Abstract

This study analyzed the characteristics of the health system, surveillance system, and the measures adopted to face the COVID-19 pandemic in New Zealand between March 2020 and December 2021. 29 fully read articles from an integrative literature review were included, and the websites of the WHO, the World Bank, the “Stringency Index” of “ourworldindata” were consulted to collect data on the socio-demographic situation, economic indicators of the country, as well as tests, deaths, vaccines and new cases. The data were imported in CSV format and the graphs elaborated in RStudio software. The evidence points out that New Zealand can be considered a success story regarding the nationwide response to the COVID-19 pandemic, it being one of the countries with the lowest number of deaths from the disease in the world. This success was the result of a health system organization with fast internal action, high testing capacity, and contact tracing, without causing the collapse of the health system. In turn, it also pointed out that the population adhered to the confinement conditions, and faithfully followed the authorities’ instructions, even with low community participation in government decisions. Important lessons can be learnt leading to useful recommendations for a potential new epidemic with an unknown virus or similar.

Key words:
COVID-19; New Zealand; Epidemic

Introduction

The world faced a pandemic involving a new corona virus discovered in December 2019 in Wuhan province, China, causing COVID-19¹1 Sohrabi C, Alsafi Z, O'neill N, Khan M, Kerwan A, Al-Jabir A, Iosifidis C, Agha R. World Health Organization declares global emergency: a review of the 2019 novel coronavirus (COVID-19). Int J Surg 2020; 76:71-76. disease. In March 2020, the WHO declared a worldwide public health emergency, generating a set of measures for containment of the propagation of the virus, which varied from compulsory wearing of masks and social isolation to complete closure of services and borders, based on evidence from previous epidemics¹1 Sohrabi C, Alsafi Z, O'neill N, Khan M, Kerwan A, Al-Jabir A, Iosifidis C, Agha R. World Health Organization declares global emergency: a review of the 2019 novel coronavirus (COVID-19). Int J Surg 2020; 76:71-76.

2 World Health Organization (WHO). COVID-19 public health emergency of international concern [Internet]. 2020. [cited 2021 fev 20]. Available from: https://www.who.int/publications/m/item/covid-19-public-health-emergency-of-international-concern-(pheic)-global-research-and-innovation-forum
https://www.who.int/publications/m/item/...

3 Peak CM, Childs LM, Grad YH, Buckee CO. Comparing non pharmaceutical interventions for containing emerging epidemics. Proc Natl Acad Sci USA 2017; 114(15):4023-4028.

4 Hellewell J, Abbott S, Gimma A, Bosse NI, Jarvis CI, Russell TW, Munday JD, Kucharski AJ, Edmunds J. Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts. Lancet Glob Health 2020; 8(4):488-496.

5 Quilty BJ, Clifford S, Flasche S, group CCW, Eggo RM. Effectiveness of airport screening at detecting travellers infected with novel coronavirus (2019-nCoV). Euro Surveill 2020; 25(5):2000080.^-66 Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet 2020; 395(10228):931-934.. Regarding these measures, some countries, including Vietnam, Taiwan, South Korea, China and New Zealand⁷7 Summers J, Cheng HY, Lin HH, Barnard LT., Kvalsvig A, Wilson N, Baker MG. Potential lessons from the Taiwan and New Zealand health responses to the COVID-19 pandemic. Lancet Reg Health West Pac 2020; 4:100044.

8 Rossi TRA, Soares CLM, Silva GA, Paim JS, Silva LMV. A resposta da Coreia do Sul à pandemia de COVID-19: lições aprendidas e recomendações a gestores. Cad Saude Publica 2022; 38(1):00118621.^-99 Le TAT, Vodden K, Wu J, Atiwesh G. Policy responses to the COVID-19 pandemic in Vietnam. Int J Environ Res Public Health 2021; 18(2):559., were outstanding for their severe stance, maintaining operation of only the essential services for limited periods of the day. Studies have sought to identify the degree of effectiveness of the containment measures - mitigation - virus suppression on the evidence that the closure of services and schools, and home stay were effective in reducing the transmission of SARS-CoV-2, despite the damage caused to economies and general health¹⁰10 Flaxman S, Mishra S, Gandy A, Unwin HJT, Mellan TA, Coupland H, Whittaker C, Zhu H, Berah T, Eaton JW, Monod M, Team ICCR, Ghani AC, Donnelly CA, Riley S, Vollmer MAC, Ferguson NM, Okell LC, Bhatt S. Estimating the effects of non-pharmaceutical interventions on COVID-19 in Europe. Nature 2020; 584(7820):257-261.^,1111 Brauner JM, Mindermann S, Sharma M, Johnston D, Salvatier J, GavenciakT,Stephenson AB, Leech G, Altman G, Mikulik V, Norman AJ, Monrad JT, Besiroglu T, Ge H, Hartwick MA, Teh YW, Chindelevitch L, Gal Y, Kulveit J. Inferring the effectiveness of government interventions against COVID-19. Science 2021; 371(6531):eabd9338..

At the very beginning of the pandemic in 2020, New Zealand adopted a virus suppression strategy, called “COVID-Zero”, seeking to zero community transmission in the country by implementation of a series of measures on a scale ranging from level 1 to 4¹²12 New Zealand Government. New Zealand Covid-19 alert levels summary COVID-19 [Internet]. Govt.nz 2022. [cited 2022 jul 7]. Available from: https://covid19.govt.nz/about-our-covid-19-response/history-of-the-covid-19-alert-system/#alert-levels
https://covid19.govt.nz/about-our-covid-... . The higher the level, the more severe and more complete the closure of ports of entry and non-essential services¹²12 New Zealand Government. New Zealand Covid-19 alert levels summary COVID-19 [Internet]. Govt.nz 2022. [cited 2022 jul 7]. Available from: https://covid19.govt.nz/about-our-covid-19-response/history-of-the-covid-19-alert-system/#alert-levels
https://covid19.govt.nz/about-our-covid-... . However, as of September 2021, since the aim of total elimination became unsustainable, the country began to adopt a virus coexistence and control policy, investing in actions coupled with incentives for vaccination, contact monitoring, and even asymptomatic testing¹³13 Blair A, Pasquale M, Gabeff V, Rufi M, Flahault A. The end of the elimination strategy: decisive factors towards sustainable management of COVID-19. Epidemiol 2022; 3(1):135-147..

Throughout the pandemic period, March 2020 to July 2022, that claimed the lives of nearly 6 million worldwide, New Zealand recorded 1,628 deaths, and slightly more than 1.4 million infections. It is important to note that, until December 2021, the analysis period of this study, 51 deaths and 420,000 cases of infection had been registered¹⁴14 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. New Zealand: coronavirus pandemic country profile [Internet]. Our World in Data 2020. [cited 2021 jan 18]. Available from: https://ourworldindata.org/coronavirus/country/new-zealand
https://ourworldindata.org/coronavirus/c... . Faced with the severity of the pandemic and the magnitude of the data across the world, analyzing the experience in New Zealand’s response to the pandemic in the 2020s and 2021 can aid understanding of how the measures interfered with the course of the pandemic since the initial “COVID-Zero” control strategy and led to the subsequent relaxation of the measures.

Given the above, this study seeks to answer how New Zealand became a success story in COVID-19 control, and what was the contribution of its health system and surveillance model to this performance? Indeed, the objective of the study was to analyze the characteristics of the health system, the surveillance system and the measures adopted in the combat of the disease there.

Methodology

A case study was conducted through an integrative literature review focused on New Zealand’s response to COVID-19¹⁵15 Yin RK. Estudo de caso: planejamento e métodos. Porto Alegre: Bookman; 2005.. For identification of the studies, data were gathered through consultation of the CAPES periodicals portal: https://www.periodicos.capes.gov.br/ - PubMed Central, Science Direct, Web of Science, and Scopus. The searches in these bases were performed by title, summary and keywords, using as strategy the descriptors: “health system”, “surveillance” and “nationwide response” associated with the terms “COVID-19” and the name of the country in English. The period for inclusion of publications was from March 2020 to December 2021, including the largest number of texts that portrayed the characteristics of the New Zealand health system, the response to COVID-19 with emphasis on the surveillance and control strategies adopted.

There were 92 articles that underwent an identification process, removal of duplicates, and double-blind selection through Rayyan between two researchers, thus leaving 34 articles read in full. Of the latter, articles that did not deal with the country’s health system response, or were journal editorials or opinionative, were excluded. In the end, 29 articles were included (see the list in Table 1). These referred to one or more of the five categories or dimensions analyzed (characteristics of the country, government and the health system; evolution of the epidemic; measures adopted; governance; adhesion of the population; and health care).

The WHO website (https://COVID-19.who.int/table) and that of the New Zealand government (https://www.health.govt.nz/COVID-19) were also consulted, and, for data collection on the country’s socio-demographic situation and economic indicators, the site https://www.nz.gov was accessed. The information regarding deaths, vaccines, new cases and the Stringency Index were extracted from ourworldindata, https://ourworldindata. org/. The data were imported in CSV format, the graphics devised in the RStudio software, and the measurements included in the graphics by means of PowerPoint.

This study was developed within the scope of a research project entitled “Comparative Analysis of Health Systems in Response to COVID-19”, pursuant to a CNPq notice called MCTIC/CNPq/FNDCT/MS/SCTIE/DECIT number 07/2020. The CNPq Process No. Was 401744/2020-5. It is part of a broader project called “Analysis of COVID-19 Pandemic Health Surveillance Models and Strategies (2020-2022)”.

Results and discussion

From the documents and articles selected (Table 1) it was possible to characterize the country’s situation regarding its health system and process of organizing COVID-19 combat in five dimensions: (1) the characteristics of the country, government and health system; (2) evolution of the epidemic; (3) measures adopted in response to the pandemic; (4) governance and the population’s adhesion to the measures; and (5) health care.

Characteristics of the country, government and health system

New Zealand is an insular country, located in Oceania, with a territory of 268,838 square kilometers, and an estimated population of 4.917 million in 2021. The population is composed of approximately 16% Maori indigenous people, 7% Pacific peoples, 15% Asians and 62% Europeans and others¹⁶16 Jefferies S, French N, Gilkison C, Graham G, Hope V, Marshall J, McElnay C, McNeill A, Muellner P, Paine S, Prasad N, Scott J, Sherwood J, Yang L, Priest P. COVID-19 in New Zealand and the impact of the national response: a descriptive epidemiological study. Lancet Public Health 2020; 5(11):612-623.^,1717 Fouda A, Mahmoudi N, Moy N, Paolucci F. The COVID-19 pandemic in Greece, Iceland, New Zealand, and Singapore: health policies and lessons learned. Health Policy Technol 2020; 9(4):510-524.. The official language is English, recognized as the mother tongue by about 76% of the population¹⁸18 New Zealand Government. Guide to finding and using government services [Internet]. Govt.nz 2021. [cited 2021 dez 8]. Available from: https://www.govt.nz/
https://www.govt.nz... .

The New Zealand government is a parliamentary monarchy with a democratic, capitalist regime. It is a unitary state with highly centralized power in the national government. The English monarchy acts as head of the country, represented locally by a governor-general, whose powers cover appointment of ministers and ambassadors. In turn, the Prime Minister is in charge of the decision-making¹⁸18 New Zealand Government. Guide to finding and using government services [Internet]. Govt.nz 2021. [cited 2021 dez 8]. Available from: https://www.govt.nz/
https://www.govt.nz... .

It has high level social indicators, the human development index (HDI) in 2021 being 0.91, and the Gini Index, 0.44 in 2020. The unemployment rate varied close to 4% between December 2019 and September 2020. In 2021, the average life expectancy was 81.6, one of the longest in the world. About 99% of the population aged 15 and over is literate¹⁶16 Jefferies S, French N, Gilkison C, Graham G, Hope V, Marshall J, McElnay C, McNeill A, Muellner P, Paine S, Prasad N, Scott J, Sherwood J, Yang L, Priest P. COVID-19 in New Zealand and the impact of the national response: a descriptive epidemiological study. Lancet Public Health 2020; 5(11):612-623.^,1717 Fouda A, Mahmoudi N, Moy N, Paolucci F. The COVID-19 pandemic in Greece, Iceland, New Zealand, and Singapore: health policies and lessons learned. Health Policy Technol 2020; 9(4):510-524.^,1919 Organization for Economic Co-operation and Development (OECD). OECD Better Life Index [Internet]. 2015. [cited 2021 dez 8]. Available from: https://www.oecdbetterlifeindex.org/pt/paises/new-zealand-pt/
https://www.oecdbetterlifeindex.org/pt/p... . Around 88% of the population is reported to enjoy good health, and have illness profiles compatible with those in other developed countries, neoplasms being the main cause of death, the population of Maori origin presenting the greatest mortality and illness rates²⁰20 New Zealand Government. Annual Update of Key Results 2020/21 [Internet]. Govt.nz 2021. [cited 2021 dez 8]. Available from: https://www.health.govt.nz/publication/annual-update-key-results-2020-21-new-zealand-health-survey
https://www.health.govt.nz/publication/a... .

Through a universal health coverage system, all permanent residents have access to hospitalization, outpatient care, preventive medicine, mental health care, and pharmaceutical services, which can be provided by both public and private entities. According to the analysis undertaken, the health system is characterized by a Beveridian- based social protection system²¹21 Esping-Andersen, G. As três economias políticas do Welfare State. Lua Nova Rev Cult Política 1991; 2485-116..

The structure of the “New Zealand health and deficiency system” consists of 20 Basic Health Districts responsible for providing and financing their local health services. Part of these support services for people with disabilities and some health services are financed and acquired nationally by the Ministry of Health²²22 New Zealand Government. Ministry of Health. Building the future of health [Internet]. 2022. [cited 2022 jun 30]. Available from: https://www.health.govt.nz/new-zealand-health-system/key-health-sector-organisations-and-people/district-health-boards
https://www.health.govt.nz/new-zealand-h... . In turn, there are regional services provided by 12 public health units (PHUs) belonging to Basic Health Districts (BHDs), and which may have participation of non-governmental organizations. Public Health Units (PHUs) act in environmental health, transmissible disease control, tobacco control and health promotion programs. Non-governmental organizations (NGOs) may receive funding from the Ministry of Health and district health councils (DHCs) to provide services to the population, and these can be in private hospitals, laboratories, imagery clinics, primary health care (APS), with general practitioners and nurses, among other staff²³23 New Zealand Government. Ministry of Health. COVID-19: primary care [Internet]. 2022. [cited 2022 jun 30]. Available from: https://www.health.govt.nz/covid-19-novel-coronavirus/covid-19-information-health-professionals/covid-19-primary-care
https://www.health.govt.nz/covid-19-nove... .

Regarding the service infrastructure, in 2019, the country had 2.6 beds per 1,000 inhabitants, with a distribution ratio of doctors and nurses of 3.5/1,000 and 11.1/1,000, respectively in 2018²⁴24 World Bank. Physicians (per 1,000 people) - New Zealand [Internet]. 2022. [cited 2022 jul 10]. Available from: https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?locations=NZ&name_desc=false
https://data.worldbank.org/indicator/SH.... ^,2525 World Bank. Nurses and midwives (per 1,000 people) - New Zealand [Internet]. 2022. [cited 2022 jul 10]. Available from: https://data.worldbank.org/indicator/SH.MED.NUMW.P3?locations=NZ&name_desc=false
https://data.worldbank.org/indicator/SH.... . The country had 3.6 ICU beds/1 million inhabitants, less than the OECD average of 12 beds¹³13 Blair A, Pasquale M, Gabeff V, Rufi M, Flahault A. The end of the elimination strategy: decisive factors towards sustainable management of COVID-19. Epidemiol 2022; 3(1):135-147.^,2626 New Zealand Government. Ministry of Health. Ventilators and ICU bed capacity [Internet]. 2020. [cited 2022 jul 10]. Available from: https://www.health.govt.nz/system/files/documents/pages/ventilators_and_icu_capacity_11_may_2020.pdf
https://www.health.govt.nz/system/files/... .

New Zealand is seen as a country with a strong social policy, including action aimed at unemployment insurance - job seeker support, support for carers of children, the elderly and people with disabilities - “Supported Living Payment, and an invalidity allowance, that is, a weekly payment to help with regular and continuous costs, such as visits to the doctor or hospital, medication²⁷27 New Zealand Government. Ministry of Social Development. Benefits and payments [Internet]. [cited 2022 jul 10]. Available from: https://www.workandincome.govt.nz/products/a-z-benefits/index.html
https://www.workandincome.govt.nz/produc... . Studies reveal the government concern in the form of established social support measures during the pandemic and afterwards through support to entities and individuals affected by negative consequences, such as reduction or stoppage of businesses²⁸28 Sharma S, Walton M, Manning S. Social determinants of health influencing the New Zealand COVID-19 response and recovery: a scoping review and causal loop diagram. Systems 2021; 9(3):52.^,2929 Sokolowski MM. Regulation in the COVID-19 pandemic and post-pandemic times: day-watchman tackling the novel coronavirus. Esmerald insight 2020 15(2):206-218..

Following the 2005 avian flu epidemic, New Zealand developed plans to cope with influenza, involving adoption of measures aimed at mobilizing resources to respond to such sanitary crises. These plans included DHCs and PHUs that must maintain regional plans in their coverage areas that describe how services should be structured and provided during response to health emergencies³⁰30 New Zealand Government. Ministry of Health. New Zealand influenza pandemic action plan. Wellington: Ministry of Health; 2006.. However, there was also reference to the difficulties in preparing the country to face a pandemic, and the importance of work prior to sanitary crises, long-term investments, seeking to strengthen the capacity of the health system³¹31 Collins T, Akselrod S, Bloomfield A, Gamkrelidze A, Jakab Z, Placella E. Rethinking the COVID-19 pandemic: back to public health. Ann Glob Health 2020; 86(1):133..

Evolution of the epidemic in the country

New Zealand reported its first case of COVID-19 on 28th February, 2020. In mid-March 2020, with 20 cases, the New Zealand government introduced the first restrictive measures, and on the 25th implemented a nationwide lockdown, which remained in force for almost a month (Table 2). Given that no new cases were registered, in late May, some measures were relaxed, thus there was a return to Level 2, Then, in June, the measures were suspended, returning to Level 1¹²12 New Zealand Government. New Zealand Covid-19 alert levels summary COVID-19 [Internet]. Govt.nz 2022. [cited 2022 jul 7]. Available from: https://covid19.govt.nz/about-our-covid-19-response/history-of-the-covid-19-alert-system/#alert-levels
https://covid19.govt.nz/about-our-covid-... ^,3232 Chaple EB, Lekakis SG. La pandemia de COVID-19, estudio de casos: Australia, Nueva Zelandia y Cuba. Rev Haban Cienc Med 2020; 19(6)e3657.^,3333 Parag KV, Cowling BJ, Donnelly CA. Deciphering early-warning signals of SARS-CoV-2 elimination and resurgence from limited data at multiple scales. J R Soc Interface 2021; 18(185):20210569.. However, as new cases were detected in early August in Auckland, new contact restrictions and work at home were rapidly promulgated¹²12 New Zealand Government. New Zealand Covid-19 alert levels summary COVID-19 [Internet]. Govt.nz 2022. [cited 2022 jul 7]. Available from: https://covid19.govt.nz/about-our-covid-19-response/history-of-the-covid-19-alert-system/#alert-levels
https://covid19.govt.nz/about-our-covid-... (Figure 1 and Table 2).

Research conducted by Jefferies et al.¹⁶16 Jefferies S, French N, Gilkison C, Graham G, Hope V, Marshall J, McElnay C, McNeill A, Muellner P, Paine S, Prasad N, Scott J, Sherwood J, Yang L, Priest P. COVID-19 in New Zealand and the impact of the national response: a descriptive epidemiological study. Lancet Public Health 2020; 5(11):612-623. (2020) described the impact of New Zealand’s nationwide response to COVID-19 transmission. The authors found that much of the transmission had begun through cases imported by young people. The cases reached the elderly of lower socio-economic status and more likely to suffer severe consequences¹⁶16 Jefferies S, French N, Gilkison C, Graham G, Hope V, Marshall J, McElnay C, McNeill A, Muellner P, Paine S, Prasad N, Scott J, Sherwood J, Yang L, Priest P. COVID-19 in New Zealand and the impact of the national response: a descriptive epidemiological study. Lancet Public Health 2020; 5(11):612-623.. However, the transmission hit the entire country, the highest incidence being in popular tourist areas and in large gatherings, such as marriages, thus spreading transmission to a broader range of age groups³⁴34 Mazey S, Richardson J. Lesson-drawing from New Zealand and Covid-19: the need for anticipatory policy making. Polit Q 2020; 91(3):561-570.. Although there were no significant differences regarding the severity of cases among the ethnic groups during the first year of the pandemic, in the subsequent year, due to short-term regional restrictive/blocking measures, a greater number of cases were found, concentrated in economically disadvantaged geographical areas¹⁶16 Jefferies S, French N, Gilkison C, Graham G, Hope V, Marshall J, McElnay C, McNeill A, Muellner P, Paine S, Prasad N, Scott J, Sherwood J, Yang L, Priest P. COVID-19 in New Zealand and the impact of the national response: a descriptive epidemiological study. Lancet Public Health 2020; 5(11):612-623.^,2828 Sharma S, Walton M, Manning S. Social determinants of health influencing the New Zealand COVID-19 response and recovery: a scoping review and causal loop diagram. Systems 2021; 9(3):52.^,3232 Chaple EB, Lekakis SG. La pandemia de COVID-19, estudio de casos: Australia, Nueva Zelandia y Cuba. Rev Haban Cienc Med 2020; 19(6)e3657..

The power of the measures can be seen in the study by Douglas et al.³⁵35 Douglas J, Mendes FK, Bouckaert R, Xie D, Jiménez-Silva CL, Swanepoel C, Ligt J, Ren X, Storey M, Hadfield J, Simpson CR, Geoghegan JL, Drummond AJ, Welch D. Phylodynamics reveals the role of human travel and contact tracing in controlling the first wave of COVID-19 in four island nations. Virus Evol 2021; 7(2):veab052. (2021), which revealed a dramatic reduction from 7.5 cases/per million inhabitants on the day the blockade started to 0.4 25 days later³⁵35 Douglas J, Mendes FK, Bouckaert R, Xie D, Jiménez-Silva CL, Swanepoel C, Ligt J, Ren X, Storey M, Hadfield J, Simpson CR, Geoghegan JL, Drummond AJ, Welch D. Phylodynamics reveals the role of human travel and contact tracing in controlling the first wave of COVID-19 in four island nations. Virus Evol 2021; 7(2):veab052..

In 2021, there were 26 deaths. By the end of the year, the total accumulated since the start of the pandemic was 51, one of the lowest mortality rates among the OECD¹⁴14 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. New Zealand: coronavirus pandemic country profile [Internet]. Our World in Data 2020. [cited 2021 jan 18]. Available from: https://ourworldindata.org/coronavirus/country/new-zealand
https://ourworldindata.org/coronavirus/c... countries (Figure 2). There had been almost 18,000 infections. From the point of view of the variants, the first case of Delta occurred in August 2021, and, by September, there were 1,249, of which 818 (65%) occurred in people from the Pacific region, in one of the District Health Council areas³⁶36 Smith A, Fereti S, Adams S. Inequities and perspectives from the COVID-Delta outbreak: the imperative for strengthening the Pacific nursing work force in Aotearoa New Zealand. Nurs Prax Aot NZ 2021; 37(3):94-103.. With the increase in cases, in October 2021, the government announced the abandonment of the “COVID-Zero” strategy, and proposed a modification to its pandemic confrontation scheme, consisting of a new protection system at three, more flexible levels, replacing, as of December 2021, the alert levels by a new configuration in three colors: red, orange and green. In July 2022, the situation in New Zealand was ranked orange³⁷37 New Zealand Government. Ministry of Health. COVID-19: minimization and protection strategy for Aotearoa New Zealand [Internet]. 2022. [cited 2022 maio 10]. Available from: https://www.health.govt.nz/our-work/diseases-and-conditions/COVID-19-novel-coronavirus/COVID-19-response-planning/COVD-19-minimisation-and-protection-strategy-aotearoa-new-zealand
https://www.health.govt.nz/our-work/dise... .

The arrival of the Omicron variant in late 2021 led to an explosion of cases in 2022, leading to over 151 deaths between January and March, 70 of which occurred between 10th and 17th¹⁴14 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. New Zealand: coronavirus pandemic country profile [Internet]. Our World in Data 2020. [cited 2021 jan 18]. Available from: https://ourworldindata.org/coronavirus/country/new-zealand
https://ourworldindata.org/coronavirus/c... . Nevertheless, in 2022, the country achieved vaccination coverage of 95% of the population in the primary scheme, and, since August 2021, maintained its rate above 80% ¹⁴14 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. New Zealand: coronavirus pandemic country profile [Internet]. Our World in Data 2020. [cited 2021 jan 18]. Available from: https://ourworldindata.org/coronavirus/country/new-zealand
https://ourworldindata.org/coronavirus/c... . According to the Stringency Index (SI), it was possible to observe that NZ reached high rigidity values in the execution of its measures, peaking as high as 96.3% in some of the months analyzed (Figures 1 and 2). There was also greater strictness in the enforcement of the measures from June to August 2020, which proved to be important for the overall pandemic control¹⁴14 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. New Zealand: coronavirus pandemic country profile [Internet]. Our World in Data 2020. [cited 2021 jan 18]. Available from: https://ourworldindata.org/coronavirus/country/new-zealand
https://ourworldindata.org/coronavirus/c... . In August 2021, when new cases arose, it was clear that the measures assumed greater severity, as indicated by the SI returning to 96.3% (Figures 1 and 2; Table 2).

Measures adopted in response to the COVID-19 pandemic

The policy adopted by New Zealand in 2020 was guided by their COVID-Zero strategy, based on the proposal to suppress the circulation of the virus, to the point where the case curve would be flattened, community transmission of the virus having ceased. Pursuing this process, NZ succeeded in temporarily eliminating the circulation of the virus. Until August 2020, no cases had been registered for 101 days .

Throughout the COVID-19 pandemic, the emphasis of the actions taken in New Zealand were focused on: a) PCR tests among priority populations; b) Registration of all symptomatic people in the My COVID Record or through 0800 222 478; c) Quick tests available in various locations; and d) Quick tests for asymptomatic medical care staff, and case confirmation among workers¹²12 New Zealand Government. New Zealand Covid-19 alert levels summary COVID-19 [Internet]. Govt.nz 2022. [cited 2022 jul 7]. Available from: https://covid19.govt.nz/about-our-covid-19-response/history-of-the-covid-19-alert-system/#alert-levels
https://covid19.govt.nz/about-our-covid-... .

In this process, the government expressly recommended closure of schools and non-essential services, prohibition of social gatherings, mandatory quarantine for travelers, and border closure, except for residents³⁸38 Sakib MN, Butt ZA, Morita PP, Oremus M, Fong GT, Hall PA. Considerations for an individual-level population notification system for pandemic response: A review and prototype. J Med Internet Res 2020; 22(6):19930.. Being insular, there was a great movement to reduce the risk of contamination from abroad, creating structures to apply to all incoming travelers, keeping them in compulsory quarantine¹⁶16 Jefferies S, French N, Gilkison C, Graham G, Hope V, Marshall J, McElnay C, McNeill A, Muellner P, Paine S, Prasad N, Scott J, Sherwood J, Yang L, Priest P. COVID-19 in New Zealand and the impact of the national response: a descriptive epidemiological study. Lancet Public Health 2020; 5(11):612-623.^,3333 Parag KV, Cowling BJ, Donnelly CA. Deciphering early-warning signals of SARS-CoV-2 elimination and resurgence from limited data at multiple scales. J R Soc Interface 2021; 18(185):20210569.^,3939 Baker MG, Kvalsvig A, Verrall AJ, Wellington N. New Zealand's COVID-19 elimination strategy. Med J Aust 2020; 213(5):198-200.

40 Steyn N, Plank MJ, James A, Binny RN, Hendy SC, Lustig A. Managing the risk of a COVID-19 outbreak from border arrivals. J R Soc Interface 2021; 18(177):20210063.^-4141 Desforges M, Gurdasani D, Hamdy A, Leonardi AJ. Uncertainty around the long-term implications of COVID-19. Pathogens 2021; 10(10):1010-1267..

The first wave, the implementation of the measures effectively eliminated community transmission of COVID-19, there being no detection of new cases from 14th May to 9th June 2020¹⁴14 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. New Zealand: coronavirus pandemic country profile [Internet]. Our World in Data 2020. [cited 2021 jan 18]. Available from: https://ourworldindata.org/coronavirus/country/new-zealand
https://ourworldindata.org/coronavirus/c... ^,4242 Huang Q S, Wood T, Jelley L, Jennings T , Jefferies S, Daniells K, Nesdale A, Dowell T, Turner N, Campbell-Stokes P, Balm M, Dobinson HC, Grant CC, James S, Aminisani N, Ralston J, Gunn W, Bocacao J, Danielewicz J, Moncrieff T, McNeill A, Lopez L, Waite B, Kiedrzynski T, Schrader H, Gray R, Cook K, Currin D, Engelbrecht C, Tapurau W, Emmerton L, Martin M, Baker MG, Taylor S, Trenholme A, Wong C, Lawrence S, McArthur C, Stanley A, Roberts S, Rahnama F, Bennett J, Mansel C, Dilcher M, Werno A, Grant J, Linden AVD, Youngblood B, Thomas PG, Consortium N, Webby RJ. Impact of the COVID-19 non pharmaceutical interventions on influenza and other respiratory viral infections in New Zealand. Nat Commun 2021; 12(1):1001.^,4343 Lee A, Thornley S, Morris AJ, Sundborn G. Should countries aim for elimination in the covid-19 pandemic? BMJ 2020; 370:m3410.. Thus, studies show that the success in NZ’s pandemic control was largely due to the strength and severity of the measures¹⁶16 Jefferies S, French N, Gilkison C, Graham G, Hope V, Marshall J, McElnay C, McNeill A, Muellner P, Paine S, Prasad N, Scott J, Sherwood J, Yang L, Priest P. COVID-19 in New Zealand and the impact of the national response: a descriptive epidemiological study. Lancet Public Health 2020; 5(11):612-623.^,4444 Wilson G, Windner Z, Dowell A, Toop L, Savage R, Hudson B. Navigating the health system during COVID-19: primary care perspectives on delayed patient care. N Z Med J 2021; 134:17-27..

There was relatively early recognition by New Zealand of the vital importance of epidemiological modeling in the monitoring of COVID-19 behavior, by means of statistical tests in which there was no blockade. It is estimated that, in 2020, more than 14,000 deaths would have occurred in the country, if the measures had not been adopted⁴⁵45 Cook L, Gray A. Official statistics in the search for solutions for living with COVID-19 and its consequences. Stat J IAOS 2020; 36(2):253-278.. The strategy also included provision of free COVID-19 tests, and treatment for anyone with symptoms¹⁴14 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. New Zealand: coronavirus pandemic country profile [Internet]. Our World in Data 2020. [cited 2021 jan 18]. Available from: https://ourworldindata.org/coronavirus/country/new-zealand
https://ourworldindata.org/coronavirus/c... .

A study by Chaple & Gillies-Lekakis³²32 Chaple EB, Lekakis SG. La pandemia de COVID-19, estudio de casos: Australia, Nueva Zelandia y Cuba. Rev Haban Cienc Med 2020; 19(6)e3657. (2021), comparing Cuba, Australia and New Zealand, countries that combated the pandemic with more drastic measures, listed social distancing, border closure and isolation of cities, provinces or states as measures that contributed to the control in the first year³²32 Chaple EB, Lekakis SG. La pandemia de COVID-19, estudio de casos: Australia, Nueva Zelandia y Cuba. Rev Haban Cienc Med 2020; 19(6)e3657..

What was unique in NZ was the establishment of control posts for the circulation of people in the rural areas, led by Maori/Iwi communities as a form of humanitarian, cultural and community response to COVID-19⁴⁶46 Dutta MJ, Elers C, Jayan P. Culture-centered processes of community organizing in COVID-19 response: notes from Kerala and Aotearoa New Zealand. Front Commun 2020; 5:62.. These communities contributed to the policing at some of the control posts, operated later in conjunction with the official police service⁴⁶46 Dutta MJ, Elers C, Jayan P. Culture-centered processes of community organizing in COVID-19 response: notes from Kerala and Aotearoa New Zealand. Front Commun 2020; 5:62.^,4747 Deckert A, Long NJ, Aikman PJ, Appleton NS, Davies SG, Trnka S, Fehoko E, Holroyd E, Jivraj N, Megan L, Anatias NM, Pukepuke R, Roguski M, Sterling R, Tunufa'i L. 'Safercommunities... together'? Plural policing and COVID-19 public health interventions in Aotearoa New Zealand. Policing Soc 2021; 31(5):621-637..

It is noteworthy that the restrictions on entry to the country were implemented before the WHO recommendation. They were imposed as of the very first case in the country, which was on 28th January, 2020. The National Center for Health Co-ordination, in response to the epidemic, remained active throughout the entire period.

The gradual relaxation of the blockade began in June 2020, with flexibility regarding certain restrictions, such as allowing small gatherings of up to 10 people.

New Zealand complemented the traditional approaches to the pandemic with new tools, such as digital technology through a mobile application called “NZ COVID Tracer” for location and registration of all new cases³²32 Chaple EB, Lekakis SG. La pandemia de COVID-19, estudio de casos: Australia, Nueva Zelandia y Cuba. Rev Haban Cienc Med 2020; 19(6)e3657.. New Zealand also introduced a testing policy, which advanced from taking tests of anyone with symptoms in 2020 as a major posture, to the inclusion and testing of everyone, irrespective of symptoms, as of 2021¹⁴14 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. New Zealand: coronavirus pandemic country profile [Internet]. Our World in Data 2020. [cited 2021 jan 18]. Available from: https://ourworldindata.org/coronavirus/country/new-zealand
https://ourworldindata.org/coronavirus/c... . In a similar manner, the tracking policy included all cases characterized as comprehensive tracing (all cases) in the two years under analysis¹⁴14 Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, Hasell J, Macdonald B, Beltekian D, Roser M. New Zealand: coronavirus pandemic country profile [Internet]. Our World in Data 2020. [cited 2021 jan 18]. Available from: https://ourworldindata.org/coronavirus/country/new-zealand
https://ourworldindata.org/coronavirus/c... .

Governance in conducting the pandemic and adhesion of the population to the measures

The co-ordination of the pandemic response in New Zealand was related to the strength and leadership of the Prime Minister, Jacinda Arden, who conducted the entire pandemic control strategy alongside the Director General of Public Health, Ashley Robin Bloomfield. The latter had followed a professional career at the Ministry of Health since 2004, held a master’s degree in Public Health, and was a specialist in non-transmissible diseases.

The New Zealand Prime Minister was acknowledged for establishing the “gold standard” of pandemic management, the proactivity of which placed the country at the top of the COVID-19 performance index ranking. A study conducted by Porchen & Assefa⁴⁸48 Chen YY, Assefa Y. The heterogeneity of the COVID-19 pandemic and national responses: an explanatory mixed-methods study. BMC Public Health 2021; 21(1):835. (2021), comparing nine countries with different income levels, found that she had conveyed clear, consistent messages, which had inspired confidence and security, contributing to even greater adherence on the part of the population⁴⁸48 Chen YY, Assefa Y. The heterogeneity of the COVID-19 pandemic and national responses: an explanatory mixed-methods study. BMC Public Health 2021; 21(1):835.^,4949 Dada S, Ashworth HC, Bewa MJ, Dhatt R. Words matter: political and gender analysis of speeches made by heads of government during the COVID-19 pandemic. BMJ Glob Health 2021; 6(1):003910.. The government published daily briefings about the corona virus situation and promoted social media campaigns ever since the start in January 2020⁴⁸48 Chen YY, Assefa Y. The heterogeneity of the COVID-19 pandemic and national responses: an explanatory mixed-methods study. BMC Public Health 2021; 21(1):835.. It was pointed out that the Prime Minister had adopted what the authors called the “ethical care approach”, in which, for six months, all ministers and executives working in government agencies accepted a 20% cut in salary to express their solidarity with those who had lost their jobs or suffered cuts in income⁴⁸48 Chen YY, Assefa Y. The heterogeneity of the COVID-19 pandemic and national responses: an explanatory mixed-methods study. BMC Public Health 2021; 21(1):835.. Another research work that analyzed the discourses of 20 heads of state around the world, including New Zealand, stressed that female leaders more often addressed the impact at the individual level, and extended their concerns to the risks of developing mental health problems and domestic violence⁴⁹49 Dada S, Ashworth HC, Bewa MJ, Dhatt R. Words matter: political and gender analysis of speeches made by heads of government during the COVID-19 pandemic. BMJ Glob Health 2021; 6(1):003910..

An important fact in the case of New Zealand was the population’s adherence to the isolation measures, respecting, in an exemplary and disciplined manner, the confinement conditions, as well as faithfully following all the authorities’ other instructions and recommendations³²32 Chaple EB, Lekakis SG. La pandemia de COVID-19, estudio de casos: Australia, Nueva Zelandia y Cuba. Rev Haban Cienc Med 2020; 19(6)e3657.. On the other hand, studies also revealed criticism of the process of including traditional communities in the health system, and also of the adequacy of guidelines in the different languages, especially for the Maoris and refugees for whom language represented an obstacle to understanding the measures, disseminated mostly in English⁵⁰50 Jones R. COVID-19 and Maori health: 'The daily 1pm briefings have been an exercise in whiteness' [Internet]. 2020. [cited 2022 jul 10]. Available from: https://thespinoff.co.nz/atea/13-05-2020/covid-19-and-maori-health-the-daily-1pm-briefings-have-been-an-exercise-in-whiteness/
https://thespinoff.co.nz/atea/13-05-2020... . In spite of such evidence, they also cited the existence of care actions benefiting these communities, including telephone numbers managed by volunteers helping the blockade, digital screening of services rendered by churches and their work with local organizations in the distribution of food packages⁵¹51 Elers C, Jayan P, Elers P, Dutta MJ. Negotiating health amidst COVID-19 lockdown in low-income communities in Aotearoa New Zealand. Health Commun 2021; 36(1):109-115..

New Zealand also pioneered a social bubble model that allowed a particular group of people to maintain close physical contact with each other while practicing physical distancing rules with others outside the group⁵²52 Han E, Tan MMJ, Turk E, Sridhar D, Leung GM, Shibuya K, Asgari N, Oh J, García-Basteiro AL, Hanefeld J, Cook AR, Hsu LY, Teo YY, Heymann D, Clark H, McKee M, Legido-Quigley H. Lessons learnt from easing COVID-19 restrictions: ananalysis of countries and regions in Asia Pacific and Europe. Lancet 2020; 396(10261):1525-1534..

The role of indigenous peoples in monitoring mobility or the effects of language. along with the role of the government, raised questions in understanding the special nature of New Zealand’s response. It can be suggested that its success was achieved because politics and science in this democracy spoke with the same coherent voice, and the government and communities implemented the program carefully. No false choice between economics and COVID was required, and discordant voices kept relatively silent. However, the latter did not happen in Brazil or the United States⁶6 Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet 2020; 395(10228):931-934.^,4343 Lee A, Thornley S, Morris AJ, Sundborn G. Should countries aim for elimination in the covid-19 pandemic? BMJ 2020; 370:m3410..

Health care

In spite of the degree of organization of the care based on the existence of the DHCs and their areas of expertise, situations were identified that revealed deficiencies in the process of reference and articulation between primary care and other levels of care, mainly in rural areas.

A significant aspect of the New Zealand health system was referred to in Berger et al.¹⁷17 Fouda A, Mahmoudi N, Moy N, Paolucci F. The COVID-19 pandemic in Greece, Iceland, New Zealand, and Singapore: health policies and lessons learned. Health Policy Technol 2020; 9(4):510-524., 2021, namely the small number of nurses specialized in the prevention and control of infections at national level, which required adjustment to the new pace and ways of working in the face of the situation⁵³53 Berger S. Encounters with uncertainty and complexity: reflecting on infection prevention and control nursing in Aotearoa during the COVID-19 pandemic. Nurs Prax Aot N Z 2021; 37(3):15-19.. To overcome such limitations, the anticipation of actions was viewed as positive, and different strategies were implemented to rationalize hospital resources and minimize the risk of staff exposure

In the hospitals, centers had to adapt routines and restructure existing staff teams. Hospital leaders were called upon to think about reorganization strategies in order, in many cases, to deal with a lack of staff. Non-urgent operations, endoscopies and clinical consultations were postponed due to the allocation of operating rooms to COVID-19⁵⁴54 Panda N, Sinyard RD, Henrich N, Cauley CE, Hannenberg AA, Sonnay Y, Bitton A, Brindle M, Molina G. Redeployment of health care workers in the COVID-19 pandemic: a qualitative study of health system leaders' strategies. J Patient Saf 2021; 17(4):256-263.^,5555 Toh KHQ, Barazanchi A, Rajaretnam NS, Tan J, Linton T, Murray M, Fagan P, Koea J. COVID-19 response by New Zealand general surgical departments in tertiary metropolitan hospitals. ANZ J Surg 2021; 91(7-8):1352-1357..

All the centers adopted the telemedicine strategy as the main means of communication among the doctors and for medical-patient consultations. This raised the issue of the applicability of telemedicine in health care in the future⁵⁵55 Toh KHQ, Barazanchi A, Rajaretnam NS, Tan J, Linton T, Murray M, Fagan P, Koea J. COVID-19 response by New Zealand general surgical departments in tertiary metropolitan hospitals. ANZ J Surg 2021; 91(7-8):1352-1357..

However, low articulation among the various health services⁵⁶56 Duncanson M, Wheeler BJ, Jelleyman T, Dalziel SR, McIntyre P. Delayed access to care and late presentations in children during the COVID-19 pandemic New Zealand-wide lockdown: a New Zealand paediatric surveillance unit study. J Paediatr Child Health 2021; 57(10):1600-1604.

57 Imlach F, McKinlay E, Kennedy J, Pledger M, Middleton L, Cumming J, McBride-Henry K. Seeking healthcare during lockdown: challenges, opportunities and lessons for the future. Int J Health Policy Manag 2021; 11(8):1316-1324.^-5858 Nixon G, Blattner K, Withington S, Miller R, Stokes T. Exploring the response to the COVID-19 pandemic at the rural hospital-base hospital interface: experiences of New Zealand rural hospital doctors. N Z Med J 2021; 134(1545):11-21. was also in evidence. It is referred to in the work by Duncanson et al.⁵⁶56 Duncanson M, Wheeler BJ, Jelleyman T, Dalziel SR, McIntyre P. Delayed access to care and late presentations in children during the COVID-19 pandemic New Zealand-wide lockdown: a New Zealand paediatric surveillance unit study. J Paediatr Child Health 2021; 57(10):1600-1604. (2021). Reduced access to primary and secondary care during the pandemic generated potential health care deficiencies for children, particularly the newborn. A study carried out by Imlach⁵⁷57 Imlach F, McKinlay E, Kennedy J, Pledger M, Middleton L, Cumming J, McBride-Henry K. Seeking healthcare during lockdown: challenges, opportunities and lessons for the future. Int J Health Policy Manag 2021; 11(8):1316-1324. (2020) revealed that, due to excessive focus on COVID-19 and the difficulties in contacting the normal hospital services, more than half of the interviewees postponed seeking health care during the blockade, indicating low integration of the health services. From the point of view of primary care, there were difficulties related to the use of new technologies, new forms of work and environmental safety. For individuals it was the fear of infection, the recognition of service overload, deficient management and low screening capacity⁵⁷57 Imlach F, McKinlay E, Kennedy J, Pledger M, Middleton L, Cumming J, McBride-Henry K. Seeking healthcare during lockdown: challenges, opportunities and lessons for the future. Int J Health Policy Manag 2021; 11(8):1316-1324..

The work by Nixon⁵⁸58 Nixon G, Blattner K, Withington S, Miller R, Stokes T. Exploring the response to the COVID-19 pandemic at the rural hospital-base hospital interface: experiences of New Zealand rural hospital doctors. N Z Med J 2021; 134(1545):11-21. (2021) mentioned a good local response from rural hospitals, but a lack of understanding on the part of the DHCs about these hospitals, leading to uncertainty about the transfer of COVID-19⁵⁸58 Nixon G, Blattner K, Withington S, Miller R, Stokes T. Exploring the response to the COVID-19 pandemic at the rural hospital-base hospital interface: experiences of New Zealand rural hospital doctors. N Z Med J 2021; 134(1545):11-21. patients in a grave condition.

Seeking to overcome such deficiencies, McBride’s⁵⁹59 McBride P, Hoang T, Hamblin R, Li Y, Shuker C, Wilson J, Bramley D. Using REACH, a new modelling and forecasting tool, to understand the delay and backlog effects of COVID-19 on New Zealand's health system. N Z Med J 2021; 134(1544):159-168 work revealed the testing of a tool to identify waiting list delays and elective consultations in order to understand the effects of these backlogs on COVID-19 and avoid future problems.

In any case, Gozenbach⁶⁰60 Gonzenbach TP, McGuinness, SP, Parke RL, Merz TM. Impact of non pharmaceutical interventions on ICU admissions during lockdown for coronavirus disease 2019 in New Zealand: a retrospective cohort study. Crit Care Med 2021; 49(10):1749-1756. (2021) revealed in his study that non-pharmaceutical interventions were associated with a significant decrease in the elective and acute ICU admissions, and the use of ICU⁶⁰60 Gonzenbach TP, McGuinness, SP, Parke RL, Merz TM. Impact of non pharmaceutical interventions on ICU admissions during lockdown for coronavirus disease 2019 in New Zealand: a retrospective cohort study. Crit Care Med 2021; 49(10):1749-1756. resources.

Final considerations

The evidence of this integrative review points out that New Zealand can be considered a success case regarding the nationwide response to the COVID-19 pandemic, indeed one of the countries with fewer deaths from the disease. The alliance between government leadership, population adherence and the existence of compensatory policies and community transmission reduction strategies resulted in pandemic control until the entry of the Omicron variant at the end of 2021. As for the relevance of the strategy, New Zealand was the only country to be able to zero the transmission of COVID-19 for a period of more than 100 days. In fact, three aspects considered important in comparative studies among countries⁶¹61 Machado CV, Pereira AMM, Freitas, CM. As respostas dos países à pandemia em perspectiva comparada: semelhanças, diferenças, condicionantes e lições. In: Machado CV, Pereira AMM, Freitas CM, organizadores. Políticas e sistemas de saúde em tempos de pandemia: nove países, muitas lições. Rio de Janeiro: 2022. p. 323-342. were observed in the New Zealand case: 1) a great density of governance and national co-ordination strategies; 2) comprehensive pandemic containment and mitigation measures, with control actions, physical distancing, wearing of masks, among others associated with vulnerable group protective action; and 3) good health system response capacity, with safeguards for identification, testing and health care. In contrast, the Brazilian case was emblematic because, from the point of view of governance, there was denial by the national leadership, fragmented response and little articulation between legal and normative measures at the federal, state and municipal levels, along with divergent information and lack of communication with the public⁶¹61 Machado CV, Pereira AMM, Freitas, CM. As respostas dos países à pandemia em perspectiva comparada: semelhanças, diferenças, condicionantes e lições. In: Machado CV, Pereira AMM, Freitas CM, organizadores. Políticas e sistemas de saúde em tempos de pandemia: nove países, muitas lições. Rio de Janeiro: 2022. p. 323-342..

New Zealand’s success was the result of organization of a rapid-response internal health system , which was able to reduce the effects of the pandemic without collapse of the system. In turn, the extensive economic package released by the government contributed to reducing and alleviating problems arising from the intense blockade in the first two years. However, this was not without damage from the economic point of view, mainly because tourism is a major source of revenue.

It is concluded that the early, proactive, rigid intervention, along with applying previous experience in disease transmission and the evolution of test strategies, were important lessons that may be recommended as useful for potential new epidemics of unknown viruses or similar pandemics.

It is worth mentioning the importance of following the analysis of New Zealand’s experience in facing the COVID-19 pandemic, mainly from 2022 when the highest incidence and mortality occurred, and its implications for the organization of the health system and the return to economic and social activities, including reopening the country to foreign tourism. Furthermore, it is relevant to analyze in subsequent studies the role of pre-existing social policies and those implemented during the pandemic, especially for the traditional communities and more vulnerable social groups.

References

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History