) was fixed as the primary endpoint for evaluating
the European Union (EU) to report a coronavirus case [4]. the outcome of measures taken by these 6 selected nations.
Since then, there has been a steady rise in the number of
cases in the EU countries. As of March 10, 2021, a total of Preparedness and Containment Strategies
35,636,156 cases had been reported from the EU, wherein The victory of a nation over a pandemic strongly depends
846,378 people succumbed to the illness [5]. The European upon the existing health care system (in terms of health
lifestyle of taking a summer holiday abroad and “mass infrastructure, early mobilization of available resources,
movement” of holidaymakers soon after the relaxation of services rendered by trained health care professionals),
draconian lockdown measures has been a significant factor expertise in dealing with an emergency, and the early
in spreading the disease. While some countries were hit mitigation strategies adopted. The response of each nation
harder during Europe’s first wave, the second wave was felt to the pandemic in terms of identifying the severity, reducing
more widely and included countries that largely escaped the incidence of infections and the mortality rate, supporting
the initial outbreak. Although vaccination against COVID-19 health care professionals, and safeguarding vulnerable
started in December 2020, COVID-19 maintains its foothold populations exhibits the preparedness of the nation for
in EU countries. managing the pandemic. Adequate preparedness not only
Nations that prudently executed surveillance, quarantine, reduces the strain on the health care system, but helps
lockdown, and isolation were able to tame the virus, whereas to cope promptly with the health consequences of the
those that delayed were severely affected by the pandemic pandemic.
[6]. The Global Health Security (GHS) index ranks countries
based on their preparedness to counteract epidemics and France
related capabilities. It was believed that the nations that France reported the index COVID-19 case on January 24,
ranked top in the GHS index would manage the pandemic 2020, which was also the primary case reported in the EU as
well, but the real scenario was different. This review aimed a whole [8]. Unchecked communal gatherings, transmission
to examine the COVID-19 containment strategies employed of infection through sailors and airline carriers, and local
by the worst-affected European countries and their impact municipal elections paved an easy way for the infection to
on COVID-19 management, which could guide other nations spread among the French population [8,9]. On January 27,
in planning their strategies against upcoming pandemics. 2020, a health crisis center was established and the Pasteur
Institute developed a rapid diagnostic kit. With the aim
Materials and Methods of preparing the health care system to face a pandemic
of global concern, on February 13, 2020, the organization
A thorough literature search was performed to retrieve plan for the response of the health system (ORSAN) was
the containment strategies of the selected nations between activated [10]. On March 5, 2020, gatherings of more than
January 2020 and February 2021, using Science Direct, 5,000 people in enclosed spaces were banned, and the
Scopus, MEDLINE, Google Scholar, and the official websites number of people permitted to gather was further reduced
of the WHO and the concerned nations. The keywords were in the following days. A ban of ships carrying more than
COVID-19, pandemic, SARS-CoV-2, preparedness, and 100 people calling in or anchoring in inland and territorial
containment strategies. Among the European nations, the waters came into force on March 14 [11]. A lockdown was
most affected countries (Russia, Germany, Spain, France, imposed on March 17, 2020 and later extended until May
Italy, and the United Kingdom [UK]) were selected. The 11, 2020 (Figure 1B) [12]. Commonly employed preventive
available data from these countries included COVID-19 cases strategies, such as physical distancing, personal hygiene,
(date of the positive index case, number of tests performed, limitation on public gatherings, use of face masks in public
number of positive cases, and deaths), mitigation (availability spaces, periodic ventilation of closed spaces, and isolating

2 https://doi.org/10.24171/j.phrp.2021.0068
Shine Stephen et al.

cases with symptoms and testing them as early as possible, COVID-19. Germany reported its index case on January
were enforced by the health authorities [13]. With the 27, 2020. Taking heed from other severely hit countries,
successful implementation of these containment measures, Germany’s risk-averse attitude and proactive behavior
the number of cases per day was limited to 120 on May 17, presumably enabled limited draconic measures in the
2020. country compared to other EU countries. By mid-March,
By the end of July 2020, people’s complacency regarding stringent measures to contain the pandemic were enforced,
hygiene measures during the summer and lifting of including a “contact ban” that delimited public assemblage
restrictions led to the emergence of the second wave, and to 2 people (outside families), physical distancing measures
France reported its highest number of COVID-19 cases on of at least 1.5 meters, and shutdown of schools and non-
November 7, 2020 (86,852 cases) since the beginning of essential businesses [17]. However, a curfew was never
the pandemic [14]. At the end of June 2020, the incidence imposed. Travelers arriving in the country from high-risk
rate, effective reproduction number (R), and reverse nations had to quarantine for a fortnight and were urged to
transcription-polymerase chain reaction (PCR) positivity furnish information about potential exposure along with
rate were 5.14 (per 100,000 population), 0.99, and 1.44% their contact information. Borders to adjoining countries
respectively, but by the end of November 2020, these were closed on March 15, and a lockdown was imposed until
values increased to 491 (per 100 000 population), 1.4, and April 19, 2020 [17].
20%, respectively [15]. With the surge in coronavirus cases, The German government made it mandatory for all
further restrictions were imposed on public movement health care providers to notify any suspected cases of
and social gatherings, such as night curfews, lockdowns, COVID-19 to local public health authorities within 24 hours.
and border closure to nations outside the EU. As of March Germany’s national pandemic plans were in accordance
10, 2021, France still has weekend lockdown measures in with the guidelines of the Robert Koch Institute (RKI), and
place in active circulation zones. Witnessing a resurgence they mandated the publication of periodic situation reports
of coronavirus cases, hospitals were geared up with more for national and international public health zones. Having
intensive care unit (ICU) beds to accommodate new cases a response plan in place and being a federalized country
[16]. On March 10, 2021, France had a total of around 3.9 allowed the government to counteract the pandemic quickly.
million coronavirus cases, or approximately 60,624 cases Protocols for testing, case detection, contact tracing, and
per million population (Figure 1A) [5]. treatment strategies were prepared even before the index
case was reported [18]. Having laboratories with proficiency,
Germany accreditation, and machinery to conduct PCR assays and
Germany was not among the EU countries initially hit by announce diagnoses, Germany scaled up their testing capacity.

A B 2020
2020
2021
2021
France Germany Italy Russia Spain United Kingdom Country Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
7,000 Country Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
France Germany Italy Russia Spain United Kingdom
7,000
6,000 France
6,000 France
Cases per million

5,000
Germany
Cases per million

5,000
4,000 Germany
4,000 Italy
3,000
3,000 Italy
2,000
Russia
2,000 1,000 Russia
1,000 Spain
0
Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Spain
0 United
Feb Mar Apr May Jun Jul 2020 Sep Oct Nov Dec Jan Feb 2021
Aug Mar Kingdom
United
2020 2021 Kingdom
First lockdown Second lockdown Third lockdown

FirstFirst unlock
lockdown Second
Second unlock
lockdown Thirdlockdown
Third unlock
Mandatory Ban on social Vaccination
Firstface
unlock
mask Second unlock
gathering Third unlock
Mandatory Ban on social Vaccination
face mask gathering
Figure 1. (A) Timeline comparing coronavirus cases per million population among the selected nations. (B) Timeline
comparing containment measures against coronavirus disease 2019 (COVID-19).

https://doi.org/10.24171/j.phrp.2021.0068
3
 COVID-19 response strategies in European countries

Testing was made free of cost to everyone upon medical or middle of March. As of March 31, 2020, the country’s testing
epidemiological indication through the Coronavirus Relief rate were only up to 5,000 tests in a day; a much lower figure
Bill. As of March 10, 2021, Germany reported 30,164 cases per than in other European countries [23]. A lockdown was not
million population and 873 deaths per million populations, imposed until March, 2020; later, a “stay at home” order was
which signifies the quality of Germany’s health care system announced to save lives and protect the National Health
(Table 1). Service (NHS) staff. The government passed the Coronavirus
Act-2020 on March 19, which granted the government power
United Kingdom to regulate areas of health service, social care, and public
The UK refers to a political union between England, Wales, activities including local councils [24].
Northern Ireland, and Scotland. The UK reported its index Until March 3, 2020 a definitive action plan was not drafted
case of COVID-19 on January 31, 2020, even though screening by the government despite witnessing early spread of virus
for travelers from Wuhan, China started by late January at throughout February. A public health information campaign
Heathrow airport [19]. Upon early reports of the outbreak with the slogan “Catch it, bin it, kill it” was launched to limit the
from Wuhan, Public Health England, the main agency spread of the virus within the country by facilitating behavior
responsible for health advice and directives, raised the risk change among the public [25]. The 2020 UK local elections
level of the pandemic from “very low” to “low” and subsequently were postponed for a year on March 13 as a precautionary
to “moderate” following declaration of the outbreak as a measure. On April 2, the government announced a “five-
public health emergency of international concern [20]. The pillar” strategy to scale up virus testing in the UK, which
governmental response against the pandemic was based on included intensifying swab testing in public labs and NHS
the national pandemic influenza plan of 2011, which delivers hospitals, nationwide surveillance, and capacity-building,
data about the expected impact of the pandemic and provides to have 100,000 tests a day. Although the UK enforced
certain norms to aid in planning the pandemic response [21]. containment measures against the spread of COVID-19, the
Later, written guidelines were made available at all airports months preceding September observed some relaxations in
for unwell travelers, and people returning from affected imposed restrictions, including the reopening of higher schools,
countries were advised to self-isolate for a fortnight if they which led to a resurgence of infections during September.
developed flu-like symptoms [21]. Authorities urged the Owing to all these factors, the government was forced to
public to refrain from non-essential travel and to avoid social impose a second lockdown (Figure 1B). On December 14,
gatherings. On February 10, the government enacted the 2020, the health authorities of the UK reported a new SARS-
Health Protection (Coronavirus) Regulations-2020 act, which CoV-2 variant, “SARS-CoV-2 VUI 202012/01” (variant under
provided discretionary powers to the authorities to impose investigation, year 2020, month 12, variant 01), to the WHO;
quarantine under threat of legal proceedings and to impose this variant is much more transmissible than the previous
restrictions on people and situations leading to spread of strain [26]. As of March 10, 2021, the UK reported 4,234,924
the virus. The government-imposed closure of public places cases and 124,987 deaths from COVID-19. Notably, the UK has
(pubs, restaurants, indoor sports and other leisure facilities) the highest deaths per million among the nations investigated
under the provisions of these regulations, and hospitals herein (Table 1).
started drive-through testing centers for COVID-19 [22].
Although the UK initiated testing for detecting coronavirus Spain
cases in January 2020, it conducted very few tests until the The first case of COVID-19 was confirmed in Spain on January

Table 1. COVID-19: incidence, CFR, and recovery Index of selected nations

Deaths per
GHS rank Country CFR (%) Recovery index
million population
2 United Kingdom 1,834 2.9 66.79
11 France 1,370 2.3 60.30
14 Germany 873 2.8 72.62
15 Spain 1,539 2.1 54.38
31 Italy 1,669 3.4 58.66
63 Russia 622 2.0 70.38
Data as on March 10, 2021 (source: http://www.worldometers.info).
COVID-19, coronavirus disease 2019; CFR, case fatality rate; GHS, Global Health Security.

4 https://doi.org/10.24171/j.phrp.2021.0068
Shine Stephen et al.

31, 2020, after a German traveler tested positive in La Gomera, health authorities, the Ministry of Defense created 800
Canary Island. Shortly thereafter, all direct flights from multifunctional bedded medical centers in several regions of
affected nations to Spain were canceled from March 10 to Russia to treat COVID-19 patients. Around 2,000 highly skilled
March 25, 2020, and a lockdown was imposed on March 14, doctors, nurses, and other medical staff were deployed at
2020, which was later extended through June 21 (Figure 1B). various medical centers. The national government allocated
Borders were closed, and all non-essential employees were 8.8 billion Russian rubles (approximately 120 million United
asked to stay at home from March 30 to April 9, 2020 to States dollars) to set up these infectious disease centers [32].
flatten the curve and contain the pandemic [27]. A COVID-19 In an unprecedented measure, Russia suspended all
diagnostic application, CoronaMadrid, was developed by national and international regular flights except rescue flights
the Spanish government; this self-assessment application bringing Russian citizens by March 27, 2020 [33]. Trains to
encouraged COVID-suspected nationals to perform an China and North Korea were also suspended and work visas to
assessment when they thought they had COVID-19 symptoms. Chinese citizens stopped being issued on February 19, 2020.
People received instructions and recommendations about On March 30, in a bid to curb the spread of COVID-19, Russia
COVID-19, through the same application [28]. On October closed its borders completely except for goods and cargo
20, 2020, Spain became the first European nation to report [34]. In October 2020, owing to the surge in coronavirus
1 million cases. With the resurgence of coronavirus cases cases, a night-time curfew was implemented and the use
after an initial decline, stringent measures were employed, of face masks was made mandatory. A nationwide aggressive
including a partial lockdown (October 21, 2020), declaration testing regimen was put in place, which was later appreciated
of emergency (October 25, 2020), imposition of overnight by the WHO. On December 15, 2020, the nation started a
curfew, and reinforced quarantine. Spain still dominates the vaccination program against COVID-19 to halt the rise in
EU in the number of coronavirus cases per million population cases (Table 2). On March 10, 2021, Russia had conducted more
(67,963) (Table 1) [29]. The scarcity of ICU beds, ventilators, than 113 million COVID-19 tests (779,571 tests/million population)
and numerous health care workers falling ill led to a high [29]. Russia has 29,873 cases per million population (Table 1)
death rate (1,539 deaths per million population) [29]. Among [29]. Among the severely affected European countries, Russia
the 6 European countries analyzed, Spain still has the lowest has the lowest death rate, with 622 deaths per million population
recovery index (54.38) (Table 1). and a case fatality rate (CFR) of 2%, which is the lowest among
the nations studied (Table 1) [35].
Russia
The world’s largest country by area, Russia reported its index Italy
COVID-19 case on January 31, 2020 [30]. Russia prepared for COVID-19 entered Italy on January 31, 2020, through 2
the ongoing pandemic through repurposing existing facilities, Chinese tourists. With the identification of the primary
building new hospitals, procuring the requisite diagnostic coronavirus cases, a state of emergency was declared and
and resuscitation equipment, and embarking upon intense all flights to and from China were suspended. Since the
and swift retraining of their health care workers. When the first confirmed case, emergency medical number-112 was
outbreak began, the health administration created more than designated exclusively for COVID-19, and the emergency
1,77,000 beds exclusively for COVID-19 patients, including medical team performed a primary assessment, screening,
25,000 ICU beds [31]. In collaboration with the Russian counseling, or hospitalization based on the situation at hand.

Table 2. COVID-19 vaccination status in the selected nations

Population
Start date Doses administered
Country Vaccine manufacturer vaccinated
(mm/dd/yyyy) per 100 people
(million)
United Kingdom 12/12/2020 Pfizer/BioNTech, AstraZeneca, 23.77 35.02
Moderna
France 12/27/2020 Pfizer/BioNTech 5.97 8.80
Germany 12/27/2020 Pfizer/BioNTech 8.16 9.74
Spain 01/04/2021 AstraZeneca 4.85 10.37
Italy 12/27/2020 Pfizer/BioNTech 5.78 9.56
Russia 12/15/2020 Sputnik V 6.69 4.59
Data as on March 10, 2021 (source: ourworldindata.org).
COVID-19, coronavirus disease 2019.

https://doi.org/10.24171/j.phrp.2021.0068
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 COVID-19 response strategies in European countries

Initially, Italy did not screen contacts linked to confirmed upsurge in the number of cases starting in August 2020 [39].
cases or recent travelers to outbreak regions until they Digital technology was aptly employed, wherein precise data
showed symptoms. By February, partial quarantine was regarding the pandemic were procured and communicated
imposed on identified clusters, and on March 9, 2020, a with the public, and contact tracing was reinforced with the
quarantine was imposed all over the country. A nationwide help of technology. Amidst the upsurge of coronavirus cases,
lockdown came into force from March 10 until April 13, 2020 numerous religious meetings and municipal elections were
(Figure 1B). As a primary initiative, all the residents of Vò held, leading to a further escalation of cases [9]. Even though
(a commune in Italy) were screened, including those who there was a change in the political structure after elections
did not have symptoms, which allowed them to quarantine in July 2020, the health care policies pertaining to social
and reduce the spread of the virus. Technological advances, care remained unchanged. France experienced one of the
specifically artificial intelligence-powered robots, were world’s worst outbreaks of COVID-19 in the spring, and cases
deployed in hospitals to screen and care for patients. increased after the first phase of the lockdown (March 16,
With a loosening of containment strategies, Italy witnessed 2020 to May 11, 2020). Despite the exquisite French public
a second wave of the pandemic by July 2020. Shortly thereafter, health system, the operation of top-down, centralized
a state of emergency was declared, use of face masks was made control measures slowed their response to the fast-moving
mandatory in public gatherings, and demonstrations and crisis. Owing to their shortage in the logistic capacity in terms
meetings were banned. The health system was restructured and of scanty accredited laboratories and reagents for testing;
expanded with the installment of sophisticated ICU beds. widespread testing could not be practiced, resulting in 1370
Millions of doses of flu vaccine were procured to be distributed deaths per million population (Table 1) [5]. The number of
among the public [36]. All schools and universities remained physicians per 1,000 population was also very low (3.3 per
closed from October 15, 2020 until October 30, 2020. By the 1,000 population) when compared to France’s counterparts
end of October, a regional lockdown was imposed in affected (Figure 2). In a recent study published, only 31% of persons
areas. Although vaccination was started on December 27, with having COVID-19-like symptoms sought medical care
2020, it was not sufficient to control the increasing number despite governmental recommendations [40]. France hopes
of coronavirus cases, as the initial doses of vaccines were to contain the spread of pandemic through its vaccination
administered to health care workers and immuno-compromised program [41].
people. On March 10, 2021, Italy had 51,711 cases per million The index case of coronavirus in Germany was reported
population and a high CFR of 3.4% (Table 1) [29]. It is predicted from Munich, which is home to a biosafety level-3 lab that
that the situation will further deteriorate with the invasion of had the capacity to perform PCR testing shortly after China
newer virus strains (e.g., the UK, Brazilian, and South African released the genetic sequence of the coronavirus. By the
variants) and scarcities in vaccine supply [37]. time initial clusters of cases were brought under control,
protocols were established and in place for diagnosing,
Discussion isolating, and treating COVID-19 patients safely. Germany
was quick to lockdown (Figure 1B) and scaled up its testing
The actual response of each country to COVID-19 did not capacity, and then repeatedly adapted this program to
correlate well with their respective GHS index (Table 1). respond to changes in the epidemic dynamics. Widespread
It was predicted that the nations occupying the top positions testing is acknowledged as the primary reason for a lower
in the GHS index would perform better during a pandemic. number of deaths per million population (873 deaths) in
However, in the real scenario, the nations with well-established Germany, as it enabled the detection and management of
primary health care that employed advanced health technology cases at an earlier stage. The decentralized approach to
with transparent communication demonstrated a remarkable managing a pandemic was a good way to deal with a quickly
performance. This was also evident in their respective global changing pandemic. This was accomplished by collaborating
COVID-19 recovery index (GCI). The daily recovery status of with local health authorities through the RKI, which tailored
patients from COVID-19 is taken into consideration to evaluate responses according to local needs. Being the fourth-largest
the GCI [38]. Germany and Russia stood high among the economy in the world, Germany spends roughly 11% of its
nations studied in terms of the GCI (Table 1). The measures gross domestic product (GDP) on health care (Figure 2) [42].
followed by these nations could serve as a guide for other In the EU, Germany has the highest number of hospital
nations in the present and upcoming pandemics. beds (8.3), nurses (13.2) and physicians (4.2) per 1,000 people
Until the end of July 2020, France maintained the number (Figure 2) [43,44]. When COVID-19 arrived in Germany,
of coronavirus cases under control, whereas there was an ICU bed capacity was increased from 12,000 to 40,000

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Shine Stephen et al.

for epidemics and related capabilities. Although the UK

occupies the second position in GHS ranking among all
Percentage of 3–5 6–10 10–12 195 nations, the UK’s health system was overstretched well
GDP allotted for
health sector before the pandemic hit the UK (Table 1). Among the UK’s 19
counterpart nations, the UK had the third-lowest number of
available hospital beds per 1,000 population [45]. The nation
believed in and propagated herd immunity as a permanent
Number of 2–3 3–6 6–9 solution to contain the pandemic, despite the WHO’s warning
hospital beds per regarding tracking, tracing, and isolating COVID-19 cases. In
1,000 population
response to widespread criticism regarding the government’s
delayed approach to initiate mass testing and tracing of
infected COVID-19 cases, attempts were made to increase
the testing capacity [46]. With the nation’s precarious delay
Number of 5–9 11–14
nurses per in combating the pandemic, the CFR rose to 11.56%, which
1,000 population was much higher than the global average and the average
among the UK’s European counterparts. The health care
capacity in terms of beds was also very low (2.5 per 1,000
population) when compared to the other selected nations
Number of 2–3 3–4 4–5
(Figure 2). Although a contact tracing app was developed
physicians per
1,000 population through the NHS in the first week of May 2020, alleging
security reasons, its implementation was suboptimal [47].
However, since September 2021, with the resurgence of the
Country or region
second wave of the virus and the emergence of the mutated
United Kingdom Italy
variant (UK strain), the government was forced to tighten
Spain Germany
containment measures, including lockdowns, after a phased
France Russia
easing of imposed restrictions. On December 2, 2020, with
Figure 2. Existing health system capacities of the selected nations. the arrival of the Pfizer/BioNTech vaccine against COVID-19,
GDP, gross domestic product. the UK was the first country to approve a vaccine for use in
humans. By December 8, an immunization program was
launched [48]. As of February 26, 2021, 3 vaccines have been
beds quickly. This is considered the primary reason why approved to be used in the UK, which has announced the
Germany achieved a brilliant recovery index (72.62) (Table 1), goal of vaccinating all UK nationals by the end of July 2021
which was the highest among the nations studied. Citizens (Table 2).
and permanent residents of Germany are covered through The COVID-19 pandemic tested the integrity, strength
health insurance. Endowed with ample human resources and pandemic preparedness of the Spanish health care
and physical infrastructure, Germany possesses a robust system. A health alert and emergency coordination center
health care system, which—in combination with the rapid was established in 2004, with the aim of identifying and
initial advances that were made after the detection of controlling situations causing health crises (national and/or
COVID-19—augmented Germany’s efficacious containment international) that significantly affect the public health [49].
strategies. The restrictions imposed by the government were The response towards the COVID-19 pandemic signifies
wholeheartedly accepted by the public and became vital the importance of scrutiny of the Spanish health care
in curtailing the progression of the pandemic. The federal system, which was believed to be a strong health sector.
system of the government focused on collecting and analyzing The increase in the number of cases was attributed to the
the data and transparently communicating outcomes to the letdown of both societal and governmental norms. Basic
people, leading to unusual levels of public support. Judicious infection control measures, like social distancing and use of
decision-making at the highest level of the government, face masks, were erroneously not followed during the initial
relying on expert advice from scientists mixed with the trust phases of the pandemic [50]. The latest survey results from
that the public holds in the government, enabled Germany the WHO and Spain’s Carlos III Institute of Health revealed
to manage the crisis swiftly. that almost half of the Spanish citizens still believed that
The GHS index ranks countries based on their preparedness there was only a low to medium risk of contracting the virus

https://doi.org/10.24171/j.phrp.2021.0068
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 COVID-19 response strategies in European countries

through social gatherings [51]. services. Consequently, Russia’s physician-to-population

The economic crisis of 2008 debilitated Spain’s public ratio (4 per 1,000 population) and available hospital beds (7.1
health and health system capacity. The health care system per 1,000 population) have been quite high in comparison
was shrunken, leading to a severe reduction in the number to its European counterparts for decades (Figure 2) [56].
of health care providers. The health care system operated This has helped the Russian health care system launch a
with an extremely low level of personnel (5.9 nurses per better institutional response during the pandemic. Other
1,000 population), whereas the EU is reported to have 9.3 judicious responses like timely border closure, the long
nurses per 1,000 population (Figure 2) [52]. A decentralized experience of the public health care system in controlling
health care system under 17 autonomous communities [53] infectious diseases like plague, enhanced testing capacity,
and the presence of a significant proportion of the elderly economic stimulus measures, low population density across
population resulted in a mortality rate of 1,539 per million the country, and digitalization in public health may have
population (Table 1). Moreover, studies have suggested effectively limited the fatality rate compared to other nations.
that Spain might have underestimated the infection and The overall governmental measures against COVID-19 met
mortality rates due to the negligence in reporting and lack the requirements of quality, availability, and provision of health
of a robust testing strategy [54]. The use of low-quality care services, drugs, and other consumables. The endurable
testing kits is also considered a reason for the upsurge in investment in health care and the prudent implementation of
the number of cases. measures combating COVID-19 helped Russia take the upper
Since Russia shares China’s land boundaries, Russia hand over the pandemic by limiting the CFR to 2% (Table 1)
had the potential to become a major focus of epidemic with a recovery index of 70.38 (Table 1).
spread. With the advent of COVID-19 in China, numerous Although Italy was placed in the 31st position in the GHS
systematic steps were implemented by the Russian index ranking, the Italian health system occupies the second
Federation, including administrative, organizational, position in overall health system performance among 191
technical, sanitary, and hygienic measures. These initiatives countries. The Italian constitution ensures the right to health
have given Russia to prepare to handle the situation, divert and free medical to all its citizens, based on the principles of
human and fiscal resources, and boost the health care universality, equality and equity through Article 32. Health
system’s readiness to deal with the epidemic. Russia is care in Italy is delivered through 3 different levels of health
the only nation in which the public health service is kept services: primarily through collective preventive and public
accountable for its citizens’ sanitary and epidemiological health (including preventive measures through vaccinations
welfare. The system is well equipped with approximately and health promotion campaigns); secondly through district
100,000 trained professionals, including epidemiologists, assistance with health and social health activities and
researchers, scientists, and technicians. The sanitary- services (e.g., outpatient services, home care, rehabilitation,
epidemiological service succeeded in preventing the primary and old age homes); and thirdly through hospital services
transmission of COVID-19 from mainland China, which [57]. With expenditures of 8.8% of the GDP on health, Italy
further provided adequate time to prepare and reorganize has not been able to provide adequate health care to the
the health care facilities to combat the pandemic. Airports, public due to the increasing number of elderly people (Figure
railway stations, and other public transport facilities were 2). Moreover, the Italian health care system relies on a triage
well equipped with sanitary quarantine centers (SQC), policy, wherein critically ill patients receive health care rapidly,
in which epidemiologists worked relentlessly to check whereas less critically ill patients have to wait for their turn.
the occurrence of any infectious disease in the Russian Unfortunately, the majority of the COVID-19 patients are either
Federation. SQCs played a pivotal role in the prevention of asymptomatic or have mild to moderate symptoms. During
the spread of COVID-19 in Russia [55]. the early stage of the pandemic, the Italian health care
The Russian health care system’s response towards system failed to identify these patients, which resulted in a
COVID-19 was deeply ingrained through its historical surge of COVID-19 cases. This strategy stressed the already
inheritance of the Semashko health system (named after exhausted health care system and caused the situation to
Dr. Nikolai Semashko, one of the major founders and deteriorate. Furthermore, the highly decentralized health care
organizers of the public health system in the Soviet Union), delivery system, lack of proper testing strategy, shortages in
which already emerged victorious by successfully delivering the supply of personal protective equipment for health care
universal health coverage to the Russian citizens by 1930. providers, lack of preparation to face a pandemic, and lack
The Semashko tradition has made the therapeutic health of proper protocols for the initial management of COVID-19
care system inclined towards institutional-based medical patients made the situation arduous [58,59].

8 https://doi.org/10.24171/j.phrp.2021.0068
Shine Stephen et al.

What Steps Can Nations Follow? academic curriculum, emphasis should be placed on the
Owing to increased encroachment into wildlife habitats, significance of having a balanced human ecosystem and the
the COVID-19 pandemic will not be the last time a virus would repercussions that could result from encroachment into
threaten human existence [60]. The unprecedented COVID-19 wildlife. Biosafety labs should be relentlessly monitored
pandemic has challenged existing health care systems and and reinforced to prevent any accidental or intentional
revealed their efficiency (or lack thereof). The nations that entry of viruses into the outside world. As a dilemma exists
were able to contain the virus have reiterated the perennial regarding the origin of SARS-CoV-2, the recent G7 summit
truth that multi-level coordinated and comprehensive reiterated the need for a better understanding of the origin
strategies are imperative to combat any outbreak from of the virus [61]. The public must be educated and should
progressing into a pandemic. It is imperative to note that incorporate health behavior practices into day-to-day life.
a reasonable proportion of GDP investment in health, All of these steps could prevent pandemics.
including the health system capacity in terms of the number During the preparedness phase, epidemiological institutes
of physicians, nurses, and hospital beds served as a feature should be built, which could help with the swift identification
demarcating nations’ pandemic responses (Figure 2). Hence, of a virus and its characteristics. It is imperative for every
nations could adopt sensible efforts for capacity-building nation to have tailored pandemic preparedness plans,
and resource allocation for the health sector. and the plans should be tried out during inter-pandemic
The strategies ought to pay due attention to all phases of periods to evaluate their efficiency and flaws. As primary
the preparedness and response framework (prevention, health centers (PHCs) remain the initial contact between
preparedness, response, and recovery) (Figure 3). In the patients and the health care system, PHCs should be

Figure 3. Global strategic model for future pandemics.

PHC, primary health center.

https://doi.org/10.24171/j.phrp.2021.0068
9
 COVID-19 response strategies in European countries

fostered. Boosting industrialization could help nations to be Conflicts of Interest

independent in fulfilling their needs [62,63]. Dependence on The authors have no conflicts of interest to declare.

other nations for commodities resulted in exportation and Funding

importation of the virus on a global scale. None.

In the response phase of a pandemic, communicating Availability of Data

“what is unknown” along with “what is known” to the general All data generated or analyzed during this study are included in this
public would ensure their cooperation and trust towards published article. For other data, these may be requested through the
corresponding author.
the government. A nation needs to act in accordance to its
pandemic preparedness plan or in accordance to evidence- Authors' contributions
Conceptualization: AI, SS; Data curation: JJ, NK, RS, MD; Writing–original
based practices [64,65]. Resources should be mobilized in
draft: SS, AI, RVR, SJ, SMA, ASN; Writing–review & editing: NK, RS, MD.
accordance to priorities and needs. Active surveillance should
be carried out to identify all cases. Adequate investment in
technology would help with all these response strategies. References
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