Main Report - NZ Royal Commission

Whītiki Aotearoa:
Lessons from COVID-19 to

prepare Aotearoa New Zealand
for a future pandemic
Main Report
PHASE
NOVEMBER 2024
ONE
2
NAKU TE ROUROU
NAU TE ROUROU
KA ORA AI TE IWI
WITH YOUR BASKET
AND MY BASKET THE
PEOPLE WILL THRIVE
i
Navigating our reports |
Te wherawhera i ā mātau pūrongo
2024 – Phase One

This is Part One of the Main Report for Te Tira Ārai Urutā the Royal
Commission of Inquiry into COVID-19 Lessons Learned. To see
the entire report suite, visit covid19lessons.royalcommission.nz
Main Report:
Part One: Part Two: Part Three:

Preliminaries Looking Back Moving Forward
THIS
DOCUMENT
Supporting documents:
Experiences Summary Consolidated

of the report lessons and
COVID-19 recommendations
pandemic
2026 – Phase Two
Main
Report
Acknowledgements |
He mihi
The COVID-19 pandemic impacted everyone in Aotearoa New Zealand and

around the world. The response to the pandemic required extraordinary
effort, sacrifice and resilience from all of us.
Considering the scale of the COVID-19 While our task has been primarily to
pandemic, and the national response recommend how Aotearoa New Zealand
to it, it is no surprise that completing can prepare for and respond to a future
our Inquiry has been a collaborative pandemic, we also want to acknowledge
undertaking. Our work as Commissioners the enormous effort of everyone who
has benefited from the inputs and delivered the response to the last
insights we received from thousands pandemic, COVID-19. We know that
of New Zealanders, both here and without your tireless work and dedication,
overseas, and from our networks of New Zealand’s response would have
international colleagues. fallen far short.
These contributions came through many
channels. Between February 2023 and
September 2024, we met with more than
“ Chairing this Inquiry has been both
1,600 individuals from across Aotearoa a huge privilege and a genuinely
New Zealand and from overseas. We stimulating and rewarding task. ”
would like to acknowledge and thank Professor Tony Blakely
each of you for generously sharing your
pandemic experiences and insights.
Thank you to the nearly 13,000 individuals,
whānau (families) and organisations
who made submissions to the Inquiry.
We know that sharing these experiences
could be difficult for people. We appreciate
the time and effort each submission took
and are grateful for them all.
Thank you to everyone who provided
written evidence to the Inquiry. We
greatly appreciate the time and effort
that went into preparing and submitting
this material to us.
AOTEAROA NEW ZEALAND ROYAL COMMISSION COVID-19 LESSONS LEARNED • MAIN REPORT: PART 1 – PRELIMINARIES iii
Thank you to the healthcare and essential To those who did their best to ensure
workers, the social service providers and that life’s milestones – births, deaths,
the educators for the work you did under marriages – could still be celebrated
challenging circumstances. To Aotearoa and honoured in some way, despite
New Zealand’s communities and leaders – the challenges. To those who made
iwi, Pacific peoples and ethnic communities. sure access to government and public
To the non-governmental organisations, services (the courts, social assistance,
volunteers and others who supported the housing and more) was maintained.
people who were most vulnerable to the To those who helped people safely
pandemic or impacted by it. To everyone return to or leave Aotearoa New Zealand,
who made sure the information necessary including the country’s offshore workforce,
to safely navigate through COVID-19 was or who were deployed to the managed
provided. To those who kept the workers isolation and quarantine (MIQ) facilities.
employed, and to those who kept working To the New Zealand Police and Defence
during the pandemic. To those who Force personnel who kept everyone safe,
provided the necessary services for life – even when it sometimes meant being in
food, water, electricity. harm’s way.
To those across Aotearoa New Zealand
who lifted people’s spirits and drew
them together through arts, culture and
Under extraordinary sport. To all those who supported their
whānau, friends and neighbours through
circumstances, uncertain times. To the kiwi diaspora
you all displayed remarkable
living overseas, who relayed much-
resilience, compassion and
commitment that helped get appreciated information and aroha from
Aotearoa New Zealand through the elsewhere even when they could not
pandemic: a heartfelt thank you. easily make it home in person. To those
who had to make the difficult decisions
that would affect the entire nation.
Under extraordinary circumstances,
you all displayed remarkable resilience,
compassion and commitment that helped
get Aotearoa New Zealand through the
pandemic: a heartfelt thank you.
iv AOTEAROA NEW ZEALAND ROYAL COMMISSION COVID-19 LESSONS LEARNED • MAIN REPORT: PART 1 – PRELIMINARIES
We also want to record our thanks to the A huge thank you to those in the government
people who made the Inquiry tick and and private sectors who helped us connect
this report a reality. Firstly, thank you to effectively with important communities,
former Commissioner, the Honourable raised awareness of our work, ensured
Hekia Parata (Ngati Porou, Ngāi Tahu) many New Zealanders could contribute
for your significant contribution to Phase to the Inquiry through a public submission
One. Thank you to Dr Justine Cornwall, or an in-person conversation, and
Executive Director of the Inquiry, for supported us with the analysis of the
your hard work and leadership, and your public submissions we received. We
tireless enthusiasm and commitment could not have done it without you.
despite the scale of the task. Thank you
Finally, we would like to thank our partners
to Anita West, whose early and able
for their encouragement and support
leadership enabled a quick and efficient
throughout our work on the Inquiry.
establishment of the Inquiry – and
recruitment of an outstanding Secretariat
team. Thank you to Jane Meares and
Asher Emanuel, Counsel Assisting for the
Inquiry, for your exemplary legal expertise.
And thank you to every member of the
Secretariat, for your tireless efforts to
collect and analyse evidence, organise
engagements, communicate with our
stakeholders, coordinate the natural
justice process, assist with drafting the
report and many more tasks besides – it
has been a privilege to work with you. Our
thanks also to the Department of Internal
Affairs who supported the Inquiry, and
in particular to the Department’s Chief
Executive, Paul James.
“ I sincerely hope that our Phase One

work – and indeed Phase Two – will
make a real difference for this
country that I am so proud of. ”
John Whitehead
AOTEAROA NEW ZEALAND ROYAL COMMISSION COVID-19 LESSONS LEARNED • MAIN REPORT: PART 1 – PRELIMINARIES v
Contents |
Ngā kaupapa
Part One: Preliminaries
01 Commissioners’ foreword 3
02 Summary – our lessons and recommendations 10

Introduction 10
Lessons learned from looking back 11
Lessons learned for the future 13
Recommendations 14
03 About the Inquiry 16

Why and how the Inquiry was established 16
Our terms of reference 17
Our approach to the Inquiry 19
How we gathered and used evidence 21
04 About the report 28
05 Pre-pandemic Aotearoa New Zealand: an overview 29
06 Endnotes 37
1 AOTEAROA NEW ZEALAND ROYAL COMMISSION COVID-19 LESSONS LEARNED • MAIN REPORT: PART 1 – PRELIMINARIES
Part One:
Preliminaries |
He Whakataki
2
Commissioners’
H1 | foreword |
0.0
01 Te ReoWhakataki
Kupu Translation
Among the many shocks COVID-19 dealt Aotearoa New Zealand was a
profound and prolonged loss of certainty. When we first saw footage of
deserted streets in Wuhan and overflowing wards in Italian hospitals, we
were bewildered. What was this new infection, would it affect us and how
bad would it get? When would things go back to normal?
Very soon, it was clear there would be Most of us learned to live with the
no escaping COVID-19 and normal life unknowns, the instability and the
would be on hold for some time to come. sheer strangeness of it all. We recognised
By mid-March 2020, the Government that, however tough things seemed
knew it needed to respond strongly, given here, many other countries had it far
the risk that COVID-19 would otherwise worse. International comparative studies
over-run our health system and cause have since borne that out. Our COVID-19
many deaths. As an island state, we had mortality rate was much lower than
an opportunity unavailable to many most other countries, including the
countries already in the grip of COVID-19: United States and the United Kingdom
we could stamp it out to the extent it had (see Chapter 1 for an overview of
reached Aotearoa New Zealand already Aotearoa New Zealand’s comparative
and then do our best to shut out further pandemic outcomes).
incursions, at least for a while. And so, at
Our health system was never overwhelmed
the end of March 2020, the Government
by COVID-19 cases, although it was often
made the difficult decision to, in effect,
strained in other ways. While our use of
close the borders and put the whole
lockdowns was among the most stringent
country into lockdown.
in the world, it was relatively sparing: we
spent more of 2020 free from onerous
restrictions than people elsewhere. A
Almost overnight, the routine generous economic response cushioned
and familiar was upended. people from the worst of the pandemic’s
immediate impacts and – initially at least
– Aoteaora New Zealand’s social and
economic outcomes were better than
most other OECD countries.1
Almost overnight, the routine and familiar
was upended. Everyday activities we took
for granted – going to work or school,
catching up with family and friends, a
quick trip to the shops – were suddenly
out of reach. Our lives were governed by
strict rules that were rolled out rapidly and
rolled back again as outbreaks waxed and
waned. To navigate this new landscape,
we acquired a whole new vocabulary:
alert levels, locations of interest, personal
protective equipment (PPE), rapid antigen
tests (RAT), traffic lights.
But still, the pandemic hit Aotearoa cannot look away from the undeniable
New Zealand hard, and it was harder on harm New Zealand sustained. Contentious
some people than others. For more than public health measures like vaccine
4,000 New Zealanders who died between mandates wore away at what had initially
2020 and the end of October 2024, been a united wall of public support
COVID-19 either caused or contributed for the pandemic response; along
to their deaths.2 Many others became with the rising tide of misinformation
seriously ill and some remain so today, and disinformation, this created social
due to long COVID. A disproportionate fissures that have not entirely been
share of the health burden fell on Māori repaired. Certain groups, many already
and Pacific peoples.3 And of course disadvantaged or vulnerable well before
the pandemic’s impacts extended well the pandemic, were left worse off when
beyond health. Some people lost jobs it subsided. As a country that has always
or businesses (although government professed its belief in equity and fairness
intervention mitigated these losses), – values also enshrined in te Tiriti | the
while others in essential roles had to Treaty of Waitangi – we need to make
keep working when they didn’t feel safe sure the response to the next pandemic
to do so. Rights most of us take for does not lead to inequitable and
granted were curtailed. Families were damaging outcomes.
separated from relatives overseas, and
How can we do better next time? The
some New Zealanders were unable to
importance of answering that question
get home. Ongoing disruptions in the
is, in essence, the reason for our Inquiry.
education sector saw some young people
Our terms of reference require us to
drop out. Women gave birth without
review Aotearoa New Zealand’s response
the support of friends or family. People
to COVID-19 and identify lessons that
died alone or with only a few loved ones
will ensure we are better prepared for
present. In 2024, this country (like many
another pandemic. In fact, we think
others) is still reckoning with the array of
many of our lessons can be usefully
economic and social challenges which the
applied to other threats that could also
pandemic either caused or worsened.
disrupt our country in this century of
Whatever satisfaction we draw from the heightened risk – whether these hazards
fact that Aotearoa New Zealand emerged are familiar or unprecedented, natural
from the pandemic in considerably better or human in origin.
shape than many other countries, we
How can we do better next time?

The importance of answering
that question is, in essence, the
reason for our Inquiry.
AOTEAROA NEW ZEALAND ROYAL COMMISSION COVID-19 LESSONS LEARNED • MAIN REPORT: PART 1 – PRELIMINARIES 4
Aotearoa New Zealand must have (or
have access to) a suite of the very best
There will be another epidemiological, economic and social
pandemic and it will not tools and resources: treatments, vaccines,
be the same as COVID-19. technologies, economic and social
supports, data and knowledge.
Of course, no country can afford the
investment needed to maintain all
We cannot know when or where the next possible preparedness and policy
pandemic will break out, nor what form it responses in an optimal state. But, by
will take. But we can be sure of some things. quantifying the likelihood of future
There will be another pandemic and it will pandemic scenarios, and knowing the
not be the same as COVID-19. It will most best way to prepare and respond to
likely be triggered by another respiratory them should they occur, Aotearoa New
virus, perhaps even another coronavirus, Zealand can make rational and cost-
although an influenza virus is more likely. effective decisions about investment and
But in all likelihood, its transmission preparedness. We can put ourselves in
characteristics and virulence (the rate of a better position still if we also lay the
fatal cases) will be different and therefore groundwork now for the agile response
warrant different policy response options. strategies and delivery mechanisms
If we have prepared well, those options we may need in future – and underpin
will be better than last time. Our society them with even better decision-making
will be different too, not least because arrangements and structures across
of the scars which COVID-19 left behind. government than we had in COVID-19.
Our personal and collective resilience,
It is not just Government that must
our social cohesiveness, our willingness to
take up these challenges. When the
comply with restrictions and our tolerance
response to COVID-19 was at its most
of risk – all severely tested by COVID-19 –
effective, it was due not only to the hard
may be greater or less than last time.
work of public servants and politicians
This uncertainty presents challenges, but but also to businesses and industries,
it does not make us powerless. As this iwi and Māori, Pacific communities and
report sets out, there is much Aotearoa other ethnic communities, social service
New Zealand can do – and needs to do – providers, charities, volunteers and
to get ready for the next pandemic. many more. They knew the needs of
We can start by developing a range their sectors or communities, they knew
of pandemic scenarios, working out how to reach them, and they could often
the probability of them occurring and do what central government could not.
identifying their likely effects – not only The response to the next pandemic,
on public health but on all aspects of and preparations for it, must therefore
our wellbeing. From this basis, we can harness their strengths.
decide where to prioritise investments,
then plan and practise accordingly.
COVID-19 showed us the capacity of response happen. It has been one of the
New Zealanders, individually and biggest privileges of our working lives to
collectively, to rise to a challenge that meet them and hear their reflections.
proved bigger and more complex than
Aotearoa New Zealand has much to
was initially anticipated. As we travelled the
be proud of when it looks back on its
country hearing from people about their
response to COVID-19. But, as nearly
experiences, we were repeatedly struck
everyone we engaged with over the
by the extraordinary effort, commitment
course of the Inquiry agreed, there is
and selflessness shown throughout
significant room for improvement.
the pandemic. Across the private and
Not only will the next pandemic be
public sectors alike, people worked huge
different, but our response must be
hours, often from home in less than
different too – and better. This report
ideal and sometimes stressful conditions.
aims to make a practical contribution
They did the best they could, making to that goal. We have looked back,
difficult decisions on the basis of honestly and scrupulously – not to
imperfect information. They found assign blame, but to enable us to move
ways to keep things going in a rapidly- forward, as prepared as we can be,
changing and sometimes frightening for what will be a challenging future.
environment. Whether they contributed
Na mātou noa, na
on the national stage or away from
the public eye, these people made
Aotearoa New Zealand’s pandemic
Professor Tony Blakely, John Whitehead CNZM KStJ, Grant Illingworth KC,i
Chair Commissioner Commissioner
i Grant Illingworth KC was appointed as a commissioner for Phase One of the Inquiry from 2 August 2024 to 28
November 2024, with his appointment to continue into Phase Two. He was later appointed as the Chair for Phase
Two. His appointment to Phase One was made at a time when evidence collection had been completed. In accordance
with the terms of reference for Phase Two, Mr Illingworth has not had access to any non-public material gathered in
evidence during Phase One. This includes consideration of any evidence that was adduced during the natural justice
process, or any other involvement in that process. His primary role during Phase One has been to review near-final
drafts of this report. Mr Illingworth notes and emphasises that there are areas in the report that overlap with the
Phase Two terms of reference, and that Phase Two of the Inquiry may look more deeply into some issues and make
findings, identify lessons and make recommendations beyond those in the Phase One report.
I roto i ngā mea ohorere maha i puta i te KOWHEORI-19 ki Aotearoa ko te
kaha o te noho rangirua. I tā tātau kitenga tuatahi o ngā tiriti mahue i Wuhan
me te pokea o ngā hōhipera i Ītari, i pōkīkī tatau. He aha tēnei mate hou, ka
pā mai ki a tātau, ā, he pēhea te kino? Āhea tātau ka hoki ki ngā ritenga noa?
Kāore i roa ka pā mai te māramatanga e urutā whakataurite o Aotearoa). Kāore i

kore e taea te karo te KOWHEORI-19, ā, pokea tā tātau pūnaha hauora e te kēhi
ka tārewa ō tātau ake ao mō tētahi wā. KOWHEORI-19, ahakoa i pēhia i ētahi atu
I te weherua o Maehe 2020, i mōhio te āhuatanga. Ahakoa ko tā tātau whakamahi
kāwanatanga me taikaha tana urupare, noho rāhui tētahi o ngā mea tino pākaha i
nā te mōrea o te KOWHEORI-19 ka pokea te ao katoa, he itiiti noa te whakamahinga:
tā tātau pūnaha hauora, ā, ko te mutunga ko te nuinga o te tau 2020 i noho wātea
he parekura. Hei whenua ā-motu, ko tō i ngā rāhuitanga tēnā i ngā tāngata o
tātau waimarie, rerekē ki ētahi atu whenua whenua kē. Nā te urupare ōhanga ohaoha
e pēhia ana e te KOWHEORI-19: ka taea e kāore i pā mai te tino kino o ngā pānga
tātau te aukati te hōrapatanga o te mate, wawe tonu o te mate urutā – heoi, i te
ahakoa kua tae mai, otirā mō tētahi wā. tuatahi – i pai ake ngā putanga pāpori me
Nō reira, i te pito o Maehe 2020, i tau i te te ōhanga o Aotearoa tēnā i te nuinga o
Kāwanatanga te whakatau uaua, kia katia ētahi atu whenua OECD.
ngā pae o te whenua ka whakatau kia
Engari, i kaha pākia a Aotearoa e te
noho rāhui te whenua katoa.
mate urutā, ka mutu i uaua kē atu mō
Me kī, i te hikitanga o te awatea kua ētahi tāngata. Mō ngā tāngata neke atu
rerekē katoa ō tātau ao. Ko ā tātau mahi i te 4,000 o Aotearoa i mate i waenga i
o ia rā – te haere ki te mahi, te kura, te te 2020 me te paunga o Oketopa 2024,
whakawhanaunga ki te whānau me ngā i mate rātau i te KOWHEORI-19, i whai
hoa, te haere ki ngā toa – kua kore ērā e wāhi ai rānei te KOWHEORI-19 ki tō rātou
taea ināianei. I noho tātau i raro i ngā ture matenga. He maha hoki te hunga i tino
pākaha i whakatakotoria wawetia, ka mutu māuiuitia, ā, pērā tonu ana i tēnei rā, nā
i whakatakotoria anōtia i te putanga me te KOWHEORI roa. He nui rawa te Māori
te hekenga o te mate. Kia puta ai tēnei me ngā uri o ngā Moutere i pāngia e te
āhuatanga hou, i whakaarahia ngā kupu mate. Ka mutu, arā kē atu te whānui o
kōrero hou; ngā taumata whakatūpato, te pānga o te mate urutā i tua atu i te
wāhi pūtake, PPE, ngā whakamātautau hauora. I kore ngā tūranga mahi, ngā
ākipaturopi tere (RAT), ngā rama ikiiki. pakihi a ētahi (ahakoa i whakangāwaritia
ēnei ngaronga e ngā āwhina a te
Mō te nuinga, i tau tā tātau noho i roto
kāwanatanga), ā, ko te hunga i ngā
i te kore mōhio, te āhuatanga pāhekeheke
tūranga waiwai i mate ki te mahi tonu
me te tino rerekē o aua mea katoa. I mōhio
ahakoa kāore i te tino haumaru ki a rātau.
tātau, ahakoa ngā uauatanga o konei, he
I tauporoa ō tātau tika. I noho wehe ngā
kino ake ngā āhuatanga i whenua kē. Kua
whānau mai i ō rātau whanaunga i tāwāhi,
puta i ngā rangahau whakataurite o te
ā, kāore ētahi tāngata o Aotearoa i āhei
ao tērā. He iti iho te rahinga o te hunga
ki te hoki mai ki te kāinga. Nā te haere
i mate i te KOWHEORI-19 i konei tēnā i
tonu o ngā whakararuraru i te rāngai
ētahi atu whenua, tae atu ki Amerika me
mātauranga i wehe mai ētahi tamariki.
Piritana Nui (tirohia te Upoko 5 mō te
I whakawhānau ngā wāhine me te kore
tirohanga whānui o ngā putanga mate
whai tautoko a ngā hoa, whānau rānei.
I mate mokemoke ētahi tāngata, he E kore tātau e mōhio ki te wā, te wāhi
tokoiti rānei te whānau i reira. I te tau rānei ka pakaru mai mate urutā whai ake,
2024, kei te pā tonu ngā uauatanga tōna āhua rānei. Engari tērā ētahi mea e
ōhanga me te pāpori ki tēnei whenua tino mōhio ana tātau. Ka pā anō he mate
(pērā i ētahi atu) mai i te mate urutā, urutā, ā, kāore e rite ki te KOWHEORI-19.
kua tino hē kē atu rānei. Kāore e kore ka pupū ake i tētahi atu
huaketo arahau, tētahi atu mate korona
Ahakoa te āhuareka ki a tātau i te mea i
rānei, heoi tērā pea ko tētahi mate
pai ake te āhua o Aotearoa mai i te mate
rewharewha. Engari tērā tonu pea ka
urutā tēnā i te maha o ētahi atu whenua,
rerekē ōna āhuatanga hōrapa me te nui
e kore e taea te tahuri atu mai i te kino
o te hunga ka mate, nō reira me rerekē
i pā ki Aotearoa. Ko ngā whakaritenga
ngā kōwhiringa urupare kaupapahere.
hauora tūmatanui tautohetohe pērā i
Mēnā kei te tino takatū tātau, kai pai ake
ngā mana rongoā āraimate i wetewete
aua kōwhiringa tēnā i mua. Ka rerekē hoki
haere i ngā tautoko mō te urupare ki te
tātau te iwi whānui, tētahi take nā ngā
mate urutā; i te taha o te nui haere o ngā
pānga mauroa o te KOWHEORI-19. Ko tō
mōhiohio parau me te horihori, i uru mai
tātau tū pakari takitahi, takitini, tō tātau
te wehewehe i waenga i te iwi, ā, kāore
pipiri ā-pāpori, tō tātau hiahia kia ū ki
anō tērā kia tino tau. Ko ētahi rōpū ake, he
ngā here me tō tātau rata ki te mōrea –
maha rātau he rawakore, he whakaraerae
i tino whakamātauria ēnei mea katoa e
rānei i mua noa atu i te mate urutā, i tino
te KOWHEORI-19 – ka nui ake, ka iti iho
hē kē atu i te maurutanga atu. I te mea he
rānei pea tēnā i mua.
whenua tēnei kua roa e whakapuaki ana
i tōna pono ki te mana ōrite me te tōkeke Ka pā mai te whakapātaritari i tēnei mea
– ngā uara kei roto i te Tiriti – me mātua pāhekeheke, engari ehara i te mea kua
whakarite tātau kia kaua e pā mai ngā mana-kore tātau. E kī ana tēnei pūrongo,
putanga kore tōkeke, tūkino rānei i he nui ngā mea ka taea e Aotearoa – ka
te urupare ki te mate urutā whai ake. mutu me pērā ka tika – kia takatū ai
mō te mate urutā ā muri ake. Ka taea
Me pēhea e pai ake ai ā muri ake? Ko te
e tātau te tīmata mā te waihanga i ngā
mea hira o te whakautu i taua pātai, me
tūmomo āhuatanga mate urutā rerekē,
kī koinā te pūtake mō tā mātau Uiui. E
te whiriwhiri i te tūponotanga o te pā mai
herea ana mātau e ā mātau tūtohu mahi
me te tautuhi i ōna pānga ka taea – kaua
kia arotakehia te urupare a Aotearoa ki
i te hauora tūmatanui anake engari ki
te KOWHEORI-19 me te whakaatu i ngā
ngā āhuatanga katoa o te oranga. Mai
akoranga hei whakarite ka takatū ake tātau
i tēnei āhuatanga, ka taea te whakatau
mō tētahi mate urutā. Otirā, e whakapono
me haumi ki hea, kātahi ka whakarite
ana mātau ka taea te whakamahi te nuinga
mahere me te whakatinana hoki. Me
o ā tātau akoranga ki ētahi atu mōrea ka
mātua whai a Aotearoa (te āhei atu rānei)
whakararu pea i tō tātau whenua i tēnei
ki ngā momo utauta me ngā rawa mātai
rau tau whakamōrearea – ahakoa he
tahumaero, ōhanga me te pāpori tino pai
pūmate ēnei e mōhiotia ana, he mea hou
rawa; ngā maimoatanga, ngā āraimate,
rānei, he tūturu, he whaihanga rānei.
ngā hangarau, ngā tautoko ōhanga me te
pāpori, ngā raraunga me ngā mōhio.
Otirā, e kore e taea e tētahi whenua I whakaatu te KOWHEORI-19 i te kaha
kotahi ngā haumitanga e hiahiatia ana o Ngāi Aotearoa, ā-takitahi, ā-takitini
mō ngā momo takatū me ngā urupare hoki, ki te whakatūtaki i te wero tino nui
kaupapahere katoa ki te āhuatanga ake, matatini ake ki tērā i whakaarohia
tiketike. Engari, mā te rapu kia mārama ai. I a mātau i huri haere i te motu ki
ai ka pēhea ngā mate urutā o muri mai, te whakarongo ki ngā whakaaro o ngā
me te mōhio ki te āhuatanga pai rawa tāngata, hoki atu, hoki atu i mīharo mātau
mō te takatū me te urupare ki te pā ki ngā mahi, te pūmau me te ohaoha
mai, ka taea e Aotearoa ngā whakatau i whakatauiratia puta noa i te mate
i runga i te mārama, i te tika o te utu urutā. Puta i ngā rāngai tūmataiti me te
mō te haumitanga me te takatū. Ka tūmatanui, he tino maha ngā haora i te
pai ake mō tātau mēnā ka tahuri tātau mahi ngā tāngata, otirā mai i te kāinga i
ki te whakariterite ināianei mō ngā ngā āhuatanga kāore i pai, ā, kāore i tika.
rautaki urupare kakama me ngā tikanga I tino kaha rātau, ki te whakatau tikanga
whakarato ka hiahia pea tātau ā muri ake ahakoa kāore i whānui ngā mōhiohio.
– me te paihere i ērā ki ngā whakaritenga I kitea e rātau ngā ara kia mahi haere
whakatau tikanga me ngā hanganga puta tonu i roto i tētahi taiao tere te hurihuri,
noa i te kāwanatanga kia pai ake ki tērā whakawehi hoki i ētahi wā. Ahakoa i
i te KOWHEORI-19. tautoko rātau i mua i te aroaro o te motu,
muna rānei, nā ēnei tāngata i tutuki ai te
Ehara ko te Kāwanatanga anake me kawe
urupare mate urutā o Aotearoa. Koinei
ake i te mānuka. I te wā i tino whaitake
tētahi o ngā hōnore nui rawa o ō mātau
ai te urupare ki te KOWHEORI-19, ehara
ao mahi te tūtaki ki a rātau me te
nā te whakapau kaha a ngā kaimahi
whakarongo ki ō rātau whakaaro.
kāwanatanga me ngā kaitōrangapū anake
engari nā ngā pakihi anō hoki me ngā Ka nui te ngākau whakahī o Aotearoa i te
rāngai, ngā iwi me te Māori, ngā uri o ngā hoki o ngā whakaaro ki te urupare ki te
Moutere me ētahi atu hapori mātāwaka, KOWHEORI-19. Heoi, ahakoa i whakaae
ngā kaiwhakarato ratonga pāpori, ngā te nuinga o ngā tāngata i toro atu mātau
kaupapa aroha, ngā kaitūao me te maha i roto i te Uiui, he nui tonu ngā wāhi hei
atu. I te mōhio rātau ki ngā hiahia o ō rātau whakapai ake. Ka rerekē te mate urutā
rāngai, hapori rānei, i mōhio rātau me whai ake, nō reira me rerekē anō tā tātau
pēhea te toro atu, ka mutu ka taea e rātau urupare – ka mutu me pai ake. E whai ana
ngā mea kāore i taea e te kāwanatanga. tēnei pūrongo kia whaitake te tautoko i
Nō reira ko te urupare ki te mate urutā taua whāinga. Kua hoki mātau ki te tirotiro,
whai ake, ā, kia takatū hoki mō tērā, me i runga i te tika me te uhupoho – kaua ki te
mātua whakamahi i ō rātau kaha. whakatau hē engari kia anga whakamua
ai tātau, kia tino takatū ai tātau, mō tētahi
anamata whakapataritari.
Summary – our lessons and recommendations |
02 He whakarāpopototanga – ā mātau akoranga
me ā mātau tūtohutanga
Introduction
Our core task is to identify the lessons that can be learned from Aotearoa
New Zealand’s response to COVID-19 between February 2020 and October
2022, and to use those lessons to make recommendations for how the country
should prepare for any future pandemic. To do this, our Inquiry examined
many aspects of the response to gain a comprehensive understanding of what
unfolded in New Zealand during the COVID-19 pandemic.
We set out to establish:
What How the response What could

worked well affected individuals, have been
families and whānau, done better
communities and
the economy
We also considered how the pandemic was managed in other international

jurisdictions to learn from different approaches.
From reviewing Aotearoa New Zealand’s The insights from all our ‘lessons learned’
COVID-19 pandemic experience and provide the basis for the Inquiry’s
response, we have identified a wide-ranging recommendations, which detail the practical
set of lessons that we consider will help steps we consider the Government of
the country respond better to any future Aotearoa New Zealand, and its agencies,
pandemic. We present them in two ways should now take. They have been developed
in this report: the lessons we learned from based on areas of the COVID-19 response
looking back at New Zealand’s COVID-19 that were particularly challenging, had the
pandemic experience and response; biggest impact, can be most feasibly tackled
and looking forward, the lessons that will by the government – and, importantly,
ensure New Zealand is better prepared for offer the greatest opportunities for better
the future. Our approach looks beyond preparedness as we look to the future.
COVID-19 to a wide range of pandemic
scenarios, as the next pandemic could
originate from a different pathogen that
spreads and affects people quite differently.
Lessons learned from looking back
The ‘Looking Back’ part of this report reviews and draws lessons from the
key areas of the Aotearoa New Zealand’s pandemic response specified in our
terms of reference.
Chapters 1 to 8 provide an overview of some key pandemic events, impacts,

decisions and outcomes (and how Aotearoa New Zealand compared with other
countries), and examine the following topics:
• The all-of-government response
• Lockdowns
• Border and quarantine measures
• The health system response
• Economic and social measures and impacts
• Vaccination
• The use of mandatory measures
In Chapter 9, we provide a summary of Aotearoa New Zealand’s pandemic story
and what we learned from it.
Overall, compared to other jurisdictions, The initial success of the elimination

the evidence shows that the COVID-19 strategy allowed the country to spend
response in Aotearoa New Zealand was less time under strict lockdown conditions
effective at protecting people from the than many other parts of the world,
health effects of the virus. The public meaning daily life and economic activity
health response successfully prevented were broadly able to return to ‘normal’
widespread infection until most of the much earlier. This was coupled with a
population was vaccinated. The health swift and generous economic and social
system was never overwhelmed, and response which cushioned many people
many of the potentially unequal health and businesses from the pandemic’s
impacts on disadvantaged or vulnerable worst impacts – and saw Aotearoa
populations were minimised or mitigated. New Zealand’s economy perform well
compared to other countries in the initial
phases of the pandemic. We highlight
examples in the ‘Looking Back’ chapters
where we identified aspects of the
response working well.
However, the response was not perfect
and over time some aspects proved
challenging, particularly in terms of The swift response saw
delivery and adapting as circumstances Aotearoa New Zealand’s
changed. We also identified unintended economy perform well
consequences that stemmed from certain compared to other
decisions or approaches that could have countries in the initial
benefited from greater flexibility. As was phases of the pandemic.
the case overseas, the pandemic (and
aspects of the response to it) had negative
impacts on Aotearoa New Zealand’s
economy, society, individuals and families
that were significant, cumulative and
unevenly distributed over time. We also identified
unintended consequences
We assess many of these impacts in that stemmed from certain
detail in the ‘Looking Back’ chapters. For decisions or approaches
example, we consider and draw lessons that could have benefited
learned from the impacts of lockdowns from greater flexibility.
and border restrictions on individuals and
groups; missed opportunities to ensure
the vaccine rollout reached vulnerable
populations as equitably as desirable; and
the social and economic consequences of
certain mandatory measures, particularly
vaccine requirements. We recognise
the full extent of the impacts from the
COVID-19 pandemic may not be wholly
understood for some time. Current and
future research will continue to add to
our overall understanding of the
pandemic and enhance future planning
and decision-making.
Lessons learned for the future
After reflecting on what can be learned from looking back at Aotearoa

New Zealand’s response to the COVID-19 pandemic, we turn to our lessons
for the future. We begin by acknowledging the many ways in which COVID-19
has shifted the global context in which the next pandemic will unfold.
• One critical overall observation • Our overarching high-level lesson

we have made, and which applies from COVID-19 is that:
internationally, is that the foundations
for future pandemic responses must
successfully managing a
be put in place ahead of time. We
pandemic requires a response
cannot predict the exact nature of the
that looks after all aspects
next pandemic, or the economic and
of people’s lives.
social situation in which it might occur,
but there are many tools available –
scenario planning, ethical and human This means first recognising the
rights frameworks, cost-effectiveness various ways people’s lives will be
tools and more – that can assist with affected by a future pandemic, and
planning, proactive management, then creating a balanced pandemic
and making decisions about where response that minimises both
to focus resources. immediate and long-term harms.
• We then present six thematic Supporting this lesson are five more
lessons more specific to Aotearoa that highlight the importance of:
New Zealand on what we learned
for the future. These describe the Make good decisions
high-level elements we consider
are essential to ensure we are fully Build resilience in the
prepared for, and respond well to, health system
the next pandemic.
Build resilience in economic
and social systems
Work together
Build the foundations for

future responses
Recommendations
The foundations for a The uncertainty posed by the nature and
future pandemic response context surrounding any future pandemic in
must be put in place Aotearoa New Zealand presents challenges,
ahead of time. but it does not make us powerless. Our
recommendations outline the practical
steps that the Government of New Zealand,
and its agencies, should take to ensure any
Within each thematic lesson, a range of future pandemic response is effective and
‘sub-lessons’ elaborate on how our looks after all aspects of people’s lives.
Inquiry considers Aotearoa New Zealand Our recommendations call for action
can develop balanced and effective across many areas of government, but
pandemic responses in the future. For all support a common overall objective:
example, decision-makers need to keep ensuring pandemic preparations and any
sight of the overall and multi-faceted future pandemic responses have a clear
purpose of a pandemic response while purpose and are people-centred. While
being adaptable; and we emphasise the directed at central government, other
importance of good quality advice and communities and organisations throughout
evidence, robust processes, and a firm New Zealand may also find aspects of our
commitment to responsiveness, clear recommendations relevant and useful in
communication and transparency. their own pandemic planning.
Ahead of the next pandemic, we highlight
the importance of strengthening Aotearoa Recommendations are organised
New Zealand’s public health capacity in six groups:
and increasing the resilience of the
healthcare system. Strong economic and 1. Strengthen all-of-government
social systems must also be fostered to coordination and accountability
support resilience and New Zealand’s for pandemic preparedness
ability to absorb shocks like pandemics.
We discuss the critical importance of
2. Ensure an all-of-government pandemic
government agencies working together
plan, response structure and
and maintaining relationships with iwi
supporting processes are developed
and Māori, communities, businesses,
and ready for a pandemic response
faith groups and non-governmental
organisations who, as the COVID-19
response demonstrated, can reach people 3. Strengthen the public health measures
the government often cannot. Future that may be required in a pandemic
pandemic responses in New Zealand
should also uphold te Tiriti o Waitangi (the 4. Ensure all sectors are prepared for
Treaty of Waitangi) and we discuss how a pandemic and ready to respond
the government might work in partnership
with Māori in the development, design 5. Ensure enablers are in place
and delivery of the response.
6. Implement the Inquiry’s
recommendations
We recommend a central agency It is important these sectors are prepared
function be established to coordinate all- to keep necessary goods and services
of-government preparation and response going as much as possible during a
planning for pandemics (and other pandemic, while protecting the long-term
national risks), supported by strengthened capability to continue delivering what will
scenario planning, modelling capability, be needed in the future.
and external expertise. Oversight and
It is also important to ensure enablers
accountability for pandemic preparedness
are in place: public sector agencies need
should be strengthened and made more
to improve the way they work with iwi
publicly transparent. An all-of-government
and Māori to support the Crown in its
response plan for a pandemic should be
relationship with Māori under Te Tiriti
developed and regularly practised, and
o Waitangi (the Treaty of Waitangi); we
an all-of-government response structure
also recommend all relevant legislation
ready to be activated if needed.
be reviewed to ensure it is fit for purpose
We make specific recommendations for any future pandemic, and that core
designed to ensure the public health infrastructure is in place and ready to
measures that may be required in a support each sector’s pandemic response.
pandemic can be enabled. This includes Finally, we outline how the Inquiry’s
the Ministry of Health refining the health Phase One recommendations should
system pandemic plan and linking it be implemented.
with the all-of-government response
While our recommendations are drawn
plan. We also set out recommendations
from the lessons learned from the
for ensuring plans are in place for scaling-
COVID-19 pandemic, they are designed and
up and implementing significant public
intended to apply to any future pandemic
health measures; and which address
– some also apply to other major national
planning for when and how border
emergencies. While we cannot predict
restrictions, lockdowns and vaccine
when the next pandemic will be, or what
requirements might be used.
form it will take, there is much we can do
Recommendations are also provided to to ensure we are prepared for whatever
help ensure the economic, social, education the future may bring.
and justice sectors are all prepared for a
To review our recommendations
pandemic and ready to respond: each
in full please refer to the separate
sector should have a pandemic plan and
document – Consolidated lessons and
consider what they need to do to support
recommendations.
activity within their sector to help the
country safely keep going in a pandemic.
About the Inquiry |
03 He kōrero mō te Uiui
Why and how the Inquiry was established

The Government announced the establishment of the Royal Commission of
Inquiry into COVID-19 Lessons Learned I Te Tira Ārai Urutā on 5 December
2022. The announcement came not long after the public health measures
– mask wearing, vaccine mandates, isolation requirements and more – had
been retired. Likewise, the extraordinary powers that the Government was
able to exercise under legislation throughout the pandemic had been largely
wound back.
Even though the SARS-CoV-2 virus was They would be supported by a secretariat,
still very much a part of daily life, Cabinet with the Department of Internal Affairs
considered the time was right ‘to invest serving as the host agency. The Inquiry
in a process to learn from Aotearoa New would start hearing evidence from
Zealand’s COVID-19 experience and to use February 2023 and deliver its report by
those lessons to strengthen New Zealand’s mid-2024 (later extended to the end of
preparedness for any future pandemics’. November 2024).
Ministers decided it was fitting for this task
Following the 2023 election, the new
to be undertaken by a Royal Commission
Government signalled it was considering
– the highest form of public inquiry –
changes to the Inquiry’s terms of reference.
given the magnitude of the COVID-19
After a public consultation process, it
emergency, the scale and complexity of its
announced in June 2024 that a second
impacts, and the toll it had taken on the
inquiry phase would begin when Phase
country’s social and economic wellbeing.4
One ended. It would have different terms
The then-Prime Minister Jacinda Ardern of reference and new commissioners.
confirmed that epidemiologist and public Grant Illingworth KC was appointed as a
health medicine specialist Professor Tony commissioner, and later appointed chair of
Blakely would lead the Royal Commission. Phase Two, alongside fellow commissioners
He would be joined by two members, Judy Kavanagh and Anthony Hill. The Phase
former Cabinet Minister, the Honourable Two report is scheduled to be submitted
Hekia Parata (Ngati Porou, Ngāi Tahu) and by 26 February 2026.
former Treasury Secretary John Whitehead i
CNZM KStJ. All three were subject matter
experts who brought a ‘unique set of skills’
to the Inquiry, the Prime Minister said.
Our terms of reference
Our terms of reference5 set the parameters • The economic response – the
for both the scope and style of the Phase support available to individuals and
One Inquiry. They confirmed our core task: businesses (such as the wage subsidy);
to look at how to strengthen Aotearoa the exemptions that were put in
New Zealand’s preparedness for future place for specific industries (farming,
pandemics. We were asked to give effect for example); and the Government’s
to this by identifying what lessons could be economic response more generally.
learned from New Zealand’s response to • Government decision-making,
COVID-19 between February 2020 and communication and engagement –
October 2022, and how those lessons what decision-making structures and
could be applied in preparation for any arrangements were used to manage
future pandemic. and deliver the response? How did
Specifically, we were asked to consider: people and communities receive
information and how did Government
• The public health response and the
engage with them, in order to limit
delivery of health services – including
the spread of the virus and ensure
things like border closures and MIQ
everyone was kept safe?
arrangements; the approval and
mandating of vaccines; lockdowns Our terms of reference were therefore
and isolation arrangements; as well as broad. Across health, economic and
modelling and surveillance systems, social aspects of the country’s response,
vaccine passes, gathering limits and the Inquiry was asked to examine the
PPE, along with continued delivery of legislative, policy and operational settings
necessary health services. applying throughout the response and
to consider: what can be learned that
• The provision of goods and services
could improve Aotearoa New Zealand’s
– such as how people’s everyday needs
preparedness and response to a future
were met during the pandemic; the
pandemic? The terms of reference also
provision of lifeline utilities and services
required us to examine how the pandemic
(water, electricity and so on); how
response addressed the interests of Māori,
education and childcare services were
consistent with the te Tiriti o Waitangi
delivered, along with other essential
relationship, and any disproportionate
services that the Government provides,
impacts the pandemic may have had
like regular superannuation payments
on particular population groups and
or housing.
communities. We were also invited to
assess the effectiveness of the various
pandemic strategies, settings and
measures (both health and economic)
that were adopted.
Our terms of reference exclude certain and adverse effects). An evaluation of
aspects of the pandemic response. that kind is obviously out-of-scope for
Out of scope matters included specific present purposes. However, the more
clinical decisions, the wider health system general concept of vaccine ‘effectiveness’
reforms, decisions of the courts and is qualitatively different. It includes, for
oversight bodies, the private sector’s example, how well the Pfizer vaccine
operations (beyond delivering essential performed in reducing transmission and
services), particular decisions taken protecting against serious illness and
by the Reserve Bank of New Zealand’s death in Aotearoa New Zealand. We have
independent monetary policy committee obviously had to consider issues of that
during the COVID-19 pandemic, adaptation kind as they underpin the rationale for
of court procedures and parliamentary an elimination strategy, the pace at which
processes, and the conduct of the a country opens up as vaccine coverage
general election. In addition, ‘the specific increases, and the deployment of vaccine
epidemiology of the COVID-19 virus requirements such as mandates, employer
and its variants’ and ‘vaccine efficacy’ vaccine policies and vaccine passes.
were out of scope. As regards the first
The terms of reference emphasise that
exclusion, an analysis of matters such as
the Phase One Inquiry’s aim is to extract
the detailed structure, immunology and
lessons for the future. We should not take
cellular interaction of the SARS-CoV-2 virus
a legalistic and adversarial approach (see
is out-of-scope; but widely understood
‘Our approach to the Inquiry’) and should
and elementary points like the increasing
use the least formal information-gathering
infectivity and changes in virulence of
processes possible. We were required to
variants (such as the Delta and Omicron
utilise publicly-available information as
variants) are not excluded from our
much as possible and seek any additional
consideration. Similarly, in medical usage
information we needed in an efficient and
there is a well-established distinction
targeted way.
between ‘efficacy’ and ‘effectiveness.’
Simply put, an assessment of efficacy
would involve a systematic review, in
deep detail, of a vaccine’s ability to
provide protection against a virus (and
its variants), with laboratory studies and
clinical trials (including immunological
and specific vaccine safety, side effects
Our approach to the Inquiry
Throughout Phase One, our approach has been:
Non-adversarial: Under the Inquiries Act 2013, a Royal Commission must

conduct its inquiry in accordance with that Act and
the terms of reference, but otherwise as it considers
appropriate. Our terms of reference directed us to use
a non-adversarial approach.
Scenario-focused: Our work has been informed by scenario thinking – a way

of understanding and planning for future events when, like
pandemics, we do not know what ‘type’ they will be nor when
they will occur. The next pandemic could play out in many
ways, depending on the specific pandemic agent involved
(such as a virus), the response measures adopted, and
the social, economic and political context in which it
occurs. However, using scenarios, we can still determine
and plan for the most likely types of pandemics that will
occur and the likely range of economic and social impacts;
we are not powerless.
Our lessons and recommendations seek to strengthen
Aotearoa New Zealand’s readiness to meet a range of
future pandemic scenarios. They also urge those tasked
with preparing for and delivering future pandemic
responses to ensure scenario thinking – supported by
modelling – is at the heart of those preparations. For more
on scenario thinking and its application to pandemic
policy and investment decisions, see Appendix C.
Exploratory, Rather than undertaking an overly forensic analysis

holistic and of past activities and decisions, we inquired into the
forward-looking: areas identified in the terms of reference from a broad
and holistic perspective, looking for common issues
and themes in the pandemic response. We focused
on inquiring deeply enough to extract lessons, but the
breadth of our terms of reference meant we did not need
to dig exhaustively into every last detail of what happened.
This allowed us to develop lessons and recommendations
that span several areas, are sustainable and flexible, and
can have real system-level impact in the next pandemic,
whatever its cause, trajectory and duration.
Non-duplicative: As required by our terms of reference, we have not sought
to duplicate the already existing extensive analysis of
Aotearoa New Zealand’s response to COVID-19 and the
lessons arising already undertaken by others (see ‘Existing
reviews’). We have certainly taken account of this valuable
work, but much of it is specific to COVID-19 or addresses
only particular aspects of the response. Our approach has
been broader and explicitly focused on a range of possible
future pandemics. Consistent with our remit – and our
public feedback process – we have indeed ‘looked back’
on the COVID-19 experience. But we have done so with
the express aim of learning how New Zealand can prepare
itself to ‘move forward’ with more confidence in either
similar, or potentially somewhat different, circumstances.
Finally, we want to clarify the relationship We consider that the breadth of the
between this Phase One report and work carried out in this initial phase and
Phase Two of the Inquiry. This report is presented in this report prepares the
the result of work planned and undertaken ground for, and will complement, the next
independently of the terms of reference phase of the Inquiry. Phase Two will look
governing Phase Two. We were guided deeper into some of the same areas and
by the original terms of reference, and also address the issue of vaccine safety
had in fact completed our evidence- and harm, excluded from the scope of
gathering and begun drafting this report Phase One.
when Phase Two was established.
How we gathered and used evidence
As our remit was to inquire into many
dimensions of Aotearoa New Zealand’s
response to COVID-19 – public health, Evidence snapshot
economic and social – our evidence base
has been necessarily wide-ranging. We The Phase One Inquiry received
have considered information from many evidence and information from
sources, including: across the length and breadth
• investigations, reports, reviews of Aotearoa New Zealand. We:
and research (both domestic and
international) and other publicly
available information – including Received more than
Cabinet papers, and minutes of
advisory groups and oversight
133,000
pages of evidence
bodies proactively released by
government agencies;
• written evidence provided by
government departments and Held nearly 400
other parties; meetings, almost
• additional evidence requested a third of them
by the Inquiry; outside Wellington
• public submissions; and
• evidence gathered via direct
engagements with key stakeholders, Met with over
decision-makers, public servants,
independent experts, and 1,600
communities most impacted by people
the pandemic. These engagements
took the form of face-to-face or
virtual meetings, interviews and
Heard from nearly
correspondence.
13,000 New Zealanders
through our public
submissions process
The views, suggestions and

evidence provided by these
people and groups have been
incorporated into our assessment
of the overall COVID-19 response
and helped us to identify key
lessons for the future.
Existing pandemic reviews (domestic and international)
As noted above, the terms of While they certainly offered useful insights
reference asked us to consider existing about particular pandemic phases, their
investigations, reports and reviews relating specificity and limited parameters meant
to the COVID-19 response although we we sometimes needed to seek out more
were to avoid repeating work already information and perspectives that shed
undertaken and were free to reach light on their findings. None had sought
different conclusions. Seventy-five reviews to provide a comprehensive, holistic,
of the domestic response had been future-oriented picture of the entire
produced since 2020, generating 1,639 pandemic response, nor considered what
recommendations. lessons might apply for future pandemics
The Cabinet paper ‘Establishing an that are different from COVID-19.
inquiry into New Zealand’s preparedness Similarly, we reviewed the considerable
for a future pandemic’ (October 2022) body of literature and evidence on the
summarised the 37 domestic reviews international COVID-19 experience. It
most relevant to our work.6 They encompassed formal inquiries, like ours,
included rapid reviews of the initial all- into other countries’ responses, and
of-government operating model and assessments by independent and
governance arrangements, material international bodies. Those which have
produced by the COVID-19 Independent been particularly helpful to our work
Review and Improvement Advice Group, include:
the Office of the Auditor-General’s report
• UK Covid-19 Inquiry – Resilience and
into all-of-government coordination in
preparedness (Module 1)7
the first year of the response, reviews
of COVID-19 clusters in aged-care • Commonwealth Government of Australia
facilities, a report on the implementation COVID-19 Response Inquiry8
of the COVID-19 Surveillance Plan and • Fault Lines: an independent review
Testing Strategy, and inquiries into the into Australia’s response to COVID-199
MIQ booking system, isolation facilities • Australian Government Crisis
and prisons. Management Framework10
Starting from this list and supplementing • Dutch Safety Board, Investigations
it with other reviews and analysis we into the Approach to COVID-19 crisis11
identified, we amassed a comprehensive • OECD Policy Responses to Coronavirus
record of findings and data about the (COVID-19)12
Aotearoa New Zealand pandemic
• Fiscal Monitor Database of Country
response. The existing reviews inform the
Fiscal Measures in Response to the
analysis, lessons and recommendations
COVID-19 Pandemic13
set out in this report, and are referenced
throughout. However, many of these • Independent Panel for Pandemic
reviews focused on specific topics, Preparedness and Response, co-chaired
usually operational, and a particular by Her Excellency Ellen Johnson Sirleaf
point in time. and the Right Honourable Helen Clark.14
Direct engagements
The Phase One terms of reference • iwi and Māori organisations (who in
did not direct us to undertake public many cases also led the pandemic
hearings. However, we wanted to engage response in their own communities)
authentically with a wide range of groups • representatives of the health,
and individuals in order to fully understand education, and business sectors
the complex and multi-faceted impact of
• individual business owners
the pandemic, and to inform our lessons.
For example, when considering how • researchers and experts in a wide
the next pandemic response could best range of disciplines
support the wellbeing of essential workers • members of the disabled community
(such as people working in supermarkets • members of the Pacific and other
or at the border) or communities and ethnic communities
population groups likely to be especially
• representatives of numerous
impacted (Māori and Pacific peoples, for
stakeholder groups – peak bodies
example), we knew that those were the
for specific sectors and professions;
people we needed to talk to.
media and communications; local
Starting in June 2023, we undertook authorities; faith groups and more.
an extensive programme of targeted, • advocacy groups representing a wide
in-person (and sometimes virtual) range of viewpoints, including those
engagements – interviews, hui and sceptical of, or opposed to, aspects
facilitated group meetings. Over the of the pandemic response.
next 15 months, the people and groups
• people and groups who were not
we met with included:ii
involved in delivering the response
• those who implemented the but were willing to share how it had
response (including representatives affected them. We were particularly
of government agencies, the keen to meet with those whose voices
private sector, non-governmental went largely unheard in the pandemic
organisations, community groups, so we could better understand the
charities and not-for-profit groups, human impact of COVID-19 policies,
and more) legislation, regulations and public
• key government decision-makers health measures.
• the public service leaders and
officials advising them
ii A complete list is available at https://www.covid19lessons.royalcommission.nz/the-inquiry/record-of-inquiry-engagements.
Public input
The final stage of our engagement
approach was to call for public input An awareness campaign ran alongside
through an online submissions process. the final stage of our engagement,
An awareness campaign ran alongside using a variety of channels
it, using a variety of channels. As part
of the campaign, we had a presence at
various public-facing events ranging from
community markets and A&P (agricultural
and pastoral) shows to music festivals.
This was an excellent opportunity to talk
informally about COVID-19 and what
could be learned from it with people
holding a wide range of viewpoints – and
to encourage or support them to make
a submission.
We also worked with partners to connect
with ‘hard to reach’ communities and
individuals who might not otherwise
have engaged with us. Where appropriate,
we employed a trauma-informed
approach, recognising that for some
people – such as those who experienced
the death of a loved one – the effects
of the pandemic were significant and
continue to be felt deeply.
Confidentiality arrangements
Our engagements were held in private. confidentiality of all non-public evidence
Everyone taking part was assured gathered during the Inquiry – whether
that any notes or recordings made through direct engagements, in
by Commissioners or staff from the written evidence or through the public
Secretariat would remain confidential submissions process. In all cases, we
until the end of the Inquiry (at which point wanted to encourage discussion and
the provisions of our fourth procedural evidence that was rich, free and frank,
minute, which sets out the Inquiry’s final and given without fear of repercussions.
non-publication orders, would apply). Preserving confidentiality would also
allow us to ascertain all the facts
These arrangements were consistent
necessary to support robust lessons
with our general approach to the
and recommendations.
We issued three procedural Minutes confirming our approach:
Minute 1 – Interim Minute 2 – Inquiry Minute 3 – Inquiry

non-publication orders15 meeting procedure and procedures for public
On 2 June 2023, we put in place information-gathering16 and other submissions17
an interim order forbidding the First issued on 17 July On 6 December 2023, the
publication of all evidence and 2023 and re-issued on 27 Inquiry’s third procedural
submissions provided to the September 2023, this Minute minute addressed how
Inquiry until further orders were gave guidance on who could information received
made. The Minute also specified attend engagements, how the through the public
that there would be no public Inquiry would look after and submission process
access to Inquiry meetings or use the information provided would be treated. Where
to correspondence relating to to us, how people’s views confidentiality was
information requests. would be attributed in the requested, it was granted.
final report, and the natural
justice processes that would be
undertaken (discussed further
in the Conclusion).iii
Of course, maintaining confidentiality cited, unless we sought and received

has not prevented this report from permission from the source to quote
referring to the information we gathered from or otherwise identify their evidence.
and drawing conclusions, lessons and Likewise, statements or views are not
recommendations from it. But it does attributed to specific organisations or
mean much of the evidence that informs individuals except with their agreement.
our analysis has not been formally Publicly-available sources are cited.iii
iii The Inquiries Act 2013 requires us to ensure that if the Inquiry makes a finding that is adverse to any person, that person is
aware of the matters on which the finding is based and has had the opportunity to respond before our report is finalised.
The analytical process
The lessons and recommendations We then turned our attention to the
set out in this report are founded in a future, using the most actionable insights
thorough and careful analysis of the arising from what we learned looking
information and evidence relevant to back to develop lessons for the
our terms of reference. future. We then developed a suite
of recommendations giving practical
We began by examining each topic
effect to the lessons. Our lessons and
within the Inquiry’s scope – identifying
recommendations are presented in the
the relevant legislative, regulatory and
‘Moving Forward’ chapters (Part 3).
operational settings and then analysing
the relevant evidence through a series
of research questions. We applied a
consistent analytical framework across
This approach allowed us to
the various matters under inquiry and
manage the breadth of the terms of
considered cross-cutting issues, including reference, to undertake a thematic
ethical and human rights perspectives, analysis that approached the topics
cost-effectiveness, optimal policy-making for inquiry in an integrated way, and
and implementation arrangements, te to avoid ‘siloed’ assessments.
Tiriti and equity. This approach allowed
us to manage the breadth of the terms
of reference, to undertake a thematic
analysis that approached the topics for
inquiry in an integrated way, and to avoid
‘siloed’ assessments.
On the basis of this analytical work, we
identified lessons about Aotearoa New
Zealand’s COVID-19 response – namely,
whether it was effective in limiting both
the spread of infection and the impact
of the virus on vulnerable groups and
the health system. These lessons from
looking back at the pandemic, and the
analysis supporting them, are set out in
the ‘Looking Back’ chapters of this report
(Part 2).
Conclusion
We are confident in the robustness to check the accuracy of parts
of our evidence-gathering and of our report. We were mindful
analytical processes. We cast of the need to ensure that, in
a wide net, looked closely at accordance with the Inquiries Act
international pandemic experiences 2013, we undertook a fair process
and outcomes as well as Aotearoa and gave those who were referred
New Zealand’s, encouraged candid to in the report – or against
conversations, and deliberately whom we proposed to make an
sought out a diversity of views and unfavourable finding or statement –
pandemic experiences – including were given the opportunity to review
from people and groups who those statements. We carefully
remained ‘below the radar’ during considered all responses received
the pandemic or are considered and changes were made to the
hard to reach. draft report as appropriate.
Supported by the Secretariat, we As a result, we consider our
have weighed, assessed and cross- lessons and recommendations are
checked the evidence. We ensured soundly based. We trust they will
we tested our assumptions, and we help ensure Aotearoa New Zealand
took account of a range of scenarios is well-prepared to respond to a
and counter-factuals. We requested future pandemic.
those whose evidence was relied on
About the report |
0.0
04 He kōrero mō te pūrongo
This report comprises three parts:
broad reflections on what the country’s

experience of COVID-19 taught us.
Part One: Part Two: Part Three:
Preliminaries Looking Back Moving Forward
Part Three: Moving Forward contains
two chapters. Chapter 10 sets out the six
broad lessons we consider Aotearoa New
• Zealand should learn for the future and
apply when preparing for, and responding
This first part provides essential to, the next pandemic. Chapter 11 details
context about the Inquiry, the report
our recommendations for action. While
and the state of Aotearoa New Zealand in
they are directed at central government
the immediate pre-pandemic period.
and its agencies, our recommendations
Part Two: Looking Back examines and are also relevant to the many groups
assesses Aotearoa New Zealand’s response and sectors outside of government
to the COVID-19 pandemic. The first chapter which – as we saw during COVID-19 – will
provides context: using graphs and other undoubtedly make critical contributions
visuals, it is a brief reminder of some of the to the next pandemic response. They
key pandemic events, impacts, decisions and include communities, iwi and Māori,
outcomes New Zealand experienced and non-governmental organisations, local
how they compared with other countries. government and the private sector.
With this context in mind, we present our A series of appendices concludes the report.
analysis and lessons on seven key aspects of These present detailed epidemiological,
the pandemic response in Chapters 2 to 8: legal and governance information that
• all-of-government arrangements, supports the ‘Looking Back’ chapters in
• lockdowns, particular. A glossary is also included.
• border restrictions and quarantine, Endnotes appear at the end of
• the health system, each chapter. As noted earlier, the
confidentiality arrangements put in place
• economic and social impacts,
to encourage the free and frank sharing
• vaccination, and of information throughout Phase One
• the use of mandatory measures. mean we cannot formally cite much of the
evidence provided in direct engagements
In each chapter, our approach is to begin
with stakeholders. Publicly-available
by describing ‘what happened’, usually
sources are cited, and we have tried to
in a broadly chronological sequence and
provide as much information as possible
with little evaluative commentary. Short
(including URLs) to help readers access
‘spotlights’ feature throughout, highlighting
them if they wish. Please note that some
particular pandemic policies or measures
hyperlinks in this report may no longer
and their impacts. We then set out our
work at the time of publication. Most links
assessment of that particular topic,
should still be accessible when copied
drawing together our major conclusions
and pasted into the National Library
at the end of each chapter. Finally in
webarchive: https://ndhadeliver.natlib.
Chapter 9, we take stock of New Zealand’s
govt.nz/webarchive/
pandemic response and set out some
Pre-pandemic Aotearoa New Zealand:
05 an overview | I mua i te mate urutā i
Aotearoa: he tirohanga whānui
In the ‘Looking Back’ chapters that follow, we examine Aotearoa New Zealand’s
experience of the COVID-19 pandemic in detail. Before doing so, however, it
is important to set the scene and recall the economic, social and historical
context in which these events occurred. While the COVID-19 pandemic was
universal in reach, the way it was experienced around the world was far from
uniform. In New Zealand, as elsewhere, a range of pre-existing and locally-
specific conditions shaped the course of the pandemic itself and the response.
This will be true of the next pandemic too.
This short section therefore briefly history or sheer luck, while others were
revisits Aotearoa New Zealand’s pre- the result of deliberate policy and design.
pandemic landscape, summarising some Some allowed New Zealand to avoid,
of the distinctive features, strengths and delay or mitigate some of the pandemic’s
vulnerabilities that came to bear on how worst impacts, while others may have
the pandemic and the response unfolded. hindered the response – issues we consider
Some were accidents of geography, throughout the following chapters.
In Aotearoa New Zealand,

as elsewhere, a range
of pre-existing and locally-
specific conditions shaped the
course of the pandemic itself
and the response.
On the eve of the pandemic . . .
As an island nation, Aotearoa Aotearoa New Zealand’s

New Zealand’s remoteness – along with population (5 million) was fast
its thinly-spread population – was set to becoming more ethnically diverse.19 At the
play a significant part in how COVID-19 2018 Census, 71 percent of the population
would affect the country. Because of identified as being of European ethnicity,
its distance from other countries, and with significant Māori, Pacific and Asian
comparatively smaller volume of inbound populations (17, 8 and 15 percent
travellers, the likelihood of infected respectively). Many people identified
people entering New Zealand early in a with more than one ethnic group –
pandemic was less than other countries. approximately 11 percent.20 More than
This proved important as the COVID-19 a quarter of New Zealanders were born
pandemic played out. Another factor overseas, and a significant number
that was likely to affect the spread of any (thought to be between 600,000 and
infectious disease was New Zealand’s one million) were living overseas.
low population density – at just 19 people
The diversity of the population would
per square kilometre, it was half the
present some challenges during the
OECD average.18
pandemic response, given the pace of
events and the need to make information
available in culturally responsive ways.
Meanwhile, the large expatriate population
would be particularly affected by the
border restrictions and quarantine
requirements in effect during the pandemic.
Overall, the population was also ageing,
with the total number of people aged 65 or
older growing rapidly. However, Māori and
Pacific populations were generally younger
and growing faster than the European
population. As has long been the case,
Māori life expectancy – 77 years for women
and 73 years for men – was considerably
lower than for non-Māori, although the gap
had been slowly reducing.21 This disparity
pointed to underlying differences in health
status across the population – a significant
issue the health response needed to take
account of during COVID-19.
Te Tiriti o Waitangi | the Treaty Many statutes, including some relied on
of Waitangi, the agreement written and during the COVID-19 response, required
signed by the Crown and Māori in 1840, government officials and agencies to ‘have
held an increasingly important place in regard to’, ‘take into account’ or ‘give effect
the life of Aotearoa New Zealand, its laws to’ its principles in order to protect Māori
and government policies – including those interests. Those principles – identified
used to enable the COVID-19 response. over the past 40 years by the executive
branch of government, Parliament, the
The three articles of te Tiriti | the Treaty
courts and the Waitangi Tribunaliv – are
set out the relationship between the treaty
sometimes distilled into three broad
partners, and their respective duties and
principles: partnership (often described
obligations, although there are some
as the overarching principle, with other
differences between the te reo Māori
important principles embedded within it),
and English versions:
protection and participation. The extent
• Article One affirms that Māori cede to which the Government’s COVID-19
to the Crown ‘kāwanatanga’ (or response upheld these principles would
governorship); the English version be tested in November 2021, when the
uses the term ‘sovereignty’. Waitangi Tribunal held a priority inquiry
• Article Two guarantees Māori ‘te tino into the effects of the response on Māori.
rangatiratanga’ over their lands, villages, Although te Tiriti was an integral part of
and all their properties and treasures. the national landscape by 2020, and had
The English version renders this as always been of the utmost importance
‘exclusive and undisturbed possession of to Māori, it is fair to say that views on
their lands and estates, forests, fisheries, its contemporary status and application
and other properties’. But many think differed widely across the community as
Māori signatories understood ‘te tino a whole. Increasingly, public discourse
rangatiratanga’ to mean much more emphasised its articles as well as, or
than mere possession – the unqualified instead of, the principles. Differing
exercise of their chieftainship, self- expectations of how te Tiriti would be
determination, perhaps something applied in the pandemic, and how iwi
more like sovereignty.22 and hapū would be involved in decision-
• Article Three assures Māori they making and delivery of services, became
will have the Queen’s protection apparent during the pandemic response.
and all rights (tikanga) accorded to
British subjects.
iv The Waitangi Tribunal was established under legislation in 1975 as a permanent commission of inquiry into alleged Crown
treaty breaches.
The economy was performing The health of Aotearoa
moderately well against several key New Zealand’s total population
measures, and the Government’s fiscal had consistently ranked well
position was strong, providing head- internationally. For more than 25 years,
room for fiscal support and investment people’s average life expectancy
during the pandemic response. In had steadily increased, as had the
2019, the OECD had rated Aotearoa amount of time they live in good health.24
New Zealand’s levels of both employment Health outcomes and spending levels
and unemployment as ‘very good’ and were in line with other OECD countries.25
economic growth – an important driver of
However, as the Ministry of Health
wellbeing that contributes positively to jobs
acknowledged in a 2017 ministerial
and income – had stabilised at around 2½
briefing, the health of some groups –
percent. The same OECD survey also raised
Māori, Pacific peoples, people in lower
concerns about low household incomes,
socio-economic areas, disabled people
the availability and cost of housing, the
– was persistently worse than the general
unequal distribution of wealth and several
population’s. These groups were more
other indicators of wellbeing.23 Pre-existing
likely to have cardiovascular disease,
disparities in household incomes and
psychological distress, respiratory illness,
resources meant some whānau would
diabetes and chronic pain; they also faced
be more impacted during the pandemic
greater barriers to accessing healthcare
than others, and decisions about support
(cost, transport, cultural difficulties
measures had to take account of diverse
and more). For Māori, these disparities
and complex needs.
contrasted starkly with the equal rights
and privileges they are guaranteed under
te Tiriti o Waitangi.26 Shortly before
COVID-19 reached New Zealand, a
Waitangi Tribunal inquiry into the primary
healthcare system found the Crown had
breached te Tiriti by failing to ensure the
system addressed persistent Māori health
inequities. The pre-existing differences in
health status across the population were
among the many factors that had to be
considered when deciding how best to
target and prioritise health services
during the pandemic – including access
to vaccines.
The healthcare system itself The public health service was
was a large, complex and widely- the part of health system that delivered
distributed network of public and communicable disease control,
private organisations under growing environmental health and health
pressure. The publicly-funded system prevention services. Aotearoa
provided specialist and hospital care New Zealand had 12 public health
that was free at the point of use. Public units that served the population in
funding also subsidised most primary each region, in collaboration with local
care, prescriptions and community care government and healthcare services.
services (such as aged residential care, They were supported by the Institute
disability supports and maternity care). of Environmental Science and Research
A fully private system operated alongside (ESR), the country’s national reference
the public system, with private providers laboratory and provider of national
offering specialist and some hospital care analysis and reporting of communicable
in separate facilities. The entire healthcare diseases. Public health services managed
system employed the country’s largest disease outbreaks and responded to
single industry workforce,27 comprising reports of notifiable diseases, including
approximately 220,000 full-time equivalent through contact tracing: that is, identifying
staff or 8.5 percent of the total workforce. people who had been in close contact
The delivery of hospital and primary care with the person originally diagnosed,
varied between regions, with no common supporting them to be tested and – if
national approach. Although the health of necessary – undergo treatment. Medical
New Zealanders overall was in line with Officers of Health (doctors who have
other similar countries, the Government at specialised in public health) and Health
the time had acknowledged that the health Protection Officers (trained public health
system was not working for everyone, and workers) had statutory powers under the
ways to reform the system were under Health Act 1956 to require members of
investigation. The vulnerabilities and the public to comply with contact tracing
challenges already evident in the health and (if necessary) quarantine or isolation.
system would become significant pressure- A national notification and surveillance
points in the pandemic response. system collected information on cases
of notifiable diseases.
Some urgent social problems The education system had three
and inequalities were confronting levels: early childhood education
Aotearoa New Zealand, including a housing (comprising a mix of services, led variously
crisis, child poverty, family violence, and by teachers, whānau, parents and
mental health and wellbeing. The OECD had private sector operators), primary and
recently drawn attention to New Zealand’s secondary schooling (state, integrated/
high suicide rate (especially among young special character and private schools,
people), ‘woeful’ child wellbeing outcomes, including Māori-medium kura) and tertiary
and high levels of family violence.28 Despite education (technical/vocational education
the promises enshrined in te Tiriti and the providers, wānanga and universities).
benefits that treaty settlements had brought All parts of the system faced a common
some iwi and hapū, Māori experienced challenge: it was not keeping pace with
worse outcomes than non-Māori in many the educational needs of an increasingly
areas. Other groups and communities also diverse country. Various system-wide and
faced persistent disadvantage.29 Critics said sector-specific reforms were underway.
funding for social services, and benefits, was However, statistics consistently showed
inadequate to meet needs. The COVID-19 marked inequities in educational
pandemic would place additional pressure outcomes and participation rates for
on all these groups, which – as had been some groups, including Māori and Pacific
decisively demonstrated in all kinds of peoples. Digital access was also highly
national and global emergencies in the variable across the country and between
past – were less able to absorb the shock population groups – something that
arising from such crises.30 became problematic during the pandemic
Numerous programmes and services when many educational institutions
existed to support individuals, families switched to online learning.
and communities facing such hardships. The lucrative international education
Many services targeted specific populations sector was important for the country
or issues. Some were delivered directly and would be critically affected by the
by government agencies, and others by border restrictions in effect during the
philanthropic and voluntary organisations pandemic. In 2018, international education
that the Government contracts with or contributed over $4.9 billion to the
commissions. Some providers operated national economy and was the country’s
in just one location while others had fifth largest export industry.32 More than
sophisticated national operations, paid 117,000 international students were
staff and multiple contracts with a range enrolled in schools, universities, technical
of government agencies. In the immediate training institutes, polytechnics, private
pre-pandemic period, 22 government training establishments and English
agencies were either delivering, contracting language schools.33
or commissioning social services.31 Given
the complexity of the sector, and the many
non-governmental agencies working to
meet the needs of local communities during
the pandemic, significant coordination and
co-operation would be required across
funding agencies to support the response.
The emergency management In the event of an emergency involving
system was under pressure as some infectious human diseases, the law
familiar hazards became more frequent provided for the Ministry of Health to
and severe, while new threats emerged. lead the national response and gave the
A ministerial review established in 2018 Director-General of Health certain powers
had recommended modernising the which could be exercised independently
existing national emergency management of government ministers. The Ministry was
system so it could better respond to the thus at the forefront of the response to
increasingly complex demands it faced.34 COVID-19 from the very start.
By the end of 2019, the reforms were The various roles and functions already
well underway and the system was being established across the emergency
overhauled to clarify roles, strengthen management system would add to the
leadership, better partner with iwi and overall complexity of rapidly activating
Māori, and focus on the wellbeing of the pandemic response.
people in emergencies. A new ten-year
National Resilience Strategy was being
implemented and a new agency – the
National Emergency Management Agency
(NEMA) – had been established to provide
national system-wide leadership,
coordination and stewardship before,
during and after emergencies. It replaced
the Ministry of Civil Defence and
Emergency Management,35 and would play
a key role in the response to COVID-19.
Aotearoa New Zealand’s human Ethics frameworks also formed part
rights framework included a mix of of the landscape for decision-makers.
domestic laws, international laws, and The need to define fundamental values
the various United Nations treaties and or ethics that should be used to balance
rights declarations which New Zealand different interests when making urgent
has ratified.v A key part of the domestic decisions in a public health crisis such as a
framework was, and remains, the pandemic was recognised internationally.
New Zealand Bill of Rights Act 1990. This The most globally influential ethics
Act affirms a range of rights and freedoms framework was developed in Canada,
– including the right to refuse to undergo following the 2005 Severe Acute
medical treatment (section 11), freedom Respiratory Syndrome (SARS) epidemic,
of expression (section 14), and freedom and promoted in the Oxford Handbook
of movement (section 18) – all of which of Public Health Policy.36 It influenced the
were shown to be relevant in a pandemic. development of Aotearoa New Zealand’s
The rights and freedoms affirmed by the first statement of ethical values for a
New Zealand Bill of Rights Act are not pandemic, Getting Through Together,
absolute. Rather, they are subject to issued in 2007 by the National Ethics
‘such reasonable limits prescribed by law Advisory Committee.37
as can be demonstrably justified in a free These ethics frameworksvi were available
and democratic society’ (section 5) and to support decision-makers having
to other Acts of Parliament (section 4). to make, and communicate, complex
decisions about public health measures
– including how and when to implement
measures to make the best use of
available resources and place the fewest
restrictions on personal freedoms. In a
pandemic, such decisions might include
prioritising access to vaccines and hospital
beds, and weighing up the benefits of
closing borders or lockdowns against the
wider impacts on society.
The issues highlighted in this brief overview, and how they

played out during the pandemic, are addressed in more
detail in Chapters 2 to 9 of this report.
v Further detail is provided in Appendix A.

vi Further detail is provided in Chapter 10.
Endnotes |
06 Tuhinga āpiti
1. Michael G. Baker, Amanda Kvalsvig, Michael Plank, 4. Cabinet Paper and Minute, Establishing an inquiry into
Jemma L. Geoghegan, Teresa Wall, Colin Tukuitonga, New Zealand’s preparedness for a future pandemic,
Jennifer Summers, Julie Bennett, John Kerr, Nikki CAB-22-MIN-0464, 25 October 2022, https://www.
Turner, Sally Roberts, Kelvin Ward, Bryan Betty, covid19lessons.royalcommission.nz/assets/Uploads/
Q. Sue Huang, Nigel French, and Nick Wilson, Royal-Commission-of-Inquiry-Lessons-Learned-
‘Continued mitigation needed to minimise the Aotearoa-New-Zealands-response-to-COVID-19-
high health burden from COVID-19 in Aotearoa That-Should-Be-Applied-in-Preparation-for-a-Future-
New Zealand’, New Zealand Medical Journal 136, no. Pandemic.pdf
1583 (6 October 2023), 67-91, pp 77-79, https://doi. 5. Royal Commission of Inquiry (COVID-19 Lessons)
org/10.26635/6965.6247, https://nzmj.org.nz/journal/ Order 2022, version 8 December 2022, https://www.
vol-136-no-1583/continued-mitigation-needed-to- legislation.govt.nz/regulation/public/2022/0323/6.0/
minimise-the-high-health-burden-from-covid-19-in- LMS792965.html
aotearoa-new-zealand
6. The 37 reports identified as most relevant to the
Thomas Hale, Noam Angrist, Rafael Goldszmidt, Royal Commission’s work were set out on 25 October
Beatriz Kira, Anna Petherick, Toby Phillips, Samuel 2022 in the Cabinet Paper and Minute, Establishing
Webster, Emily Cameron-Blake, Laura Hallas, an inquiry into New Zealand’s preparedness for a
Saptarshi Majumdar, and Helen Tatlow, ‘A global future pandemic, CAB-22-MIN-0464, 25 October
panel database of pandemic policies (Oxford 2022, https://www.covid19lessons.royalcommission.
COVID-19 Government Response Tracker)’, Nature nz/assets/Uploads/Royal-Commission-of-Inquiry-
Human Behaviour 5, no. 4 (2021), 529-538, https:// Lessons-Learned-Aotearoa-New-Zealands-response-
doi.org/10.1038/s41562-021-01079-8, https://www. to-COVID-19-That-Should-Be-Applied-in-Preparation-
nature.com/articles/s41562-021-01079-8 for-a-Future-Pandemic.pdf
Edouard Mathieu, Hannah Ritchie, Lucas Rodés-Guira,
7. UK Covid-19 Inquiry, ‘What is the UK Covid-19
Cameron Appel, Charlie Giattino, Joe Hasell, Bobbie
Inquiry?’, https://covid19.public-inquiry.uk/
Macdonald, Saloni Dattani, Diana Beltekian, Esteban
Ortiz-Ospina, and Max Roser, COVID-19: Stringency The Rt Hon the Baroness Hallett DBE, Module 1
Index, https://ourworldindata.org/covid-stringency- Report – The resilience and preparedness of the United
index Kingdom, UK Covid-19 Inquiry (UK, 18 July 2024),
Samik Datta, Giorgia Vattiato, Oliver J. Maclaren, Ning https://covid19.public-inquiry.uk/wp-content/
Hua, Andrew Sporle, and Michael J. Plank, ‘The impact uploads/2024/07/18095012/UK-Covid-19-Inquiry-
of Covid-19 vaccination in Aotearoa New Zealand: A Module-1-Full-Report.pdf
modelling study’, Vaccine 42, no. 6 (2024), 1383-1391, 8. Department of the Prime Minister and Cabinet
https://doi.org/10.1016/j.vaccine.2024.01.101, https:// Commonwealth of Australia, ‘Commonwealth
pubmed.ncbi.nlm.nih.gov/38307744/ Government COVID-19 Response Inquiry’,
https://www.pmc.gov.au/domestic-policy/
OECD, COVID-19 and Well-being: Life in the Pandemic
commonwealth-government-covid-19-response-
(Highlights), OECD Publishing (Paris, 25 November
inquiry#:~:text=The%20purpose%20of%20the%20
2021), https://www.oecd.org/content/dam/oecd/en/
inquiry,to%20the%20COVID%2D19%20pandemic
publications/support-materials/2021/11/covid-19-
and-well-being_298c2553/COVID-19-and-Well-being- 9. Peter Shergold, Jillian Broadbent, Isobel Marshall, and
Highlights.pdf Peter Varghese, Fault Lines: an independent review into
Australia’s response to COVID-19 (20 October 2022),
2. As at 30 October 2024. Health New Zealand Te Whatu
https://www.paulramsayfoundation.org.au/news-
Ora, ‘COVID-19: Case demographics’, updated 29
resources/fault-lines-an-independent-review-into-
October 2024, https://www.tewhatuora.govt.nz/
australias-response-to-covid-19
for-health-professionals/data-and-statistics/covid-19-
data/covid-19-case-demographics/ 10. Commonwealth of Australia, Australian Government
Crisis Management Framework, Department of the
3. Jennifer Summers, Amanda Kvalsvig, Lucy Telfar
Prime Minister and Cabinet (18 September 2024),
Barnard, Julie Bennett, Matire Harwood, Nick Wilson,
https://www.pmc.gov.au/sites/default/files/resource/
and Michael G. Baker, ‘Improvements and Persisting
download/agcmf-framework-2.pdf
Challenges in COVID-19 Response Compared with
1918–19 Influenza Pandemic Response, New Zealand
(Aotearoa)’, Emerging Infectious Diseases 29, no. 9
(2023), https://doi.org/10.3201/eid2909.221265,
https://wwwnc.cdc.gov/eid/article/29/9/22-1265_
article
11. Dutch Safety Board, Summary – Approach to COVID-19 19. Stats NZ, National population estimates: At 31
Crisis Part 1: through to September 2020 (The Hague, March 2020 – Infoshare tables (18 May 2020),
16 February 2022), https://onderzoeksraad.nl/en/ https://www.stats.govt.nz/information-releases/
onderzoek/approach-to-covid-19-crisis/ national-population-estimates-at-31-march-2020-
Dutch Safety Board, Summary – Approach to COVID-19 infoshare-tables#:~:text=At%2031%20March%20
Crisis Part 2: September 2020 through to July 2021 (The 2020%3A%201%20New%20Zealand%E2%80%99s%20
Hague, 12 October 2022), https://onderzoeksraad. estimated,and%20females%20was%2036.2%20
nl/en/onderzoek/approach-to-covid-19-crisis-part-2- and%2038.5%20years%2C%20respectively
september-2020-july-2021/ 20. Stats NZ, ‘Population projected to become more
Dutch Safety Board, Summary – Approach to COVID-19 ethnically diverse’, updated 28 May 2021, https://
Crisis Part 3: January 2020 through to September www.stats.govt.nz/news/population-projected-to-
2022 (The Hague, 25 October 2023), https://www. become-more-ethnically-diverse
onderzoeksraad.nl/wp-content/uploads/2023/12/ 21. Stats NZ, National and subnational period life tables:
approach_to_covid_19_crisis_part_3_summary.pdf 2017–2019 (20 April 2021), https://www.stats.govt.
12. OECD, ‘OECD Policy Responses to Coronavirus nz/information-releases/national-and-subnational-
(COVID-19)’, https://doi.org/10.1787/5b0fd8cd-en period-life-tables-2017-2019/
13. International Monetary Fund, ‘Fiscal Monitor Database 22. For a detailed discussion of the texts’ wording, see
of Country Fiscal Measures in Response to the Waitangi Tribunal, He Whakaputanga me te Tiriti The
COVID-19 Pandemic’, updated October 2021, https:// Declaration and the Treaty: the report on stage 1 of
www.imf.org/en/Topics/imf-and-covid19/Fiscal- the Te Paparahi o Te Raki Inquiry (2014), pp 412-418,
Policies-Database-in-Response-to-COVID-19 https://forms.justice.govt.nz/search/Documents/WT/
wt_DOC_85648980/Te%20Raki%20W.pdf
14. The Independent Panel for Pandemic Preparedness
and Response, https://theindependentpanel.org/ 23. OECD, OECD Economic Surveys: New Zealand 2019,
OECD Publishing (Paris, 2019), https://www.oecd-
15. Royal Commission COVID-19 Lessons Learned,
ilibrary.org/content/publication/b0b94dbd-en
Minute 1: Interim non-publication – evidence and
submissions received by the Royal Commission of 24. Ministry of Health, Briefing to the Incoming Minister
Inquiry into COVID-19 Lessons, 2 June 2023, https:// of Health, 2017: The New Zealand Health and Disability
www.covid19lessons.royalcommission.nz/assets/ System (Wellington, 7 December 2017), p 4, https://
Uploads/Minute-1-Interim-non-publication-evidence- www.health.govt.nz/publications/briefing-to-the-
and-submissions-received.pdf incoming-minister-of-health-2017-the-new-zealand-
health-and-disability-system-0
Minute 2: Inquiry meeting procedure and information 25. Health and Disability System Review, Health and
gathering, 17 July 2023, https://www.covid19lessons. Disability System Review – Interim Report. Hauora
royalcommission.nz/assets/Uploads/minute-2-27- Manaaki ki Aotearoa Whānui – Pūrongo mō Tēnei Wā
September.pdf (Wellington, 3 September 2019), https://www.health.
govt.nz/publications/health-and-disability-system-
review-interim-report
Minute 3: Inquiry procedures for public and other
submissions, 6 December 2023, https://www. 26. Ministry of Health, Briefing to the Incoming Minister
covid19lessons.royalcommission.nz/assets/Uploads/ of Health, 2017: The New Zealand Health and Disability
Minute-3-Inquiry-procedures-for-public-and-other- System (Wellington, 7 December 2017), pp 10-11,
submissions.pdf https://www.health.govt.nz/publications/briefing-
to-the-incoming-minister-of-health-2017-the-new-
18. As at 2019, according to the World Bank. It
zealand-health-and-disability-system-0
estimated worldwide population density at 60
people per square kilometre. See World Bank 27. Health and Disability Review Transition Unit, Briefing
Group, ‘Population density (people per sq. km of to the incoming Minister of Health – Health and
land area)’, https://data.worldbank.org/indicator/ Disability System Review (17 December 2020), https://
EN.POP.DNST?end=2019&most_recent_value_ www.dpmc.govt.nz/publications/briefing-incoming-
desc=false&start=1961&view=chart minister-health-dec-2020
28. As documented by international bodies including: 32. TNS Kantar, New Zealand Perceptions of International
OECD, OECD Economic Surveys: New Zealand 2019, Education Infographic, Education New Zealand
OECD Publishing (Paris, 2019), p 78, https://www. (December 2019), https://intellilab.enz.govt.nz/
oecd-ilibrary.org/content/publication/b0b94dbd- document/607-new-zealand-perceptions-of-
en; UNICEF Aotearoa, ‘New report card shows that international-education-infographic
New Zealand is failing its children’, media release, 3 33. Education New Zealand, ‘By the numbers – Enrolment
September 2020, https://www.unicef.org.nz/media- data and Perceptions survey’, updated 12 December
releases/new-report-card-shows-that-new-zealand- 2019, https://www.enz.govt.nz/news-and-research/
is-failing-its-children; OECD, SF3.4: Family violence (31 ed-news/by-the-numbers-enrolment-data-and-
January 2013), p 3, https://www.oecd.org/els/soc/ perceptions-survey
SF3_4_Family_violence_Jan2013.pdf
34. National Emergency Management Agency, Briefing
29. New Zealand Productivity Commission, A fair chance to the Incoming Minister for Emergency Management
for all: Breaking the cycle of persistent disadvantage (2 November 2020), pp i, 7, https://www.beehive.
(June 2023), p 15, https://www.treasury.govt.nz/ govt.nz/sites/default/files/2020-12/Emergency%20
sites/default/files/2024-05/pc-inq-fcfa-fair-chance- Management.pdf
for-all-final-report-june-2023.pdf. The Productivity
35. National Emergency Management Agency, Briefing
Commission defines persistent disadvantage as
to the Incoming Minister for Emergency Management
‘disadvantage that is ongoing, whether for two or
(2 November 2020), p 12, https://www.beehive.
more years, over a life course, or intergenerationally’.
govt.nz/sites/default/files/2020-12/Emergency%20
It has three domains: being left out, doing without,
Management.pdf
and being income poor.
36. Maxwell Smith and Ross Upshur, ‘Pandemic Disease,
30. Megan Reid, ‘Disasters and Social Inequalities’,
Public Health, and Ethics’, in The Oxford Handbook of
Sociology Compass 7, no. 11 (20 November 2013),
Public Health Ethics, ed. Anna C. Mastroianni, Jeffrey P.
984-997, https://doi.org/10.1111/soc4.12080, https://
Kahn, and Nancy E. Kass (Oxford Handbooks, 2019;
compass.onlinelibrary.wiley.com/doi/full/10.1111/
online edn, Oxford Academic, 8 Jan. 2019), https://doi.
soc4.12080
org/10.1093/oxfordhb/9780190245191.013.69
United Nations Office for Disaster Risk Reduction
(UNDRR), ‘Poverty and inequality’, updated 18 April 37. National Ethics Advisory Committee, Getting Through
2024, https://www.preventionweb.net/understanding- Together: Ethical values for a pandemic, Ministry of
disaster-risk/risk-drivers/poverty-inequality Health (Wellington, 10 July 2007), https://neac.health.
govt.nz/assets/Uploads/NEAC/publications/getting-
CERA (Canterbury Earthquakes Recovery Authority),
through-together-jul07.pdf
Understanding Social Recovery (1 April 2016), https://
quakestudies.canterbury.ac.nz/store/object/524767?
search=understanding%2520social%2520recovery
31. Ministry of Social Development, Social Sector
Commissioning 2022–2028 Action Plan (2022), p 4,
https://www.msd.govt.nz/about-msd-and-our-work/
publications-resources/planning-strategy/social-
sector-commissioning/
Contents |
Ngā Kaupapa
Introduction 4
Chapters:
1 A snapshot of Aotearoa New Zealand’s pandemic experience 8
1.1 Timeline of key events 10
1.2 Aotearoa New Zealand’s COVID-19 experience 14
1.3 Some key international comparisons 15
1.4 Endnotes 27
2 All-of-government preparations and response 28

2.1 Introduction 29
2.2 Context 30
2.3 What happened: governance and decision-making structures 39
2.4 What happened: pandemic strategy and tools 46
2.5 What happened: public information and communication 58
2.6 Our assessment 62
2.7 What we learned looking back 81
2.8 Endnotes 85
3 Lockdowns 92
3.1 Introduction 93
3.2 What happened 96
3.5 Endnotes 138
AOTEAROA NEW ZEALAND ROYAL COMMISSION COVID-19 LESSONS LEARNED • MAIN REPORT: PART 2 – LOOKING BACK 1
4 Keeping the country closed: border restrictions and quarantine 145
4.1 Introduction 146

4.5 Endnotes 175
5 The health system response 180

5.2 Health system preparedness 183
5.3 What happened: public health 185
5.4 What happened: preparing the wider system 194
5.5 What happened: non-COVID-19-related care 203
5.8 Endnotes 234
6 Economic and social impacts and responses 241

6.2 What happened: economic impacts and responses 244
6.3 Our assessment: economic impacts and responses 258
6.4 What happened: social sector impacts and responses 274
6.5 Our assessment: social sector impacts and responses 286
6.6 The social and economic ‘long tail’ 306
6.8 Endnotes 313
2 AOTEAROA NEW ZEALAND ROYAL COMMISSION COVID-19 LESSONS LEARNED • MAIN REPORT: PART 2 – LOOKING BACK
7 Vaccination 325
7.5 Endnotes 355
8 Mandatory measures 360

8.2 What happened: testing, contact tracing, and masking requirements 364
8.3 Our assessment: testing, contact tracing and mask requirements 373
8.4 What happened: Vaccination requirements 381
8.5 Our assessment: Vaccination requirements 399
8.6 Controversy over compulsory measures 417
8.8 Endnotes 427
9 Taking stock 440

9.2 The story of the response 442
9.3 Moving on 451
Introduction |
Kupu whakataki
Our core task is to identify what lessons
can be learned from Aotearoa New Zealand’s
response to COVID-19, and then use those
lessons to recommend how we should
prepare for a future pandemic. To do so, we
must first examine the COVID-19 response
to establish what worked well; how the
response affected individuals, family and
whānau, communities and the economy;
and what could have been done better.
That is what this section does – not to
attribute blame, but to build a robust,
well-evidenced foundation for the lessons
and recommendations that follow.
We examine and evaluate the response from many angles
How well did Aotearoa New Zealand emerge from

the pandemic compared with other countries?
In the face of the (initially unknown) threat that COVID-19

represented, what policies, strategies and measures did
the Government adopt?
What part was played in the response by groups outside

central government – iwi and Māori, communities,
business, charities and local authorities, to name a few?
What were the effects of the response – positive and

adverse, intended and unintended – on the general
population and on specific groups and sectors?
What did decision-makers do to prevent or reduce the

worst impacts?
In considering such questions, we are aware of the huge advantage we have

over those responding to the pandemic in 2020–2022, rapidly, under huge
pressure and often with scant information. Unlike them, we have the wisdom
of hindsight. The decisions and measures we are scrutinising now reflect
the circumstances and pressures of that particular and extraordinary time.
We cannot be certain what other decisions might have been made if people had
known more about the virus then, if COVID-19 had reached us earlier or if it had
evolved differently. But we have looked for evidence that decision-makers were
actively considering what scenarios might unfold and how to respond if they did.
The conclusions we reach about the pandemic response reflect this expectation.
Because this section aims to support our lessons for
the future and our recommendations, it provides a
focused and selective account of preparations for,
response to and recovery from the pandemic.
It is not a comprehensive day-by-day chronicle of Aotearoa New Zealand’s
experience. As required by our terms of reference, we have drawn on but do not
duplicate the many comprehensive reports and chronologies already produced
by government agencies, reviewers, independent researchers and others.1
Nor is this section a forensic examination of every decision and development
made between February 2020 and October 2022. Instead, it addresses those
aspects of the response that proved most challenging, had the biggest impact,
can be most feasibly tackled by Government – and, crucially, that offer the
biggest opportunities for learning as we look to the future.
‘Looking Back’ begins with a brief, largely visual snapshot of some of the key
pandemic events, impacts, decisions and outcomes Aotearoa New Zealand
experienced and how they compared with other countries. The eight chapters that
follow each address a different aspect of the pandemic response in detail: the all-of-
government response (Chapter 2), lockdowns (Chapter 3), border and quarantine
measures (Chapter 4), the health system response (Chapter 5), economic and social
measures and impacts (Chapter 6), vaccination (Chapter 7) and finally the use of
mandatory measures (Chapter 8). Each chapter follows a broadly consistent pattern:
we begin by describing ‘what happened’, usually in a broadly chronological sequence
and with little evaluative commentary. Short ‘spotlights’ feature throughout,
highlighting particular pandemic policies or measures and their impacts. We then
set out our assessment of that particular topic, summarising our major learnings
from the pandemic at the end of each chapter. Finally, Chapter 9 takes stock of
New Zealand’s pandemic response overall and sets out some broad reflections on
what the country’s experience of COVID-19 taught us.
While the use of topic-specific chapters imposes a degree of order on our subject
matter, in reality the many elements of the response cannot be readily separated
into discrete strands. In a pandemic, everything affects everything else. It is
impossible to consider lockdowns without also talking about education and mental
health, for example, or vaccine mandates without also mentioning unemployment
and social cohesion. As a result, there are inevitable and necessary overlaps
between the chapters. Particular themes – te Tiriti o Waitangi obligations, the
steadfastness of communities, economic consequences and, crucially, COVID-19’s
human impacts – resurface in each. This reflects the unique nature of the period we
have examined: the COVID-19 pandemic was truly an ‘everything, everywhere’
event for this country and the world.
A reminder about our use of evidence in this section:
In Part One, we described the breadth and depth of the evidence provided to us
and the range of sources it came from – official records, independent reviews
and reports, academic studies, and engagements with senior officials and
decision-makers, iwi leaders, community groups, experts in disciplines like
economics and public health, and members of the public.
From the start, and as our terms of reference envisaged, we knew that everyone
who shared information or experiences with us needed to do so freely and frankly,
and without fear of repercussion. This would allow us to get the fullest picture
of what happened in the pandemic response, and to draw out useful lessons as
efficiently as possible. We therefore agreed to certain confidentiality arrangements
(summarised under ‘How we gathered and used evidence’ in Part One of this report).i
As a result of these arrangements, much of the non-public evidence which was
provided to the Inquiry and informs our analysis is not cited in the chapters that
follow – unless we sought and received permission from the source to quote from
or otherwise identify their evidence.
Likewise, statements or views
are not attributed to specific
organisations or individuals except
with their agreement. Publicly- This section is founded in a
available sources are cited. thorough and careful analysis
of information relevant to our
In sum, this section is founded in terms of reference.
a thorough and careful analysis of
information relevant to our terms
of reference. As outlined in the
discussion of our methodology in
Part One, we have followed a robust process – weighing, assessing and cross-
checking the evidence, testing our assumptions and considering the many possible
counter-factual scenarios. As a result, we are confident that all our lessons
and recommendations are soundly based.
i For more details of the Royal Commission’s non-publication orders and other confidentiality arrangements,
see ‘Procedural Minutes’, https://www.covid19lessons.royalcommission.nz/the-inquiry/procedural-minutes/
CHAPTER 1:
1 A snapshot of Aotearoa
New Zealand’s
pandemic experience |
He tirohanga ki ngā
wheako o Aotearoa
mō te mate urutā
What’s in this chapter
Many people are still living with the after-effects of the COVID-19
pandemic. But for others, it may already feel quite remote. Indeed,
the slightly surreal experience of revisiting relatively recent COVID-19
memories was something many submitters and stakeholders remarked
on during the Inquiry. For future readers, the events of the COVID-19
pandemic may be firmly in the category of ‘history’ by the time they are
engaging with this report.
The aim of this chapter is therefore to reorient, remind or indeed
introduce readers to some of the key pandemic events, impacts, decisions
and outcomes in Aotearoa New Zealand. In presenting a high-level
snapshot of the country’s COVID-19 experience and response, it provides
necessary context for the detailed analysis and assessment to be found in
the eight Looking Back chapters that follow.
The chapter is largely visual, telling the story of Aotearoa New Zealand’s
COVID-19 experience via:
• a high-level timeline setting out key events during the pandemic
period; and
• a series of facts, figures and graphics providing international
comparisons for some of the key aspects of the COVID-19
pandemic in Aotearoa New Zealand.
Timeline of key events |
1.1 Wātaka o ngā āhuatanga hira
December 2019 – March 2020 April 2020 – July 2021
12/8/2020
1/12/2019 21/2/2020 16/3/2020
9/4/2020 Covid-19 panic buying:
First cases of First New Zealand Self-isolation
All international PM calls for calm as
mysterious illness COVID-19 case is requirement for
arrivals in hundreds queue
emerge in Wuhan retrospectively all arrivals into
New Zealand outside supermarkets
are required
City, Hubei, China identified New Zealand Source: https://www.rnz.co.nz/news/national/423310/covid-19-panic-
to undertake
begins buying-pm-calls-for-calm-as-hundreds-queue-outside-supermarkets
managed isolation
6/1/2020 5/3/2020
19/3/2020 and quarantine
WHO reports First table-
New Zealand’s (MIQ) 19/8/2020 20/1/2021 19/3/2021
cluster of top COVID-19
planning exercise border is closed Businesses and Quarantine Free Trans-Tasman
pneumonia cases to all except 27/4/2020 workplaces
held by the Travel from Quarantine Free
of unknown cause returning New Strict lockdown are required to
Department of Pacific starts with Zone begins (and
Zealand citizens ends, and New display NZ COVID the Cook Islands ends on 23 July
Prime Minister
2/2/2020 Zealand enters Tracer QR code 2021)
and Cabinet 29/3/2020
Ministers agree to Alert Level 3 posters 19/2/2021
First New 30/4/2021
place restrictions First COVID-19
11/3/2020 Zealand 20/5/2020 2/11/2020 Vaccine mandate
on entry into vaccine arrives in
WHO declares COVID-19 NZ COVID Tracer Minister for for all border
New Zealand for New Zealand
COVID-19 a related app is released COVID-19 and MIQ workers
travellers arriving
pandemic death Response introduced
from or through
occurs portfolio is
China
created
2019 2020 2021
5/2/2020 26/5/2020
7/1/2020 New Zealand COVID-19 31/3/2021
Mysterious Government- Vaccine Strategy First case of 28/7/2021
pneumonia chartered 11/3/2020 announced, and Delta variant Vaccination
outbreak sickens repatriation flight COVID-19 NZ COVID-19 of COVID-19 is rollout begins
dozens in China from Wuhan lands Government Vaccine Taskforce identified in for general
in New Zealand 25/3/2020 13/12/2020
website is is established New Zealand population
New ‘Make Summer
launched
Zealand 14/5/2020 Unstoppable’ 1/6/2021
26/3/2021
goes into $50 billion public information WHO identifies
Vaccination
6/3/2020 Alert Level 4 COVID-19 campaign is Delta
rollout begins for
31/1/2020 National Crisis (lockdown) Response and launched frontline health
Director-General Management Recovery Fund is 20/5/2021
workers
of WHO declares Centre activated 17/3/2020 announced 30/8/2020 $1 billion is
novel coronavirus Economic Face coverings are 3/2/2021 invested into
to be a public 28/2/2020 support 15/4/2020 made mandatory First COVID-19 whānau Māori
health emergency First COVID-19 package is Ministry of for people aged vaccine (Pfizer/ wellbeing to assist
Source: https:// of international case announced announced, Education 12+ on public bioNTech) economic and
abcnews.go.com/ concern – the and contact including wage launches Home transport and provisional social recovery
Health/mystery- WHO’s highest tracing begins for subsidy and Learning TV aircraft at Alert approval is from the effects
pneumonia-outbreak- level of alarm positive cases leave support channel Level 2 and above announced of COVID-19
sickens-dozens-china/
story?id=68094861
10 AOTEAROA NEW ZEALAND ROYAL COMMISSION COVID-19 LESSONS LEARNED • MAIN REPORT: PART 2 – LOOKING BACK AOTEAROA NEW ZEALAND ROYAL COMMISSION COVID-19 LESSONS LEARNED • MAIN REPORT: PART 2 – LOOKING BACK 11
August 2021 – February 2022 March 2022 – December 2022
17/8/2021 1/11/2021 29/11/2021 2/3/2022 12/9/2022

First case of Delta Full vaccination Vaccine booster Parliament End of the ‘traffic
variant in the required for doses available grounds anti- light’ system, with
community is non-New Zealand vaccination/ most restrictions
announced citizens arriving in 20/12/2021 mandate lifted
New Zealand 90% vaccination occupation ends
of eligible New
1/9/2021 1/5/2022 27/9/2022
Zealanders
Auckland and 6/11/2021 All Government-
achieved Quarantine
Northland remain All Corrections issued vaccine
free travel for
in Alert Level 4 workers required mandates ended
17/1/2022 vaccinated visa
lockdown, while to have first dose
New Zealand waiver travellers
the remainder of of the vaccine
Police and from certain
the country goes 15/11/2021 countries
Defence Force
to Alert Level 3 Health and are required
disability, to be fully 2/7/2022
16/10/2021 education workers vaccinated Vaccine mandates
New Zealand- are required to be ended for border
wide vaccine vaccinated and Corrections
drive is held workers
2021 2022
8/2/2022
18/10/2021
Parliament
Alert Level System
grounds anti- 5/12/2022
is replaced with
vaccination/ The Front Page: How can
the ‘traffic light’
mandate New Zealand find social
system (COVID-19
23/11/2021 occupation unity again?
Protection
My Vaccination begins
Framework)
Pass launched
1/2/2022 12/8/2022
Source: https://www.nzherald.co.nz/
22/9/2021 14/11/2021 55 million First cruise ship
nz/the-front-page-how-can-new-
Auckland returns MIQ is reduced to rapid in over two years
zealand-find-social-unity-again/
to Alert Level 3 7 days followed by antigen tests enters New
XL4LOV7DQNGHBI2ER2PREIM3HM/
home isolation for (RATs) are Zealand
18/8/2021 arrivals into New confirmed
New Zealand goes Zealand for delivery 27/6/2022
into Alert Level 4 Final MIQ facilities
(lockdown) closed
4/4/2022
Vaccination
requirements
20/8/2021
removed for
Covid 19 coronavirus Delta outbreak: Auckland
most businesses
testing centre security staff cop abuse
and venues
Source: https://www.nzherald.co.nz/nz/covid-19-coronavirus-delta-outbreak-auckland-
testing-centre-security-staff-cop-abuse/Z3CTF4HJXENWVX5QMKRSSYCTWM/
Aotearoa New Zealand’s COVID-19 experience |
1.2 Ngā wheako o Aotearoa mō te mate
KOWHEORI-19
1.2.1 Overall, Aotearoa New Zealand’s COVID-19 response

was effective
Compared to other jurisdictions, Aotearoa New Zealand’s COVID-19 response
was effective at both protecting people from the health effects of the virus, and
minimising the potential economic, social and wellbeing impacts of a global
pandemic. That is not to say the response was perfect; it wasn’t, and challenges
emerged as the response wore on. We look at these challenges, and other areas
where lessons can be learned, in the following chapters.
Pandemics are first and foremost health emergencies, and the public health
response to COVID-19 in Aotearoa New Zealand successfully prevented widespread
infection until most of the population was vaccinated. In doing so, it is estimated to
have saved thousands of lives.2 Aotearoa New Zealand’s health system was never
overwhelmed in the terrifying and devastating way those in other countries were,
and many of the potentially unequal health impacts on disadvantaged or vulnerable
populations – importantly including Māori, given their experience in the 1918
pandemic – were minimised or mitigated.
The benefits of Aotearoa New Zealand’s COVID-19 response also went beyond
public health. The initial success of the elimination strategy allowed the country
to spend less time under strict lockdown conditions than many other parts of the
world, meaning daily life and economic activity were able to return to ‘normal’ much
earlier. This was coupled with a swift and generous economic and social response
which cushioned many people and businesses from the pandemic’s worst impacts.
While these benefits were not achieved without costs – which the coming chapters
will also discuss – it is important that we begin this report with an acknowledgement
of the success of Aotearoa New Zealand’s response on a range of measures. It was
praised as an exemplar around the world, especially in the first two years. For a
lessons-focused Inquiry like ours, there is as much to learn about preparing for a
future pandemic from what went well during Aotearoa New Zealand’s COVID-19
response as there is about what could have gone better.
In this chapter, we present some key international comparisons that illustrate the
effectiveness of Aotearoa New Zealand’s overall COVID-19 response. For more
detail and analysis on the topics and issues highlighted, see the corresponding
chapter(s) indicated throughout the text.
Some key international comparisons |
1.3 Ētahi whakatauritenga hira o te ao
1.3.1 Low COVID-19 case numbers, hospitalisations and deaths

By preventing widespread COVID-19 infection until the population was vaccinated
and the virus had become less deadly, Aotearoa New Zealand’s COVID-19 response
protected Māori and Pacific communities and also prevented the premature
deaths of thousands of New Zealanders – particularly older people, people living in
disadvantaged circumstances, and people with co-morbidities, disabilities and/or
medical vulnerabilities.
Aotearoa New Zealand’s COVID-19 case numbers were much

lower than comparable countries in the first two years of
the pandemic
Figure 1: COVID-19 cases (confirmed) per million people, 2020–2021
Due to limited testing, the number of confirmed cases is lower than the true number of infections.
Detection of COVID-19 cases falls over time as fewer people got tested in the later stages of the pandemic.
Source: Our World in Data, 2024, Cumulative confirmed COVID-19 cases per million people,
https://ourworldindata.org/covid-cases
In the first two years of the pandemic, Aotearoa New Zealand had far fewer
COVID-19 cases than most other countries. Most New Zealanders were not
exposed to COVID-19 infection until 2022, by which time almost everyone had
been vaccinated. This meant New Zealand had far fewer hospitalisations and
deaths from COVID-19 compared with countries where the virus had circulated
widely before vaccination became available.
Aotearoa New Zealand’s peak COVID-19 hospitalisation rate was

around half the peak in the United States and United Kingdom
Aotearoa US and UK
6
New Zealand
3
admissions per admissions per
100,000 population 100,000 population
per day per day
Aotearoa New Zealand’s COVID-19 hospitalisations peaked in March 2022, at

just under three admissions per 100,000 population per day. By comparison, the
United States and the United Kingdom experienced peak hospitalisation rates of
more than 6 admissions per 100,000 population per day – approximately twice
as high as that in Aotearoa New Zealand.ii Unlike other countries, New Zealand
also recorded very few COVID-19 deaths among people living in residential
facilities such as aged care homes.
ii Source: Based on data from Our World in Data, 2024, Weekly new hospital admissions for COVID-19 per million,
https://ourworldindata.org/grapher/weekly-hospital-admissions-covid-per-million
Fewer people died from COVID-19 – or any cause – in Aotearoa
New Zealand than in other OECD countries during the
pandemic period
Aotearoa New Zealand experienced fewer COVID-19 deaths per head of population
than almost any other OECD country. Moreover, Aotearoa New Zealand experienced
‘negative’ excess mortality (fewer deaths than would have been expected in a
‘normal’ year) from early 2020 until early 2023 (Figure 2).iii
Figure 2: Excess mortality (all causes) per million people, 2020–2023
Source: Our World in Data, 2024, Data Page: Excess mortality: Cumulative deaths from all causes compared
to projection based on previous years, per million people. Data adapted from Human Mortality Database,
World Mortality Database, Karlinsky & Kobak. Retrieved from https://ourworldindata.org/grapher/cumulative-
excess-deaths-per-million-covid
iii This fact is attributed to the positive impact of lockdowns and other infection control and public health measures
on the transmission of other infectious diseases.
Aotearoa New Zealand achieved a high level of vaccine coverage
Aotearoa New Zealand’s vaccination rollout was slightly slower to get started
than in some other countries, but achieved a high level of coverage compared
to international averages – and did so quickly. By 26 November 2021, 80 percent
of the eligible population had received two doses of the vaccine – a considerable
achievement given no vaccine rollout of this magnitude and speed had been
attempted in Aotearoa New Zealand before.
Figure 3: Vaccine coverage by time for Aotearoa New Zealand

and comparator countries, 30 December 2020–1 July 2022
Source: Our World in Data, 2024, Data Page: Share of people who completed the initial COVID-19 vaccination
protocol. Data adapted from Official data collated by Our World in Data, World Health Organisation, Various
sources. Retrieved from https://ourworldindata.org/grapher/share-people-fully-vaccinated-covid
For more on the vaccine rollout, see Chapter 7.

For more on case numbers, hospitalisations, mortality
and the health system response, see Chapter 5.
For more on the use of measures to encourage vaccine
uptake, see Chapter 8.
Aotearoa New Zealand’s lockdown measures were strict,
but New Zealanders spent less time in lockdown than many
other countries
Figure 4: Oxford stringency index for Aotearoa New Zealand

and comparator countries, 2020–2022 inclusive
Source: Blavatnik School of Government, University of Oxford – with minor processing by Our World in Data, 2023,
COVID-19: Stringency Index (New Zealand, Australia, Taiwan, United Kingdom, United States and Sweden), https://
ourworldindata.org/explorers/
This stringency index compares the levels of restrictions (e.g. closure of schools and workplaces, limits on
gatherings, etc.) across countries and over time. Where a country (or a region within the country) is in ‘lockdown’,
the stringency index is higher.
Under Alert Level 4 (full lockdown) Aotearoa New Zealand’s control measures were
at the top of the stringency scale and stricter than many other countries. But
New Zealanders spent comparatively little time under these conditions. After the
initial lockdown, Aotearoa New Zealand spent much of 2020 and the first half
of 2021 at Alert Level 1. During these periods, people faced far fewer domestic
restrictions – apart from border restrictions affecting their ability to travel or, for
some, to return home – than many other countries, including those pursuing
suppression or mitigation strategies. As a result, New Zealanders were able to
enjoy relatively normal lives for long periods of time: for example, people could
gather in large numbers again, and travel domestically to visit family and friends.
For more on Aotearoa New Zealand’s use of lockdowns,

see Chapter 3.
1.3.2 Strong economic and social outcomes
Aotearoa New Zealand’s economy recovered more quickly
and strongly than other comparable countries
In Aotearoa New Zealand, as elsewhere, the arrival of the pandemic was
accompanied by an immediate dip in GDP, reflecting the global impact of
lockdowns on employment and economic activity. While Aotearoa New Zealand’s
initial GDP fall was similar to that experienced in other OECD countries, the
economy recovered more quickly and strongly here than elsewhere. This was
due to a combination of factors, including the initial success of the elimination
strategy allowing daily life and economic activity to resume quickly in 2020, and
the protective effect of Aotearoa New Zealand’s generous economic support
measures on jobs and incomes. By the third quarter of 2020, the economy
regained its pre-pandemic levels – earlier than any other OECD country – and
remained above this level through to the end of 2022.
Figure 5: Change in real GDP for Aotearoa New Zealand and comparators
during the pandemic
1. EU countries that are members of the OECD

Source: OECD, 2022, OECD Economic Surveys: New Zealand 2022, p 12, https://www.oecd.org/en/publications/
oecd-economic-surveys-new-zealand-2022_a4fd214c-en.html
For more on the economic and social impacts and

measures during the pandemic, see Chapter 6.
Aotearoa New Zealand’s unemployment rates remained low
While there was concern early on that the COVID-19 pandemic might precipitate
widespread job losses and high unemployment, these risks did not eventuate.
Aotearoa New Zealand has consistently had higher employment rates (and lower
unemployment rates) than the OECD average, and this remained the case during
the pandemic.
Figure 6: Unemployment rate across OECD countries, 2019–2021
Source: Treasury, 2022, Our wellbeing throughout the COVID-19 pandemic, p 20, https://www.treasury.govt.nz/
publications/tp/our-wellbeing-throughout-covid-19-pandemic
Learners missed fewer days of school in Aotearoa New Zealand
than in most comparable countries
When compared internationally, the disruption to education caused by the
COVID-19 pandemic in Aotearoa New Zealand was less than that of other OECD
countries. Relative to other countries, students here missed fewer days of school
instruction, largely due to Aotearoa New Zealand’s shorter time spent in lockdown.
In terms of student learning and achievement, Aotearoa New Zealand maintained
its relative position compared to other OECD nations.3 This suggests that while
students around the world experienced loss of learning from the pandemic, the
impact here was no more so than in other comparable countries.iv
Figure 7: COVID-19 school disruptions, 16 February 2020–31 October 2021
Source: Treasury, Our wellbeing throughout the COVID-19 pandemic, p 77, https://www.treasury.govt.nz/
publications/tp/our-wellbeing-throughout-covid-19-pandemic
iv However, this was not the case for all learners, with negative impacts more pronounced for Māori and Pacific students
and those from lower socio-economic backgrounds – this is discussed in more detail in Chapter 3.
While the pandemic disrupted learning outcomes worldwide,
Aotearoa New Zealand learners continued to perform above
the OECD average
The impact of school closures on student achievement and academic progress
during the pandemic is challenging to assess. However, testing by OECD’s
Programme for International Student Assessment (PISA)v in 2022 can be compared
with pre-pandemic PISA ratings, especially 2018.
The overall results of the 2022 student testing were mixed.4 They showed that while
student learning outcomes declined in some countries during the pandemic years,
others remained steady and some actually improved.5 Aotearoa New Zealand’s
maths scores were 15 points lower than in 2018 (as was the OECD average),
while reading and science scores were largely unchanged.6 In all three areas,
New Zealand maintained its relative position compared to other OECD nations,
suggesting New Zealand students did experience loss of learning from the
pandemic, particularly in maths, but no more so than in other comparable
countries.7 Students from low socio-economic backgrounds had a larger drop in
maths than more socio-economically advantaged students.8 Considering the overall
disruption experienced by learners across the education system during COVID-19,
it is positive to see in this data that New Zealand students maintained their relative
position and that the country was broadly in line with others in terms of the impact
on learning outcomes.
v The Programme for International Student Assessment (PISA) is an OECD initiative that compares the standardised
reading, maths, and science scores of 15-year-old students selected at random from 81 participating countries,
including New Zealand. It is undertaken every two years. There were approximately 250,000 participants in the 2022
study, conducted across 2021-22.
Figure 8: Aotearoa New Zealand’s mean PISA scores compared with other
OECD countries (2022)
Aotearoa New Zealand performs relatively well in reading and science,

less so in mathematics. Aotearoa New Zealand’s mean PISA score compared
to other OECD countries is…
Maths Reading Science

1 Japan Ireland* Japan
Korea …lower
Korea Japan
Estonia Korea Estonia than these
Switzerland Estonia Canada* countries
Canada* Canada* Finland
6 Netherlands* United States*
Ireland* Aotearoa NZ* 7 Australia*
Australia* Aotearoa NZ* 7
Belgium Ireland* …similar
Denmark* United Kingdom* Switzerland
United Kingdom* Slovenia to these
Finland
United Kingdom* countries
11 Poland Poland United States*
Czech Republic Denmark* Poland
Austria Czech Republic
Rank across OECD
Australia* Sweden Czech Republic

Slovenia Switzerland Sweden
16 Italy Latvia*
Finland Latvia* Austria Denmark*
Sweden Germany Germany
Aotearoa NZ* 19 Belgium Austria
Lithuania Belgium
Portugal
21 France Germany Norway Netherlands*
Latvia* France
Hungary Spain Hungary
Spain France Lithuania …higher
Portugal Israel Spain than these
26 Italy Hungary Portugal countries
Norway Lithuania Norway
United States* Slovenia Italy
Slovak Republic Netherlands* Israel
Iceland Chile Slovak Republic
31 Israel Slovak Republic Iceland
Greece Greece Chile
Chile Iceland Greece
Mexico Mexico Colombia
Colombia Colombia Mexico
Countries with a * did not meet PISA Technical standards for sampling.
Source: Ministry of Education, PISA 2022: Aotearoa New Zealand Achievement Summary (Summary Infographic
pdf), https://www.educationcounts.govt.nz/publications/schooling2/large-scale-international-assessments/pisa-
2022-aotearoa-new-zealand-summary-report#:~:text=In%202022%20Aotearoa%20New%20Zealand’s,to%20
or%20PISA%202018
1.3.3 Conclusion
This brief chapter is not intended to give a comprehensive account of Aotearoa
New Zealand’s COVID-19 experience – readers will find a more detailed analysis
of the key events and decisions that occurred and the array of health, economic
and social outcomes they led to in Chapters 2 to 9.
Instead, it has offered a selective snapshot of how Aotearoa New Zealand fared,
compared with other countries, on some key measures. Collectively, the data
presented here tells the story of a national response that was effective on
many counts.
Aotearoa New Zealand, like countries everywhere, was caught off-guard by
COVID-19. We were not prepared for a response that had to be sustained for such
a long time, nor for a virus that evolved as it did. And we were affected by other
problems that were harder-to-measure – among them societal fragmentation, staff
burnout in many sectors and the challenges of balancing collective safety with the
rights of individuals. We turn now to examine what this meant for the key elements
of New Zealand’s pandemic response, starting with the plans, systems, decision-
making structures and strategies adopted across government.
Endnotes |
0.0
1.4 Tuhinga āpiti
1. Department of the Prime Minister and Cabinet, 4. OECD, ‘PISA 2022: Aotearoa New Zealand Achievement
Timeline of Significant COVID-19 Events and Key Summary’, 5 December 2023, https://www.oecd.org/
All-of-Government Response Activities (Version en/publications/pisa-2022-results-volume-i_53f23881-
1), September 2023, https://www.dpmc.govt.nz/ en.html
publications/proactive-release-timeline-aotearoa- 5. Ministry of Education, PISA 2022: Aotearoa
new-zealands-significant-events-and-key-all- New Zealand Achievement Summary (2022),
government-activities https://www.educationcounts.govt.nz/publications/
McGuinness Institute, COVID-19 Nation Dates (1st ed.) schooling2/large-scale-international-assessments/
(Wellington, 2023), https://nationdatesnz.org/ pisa-2022-aotearoa-new-zealand-summary-
covid-19-nation-dates-1stedition report#:~:text=In%202022%20Aotearoa%20New%20
2. Michael G. Baker, Amanda Kvalsvig, Michael Plank, Zealand’s,to%20that%20for%20PISA%202018
Jemma L. Geoghegan, Teresa Wall, Colin Tukuitonga, 6. Steve May and Emma Medina, PISA 2022:
Jennifer Summers, Julie Bennett, John Kerr, Nikki Aotearoa New Zealand Summary Report, Ministry
Turner, Sally Roberts, Kelvin Ward, Bryan Betty, Q. of Education (Wellington, December 2023), p 3,
Sue Huang, Nigel French, and Nick Wilson, ‘Continued https://www.educationcounts.govt.nz/__data/assets/
mitigation needed to minimise the high health burden pdf_file/0015/224601/PISA-2022-summary-report.pdf
from COVID-19 in Aotearoa New Zealand’, New Zealand
7. Steve May and Emma Medina, PISA 2022: Aotearoa
Medical Journal 136, no. 1583 (6 October 2023), 67-91,
New Zealand Summary Report, Ministry of Education
https://doi.org/10.26635/6965.6247, https://nzmj.org.
(Wellington, December 2023), p 3, https://www.
nz/journal/vol-136-no-1583/continued-mitigation-
educationcounts.govt.nz/__data/assets/pdf_
needed-to-minimise-the-high-health-burden-from-
file/0015/224601/PISA-2022-summary-report.pdf
covid-19-in-aotearoa-new-zealand
(Wellington, December 2023), p 3, https://www.
(Wellington, December 2023), https://www.
CHAPTER 2:
2 All-of-government
preparations and
response |
Ngā whakaritenga
me te urupare a te
kāwanatanga whānui
Introduction |
0.0
2.1 Kupu whakataki
This chapter begins at the start of 2020, when the scale of the threat
presented by COVID-19 and its possible implications for Aotearoa
New Zealand were becoming apparent.
It briefly describes and then evaluates the plans, systems, governance

mechanisms, decision-making structures and strategiesi that were central to
the Government’s pandemic response over the next two years, and how they
were communicated to the public.
The themes running through the chapter – preparedness, decision-making,
strategy – are broad and intertwined. They also resurface repeatedly throughout
Chapters 3 to 8 and we will return to them again in Chapter 9 where we summarise
our high-level learnings after looking back at the entire pandemic response from
2020 to 2022.
We begin with some essential context: section 2.2 provides a brief

evaluation of the state of pandemic preparedness and emergency
management arrangements across government at the point COVID-19
emerged. This was the base from which the Government’s COVID-19
response began.
Sections 2.3 to 2.5 then describe the evolution of key aspects
of the response over the course of the pandemic – first governance
and decision-making structures (2.3), then national pandemic
strategies and tools (2.4), and finally the use of public information
and communications tools to mobilise support for the pandemic
response (2.5).
Our assessment of all these aspects of the response and their impact
is in section 2.6.
i A more detailed description of the legislation, emergency plans, systems and structures supporting the COVID-19
response is provided in Appendix A.
Context: the state of Aotearoa New Zealand’s
pandemic preparedness and emergency management
0.0
2.2 arrangements before COVID-19 | Horopaki: te āhua
o te takatū ki te mate urutā o Aotearoa me ngā whakaritenga
whakahaere ohotata i mua o te KOWHEORI-19
National and international preparedness for pandemics has been a high-

profile public health issue in recent decades as potent infectious diseases
– Ebola, severe acute respiratory syndrome (SARS), Middle East respiratory
syndrome (MERS), various influenza viruses – have emerged or re-emerged
with increasing frequency.
Across the world, numerous pandemic strategies and plans have been drafted,
enhanced surveillance and testing regimes adopted, and simulation exercises
conducted.1 Yet the Director-General of the World Health Organization, Tedros
Adhanom Ghebreyesus, was frank in his appraisal of what the ‘preparedness
project’ had achieved by 2020:2
“ Over the years we have had many reports, reviews and recommendations all saying the same
thing: the world is not prepared for a pandemic. COVID-19 has laid bare the truth: when the
time came, the world was still not ready.” 3
Faced with a pandemic of this scale and a virus about which so little was known,
it was impossible for any country to have made infallible preparations. Quite simply,
the World Bank noted, ‘there are limits to preparedness’.4 Any assessment of
Aotearoa New Zealand’s readiness to respond to the COVID-19 pandemic needs
to place it in this global context.
Before COVID-19, Aotearoa New Zealand had in fact scored well in a World Health
Organization assessment of its capacity to respond to health security threats.5
Another assessment of international pandemic preparedness, the Global Health
Security Index, had scored New Zealand slightly above the average for high-income
countries.6 But that assessment also revealed that, collectively, international
preparedness was weak.ii A similar conclusion was reached by the Independent
Panel for Pandemic Preparedness and Response, which identified a worldwide
failure to invest sufficiently in pandemic preparedness – although what an
appropriate level of investment would be, both globally and nationally, has not
yet been determined.7
Before COVID-19, a range of existing systems, legislation, plans, structures and
capabilities were available to support a pandemic response. This put New Zealand
in a good position when COVID-19 first emerged. However, there were areas of
weakness. In particular, the Civil Defence Emergency Management System was
primarily geared towards natural hazard emergencies, the New Zealand Influenza
Pandemic Plan 2017 was inadequate for a pandemic like COVID-19, and the risk
management system did not work as well as it could have.
For more detail on the various systems, structures, plans and models covered
in this section, please see Appendix A.
ii To assess overall preparedness, the Global Health Security Index 2019 studied 195 countries’ pandemic readiness
across six dimensions/categories – prevention of the emergence of pathogens, early detection, rapid response
and mitigation, sufficiency and robustness of the health system, commitment to improving national capacity and
financing and a country’s overall risk environment and vulnerability to biological threats. However, a major gap has
been identified between countries’ preparedness levels – as measured in the Index – and COVID-19 death rates. For
example, the top-ranked country in the Index was the United States of America whose death rate as at March 2023
was 341 per 100,000 people (according to Johns Hopkins University: see https://coronavirus.jhu.edu/data/mortality).
Health researchers say this suggests more accurate ways to measure countries’ pandemic preparedness and response
capabilities are needed: see Crosby, S, Dieleman, JL, Kiernan, S and Bollyky TJ (2020), All Bets Are Off for Measuring
Pandemic Preparedness, Think Global Health, 30 June 2020, https://www.thinkglobalhealth.org/article/all-bets-are-
measuring-pandemic-preparedness.
2.2.1 A well-established civil defence and emergency
management system was in place
The evidence we have reviewed shows a well-established civil defence emergency
management system was in place at the start of 2020. It was led by the National
Emergency Management Agency (NEMA) and included 16 regionally-based Civil
Defence Emergency Management Groups (collectives of local and/or unitary
authorities within each region). Depending on the nature of the emergency,
different agencies would be expected to take on the role of ‘lead agency’ (for
example, the New Zealand Police would be the lead agency for a terrorism incident).
In addition, in a significant crisis or emergency, the Officials Committee for Domestic
and External Security Coordination (ODESC) system could be activated.8 ODESC is
a group of senior officials, chaired by the Chief Executive of the Department of the
Prime Minister and Cabinet. In 2020, its role was to coordinate an all-of-government
response to an event and support ministers in developing the strategic direction,
policies and resourcing required to deal with a crisis.
In 2020, the emergency management system was practised in dealing with disasters
such as severe weather events and earthquakes. Many of the people working
within it – and some based in other parts of government – were highly experienced
in crisis response and/or trained in using the standardised Coordinated Incident
Management System.
Because the Civil Defence Emergency Management System is tasked with
responding to emergencies arising from all hazards and risks, it was in principle
capable of responding to a pandemic – which was identified as a potential threat
to the country in the National Risk Register.9 Plans drawn up before 2020 by the
16 regional Civil Defence Emergency Management Groups showed many had
identified a human disease pandemic as a potential risk with significant national
and local consequences.10
However, in reality the system was not prepared for a pandemic of the nature and
scale of COVID-19, which required a prolonged response and had widespread and
complex national impacts. For example, Civil Defence Emergency Management
Groups are typically involved in providing emergency welfare support in a particular
region or area and for short periods of time only, perhaps a few days or weeks but
rarely months – let alone years.
2.2.2 Aotearoa New Zealand had a system for identifying
national-level hazards and risks
A National Risk Framework is used across government to drive decision-making
that ‘advances New Zealand’s long-term prosperity, and strengthens our resilience
to the most significant hazards and threats we face’.11 Broadly, it involves identifying,
managing and proactively planning for national risks, including by maintaining a
National Risk Register of the most significant risks Aotearoa New Zealand faces.12
In 2020, the register listed ‘threat-type’ risks (such as terrorism and cyber security),
which were overseen by the Security and Intelligence Board (now known as
the National Security Board), and a larger group of ‘hazard-type’ risks, including
pandemics.13 This latter group of risks was overseen by the Hazard Risk Board
(now the National Hazards Board).14
However, this system had limitations. The Inquiry heard that while the register
identified risks, the system did not then actively oversee whether and how those
risks were being prepared for across government. There were limited formal
oversight or accountability mechanisms to ensure agencies had appropriate plans
in place to prepare for (and mitigate if possible) significant national risks. The
evidence also showed that the Hazard Risk Board was not functioning optimally in
early 2020. As the Auditor-General noted, it had not been meeting regularly and was
‘struggl[ing] to carry out strategic governance properly.’15
Despite evidence that the New Zealand national risk assessment and management
system had little real bite, we recognise that this was also true of other countries.16
The system was not prepared

for a pandemic of the nature
and scale of COVID-19,
which required a prolonged
response and had complex
national impacts.
2.2.3 Legislation was in place which could quickly be built upon
The system was well supported by legislation which set out the initial powers
and requirements needed by government and others to manage the emerging
pandemic. Appendix A provides a fuller account of the relevant statutes and
other instruments, many of which remain in effect today, but in brief they were:
• The Health Act 1956,17 which provided broad powers to manage infectious
diseases – including powers to require people to isolate or quarantine, close
premises, limit gatherings and undergo medical testing.
• The Civil Defence Emergency Management Act 2002,18 which set out a
framework to prepare for, deal with and recover from local, regional and national
emergencies. It included powers that can be used to support emergencies
such as pandemics. For example, the Act gave the Minister the mechanism to
declare the state of national emergency on 25 March 2020, and unlock powers
in the Act to support the response, such as requisitioning carparks for testing
purposes.19 The Act also included a permanent legislative authority to assist the
Crown in reimbursing local authorities for response and recovery costs in an
emergency, without need for a further appropriation.20 This ability was critical
in the first part of the response, enabling agencies to quickly deliver necessary
(and sometimes costly) supports such as food parcels until the Budget was
passed on 14 May 2020, which provided more specific allocation of funding.
• National Civil Defence Emergency Management Plan Order 2015,21 which set
out guiding principles, roles and responsibilities for government agencies, local
government, lifeline utilities, emergency services and other groups involved
in reduction, readiness, response and recovery from emergencies at the
national level. The plan took an ‘all hazards, all risks approach’ to emergency
management and applied regardless of the cause of the emergency – including
‘infectious human disease pandemics’.
• The Epidemic Preparedness Act 2006,22 which provided mechanisms to help
manage a public health emergency arising from a major outbreak of a highly
infectious disease. It complemented the Health Act 1956. It allowed some
non-health statutory requirements to be relaxed if they were not able to be
complied with during an epidemic, enabling certain activities to continue to be
undertaken by people and government agencies.
In addition to these statutes, the COVID-19 Response (Urgent Management
Measures) Legislation Act 2020 – an ‘omnibus’ bill which amended other existing
Acts – was passed on 25 March 2020.23 Later, some new legislation and amendments
were considered necessary and introduced as the response evolved; the bespoke
COVID–19 Public Health Response Act 2020 was passed in May 2020 (described in
Appendix A and section 2.3.2).
Bespoke legislation that had been developed following the Canterbury and
Hurunui/ Kaikōura earthquakes,24 alongside the Epidemic Preparedness Act 2006,
provided models that the COVID-19 response could draw on. This enabled bespoke
COVID-19 legislation to be drafted and implemented at pace and meant there was
a good understanding of the levers, powers, checks and balances required when
developing legislation of this kind.
The Legislation Design and Advisory Committee’s submission to the Select
Committee inquiry into the operation of the COVID–19 Public Health Response Act
2020 (in July 2020) noted that ‘bespoke legislation will almost certainly be required’
in the case of significant emergencies, particularly where there is concern that
existing tools will need to stretch too far to fit the response measures as they
evolve. It also noted the role of individual departmental stewardship in maintaining
awareness of the tools available in their current legislation and undertaking ongoing
reviews with an eye to maintaining operations and responding in an emergency.25
However, the Law Commission’s 2022 Study Paper on the legal framework for
emergencies also noted:
“ The current preference for enacting bespoke legislation to deal with emergencies after
they have emerged is perhaps an indictment of the usefulness of the existing standing
rules or evidence of a concern about their possible misuse or both. More needs to be done
in standing legislation for the reason that it will not always be possible to enact bespoke
legislation in time or with appropriate public input. ”
26
These issues are discussed further in Lesson 6.
Like other emergencies,

bespoke legislation was
quickly developed for the
COVID-19 response.
2.2.4 The New Zealand Influenza Pandemic Plan was useful
at the start of the response
The New Zealand Influenza Pandemic Plan 2017 27 was Aotearoa New Zealand’s sole
pandemic-specific response plan at the time COVID-19 emerged. Like most national
pandemic plans, this Plan was designed principally to respond to an influenza
pandemic. However, the Plan noted it ‘could reasonably apply to other respiratory-
type pandemics (such as severe acute respiratory syndrome – SARS)’.28
Aspects of the Plan were useful early on, such as the guidance it provided on
organising intersectoral workstreams and information on which public health
measures to activate in the initial stages. In the first few weeks of the COVID-19
response, the public health strategy adopted by the Government followed the
‘keep it out’ and ‘stamp it out’ phases of the Plan.
In the context of COVID-19, however, the Influenza Pandemic Plan had significant
limitations. These limitations were by no means unique to New Zealand, with similar
limitations apparent in many countries’ pre-COVID-19 pandemic plans. For example,
the Plan focused on coordinating the immediate ‘emergency’ pandemic response
and did not set out structures for coordinating or governing an all-of-government
response that would be required over a prolonged period.
Perhaps most significantly, the Plan lacked a framework for reviewing the high-level
response strategy and adapting it over time as the situation changed. While the Plan
recognised the need to anticipate repeated waves of infection, it was expected that
these could be managed using a mix of existing approaches (as set out under the
‘keep it out’, ‘stamp it out’ and ‘manage it’ phases), guided primarily by public health
indicators.29 The need for high-level strategic planning and adjustment across all
sectors of society, and over several years, had not been envisaged.
Some elements of the Plan might have been useful in the response to COVID-19,
but they needed more work. While the Plan emphasised the importance of
engaging with Māori ‘as tāngata whenua’, for example, such engagement was
largely envisaged in terms of communicating key messages and ensuring Māori
had access to resources. The Plan did not address the role of Māori and iwi in
decision-making, or in designing and providing services (including healthcare
services), which the Crown’s te Tiriti | the Treaty obligations require it to provide
for. The Plan did reference the health sector’s Māori Health Strategy (He Korowai
Oranga), and ‘encourage[d] the inclusion of Māori in district, regional and national
pandemic planning’.30
A senior health official told us the Plan did not sufficiently address the need for
government agencies to practise for the pandemic response. The Auditor-General,
in his review of the all-of-government COVID-19 response, emphasised the
importance of regular exercises to improve readiness and response arrangements31
and referred to the Ministry of Health’s own evaluation of the 2017/18 exercise,
which found that the 10-year interval between exercises was too long.32
2.2.5 Useful models of collaborative cross-agency work had
been established
Before 2020, notable examples of government agencies working together to good
effect on common issues included the Justice Sector Leadership Board and Te Puna
Aonui, the Joint Venture for the Elimination of Family Violence and Sexual Violence.iii
When the Public Service Act 2020iv was passed in the first year of the pandemic,
it confirmed the importance of this collaborative, cross-agency approach. Among
other things, it formalised a public service leadership team to provide government-
wide leadership.33
Initiatives like Te Puna Aonui and others had helped break down existing silos,
created mutual goodwill and built strong relationships – all of which were usefully
leveraged throughout the pandemic response. As the (then) Public Service
Commissioner Peter Hughes told us, the existence of the public sector leadership
team ‘gave us a real tailwind’ going into the pandemic: ‘they knew how to work well
together already, which gave [us] a team basis for COVID-19’.34
The Border Executive Board (established in December 2020 to deliver an integrated
and effective border system in the context of COVID-19) was a good example of
this collective responsibility in action, in this case through an interdepartmental
executive board. The Inquiry heard that less formal arrangements at chief executive
level could also be very productive in managing COVID-19. Examples included
the justice and transport sectors – where existing strong relationships and clear
common objectives enabled chief executives to work together on the significant
challenges facing their sectors – and the Caring for our Communities Chief
Executives Group, who came together to help with rapid and coordinated delivery
of resources to where they were needed, developing innovative ways to work
through barriers. These leadership groups also proved invaluable in helping
agencies work closely with the private sector. This was critical for implementing
some measures; for example, transport agencies needed to work closely with
airlines to safeguard the sustainability of supply lines.
iii The former brings together the leaders of six core justice agencies – the Ministry of Justice, New Zealand Police,
Department of Corrections, Oranga Tamariki, the Serious Fraud Office and the Crown Law Office – to collaborate on
system-wide issues, govern significant cross-agency work programmes and lead agencies with united purpose. Te Puna
Aonui brings together nine government agencies and four associate agencies to align whole-of-government strategy,
policy and investment to eliminate family violence and sexual violence.
iv Enacted in August 2020, it provided for new system leadership roles and organisational forms that would give agencies
greater flexibility in the way they organised around government priorities, and make it easier for them to join-up
around complex problems.
2.2.6 New Zealand’s public service was flexible, agile
and dedicated
The flexibility and adaptability of the public service before COVID-19 paid off during the
response. Staff stepped up to develop and deliver a coordinated, novel and innovative
government response to COVID-19 – at pace and in the face of considerable uncertainty.
As a senior public sector official explained to us, this flexibility was supported by pre-
existing mechanisms that allowed for the movement of people across the public service
and enabled a range of expertise to come together in a highly informal environment.
2.2.7 Some agencies had strong relationships with communities

There were some areas where government agencies had strong relationships with
communities. Where these relationships already existed, there was higher trust in,
and devolution of, decision-making at the community level.
As the pandemic response evolved, relationships between government agencies
and communities often improved as communities were able to show their
effectiveness and government agencies grew in confidence with the approach.
We heard from many government and community organisations that there is great
value in developing these relationships in advance, for improved commissioning
and delivery of services in the present as well as to set the foundation needed to
respond to a future crisis.
“ Have the ten thousand cups of tea now, on the day-to-day work, so that when you’ve
got to work at pace, no-one’s saying ‘let’s have a cup of tea. We’ll have a think about
whether we want to jump on this with you.’ Critical thing is how you maintain that
relationship and are ready to go. ”
We heard that when local providers were valued and empowered, it resulted in
locally-tailored solutions that are more effective than standard responses. This
impact was demonstrated in a compilation of case studies of community action
during 2020. This included examples of government agencies working differently
during COVID-19, such as seconding staff directly into local organisations, to deliver
a more localised response. That report on community-led responses noted the best
outcomes were achieved in communities where the strongest existing relationships
were already in place.35
What happened: governance
and decision-making structures |
2.3
0.0 I aha: ngā hanga mana whakahaere
me te whakatau tikanga
The preceding overview of the country’s pre-COVID-19 pandemic

preparedness and emergency management arrangements indicates
the base from which the Government’s COVID-19 response began.
It was a mix of positives and negatives. The country had well-established systems
for managing both emergencies and risk, which theoretically covered national
pandemics; in practice, however, they were mostly geared towards regional natural
disasters. Some sound legislation and governance structures were in place, along
with a dedicated public service workforce. But, as happened in most other countries,
many of these preparations and pre-existing arrangements proved insufficient to
meet the scale and duration of a pandemic that required an unprecedented all-of-
government response.
While some of the mechanisms needed to deliver a response of this kind were
established quickly, many evolved over the course of the pandemic. In this section,
we focus on the evolution of governance and decision-making structures.
In the first year of the pandemic, three broad approaches to organising the all-
of-government response were tried. The first involved the standard ‘lead agency
plus ODESC oversight’ model. Then came a bespoke approach, marked by the
establishment of ‘the Quin’ (discussed further in section 2.3.2). It was followed by an
approach designed to support a longer-term response, through a COVID-19 Group
established within the Department of the Prime Minister and Cabinet. Originally
an informal arrangement, by the end of 2020 this group had been formalised and
its mandate expanded. We describe each of these in turn: our assessment of their
utility and effectiveness is set out in section 2.6.
The country had well-

established systems for
managing emergencies,
but they were mostly
geared towards regional
natural disasters.
2.3.1 Government initially adopted the standard ‘lead agency
plus ODESC’ model
The lead agency model, with ODESC providing oversight, swung into action in
January 2020 when the chair of ODESC was briefed on system readiness and risks
for managing a potential pandemic. The first Watch Groupv meeting was held on
27 January 2020 and the Department of the Prime Minister and Cabinet activated
the crisis response arrangements the same day. ODESC met for the first time on
31 January 2020 to help coordinate a cross-agency response. At this point, the
pandemic response was organised in the same way as all-of-government responses
to other national emergencies:
Figure 1: The initial pandemic response model – lead agency with

ODESC oversight
Source: Adapted from Department of the Prime Minister and Cabinet, 2024, Guide to the National CDEM Plan
2015, p 4, https://www.civildefence.govt.nz/assets/Uploads/documents/publications/guide-to-the-national-
cdem-plan/Guide-to-the-National-CDEM-Plan-2015.pdf
v Under the ODESC system, Watch Groups comprising senior officials from relevant agencies are established to monitor
potential, developing or actual crises. See Appendix A.
Under this model, the Ministry of Health – identified in the National Civil Defence
Emergency Management Plan 2015 as the lead agency for emergencies arising from
infectious human diseases – had the ‘primary mandate’ for managing the COVID-19
response, although it was not expected to work alone. The Ministry’s responsibilities
included monitoring and assessing the situation, planning for and coordinating the
national response, reporting to ODESC and providing policy advice, and coordinating
the dissemination of public information.36
Meanwhile, ODESC provides the Prime Minister and Cabinet with advice on priorities
and mitigation of risks beyond the lead agency’s control, and exercises policy
oversight. ODESC also helps ensure the lead agency and those supporting it had
the resources and capabilities required for an effective response.
This model was quickly deemed by officials at the time as unsuited for responding
to the scale of the evolving pandemic. There were several reasons. At the core
of the ODESC model is a group of chief executives who work as a collective, not
a functioning governance arrangement for delivering the strategic advice and
decisions needed for the response over time. ODESC did not have the systems
and resources to oversee a crisis as all-encompassing as COVID-19, and outside
of ODESC, there was no all-of-government structure that could step in if the lead
agency model was not appropriate.vi This was the case with the COVID-19 response,
which was far more wide-reaching than a single agency could be expected to
manage. This meant that, in the early days, the Ministry of Health was trying to fulfil
multiple functions – including leading the health system response and associated
technical aspects, leading other critical elements of the response such as managed
isolation and quarantine (MIQ), providing strategic advice to ministers, and trying to
coordinate activities across government.
As one stakeholder told us, ‘An everything crisis requires an everything response’
– a sentiment we heard from many senior response officials. Accordingly, an
alternative all-of-government model was introduced in March 202037 and remained
in place until the end of June 2020.
vi For example, in situations where the lead agency lacked the capacity or capability to coordinate the response, the
response required actions that exceeded what a lead agency could reasonably coordinate, or if the crisis was likely to
require a prolonged response.
2.3.2 A bespoke all-of-government approach was developed
An early indicator of a shift in approach came after the Chair of ODESC directed the
National Crisis Management Centre to be activated on 6 March 2020. The ODESC
Chair created a new position on 11 March 2020, the All-of-Government Controller,
to oversee the all-of-government response.vii Leadership and governance structures
were also modified, including the establishment of a new leadership body, the Quin.
It comprised the All-of-Government Controller (John Ombler, as Chair) and four
key response leaders: Dr Ashley Bloomfield, the Director-General of Health; Sarah
Stuart-Black, the Director of Civil Defence Emergency Management; Mike Bush, head
of the Strategic Operations Command Centreviii whose role included overseeing
and providing direction to cross-agency activities; and Dr Peter Crabtree, the All-of-
Government Strategy and Policy Lead.38
An all-of-government communications function was also created early in the
response. In a standard emergency response, the lead agency (in this case the
Ministry of Health) is responsible for the provision of public information. However, it
quickly became apparent that the public communications task was going to be more
significant than the Ministry of Health could manage alone. In February 2020, ODESC
members agreed there was a need for ‘more aggressive and direct communications’
about COVID-19 and the Chair of ODESC commissioned a review of the Ministry of
Health’s capacity to deliver the necessary communications functions. This led to
the creation of a new All-of-Government National Public Information Management
Team within the National Crisis Management Centre, thereby shifting primary
responsibility for public communications from the Ministry of Health to the all-of-
government crisis management centre.
Alongside these new arrangements – and in another sign of the need for bespoke
solutions to support the COVID-19 pandemic response – new legislation was also
being developed, including the COVID-19 Public Health Response Bill. When enacted,
it would become the lynchpin of the pandemic response, replacing the Health Act
1956 as the primary legal basis for the Government’s use of mandatory public
health measures.ix The Bill’s Explanatory Note indicated the Government’s rationale
for its development: it provided a ‘fit-for-purpose legal framework for managing
the unprecedented circumstances of the COVID-19 epidemic in a coordinated and
orderly way, even if there is no longer a national state of emergency’. It would also
establish ‘decision-making processes that are more modern and consistent with
recommended practice by legal academics and others’.39
vii Former Deputy State Services Commissioner John Ombler was appointed the All-of-Government Controller and held
the role until late October 2020; he was at the same time Deputy Chief Executive of the All-of-Government Response
Group in the Department of the Prime Minister and Cabinet.
viii Mike Bush was still the Commissioner of Police when he took up this role and held both roles until 2 April 2020 when
his term as Commissioner finished.
ix The Act came into effect just a day after the Bill was introduced to Parliament.
By mid-March 2020, the structure of the all-of-government response looked very
different from the arrangements in place only two months earlier:
Figure 2: The bespoke response model as of mid-March 2020
Source: Adapted from Department of the Prime Minister and Cabinet, 2023, National Crisis Management
Centre (NCMC) National Action Plan, p 31, https://www.dpmc.govt.nz/sites/default/files/2023-04/rpt-national-
action-plan-v2-1april.pdf
2.3.3 The model was refined over time
Rapid reviews of the model were carried out in April40 and October of 202041 to check
if it was providing the leadership and coordination necessary for the response.x
The aim of the first review, commissioned by the chair of ODESC not long after the
introduction of the Quin in mid-March 2020, was to identify what arrangements would
best support the all-of-government response into the future. Recognising that ‘what
got the country through the first phase [of the pandemic] would not be sustainable
or fit for purpose in the medium term’, the review called for ‘a refreshed mandate and
simplification of existing structures and accountabilities’42 going forward.xi
Thus, when the National Crisis Management Centre was deactivated on 30 June 2020,
many of its functions transferred to a newly-established COVID-19 All-of-Government
Response Group within the Department of the Prime Minister and Cabinet. The
Group’s leadership team effectively replaced elements of the Quin from this point
on (noting that the Director-General of Health and the Director of Civil Defence
Emergency Management retained their statutory roles, and the Ministry of Health
was still the lead agency). As at December 2020, over 80 percent of the staff in the
All-of-Government Response Group were seconded from other agencies across
the public service.43
The Group was charged with developing ‘a more forward-looking work programme’.
It had four key areas of responsibility: providing Cabinet with strategy and policy
advice; operational coordination; data analytics, monitoring, reporting and insights;
and public communications.44 To avoid duplication of effort, it was to undertake only
work that other agencies could not do, and some response activities that had been
led centrally – such as the managed isolation and quarantine (MIQ) system – were
transferred to relevant agencies (in this case, to the Ministry of Business, Innovation
and Employment).45
The second rapid review of the all-of-government response released in October
2020 recommended ‘declutter[ing] the governance landscape’.46 This led to the
establishment of a COVID-19 Chief Executives Board on 17 November 2020. It
comprised 12 departmental chief executives,xii who were expected to reflect the
views of their sectors and stakeholders (which included iwi, the private sector,
non-governmental organisations, and vulnerable communities). The Board’s role
was to ensure that ‘the system is informed, is doing what it needs to, at the pace
required, and that risks are identified and mitigated.’47 It met for the first time
in mid-November 2020.
x In line with our terms of reference, we have not sought to replicate the work of these reviews (nor that of the Office of
the Auditor-General into the all-of-government coordination in the first year of the response). Rather, we have used
their findings, alongside our own evidence, to inform this analysis and our subsequent lessons.
xi The Auditor-General also noted that the new arrangements put in place during 2020 (in particular the Quin) posed
challenges for those working in the system. These included strained relationships between the National Crisis
Management Centre and the Ministry of Health.
xii Board members were from the Department of the Prime Minister and Cabinet, New Zealand Customs Service, Ministry
of Justice, Ministry of Foreign Affairs and Trade, Ministry of Business, Innovation and Employment, the Treasury,
Ministry of Social Development, Te Puni Kōkiri, Ministry of Transport, Ministry of Health. The heads of the Crown Law
Office, Te Kawa Mataaho and the COVID-19 Group were ‘additional members’.
The first year of the pandemic ended with Cabinet approving a recalibrated
COVID-19 response system (shown below) and confirming funding for it until the
end of June 2022. The new arrangements also recognised that a single agency
could not manage the full response alone, and multiple lines of accountability
were required. The role of the COVID-19 Group in the Department of the Prime
Minister and Cabinet was enhanced, and it was now mandated to provide strategic
leadership and central coordination of the all-of-government response. The entire
system became accountable to the Minister for COVID-19 Response, a position
created in November 2020.
Figure 3: Institutional and governance arrangements

(Cabinet 2 December 2020)
Source: Adapted from Department of the Prime Minister and Cabinet, 2020, COVID-19 Response Paper 1 –
Overview of Institutional and Governance Arrangements and Funding – CAB-20-MIN-0095
What happened: pandemic strategy and tools |
2.4
0.0 I aha: te rautaki me ngā utauta mate urutā
Having described the structures that the Government used to make

decisions and run the response to COVID-19, we turn now to the evolution
of the response strategy and how it was communicated.
2.4.1 The international context: three main strategic goals

Reviews of global COVID-19 responses describe three main strategic goals that
countries adopted to guide their pandemic responses: elimination, suppression and
mitigation.48 Some island jurisdictions were able to adopt an early ‘exclusion’ goal:
namely, they kept the virus out by effectively closing their borders before any cases
had occurred in their populations. An elimination goal will normally be time-bound,
and at some point would be replaced by measures aimed at the third strategic goal
– suppressing and/or mitigating the impacts of the pandemic agent. The three goals
can be broadly summarised as follows:
Figure 4: National public health strategies used in response to the

COVID-19 pandemic
Public Specific Common public

Strategy*
health aim objectives health measures
Elimination Eliminate any • Prevent entry of • Tight border restrictions,

community new cases into quarantine of new arrivals
transmission population • Strict isolation of cases
• Prevent • Contact tracing, isolation
transmission from and testing of contacts
any existing cases
• Public health and social
• Identify and stop measures, e.g. physical
any chains of distancing, use of facemasks,
transmission restrictions on movement
and gatherings, closure of
schools and workplaces.
At the most stringent level
(including mandatory
requirements) these
measures are commonly
described as ‘lockdown’
Public Specific Common public
Strategy*
health aim objectives health measures
Suppression Active • Reduce rate of • Border checks/restrictions

measures transmission • Isolation of cases (usually
to reduce • Prevent health home isolation)
transmission system from being • Contact tracing and testing
overwhelmed of contacts
• Protect vulnerable • Public health and social
groups from measures to reduce peaks
infection in transmission. Where case
(sometimes called rates become very high, strict
‘shielding’) measures (e.g. lockdowns)
may be used to prevent the
health system from being
overwhelmed
Mitigation Protect • Protect vulnerable • Self-isolation of cases

vulnerable groups from • Public health measures
groups from infection focused on vulnerable
infection • Minimise disruption groups, e.g. facemasks for
to normal social and visitors to hospitals or aged
economic activities care facilities
*In some jurisdictions (e.g. Australia) the term ‘aggressive suppression’ is used in place of ‘elimination’. In some analyses
(e.g. König & Winkler, 2021)49, suppression and mitigation strategies are treated as a single approach.
Source: Adapted from 3 sources: Baker MG, Wilson N, Blakely T. , 2020, Elimination could be the optimal response
strategy for covid-19 and other emerging pandemic diseases. BMJ 2020;371:m4907 https://doi.org/10.1136/bmj.
m4907; Wu S, Neill R, De Foo C, Chua AQ, Jung AS, Haldane V, Abdalla SM, Guan WJ, Singh S, Nordström A, Legido-
Quigley H. Aggressive containment, suppression, and mitigation of covid-19: lessons learnt from eight countries.
BMJ 2021 29;375:e067508 https://doi.org/10.1136/bmj-2021-067508; Grout L, Gottfreðsson M, Kvalsvig A, Baker MG,
Wilson N, Summers J. Comparing COVID-19 pandemic health responses in two high-income island nations: Iceland and
New Zealand. Scandinavian Journal of Public Health. 2023;51(5):797-813. https://doi.org/10.1177/14034948221149143
In responding to COVID-19, New Zealand used all three strategies: elimination until
late 2021, suppression briefly from late 2021 to early 2022, followed by mitigation.
As highlighted in the following sections the transitions from one strategy to the next
were fuzzy and not always well-signalled.
2.4.2 Aotearoa New Zealand quickly adopted an elimination
strategy when it became apparent that zero transmission
was achievable
In the first weeks of the pandemic, New Zealand’s public health response drew
on elements of the New Zealand Influenza Pandemic Plan 2017,50 but without
articulating a clear overall goal. At the day-to-day level, there was a strong initial
focus on ‘keeping it out’ and ‘stamping it out’, which (as outlined in the Plan) would
buy the time for planning. At this stage, the response was largely based on the
assumption that New Zealand would ‘flatten the curve’ to protect health services
using a mitigation strategy or would suppress the virus and repeatedly ‘stamp out’
outbreaks. This assumption was also reflected in public discussions and information.
By mid-March 2020, a (now locally famous) graph was circulating among decision-
makers and politicians:51
Figure 5: COVID-19 mitigation versus suppression
Source: Department of the Prime Minister and Cabinet, 2023, Systems architecture (Health System preparedness),
p 4, https://www.dpmc.govt.nz/sites/default/files/2023-01/Systems-architecture-Health-System-preparedness.pdf
Two public health strategies were being considered at the time. One was
suppression – using public health measures to suppress viral transmission and
‘flatten’ peaks of infection. The other was mitigation, where ‘light touch’ to moderate
public health measures are used to flatten and make longer the first wave of
transmission to lessen the pressure on health services, and simultaneously protect
vulnerable people from infection (see section 2.3.1 for further discussion of the
different public health strategies). The graph suggested that neither of these
approaches would be sufficient to prevent the health system from becoming
overwhelmed. With a mitigation strategy (blue line), the peak of infection would
be less than if no measures were used (‘unmitigated spread’ – the orange line), but
the number of people becoming sick and needing hospital care would substantially
exceed health system capacity (dotted line). Even with a suppression strategy –
leading to repeating waves of infection of much smaller magnitude (green line) –
the health system might be overwhelmed at points of peak infection.
Seeing this graph was described to us as a ‘penny dropping’ moment. Many realised
that – even under a suppression strategy – there was a risk that New Zealand’s
health system would be overwhelmed. This realisation was presented to us as the
point at which it became clear that decision-makers needed to consider taking
extraordinary measures in order to protect the population from a potentially
catastrophic scenario.
That the vast majority of decision-makers were not thinking of elimination as a
potential strategy before mid to late March 202052 reflected WHO’s advice not to use
travel and trade restrictions (which would be necessary if pursuing elimination) as
control measures.53 This aligned with prevailing expert opinion at the time, which
held that border controls could delay entry of a pandemic but not prevent it.54
However, as events evolved in late March, New Zealand – along with other countries
in the region – elected to break with this advice.
On 23 March 2020, the country moved into Alert Level 3 (effectively, a ‘soft’ lockdown)
and announced that Alert Level 4 (or a ‘hard’ lockdown) would start at 11:59 pm
on 25 March 2020. Noting what was occurring elsewhere in the world, officials
indicated that we had ‘a short window of opportunity to take a trajectory more
similar to Singapore and others who have taken an early and strong approach to
containment.’55 A ‘go hard, go early’ approach might avoid the trajectory of Europe
where hospitals had been overwhelmed by people sick from COVID-19 infection. At
this stage, there was not a consistent view or realisation that elimination was possible
or even the goal in Aotearoa New Zealand.
The combination of strict border restrictions and stringent public health and social
measures was even more successful than anticipated, and – over the next few
weeks – it became apparent that eliminating the virus was a viable possibility.
2.4.3 Elimination
The pursuit of zero transmission (most of the time, knowing there would likely be
some occasional incursions) emerged as the goal for Aotearoa New Zealand, to be
achieved through an elimination strategy. On 9 April 2020, papers for the COVID-19
Ministerial Group explicitly articulated the elimination strategy for the first time:
“ Our overall approach is to eliminate the virus from New Zealand. We will keep it out of
the country with border restrictions and stamp it out wherever and whenever it occurs,
minimise its spread and severity with systematic public health measures, […] and do all
this until a vaccine or effective treatment emerges. ” 56
The strategy was embarked on at a time of high

uncertainty. Decision-makers were informed
New information on the by data and high-level modelling, as well as
virus – and how to prevent its the international situation, and advice on how
transmission – was coming Aotearoa New Zealand and our population
in daily. Decisions had to be would be impacted. New information on the
made quickly, with imperfect virus – and how to prevent its transmission –
information, and at pace.
was coming in daily. Decisions had to be made
quickly, with imperfect information, and at pace.
Officials attempted to look ahead at what was
coming so they could offer advice on what was needed next, but this forward gaze
was only able to anticipate events that lay a few weeks ahead.
Advice from this period refers to a future time when ‘a vaccine or effective
treatment’57 would be available. However, there appears to have been no explicit
forward work programme available to reassess the elimination strategy. Nor was
it specified how and when a range of scenarios and policy response options for
future strategic directions would be considered as the situation evolved or as new
options for managing the virus became available.
Spotlight:
The Alert Level System | Te Anga Taumata Whakatūpato
In the early stages of its response, Aotearoa New Zealand adopted a

graduated set of public health measures or ‘alert levels’, which was
central to the country’s COVID-19 response.
Prior to COVID-19 – and consistent with international guidance – New Zealand’s

planned response to a pandemic did not include the possibility of closing the
country’s borders and eliminating transmission over a sustained period.58 The
initial strategy was to prevent or delay the virus’s arrival (‘keep it out’) and control
any initial outbreaks (‘stamp it out’) in order to buy time for the country to prepare
for widespread transmission and resultant illness (as seen in other countries). This
initial strategy was supported by the introduction of a range of public health and
social measures intended to limit the spread of infection.
In this early stage of the COVID-19 response, combinations of public health and
social measures were grouped into four levels or ‘settings’ of increasing strictness.
The Alert Level System become a central feature of New Zealand’s COVID-19
response. It gave decision-makers a simple way of ‘turning the dial up’ (or down)
on infection control measures, and it gave the public a clear set of rules about what
measures and restrictions they needed to follow at any point in time.
Figure 6: COVID-19 Alert Levels
Source: Department of the Prime Minister and Cabinet, 2021, COVID-19 Alert Levels detailed table, p 1,
https://covid19.govt.nz/assets/resources/tables/COVID-19-Alert-Levels-detailed-table.pdf
51
At lower system settings (Alert Levels 1 and 2) people were encouraged or
required to physically distance from one another, to avoid unnecessary
travel, and (later) to wear facemasks on public transport and other shared
indoor spaces. Alert Level 2 also included limits on large gatherings. As
the risk or scale of transmission grew, higher alert levels and increasingly
stringent measures came into effect. Alert Levels 3 and 4 can be understood
as ‘lockdowns’ (and this is how they were popularly known), because they
involved closures of schools and businesses, restrictions on gatherings,
and stay-at-home orders (see Chapter 3 for more on New Zealand’s use
of lockdowns during the pandemic).
Cabinet adopted the Alert Level System on 20 March 2020. The country
moved to Alert Level 3 on 23 March 2020, followed 48 hours later by
Alert Level 4. This marked the beginning of New Zealand’s first national
COVID-19 lockdown.
Decisions about moving up or down the alert levels, or adjusting the
settings at each level, were made by Cabinet, taking particular account
of advice from the Ministry of Health (as the lead agency in the state of
national emergency) about the public health risk posed by COVID-19,
as well as advice on specific non-health factors (such as the impact on
the economy, society, and at-risk populations and operational issues).
Sometimes Cabinet set the whole country at the same alert level; at other
times, different regions were at different alert levels.
Once Cabinet made its decisions, a team of officials in Wellington was
charged with developing operational policy. This typically happened at
pace and with little or no time for broader engagement – including with
those in the public and private sectors who would need to implement the
relevant changes. Whenever alert levels changed or the settings at each
level were adjusted, people on the ground had to find quick solutions
for a raft of unanticipated operational challenges. Putting policy changes
into practice become easier as people learned and adapted, but the
speed and frequency of change remained a challenge.
52
2.4.4 Moving from elimination to ‘minimisation
and protection’
Just as it was difficult to identify exactly when the elimination strategy began,
it is difficult to pinpoint exactly when it ended.
In August 2021, Aotearoa New Zealand recorded its first community-transmitted
case of the new, and highly infectious, Delta variant. Unlike previous incursions,
it was unclear if the resulting Delta outbreak could be brought under control. If
not, the result would be established COVID-19 transmission and the end of the
elimination phase of New Zealand’s COVID-19 response. An immediate nationwide
return to Alert Level 4 lockdown was announced. The Alert Level System was again
successful for most of the country, and community transmission was prevented in
most regions – apart from Auckland, where Delta took hold. While the rest of the
country moved back down the alert levels after a few weeks, Auckland spent more
than three months in Alert Level 3 or 4 lockdown in the second half of 2021, and
case numbers there continued to grow. Outbreaks also took hold in Northland and
Waikato, prompting regional lockdowns. (See Chapter 3 for more on the use of
lockdowns in this period.)
By October 2021, Auckland had spent seven weeks in a lockdown that had initially
been signalled to last for at least one week, and ministers and officials were aware
that ‘social licence’ for compliance was beginning to erode.59 On 4 October 2021,
the Prime Minister noted in a press conference that New Zealand would ‘move to
a framework that reflects a more vaccinated population’, thus transitioning away
from the elimination strategy.60 There had been no lead-in discussion prior to this
press conference about when to move from elimination to either suppression
or mitigation and the announcement was not prominent in the Prime Minister’s
remarks, though it was picked up and reported by the news media.61 The Prime
Minister did not clearly identify the strategic goal that would replace elimination,
though her description of ‘controlling the virus to the best of our ability’ is consistent
with a suppression strategy.62
Other sources support the inference that Aotearoa New Zealand started
transitioning to a suppression strategy around this time, although there were
no public communications on this transition. On 8 October 2021, the Strategic
COVID-19 Public Health Advisory Group recommended the adoption of a
‘minimisation and protection’ strategy.63 This advice took account of ‘the wish
to avoid lockdowns’ while still ‘minimis[ing] the occurrence of COVID-19 and
protect[ing] people as far as possible from the adverse effects of this disease’.
In practice, it involved a mixture of ‘suppression’ and ‘mitigation’ elements.
Officials had been preparing advice on a new ‘COVID-19 Protection Framework’ (also
known as the ‘traffic light’ system) to replace the Alert Level System once population
vaccination was sufficiently high. Cabinet had agreed to this approach in principle
on 27 September 2021; it was confirmed on 18 October 202164 and subsequently
aligned with the new ‘minimise and protect’ strategy.65 The move to the new ‘traffic
light’ system was announced on 22 October 2021 and took place on 2 December
2021.66 Auckland and several other regions were set at ‘Red’, and the rest of the
country at ‘Orange’.67
The introduction of the ‘traffic light’ system and the associated transition away from
the elimination strategy were somewhat contentious. The National Iwi Chairs Forum
had wanted the transition to be delayed on the basis that more time was needed to
ensure adequate vaccination among Māori. Despite significant efforts, vaccination
levels continued to be substantially lower in Māori and Pacific communities68 and
were not projected to reach 90 percent across Auckland until mid-December 2021.69
Similarly, a group of health and science experts convened by the Prime Minister’s
and Ministry of Health’s Chief Science Advisors recommended that the shift to the
‘traffic light’ system should not take place until vaccine coverage was at least 90
percent, including for Māori.70 This was also in line with advice from Health officials.
However, representatives of local government and the social sector in Auckland
told us that alternative views were also being advanced. There was anger at the
ongoing extension of the lockdowns, a belief that Wellington didn’t understand
what it was like on the ground in Auckland, and a loss of hope at the lack of an
end date. Businesses in central Auckland were also calling for a plan and clearer
communication on when the Auckland lockdown would end. These issues are
discussed further in later chapters in this report.
Official documents from this period also illuminate the challenging situation in which
the Government found itself. On one hand, there was clear recognition of ‘eroding
social licence’ among the Auckland population ‘who [have] endured a significant
time at heightened Alert Levels’.71 Advice highlights the ongoing and increasing
challenges related to financial support and economic, social and wellbeing impacts.
General fatigue amongst the public was increasing and willingness to comply with
some public health measures was reportedly reducing.72 On the other hand, officials
were also acutely aware of the risks of removing restrictions while vaccination
levels remained low in vulnerable population groups. The specific demographics of
Auckland were relevant here, with recognition that South Auckland communities in
particular ‘feature[d] a younger age structure, lower rates of vaccination and [were]
likely to be at greater risk of hospitalisation’.73
Confirmation that Aotearoa New Zealand was no longer pursuing elimination
was hard for some people to adjust to. We heard about reluctance on the part of
decision-makers to explicitly announce the end of the elimination strategy because
of anticipated public fallout from the health impacts of COVID-19 becoming
established. Similarly, the Community Panel cautioned that a move to the ‘traffic
light’ system would ‘create a lot of uncertainty and anxiety’.74
Spotlight:
Traffic Lights – the COVID-19 Protection Framework |
Ngā Rama Ikiiki – te Anga Ārai KOWHEORI-19
The introduction of the COVID-19 Protection Framework was presented

75
as supporting the new strategic goal of ‘minimisation and protection’.
The ‘traffic light’ system had only three levels (compared with the four alert levels)
and used less stringent controls (see Figure 7). Significantly, it did not involve
lockdowns or the closure of businesses and schools.76 Another key change was
greater freedom for those individuals who could demonstrate they had been
vaccinated against COVID-19, although this (and the use of My Vaccine Pass) was
removed in early April 2022. Capacity limits were also increased at this point.76
The ‘traffic light’ system was deliberately pitched at a more general level of detail
than the Alert Level System on the basis that lead agencies would develop more
comprehensive guidance for each sector.75
Figure 7: COVID-19 Protection Framework (summary)
Colour setting Control measures
Green • Mandatory record-keeping (for contact tracing)

• Face coverings mandatory on flights
• With evidence of vaccination: no gathering limits or mask mandates
(except on flights)
• Without evidence of vaccination: gathering limits of 100, mandatory
face coverings and physical distancing in close contact settings
Orange • Mandatory record-keeping (for contact tracing)

• Face coverings mandatory on flights, public transport/taxis, retail,
public venues
• Physical distancing in public facilities and retail settings
• With evidence of vaccination: no gathering limits
• Without evidence of vaccination: gathering limits of 50 at private
gatherings; not able to participate in close contact businesses,
events or gyms
Red • Mandatory record-keeping (for contact tracing)

• Face coverings mandatory on flights, public transport/taxis, retail,
public venues
• Physical distancing in public facilities and retail settings
• Gathering limit of 100 in public facilities
• With evidence of vaccination: gathering limits of 100 and physical
distancing in most settings outside the home (physical distancing but
no specific capacity limit in tertiary education)
• Without evidence of vaccination: gathering limits of 25 at private
gatherings; not able to participate in close contact businesses, events
or gyms (online participation only in tertiary education)
Source: Adapted from Department of the Prime Minister and Cabinet, 2021, COVID-19 Implementing the COVID-19
Protection Framework [CAB-21-MIN-0497], p 31, https://www.dpmc.govt.nz/sites/default/files/2023-01/COVID-19-
Implementing-the-COVID-19-Protection-Framework.pdf
55
There were no specific criteria for moving between different traffic light
levels, although Cabinet agreed that the following factors would be taken
into account in decision-making:
• Health factors: vaccination rates, health system capacity, testing
and contact tracing capacity, COVID-19 transmission.
• Non-health factors: effects on economy and society, impacts on
at-risk populations, public attitudes, operational considerations.77
The COVID-19 Protection Framework (‘traffic light’ system) was widely
viewed as less clear than the Alert Level System. An expert health group
reviewing a draft version was ‘near unanimous in its skepticism about
this framework in its current form’.78 (The group was particularly critical
of the lack of Māori input or ‘codesign’ of the framework). Many of the
group’s recommendations were incorporated into the final version of
the framework. Public survey data from late 2021 suggested that the
introduction of the ‘traffic light’ system was associated with significant
public confusion.79 The Human Rights Commission noted that businesses
and members of the public had found the ‘traffic light’ system difficult to
understand and implement. The Chief Human Rights Commissioner was
also concerned that the system’s differential treatment of vaccinated and
non-vaccinated people could undermine social cohesion and exacerbate
intolerance, noting in March 2022 that ‘the ‘traffic light’ system has caused
a lot of distress to some people’.
The ‘traffic light’ system was retired on 12 September 2022, although
related mask mandates remained in place for healthcare and aged
care settings.80
56
2.4.5 Retiring the ‘minimisation and protection’ approach
The phrase ‘minimisation and protection’ was never widely adopted or understood
by the public. Agencies, other stakeholders and submitters to the Inquiry were
generally unclear about when the elimination strategy ended and what strategic
goal replaced it.
According to the Ministry of Health, the minimisation and protection approach
(officially the COVID-19 Protection Framework) was in place from December 2021
to September 2022.
In September 2022 Cabinet agreed to formally retire the minimisation and
protection strategy and move to a ‘long-term approach to managing COVID-19’.81
The ‘traffic light’ system was formally discontinued at this time, signalling the end
of Aotearoa New Zealand’s COVID-19 pandemic response.
The phrase ‘minimisation

and protection’ was
never widely adopted or
understood by the public.
What happened: public information
2.5
0.0 and communication | I aha: ngā mōhiohio
tūmatanui me te tuku whakamōhio
Clear, effective, and accurate public information and communication were

crucial to Aotearoa New Zealand’s experience of the COVID-19 pandemic
and the effectiveness of the response. Here we discuss how critical
information was conveyed to the public – largely a success story in the
early stages, but with challenges as the response progressed over time.
2.5.1 Unite Against COVID-19

It was recognised early on that the success of the response broadly rested on
whether the New Zealand public – the ‘team of five million’xiii – would support the
unprecedented health measures being introduced to help manage the threat from
COVID-19. It was well understood by both ministers and officials that the quality of
public communications would be a critical factor in the success of the response.
The new All-of-Government National Public Information Management Team
established in March 2020 within the National Crisis Management Centre (see
section 2.3.2) engaged an external agency, Clemenger BBDO, to support the
development and delivery of the ‘Unite Against COVID-19’ campaign.
Launched on 18 March 2020, just five days after it was commissioned, the campaign
was designed to be a rallying call to collective action. It aimed to get the whole
country to identify as ‘on the team’ and to follow the ‘game plan’.82 Importantly, the
‘Unite’ concept also promoted social cohesion, which would be critical for a collective
crisis response. The branding was deliberately designed with a focus on empathy,
recognising a well-established principle of crisis communications that ‘sustained
compliance in a crisis relied on not overwhelming people and minimising the sense
of hopelessness’.
The campaign’s key messages were simple and actionable, and the fonts, colours,
and design elements were chosen purposefully to be reassuring, and to avoid
alarming or excessively medicalised messages (a striking contrast to the messaging
in some jurisdictions, such as ‘It’s up to you how many people live or die’, used in
Oregon in the United States).83 The simple design also knowingly made it easy for
other agencies, and even community organisations, to produce their own tailored
material aligned with the campaign.
xiii The precise origin of the ‘team of five million’ is unclear. On the first day of Alert Level 4 lockdown, 24 March 2020, the
front page of the New Zealand Herald used the term ‘Whānau of 5 million’. The Prime Minister and others began using
the phrase ‘Team of five million’ soon afterwards.
The graphic below 84 (Figure 8) illustrates how these elements were incorporated into
the final design.
Figure 8: Unite Against COVID-19 design
Source: Unite Against COVID-19, 2020
The Unite against COVID-19 public information campaign was quickly established
as an effective brand achieving high levels of recognition.85 It later received multiple
awards for design and communication.
2.5.2 Digital channels

In addition to traditional channels such as press, television and radio, digital tools
were launched. The www.covid19.govt.nz website was intended to be a key source
of information for New Zealanders about the pandemic and the Government’s
response. The new website attracted more than 800,000 visitors within a few days
of launch. It was seen as a trusted source of information, especially in the first year
of the pandemic.
Social media was also a crucial plank of the communications response. Regular
campaign updates were posted to official ‘Unite Against COVID-19’ accounts via
Facebook, Twitter, Instagram and YouTube. In these public forums, thousands of
questions received direct responses from the teams handling public information
and communications. These comments were also used to identify any common
themes that could then inform the key messages developed for the daily 1pm
press briefings that became a key feature of the response.
2.5.3 The 1pm daily briefings
From early in the pandemic,xiv ministers and senior officials held daily 1pm briefings
about case numbers, alert levels, and current settings. The Ministry of Health was
responsible for the briefings, which were usually conducted by the Prime Minister
and the Director-General of Health.xv
Journalists attending the 1pm briefings could ask questions of the speakers at the
end of their prepared remarks. The briefings were also live-streamed by multiple
media outlets and quickly became routine viewing for many New Zealanders.
Stakeholders explained the rationale behind the briefings in the following terms:
“ The decision to concentrate the release of key information to one or two consistent
times each day (updates were also provided at 6pm during key phases of the pandemic)
was a deliberate decision to create a degree of certainty for people that is best practice
in disaster response. ”
The success of the format saw ‘the 1pm’ become an important tool for conveying
accurate information, mobilising community support for Government measures and
generating public trust and confidence in the response. The daily briefings remain a
memorable feature of the pandemic experience.
Not surprisingly, the former Director-General told the Inquiry that the 1pm briefings
‘took up a large part of my day’. He felt this was appropriate given their importance
as a communication tool that was proving very effective for establishing public
trust, ensuring compliance with public health measures and ultimately stopping the
spread of the disease.
Other ministers and senior officials sometimes presented the briefings, but the
public came to expect to see the Prime Minister at the briefings; there would often
be calls for her return if she missed one.
Former press secretaries told us that, in their view, the combination of the Prime
Minister’s corralling of public sentiment to promote unity with the Director-General’s
factual information made the 1pm briefings work as a public communications tool,
with flow-on effects for the early success of the elimination strategy.
xiv The first briefing (although not yet a daily occurrence), was held on 27 January 2020, fronted by the Director-General of
Health Dr Ashley Bloomfield, and Director of Public Health Dr Caroline McElnay. The first briefing fronted by the Prime
Minister was on 14 March 2020.
xv This phenomenon – and the unprecedented exposure it attracted for the Prime Minister and Director- General – was
not unique to New Zealand. A similar ‘duo’ approach, in which a senior politician and a senior official jointly fronted
regular briefings, was used in other jurisdictions including Australia, Canada, the United Kingdom and the United
States. The former Director-General told us he did not see the role he played in the briefings as unusual in this regard.
Daily briefings were the most praised aspect of the communications response in the
public submissions to the Inquiry and were frequently characterised as informative
and reassuring. Submitters often mentioned the former Director-General of Health
Ashley Bloomfield and former Prime Minister Jacinda Ardern by name, praising their
calm and collected communication style. Reinforcing the psychological advice that
informed the briefings, submitters commended their regularity, both as a reliable
source of information and for providing context to the pandemic as it evolved.
“ In my honest opinion, the thing that anchored us was the constant flow of updates.
The lunchtime press conferences put us at the centre of a shared task of staying home
and ending this as soon as possible – hearing from not just politicians, but experts in
the public health sphere. ”
2.5.4 Reaching multiple communities

Key public health information was translated into a wide range of languages and
formats to help different communities understand what was being asked of them
during the response. For example, a physical copy of ‘Our plan – the four Alert
Levels; Your plan – for staying at home’ was delivered to letterboxes nationwide.
It was translated into 16 languages online, and a New Zealand Sign Language
version was available. By mid-2022 Unite Against COVID-19 content was available
in 27 languagesxvi and five alternative formats.
Many community organisations worked to ensure the provision of accurate,
timely information to their members. We heard that an ‘alliance’ of community
organisations and ethnic community media outlets formed organically to
‘collaborate to fill the gaps’ through various activities – translating and sharing daily
updates and critical information, actively dispelling misinformation, and identifying
providers who could meet unmet needs.86
Many individuals and groups told the Inquiry that one of their key jobs during
the response was to translate the 1pm briefing for their communities. What this
involved varied according to need: it could include direct language translation,
making the meaning of what was said culturally relevant and/or translating what
it meant from a practical viewpoint. Some (particularly representatives of Pacific
media) said that communities should have received information that was culturally
appropriate and delivered by people who were significant in their own culture.
Some public submitters described taking on this role in the pandemic:
“ I reached out to non-English speaking Chinese migrants in my community, setting up zoom

meetings to teach them painting in order to help them with their isolation and ensure that
they were adequately informed as they didn’t seem to be getting sufficient information in
Mandarin and Cantonese. ”
xvi These languages were: Te Reo Māori, Arabic, Chinese (Simplified), Chinese (Traditional), Cook Islands Māori, Farsi, Fijian,
French, Gujarati, Hindi, Japanese, Kiribati, Korean, Niuean, Punjabi, Rotuman, Samoan, Somali, Spanish, Tagalog, Tamil,
Thai, Tokelauan, Tongan, Tuvaluan, Urdu, Vietnamese. Alternative formats included: New Zealand Sign Language, easy
read, large print, audio and braille. Video content with audio description was also available.
Our assessment | Tā mātau arotake:
2.6
0.0 rautaki, mana whakahaere, whakatau
tikanga me te tuku whakamōhio
Sections 2.1–2.5 have described the evolution of the COVID-19 response

strategies that the government pursued, and the governance arrangements,
decision-making structures and communications tools used to develop and
deliver them. We now turn to consider the utility and effectiveness of these
elements of the all-of-government response.
2.6.1 Governance and decision-making: getting the model right

Finding the right structure for the all-of-government response to a rapidly-changing
and highly unpredictable crisis like the COVID-19 pandemic was challenging.
Throughout 2020, several governance and decision-making models were tried and
replaced, or modified. While this showed commendable adaptability, as the Public
Service Leadership Team noted, ‘it took longer than desired to stand-up enduring
arrangements that would enable a strong all-of-government response beyond the
ODESC and lead agency model’.87
We heard from numerous stakeholders that, up until the end of June 2020, there was
confusion about the roles and responsibilities of agencies, oversight groups, teams,
and governance bodies. Coordination across agencies was lacking, and while the goal
of elimination was clearly established by April 2020, the specifics of how it would be
achieved and the role agencies would play were less clear. Without a prior plan for
setting up an all-of-government response structure (and instead relying on rapid
reviews to identify gaps and ways of improving a bespoke operating model), some core
elements were missing – such as a separate function focused entirely on developing
forward-looking, longer-term cross sector strategy (see section 2.6.1.1).
Our evidence does not point to any single reason why it took a while to settle on
a clear all-of-government strategy, coordination and governance function to lead
the response. There was a desire to avoid unnecessary structural change when
people were fully engaged in fighting the pandemic, and a wish to ensure such
change was deliberate and informed by independent advice (namely, the two rapid
reviews in April 202088 and October 202089). However, a compounding factor was
also that alternatives to the lead agency model plus ODESC arrangement – if a crisis
demanded a response that was well beyond the remit of a single agency – had
not been considered or prepared for before COVID-19. We note that the United
Kingdom COVID-19 Inquiry report on resilience and preparedness also came to
similar conclusions. It found that the lead government department model for whole-
system civil emergency preparedness and resilience was ‘not appropriate’.90 While
the United Kingdom inquiry recommended the lead agency model be abolished, we
do not agree with this in the Aotearoa New Zealand context. There are situations
where the scale and nature of an emergency may be appropriate for a lead agency
model. Rather, we support something more like the approach taken in the recently-
revised Australia Government Crisis Management Framework: it retains the lead
agency model but recognises that whole-of-government coordination is necessary
when dealing with crises that have extreme to catastrophic impact or complexity.91
2.6.1.1
The need for a separate strategy function
Best practice in emergency management is to establish a separate strategy function
in the early days of a crisis, thereby ensuring a focus on longer-term recovery that is
separate from the day-to-day aspects of the response itself. The strategy function’s
role is to focus on the future (including playing out the current scenario, likely
other scenarios, and the best response to these) and look towards an exit from
the response or the establishment of a ‘new normal’.
Despite attempts, a broader, integrated, long-term strategic planning approach
never got underway satisfactorily during New Zealand’s response to COVID-19. On
paper the first bespoke structure put in place during the response (see Figure 4)
included a ‘strategy and policy’ function. However, we heard that it was impossible
for those involved to look more than a few weeks ahead, even though they
wanted to do so, because the more immediate demands of the policy response
understandably consumed their focus. This was reflected in the priorities of senior
leaders, who were expected to concentrate on delivering the immediate response
in the context of a changing environment and new emerging issues. Some senior
ministers and officials that we spoke to were aware of this challenge, recalling their
absorption in the operational details of the response and the struggle to find the
time and space to look beyond these immediate priorities.
The early reviews of the all-of-government response also highlighted the absence
of, and need for, a separate strategy function. The second rapid review,92 in October
2020, recommended that the Department of the Prime Minister and Cabinet’s
COVID-19 Group develop a medium-term strategy and work programme for
Cabinet’s consideration. The strategy function was eventually given to the COVID-19
Group. But it did not have the mandate to look beyond the elimination strategy to
what might come next: rather, it was limited to ‘coordinat[ing] an integrated strategic
agenda across government, based on the elimination strategy framework’.93
The creation of the Red Team within the Department of the Prime Minister and
Cabinet was an attempt to create space for alternative thinking.xvii Charged with
scrutinising and challenging the all-of-government response to the resurgence of
COVID-19 in August 2020, it remained in place for four weeks. Senior officials who
were there at the time told us that the Red Team struggled to fulfil this function
due to a focus on operational concerns. Others suggested that the team might
have made more of an impact if it had included more members from outside
government. Regardless, there was agreement that a scrutiny mechanism is an
important but tricky function to put in place. It needs to be both close enough to
the response to understand the challenges, but not too involved to be captured
or unable to maintain independence. In this instance, further work was needed
to implement this function well, but it did not eventuate.
xvii A ‘critical friend’ or red team function is a common part of strategic crisis response – bringing together a group of
impartial and experienced experts, with access to data and information to enable impartial analysis to inform strategic
decision-making. In this case, the team was initially set up for the purpose of an exercise of the COVID-19 testing and
tracing system, but at the beginning of the August 2020 outbreak it provided a focused, accurate and dispassionate
view of the initial situation. Further into the response, the scope of the Red Team’s work was redefined – it was tasked
with, and provided, evidence and questions to influence strategic and operational focus and priorities.
Other evidence we gathered (through interviews with senior officials, and examination
of minutes of meetings and advice to ministers) also suggested that consistent strategic
governance remained elusive throughout the response, despite the best efforts of
ministers and officials. A range of different mechanisms were tried to provide this
strategic oversight – the Quin, the National Response Leadership Team,xviii and finally
the COVID-19 Chief Executives Board established in November 2020 – and met with
some limited success. For example, the terms of reference of the COVID-19 Chief
Executives Board included providing system leadership as New Zealand navigated
the COVID-19 pandemic over the next two to three years.94 However, meeting
minutes show that the Board spent most of its time focusing on operational detail
and coordination rather than system leadership.95 Possible reasons suggested for this
emphasis included the composition of the Board (many members were experienced in
operational delivery), the Board’s limited accountability, a focus on addressing the 1,000
plus recommendations from the many reviews related to the response, timing and
commissioning. This is not to say that no one was ‘doing strategy’ across government.
Indeed, officials told the Inquiry about strategic work they were involved in, and there
is evidence in Cabinet papers that individual
agencies gave advice with a broad focus that
included consideration of what was coming “ No one was thinking about how we
next. However, this thinking was happening in would get off the horse ..... everyone
discrete areas and was not always connected was on the dance floor and there
across agencies or sectors. was no one on the balcony, looking
down at what was happening. ”
The Inquiry heard from multiple sources
(including ministers, senior officials, external
advisors to Government and the public) that
the response was ultimately affected by the lack of a protected space for long-term,
integrated strategic planning. This gap was described in phrases such as ‘no one
was thinking about how we would get off the horse’ and ‘everyone was on the dance
floor and there was no one on the balcony, looking down at what was happening’.
We also heard differing accounts from ministers and officials as to why there was a
lack of connected advice on long-term strategy. Whatever the cause, our view is that
the presence of a dedicated, centralised strategic function with appropriate capacity
would have helped provide clarity in driving, and delivering, strategic advice and
longer-term planning.
xviii Established in August 2020 the National Response Leadership Team was made up of the Chief Executive of Department
of the Prime Minister and Cabinet, Chief Executive of National Emergency Management Agency, Deputy Chief Executive
in charge of the Covid-19 Group, Secretary to the Treasury and the Commissioner of Police to provide all-of-government
advice to Cabinet or Covid-19 Ministers, and also to provide non-health advice to the Director-General of Health (to inform
his use of powers under the Covid-19 Public Health Response Act). See Cabinet Paper and Minute, Implementing a rapid
response to COVID-19 cases in the community and refinements of COVID-19 Alert Level settings, CAB-20-MIN-0387, 10
August 2020, https://www.dpmc.govt.nz/sites/default/files/2023-01/SE11-Minute-and-Paper-Rapid-Response-and-Changes-
to-COVID-19-Alert-Level-Settings-10-August-2020-.pdf
2.6.1.2
Coordinating advice to decision-makers and ensuring a range
of perspectives
Among its other constraints, the lead agency plus ODESC model was not well suited for
providing decision-makers with coordinated advice from different agencies. Even the
all-of-government governance structure eventually adopted did not fully resolve the
challenges of ensuring multiple perspectives were reflected in the advice provided.
Early on in the response, Cabinet appropriately recognised that while they were
facing a public health emergency, that was not all: any actions they took to curb
transmission and save lives would also have significant social and economic
implications.96 However, they recognised that these actions were also the best
response in the initial stages – not only for public health reasons, but to minimise
the economic and social costs. As the Minister of Finance, Grant Robertson, told
Parliament on 17 March 2020: ‘Our first response is a public health one. It is our
fundamental duty. It is also the first and best economic response.’97
There were requirements for health and non-health factors (such as economic,
social, impacts on population groups, operational) to be considered in response
decision-making.98 For example, the COVID-19 Public Health Response Act 2020
required consideration of whether COVID-19 orders were appropriate and
proportionate.99 Advice from other agencies (such as the Treasury or operational
agencies) was included in papers to Cabinet, but we were told that the public
health advice remained ‘front and centre’. On the whole, over the period when
the elimination strategy and its zero transmission goal were guiding the response,
public health advice and the health risks associated with COVID-19 were the primary
driver of decision-making.100 In the context of a health pandemic, the centrality of
health advice early on to ensure we avoided the health system being overwhelmed
and rates of deaths as experienced in other jurisdictions, was appropriate.
A review by an independent advisory body in September 2020 identified that this
focus presented problems over time:
“ Too often decision-making papers have gone to Cabinet with little or no real analysis
of options and little evidence of input from outside health or even from different parts
of the health Ministry or sector. While this may have been understandable in the first
weeks of the response it should not be continuing eight months into an issue as we are
currently facing. ”
101
Over time, a wider range of advice was incorporated in Cabinet papers, including
advice on the impact of options on specific population groups,102 as well as more
comprehensive advice on economic and social impacts and considerations.
However, the range of advice remained variable. We heard from a senior Minister,
Members of Parliament and senior officials that a focus on health perspectives
continued throughout the response. For example, we were told that before and
during the 2021 Delta outbreak, ‘Cabinet papers were coming in as DPMC papers,
but really were Health papers, and we were bolting on Treasury and social advice.’
Senior officials we met with said both process and cultural factors probably partly
accounted for the emphasis on health considerations (over others) in the decision-
making process. The Inquiry was consistently told by officials that key policies were
developed by a small group of decision-makers and advisers, with little scope for
broader input. We also heard that administrative processes also meant health advice
was prioritised, particularly in the early days. For instance, the Ministry of Health
provided its input to Cabinet papers last so that the information was as up-to-date
as possible; however, this meant other agencies were unable to offer their own
perspectives based on the latest information. While the situation improved over time,
the timing and input to Cabinet advice remained a challenge for operational agencies
– who were managing the complexities of implementing health orders at pace across
very complex systems and sectors – throughout most of the response.
Other senior officials (both from all-of-government and from the Ministry of Health)
talked about agency culture challenges, which likely prevented more holistic
advice being developed and may have inhibited greater coordination between
agencies. This challenge was also mentioned by some external commentators.
Several stakeholders described the early stages of the response as being hampered
by a lack of cultural alignment between officials from an ‘emergency response’
background and senior health officials, who struggled to align a ‘command and
control’ framework with a complex and highly devolved health system. This was
exacerbated by a common perception that health officials were reluctant to accept
outside advice or input, or to share responsibility with other agencies.
To some extent, this was also a structural problem arising from the reliance on a
health-led pandemic response to weigh up all the impacts decisions might have –
especially when there were significant information gaps, including real-time data
and situational reporting.
The range of advice available had consequences for decision-makers. One
senior Minister told us that, without broader advice that took account of wider
considerations beyond health objectives, they felt ill-equipped to make any decision
not recommended by health experts. This is not to say that advice on the broader
impacts was never given, but it was not consistent or prioritised.
One of the reasons this is problematic is that many of the decisions made during
the response required significant trade-offs and compromises. This was problematic
for several reasons. For one, they required Cabinet to weigh up the impact of a
decision (on a matter such as regional lockdowns or vaccine exemptions) on health
outcomes, on different population groups, on human rights and treaty obligations
and on the economy, not to mention on the need to maintain ongoing social licence.
Weighing up so many different impacts required robust advice from a range of
agencies and perspectives. In our view, some decisions made in the COVID-19
response had unintended consequences that might have been prevented or
mitigated had wider advice been given and acted upon (such as employer vaccine
requirements and vaccine passports).
At a practical level, the Inquiry received evidence about many occasions where
policy decisions with operational implications were made with limited advice
from non-health agencies. As a result, significant implementation or enforcement
challenges emerged – examples described elsewhere in the Looking Back chapters
include the rapid imposition of regional boundaries, aspects of mask wearing and
other personal protective equipment (PPE) requirements (such as requiring children
in early childhood education to wear facemasks) and workplace distancing. When
implementation or enforcement problems were encountered, it led to delays,
rework and people on the ground having to come up with their own workarounds.
That the response’s primary focus remained on COVID-19 health outcomes may
also have contributed to the system’s blind spot when it came to how the response
would evolve over time (see previous section). It was certainly reflected in an
ongoing tendency for decisions to be made on the basis of a ‘zero risk’ approach
– in other words, always opting for the option with the lowest possible risk of
COVID-19 transmission, even if the other costs of so doing might be high.
2.6.1.3
Maintaining quality control and consultation processes in a
crisis and beyond
Early in the response, speed was paramount. Cabinet and ministers needed to
make complex decisions and relied on officials to provide sound advice, at pace in
an environment where information (about the COVID-19 virus and the response of
the rest of the world) was changing hourly. Many innovative and adaptive techniques
were used to enable this: ministers and senior officials alike told us how effective
it was having the right people in the room around a whiteboard. However, the
urgent circumstances meant some long-established practices – intended to ensure
that advice to Cabinet is robust, high quality, considers a full range of options and
has input from a range of perspectives or relevant stakeholders – had to be
temporarily suspended.
As with other departures from usual practice during the pandemic, this was justified
at the beginning of the response. But the balance should have then shifted back
towards more normal practices – albeit recognising there would still be occasions
where urgency was essential. However, the nature of the evolving pandemic meant
that some aspects of good practice were not reestablished as the ‘default’ for a long
time. For example, requirements for regulatory impact statements for COVID-19-
related matters were not reestablished until early 2022. Likewise, the time to consult
on changes to COVID-19 orders was often very limited.xix
xix Due to increasing transmission of the Omicron variant, there were 25 changes to key COVID–19 orders between
January and April 2022 – equating to a regulatory proposal every 3–4 days on average (e.g. Air Border Order,
Maritime Border Order, Isolation and Quarantine Order and the Required Testing Order).
Many standard government decision-making processes are designed to ensure an
appropriately broad range of inputs are included in advice, so there are risks in retaining
the ‘emergency approach’ for too long. A senior Minister and several senior officials told
the Inquiry about the appealing sense of freedom and empowerment that came from
having permission to move quickly and suspend normal processes. But while limiting
consultation and engagement sped up decision-making, it also increased the risk of
‘groupthink’, a lack of critical review and full consideration of operational impacts.
The Inquiry heard of many areas where outcomes could have been improved
(sometimes significantly) had broader perspectives been sought or considered:
among them were the establishment of regional boundaries, the drafting of
legislation and regulations, implementation of PPE requirements, and the vaccine
rollout (all covered in more detail elsewhere in this report). However, the Inquiry
also heard that despite reasonable periods set aside for consultation and
engagement – for example, with regional groups to map regional boundaries as
part of resurgence planning – decisions ultimately had to be implemented more
quickly than anticipated.
We saw some evidence of efforts being made to bring in broader perspectives.
Advisory groups were established to give ministers opportunities to engage with
particular key stakeholders or seek specific expertise to inform decisions. They
included the Business Advisory Council, the Strategic COVID-19 Public Health
Advisory Group, and the Community Panel.103 Likewise, some elements of good
practice were retained throughout the pandemic response, including efforts to
provide transparency in decision-making. Cabinet papers were routinely releasedxx
and agencies were required to continue to meet all their normal obligations under
the Official Information Act 1982.
2.6.1.4
Looking after the public service workforce
The Inquiry heard many stories about the efforts of individuals across the public
service whose innovation and dedication enabled the delivery of New Zealand’s
response, often at great personal cost. This enormous effort has been well recognised
– both nationally and internationally. Reviews of the initial phase reflected on the public
service’s role in building a strong foundation for New Zealand’s COVID-19 response:
“ The nature of the challenge, its rapid and silent spread and the compressed timeframes
within which officials and decision makers were required to operate is unprecedented
in modern times…… The urgency, pressure, and timeframes within which people were
operating was extraordinary. Overlaying that was an absence of a credible precedent to
follow……nothing of this scale globally and or domestically had been experienced.” 104
“ Many public servants worked extraordinary hours in extraordinary circumstances to help

keep New Zealanders safe and to mitigate the pandemic’s other impacts. Officials were
resourceful and showed initiative. They faced a complex task, prolonged uncertainty, and
constant pressure. The ability of public servants to work together under significant stress
was, and continues to be, critical to the success of the response. ”
105
xx Albeit with much of the Bill of Rights Act advice redacted. Normal practice is for Bill of Rights Act issues within Cabinet
papers to be addressed by policy departments, and to be released along with the rest of the paper. However, during
the pandemic, advice on Bill of Rights Act issues was often provided by Crown Law, and was thus routinely withheld
on the grounds of legal privilege.
However, given the pace of change and the significant uncertainty officials had to
deal with throughout the response, it was inevitable that workforce challenges also
surfaced. For example, recruitment and retention to service the communications
response was challenging. Chief executives of government agencies were reportedly
sometimes reluctant to release staff to the central unit and there was no requirement
for them to do so. Some other areas of the all-of-government response also struggled
to access staff with the skillsets they needed. Others had staff cycle in and out for
short periods of time – sometimes as little as six weeks.
We heard often about the immense and unrelenting pressure on many public
servants. Working conditions were extremely challenging, requiring staff to operate
on an ‘emergency’ footing for sustained periods. Burnout was common, and we
heard from some who were part of the effort that they would not volunteer to
repeat the experience.
2.6.2 Pandemic strategy: positive outcomes, challenging

transitions
2.6.2.1
The success of the elimination strategy
From April 2020 until October 2021, Aotearoa New Zealand’s COVID-19 response
was guided by the strategic goal of elimination. During most of this period the
pandemic response was widely viewed as coherent and effective, with a clear sense
of the overall public health goal and the actions needed to support it. This clarity
of purpose sustained the coordinated effort of the many individuals, whānau,
iwi, non-governmental organisations (NGOs), councils, agencies and businesses
that mobilised to protect the health of their communities. New Zealand was
widely praised internationally for having one of the strongest responses to the
COVID-19 pandemic.106
The initial Alert Level System was an innovative communication and policy tool that
proved highly effective in supporting widespread compliance with public health
restrictions. It was developed by a team of dedicated officials working at pace. The
system drew on established infection control tools, but presented these in a simple
and coherent way. It provided an effective means of communicating the risk level
posed by the outbreak and the measures required under each level.
During this period, public health and social measures were employed with a
clear focus on preventing and eliminating transmission of COVID-19 within the
New Zealand population. Strict border controls and quarantine of incoming
travellers were in place to prevent entry of the virus into New Zealand, and domestic
infection control measures were organised into a settings-based approach via the
Alert Level System and used to eliminate any chains of COVID-19 transmission that
did make it past the border (although it struggled with Delta in Auckland).
This combination of border controls and domestic alert level settings was effective
in achieving the strategic goal of elimination. Community transmission was
eliminated on 8 June 2020, and more than 100 days followed with no new cases.
Small outbreaks in Auckland in August 2020 and February and March 2021
prompted Cabinet to return Auckland to Alert Level 3 lockdown several times (see
Chapter 3). These initial regional lockdowns were relatively brief, lasting between
a few days and two weeks, and the package of measures (the regional lockdown,
intensive contact-tracing, testing, isolation and other targeted public health
measures) were successful in eliminating community transmission, allowing a return
to relatively normal conditions (compared with the substantial disruption being
experienced elsewhere in the world).
The successful deployment of public health and social measures in service of
the elimination strategy involved the coordinated effort of thousands of people
around the country. Working together, individuals, whānau, hapū, iwi, NGOs,
councils, agencies and businesses deployed infection control measures such as
locally-led checkpoints, developing their own protocols for gatherings, tangihanga
and funerals, and running or supporting vaccination clinics. These groups and
organisations also distributed significant resources, food, equipment and other
essentials to support communities and households to enable people to remain
safe in lockdown or isolation as required (see Chapters 3, 6 and 7 for more detail).
Many public submissions to the Inquiry expressed support for the elimination
approach, associating it with positive health outcomes, lesser economic impacts,
feelings of safety, limited disruptions to daily life and protection of the health
system from being overwhelmed.
“ The elimination strategy worked and the country benefited from that in health outcomes
as well as economically. NZ was able to carry on a normal life for 1.5 years thanks to that
strategy while the rest of the world struggled, something too often forgotten now. ”
Over time voices became less unanimous and there were growing calls to open
Aotearoa New Zealand’s borders.107
2.6.2.2
The difficulties of moving on
At the beginning of the pandemic, the Government showed agility in its decision-
making, adopting a strategy that was widely endorsed and contributed to good
public health outcomes.108 Through a combination of prompt and bold early
decision-making, and some fortunate timing and circumstances, by early April 2020
a clear strategy was in place, and a combination of measures including border
closures and the Alert Level System were deployed effectively to support it.
However, despite the opportunity to regroup after this initial success, there was
limited integrated, strategic planning as the pandemic progressed. As discussed
in section 2.6.1.1, the Inquiry considers that this is partly attributable to the lack
of a separate strategy function within the all-of-government response structure.
There was comprehensive, cross-agency strategic planning in discrete areas (such
as looking to vaccine procurement, resurgence planning, or safe reopening of the
border). But once the elimination strategy was established and demonstrated to be
effective, other options (including what would replace the elimination goal) received
less timely consideration than they could have.
Between April 2020 and September 2021, the implicit assumption appears to have
been that the elimination strategy would remain in place until population-level
immunity could be achieved through vaccination. This assumption is evident in two
key documents from 2020. The COVID-19 Health and Disability System Response
Plan (prepared by the Ministry of Health in April 2020) noted that elimination
would be pursued ‘until a vaccine becomes available to achieve population-level
immunity’.109 A December 2020 report to the Minister for COVID-19 Response noted
that ‘a vaccine will support a return to a new normal, [but] we need to continue
our Elimination Strategy for the next six to twelve months’.110 However, neither
document covers what would be involved in phasing out the elimination strategy,
or what public health goal might replace elimination once high levels of vaccination
were achieved.
In the following year (2021), the elimination strategy increasingly came to be
seen as an enduring goal, rather than a time-limited phase linked to achieving
population-wide vaccination. A May 2021 update prepared by the Department
of the Prime Minister and Cabinet considered how the COVID-19 response might
be strengthened within the parameters of the existing elimination strategy. This
report signalled that Aotearoa New Zealand would maintain its elimination strategy
even once the border reopened, referring to ‘continuing to refine our Elimination
Strategy whilst starting to rebuild contact with the world’.111
Government announcements over this time (e.g. ‘Reconnecting New Zealanders
with the World’) saw coexistence of selectively re-opened borders as consistent with
an elimination strategy – supported by a vaccinated population.112
When the tools supporting the elimination strategy were struggling to eliminate
Auckland’s Delta outbreak starting August 2021, there was no ‘Plan B’ or threshold
at which to move to suppression. While the Associate Minister of Health had
sought advice from the Strategic COVID-19 Public Health Advisory Groupxxi back in
June 2021 on whether there was a need to revisit the elimination strategy as the
country moved to a highly vaccinated population, she had been told that retaining
the elimination strategy at that point in time was the best approach (but that the
strategy should be regularly reviewed).
“ In our current view, the elimination strategy is still viable and, indeed, optimal as
international travel resumes. It does not mean “Zero COVID”, but it does mean stamping
out clusters of COVID-19 as they occur. The strategy should be reviewed regularly. ”
113
The ‘breathing room’ created by the successful elimination of community transmission

between June 2020 to August 2021 was in our view not used to best effect. The
opportunity was missed to review the ongoing optimisation, then exit, of the elimination
strategy, consider adaptation for potential new virus scenarios and adequately prepare
other response options for changes in circumstances (including the cumulative and
shifting impacts across health, social, wellbeing and economic outcomes). Although
discussions on future strategic options were being canvassed during mid-2021,
ultimately there was no agreed strategic plan on moving out of elimination until after
the end of the elimination strategy had been publicly announced in October 2021.
It is important to note the context at the time – Delta was still the dominant strain
in October 2021, and the world had not yet learnt about Omicron, with its much
higher transmission rates (and therefore probably impossible to manage with an
elimination strategy). Despite this, the lack of well-integrated advice on, and an
agreed plan for, a post-elimination strategy is surprising. This is especially so given
that the elimination goal was originally envisaged as a means of protecting the
population until high levels of vaccination could be achieved.
xxi The Strategic COVID-19 Public Health Advisory Group was responsible for providing independent advice and analysis to
the responsible Minister and the COVID-19 Ministerial Group on epidemiological modelling and analyses in relation to
COVID-19 vaccine rollouts and any changes to the approach to public health protections and border settings.
The Inquiry heard that the early and widely recognised success of the elimination
strategy may have made decision-makers reluctant to move on from a ‘zero risk [of
viral transmission]’ approach to COVID-19. A firm commitment to the elimination
strategy combined with the centrality of health-focused advice and public pressure
meant that, for much of the COVID-19 response, decision-makers were strongly
occupied with how to minimise the risk of viral transmission. The Inquiry was told
that this tendency to prioritise lowering risk of viral transmission to as close to zero as
possible made it difficult for officials to present options based on a more nuanced risk
assessment, or for decision-makers to consider whether this approach to balancing
health benefits and wider social and economic costs continued to be appropriate.
“ The elimination strategy was a zero-risk strategy – I think this was good, but we didn’t
concede defeat early enough. Once it was clear we wouldn’t get to zero [transmission
in the Auckland Delta outbreak] we still tried to pursue something that looked like this.
Should have pivoted sooner – i.e. we weren’t going to get Auckland back to zero [cases]. –
a senior Government minister. ”
The shift from elimination to suppression (‘minimisation and protection’) was a

hugely challenging transition operationally. For example, where some future plans
had been made – such as for a gradual re-opening of the border – they had been
consistently positioned as taking place under an implicit scenario in which high
vaccination could achieve something approaching herd immunity and it would be easy
to keep stamping out small outbreaks. This was not the scenario that transpired.
The lack of integrated planning exacerbated operational challenges for agencies,
businesses and communities. It also created confusion across government and
the wider public on what the objectives of the new approach were, and their
likely consequences. The lack of strategic clarity in the COVID-19 response at this
time is well understood publicly and has been acknowledged by many involved.
Honourable Chris Hipkins, who was the Minister for COVID-19 Response in late
2021, spoke frankly about this with us:
“ There was no bump free pathway to get from elimination to life as normal – there was always
going to be disruption on the way… We needed to have a group of people more removed and
planning for the next steps – we had everyone focused on ‘right now’. We really needed to
think beyond the horizon – we didn’t nail that. ”
We heard similar comments from other
senior ministers, and several have expressed
such sentiments publicly, including Hon “ It seems in hindsight that the
Chris Hipkins.114 last Auckland lockdown was
too long. People were pushed
This understanding was also reflected in the too far and became resentful
submissions we received. While numerous and critical and soon forgot
submitters expressed strong support for the what had been avoided. ”
elimination strategy as deployed early in the Public submission to the Inquiry
pandemic, many comments indicated a view
that elimination became less viable as time
went on.
“ During the pandemic I felt that the government did the right thing by immediately closing
the borders and putting us in lockdown. However, as time went on and other countries
took different approaches to travel and movement, I felt NZ was very blinkered. ”
People affected by the long lockdowns in Auckland in 2021 were particularly

critical of the way the Government held on to the elimination goal without
articulating an alternative.
There was also criticism of how quickly the approach changed once the elimination
strategy was abandoned, leaving many – especially those with disabilities, chronic
health conditions, and compromised immune systems – feeling vulnerable. This was
exacerbated by the lack of signalling that New Zealand would need to phase out of
the elimination strategy and consider how to live with COVID-19 in the community.
It was not well understood or communicated that an elimination strategy was
always going to be time-limited, and that high levels of infection might be an
unavoidable part of the exit.
“ As someone with a disabled wife, I felt severely neglected by the government when they
chose to drop the elimination approach to COVID-19 without developing the proper
infrastructure that would allow for us and the other disabled people we know to continue
to participate in society at all. ”
These challenges were by no means unique to Aotearoa New Zealand. Reviews

of the COVID-19 response in other countries have highlighted similar challenges
in trying to undertake long-term thinking and planning alongside the immediate
pressures of responding to a national crisis. A review of the COVID-19 response
in the Netherlands highlighted how difficult it was for the government to consider
the ‘bigger picture’ and the possibility of a shift in approach given the demands
of having to respond to a continually evolving situation while under intense
political scrutiny regarding operational aspects of the pandemic response.115
An independent review of Australia’s response to COVID-19 noted that – despite
their early success in responding to COVID-19 – governments (state and federal)
were often slow to adapt to changing circumstances.116
2.6.3 Public communications
Communications and information are an essential lever of government in a crisis,
particularly when the situation is novel or uncertain and where the public risks
serious illness or loss of life, as was the case with the pandemic. The need for direct,
clear and reassuring public communications was well-understood by those involved
as a critical element of the pandemic response and was considered fundamental to
the success achieved.
Public submissions to the Inquiry reinforced the value placed on good communication
and clear information during an emergency and many endorsed the approach to
public communications during the pandemic. Some submitters particularly noted the
positive impact on social cohesion of the empathetic approach to public messages.
“ The ‘be kind’ [message] and caring for the vulnerable rather than just business as
usual was vital, with unexpected benefits of time spent getting to know neighbours
and wider community better. ”
During the elimination phase of the pandemic, public communications were highly
effective at setting out what actions and behaviours were required by the public to
help limit the spread of the disease, and in doing so appealing to collective values and
harnessing the energy of individuals, households, whānau and communities behind
the response. There was a tangible sense of solidarity among many communities
during the first lockdown, and a high degree of compliance with its conditions.
Aspects of Aotearoa New Zealand’s approach were emulated by other jurisdictions,
such as the United Kingdom’s adoption of an alert level system similar to
New Zealand’s in May 2020. New Zealand’s ‘empathetic communication’ during
the pandemic and the Prime Minister’s high degree of public engagement
were highlighted as an example of best practice by the OECD in 2021.117 Public
submissions to our Inquiry reinforced the value placed on good communication
and clear information during an emergency and many endorsed the approach
to public communications during the pandemic.
“ Communication about what we needed to do, and why, was very clear and easy
to follow. ”
2.6.3.1
Establishing an all-of-government public communications function
The COVID-19 pandemic was an ‘everything, everywhere, all at once’ crisis requiring
critical, accurate public information and communication on a wide range of topics
and to a wide range of audiences at a previously uncontemplated scale. In this
context, stakeholders agreed that it was appropriate for the provision of public
information to be an all-of-government function led out of the National Crisis
Management Centre (and subsequently the COVID-19 Group in Department of
the Prime Minister and Cabinet from July 2020), rather than by the lead agency.
Officials from the Ministry of Health told us that the newly devised structure served
the early stages of the response well. It was seen as critical to ensuring that public
information could be delivered at the scale and level of service required, and
the physical location of the new team in the National Crisis Management Centre
enabled close collaboration with those leading different parts of the response.
The Department of the Prime Minister and Cabinet told us that the value of the
centralised COVID-19 public information function cannot be overstated and they
saw it as an essential part of the overall success of the COVID-19 response.
There were teething problems with establishing a new communications function in
the early stages of the pandemic. There was some initial confusion over the split of
roles and responsibilities between the new all-of-government team and the Ministry
of Health’s existing communications teams. Most of these were worked through
relatively quickly with support from staff within the Prime Minister’s Office.
However, the fact that the All-of-Government Public Information Management
Team did not have specific responsibility for community engagementxxii became
an issue as the response moved beyond the early days of the pandemic.118 From
March to May of 2020, public messages and channels had to be developed and
deployed quickly in order to keep up with the constantly changing nature of the
pandemic. There was limited opportunity for widespread community engagement.
Efforts were made to ensure messages reached more diverse audiences such as
work undertaken with Niche Mediaxxiii and, as the pandemic developed, other steps
were taken to improve community engagement, including development of tailored
resources, messaging and content for a range of audiences. However, it took
too long to establish meaningful engagement with a wide range of communities,
particularly with iwi and Māori. As a result, important public information was not
always reaching everyone who needed it.
In their engagements with us, members of the all-of-government team recognised
that they did not have the capacity to build the partnerships they needed for this
aspect of the response, and acknowledged that it was a difficult time to engage with
communities because the communities were busy responding to the challenges
posed by the pandemic, including keeping their own people safe.
2.6.3.2
Increasing complexity and changing public sentiment
Public communications and messages early in the pandemic response were
reasonably straightforward, and were able to be framed positively. This reflected
the highly focused nature of the response at the time – while lockdown measures
were drastic, the message that needed to be conveyed to the public was simple
and easy to follow: ‘stay home, save lives’.
xxii A Noting Paper sent to Cabinet establishes the new communications function, setting out its remit but it does not
accord any formal responsibility for community engagement to the newly established ‘National Public Information
Management Team’. Instead, it sets this out as the responsibility of individual agencies who should be carrying out
this work with their own stakeholder groups.
xxiii Niche Media are an agency specialising in ethnic communications and multi-cultural marketing, and were contracted to
provide cultural advice to the communications team, and helped get messages into communities, deploying advertising
with iwi radio stations and also Pacific radio stations during March–April 2020.
However, as time passed, government objectives shifted to gradually allowing
people to resume ‘normal’ activity, with a range of restrictions and caveats to protect
public health. This involved a raft of new policy settings that changed frequently and
were more complex than the relatively blunt tools of the early lockdowns. The all-of-
government communications team often had limited time to prepare to implement
decisions that required rapid and clear public information.
As the pandemic wore on, people’s attitudes to the Government’s messages and
policies also changed, and public messaging needed to evolve in response. Social
research was used to understand and track this change in sentiment.
The empathetic messaging that was a strong feature of the Unite Against COVID-19
campaign and early communications response came to be seen by some people as
condescending. Phrases such as ‘team of five million’ and ‘be kind’ were criticised
by some public submitters to our Inquiry as patronising or even hypocritical when
aspects of the response, such as long lockdowns in Auckland or the introduction
of vaccine mandates, felt ‘unkind’ to some citizens. New Zealanders overseas also
found the phrase grating and exclusive:
“ I would echo this; the us and them division came from the top (team of 5 million
vs. the “risks” overseas). The lottery made people feel like a number not a person.
The amount of abuse I received was very entrenched in New Zealand (e.g. “you left
this country, you don’t deserve to come back”). ”
The time pressure and the nature of the single daily briefing also created challenges
for members of the press. The briefings were a key opportunity for journalists to ask
questions of the people in charge of the response. During lockdowns, attendance
was limited, and only Wellington-based reporters could attend, so members of the
Parliamentary press gallery often had long lists of questions on behalf of colleagues
as well as themselves. The short timeframes, limited presenters and the livestream
also created a difficult environment for journalists to ask questions that were
technical or nuanced in nature.
It was previously unheard of for government press conferences to generate such high
public viewership, and on occasion, individual journalists were subjected to public
anger or criticism in response to their questions, sometimes because they were
perceived to be too critical of decision-makers, and sometimes the opposite.
The combination of reasonably dispassionate health advice with a ‘political
message of unity’ that senior press secretaries told us made the daily 1pm briefings
successful may also have come to undermine their effectiveness. Some public
submitters felt that having the Prime Minister and Director-General present the
briefings together unduly politicised the information. This was commented on as
particularly pertinent in the lead up to the 2020 General Election.
“ Don’t grandstand on TV daily etc and make it all about the Government. It should
be all about the recommendations of an expert apolitical medical panel. ”
2.6.4 Diverse communications for diverse audiences?
The lack of ethnic diversity amongst the key spokespeople at the 1pm podium was
seen as problematic for some communities we spoke with. Failing to reflect the
diversity of New Zealand’s demographics became an issue for communities, and
in turn whether or not they felt included in ‘the team of five million’.
Some mitigations were put in place over time to communicate more directly with
these audiences, but the one-size-fits-all response did not adequately address
the needs of Aotearoa New Zealand’s diverse population. Many Māori and Pacific
communities wanted to see their own leaders on the podium and felt this would
have helped their communities to feel more engaged, which in turn would have
had a positive impact on compliance, especially as the pandemic wore on and many
people, particularly Aucklanders, grew tired of the focus on COVID-19.
There were also issues with the quality, speed and cultural appropriateness of some
translated content, and producing it at high speed was particularly challenging.
Government communications officials acknowledged this in our direct engagements,
calling it a ‘pain point’.
Expected turnaround times for translated material were extremely tight; often
translations were required for changes that had already been announced publicly.
Sometimes the information was superseded by the time the translated material
was ready. This was no fault of the often small, community-based, and sometimes
volunteer organisations who were asked to produce this material. One stakeholder,
whose organisation translated many government communications into accessible
formats for disabled people, told us:
“ My team were working all hours of day and night. We couldn’t have done anything more
or differently because of the changing information and how quickly it was evolving. ”
Despite these considerable efforts by many, we heard from some stakeholders

that the constantly changing requirements and messages were hard to keep up
with. For some communities this was exacerbated by a lack of timely, accessible
information resulting in ‘information voids’ that were filled by other sources,
such as word of mouth from trusted family members or unofficial online sources.
In some cases, this led to people relying on inaccurate information or risked their
exposure to misinformation and/or disinformation.
Spotlight:
The rise of misinformation and disinformation |
Te ara haere mai o ngā mōhiohio parau me te horihori
Misinformation and disinformation related to COVID-19 and the

Government’s response became an increasing challenge as the
pandemic wore on.
Experts told us that conditions were ripe for the spread of misinformation and
disinformation going into the pandemic and that during the pandemic there was
a marked increase in the volume, diversity of topics and tenor (particularly the
severity of language) of disinformation circulating on topics related to COVID-19.
In a study commissioned by the Classification Office during the pandemic, the majority
of participants (65 percent) believed groups or organisations were intentionally
spreading false or misleading information about COVID-19, and three-quarters
believed false information about COVID-19 was an urgent and serious threat to
New Zealand society.119
Disaffection over the introduction of vaccine mandates (and to some extent, other
pandemic measures), combined with the increasing circulation of false and misleading
information about the pandemic and response, from both domestic and international
sources, culminated in the dramatic occupation of Parliament grounds by protesters
early in 2022, perhaps the most visible expression of the pandemic’s impact on social
cohesion and trust. The Chief Human Rights Commissioner viewed the decision by
senior ministers and officials not to engage directly with the protestors as detrimental.
Meanwhile, from the second half of 2021 at least, some senior ministers were aware
of the pandemic’s increasing impact on ‘social licence’, especially the use of extended
lockdowns in Auckland, but did not feel that there were viable alternatives at that time.
The characterisation of the Government as the ‘single source of truth’ also came to
be seen by some as unhelpful. Early in the pandemic, the Prime Minister had used
the phrase ‘single source of truth’ to emphasise that the information being conveyed
from the government could be relied upon by the public, in response to a question
about COVID-19-related misinformation:
“ I want to send a clear message to the New Zealand public. We will share with you the most up-
to-date information daily. You can trust us as a source of that information. You can also trust the
director-general of health and the Ministry of Health for their information. Do feel free to visit
it anytime to clarify any rumour you may hear. COVID19.govt.nz. Otherwise, dismiss anything
else. We will continue to be your single source of truth. We will provide information frequently.
We will share everything we can. Take everything else you see with a grain of salt. ”
120
These comments were an attempt to tackle misinformation and disinformation by

encouraging people to access evidence-based material available on the government
website. However, the phrase was frequently quoted in submissions as something
that contributed to a sense of mistrust.
“ At the beginning of Covid I was very much on board with the lockdowns, but as the mandates
started rolling out, followed by the vaccine pass system, and the subsequent divisions and
fractures within and amongst families and people, becoming visible, and this, alongside the
silencing of highly experienced voices that thought differently to the ‘one narrative for all’ and
the ‘single source of truth,’ I no longer believed the government was handling Covid in a way
that was not harmful. ”
79
The damage to social cohesion and spread of misinformation and
disinformation during the pandemic impacted the effectiveness of the
public health response over time.121
Many stakeholders have commented that the breakdown of social
cohesion that occurred during this pandemic, particularly the rapid
spread of misinformation and disinformation, loss of social licence for
the long lockdowns in Auckland, and fractures that developed within and
between communities over the mandates, will shape how the population
is likely to respond to public health responses like lockdowns and vaccine
requirements in any future pandemics. People told us about:
• Impacts of misinformation and disinformation including increased
vaccine hesitancy, mistrust of experts and impacts on academic
freedom, harm to targeted individuals and mistrust of government.
• Breakdown of personal, family/whānau, community and employment
relationships over vaccine mandates and vaccination status.
• Increased public anxiety, antisocial behaviour, stress and violence.
• Anger at long lockdowns and restrictions, especially in Auckland,
including a strong sense from Aucklanders that ‘Wellington’ did not
understand what they had been through.
• A sense that people would be very unwilling to comply with lockdown
and vaccine requirements in a future pandemic.
The evidence from experts on some of these matters is mixed. We
heard a range of opinions from researchers of misinformation and
disinformation for example, who, while agreeing that disinformation had
been a significant challenge and that the pandemic had exacerbated it,
differed on the extent to which it presented an ongoing risk and challenge
to trust and social cohesion. Some thought we had largely reverted to
pre-pandemic trust levels, while others were more concerned that trust
levels would continue to decline.xxiv All agreed that those who are already
marginalised and with low trust in government (including Māori) are
most susceptible to disinformation, and that fostering and maintaining
trust and social cohesion is key to countering its impacts. Reports by
multiple government agencies support a continued focus on the risk of
misinformation and disinformation.122
Looking to the future, the Ombudsman suggested that increased
transparency and oversight by independent integrity bodies may
help take some of the ‘sting’ out of public disaffection at times of
emergency powers in future.
xxiv Data from the 2023 General Social Survey found that trust held by
New Zealanders in institutions like the health system, education
system, Parliament, media, police and courts has declined since 2021,
according to wellbeing statistics released by Stats NZ.
80
What we learned looking back |
0.0
2.7 Ngā akoranga i te titiro whakamuri
1. Pockets of pandemic preparedness existed at the

start of 2020 which helped the initial response.
However, all-of-government readiness proved
insufficient for an event of the scale, impact and
duration of the COVID-19 pandemic.
• Before COVID-19, a range of existing systems, legislation, plans,
structures and capabilities were available to support the response.
However, many turned out to be insufficient for a pandemic on the
scale of COVID-19, which required a prolonged response and had
widespread and complex national impacts. Many other countries
found themselves in a similar position.
• The New Zealand Influenza Pandemic Plan, last updated in 2017,
provided much useful support to the health response in the initial
weeks. But, as often happens with plans, it was soon overtaken
by events – in this case by factors specific to COVID-19 and the
development of the elimination strategy.
• While the pre-pandemic system of risk management was useful in
identifying national risks – including pandemics – there was scope
for stronger oversight and accountability mechanisms to ensure
those risks were adequately prepared for across government.
• As happened in other countries such as Australia and the United
Kingdom, Aotearoa New Zealand found the response to the
COVID-19 pandemic required more integrated all-of-government
coordination than the lead agency model was able to deliver.
Governance changes were quickly made to recognise this, although
the Inquiry was told that this took longer than desirable. Having an
all-of-government model ready to go would have avoided having to
develop such a structure during the busy initial response.
2. Government made hard decisions quickly under
pressure but, over time, some shortcomings emerged
which were not adequately addressed.
• The all-of-government structures set up in the early stages of
the COVID-19 response had a clear focus on elimination. They
supported the rapid delivery of this strategy which formed the
basis of New Zealand’s response. Unfortunately, a separate
long-term strategy function – that could sit above the fray of the
day-to-day response, allow future scenarios to be considered,
and deliver integrated long-term planning supporting a smooth
transition across later stages of the pandemic – did not evolve.
• In the early stages of the pandemic response, it was appropriate
for decisions to be made quickly with a particular focus on
technical public health advice. However, over time, the process
by which advice was provided (in order to incorporate the most
up-to-date health information) meant fewer opportunities for
non-health matters to be considered. Opportunities to consider
proportionality across health, social and economic objectives
were also limited.
• The emergency nature of the pandemic meant some standard
policy practices were (appropriately) suspended during the early
stages of the response. This included adequate opportunities
for stakeholder and agency consultation, and transparent and
thorough assessment of regulatory impacts. It took longer than
desirable to adequately re-establish all aspects of standard
policy practice.
3. Enormous efforts by public servants (supported by

individuals from across communities, iwi, academia
and the private sector) and the flexibility and
adaptability of New Zealand’s public service enabled
the rapid setup and delivery of an effective response
to COVID-19.
4. Aotearoa New Zealand’s elimination strategy, and the
use of public health and social measures to support it,
were highly effective at stamping out pre-Delta chains of
transmission when they arose and giving the country long
periods without transmission.
• The initial Alert Level System was a world-leading and innovative
communication and policy tool that proved highly effective in supporting
widespread compliance with public health restrictions.
• The success of the elimination strategy relied on the coordinated effort of
thousands of people around the country who supported the deployment
of public health and social measures.
5. However, a determined focus to keep pursuing an

elimination strategy, and a lack of strategic planning for
the longer term, affected the Government’s ability to
prepare for and respond to new developments and shift
direction soon enough.
• Once the elimination strategy was established and demonstrated to be
effective, its success resulted in less emphasis on all-of-government, long-
term, strategic planning – work that could test options and scenarios on
how and when to adjust or move beyond elimination, what would replace
the elimination goal, and that could integrate health and social, economic
and wellbeing goals.
• This reduced focus on evolving the long-term, strategic focus to guide
forward direction added pressure to how the Government navigated the
complexities and impacts arising from new events (such as the emergence
of new variants), adapting tactics (such as moving from PCR to rapid
antigen testing, removing vaccine mandates), and moving beyond, and
ultimately exiting elimination (for example, the shift to caring for those
with COVID-19 in the community).
6. In the early stages of the pandemic, the public
communications response was highly effective and
contributed to the success of the elimination
response. But communications became more
challenging as the pandemic wore on.
• Government messaging was initially very effective, but it became
more challenging to convey messages as new settings were
announced and government objectives shifted.
• Greater engagement with communities during the response
could have improved the effectiveness of communications by
ensuring individuals, families and communities better understood
how to comply with Government directives.
• The transition out of the elimination strategy was not well
signalled or communicated ahead of time. This had an
unsettling impact on people, which was compounded by a
rise of misinformation and disinformation (both about the
virus itself and the Government response).
Endnotes |
2.8
0.0 Tuhinga āpiti
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nih.gov/pmc/articles/PMC9760677/ 11. Department of the Prime Minister and Cabinet,
2. Andrew Lakoff, Unprepared: Global Health in a Time ‘National Risk Framework’, updated 13 March 2024,
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and Michael J. Deml, ‘The Legacy of the Pandemic resilience/national-risk-framework
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pmc/articles/PMC9760677/ national-risks
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Peter Varghese, Fault Lines: an independent review into Background paper to Te Tai Waiora: Wellbeing in
Australia’s response to COVID-19 (20 October 2022), Aotearoa New Zealand 2022 (AP 22/01), The Treasury
https://www.paulramsayfoundation.org.au/news- (Wellington, 24 November 2022), https://www.
resources/fault-lines-an-independent-review-into- treasury.govt.nz/publications/ap/ap-22-01
australias-response-to-covid-19 Classification Office, The Edge of the Infodemic:
117. OECD, OECD Report on Public Communication: The Challenging Misinformation in Aotearoa (Wellington,
Global Context and the Way Forward, OECD Publishing June 2021), https://www.classificationoffice.govt.nz/
(Paris, 21 December 2021), p 149, https://www.oecd- resources/research/the-edge-of-the-infodemic/
ilibrary.org/content/publication/22f8031c-en
CHAPTER 3:
3 Lockdowns |
Ngā noho rāhui
Introduction |
3.1
0.0 Kupu whakataki
The decision to use lockdowns in Aotearoa New Zealand was informed

by experience in other countries – both positive and negative.
The first reported case of COVID-19 in Aotearoa New Zealand was detected
on 28 February 2020, more than two months after the virus was identified in
China, and a week or so after small clusters were identified in Europe and the
United States. This delay – attributable partly to geographic isolation, and partly
to good luck – meant Aotearoa New Zealand had an important opportunity to
assess what was happening in other countries before taking action.1
In particular, once COVID-19 started to spread significantly in other countries,
decision-makers were able to compare the experience of Italy and parts of
the United States (where rapid community transmission had already
overwhelmed hospitals and caused many deaths) with that of China, Taiwan
and Singapore (where authorities had adopted strong restrictions which
somewhat contained the virus).2 On that basis, Cabinet made an informed
decision to adopt ‘aggressive and effective containment measures’ such as
closing the border.3 As part of this approach, Aotearoa New Zealand, like much
of the world, went into ‘lockdown’ in late March 2020.i However the rationale
for New Zealand’s lockdown – to break chains of transmission – soon diverged
from the rationale in most other parts of the world, where lockdowns were
used to keep transmission down to an ‘acceptable’ level.4 This usually meant
a level that did not overwhelm health services.
As the need for such a tool had never been anticipated or prepared for, Aotearoa
New Zealand had no apparatus in place for an all-of-society lockdown ahead of
the COVID-19 pandemic. The whole public sector – including those working in
both frontline and public health roles – was operating without a playbook, as
indeed was everyone in Aotearoa New Zealand.

i ‘Lockdown’ was not an official legal term but was used by Prime Minister Jacinda Ardern in a press release
announcing the first lockdown (see endnote 4 for details). It emerged in global use early in the COVID-19 pandemic
to describe combinations of public health measures that heavily curtailed people’s movement in the interests
of stopping the virus. Levels 3 and 4 of New Zealand’s Alert Level System can be understood as ‘soft’ and ‘hard’
lockdowns, respectively, because they required people to stay at home, closed schools and businesses, and involved
heavy restrictions on public gatherings. We use ‘lockdown’ to describe these aspects of the response, since they were
a defining part of the pandemic experience, and most people remember and refer to them this way.
Two key Cabinet papers from this period drew expressly
on international comparisons.
The first (recommending the adoption of the Alert Level System)
states:
‘New Zealand has a stark choice. Iran and Italy show

dramatically what happens when action is taken too
late. Their health systems are overwhelmed which is
leading to alarming case fatality rates. The UK appears
to be following Italy’s trajectory with a two-week lag.
The UK only began responding with significant public
health measures after the exponential growth in cases
occurred. Following the UK may be Australia in 8–10
days. Without further action, New Zealand may follow
the path of Australia, where community transmission
is occurring in New South Wales. New Zealand needs
to act decisively to increase containment measures
if we want to stay on the trajectories of Singapore
and Taiwan, notwithstanding cultural differences.
As an island nation this is feasible.’
The second Cabinet paper (recommending the move to Alert

Levels 3 and 4) states:
‘COVID-19 is rapidly spreading around the world,

particularly in Europe and the United States. To date,
East Asian countries and territories have been most
effective at containing COVID-19 through aggressive
and effective containment measures. New Zealand
needs to take similar, and urgent, action if we are to
avoid exponential growth rates.’
See endnotes 2–3 for details of these documents.
We begin by describing the use of lockdowns in Aotearoa New Zealand

and their effects – not only on COVID-19 transmission and cases, but
on daily life, access to essential goods and services, work, schools (and
other places of learning), employment and more. We also describe how
agencies and communities everywhere stepped up to mitigate the worst
impacts of the lockdowns, especially on those who were most vulnerable.
We examine the lockdowns in three distinct stages.
• Section 3.2.1 describes the first national lockdown (Alert Levels 3
and 4) which occurred between March and May 2020 and lasted
seven weeks.
• Section 3.2.2 addresses the series of brief Level 3 lockdowns in
Auckland during late 2020 and early 2021, each lasting from a few
days to a few weeks.
• The return to Alert Levels 3 and 4 in the second half of 2021 lasted
three weeks for most of the country, but stretched on for several
months in Auckland, with shorter regional lockdowns for Northland
and Waikato; this period of lockdowns is described in section 3.2.3.
In section 3.3, we set out our assessment. We consider not only what
lockdowns achieved as a public health measure, but also their impacts
– short-term and more lasting – on people, communities, the economy,
education and more. Overall, we find that lockdowns were successful for
the immediate task at hand. But Aotearoa New Zealand might have been
less reliant on lockdowns to achieve elimination had the country benefited
from earlier and greater investment in public health capacity. The success
of the elimination strategy meant people in Aotearoa New Zealand spent
less time living under stringent public health and social restrictions than
populations in many other countries. At the same time, many people
felt that lockdowns were kept in place for too long, particularly the final
lockdown (focused on Auckland) of 2021.
What happened |
3.2 I aha
3.2.1 The first national lockdown, March–May 2020

Aotearoa New Zealand spent seven weeks in Alert Level 3 and 4 lockdown between
March and May 2020. The need for lockdown-like conditions was anticipated when
Prime Minister Jacinda Ardern announced the Alert Level System on 21 March 2020,
and from there things moved quickly. On 23 March 2020,5 the number of confirmed
cases in New Zealand passed 100,6 and the Prime Minister announced that the
country had moved to Alert Level 3, to be followed by Alert Level 4 in 48 hours.7
From this point, New Zealand was in ‘lockdown’.
This decision was informed by concurrent international experience (observing what
was happening in countries that had acted swiftly or less boldly) and Ministry of
Health officials’ assessment that it was highly likely community transmission was
occurring in Aotearoa New Zealand. In making this decision, Cabinet considered
the many potential implications of the restrictions, including wide-ranging economic
impacts (and proposed mitigations), te Tiriti o Waitangi considerations, and the
very significant social implications, especially
for people who might be disproportionately
impacted (including Māori, Pacific
communities and older people).8 “ If community transmission
At Alert Level 4, everyone was instructed takes off in New Zealand
to stay at home in their household ‘bubble’ the number of cases will
other than for essential personal movement. double every five days. If
Gatherings were cancelled and public venues that happens unchecked,
were closed, as were all businesses other our health system will be
than those recognised as essential services inundated, and thousands
like supermarkets, pharmacies, healthcare of New Zealanders will die …
clinics, petrol stations, and lifeline utilities. Moving to Level 3, then 4,
Educational facilities were all closed for in- will place the most significant
person learning. ‘Safe’ recreational activity restrictions on our people
(walking, running, and cycling – but not in modern history but they
swimming) was allowed in people’s local area, are a necessary sacrifice to
save lives. ”
9
but any travel was severely limited, as were
activities where there could be a higher risk of Right Honourable Jacinda Ardern,
injury. Public facilities, including playgrounds, 23 March 2020
were closed. Aotearoa New Zealand remained
at Alert Level 4 for almost five weeks.
3.2.1.1
Case numbers fell, enabling Aotearoa New Zealand to move
down alert levels
For the first two weeks of the initial 2020 lockdown, case numbers continued to
grow, and some people became very unwell from COVID-19. The first COVID-19-
related death in Aotearoa New Zealand was recorded on 29 March 2020, a few days
after the country entered Alert Level 4 or a ‘hard’ lockdown.10 By 5 April 2020, the
total number of recorded cases was 1,000.11
However, from that peak, case numbers began to fall. This success is not
attributable to the lockdown alone, but to the combination of measures that
were being deployed in pursuit of the elimination strategy (namely, the evolving
international border restrictions and increasing contact tracing and isolation of
people infected with COVID-19). Undoubtedly, though, given the context and other
available options, lockdown conditions were a key component in the success in
eliminating transmission of the virus in Aotearoa New Zealand (for a more detailed
discussion of the epidemiology, see Appendix B).
In the last week of April 2020, the whole country moved down to Alert Level 3 –
a ‘softer’ version of lockdown, with less stringent conditions than Alert Level 4.
Cabinet had previously agreed to specific factors that would guide decisions on
moving between alert levels, a recognition of the difficult balancing of interests
such decisions would demand. They would take account of health considerations
(level of community transmission, testing and tracing capacity, adherence to
border and managed isolation and quarantine (MIQ) measures, and health system
capacity), social and economic factors, public attitudes and adherence, and ability to
operationalise measures.12
The decision to move to Alert Level 3 was informed by the growing social, economic,
fiscal and non-COVID-19 health costs of Alert Level 4 restrictions and the Director-
General of Health’s advice that undetected community transmission was unlikely,
that there was sufficient testing capacity and capability, strong processes for
managing outbreaks in high-risk settings, robust border measures, and sufficient
health system capacity.13
At Alert Level 3, people were still instructed to stay at home other than for essential
personal movement but were allowed to expand their immediate bubble to connect
with close family/whānau, bring in caregivers, or support isolated people (though this
extended bubble had to remain exclusive). Schools (up to Year 10), kura and early
learning centres re-opened but attendance was voluntary. Businesses were able
to re-open, but only if they could operate without physical contact with customers.
Workers who could operate from home were required to do so. Gatherings of up to
10 people were allowed, but only for weddings, funerals and tangihanga.14
Case numbers continued to fall, supported by the public’s high compliance with
restrictions and the progress made in scaling up key public health systems (including
testing, contact tracing and isolation). The first lockdown ended on 13 May 2020
when the whole country moved to Alert Level 2. (See Appendix B for a more detailed
account of case numbers, hospitalisations and deaths at different stages
of the response).
3.2.1.2
Most people complied with the first lockdown, there was a
strong sense of solidarity, and agencies took a light-touch
approach to enforcement
Despite the general uncertainty and lack of preparedness, high public compliance
with the strict lockdown settings maximised the chances of rapidly stopping
community transmission of COVID-19. People, systems and communities rose
to the occasion, and many examples of innovation, collaboration and resilience
helped to enable compliance with these challenging measures.
Social cohesion and trust in government stood out as a key enabler of an effective
societal pandemic response.15 During COVID-19, high levels of social cohesion were
shown to support greater social licence for action and effective community-led
responses, and were associated with lower infection and death rates.16 According to
various measures, levels of social cohesion and trust were relatively high in Aotearoa
New Zealand prior to COVID-19.17 This strong base – mobilised in public appeals to
the ‘team of 5 million’ to ‘Unite Against COVID-19’ – supported high compliance with
lockdowns and other measures, at least in the early stages of the response.18 (See
Chapter 2 for more on public information and official communications, including the
Unite Against COVID-19 campaign.)
In keeping with the emphasis on solidarity and kindness in public communications,
responsible agencies generally took a principles-based, ‘light touch’ approach to
enforcing lockdown rules where possible (although the Inquiry was told by some
people that they considered enforcement to be ‘harsh’). Police had significant
enforcement powers, first under existing legislation and later under the COVID-19
Public Health Response Act 2020, but chose to use them sparingly, prosecuting only
the most serious and persistent breaches. In the first week of the lockdown, they
announced they would use a graduated model known as the ‘4 Es’ (engage, educate,
encourage, enforce) to support compliance with lockdown rules. This approach drew
on pre-existing Police principles of policing by consent and prioritised maintaining
the trust and confidence of communities.19 The ‘4 Es’ became the basis of a wider
All-of-Government Compliance Response, agreed between all major enforcement
agencies in April 2020, to support a collaborative and consistent approach to
compliance and enforcement for the COVID-19 response.20
Despite the predominant mood of public solidarity, and agencies’ trust-based
approach to compliance, there were some early signs of disharmony about
lockdown rules, along with some confusion and the perception of some mixed
messages. For example, while the dominant messaging was to ‘be kind’, there was
high public interest in perceived breaches of lockdown rules. A few days into Alert
Level 4, on 29 March 2020, Police launched an online tool where people could report
suspected rule violations. More than 80,000 reports were received over the next
month; more than the total number of 111 calls in the same period.21 (We return to
the topic of social cohesion in Chapter 8.)
3.2.1.3
Iwi and Māori, and many communities, provided significant
leadership and support
Iwi and Māori and many communities of different kinds – neighbourhoods, cultural
groups, online groups, non-governmental organisations (NGOs) and community
organisations, religious institutions, families, whānau and aiga – stepped up during
the first Alert Level 3 and 4 lockdowns to provide essential local leadership, support
each other and address local needs.
There are many well-documented examples of community groups taking charge
of the response on the ground. Sometimes in partnership with government, and
sometimes independently, they sourced kai, medicine, resources and other essential
items, and distributed them to those who needed them. Recognising people needed
more than food and medicine, they provided other support too, ranging from making
direct donations, offering transport to essential destinations, enabling technology
and data connections, and linking individuals, households, families and whānau
with government support (see Chapter 6 for more on the social response). Existing
hubs such as marae and places of worship (and the relationships and community
knowledge that came with them) meant support could be tailored to individual
needs. Community organisations, both formal and informal, were also well placed
to meet unseen needs such as for fellowship and connection. Many people trusted
community organisations to sort, curate, and act as conduits for reliable information.
New grassroot groupings, such as community social media groups, were created
that enabled people to check on and help each other. Some organisations ran phone
trees to check on older people and other potentially vulnerable groups.
Within ethnic and migrant communities, there was strong guidance and
engagement from many community leaders. Communication across many
languages was particularly important. Within Pacific and Māori communities,
clusters of churches, marae, sports clubs, health centres and community support
groups provided networks of support and information, connecting people to
resources and services and advocating for those who were more vulnerable.
Several community organisations networked their personal capabilities to help
support the broader pandemic response, such as using their personal 3D printers
to make face shields for essential workers.
Pacific churches generally played a strong leadership role in addressing specific
challenges faced by their communities. Physical distancing is difficult when families
live in multigenerational and often crowded homes. Pacific households have the
lowest level of home internet access compared with other New Zealand ethnicities
and are over-represented in low-income occupations (such as retail, food supply,
and health, disability and aged care), many of which were classified as essential
during the pandemic. Churches used their existing relationships and built new ones
to ensure the needs of their communities were met. They linked in closely with
Government to understand what was happening, and what response was needed
from their communities.22
In combination with the work of social sector agencies (covered in section 3.2.1.7),
these multi-faceted community efforts undoubtedly alleviated many of the potential
negative impacts of lockdowns on individuals and groups.
Iwi and Māori leadership

Iwi and Māori played a significant leadership role in mobilising their communities
and mitigating the negative impacts of lockdown. Early in the pandemic, iwi, hapū
and marae across the motu developed plans that adapted tikanga and kawa to the
challenges presented by not being able to interact in person. This included hapū and
marae committees temporarily closing marae, restricting papakāinga access, and
developing new protocols for tangihanga and tupāpaku under lockdown conditions,
despite significant personal, cultural and spiritual impacts.23
Iwi and Māori also worked closely with law enforcement in response to COVID-19 to
encourage compliance. Māori leaders we engaged with told us that iwi and Māori
‘policed ourselves’ to follow the rules, and this appears to be borne out by the data:
while Māori unfortunately are generally over-represented in Police enforcement
action, and this remained the case during the pandemic, this happened at
significantly lower levels than usual.
Spotlight:
Te Tiriti o Waitangi partnership in action |
Te whakatinanatanga o te hononga Tiriti
Iwi and Māori in Tairāwhiti, Bay of Plenty, Taranaki and Te Tai

Tokerau stood up checkpoints to limit the movement of people
and control the spread of COVID-19, just as they had done a
century before to control the 1918 flu.
Almost 50 roadside checkpoints were established, resourced and led

by iwi and Māori, staffed by volunteers, and often operated in partnership
with NZ Police. In addition to protecting local residents (both Māori
and non-Māori), such checkpoints were valuable for disseminating
information and contributed to a sense of trust between Police, Māori,
and the wider community, although some parts of the population found
them challenging.24
Coming out of the initial lockdowns, iwi and hapū representatives have
spoken publicly about the positive impact of the partnership between
Māori and Police on iwi checkpoints.
Tina Ngata (Ngāti Porou) noted that:
“ like all relationships with the Crown, it has not been without challenges,
and it is still a work in progress, but in supporting our protection of our
communities, New Zealand Police have stepped into their partnership
[with Māori] responsibilities in their fullest sense. ”
25
Rahui Papa (Waikato-Tainui) spoke of how strengthened relationships

with Police had seen issues:
“ resolved quickly and efficiently, with cultural considerations at the forefront.

The place of tikanga and best practice in these relationships is an example,
not just for a pandemic context, but further into the future. ”
26
101
Police representatives made similarly positive comments. Eastern Bay
of Plenty area commander Stuart Nightingale said that the community
safety zones provided additional protection to the remote and vulnerable
community of Te Whānau-ā-Apanui and had:
“ clearly achieved what they set out to do. Community policing means
working in partnership and building solutions to problems in conjunction
with the communities we serve. ”
27
Other community leaders also expressed gratitude to iwi for the

checkpoints. South Taranaki Mayor Phil Nixon said:
“ I really support what they’re wanting to do to protect our community.

They’re going to great lengths to look after us. ”
28
On the other hand, our Inquiry heard from some public submitters
who found the roadblocks challenging.
Shortly after the initial lockdown, the COVID-19 Public Health Response
Bill was introduced to Parliament. The original version proposed to make
it unlawful for anyone other than Police to run roadblocks, which some
felt was ‘tone deaf’ to the rights of iwi to exercise tino rangatiratanga in
their own rohe.29
102
3.2.1.4
An essential services category was established to ensure access
to critical goods and services while limiting people’s movements
Like most countries, Aotearoa New Zealand established an essential services
category during COVID-19 lockdowns to ensure continued access to food, critical
goods, and lifesaving and preserving services. This largely determined who could
leave the house, go to work, and travel locally at Alert Level 4.
Existing legislation and international guidance provided a starting point for the
definition of ‘essential’ services.30 However, no detailed work had been done
in Aotearoa New Zealand pre-2020 to define the scope of essential services,
businesses and workers in a pandemic context.
The Alert Level System was announced on 21 March 2020. The strict limitations
envisaged at Alert Level 4 meant that a formal definition of essential services
would immediately be required if the country moved to that level. As with many
other aspects of the response at this time, advice was being developed at pace and
without time to refine and test definitions and approaches. An initial list of essential
services was appended to Cabinet Papers recommending the move into lockdown
(Alert Levels 3 and 4), with an understanding that the list would be continuously
reviewed and adjusted.
Cabinet adopted four principles to guide this process: prioritising public health and
allowing the Government to scale-up the response, while at the same time ensuring
the necessities of life and maintaining public health and safety.31 These reflected
decision-makers’ primary focus at the time on reducing community transmission
of the virus (discussed in Chapter 2). Notable criticisms of the essential services
scheme include that it struggled to keep up with the (often changing) needs of
business and the community, and was sometimes applied in what appeared
to some to be an arbitrary fashion (for example, supermarkets could open but
butchers could not).
As the country moved into Alert Level 4 late on 25 March 2020, the Director-General
of Health used existing powersii to close all premises except for ‘businesses that
are essential to the provisions of the necessities of life and those businesses that
support them’.32 The Ministry of Business, Innovation, and Employment (MBIE) was
tasked with administering and regularly updating a definitive list of essential services.
Despite the flexibility built into this approach, some essential services, industries and
oversight mechanisms that should have been operational were initially excluded (e.g.
victim support and court workers), and it wasn’t always straightforward to address
some of these omissions. In addition, as time went on, some things that were not
essential in the short term (like various maintenance activities) became essential.
Officials we engaged with told us their advice to Cabinet at the time highlighted that
the essential services approach was unlikely to be sustainable over an extended
time frame and that a different approach would be needed at lower alert levels.
ii Under section 70 of the Health Act 1956, for the purpose of preventing the outbreak or spread of an infectious disease,
and if authorised to do so by the Minister, in a state of emergency or while an epidemic notice is in force, the medical
officer of health may exercise a range of special powers, including to “require to be closed, until further notice or for a
fixed period, all premises within a health district (or stated area of a health district) of any stated kind or description.”
See: https://www.legislation.govt.nz/act/public/1956/0065/latest/DLM307083.html
Approximately half a million people regularly left home to go to work during
Alert Level 4.33
Formal use of the essential services category to require certain types of premises
to close ended when the country moved to Alert Level 3 on 27 April 2020.34 It was
replaced by a requirement for businesses that re-opened to meet specific, strict
requirements for physical distancing, contact tracing, and contactless delivery.
Businesses accessed by the public (retail, hospitality) could open but only for online
or phone purchases, and contactless delivery or collection. This reflected a shift
from essentiality to safety. Alert Level 3 settings also required anyone who could
work from home to continue to do so.
Around 1.3 million people regularly left home to work during Alert Level 3, about
49 percent of the workforce.35
Figure 1: Number of people ‘going to work’ (essential service workers),

working from home and unable to work under Alert Levels 4 and 3
Source: Ministry of Business, Innovation and Employment, 2020, Essential services workforce fact sheet, p 1,
https://www.mbie.govt.nz/assets/essential-services-workforce-factsheet.pdf
3.2.1.5
Many businesses, households, community groups and individuals
switched to working, learning and socialising online
Workers who were not employed by essential services (and some who were, whose
jobs could be done remotely) switched to working from home during lockdown.
Around Aotearoa New Zealand and the world, businesses, schools and community
organisations rapidly switched to remote ways of working and connecting. This
was critical to the successful use of lockdowns: the World Health Organization’s
independent panel on pandemic preparedness later found that good digital access
was one of three necessary prerequisites for effective stay-at-home orders (along
with adequate household income and a high level of trust in government).36
The fact that broadband infrastructure had been rolled out to most of the country
in recent years proved vital to allow most people in Aotearoa New Zealand to work,
learn, socialise, and keep entertained online during lockdown. However, there were
some key gaps in coverage, especially in rural areas.37 Beyond infrastructure, there
were other barriers to digital access for some, including affordability of devices and
connections, and lack of skills or knowledge. As one stakeholder put it to us:
“ If you’re rural you don’t have the connection. If you’re poor, you don’t
have the devices. If you’re old, you don’t know how to use the device. ”
Those fitting into one or more of these categories were a minority of the total
population, but a significant one.
Some sectors and workforces were better prepared for (and better suited to)
remote work than others. This reflected a wide variety of factors including pre-
existing digital access, varying levels of skills and investment in IT capability, working
from home conditions and the nature of the work (if it was desk-based or face-to-
face, for example).
COVID-19 provided the catalyst for public sector agencies and workforces to switch
to remote working. Many thousands were sent home to work and continued to
deliver essential public services in a completely new way. For example, the justice
system was able to build on the limited audio-visual links already available in some
courts to enable remote participation on a much wider basis. In some cases, as
with the Ministry of Social Development, this involved a near-total overhaul of their
operating model.
3.2.1.6
Schools, kura, early learning centres and tertiary education
providers were closed for in-person learning, and switched to
remote learning where possible
Schools, kura, early learning centres and tertiary institutions were closed for
in-person learning from 24 March 2020 to 28 April 2020.iii Under Alert Level 3,
education providers could be open for children up to Year 10 for families that
needed them. Their closure for most in-person learning required educational
settings to rapidly switch to deliver remote (and later hybrid) learning.
Cabinet authorised $87.7 million to support the switch to remote learning. This
sum was to cover connecting the homes of 40,000 eligible learners to the internet,
providing schools with 49,000 fit-for-education devices for students, producing
English and Māori medium educational television broadcasts, and distributing
printed learning resource packs to most schools and early learning centres.38
The Government also funded digital access for some tertiary students, increased
the course-related costs component of student loans, and provided $56.8 million
through the COVID-19 Response and Recovery Fund (see Chapter 6 for more on this
fund) in recognition of the loss of international students.39 This was in addition to
the decision to continue to fund tertiary education organisations at the levels set out
in their investment plans for on-Plan funds, irrespective of any potential reduction
in student numbers (a transfer of the Tertiary Education Commission’s grants
obligations to 2020 of $1.1 billion).40
Budget 2020 also included a $50 million Urgent Response Fund to help early
learning services, schools and kura to improve attendance and manage any
learning, social, emotional, mental or other wellbeing needs related to the COVID-19
lockdown.41 This was distributed using the Equity Index to target schools and
communities in greatest need. In total, a reported $199 million was invested in new
education initiatives in 2020, most in direct response to COVID-19.42
During Alert Levels 3 and 4, most schools explicitly prioritised student wellbeing
over academic learning, recognising that they could not expect a ‘normal’ workload
under extraordinary circumstances. Despite this, many students and teachers were
worried about falling behind.
iii The 48-hour period 24-25 March was designated Level 3 and allowed schools, kura and early learning centres to remain
open for the children of essential workers.
Delivering remote learning proved challenging at all levels. It was not practical or
appropriate to fully deliver the early childhood curriculum remotely, given the age
of these children and the fact that most of their learning is play-based. Nevertheless,
most early learning services provided some form of remote teaching and learning,
focused on identifying and building on learning opportunities at home.43 Many
teachers and educators worked hard to rapidly upskill and adapt to deliver the
primary and secondary school curricula remotely, though the experience of this
was variable.44 The tertiary sector’s move online was also patchy and depended
on individual institution size and capability. Whilst some pivoted promptly and
efficiently, smaller and regional institutions took longer. Many tertiary institutions
opted to deliver remotely beyond May 2020, given the volatile environment and
repeated alert level changes in Auckland. For staff at all levels, the additional
workload associated with the shift was considerable.
Tertiary education providers could return to limited in-person learning at their
discretion from 28 April 2020, at Alert Level 3, although the Ministry of Education
advised that staff and students should continue working or learning from home
where possible.45 Most providers remained online or delivered hybrid options.
From 14 May 2020, schools, kura and early learning centres began a phased return
to in-person learning, ahead of the move to Alert Level 2 on 18 May 2020.46 Strict
precautions would be in place, including designated bubbles, social distancing
and hygiene routines. Some disruptions continued even once schools reopened,
when close contacts were required to isolate, or schools that had been sites of
transmission were required to close.
Spotlight:
Life in lockdown | Te ao o te noho rāhui
In some ways, lockdown might be seen as putting everyone

in ‘the same boat’. But the reality was that the experience
across the lockdowns varied greatly depending on individual
circumstances, temperament, family situation, income, safety
and stage of life.
Snippets from our public submissions give a flavour of the myriad

experiences, positive and negative.
“ We took long walks [with] the pram to look at the neighbourhood. We watched
the forklift unloading groceries outside the supermarket. And we set our daily
routines around the 1pm update, with the sound of voices lulling our toddler to
sleep on the sofa. We look back really fondly on these times; they were happy
days for our family. ”
“ I loved how quiet it was. I could hear the birds and nature. Walk in the middle of
the road on quiet streets and experience it differently. […] It was also a really nice
opportunity to enjoy recreational activities/hobbies again and felt like I was living
again, and not living to work. ”
“ I felt immense pressure as a mum to deliver/be present with work, as well

as present for my son’s learning and general entertainment/parenting. ”
“ The 108 day Auckland lockdown began to take a toll on my mental health with
feelings of hopelessness and despondency, lack of energy and overall depression. ”
“ [B]eing confined to your property all day and night was quite draining on my mental
health. [S]omething I didn’t realise would be the case until we were in the situation.
Living with 4 other adults in a flatting situation at the time. [We f]ound that we all
would drink alcohol each evening out of boredom and mental stress from being
confined to our property and not having freedom to do what we wanted. ”
“ It was tough. We have 3 young children at primary school level [and]

trying to maintain their schooling online plus both parents working full time,
it was a struggle to find space to all work together. In addition, we had 4
pensioners in our bubble. Lockdown in Auckland was overall challenging.
Sharing space and devices was also a challenge. ”
108
3.2.1.7
The social sector stepped up
In the social sector, the COVID-19 response was a step-change in the way
government worked. The sector’s initial response to the lockdowns was
characterised by high agility, flexibility and collaboration between government, iwi,
and community partners together with an immediate injection of (mostly time-
limited) funding. As well, there was a strong focus on outcomes.47 Providers were
empowered to tailor their services to the needs and aspirations of the communities
they were working with, and commissioning agencies relaxed requirements for
outputs and reporting. A range of funding responses was put in place in the early
phase of the pandemic, including specific funding tagged for disabled people, family
violence and sexual violence, Māori, Pacific people and community solutions.48
More so than usual, government agencies operated a ‘no wrong door’ policy for
those seeking support and worked closely with community groups and social service
providers to ensure that families in need were able to access what they required,
including food grants online, food parcels delivered, housing needs met urgently,
and support to access household goods, clothes and appliances.
Service providers – which included NGOs, community groups, iwi and Māori
organisations, and volunteers, as described in section 3.2.1.3 – often went above
and beyond during this period. Many delivered services without contracts or
funding, using their own resources, until government systems caught up. For more
detail on the social and community sector response and impacts, see Chapter 6.
3.2.1.8
Immediate housing support was provided to those who were
sleeping rough or living in insecure accommodation
The defining characteristic of lockdown was the requirement for people to stay
at home. There were many groups for whom this was challenging or dangerous –
among them people at risk of family or sexual violence, people living in cramped
or overcrowded housing, medically frail or very elderly people who lived alone, and
so-called ‘marginalised’ groups including gang members and people with addictions.
Some of the most immediately vulnerable under ‘stay at home’ conditions were
those who had no home at which to stay – people who were sleeping rough, couch-
surfing, living in cars, or in highly unstable and unsuitable accommodation.
Ministers and officials understood that the transient movement of people living in
insecure housing risked undermining the effectiveness of lockdowns as a tool to
suppress and eliminate COVID-19, and that there had been little to no pandemic
preparation in the housing and accommodation sector.49 In response, central
government agencies worked quickly with community housing providers, social
services, iwi and other Māori organisations, and local government to provide
temporary and emergency housing support for people who were in insecure housing
or rough sleeping. This was enabled by direct, fast communication, the swift adoption
of permissive ‘high trust’ contracting models, and ample and immediate funding.
In March 2020, Government instituted an immediate freeze on residential rent
increases, and introduced new protections against the termination of tenancies.50
3.2.1.9
The first lockdown ended on 14 May 2020
On 14 May 2020, Aotearoa New Zealand moved to Alert Level 2. This marked the
end of the first national lockdown, though significant restrictions were still in place.
Cabinet delayed allowing social gatherings in public or private venues of more than
10 people, with a view to increasing this limit over time, and it delayed opening
bars and clubs for an additional week. People were now permitted to connect with
friends and family, go shopping or travel domestically – providing they followed
public health guidance, including keeping physical distancing of 2 metres when
out in public, and 1 metre in controlled environments like workplaces. Schools and
educational facilities re-opened for in-person learning, with strict hygiene measures.
Businesses could open to the public, including hospitality businesses, and record-
keeping was required to allow contact tracing. Gatherings like weddings, funerals
and tangihanga remained limited to 10 people. Masks were required on public
transport. Those who could were still encouraged to work from home.51
Case numbers continued to fall at Level 2 and by 8 June 2020 when Cabinet met,
there were no active community cases left. The country moved to Alert Level 1 on
9 June 2020 based on the high confidence that COVID-19 had been eliminated from
Aotearoa New Zealand.52
Figure 2: COVID-19 cases and timing of first lockdown, March–April 2020iv
Source: Based on data from Ministry of Health GitHub data, 2024, COVID-19 data, https://github.com/minhealthnz/
nz-covid-data
iv ‘Cases at the border’ are those detected in incoming travellers in MIQ.
3.2.2 Brief Level 3 lockdowns in Auckland in late 2020 and
early 2021
3.2.2.1
Auckland spent two and a half weeks back in Level 3 lockdown
in August 2020
On 11 August 2020, after 102 days without community transmission, four people
tested positive for COVID-19 in Auckland. Ministers with power to act decided to
take a precautionary approach, and – in addition to contact tracing and stepped-up
testing – moved Auckland into an Alert Level 3 lockdown, and the rest of the country
into Alert Level 2, from midday on 12 August 2020.53 This was the first use of a
regional lockdown.
For two and a half weeks, schools and early learning centres closed again except for
those who ‘need to attend’ – mainly the children of essential workers. Others returned
to online learning. Those who could do so went back to working from home.
On 30 August 2020, Auckland moved into a newly-created ‘Alert Level 2.5’. This
was based on advice that, while the number of confirmed cases was increasing,
the cluster was under control. Decision-makers were also conscious of the costly
nature, both economically and socially, of holding Auckland at higher alert levels,
the challenges inherent in implementing regional boundaries, and that Pacific and
Māori communities were disproportionately affected by this outbreak.
While this decision ended the first regional lockdown, the new settings were more
restrictive than the original Alert Level 2. Social gatherings (including weddings)
were limited to 10 people, except for funerals and tangihanga, which were allowed
up to 50 people in attendance. Hospitality businesses could not serve groups
larger than 10, and masks were mandatory on all public transport in Auckland.54
Aucklanders were also asked, but not required to, comply with Level 2.5 settings
wherever they went (including outside of Auckland), even though the rest of the
country was at Alert Level 2.55 This temporary ‘half step’ was in place for three weeks
and was not used again in the pandemic. By 8 October 2020, the whole country was
back at Alert Level 1.56
3.2.2.2
Auckland moved in and out of Level 3 lockdown several times
in early 2021
For a few weeks in February and March 2021, Auckland again moved in and out
of Alert Level 3 lockdown several times, after more community transmission was
detected.57 At this time, the total time spent in Level 3 lockdown was relatively
brief – three days initially, and later one week – but it came at a disruptive time at
the beginning of the school year. In June 2021, Wellington spent nearly a week at
Alert Level 2 after a visitor from Australia tested positive following a short but busy
weekend in the city.58 Aside from these short-lived regional disruptions, 2021 saw
Aotearoa New Zealand remaining largely out of lockdown until the arrival of the
Delta variant in August.
Figure 3: COVID-19 cases and periods under lockdown/restricted settings

(February–March, June and August–December) in 2021
Source: Based on data from Ministry of Health GitHub data, 2024, COVID-19 data, https://github.com/minhealthnz/
nz-covid-data
3.2.3 Delta lockdowns in late 2021
3.2.3.1
The entire country spent three weeks back in lockdown in
August and September 2021
In 2020 and early 2021, lockdowns had proved to be an effective tool for achieving
and maintaining New Zealand’s elimination strategy. Their effectiveness had derived
from high levels of trust and social cohesion, strong support from communities,
social and economic supports, and clear communication. As the use of lockdowns
continued in 2021, decision-makers had to make increasingly challenging decisions.
These involved weighing up a range of competing considerations – social and
economic, as well as public health – which would have different impacts across
population groups.
This phase of the lockdowns began after the World Health Organization indicated
in June 2021 that the Delta variant was becoming the dominant strain globally.
Delta was substantially more infectious than previous variants, making it harder to
contain. It also caused more serious clinical illness.59
On 17 August 2021, a community case of COVID-19 was detected in Auckland.
Officials assumed (correctly) that the case was the highly transmissible and
more virulent Delta variant. The sick person had been active in the Auckland
and Coromandel regions, and it was considered likely that the virus was already
circulating elsewhere, so the Prime Minister announced an imminent Level 4
lockdown for the whole country. While the initial indication was that this would be
another short-lived lockdown, the country remained in Level 4 lockdown for the
next two weeks, and Auckland for much longer.
For the second half of August 2021, New Zealanders returned to settings and
experiences that were largely familiar from the first Level 4 lockdown. This recent
experience meant many people and organisations were better placed to respond
with systems, processes, policies and technology already in place to manage in
lockdown. The essential worker category was revived, online learning resumed,
those who could worked from home, and community organisations again stepped
up. Schools, kura, early learning centres and tertiary education providers returned
to remote and online learning, and for the first time, the Ministry of Education
distributed specific learning resources targeted at learners with sensory needs.
After two weeks, all regions except Northland and Auckland moved down to Alert
Level 3, with Northland following a few days later. On 7 September 2021, all regions
except Auckland finally moved out of lockdown to a strengthened Alert Level 2 (in
which mask wearing was required in most public areas and permitted gathering
sizes were reduced – see Chapter 8 for more on compulsory mask wearing).60
While some Delta cases were reported outside of Auckland, the combination of
contact tracing and other public health measures was effective in these regions and
community transmission did not take hold.
Auckland, however, remained at Alert Level 4.61 While Northland was theoretically
at the strengthened Level 2 from 7 September 2021, the ongoing lockdown in
Auckland meant it was effectively cut off from the rest of Aotearoa New Zealand (see
also section 3.2.3.3). The Auckland lockdown continued to be extended, although it
was stepped back down to Level 3 from 22 September 2021.62
3.2.3.2
The Delta lockdowns were much longer for Auckland (and some
other regions)
By 4 October 2021, Auckland had spent 49 consecutive days in either Alert Levels
3 or 4. The public health risk remained, but ministers and officials were aware that
there was ‘eroding social licence for heightened restrictions amongst compliant
parts of the Auckland population’.63 Increasing vaccination rates were added as
a further factor in Cabinet decision-making. Cabinet decided the country would
transition away from the Alert Level System to the new COVID-19 Protection
Framework, which would allow them to retire use of lockdowns as vaccinations
provided an additional tool in the control of COVID-19.64 While the intention just
one week previously had been to still control the Delta outbreak and ‘get back to
zero cases in Auckland’,65 officials now recommended a ‘phased approach to step
down restrictions over time as part of a gradual transition to the new “traffic light”
framework’.66 This is what happened in practice, as cases in Auckland continued
to rise while the costs of a prolonged lockdown accumulated.
By mid-October 2021 it was evident the Delta outbreak would not be easily eliminated.
Focus shifted to maximising vaccine uptake in order to allow restrictions to be
loosened – including a staged re-opening of Auckland schools.67 Health officials had
previously advised that the transition to the new ‘traffic light’ system could occur once
90 percent of the eligible population had been vaccinated68 and the Prime Minister
now presented this as the target that would allow Auckland to move out of lockdown.69
But despite significant efforts in the following weeks, vaccination levels continued to
be substantially lower in Māori and Pacific communities70 and were not projected to
reach 90 percent in Auckland District Health Board (DHB) areas until mid-December.71
When elimination was no longer possible, the justification for lockdowns shifted
to protecting people (particularly vulnerable groups) from the severe impacts
of COVID-19 infection, but this shift was not well-communicated to the public
(as discussed in Chapter 2). Official documents from this period illustrate the
challenging situation in which the Government found itself. On one hand, there
was clear recognition of ‘eroding social licence’ among the Auckland population
‘who [have] endured a significant time at heightened Alert Levels’,72 coupled with
ongoing economic and social impacts for businesses and families. Advice highlights
the ongoing and increasing challenges related to financial support and economic,
social and wellbeing impacts. General fatigue amongst the public was increasing and
willingness to comply with some public health measures was reportedly reducing.73
On the other hand, officials were also acutely aware of the risks of removing
restrictions while vaccination levels remained low in vulnerable population groups.
The specific demographics of Auckland were relevant here, with recognition that
South Auckland communities in particular ‘feature[d] a younger age structure, lower
rates of vaccination and [were] likely to be at greater risk of hospitalisation’.74
In seeking to balance these concerns, officials developed proposals to modestly
relax Alert Level 3 settings in Auckland in a staged manner. From 5 October 2021,
Auckland was placed at Alert Level ‘3.1’ which permitted small gatherings in some
contexts.75 A subsequent move to ‘Level 3.2’ on 9 November 2021 allowed the
opening of some public facilities (including libraries and museums) with use of
facemasks and physical distancing, and gatherings of up to 25 people.
Level 3.3 was never activated, because on 2 December 2021, Cabinet adopted the
‘minimisation and protection’ approach and Aotearoa New Zealand moved to the
‘traffic light’ system to manage the COVID-19 response. Auckland was put at the ‘Red’
level, along with several other regions that were considered to be at greater risk, either
because of low vaccination rates or because they were popular holiday destinations.
At the ‘Red’ traffic light level, Auckland was technically out of ‘lockdown’, although
some significant restrictions remained in place, and schools and early learning
centres did not completely re-open for in-person learning until February 2022.
In total, Auckland spent more than six months at Alert Level 3 or 4, compared to
74 days for most of the rest of the country.
There was widespread criticism in our
public submissions of the duration of
the Auckland lockdown. People spoke “ Children being locked out of school,
about hardships they faced during even for a short period, disrupts their
this time, and about the additional relationships, a deeply distressing and
potentially damaging thing for children
alienation and burden they felt was
approaching and in their teens. ”
carried by those in Auckland. We
Public submission to the Inquiry
heard this may have had a particular
impact on older people, as well as
children and young people.
We also held direct engagements with bereaved families who were unable to be with
sick or dying loved ones or attend their funerals due to the Auckland lockdown and
heard of the level of trauma and distress they experienced. For some, these issues
impacted on their trust in government, and their willingness to follow the rules.
Alongside this, the Government was also criticised for having transitioned to the
new ‘traffic light’ system before the 90 percent vaccination goal had been reached.
In the Haumaru report,76 released in late 2021, the Waitangi Tribunal found the
Crown had breached te Tiriti o Waitangi principles in its decision to transition to
the COVID-19 Protection Framework without meeting the original vaccination
threshold. This decision was regarded as putting Māori at disproportionate risk of
Delta infection compared with other population groups, given their lower vaccination
coverage at the time of the transition. The Tribunal also noted that this decision
was made despite the strong opposition of Māori health experts and iwi leaders.
With the ending of the Auckland lockdown, Māori health providers were under
pressure to vaccinate their communities as quickly as possible in order to protect
them from the health consequences of COVID-19 infection. The Tribunal found that
this undermined their ability to ensure equitable care for Māori.77
We will return to what can be learned for the future from the intensity and length
of the Delta lockdown in the ‘Looking Forward’ part of our report.
3.2.3.3
The boundary between Auckland and the rest of the country
presented challenges
Regional boundaries, while valuable, were hard to implement – particularly at
short notice and with no prior preparation across the system. These timing and
preparedness issues caused many challenges for communities, businesses, workers
and enforcement.
Implementing a regional boundary around Auckland was extremely challenging –
particularly when done at such short notice – and those responsible worked hard to
understand and balance the many practical issues this created for those on either
side of the boundary line. We heard that policies relating to the boundary were not
always based on local advice, and while some challenges were unavoidable, in other
cases local input would have helped improve outcomes. Some communities were cut
off from essential supplies (such as being able to access their normal pharmacy and
medications) and checkpoints were sometimes in impractical locations (some lacked
enough space for trucks to queue and had no amenities for checkpoint staff). These
issues meant that boundaries were often changing in an attempt to resolve them.
Enforcement of boundaries also proved difficult with thousands of cars crossing
the boundary every day, most of them for legitimate, necessary and permitted
reasons.78 People crossing the regional boundaries in the last quarter of 2021 were
also required to provide evidence of a COVID-19 saliva test within the last 7 days,79
which added further stress at the checkpoints, and for those wishing to cross.
This requirement was introduced on the advice of Ministry of Health officials80 to
mitigate the risk that essential workers might unknowingly transmit the virus across
boundaries (for more on compulsory testing, see Chapter 8).
There were also unique pressures for Northland from the regional boundaries
which saw them cut off from the rest of the country, apart from limited channels
through Auckland. Businesses in Northland effectively became stranded from the
rest of Aotearoa New Zealand, while other businesses throughout New Zealand
(for example, the construction sector) were impacted by reductions in supplies of
goods and services. We heard from some in Northland that they felt forgotten or
overlooked and ‘lumped into Auckland’s mess rather than being treated as our
own region’.
Spotlight:
Beginnings and endings in lockdown |
Te tīmatanga me te otinga i te noho rāhui
Welcoming a new baby and farewelling a loved one are two of the most
profoundly significant events in many people’s lives. They are also events
that can rarely be planned or controlled. While most aspects of daily life
ground to a halt during lockdown, babies continued to be born, and people
continued to die – some from the virus itself.
But the support available to people going through these major life events, and the
conditions in which they did so, changed dramatically. These were some of the most
challenging and controversial aspects of the lockdowns and featured strongly in our
public submissions.
Giving birth
Some submitters described the anxieties of expectant parents facing the prospect
of giving birth without their partners or support people, or being unable to access
the usual checkups during the perinatal period (pregnancy and the first year after
birth). Others described difficulties finding a midwife, felt inadequately supported
through post-natal depression or a traumatic birth, or had to stop IVF and other
time-critical fertility treatments.
While some had positive experiences of giving birth during lockdown and expressed
gratitude for a safe, COVID-19-free birthing environment and extra time together
as a family, others relayed traumatic experiences. One submission (which we feel
merits quotation at length) evoked the fear, grief and stress experienced by many
birthing parents:
“ I birthed my fourth child three days into the March 2020 lockdown. I was still in theatre getting
stitched up when my husband was asked to leave the hospital, even though he posed zero risk
to the staff or myself. I was in shock from an attempted vaginal birth and then [being] rushed
through to theatre for an emergency caesarean. I nearly lost my baby and was at high risk of
something going wrong and I needed support. I was drugged up and I didn’t feel safe to be left
alone. I could not think straight, and I was scared. I spent four nights in hospital, unable to see my
husband or three other children who had never really spent a night away from me. I couldn’t walk
and had nerve damage from my epidural. I could barely move so co-slept with my newborn in a
hospital bed as no nurse was checking on me or wanted to help me move my baby from feeding
and safely back in the bassinet. This was because they didn’t have a protocol for a lockdown
situation. I felt unsafe in the hospital. […] I hate to think what first time mothers experienced
during lockdown; I was lucky that I knew what I was doing but the damage has been done. I have
needed therapy and counselling and have PTSD from the lockdown experience. It was the most
stressful time of [my] life. It is a time I will never get back, birthing a baby is a sacred and ‘once
in a lifetime’ experience, and I am heartbroken that that was my last experience of childbirth. ”
117
Farewelling a loved one
Distress at not being able to visit a dying loved one in a rest home,
hospice or hospital care was one of the most recurring themes in our
public submissions and engagements we held with bereaved families.
The limited number of people able to attend funerals and tangihanga
during lockdown was another. The predominant view expressed by
submitters was that these restrictions were cruel and unnecessary. Some
were frustrated that the approach was not flexible enough and failed to
take into account unique circumstances, others we spoke to described
challenges in accessing the exemption process, a lack of clarity in who
could apply, and the unsatisfactory automated response they received.
However, where exemptions were granted, such as permission to
travel to a funeral, people were grateful. Many people felt their grieving
process had been impeded or incomplete, and that this had long-term
consequences. Again, here is one submitter whose experience was
echoed by many.
“ During lockdown, dad died. […] We couldn’t be with him and had to put a huge
amount of trust in staff at the home to care for dad and to love him like we did.
Nobody would love him like we did. Nobody would care for him like we did.
Nobody could hold him like we could have had we been allowed to be with him
when he died. The whole experience was absolutely awful. We weren’t able to be
together as a family and grieve. ”
Some submitters did however express a willingness to forego the ability to

farewell a loved one if it meant that, overall, fewer people would die:
“ Not being able to attend funerals or say final goodbyes is hard… But […] missing
out on a funeral, or even three funerals, is a less bitter pill to swallow than being
able to attend, but needing to attend twice as many. ”
118
Our assessment |
3.3 Tā mātau arotake
3.3.1 Aotearoa New Zealand’s use of lockdowns during

the COVID-19 pandemic, while stricter than many countries,
was comparatively sparing in terms of time spent in
lockdown conditions
We start our assessment of the use of lockdowns by acknowledging that, during
the first couple of months of the pandemic response, decision-makers were dealing
with very high levels of uncertainty. The situation at that time required a different
kind of risk tolerance than later in the pandemic, when developments such as the
availability of vaccines and greater understanding of the effectiveness of public
health measures had significantly changed the pandemic landscape. This should be
taken into account as part of the context within which the use of lockdowns occurred.
How Aotearoa New Zealand’s use of lockdowns compared with other countries is
demonstrated in the COVID-19 ‘stringency index’, developed by University of
Oxford researchers to compare the strictness of national COVID-19 responses
across the world.81 Based on policies in nine areas (public information/advice,
gathering restrictions, cancellation of public events, restrictions on movement,
stay-at-home requirements, workplace closures, school closures, closure of
public transport, and border/international travel controls), countries were given
a stringency score between 0 (no restrictions) and 100 (maximum restrictions).
Figure 4 shows the changing stringency score for a selection of jurisdictions –
including New Zealand, Australia and Taiwan (all of which followed an elimination
strategy), the United Kingdom and the United States (which used suppression for
much of 2020–22), and Sweden (which pursued a mitigation strategy).v
Under Alert Level 4 (full lockdown) Aotearoa New Zealand’s control measures
were at the top of the scale, stricter than other countries. But New Zealanders
spent comparatively little time under these conditions.82 After the initial lockdown,
Aotearoa New Zealand spent much of 2020 and the first half of 2021 at Alert
Level 1. During these periods, people faced far fewer domestic restrictions –
outside international border restrictions affecting their ability to travel or, for
some, to return home – than many other countries, including those pursuing
suppression or mitigation strategies. As a result, New Zealanders were able to
attend large-scale events such as concerts and sports matches.
Very few countries avoided using mandatory lockdown-type measures as
part of their COVID-19 response. Remarkably, Taiwan managed to eliminate
COVID-19 transmission in 2020 without a lockdown by mounting a rapid and
highly effective public health response – including strict border restrictions,
isolation and contact tracing, alongside widespread use of facemasks.83 Previous
experience with SARS (in 2003) meant mask wearing was widely normalised
in Taiwan, which also had well-developed pandemic response capability.
v Note that these graphs reflect the most stringent location in each country. For example, New Zealand’s 2021
stringency score largely reflects what was happening in Auckland, with most other regions experiencing comparatively
few restrictions.
Taiwan also made use of extensive electronic monitoring – including tracking
of people’s cellphones – to ensure compliance with isolation and quarantine
restrictions.84 While lockdowns were not mandatory, most people in Taiwan
did dramatically reduce their mobility achieving nearly the same effect as a
mandatory lockdown.
Several Pacific Island nations – including Samoa, Tonga, the Solomon Islands, Tuvalu
and Tokelau – protected their populations by closing their borders before any cases
of COVID-19 had reached them (i.e. an exclusion strategy).85 These countries were
able to avoid stringent domestic measures such as lockdowns, since they were cut
off from any source of infection. Some of them managed to remain ‘COVID free’ for
several years (for example, Tokelau had still not experienced a single COVID-19 case
by June 2022).86 While border closures protected these islands from the potentially
devastating effects of infection, they also carried massive social economic impacts –
particularly for those whose economies relied heavily on tourism.
Figure 4: COVID-19 stringency index – New Zealand, Australia,

Taiwan (elimination), United Kingdom and United States (suppression)
and Sweden (mitigation)
Source: Blavatnik School of Government, University of Oxford – with minor processing by Our World in Data, 2023,
COVID-19: Stringency Index (New Zealand, Australia, Taiwan, United Kingdom, United States and
Sweden), https://ourworldindata.org/explorers/covid?uniformYAxis=0&country=NZL~AUS~TWN~GBR~USA~SWE&-
Metric=Stringency+index&Interval=Cumulative&Relative+to+population=true
The stringency index is a composite measure based on nine response indicators including school closures,
workplace closures and travel bans, rescaled to a value from 0 to 100 (100 = strictest)87
3.3.2 Aotearoa New Zealand would have been less reliant
on lockdowns to eliminate COVID-19 infection if there had
been greater prior investment in its core public health tools,
capacity and capability
As discussed in Chapter 5, Aotearoa New Zealand’s health system (as in many other
countries) needed to rapidly scale-up its core public health tools – such as contact tracing,
case isolation and in-country quarantine – to meet the demands of the COVID-19
response. Likewise, it needed to significantly strengthen the capacity and capability
of the public health system. Had there been greater investment in these areas before
COVID-19 arrived, decision-makers might have had more options to limit the spread
of the virus. Later, uneven implementation of other parts of the pandemic response
(such as the vaccine rollout, which took longer to reach different population groups;
see Chapter 7) also reduced the range of options available to decision-makers.
With their options limited, decision-makers had to rely more heavily on lockdowns
to reduce the spread of the virus than might otherwise have been the case. For
example, as outlined earlier, Taiwan – which had well-developed public health
infrastructure prior to the arrival of COVID-19 – was initially able to eliminate viral
transmission without resorting to lockdowns.88 In our view, if Aotearoa New Zealand
had benefited from similar investment in key public health tools, capacity and
capability – and if the uptake of other measures such as mask wearing had been
more widespread – it might have been possible to eliminate COVID-19 transmission
early in the pandemic with less reliance on lockdowns.
3.3.3 Deciding when to start and end public health and social
measures such as lockdowns is challenging and requires
difficult trade-offs in the face of uncertainty
Deciding when to end lockdowns was extremely challenging. Decision-makers had
to balance the aim of protecting people from COVID-19 against the growing social
and economic impacts of requiring large parts of the population to remain under
tight restrictions. While vaccination reduced the risks associated with COVID-19
infection, the picture was complicated by the different rates of vaccine coverage
across different population groups, particularly the lower levels of vaccination for
Māori and Pacific peoples (covered in more detail in Chapter 6).
There was no established methodology or approach to inform decision-makers of
the optimal time to move away from using lockdowns as a primary public health
management tool – and indeed in a future pandemic, it would be challenging to
develop a formulaic approach as there are so many moving parts and the context
constantly changes. While the Government had indicated that reaching a target of
90 percent vaccination coverage across each region was the likely trigger for ending
lockdowns,89 subsequent advice placed much greater focus on the need to protect
vulnerable communities – including Māori and Pacific communities.
When it came to ending the use of lockdowns, decision-makers were receiving
advice on a range of factors, including: vaccination levels, evolving evidence on
vaccine protection, reducing social licence and the experiences of other countriesvi
as they relaxed public health and social measures.90 The advice was also informed
by modelling that took account of vaccination coverage, use of public health
measures, and the strength of testing, contact tracing and isolation systems.
Regarding the Delta outbreak and late-2021 Auckland lockdowns, international
evidence was emerging that showed vaccine-related protection from COVID-19
transmission started to wane some weeks following vaccination.91 Officials were
aware of this, and the Inquiry understands that waning immunity was included
in models from January 2022 to help inform decisions about management of the
Omicron outbreak.92 From evidence the Inquiry has seen, waning immunity was
not included in modelling prior to January 2022.
Time lags are also a factor that needs to be considered when it comes to deciding
whether or when to relax public health and social measures. Relaxing them
raises the risk that the virus will start taking off (again). But that will take time to
happen. Although it is a delicate balancing act, it is possible to relax public health
and social measures while still completing a vaccination rollout – and then catch
any resurgence as or if it arises. For example, in late 2021 – when Delta was the
dominant COVID-19 variant – the Australian states of Victoria and New South Wales
released lockdowns with lower population vaccination levels (around 70 percent)93
without any associated increase in case numbers.
The final decision on when to transition to the ‘traffic light’ system (and move out of
lockdowns) was a judgement call. It was based on a range of considerations, all of
which had a degree of uncertainty. In making this decision, Cabinet had to balance
many different outcomes and impacts – health, social and economic – as well as
equity considerations. While some senior ministers we spoke to thought that, in
hindsight, the last round of Auckland lockdowns perhaps went on too long, others
felt that the need to protect equity in health outcomes meant they could not have
made any other decision.
Ultimately, decisions to lift public health and social measures will always be
judgement calls. We consider it essential that the fullest range of information
is provided to decision-makers so that they can consider tradeoffs and make
decisions based on the best information available at the time. Transparency of
this information with the public, and justification of how the decisions were made,
is also essential.
vi Countries included Australia, Singapore, Iceland, France, Israel, Denmark, Norway, the United States,
the United Kingdom, Canada and Germany.
3.3.4 There was confusion and frustration around the ‘essential
services’ designation, which some felt was discriminatory and
unfairly harsh
A theme in public submissions was that the ‘essential’ designation was sometimes
confusing, and that ‘essential services’ should have been more clearly defined
and communicated. We heard similar frustrationsvii directly from stakeholders.
Submitters and stakeholders often reflected a view that central government did
not understand the operational realities of essential industries and their workers.
A particular concern was that the designation undermined competition and
disadvantaged smaller businesses – for example, by allowing major supermarkets
to open but not small-scale food providers such as butchers and produce stalls.
There was criticism that the Government was both indecisive and imprecise over
what were essential services.
“ Decisions made by the Government need to be substantiated by the evidence and

the science which under-pinned those decisions e.g. why was it considered safer for
supermarkets serving many people at a time to stay open than for small food supply
businesses, which could easily limit customers to one or two at a time? ”
Public submission to the Inquiry
At Alert Level 4, the scheme did not allow ‘safe’ work where there was little risk of
viral transmission (for example, people working outdoors on their own, such as
bulldozer drivers). There was little flexibility for employers to apply judgement at the
margins as to what was essential or safe work. We heard from representatives of
the forestry, road construction and non-food manufacturing sectors, for example,
that they believed parts of their sector could have operated safely, helping to reduce
the economic and social impacts of lockdown. It is likely that such constraints
imposed unnecessary economic costs, both immediately and over the long term,
for little health benefit.
It is also possible that some businesses misused the ‘essential service’ designation
to require staff to be onsite when this was not necessary or appropriate under Alert
Level 4 conditions. Unions (which were confirmed to be essential services when
representing their members at work) told us this was a common problem.
vii For example, from Infrastructure New Zealand: ‘There was a significant lack of clarity as to the definition of essential
services. It was obvious this had not been thought about prior to the lockdown and rules and definitions were being
developed under urgency with less than perfect information.’
3.3.5 Essential workers reported challenging experiences
Workers in essential services continued to go to work during lockdown, putting
themselves at risk of exposure to the COVID-19 virus,viii and sometimes taking
extraordinary measuresix to protect their families.94 They encompassed a wide
variety of professions, from specialist health providers to sign language interpreters,
port workers to checkout operators, prison staff to journalists. Many worked in
low-wage or blue-collar jobs in retail, transport or sanitation.95
More than a quarter of our public submissions came from essential workers. Some
were celebrated and praised for their efforts and sacrifices during the pandemic
(particularly healthcare workers, mirroring the daily applause rituals thanking
frontline health workers around the world). Leaders from a major supermarket
chain told us ‘the community respected our staff – we got brought home made
baking […] our staff were proud of their contribution’. One port worker commented
that ‘it was interesting to be seen as essential – it was a change in perspective
compared to most people’s view of waterside workers’.
Others though – or even the same workers at different times – faced abuse, anger,
fear, discrimination or distress from the public. Incidents of people intentionally
spitting at essential workers were reported.96 One public submitter described the
impact in these terms:
“ The first day of the first lockdown we had to call police three times, got spat in the face,
called an ambulance and a glazier. That was just day 1. ”
Essential workers were praised for their

efforts and sacrifices. But the Inquiry
also heard of essential workers being
stigmatised due to fear of infection.
viii Between 17 March and 12 June 2020, 167 health care and health support workers were infected with COVID-19 (11
percent of all cases). Ninety-six or 57.5 percent were likely to have been infected at work. Nine required hospitalisation
as a result, two in intensive care (see endnote 94 for source). It must be noted that the cumulative infection risk of
essential workers through 2020 and 2021 was considerably less than in other countries, and most essential workers
were younger and less vulnerable to serious illness from COVID-19. However, they were still at risk of becoming
infected themselves and also of ‘taking it home’ to vulnerable family and friends. In another pandemic, the risks to
essential workers may be greater.
ix Senior Police officers told us that they heard ‘stories of our people living in tents at home because families didn’t want
them to come into the home or stripping off to be hosed down to be entering the house, or relationships strained
because exposing greater family potentially to infection’. A union member in an essential workforce told us that: ‘I did
not see my family for months as I isolated myself so they would not get COVID – we put much effort into following the
rules and then saw people not following rules and increasing risks’. See also endnote 94.
Some described fearing for their safety, and a lack of protection and support to
manage their risk of COVID-19 infection and transmission. However, we also heard
from essential workers who were proud of their efforts and pleased to have been part
of the pandemic response:
“ Overall it felt like a privilege to still be working when so many others could not. It allowed
us to retain a sense of structure and normality, and to feel as though we were contributing
something useful. ”
Thanks in large parts to the efforts of these workers, during Alert Levels 3 and 4,
the ‘essentials’ of life – sufficient food supplies, functioning lifeline utilities, a sound
financial sector, supply chains, health and emergency services, access to courts and
public safety – were fundamentally maintained. While international supply chain
congestion caused problems, at a national level there were no shortages of food
and essential goods (although there was some panic buying and product shortages
early on – especially of toilet paper and flour). Lifeline utilities continued to function
and there were no concerns about a shortage of fuel.97 Courts remained open
through COVID-19, adapting as required to operate safely while also ensuring that
access to justice, fair trial and other rights were maintained as far as possible in
the circumstances.
“ Overall it felt like a privilege to still be

working when so many others could not.
It allowed us to retain a sense of structure
and normality, and to feel as though we were
contributing something useful. ”
Public submission from an essential worker
Spotlight:
Impact of lockdowns on business |
Ngā pānga o ngā noho rāhui ki ngā pakihi
Depending on the alert level in place, the daily challenges which

businesses faced in lockdown could include whether they were allowed
to operate at all and if so, under what conditions; whether their suppliers
could operate and deliver needed goods and services; whether they still
had customers; were staff members healthy and able to work; were they
as business operators healthy, and were their families okay.
When the first Alert Level 4 national lockdown started on 23 March 2020, 30 percent
of employed people could work outside home while 42 percent of people were able
to work from home. Another 35 percent had jobs or businesses but did not work
during that week.98
Figure 5: Proportion of employed people by work location and

COVID-19 alert level
Source: Stats NZ, 2020, Four in 10 employed New Zealanders work from home during lockdown,
https://www.stats.govt.nz/news/four-in-10-employed-new-zealanders-work-from-home-during-lockdown/
The different levels of lockdown also affected the level of industry activity in
ways that varied across sectors. For agriculture, moving from Level 4 down to
Level 3 saw normal activity increase from 85.2 percent to 93.4 percent, but for
the accommodation and food sector, normal activity grew from 13 percent to
21 percent.99
126
Figure 6: Percentage of industry able to operate at
Alert Level 3 and 4
Source: Brad Olsen/Infometrics, 2020, This pandemic is not over yet – not by a long shot,
https://www.infometrics.co.nz/article/2020-08-this-pandemic-is-not-over-yet-not-by-a-long-shot
127
Meanwhile, analysis undertaken for Auckland Council in 2020 showed the
impact of different alert levels on specific groups of workers. While overall
activity increased with the move from Level 4 to Level 3, 34 percent and 31
percent of small business employees and the self-employed respectively
remained unable to work in the Level 3 lockdowns, compared to only 27
percent of all employed people in Auckland.100
Figure 7: Impacts of lockdown levels on employment and

small business – Auckland
Source: Based on Auckland Council, 2020, Auckland economic update – Covid-19 economic update –
groups at level 3 in May 2020, https://www.knowledgeauckland.org.nz/media/1817/05may-2020-
covid-19-economic-update-4-groups-in-lockdown-employment-level-3-may-2020.pdf
128
3.3.6 Impacts on business were mixed
Prominent business leaders were amongst the first to urge, and then support, the
lockdowns, and we heard that many parts of the response – including lockdowns –
were initially seen as positive by businesses. However, over time some felt that the
consequences of lockdowns on businesses were not adequately mitigated (for more
on the economic response and impacts, see Chapter 6).
For some businesses the lockdowns, and the rules about who could operate, led
to increased debt, mental health issues, and in some cases the closure of their
business. We heard frequent reports of hardship for businesses not able to operate
during Alert Level 4 – such as butchers, hospitality and restaurants – with this
hardship extending to some employees and suppliers. CBD businesses were also
hit hard, as were some sectors such as tourism and some parts of hospitality. Many
saw the restrictions as unfair (for example, allowing supermarkets to operate but
not some of their competition). In general, large businesses were more able to
absorb the financial shock than small businesses.
As the different waves of COVID-19 impacted Aotearoa New Zealand with further
national and regional lockdowns, business confidence became increasingly shaky
due to ongoing uncertainty, and price inflation. Small businesses that had used their
reserves during previous lockdowns increasingly wondered if it would remain viable
for them to keep operating.101
The impact of lockdowns was particularly felt by small businesses, with many sectors
impacted, including tourism, retail, hospitality, personal services and trades. We were
told that, despite (welcomed) government support measures, many small businesses
faced challenges as to their future viability. Small business balance sheets suffered,
and many increased home mortgages to keep their businesses afloat.
“ The first lockdowns had many business owners facing complete uncertainty and fear
regarding completely losing their business, their customers, their ability to produce, their
staff, their personal homes (which most often financially guarantee such businesses),
their life’s work, and their future...”
Small business owners noted the mental health repercussions for both the business
owners and their employees of not being able to operate during lockdowns. For
small business owners from ethnic minorities this was exacerbated by factors
such as communication difficulties and a lack of awareness of supports. Other
representatives of small business noted the combination of the financial effect of
lockdowns and subsequent higher interest rates on business viability. There were
concerns about the lack of confidence from the impact of cumulative lockdowns.
While some sectors were well positioned to work digitally during lockdowns
(e.g. banking and finance, technology sectors in general), others simply could not
operate in this way (e.g. construction). For businesses that were able to continue
to function, there were still issues to deal with, including how to keep staff shifts
separate, integrating social distancing into operations, and mental health issues
for staff.
3.3.7 Some people faced particular difficulties in lockdown
While lockdowns contributed to increased anxiety and stress for many people,
there were some for whom this was particularly challenging. For those with existing
mental health issues, this increased stress was a significant issue. Women and
children at risk of violence due to the heightened stress had reduced opportunities
to seek support. Disabled people and older people relying on in-home care faced
significant challenges in getting appropriate personal protective equipment (PPE)
and maintaining adequate levels of care.102 See Chapter 6 for more examples.
3.3.8 Working from home posed its own challenges

People who were employed, but not designated essential workers, were required
to work from home if they could during Alert Level 3. This posed a different
set of challenges. While some workers and employers were well-equipped to
make this happen, others were not. We heard frustration from submitters that
the Government seemed to assume that most people could work from home
comfortably when this was not the case for all. There were issues with adequate
technology, internet access, cramped or inappropriate workspaces, distractions
and competing domestic demands.
The difficultly of working from home while
trying to supervise children and support
“ Trying to work an 8-hour day, while
them with remote learning has been well assisting kids with homeschool was
documented publicly and by researchers.103 nearly impossible. ”
Going into the pandemic, the vast majority Public submission from a parent
of unpaid work was performed by women,
particularly caring and community roles.
The pandemic placed many with significant
caring responsibilities (most often women) under considerable additional stress.104
During the Alert Level 4 lockdown in 2020, women were more likely to report a
significant increase in caring demands.105 These effects were felt by a range of
women, including young women who picked up additional care responsibilities in
their household during the pandemic.106
We heard from submitters that the additional stress placed on working parents
(and others juggling significant care demands) was not well acknowledged. This
applied to the government response (for example, no provision of childcare at Alert
Level 4), and the actions of employers (for example, not adjusting workloads to take
into account additional domestic responsibilities). The difficulties of juggling these
competing demands, as well as the social disconnection of working from home, took
a toll on many people’s mental health.x
“ Trying to work an 8-hour day, while assisting kids with homeschool was nearly
impossible. Essential workers working outside the home could access childcare
but parents working from home could not. Finding a way to better support all
types of households in the future would be advisable. ”
x Mental health impacts are discussed in more detail in Chapter 6.
However, there were also benefits from the increased flexibility of working from
home, the availability of new digital tools for work, connection and collaboration,
and the normalisation of hybrid work. Some submitters appreciated how the
pandemic normalised working from home, while others celebrated the innovation
this requirement had prompted.
“ I run my own Personal Training business, the pandemic challenged me to embrace

technology and grow my business online which I never would’ve done otherwise.
I’ve now incorporated that into my business today. ”
3.3.9 People in informal and precarious work were hit hard

Many people undertake (or commission) some informal work in normal, non-
pandemic circumstances: tradespeople do cash jobs, people pay family members to
babysit, a stay-at-home parent might clean one or two houses while their children
are at school. For some, this supplements their main income, while for others, it is
their income.
Such informal economic activity is sometimes referred to as the ‘grey economy’. Like
everything else, much of this kind of work stopped during Alert Level 4 lockdown in
the early phases of the pandemic, and people undertaking it were not eligible for the
wage subsidy or income relief payments. Because it is informal and undocumented,
and operates outside the tax net, it is very difficult to know how many people lost
income this way and what the impacts were.
We also heard from some stakeholders and submitters that people in precarious
employment were a particularly vulnerable group. This included people whose
employment was too inconsistent to qualify for income support, casual sub-
contractors, and workers whose employers didn’t apply for the wage subsidy
but instead closed or laid off staff (for further discussion on economic supports,
see Chapter 6).
Our engagements with officials involved in designing COVID-19 income protections
and employment support suggested little consideration was given to these issues.
3.3.10 There were significant educational impacts, but these

were likely in keeping with those experienced worldwide
While the disruption to education for students in Aotearoa New Zealand was less
than in most other OECD countries, it still had a significant and negative impact
– particularly for Māori and Pacific students, those from lower socio-economic
backgrounds, and likely for students in Auckland.
By the end of 2020, and up until mid-2021, the elimination strategy had served
Aotearoa New Zealand school students well in terms of minimising the interruption to
their education. Relative to other countries, students here missed fewer days of school
instruction in 2020, with the third lowest number of days closed in the OECD.107
Figure 8: Number of instruction days (excluding school holidays, public

holidays and weekends) where schools were fully closed in 2020 –
primary and upper secondary, OECD
Source: OECD, 2021, The state of school education: One year into the COVID pandemic, p 9, https://www.oecd.org/
content/dam/oecd/en/publications/reports/2021/04/the-state-of-school-education_b929a614/201dde84-en.pdf
The impact of school closures on student achievement and academic progress

was not immediately clear, but later, in the first PISA studyxi since the start of
the pandemic, covering the period from 2021-2022, Aotearoa New Zealand’s
maths scores were 15 points lower than in 2018 (as was the OECD average), while
New Zealand’s reading and science scores were largely unchanged from 2018
scores.108 In all three, New Zealand maintained its relative position compared to
other OECD nations, suggesting New Zealand students experienced loss of learning
from the pandemic, particularly in maths, but no more so than in other comparable
countries.109 Students from low socio-economic backgrounds had a larger drop in
maths than more socio-economically advantaged students.110
xi The Programme for International Student Assessment (PISA) is an OECD initiative that compares the standardised
reading, maths and science scores of approximately half a million 15-year-old students selected at random from 81
participating countries, including Aotearoa New Zealand. It is undertaken every two years.
Looking back at the cumulative impacts of the pandemic, a 2023 ERO report found
significant, concerning, and ongoing impacts on learners’ progress.111 These mostly
exacerbated existing trends and were in line with global experience. They included:
• A serious impact on attendance. Regular school attendance in Aotearoa
New Zealand dropped as low as 40 percent in Term 2 of 2022 and remains
low. By the end of 2022, regular attendance had only recovered to 51
percent, suggesting COVID-19 disruptions have led to longer-term impacts
on attendance.
• Challenging behaviour – 41 percent of principals reported behaviour was
worse than they would previously have expected for the time of year (they
were surveyed in March).
• Progress and achievement – nearly half of principals in 2023 said learning
was worse than would previously have been expected. Principals in schools
serving poorer communities are more than three times as likely as those
serving better-off communities to say that their learners are behind by two
or more curriculum levels.
• NCEA levels had fallen to below where they were at in 2019.
• Learners in poorer communities, Māori and Pacific students were
more impacted.xii
In the tertiary sector, qualification, course completion rates and first year retention
rates remained fairly stable through the pandemic period, compared to 2019.112
However, there is evidence that some groups have been more impacted than
others. There have also been well-documented impacts on the wellbeing of
educators and staff at all levels.113
Students in Auckland experienced more significant disruptions to their education
than those in the rest of the country. For most of the country, school closures were
limited to five weeks in March and April 2020, two weeks in August 2020, and three
weeks in August 2021. But Auckland schools were closed for an additional 15 weeks
in the second half of 2021. There is no strong evidence about the specific regional
educational impacts of Auckland’s multiple lockdowns. But there was already
emerging evidence in early 2021 that student engagement there was more affected,
with 26 percent of Auckland teachers reporting that their learners were engaged,
compared to 51 percent outside of the region.114
In a report released in June 2021, the Ministry of Education found that, nationally,
learning progress in reading and maths for many student groups was ‘essentially
unchanged or even positive’ compared with 2019. When this data was updated in
mid-2022, the Ministry said they showed ‘that the effects of Covid-19 on learning
progress were not severe’.115
xii ERO identifies Pacific students as a group whose learning has been particularly impacted. A follow-up report on the
pandemic’s specific impacts for Pacific learners noted their achievement declined in 2021 after an increase in 2020.
The fall was more pronounced for Pacific learners than the general population and Pacific learners continue to sit
below the general population for achievement at NCEA levels 1, 2 and 3 and for university entrance. See: Learning in a
Covid-19 World: The impact of Covid-19 on Pacific Learners.
A considerable number of submissions raised concerns about the disruptions
lockdowns caused to children and young people’s education, and specifically the
impact of this on their mental health. Submitters thought the social isolation caused
by school closures had contributed to multiple impacts on young people, including
increased anxiety, impaired communication and social skills, and a trend towards
disengagement from education. These observations from submitters are supported
by other evidence showing a disproportionate impact of the pandemic on child and
youth mental health, including surveys of children and young people themselves,
academic research, and data about demand
and call volumes for child and youth mental
health services and support.116 Not all of this
Some residents felt South
can be directly attributed to the closure of Auckland was unfairly
educational facilities, but this was clearly a stereotyped and that
contributing factor, especially in relation to COVID-19 outbreaks occurring
high rates of loneliness and social isolation elsewhere did not receive the
among young people. See Chapter 6 for more same negative coverage.
on the pandemic’s impact on mental health
and wellbeing.
3.3.11 Auckland – especially South Auckland – did it tough

The cumulative impacts of repeated lockdowns on Aotearoa New Zealand’s largest
city were multifaceted, encompassing economic, mental health and wellbeing,
educational outcomes and social cohesion.
Maintaining the trust of South Auckland communities was important. These
communities – with their high proportion of essential workers, many of whom
worked in or around Auckland Airport – were disproportionately impacted by
repeat outbreaks and lockdown requirements. There were high levels of fear and
anxiety within these communities, and we heard about older people reluctant to
leave home and families keeping children away from school even when restrictions
were lifted. Public health messaging about ‘bubbles’ and limiting purchases of
grocery items impacted large households with multigenerational families who
shared resources or provided care for elderly family members in other households.
There was also evidence of children with disabilities left without carer support.117
None of these challenges were unique to South Auckland, but they appear to have
been particularly concentrated there. South Auckland community providers told
us that the COVID-19 response did not always anticipate or address unintended
consequences such as these.
An unfortunate public narrative also emerged whereby South Auckland was
regarded as more likely than other areas to host an ‘out of control’ outbreak
requiring aggressive alert level changes. Community leaders felt this narrative
was based not only on population density, but on negative preconceptions about
the population in that part of Auckland. Some residents felt South Auckland was
unfairly stereotyped and that COVID-19 outbreaks occurring elsewhere did not
receive the same media coverage.118
1. Lockdowns – in combination with tight border

restrictions – proved to be an effective tool for
achieving and maintaining Aotearoa New Zealand’s
elimination strategy in 2020 and early 2021.
• Aotearoa New Zealand’s use of lockdowns early in 2020, while
stricter than many countries, worked. Aotearoa New Zealand
was able to spend large amounts of time in 2020 free from the
restrictions experienced by many other parts of the world.
• Lockdowns at least initially were supported by high levels of trust
and social cohesion, strong support from communities, social and
economic supports, and clear communication.
2. Aotearoa New Zealand would have been less reliant

on using lockdowns to eliminate COVID-19 infection
with greater preparation of, and investment in, core
public health functions.
• Decision-makers’ options were initially limited by the capacity
and effectiveness of the tools available (such as contact tracing)
and how effectively measures such as mask wearing were taken
up by the population.
• We note that some Pacific countries (such as Samoa, Tonga and
Tokelau) avoided the need for lockdown measures altogether by
closing their borders before any COVID-19 cases had occurred,
suggesting Aotearoa New Zealand could benefit from earlier border
restrictions (in other words, adopting an exclusion strategy) in a future
pandemic if the pathogen is particularly infectious and virulent.
3. Deciding when to introduce, and when to stand
down, measures such as lockdowns is extremely
challenging and requires difficult trade-offs in the
face of uncertainty.
• Decisions about when to start and end measures such
as lockdowns involve weighing up a range of competing
considerations – social and economic, as well as public health –
and considering impacts across different population groups.
• During the COVID-19 response, decisions around use of
lockdowns were informed by a range of advice and evidence,
including modelling that took account of vaccination coverage,
use of public health measures, and the strength of testing,
contact tracing, and isolation systems. The Inquiry has not seen
evidence that waning protection from vaccination was included in
modelling to inform decisions around when to end lockdowns in
late 2021, although it was used in modelling from early 2022.
• Many members of the public – and some senior ministers –
felt that the last Auckland lockdown went on for too long. Our
assessment is that the Government’s decision-making on when
to end the final Auckland lockdown reflected its judgement that
allowing more time for Māori and Pacific communities to reach
higher levels of vaccination was justified by the benefits they
would gain, in the form of greater protection against the severe
impacts of COVID-19.
• However, we are of the view that other factors such as waning
protection and assessments of likely resurgence could have been
considered alongside vaccine coverage. For example, we note
that lockdowns in the Australian states of Victoria and New South
Wales ended earlier and at lower vaccination coverage levels than
that at which the Auckland lockdown was relaxed, without any
associated increase in case numbers. In a future pandemic we
think these considerations should also be included in advice to
decision makers.
4. Some elements of the lockdowns were particularly

difficult to implement, especially at short notice.
• Both regional boundaries and the essential worker framework,
while valuable, were hard to implement rapidly and with no prior
preparation across the government system. These timing and
preparedness issues caused many challenges for businesses,
communities and government.
5. Lockdowns had disproportionate impacts on some groups.
• While students’ education was less disrupted in Aotearoa New Zealand
than in most other OECD countries, lockdowns still had a significant and
negative impact – particularly for Māori and Pacific students, those from
lower socio-economic backgrounds, and students in Auckland.
• The impacts of repeated lockdowns on Auckland were cumulative and
multifaceted, encompassing economic, physical and mental health and
wellbeing, educational outcomes and social cohesion.
6. Efforts by iwi, Māori and communities of all kinds

undoubtedly alleviated some potential negative impacts
of lockdowns on individuals and groups.
• Iwi, Māori and many others – neighbourhoods, cultural groups, online
groups, non-governmental and community organisations, religious
institutions, families, whānau and aiga – stepped up during the first Alert
Level 3 and 4 lockdowns to provide essential local leadership, support
each other and address local needs. Their pre-existing relationships within
their local communities (and, in some cases, with Government) were
invaluable in enabling this to happen.
Endnotes |
3.5 Tuhinga āpiti
1. McGuinness Institute, COVID-19 Nation Dates (1st ed.) 13. Cabinet Paper and Minute, Review of COVID-19 Alert
(Wellington, 2023), p 35, https://nationdatesnz.org/ Level 4, CAB-20-SUB-0176 and CAB-20-MIN-0176, 20
covid-19-nation-dates-1stedition April 2020, https://www.dpmc.govt.nz/sites/default/
2. Brook Barrington, John Ombler, Ashley Bloomfield, and files/2023-01/Paper-and-Minute-Review-of-COVID-19-
Juliet Gerrard, COVID-19 – Current state, trajectories Alert-Level-4.PDF
and interventions, 20 March 2020, p 2, https://www. 14. Rt Hon Jacinda Ardern, ‘Alert Level 3 restrictions
dpmc.govt.nz/sites/default/files/2023-01/COVID-19- announced’, media release, 16 April 2020,
Current-state-trajectories-and-interventions.pdf https://www.beehive.govt.nz/release/alert-level-3-
Cabinet Paper and Minute, COVID-19: Moving to Alert restrictions-announced
Level 3 and Level 4, CAB-20-SUB-0133 and CAB-20- 15. Sophie M. Rose, Michael Paterra, Christopher Isaac,
MIN-0133, 23 March 2020, p 3, https://www.dpmc.govt. Jessica Bell, Amanda Stucke, Arnold Hagens, Sarah
nz/sites/default/files/2023-01/COVID-19-Moving-to- Tyrrell, Michael Guterbock, and Jennifer B. Nuzzo,
Alert-Level-3-and-Level-4.pdf ‘Analysing COVID-19 outcomes in the context of the
3. Cabinet Paper and Minute, COVID-19: Moving to Alert 2019 Global Health Security (GHS) Index’, BMJ Global
Level 3 and Level 4, CAB-20-SUB-0133 and CAB-20- Health 6, no. 12 (10 December 2021), e007581,
MIN-0133, 23 March 2020, pp 3, 4, https://www.dpmc. https://doi.org/10.1136/bmjgh-2021-007581, https://
govt.nz/sites/default/files/2023-01/COVID-19-Moving- gh.bmj.com/content/6/12/e007581
to-Alert-Level-3-and-Level-4.pdf 16. Sophie M. Rose, Michael Paterra, Christopher Isaac,
4. For the Prime Minister’s use of the terms ‘lockdown’ Jessica Bell, Amanda Stucke, Arnold Hagens, Sarah
and ‘chain of transmission’, see Rt Hon Jacinda Ardern, Tyrrell, Michael Guterbock, and Jennifer B. Nuzzo,
‘Prime Minister’s statement on State of National ‘Analysing COVID-19 outcomes in the context of the
Emergency and Epidemic Notice’, media release, 25 2019 Global Health Security (GHS) Index’, BMJ Global
March 2020, https://www.beehive.govt.nz/speech/ Health 6, no. 12 (10 December 2021), e007581,
prime-minister%E2%80%99s-statement-state-national- p 9 https://doi.org/10.1136/bmjgh-2021-007581,
emergency-and-epidemic-notice https://gh.bmj.com/content/6/12/e007581
5. Rt Hon Jacinda Ardern, ‘PM Address – Covid-19 17. Ministry of Social Development, Te Korowai Whetū
Update’, media release, 21 March 2020, https://www. Social Cohesion baseline report summary: Social Cohesion
beehive.govt.nz/speech/pm-address-covid-19-update in Aotearoa New Zealand 2022, p 3, https://www.msd.
6. McGuinness Institute, COVID-19 Nation Dates (1st ed.) govt.nz/documents/about-msd-and-our-work/work-
(Wellington, 2023), p 38, https://nationdatesnz.org/ programmes/community/social-cohesion/baseline-
covid-19-nation-dates-1stedition report-summary-a4-full-v1.pdf
Craig Fookes, Social Cohesion in New Zealand:
7. Rt Hon Jacinda Ardern, ‘New Zealand moves to
Background paper to Te Tai Waiora: Wellbeing in
COVID-19 Alert Level 3, then Level 4 in 48 hours’,
Aotearoa New Zealand 2022 (AP 22/01), The Treasury
media release, 23 March 2020, https://www.beehive.
(Wellington, 24 November 2022), p 20, https://www.
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treasury.govt.nz/publications/ap/ap-22-01
level-3-then-level-4-48-hours
18. Collin Tukuitonga, ‘COVID-19 in Pacific Islands
8. Cabinet Paper and Minute, COVID-19: Moving to Alert
People of Aotearoa/New Zealand: Communities
Level 3 and Level 4, CAB-20-SUB-0133 and CAB-20-
Taking Control’, in COVID in the Islands: A comparative
MIN-0133, 23 March 2020, https://www.dpmc.govt.nz/
perspective on the Caribbean and the Pacific, ed. Yonique
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Campbell and John Connell (Singapore: Springer
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9. Rt Hon Jacinda Ardern, ‘New Zealand moves to David Skegg, ‘The Covid-19 Pandemic: lessons for our
COVID-19 Alert Level 3, then Level 4 in 48 hours’, future’, Focus on Covid-19: Governance in a pandemic
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10. McGuinness Institute, COVID-19 Nation Dates (1st ed.) 19. Jared Savage, ‘Covid 19 coronavirus: Police
(Wellington, 2023), p 39, https://nationdatesnz.org/ Commissioner Andrew Coster promises frontline
covid-19-nation-dates-1stedition staff will be careful in exercising ‘remarkable’ powers
11. Jane Patterson, ‘PM: NZ has “made a good start” to stop spread of virus’, The New Zealand Herald,
against Covid-19’, Radio New Zealand, 5 April 2020, 14 May 2020, https://www.nzherald.co.nz/nz/
https://www.rnz.co.nz/news/covid-19/413508/pm-nz- covid-19-coronavirus-police-commissioner-andrew-
has-made-a-good-start-against-covid-19 coster-promises-frontline-staff-will-be-careful-in-
12. Cabinet Paper and Minute, COVID -19: Preparing exercising-remarkable-powers-to-stop-spread-of-virus/
to Review New Zealand’s Level 4 Status, CAB-20- QWVLPGWCBBYFG6FJY5JRLFTRKM/
SUB-0161 and CAB-20-MIN-0161, 14 April 2020, https://
www.dpmc.govt.nz/sites/default/files/2023-01/COVID-
19-Preparing-to-Review-New-Zealands-Alert-Level-4-
Status.pdf
20. Cabinet Paper and Minute, Approach to Enforcement 28. Te Aniwa Hurihanganui, ‘MPs’ questioning of legal iwi
under Level 2, SWC-20-MIN-0046, 13 May 2020, https:// checkpoints ‘really is racism’’, RNZ, 1 May 2020, https://
covid19.govt.nz/assets/Proactive-Releases/proactive- www.rnz.co.nz/news/te-manu-korihi/415617/mps-
release-2020-october/AL26-PAPER-AND-MINUTE- questioning-of-legal-iwi-checkpoints-really-is-racism
APPROACH-TO-ENFORCEMENT-UNDER-LEVEL-2-13- 29. Jane Kelsey, ‘Covid 19 coronavirus: Jane Kelsey:
MAY-2020.pdf Govt’s urgent legislation tone deaf to Māori’, The
Ministry of Health, WorkSafe, New Zealand Police, and New Zealand Herald, 15 May 2020, https://www.
Ministry of Business, Innovation and Employment, nzherald.co.nz/nz/covid-19-coronavirus-jane-
Briefing for Joint Ministers: All-of-Government kelsey-govts-urgent-legislation-tone-deaf-to-maori/
COVID-19 Compliance Response, BR/20/39, 1 May T3RSVVILQIPT5FVEOJ7MGCUH7I/
2020, https://covid19.govt.nz/assets/Proactive- Irihapeti Edwards and Stephanie Muller-Pallares,
Releases/proactive-release-2020-june/BRIEFING-All-of- ‘Partnership and Privilege’, E-Tangata, 7 June 2020,
Government-COVID-19-Compliance-Response.pdf https://e-tangata.co.nz/comment-and-analysis/
21. New Zealand Police, Annual Report 2019/20 (2020), partnership-and-privilege/
p 46, https://www.police.govt.nz/sites/default/files/ 30. Schedule 1, Employment Relations Act 2000, version
publications/annual-report-2019-2020.pdf 30 June 2024, https://www.legislation.govt.nz/act/
22. Ministry for Pacific Peoples, Impact of COVID-19 public/2000/0024/latest/DLM58317.html
Lockdown on Pacific Churches (2021), https:// Civil Defence Emergency Management Act 2002,
www.mpp.govt.nz/assets/Reports/MPP_ version 1 July 2024, https://www.legislation.govt.nz/
PacificPeoplesCOVID2020web.pdf act/public/2002/0033/99.0/DLM149789.htmls85
Te Hiringa Mahara New Zealand Mental Health International Labour Organization, ‘Chapter 5 –
and Wellbeing Commission, Covid-19 insights series: Substantive provisions of labour legislation: The
Pacific connectedness and wellbeing in the pandemic right to strike’, updated 10 December 2001, https://
(Wellington, June 2023), https://www.mhwc.govt.nz/ webapps.ilo.org/static/english/dialogue/ifpdial/llg/
news-and-resources/covid-19-insights-series-pacific- noframes/ch5.htm#6
connectedness-and-wellbeing-in-the-pandemic/ 31. Cabinet Paper and Minute, COVID-19: Moving to Alert
Pasifika Medical Association Group, ‘Church partners Level 3 and Level 4, CAB-20-SUB-0133, 2020, p 14,
vital to accessing Pacific families during Covid-19 https://www.dpmc.govt.nz/sites/default/files/2023-01/
resurgence’, updated 2 September 2020, https:// COVID-19-Moving-to-Alert-Level-3-and-Level-4.pdf
pmagroup.org.nz/updates/church-partners-vital-to-
32. Section 70(1)(m) Health Act Order, 25 March 2020,
accessing-pacific-families-during-covid-19-resurgence
https://www.health.govt.nz/system/files/2024-05/b_-_
23. Annie Te One and Carrie Clifford, ‘Tino Rangatiratanga covid-19-section-701m-notice-to-close-premises-
and Well-being: Māori Self Determination in the Face and-forbidding-congregation-in-outdoor-places-of-
of Covid-19’, Frontiers in Sociology 6 (3 February 2021), amusement-or-recreation-25-march-2020_1_0.pdf
613340, https://doi.org/10.3389/fsoc.2021.613340,
33. Ministry of Business, Innovation and Employment, The
https://www.frontiersin.org/articles/10.3389/
workforce under Alert Levels 4 and 3: September 2021
fsoc.2021.613340/full
factsheet (10 September 2021), https://www.mbie.govt.
Ella Henry, ‘Māori and social innovations in response
nz/dmsdocument/16922-the-workforce-under-alert-
to COVID-19’, updated 9 March 2022, https://
levels-4-and-3-september-2021-factsheet
socialinnovation.blog.jbs.cam.ac.uk/2022/03/09/maori-
and-social-innovations-in-response-to-covid-19/ 34. Cabinet Paper and Minute, COVID-19: Moving to Alert
Level 3 and Level 4, CAB-20-SUB-0133 and CAB-20-
24. Annie Te One and Carrie Clifford, ‘Tino Rangatiratanga
MIN-0133, 23 March 2020, https://www.dpmc.govt.nz/
and Well-being: Māori Self Determination in the Face
sites/default/files/2023-01/COVID-19-Moving-to-Alert-
of Covid-19’, Frontiers in Sociology 6 (3 February 2021),
Level-3-and-Level-4.pdf
613340, https://doi.org/10.3389/fsoc.2021.613340,
COVID-19 Public Health Response (Alert Levels 3
https://www.frontiersin.org/articles/10.3389/
and 2) Order 2020, revoked 22 August 2020,
fsoc.2021.613340/full
https://legislation.govt.nz/regulation/
Office of the Auditor-General, ‘Partnership under
public/2020/0187/12.0/LMS389738.html
pressure (with a splash of T-sauce)’, https://oag.
parliament.nz/blog/2020/partnership-under-pressure 35. Ministry of Business, Innovation and Employment,
The workforce under Alert Levels 4 and 3: September 2021
25. Tina Ngata, ‘COVID-19 and the Māori duty to
factsheet (10 September 2021), https://www.mbie.govt.
protect’, Overland, 7 May 2020, https://overland.org.
nz/dmsdocument/16922-the-workforce-under-alert-
au/2020/05/covid-19-and-the-maori-duty-to-protect/
levels-4-and-3-september-2021-factsheet
26. New Zealand Police, ‘Iwi and Police stronger together’,
updated 22 September 2021, https://www.police.govt.
and Response, COVID-19: Make it the Last Pandemic
nz/news/release/iwi-and-police-stronger-together
(12 May 2021), p 39, https://recommendations.
27. Meriana Johnsen, ‘Covid-19: Remote communities in theindependentpanel.org/main-report/assets/images/
Far North want checkpoints to remain in level 2’, RNZ, COVID-19-Make-it-the-Last-Pandemic_final.pdf
13 May 2020, https://www.rnz.co.nz/news/te-manu-
korihi/416492/covid-19-remote-communities-in-far-
north-want-checkpoints-to-remain-in-level-2
37. New Zealand Government, ‘Digital Inclusion Action Ministry of Education, ‘He Pitopito Kōrero: COVID-19
Plan 2020–2021’, updated 3 December 2020, https:// Update – 1 May 2020’, updated 1 May 2020, https://
www.digital.govt.nz/dmsdocument/174~digital- bulletins.education.govt.nz/bulletin/he-pitopito-
inclusion-action-plan-20202021/html korero/issue/covid-19-update-1-may-2020/date/2020-
38. Ministry of Education, Education Report: COVID-19 05-01#planning-for-alert-level-2
Response – Distance learning package, R-1234656, 46. Ministry of Education, ‘Special School Bulletin’,
29 July 2020, https://assets.education.govt.nz/ updated 11 May 2020, https://mailchi.mp/education/
public/Uploads/R-1234656-Education-Report- special-bulletin-11-may-with-corrected-link-to-pm-
COVID-19-Response-Distance-learning-Redacted. announcement
pdf#:~:text=On%2023%20March%202020,%20 47. Cabinet Paper and Minute, COVID-19 Support for
Cabinet%20authorised%20the Essential Social Sector Services and Communities, 26
Cabinet Minute, Additional Item: Providing Students March 2020, https://www.msd.govt.nz/documents/
with Remote Access to Online Digital Resources, CAB- about-msd-and-our-work/covid-19/unite-against-covid/
20-MIN-0136, 23 March 2020, https://assets.education. minute-and-paper-covid-19-support-for-essential-
govt.nz/public/Uploads/R-234-Online-Digital- social-sector-services-and-communities.pdf
Resources-CAB-20-MIN-0136-Minute.pdf
48. New Zealand Government, Summary of Initiatives
Cabinet Paper and Minute, COVID-19: Emergency
in the COVID-19 Response and Recovery Fund (CRRF)
funding to enable distance learning for early learning
Foundational Package, The Treasury (29 May
and schooling, 7 April 2020, https://assets.education.
2020), https://www.treasury.govt.nz/publications/
govt.nz/public/Documents/our-work/information-
summary-intiatives/summary-initiatives-crrf-
releases/Issue-Specific-release/Unite-Against-COVID/
budget2020#introduction
Cabinet-Paper/8.Emergency-Funding-to-Enable-
Cabinet Paper and Minute, COVID-19 Support for
Distance-Learning-for-Early-Learning-and-Schooling.pdf
Essential Social Sector Services and Communities,
39. The Treasury, COVID-19 Response and Recovery Fund 26 March 2020, pp 13-17, https://www.msd.govt.nz/
(CRRF) funding decisions, https://www.treasury.govt. documents/about-msd-and-our-work/covid-19/unite-
nz/publications/data/covid-19-response-and-recovery- against-covid/minute-and-paper-covid-19-support-for-
fund-crrf-funding-decisions essential-social-sector-services-and-communities.pdf
40. Tertiary Education Commission, Annual Report for the 49. Cabinet Paper, Immediate Housing Response to
year ended 30 June 2021 (Wellington, November 2021), COVID 19, https://www.hud.govt.nz/assets/Uploads/
p 124, https://www.tec.govt.nz/assets/Publications- Documents/Cabinet-Paper-Immediate-Housing-
and-others/TEC_Annual-Report_2021.pdf Response-to-COVID-19.pdf#:~:text=In%20order%20
41. Ministry of Education, ‘Urgent Response Fund 2020/21’, to%20reduce%20these,overcrowded%20situations%20
updated 9 December 2021, https://www.education. with%20shared%20facilities
govt.nz/our-work/information-releases/issue-specific- 50. Part 5 and Schedule, COVID-19 Response (Urgent
releases/urgent-response-fund/#:~:text=The%20$50%20 Management Measures) Legislation Act 2020, https://
million%20Urgent%20Response%20Fund%20was www.legislation.govt.nz/act/public/2020/0009/latest/
42. School News, ‘$199 million education wellbeing LMS326982.html
package now complete’, updated 4 August 2020, 51. Cabinet Paper and Minute, Review of COVID -19 Alert
https://www.schoolnews.co.nz/2020/08/199- Level 3, CAB -20 -SUB -0220 and CAB -20 -MIN -0220,
million-education-wellbeing-package-now- 11 May 2020, https://www.dpmc.govt.nz/sites/default/
complete/#:~:text=%2450%20million%2C%20in%20 files/2023-01/Paper-and-Minute-Review-of-COVID-19-
2020%2F21%2C%20for%20an%20Urgent%20Response- Alert-Level-3.pdf
,wellbeing%20needs%20directly%20related%20to%20
52. Cabinet Paper and Minute, Review of COVID-19 Alert
the%20COVID-19%20lockdown
Level 2, CAB-20-SUB-0270 and CAB-20-MIN-0270, 8
43. Education Review Office, Learning in a Covid-19 World: June 2020, https://www.dpmc.govt.nz/sites/default/
The Impact of Covid-19 on Early Childhood Education files/2023-01/AL2-Minute-and-Paper-CAB-20-MIN-0270-
(19 January 2021), p 14, https://evidence.ero.govt.nz/ Review-of-COVID-19-Alert-Level-2-8-June-2020.PDF
documents/the-impact-of-covid-19-on-early-childhood-
53. Cabinet Minute, COVID-19 resurgence: first review of
education-january-2021
alert levels, CAB-20-MIN-0396, 14 August 2020, para
44. Education Review Office, Learning in a Covid-19 World: [1] of Minute of Decision, https://www.dpmc.govt.nz/
The Impact of Covid-19 on Schools (19 January 2021), sites/default/files/2023-01/FR01-14082020-COVID-19-
p 20, https://evidence.ero.govt.nz/documents/the- Resurgence-First-Review-of-Alert-Levels.pdf
impact-of-covid-19-on-schools-january-2021 Cabinet Paper and Minute, Managing regional
45. Ministry of Education, Bulletin – Tertiary Provider boundary issues during Alert Levels, CAB-20-MIN-0401,
Bulletin: COVID-19, 29 April 2020, https://www. 17 August 2020, https://www.dpmc.govt.nz/sites/
education.govt.nz/assets/Documents/Further- default/files/2023-01/Managing-regional-boundary-
education/COVID-19-Bulletin/COVID-19-Tertiary- issues-during-Alert-Levels4472241.1.pdf
Provider-Bulletin-29-4-20.pdf
54. It appears there are no official sources still online citing Cabinet Paper and Minute, COVID-19 Response: 20
the rules for Alert Level 2.5. The McGuinness Institute September 2021 Review of Alert Settings, CAB-21-
relies on media coverage, as have we, for example: MIN-0379, 20 September 2021, https://www.dpmc.
Lana Andelane, ‘COVID-19: Auckland to move to ‘level govt.nz/sites/default/files/2023-01/ALC8-20092021-
2.5’ on Sunday – what you need to know’, Newshub, 30 COVID-19-Response-20-September-Review-of-Alert-
August 2020, https://www.newshub.co.nz/home/new- Level-Settings.pdf
zealand/2020/08/covid-19-auckland-to-move-to-level- 63. Cabinet Paper and Minute, COVID-19 Response:
2-5-on-sunday-what-you-need-to-know.html 4 October 2021 Review of Alert Settings, CAB-21-
55. Quoted in: MIN-0407, 4 October 2021, p 2, https://www.dpmc.
Lana Andelane, ‘COVID-19: Auckland to move to ‘level govt.nz/sites/default/files/2023-01/ALC9-04102021-
2.5’ on Sunday – what you need to know’, Newshub, 30 COVID-19-Response-4-October-Review-of-Alert-Level-
August 2020, https://www.newshub.co.nz/home/new- Settings.pdf
zealand/2020/08/covid-19-auckland-to-move-to-level- 64. Cabinet Paper and Minute, COVID-19: A Strategy for
2-5-on-sunday-what-you-need-to-know.html a Highly Vaccinated New Zealand, CAB-21-MIN-0393,
56. Cabinet Paper and Minute, COVID-19 Resurgence: 27 September 2021, https://www.dpmc.govt.nz/sites/
Sixth Review of Alert Levels, CAB-20-MIN-0462, 5 default/files/2023-01/COVID-19-A-Strategy-for-a-
October 2020, https://www.dpmc.govt.nz/sites/default/ Highly-Vaccinated-New-Zealand.pdfV2.pdf
files/2023-01/FR06-05102020-COVID-19-Resurgence- 65. Cabinet Paper and Minute, COVID-19: A Strategy for
Sixth-Review-of-Alert-Levels.pdf a Highly Vaccinated New Zealand, CAB-21-MIN-0393,
57. Cabinet Paper and Minute, COVID-19: Auckland 27 September 2021, p 2, https://www.dpmc.govt.nz/
Community Cases, CAB-21-MIN-0020, 14 February sites/default/files/2023-01/COVID-19-A-Strategy-for-a-
2021, https://www.dpmc.govt.nz/sites/default/ Highly-Vaccinated-New-Zealand.pdfV2.pdf
files/2023-01/COVID-19-auckland-community-cases- 66. Cabinet Paper and Minute, COVID-19 Response:
14-february-2021.pdf 4 October 2021 Review of Alert Settings, CAB-21-
Cabinet Paper and Minute, COVID-19 Resurgence: MIN-0407, 4 October 2021, https://www.dpmc.govt.nz/
Second Review of Alert Level Settings in Response sites/default/files/2023-01/ALC9-04102021-COVID-19-
to Further Auckland Community Cases, CAB-21- Response-4-October-Review-of-Alert-Level-Settings.pdf
MIN-0064, 11 March 2021, https://www.dpmc.govt.
nz/sites/default/files/2023-01/COVID-19-Resurgence-
second-review-alert-level-settings-further-auckland-
MIN-0415, 11 October 2021, https://www.dpmc.
community-cases-11-March-2021.pdf
govt.nz/sites/default/files/2023-01/ALC10-11102021-
58. RNZ, ‘Wellington Covid-19 visitor: Locations of interest COVID-19-Response-11-October-Review-of-Alert-Level-
include Te Papa, central city bar and pharmacy’, 23 June Settings.pdf
2021, https://www.rnz.co.nz/news/national/445348/
68. Cabinet Paper and Minute, COVID-19: A Strategy for a
wellington-covid-19-visitor-locations-of-interest-include-
Highly Vaccinated New Zealand, CAB-21-MIN-0393, 27
te-papa-central-city-bar-and-pharmacy
September 2021, para 14, https://www.dpmc.govt.nz/
59. Adrian Field, Anne Bateman, Nan Wehipeihana, Kahiwa sites/default/files/2023-01/COVID-19-A-Strategy-for-a-
Sebire, Kellie Spee, Emily Garden, Michelle Moss, and Highly-Vaccinated-New-Zealand.pdfV2.pdf
Adela Wypych, Delta Response Rapid Review, Ministry of
69. Rt Hon Jacinda Ardern, ‘New COVID-19 Protection
Health (Wellington, 14 June 2022), https://www.health.
Framework delivers greater freedoms for vaccinated
govt.nz/publications/delta-response-rapid-review
New Zealanders’, media release, 22 October 2021,
60. Cabinet Paper and Minute, Covid-19 Response: 6 https://www.beehive.govt.nz/release/new-covid-19-
September Review of Alert Level Settings, CAB-21- protection-framework-delivers-greater-freedoms-
MIN-0360 (Revised), 6 September 2021, https:// vaccinated-new-zealanders
www.dpmc.govt.nz/sites/default/files/2023-01/ALC6-
70. Cabinet Paper, COVID-19 Response: 1 November
06092021-COVID-19-Response-6-September-Review-
2021 Review of Alert Level Settings, 1 November 2021,
of-Alert-Level-Settings.pdf
61. Cabinet Paper and Minute, Covid-19 Response: 6 AL8-01112021-COVID-19-Response-1-November-2021-
September Review of Alert Level Settings, CAB-21- Review-of-Alert-Level-Settings.pdf
MIN-0360 (Revised), 6 September 2021, https://
71. Cabinet Paper and Minute, COVID-19: Transition to
the COVID-19 Protection Framework and the Auckland
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CHAPTER 4:
4 Keeping the country

closed: border
restrictions and
quarantine |
Ka noho kati te
whenua: ngā rāhui
pae whenua me te
noho taratahi
Introduction |
4.1 Kupu whakataki
On 19 March 2020 the Government announced that the country’s borders

would close to all travellers except returning New Zealand citizens and
residents from 11.59 pm that night. This was an unprecedented move.
Technically, Aotearoa New Zealand’s borders did not in fact ‘close’, neither
then nor later. No legal mechanism was ever in place preventing people or
goods from arriving: planes continued to land and ships to dock (apart from
cruise ships) throughout the pandemic. But a changing combination of
immigration settings and public health regulations – particularly the
requirement to quarantine in a designated facility – meant that, for all
practical purposes, most non-New Zealanders could not enter the country
for two years.
New Zealand citizens and residents, whose legal right to enter was never
extinguished, had varying responses to these restrictions. While some were
supportive, others felt as if the border had closed to them too.
“ As a New Zealander living in Australia, I felt very proud of New Zealand’s response to the
pandemic & grateful to the NZ Government of the time for keeping our whānau safe.
Although borders were closed and I couldn’t return from Australia, the clear communication
& leadership from [Prime Minister] Jacinda & [Director-General of Health] Ashley meant I fully
understood and supported the reasons why. ”
“ Restricting people from returning home is incredibly damaging. ”
This chapter examines and evaluates the border restrictions and

quarantine requirements that collectively kept the country’s borders
closed for the duration of the pandemic.i
• In section 4.2.1, we describe the mechanisms used to close the air
and maritime borders, how the borders were managed over the
next two years, and the gradual steps towards reopening them. We
also look at the regime for granting border exceptions to particular
people in certain circumstances, and how the visa system changed
over the period in which the borders were closed. The broader
economic impacts of the border closure – on the labour market,
the supply chain, tourism, the maritime industry and more – are
discussed in Chapter 6.
• Section 4.2.2 traces the development of the MIQ (managed isolation
and quarantine) system from its rapid establishment in
April 2020.
• Our assessment of the utility and impact of the border and
quarantine measures adopted during the pandemic response is
set out in section 4.3. While we consider these measures were
effective in stopping the virus from entering the country, and limiting
its spread when it did, we also recognise the social, economic and
personal costs were very high. How those costs might be mitigated
in a future pandemic is something we return to in our lessons for the
future and recommendations.
i While it might be more accurate to refer to border ‘restrictions’, we often use border ‘closure’ in this chapter
since that was the term widely adopted (including by the Government) throughout the pandemic and since.
What happened |
4.2 I aha
4.2.1 ‘Closing’ the border, March 2020 – July 2022

From early 2020, Aotearoa New Zealand began amending the Immigration
Instructionsii to refuse entry to people from certain countries, due to soaring
COVID-19 case numbers in certain overseas locations. These instructions were
specifically to manage the COVID-19 outbreak. They reflected the advice of health
officials, who monitored which locations posed the greatest risk according to their
infection and transmission rates and also (to an extent) the effectiveness of the
public health systems and measures in place there.
On 2 February 2020, the Government announced the first such ban, which applied
to foreigners travelling from mainland China. Returning New Zealand citizens and
residents (plus immediate family members) and people already in transit were
allowed to enter but expected to self-isolate for 14 days. At the end of the month,
travellers from Iran were refused entry, and arrivals from northern Italy and South
Korea were required to self-isolate soon after. Another category of travellers was
refused entry on 14 March when the Government announced cruise ships could
no longer enter New Zealand’s territorial waters. Officials kept all such border
restrictions under constant review: according to the Ministry of Health, the aim
was to ensure they were sufficiently stringent to support the ‘Keep it Out’ approach
(covered in Chapter 2), while remaining proportionate.
However, temporary bans on foreign travellers from high-risk destinations did not
succeed in stopping COVID-19 from reaching Aotearoa New Zealand. The COVID-19 virus
began spreading in the community between early and mid-March 2020. At that point,
events began moving very quickly. Over a 12-day period, New Zealand’s first COVID-19
case was reported, COVID-19 became a quarantinable disease under the Health Act
1956, and the World Health Organization declared a global pandemic. On 19 March 2020,
Cabinet agreed that the country’s borders would be closed to everyone except
New Zealand citizens and residents (with case-by-case border exceptions granted in
other specific cases).1 By midnight, these tight border restrictions had come into effect.
Some strong public messages accompanied the Government’s announcement.
New Zealanders and residents who were currently out of the country were urged
to return while flights were still available. Foreign nationals temporarily in Aotearoa
New Zealand should leave as soon as possible to be sure of getting home. People living
here should avoid travelling offshore. And while these measures were necessary to
protect public health, they were temporary and would be regularly reviewed.2
For the next two years, the border remained effectively closed to everyone except
those qualifying for ‘border exemptions’:iii
• New Zealand citizens and permanent residents, along with their partners,
guardians and children (if ordinarily resident in New Zealand, travelling with
the person or having a visa based on that relationship);
• Australian citizens and permanent residents ordinarily resident in Aotearoa
New Zealand;
ii Immigration Instructions are the statutory mechanism whereby tools associated with visa products are set and give
effect to the policy setting. Immigration Instructions are established under s22 and s23 of the Immigration Act 2009.
iii This term applied to categories or people who were exempt from the border restrictions. This group differed from
‘border exceptions’.
• air and cargo ship crew;iv and
• diplomatic and consular staff.3
Border exceptionsv could be granted to other people on a case-by-case basis if their
reason for entering the country was deemed to be critical (the definition of which
evolved over time).4 From 9 April 2020, arrivals were required to enter a managed
isolation facility or quarantine facility on arrival and to hold a valid visa (see section
4.2.1.1 for more on exceptions and visas).
The effect of the border closure on passenger volumes was immediate and
dramatic. Typically, Aotearoa New Zealand has more than seven million arrivals
each year. Between March 2020 and March 2021, just 165,000 arrived. Alongside
this 98 percent drop in arrivals was a 96 percent decline in departures. This rupture
in the country’s connections with the world had major impacts on people’s lives and
on many sectors of the economy – including international education, tourism and
hospitality – and created labour shortages in industries relying on temporary and
migrant seasonal labour.5
Arrangements for the maritime border, which is dominated by cargo rather than
people, were somewhat different from those at the air border. Cruise ships were
refused entry for the duration of the pandemic. Under the COVID–19 Public Health
Response (Maritime Border) Order 2020 that came into effect on 30 June 2020, most
other categories of foreign vessels – including cargo ships, fishing ships and those
arriving for humanitarian reasons – were still allowed to berth. However, there were
strict restrictions on the movement of crew, the loading and unloading of cargo and
catch, and other activities.6
In normal times, multiple government agencies share responsibility for controlling
the flow of people and goods across the border – Immigration New Zealand (as part
of the Ministry of Business, Innovation and Employment), the New Zealand Customs
Service, the Ministry for Primary Industries, Maritime New Zealand, the Aviation
Security Service, New Zealand Police and the New Zealand Security Intelligence
Service. Although the agencies have historically worked closely together, inter-agency
collaboration became critical during the pandemic. The Border Executive Board,
comprising the six public service departments with border functions,vi provided
oversight and coordination. And as the job of operationalising new and often untested
border measures involved the private sector – airports, airlines, ports, shipping
companies and others – maintaining close and collaborative relationships with these
stakeholders was also critical.
Over the course of the pandemic, policies and measures for controlling the
border – and MIQ (managed isolation and quarantine) – were constantly reviewed,
adjusted and added to as circumstances changed, globally and domestically.
iv Under regulation 25 of the Immigration (Visa, Entry Permission, and Related Matters) Regulations 2010, air crew,
some marine crew, and some foreign military personnel were already exempt from having to apply to enter Aotearoa
New Zealand.
v This term applied to categories of non-New Zealanders that could be approved, case-by-case, to enter New Zealand.
vi The Border Executive Board was established as an interdepartmental executive board in December 2020 under the
Public Service Act 2020 (Schedule 2, Part 3), specifically to support New Zealand’s defence against COVID–19 and other
risks. It started in January 2021. The member agencies are the New Zealand Customs Service and the Ministries of
Business, Innovation and Employment; Foreign Affairs and Trade; Health; Primary Industries; and Transport. It replaced
the previous chief executive group (the Border Sector Governance Group), which involved the New Zealand Customs
Service, the Ministry for Primary Industries, the Ministry of Transport and Immigration New Zealand.
According to the Ministry of Business, Innovation and Employment, initial measures
were ‘ad-hoc’ and designed ‘to manage the risk of COVID-19 reaching and being
transmitted here, as the rising threat was identified and as the science on COVID-19
developed in its infancy’. But as it became apparent the pandemic would last for
more than a few months, the approach to border management evolved. Pressure
built to meet the needs of industry and business for critical workers from overseas
and to retain skilled foreign workers already here (alongside keeping COVID-19 out),
and new measures were introduced to support these goals.
Work on options for reopening the border began early in the pandemic, and there
were short-lived periods of quarantine-free aviation travel with parts of Australia
and the Pacific in the first half of 2021. In mid-2021, Cabinet signalled that it was
time to plan to progressively change New Zealand’s border settings. The elimination
strategy had put the country in a unique position, giving it ‘choices and options that
are not open to other countries’, the Prime Minister advised.7 Under what became
known as ‘Reconnecting New Zealand to the World’, border settings would start
moving towards a more sophisticated, risk-based approach for individual travellers
whereby ‘the restrictions we impose on travellers are proportionate to the public
health risk’.8 The goal was to allow as many people as possible to enter quarantine-
free – supported by ‘ongoing layers of protection’ in the form of vaccination, testing
and other measures – until border restrictions could be lifted completely.
The emergence of the Omicron variant at the end of 2021, first overseas and then in
Aotearoa New Zealand, significantly impacted this planned approach to reopening
the border (see the epidemiological discussion in Appendix B for more detail about the
course of the virus during this period). The first step towards reconnection – whereby
vaccinated New Zealanders (and others eligible under existing border exceptions) could
enter the country from Australia without going into MIQ – took effect on 28 February 2022.
That same day, a briefing to the Minister for COVID-19 Response stated ‘public health
advice from the Ministry of Health is that the relative COVID-19 transmission risk posed
by international arrivals is no longer higher than the domestic risk of COVID-19, and
therefore self-isolation and MIQ are not required for public health risk management
at this time’. This briefing recommended removing the remaining MIQ and self-isolation
requirements for fully vaccinated New Zealand citizens and residents (and others able
to enter Aotearoa New Zealand) arriving from countries other than Australia by 5 March
2022, essentially bringing forward the next stage of the ‘Reconnecting New Zealand’
plan.9 It also described the operational complexities of rapidly removing MIQ and self-
isolation requirements, such as coordinating the release of around 1,450 people from
MIQ and informing staff whose positions would be affected.
While the Government did bring forward the dates for opening the border and
removing MIQ requirements, some stakeholders we met with criticised it for failing
to lift border restrictions more quickly. We will return to this issue, and especially
the interconnectedness of health measures and factors weighing against opening
the border, in our lessons for the future.
On 31 July 2022, Aotearoa New Zealand’s borders fully reopened to all travellers and
visa-holders from anywhere in the world. All quarantine and isolation requirements
were removed.
4.2.1.1
Border exceptions
Throughout the pandemic, people wanting to enter Aotearoa New Zealand who
were not citizens or residentsvii could be granted a border exception in specific
circumstances. Cabinet agreed parameters for making these decisions on 19 March
2020.10 Border exceptions could be granted in five categories – those travelling
for humanitarian reasons, essential health workers and ‘other essential workers’,
citizens of Samoa and Tonga travelling to New Zealand for essential reasons, and
people who were partners or dependants of temporary work or student visa holders
and normally lived in New Zealand. However, receiving permission to cross the
border did not equate to securing a place in MIQ, which remained a stumbling block
for many.
By 28 May 2020, 11,842 people had expressed interest in obtaining an exception to
border restrictions across the five categories. The bar was high: of those applying,
only around 20 percent (2,354 people) were deemed to meet the criteria.11
In June 2020, ‘essential workers’ seeking border exceptions became known as
‘critical workers’, and Cabinet’s original parameters for granting border exceptions
evolved into a more specific set of criteria for short- and long-term workers. The
threshold for entering the country as a critical worker would remain high, and
individuals could not simply apply: their intended employer had to lodge a request
first.12 But with the initial COVID-19 outbreak now under control and the country
no longer in lockdown, the Ministers for Economic Development and Immigration
advised their Cabinet colleagues it was time to ensure ‘our border restrictions are
responsive to the needs of businesses. We need to ensure access for essential
workers required for significant economic activities, without whom key projects
will be delayed or the economy affected.’13 On 8 June 2020, Cabinet agreed that
6-month border exceptions could be granted to critical workers if their employer
could demonstrate:
• they had unique experiences and technical or specialist skills not obtainable
in Aotearoa New Zealand; or
• they were doing significant work on a major infrastructure project, a
nationally or regionally important event, or a government-approved
programme; or if their work supported a government-to-government
agreement or had significant wider benefit to the economy; and
• the role was time-critical (in other words, if the worker failed to come,
the project, work or event would stop, be severely compromised, or
incur significant costs).
In order to respond to the large volume of requests and to streamline the
assessment process, Cabinet agreed that Immigration New Zealand would decide
exceptions under the ‘other essential worker’ category, instead of ministers.14
vii Or in one of the other four groups exempt from border restrictions – see list in section 4.2.1.
The classes of critical workers granted border exceptions increased and diversified
over time, in response to the needs of sectors. Over the course of the pandemic,
those granted border exceptions ranged from dairy workers, Recognised Seasonal
Employer scheme workers, agricultural machinery operators, silviculturists and
shearers to veterinarians, teachers, technology sector specialists and auditors.15
Between April 2020 and August 2022, 39,690 workers were granted a border
exception and visa (in most cases, a Critical Purpose Visitor Visa; see section
4.2.1.2). Of those, 17,271 were ‘other critical workers’ and 7,746 were critical health
workers. Another 9,924 were workers from the Pacific entering under the Recognised
Seasonal Employer scheme. In addition, nearly 11,000 dependants of critical workers
were allowed to enter.
However, the number of exceptions granted did not equate to the number of
approved workers (and their families) entering the country. As the Ministry of
Business, Innovation and Employment acknowledged, the actual arrivals of
critical workers and other border exceptions throughout the pandemic remained
dependent on MIQ capacity and the speed with which visas could be granted.
Border exceptions during the course of the pandemic totalled 71,334 visas
approved, with 57,237 people arriving in Aotearoa New Zealand between
April 2020 and August 2022.
The border exceptions regime was phased out
in stages from April 2022 as border restrictions
Between April 2020
were progressively removed. Classes of workers and August 2022,
who had been entering the country by means
of border exceptions could now apply for entry 39,690
workers were granted
through standard immigration pathways. a border exception
and visa.
4.2.1.2
Visas
Under the Immigration Act 2009, anyone who is not
a New Zealand citizen needs both entry permission
and a visa (or visa waiver) in order to enter the country.
Before the pandemic, Aotearoa New Zealand was issuing over one million visitor
visas per year.16 But during the two years the border was closed, the availability of
visas was heavily restricted.
Processing of visa applications of all kinds came to a near halt from 19 March 2020,
although people could still lodge some applications online. Offshore visa processing
offices closed. Operating at significantly reduced capacity, Immigration New Zealand
stopped accepting or processing applications for all temporary visas from offshore,
such as those normally available to students and visitors. Resident visa applications
from offshore were not processed either. New selections of applications for the
Skilled Migrant Category Resident Visa were paused until a new visa category was
introduced in 2021 that allowed people already in Aotearoa New Zealand on work
visas (and who met other conditions) to apply for residency.17
With normal processing largely on hold, Immigration New Zealand instead
prioritised applications from essential workers and visa-holders already in the
country whose visas were expiring. Two new kinds of visas were introduced in
2020 for these groups.18 In September 2020, the COVID-19 Short-term Visitor
Visa allowed people to stay in Aotearoa New Zealand for two months if they were
unable to return home because of COVID-19 and their existing visa was about to
expire; it meant they could ‘remain lawful’ while making arrangements to leave.
At the same time, onshore visitor visas due to expire in the next two months
were automatically extended by five months.19 In June and October 2021, further
automatic extensions were made to some onshore visas (Working Holiday and
Supplementary Seasonal Employment (SSE)) for six months.20
Public submissions to the Inquiry described the stress and uncertainty some visa-
holders experienced over this period. This included those faced with returning to
another country where COVID-19 infection rates were high, visa-holders who were
out of Aotearoa New Zealand when the border closed and did not know when
they could get back in, and some who were in the country and waiting for visa
certification but were excluded from government support and welfare while visa
processing offshore was on hold. As the border progressively reopened in 2022,
normal visa pathways and processing gradually resumed. With the end of the
border exemption regime, the Critical Purpose Visitor Visas were gradually phased
out. Applications for all work visas reopened on 4 July 2022, and for student and
visitor visas at the end of that month.21
4.2.2 Quarantine and isolation

4.2.2.1
2020: Establishing and expanding the MIQ system
The first international arrivals to enter a managed facility due to the risk of COVID-19
were repatriated New Zealanders from Wuhan: they spent 14 days quarantining
in campervans at a military training centre in Whangaparāoa in February 2020.
Over the coming weeks, arrivals from a growing number of high-risk countries also
quarantined at New Zealand Defence Force facilities before quarantining at home.
As the global pandemic accelerated, Aotearoa New Zealand’s quarantine
arrangements became increasingly stringent. Under a health order issued on
16 March 2020, arrivals from all countriesviii were ‘expected’ to quarantine at home
for 14 days. Once the border closed three days later, a second health order was
issued which ‘required’ all arrivals to quarantine at home (except aircrew who had
used personal protective equipment (PPE)). A third order issued on 9 April 2020
required everyone arriving by air (except aircrew and diplomatic staff) to quarantine
at a designated facility rather than at home.22
viii Except Category 2 countries, namely all Pacific Islands Forum members (apart from Australia and French Polynesia) as
well as Tokelau and Wallis and Futuna. Travellers from these countries only needed to quarantine if unwell.
This marked the start of the government-run MIQ system that, within three months,
saw all incoming travellers being accommodated in 32 hotels across five regions.
Until late 2021, most people in the community who tested positive for COVID-19
also completed their required 14 days of isolation in MIQ facilities.
Initially, the MIQ system was coordinated and resourced by a multi-agency team
attached to the National Crisis Management Centre. It was led by the Ministry of
Health, assisted by the New Zealand Defence Force and others.23 As the Ministry
of Health’s capacity came under increasing pressure, responsibility shifted to
the Ministry of Business, Innovation and Employment (partly because of its pre-
existing role in providing temporary accommodation in response to civil defence
emergencies), which became the lead agency from 13 July 2020, again supported
by the Defence Force. However, the Ministry of Health remained in charge of health
matters, including overseeing the work of the district health boards whose staff
carried out testing, health checks and screening in MIQ facilities. The system also
relied heavily on staff from the Aviation Security Service, New Zealand Police, the
Defence Force, Customs, the hotels themselves and security firms, working either
on-site or in support roles such as transport. Ministerial responsibility for the MIQ
system rested first with the Ministers of Health and Housing, before the Minister
for COVID-19 Response took over in November 2020 when that role was created.
The 9 April 2020 order making quarantine mandatory for air travellers expired on
22 June 2020 after two extensions.ix It was immediately replaced by the COVID-19
Public Health Response (Air Border) Order 2020, which included additional
requirements and stipulated some situations in which people could be allowed to
leave MIQ, such as for medical care or court proceedings.24 People might also be
permitted to leave if the Director-General of Health (later the Chief Executive of the
Ministry of Business, Innovation and Employment) agreed they had an ‘exceptional
reason’, and after an assessment of the likely risk to public health. Permission to leave
was rarely granted. Pilots, flight crews and marine crews flying in to join their ships
were exempt from quarantine to help keep supply chains and transit routes open.x
A similar order setting out isolation and quarantine requirements at the maritime
border was introduced in mid-2020. Most people arriving by sea were required to
spend 14 days in isolation or quarantine on board their ship. Exemptions included
those who had been at sea for at least 29 days and had no contact with anyone
other than shipmates (providing none had COVID-19), and crews arriving by air
to join a ship leaving Aotearoa New Zealand immediately.25
ix This and all subsequent orders relating to quarantine and isolation were issued under the COVID-19 Public Health
Response Act 2020, which became effective on 13 May 2020, rather than the Health Act 1956 under which the first
orders were made.
x Section 4(1) sets out the full list of those exempted from quarantine requirements (known as excluded arrivals): any
aircraft pilots or flight crew members; any maritime crew members transferring to a ship (within the meaning of the
Health Act 1956) immediately after their arrival in New Zealand; any medical attendants assisting with medical air
transfers; any person designated by the Director-General as critical to providing services to assist with the response
to COVID-19; any person who is entitled to any immunity from jurisdiction (diplomats etc); and any member of the
New Zealand Defence Force returning from service outside of New Zealand.
At the time the international border closed, an estimated 80,000 New Zealanders
were thought to be temporarily overseas, while another 800,000 were living
overseas permanently.26 There was no way of knowing how many of them would
return home and need to stay in MIQ facilities, making it very difficult for officials to
assess the capacity required or likely demand. This difficulty was compounded by
the absence of regular patterns to arriving flights and the delay or cancellation of
many scheduled flights.
In the first two months of the pandemic, the number of travellers arriving by air was
around 2,600 per fortnight. This number was expected to decline over time.27 But
by mid-2020, demand for MIQ spaces was increasing, particularly from returning
New Zealanders. Mechanisms for either managing demand, or growing supply, were
needed. An airline quota system was introduced so arrivals did not outstrip capacity,
and officials also began working on an MIQ booking system. More hotels were
brought into service. By July 2020 – with nearly 6,000 people arriving a fortnight –
MIQ facilities could accommodate 6,261 people (or 4,500 rooms, which later
became the measurement of capacity).28
Conditions at MIQ facilities had changed since the start of the pandemic, particularly
after security breaches at some hotels. They now had an increased police presence
and extra security staff. From August 2020, the Government further strengthened
security arrangements and required MIQ workers to undergo regular COVID-19
testing.xi The New Zealand Defence Force became an integral and visible part of
MIQ with more than 6,000 personnel eventually working across the MIQ system,
including providing security at the facilities. It was the largest commitment of
Defence Force personnel to a single response in more than 50 years.29
Amendments to the COVID-19 Public Health Response Act 2020 ushered in two
significant changes to MIQ operations from August 2020. First, this enabled the
Government to recover some MIQ costs by charging users (although New Zealanders
entering and staying in the country longer than 90 days were exempt, and waivers
could be granted in certain other circumstances).xii The primary aim was to make
the MIQ system more financially sustainable, but it was also hoped this would lower
demand by discouraging brief visits. Arrival numbers did in fact fall to around 5,000-
5,500 people per fortnight from August 2020, leaving some MIQ capacity unused.30
xi This was done by means of tools including the COVID-19 Public Health Response (COVID-19 Testing) Order 2020
(15 August) and its subsequent amendment (18 August); the COVID-19 Public Health Response (Security of Managed
Isolation and Quarantine Facilities) Order 2020 (20 August); and the COVID-19 Public Health Response (Required
Testing) Order 2020 (30 August) and its subsequent amendments in 2020 (7 and 17 September, 26 November).
xii The charges – detailed in the COVID-19 Public Health Response (Managed Isolation and Quarantine Charges)
Regulations 2020, issued under s33A of the Primary Act – were initially set at $3,100 for the first or only person in a
room, plus $950 for each extra adult and $475 for children aged 3 years or older. There was no charge for younger
children. Charges for some temporary entry visa-holders increased to $5,520 (for the first person) on 25 March 2021.
From 1 June 2021, the period that New Zealanders (and Australians) had to stay in Aotearoa New Zealand before
being exempt from charges increased from 90 to 180 days.
Second, the Government could now require people to register to enter an MIQ facility
before they arrived in the country. This paved the way for the online Managed Isolation
Allocation System (MIAS), introduced on 5 October 2020. Intending travellers were
required to obtain either an online or offline MIQ voucher. The Ministry of Business,
Innovation and Employment emphasised to the Ombudsman (when he later initiated
a review of MIAS) that the online allocation system was a ‘minimal viable product
booking system’, stood up ‘under great urgency, during a time of national emergency.’
The Ombudsman noted no concerns with the initial rollout of the system, and indeed
considered that the Ministry deserved credit for implementing it at speed.31
For an online voucher, the traveller would first visit the MIAS website to secure a
date on a ‘first come, first served’ basis.32 After selecting and temporarily holding a
room for specific dates, they would then complete their flight arrangements through
their preferred airline. Finally, they would return to the MIAS system to provide flight
details and finalise the booking.
An offline emergency allocation system was also created as a way to prioritise urgent
and other specific travellers. To obtain a voucher under an emergency allocation,
people needed to submit an application to the Ministry of Business, Innovation and
Employment, who then assessed the application against criteria set by the Minister.33
A proportion of MIQ rooms were set aside for each of three allocation categories:
emergency, time-sensitive and group (the latter could be used for seasonal workers
and visiting and returning sports teams, for example).34 From data provided to the
Inquiry by the Ministry of Business, Innovation and Employment, it is difficult to
accurately determine the number of vouchers allocated through the offline system,
but it was a relatively small proportion – we estimate they comprised between 5
and 10 percent of all MIQ allocations made from 2021.
Decisions about emergency allocations were
some of the most fraught aspects of MIQ,
and the criteria were amended through the
Decisions about emergency pandemic in response to changing needs and
allocations were some of the experience. For example, an ‘emergency’ was
most fraught aspects of MIQ.
initially defined as an imminent threat to life
or a serious risk to health. In late 2020, the
criteria were broadened to include ‘ensuring
a child had care, critical care of a dependent
person, the provision of critical public or health services, people unable to legally
remain overseas, national security, national interest or law enforcement reasons,
and visiting a dying close relative in New Zealand’.35 The impacts of the emergency
allocation system are discussed in section 4.3.5.1.
From 3 November 2020, travellers were legally required to have an MIQ voucher
before flying to Aotearoa New Zealand.xiii
xiii Made under the COVID–19 Public Health Response (Air Border) Order (No 2) 2020. It did not apply to people who were
exempt from a requirement to enter a managed isolation and quarantine facility.
4.2.2.2
2021: Pressure mounts
By 19 January 2021, 100,000 returning New Zealanders and other eligible people had
entered MIQ facilities (including critical workers and others qualifying for a border
exception). For the next six months, demand for MIQ declined. Meanwhile, the
Government repeated its calls for New Zealanders travelling overseas to return home.
Quarantine-free travel from (but not to) the Cook Islands began on 21 January 2021, and
a similar arrangement with Niue began in March. When two-way quarantine-free travel
with Australia – the ‘trans-Tasman bubble’ – began in April 2021, demand for MIQ spaces
fell further. With the prospect of reconnection with the outside world now seemingly on
the horizon, an eventual relaxation of MIQ requirements also looked possible.
Officials were also providing advice to the Government on options for risk-based
pathways for entry into Aotearoa New Zealand, which would have reduced the
demand for MIQ spaces. In July 2021 Cabinet approved a ‘Reconnecting New Zealand
to the World’ work programme, which considered imposing different testing and
quarantine requirements on travellers based on the risk status of their country
of origin and vaccination status. For example, vaccinated travellers from low-risk
countries would be permitted to quarantine for a shorter period at home, instead of
in MIQ.36 Between October and December 2021, home quarantine (instead of MIQ)
for a small number of incoming travellers was piloted.37 However, by the time this
pilot was completed, it had been overtaken by events.
From May 2021 onwards, repeated COVID-19 outbreaks in Australia saw quarantine-
free travel with specific states paused. On 23 July 2021, amid concerns about
growing outbreaks of the Delta variant in Australia, the trans-Tasman bubble was
suspended completely. MIQ capacity had to be made available for New Zealanders
returning from Australia, reducing the number of rooms available for other
travellers. At the same time, the growing number of local people infected with the
highly transmissible Delta variant (the first community Delta case was reported on
17 August 2021) was also putting facilities under pressure. Until this point, it had
been possible to accommodate almost all domestic COVID-19 cases in MIQ facilities
for their 14-day isolation. Now it was feared that community cases might overwhelm
MIQ capacity – forcing, for example, the cancellation of vouchers assigned to people
arriving from overseas.38 Despite this concern, community cases who could not
safely isolate at home were still required to isolate in an MIQ facility.
Meanwhile, a new approach to allocating MIQ places via the online voucher system
was in development. Earlier in 2021, the Ministry of Business, Innovation and
Employment had considered switching to a waitlist system. But the view at that time
– partly due to the drop in demand caused by quarantine-free travel – was that the
cost, complexity and time required to implement a waitlist system outweighed the
benefits.39 In July and August 2021, officials and industry experts again examined
alternatives to ‘first come first served.’ This time, they recommended a ‘virtual
lobby’ system on the basis this would meet requirements in terms of cost, speed of
implementation (a solution was needed urgently), and transparency for travellers.
The minister approved the virtual lobby option, which was rolled out in September
2021. The Ombudsman would later question this decision in his 2022 review of the
MIQ allocation system, since the virtual lobby was unable to prioritise travellers on
the basis of need. While people with an urgent need to travel could be prioritised
through the offline emergency allocations process, the Ombudsman was critical of
that process.40
The virtual lobby system went live on 20 September 2021. In order to hold an
available date in MIAS (and thereby obtain a voucher), a prospective traveller had
to first get to the front of a randomised queue whenever a virtual lobby was held.
In the first virtual lobby, which took place that month, 31,900 people were in the
queue vying for 3,200 rooms; many were still queuing when it ended. Seven more
lobbies were held, the last on 18 November 2021.41 The number of people queuing
in each dropped off and some rooms remained unallocated, especially after the
Government announced its border reopening plans at the end of November 2021.42
4.2.2.3
2022: MIQ winds down
Quarantine and isolation settings changed with the transition from the Alert Level
System to the COVID-19 Protection Framework (the ‘traffic lights’) in December 2021,
and again when the Omicron variant arrived in Aotearoa New Zealand (as discussed
in section 4.2.1). As case numbers grew quickly, the Government announced a
three-phase approach to managing Omicron with shorter isolation periods required
in each phase.43 There would be a complete shift to self-isolation for all community
cases, with decreasing periods of self-isolation at each phase and wellbeing support
for those isolating at home through the Care in the Community programme (see
Chapter 6). This was brought into effect on 25 February 2022 by the COVID-19 Public
Health Response (Self-isolation Requirements and Permitted Work) Order 2022.
As we have already noted, once Omicron was circulating in the community,
international arrivals no longer posed a greater risk of COVID-19 transmission than
anyone else; thus, the border restrictions and MIQ were no longer justified from
a public health perspective.44 From 28 February 2022, vaccinated New Zealanders
and other eligible travellers from the rest of the world were permitted to travel
to Aotearoa New Zealand without entering MIQ. From 5 March 2022, they were
no longer required to self-quarantine at home. On 3 May 2022, the Government
removed the requirement of the COVID-19 Public Health (Maritime Border) Order
(No 2) 2020 for people arriving by sea to enter MIQ.
On 1 July 2023, the health system resumed responsibility for national quarantine
and isolation arrangements.45 The MIQ system was rapidly wound down as demand
for spaces fell. Defence Force personnel stationed at MIQ facilities returned to their
usual duties and the facilities were closed. All but a few resumed their previous
function as hotels.46
By the end of June 2022, approximately 230,000 border arrivals and 5,000
community cases (and their close contacts) had gone through MIQ during the
previous two years.
Our assessment |
0.0
4.3.1 Closing the border and requiring all international

arrivals to quarantine/isolate was effective in supporting
the elimination strategy
Border controls and quarantine/isolation requirements were two of the four
key pillars supporting the Government’s elimination strategy. As we have noted
elsewhere, the elimination strategy was highly effective in containing COVID-19
transmission until most of the population was vaccinated. The decision to close
the border and require all international arrivals to enter managed quarantine was
essential to the success of that initial strategy. Both measures undoubtedly saved lives
and reduced the burden on the health system in the critical pre-vaccination period.
While the managed quarantine system was effective in keeping COVID-19 out
of Aotearoa New Zealand, there were occasional breaches. In the year to June
2021, researchers identified 10 instances where COVID-19 was transmitted from
someone in a quarantine or isolation facility to a border worker or (occasionally)
the wider community, and an outbreak occurred. In many cases the exact route of
transmission was unclear, but most cases were thought to involve aerosol particles
carrying COVID-19 into shared spaces (such as common exercise areas or smoking
areas).47 Based on experience in New Zealand and Australia (combined), the
researchers estimated the rate of quarantine escape was 5 per 100,000 travellers
in the period to June 2021.
The quarantine system successfully prevented the vast majority of COVID-19
infected travellers from seeding infection into Aotearoa New Zealand. As Figure 1
in this chapter illustrates, a small but steady stream of incoming travellers were
COVID-19 positive at the point they entered New Zealand, but the MIQ system
successfully prevented these cases from giving rise to COVID-19 transmission in
the community.
Figure 1: Daily COVID-19 cases detected at the New Zealand border and
in the community, June 2020 to September 2021
Source: Based on data from Ministry of Health GitHub data, 2024, COVID-19 data, https://github.com/
minhealthnz/nz-covid-data
Rates of quarantine escape depended on a wide range of factors – such as levels of

infection in the countries travellers are coming from, the behaviour of the infectious
agent (the transmissibility of COVID-19 variants), duration of quarantine/isolation,
characteristics of the quarantine/isolation facility, infection control practices
among both travellers and border workers, and vaccination coverage and efficacy
in preventing transmission.48 The introduction of additional protective measures
provided further safeguards that may have reduced the risk of quarantine breaches.
For example, pre-departure testing of people coming to Aotearoa New Zealand from
all countries except Australia, Antarctica and most Pacific Islands was introduced
in January 2021.49 Vaccination of border workers began in February 2021 and was
mandated from May 2021.50
Allowing New Zealanders to return while protecting those already here was a
difficult trade-off for the Government to manage. As noted by the authors of the
quarantine escape study, ‘The most direct way to substantially reduce the risk of
SARS-CoV-2 escaping quarantine [was] to reduce the number of arriving travellers
from areas with high infection levels’. But limiting citizens’ return travel raised
complex ethical, human rights and legal issues, and created significant distress
for those affected (see the ‘Stranded Kiwis’ section). The authors noted
that New Zealand’s quarantine escape rate was higher than that in Australia
(although numbers were small and the difference was not statistically significant).
They suggested the quarantine escape rate would be lower if quarantine took place
in ‘better or purpose-built quarantine facilities in rural locations’, citing the success
of Australia’s Howard Springs facility,xiv which had no quarantine escapes.51
The operation of quarantine facilities was costly and required the support of a large
workforce – covering transport, hospitality, security, cleaning, catering, health care,
operations and logistics. Using hotel facilities (which would otherwise have been
largely empty) was more cost-efficient initially than building bespoke quarantine
facilities, while the location of hotel facilities near Aotearoa New Zealand’s
international airports had practical advantages.
In our lessons for the future and recommendations, we return to what this means
for the development of quarantine and isolation options for a future pandemic.
4.3.2 However, the social, economic and personal costs of

the border restrictions and quarantine requirements were
very high
While border controls and quarantine and isolation requirements were an essential
part of the elimination strategy, we saw evidence that the social, economic and
personal costs of these measures were very high. Describing the initial border
closure in March 2020, senior managers at Auckland Airport told us of ‘a massive
financial and operational impact on the airport. We spent the first few weeks
working out whether we had a viable business.’ A submission from the Royal Australian
and New Zealand College of Psychiatrists addressed impacts of a different kind:
“ Border restrictions and the Managed Isolation and Quarantine (MIQ) system caused
psychological distress … New Zealanders had no certainty about when they would be
able to return home... Some groups experienced lasting distress and trauma due to
not being able to come home or leave with certainty of being able to return. ”
xiv Although not purpose-built for quarantine, this refurbished ‘cabin-style style’ facility near Darwin shares many of the features
of a purpose-built facility. Originally built as mining accommodation, it consists of many cabins with space between them,
allowing good natural ventilation and thereby avoiding the risks of aerosol transmission in spaces like hotel corridors.
For those who had found themselves on the ‘wrong’ side of the border, two years
later it was still hard ‘to get across how deeply the experience of feeling abandoned
and cut off’ had affected them, a spokesperson for Grounded Kiwis (a group
representing New Zealanders overseas trying to return during the pandemic) told
us. Similar feelings were expressed in public submissions; one submitter, unable
to see her two daughters for 18 months due to international border restrictions,
reflected that: ‘As much as I would like to forget the trauma, it’s simply not possible
– this is time that we can never get back and has changed us individually and
changed our dynamics as a whānau.’ Other submissions highlighted the plight
of international students who were isolated from their families or from their
New Zealand universities (if they were offshore when the border ‘closed’). Some
experienced financial hardship and deteriorating health and wellbeing, adding to
the pressure on New Zealand’s health system.
In drawing attention to such adverse impacts, we recognise that closing the
international border and setting up a nation-wide managed system for quarantine
and isolation were extraordinary undertakings – unprecedented, and indeed almost
unimaginable before March 2020. The fact that these measures were implemented
so swiftly, and provided such a robust line of defence during the elimination phase,
is commendable. We acknowledge the hard work of all the agencies, sector groups,
businesses and workers who made those achievements possible. As Auckland
Airport management said of their employees: ‘There was a lot of goodwill with our
staff. They were very willing to work long hours to “keep New Zealand open”.’
4.3.3 Decisions about closing and managing the borders were

made at speed and policy-makers did not always understand
the operational implications. This created challenges and
frustrations for those putting decisions into practice
As we have already described, the decision to close the border on 19 March 2020
was made very quickly. Putting it into effect was time critical and operationally
complex, requiring coordination and cooperation between multiple government
agencies, airlines, airports, port and shipping companies and others. Given the pace
at which change was occurring, communication between government, agencies and
businesses was not always clear, adding considerable confusion and uncertainty.
At Aotearoa New Zealand’s busiest airport, Auckland, the hours leading up to the
closure were frantic:
“ We did not know what flights were in the air or were scheduled to be in the air when the
border closure came into effect. Singapore was asking us whether a particular flight should be
boarded or not, given New Zealand’s border restrictions. We should have said, “Don’t board
because the border will be closed …” … Instead, we said that the legislation is being reviewed,
so go ahead and board, which they did. They arrived and had to fly right back. … Singapore
Airline staff on the ground were calling us because they could not get hold of anyone from the
Government. So, we were coordinating a three-way conversation between Singapore Airlines,
the NZ Government (through the Ministry of Transport), and the Auckland Airport. The Ministry
of Transport was trying to talk with other government departments, to clarify the situation. ”
The need for speed and agility did not abate. For the next two years, border
arrangements continued to be monitored and rapidly adjusted as the pandemic
changed course, locally and overseas: between January 2021 and October 2022, for
example, around 58 changes were made to air border settings alone. While it was
positive that rules were adjusted in response to changing circumstances, agencies
have also told us it was a challenge to manage the many regulatory instruments
(statutes, orders and more) that supported the border settings, which they said
‘grew in complexity as the duration of the pandemic extended’.
Throughout, officials from the Ministry of Business, Innovation and Employment
engaged with the New Zealand Council of Trade Unions and Business New Zealand
on a range of topics. The Ministry also worked with peak sector bodies (such as
Retail New Zealand, the Employers and Manufacturers Association, Hospitality
New Zealand) and key businesses to support good communications and resolve
any emerging issues. Despite these efforts, however, we also heard that the private
sector felt it had few avenues for contributing its expertise, leaving some businesses
feeling ‘disempowered and frustrated’.
The fast-moving environment sometimes meant that policies were introduced
without sufficient consultation with the operational agencies responsible for putting
them into effect, leading to difficulties on the ground. We heard specific criticism
that health officials did not always appreciate the operational complexities their
decisions created at the border. For example, there was some variation in how ships
and shipping companies were treated across different ports. While acting on the
same Ministry of Health guidance, local medical officers of health could implement
this differently depending on their local port’s preferred response to risk.
Health New Zealand | Te Whatu Ora, when it reviewed its role in the MIQ system
in 2022, acknowledged its decision-making processes were affected by capacity
constraints, the constant need for speed, and the fact they were working in
essentially uncharted territory. It is important to acknowledge that, even if health
officials are not experts when it comes to managing the border, infection control
and health system expertise will remain essential when decisions are made about
using border restrictions in another pandemic. That expertise is vital if those
restrictions are to successfully prevent the virus from spreading within quarantine
facilities and escaping into the community. We will return to this in our lessons for
the future in Part 3.
4.3.4 The border exceptions process evolved in response to
changing needs as the pandemic wore on, while the lack of
integration between MIQ and visa processes was very difficult
for travellers
With the border closed to everyone except citizens and residents, an exceptions
process was needed to allow non-New Zealanders who had legitimate needs to
enter Aotearoa New Zealand. The list of exceptions was extended as the pandemic
continued and as worker shortages, which could be tolerated for a short time, became
more problematic. For example, seasonal workers from the Pacific were allowed
into the country to fill labour shortages in the horticultural and wine-growing sectors.
Exceptions were also granted to critical health workers (and their dependants), specialist
agricultural operators for harvesting and processing of crops, veterinarians and
many more.52 The parameters and criteria for exceptions evolved over time based
on changing needs and experience.
By the beginning of August 2022, 39,690 workers had been approved a visa under
a border exception, and 32,547 had actually arrived in the country.
This gap between those who had been approved to enter and those entering the
country points to the impact of limited MIQ capacity. In this case, it was overseas
workers with border exceptions who were impacted. But New Zealand citizens
desperate to return home also came up against the same barriers (as we discuss in
section 4.3.5.1). Frustrations were heightened by the perception that some groups,
such as sports teams, were ‘taking up’ MIQ spots that could otherwise have been
available to New Zealanders desperate to come home.
4.3.5 While there was little operational readiness to deliver
quarantine on a large scale, the legislation was sufficiently
enabling and the MIQ system was rapidly implemented.
But as time went on, problems became apparent
Going into the pandemic, the Health Act 1956 gave the Government the power to use
quarantine and isolation. However, the legislation was suited more for quarantining
individuals, and officials told us it was challenging to apply it at such a large scale.
The government’s existing quarantine plans assumed an influenza pandemic.
The guiding document, the New Zealand Influenza Pandemic Plan 2017, required
the Ministry of Health and district health boards to be prepared to use ‘local
quarantine facilities’.53 In practice, this meant the district health boards maintaining
contracts with local motels and other accommodation providers for potential
quarantine purposes; however, we heard that some of these contracts had lapsed
before COVID-19 emerged. The possibility of quarantining entire communities
and placing travellers in mandatory quarantine on arrival was canvassed in the
plan, but such measures were considered unlikely to be effective and therefore
not included in pandemic planning.54
Despite the lack of prior planning – and the initial uncertainty as to how long COVID-19
would affect the country – the MIQ system was nonetheless up and running very
quickly. Over time, however, the system came under increasing strain, as did the
travellers depending on it. Many of the contributing factors have already been
thoroughly examined in reviews by government agencies, researchers and independent
authorities such as the Ombudsman and the High Court. We have considered their
findings and insights alongside other evidence received during our Inquiry, but have
not repeated their detailed analyses. The main concerns they raised are outlined in
section 4.3.5.1.
4.3.5.1
Managing MIQ capacity and demand
Whether and when most people could enter Aotearoa New Zealand was ultimately
determined by MIQ capacity, not by border settings. It is therefore unsurprising that
MIQ capacity, and the mechanisms the Government used to manage and prioritise
demand, became highly contentious issues. The lingering anger, distress and
mistrust they caused were evident in many of the public submissions we received
and in our discussions with stakeholder groups (see ‘Spotlight’ in this section).
From the start of the pandemic, the likely demand for MIQ places and the capacity
that would therefore be required were hard to predict. It was unknown how many
of the thousands of New Zealanders living overseas would want to return, and
when, or how many New Zealanders would choose to leave New Zealand with the
expectation of returning.
In the event, demand was higher than the system’s capacity, and options to increase
the availability of MIQ places were limited. We note that the Ombudsman reviewed
the Ministry of Business, Innovation and Employment’s actions in managing MIQ
capacity and accepted that it had limited ability to significantly increase or free
up capacity.55 We also heard from officials that, despite the perception that MIQ
capacity was largely constrained by hotel availability, in fact the main constraints
were the need to rotate MIQ facility staff and the availability of the health workforce.
It was in response to the high demand for MIQ spaces that the Ministry of Business,
Innovation and Employment – from necessity – created the Managed Isolation
Allocation System (MIAS) in October 2020. For users, the system required an anxious
wait online to secure an MIQ voucher through what many perceived as a lottery. As
one user noted, ‘we basically have to spend hours constantly refreshing a screen
and as soon as a spot appears and we attempt to click and claim, we are crushed
with an “already taken” notice’.56 At the same time, constraints in MIQ capacity
meant there had to be a system for allocating places, and that many prospective
travellers would miss out.
The system included an offline allocation mechanism intended to prioritise travellers
with urgent or compassionate reasons for entering Aotearoa New Zealand. A set of
criteria was developed for emergency allocations with the goal of ensuring fairness
and consistency across decisions. Officials spoken to by the Inquiry told us that
emergency allocation decisions were some of the most difficult and fraught that
they had to make during the pandemic.
In a judicial review application to the High Court, Grounded Kiwis challenged aspects
of the MIQ system, which they said operated as unjustified limits on citizens’ right
to enter New Zealand. The High Court held that while the system did not in and of
itself amount to an infringement of New Zealanders’ right to enter their country,
the evidence indicated that at least some New Zealanders had experienced
unreasonable delays in exercising their right to enter. The judge found that:
“ Although MIQ was a critical component of the Government’s elimination strategy that was
highly successful in achieving positive health outcomes, the combination of the virtual
lobby and the narrow emergency criteria operated in a way that meant New Zealanders’
right to enter their country could be infringed in some instances in a manner that was not
demonstrably justified in a free and democratic society. ”
57
The Ministry of Business, Innovation and Employment accepted the Court’s

findings.58 Evidence cited by the Ombudsman in his review of the MIQ allocation
and booking system shows that officials and ministers were aware of the system’s
potential limitations when developing it in 2020. In particular, they recognised the
system lacked the capacity to prioritise travellers with urgent needs, especially given
demand exceeded supply. They were also aware of the potential risk of temporary
visa-holders being allocated places ahead of New Zealanders, and of long waits for
New Zealand citizens and residents wanting to return home.59 However, given the
urgency as well as challenges in how to assess ‘need’ in a rapidly changing situation,
it was felt other options were not feasible.
In fact, the possible risks which officials identified were exactly what transpired
– despite the introduction of the virtual lobby system (which for many people
amplified their anxieties and frustrations) and despite the offline allocation
system providing an alternative pathway for travellers with the greatest needs.
In reality, those seeking an offline allocation voucher – including people dealing
with emergencies and hoping for compassionate treatment – had to meet a set
of criteria which were ‘interpreted strictly and require[d] an inflexibly prescribed
form of evidence’, according to the High Court.60 As the Ombudsman found in
his 2022 report on the MIQ allocation system, the offline option simply ‘did not
encompass the situations of many people with a genuine need to travel’.61 In public
submissions to the Inquiry, we also heard that the system felt depersonalised, that
people wanted to speak to someone directly, not fill in an application form. As one
submitter said of the MIQ system more generally, all the thousands of overseas
New Zealanders wanted was ‘something like a helpline where they can actually …
speak to a real person for counselling or advice and help on their situation’.
This and other public submissions lent weight to the Ombudsman’s comments
about the shortcomings of the MIQ allocation system as a means of fairly managing
capacity and prioritising people with urgent or compassionate reasons for travelling
– such as pregnant women, separated families or people visiting relatives who were
unwell. Even when the emergency management criteria were at their widest, the
Ombudsman noted, ‘[they] were too limited to capture large numbers of people
with a genuine need to travel’.62
Spotlight:
Stranded Kiwis | Ngā tāngata o Aotearoa kua raru ki wāhi kē
On 18 March 2020, the Minister of Foreign Affairs and Trade Winston

Peters urged the estimated 80,000 New Zealanders63 thought to be
temporarily overseas to ‘come home now’ if they could: ‘If you’re
travelling, it’s very likely you could be shut off very shortly.’64
The next day, the Ministry of Foreign Affairs and Trade issued a safe travel
notice echoing this message. By now the Ministry was receiving 100 calls a day
from anxious New Zealanders, mostly asking for Government assistance with
repatriation.65 On that day alone, 6,700 passengers returned to New Zealand.66
By 29 March 2020, some 20,000 New Zealanders had returned.67 Others would
remain effectively stranded overseas for weeks or months, unable to get flights
or – once the MIQ system was in place – to secure a spot in MIQ. They were a
diverse group: students, young professionals working overseas, seafarers and
superannuitants. However, many shared a sense of anxiety, frustration or pain
at being unable to get home:
“ It was massive impact wise. I had been made redundant recently and wanted to travel
home to NZ, but with the uncertainty around when this could happen, applying for jobs,
or rather knowing which country to apply for jobs, made life diﬃcult. ”
We also heard from submitters left distressed and angered by an MIQ system
they considered did not prioritise, or allow exemptions for, people stranded
overseas in difficult circumstances, including those wanting to come home to
say goodbye to dying relatives.
“ [T]he fact that quarantine spots were made available to entertainers and other non-Kiwis
also made me furious. Many friends were unable to attend key family events, and some
even missed their parent’s last moments, or were unable to attend the funeral. ”
Among those who managed to get an MIQ spot, there was gratitude for the system
that had allowed them to get home – as we heard in the public submissions.
“ We were very impressed by how the entire NZ quarantine system had been set up on
relatively short notice and with the cooperation of a huge number of varied organisations
and personnel. ”
168
Some submitters appreciated that even if Aotearoa’s New Zealand’s border
and quarantine controls meant they could not readily come home, they
helped the country avoid the devastating impacts experienced elsewhere:
“ I would like to stress that the closure of the international border did not bother
me, and that I understood that stringent border control was necessary to maintain
normal life internally in NZ … [and] prevented a substantial increase in mortality
rates over a sustained period of time. ”
The voluntary organisation Grounded Kiwis, formed in mid-July 2021, helped

people make emergency applications for MIQ spots. The group told us that
the evidentiary burden fell entirely on applicants, but the evidence needed
to support an application was often simply unavailable. ‘This system didn’t
work and wasn’t fit for purpose. People in really dire situations could not get
spots,’ Grounded Kiwis said.
“ We applied for an emergency room allocation through category 5 under financial

hardship but we were denied despite supplying endless proof of our situation and
sleeping on a friend’s couch in Brisbane. ”
68
Grounded Kiwis also advocated on behalf of people shut out by the

‘virtual lobby’ system, writing to the Ministry of Business, Innovation and
Employment in September 2021: ‘The equity issues of using a lottery style
system for what is a fundamental right of citizens, the insufficient MIQ supply
to meet demand, and the failure to consider alternatives to MIQ, continue to
cause immense concern’.69 Submissions we received echoed this sentiment,
describing the so-called lottery as ‘cruel’, ‘unfair’ and ‘criminal’. Messages which
Grounded Kiwis received during the pandemic from New Zealanders stranded
overseas give insight into the despair felt by people who were separated from
home and whānau, often under financial as well as emotional pressure, their
lives ‘in limbo’ for an apparently indeterminate time:
“ It’s life shattering because my wife is sick in NZ and my two little children are
with her. I’m trying to get back to help care for all three of them. ”
The distress did not always end when the border reopened and MIQ
ended. Some public submitters told us that, two years on, they still felt
‘hopeless’ and ‘disenfranchised’ from the place they once called home.
“ The treatment of myself, and other overseas citizens, by the MIQ

system, and specifically the emergency application request system …
has left me with a profound sense of anger, bitterness, and, at
times, a hatred of the country of my birth and the functioning
of its government. ”
169
4.3.5.2
Facilities and staffing
The use of hotels as MIQ facilities presented challenges for infection control and
wellbeing – particularly the lack of outdoor space for physically-distanced exercise,
the absence of appropriate facilities for children, and challenges accommodating
people with specific needs.
It also raised challenging workforce issues. The more than 3,700-strong MIQ
workforce70 comprised a mix of government employees from multiple entities
alongside private sector employees (mostly hotel staff) and subcontractors, all
on a variety of employment contracts. Many worked long hours in conditions
acknowledged to be demanding; some staff reported being stigmatised at home or
in their communities and required ‘strong pastoral care’.71 Alongside these workers,
600 Defence Force staff were deployed at MIQ facilities at any given time. While
the Ministry of Business, Innovation and Employment described their presence as
‘important in terms of supporting public trust and confidence in the MIQ system’,72
there is also evidence of tensions between the military and civilian cultures.73 Some
MIQ users clearly found the military (and Police) presence confronting. One woman
felt they were ‘treated like criminals. Our exercise yard was a car park where we
were observed by security and managed by military, told to walk in a circle and not
speak to anyone.’ However, we also heard about MIQ facilities in the Waikato whose
operating ethos – mahi tahi, or working together – was borrowed from the Defence
Force: public health officials told us of an ‘amazing local relationship with the armed
forces managing the facilities – they enjoyed working here’.
The fact that MIQ facilities were not purpose-built for quarantine created a range
of problems for staff and users. An assessment commissioned in April 2021 found
the hotels were ‘not optimally configured to manage separation of returnee flows
on entry, exit and inside the building’, and security and ventilation systems needed
remediation.74 Although the Ministry of Business, Innovation and Employment
canvassed the possibility of building dedicated quarantine facilities – or refurbishing
existing buildings to the necessary public health standards – the time and cost
involved meant these were not seen as realistic solutions to immediate needs.75
Later, officials developed a business case for establishing future MIQ facilities; with
options including a mix of Crown-owned bespoke facilities and hotels. But by early
2022, the situation had changed so significantly that this advice was considered no
longer relevant, and the MIQ system was wound down.
Despite all the challenges, it is clear that hotels were made to work as quarantine
facilities. The evidence shows that the MIQ system learned from its mistakes and
the frequent reviews of its operations,xv and made improvements in response. For
example, following some well-publicised instances of people spreading COVID-19 into
the community after leaving MIQ, procedures were strengthened to ensure thorough
cleaning and ventilation, and steps were introduced to minimise the risk of guests
becoming infected after their final test (required on day 12 of their 14-day stay).
xv For example, the ‘Rapid Assessment of MIQ’ commissioned by the Ministry of Business, Innovation and Employment in
April 2021, and the Ombudsman’s report into conditions in six MIQ facilities he inspected in Oct–Dec 2020.
4.3.5.3
Community cases
From August 2021, as Delta cases were increasing, accommodating community
cases in MIQ began to create significant operational and governance challenges for
the MIQ system. It was not in fact a new development – providing accommodation
for positive cases who could not safely isolate at home had always been one of
the functions of MIQ. But the rapid increase in the number of community cases
during the Delta outbreak meant that a significant number of MIQ rooms had to
be removed from the available inventory for international arrivals to accommodate
community cases. By the beginning of November 2021, 360 community cases were
in MIQ facilities, along with 25 close contacts in managed quarantine.76
According to the review of MIQ governance, ‘The evolution of MIQ from a border
protection response to a mixed border/domestic response has changed the risk
profile for MIQ. … [D]omestic cases are placed in MIQ by way of an assessment
under a health order and have little time to prepare. The nature of
the circumstances that give rise to the health order can further raise risks.’77
Senior MIQ managers interviewed as part of a review of MIQ governance shed
more light on those risks. In the past, MIQ had worked well as a border intervention:
‘We knew our swim lane,’ said one interviewee. Now, ‘the most vulnerable and
unwell people are being triaged into MIQ by medical officers of health’, placing
pressure on a system not designed for people who were presenting with
‘vulnerabilities, health concerns, addictions or violent behaviour’. There was no
over-arching all-of-government plan to help the system adapt to its community
care role, and gaps in governance were evident, interviewees reported.78
Health officials were also concerned about an increasing emphasis on using MIQ as
part of the domestic pandemic response. One told us that apparently little attention
had been paid to how increasing community case numbers might impact MIQ
capacity. At that time, little work had been done on other options for supporting
community cases, such as the Care in the Community programme – despite
‘knowing that we were going to run out of managed isolation beds’. Other health
officials and MIQ healthcare workers described accommodating domestic cases
as operationally challenging. This was not its primary purpose, and the distinctive
needs of this particular category of cases presented clinical, social, legal and equity
risks. Those ordered into MIQ often arrived with ‘high and complex clinical and
psychosocial needs’ of a kind that the facilities and staff were not prepared for.
Many also needed translation services, which were hard to find at short notice.
However, health officials also noted that the profile and needs of the ‘typical’ MIQ user
were already changing by the time the number of community cases in MIQ started
increasing. At the start of the pandemic, most returnees ‘had been travelling overseas,
and therefore generally had low health needs. Over time, a greater proportion of
returnees were … returning to Aotearoa New Zealand to get away from challenging
pandemic environments overseas, or for challenging family circumstances (e.g. to visit
dying relatives, or to attend a funeral). It became more common for these returnees to
have higher and more complex health and wellbeing needs – including mental health
and addictions needs – than those arriving earlier in the response.’
4.3.5.4
Governance and decision-making
Responsibilities for the MIQ system were split between the Ministry of Health and
the Ministry of Business, Innovation and Employment. This may have been the only
practical option at the time the system was established, but it led to frustrations and
some operational problems.
The split responsibilities also affected governance and decision-making. A review
carried out by the Ministry of Business, Innovation and Employment in November
2021 found that some governance elements were working effectively. However, ‘the
number of different governance entities and lack of a clear point of responsibility
for the overall COVID-19 response expose the challenge of coordinating the
response and planning at a system level’. That challenge had fallen to the Minister
for COVID-19 Response.79 Among specific concerns the review raised:
• The separation of responsibilities between the Ministry of Business, Innovation
and Employment and the Ministry of Health was problematic. ‘[MBIE] is a
recipient of health advice, and largely unable to influence decisions already
made by the Ministry of Health (MoH). Whilst MIQ has MoH involvement in its
operational governance processes it does not have its own clinical expertise’
the reviewers noted.80 The Minister for COVID-19 Response also expressed
frustration with the separation of responsibility, writing on a 2021 Ministry of
Health briefing about the implications for the health system of more returning
travellers passing through MIQ facilities: ‘I’m disappointed that this is not joint
advice with MIQ. I would like you to work together to set out a way forward
ASAP. This approach is not constructive’.
• The lack of a single point of integration (below ministerial level) for the COVID-19
response made aligning policy and operations more difficult and raised the
risk of trade-offs not being fully considered from a system-wide perspective.
MIQ leaders interviewed by the reviewers reported ‘no clear visibility of an
overall COVID-19 response plan’ and ‘[no] significant level of conversation
about future direction’. One example was the heavy commitment of Defence
Force personnel to MIQ, a potential risk to the Defence Force’s capacity to
respond had another major crisis or threat arisen during this period.81
• While the challenges of getting accurate data from varied sources in a fast-
paced environment should be acknowledged, a review carried out in November
2021 found inadequacies in the governance and management of MIQ data.82
4.4
1. Restrictions on who could enter Aotearoa

New Zealand, and compulsory quarantine at the
border, were key to the success of New Zealand’s
elimination strategy.
• Both measures undoubtedly saved lives and reduced the burden
on the health system in the critical pre-vaccination period.
2. Aotearoa New Zealand was inadequately prepared

to use these measures before COVID-19. While
setting up new border processes and MIQ quickly
was a significant achievement, both systems had
significant shortcomings.
• Before COVID-19, Aotearoa New Zealand had no plans in place
for large-scale quarantine, either domestically or at the border.
The fact that MIQ was operating so quickly is a huge achievement
that deserves to be acknowledged.
• While making use of hotels that would otherwise have stood
vacant was an efficient solution, the design of these buildings
made it difficult to implement infection prevention and control
measures. Supporting people’s wellbeing in hotel environments
was also difficult.
• While those involved in running the MIQ system should be
rightly proud of their achievements, the High Court and the
Ombudsman both made findings that speak to the issues with
the MIQ system. In particular, the booking system for MIQ had
significant shortcomings, the criteria for emergency allocations
were narrow and many emergency applicants felt the process
was impersonal and lacking in compassion.
• The Inquiry is aware of the difficulties experienced by some
people working in MIQ facilities. They included Defence Force
personnel and other staff who faced increased exposure to the
virus and were sometimes stigmatised.
3. While border restrictions and the MIQ system adapted in
response to changing circumstances and new information,
the accommodation of community cases and the transition
to home isolation was challenging.
• Despite some high-profile incidents of COVID-19 ‘escaping’ MIQ, the MIQ
system learnt from these incidents and adapted accordingly. Changes
were also made to better support the wellbeing of people in MIQ in
response to independent reviews.
• Planning to reopen the border began reasonably early in the pandemic.
This work was evident in the experiments with quarantine-free travel with
Australia and the Pacific, and the flow of advice to the Government on the
‘Reconnecting New Zealand to the World’. The arrangements for border
and MIQ exemptions also evolved throughout the pandemic in response
to changing needs and pressures.
• Accommodating community cases in MIQ was particularly challenging
and inadequately thought through. Rising case numbers during the Delta
outbreak threatened to overwhelm MIQ capacity, which partly forced the
adoption of home isolation in late 2021.
4. Border restrictions and MIQ took a significant toll on

Aotearoa New Zealand, particularly because demand for
MIQ spaces outstripped capacity and because of the length
of time restrictions were in place for.
• The border closure took a significant toll on New Zealanders both
here and overseas. While many public submissions to the Inquiry
acknowledged that MIQ kept New Zealanders safe, being separated from
family and loved ones was a hugely painful experience for many.
• The progressive lifting of MIQ requirements did not finally begin until the
end of February 2022, at which point Omicron was freely circulating in
Aotearoa New Zealand (meaning infected arrivals posed little additional
risk), and domestic cases were isolating at home. Submissions to the
Inquiry emphasised the frustration that this caused for many.
• Ultimately, decision-makers’ limited range of options for quarantine and
isolation of international arrivals constrained their ability to mitigate
some of the negative consequences of the border restrictions. In a future
pandemic, having a larger and more flexible range of quarantine and
isolation options ready to activate could create more opportunities for
decision-makers to use these vital pandemic response tools in a way that
has fewer negative impacts.
Endnotes |
4.5 Tuhinga āpiti
1. Briefing to Ministers with Power to Act from All of 9. Department of the Prime Minister and Cabinet,
Government Group, Stronger COVID-19 Border Briefing: Reconnecting New Zealanders: Updated
Measures, 19 March 2020, p 8, https://www.dpmc. Advice on Isolation Settings at the Border, DPMC-
govt.nz/sites/default/files/2023-01/Stronger-COVID-19- 2021/22-1542, 28 February 2022, rec 3 and p 2,
Border-Measures-19-03-2020.pdf https://www.dpmc.govt.nz/sites/default/files/2023-01/
Cabinet Minute, Stronger COVID-19 Border Measures, Reconnecting-New-Zealanders-Updated-Advice-on-
CAB-20-MIN-0122, 19 March 2020, https://covid19. Isolation-Settings-at-the-Border.pdf
govt.nz/assets/Proactive-Releases/proactive-release/ 10. Cabinet Minute, Stronger COVID-19 Border Measures,
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73. David Fisher, ‘Covid 19 coronavirus: Pandemic pressure 77. Ministry of Business, Innovation and Employment,
at MIQ facilities creates military-civilian culture clash’, MIQ Governance Review – October – November 2021
New Zealand Herald, 20 July 2021, , https://www. (25 February 2022), p 8, https://www.mbie.govt.nz/
nzherald.co.nz/nz/covid-19-coronavirus-pandemic- dmsdocument/19959-miq-governance-review
pressure-at-miq-facilities-creates-military-civilian- 78. Ministry of Business, Innovation and Employment,
culture-clash/A7ZOW5ZJ4PF2K7GUMIFQUVJLOE/ This MIQ Governance Review – October – November 2021 (25
article comments on a series of Defence Force reviews February 2022), pp 23-25, https://www.mbie.govt.nz/
into its role in MIQ. dmsdocument/19959-miq-governance-review
74. Ministry of Business, Innovation and Employment, Aide 79. Ministry of Business, Innovation and Employment,
Memoire: Rapid Assessment of MIQ, 18 May 2021, MIQ Governance Review – October – November 2021
Annex One: Murray Jack and Katherine Cornich on (25 February 2022), p 4, https://www.mbie.govt.nz/
behalf of MBIE, ‘Rapid Assessment ’ (9 April 21), p 31, dmsdocument/19959-miq-governance-review
https://www.mbie.govt.nz/dmsdocument/27505-rapid-
assessment-of-miq-final-report-pdf
MIQ Governance Review – October – November 2021
75. Ministry of Business, Innovation and Employment, Aide (25 February 2022), p 10, https://www.mbie.govt.nz/
Memoire: Rapid Assessment of MIQ, 18 May 2021, dmsdocument/19959-miq-governance-review
Annex One: Murray Jack and Katherine Cornich on
behalf of MBIE, ‘Rapid Assessment ’ (9 April 21), p 31,
https://www.mbie.govt.nz/dmsdocument/27505-rapid-
(25 February 2022), p 17, https://www.mbie.govt.nz/
assessment-of-miq-final-report-pdf
dmsdocument/19959-miq-governance-review
Peter Boshier, Chief Ombudsman’s final opinion on
Ombudsman (12 December 2022), pp 65-66, https:// MIQ Governance Review – October – November 2021 (25
www.ombudsman.parliament.nz/resources/chief- February 2022), pp 10, 13, https://www.mbie.govt.nz/
ombudsmans-final-opinion-managed-isolation- dmsdocument/19959-miq-governance-review
allocation-system
(25 February 2022), p 8, https://www.mbie.govt.nz/
dmsdocument/19959-miq-governance-review
CHAPTER 5:
5 The health
system response |
Te urupare a te
pūnaha Hauora
0
8
1
Introduction |
5.1 Kupu whakataki
In addition to preventing people becoming sick and dying from COVID-19, part
of the rationale for the elimination strategy and the wider response was to
ensure the health system was not overwhelmed by COVID-19.1 By the time
the virus reached Aotearoa New Zealand, its potential to do so – and what an
overwhelmed health system looked like – was already apparent. Graphic images
from hospitals in Italy and elsewhere showed every available bed occupied by
COVID-19 cases, operating theatres turned into makeshift intensive care units,
and patients being treated in overflowing corridors and administration areas.
Meanwhile, the wider health needs of many citizens in those countries went
unaddressed due to the cancellation of nearly all ‘planned care’ (that is, specialist
medical and surgical care for people who do not need to be treated right away).
For Aotearoa New Zealand, it was a frightening demonstration of what might lie
ahead. If the sophisticated health systems of developed countries like Italy and
France could be so quickly swamped by surging COVID-19 case numbers, what
would happen here?
As described in the pre-pandemic context chapter in Part One, this country’s
health system comprised a large and complex network of organisations. In 2020,
publicly-funded specialist and hospital care was overseen by 20 district health
boards (DHBs), with control of communicable diseases (such as contact tracing)
sitting with 12 public health units spread throughout the country.i Primary
care – delivered by a range of private, non-governmental organisations (NGOs)
and not-for-profit providers – sat somewhat apart from hospital-based services.
The Ministry of Health provided overall system leadership, including policy
and regulation, high-level pandemic preparation, and monitoring. This chapter
focuses on the health system response to COVID-19 in relation to these publicly-
funded functions.ii
If the sophisticated health

systems of developed countries
like Italy and France could be
so quickly swamped by surging
COVID-19 case numbers, what
would happen here?
i This devolved model has since been replaced with a single planning and funding agency, Health New Zealand |
Te Whatu Ora, including a National Public Health Service.
ii From time to time, we touch on – but do not comprehensively address – the pandemic response in
other important parts of the health system (like disability support services, oral health care, and ambulance services).
We do not cover the parts of the health system that are entirely private. Furthermore, while primary care is a vital
part of the health system, data on delivery models and service provision are less accessible for primary care than for
specialist and hospital-based services. Discussion of primary care is therefore less prominent in this chapter.
What’s in this chapter?
This chapter starts by considering how ready the health system was
for the emergence of a global pandemic of the nature of COVID-19.
Then, in the ‘What happened’ section we focus on three things:
• The activation of public health services and public health and
social measures to respond to the virus itself – early steps taken,
testing, contact tracing and, briefly, vaccination (which is addressed
in detail in Chapter 7).iii
• How the wider health system geared up to respond to COVID-19
cases, including the steps taken by DHBs, hospitals and other
healthcare settings to manage potential cases safely, and how
services and resources were reprioritised and deployed to be ready
for an influx.
• The provision of non-COVID-19-related healthcare throughout
the pandemic. We look at what was done to ensure people could
still access health and disability services, including steps to prevent
further outbreaks within services, reorient service delivery and
preserve workforce capacity for non-COVID-19 services. We also
address disruptions to healthcare delivery resulting from efforts
to prepare to respond to COVID-19.
Finally, in section 5.6, we assess how all three areas impacted
the health system itself, the population at large, and its most
vulnerable members.
iii We do not, at this stage, look at decisions to mandate these measures in certain circumstances
or for certain groups of people: vaccine and testing mandates are addressed in Chapter 8.
Health system preparedness |
5.2 Te takatū a te pūnaha hauora
5.2.1 Pre-existing pressures

Despite its strengths, Aotearoa New Zealand’s health and disability system
was already facing multiple pressures going into the pandemic. They included:
• The state of healthcare infrastructure. Many facilities were ageing, and
a queue of capital investment projects awaited funding.
• Workforce capacity. Shortages existed in many areas of the health
workforce for some time before the pandemic. By the start of 2020, staff
shortages were affecting wait times and the quality of patient care in some
areas, as well as contributing to heavy workloads and staff burnout. As
some parts of the health system relied heavily on workers from overseas,
maintaining sufficient workforce capacity depended on immigration settings.
• Growing needs associated with an ageing population with increasingly
complex health and disability services.
• Fragmentation and a lack of cohesion across and between health system
providers, and unwarranted variation in service delivery between regions
and social groups.
• Cost pressures were reflected in the growing fiscal deficits recorded
by the country’s twenty district health boards.2
• Some population groups and communities experienced persistently worse
health outcomes, often exacerbated by poorer access to healthcare services.
They included Māori, Pacific peoples, people in lower socio-economic
areas, people with disabilities and some rural communities. Although the
Crown has te Tiriti obligations to actively protect Māori health, the Waitangi
Tribunal found in 2019 that the health and disability system had repeatedly
failed to address many of the intergenerational health problems and
inequities Māori faced.3 Inequities in service provision were also apparent
between regions, due in part to complex governance arrangements.4
The demands of responding to a national pandemic would only intensify these
pre-existing vulnerabilities and pressures. As the Ministry of Health noted in its
evidence to our Inquiry:
“ In the event of a pandemic, significant, extraordinary sector wide effort was going
to be required.”
In this regard, Aotearoa New Zealand was far from alone. Health systems in most
comparable countries were also struggling with similar population and workforce
challenges, and events in the first wave of the pandemic showed that few health
systems were equipped to cope with such an emergency, regardless of their level
of resourcing.
5.2.2 Prior assessment of pandemic preparedness
Prior to the arrival of COVID-19, Aotearoa New Zealand was thought to be
reasonably well-prepared for a major public health emergency, compared
to other countries.
In a 2019 assessment of global health security led by Johns Hopkins
University, New Zealand had ranked 35th iv out of 195 countries.5 The previous
year, a World Health Organization (WHO) evaluation of capacity to detect,
report and respond to acute public health events and emergencies had
assessed New Zealand as being reasonably well prepared.v In New Zealand’s
health system, the WHO assessors saw evidence of ‘a system and culture of
continuous, collaborative improvement through learning from exercises and
real-world events that has led to continued investment in preparedness’.6
Despite this positive rating, the WHO’s assessors had also emphasised that
ongoing vigilance and improvements to New Zealand’s public health systems
were needed in advance of a major emergency. They pointed to weaknesses
in surveillance, noting that some public health units ‘continue to use paper-
based forms for data collection and manually enter the results … leading to
a high risk of errors’.7 They also highlighted a need for stronger cross-agency
work on pandemic preparedness, supported by ‘a formal communication
plan for stakeholder engagement and management, including sharing
resources and joint emergency response exercises’. More generally, they
recommended relevant agencies work together ‘to improve the information
and intelligence systems that support decision-making in emergencies’.8
Some of the WHO’s concerns about information and intelligence capacity
were highlighted again by an independent review of New Zealand’s wider
health and disability system in 2020.9 That review found gaps in several
population health intelligence functions,vi including monitoring and
analysing population changes, investigating patterns of disease and health,
interpreting and providing information to support health and disability
service activities, investigating variations in health outcomes, and helping
ensure strategic decisions were evidence-based.
iv The United States was ranked first in this assessment, while Australia ranked 4th and Singapore ranked 24th.
v New Zealand top-scored (5 out of 5) for around half the assessment indicators. By comparison, the United
States received the top rating for 42 percent of indicators, while Australia and Singapore top-scored on
65 percent. The indicators measure capacity in various areas relating to countries’ obligations (under the
International Health Regulations) to be able to prevent, detect and respond to acute public health threats
such as infectious diseases.
vi Of which infectious and notifiable diseases are just one component.
What happened: activating public health and
infection control measures in response to
5.3 COVID-19 | I aha: te kōkiri i ngā whakaritenga
hauora tūmatanui me te whakahaere
pokenga ki te KOWHEORI-19
5.3.1 The early health system response

The Ministry of Health took the first steps in the Government’s pandemic response
as soon as the World Health Organization sent member states a disease outbreak
alert about the situation in Wuhan, China on 5 January 2020. The following day,
the Ministry issued its first National Health Advisory to district health boards and
general practitioners, setting out advice on how to reduce the general risk of acute
respiratory infections. Monitoring teams began following developments. The first
media briefing about what was now an emerging global pandemic took place on
27 January 2020, fronted by the Director-General of Health Dr Ashley Bloomfield
and the Director of Public Health Dr Caroline McElnay.
As emergency management preparations ramped up across government
throughout February 2020 (see Chapter 2), the Ministry established several expert
groups to gather information and advise ministers and the health sector about the
SARS-CoV-2 virus.
Chief among these was the COVID-19 Technical Advisory Group, comprising 14
epidemiologists, virologists and laboratory science experts. In addition, four sub-
groups were established to help the system prepare for the COVID-19 threat.
Health officials engaged closely
with international scientific networks
and information sources, especially with
state and federal agencies in Australia.
Health officials engaged closely
The relationship with Australia was with international scientific
particularly valuable when COVID-19 networks and information,
testing began: until New Zealand especially with Australia.
established its own COVID-19 testing
capability in early February 2020, the
first samples taken here were sent to a
Melbourne laboratory for processing.
The Ministry’s emergency operations centre, the National Health Coordination
Centre, was pivotal in the early part of the health system response. It was activated
on 28 January 2020 (as intended in the pandemic plan) and used the Coordinated
Incident Management System approach, which Aotearoa New Zealand followed
in all kinds of emergencies (see Chapter 2 for more about the wider emergency
management response).
With the National Health Coordination Centre in place to coordinate system-wide
preparedness and response, the Ministry of Health next established an Incident
Management Teamvii to deal with COVID-19 incidents and outbreaks. If a community
case was identified, this team would be activated and became the point of contact
for public health units, district health boards, ministers, the Ministry’s own
leadership team, and other stakeholders.10
In light of the escalating public health risk, the Ministry advised Cabinet to make
the novel coronavirus a notifiable infectious disease – a legal mechanism that
would help with the detection of cases by making it compulsory to report them.
This came into effect on 30 January 2020.
By the end of January 2020, there were an estimated 98 cases globally, outside
of China. At this stage, officials considered it was very likely one or more
imported cases were already in Aotearoa New Zealand, given there were regular
direct flights between here and China. Twenty percent of the confirmed cases
in China had become severely ill, and the mortality rate there was around 2–3
percent. The Ministry of Health was part of an all-of-government effort to repatriate
New Zealanders in China; officials were deployed to Wuhan to help with a
repatriation flight on 5 February 2020, and managed the quarantine of passengers
once they reached Auckland.
As described in Chapter 2, the New Zealand Influenza Pandemic Plan 2017 was
at this point the blueprint for the Ministry’s response. Given the potential severity
of the threat COVID-19 presented, the focus was now on the ‘Keep It Out’ and
‘Stamp It Out’ stages set out in the Plan.
Ministry of Health officials considered at the time (and since) that a precautionary
approach was warranted to buy the country some time. In providing evidence to the
Inquiry, the Ministry noted that:
“ More time allowed us to gain a deeper understanding of the virus, including the best way
to manage the disease, to prepare to mobilise further responses in the health sector and
other sectors, and to reinforce public understanding of appropriate hygiene measures.”
On 16 March 2020, Professors Nick Wilson and Michael Baker from the University
of Otago in Wellington provided the Ministry with a report modelling potential
health outcomes if COVID-19 were to spread through the New Zealand population.11
This was essentially a ‘thought experiment’ about what might potentially occur if no
public health or social measures were introduced to mitigate or suppress the virus.
(As the authors acknowledged, the absence of any social measures was unrealistic
– people would change their behaviour on a voluntary basis, even if no mandatory
measures were introduced – but the modelling was intended to give a sense of the
potential health impacts for different levels of infectiousness.)
vii This was different from another group, also called the Incident Management Team, that had operated before the
National Health Coordination Centre was activated, to undertake initial planning and coordination activities.
The report outlined two potential
scenarios. Under the less severe
scenario (if COVID-19 turned out to be Suppression of the virus would
only moderately infectious), the model be insufficient to prevent the
suggested there could be a total of health system from being
92,500 hospitalisations, 6,480 people overwhelmed with the burden of
requiring ventilation in intensive care illness falling disproportionately
on Māori, Pacific people,
units (ICU) and 8,190 deaths. Under the
people with disabilities and
more severe scenario (i.e. if COVID-19 was older communities.
highly infectious), the model suggested
there could be 124,000 hospitalisations,
8,690 people requiring ventilation, and
10,983 deaths. In both scenarios the vast majority of deaths (87 percent) would be
in the 65+ age group. On the basis of these projected health outcomes, the report
concluded there was justification for putting ‘substantive societal and government
resources’ into what was then referred to as a suppression strategy.
Along with another modelling study from the United Kingdom, this analysis
not only demonstrated the potential impact of COVID-19 on the health system,
but also prompted health officials to recognise the need to step up Aotearoa
New Zealand’s response and make critical decisions quickly.
By 19 March 2020, global case numbers were growing exponentially; it had taken
only 12 days for 100,000 reported cases to become more than 200,000. The same
thing was happening on a smaller scale in Aotearoa New Zealand, where cases had
nearly doubled overnight, from 11 to 20. It was now clear that managing the virus
through suppression12 (‘flattening the curve’) would not be sufficient to prevent the
health system from being overwhelmed. Moreover, as the Ministry of Health noted
to the Inquiry:
“ the burden of this failure would fall disproportionately on Māori, Pacific, disability,
and older communities. We therefore needed to prevent COVID-19 from escaping
beyond the border and into the community as far as possible and eliminate chains
of transmission in the community as soon as they emerged.”
Border restrictions took effect that night.
5.3.2 Strengthening public health and infection control
functions to respond to the virus
With a global pandemic now in full swing, the Ministry of Health and district health
boards were responsible for ensuring Aotearoa New Zealand’s health system
response was effective and coordinated.13 The actions to be taken by each part
of the health and disability sector were set out in the Ministry’s COVID-19 Health
and Disability Response Plan (published in April 2020), which emphasised the
importance of ‘strong leadership across the sector’.14
The health system’s response was two-pronged. First, public health functions
necessary to limit and stamp out transmission – testing, isolation of identified
cases, contact tracing and quarantine of close contacts – were stepped up. These
matters are covered in this section. Second, hospitals and other healthcare facilities
implemented changes to help them care safely for COVID-19 cases and prepare for
a potentially large influx of patients. (These matters are covered in section 5.4.)
5.3.2.1
Contact tracing
During an outbreak of a notifiable infectious disease, contact tracing can be a key
tool to stamp out or slow down transmission. Once a new case of infection has
been identified, contact tracing can identify other people who might also have
been exposed, and notify them so that they can isolate themselves and/or access
treatment. If contact tracing is successful, contacts will be isolated before they
have a chance to infect others, thus limiting the spread of an infectious disease.15
Importantly, contact tracing is only effective if undertaken quickly (as soon as
possible after someone is newly diagnosed with infection), and if there is a
reasonable time delay between someone being exposed to infection and becoming
infectious themselves (the incubation period).viii The initial variant of the COVID-19
virus had an incubation period of about five days. This meant there was sufficient
time to identify and isolate ‘contacts’ of newly diagnosed cases before they became
infectious and passed the virus on to others. In other words, effective contact
tracing and isolation could prevent further spread of infection.
Contact tracing in Aotearoa New Zealand is generally carried out by public health
units.ix When someone is diagnosed with a notifiable disease, unit staff trace and
interview people with whom the confirmed case has recently been in contact.
Under ‘normal circumstances’, contact tracing happens on a modest, localised
scale (for example, to stamp out a measles outbreak in a particular community).
But in a pandemic, contact-tracing capacity needs to be scaled-up quickly and
expanded to cover multiple locations. The higher the case numbers, the more
contact tracers are required, and the bigger their task.
viii The ‘incubation period’ is the time it takes for a person exposed to infection (that is, having contact with someone
already infected) to develop the infection themselves and then to become ‘infectious’ (i.e. be capable of passing the
infection on to those around them).
ix There are twelve such units in Aotearoa New Zealand. They are staffed by public health nurses, health protection officers
and Medical Officers of Health who are public health medicine specialists experienced in communicable diseases control.
Other agencies – including general practice, family planning, youth and student health services, maternity and prison
services – may also conduct contact tracing depending on the disease outbreak and expertise required.
Aotearoa New Zealand’s contact-tracing capacity was very limited at the start of the
pandemic – the Director-General of Health, Sir Ashley Bloomfield, described it to us
as a ‘cottage industry’. Its limited capacity was confirmed in April 2020 when a rapid
audit by Dr Ayesha Verrall (then a public health academic, and not yet a member
of parliament or minister) found public health units would need to scale-up their
contact-tracing capacity ‘three to four fold’ to deal with COVID-19.16
Initially, public health units in regions with high COVID-19 case numbers were
boosted by extra staff brought in from units in regions with no cases. Then in March
2020, the Ministry of Health established a National Close Contact Service to provide
centralised coordination and nationally consistent processes. This service was
staffed by a broad range of health professionals, including those who had recently
retired, students, or professionals who normally worked in private healthcare. The
Service evolved as the Ministry sought to enhance the coordination, consistency
and scale of contact tracing: it became the National Investigation and Tracing Centre
later in 2020 and the National Case Investigation Service in November 2021.
The national telehealth service provider Whakarongorau Aotearoa was also deployed
as part of the effort to rapidly scale-up contact-tracing capacity. It recruited and trained
large numbers of contact tracers who would work remotely. (See section 5.5.3.3 for
more on the activities of Whakarongorau Aotearoa during the pandemic response.)
As well as rapidly growing the contact-tracing workforce, the Ministry of Health
sought to improve contact-tracing capacity by creating a new digital platform. Over
the course of a few weeks, the Ministry’s digital team developed the National Contact
Tracing Solution to store details about COVID-19 cases, close contacts, and their
management (what advice they had been given about self-quarantining, for example).
The NZ COVID Tracer app

Developing and piloting a smartphone app to assist with contact tracing was one
of the key recommendations made by Dr Verrall in her early capacity audit.17 The
Ministry of Health moved quickly to implement the recommendation, partnering
with Auckland-based design company RUSH Digital to develop the NZ COVID Tracer
app. Its purpose was to create a virtual diary of people’s activities and interactions.
The Privacy Commissioner was consulted during the app’s development, and publicly
endorsed it as ‘a privacy-friendly solution for contact tracing which New Zealanders
should feel secure in downloading and using’.18 It was launched on 20 May 2020 as
a voluntary contact-tracing measure. While the app’s use was never mandated, the
Government later made it compulsory for businesses and event organisers to display
QR codes so people could ‘scan’ into their premises,19 and for certain businesses and
organisers to keep records of who had attended20 – both of which were most easily
accomplished via the app. (These measures are discussed further in Chapter 8.)
The app’s functions were built iteratively, with arguably its most useful function –
the ability to consent to sharing location data via QR code scanning – added as part
of an update in June 2020. Bluetooth capability, which theoretically allowed people
to be directly notified when they had been in close proximity with a confirmed case,
was added in December 2020. Between 1 July 2020 and 30 June 2021, an average
of 807,000 scans were made each day using the app.
5.3.2.2
Testing
Testing is a vital component of any pandemic response, both for identifying
who is infected and for confirming who is not. From early in 2020, people with
respiratory and other symptoms were encouraged to undergo diagnostic
testing to assess whether they were infected with COVID-19. Groups considered
to be at higher risk of having contracted the virus – including people entering
Aotearoa New Zealand from other countries, workers whose jobs brought them
into contact with overseas arrivals, and healthcare workers – underwent
regular testing.
Two main types of COVID-19 tests were used in Aotearoa New Zealand at different
stages of the COVID-19 pandemic: Polymerase Chain Reaction (PCR) tests,x which
identified genetic material from the virus in the form of ribonucleic acid (RNA),
and Rapid Antigen Tests (RATs), which detected protein from the virus, both via
nasal swab.
PCR tests
PCR tests were the first form of testing available in Aotearoa New Zealand, and
the most accurate. They had to be administered by health professionalsxi and
processed in laboratories. It could take hours or days to get a result. Workforce
and laboratory capacity constraints limited the number of PCR tests that could
be carried out.
One response to these constraints was the ‘pooling’ of samples (when a large
number of samples are all tested together). This approach is very efficient if
there are very low levels of infection in the population: if the whole ‘pool’ returns
a negative result, a single test provides results for 50 (or whatever the pool size)
people. However, if the ‘pool’ returns a positive result, each sample must be
re-tested individually to determine which ones were positive.
While this approach was used effectively through 2020 and 2021, it started to
become problematic in early 2022 when the arrival of the Omicron variant led
to widespread community infection. Community case numbers soared,
severely straining laboratory capacity.
Since testing of ‘pooled’ samples was no longer efficient, the surge in positivity
rates caused by the Omicron outbreak led to an effective reduction in testing
capacity just as population testing rates increased. As a result, laboratories were
unable to process tests in a timely manner. By late January 2022, PCR test results
were taking up to a week to return. By early March, laboratories had a backlog
of approximately 30,000 samples more than five days old; these were assigned
for destruction due to their reduced clinical relevance.21
These capacity issues were eventually resolved by the transition to RAT tests.
x Previously, this technology had only been used in Aotearoa New Zealand to any significant extent by the
Institute of Environmental Science and Research (ESR).
xi PCR testing was usually carried out by rotating a testing swab against the tissues at the back of a person’s nose
(a nasopharyngeal swab). Later in the pandemic, PCR testing was also conducted using saliva samples – but this
approach was not widely used in Aotearoa New Zealand.
RAT tests (or RATs)
While less accurate than PCR tests, RAT testsxii could be self-administered and
processed and gave results within 15 minutes.22 From early in the pandemic, RAT
tests were widely used overseas to test for COVID-19. But they were not authorised
for use (or importation) in Aotearoa New Zealand until early 2022, due to concerns
about their lower accuracy.23 In the context of the elimination strategy, some
health experts felt the greater accuracy of PCR tests was necessary to ensure as
many cases of COVID-19 were detected and isolated as possible. Officials also had
concerns about the poor quality of some RAT test kits available internationally.
With the decision to move out of the elimination strategy in October 2021 (see
Chapter 2), the ban on RAT tests was modified to allow importation and use of
tests approved by the Ministry of Health.24 A ministry advisory team had by this
time evaluated over 600 different RAT tests, of which 25 were eventually approved
for use. The transition from PCR to RAT tests did not go smoothly, however. While
importation was now permitted, supplies were limited. The Ministry worked to
source and distribute RAT tests to those that needed them,25 but their ability to do
so was impaired by global supply shortages and the time taken for orders to reach
Aotearoa New Zealand. An external review later found a lack of forward planning
had delayed the transition to RAT testing and necessitated a continued reliance
on PCR testing – contributing to testing capacity being overwhelmed in early 2022
(as described in the previous section).26
By mid-March 2022, RAT tests were the primary COVID-19 testing modality27
and were freely available from GPs, pharmacies, schools and other community
locations. In its evidence to our Inquiry, the Ministry of Health described ‘significant
effort’ to ensure equitable access to tests, including the establishment of a ‘Māori-
provider distribution channel’ in February 2022 that created ‘a network of over
1,000 community partners to ensure that Māori have good access to tests’.
5.3.2.3
Surveillance and wastewater testing
Accurate information about COVID-19 case numbers was a critical input for Cabinet
decisions about alert level changes and the addition, removal, or alteration of
other public health and social measures throughout the pandemic. The Ministry
of Health therefore put significant effort into providing accurate daily counts of
newly diagnosed cases throughout the pandemic period.
Early on, this ‘surveillance’ of the virus was based on individual case notifications.
In 2020, surveillance involved routine testing of border workers and new arrivals in
managed isolation and quarantine (MIQ), as well as wider efforts prompted by specific
outbreaks: comprehensive contact tracing and testing during the initial outbreak in
March/April 2020 and focused efforts in response to localised outbreaks like that which
prompted a short national lockdown in August 2020. Case identification relied on case
PCR testing, while genome sequencing was undertaken on positive tests to identify
specific COVID-19 variants.
xii Compared to PCR tests, RAT tests have lower ‘sensitivity’ – meaning they may occasionally return a negative
test result even if the person has COVID-19, especially early in the infection before viral ‘shedding’ is high. But
because RAT tests are much faster and easier to administer than a PCR test, they may be more effective at a
population level when infection rates are high and the strategy is to suppress or mitigate the spread of COVID-19.
These efforts were later supplemented with regular wastewater testing, using
methods developed by ESR during the COVID-19 response.28 This involved routine
sampling to reveal whether the virus was present in municipal wastewater.
If detected, it indicated the presence of COVID-19 infection in the community
(possibly without the knowledge of those infected). These approaches were
formalised in a comprehensive COVID-19 Surveillance Strategy in January 2021.
5.3.2.4
Facemask guidance
Outside of healthcare settings, the routine use of facemasks as a precaution against
catching or transmitting infectious diseases was not normal practice in Aotearoa
New Zealand before COVID-19. Nor was there a culture of wearing masks when ill.
This changed dramatically during the pandemic response, in which masks played
an important – and sometimes controversial – role. The widespread use of masks
was important for protecting people who were vulnerable to the virus. From being
rarely seen in public settings in Aotearoa New Zealand before 2020, facemasks
became ubiquitous, especially during the second half of 2021 and early 2022. For
many, they are now an instantly evocative symbol of the COVID-19 experience.
Evidence about the effectiveness of masks to prevent COVID-19 transmission
evolved over the course of the pandemic, and the way they were used as a public
health tool varied accordingly.xiii On 6 April 2020, the World Health Organization
issued guidance recommending workers in healthcare settings wear masks – but
only to prevent the transmission of COVID-19 from medical procedures involving
infected patients. This was updated on 5 June 2020, and while the updated guidance
applied more broadly than just to medical procedures, it was still focused on health
workers.29 It took longer for the World Health Organization to recognise that
COVID-19 was spread by airborne particles,xiv often but not always between
people within 1 metre of each other.30
xiii Here we touch on the overall role of masks as a public health tool in the COVID-19 response. Later, in Chapter 8,
we address how and when mask use was made compulsory.
xiv Terminology used to describe the transmission of pathogens through the air varies across scientific disciplines, organisations
and the general public. This caused considerable confusion during the COVID-19 pandemic because the World Health
Organization was reluctant to describe it as an ‘airborne’ virus. In 2024, the World Health Organization published revised
terminology of ‘transmission through the air’ with sub-categories of ‘airborne transmission’ and ‘direct deposition’. The
phrase ‘aerosol transmission’ is often used to describe the airborne transmission of particles of lesser size than a droplet.
In 2020, the (slow) global recognition that COVID-19 could be transmitted via small airborne particles (that is, aerosol
transmission) led to delays in introducing measures that would reduce the risk of transmission such as widespread use
of facemasks and improved ventilation.
Spotlight on masks:
Effective if worn correctly, consistently and by nearly
everyone | Te āta tirotiro ki ngā ārai kanohi – he
whaitake mēnā ka tika, ka auau te mau, ā, e te nuinga
It’s now well established that mask wearing can reduce the spread
of respiratory infections like COVID-19.31 Wearing masks not only
protects people during one-to-one encounters, but also lowers the
overall spread of respiratory viruses in the community. Studies
conducted during COVID-19 showed that requiring people to
wear masks significantly reduced transmission in the population,
contributing to ‘flattening the curve’ of infection.32
The protective effects of mask wearing are increased if people wear
them correctly and consistently. Protection is also greater with
masks that are designed to remove particles from the air – such as
respirators or ‘N95s’ (masks containing particle-removing filters).
The more people wearing masks, and the better the quality of the
masks, the more effective they will be in reducing transmission
of infection.33 However not everyone can wear a mask. There are
a few conditions where mask use isn’t feasible or appropriate, so
it is important to have exemptions to any required mask wearing.
Wearing your own mask correctly can help protect others who –
for reasons outside their control – may be unable to wear a mask.
While masks are not a cure-all, they are an effective public health
measure that carries a low cost – both financially, and in terms
of their impact on human rights (compared with other possible
measures, such as restrictions on movement or vaccine
mandates). These factors make masks an essential
tool in the public health toolkit.
By August 2020, officials at the Ministry of Health were satisfied there was
enough evidence to support mask use for them to play a significant part in the
response to the community outbreak of that month. As well as their direct role
in preventing transmission, there was evidence that mask wearing enhanced
other behaviours that discouraged spread, with studies suggesting people were
more likely to follow social distancing guidelines when around a person wearing
a mask or if they were wearing a mask themselves. They began to be mandated
in some settings from 19 August 2020 (see Chapter 8).
What happened: preparing the wider health
system to cope with COVID-19 cases | I aha:
5.4 te whakarite i te pūnaha hauora whānui kia
tū pakari ki ngā kēhi KOWHEORI-19
Beyond strengthening public health measures to stop the spread of the virus,
the health system also needed to prepare for a potentially dramatic influx
of people unwell with COVID-19, should community transmission become
established. As noted earlier, Aotearoa New Zealand’s healthcare infrastructure
was under strain in many parts of the country before the pandemic and was
not well set-up to care for large numbers of people with contagious respiratory
infections, while keeping staff and other patients safe.
As in other parts of the world, prior to the arrival of COVID-19, delivery of
healthcare in Aotearoa New Zealand was heavily reliant on face-to-face contact
between health workers and sick people. This created additional risk in the
context of a pandemic. Hospitals and other healthcare services therefore
needed to implement changes that would allow them to care safely for people
with suspected or confirmed COVID-19 and prevent the virus from spreading
at their facilities. Such changes included upgrading buildings (or changing how
they were used), introducing new infection control measures (or expanding
existing ones), and managing who came into health facilities.
Several guidelines and frameworks were developed to help health and
disability service providers assess their level of risk from COVID-19 and escalate
or relax infection control measures (including visitor restrictions) accordingly.
These frameworks were also intended to ensure a degree of national
consistency in operational decisions, and to inform decision-makers about
how much to defer or reprioritise non-COVID-19 healthcare services to
manage COVID-19-related demands.
Aotearoa New Zealand’s

healthcare infrastructure was
not well set up to care for
large numbers of people with
contagious respiratory infections.
5.4.1 Changes in healthcare facilities to provide safe care
in a respiratory pandemic
The state of healthcare infrastructure in general, and hospital facilities in
particular, was negatively impacting the health system even before the
arrival of COVID-19.
In the course of our Inquiry, we heard about a range of pre-existing challenges
that made it difficult for healthcare facilities to reduce the risk of cross-
infection from a contagious respiratory illness like COVID-19. These included:
• Aspects of building layout that made it difficult to separate potentially
infectious patients (for example, emergency departments connected
to wards via a single corridor).
• Ventilation systems that were not suited to reducing disease spread
via airborne particles.
• A shortage of negative pressurexv rooms.
• Single nursing stations that made it hard to keep those working
with infectious patients separate from other staff.
• Lack of suitable space near entrances and exits for correctly changing
into and out of personal protective equipment (PPE).
While these issues were particularly prominent in hospitals, we also heard
that many community health services and primary care facilities were poorly
designed for separation of infectious and non-infectious patients and for
appropriate ventilation and air flow.
The consequences of these infrastructure challenges for managing an
outbreak of a highly infectious disease like COVID-19 became quickly apparent.
xv Negative pressure rooms have high-flow ventilation systems that continually move air out of the room
(and then out of the building), ensuring potentially contaminated air doesn’t recirculate back into
corridors and other parts of the facility.
5.4.1.1
New patient management protocols and workflow processes
Hospitals undertook substantial work to adjust patient management and workflow
processes in order to keep patients with respiratory symptoms (or confirmed
COVID-19 cases) separate from others.
Such adjustments included redesigning work spaces,34 physically separating
patients with respiratory symptoms as soon as they entered an emergency
department, testing patients for COVID-19 at hospital entrances, setting up
separate COVID-19 wards (for example, Auckland Hospital converted two wards
for this purpose), and rostering staff to work in separate groups to limit their
potential exposure to COVID-19.
How each hospital designed and implemented these changes was shaped by the
age and quality of their existing infrastructure. Options for improving ventilation and
patient flows were more limited where buildings were outdated, and changes required
a mix of pragmatism and innovation. For example, staff at Palmerston North Hospital
(which had longstanding issues with outdated facilities)35 used pull-down screens
to create separate ‘red’ zones for COVID-19 patients in the operating theatre and
intensive care unit and retrofitted a substantially improved ventilation system.
Palmerston North Hospital engineer with the pull-down screen used to create a separate
‘red’ zone in the operating theatre.
5.4.1.2
Shoring up capacity to care for ventilated patients
The ability to care for patients requiring mechanical ventilation (when a machine
helps someone to breathe) is an important aspect of health system capability in
a pandemic. It was particularly important for COVID-19: people who became very
sick with the virus often required ventilation. Sick patients who require ventilation
are usually cared for by specially trained staff in a hospital’s intensive care unit
(ICU), although ventilation can also be provided in other parts of the hospital
(such as operating theatres and high-dependency units).
New Zealand’s intensive care capacity was lower than in many other countries at
the start of the pandemic. A report by the OECD noted the country had 3.6 ICU beds
per 1,000 population (compared with an OECD average of 12.0).36 This was well
below the capacity in countries such as Italy and Spain, where hospitals had been
overwhelmed in the early stages of COVID-19. Global demand for ventilators was
soaring, with orders far exceeding global supply.37
Capacity to care for ventilated patients was therefore an area receiving a lot of
attention in the early pandemic response. Cabinet agreed to support additional
ICU capacity as part of an initial funding boost for the health response on 17 March
2020. On 31 March 2020, the Minister of Health told the Epidemic Response Select
Committee that considerable progress had been made in preparing for a surge
in COVID-19 admissions, including ‘a huge amount of work […] to determine how
we can scale-up that ICU capacity’. This included securing additional ventilators,
repurposing operating rooms, and running refresher and new training courses
to ensure there was sufficient staff capability to care for ventilated patients.38
The importance of capacity to care for ventilated patients was reinforced by
the COVID-19 Ministerial Group on 9 April 2020 when it agreed the criteria to be
considered when deciding to move between alert levels. These included satisfying
the Director-General of Health that there was sufficient general health system
capacity, including workforce and ICU capacity.39
Weekly situation reports to ministers attempted to track ICU and ventilator capacity.
As early as 29 March 2020, it was reported there was ‘sufficient’ capacity with
533 ‘ventilated ICU beds’ available.40 An update on 3 May 2020 again reported 533
ventilators in DHBs, with another 357 ventilator machines on order. A further
247 ‘potential ventilators’ were available in private hospitals and other providers.41
While physical spaces and ventilator units were identified fairly readily, a more
challenging issue was training a pool of staff who could provide care for ventilated
patients – which is a highly specialised skill. An update from early June 2020 noted
that over 500 doctors and 800 registered nurses had been registered as part of a
‘surge capacity database’ listing around 10,000 people from the wider health sector,
although it is not known how many of these were capable of caring for ventilated
patients. Of this ‘surge capacity’, the update noted that 33 had been deployed into
roles, but it was not clear whether these roles included this responsibility.42
While these reports demonstrate significant effort and at least some potential
to surge capacity to care for ventilated patients, the Inquiry saw no evidence of
a sustained ability to increase this capacity during the first 18 months of the
pandemic response. According to the Ministry of Health, despite the early availability
of funding, ICU capacity in July 2022 was similar to that at the start of 2020, with
national numbers remaining the same at around 260. In November 2021, Cabinet
established a contingency fund to increase ICU capacity, and in February 2022 the
Ministry of Health sought to draw on it to increase critical care bed numbers to
around 345 beds (including staffing). The Ministry advised us that – by January
2024 – funded ICU capacity was 312.
We were unable to ascertain what number of ventilated patients the health
system could have surged capacity to care for, had COVID-19 case numbers
and hospitalisations dramatically increased. Certainty about surge capacity
will be important for future pandemics.
5.4.1.3
Retrofitting and upgrading hospital facilities
As well as changing patient management and workflow processes to improve
infection control, many hospitals also undertook extensive retrofitting to reduce
the likelihood of COVID-19 being transmitted between patients. As noted previously,
this work typically focused on improving ventilation and managing the flow of
patients so people with respiratory symptoms or confirmed COVID-19 could be
physically separated from other patients. Many hospitals installed air purification
units (also known as HEPA filters or ‘scrubbers’) to remove airborne particles
and reduce the risk of droplet spread.
We heard differing accounts of the extent to which there was central support or
guidance for this upgrading work. Health officials told us the Ministry ‘played a
strong coordination role’ by meeting regularly with Chief Medical Officers and DHB
chairs to check on progress. In contrast, we heard from some hospital staff that
they received limited practical guidance on what was expected by way of retrofitting
or what standards were required for building ventilation. The Royal New Zealand
College of Urgent Care (the peak body for urgent care medicine) told the Inquiry
that there was ‘no official guidance available from the Ministry about the mitigation
of SARS-CoV-2 transmission by ventilation or air filtration’.
While additional funding ($100 million) was made available to hospitals to support
this upgrading work, this wasn’t announced until December 2021.43
As a result, we were told that hospitals developed their own approaches to upgrading
their physical infrastructure and relied heavily on the knowledge of their own staff.
As one stakeholder put it, ‘each hospital did its own thing’. Not everyone viewed this
as a problem. Some staff found it enabling to be allowed to ‘just get on with it’ and
‘not be paralysed by the need for perfection’. According to one: ‘We were permitted to
take risks, to make decisions without having to go through burdensome processes’.
5.4.2 New infection control practices
In material provided to us in evidence, the Ministry of Health has acknowledged
that ‘there was no national infection prevention and control capability at the start
of the pandemic’.
This was quickly recognised as a gap, with efforts made to embed suitable expertise
to review evidence and issue guidance about such matters as hand hygiene, mask
use, physical distancing and ventilation. In the context of the pandemic, a range of
new infection control practices were introduced – including COVID-19 screening in
emergency departments, separate workflows and staff teams to manage patients
with suspected or confirmed COVID-19, and dedicated COVID-19 wards.
For health workers, the initial absence of such guidance, and later its frequently
changing nature, created additional pressures during an already very challenging
period. We heard from numerous professional bodies and colleges representing
different healthcare workers about the stresses this placed on their members,
especially early in the pandemic when there was limited evidence about the virus,
its spread, and what worked to keep staff and patients safe.
There were repeated references in our direct engagements to New Zealand’s lack of
expertise, capacity and central coordination in infection prevention and control, which
was referred to as one of ‘the Cinderellas of the health system’. A specialist body told
the Inquiry that ‘there were not enough trained staff’ to ensure adequate infection
prevention and control practices across all aspects of the COVID-19 response.
These challenges were evident in primary and community health settings as well
as hospitals. We heard that running GP and outpatient clinics under more stringent
infection control measures meant patient appointments had to be spaced further
apart to maintain social distancing and allow time to sanitise equipment, creating
extra workloads for staff and longer wait times for patients.
5.4.2.1
Access to personal protective equipment (PPE)
PPE was an important part of infection prevention and control in healthcare settings,
benefitting patients and staff alike and helping to maintain people’s access to health
services. However, accessing it was a particular pressure point for many health
workers during the pandemic.
Under the New Zealand Influenza Pandemic Plan 2017, DHBs were responsible
for maintaining PPE stocks. It was assumed at the start of the pandemic response
that this equipment would be available (and adequate) straight away. However,
it was quickly established that much of the stock had not been well maintained or
rotated and was now out of date and unfit for use.44 We are not aware of evidence
that quantifies how serious these stock issues were, but we heard from senior
health officials we engaged with directly that they were considered serious enough
that they might compromise the health system’s ability to prevent or mitigate a
COVID-19 outbreak.
The Ministry of Health managed the procurement and distribution of PPE for
publicly-funded health workers. Under normal circumstances, the Ministry would
spend about $25 million a year on PPE. By 30 June 2020, it had spent approximately
$200 million to procure, store and distribute more than 46 million items of PPE, with
another 165 million on hand ready to be deployed.
Centralised procurement and distribution were effective in providing PPE to
hospitals, but worked less well for community-based services. We heard from
many organisations and individuals about health workers in both primary and
community care having difficulty getting PPE during the pandemic. Those affected
included employees in general practices, hospital and community-based midwives,
home care and disability support workers, pharmacists, and aged residential care
workers.45 Difficulties in getting PPE, or the right PPE, also contributed to a slowing
down of service delivery. In early 2020, urgent care doctors were so concerned
about access to PPE – and a perceived lack of information about whether, when,
and what kind of PPE would be made available to them – that some went so far
as to source their own, including by importing it directly.
5.4.2.2
Infection control and visitor policies in hospitals and aged
residential care facilities
For most of the pandemic period, DHBs had strict policies for those visiting or
supporting patients in hospital. In general, no one could enter if they, or the patient
they were visiting, had or were suspected of having COVID-19.
At ‘red’ and ‘orange’ hospital alert levelsxvi – alongside other increasingly stringent
infection control measures – no visitors were allowed (or could only be permitted
by a clinical nurse manager or senior manager on shift; in such cases, only one
visitor or legal guardian was granted access).46 At all levels visitors needed to follow
hand hygiene and PPE requirements, participate in contact tracing, and could expect
to be turned away if unwell with COVID-19 symptoms.
These strict hospital visiting policies were intended to protect patients, staff,
visitors and the wider public against COVID-19 by limiting potential exposure
and transmission between patients and their visitors and support people. The
restrictions were intended to be adjusted according to the DHBs’ own alert level
status under the National Hospital Response Framework (see section 5.4.3).47
However, in practice, there were instances where DHBs diverged from the national
approach, with some using stricter policies than it would suggest.48
Visitor restrictions were also applied in aged residential care. Aged residential care
residents are more vulnerable than the wider population to the adverse impacts of
viruses in general, and were at particular risk of contracting COVID-19 due to their
close contact with others.49
xvi The alert levels were specific to hospitals and (despite the similar terminology) were not the same as the national Alert
Level System – see next section.
These risks came into sharp focus early in the pandemic, when several early clusters
were located in such facilities in Aotearoa New Zealand. A subsequent review found
the sector had reasonable infection control practices and readiness for infectious
outbreaks, and these were quickly activated.50
Some aged care providers moved their facilities into lockdown-like conditions
earlier than the rest of the country. Steps taken within aged care facilities
included introducing visitor restrictions, limiting contact between residents, and
isolating residents by themselves or within bubbles as required (although this was
challenging for some residents with dementia). In many facilities, lockdown-like
facilities were maintained for much longer than the time the rest of the country
spent at Alert Levels 3 and 4.
By March 2022, the Minister of Health had become concerned about the effects
of extended social isolation on aged care residents. By this time, the general
population was living with lower restrictions under the new COVID-19 Protection
Framework, or ‘traffic light’ system, but many residents of aged care facilities
remained subject to strong restrictions.
In May 2022, the Ministry of Health issued new guidelines for safe visiting and social
activities in aged residential care. These outlined a series of principles, including
that ‘social connection and physical contact with whānau are fundamental to the
health and wellbeing’ of aged care residents, and that it was essential to enable
safe visiting, social activities and outings even during a COVID-19 outbreak or when
community transmission was widespread.51
...social connection and physical

contact with whānau are
fundamental to the health and
wellbeing of aged care residents.
5.4.3 Prioritising services and redeploying resources
in response to COVID-19 risk
As well as making changes to patient management systems, retrofitting and
improving hospital facilities, and issuing new infection control guidelines and
equipment, hospitals and other health services had to be ready to reprioritise their
services and redeploy their resources in readiness for a potential influx of COVID-19
cases; if nothing else, the frightening scenes of overwhelmed hospitals in other
countries in early 2020 had shown the importance of this.
As mentioned earlier, several national guidelines helped health services not only
to escalate or relax infection control measures in response to COVID-19, but also
to make decisions about how much to adjust non-COVID-19-related services.
One key framework was the National Hospital Response Framework, which was
developed by the Ministry of Health in collaboration with DHBs in March 2020. This
aimed to support DHBs to safely deliver and maximise patient access to non-COVID-19
hospital services (such as in-patient care, surgeries and specialist appointments), while
also protecting hospital capacity to deal with COVID-19-related demand as it arose.52
The national response framework provided guidance on how to scale infection
control measures and clinical services up or down according to different levels
of perceived COVID-19 risk, and DHBs’ capacity to manage this risk.
There were four ‘alert levels’ ranging from ‘green’ (low perceived risk of COVID-19 impact)
to ‘red’xvii (high perceived risk of ‘severe’ impact).53 Different hospital facilities within
a DHB, or even departments within a single hospital, could be at different alert levels at
any given time. Each DHB was required to report their overall alert level
to the Ministry on a daily basis, so that ‘a national view of escalation’ could be compiled.
The framework recognised that, even at times or in regions where there were no
active COVID-19 cases, the provision of ‘business as usual’ care would need to
remain prepared for a possible surge during an active pandemic. At the lowest, or
‘green’ level of risk, hospitals were expected to be ready for any COVID-19 cases that
presented, although planned care continued as usual. Specialist clinics were also
expected to continue, but remotely – for example by videoconference.
At the highest, or ‘red’ level of risk, hospitals were encouraged to discharge as many
patients as possible and cancel any surgery not considered an emergency. This would
ensure all possible capacity was available to respond to people presenting with COVID-19.
In practice, this system came to guide not only hospital-based care, but the
overall provision of non-COVID-19 health services during the response. A parallel
framework was developed for primary and community health services, which
evolved over time.54 DHBs were tasked with sharing their plans for managing
hospitals at different (health) alert levels with primary and community providers,55
and it was expected that the primary and community sectors would respond to
COVID-19 risk ‘in sync’ with the hospitals.56
xvii Note that this traffic light system was distinct from the national Alert Level System and COVID-19 ‘traffic light’ system,
as it was unique to the health system. It allowed DHBs to assess localised COVID-19 risks and their capacity to
manage those, and also make decisions on service availability and infection control given those circumstances.
What happened: provision of non-COVID-19
-related healthcare during the pandemic |
5.5 I aha: te whakaratonga o ngā ratonga
hauora ehara mō te KOWHEORI-19
i te wā o te mate urutā
In addition to managing the health system response to COVID-19, the Ministry of

Health and DHBs were responsible for ensuring New Zealanders could continue
to receive appropriate preventive, diagnostic, therapeutic and supportive care
for non-COVID-19 health conditions. This was a challenging task given the need
to simultaneously upgrade infection prevention and control settings, scale-up key
public health functions, and ensure sufficient health system capacity was held
ready in case of rapid increases in COVID-19 infection and illness.
The national response frameworks for hospitals and community care outlined
in the previous section were the primary mechanisms used to balance all these
considerations. The intent of these frameworks was to allow ‘business as usual’
health services to be delivered to the greatest extent possible during the pandemic,
while still enabling the system to be ready to cope with an outbreak of community
transmission, should this occur.
5.5.1 Reprioritising primary care, routine screening,

immunisations and hospital-based care
Holding a health system ready for a potential influx of cases during a pandemic will
inevitably require the reprioritisation of ‘business-as-usual’ services. As noted by a
senior health official in one of our direct engagements:
“ Even in a context where you don’t have any active COVID cases in a hospital, all the other
infection prevention and control measures slowed down services. It’s quite difficult to
measure these impacts and work out what is a reasonable level of planned care.”
In practice, it seems most DHBs took a cautious approach to this assessment. As a

result, many non-COVID-19-related healthcare services were temporarily suspended
or deferred during the pandemic. These decisions were first required during the
national lockdown in March and April 2020.
5.5.1.1
Care for non-COVID-19 health issues during lockdowns
Not surprisingly, the delivery of ‘business as usual’ health services was
heavily disrupted in March, April and May 2020.
During this time, we heard that many district health boards around the country
assessed themselves as ‘red’ on the national response framework – at the highest
perceived risk of severe impact from COVID-19. At this level, they provided
emergency and urgent care only – in order to preserve capacity.
According to a working report by the Ministry of Health in November 2020, inpatient
stays in public hospitals declined sharply during the Alert Level 3 and 4 lockdown:
in April 2020, the first full month in lockdown, the number of stays fell by almost
40 percent and remained at historically low levels in following months. However, by
June 2020, there were signs that hospitals were beginning to reduce the backlog.57
The lockdown also affected general practices. The Ministry’s report showed general
practice consultations declined in late March and April 2020, and had not reverted
to pre-lockdown levels by July of that year.58 Patient experience survey data
found one in three (34.4 percent) of respondents reported that the Level 3 and 4
lockdowns in 2020 affected their access to general practice: they felt they weren’t
supposed to attend or that their health problem wasn’t urgent enough, or they
delayed or substituted general practice care.59
These disruptions prompted some immediate concerns. In a letter to the Minister
of Health in April 2020, the Health and Disability Commissioner expressed concern
about ‘unmet need’ that was building in the community due to the reduction in
healthcare service activity. He noted that the consequences would be ‘particularly
serious for those for whom early diagnosis and treatment is the key to success,
including cancer and coronary disease’, raising ‘clear equity issues’.
The Commissioner called for the health system to act now in preparation for
the surge in demand that would occur once lockdown ended – including by
strengthening coordination between primary, secondary and private providers to
ensure ‘maximum availability of and access to services’. His letter also highlighted
‘inconsistencies across the country in the ways in which DHBs are applying the
National Hospital Response Framework’, with some DHBs declining primary care
referrals and referring other patients back to primary care.60
Responding to the Commissioner’s concerns, the Ministry of Health noted that while
DHBs were ‘redesigning workspaces and reassigning workers to ensure preparedness
for a possible influx of COVID-19 patients’, many non-urgent surgeries were deferred
for this purpose. This was consistent with the framework if DHBs had determined they
needed to lift the status of their facilities to ‘red’ or other higher levels. However, ‘care
will continue to be provided according to a patient’s clinical priority. DHBs will actively
review waiting lists and manage a patient’s risk of deteriorating whilst waiting’. The
Ministry said it had been ‘clear with DHBs that any deferred patients […] must not be
removed from waiting lists’, but also noted that ‘limiting the risk of COVID-19 infection
remains a key priority’. This reflected the challenge of balancing the health system’s
response to the pandemic with its responsibilities to provide non-COVID-19 care.61
By November 2020, the new Health and Disability Commissioner told the incoming
Minister of Health that her office had received 224 complaints related to COVID-19,
representing 15 percent of all complaints received that year. Many centred
on reduced access to care and delayed treatment in primary, secondary and
emergency healthcare.62
In 2022 and 2023, the Health Quality and Safety Commission documented
numerous pandemic impacts on wider health services, some of which are covered
in section 5.6. Relevant to this section, the Commission reported that planned care
in hospitals returned to normal levels in mid-2021 after falling sharply during the
first national lockdown.
However, the situation worsened considerably following the Delta outbreak and
the long regional lockdowns that began in August 2021. Afterwards, planned care
remained ‘consistently lower’ than expected on the basis of earlier years.63
5.5.2 Steps taken to preserve wider health system capacity
and workforce during the pandemic
Despite the disruptions that inevitably occurred, considerable efforts were also
made to preserve wider health system capacity and ensure the health workforce
was available to deliver necessary and ongoing care. A number of different
strategies were utilised to expand the available health workforce, including
recruiting health professionals who were working outside the health system.
When health workers were absent from work with COVID-19 or redeployed into
other parts of the sector, there could be flow-on effects for other services. In
response to these challenges, steps were taken throughout the pandemic to
minimise system capacity disruptions and ensure that health workers could
keep coming to work.
5.5.2.1
Deeming health workers ‘essential’
When the country first went into Alert Level 4 lockdown, most health services
were deemed ‘essential’.64 This was intended to preserve access to essential
healthcare during lockdown, and to minimise disruption to the health workforce.65
See Chapter 3 for more on the definition of essential services.
While the classification of health workers as essential was deliberately quite broad,
it did not necessarily correspond to what was understood to be essential in the
moment. For example, we heard of some people in preventative or community
health roles, who were essential workers, often being redeployed into other
areas considered to be more ‘essential’. A report for the Well Child Tamariki Ora
governance group in June 2020 found that:
“ […] not all organisations understood that WCTO staff were still providing an essential
service and WCTO staff were redeployed to other areas of business. This will have an
impact on the work required to catch-up with whānau who may not have received
contact during the lockdown period.” 66
...considerable efforts were

also made to preserve wider
health system capacity.
5.5.2.2
Enabling some health workers to return to work early after a
COVID-19 diagnosis
In April 2020, the Northern Regional Health Coordination Centre (supporting
Auckland, Counties Manukau, Waitematā and Northland DHBs) developed an
evidence-based risk matrix67 to help make decisions about when staff who had
been infected with COVID-19 could safely return to work should staff absences
be putting critical (e.g. lifesaving) services at risk. The framework was then
adapted in May 2020 by the Royal New Zealand College of General Practitioners
for GP services delivered in general practice and in the wider community,
including schools, with several versions for different alert level settings.68
This practice continued through into 2022, and was supported by the Ministry
of Health for all critical health services, and under specific conditions. An order
issued in May 2022 allowed the Director-General to make an exemption to stay
at home orders, but only if the person was a critical health worker whose work
was required to prevent immediate risk of death or prevent serious social or
economic harm to significant numbers in the community. If all other options
had been exhausted, they were not acutely unwell, and agreed, they could
return to work.69
As a result, throughout the pandemic, some essential health workers were given
special dispensation to return to work early following a COVID-19 diagnosis,
subject to specific conditions.
5.5.2.3
Temporarily exempting some staff from vaccination
requirements to prevent disruptions to critical services
Later in the pandemic, when vaccination mandates were in place for the
health and disability workforces (see Chapter 8), DHBs could apply for
temporary exemptions to staff vaccination requirements if there was a risk of
‘significant service disruption’ to a critical health service due to a lack of available
vaccinated workers.70
To qualify, the DHB had to show that a critical health service would not
be able to be provided, that no alternative option was available, and that
the organisation had done all they could to mitigate the risk of COVID-19
transmission from having unvaccinated staff.
5.5.3 Innovation and adaptation in service delivery
Despite significant disruption and pressure, people in the health system worked hard
to find ways of continuing to provide care without relying on face-to-face contact.
There were many examples of innovation and adaptation that allowed ‘business as
usual’ healthcare to continue as much as possible. These included the rapid adoption
of alternative models and methods, such as telehealth and remote delivery.
5.5.3.1
Community and iwi and Māori health providers quick to mobilise
We heard many examples of iwi and Māori health providers quickly adapting,
developing new models, and taking a holistic and flexible approach to ensure
their communities had ongoing access to essential services, including healthcare.xviii
The Ministry of Health recognised and supported the strength of this response –
as one senior health official told us: ‘Māori got the “why” of the protection measures
and mobilised rapidly – sometimes ahead, sometimes more rigorously than the
national response’.
Examples of iwi and Māori initiatives included:
• A Māori primary health organisation’s six general practices partnered with
an acute care centre and a local supermarket to deliver food, health and
hygiene packages, testing, and later vaccination to their wider community.
• Māori health providers purchased and distributed mobile phones to
households they knew didn’t have them, ensuring they could maintain
communications during lockdown. These providers also stepped up to fill
gaps when required – for example, when Police were unavailable to attend
mental health crisis callouts.
“ Māori got the “why” of the protection

measures and mobilised rapidly –
sometimes ahead, sometimes more
rigorously than the national response. ”
xviii This was not limited to the health sector – we heard similar evidence about iwi and Māori pandemic responses in
general. For more, see section 3.2.1.3 in Chapter 3 on lockdowns, section 6.4.1.2 in Chapter 6 on the economic and
social response, and section 7.3.2 in Chapter 7 on the vaccination rollout.
5.5.3.2
Rapid uptake of new technologies
As happened in other sectors, the arrival of COVID-19 and the first national
lockdown required the health sector to shift rapidly to using new technologies.
Many of these existed already or were being piloted in small pockets, but they
were rapidly adopted at scale early in the pandemic.
E-prescribing – whereby medications were prescribed, dispensed, administered
and recorded electronically – was one such technology. Because it could be done
remotely, it was a useful tool during the COVID-19 pandemic, reducing exposure
to the virus among patients and health professionals. It offered other advantages
too, such as improving patient access, convenience, and reduced harm from
medication errors and adverse drug events.71
A gradual shift to e-prescribing had begun before the pandemic, but it was rapidly
accelerated in March 2020 – in fact, we were told it was effectively adopted
nationwide overnight, two days before the first national lockdown. While some
technical barriers affected transmission between general practitioners (GPs) and
pharmacies,72 we heard that the move to e-prescribing was overall a ‘superb’
example of how the health system can make significant changes when it ‘identifies
priorities and steps into action’. In the words of one GP: ‘We’ve been talking about
the barriers to e-prescriptions for 15 years. Lo and behold, it happened in 48 hours’.
Similarly, there was a rapid uptake of online
systems for communication between health
“ We’ve been talking about the professionals and patients (or ‘patient portals’)
barriers to e-prescriptions for early in the pandemic, as well as an ‘extraordinary’
15 years. Lo and behold, it increase in the use of phone and virtual
happened in 48 hours. ” consultations. Health staff made videos showing
patients the correct way to swab themselves for
COVID-19 testing. National telehealth services
scaled-up to provide additional support.
The Ministry of Health also took steps to ensure that wherever there were qualified
health and disability workers willing and able to work during the COVID-19
response, they would be connected with employers who needed them. To this
end, an online portal was established to connect health and disability workers with
sector employers. More than 3,700 workers registered an interest to work, and 25
employers used the service.
5.5.3.3
Additional support from national telehealth services
Whakarongorau Aotearoa, the National Telehealthxix Service was established
in 2015, a consolidation of several existing phone support lines into one entity
using the same cloud-based system. At the time of writing, it comprises more
than 35 services.73
Under ‘normal’ circumstances, Healthline and the many mental health and addiction
phone lines that are part of Whakarongorau can be considered a ‘backstop’ to
primary health services. But during the pandemic, when people’s ability to access
standard healthcare was significantly reduced, they were critical and became the
first port of call for many. This was reflected in increased call and text demand
across many of these services:
• Calls to Healthline jumped from an average of 30,000 calls per month
pre-pandemic to almost 74,000 calls in March 2020.
• Texts and calls to mental health and addiction support services (depression,
gambling support, assistance with alcohol and other drugs) increased. They
peaked in March–April 2020, with 20,483 calls received in April alone. Call
volumes did not return to pre-pandemic levels until late 2021/early 2022.
• Calls to Plunketline (especially maternal mental health related calls) rose
sharply in late 2020, peaking in the second quarter of 2021 at four times
the number of calls received before the pandemic.74
People contacted these telehealth services about a myriad of issues – including
family violence, mental health, lockdown rules, and COVID-19 symptoms and testing.
Agreements and operating protocols with other agencies meant health lines were
able to refer callers to appropriate alternative services (businesses wanting advice
on implementing COVID-19 requirements were referred to MBIE helplines, for
example). If necessary, they could also prioritise callers they referred to these
other lines, so they were dealt with urgently.
We heard from several sources that Whakarongorau was a pandemic success story.
According to one senior health official:
“ Whakarongorau were unbelievably invaluable in the response […] if they didn’t exist,
we’d have struggled to build a national workforce as fast as we did to do what they did.
They grew from a few hundred people to over 3,000 in a number of months.”
Factors in the service’s success were described as its ‘scalability’, its strong
pre-existing relationship with the Ministry of Health and the Auckland Regional
Public Health Service, a high-trust contracting model, its use of remote technology
that allowed people to work from home, and to rapidly recruit, train and surge
their workforce.
xix ‘Telehealth’ refers to health care delivered using mobile and digital technology.
Spotlight:
Delivery of cancer care during the pandemic |
Te tuku manaaki mate pukupuku i te wā o te mate urutā
Cancer care is a case study of a highly dedicated sector which responded to the
pandemic by mobilising rapidly, remaining focused and coordinated, and exercising
good system stewardship – strategies that helped minimise disruption to usual
healthcare.75 Aotearoa New Zealand’s cancer care sector performed well when
compared internationally.76
Initially there were major disruptions to cancer screening, diagnostics, treatment

and care. In the rush to protect the health system from the potentially devastating
impacts of COVID-19, cancer screening and diagnostics were particularly affected.
New cancer registrations fell by 40 percent in April 2020 compared to same month
the previous year, meaning one thousand fewer cancer diagnoses.77 Workforce
disruptions, reduced efficiency due to physical distancing and infection control
requirements, and difficulties for patients needing to travel were also challenging.
The three national screening programmes (breast, cervical and bowel) were paused
temporarily during the first national lockdown in April 2020.78 They gradually
resumed from May 2020 under Alert Level 2 to the point where most eligible people
due for screening were able to access it by August 2020.79
Also during the lockdown period, thresholds for referring cancer patients from
primary to secondary care were raised, and there was a sharp reduction in some
diagnostic procedures like endoscopies and colonoscopies.80 There were grave
concerns that this would result not only in system backlog, but preventable harm
and mortality.81
DHBs had at this point been asked to work to the National Hospital Response
Framework (see section 5.3) when making decisions about clinical care prioritisation
and service availability, given local COVID-19 risks. As noted in other parts of this
chapter, there was variation in how the framework was interpreted. It was ‘high
level’, and clinical leaders needed additional guidance tailored to cancer care.
The newly established Cancer

Control Agency – Te Aho o Te Kahu
– supported hospitals to maintain
cancer-related care during
the pandemic, with a strong
focus on equity and protecting
the vulnerable.
210
Together with specialty working groups, the newly established
Cancer Control Agency – Te Aho o Te Kahu – worked rapidly to
develop cancer-specific guidelines aligned with the National Hospital
Response Framework. These supported hospitals to safely maintain
necessary cancer-related care during the pandemic. The guidelines
had a strong focus on equity and protecting the vulnerable and
immunocompromised.82 Māori partners were involved in decisions about
which services to prioritise.83 An Agile Response Team provided rapid
clinical support and coordination.
This approach was accompanied by innovations in service delivery
which, in combination, ensured patients could continue to receive cancer
care. Despite the many disruptions that occurred in April 2020, half of
first specialist assessments that month – and 80 percent of follow-up
appointments – were held remotely via telehealth platforms.84
A collaboration with Pharmac allowed patients to maintain access to
cancer medicines by providing alternatives that could be given less
frequently or administered in the community.85
The cancer response was supported by timely monitoring of service
provision – a key component of effective health system stewardship.
From April 2020, a data response group established by the Cancer
Care Agency produced monthly reports on diagnostic testing, new
cancer registrations and treatments. This provided the health sector
with near-real-time monitoring of cancer care. Clinicians could adapt
service delivery and target their public messaging in response, while
officials and ministers had up-to-date information to inform decisions
about potential interventions.86
Despite these very active efforts to maintain cancer care delivery, it was
not possible to completely avoid service disruption. Screening for breast
cancer was low through 2020 and 2021, and many support services
for cancer patients (such as volunteer transport to treatment) were
interrupted. The reduction in in-person care also meant many family
and friends of patients took on extra responsibilities, such as managing
medication and changing bandages. Such responsibilities can increase
carers’ distress and impact their quality of life.87
Overall, though, continuity of cancer services was maintained
throughout the pandemic period. In fact, the Health Quality and
Safety Commission reported that new cancer registrations actually
increased by five percent in 2021 (compared with 2018/19).
There were also positive equity trends in the provision of some
services, and increased rates of diagnostic procedures
for Māori.88
211
Our assessment of the outcomes
5.6 and impacts | Tā mātau arotake
i ngā putanga me ngā panga
5.6.1 Aotearoa New Zealand’s health system was not

overwhelmed, and most people – especially vulnerable
groups – were well protected from COVID-19
It is well established that pandemics (and other kinds of crises and disasters) will
have the greatest negative impacts on the parts of the population who are already
facing systemic inequities and underlying disadvantages. This is true of both the
direct impacts of the pandemic virus or pathogen itself, and of the indirect economic,
social and health impacts that can result from a pandemic. Proactive steps can – and
should – be taken to mitigate this likely effect as much as possible.
When considering the health system response to the COVID-19 pandemic
in Aotearoa New Zealand then, we have been mindful of both historical and
international examples. The 1918 influenza pandemic and its devastating
impact on indigenous peoples here and around the world, has been a salient
consideration (as it was for the Government and for many Māori during the
pandemic response). So too have examples of health systems overwhelmed by
COVID-19 in Italy, the United Kingdom, India, the United States and elsewhere.
Keeping these ‘counterfactual’ examples in
mind has helped us to interpret the evidence
we saw and heard about the wider health “ It was hard. Really hard. But having
impacts of New Zealand’s COVID-19 response. tens of thousands of whānau and
It is of course impossible to know exactly friends die would have been harder. ”
what might have happened under alternative
circumstances and if different decisions had
been made (although Appendix B provides some scenarios to consider).
We also note that work on major health care reforms was underway while
Aotearoa New Zealand was dealing with the COVID-19 pandemic. They were
introduced on 1 July 2022.xx
There can be no doubt that New Zealand’s COVID-19 response – particularly
the success of the elimination strategy, and the time this bought to achieve high
levels of vaccination coverage – was highly effective at protecting public health,
preventing the health system from being overwhelmed, and minimising unequal
health impacts for disadvantaged or vulnerable populations, including Māori.
Many public submitters to our Inquiry expressed gratitude for how the COVID-19
response protected public health, and the health system.
“ I was so very proud of how our government & public health initially handled the
pandemic – protecting the health of the people of New Zealand was at the centre.”
“ ...the way the Government and government departments and officials handled the pandemic
and responded with public health measures absolutely saved lives. It was hard. Really hard.
But having tens of thousands of whānau and friends die would have been harder.”
xx These changes increased central governance of publicly-funded hospital and specialist services by replacing
20 district health boards with a new Crown entity, Health New Zealand. A new Māori Health authority,
Te Aka Whai Ora, was established to monitor the state of Māori health and commission services.
5.6.1.1
Low infection, hospitalisation and death rates
The public health and infection control measures activated during the pandemic
were deployed in service of the overarching elimination strategy that governed
New Zealand’s COVID-19 response from late March 2020 until late 2021. This
strategy, and the measures deployed in support of it, were highly successful in
preventing the health system from being overwhelmed and in protecting the
health of people living in Aotearoa New Zealand.
COVID-19 was largely absent from the country until early 2022. While the lockdowns
of early 2020 and late 2021 were highly disruptive, they also ensured that case
numbers were very low. Following the initial success of the first national lockdown in
2020, community transmission was successfully re-eliminated in August of that year.
Not until the arrival of the Delta variant in August 2021 did it became re-established
– and even then, case numbers, hospitalisations, and deaths in this period were very
low – barely visible compared with what came later in 2022. As Figure 1 shows, the
first two significant ‘waves’ of COVID-19 infections in Aotearoa New Zealand only
occurred in 2022, the first in March/April and the second in July/August.
Figure 1: COVID-19 cases, hospitalisations and deaths in Aotearoa

New Zealand, 2020–2022.
Source: Based on data from Ministry of Health
When COVID-19 transmission did eventually become widespread in Aotearoa

New Zealand, the population had high levels of immunity from vaccination. Not only
did this protect many people from developing severe illness when infected with
COVID-19, it also meant that New Zealand’s health system was never overwhelmed.
Aotearoa New Zealand’s hospitalisations and deaths from COVID-19 have been
much lower than those seen in countries where the first waves of infection occurred
before vaccination.
New Zealand’s COVID-19 hospitalisations peaked in March 2022 at just under three
admissions per 100,000 population per day (as seen in Figure 1). While there were
challenging moments for New Zealand’s hospitals, particularly when COVID-19
waves coincided with high rates of other respiratory infections like influenza and
RSV, the system was largely able to absorb these peaks. By comparison, the United
States and the United Kingdom experienced peak hospitalisation rates of more
than 6 admissions per 100,000 population per day, twice the peak in Aotearoa
New Zealand, and their hospital systems struggled accordingly.89
Aotearoa New Zealand experienced fewer COVID-19 deaths per head of population
than almost any other OECD country,xxi as reflected in its exceptionally low excess
mortality. (The measure of ‘excess mortality’ is commonly used to compare the
impact of COVID-19 on death rates in different countries.)xxii In fact, New Zealand
had ‘negative’ excess mortality (i.e. fewer deaths than would have been expected
based on previous years) from early 2020 until early 2023 (see Figure 2), a fact
attributed to the positive impact of lockdowns and other infection control and
public health measures on the transmission of other infectious diseases.
Figure 2: Excess mortality (all cause) per million people, 2020–2023
Source: Our World in Data, 2024, Data Page: Excess mortality: Cumulative deaths from all causes compared to
projection based on previous years, per million people. Data adapted from Human Mortality Database, World
Mortality Database, Karlinsky & Kobak, https://ourworldindata.org/grapher/cumulative-excess-deaths-per-
million-covid [online resource]
xxi Because the risk of dying from COVID-19 is much higher for older people, the death rate per head of population
was much higher for countries with older age structures – as is typically the case in high income countries (such
as those in the OECD). Globally, mortality per head of population was lowest for low-income countries (including
much of sub-Saharan Africa), and somewhat lower in many middle-income countries.
xxii In this context, excess mortality is the cumulative difference between the reported number of deaths since
1 January 2020 and the projected number of deaths for the same period based on previous years.
5.6.1.2
Effective protection of vulnerable populations
The need to protect vulnerable groups was an important consideration for decision-
makers in the decision to pursue an elimination strategy in the early stages of
New Zealand’s COVID-19 response. The experience of the 1918 influenza pandemic
and the Crown’s responsibilities to Māori under te Tiriti o Waitangi were prominent
considerations in the minds of senior officials and decision-makers, as were the many
pre-existing social determinants of health that disproportionately disadvantaged
particular ethnic groups, household types, income levels and disabled people.
One senior Ministry leader told us that ‘equity underpinned what we were doing from
the get-go, even if it wasn’t explicitly stated’. According to another, ‘We were conscious
of the toll of the 1918 pandemic on Māori and wanted to avoid a similar situation.
We were also conscious of the need to protect older people, especially those in aged
care, Pacific people, people with disabilities, and people in mental health institutions’.
Our assessment of the evidence overwhelmingly supports the conclusion that the
elimination strategy (and the public health and infection control measures that
enabled it) offered the best protection for the population as a whole, and greater
protection for Māori, Pacific people, older people and medically vulnerable people
than would have been possible with either a suppression or mitigation strategy.
The story is complicated, however, because these groups did experience more
severe impacts from COVID-19 than the general population. Severe illness from
COVID-19 was more common in less privileged ethnic and socioeconomic groups,
who were more likely to be hospitalised and to die from their illness.
Figure 3: COVID-19 case, hospitalisation and death rates by ethnicity,

2020–2022
Source: Based on data from Ministry of Health. Rates are age-standardised to the WHO world standard population.
In Figure 3, the risk of catching COVID-19 was fairly even across Māori, Pacific and
other ethnic groups (allowing for some slight differences in case detection rates).
However, adjusted for age, Pacific peoples were more than twice as likely to be
hospitalised and to die from COVID-19 compared with non-Māori non-Pacific
peoples (predominantly Pākehā or European New Zealanders).
Māori were nearly twice as likely to become severely unwell with COVID-19.xxiii
In relation to deprivation, people living in the most deprived neighbourhoods were
twice as likely to be hospitalised and to die from COVID-19 than those living in the
richest neighbourhoods (see Appendix B for more details). Such inequalities are in
part a function of different risk factors – such as higher rates of certain diseases,
or higher rates of smoking – that often occur together in low-income groups.
While such inequalities are certainly concerning, they are smaller than those seen
in previous pandemics.90 Historical examples including influenza pandemics in 1918,
1957 and 2009xxiv suggest that – in the absence of an effective elimination strategy
and vaccine rollout – the absolute gap in COVID-19 death rates between Māori/
Pacific people and people with European ethnicity would have been even higher.
While these conclusions about Aotearoa New Zealand are not directly comparable
with other countries (because of New Zealand’s unique population distribution and
ethnic make-up), they are consistent with international findings showing COVID-19
was more likely to cause severe infection in people with lower incomes, education
and/or poorer housing conditions.91
Although the 2021 Delta outbreak had a disproportionate impact on Māori and
Pacific communities, most New Zealanders (including Māori and Pacific people)
were not exposed to COVID-19 until the less virulent Omicron variant was circulating.
By this time, most had been vaccinated. Collectively, these factors – propelled by
the success of the elimination strategy – reduced the potential health impacts of
COVID-19 for everyone, including vulnerable groups.
Another success factor that helped prevent even greater illness and deaths
among at-risk groups was the mobilisation of these groups themselves, including
the rapid response by community health providers, iwi and Māori organisations,
and ethnic communities (see section 5.5.3.1). Some public submissions praised
Māori-led pastoral care and outreach to isolated community members, as well
as similar efforts by Pacific communities: according to one submitter, ‘Māori and
Pacific communities did the right thing by going door to door to people who
needed more understanding and assistance of the effects of COVID’.
Finally, it is worth addressing the extreme variation in COVID-19 death rates
between different age groups. This was a prominent feature of the pandemic, but
is sometimes missed (or treated as too obvious to mention). A global analysis of
COVID-19 death rates has found that a 90-year-old person infected with the virus
was approximately 10,000 times more likely to die from it than a 7-year-old.92 In
Aotearoa New Zealand, the vast majority of COVID-19 deaths and hospitalisations
also occurred among older people, but many more such deaths would have likely
occurred had the elimination strategy not been so effective.
xxiii For the 2020–2022 period, the relative risk of hospitalisation from COVID-19 was 1.85 for Māori and 2.71 for Pacific
peoples compared with other ethnicities (predominantly Pākeha/NZ European), while the relative risk of death was
1.91 for Māori and 2.22 for Pacific peoples. Rates are age-adjusted to the WHO world population.
xxiv In the 1918 influenza pandemic, Māori were seven times more likely to die than European New Zealanders of the
same age, while in the 1957 pandemic they were six times more likely to die compared with European New Zealanders.
Even in the relatively mild 2009 influenza (H1N1) pandemic, Māori had 150 percent higher mortality than European
New Zealanders, while Pacific people had more than four times the risk of dying.
5.6.1.3
People staying in hospitals and aged residential care settings
were well protected, but there were social costs
Given the greater susceptibility of older people and people who were already unwell
or immunocompromised, it was appropriate that hospitals, aged residential care
facilities, and other residential care settings should have strong infection control
practices in place during the pandemic. Such restrictions were also important to
protect staff and prevent these kinds of facilities from becoming sites of ‘super-
spreader’ events or major vectors of transmission back out into the community.
The importance of these measures was reinforced by five early COVID-19 clusters
in aged residential care facilities, one of which resulted in some of the first deaths
from COVID-19 in Aotearoa New Zealand.93
Aside from these early clusters, aged care facilities were highly effective in
protecting their residents from COVID-19 and New Zealand saw significantly fewer
aged care deaths during the pandemic, compared to other countries. Across the
two years from March 2020 until March 2022, mortality rates among aged
residential care residents were essentially the same as for the two years prior.
In 2020 and 2021, very few deaths with COVID-19 were recorded among aged
residential care residents, and where they were recorded, they accounted for
approximately one percent of monthly deaths. In contrast, by January 2021, it
was estimated that 75 percent of all COVID-19 deaths in Australia had occurred
among care homexxv,94 residents.95
New Zealand’s lower death rates in aged care facilities have been attributed to
the strict protective measures that were taken in these facilities (particularly strict
visiting protocols) and – from mid-2021 onwards – high vaccination rates among
residents. Overall, the aged care sector galvanised effectively to advocate for the
needs and interests of its residents, and was proactive in generating nationally
consistent and fit-for-purpose guidelines and advice for care homes.96 Beyond
the initial clusters, the overall absence of severe outbreaks in New Zealand’s aged
residential care facilities was a major success story of the pandemic. However,
this was not without harm for residents who lived through long periods of limited
contact with their loved ones.
New Zealand saw significantly

fewer COVID-19 deaths among
care home residents than
other countries.
xxv While the country comparisons in the report cited in endnote 94 include different forms of long term care, the 75
percent estimate for Australia is specific to aged residential care, https://www.health.gov.au/resources/collections/
covid-19-outbreaks-in-australian-residential-aged-care-facilities-2021
Negative impacts of strict visitor limits and reduced social contact
Prolonged social isolation and visitor restrictions are known to have negative
physical and emotional impacts on residents of aged care facilities, as well as their
families/whānau, and staff.97 This may be especially true for people with dementia,
to whom it could be challenging to convey the purpose and scope of the restrictions.
Other restrictions also took a toll, such as the inability of residents to gather for
communal meals, and the increased time involved in staff having to attend to each
resident separately. This is illustrated in the following excerpt from a public submitter:
“ I work in a resthome. We have had 2 outbreaks and 2 resulting deaths. […] Locking the
doors to family/friends was awful – I understand the need when we were trying to eliminate
Covid from the country, but it seemed inhumane later. Residents had meals in their rooms
on disposable plates etc and it was very obvious that the amount they ate was considerably
less than when in the dining room. Our dementia patients in particular need prompts of
seeing others eating to do the same. Keeping food hot was impossible. The time taken to
do tasks increased hugely. Most staff did their absolute best but we felt like we were
winging it at times.”
The Health and Disability Commissioner received many complaints in 2020 about
the impact of the pandemic on the health system, including visitor restrictions.98
When we met with the present Commissioner, she noted that visitor restrictions
are a very strong public health measure, and expressed the view that a more
compassionate, risk-based approach could have been applied, particularly later
in the pandemic.
Even once vaccination rates were high and Aotearoa New Zealand had transitioned
to the minimisation and protection strategy, some aged residential care providers
were slow to lower restrictions, despite official health advice that the risks to residents
were now lower. In advice to ministers at this time, health officials expressed concern
that this constituted an unfair restriction on the rights of aged care residents.
Prolonged social isolation and

visitor restrictions are known
to have negative physical and
emotional impacts on residents
of aged care facilities.
Similarly, the inability to visit loved ones in hospital – or be visited – was a
source of considerable hurt for many people during the pandemic. We received
public submissions that gave moving accounts from affected patients and family
members alike:
“ Being rushed to hospital because I had a racing heart […] My husband was not allowed
to come with me. I was so scared that I would die without my husband of 43 yrs plus
seeing my sons and grandkids.”
“ In September 2021 my sister was diagnosed with a return of her breast cancer which
was now terminal. As she lived in Auckland and I didn’t, it was extremely hard to take
the fact that I could not be of any assistance to her for her cancer treatment appointments
etc. as the border was closed. My sister died the day the Auckland lockdown was ending
at midnight.”
A qualitative study of visitor restrictions

in cases where people died alone
found evidence of deep distress, loss “ My birth experience was lonely. I wanted
of dignity, and long-term harm. Family my mother there but was only allowed
members in the study felt as though one person so I had my partner there who
they had abandoned their dying family was distraught at being back at the same
hospital his father had died at a few months
member, despite the circumstances
before. It was a lonely, isolating experience
beyond their control. Their associated to feel so on your own during birth. ”
grief was exacerbated by other losses
during COVID-19. Both clinicians and
family members involved in the study
questioned the level of compassion evident in the health system during this time.99
Senior DHB leaders told us in direct engagements that strict visitor policies were one
of the hardest public health protection measures for them to manage. Some told us
that these restrictions affected the provision of care to patients, relationships with
family and whānau, and expressed a view that they were too restrictive, especially
when people were dying and unable to have whānau present. We heard the view
that while well-intended, the personal consequences – and, in some cases, trauma
– caused by such restrictions will be enduring for many families. This view was also
evident in the public submissions we received.
5.6.2 COVID-19 revealed pressure points in the health system
that – if not addressed – may present risks in a future pandemic.
The overall story of Aotearoa New Zealand’s health system response to COVID-19 is a
complicated one. It is simultaneously a story of remarkable success at protecting public
health (via the elimination strategy) and a cautionary tale of potentially disastrous
pandemic impacts (on an already strained system) that were narrowly averted.
These are two sides of the same coin: had the elimination strategy not successfully
prevented the health system from being overwhelmed, the vulnerabilities revealed
and exacerbated by the pandemic might have had much greater consequences.
To borrow an eloquent phrase from the Health Quality and Safety Commission, the
pandemic added to ‘a rising tide’ of need in New Zealand’s health services, rather
than causing a ‘sudden tsunami’ as occurred in many other countries.100
The dual successes and challenges in the health system response to COVID-19
provide ample opportunities to learn from what occurred (and from what didn’t)
and to apply these lessons in preparing for future pandemics. We return to these
opportunities in the ‘Looking Forward’ parts of our report.
Some of the pressure points that COVID-19 revealed in New Zealand’s health
system – including workforce issues, ageing infrastructure, pandemic readiness,
regional inconsistencies and underlying health inequities – are assessed below. They
presented some significant risks; while not all of them were realised during
the COVID-19 pandemic, Aotearoa New Zealand may not be so fortunate next time.
5.6.2.1
Public health capacity to respond to a pandemic
Testing capacity
Individual diagnostic testing is a critical tool in any pandemic response and
underpins the effectiveness of many other response measures. For example,
being able to quickly and accurately determine whether or not someone has a virus
means that unnecessary quarantine of non-infected individuals can be avoided.
Aotearoa New Zealand’s capacity to carry out diagnostic testing was limited during
the COVID-19 pandemic in two ways: by the limited laboratory capacity to carry
out PCR tests, and by the slowness to approve alternative testing options.
PCR tests, which were the primary method of COVID-19 testing in Aotearoa
New Zealand for much of the pandemic, must be processed in a laboratory.
Most diagnostic laboratories in New Zealand are privately owned by a small
number of companies. Many are embedded in hospitals and only carry out work
for the public health system; others deliver a range of private laboratory services.
While this laboratory network stepped up in the face of COVID-19, the pandemic
severely strained New Zealand’s diagnostic testing capacity.
In early 2020, laboratories that could deliver PCR tests organised themselves into
a voluntary National Laboratory Network Group, which worked directly with the
Ministry of Health.101 Despite their competitive commercial relationship, laboratories
collaborated to ensure samples got processed, for example by sending samples to
other labs that had capacity.
As the pandemic wore on, the vulnerabilities in New Zealand’s diagnostic testing
system became more apparent. An article published in September 2020 provides
some early examples of the issues this caused:
“ Each individual lab was responsible for its own supply chain. Because global supplies
of the components needed for COVID-19 tests were severely constrained, the
every-lab-for-itself approach resulted in suboptimal results for the country as a whole.” 102
While many laboratory staff willingly stepped up and worked long hours in
challenging conditions, the negative ongoing impacts on the testing workforce
have been evident in subsequent strike action, with workers saying they are
burnt out from operating under poor conditions during the pandemic.103
A review carried out in May 2022 found that the Ministry had not communicated
anticipated increases in demand to laboratories, which might have helped ensure
sufficient testing capacity throughout the pandemic response.104 The review also
noted a lack of forward planning about how to build the capacity that might be
needed in future, since relying solely on PCR testing was only practical when
COVID-19 infection was uncommon and tests could therefore be pooled (see section
5.3.2.2). The authors concluded that the Government may not have fully understood
the capacity constraints mounting in the laboratory sector in late 2021. Their review
said the significance of positivity rates as an ‘advance indicator’ of PCR capacity
was not properly communicated to decision-makers – nor used meaningfully in
modelling – despite messaging from laboratories. This meant concerns about rising
positivity rates and the effects on testing capacity did not inform decisions about
when the shift to rapid antigen tests (RATs) would be needed.105
This contributed to the laboratory testing system becoming overwhelmed in
early 2022 when COVID-19 began to circulate widely.
The issue of capacity constraints in laboratories was connected with the lack
of alternative testing options. As we noted in section 3.2, the Government did
not approve the use or importation of RAT tests – which are self-administered
and give a result within 15 minutes – until late 2021. The lack of diagnostic
testing options outside of PCR tests caused frustrations for many, including
business representatives who told us that testing options which returned
rapid results should have been available sooner.
Some public submissions described the challenges of accessing PCR tests faced by
disabled people or those without access to a vehicle (for drive-through PCR tests).
“ My Aunt sat in her car with 2 masks on for five hours waiting to get a covid test. There’s
no way I could have gotten my ADHD Autistic son to wait that long, it would be cruel.”
“ When I had symptoms & needed to be tested I made repeated enquiries about arrangements
for those of us unable to drive […] My phone call resulted in the suggestion that I hire a taxi.
Somehow I don’t think a taxi driver would want to wait in a queue with me for hours coughing.”
“ Being able to access testing, and later test kits, for free was, I believe, absolutely essential.
We live in a low socio-economic area and I’m not sure that families here were really able to
afford multiple test kits, not with the cost of living crisis we’re currently in.”
Once the decision to transition to RAT testing was finally made in late 2021, the
rollout of tests was hampered by lack of supply. As imports of RAT tests had been
banned for most of 2020 and 2021,106 stockpiles had not built up in anticipation
of a change in testing strategy.107 Until adequate supplies could be secured, the
implementation of other public health measures – such as the use of testing
to determine whether people were safe to go to work – was hampered.
Once RAT tests were permitted and freely available, it was much easier for people
to take up voluntary testing.
More effective and efficient COVID-19 testing would have been achieved if there
had been more pragmatic use of alternatives to PCR tests (alongside PCR testing,
when higher accuracy was needed) and earlier planning for the rollout of RAT
tests. In planning for a scenario with a highly vaccinated population and less
reliance on stringent public health measures, the benefits of RAT testing should
have been seen in advance as outweighing their lower accuracy, and planned for
by ordering and stockpiling tests in advance of when they needed to be deployed.
Approving and acquiring RAT tests earlier may also have mitigated some of
the issues with laboratory capacity for PCR testing, ameliorated frustrations
experienced by businesses and individuals, and supported more effective
implementation of other public health policies.
Issues with COVID-19 testing reinforce the challenges created by a lack of
forward strategic planning and an overly narrow approach to risk assessment
and management (discussed in Chapter 2).
Under an elimination strategy, it was certainly beneficial to make use of high
accuracy PCR tests for suspected cases, close contacts and people working at
the border. However, for employers trying to get their businesses back up and
running after lockdowns, earlier access to quick, self-administered options like
RAT tests would have been very useful. Earlier access to RAT tests would also have
assisted with the transition from elimination to the ‘minimisation and protection’
phase of the response, when priority shifted from very high accuracy to higher
availability of COVID-19 tests. As it was, the pivot to RAT tests was hampered
by supply chain limitations and global shortages of key products, pointing to
additional areas in which future pandemic preparedness could be strengthened.
Contact-tracing capacity
The delivery of effective contact tracing during
the COVID-19 pandemic was a success, but also a Contact tracing is a vital
vulnerability in the early stages of the pandemic. tool in stamping out or
slowing down transmission
Contact-tracing capacity was very limited at the during a pandemic.
start of the pandemic,108 and it took time to be
scaled-up to an effective and integrated service.
Once it was in place, central coordination provided
for national consistency, but there were concerns that the system wasn’t sufficiently
flexible or responsive to the needs of vulnerable and high-risk people. We heard
that some groups, particularly Māori and Pacific people, were reluctant to engage
with ‘mainstream’ services and were more comfortable discussing who they may
have been in contact with when the contact tracer was someone from their own
community. Given the critical importance of rapid contact tracing for the effective
isolation of positive cases, these issues should be addressed to be better prepared
in the future.
The platform developed by the Ministry of Health’s digital team in response to COVID-19,
the National Contact Tracing Solution, was key to making national contact tracing
operate smoothly. Health staff emphasised that such fundamental technology should
be maintained so it can be quickly deployed in a future pandemic. We are not aware
of a formal evaluation of the quality of contact tracing in Aotearoa New Zealand as it
evolved in 2020, driven by the National Contact Tracing Solution. In our engagements
we heard that while there were some initial challenges with the IT platform, overall it
worked well, and that local efforts to scale-up contact tracing, including bringing in
new contact tracers under the supervision of experienced staff, paid off.
The COVID Tracer App was a ubiquitous part of many New Zealanders’ experience
of the pandemic. We heard through public submissions that many people found the
app easy to use and a useful reminder to be conscious of COVID-19 precautions.
“ The use of the Covid app was fantastic and provided a degree of comfort knowing
your potential exposure would be notified to you.”
However, the app may not have been as useful for contact tracing as was
envisaged (see also Chapter 8). Recent research from the University of
Otago has concluded:
“ The QR-code-based function of the NZCTA likely made a negligible impact on the
COVID-19 response in New Zealand in relation to isolating potential close contacts
of cases but likely was effective at identifying and notifying casual contacts.” 109
Contact tracing, along with accurate testing and effective isolation and/or treatment
options, is a vital tool in any pandemic response. The fact that there was no national
contact-tracing capability before COVID-19 exposed this vulnerability in our public
health system. In the event, the Ministry of Health was able to rapidly establish the
National Close Contact Service and evolve this service as the pandemic progressed.
But with better preparation, Aotearoa New Zealand could be more confident that
such a system can be quickly scaled-up, and be effective, in another pandemic.
5.6.2.2
Hospital and system capacity to manage an infectious outbreak
Intensive care capacity
As noted in section 5.4.1.2, Aotearoa New Zealand had limited intensive care
capacity going into the pandemic. Evidence available to our Inquiry suggests this
was not substantially increased during the first two years of the COVID-19 response,
although in early 2022, $100 million capital funding and $544 million operational
funding was agreed for enhanced ICU capacity.
Figure 4. Capacity of intensive care beds in selected OECD countries,

2020 (or nearest year)
Source: OECD, 2020, Beyond containment: Health systems responses to COVID-19 in the OECD,
OECD Policy Responses to Coronavirus (COVID-19), https://doi.org/10.1787/6ab740c0-en.
Health system capacity includes staff, supplies and space.110 In the case of capacity
to manage ventilated patients, the availability of trained staff and suitable hospital
accommodation is just as critical as the availability of ventilators. While Aotearoa
New Zealand reportedly acquired additional supplies of ventilators in the first year
of the pandemic,111 and non-ICU nurses received some training in preparation for
a surge in demand,112 critical care nurses expressed doubt that there had been
a surge in staff training or numbers.113
Because of the effectiveness of the elimination strategy and subsequent vaccine
rollout, Aotearoa New Zealand never experienced the dramatic peaks in illness
that overwhelmed hospitals in many other countries. We were therefore fortunate
that our capacity to care for patients needing ventilation was never tested, and
the absence of meaningful expansion in 2020 and 2021 did not limit our
pandemic response.
Workforce issues
The health system was experiencing many long-standing and destabilising
workforce issues entering the pandemic, which complicated both the health system
response to COVID-19 and the continuous delivery of ‘business as usual’ healthcare.
The Inquiry heard that – pre-COVID-19 – longstanding budgetary constraints
meant the public health workforce (responsible for public health activities such as
contact tracing) had limited ability to develop its capacity or to build the kinds of
relationships with local communities that would be needed in a pandemic response.
Across the wider health workforce, key challenges included widespread staff
shortages, pay equity issues within and between disciplines, high staff turnover
and a high incidence of work-related stress, burnout and mental health challenges.
The health workforce had not increased in line with growing population health
needs, was not representative of the population being served and in parts
of the sector was ageing (especially in general practice, aged care and home
care). Some services (such as palliative care, home and community support and
ambulance services) relied heavily on volunteers, which became a vulnerability
where volunteers were older people who were being advised to stay at home.114
There were persistent staff shortages in many disciplines, including midwifery,
sonography, clinical psychology, disability support and community health workers,
and healthcare workers in rural areas.115 These issues were not unique to Aotearoa
New Zealand, and will remain a major issue for many countries in future pandemic
preparation, response and recovery.
Pandemics can have a severe physical and psychological toll on health workers.
In Aotearoa New Zealand, the health system response to COVID-19 stretched
the workforce and exacerbated many pre-existing issues. This was despite the
elimination strategy preventing substantial waves of COVID-19 infection and
hospitalisations in 2020 and 2021, which greatly reduced the pressures on the
health system and staff compared to those endured in other countries.
The health workforce had to deal with multiple challenges – including long working
hours, difficulty accessing PPE (particularly in primary and community care), fear of
the virus or of transmitting the virus, being personally attacked for doing their job,116
having to adapt to constantly changing information and the sense that the pandemic
was relentless. As well as evidence from professional bodies and colleges, we heard
direct accounts from health professionals about some of these challenges in our
public submissions. Some health workers who made public submissions described
working during the pandemic as ‘stressful’, ‘overwhelming’, and ‘terrifying’.
“ Heading into the initial stages of the pandemic was extremely worrying. We had been
viewing colleagues’ experiences overseas and had no doubt we were in for the same
bumpy ride... not having enough PPE, being overwhelmed with patients, and being at
risk of death or morbidity from covid ourselves.”
“ As a Registered Nurse it was fundamental to assist in stopping the spread fast […] Our
lives changed, and for a few months we did not see our 14 year old daughter due to us
not wanting to make her unwell and vice versa, especially due to my work.”
However, submissions and engagements also showed how vital and valuable health
workers felt at the beginning of the pandemic. As one health professional told us:
“ I love a good crisis – it was exciting to know we could make a difference. It’s what we trained
for, and it was great to be able to put my knowledge to work.”
Health workforce leads from Health New Zealand |Te Whatu Ora noted that
staff turnover at this time was low.
We heard from many sources – in both direct engagements and written evidence
– that the health workforce is in a worse position now than before COVID-19, as a
direct result of pandemic pressures.117 While this situation is not unique to Aotearoa
New Zealand, it is nevertheless serious, for many reasons – not least for future
pandemics. In 2023, Health New Zealand | Te Whatu Ora estimated the health
system had a shortfall of around 4,800 nurses, 1,700 doctors (including general
practitioners), and 1,050 midwives.118 The agency
acknowledged that the workforce ‘has been
under too much pressure for too long’ with the
pandemic contributing to attrition in key roles “ I have immense pride for what our
PHO contributed, but also total
(such as midwifery).119 The difficult experience
exhaustion. The three plus years
of working through the pandemic – and its of the pandemic has meant so much
impact on staff retention – is highlighted in the of our lives have been put on hold. ”
following comments from health workers who
made public submissions:
“ It was all-consuming – in the PHO backrooms we lived and breathed COVID-19 non-stop,
7 days a week. It felt like we could never get away.”
“ Working through the pandemic broke me, as it did many of my friends and colleagues.
I am not the same person I was before the pandemic and I can see why many left the
profession. We were used as workhorses but we were burnt out from being overworked
before the pandemic started and it only got worse.”
5.6.2.3
Ability of the wider system to deliver ongoing non-pandemic care
From the evidence we have seen and heard, it seems many DHBs took a strongly
and often overly precautionary approach to managing the risk of COVID-19
transmission in healthcare settings throughout the pandemic period.
This led to many services being paused or limited for long periods. Impacts included
delayed diagnosis and treatment (including potentially serious conditions such
as cancer,xxvi diabetes, stroke and heart disease), and missed opportunity for
preventive care (such as childhood immunisations). Some of these impacts are
still being felt.
Assessing pandemic risk

As set out in sections 5.4 and 5.5 earlier in this chapter, the main mechanism used
for scaling ‘business as usual’ health service provision up or down according to
the demands and risks posed by COVID-19 was the National Hospital Response
Framework. At ‘red’ level, hospitals were encouraged to discharge as many patients
as possible and cancel any non-emergency surgery to ensure all available capacity
was available to respond to COVID-19.
We have requested, but have not received, any evidence documenting how
many DHBs assessed themselves at each risk level and for how long throughout
the pandemic.
However, we heard from several stakeholders that many DHBs held themselves at ‘red’
for long periods. Several – including senior officials and former ministers – expressed
frustration about this. We heard it called a ‘misuse’ of the framework, while others
expressed the view that too many services were cancelled, for too long. One senior DHB
leader put it simply, saying ‘We didn’t need to defer as much planned care as we did’.
Some public submissions to our Inquiry illustrated the real life – and sometimes
tragic – consequences of this deferred care for patients and their family members:
“ I had an injury during covid that needed surgery – it took 9 months to get an MRI to diagnose
the issue and 15 months to have the surgery. The delay was because the local health system
didn’t have capacity to see me to organise a referral, and then hospitals lacked space for me
to have surgery.”
“ All non-urgent appointments were deferred. This was an urgent and necessary diagnostic
appointment that should still have gone ahead. You do not mess with cardiac concerns.
Nobody could have foreseen the outcome, but the one month appointment delay was
simply more time than my father’s heart could take and he died in the street from a massive
heart attack, four days shy of his rescheduled angiogram appointment. In my eyes, he is
a Covid casualty.”
xxvi Though in the case of cancer care, service provision was largely maintained through a range of efforts – see the
spotlight on cancer care during the pandemic in section 5.5.3.
Inconsistencies also seem to have occurred in the way the national response
framework was applied from region to region, at least in the early stages of the
response. In April 2020, the Health and Disability Commissioner wrote to the
Minister of Health expressing concern that DHBs were not applying the framework
consistently. The letter noted ‘unwarranted inconsistencies’ between DHBs in how
services were accepting GP referrals, which services were being withdrawn, and
which planned care was being cancelled:
“ The system needs to operate in a nationally consistent and coherent way. Geographical
inequities in services is already an issue I see across complaints to my Office, and I am
concerned that this will be exacerbated by current sector behaviour. While I recognise that
each DHB will need to respond to its particular service pressures and the complexities and
risk profile of its local population, it is my expectation that there is consistent nationally
mandated behaviour among DHBs within each alert level.” 120
The letter also pointed to a confusion between the national Alert Level System and
the National Hospital Response Framework, noting that ‘elements of overlap, and
a lack of clarity as to the interaction of these two frameworks, have led to some
confusion in service decisions’.121
The Ministry of Health subsequently made minor modifications to the decision-
making framework,122 but senior stakeholders we met with still expressed the view
that non-COVID-19 care had been disrupted to
a greater extent than was necessary during
the pandemic response.
The pandemic is thought to
have contributed to reductions
Impacts of deferred and delayed care
in childhood immunisations
To the extent that it is possible to measure and screening for some
them, the pandemic’s disruptive effects cancers – particularly for
Māori, Pacific people and
on the provision of non-COVID-19 health
families living in poverty.
services have been documented by the
Health Quality and Safety Commission in
two reports in 2022 and 2023. Among its
conclusions are that the pandemic contributed to:
• Reductions in the rate of childhood immunisations, with coverage for six-
month-olds falling from 80 percent in 2020 to 66 percent in 2022, and
coverage for 24-month-olds falling from 91 percent to 83 percent in the same
period. Māori and Pacific babies, and babies in families living in poverty, were
particularly impacted.123
• Reductions in rates of screening for breast and cervical cancer, with breast
screening falling from 72 percent in 2019 to 66 percent in 2020 and remaining
at a lower level two years later. Pacific women experienced the greatest
change, and coverage for Māori remained the lowest for any ethnicity. Cervical
screening rates (which had been slowly declining since 2016) fell more sharply
in 2020, and – after a slight uptick in 2021 – were by 2022 at their lowest level
in 14 years, at 67 percent.124
• A ‘clogging’ of access to planned care, with the percentage of patients waiting
longer than four months for their first specialist appointment increasing
substantially, particularly during 2021. Meanwhile, the number of patients
who, once seen, were given a commitment to treatment but did not receive it
within four months more than doubled from 2021 to 2022.125
Monitoring and responding in real time

Early in the pandemic, the Ministry of Health sought funding to address healthcare
backlogs occurring as a result of service disruption during the first pandemic
lockdown. With $285.5 million of funding over three years, the Waiting List
Initiative was intended ‘to address the COVID-19 backlog and reduce planned care
waiting lists impacted by the response to COVID-19’.126 DHBs were asked to submit
‘Improvement Action Plans’ detailing how they would tackle the backlog of deferred
care from the initial 2020 lockdown, which the Ministry estimated to have resulted
in approximately 114,000 cancelled health appointments.127 Such plans were
expected to include additional clinics and theatre sessions and possible use of
private providers.
However, we have not been able to find evidence that the Ministry of Health
actively monitored the impacts of the COVID-19 response on provision of non-
pandemic care. The Ministry did not publish any follow-up reports on healthcare
disruption after an initial one following the first COVID-19 outbreak.128 We were
also unable to find evidence that the Ministry sought to change guidance to DHBs
or to increase prioritisation of non-pandemic care in the COVID-19 response.xxvii
We acknowledge that health officials and DHB staff were working under
extreme pressure through much of the pandemic period and may have lacked
the ‘bandwidth’ to address all of the many unanticipated consequences of the
COVID-19 response. It is also unclear to what extent ministers were prioritising
non-COVID-19 care in their decision-making or requests for advice. At the same
time, the example of cancer care (see Spotlight) illustrates that it is possible to
more effectively protect delivery of non-pandemic care, particularly where
there is effective real-time monitoring of service delivery and focused innovation
to deliver care through alternative models.
xxvii The Inquiry sought evidence on what processes the Ministry of Health had for monitoring the impact of
COVID-19 on health care disruption, for reviewing guidelines in response to such information, and on what
measures were taken to support the health system in recovering from the disruption resulting from the
COVID-19 response. The Ministry had not provided this information at the time of writing.
In direct engagements, Ministry of Health officials told us about their frustrations
with the lack of real-time data on health system capacity, underpinned by
inadequate IT systems:
“ … where we were at the start of the response, trying to get numbers out of different parts
of the country, e.g. bed occupancy data, we were ringing places, there were calls to wards…
a fairly painful process. But the bare bones of the information we needed was there and
a whole bunch of reporting was stood up quickly, got into a rhythm that worked. Looking
forward, you definitely want to do this in a more robust and reliable way.”
In 2022, the newly-formed Health New Zealand | Te Whatu Ora acknowledged

that ‘several thousand people are waiting more than 12 months for access to an
array of services, despite a maximal waiting time requirement of four months; and
many thousands more are waiting between four and 12 months.’129 The agency
launched a Planned Care Taskforce aimed at reducing waiting times and eliminating
‘the growing inequity of access affecting Māori and Pacific on planned care waiting
lists’.130 The Taskforce Plan described the pandemic as having had ‘a profound
adverse effect’ on waiting lists, but noted that waiting times had been increasing
even before this occurred.
The intent of the national response framework (and associated guidance) was
to balance the need for ‘usual’ healthcare with the need to protect capacity for
responding to surges in COVID-19. Implicit in this is an understanding that the
extent to which other services were deferred or cancelled would be adjusted in real
time in response to the changing level of COVID-19 risk to the health system.
In this respect, the evidence we have heard and reviewed suggests the framework did
not work as well as intended. At times when community transmission of COVID-19
was occurring and growing – in early 2020 heading into the first national lockdown,
for example, or during the Delta outbreak in late 2021 – it is understandable that
many non-COVID-19-related procedures would be deferred or cancelled. However, by
mid-2020, the elimination strategy had succeeded and there followed a long period
with no community transmission. From our understanding of the evidence we have
reviewed and the stakeholders we have spoken to, it seems that during this period,
more non-COVID-19-related care could have resumed – and sooner – than it did.
Innovating to ensure continuity
Despite these challenges, many parts of the health system worked hard to ensure
that as much care as possible could continue to be delivered during the pandemic.
Many primary care practices adapted quickly, for example, by moving to telephone
or video conference appointments. While these could be challenging, such
innovations also made access easier in some contexts, for example for people who
faced long travel times to get to a doctor’s office. Healthcare providers adapted to
using new channels of communication such as social media to provide information
to their patients.
Innovation was also evident in the way the vaccination workforce was expanded.
The category of health professionals who could administer vaccines was expanded
to include non-regulated healthcare professionals such as healthcare assistants,
with training provided. Qualified health professionals with inactive practising
certificates were also encouraged to come back to the workforce to support several
COVID-19 initiatives.
COVID-19 also provided the catalyst for some changes that had long been needed
but not quite made it over the line, such as the introduction of e-prescriptions.
Many similar adaptations introduced during the pandemic have continued to be
used by healthcare services to provide extra flexibility for their patients.
Healthcare providers
adapted to using new
channels of communication
such as social media to
provide information to
their patients.
1. Aotearoa New Zealand’s health system – like those of

other countries – was not well prepared for a pandemic
of the scale and duration of COVID-19.
• While the country had done fairly well in recent assessments of pandemic
preparedness, meeting the demands of the COVID-19 response required
‘significant, extraordinary sector-wide effort’.
• Publicly funded health services faced long-standing challenges with
workforce capacity, financial deficits and long waiting lists for some
planned healthcare. These issues were exacerbated by the demands
the pandemic placed on the health system.
2. The elimination strategy was highly effective in

preventing the health system from being overwhelmed
and protecting vulnerable groups, although there were
notable costs.
• By preventing widespread COVID-19 infection until the population was
vaccinated and the virus had become less deadly, the elimination strategy
prevented the premature deaths of thousands of New Zealanders –
particularly older people, Māori, Pacific peoples, and people living with
disabilities or medical vulnerabilities.
• Peak hospitalisation rates in Aotearoa New Zealand (in March 2022) were
around half those in the United Kingdom (January 2021) and the United
States (January 2022). Unlike other countries, New Zealand recorded very
few COVID-19 deaths among people living in residential facilities such as
aged care homes.
• While strict public health and infection prevention measures were
effective in keeping people safe from COVID-19, this came at a significant
human cost. People who were in aged care, in hospital or who were sick
or dying were isolated from families and loved ones, causing distress and
suffering to many.
3. While many people and organisations worked hard to provide
effective public health and clinical care, the pandemic exposed
some key vulnerabilities and pressure points in our health system.
• There was a scramble to scale-up public health functions such as testing and
contact tracing, which started from a low baseline. Given this starting point, the
expansion of these functions was generally done well, although limited forward
planning and flexibility caused problems in some areas (such as the shift in
COVID-19 testing from PCR to RAT tests).
• Dated infrastructure made it difficult to apply best-practice infection control
measures, including air ventilation, in many healthcare facilities. However,
innovative approaches and substantial effort by staff produced good results.
• Although efforts were made to expand health system capacity in areas such
as caring for ventilated patients, we did not find evidence of sustained
increases in capacity during the pandemic.
• While the country’s health system was never overwhelmed by people sick
from COVID-19 (as happened internationally), the pandemic took a substantial
toll on healthcare workers. An already stretched health workforce is now in
a worse position because of the pandemic, representing a key vulnerability
for the health system going forward.
4. Provision of non-COVID-19 care was substantially disrupted

during the pandemic, to a greater extent than was necessary.
• Many parts of the health system – including general practices, Māori and
Pacific providers, emergency departments, pharmacies, midwifery, cancer
services and others – worked extremely hard to deliver as much care as
possible during the pandemic.
• With hindsight, the health system took an overly cautious approach to
reducing non-COVID-19 care in order to protect its capacity to provide
pandemic-related care. This resulted in avoidable delays or omissions in
healthcare, with ongoing consequences for the health of those affected.
• Efforts were made to balance the risk of hospitals being overloaded with
the need to continue delivering necessary care, but effective decision-making
was hampered by a lack of real-time data on hospital capacity, occupancy
and staffing levels. Improving data systems and infrastructure to support
smart decisions about the utilisation of resources would be beneficial not
only in a future pandemic, but in general.
• Delays in providing healthcare had significant negative impacts on the
health of New Zealanders. The Health Quality and Safety Commission
found the pandemic contributed to lower childhood immunisations,
reduced participation in cancer screening programmes, and increased
waiting times for specialist care and planned surgery.
Endnotes |
5.8 Tuhinga āpiti
1. Ministry of Health, Aotearoa/New Zealand’s COVID-19 13. Department of the Prime Minister and Cabinet,
elimination strategy: an overview, 7 April 2020, pp 5-6, COVID-19 National Response Plan Quarter 2 (16 April
https://www.health.govt.nz/system/files/documents/ 2021), p 11, https://www.dpmc.govt.nz/sites/default/
publications/aotearoa-new_zealands_covid-19_ files/2023-01/National-Response-Plan-Quarter-2.pdf
elimination_strategy-_an_overview17may.pdf 14. Ministry of Health, COVID-19 Health and Disability
2. Ministry of Health, Briefing to the Incoming Minister of System Response Plan (Wellington, 15 April 2020),
Health, 2017: The New Zealand Health and Disability p 1, https://www.health.govt.nz/publications/covid-19-
System (Wellington, 7 December 2017), https://www. health-and-disability-system-response-plan
health.govt.nz/publications/briefing-to-the-incoming- 15. Nigel French, Howard Maxwell, Sue Huang, Fiona
minister-of-health-2017-the-new-zealand-health-and- Callaghan, Kristin Dyet, Jemma Geoghegan, David
disability-system-0 Hayman, Amanda Kvalsvig, Michael Plank, and Pippa
3. Waitangi Tribunal, Hauora: Report on Stage One of the Scott, Likely future pandemic agents and scenarios: An
Health Services and Outcomes Kaupapa Inquiry (Lower epidemiological and public health framework, Te Niwha
Hutt, 2023), https://forms.justice.govt.nz/search/ (November 2023), https://www.teniwha.com/research-
Documents/WT/wt_DOC_195476216/Hauora%20 projects/likely-future-pandemic-agents-and-scenarios
2023%20W.pdf 16. Ayesha Verrall, Rapid Audit of Contact Tracing for
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Scott, and Diana Sarfati, ‘The impact of the COVID-19 Psychology, Victoria University of Wellington, 2024),
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media/mpcbjbn2/briefing-to-the-incoming-minister- 110. Cabinet Paper and Minute, COVID-19: Alert Level
10-nov-2020.pdf Framework for Levels 1, 2, and 3: Details and
99. Aileen Collier, Deborah Balmer, Eileen Gilder, and implementation, CBC-20-MIN-0041, 15 April 2020, p 6,
Rachael Parke, ‘Patient safety and hospital visiting https://www.dpmc.govt.nz/sites/default/files/2023-01/
at the end of life during COVID-19 restrictions in Alert-Level-Framework-Details-and-Implementation.pdf
Aotearoa New Zealand: a qualitative study’, BMJ 111. Emma Russell, ‘Covid 19 coronavirus: Hundreds
Quality & Safety 32, no. 12 (14 February 2023), 704-711, of ICU-ventilators have arrived to ‘future-
https://doi.org/10.1136/bmjqs-2022-015471, https:// proof’ New Zealand’, The New Zealand Herald, 9
qualitysafety.bmj.com/content/qhc/32/12/704.full.pdf September 2020, https://www.nzherald.co.nz/nz/
100. Health Quality & Safety Commission, A window covid-19-coronavirus-hundreds-of-icu-ventilators-
on quality 2022: COVID-19 and impacts on our have-arrived-to-future-proof-new-zealand/
broader health system (Part 2) (Wellington, 1 June QWBNSR5DREPH3XHJ6SJRBHN75A/
2023), p 17, https://www.hqsc.govt.nz/resources/ 112. New Zealand Parliament, Inquiry into the Government
resource-library/a-window-on-quality-2022-part-2- response to COVID-19 – Hansard transcript of 31
whakarapopototanga-matua-he-tirohanga-kounga- March 2020, p 22, https://www.parliament.nz/en/
2021-wahanga-2/ visit-and-learn/history-and-buildings/special-topics/
101. Allen + Clarke, COVID-19 PCR Testing Backlog: Rapid epidemic-response-committee-covid-19-2020/
review, Ministry of Health (Wellington, 4 May 2022), p hansard-transcripts-epidemic-response-
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march-2020/
102. Blair Cameron, Captaining a Team of 5 Million: New
Zealand Beats Back Covid-19, March – June 2020, 113. RNZ, ‘ICU surge capacity: Nurses question training and
Innovations for Successful Societies (September numbers’, 19 November 2021, https://www.rnz.co.nz/
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publications/captaining-team-5-million-new-zealand- question-training-and-numbers
beats-back-covid-19-march-%E2%80%93-june-2020
114. Jason K. Gurney, Elinor Millar, Alex Dunn, Ruth Pirie, 121. Anthony Hill (Health and Disability Commissioner) to
Michelle Mako, John Manderson, Claire Hardie, Chris David Clark (Minister of Health), GP referrals and access
G. C. A. Jackson, Richard North, Myra Ruka, Nina to hospital services, 16 April 2020, https://www.hdc.org.
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pandemic on cancer diagnosis and service access in 122. Ministry of Health, COVID-19 National Hospital
New Zealand-a country pursuing COVID-19 elimination’, Response Framework, H202117544, obtained under
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6065(21)00036-5/fulltext Ministry of Health, COVID-19 Community Response
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health.govt.nz/publications/health-and-disability- community-response-framework-v30-final.pdf
system-review-final-report 123. Health Quality & Safety Commission, A window on
116. Sarah Johnson, ‘Spat at, abused, attacked: healthcare quality 2022: COVID-19 and impacts on our broader
staff face rising violence during Covid’, The Guardian, health system (Part 2) (Wellington, 1 June 2023),
7 June 2021, https://www.theguardian.com/global- pp 30-31, https://www.hqsc.govt.nz/resources/
development/2021/jun/07/spat-at-abused-attacked- resource-library/a-window-on-quality-2022-part-2-
healthcare-staff-face-rising-violence-during-covid whakarapopototanga-matua-he-tirohanga-kounga-
Otago Daily Times, ‘Covid 19 Omicron outbreak: 2021-wahanga-2/
Nurses abused over virus safety precautions’, 124. Health Quality & Safety Commission, A window on
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Stephen Forbes, ‘Covid-19: Union and frontline whakarapopototanga-matua-he-tirohanga-kounga-
worker say staff at Middlemore Hospital facing 2021-wahanga-2/
increasing abuse’, Stuff, 8 March 2022, https://
125. Health Quality & Safety Commission, A window on
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broader health system (Part 2) (Wellington, 1 June
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resource-library/a-window-on-quality-2022-part-2- 127. Cabinet Paper, Planned Care $282.5 Million COVID-19
whakarapopototanga-matua-he-tirohanga-kounga- backlog and waiting list initiative, p 2, https://covid19.
2021-wahanga-2/ govt.nz/assets/Proactive-Releases/proactive-release-
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118. Health New Zealand Te Whatu Ora, Health workforce
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tewhatuora.govt.nz/publications/health-workforce- 128. Ministry of Health, COVID-19 disruptions to hospital and
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119. Health New Zealand Te Whatu Ora, Health workforce
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tewhatuora.govt.nz/publications/health-workforce- 129. Health New Zealand Te Whatu Ora, Planned Care
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120. Anthony Hill (Health and Disability Commissioner) to
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planned-care-taskforce-reset-and-restore-plan/
CHAPTER 6:
6 Economic and social

impacts and responses |
Ngā pānga me ngā
urupare ōhanga me
te pāpori
Introduction |
6.1 Kupu whakataki
The strict public health measures introduced in March 2020, especially the border
closure and national lockdowns, were essential to protect the economy and society
from the immediate and devastating effects of the pandemic if the virus had been
allowed to spread unchecked. However, they placed significant pressure on the
economic and social fabric of Aotearoa New Zealand. Over the next two years and
beyond, this pressure affected the incomes of many households and businesses,
housing, employment, the supply chains New Zealanders relied on for essential
goods and services, and nearly every other area of the economy. The pandemic also
highlighted or exacerbated many existing social challenges – including unaffordable
housing, high rates of mental ill health, long-standing inequities for Māori and other
groups, and the persistent disadvantage experienced by a significant proportion
of the population. Even people who were doing well before the pandemic found
themselves struggling; financially, emotionally and socially. Some were more
susceptible to loneliness and isolation; others suddenly had to get by with less
income, while for some, their previously manageable living arrangements became
unsafe. The Government’s response sought to mitigate many of these factors,
although in some cases it may have made them worse (demonstrated by house
price increases, for example).
The wide-ranging social and economic effects of the pandemic, and of the
Government’s response to it, are the subject of this chapter.
• The first part of this chapter focuses on how the economy

was affected by COVID-19 over time, and the economic and
fiscal policies (and other measures) Government introduced in
response. After a period of initial uncertainty, the Government’s
economic response came in three successive waves which
are described in section 6.2.1.2. In section 6.2.1.3, we turn our
attention to the monetary policy response led by the Reserve
Bank of New Zealand, to ensure that financial markets at large,
and the banking system specifically, continued to operate
efficiently and safely. Our description of the economic response
ends with an overview of the steps the Government took to
protect international and domestic supply chains (section 6.2.1.4).
• In section 6.3, we move from description to evaluation.
We start by assessing the outcomes of the Government’s
economic response, both positive and negative, and how they
affected households, businesses, the workforce and supply
chains. We also considered the longer-term legacy of both the
pandemic and the response – which, the evidence shows, had a
sustained economic tail of higher inflation and living costs that
is likely to involve a protracted period of lower productivity,
lower economic growth, and widening inequalities in wealth.
As we make clear throughout the chapter, these outcomes can
only partly be attributed to the pandemic and the nature and
timing of Aotearoa New Zealand’s domestic policy responses.
We provide frequent international comparisons to help clarify
the broader global picture.
• In the second part of the chapter, we examine the social aspects
of the COVID-19 response. Section 6.4 describes the measures
the Government put in place to ensure people had sufficient
social support to weather the pandemic’s impacts, and to comply
with public health measures. Some government agencies made
significant changes to their usual operating models, partnering
with community groups, and adopting innovative and flexible ways
of working. Communities, iwi and Māori, volunteers and other
groups also stepped up and often took the lead on the ground,
ensuring their people had the support and services they needed.
These local responses are described in section 6.4.2.2.
• Having described the social sector landscape, section 6.5 presents
our assessment of the pandemic’s many social impacts – including
on vulnerable groups – and the extent to which the response was
effective in addressing or mitigating them.
• Finally, section 6.6 offers some reflections on the long tail of social
and economic after-effects which were created or exposed by
the pandemic. As of late 2024, many continue to reverberate;
others are only just emerging. More are likely to reveal themselves
in the years to come, emphasising that – even while we turn our
minds to the challenge of preparing better for the next pandemic –
the impact of the COVID-19 pandemic is still far from over.
What happened: economic impacts and responses |
6.2 I aha: Ngā pānga me ngā urupare ōhanga
6.2.1 What happened

The COVID-19 pandemic was a global event, and its impacts on Aotearoa
New Zealand’s economy cannot be separated from global economic conditions
that existed when it started or were created by it. We touch on these influences
and draw brief international comparisons throughout this chapter.
Broadly speaking, New Zealand’s economic response to the pandemic, as well
as the trajectory of economic developments that unfolded, were in line with
what happened elsewhere.1 There were some differences that can be attributed
to both the relative generosity, and extended duration, of New Zealand’s
economic response.
Central government borrowedi and reprioritised existing spending to fund the key
elements of the pandemic response – from scaling-up critical public health functions
like contact tracing, to providing wage subsidies for affected workers, delivering
housing and social support to help people isolate safely, and offering support for
businesses and recovery initiatives. These actions were aimed at supporting strict
public health measures including border closures, temporary lockdowns and social
distancing, while also cushioning their adverse economic and social impacts.2
The Reserve Bank of New Zealand took early action simultaneously with central
banks around the world, to address vulnerabilities in global financial markets. It
supported the economic response by purchasing debt on the open market, a move
intended to lower interest rates and allow financial markets and the banking system
to keep functioning. The Reserve Bank also prioritised ensuring households and
businesses had ongoing access to credit, at reasonable rates.
6.2.1.1
Initial uncertainty
Very early in 2020, there were perceptions that COVID-19 might be similar to
the 2002-2004 SARS outbreak, which had a relatively small economic impact on
Aotearoa New Zealand.3 By late January and early February 2020, however, it
became apparent to both the Treasury and the Ministry of Business, Innovation
and Employment that the outbreak of COVID-19 in China had already started
creating difficulties for New Zealand export sectors that were particularly exposed
to the Chinese market (specifically forestry, rock lobsters and tourism) and
that these difficulties would likely only increase.
As more information came to light from around the world, the Treasury worked
on scenarios and an initial framework for policy responses. In early March 2020,
it provided advice to Ministers on an overall intervention strategy for economic
policy.4 The briefing noted that New Zealand was likely to face a long-lasting
economic shock and set out potential components of an economic response.
They included a targeted wage subsidy scheme, a broader package of options
to support economic activity, and a large fiscal stimulus package.
i By issuing government debt.
This briefing suggested a set of principles to guide any economic response: that
it should be balanced and proportionate, aligned with the broader Government
direction, sustainable, easy to implement and adopt a ‘least regrets’ii approach.5
It also advised caution, and referred to potential long-term fiscal sustainability
challenges and the need for robust exit strategies.
In these early stages, there was deep uncertainty about the potential economic
impacts. Subsequent scenario-based estimates which the Treasury developed in
April 2020 suggested that GDP might fall by between 13 and 33 percent, and that
the unemployment rate might climb to as high as 13 percent, or even up to 26
percent in the most severe scenario.6 These highly pessimistic scenarios did not pan
out, no doubt partly because of the policy responses Government introduced. In
reality, while GDP fell sharply in the first quarter of 2020, as an annual measure it
fell by only 2 percent.7 Unemployment peaked at 5.2 percent in mid-2020, from a
pre-pandemic level of 4.1 percent.8 No doubt, these better-than-scenario outcomes
reflected, at least in part, the speed and generosity of the Government response.
Figure 1: GDP 2017–2023, quarterly and annual change
Source: Based on data from Stats NZ, 2024, Gross domestic product (GDP),
https://www.stats.govt.nz/indicators/gross-domestic-product-gdp/
ii A ‘least regrets’ approach to decision-making is one that aims to minimise the risk of the worst possible outcomes.
6.2.1.2
The trajectory of the Government’s economic and fiscal
policy response
The main economic policy agencies (led by the Treasury and the Ministry of
Business, Innovation and Employment) advised an all-of-government approach
to developing and managing the Government’s fiscal and broader economic
policy response to the pandemic. The response was developed with Ministers
and agreed by Cabinet.
The Government initially used a ‘3 waves’ model to structure its economic
response. The model was based on a standard adverse events recovery framework
used by the Organisation for Economic Co-operation and Development (OECD).
It was explained to the public by then-Finance Minister Grant Robertson on
24 February 2020.9 A few days later, he described the successive phases of
the economic response – fighting the virus and cushioning the blow (wave 1);
positioning for recovery and kickstarting the economy (wave 2); and resetting
and rebuilding the economy (wave 3).10
As the pandemic continued, and the country moved up and down the Alert Level
Framework, the ‘3 waves’ terminology became less useful and eventually fell out
of use. The three budgets that followed (2020, 2021, 2022) included initiatives for
all three waves. There was some inevitable blurring and overlapping between the
waves because the pandemic continued for much longer than initially expected,
and changes in alert levels due to community outbreaks made it necessary to
return to, or extend, earlier support measures. The discussion of the Government’s
economic and fiscal policy response that follows is therefore organised around
Budgets 2020, 2021 and 2022 rather than the waves as initially defined.
The Government initially used

a ‘3 waves’ model to structure
its economic response.
Response: March 2020 Economic Response Package and Budget 2020
On 12 March 2020, the Government announced an immediate ‘business continuity
package’ in response to COVID-19. It included a targeted wage subsidy scheme for
workers in the most affected sectors.11 On 17 March, this proposal was expanded
into a $12.1 billion COVID-19 Economic Response Package including $5.1 billion in
wage subsidies, a $500 million boost in health funding, and $2.8 billion in social
supports.12 A range of business tax measures were also introduced, along with a
package of support for the heavily impacted aviation sector.
In May 2020, the COVID-19 Response and Recovery Fund (a notional fund
outside the budget process) was announced. In total, $70.4 billion was allocated
to COVID-19 response and recovery initiatives, including the initial response
package of $12.1 billion (announced 17 March 2020) and $58.4 billion allocated
from the COVID-19 Response and Recovery Fund before its closure in Budget 2022.
The amount allocated for each initiative was the expected fiscal impact across
the forecast period at the time the decision was taken. The Treasury advised
Government to focus the support package as much as possible on broad-based,
economy-wide measures like wage subsidies and tax relief measures. This advice
reflected considerations of efficiency, a wish to avoid targeting support at specific
sectors and industries, and the expectation that the shock itself would have
widespread effects. While these considerations were reflected in the package,
Budget 2020 also funded some more targeted measures. These included specific
support for affected sectors (like aviation, tourism and the cultural sector) and
direct financial support for specific companies, like that available through the
Strategic Tourism Assets Protection Programme.13 The package also included
a range of support measures for education and the social sector at large.14
The overall COVID-19 Response and Recovery Fund package represented the
second highest additional spending and/or revenue foregone in relative terms
by any OECD government in response to COVID-19 (although it should be
noted that some countries resorted, substantially in a number of cases, to a
variety of less direct supports, including guarantees, loans and equity, that
New Zealand used only sparingly).15 Treasury officials advised the Government
that the benefits of this spending would outweigh the possible costs of debt
rising above 50 percent of GDP. Treasury considered that the economic
supports were proportionate to the health response, given the stringency of
the public health measures taken at times during the pandemic.
Some of the people who made public submissions to our Inquiry expressed
appreciation for the generosity of this economic response:
“ I was grateful for the economic support from the government so that I could stay
in business, keep paying my workers, and continue contributing to the economy.”
“ When the government announced a financial support package for people to stay at
home, I felt enormous relief as this would be what was needed to allow people to
survive financially when they couldn’t work.”
Spotlight:
The COVID-19 Wage Subsidy Scheme |
Te Kaupapa Utu Moni Āwhina KOWHEORI-19
The largest single item of expenditure during the response – $18 billion in total –
was the COVID-19 Wage Subsidy Scheme, including its extensions and variations.
It supported workers indirectly by enabling businesses (including people who were
self-employed) to continue to pay and employ their staff.16
The scheme had two core objectives: to maintain employment and keep workers
connected to their jobs, and to support workers’ incomes during temporary
disruption caused by COVID-19. It was available to businesses that had lost at least
30-40 percent of their revenue (the percentage varied during the course of the
scheme) due to COVID-19 during specified periods (five in total, usually coinciding
with national or regional lockdowns). The eligibility criteria for the scheme were
tightened over time.17
At its peak, the Wage Subsidy Scheme covered 72 percent of employing firms
and supported 59 percent of total employment.18 Two independent evaluations
found that payments generally flowed through to workers from their employers
as intended.19 One found that firms appear to have largely complied with their
obligations to pass on the subsidy payments to their workers and to pay them
at least 80 percent of their previous earnings when possible.20
Many public submitters to our Inquiry commented on the scheme. Their
comments reflected gratitude for the stability it provided, complaints about
its adequacy, questions about its fairness, and concerns about its long-term
economic implications.
“ My company took advantage of the wage subsidy – it was good to be pretty confident
we’d keep our jobs.”
“ We could pay our staff and not worry about the expense, which would have put our business
close to going under […] It relieved stress in a very fraught time. I was incredibly impressed
about how quickly it was rolled out, and how fast the payment was.”
“ The subsidy payment […] was well less than 50 percent of my normal income which
left me short for paying my normal outgoings and hence getting behind in payments
and therefore into debt.”
“ Employers that did not need the subsidy should have been made to pay it back,
i.e. those that made significant profits.”
“ Be aware that economic decisions made will have impacts into the future (like inflation)
which we are now suffering from, while the wage subsidy was necessary at the time, it
went on for too long.”
The Wage Subsidy Scheme was developed jointly by the Treasury, the Ministry
of Social Development, the Ministry of Business, Innovation and Employment,
and Inland Revenue early in the pandemic. It was largely based on a previous
scheme that the Ministry of Social Development had implemented during
earlier crises, including the Canterbury and Kaikōura earthquakes.
248
Initially it was designed to focus on the sectors most affected; at that stage these
were forestry and tourism. As the full implications of the pandemic became clear
during March 2020, it was rapidly repositioned as a broad-based scheme and
was launched nationally for all sectors on 17 March 2020.21
The Ministry of Social Development was the main delivery agency, in part
because operational barriers ruled out Inland Revenue. Due to legislative barriers,
ACC (which had the required functionality in their system and offered to help)
could not deliver it either.iii
Implementing such a wide-reaching wage subsidy in a short period of time in
March 2020, under extremely testing circumstances, was a great achievement
– a workforce had to be trained, while at the same time much of the work and
income functions of the Ministry of Social Development had to pivot to online-
only delivery. The Ministry used the payment mechanism established for the
Kaikōura earthquake response, which limited the ability to apply a greater level
of calibration and targeting. It needed to be implemented quickly and by
necessity (in the absence of a fully designed system pre-pandemic and the
unavailability of the Inland Revenue system), relied on a high-trust model. This
inherently came with a risk of fraud.
When the Office of the Auditor-General reviewed the Wage Subsidy Scheme in
2021, it reported that ‘many of the steps public organisations took to protect the
Scheme’s integrity were consistent with good practice guidance for emergency
situations’,22 but recommended that ‘when public organisations are developing
and implementing crisis-support initiatives that approve payments based on
“high-trust” they ... put in place robust post-payment verification measures’.23
The Auditor-General also recommended that the Ministry of Social Development
carry out further enforcement work’.24 Later, a Martin-Jenkins evaluation of
the Wage Subsidy Scheme noted that the relationship between the policy and
operational risks (including integrity) had not been sufficiently explored when
the scheme was being developed. Throughout the scheme’s successive phases,
Martin-Jenkins said agencies had worked to identify and mitigate risks to improve
its operation.25
During our Inquiry, public criticisms were made of the Ministry of Social
Development’s approach to compliance through a High Court judicial review,
which was dismissed, and an Advertising Standards Authority complaint, which
was partially upheld.26 We are aware of criticisms by the peer reviewer of the
methodology used in the Martin-Jenkins evaluation.27
iii Inland Revenue was in the middle of upgrading to a new IT system and, under their legislation, Inland Revenue
and ACC were not authorised to perform this function. The Ministry of Social Development’s system did not have
the functionality to achieve more granular targeting/tailoring of the response – it was a blunt tool. Needing to
pass legislation would have slowed down getting Wage Subsidy Scheme payments ‘out the door’.
249
Some ineligible businesses were paid the subsidy. As of 27 September 2024,
companies had made over 25,000 repayments, totalling $827 million. In
addition, 30 people had been convicted of fraud and sentenced, while a
further 48 were still before the courts.28 At the time of writing this report,
prosecutions were still ongoing. Civil recovery action was underway against
fifty businesses.29
It was not always straightforward for employers to implement the wage
subsidy. For example, businesses had to try their hardest to pay employees
at least 80 percent of their usual wages while receiving the subsidy for
them. If that wasn’t possible, they had to pay employees at least the subsidy
payment rate. Some businesses apparently believed this relieved them of the
responsibility of paying more than 80 percent of the wage, even if they could,
and the interaction with employment law was complicated. The Ministry of
Business, Innovation and Employment managed this aspect of the Wage
Subsidy Scheme and provided phone and online support about the scheme.
We were told that the situation was sometimes unclear to employers and
employees alike, and we consider greater clarity and guidance could have
been provided.
Despite these challenges, the subsidy supported millions of workers,
including by protecting employment and thousands of businesses at
a critical time. We will return to its effectiveness and impacts in the
next section.
250
Recovery: Budget 2021
A year on from Budget 2020, Aotearoa New Zealand was enjoying the fruits of the
early success of the elimination strategy. While the international border remained
‘closed’, there was no community transmission of COVID-19, the entire country
was at Alert Level 1, and most people could go about their daily lives relatively
unencumbered. The pandemic appeared to be over (in Aotearoa New Zealand at
least), vaccinations were on their way, and the Government had reason to believe
that the main task for the economy was now recovery.30
The May Budget 2021 reflected this focus. It retained the Response and Recovery Fund,
but with refreshed policy goals: to continue to keep New Zealanders safe from COVID-19,
accelerate the recovery and rebuild, and lay foundations for the future. Key investments
included $4.6 billion from the COVID-19 Response and Recovery Fund, mainly focused
on accelerating housing construction; $1.5 billion for the COVID-19 vaccine rollout, which
was then getting underway; and a $300 million ‘green investment fund’. All investments
were aimed at supporting the recovery and rebuild from COVID-19.
In the second half of 2021, during the Delta outbreak and the Auckland lockdown,
the Government added a further $7 billion to the Response and Recovery Fund,
although not all of it was allocated. This extra funding was targeted at further
economic support (including for the wage subsidy in the extended Auckland
lockdown) as well as building resilience in the health system, supporting the
vaccination rollout, and border and managed isolation and quarantine (MIQ)
provision. These, and similar initiatives such as Jobs for Nature,iv were intended to
use the opportunities created by COVID-19 to ‘build back better’. We return to this
theme with reference to Budget 2022.
Key investments included

$4.6 billion from the COVID-19
Response and Recovery Fund,
mainly focused on accelerating
housing construction.
iv Part of the COVID-19 recovery package, Jobs for Nature was a $1.19 billion programme that managed funding across
multiple government agencies to benefit the environment, people and the regions. It was intended to help revitalise
communities through nature-based employment and to stimulate the economy post COVID-19.
In total, more than $70 billion of direct funding and tax relief was allocated to the
COVID-19 response in Budgets 2020 and 2021, or about 22 percent of 2019 GDP.
Not all of it was spent.31 The largest areas of COVID-19-specific appropriation (as
calculated on 31 May 2023) were:
• $18.3 billion on business support subsidies (including variants of the Wage
Subsidy Scheme between March 2020 and December 2021).
• $4.2 billion for the national response to COVID-19 across the health sector.
• $2.9 billion for the COVID-19 Resurgence Support Payment (a grant scheme that
provided firms with non-repayable support to assist transitions between alert levels).
• $2.5 billion for implementing the COVID-19 vaccine strategy.
• $2.4 billion for the Small Business Cashflow Scheme (advanced as loans to
small businesses with a 5-year repayment period).v It is too early to know how
much of this will be repaid.
• $1.6 billion on isolation and quarantine management.
• $1.6 billion on COVID-19 Support Payments (payments to ongoing and viable
businesses or organisations that experienced a 40 percent or more drop in
revenue due to public health restrictions, impacts of supply chain disruptions,
and lower recreation-related movements – for example, central city businesses
that were affected by people working from home).
In addition to these initiatives, the Response and Recovery Fund funded a large
number of other support measures, both general and sectoral. These included the
COVID-19 Short-Term Absence Payment and the COVID-19 Leave Support Scheme
(which provided workers with support to encourage them to self-isolate when they
had COVID-19 or were waiting for a test); sectoral support for those areas most
affected by the pandemic (including tourism and international education); Jobs for
Nature (see footnote iv); and the arts, culture, recreation and sport sectors.
Rebuild: Budget 2022

From mid- to late-2021, some of the medium- to long-term impacts of the economic
response to COVID-19 (as well as wider global factors) had started to become
apparent, particularly in the form of higher interest rates, increasing costs of living,
and continued upward pressure on house prices.
This was reflected in some of the priority spending areas in Budget 2022. By this
time, the Response and Recovery Fund had been wound up and the Government’s
focus had shifted to ‘building back better’. This involved investing in infrastructure to
make Aotearoa New Zealand less vulnerable to future shocks, cushioning the impact
of inflation, improving physical and mental wellbeing, and reducing fuel taxes and
road user charges to offset rising energy costs.
v With two years interest free and a below-market interest rate of 3 percent per annum after that.
6.2.1.3
The monetary and financial policy response
‘Monetary policy’ refers to the actions the Reserve Bank of New Zealand takes
to achieve and maintain price stability (and, at the time of COVID-19, to support
maximum sustainable employment). For the purposes of this report, ‘financial policy’
refers to the measures taken by the Reserve Bank to protect and promote the
stability of the financial system. The Reserve Bank has operational independence
from the government in choosing which policy instruments it will use to pursue
these monetary and financial policy objectives.
During the pandemic, the Reserve Bank maintained low short-term wholesale
interest rates, put further downward pressure on other interest rates by purchasing
government bonds and funding lending for banks, and relaxed lending restrictions
on the loan to value ratio.32 All these measures were intended to soften the impact
of the downturn, giving businesses and households access to affordable borrowing
if needed. In addition, the Reserve Bank used various means to ensure that the
financial markets at large, and the banking system specifically, continued to operate
efficiently and safely.
According to the OECD, central banks around the world – including New Zealand’s
– acted simultaneously in responding to COVID-19 ‘with scale and speed to stabilize
financial markets and cushion the contraction in real activity’.33
‘Monetary policy’ refers to the

actions the Reserve Bank of
New Zealand takes to achieve
and maintain price stability.
Monetary and fiscal policy coordinationvi
The Reserve Bank of New Zealand and the Treasury are in regular communication,
and exchange information through a range of channels to inform their respective
monetary and fiscal policy decisions. However, they do so without compromising
the operational independence of the Reserve Bank or undermining the sensitivity
of the information Treasury provides to politicians to inform fiscal policy decisions.
Examples of this ongoing contact include working-level meetings, regular
meetings between the Reserve Bank Governor and the Secretary to the Treasury,
collaboration on briefings to the Prime Minister and Minister of Finance in advance
of the Reserve Bank’s Monetary Policy Statements, and pre-Budget Treasury
briefings to the Reserve Bank. In addition, a Treasury observer participates in the
deliberations of the Monetary Policy Committeevii about forecasts and risks in the
economy, but does not have a say in decisions. The Reserve Bank and the Treasury
have a Memorandum of Understanding (which was in place before COVID-19)
formalising much of this working relationship.34
During the COVID-19 period, information-sharing and engagements between
the two institutions continued. For example, the Treasury representative on the
Monetary Policy Committee regularly advised the Reserve Bank about the high-level
figures for the Budget (but without providing actual details) to inform its monetary
policy decisions. The information the Reserve Bank was given access to was likely
to have included the main macroeconomic drivers of the Budget (such as levels
of fiscal stimulus (impulse), percentage changes in tax forecasts, estimates of fiscal
increase/reduction (as a percent to GDP). This exchange of information would have
assisted the Monetary Policy Committee to think about the balance of risks when
making monetary policy decisions before the publication of Budget information.
Nevertheless, there was no active coordination of monetary and fiscal policy in
the economic response to the pandemic, in the sense of having a broad common
understanding of how they might interact with each other. Such an understanding
can matter enormously in a crisis, where matters are evolving fast. If (for example)
both Reserve Bank monetary policy and Treasury fiscal policy are strongly
stimulating the economy, they may create too much stimulus. Or, if monetary and
fiscal policy diverge, they may unintentionally work against each other. However,
we saw no evidence of the Reserve Bank and the Treasury jointly advising the
Government in a coordinated manner on the broad pattern of how the quantum
and mix of fiscal and monetary stimulus should be provided, and how these
should be adjusted as the pandemic evolved.35
vi See https://www.treasury.govt.nz/sites/default/files/2024-08/an24-07.pdf for a recent and thoughtful discussion

on monetary and fiscal policy coordination.
vii The Monetary Policy Committee was established by the Reserve Bank of New Zealand (Monetary Policy) Amendment
Act 2018. The new Act replaced the Governor as sole decision-maker with a Monetary Policy Committee (MPC) as the
decision-making body. The Remit (under the Act), issued by the Minister of Finance, sets the inflation target and the
MPC has operational independence on how the target will be achieved. The MPC has four internal and three external
members. The Minister of Finance appoints both internal and external members based on recommendations from
the Board of the Reserve Bank.
6.2.1.4
Pressures on supply chains
While Aotearoa New Zealand’s geographical remoteness worked in our favour –
simply put, our distance from other countries helped keep the virus out – we
were exposed to weaknesses in international supply chainsviii that developed
during the pandemic. These weaknesses influenced the way that domestic
supply chains operated.
There were several contributing international influences. The availability of raw
materials as inputs for manufacturing became more constrained,36 and some
countries ‘reshoring’ production to promote self-sufficiency and unwind trade
integration37 disrupted trade and supply chains. International shipping delays
and supply shortages – along with the impact of other countries’ public health
restrictions on supply chains, and port congestion in other countries38 – all created
problems and uncertainty for New Zealand. These included delays to incoming
shipping services, ships ‘bunching’ at New Zealand ports, problems with container
availability and positioning and over time, substantially higher international shipping
freight rates. This led to uncertainty and higher costs for importers and exporters,
and their customers. Meanwhile border closures led to large-scale reductions in
aviation services and air cargo capacity to and from New Zealand, and higher air
cargo freight rates.
These problems were international in origin, but they were compounded by
a range of domestic factors. These included the failed automation project at the
Port of Auckland,39 a short-lived requirement that only essential cargo be handled
at ports (which led to congestion problems at ports), and the way that businesses
had to organise themselves (for example, through completely separate shift
crews) to manage infection risks.
Some stakeholders also described a general lack of understanding of key supply
chain issues before the pandemic, especially within the public sector. This extended
to a lack of understanding about the inputs required by manufacturers of essential
goods. As an example, the Ministry of Health initially determined that forestry
operations and wood processing at the Kinleith Mill were not essential industries;
in fact, the mill is the only New Zealand supplier of chlorineix for drinking water.
viii In simple terms, a supply chain is a sequence of processes involved in the production and distribution of
a commodity. Supply chains include – but are also broader than – transport and logistics systems. They describe
any chain of processes, businesses and movements by which a product is produced and distributed.
ix Chlorine is a byproduct from the mill’s manufacturing process.
The Government took action to protect supply chains
In response to supply chain issues, the Government established a Supply
Chain Group and accompanying Ministerial Group in 2022. Also significant was
its decision right at the start of the pandemic to ensure the aviation system
continued functioning, albeit at a reduced level. Submitters praised the rapid
response of the Ministry of Transport in this area.
The Government made payments through the Ministry of Transport to a number
of airlines (including Air New Zealand) to maintain air cargo capacity, and to
ensure as much as possible that airlines retained a presence in the New Zealand
market. That was considered essential for the anticipated ‘bounce-back’ once
the border reopened. The Government ensured through loans and additional
funding that Air New Zealand and the Airways Corporation were kept afloat
and operating, and that border agencies had sufficient funding streams to keep
operating despite the decline in air passengers. Separately, New Zealand Trade
and Enterprise underwrote air cargo capacity on Air Zealand flights for exporters.
The Government did not play as direct a role
in keeping maritime supply chains open.
Being able to exchange crew Chartering or requisitioning ships was briefly
in New Zealand gave shipping discussed as a ‘worst-case scenario’40 but not
companies one more reason to
progressed. The Government did, however,
continue to serve the country.
carry out a number of actions that helped
facilitate continued trade. The Maritime Border
Order of June 2020 – which formalised the
Government’s approach to maintaining export and import trade while managing
infection risk from ships’ crew – allowed international crew changes while ships
were in Aotearoa New Zealand. Many other countries did not allow crew changes,
which led to welfare issues. Being able to exchange crew in New Zealand gave
shipping companies one more reason to continue to serve the country.
In general, the provision and efficiency of shipping and related services to
Aotearoa New Zealand throughout the pandemic remained in the hands of the
sector – with shipping companies, importers and exporters, freight forwarders,
logistics companies and port companies.
In some parts of the supply chain, pre-existing relationships between
government decision-makers and supply chain operators were limited or entirely
absent. Examples included food exports and the local packaging supply sector,
food manufacturing and the waste recovery and recycling sector, shipping
and building supplies. While these relationships took a while to establish, they
became indispensable; stakeholders told us that building them was a positive
outcome from the pandemic.
Government agencies and sectors liaised closely to manage supply chain
problems as they arose – whether this meant the Ministry of Foreign Affairs
and Trade or New Zealand Trade and Enterprise working internationally; or
officials, cargo interests and interisland shipping providers working through
the availability of space on the Cook Strait ferries. Officials also worked closely
with the major supermarket chains. The Ministry of Foreign Affairs and
Trade regularly collected and disseminated information to businesses about
international trade and supply chain trends. New Zealand Trade and Enterprise
set up a supply chain advisory service and increased its ability and capacity
to help exporters in the market who were unable to travel. We heard that the
ability of the Ministry of Transport to work between the international transport
sector and the Ministry of Health was important.
Government agencies and

sectors liaised closely to
manage supply chain
problems as they arose.
Our assessment: economic impacts and responses |
6.3 Tā mātau arotake: ngā ōhanga o te mate urutā
me te urupare a te Kāwanatanga
6.3.1 The initial package of economic measures was

comprehensive and generous, and met its immediate aims
At a high level, this initial package delivered against its immediate aims. These were
to support the public health response by maintaining economic activity, sustaining
business confidence, protecting employment, protecting incomes, sustaining
financial stability, and ensuring that all essential services were accessible. A 2021
OECD report indicated that, in doing so (initially at least), Aotearoa New Zealand
had generated better economic and social outcomes than most other OECD
countries. Initially, the Reserve Bank and the Treasury were also concerned that
the health crisis could develop into a financial crisis. This too was successfully
avoided. Moreover, it had achieved these outcomes with restrictions that were of
comparatively short duration and, over the course of the pandemic, less stringent
on average than in many other countries.41
Likewise, Aotearoa New Zealand’s monetary
policy response was in line with those of other
Aotearoa New Zealand had countries that successfully pursued the same
generated better economic intended short-term outcome: cushioning the
and social outcomes than
most other OECD countries.
impact of the COVID-19 pandemic on their
people.42 New Zealand maintained a relatively
stable economic position, prevented large scale
unemployment, supported people’s incomes, and
the economy rebounded very fast in 2020 and 2021 – both in absolute terms and
relative to other comparable OECD economies.
By and large, in terms of the initial (2020–22) macroeconomic impacts of the
pandemic, as well as the economic policy responses to it, Aotearoa New Zealand
performed comparatively well.43
Figure 2: Inflation and unemployment in mid-2022 –
international comparisons
Note: The data is sourced from the OECD database. The latest available data points have been used; unemployment
data for 2022Q3 for New Zealand (NZL), Australia (AUS), Canada (CAN), United States (USA), Israel (ISL), Chile (CHL),
Mexico (MEX), Japan (JPN) and South Korea (KOR), and 2022Q2 for other countries, inflation data for 2022Q3 for all
countries, except Costa Rica (CRI) for which only 2021Q4 data is available. Turkey has been omitted since it is an
outlier with an exceptionally high inflation rate of 81%.
Source: Reserve Bank of New Zealand, 2022, In Retrospect: Monetary Policy in New Zealand 2017–22 | Titiro
whakamuri kōkiri whakamua, p 10, https://www.rbnz.govt.nz/hub/publications/monetary-policy-statement/rafimp
Figure 2 shows that in mid-2022, New Zealand performed well compared to

other OECD countries in terms of both inflation and unemployment. But as we
explain in this chapter the early generosity of New Zealand’s economic policy
response – followed by the start of the reversal in monetary policy from October
2021, in combination with the impact of international events such as the war in
Ukraine and ongoing supply shocks – led to deteriorating economic performance
in terms of unemployment and real GDP growth.
6.3.2 The generosity of the initial response and the length of
time it continued has slowed Aotearoa New Zealand’s subsequent
economic recovery, and the effects continue to be felt
The success of the initial economic response – including the Response and Recovery
Fund, and the monetary and fiscal policies that were adopted – had a flipside. From
mid-2021 onwards, both the pandemic itself and the policy responses to it started
having economic and social impacts across society, sectors and regions that were
strong, unevenly distributed and negative. At the same time, the Government had
to act to address the inflationary pressures and the sharp rise in public debt created
by the initial response, within tight time constraints. Overall, these factors led to a
slow and protracted medium- to long-term economic recovery, the effects of which
are still with us in 2024.
To understand how this unfolded, it is necessary to go back to early 2020. Aotearoa
New Zealand was then in a relatively stable economic position, with low interest
rates and low public debt. Economic institutions were in reasonably good shape,
with the independent operation of monetary policy now decades old and well-
entrenched. Successive governments had created an ongoing ‘fiscal buffer’ of
internationally relatively low levels of public debt (AAA rated by Standard & Poor’s)
by the operation of generally fiscally responsible policies as required in the Public
Finance Act 1989. As the COVID-19 response began, there was a sharp slowdown
in economic activity and a drop in employment, both of which were unevenly
distributed across industries and regions, as well as social groups.
This downturn was followed by an equally sharp economic rebound in the second
half of 2020, reflecting the generosity and timeliness of the financial support
packages put in place (see Figure 1). This reduced the adverse short-term economic
impacts of the pandemic, but at the expense of contributing to a gradual climb in
the cost of living and broader inflationary pressures including rising house prices.
As we note elsewhere in this chapter, these impacts cannot be attributed exclusively
to domestic policy responses; global developments (including the war in Ukraine)
also played a significant role.
By the third quarter of 2020, real GDP (a measure of total production of goods and
services) had already recovered to its pre-COVID-19 level, earlier than in any other
OECD country.44 The unemployment rate fell quickly to a trough of 3.2 percent, its
lowest level in 40 years (December 2021 quarter).45
Accompanying the strong rebound in economic activity, but also reflecting severe
supply-side constraints, were strong inflationary and cost-of-living pressures (including
on food and petrol prices). House prices rose strongly throughout 2020 and 2021.
Inflation began to rise quickly around mid-2021, fuelled initially by excess demand and
pandemic-induced supply chain tensions, and later aggravated by the war in Ukraine.
In response, the Reserve Bank raised the Official Cash Rate by 525 basis points
to 5.5 percent between October 2021 and mid-2023.46 The effects can be seen in
increases to the Consumer Price Index during the period: the annual percentage
change grew to 7.3 percent in June 2022, but had decreased sharply to 2.2 percent
by September 2024.47
All these developments – high interest rates, the increase in government debt,
sharply rising house prices (shown in Figure 3 in absolute terms and against other
advanced economies) – have had adverse effects that are likely to be felt for some
time to come. More generally, the arrival of COVID-19, and the policy measures used
to manage the health impacts, may have reduced the productive capacity of the
economy (causing more inflation for a given level of demand). See section 6.6, which
addresses the ‘long tail’ effects of the pandemic and the policy responses to it.
Figure 3: Advanced economies – selected residential property prices

2010–2024
Note: The figure shows the ‘real’ (inflation adjusted) cumulative increase in house prices from a base of
March 2010 = 100.
Source: BIS Data Portal, 2024, Advanced economies – Selected residential property prices, Real, Index,
2010 = 100, https://data.bis.org/topics/RPP/BIS%2CWS_SPP%2C1.0/Q.5R.R.628
Most of the fiscal impact of the COVID-19 response (including the collateral
fiscal effects of monetary policy, positive and negative), as well as the
impacts of the economic downturn, are forecast to be absorbed by the
Government’s balance sheet, via increasing borrowings (that is, through
higher debt) and reducing net worth. Net core Crown debtx is expected
to reach 43.5 percent of GDP by the end of the 2024–25 financial year,48
having been 19 percent of GDP at 30 June 2019.
By this measure, the Government’s
balance sheet is healthier than most
other countries, even though Aotearoa
“New Zealand is doing pretty New Zealand’s fiscal response to the
well in a global context if pandemic was relatively generous.
you’re just talking about Nevertheless, reports on the New Zealand
levels of credit ratings. ”
economy by the OECD (cited earlier)
and the International Monetary Fund49
both raised concerns about the fast and
significant rise in net government debt,
as shown in the top panel in Figure 4. The rise will also be considered in
the next review of New Zealand’s international credit ratings, although this
country’s comparatively strong international performance (see right-hand
panel in Figure 4) will help counter any immediate threat to our credit rating.
According to Martin Foo, the Director of Sovereign and International Public
Finance Ratings for United States-based credit rating agency Standard and
Poor’s Global Ratings, the agency remained comfortable with the AAA credit
rating it upgraded New Zealand to in 2021. ‘New Zealand is doing pretty well
in a global context if you’re just talking about levels of credit ratings,’ Martin
Foo told the New Zealand Herald in August 2024. ‘But there is no doubt,
the response to the pandemic was costly. It did result in a big expansion
in the size of government.’50 It should be noted that New Zealand enjoys
the highest sovereign credit rating from Standard & Poor’s Global Ratings
and Moody’s, while Fitch Ratings rates New Zealand at AA+, which has not
changed since before the pandemic. Nevertheless, Martin Foo’s statement
can be interpreted as a warning that we should be cautious.
x This is the Government’s debt, adjusted for its total cash or liquid assets.
Under the Public Finance Act 1989, governments are required to manage their
expenditure and revenue policies to maintain prudent levels of public debt.
Successive governments have taken the view that public debt needs to be
relatively low for several reasons:
• As a small economy, Aotearoa New Zealand does not have the economic
heft to cope with international shocks; much bigger economies have more
scope to ride these out.
• New Zealand’s economy is not as diversified as many others, meaning that
specific shocks may have a much bigger relative effect.
• New Zealand is also relatively highly exposed (as we have seen)
to natural disasters such as earthquakes, etc.
• Low public debt offsets relatively high private debt in the
New Zealand economy.
• Low debt also reduces the risk margin to be found in interest rates.
This provides other benefits to the New Zealand economy, reducing
the financing costs of investment and improving our access to
international financial markets in the case of financial crises.
• Low debt also – obviously – reduces the fiscal burden of servicing debt.
Fundamentally, all country-specific interest rates carry a risk premium within
them. For example, New Zealand’s interest rates are typically higher than those
for the United States. In part, this is because we are small and the United States
is big (and therefore better able to absorb negative developments) and partly
also because the $US is a reserve currency – meaning lots of currency players
invest in the United States when things internationally look fragile, which keeps
their interest rates lower. Internationally, poor economic policies also result in
higher risk premiums. Essentially, arbitrage ensures our interest rates adjust to
reflect these factors and maintain some stability in our exchange rate.
Internationally, poor
economic policies
also result in higher
risk premiums.
Figure 4: Government Debt
General
Government
Debt
(Percent of GDP)
Net
Public
Debt
(Percent of GDP)
The government debt ratio is projected to stabilise after peaking in the medium term (figure on top) and is expected
to remain low compared to other advanced economies (figure on bottom).
Source: Based on data from The Treasury, 2024, Current and past Budgets, https://www.treasury.govt.nz/
publications/budgets/current-and-past-budgets; Based on data from IMF Fiscal Monitor Database 2024 and
Royal Commission staff calculations.
The debt figures shown in Figure 4 are calculated using the International Monetary
Fund’s Government Finance Statistics methodology. This differs from the methodology
used by the New Zealand Treasury but is more comparable across countries.
With the benefit of hindsight, we have considered the factors that might lie behind
this apparent ‘overshoot’ of macroeconomic stimulation – the monetary and fiscal
expansion being too high for too long during the pandemic. While immediate
attention might be drawn to the ‘least regrets’ stance taken at the beginning of the
pandemic by both the fiscal and the monetary authorities, we believe this approach
was fundamentally sound. Little was known about the nature and likely impact of the
virus at that stage, apart from what might be inferred from the then-severe events
unfolding overseas, in Italy and elsewhere.
As we have commented earlier in this report (see Chapter 2), adapting and planning
for forthcoming possible scenarios during the ‘honeymoon’ period created by the
undoubted initial success of the elimination strategy was generally slow.
There was a tendency to hold on to existing public health and indeed other settings
for too long. We think this factor also contributed here. Having said that, we recognise
that the Reserve Bank did begin tightening monetary policy from October 2021,
eventually raising the cash rate by a full 525 basis points. The Treasury, on several
occasions, reinforced the need for exit strategies and recommended some pull-back
on fiscal support. The Government did respond to these urgings – for example by
changing the criteria for the subsequent rounds of the Wage Subsidy Scheme – but
the overall picture was one of being cautious about change for too long.
There may have been other, more technical factors at play also. For example, the
initial economic and financial response to the pandemic was largely viewed as a
demand shock.xi While the fact that there was (and would be) a substantial supply
component to the shock was recognised reasonably soon afterwards, it is probably
fair to say that the decomposition was not well understood and the focus on demand
attracted the main attention from the authorities.
The Treasury and the Reserve Bank have a long-established history of sharing information
while ensuring they protect the Reserve Bank’s independent operation of monetary
policy and the Treasury’s own role of providing independent fiscal and macroeconomic
advice to the Government of the day. We think this is entirely appropriate,recognising
that collaboration of this sort does not – and should not – blur respective accountabilities.
Nevertheless, some gaps in the Treasury and Reserve Bank coordination in an
emergency were revealed, despite the fact that it was good by international
standards. The pandemic experience has thus provided an opportunity to reflect
on how those gaps arose and how they could be avoided in another crisis situation.
At present, there is no commonly understood ‘playbook’ for how (and how much)
to coordinate monetary and fiscal policy in future crisis scenarios (including varying
pandemic scenarios), including which policies might have the advantage at which
stage of the crisis. In addition, those involved need to have a good grasp of the
kind of information which might be of value to the other organisation, without
overstepping the bounds of what should or should not be disclosed. There may
also have been occasions during the pandemic when information from other players
(such as the Ministry of Business, Innovation and Employment and the Financial
Markets Authority) could have been useful. These gaps in information sharing and
coordination of policy could also have contributed to a ‘less than smooth’ pattern
of macroeconomic stimulation and constraint over the period of the pandemic.
In summary, we think the ‘least regrets’ approach at the beginning of the pandemic
was appropriate. Nevertheless, as the pandemic evolved all of the information and
tools available to authorities were not used to achieve the right balance between
avoiding deflation (and possible financial crisis) and economic depression in the short
term and limiting the extent of the unavoidable price that is paid in terms of inflation,
debt and lost productivity in the medium to long term.
xi A ‘demand shock’ refers to a downward adjustment to economic activity due to less spending
by the government and/or private sector.
6.3.3 The pandemic’s economic impacts put many households
and businesses under great pressure, especially during lockdowns
The initial phase of COVID-19 left many businesses unable to operate. The incomes
of millions of New Zealanders were thus at risk, creating potentially huge ripple
effects that worsened the economic downturn created by the pandemic. However,
the Government did provide assistance to lower-income New Zealanders in its
March 2020 economic package and in Budgets 2020 and 2021, by means of either
benefit increases or the Winter Energy Payments.
The Wage Subsidy Scheme (see spotlight in section 6.2.1.2) was devised to enable
businesses to maintain levels of employment and worker attachment to roles,
and to provide workers in permanent full-time or part-time roles with continued
income. In addition, individuals who lost their employment (including self-
employment) because of the pandemic could access the non-means tested
COVID-19 Income Relief Payment.51 Despite the fact that not all income earners
received the wage subsidy, these measures were well received and used.
Over the five waves of the Wage Subsidy Scheme, 2,026,054 applications were
approved (with 340,226 declined).52
Alternative mechanisms – such as delivering income support through the income
tax system – might have offered some advantages (such as better targeting), but this
approach would have been less effective in maintaining levels of employment and
worker attachment to roles (one of the primary purposes of the Wage Subsidy Scheme).
While wage subsidy and other supports were available to help those in traditional
employment, people in other situations struggled. For example, casual workers
whose employers did not apply for the wage subsidy did not receive any wage
subsidy payments.
Another group which experienced significant economic hardship during the
pandemic was temporary visa-holders. This group included people on two-year
work permits, international students and Recognised Seasonal Employer workers:
when their employment ended, they were ineligible for most types of supportxii and
were also significantly impacted.53 It was not until July 2020 – five months into the
pandemic – that the Department of Internal Affairs and the Red Cross partnered to
provide humanitarian relief to temporary visa-holders. This took the form of food
supplies, housing assistance or support to return to their home country.
xii As part of the Community Wellbeing package in Budget 2020, the Government provided funding so foodbanks
and community food services could support an estimated additional 500,000 individuals and families impacted by
COVID-19 who were struggling to afford food. Access to these supports was not assessed on the basis of residency
status. See endnote 53 for more details.
Through the public submissions process, we heard first-hand accounts of the
pandemic’s economic impacts on many individuals, households and businesses:
“ As an Immigration Officer, I lost my job as the borders were closed so the company that
I was working for dropped down to skeletal staff as no one could come into the country.”
“ My husband & I are produce growers for the local markets, by closing down the Farmers
Market we now had no place to sell our produce which would not stop growing (leading
to huge waste) and we had spent months of hard work preparing our crops to sell. This
impacted our business financially and myself emotionally.”
“ I have had a small business since 2007 and was unable to work due to the lockdowns for
almost 7 months. This lost the business and my small team over $150k, which we have
never been able to bounce back from, especially now as we head into a recession.”
“ I was one of thousands of the uncounted. I lost income due to the lockdown as I was a casual
worker. I didn’t receive the govt subsidy, I couldn’t apply for unemployment benefit as I was
in a de facto relationship, so didn’t qualify there either.”
As we go on to discuss in the second part of this chapter, many social service

providers we heard from confirmed that loss of incomes increased the material
hardship many households experienced in the pandemic. Despite various new
or increased social support initiatives (discussed later in this report), we heard of
families with insufficient money for even the bare essentials like heating, internet,
food, blankets, clothing, nappies, masks and cleaning supplies. And, as we also
discuss later, the burden of these negative impacts was not shared equally across
all New Zealanders. Inevitably, those people with existing disadvantages and
vulnerabilities at the start of the pandemicxiii felt them the hardest. This made it
imperative for the government pandemic response to consider equity effects and
how they could be mitigated.
Many social service providers we

heard from confirmed that loss of
incomes increased the material
hardship many households
experienced in the pandemic.
xiii The population groups that the Ministry of Social Development identified as being at higher risk of adverse social
and psychosocial impacts in the pandemic were: older people, disabled people and people with long-term health
conditions, lower income households, Māori communities, Pacific communities, children and young people with
greater needs, young people (16 to 25 years), homeless, ethnic and migrant communities, the prison population
and people on community-based sentences and orders, and women.
6.3.3.1
Businesses experienced the pandemic differently according
to their sector, size and location54
Many businesses told us that the Ministry of Health had little understanding of
the practicalities of implementing many of the health orders in their workplaces.
Businesses expressed frustration with the Government on various matters, including:
• The borders around Auckland (and sometimes inconsistent approaches to
accessing the road corridor) made business operations around Northland
extremely difficult.
• There was a sense that Wellington was disconnected from or lacked
understanding of the impacts of various health measures on
Auckland businesses.
• Many businesses felt that they had knowledge and expertise that could have
helped Government, but they were not used – for example, employment
lawyers and professional bodies who were not consulted over the Wage
Subsidy Scheme, special COVID-19 leave and other matters that interacted
with employment legislation.
• Complex and frequent legislative and regulatory changes made it difficult to
understand and keep up with what was required. For example, we heard that
after the COVID-19 Public Health Response (Maritime Border) Order 2020
came into force, ships’ pilots were initially required to wear full personal
protective equipment (PPE) (including goggles) when transferring from one
ship to another, often on ladders in pitching seas. This was both a health
and safety issue for the pilots, and a legal quandary for their employers:
they had to choose between observing health and safety obligations or
maritime border orders.
• Businesses had access to data and networks that could have been very helpful
to government but were not often accessed.
• There were complaints from businesses about the slowness to allow rapid
antigen testing, and about the Ministry of Health objecting to the possibility
of the private sector using saliva testing instead.
• Business associations considered the Government could have given them
greater advance notice when communicating policy and other changes
to businesses.
• Operating business policies relating to requiring workforce vaccination was
a key issue for a number of businesses, and of course, for their employees.
This is covered in Chapter 8 later in this report.
Exporters
Most visibly affected were those businesses which exported services and relied
on an open border to access their markets; the regions they operated in were
also hard-hit. Tourism and the international education sector – both high foreign
exchange earners and large-scale employers – were the most obvious examples.
For other export sectors, the situation was more nuanced. Not all exporters were
allowed to operate during lockdowns. The agricultural sector was one exception
for several reasons: animal welfare, the continued health of agricultural production
systems (for example, plant health), and the need for food security meant that
many rural operations and related production simply had to continue. To allow
this to happen, the Ministry for Primary Industries developed (in just two days) a
set of rules which the agricultural sector had to comply with, and audited 8–9,000
businesses for compliance in the first two-and-a-half weeks – a considerable
achievement. This exemplifies how a principle or desired outcome can be taken
as a starting point, then a sector works out how to achieve it (in this case, how to
reduce transmission risk) while keeping other things going as best as possible.
For the duration of the pandemic, many exporters were unable to visit overseas
markets due to closed borders and disrupted air travel. Their concerns that this would
result in a loss of customers was partly offset by New Zealand Trade and Enterprise
scaling-up its overseas presence, thanks to $200 million funding from the Government
to build its capacity in overseas markets.
Lockdown-related problems
Other issues affecting businesses related mostly to the impact of lockdowns. For example:
• The closure of butchers, restaurants and other hospitality venues during lockdown
caused significant problems for pork producers while pork imports continued.
Pigs were unable to be taken off farms for processing, which led to animal
welfare risks due to continued breeding cycles and the number of pigs on-farm.
• The requirement for specialist food retailers (such as butchers) to remain closed
during lockdown meant people purchased almost all their food through the
main supermarket chains. This adversely affected those retailers: the Inquiry
heard from a number of groups about the financial and mental health issues
faced by small businesses. The closure of small retailers also had the effect of
reinforcing the supermarket duopoly. We frequently heard complaints about
the perceived unfairness of this situation, and the view that some small retailers
providing essential supplies could have operated just as safely as supermarkets.
• Retail, hospitality and other businesses that relied on direct customer
interaction were also adversely affected – not only by the lockdowns themselves,
but by the shift to people working from home after lockdowns were lifted. From
the start of 2020 until October 2022, there was a loss of consumer spending in
the Auckland city centre of about $870 million – an average loss of $675,000 per
business. Similar effects were felt in other city centres.
Often, large businesses were better able to absorb the shock than small businesses
with low capital stocks as they had larger capital reserves to call on.
Some sectors – such as banking, financial services and technology – were well
positioned to shift to digital or remote work. But other types of businesses that relied
on physical, in-situ, or in-person work (such as construction or personal services)
simply could not do so during the initial Alert Level 4 lockdown.
Working with Government

Many businesses and sector groups told us that officials making decisions about
public health settings were initially unwilling to consider options which would have
allowed non-essential industries to keep working safely – for example, road and bridge
construction could have continued because workers generally keep a considerable
distance apart anyway. Instead, several major construction projects came to a halt
during the initial Level 4 lockdown, triggering force majeure provisions. These led to
substantial commercial claims and losses, which are still being heard in the courts in
2024. It also led to key skilled workers leaving Aotearoa New Zealand, which in turn
created further delays when those skills had to be re-introduced once construction work
began again. We also heard that many of the smaller food providers and non-food
manufacturers could also have operated safely, just as the essential food production
sector managed to (and which was confirmed by audits such as the Ministry for Primary
Industries’ compliance audit of agricultural producers mentioned earlier).
Businesses also told us that government agencies were sometimes inconsistent in
their approach to public health threats. For example, government workers based
at Auckland Airport were given PPE, but employees of Auckland Airport and other
private businesses who worked in the same area could not obtain any.
Overall effects
Regardless of size, sector or location, the evidence shows New Zealand businesses
were contending with a common set of challenges throughout the pandemic. In
summary, they were:
• Worldwide, people’s behaviour changed significantly during and after the
pandemic. These changes affected how people work, go to school, are
entertained, how they shop and what they buy. For businesses, this has meant
adjusting to different patterns of demand, providing goods and services in
different ways, getting capital to invest in new activity and much more
• COVID-19 response measures profoundly impacted how people spent their
money. The largest fall in spending occurred during the initial Level 4 lockdown
in late March 2020, when spending dropped by nearly 55 percent.55 As a result
of lower spending, people saved more during the national lockdowns.
• The pandemic caused business confidence and trading activity to decline
on many occasions,56 reflecting the successive rounds of lockdowns.
• Businesses faced labour shortages due to travel restrictions and inflation,
making it hard to expand their production to meet demand.
• Although businesses could pass on to customers some of their increased
costs (which had risen due to higher input costs as a result of shortages of
labour and materials), their profitability was nonetheless negatively impacted.
6.3.4 The pandemic created or exposed numerous workforce
challenges, including shortages of workers in some sectors,
a reliance on immigration, under-investment in human
capital, inflexible legislation, pay inequities and more
At a strategic level, the pandemic presented several labour market challenges.
These were seen in, but not limited to, the inability of several business sectors (such
as healthcare and aged care) to secure the workers they needed. The pandemic also
exposed some vulnerabilities. Lack of addressing them pre-pandemic meant that we
were not as well placed in the pandemic as we could have been. Examples included:
• The degree of reliance on immigration to fill shortages of both skilled and
unskilled workers.
• A lack of investment in building human capital, especially critical human capital.
• Questions about whether legislation was fit for purpose and agile.
• Health and safety issues.
• Inequitable work conditions, including pay.
• Rigid occupational regulation.
• The black/grey economy.
Some of these topics are covered in other parts of this report. In summary, the
Government response only partially mitigated these issues businesses faced.
Generous government financial support, especially through the Wage Subsidy
Scheme, ensured that the private sector workforce was largely sustained. The
incomes of the public sector workforce were largely unaffected. Nevertheless,
a range of influences – some reflecting pre-existing conditions – fueled shortages
of both skilled workers (including university staff and specialised health workers)
and less skilled workers (some types of farm workers, and hospitality staff) in some
sectors. Those pre-existing conditions included workforce capacity and capability
gaps, and insufficient income: some workers simply went to other countries
where they could be paid more.
The wage subsidy ensured that most employment relationships were sustained
(‘attachment effect’) during the pandemic, with some potential ‘long tail’ effects
on productivity that are briefly covered in section 6.6. Of course, there were some
closures and layoffs. For some people, the pre-existing benefit rules meant that they
could not go on a benefit if others in their household were working. There were also
regional, age, gender and sectoral differences in the take-up of the wage subsidy.
Immigration settings, and the slow response to the needs of business, contributed
to workforce shortages though they were certainly not the only cause. Managed
isolation and quarantine (MIQ) restrictions also had a negative impact on the health
system, which is heavily reliant on the continued supply of international health
workers of all different skill levels.
Even though the pandemic intensified global demand for international health
workers – and Aotearoa New Zealand’s successful containment of COVID-19 may
well have made it an even more attractive option – foreign health workers faced
several challenges, including securing MIQ places. Other shortages were exposed
as border restrictions were put in place (see Chapter 4 for more on the effects
of border and quarantine measures on the workforce).
For employers and employees, the employment situation was stressful and hard
to navigate. We were told about employers having difficulty finding the underlying
legislation, regulations and guidance notes across websites; the introduction of
new concepts that were untested by the courts and had to be applied in the new
environment; and people finding it hard to quickly seek remedy or clarify the
interpretation of law.
Another major issue for employers was the emotional, psychological and
health impact COVID-19 had on their staff. Workers in essential industries often
experienced stress, some lived in crowded households, and some were reluctant
to have close contact with their families and friends – or, conversely, were shunned
as possible vectors of infection. Absenteeism at work increased. A fuller account of
these impacts can be found in the second half of this chapter.
6.3.5 The supply chain was disrupted by international and

domestic developments during the pandemic, but the impacts
have not yet been fully analysed; doing so is essential for
improving the supply chain’s resilience in another such crisis
In general, Aotearoa New Zealand did not experience food shortages or lack
essential goods. But supply chain problems nonetheless arose through a
combination of global trends, domestic public health measures (such as the need for
social distancing in ports and distribution centres) and ‘panic buying’ of some items
such as toilet paper. The two major supermarket chains (Woolworths/Countdown
and Foodstuffs) both experienced some product shortages.
There were initial fears that – because New Zealand was at the far end of international
supply chains – some shipping companies might choose to drop it from their
scheduled services. In the event, this particular risk did not eventuate. However,
shipping was nonetheless disrupted throughout the pandemic, which affected export
and import trade. Shipping reliability rates (the extent to which shipping lines met
scheduled times) to New Zealand ports plummeted, falling from 80–100 percent in
January 2020 to 0–20 percent a year later.57 This created uncertainty for importers
about when expected freight was due to arrive, while exporters could not be
confident of when they could deliver goods to overseas markets.
Shipping freight rates were also volatile. Global container shipping costs increased
by approximately 500 percent during late 2020 and 2021 to a peak in October 2021
but had fallen to pre-pandemic levels by October 2023. Bulk shipping rates also
increased sharply (again by approximately 500 percent between April 2020 and
October 2021) before falling to pre-pandemic levels by January 2023.58 Air cargo
freight rates increased too, but, despite general disruption to global aviation, the
value of cargo imported through Auckland Airport continued to increase throughout
the pandemic. This showed that demand for air cargo remained high and that, at
least on the surface, the Government’s air cargo subsidies had some effect.59
While Aotearoa New Zealand lacks data measuring the impact of supply chain
disruptions during the pandemic, we note that many other countries experienced
slower supplier delivery times.60 Substantial increases in supply chain disruptions
and backlogs were also reported: globally, supply chain disruptions (such as from
shipping delays and stock shortages) grew from approximately 25 percent in 2019
to over 70 percent in 2020/21.61 New Zealand businesses reported similar problems.
In our discussions with businesses, they also identified several domestic sources
of supply chain disruption. For example, the Auckland lockdowns restricted the
availability of Auckland-manufactured goods (such as building products) elsewhere
in the country, while there were also periodic shortages of freight capacity on the
Cook Strait ferries. Some stakeholders also cited a lack of understanding among
government officials about the interdependencies between internal supply chains
– for example, between food exports and the local packaging supply sector, or food
manufacturing and the waste recovery and recycling sector.
Combined with the broader impact of public health measures – such as the lack
of any provision to allow ‘non-essential’ industries that could continue to function
with a reasonable degree of safety to do so – these supply chain disruptions had
considerable economic impacts. For example, the non-food manufacturing sector
(which accounts for 69 percent of New Zealand’s manufacturing GDP) was unable
to operate during the August 2021 lockdown: the effects were felt both by their
downstream customers and by many export-oriented businesses that had spent
years building up their international customer bases. Their inability to supply
customers overseas led to the loss of significant current and future export markets.
From the evidence we have seen, the authorities have not yet comprehensively
analysed or assessed the pandemic’s impacts on the supply chain. However, we are
aware that the Ministry of Business, Innovation and Employment is leading work
to implement the Indo-Pacific Economic Framework’s supply chains agreement.
Through that agreement, countries commit to promoting regulatory transparency;
identifying the supply chain stress points the COVID-19 pandemic exposed, and
the critical sectors and goods affected; and coming up with practical solutions to
the supply chain disruptions that remain in the wake of the COVID-19 pandemic.
In our view, managing future risks to the supply chain and ensuring resilience is
an important component of Aotearoa New Zealand’s preparedness for a future
pandemic – a point we return to later in our lessons and recommendations.
What happened: social sector impacts
6.4 and responses | I aha: Ngā pānga me
ngā urupare a te rāngai pāpori
6.4.1 What happened

As we set out earlier in this report, some acute social problems were already
confronting Aotearoa New Zealand before the pandemic. They ranged from an
ongoing housing crisis, hardship for families in low-income households and on
benefit support, growing mental health issues, and the long-standing inequalities
or inequities faced by Māori, and a range of other groups. A significant proportion
of the population was experiencing persistent disadvantage.62
For individuals, families and communities facing hardships like these, social
services provide a much-needed safety net. During a pandemic, they also play
a critical role in minimising the spread of infection. The availability of social services
means people can comply with health measures, including staying home safely,
while still having their basic needs met.
Pre-pandemic, 697,000 New Zealanders (more than 15 percent of the population)
were estimated to be experiencing persistent disadvantage.63
International disaster literature, along with lessons from New Zealand disasters
including the Canterbury and Kaikōura earthquakes, shows that certain groups
are disproportionately impacted during natural disasters and other crises: namely,
groups already facing existing disadvantage.64 That was well known at the start of
the pandemic and, looking back from 2024, we can see this is largely what occurred.
During the pandemic, the need for various forms of social support and services
increased. They included:65
• Food grants and parcels.
• Housing support and emergency housing.
• Family violence support (including refuge, food and other supports).
• Community-based mental health and addiction support.
• Support with meeting basic needs (including blankets, clothing, cleaning
supplies, heating and devices/wifi).
• Support for individuals or families to isolate.
In normal times, responsibility for designing, funding and delivering social supports
is spread across many organisations. The Ministry of Social Development is often
seen as the lead government agency, but many others are also involved.xiv During
a crisis, the Civil Defence Emergency Management system also has welfare support
responsibilities. And while some supports are delivered directly from agencies (such
as income support and statutory care and protection), most are delivered through
a network of non-governmental organisations (NGOs), social service providers and
charities. Local government and philanthropic funders also have key roles.
xiv These other agencies include Oranga Tamariki, Ministry of Health, Ministry of Education, Ministry for Housing and
Urban Development, Ministry of Youth Development, Ministry for Disabled People, Te Puni Kōkiri, Ministry for Ethnic
Communities and Ministry of Pacific Peoples. Key independent Crown entities include ACC and Kāinga Ora.
6.4.1.1
Investment in social services and supports
Mitigating the pandemic’s potential social and wellbeing impacts was a significant
component of the COVID-19 response from the start. The initial Government
COVID-19 spending package Cabinet agreed to on 26 March 2020 included funding
to ‘ensure people have access to the food and other goods they need to survive’ and
‘services that provide a place for people to live’ during the first national lockdown.66
Specific funding was tagged for disabled people, family violence and sexual violence,
local community solutions, and for Māori and Pacific peoples. In addition, funding
was provided through Te Puni Kōkiri to boost Whānau Oraxv and launch a new fund
to support whānau, communities, marae and businesses with self-isolation and
accessing the essential support needed to remain connected to their communities.67
By the second day of the first lockdown, $27 million of targeted social relief funding
had been approved.68 This was increased substantially in May when Budget 2020
earmarked $2.9 billion for COVID-19-related social spending, including a permanent
$25 per week benefit increasexvi and a temporary doubling of the Winter Energy
Payment (intended to help people with the cost of heating their homes).69
As 2020 turned into 2021, and it became increasingly clear that COVID-19 was
no short-term blip, there was growing recognition of the scale of the investment
required for a sustained social sector response matched to community needs.70
Significant further investment in social services was made in 2022; even though
community transmission had become well-established since the arrival of the
Delta and Omicron variants, supporting people to isolate safely at home when
infected or vulnerable to infection remained critical for the overall success of the
COVID-19 response.
Starting from March 2020 and including budget allocation up to the end of June
2023, we estimate that total COVID-19 Response and Recovery Fund expenditure
on social response included $2.4 billion used to support community responses,
$3.3 billion in additional benefits to individuals and households, and $18 billion
to support the Wage Subsidy Scheme.xvii Delivering this response involved an
exceptional amount of work delivered under heavy pressure and amid rapid
change. We acknowledge the collaboration and effort this involved across the
entire sector and in local communities.
xv Whānau Ora is a Government-funded, culturally-based, whānau-centred approach to wellbeing. The Whānau Ora
Commissioning Agency works with community-based partners to support whānau in areas including health, education,
housing, employment, improved standards of living and cultural identity. See https://whanauora.nz/about-us
xvi Applying to benefits including Jobseeker Support, Youth and Young Parent Payment, Sole Parent Support and the
Supported Living Payment.
xvii This estimate is based on an analysis of the COVID-19 Response and Recovery Fund funding decisions that was
compiled and published by the Treasury on 14 June 2023. Examples of the inclusions for community responses
include: Care in the Community welfare response, public health response in communities, sustainable housing
options, and increased demand for family violence services. Examples of additional benefits to individuals and
households include: temporary income relief for the COVID-19 job loss payment, COVID-19 leave payment schemes
to employees needing to self-isolate, increases to benefits and Winter Energy Payment increases. The Wage Subsidy
Scheme estimate includes all payments and administration costs.
6.4.1.2
Delivering social services and support during the pandemic
Coordinating and planning the response
For Government, setting up the range of social services and supports needed to
get people through a pandemic, and then communicating the expectations and
rules, was very challenging – especially as it had to be done rapidly. Much was
achieved in a short period, largely by changing the way supports and services
were managed within government and delivered on the ground by providers
and community organisations.
The initial response (from March 2020) was patchy and focused on immediate
priorities. Most government agencies relaxed the reporting requirements on
existing social service and community contracts. The types of support most likely
to be needed, and the groups likely to be impacted by the pandemic, were already
known.71 How agencies and the wider sector planned to deliver against these needs
and the other demands of the COVID-19 response was less clear.
While there was little evidence of pandemic planning at a social sector level,
some agencies, including the Ministry of Social Development, had specific plans
for their agency. The Ministry told us that its early responses were guided by the
existing New Zealand Influenza Pandemic Plan 2017 and recent regional incidents –
the Whakaari/White Island eruption, the Northland drought, floods in Southland
and the response to the Canterbury and Kaikōura earthquakes.
Oranga Tamariki had earlier rolled out a new digital platform (completed in
February 2020) that enabled frontline staff to switch to remote working and
reporting. While this was lucky timing, it was also an important preparation that
enabled continuity of essential services (including social work support for children
in care) during the pandemic.72
Shifting to a collaborative approach

After the first few months, the overall social sector response was characterised by
high agility, flexibility and collaboration between government, iwi and community
partners – accompanied by an injection of (mostly time-limited) funding. Throughout
this period, some cracks were exposed in coordination and approach; for example,
instances of different agencies contracting to the same provider for different pieces
of pandemic support but taking different contracting approaches.
At the same time, it was realised the response would need to be sustained for an
as-yet unknown length of time: months and perhaps even years. In response, the
Ministry of Social Development, the lead agency in the sector, changed its operating
model significantly to make it easier for people to access support. The change also
allowed the Ministry to free up staff to work on new initiatives, including the Wage
Subsidy Scheme. It was a ‘rapid and near-total overhaul’, one senior official told
us, and necessary for two reasons: it would allow the Ministry to keep delivering
‘business as usual’ support under lockdown conditions, and also allow the rapid
development and delivery of new supports.
The Ministry of Social Development relaxed many of its standard processes,
thresholds, and stand-down times for income support; expanded access to some
benefit types, including temporary food grants; and switched from in-person to
remote and online service delivery. Along with other government agencies, the
Ministry contracted non-governmental organisations to deliver additional social
services and support, relaxed many of its compliance requirements, and notified
providers that funding would not be held back against existing contracts due
to the pandemic. We heard many of the changes made were both effective and
appreciated by the clients in the system.
Agencies also adopted new commissioning models which gave greater emphasis
to partnering with local providers, and relied on high-trust relationships between
agencies and providers.73 The agencies recognised there was simply no time to
develop and negotiate traditional output-based contracts for the services and
supports needed across the country – which, in normal times, would see agencies
assess needs and specify the volume and type of services the provider would deliver
in each period.74 Under the commissioning model, after the relevant agency and
service providers had jointly agreed on the desired outcomes, providers were largely
left to determine what services would be provided and how, as circumstances evolved.
Commissioning relies on high-trust relationships between agencies and providers.
“ During COVID, we worked with regional teams to ensure they had the right relationships
to be able to work with the right people for a community response.”
We heard from many government and community organisations that there

was great value in developing these relationships in advance – as a way of both
improving commissioning and service delivery in the present, and setting the
foundation needed to respond to a future crisis.
With relational commissioning, accountability shifted from documentation of
compliance with specific outputs to less onerous accountability. This still provided
assurance to Government but gave providers flexibility to adjust how to best
fulfil the contract. Government agencies also made changes in governance and
coordination, and these are discussed in section 6.4.1.3.
Local responses
COVID-19 social responses were not only directed from central government
agencies – they also involved coordinated efforts by thousands of people around
the country. Working together, individuals, whānau, hapū, iwi, NGOs, councils, faith
communities, agencies and businesses – including many volunteers – ensured the
health and wellbeing of their clients, their own people and communities.
“ On the ground, it was community-led responses and action that ensured people and whānau
had what they needed to get through the rāhui and stop the spread of COVID-19.” 75
There was some confusion at the start of the pandemic about what services were
essential (see discussion in Chapter 3) and how multiple providers supporting the
same communities should work together. But as time went on, the sector became
more confident in how it could best support their communities. In some cases,
that meant providers delivering services without contracts or funding, using their
own resources, until the government systems caught up. One provider of money
management services for people who cannot get bank accounts told us that, before
COVID-19, they used paper-based systems. ‘All of a sudden, we couldn’t pay these
people the money they live on each week because the bank closed, and these
people didn’t have bank accounts [to do internet banking]. We found workarounds
– e.g. running to various cash machines with organisational credit cards getting out
the maximum limit.’
Funding from charitable donations and philanthropy also contributed to the
COVID-19 response. New Zealand Red Cross told us that support from donors and
corporate partners contributed to their COVID-19 response such as the production
of New Zealand Red Cross care parcels distributed to vulnerable families.
One factor that made local service providers so effective in the pandemic response
was their well-established and trusted relationships with local communities and
families – which, in turn, gave them a deep understanding of the issues facing
individual households. While social sector agencies hold data at an aggregate level on
the needs of citizens, this is not the same as the intelligence held by on-the-ground
providers who know their community’s needs first-hand. Many providers we met with
told us how the shift to more flexible contracts with Government gave them the room
they needed to identify and best support the needs presenting in their communities,
using their local knowledge of their clients and communities to provide tailored support.
We also heard that whānau-centred service delivery and support through Whānau
Ora formed a bedrock for Māori communities during the pandemic. The flexible
arrangements government agencies put in place allowed Māori to deliver the
support whānau needed, based on manaakitanga, trust and connections. We
talked to many commentators from government and community organisations
who specifically mentioned the excellent support that Māori communities and
service providers delivered. They knew their communities well and were expert in
programmes and support that were Māori-designed, developed and delivered.76
“ Iwi understanding of their communities informed the effective distribution of welfare

support, including placement of Community Connectors within their regions.” 77
“ Tangata whenua were absolutely superb. Their inclusiveness, the way that they
came around the community, distributing fish – so many different things that
were so positive.”
As we describe in Chapter 3, in relation to lockdowns specifically, iwi and Māori

stepped up to lead and deliver many forms of essential social support during
the pandemic response. In many rohe, marae became community service hubs.
Local Māori and non-Māori came to marae for food distribution, wifi, testing and
vaccinations. In some rural and remote areas, iwi and Māori also helped people access
generators and water. According to the Ministry of Health, ‘iwi, hapū and marae
became centres of excellence for responding to the pandemic’. It was a similar story
in many other communities, where places like sports clubs, churches and health
centres became de facto social service hubs. We also heard about the importance of
schools as hubs, especially in rural areas, and the important leadership role school
principals played in the wider community. Similarly, Pacific church leaders generally
played a strong role in supporting their communities and advocating Pacific peoples’
needs during the pandemic. Government agencies partnered with communities and
local providers to deliver support.
The shift by government agencies to new commissioning modelsxviii was also critical
in enabling effective local responses. The commissioning gave greater emphasis to
partnering with local providers and strengthening provider networks in different
regions. This was particularly important in rural areas where there are usually
fewer providers. With the need to get funding and support out to communities fast,
agencies recognised they needed to leverage local knowledge so that emerging needs
could be identified, and then enable local providers to assess and deliver services
matched to those needs. According to several agencies we spoke to, and the many
providers and community organisations involved in the delivery, this was a much
better way of responding to community needs during the pandemic. It had similarities
with the Whānau Ora delivery model, which empowers Māori and Pacific providers
to develop and deliver services tailored to the unique needs of their communities.
During our Inquiry, we heard many success stories where groups in the community
came together to address local needs and shape the pandemic response on the
ground. A compilation of case studies of community action during 2020 noted
the best outcomes were achieved in communities where the strongest existing
relationships were already in place.78
“ [T]he experiences of how community-based social service organisations adapted and

responded during the COVID-19 lockdowns and alert levels showed the challenges of
the current system and offered opportunities for change. Innovation occurred, ensuring
communities and hapori were kept safe.”
There were also opportunities to improve the social response. We heard of

instances where multiple organisations were providing wrap-around services in the
same community, leading to some duplication – particularly of food parcels. In a
few cases, families used food parcels to barter for cash to cover other bills. We also
heard of some challenges arising when agencies and local providers were working
out new relationships and systems during the pandemic. Overall, the evidence
we received suggested a high degree of integrity in the response, in terms of the
assistance reaching the people who needed it. In fact, we heard many cases where
providers used their own reserves to support their community, beyond the funding
received from Government.
xviii New commissioning models included relational approaches based on high-trust and focused on outcomes,
compared with standard contracting for services that can be very prescriptive in how services and inputs and
outputs are expected to be delivered.
Overall, central government enabled successful locally-led responses by means of
clear messaging and expectations, a strong sense of shared purpose, empowering
people to work differently and adequate resourcing. Throughout our Inquiry, we
regularly heard government and community stakeholders reflect positively on
what the recalibrated approach to social service provision had achieved, and
many thought continuing this approach beyond the pandemic response would be
beneficial. We heard that the change from contracting to commissioning, and the
different accountability mechanisms that were adopted during the pandemic, were
well managed by agencies and supported efficient delivery against outcomes.
Flexible ways of delivering support were adopted

The delivery of food parcels to people stuck at home was one of the most visible
forms of social support during the pandemic, especially when lockdowns were in
force. Food parcels were often accompanied by hygiene packs containing hand
sanitizers, medicines, masks and cleaning supplies. Delivery of such essentials
meant COVID-19-positive families could stay at home in their bubbles, thereby
reducing community transmission. These deliveries were particularly important
to families living in poverty, people who had suddenly become unemployed, and
to older or immuno-compromised people. They also gave many providers an
opportunity to assess the wider situation – who was in the household, what were
their needs and whether there were any issues needing action.
Other forms of social service delivery also played an important role in the pandemic
response. Online delivery of some services – such as those for youth transitioning
out of care, mothers dealing with high-needs children, women and children at
risk of family violence, and people receiving support for mental health issues or
addiction – became a new tool. However online services only worked when the
people using them had devices and internet connections, so those things often had
to be provided too. As well as online check-ins and meetings, many providers found
innovative ways to support their clients, such as making short videos about key
points or techniques they would normally share in face-to-face sessions.
But not all services could pivot to online support. For example, care for disabled
and elderly people still had to be provided in-person, and workers depended on the
availability and coordination of PPE to be safe. Often the community sector could
not get access to PPE, restricting providers’ ability to provide safe services to high
needs clients (the procurement and distribution of PPE is covered in Chapter 5).
The pandemic also led to many health and social services becoming integrated.
This saw social service providers coordinating community pop-up testing and
mobile door-to-door testing, making pharmacy deliveries and organising local mask
distribution. The integration of services was also visible at vaccination events, which
sometimes involved non-medical staff who had been trained as vaccinators. The
success of community hubs, including marae, is another example of the integration
and coordination of the wider needs of the community.
Spotlight:
Food security during the pandemic |
Te rawaka o te kai i te wā o te mate urutā
Pre-pandemic, accessing adequate food was not a concern for most

New Zealanders; most people were accustomed to simply stopping at
the supermarket and picking up what they needed, when they needed
it. But the lockdowns and other pandemic restrictions brought the need
for food security into focus.
As discussed in the first half of this chapter, only certain grocery
retailers could operate in Alert Level 4. This put stress on households
normally reliant on specialty butchers, grocers or markets to meet
their needs. It also fuelled worries about food shortages. Retailers did
a good job of managing any hoarding or panic buying. And while there
were queues and some individuals faced challenges in getting their
groceries, overall there were no food shortages. The food supply
chains held.
But food security means more than simply maintaining commercial
food supply. For some New Zealanders, even before the pandemic,
access to adequate food was a daily concern. COVID-19 worsened
their situation, as evidenced by increasing use of both foodbanks
and hardship grants for food.
Over COVID-19, use of both foodbanks and hardship grants for food
spiked. At its peak, the Salvation Army reported that calls to their
foodbank increased ten-fold from 800 per week pre-COVID-19 to 8,000.
A survey of foodbanks by Kore Hiakai Zero Hunger Collective indicated
that they were distributing at least double the amount of food during
this period.79
The increased demand for food parcels and food grants during the
pandemic was largely due to loss of income, as well as more family
members being home all day (especially children who would normally
receive free breakfasts or lunches at school) and isolation requirements.
Ensuring widespread food security in the face of these pressures was
one of the success stories of the pandemic response.
It was achieved through the combined efforts of government agencies
and community organisations and providers. First, the Ministry of Social
Development provided some foodbanks with emergency funding so
they could stay open. Later, Civil Defence and Emergency Management
groups stepped up to support foodbanks and other community food
services to meet the demand for food from the community.80
281
The next step was investing strategically in food security. In May 2020,
Government allocated $32 million over three years to this goal, referred
to as Food Secure Communities.81 It included funding for national partners
(NZ Food Network, Kore Hiakai Zero Hunger Collective and Aotearoa
Food Rescue Alliance) to build the capacity and capability of the non-
commercial food recovery and distribution network, and $23 million to
help local community food banks meet the additional demand created
by COVID-19.82
In 2021/22 Government support for Food Secure Communities increased.
Another $150 million was allocated to community food providers over
the next three years along with investment in community distribution
infrastructure, which created significant efficiencies in procuring and
distributing food.83 Funding was made available to develop food security
plans and pilot projects to increase vulnerable communities’ access to
affordable, nutritious and culturally appropriate kai. Budget 2023 included
$24.8 million to continue the programme for two further years84 and a
further $6 million in June 2023 to meet increased demand in 2023/24.85
This was the first time that the Government had invested in a strategic
approach to building food security, in collaboration with national partners.
This initiative can help build and maintain preparedness and the critical
food security infrastructure needed in future crises.
282
6.4.1.3
New ways of working within government
Government social sector agencies improved their governance
and coordination
As it became apparent the pandemic was going to need a longer and more
sustained response, many government agencies adapted their governance
arrangements for the new environment. There were some changes in how
government agencies worked together across traditional siloes and took on
more of an oversight role across the whole social sector system.
For example, the ‘Caring for Communities’xix workstream operated at a regional level.
In 16 regions, it brought together the local Civil Defence Emergency Management
groups with regional leaders from government agencies and local government to
guide and support community planning and response activity. This activity was
supported by a chief executive group, whose members were drawn from social
sector government agencies and chaired by the Ministry of Social Development.
The chief executive group helped ensure rapid and coordinated decision-making
and allocation of resources from the centre. It used agencies’ various networks of
providers to get better collective service cover, and quickly resolved barriers and
challenges identified.
Another move to improve coordination and collaboration among agencies was
the strengthening of the Regional Public Service Leadership model. It had been
agreed in June 2019;86 initial appointments to these positions were made in late
2019 and the first half of 2020. The overall model seeks to strengthen coordination
between central agencies and regional counterparts. Designated Regional Public
Service Leads were active in the initial COVID-19 response. In July 2021, Government
changed their titles to Regional Public Service Commissioners and expanded their
scope and mandate.87 The Commissioners were intended to be conduits for all
government agencies into regions. They sought to bridge regional connections and
play a part in identifying, resolving or referring on local and regional issues with
iwi, Māori, local government, Pacific and other community leaders. While part of
the ‘Caring for Communities’ regional groups, the Commissioners’ mandate went
beyond social support to include education, training and economic development.
In November 2021, they were mandated ‘with leading the regional alignment
and coordination of the public service contribution’ to the COVID-19 Protection
Framework, including the welfare approach.88
As of 2024, the Regional Public Service Commissioner model is still maturing.
As expected with a new initiative like this, we heard of some variability in the way
it has been applied across regions. But we believe the model is a promising one
that may, in future, support better coordination between local preparedness
planning and welfare responses managed by central government agencies.
xix Despite the similar names, Caring for Communities (C4C) and Care in the Community (CiC) were not the same. The
first was a coordinating mechanism for central government agencies, set up in July 2020, with a chief executive
group chaired by the Ministry of Social Development. Care in the Community (CiC) was an all-of-government welfare
response established in November 2021 and led by Ministry of Social Development to support COVID-19 positive
households and others directed to isolate during the Omicron outbreak.
The Care in the Community welfare response formalised the new approach
In the early phases of the pandemic, central government agencies and the network
of groups delivering welfare services on the ground all had much to learn about
how best to support the community. In November 2021, anticipating a pivot to ‘living
with the virus’, some of the best practices to date were incorporated into the Care
in the Community health and welfare response.89
It was a package of supports – including health monitoring, food and non-food
essentials – for individuals and whānau who contracted COVID-19 and needed to
isolate at home. A coordinated approach was used to assess and triage people’s
welfare needs, make referrals, and ensure they could access virtual consultations
with pharmacists and other health professionals, medications such as antivirals,
and other forms of health and welfare support.90
The initial funding of $204 million included resourcing for Community Connectors
to support the welfare needs of individuals and whānau so they could isolate
safely, including connecting them to services during and when moving out of self-
isolation.91 The Cabinet paper seeking funding noted that Care in the Community
would deliver a ‘regionally-enabled and locally-led welfare approach that can
respond effectively to people in self-isolation’.92
While Care in the Community was primarily intended for those managing their
illness and isolating at home, providers could take a flexible approach to what was
provided and to whom. Some of the community needs they ended up addressing
went beyond self-isolation support. In these cases, after addressing immediate
priorities, the Community Connectors and providers focused on linking people to
support that could strengthen their independence and protect them against the
pandemic’s long-term financial, education and wellbeing impacts.93
Care in the Community was implemented by Regional Leadership Groups, Regional
Public Service Commissioners and Ministry of Social Development Regional
Commissioners, working in partnership with community providers and leaders,
iwi, Māori, Pacific peoples, ethnic communities, the disability sector, local councils
and government agencies. The Ministry of Social Development set up a COVID-19
welfare helpline, national and regional triaging teams, and new IT supports to share
information and referrals. It also undertook a real-time evaluation to generate rapid
insights and lessons from Care in the Community.94
Based on the evidence we reviewed, we think Care in the Community is another
initiative that offers a model that should be used in future pandemics, may have
utility in other crises, and has lessons for service provision in non-emergency times.
Some challenges remain unresolved
As we have seen in the preceding sections, government agencies made rapid
changes to internal operating models, the contracting and commissioning of
services, and how they worked together and with providers and communities. All
these moves made a positive impact, chiefly by letting local providers rapidly deliver
tailored support and services to the communities they worked in. However, several
issues were raised in our engagements that may warrant further consideration.
We heard from agencies, providers and local government that the response was
complicated by a lack of clarity about social service roles and responsibilities
within government agencies during a pandemic. The Civil Defence Emergency
Management Plan provides for a welfare response that is separate from the local
‘business as usual’ social services provision. We were told that the Civil Defence
approach may be appropriate in some disaster events. But a pandemic, which will
usually require a longer response, needs a different approach – one that leverages
existing relationships and knowledge.
Many groups told us that while some of the pandemic’s impacts on individuals and
groups – particularly those already identified as vulnerable – were predictable, the
funding Government provided to mitigate them was inadequate. While agencies
worked hard to disperse the funding that was available, they said vulnerable groups
and communities were nonetheless disproportionately affected by the pandemic.
For example:
• Ethnic communities were grateful for the funding they eventually received,
even though it came very late. Many also expressed appreciation for the
support given by the Ministry for Ethnic Communities.
• Advocates for women pointed to the considerable economic burden the
pandemic placed on women, including being over-represented in sectors
with greatest job loss, but the COVID-19 recovery package focused on male-
dominated sectors like construction and trades.
Finally, many community groups and
providers raised specific concerns about
the vaccination rollout, such as the We heard from agencies, providers
Ministry of Health not engaging with and local government that the response
local groups early on, or the fact that was complicated by a lack of clarity
about social service roles and
some vaccine providers used government responsibilities within government
funding to provide cash vouchers as agencies during a pandemic.
incentives to be vaccinated. These and
other vaccination issues are covered
in Chapter 7.
What happened: social impacts and
responses | Tā mātau arotake: ngā pānga
0.0
6.5 pāpori o te mate urutā me te urupare
a te Kāwanatanga
6.5.1 The pandemic and the response affected everyone,

but some people and groups experienced negative impacts
disproportionately – and these often deepened over time
The COVID-19 pandemic had far-reaching consequences for all aspects of our lives,
and everyone was impacted in some way by the pandemic and the responses to it.
Some impacts were immediately apparent and had clear causation; others emerged
later and were the result of multiple pandemic response measures and their flow-
on consequences.95 As disadvantage typically accumulates and intersects in ways
that may not be revealed in data, it is possible that the extent of the pandemic’s
impacts on some people has not yet been fully identified.
As we have already noted, people in at-risk groups and already disadvantaged at
the start of the pandemic tended to be those most impacted and had less scope to
adjust, particularly when they also had one or more exacerbating risk factors. These
included low incomes or material hardship; insecure housing; mental health and
addiction challenges; unemployment, underemployment or insecure employment;
and experience of family violence or sexual violence. When people belonged to
multiple ‘at risk’ groups, the impacts amassed, and those least able to absorb the
shocks faced the most impacts. A few weeks into the global pandemic, the OECD
highlighted what all this demanded of governments: ‘Vulnerable and disadvantaged
groups will be impacted more severely and therefore require particular attention in
the policy response.’96
These views were echoed in many of our engagements with government and
community organisations. For example, Te Pai Ora SSPAxx told us:
“ [There were] many inequities before but COVID has had a deepening effect on those.
We’re only beginning to understand those significant impacts and long tail – especially
for tamariki and rangatahi.”
The evidence we received makes it clear that, from the start of the pandemic
response, government agencies and Cabinet were aware of the risks to many
vulnerable groups. Thus, alongside ‘across the board’ measures aimed at helping
everyone withstand the impacts of the pandemic, Government did seek to mitigate
the pandemic’s harmful effects on vulnerable groups through various targeted
interventions (see section 6.4.1). For some groups, these mitigations meant they
came through the pandemic better than would otherwise be the case. Other
groups did not receive many targeted interventions, but generally came out of the
pandemic alright. But there were some groups that experienced negative impacts
that were disproportionate to others.97
xx Social Service Providers Te Pai Ora o Aotearoa.
We recognise that no government anywhere in the world can fully meet the needs
of every group in society; whatever measures are taken, some will be inadvertently
left out or disproportionately impacted, and there are limits and opportunity
costs to the amount of social welfare supports that can be provided. Nevertheless,
based on what we heard and saw, it is incumbent on us to identify some of the
pandemic’s disproportionate effects that surfaced during our Inquiry. We hope
that doing so not only builds awareness of groups who were excluded from
or poorly-served by the pandemic response, but also helps Government – or
charitable and social support agencies in the community – to better tailor
support to these groups in a future pandemic.
The following is a brief survey of the various categories of impacts we saw, and
some of the groups affected. It is not intended as a comprehensive analysis of
every vulnerable group, nor of all the impacts they experienced. Various agencies,
independent organisations and researchers have undertaken such analyses, and
their reports and reviews (detailed in the endnotes) should be consulted.
We recognise that no
government anywhere in
the world can fully meet
the needs of every group
in society.
6.5.1.1
Some vulnerable groups came through the pandemic better
than expected, as a result of targeted mitigations
Older people
When the pandemic began, the group considered to be most at risk of becoming
seriously ill or dying from COVID-19 was older people. For example, a University of
Otago modelling study published in March 2020 estimated that nearly 89 percent
of the deathsxxi that would occur under various scenarios would be people aged 60
years and over.98
In the event, more older people did diexxii (particularly those aged 80 years or
more) than people in other age groups.99 But by other health, economic and social
measures, overall this group fared comparatively better than expected – and
better than many other population groups.100 Aotearoa New Zealand’s overall low
cases and deaths compared to other countries was a major gain for the most at
risk, including older people.101 Economically, the pandemic response contributed to
growing housing prices, which tended to disadvantage younger people and benefit
people owning houses.
Older people were considered explicitly in decision-making – for example, they were
defined as ‘a high-risk and prioritised population’ in a March 2020 Cabinet paper
establishing vaccination priorities102 – and were given specific attention in COVID-19
communications. As a whole, older people generally fared relatively well financially
thanks to superannuation providing income stability. We recognise, of course, that
some older people suffered from loneliness and isolation, especially when it was
not possible for whānau to visit or support them, and of course some members of
this group would not have fared as well as others. We also heard from engagements
with groups representing older people that many resented being cast as vulnerable
and fragile, and also reacted negatively toward “ageist” attitudes towards the value
of their lives.
People experiencing homelessness or insecure housing

People experiencing homelessness are among those most at risk in the face of
disasters. During COVID-19, people sleeping rough and those in precarious housing
were well supported in the short term. Housing and supports were provided
to mitigate the transmission risk to the wider population. As a result of extra
resourcing and more than 1,200 COVID-19 accommodation places available during
the pandemic, people experiencing homelessness received better support during
the pandemic then either before or after. See also Chapter 3.
xxi The authors estimated that between 8,560 and 14,400 (0.17 percent to 0.29 percent of the population) could die in the
worst scenarios which assumed the failure of the eradication strategy, high disease reproduction numbers and lower
levels of disease controls.
xxii By this, we mean those for whom COVID-19 was officially coded as the underlying cause of death.
Māori
Those Māori who entered the pandemic with existing economic, health and social
inequities faced disproportionate impacts from COVID-19 that affected all aspects
of their hauora.103 Despite facing negative impacts, many also had strong positive
protective factors. Coupled with targeted mitigation, in our view this meant that
they came through the pandemic better than expected.
Māori experienced higher hospitalisation and death rates from COVID-19.104
However, relative inequalities were less than had been anticipated (given the
Māori health inequities entering the pandemic and experience in previous
pandemics) due to the elimination strategy.
Entering the pandemic, Māori (alongside Pacific people) already experienced the
highest rates of income poverty and material hardship across ethnic groups.105
While loss of income affected all groups during the pandemic, the Treasury noted
that ‘periods of sharp and short increases in unemployment during the pandemic
period seem to have affected Pacific peoples, Māori and Asian peoples more than
other ethnicities’.106 Higher unemployment,107 alongside over-representation of
Māori in the ‘precarious’ economy (which was not well covered by Government
wage and other support policies: see section 5.3.3 and 5.3.4) points to Māori
facing additional financial impacts on top of their pre-existing high poverty rates.
In the view of Te Puni Kōkiri, even with mitigations in place, those Māori already in
poverty experienced greater levels of material hardship and financial stress during
the pandemic.108
Māori families are more likely to be larger and multi-generational, which
complicated the concept of ‘bubbles’ and made strict compliance with lockdown
difficult. Isolation from their wider whānau and hapū meant some people lacked
their usual supports, while young people with lower access to digital devices
and connectivity fell behind when learning online.109 Māori were more likely to
experience family violence (see section 5.5.4).110 Māori also experienced cultural
impacts as the need to adapt kawa and tikanga meant important practices like
tangihanga (funeral ceremony) caused grief, harm and stress.111
But Māori also have unique cultural strengths,112 and social and institutional
infrastructure; for many, these functioned as protective factors in the pandemic.
Māori culture is whānau-centric, and in Te Ao Māori, the principles of manaakitanga
and whanaungatanga – the ethics of care and kinship responsibility – cement the
identity of Māori as tangata whenua. Iwi, hapū and marae provided the social
infrastructure that enabled many individuals and groups to respond to the crisis
effectively and appropriately.113 Iwi and Māori also benefited from targeted steps
to mitigate the predicted impacts. Government invested more than $900 million
in a range of initiatives including strengthening Whānau Ora, growing Māori job
opportunities, supporting Māori learners, building the capability of Māori non-
governmental organisations and tackling Māori housing challenges.114
6.5.1.2
For some vulnerable groups, pandemic mitigations were not
well-targeted; these groups experienced variable impacts
Children and young people
Generally, the experiences of children and young people were not given the highest
priority in the pandemic response. Cabinet was mindful of the likely impacts of
extended lockdowns on children and young people’s mental health and general
wellbeing, which was already a significant issue before the pandemic.115 The
number of critical incidents reported by Youthline and other mental health support
providers rose significantly during the pandemic: 4,371 Youthline helpline incident
reportsxxiii were generated in the 2020/21 year, up by 24 percent from the previous
year (see also section 6.5.2).116
Young people held a significant proportion of the
low-paying, casual jobs that were impacted in
the pandemic, so they were more likely to face
The full extent of COVID- employment disruptions. In December 2021,
19’s effects on children and Statistics New Zealand noted ‘Youth have been
young people may not be strongly affected by the COVID-19 pandemic ...
understood for some time.
Young people play a vital role in the labour force,
but our data shows that they experience much
higher unemployment rates than people aged
25–64 and the overall population.’117
We discuss how school closures and loss of learning affected children and young
people in Chapter 3. While the disruption to education for New Zealand students
was less than most other countries, it still had significant negative impact –
particularly for Māori and Pacific students, those from lower socio-economic
backgrounds, and likely for students in Auckland.
We heard that the rights and interests of children and young people were not
adequately considered, and child impact assessments of the COVID-19 policy
responses were not routinely undertaken. New Zealand is not the only country to
be criticised on these grounds. For example, the Australian Inquiry pointed strongly
to the unequal impacts of the pandemic (and pandemic policies) on children,
and recommended measures such as a Chief Paediatrician who – along with the
National Children’s Commissioner – would be involved more actively in decision-
making in a future pandemic.118
The full extent of COVID-19’s effects on children and young people may
not be understood for some time.119
xxiii Youthline says an incident report is created whenever a Helpline volunteer or staff member has a call, text, webchat or
email conversation with a client who is presenting with one or more of the following: (1) any care and protection risk
(including physical abuse and sexual abuse), (2) medium to high suicide risk, (3) medium to high self-harm risk.
Rainbow communities
We saw evidence that people in the Rainbow/LGBTQIA+ communities experienced
some specific impacts during the pandemic, consistent with the bias, stigmatisation
and discrimination they face throughout their lives. Research into the pandemic
experiences of Rainbow young people, undertaken for the Ministry of Youth
Development in October 2020, found that a third of those who chose to respond to
the researchers’ survey were ‘not managing well or not at all’.120 The report found
that the pandemic had ‘amplified their existing mental stress’.121
The negative impacts of COVID-19 were not experienced equally across the
Rainbow/LGBTQIA+ community, with certain sub-groups within it – young people,
disabled people, ethnic minorities, trans people and takatāpui (Māori who identify
as LGBTQIA+) – being more likely to be negatively impacted by the COVID-19
pandemic than the overall group. Representatives of Rainbow organisations we
heard from identified these sub-groups as those experiencing greater mental
health issues.
Ethnic minority communities

Ethnic communities are a large and diverse population group. At the time of the
2018 census, they comprised 941,571 people from an estimated 213 ethnic groups,
speaking 170 languages.122 Collectively, ethnic communities make up almost
20 percent of the population.123
They reported experiencing numerous challenges during the pandemic, particularly
in getting reliable, accurate information through appropriate mediums and in a
range of languages – we heard from stakeholders that new migrants and those with
low levels of English were the most likely to be negatively affected by the pandemic.
According to a survey124 undertaken by the Ministry for Ethnic Communities
during the pandemic, improving access to services and information was the most
commonly reported step that Government could take to improve support for ethnic
communities in a pandemic.
6.5.1.3
Despite policies and programmes to mitigate the pandemic’s
unequal impacts, some vulnerable groups were still
disproportionately affected
Pacific people
Pacific people were always likely to be one of the groups worst-affected by the
pandemic. The impacts they experienced – social, economic, mental and physical
– became notably disproportionate in mid- to late-2021 with the Delta outbreak in
Auckland and slower vaccine rollout for Pacific people.125
They were over-represented in low-income occupations, many of which were
classified as essential: working in supermarkets, food supply chains, and health,
disability and aged care. Pacific families were more likely to live in multigenerational
and sometimes crowded homes,126 putting them at greater transmission risk and
meaning some health measures (distancing, staying in small bubbles, or isolating
away from others at home) were impractical. Pacific families were more likely than
the general population to struggle to pay for basic household costs during the
pandemic,127 which led to some young Pacific people leaving school to help support
their families.128 Pacific households had the lowest level of home internet access
compared with other New Zealand ethnicities,129 and this had many consequences –
including for online and remote learning (see Chapter 3).
All these factors – and others, including existing health inequities, systemic bias
and inadequate targeted support – put many Pacific families under great stress,
especially in Auckland.130 Pacific people were perhaps the most overlooked in terms
of cumulative impacts.
In our engagements, we also heard that it was difficult for Pacific peoples (especially
those with English as a second language) to access clear and accurate information
about COVID-19 and what was expected from them, in their own language or in
a format they could easily access. Additionally, spirituality is at the heart of Pacific
culture; we heard from many engagements that the important roles churches play
in their communities were not well understood or valued.
Women
Women, on average, experienced more economic, health and social impacts during
the pandemic. Pre-existing disadvantages were exacerbated by the effect of some
COVID-19 response measures.131
More women than men lost their jobs, left the workforce, or lost hours and pay and
thus experienced greater employment and economic impacts, largely because they
were more likely to work in impacted sectors such as tourism and hospitality.132
Despite this, the wage subsidy was more likely to be used to support jobs held by
men,133 which points to a mismatch between what was occurring and the response.
Women also bore greater pressure to support and care for families.134 The pandemic
placed women under considerable stress – for example, those who were working
from home while caring for young children and/or sick or elderly family members.135
During lockdown in 2020, women were more likely to report a significant increase
in caring demands.136 Mothers parenting alone and balancing childcare and work
(or the loss of employment) faced multiple challenges.
Many critical women’s health services were disrupted, such as breast and cervical
screening, and maternity services, including maternal mental health.137 Being
pregnant and/or giving birth during the pandemic was very challenging for some,
especially under lockdown conditions (see spotlight in Chapter 3). Plunket saw
a 125 percent increase in maternal mental health-related calls between 2019/20
and 2020/21.138
Many women experienced a heightened risk of family violence and/or sexual
violence139 – although the story is nuanced and emerging (see spotlight in
section 6.5.4).
And even though some women entered the pandemic with existing inequalities and
were a group identified as likely to face increased vulnerabilities,140 the Inquiry has
found limited consideration of gender in targeted mitigation or recovery efforts.
This was supported across many of our engagements, including from the National
Council of Women of New Zealand:
“ Women are at the core of families and communities. When we call on community resilience,
we are calling on women’s resilience. For future pandemics, calling on communities requires
women to be supported – both in the lead-up, and while they are carrying that heavy load.”
Disabled people
Disabled people face many challenges in their day to day lives, with existing
inequities across health, economic and social outcomes. The variety of disabilities
mean the pandemic produced wide-ranging experiences for disabled people, and
for many it exposed and exacerbated existing disadvantage.
The nature of some disabilities meant disabled people with particular medical
conditions were more likely to be immuno-compromised and thus were at greater
risk from the virus. This contributed to four times the risk of hospitalisation and 13
times the risk COVID-19-attributed mortality for people with disabilities, compared
with the rest of the population during 2022.141 Some disabled people could not
wear masks, and this put them at greater risk of contracting the virus, and also
subjected them to discrimination and abuse from members of the public who didn’t
understand the mask exemptions.
Many disabled people rely on ongoing access to regular care and services, and these
were disrupted during the pandemic. For example, with staffing shortages, some
had their care services cancelled or rationed, leaving them without needed essential
care in their homes. A survey of primary care patients found that, from August 2020
to May 2022, 24 percent of disabled people could not always get care from a GP
or nurse when they wanted it (compared with 17 percent of non-disabled people).
While the results are not directly comparable due to changes in the survey question,
this difference was broadly of the same magnitudexxiv as before the pandemic.142
The impacts people experienced varied according to the nature of their disability.
Wearing masks made it difficult for the deaf and hard of hearing communities to
lip-read, while the blind and sight-impaired said suitable COVID-19 communications
were not produced rapidly enough. We also heard of instances where facilities
for testing and vaccination were not physically accessible, nor were the needs for
neurodiverse people well-considered in those places. Parents of disabled children
faced challenges with school closures, causing disruptions to routines and the loss
of extra supports that were available only at school. Disabled people were already
among those most lonely and socially isolated pre-pandemic, and the COVID-19
restrictions left some further isolated or marginalised, negatively impacting their
mental health and overall wellbeing.143
xxiv In the August and November 2019 quarters, 20 percent of disabled people could not always get
care when they wanted it, compared with 15 percent of non-disabled people.
Disabled people were identified early on as a group at greater risk.144 Government
took some steps to mitigate risks through tagged funding, but the consensus
from our engagements with officials and stakeholders was that these steps were
inadequate. Disabled stakeholders told us that in their view, isolating cases and
contact tracing was not an adequate way of protecting disabled people from
the virus; they felt that the Government should have done more to prevent their
exposure. Those in leadership and advocacy roles for disabled people found
engaging with and advising government frustrating and ineffective.145
“ We consulted and advised 18 government departments during the pandemic –

which was a complete waste of our time.”
“ Things went nowhere because there was no expertise in government to be

able to take the information and do something with it.”
6.5.1.4
Some vulnerable groups were overlooked in the response
We have already referred to groups who effectively fell through the cracks in the
pandemic response (sections 3.3 and 3.4). They included foreign workers and
international students on temporary visas and Recognised Seasonal Employer
scheme workers from the Pacific. Many lost their jobs but were unable to return to
their home countries. They were ineligible for health, social and financial support
while in Aotearoa New Zealand, although some eventually received assistance.146
People who were precariously employed or operating in the grey or gig economies
also remained below the radar, often unknown to social service providers.
Prisoners were another category of people who were heavily impacted by the
pandemic but remained largely invisible. At high risk of the virus due to their
physical environments (large populations living in close proximity with little ability
for meaningful distancing, poor ventilation, and high rates of existing health
vulnerabilities and co-morbidities), prisoners were subject to particularly stringent
infection control measures for the duration of the pandemic. Their situation is
described in the accompanying spotlight.147
Spotlight:
Prison life in the pandemicxxv |
Te noho i te whare herehere i te wā o te mate urutā
By some measures, the prison system’s response to COVID-19 was highly successful.
Aotearoa New Zealand prisons were free of the virus until 29 September 2021.
There were few hospitalisations and no deaths reported due to COVID-19.148 This
contrasted sharply with prisons overseas, which recorded very high levels of illness
and death, especially early in the pandemic, and became extremely effective
‘superspreading’ environments. In the United States, for example, the age-adjusted
risk of dying in prison due to COVID-19 (as of 2023) was six times higher than in
the general population.149 New Zealand was also one of a minority of countries to
prioritise vaccination for prisoners.150
Having witnessed the toll that COVID-19 was taking in prisons elsewhere in the world,
the Department of Corrections was determined the situation would not be repeated
here. Consequently, New Zealand prisons implemented infection control measures that
separated, isolated or quarantined prisoners. Normal services, programmes and
activities were suspended and contact with the outside world was minimised.
Many prisoners had no visitors for extended periods and limited time out of cells.
While effective, these infection control measures exacted a very high cost on prisoners
and their whānau. When the Office of the Inspectoratexxvi investigated the use of
separation and isolation between 1 October 2020 and 30 September 2021, it concluded:
“ [The suspension of visits] heightened the isolation experienced by all prisoners, and also
impacted on families in the community. All non-essential services, across the prison network,
ceased from August 2021. This had a profound impact on prisoners, who were unable to
complete rehabilitation and reintegration programmes. The focus across the prison network
shifted to maintaining minimum entitlements.” 151
In fact, the Inspectorate found, ‘Due to the length of the pandemic, there were
some prisoners who did not receive their minimum entitlementsxxvii for prolonged
periods of time’.152
It was clear from our meetings with prison staff and the Department of Corrections
that many working within the system did their utmost to keep prisoners safe and
prisons COVID-free. They also recognised that some prisoners’ high health needsxxviii
made them especially vulnerable to COVID-19.153 As a result, Corrections said, ‘we
always went the extra mile in taking a cautious approach’.
While that stringency undoubtedly kept incarcerated people safe, it also became
embedded and hard to roll back. Some prison managers – who had considerable
operational autonomy during the pandemic, within ‘guide rails’ set by Corrections
– took a cautious approach to relaxing infection controls even once the national
strategy moved on from elimination. As the pandemic progressed, Corrections
began experiencing an acute and unexpected shortage of custodial staff,
xxv We note that the experiences of young people in Oranga Tamariki youth justice residences were very different (and
more positive) than those of the adults in the prison described here.
xxvi The Inspectorate operates under the Corrections Act 2004 and the Corrections Regulations 2005. It is part of the
Department of Corrections but operationally independent to ensure objectivity and integrity. Its staff inspect and
investigate many aspects of the prison system, including prisoner complaints.
xxvii Under Section 69 of the Corrections Act 2004, prisoners must receive certain minimum entitlements, which include at
least one hour of physical exercise a day, and the ability to have at least one private visitor each week.
xxviii They are much more likely than the general population to have mental health and substance disorders, for example,
and many other co-morbidities.
296
reaching the lowest point in January 2022. This placed greater pressure
on remaining staff and affected Corrections’ ongoing capacity to return
to pre-COVID-19 settings. Corrections leaders acknowledged that rolling
back the restrictive regime was challenging after ‘running quick and
hard to introduce controls that rightly kept people safe’.
We were surprised that the option of releasing some prisoners early
was not meaningfully explored as a way to reduce COVID-19 risk in
prisons. This strategy was consistent with international best practice
and adopted by more than 100 countries.154 Corrections considered
some initial options in April 2020, but determined it was not necessary
in the Aotearoa New Zealand context. Any early release option would
involve challenging trade-offs with public safety and require significant
legislative change. Corrections told us it might be a tool the Justice
Sector could consider for the future. We agree.
Chief Ombudsman Peter Boshierxxix criticised the prolonged use
of restrictive measures. Speaking to us in December 2023, he was
concerned that many prisoners were still locked down for 23 hours a
day. The ‘convenience’ of keeping prisoners locked down during the
pandemic had created a culture among prison staff which persisted,
even though there were now better ways to protect prisoners from
COVID-19. His comments were echoed when we visited Spring Hill
and Auckland Region Women’s Prison in early 2024 to hear from
prisoners themselves.
“ Didn’t see [my kids] for two years. Talking on the phone is not the same
as hugging them.”
“ There used to be a way to work [in prison] and save up money … [now]
people are getting out with nothing. That impacts society.”
“ We got phone cards as the solution to no visits. But this was 80 men to
two phones, with only an hour out of our cells.”
“ I was grateful for the lockdowns, they saved lives. It’s just how they
handled the lockdowns [in prisons].”
“ In some units, one person got COVID, so they’d lock everyone down
because of bad ventilation.”
“ There’s a shit ton of repressed anger. People are processing

it but it’s coming out the cracks.”
xxix The Department of Corrections initially discouraged the Chief Ombudsman

and his staff from making prison inspections, despite the Ombudsman’s
statutory role to provide independent oversight. This issue was resolved by
late April 2020 once the inspection team received essential worker status.
297
6.5.2 Mental wellbeing impacts affected all ages, with young
people especially hard-hit
Like other severe crises, pandemics can
have major psychological and wellbeing
The pandemic has had an impacts.156 For Aotearoa New Zealand,
impact on the mental health COVID-19 was one of the biggest
of New Zealanders, but this challenges to our collective mental
has been unevenly felt across
the population, with the wellbeing seen in many generations.157
most vulnerable bearing Most people experienced some level of
the worst impacts.155 distress, and for many this was tolerable
and short-lived. For others the stress
developed into something more serious,
often worsening an existing mental
health condition. This is of particular concern given New Zealand’s already high
prevalence of mental health and addiction issues.158
Pandemics can affect mental health in many ways. People may feel anxiety and
fear about contracting the virus itself, or about the ever-present uncertainty the
pandemic creates.159 But as we saw in Aotearoa New Zealand (initially at least),
a strong sense of unity and a collective focus on protecting each other and
saving lives can also run alongside concern, anxiety and fear.
International literature on disasters often describes these periods of unity and
collective determination as heroic and honeymoon phases that give way to
disillusionment when people start to realise how long recovery is going to take,
and what it might take to get there.160 Some feel overwhelmed by the situation,
by the unrelenting stress and fatigue, and by feelings of anger, depression,
isolation, loneliness, frustration and grief. Hostility may increase, and financial
pressures and relationship problems set in. The fourth stage is reconstruction,
or recovery, a gradual return to life. International literature suggests
psychosocial recovery can take up to ten years.161
Population-level mental health is monitored as part of the New Zealand Health
Survey, using the Kessler scale of psychological distress.162 As the following
graph shows, rates of distress among most age groups fell between 2018/19
and 2019/20. In fact, some seemed to plateau in that first year of the pandemic,
before growing (by varying degrees) over the next three years. However, the
picture was different for younger age groups (15–24 and 25–34 years). Having
experienced consistently higher rates of distress since 2015/16, their distress
then increased more sharply than any other age group after 2020. Nearly one
in four young people (aged 15–24 years) experienced high or very high levels
of psychological distress in 2021/22.163
Age is not the only factor influencing mental health indicators – living in
poverty was also a factor behind these results. From the same survey, we
found that people living in the most deprived neighbourhoods were 2.4 times
more likely to have experienced psychological distress than those in the
least deprived neighbourhoods.164 All ethnic groups experienced increased
rates of psychological distress leading up to and through the pandemic.
Figure 5: Proportion of age group population experiencing high or very

high psychological distress in the past four weeks, 2011/12 – 2022/23
Note: adult respondents (aged 15+ years) are categorised as experiencing high or very high psychological distress if
they have a score of 12 or more on the Kessler Psychological Distress Scale (K10).
Source: Based on data from Ministry of Health (New Zealand Health Survey), 2024, Annual Data Explorer
2022/23: New Zealand Health Survey [Data File] – [topic – Mental Health], https://minhealthnz.shinyapps.io/
nz-health-survey-2022-23-annual-data-explorer/_w_6458d6d4/#!/explore-indicators
Evidence gathered during our Inquiry was consistent with this monitoring data.
It too pointed to an increase in mental health issues, especially for young people,
and was consistent with some causal effect of the pandemic and pandemic
response, in addition to trends before COVID-19 (although the exact partitioning
is difficult to know). We also heard about mental health impacts on children
below 15 years, a group not monitored by the survey data.
We know that youth mental health issues were increasingly significant before the
pandemic, and appear to have become more widespread and acute, especially
anxiety, depression, loneliness and fear.165 There are likely to be many reasons.
Children and young people experience the world, and the passage of time,
differently from adults – meaning the pandemic probably seemed endless to many,
compounded by ongoing uncertainty about when it might end and life would return
to normal. Many missed key milestones or significant childhood events during what
was a confusing, distressing and unusual time. We saw evidence that while there
were positives for some young people – having more free time, family time and
opportunities for new activities – they faced disruptions to their education, isolation
from their peers and social groups, and greater susceptibility to family violence.166
Young people with jobs were also more likely to face employment disruptions,167
contributing further to their stress. Surveys carried out during the Level 4 lockdowns
in April 2020 found young people with a previous diagnosis of mental illness fared
worse than their peers.168 We heard that some children in care faced the unique
anxiety that their foster family would not want to keep them in their ‘bubble’ during
the pandemic.
These trends were reflected in the demand placed on youth mental health services.
Calls to Youthline between 2019 and 2022 showed a 52 percent increase in critical
incidents (when a young person presents with serious risk of self-harm or suicide).169
Calls to the mental health lines of telehealth provider Whakarongorau increased
across all age groups during the pandemic, but the largest increase was in calls from
young people. While calls later dropped to historic levels for 20–24-year-olds, by late
2023 they still remained high for young people aged 13–19. Since December 2021,
Whakarongorau also recorded an increase in calls involving risks of suicide, abuse,
harm to others and self-harm, which peaked in August 2023.
Despite this evidence of high demand from young people, the Mental Health and
Wellbeing Commission reported that they had the longest wait times of any age
group for acute mental health services under the previous district health board
system in 2021/22.170 This suggests they are not being prioritised.
The Inquiry heard that the mental health effects of the pandemic are likely to have
a long tail. This view was supported by evidencexxx showing significant and maybe
even intergenerational consequences for the cohort of young people experiencing
high rates of mental distress during and since the pandemic.171
xxx For example, data from the New Zealand Health Survey 2022/23 showed that one in five (21.2 percent) young people
aged 15–24 years experienced high or very high levels of psychological distress in 2022/23, up from 5.1 percent in
2011/12. See endnote 171 for details.
6.5.3 Locally-led responses were invaluable in addressing
the social impacts of the pandemic
Marae, schools, churches, NGOs and other community networks and hubs are
crucial points for community connection, leadership, practical support and
resilience building. Their value to society as a whole often goes unnoticed, but the
COVID-19 pandemic put the spotlight on their good work, if only for a short time.
Through our discussions with stakeholders across the social sector, and other
evidence, we have learned a lot about why so many locally-led responses were
effective during the pandemic. For one
thing, people tended to have higher
degrees of trust in the communities
and groups that they were part of, ...people tended to have
higher degrees of trust in the
or that were immediately accessible communities and groups that
to them. Second, we saw that these they were part of, or that were
local responders had well-established immediately accessible to them.
strengths they could draw on quickly,
including strong leadership, trusted
relationships and diverse connections.
In our engagements, several stakeholders emphasised that those who were trusted
were best placed to make and influence decisions on how to support the needs in
the community. As one told us:
“ People trust people – and those people now need to influence processes.”
These factors and others made local groups and networks powerful assets in
the response to COVID-19.172 In our view, they must be cultivated and strengthened
as part of Aotearoa New Zealand’s preparations for another pandemic. As the
Ministry of Social Development noted after a 2022 evaluation of Care in the
Community: ‘A locally led, regionally enabled, and nationally supported approach
is emerging as a valuable framework for supporting community wellbeing and
recovery.’173 Social service providers too emphasised that this was one of the
central lessons of the pandemic:
“ The learning is that community is the place where people get their responses. Whatever
that community is you really need to resource and empower it and give it its head.”
6.5.4 Responding to the pandemic has had lasting
consequences for some providers and community
organisations
COVID-19 created huge social and wellbeing pressures for households and
communities, compounding the financial pressures described earlier in this
chapter. Right from the start of the pandemic, providers reported increasing
demand for social supports and services, and an upsurge in new clients – including
many who had not sought charitable support before. The extent and breadth
of the pandemic’s social impacts was also apparent in the sharp rise in demand
for Government support during 2020/21.174 This was largely associated with the
COVID-specific programmes of assistance introduced by the Ministry of Social
Development; demand for benefits increased too, but more slowly than expected.
Again, a significant proportion of that demand was from people who had never
before found it necessary to seek assistance from the benefit system.
The burden of the pandemic’s social and wellbeing impacts was not shared equally
across all New Zealanders. Similarly, the impacts experienced by providers and
community organisations varied. Many lacked the necessary tools and resources
to operate in the restricted and uncertain COVID-19 environment. According to the
representatives of one provider we met with, these are just some of the lessons the
social sector must learn from the COVID-19 response before the next pandemic;
by taking them on board, the sector will be better-prepared to meet the needs of
communities and those who work alongside them next time.
Initially, many struggled to get their status as essential services approved or clarified,
and to work through what the lockdown and other restrictions would mean for
them. Other providers that might have been able to operate online lacked the digital
infrastructure or staff capability to do so. And for some, the nature of their services
– and the fact that clients were unable or unwilling to interact with them online –
made it simply impossible to make the switch. For example, see the Spotlight on
family and sexual violence.
Many providers and community

groups lacked the necessary
tools and resources to operate
in the restricted and uncertain
COVID-19 environment.
During the pandemic, the pressure on small organisations with limited cash flow
was immense. In addition, nearly all organisations relying on volunteers noted
the strain they faced during and since the pandemic. In particular, they ‘lost’
older volunteers – who represented a large proportion of volunteers in many
organisations – because they were told to stay home to be safe, while many others
had additional family care responsibilities. As a result of the pandemic, it is clear
that the delivery network of NGOs and community organisations has little surge
capacity left. Providers described three years of ‘endurance working’. The health and
wellbeing – and retention – of frontline staff has become a growing issue since the
pandemic, as increased workloads are not sustainable. Staff and volunteer burnout
were common themes raised by the NGO sector. This does not bode well for the
future. We consider there is a risk that the very same network that was so critical to
the delivery of the COVID-19 response may not have adequate capacity or capability
to respond to another crisis, without some investment. This view was shared by
many organisations we heard from, including the New Zealand Red Cross:
“ Not for profit (NFP) organisations and the NFP sector are core elements of a whole of system
response effort. It is important that any Government response recognises the contribution
of the sector and makes it as easy as possible for NFPs to dock into and support government
agency responses. The Government needs a strong NFP sector to do what the Government
cannot do during these times.”
Staff and volunteer burnout

were common themes raised
by the NGO sector.
Spotlight:
What happened to family violence and sexual violence? |
I ahatia te whakarekereke whānau me te koeretanga kino?
Aotearoa New Zealand has long had unacceptably high rates of family violence
and sexual violence, especially taking into account that these types of violence are
often under-reported.xxxi In the immediate pre-pandemic period, Government took
some major steps to address family violence and sexual violence by establishing
a joint venture (now known as Te Puna Aonui) to deliver an integrated, whole-of-
government response. However, family and sexual violence remained a significant
challenge as the country moved into COVID-19.175
National emergencies and crisis situations can trigger an increase in family violence
and sexual violence, and this had already happened before the COVID-19 pandemic
– for example, during the aftermath of the Canterbury earthquakes.176 Specialist
community organisations and providers, government agencies, and some media
outlets were therefore keenly aware of the increased risk of family violence and
sexual violence as the country entered Alert Level 4 lockdown in March 2020.177
The rules at Alert Level 4 reflected Cabinet’s intention to reduce this risk where
possible. Leaving an unsafe home environment to stay somewhere else was
deemed essential travel, and many specialist support organisations continued
operating as essential services. Communications from government agencies and
NGOs reflected this, encouraging people not to remain in unsafe ‘bubbles’:
“ Sometimes it is unsafe for you to reach out for help while you are in the same space as
the person who is hurting you. If you can’t communicate safely through phone, text,
email, or social media, maybe your friends, whānau, or neighbours could help.” 178
However, not everyone who needed to hear this message did. Moreover, lockdown
conditions made it especially difficult for people at risk to access help without
alerting the perpetrator. Safe places where violence is often reported – like schools,
GPs and WellChild clinics – were either not operating or much harder to access.
“ We got quite a few calls re: domestic violence. Often it was situations like, she’d always
been in a violent relationship, but when he went out to work it was okay. Now they were
[locked down] together it was worse. She said, [to me] ‘we’re not supposed to leave the
house’, but I said ‘break your bubble next time’.”
We heard from stakeholders that, during lockdowns, some people disclosed

violence to the only people they could: essential workers like supermarket staff
and emergency workers. These workforces were not trained to receive such
disclosures and there is no data available to indicate how often such disclosures
were made or what happened as a result.
It is hard to know exactly what impact the pandemic had on the frequency of
family violence and sexual violence. Some agencies were braced for a large
rise in formal reports of violence early in the pandemic, but this did not occur.
xxxi Family violence is a pattern of behaviour that coerces, controls or harms another, within the context of a close personal
relationship, and often involves fear, intimidation, and loss of freedoms. Sexual violence involves a person exerting
power and control over another person without their informed consent, or where they are unable to provide consent
(e.g., children, vulnerable adults). In Aotearoa New Zealand, on average, Police attend a family violence callout every
three minutes. One in 3 women and 1 in 8 men will experience sexual assault in their lifetime, with even higher rates for
the takatāpui and LGBTQIA+ community. These definitions and statistics are taken from Te Puna Aonui, see: Definitions
and Prevalence Data | Te Puna Aonui
304
Still, as Police noted in an internal report at the time, a lack of formal
reporting does not necessarily indicate a lack of harm.
Many authoritative sources have reached the conclusion that an increase
in family violence and sexual violence harm did occur during the pandemic.
They note that, because of the nature of this type of offending and the
sensitivities involved in disclosure and prosecution, incident data should
never be treated as a prerequisite for action on family violence and sexual
violence. Based on the evidence we have heard and reviewed, we agree.
Reporting rates aside, there are indicators that the nature and severity
of family violence and sexual violence worsened during the pandemic.
We heard from specialist providers that in some cases, the pandemic
conditions resulted in new or opportunistic forms of violence, such as:
• Perpetrators weaponising lockdown rules to exert greater control over
victims’ movements.
• Increasing reports of financial abuse and intensive digital surveillance
as perpetrators were more easily able to track victims’ activities
in lockdown.
• Denial of vaccination emerging as a new form of coercive control (which
also served to restrict freedom of movement for victims at times when
vaccination was a prerequisite for entry to certain spaces).
• Distressing reports of international students being coerced by flatmates
or landlords into providing sexual favours in return for housing.
This underscored a gap in protection for international students
who remained in Aotearoa New Zealand during the pandemic.
It is also likely that some family and sexual violence harm during the
pandemic was prevented by the swift actions of officials, decision-makers,
specialist providers and community organisations and community
members and community members. We heard the safety of children
was front of mind for many service providers and community workers
during the pandemic.
During the pandemic, a working group on family violence and
sexual violence was quickly established and resourced to improve
collaboration and response between government agencies and
service providers, along with a Tangata Whenua Rōpū specifically
for Māori organisations to advance Māori-led solutions.
Emergency funding was provided by both government179 and
the private sector, and providers were able to use this flexibly
and creatively. For the most part, government agencies
created a supportive, high-trust environment for community
organisations and specialist services to respond effectively
to the emerging risks of family violence and sexual
violence during the pandemic. This was appreciated
by the stakeholders in the sector that we spoke to.
305
The| social and economic ‘long tail’ |
H1
0.0
6.6 Te ‘whiore
Reo Translation
roa’ pāpori me te ōhanga
COVID-19 highlighted community resilience and the power of communities to

respond and support their members. However, COVID-19 also exposed emergent
weaknesses and vulnerabilities that had been forming in our social and economic
fabric for decades – including in our governance systems, institutions, and
physical and digital infrastructures. The pandemic thereby created an unintended
opportunity to address some of the deficiencies it had surfaced.
When strict public health measures were imposed at the start of the pandemic,
the promptness and generosity of Aotearoa New Zealand’s economic policy response
cushioned the population at large (including many, but not all, businesses) from the
immediate negative economic and social impacts. This approach seemed appropriate,
given the high levels of uncertainty at this time. Nevertheless, it has left a long shadow
on the economy and society180 – a phenomenon that is certainly not peculiar to
Aotearoa New Zealand nor attributable solely to our domestic policy responses.181
As both the International Monetary Fund and the OECD confirm, the following
factors collectively contributed to high inflationary pressures (including on house
prices) and will be the cause of a protracted period of low economic growth:182
• Aggressive/generous monetary and fiscal policy responses.
• The extended duration of these generous policy stances.
• The comparably long duration of restrictions on domestic and international
movements that have exacerbated supply-side constraints.
• The subsequent decision to tighten macroeconomic policy settings, with
some urgency.
As a result of these factors and others, Aotearoa New Zealand’s economy has
experienced many enduring post-pandemic effects – on output and productivity,
employment and migration, cost of living/inflation, the housing market, government
debt and delays in much-needed infrastructure investments. The structure of
international trade has changed, particularly through the loss of tourism and
education income. So too has the overall structure of the economy, with one-off (and
sometimes lasting) systemic shifts, regional effects, and sector-specific effects.183
There is growing international evidence that initiatives such as the Wage Subsidy
Scheme – which focused on employment retention and job attachment – have led
to a relative loss of productivity through their adverse effects on labour market
dynamics (namely, the movement of people between jobs).184 However, we have
no direct evidence of this for Aotearoa New Zealand. For some, the rapid adoption
of new digital communications technologies has enabled remote working on an
unprecedented scale. This is leading to changing patterns in the structure of the
workforce and employee expectations, and flow-on changes in spatial demands in
areas where office workers have traditionally been concentrated.185 At the same time,
there is ongoing debate about the productivity benefits of continuing working from
home arrangements, compared with requiring employees to return to offices.186
Meanwhile, in his analysis of the medium-term effects of this country’s monetary and fiscal
policy responses to the pandemic, commentator Bernard Hickey187 drew attention to ‘the
massive wealth transfers’ that had occurred at the housing market peak in September 2021:
“ Official figures show the stark explosion in inequality since the onset of covid as the
Government’s interventions to print $58b and give $20b in cash to business owners helped
make owners of homes and businesses $952b richer since December 2019. Meanwhile,
renters have missed out on that asset growth and have been hammered with real wage
deflation and rents rising faster than incomes. The poorest are now $400m more in debt
and need twice as many food parcels as before Covid.”
We note that by 2024, some of the asset price inflation referred to had reversed.
Related to the long-tail economic and equity effects of the pandemic, we should also
be concerned about the potential weakening of Aotearoa New Zealand’s social service
delivery system – particularly the NGOs and community organisations providing front-
line services on behalf of government. As a result of their efforts during the pandemic
and with other sector changes, many are in precarious positions due to financial
and workforce (including volunteer) issues which now challenge their sustainability.
Our concern is with the fragility of the overall network of providers, and what that
might mean for our readiness to respond to a future pandemic.
The analysis quoted above and evidence provided in this chapter highlights the
intersection between the economic after-effects of COVID-19 and its social impacts.
For many individuals, families, households and communities, the pandemic is not
over. They continue to struggle with its consequences – long COVID, loss of learning,
mental health issues and more.188 Those with delayed diagnosis or postponed
treatment during the pandemic may now be facing shorter lives, or reduced quality
of life (for example, young children who missed Well Child Tamariki Ora health
checks are being identified in the B4 School Check as having health issues that
should have been screened and treated earlier). We have heard of families separated
for years due to the border closures, leading to relationship breakdowns that will
impact family members throughout their lifetimes. People who suffered job losses
and business bankruptcy could take years to recover.
Some of the pandemic’s impacts are only now becoming apparent. There may
be others that we are not aware of which will be long-term and intergenerational,
with potentially profound consequences for Aotearoa New Zealand and for future
human capability more broadly.189 While the measures taken clearly protected many
people, others are likely to suffer from the long-term impacts of the pandemic.
For example, the impact on young people on their physical, emotional and mental
health from disruption to their development or education during the pandemic
will take years to fully understand.
“ A lot of the impacts for vulnerable whānau would likely be experienced for the decade
afterwards […] It’s our job now to avoid this being intergenerational. Our response to
COVID is not finished. We were clear there was going to be a long tail. We need to live
up to that responsibility.”
Much of the COVID-19-related support allocated to the social sector (both to

government and non-government providers) was one-off or time-limited. It has
been steadily scaled back and sometimes removed altogether. Many government
contracting arrangements reverted to their previous settings at the tail end of the
pandemic, despite the many demonstrable examples from the pandemic of what
outcomes-based, flexible contracting arrangements could achieve.190 In our view,
there is a risk that some of the successes of the pandemic – including positive
models for Government, communities, NGOs and the private sector to work
together – may be lost.
We, like a number of experienced market commentators, are also concerned about a
potential for weakening of Aotearoa New Zealand’s economic institutions, and whether
established principles of good fiscal discipline risk being compromised as a result
of the pandemic. One such concern relates to the reduced ability of our fiscal buffers
(including access to international credit markets at reasonable prices) to respond to
another major crisis.191 Using the fiscal buffer in an emergency, such as a pandemic,
is consistent with its purpose. But its restoration, consistent with what governments
consider prudent, is necessary so it can be used when needed in the future. Failure to
do so over a sensible period of time (without creating further economic instability or
compromising infrastructural investment that promises a good social return) could
severely weaken what has previously been an institutional strength.
On the monetary policy side, we heard considerable concern from some expert
stakeholders about the use – or, perhaps more accurately, the extent – of the
Reserve Bank resorting to so-called ‘unconventional monetary policies’, particularly
the ‘large scale asset purchase’ programme.xxxii In fact, these policies are now well
accepted by international organisations (for example, the International Monetary
Fund) as part of the international monetary authorities’ arsenal and were used
extensively by other similar economies during the pandemic when interest rates
became extremely low. However, the extent of their use in Aotearoa New Zealand
was unprecedented and there is no doubt that they imposed a considerable risk to
the Crown’s balance sheet and debt position. A Crown indemnity to the Reserve Bank
was provided to ensure that the large-scale asset purchase programme could go
ahead. As interest rates increased, the Reserve Bank suffered losses on its balance
sheet that were covered by the indemnity. Although the indemnity and associated
payments between the Government and the Reserve Bank (being transfers among
entities included in the consolidated Crown accounts) do not make taxpayers any
better or worse off, nevertheless the large-scale asset purchase programme did
impose direct fiscal losses to the taxpayer in the order of $11 billion. This arose from
the fact that the programme changed the private sector’s lending to the Government
from bond holdings to settlement cash balances at the Reserve Bank.192
At its peak, the Reserve Bank purchases amounted to $54.6 billion (as of June 2021),
amounting to approximately 16.5 percent of GDP. We understand that the Reserve
Bank’s Monetary Committee has elected to follow an accelerated programme of
unwinding these purchases, which it considered the best means of meeting its
remit; this contrasts with the passive approach generally followed overseas. How
this will finally play out in terms of the overall impact on the Crown balance sheet
and debt has yet to be determined.193
xxxii The Large Scale Asset Purchase Programme (LSAP) aims to lower borrowing costs to households and businesses by
injecting money into the economy. It involves the Reserve Bank buying New Zealand government bonds from banks
in the secondary market in exchange for electronically created money. It is one of a range of monetary policy tools the
Reserve Bank uses to control inflation and lower interest rates.
Overall, though, we agree with the National Bureau of Economic Research194 and
others that the fiscal policy consequences of quantitative easing can only be assessed
alongside the prior net benefits of the large-scale asset purchase programme in
stimulating demand, their impact on growth and employment, and their impact on
stabilising the economy and the financial system. The jury is still out on how this all
played out. It is also worth noting that the International Monetary Fund 2023 report
on the state of the New Zealand economy found that, overall, the Reserve Bank’s large-
scale asset purchases during COVID-19 ‘had favorable effects on the fiscal stance’.195
The evidence we reviewed also raised questions about the coordination and assessment
of the cumulative impacts of total macro-fiscal support provided during the pandemic.
The allocation and effectiveness of government expenditure was another issue
highlighted by the evidence. The initial economic response was shaped by advice from
the Treasury and the Ministry of Business, Innovation and Employment; it addressed
frameworks, processes, criteria and exit pathways to be used in making expenditure
decisions. Once the size of the economic impact caused by public health measures
became clear, as well as the number and type of different initiatives that might be
needed, the scrutiny of expenditure decisions changed. For Budget 2020, the initial
scrutiny was particularly fast paced, with the Treasury having four days to assess over
240 initiatives, seeking almost $30 billion in new funding. The Treasury did carry out
some value-for-money analysis which involved asking some essential cost-benefit
analysis questions: for example, what the initiative would deliver, how the initiative
related to the Government’s plans, whether it was critical and urgent, the expected
costs, the risks of not funding the initiatives, and distributional analysis. The pace at
which decisions had to be made – and ongoing uncertainty over the severity, impact
and length of the pandemic – constrained the appraisal of COVID-19 Response and
Recovery Fund initiatives undertaken by departments and agencies.
Normally, when government is deciding whether to fund a proposed initiative,
any initial concerns about cost effectiveness can be at least partially addressed by
ensuring the initiative will be reviewed over time. Some economic support policies
were adjusted over time – for example, who qualified for the Wage Subsidy Scheme,
and the level of support it provided – but there was little review and adjustment
across the portfolio of Response and Recovery Fund initiatives.
For some programmes there were value for money concerns. The Office of the
Auditor-General commented on this issue in relation to the selection process ministers
used for the Strategic Tourism Assets Protection Programme and the Shovel-Ready
Projects Programme. While recognising that the urgency presented by the pandemic
meant rapid decisions were needed, the Auditor-General expressed concern that
‘significant spending of public money continue[d] to occur without appropriate
processes for ensuring value for money and transparent decision-making’.196
Finally, perhaps the most difficult long-tail impact of COVID-19 is the damage
to mental health and wellbeing.197 The added anxiety and distress caused by
the pandemic, and by some public health response measures, is compounding
Aotearoa New Zealand’s already high prevalence of mental health and addiction
problems. The increase in poor mental health among younger people is particularly
concerning. It will likely continue for decades, and possibly intergenerationally.
1. The COVID-19 pandemic disrupted all aspects of

our lives, and exposed emerging weaknesses and
vulnerabilities that had been forming in our social and
economic fabric for decades.
• We acknowledge that it was beyond the scope of a pandemic response
to address all long-standing issues.
• While some mitigations provided effective protection for many,
including for particular sectors and population groups, others missed
out or carried a heavier burden.
2. The initial package of economic measures the

Government provided was comprehensive and generous.
• The economic response met its immediate aims: to support the public
health response to the pandemic by maintaining economic activity,
sustaining business confidence, protecting employment, protecting
incomes, sustaining financial stability, and ensuring that essential
services were accessible.
• Initially at least, the package of social and economic policies – together
with the health response – achieved better social and economic
outcomes than most other comparable countries.
• At the time, the generous economic response seemed appropriate
and was widely supported. But because of the amount of spending
it required over an extended period, the economic response left a
long shadow on the economy: the level of government debt increased,
and a period of elevated interest rates was required to constrain
inflation. The cost-of-living pressures since 2021, the surge in house
prices from 2020 to 2021, and higher mortgage interest rates, are in
part attributable to the economic response to the pandemic, although
international forces have also had a significant effect.
• The pandemic revealed there is still room to improve mutual
understanding and coordination between the Treasury and the
Reserve Bank when it comes to using monetary and fiscal policy to best
effect in an emergency situation.
• We also share some concerns that were raised by others about the
duration for which the Government and the Reserve Bank provided
substantial economic support in the response. This has led to a range
of economic pressures that are taking some time to resolve.
3. When decisions were made about allocating government
expenditure during the response, the approach to
robustness, transparency and accountability was inconsistent.
• While we recognise that decisions about economic support measures had
to be made rapidly in the early pandemic period, the consideration given to
effectiveness and value for money was inconsistent. Given the significant
amount of tax-payer dollars being spent, wherever possible, sufficient
opportunities should have been given to more rigorously scrutinising and
assessing these measures, and periodically reviewing and adjusting them.
This would have ensured the decision-making process was transparent
and accountable.
4. The pandemic’s economic impacts put households and

businesses under great pressure, especially during lockdowns.
• Government introduced mitigating measures, including the Wage Subsidy
Scheme, that supported well over a million workers and their employers.
The scheme was necessarily developed very quickly and had some flaws,
but it was fit for purpose and an essential support measure.
• Businesses experienced the pandemic differently according to their
sector, size and location. They had different abilities to absorb the
shock of the pandemic.
• While key goods (including food) remained generally available, supply
chains were disrupted by international and domestic developments. It was
essentially down to good luck that supply disruptions were not more severe.
Aotearoa New Zealand needs to be more actively aware of the risks that
can threaten supply chains.
5. The social sector – including government agencies and

non-governmental and community organisations – did a
remarkable job of ensuring people had their needs met
during the pandemic.
• Many positive changes were made in how systems operated, contracts
were commissioned, and relationships were built. These new approaches
often delivered good outcomes. This capacity, or the ability to rapidly stand
it up again, should be maintained to help the sector be better prepared in
a future crisis.
• The respective roles of some social sector agencies and groups remain
unclear. Resolving these roles and responsibilities, and strengthening
regional coordination models, will enable the rapid implementation of
local supports, especially during a crisis.
6. A network of non-governmental organisations, iwi and
Māori groups, and community organisations provided the
frontline services and support that kept families safe and
well during the pandemic.
• This network’s important role needs to be recognised, valued, cultivated
and strengthened so that it can continue to deliver in future crises. It is
these organisations that give government the ability to reach families
and communities.
• Locally-led responses were invaluable in addressing the social impacts
of the pandemic, as they are based on local knowledge, strengths and
trust. Their value was particularly apparent in Māori communities.
Local responses will likely be critical in future pandemics and central
government needs to actively build relationships and trust with
communities now to enable a more effective response later.
7. The economic and social response to COVID-19 helped

prevent deaths and protected many people. But the
pandemic’s economic, social and wellbeing impacts on
individuals and families were unevenly distributed.
• Some groups came through the pandemic better than expected due to
targeted mitigations. But some groups (such as Pacific people, women
and disabled people) experienced more negative impacts, especially
those who were most disadvantaged before the pandemic.
• In a future pandemic, it is essential that government gives consideration
to mitigating harms, including the unintended consequences of
response measures. Attention should be given to the cumulative
impacts on socially, economically or health-disadvantaged groups.
8. For many individuals and families, COVID-19 is not over,

showing that wide-ranging pandemic support measures
are needed even after the immediate crisis has passed.
• Many New Zealanders continue to struggle with mental health issues,
long COVID, loss of learning, relationship breakdowns, health problems
due to delayed diagnosis or treatment, bankruptcy or loss of savings
and unemployment. The mental health, educational and social impacts
on young people are particularly concerning.
• Other impacts have not yet emerged and may well be long-term and
intergenerational. The consequences for Aotearoa New Zealand, and for
future human capability more generally, are likely to be considerable.
Endnotes |
6.8 Tuhinga āpiti
1. OECD, First lessons from government evaluations of 11. Hon Grant Robertson, ‘Cabinet approves Business
COVID-19 responses: A synthesis (21 January 2022), Continuity Package in response to COVID-19’, media
https://www.oecd.org/coronavirus/policy-responses/ release, 9 March 2020, https://www.beehive.govt.
first-lessons-from-government-evaluations-of-covid- nz/release/cabinet-approves-business-continuity-
19-responses-a-synthesis-483507d6/ package-response-covid-19
2. The Treasury and Ministry of Business, Innovation and 12. Hon Grant Robertson, ‘$12.1 billion support for New
Employment, Joint Report T2020/480: An intervention Zealanders and business’, media release, 17 March
strategy for Economic Policy Responses to COVID-19 (6 2020, https://www.beehive.govt.nz/release/121-billion-
March 2020), p 2, https://www.treasury.govt.nz/sites/ support-new-zealanders-and-business
default/files/2023-03/covid-19-t2020-480.pdf 13. The Treasury and Ministry of Business, Innovation and
3. The Treasury, Aide Memoire: Macroeconomic impact Employment, Joint Report T2020/480: An intervention
of COVID-19 on the New Zealand economy – Update, strategy for Economic Policy Responses to COVID-19 (6
T2020/274, 14 February 2020, https://www.treasury. March 2020), p 2, https://www.treasury.govt.nz/sites/
govt.nz/publications/aide-memoire/aide-memoire- default/files/2023-03/covid-19-t2020-480.pdf
t2020-274-macroeconomic-impact-covid-19-new- 14. The Treasury, ‘COVID-19 Response and Recovery
zealand-economy-update-14-february-2020 Funding – Allocation’, updated 14 June 2023, https://
The Treasury, Weekly economic updates December 2019 www.treasury.govt.nz/information-and-services/
and January 2020 (3 February 2020), https://www. nz-economy/covid-19-economic-response/overview-
treasury.govt.nz/publications/weu/weekly-economic- covid-19-response-and-recovery-fund-crrf/covid-19-
updates-december-2019-and-january-2020 response-and-recovery-funding-allocation
Westpac New Zealand, Weekly Economic Commentary:
15. International Monetary Fund, ‘Fiscal Monitor Database
Virus in the ointment (3 February 2020),
of Country Fiscal Measures in Response to the
https://www.westpac.co.nz/assets/Business/
COVID-19 Pandemic’, updated October 2021, https://
economic-updates/2020/Weekly/3.2.20-Weekly-
www.imf.org/en/Topics/imf-and-covid19/Fiscal-
Economic-Commentary-Westpac-NZ.pdf
Policies-Database-in-Response-to-COVID-19
RNZ, ‘Coronavirus’ economic impact will be ‘worse that
SARS’, economist says’, 3 February 2020, https://www. 16. The Treasury, ‘COVID-19 Response and Recovery –
rnz.co.nz/news/business/408755/coronavirus-economic- What has been achieved?’, updated 13 June 2023,
impact-will-be-worse-that-sars-economist-says https://www.treasury.govt.nz/information-and-services/
nz-economy/covid-19-economic-response/overview-
4. The Treasury and Ministry of Business, Innovation and
covid-19-response-and-recovery-fund-crrf/covid-19-
Employment, Joint Report T2020/480: An intervention
response-and-recovery-what-has-been-achieved
strategy for Economic Policy Responses to COVID-19
Ministry of Social Development, ‘COVID-19
(6 March 2020), https://www.treasury.govt.nz/sites/
Resurgence Wage Subsidy’, https://www.
default/files/2023-03/covid-19-t2020-480.pdf
workandincome.govt.nz/covid-19/previous-payments/
5. For more information, see: Reserve Bank of New resurgence-wage-subsidy.html
Zealand, In Retrospect: Monetary Policy in New Zealand Ministry of Social Development, ‘COVID-19 Wage
2017-22 Titiro whakamuri kōkiri whakamua (10 Subsidy Extension’, https://www.workandincome.
November 2022), p 41, https://www.rbnz.govt.nz/hub/ govt.nz/covid-19/previous-payments/wage-subsidy-
publications/monetary-policy-statement/rafimp extension.html
6. The Treasury, Treasury Report T2020/973: Economic Ministry of Social Development, ‘COVID-19 Wage
scenarios – 13 April 2020 (13 April 2020), p 2, https:// Subsidy March 2021’, https://www.workandincome.
www.treasury.govt.nz/publications/tr/treasury- govt.nz/covid-19/previous-payments/wage-subsidy-
report-t2020-973-economic-scenarios-13-april- march-2021.html
2020#executive-summary Ministry of Social Development, ‘COVID-19 Wage
7. Stats NZ, ‘COVID-19 sees record 12.2 percent fall in Subsidy August 2021’, https://www.workandincome.
New Zealand’s economy’, updated 17 September 2020, govt.nz/covid-19/previous-payments/wage-subsidy-
https://www.stats.govt.nz/news/covid-19-sees-record- august-2021.html
12-2-percent-fall-in-new-zealands-economy 17. Ministry of Social Development, ‘2020 COVID-19
8. Stats NZ, ‘Unemployment rate’, updated 7 August Wage Subsidy’, https://www.workandincome.govt.nz/
2024, https://www.stats.govt.nz/indicators/ covid-19/previous-payments/2020-wage-subsidy.html
unemployment-rate Ministry of Social Development, ‘COVID-19 Wage
Subsidy August 2021’, https://www.workandincome.
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Colmar Brunton, State of the Generation: May 2021, Learning from New Orleans, Haiti and Christchurch’,
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167. Stats NZ, ‘Youth unemployment rate three times 177. Anna Leask, ‘Covid 19 coronavirus: Family violence
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168. Caroline Bell, Jonathan Williman, Ben Beaglehole, covid-19-coronavirus-family-violence-tipped-to-rise-
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Charlene Rapsey, and Susanna Every-Palmer, MSZPLQTBTNN7455CH6ATX7L2EE/
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sagepub.com/doi/abs/10.1177/00048674211034317. Cabinet Paper, Action plan for family violence and
Survey participants had to be aged 18 years or older sexual violence in response to COVID-19, https://
at the time of the level 4 lockdown. covid19.govt.nz/assets/Proactive-Releases/proactive-
169. Youthline, Annual Report 2021–2022 (2022), p iii, https:// release/Action-plan-for-family-violence-and-secual-
www.youthline.co.nz/uploads/2/9/8/1/29818351/ violence-in-response-to-COVID-19.pdf
youthline_annual_report_fy22-electronic.pdf 179. Cabinet Minute, Family Violence and Sexual Violence:
170. Te Hiringa Mahara – New Zealand Mental Health Action Plan in Response to COVID-19, CBC-20-
and Wellbeing Commission, Te Huringa Tuarua 2023: MIN-0032, 8 April 2020, https://covid19.govt.nz/assets/
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171. Ministry of Health, ‘Annual Update of Key Results throughout the COVID-19 pandemic: Background paper
2022/23: New Zealand Health Survey [Data File]’, to Te Tai Waiora: Wellbeing in Aotearoa New Zealand
updated 14 December 2023, https://www.health.govt. 2022, The Treasury (24 November 2022), https://
nz/publications/annual-update-of-key-results-202223- www.treasury.govt.nz/publications/tp/our-wellbeing-
new-zealand-health-survey throughout-covid-19-pandemic
172. Ministry of Social Development, Care in the Community 181. Diego Cardona and Giles Bollinger, Our wellbeing
(CiC) welfare response – Lessons from a real-time throughout the COVID-19 pandemic: Background paper
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about-msd-and-our-work/publications-resources/ 2022, The Treasury (24 November 2022), https://
research/real-time-evaluation-of-the-care-in-the- www.treasury.govt.nz/publications/tp/our-wellbeing-
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lessons-learned.pdf Eva Alexandri, Alice Brooke, Chris Thoung, and
173. Ministry of Social Development, Care in the Community Ruairidh Milne, The economic burden of Long Covid in
(CiC) welfare response – Lessons from a real-time the UK: Report Summary, Cambridge Econometrics
evaluation, https://www.msd.govt.nz/documents/ (March 2024), https://www.camecon.com/wp-content/
about-msd-and-our-work/publications-resources/ uploads/2024/03/The-Economic-Burden-of-Long-
research/real-time-evaluation-of-the-care-in-the- Covid_Cambridge-Econometrics_March2024_Report-
community-welfare-response/real-time-evaluation- Summary.pdf
lessons-learned.pdf 182. International Monetary Fund, ‘Fiscal Monitor Database
174. Janet McAllister, Caitlin Neuwelt-Kearns, Leah Bain, of Country Fiscal Measures in Response to the
Nikki Turner, and Donna Wynd, The Most Important COVID-19 Pandemic’, updated October 2021, https://
Task: Outcomes of our collective care for low-income www.imf.org/en/Topics/imf-and-covid19/Fiscal-
children in Aotearoa New Zealand in the first year of Policies-Database-in-Response-to-COVID-19
Covid-19, Child Poverty Action Group (Auckland, 1 July
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183. OECD, OECD Economic Surveys: New Zealand 2024, 189. Diego Cardona and Giles Bollinger, Our wellbeing
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184. Tibor Lalinsky, Marianthi Anastasatou, Sofia Anyfantaki, 2022, The Treasury (24 November 2022), https://
Konstantins Benkovskis, Antonin Bergeaud, Maurice www.treasury.govt.nz/publications/tp/our-wellbeing-
Bun, Simon Bunel, Andrea Colciago, Jan De Mulder, throughout-covid-19-pandemic
Davide Fantino, Beatriz González López, Jiri Havel, 190. Ministry of Social Development, Care in the Community
Valerie Jarvis, Dmitry Khametshin, Tetie Kolaiti, Olegs (CiC) welfare response – Lessons from a real-time
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Fernando Martins, Philipp Meinen, Jaanika Meriküll, about-msd-and-our-work/publications-resources/
Miles Parker, Josip Raos, Roberta Serafini, Domagoj research/real-time-evaluation-of-the-care-in-the-
Šelebaj, Béla Szörfi, Milan Vaňko, Juuso Vanhala, and community-welfare-response/real-time-evaluation-
Matjaž Volk, The impact of the COVID-19 pandemic and lessons-learned.pdf
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Tibor Lalinsky, Jaanika Meriküll, and Paloma Lopez- 191. OECD, OECD Economic Surveys: New Zealand 2024,
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2024/2947, European Central Bank (June 2024), p
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Nils Goernemann, Sharon Jeon, Grace Lofstrom,
and Dylan Moore, ‘Why is the US GDP recovering 193. Reserve Bank of New Zealand, In Retrospect: Monetary
faster than other advanced economies?’, FEDS Policy in New Zealand 2017-22 Titiro whakamuri kōkiri
Notes (Washington: Board of Governors of the whakamua (10 November 2022), https://www.rbnz.govt.
Federal Reserve System), 17 May 2024, nz/hub/publications/monetary-policy-statement/rafimp
https://doi.org/10.17016/2380-7172.3495 194. Stephen G. Cecchetti and Jens Hilscher, Fiscal
Silvana Tenreyro, Response to the Covid-19 Consequences of Central Bank Losses, National Bureau
pandemic: UK and US experiences – Speech by of Economic Research (May 2024), https://www.nber.
Silvana Tenreyro, https://www.bankofengland.co.uk/ org/papers/w32478
speech/2021/march/silvana-tenreyro-macro-and- 195. International Monetary Fund, New Zealand: 2023
monetary-policy-conference Article IV Consultation-Press Release; Staff Report; and
185. Kangoh Lee, ‘Working from home as an economic Statement by the Executive Director for New Zealand
and social change: A review’, Labour Economics 85 (Washington, D.C., 2023), pp 64-65, https://www.imf.
(22 August 2023), 102462, https://doi.org/10.1016/j. org/en/Publications/CR/Issues/2023/08/24/New-
labeco.2023.102462, https://www.sciencedirect.com/ Zealand-2023-Article-IV-Consultation-Press-Release-
science/article/pii/S0927537123001379 Staff-Report-and-Statement-by-the-538455
186. See, for example, Hon Nicola Willis, ‘New work-from- 196. Office of the Auditor-General, Making infrastructure
home guidance for public service’, media release, investment decisions quickly (December 2023), p
23 September 2024, https://www.beehive.govt.nz/ 8, https://oag.parliament.nz/2023/infrastructure-
release/new-work-home-guidance-public-service decisions/summary.htm
187. Bernard Hickey, ‘Covid’s big winners and losers 197. World Health Organization, ‘COVID-19 pandemic
revealed’, 26 January 2022, https://thekaka.substack. triggers 25% increase in prevalence of anxiety and
com/p/covids-big-winners-and-losers-revealed depression worldwide’, 2 March 2022, https://www.
Bernard Hickey, ‘Our counterproductive Covid who.int/news/item/02-03-2022-covid-19-pandemic-
‘rekovery’’, (30 November 2021), https://thekaka. triggers-25-increase-in-prevalence-of-anxiety-and-
substack.com/p/our-counterproductive-covid- depression-worldwide
rekovery. https://thekaka.substack.com/p/our- Caroline Bell, Jonathan Williman, Ben Beaglehole,
counterproductive-covid-rekovery James Stanley, Matthew Jenkins, Philip Gendall,
188. Diego Cardona and Giles Bollinger, Our wellbeing Charlene Rapsey, and Susanna Every-Palmer,
throughout the COVID-19 pandemic: Background paper ‘Psychological distress, loneliness, alcohol use and
to Te Tai Waiora: Wellbeing in Aotearoa New Zealand suicidality in New Zealanders with mental illness
2022, The Treasury (24 November 2022), p iii, https:// during a strict COVID-19 lockdown’, Australian & New
www.treasury.govt.nz/publications/tp/our-wellbeing- Zealand Journal of Psychiatry 56, no. 7 (27 July 2022),
throughout-covid-19-pandemic 800-810, https://doi.org/10.1177/00048674211034317,
https://journals.sagepub.com/doi/
abs/10.1177/00048674211034317
CHAPTER 7:
7 Vaccination |
Te rongoā āraimate
325
Introduction |
7.1 Kupu whakataki
From the start of the pandemic, the prospect of a safe and effective COVID-19
vaccine provided a beacon of hope in an otherwise bleak global landscape.
Government messaging presented vaccination or new treatments as the
justification for – and pathway out of – the initial elimination strategy and the
restrictions it involved. This message clearly resonated with many members of
the public, including some who made submissions to our Inquiry:
“ Lockdowns were totally necessary until such time a vaccine was approved and available.
We saw what was happening in the rest of the world and it was horrifying.”
Vaccination remained fundamental to the effectiveness of Aotearoa New Zealand’s

pandemic response, even after the country moved away from the elimination strategy.
By the time community transmission became well-established, most of the population
had received at least one dose of the vaccine and a large proportion had both initial
doses on board. From this point on, optimising population immunity through vaccination
was a crucial pillar of the country’s long-term approach to managing the virus.
• This chapter begins by describing the process of identifying, procuring

and approving a suitable vaccine, which proceeded alongside the
development of Aotearoa New Zealand’s immunisation programme
(sections 7.2.1 and 7.2.2).
• In section 7.2.3, we survey how the vaccine was made available to
the community (we refer to this as ‘the vaccine rollout’) and, in 7.2.4,
the subsequent provision of boosters. Section 7.2.5 describes steps
taken to sustain population immunity once Aotearoa New Zealand
had moved away from the elimination strategy to a minimisation and
protection approach.
• Our assessment of outcomes and impacts is set out in section 7.3.
The evidence we reviewed highlights some positive outcomes:
vaccination undoubtedly protected Aotearoa New Zealand from the
very high burden of illness and death many other countries faced,
and the national rollout achieved high levels of vaccine coverage.
However, the evidence also reveals missed opportunities to ensure
vaccine uptake and access were equitable across the community –
an issue we address in sections 7.3.1.1 and 7.3.2 (which includes
a spotlight on the work of Māori and Pacific vaccine providers).
• We also assessed the management of the rollout (in section 7.3.1.2),
the way vaccine hesitancy and misinformation affected vaccine uptake
(7.3.1.3), and the efficacy of processes for procuring and approving the
vaccine (7.3.3 and 7.3.4) before presenting our final conclusions.
• Vaccine mandates are dealt with in Chapter 8, along with vaccine passes.
What happened |
7.2 I aha
7.2.1 Securing a vaccine

After the SARS-CoV-2 virus emerged in Wuhan at the end of 2019, international
efforts to develop safe and effective vaccines moved at unprecedented speed.
But how long it would take to complete trials, scale-up manufacturing, obtain
regulatory approvals and distribute adequate supplies to meet global demand
was unknown. The risk of failure was high: historically only about 20 percent
of vaccines entering human trials resulted in a successful vaccine.1 Officials
therefore advised the Government to adopt a flexible vaccine strategy and
pursue ‘multiple concurrent approaches’ to securing vaccines. The working
assumption was that at least 80 percent of the population had to be vaccinated
before Aotearoa New Zealand could start moving on from the elimination
strategy and its strictures.2
The Government announced its COVID-19 vaccine strategy on 26 May 2020.
Aotearoa New Zealand would secure access as early as possible to a safe and
effective vaccine, which would then be rolled out through a population-wide
immunisation programme (whose details were still to be determined). Vaccine
procurement would be overseen by a taskforce led by the Ministry of Business,
Innovation and Employment. It included representatives from the Ministries
of Health and Foreign Affairs and Trade, Medsafe (New Zealand’s medicines
regulator), and Pharmac (responsible for national vaccine purchasing). Cabinet
also allocated an initial $30 million to fund domestic and international vaccine
research, and to explore the potential for local vaccine manufacture.3
At the end of June 2020, Aotearoa New Zealand formally expressed interest
in participating in the COVAX Facility, a global initiative aiming to speed up
development of COVID-19 vaccines and promote more equitable global access.
At the same time, officials considered that ‘purchasing from an overseas
manufacturer is emerging as the quickest and most likely route to securing a
safe and effective vaccine for use in New Zealand’.4
In August 2020, Cabinet agreed to a vaccine purchasing strategy and funding
envelope5 (on top of the initial $30 million investment in vaccine research
and manufacturing capacity).6 Officials from the taskforce would negotiate
advance purchase agreements directly with several pharmaceutical companies
overseas. To manage the uncertain environment, a portfolio of vaccines would
be secured: while this would likely result in greater quantities of vaccine than
were actually needed, it offset the risk of some vaccine candidates becoming
available later than others – or not at all – and the risk of some vaccines having
less than desirable effectiveness or high adverse event rates.7
This ‘portfolio approach’ could be likened to an insurance arrangement,
where it was accepted there would be some surplus or ‘wasted’ vaccine, in
exchange for the certainty that at least one of the portfolio options would
result in Aotearoa New Zealand having timely access to an effective vaccine.
The approach anticipated that some vaccine doses would be sourced through
COVAX, although only around 20 percent of the country’s immunisation needs
were expected to be met from this source. In addition to purchasing vaccines for
its own population, New Zealand would also supply vaccines to several Pacific
nations including the Cook Islands, Niue and Tokelau.8
Meanwhile, the Ministry of Health had been developing a national COVID-19
immunisation strategy to roll out the vaccine across the country.9 In December
2020, Cabinet endorsed the strategy’s purpose: ‘to support the “best use”
of COVID-19 vaccines, while upholding and honouring te Tiriti o Waitangi
obligations and promoting equity’. Since vaccine supplies were likely to be
limited until at least mid-2021, Cabinet agreed that immunisation would
be prioritised via a sequencing framework ‘to ensure the right people are
vaccinated at the right time’. Under the framework, the first groups to be
immunised would be border and managed isolation and quarantine (MIQ)
workers and their household contacts (judged to be at highest risk of COVID-19
exposure) followed by health and other high-risk workers and any high-risk
household contacts. The vaccine would then be rolled out to the general
population, starting with more vulnerable groups such as older people.10
On 12 October 2020, the Government announced the first advance purchase
agreement, with Pfizer/BioNTech (Pfizer).11 The company would supply
1.5 million doses (enough for 750,000 people) of its ‘Comirnaty’ (BNT162b2)
mRNA vaccine (commonly known as the Pfizer vaccine), subject to the successful
completion of clinical trials and regulatory approval.
The initial batch of Pfizer vaccines (65,520 doses) arrived in New Zealand on
15 February 2021. Around three weeks later, the Government announced it
had purchased another 8.5 million doses, to be delivered in the second half
of 2021. Enough Pfizer doses had now been secured for everyone in the
country to receive the necessary two shots.12 The Government subsequently
also purchased Novavax, Janssen and AstraZeneca vaccines, but none of
these were used as a first-line option in the immunisation programme.
7.2.2 Regulatory approval
Health officials were conscious of the need to conduct a ‘robust and
comprehensive’ assessment of the COVID-19 vaccine that would ‘provide
assurance to the public and withstand rigorous review’.13 It was therefore important
that the Pfizer vaccine undergo independent assessment by Aotearoa New
Zealand’s medicines regulator, Medsafe, even though it had already been approved
for use in several other countries (including the United States and Australia).14
In addition to fulfilling regulatory requirements,i the approval process allowed
experts to assess the vaccine’s expected benefits and risks with specific reference
to the profile of the New Zealand population. It also allowed regulators to review
the most up-to-date evidence on vaccine efficacy and safety – including more
recent data that had not been available to regulators in other countries.
The Pfizer vaccine was provisionally
approvedii by Medsafe at the
beginning of February 2021,15
In addition to fulfilling regulatory
before the first doses arrived in
requirements, the approval process
the country. The approval process allowed experts to assess the vaccine’s
was undertaken on an accelerated expected benefits and risks with
time frame but followed the specific reference to the profile
of the New Zealand population.
normal process, including review of
company-provided data, requests
for further evidence in response to
specific questions, expert advice and
review by the Medicines Assessment Advisory Committee.iii The Pfizer vaccine
subsequently received full approvaliv in Aotearoa New Zealand in November 2023
under section 20 of the Medicines Act 1981. Medsafe continues to monitor the
safety of COVID-19 vaccines and to review any adverse events following their use
in New Zealand.16
Medsafe subsequently gave provisional approval for the use of COVID-19
vaccines produced by Novavax, Janssen and the University of Oxford/
AstraZeneca,v although only the Novavax and AstraZeneca vaccines were
ultimately used as alternatives to the Pfizer vaccine in Aotearoa New Zealand.
i The Medicines Act 1981 requires new medicines to be assessed and approved by Medsafe before being sold or
supplied in New Zealand.
ii Medicine regulators in some countries (such as the United States and the United Kingdom) have emergency
authorisation mechanisms that can be used where there is an urgent need for new drugs to be made available.
Medsafe does not have an emergency approval mechanism, but can provide time-limited provisional approval in
specific circumstances. This mechanism was used to approve use of the Pfizer Comirnaty COVID-19 vaccine.
iii A technical advisory committee that advises the Minister of Health on the risk-benefit profile of new medicines.
iv Full approval of Pfizer’s Comirnaty vaccine took account of data on the vaccine’s longer-term safety and efficacy.
This data was not available at the time the initial (provisional) approval application was made because in late 2020
the vaccine had been in use for only a short period of time.
v The COVID-19 vaccine produced by Moderna was provisionally approved by Medsafe after the pandemic response
period and was not used in New Zealand.
International assessments of vaccine effectiveness and safety
Ongoing evidence reviews have continued to evaluate the Pfizer vaccine as effective
in substantially reducing the risk of severe illness and death from COVID-19 and
safe in terms of carrying a very low risk of serious adverse side-effects.17 Guidance
from the World Health Organization’s Strategic Advisory Group of Experts on
Immunisation notes that myocarditis (inflammation of the heart) is a ‘rare adverse
event’ that can occur following administration of mRNA COVID-19 vaccines,
including the Pfizer vaccine. While noting that myocarditis following vaccination
is generally mild and responds to treatment,18 the World Health Organization
advises that people receiving the COVID-19 vaccine ‘should be instructed to seek
immediate medical attention if they develop symptoms indicative of myocarditis
or pericarditis, such as new onset and persisting chest pain, shortness of breath,
or palpitations following vaccination’.19
7.2.3 The rollout begins

Because vaccine supplies were initially very limited, the vaccine rollout was
sequenced to prioritise those considered to be at greatest risk of COVID-19
transmission, infection or illness. The first people to be vaccinated (the frontline
vaccinators themselves) received their first doses on 19 February 2021, followed
by border workers in both the North and South Islands. In March 2021, Cabinet
finalised the sequencing framework that would guide the vaccine rollout. Four
population groups would be vaccinated in sequence according to their risk profile:
• Group 1: border and MIQ workforce, and their household contacts;
• Group 2: frontline workers, medically vulnerable people (people aged
65 years and older, people with underlying health conditions and disabled
people) and people living in high-risk environments – including people in
long-term residential care, older Māori and Pacific peoples living in
intergenerational households and people living in South Auckland
(the Counties Manukau district);
• Group 3: all other medically vulnerable people (people aged 65 years and
older, people with underlying health conditions and disabled people); and
• Group 4: the rest of the population aged 16 years (later lowered to 12 years)
and older. Vaccinations would be staggered by age group.20
From March 2021 onwards, the Pfizer vaccine was rolled out nationwide to each
group in turn, with people receiving their first two vaccine doses three weeks apart
(later increased to six). The mass vaccination phase started on 28 July 2021 when
Group 4 became eligible, beginning with those aged 60 or older.
A rollout on this scale represented a significant operational challenge, particularly
given the initial requirement that the vaccine be stored at ultra-low temperatures
(-70°C). COVID-19 vaccination ‘hubs’ were set up in carparks, stadiums and other
large sites to cope with the volume. From a starting point of 2,000 doses a day,
more than 50,000 doses a day were being administered by late August 2021.21
The vaccinator workforce needed to grow to support the rollout as it expanded.
Earlier in the pandemic, professional bodies such as the Nursing Council of
New Zealand had supported the Ministry of Health to recruit trained health
professionals back into the workforce and it did so again now, issuing interim
practising certificates to trained nurses who wished to rejoin. An amendment to
the Medicine Regulations allowed the Director-General of Health and Medical
Officers of Health to authorise others – including non-regulated healthcare
assistants and pharmacy technicians – to become COVID-19 vaccinators once
they had received appropriate training.
The arrival of the Delta variant in mid-August 2021 prompted a rethink of Aotearoa
New Zealand’s vaccination settings. Technical health expertsvi recommended
that children aged 12 to 15 years should be vaccinated, noting that lowering the
eligibility age would help ensure equitable vaccination coverage among Māori
and Pacific peoples: young people represented a greater proportion of those
communities (compared with the overall population) and these groups were at
higher risk from COVID-19.22
The arrival of Delta also prompted a shift away from large-scale vaccination
‘hubs’ towards a greater number and diversity of vaccination sites to help make
access easier for ‘harder to reach populations and … those with mobility issues’.
People could now be vaccinated in general practices and pharmacies; there was
greater involvement of Māori, Pacific and other community-based providers;
and many tailored initiatives were launched to improve access for people with
disabilities. These efforts supported increased vaccine access and uptake, to the
point that Aotearoa New Zealand risked a supply shortage of the Pfizer vaccine
in mid-September 2021. Continuity of vaccine supply was secured via agreements
with Spain and Denmark, supported by direct engagement between the Prime
Minister and her counterparts in those countries.
As the population gained protection from increased vaccination coverage, the
Government started preparing for a shift in its approach. This included plans
for a gradual reopening of borders and ‘more measured domestic restrictions’ –
in other words, an end to lockdowns. On 22 October 2021, the Prime Minister
formally signalled the country would move from elimination to a minimisation
and protection approach (and from the Alert Level System to the COVID-19
Protection Framework) when 90 percent of the population in each district health
board area was fully vaccinated. The move was later scheduled for 2 December
2021, by which time the Ministry of Health estimated that 86 percent of the
eligible population was fully vaccinated.
On 16 December 2021, the Ministry of Health announced that 90 percentvii of the
eligible New Zealand population had received two doses of the COVID-19 vaccine.23
vi The Ministry of Health established the COVID-19 Vaccine Technical Advisory Group in early 2020. It comprised
14 experts including epidemiologists, virologists and laboratory science experts who provided the Ministry with
information and specialised advice. Initially, the group met twice weekly, and then monthly.
vii Real-time estimates of vaccination coverage often differ from rates calculated retrospectively, when more
comprehensive data is available (particularly in relation to numbers eligible for vaccination, i.e. the ‘denominator’).
Based on data provided to our Inquiry by the Ministry of Health, we estimate that 86 percent
of the population aged 15 years and over had received two vaccine doses by the end of 2021.
7.2.4 Vaccine boosters
By mid-to-late-2021, evidence was growing internationally that protection
against COVID-19 infection and severe disease declined in the months following
vaccination. By November 2021, official documents from health officials were
speaking to this evidence that the protection against COVID-19 infection and
severe disease that vaccines offered appeared to wane in the months following
immunisation. On 8 November, Medsafe updated its provisional approval for the
Pfizer vaccine to include administration of a third ‘booster’ dose.24
The booster rollout started in November 2021, prioritising those at increased risk
of COVID-19 exposure or illness – including frontline health workers, all people
aged 65 years or older, Māori and Pacific people aged 50 years or older and
those with medical vulnerabilities.25 In practice, this meant around two thirds of
New Zealanders were eligible for a vaccine booster.26 Sustaining as high levels of
population immunity as possible was critical, particularly given the emergence
of another highly transmissible COVID-19 variant, Omicron, around this time.viii
7.2.5 Sustaining population immunity

Given the greater social freedom and mobility allowed from December 2021
under the new protection framework, Omicron was seen as presenting a very real
threat. With the move from elimination to minimisation and protection (i.e.
a suppression and mitigation strategy) and the highly infectious nature of Omicron,
it was no longer feasible to avoid widespread COVID-19 transmission in Aotearoa
New Zealand. The focus now was on using the COVID-19 Protection Framework
to ‘flatten the curve’ and reduce the peak of infection through maintaining high
vaccination levels accompanied by public health and social measures. Over time,
population immunity would also be boosted as more people acquired – and
recovered from – COVID-19 infection (a situation known as hybrid immunity27).
Efforts were made to maximise vaccine protection before Omicron infection
became widespread in Aotearoa New Zealand. By early 2022, small quantities of
AstraZeneca and Novavax COVID-19 vaccines had been made available for adults
unable or unwilling to receive mRNA vaccines like Comirnaty (commonly known as
Pfizer)ix in order to encourage vaccine uptake. The original vaccine booster interval of
six months was reduced to four and then three months.28 Rapid uptake of booster
doses meant population immunity among the most vulnerable groups was high at
the point Omicron was peaking (see Figure 1), meaning hospitalisation and death
rates were much lower than in other countries (see Chapter 5).
viii Vaccines such as Pfizer continued to provide a high level of protection against severe illness due to COVID-19,
although this protection decreased over time. Vaccine-induced protection from transmission of COVID-19 was much
less for Omicron than it had been for previous variants. The use of booster doses was intended to reduce transmission
as much as possible (albeit less effectively than for previous variants) in order to flatten the peak of Omicron infection.
It also provided significant protection against severe illness, reducing hospitalisations and deaths arising from Omicron.
ix mRNA vaccines contain the genetic code for the ‘spike protein’ present on the surface of the SARS-CoV-2 virus
(COVID-19). Once the vaccine is administered, the human body reads the genetic code and makes copies of the
protein. The immune system learns to recognise these proteins, enabling it to fight the virus when it encounters it.
Figure 1: Vaccine uptake and COVID-19 case rates, population aged
15 years and over, April 2021–June 2022
Note: Eligibility for the 3rd vaccine (booster) dose was initially restricted to people aged 65 years or older and other
groups at increased risk of COVID-19 exposure or illness, consistent with the recommendation of the COVID-19
Vaccine Technical Advisory Group.29
By April 2022, the first Omicron wave was starting to ease. Restrictions
were gradually relaxed, and progressive reopening of the border continued.
Responsibility for purchasing and managing COVID-19 vaccines transferred from
the Ministry of Health to Pharmac in July, although ministers continued to approve
final purchasing decisions. The Government was by now developing a new approach
for the long-term management of COVID-19, which would treat it more like any
other respiratory infection. High levels of vaccination coverage and immunity across
the population would be key. With this in mind, the Government announced on 28
June 2022 that everyone over 50 years could now receive a second booster (in other
words, a fourth dose). Earlier, it had taken other steps to encourage vaccine uptake
by amending the Medicines Regulations to expand the pool of vaccinators and
allowing vaccinations to be given in more convenient and accessible places.
On 12 September 2022, the COVID-19 Protection Framework Order was revoked,
ending the minimisation and protection approach and the ‘traffic light’ system.
The last remaining vaccination mandates were removed on 26 September 2022.30
From then on, COVID-19 vaccinations became part of the national immunisation
programme, available free of charge to everyone aged over 5 years. The Pfizer
vaccine remained the main vaccine, with the number and frequency of recommended
doses varying according to age and health status.
Our assessment |
7.3.1 Vaccination saved lives and protected Aotearoa

New Zealand from the worst impacts of COVID-19
In 2024, the journal Vaccine published a study modelling the health impacts
attributable to COVID-19 vaccination in Aotearoa New Zealand between January
2022 and June 2023. It estimated that during this period vaccines saved 6,650
lives and prevented 45,100 hospitalisations.31
The study also showed the benefits of vaccination were not enjoyed equitably,
with Māori having lower vaccination rates and correspondingly higher rates of
preventable hospitalisations and deaths.32 We discuss vaccine equity in more
detail in section 7.3.2.
International comparisons of vaccine benefits and coverage are difficult, given
significant differences in the pandemic’s global trajectory and national responses.
In terms of vaccine uptake, Figure 2 shows that by late 2021, a higher proportion of
people in Aotearoa New Zealand were fully vaccinated than in some comparable
countries that began their vaccine rollouts earlier:
Figure 2: Receipt of initial COVID-19 vaccination (percentage of population)

by country
Note: For most countries, the initial COVID-19 vaccination protocol involved two doses
protocol. Data adapted from Official data collated by Our World in Data, World Health Organization, Various
The Vaccine modelling study and others emphasise that vaccination complemented
other elements of Aotearoa New Zealand’s pandemic response; together, they
‘delivered one of the lowest pandemic mortality rates of any country in the
world’.33 A group of public health experts writing in the New Zealand Medical
Journal also highlighted the interdependence of the elimination strategy (which
successfully delayed widespread COVID-19 transmission for nearly two years) and
the vaccination strategy (which delivered high population immunity before the
virus became established).34 They pointed to the lasting protective effect of these
combined strategies: even though New Zealand later experienced high rates of
infection and reinfection, especially during Omicron waves, levels of excess mortality
were exceptionally low, particularly compared with other countries.35
Such findings speak to the significant role vaccination played in protecting
New Zealand from the high burden of illness and death many other countries
faced during the pandemic. The expectation that vaccines would significantly
reduce the threat posed by COVID-19 and help bring the pandemic under control
underpinned the initial response. The country’s comparatively low rates of
COVID-19 illness and death support the decision to pursue elimination until effective
vaccines could be developed and administered to the majority of
the population.
7.3.1.1
Thanks to an enormous nationwide effort, the vaccine
rollout succeeded in achieving high levels of coverage
The rollout of the COVID-19 vaccine was the largest and most challenging immunisation
programme ever undertaken in Aotearoa New Zealand. Early estimates showed
that for every adult in the country to receive the recommended two doses, 8
million doses had to be administered (by comparison, 1.5 million doses are typically
delivered each year as part of the annual influenza vaccination programme).
The rollout achieved the Government’s’ central objective – ensuring high population
immunity before exposure to COVID-19 became widespread. This outcome is
testament to the enormous effort of officials, health providers (including primary
care providers, pharmacies and Māori and Pacific organisations), communities,
local leaders and individuals. Many members of the public who made submissions
to our Inquiry acknowledged these efforts. They were grateful that vaccines were
free of charge and easily accessible to many, and they commended the rollout’s
effectiveness and accessibility.
“ Having the mobile vaccination centres was great as it meant we didn’t have
to travel 45 minutes to the nearest larger town to access this. This was particularly
useful with small children as it was less of a logistics mission to accomplish.”
“ I found the vaccine roll out to be smooth and I was glad for the prioritisation
of vulnerable groups.”
“ The vaccination programme prevented people dying and protected those

that had health conditions.”
According to stakeholder evidence, crucial factors that enabled the rollout included
government investment in improving relevant information systems and instances
of cross-agency collaboration – such as the Ministry of Health bringing in the
New Zealand Defence Force logistical expertise to ensure vaccines were kept at
the right temperature during transportation. And we heard again and again that
Māori and Pacific health providers were particularly effective in the vaccine
rollout, especially with their own populations (although these providers were
often frustrated by what they saw as missed opportunities to mobilise earlier
and maximise their effectiveness – see section 7.3.2).
“ Pasifika providers and communities got involved and started to organise drive-in events.
The Tongans vaccinated 1,000 people in one day. This set the tone… [and] started to turn
things around. They created a fun atmosphere to draw people in. Finally, officials started
to trust them to organise and provided resources… Had we moved earlier, trusted and
engaged the communities and leaders, we would have had a different response. We got
there in the end, but why did it take so long?”
The Auditor-General acknowledged the pressure the Government was under to

deliver the vaccination programme as quickly as possible in his review of rollout
preparations released in May 2021. Public expectations for a speedy rollout were
high at the time; it was well-understood that the sooner most of the population
was vaccinated, the quicker Aotearoa New Zealand would move on from lockdowns,
reopen its borders and begin its economic recovery. This created considerable
pressure, the Auditor-General noted: ‘Other countries are moving ahead with
their vaccination programmes. In our view, it is important for the Government to
maintain public trust and confidence by ensuring that New Zealand does not fall
significantly behind’.36
In practice, Aotearoa New Zealand’s immunisation programme was very effective
in quickly delivering high levels of vaccine coverage at an overall population level.
As Figure 2 shows, New Zealand’s vaccine rollout followed a similar timeline to that
in Australia, with both countries starting their programmes somewhat later than
countries such as the United Kingdom, the United States and Singapore. But vaccine
uptake was both quicker and more sustained in New Zealand and Australia.
New Zealand achieved 80 percent vaccination with two doses on 26 November
2021,x ahead of both the United Kingdom and the United States.
Where the vaccine rollout was less successful was in delivering equitable coverage
across different population groups. Consistent with the concerns noted earlier,
there were delays in ensuring access to vaccination for some higher-risk groups –
including Māori and Pacific peoples.
x Coverage in the population aged 15 years and over, based on our analysis of vaccination data
provided by the Ministry of Health.
7.3.1.2
A highly centralised approach to the vaccine rollout meant
opportunities were missed to ensure the vaccine reached
everyone equally quickly
Despite the evident effort that went into the vaccine rollout, and the high rates
of coverage it had achieved by late 2021, opportunities were missed to ensure
vaccine access and uptake were optimised for high-risk groups, including Māori
and Pacific peoples, at the same time as for the rest of the population. Decision-
makers were aware before the rollout began of the potential for unequal vaccine
coverage (an issue we discuss further in section 7.3.2).37 While equity of coverage
was a prominent consideration in policy advice, findings from the Auditor-General’s
report – supported by accounts from community providers – suggest that delivering
on the immunisation programme’s stated commitments to equity would have
required earlier involvement of Māori and Pacific providers and a greater willingness
to relax central control in favour of more community-led provision.38 We heard from
senior figures both inside and outside of government that more could have been
done to ensure earlier involvement and better resourcing of local health providers
(particularly Māori and Pacific organisations), which might have improved early
vaccine uptake in some high-risk groups. At the same time, we are conscious that
those leading the vaccine rollout were under pressure to deliver a large and
complex programme as quickly as possible, and were managing many practical
constraints that made it difficult to involve a broad range of providers and locations
in the initial stages of the vaccine rollout.39
The vaccination rollout was initially designed with a high degree of central control.
This reflected the need to quickly deliver a large and complex programme while
carefully managing initially limited vaccine supplies. The Ministry of Health had
an enormous task in designing the vaccination programme, setting up relevant
information support systems (such as the bespoke COVID-19 Immunisation
Register) and operationalising key aspects of the vaccine rollout (such as approving
and training COVID-19 vaccinators and distributing doses to vaccination sites).40
District health boards were responsible for the vaccination sites; they were
required to use Ministry guidelines, clinical standards and information systems,
but had ‘some discretion over how they administer the vaccines to best meet the
needs of their communities’.41 The Ministry clearly took its responsibility to
steward scarce resources seriously, as is appropriate for the agency leading a
public health response of this scale.
Nevertheless, the highly centralised approach to the initial vaccine rollout –
including where and how vaccines would be provided, what training vaccinators
needed and who should be prioritised for vaccination – frustrated many local
leaders and health providers. They told us of burdensome administrative hurdles
that had to be overcome before vaccines would be delivered. And they described
missed opportunities to meet local needs or overcome access barriers (unless
they bent the rules, which some reported doing).
“ Pasifika leaders were advocating for Pacific-led vaccination centres and bespoke
training of Pacific vaccinators, ‘but the system just could not respond’.”
“ In this pandemic, we kept telling DHBs and the Ministry of Health … You have to
prepare to be mobile. To use trucks for mobile vaccinations. It took too long to get
approval, the pandemic was over. It took the length of the pandemic to get it right.”
While there was a clear and justifiable desire to ‘support the “best use” of COVID-19
vaccines’, as the Immunisation Strategy required, the Government’s highly centralised
approach unintentionally compromised the second part of that strategic objective:
‘upholding and honouring te Tiriti of Waitangi obligations and promoting equity’.
This highlights the challenge of balancing distinct and sometimes competing
goals in a complex operational environment. As we describe below, it had serious
and damaging consequences for already vulnerable groups and may have also
delayed Aotearoa New Zealand’s recovery overall. From the start of the pandemic,
Government messaging had presented vaccination as the pathway out of, and
justification for, the elimination strategy and the restrictions it involved. A stronger
and earlier focus on achieving equity in the vaccine rollout – including through
targeted measures to increase Māori and Pacific vaccination rates – would have
seen the country reach its immunisation target earlier, allowing lockdowns and
other stringent restrictions to be relaxed sooner.
At the same time, centralising the rollout made it easier to ensure the safe and
efficient delivery of a new vaccine that was in short supply. Initial requirements
meant the vaccine had to be stored and transported at very low temperatures
(-70°C), and vaccination at large, central sites was thought to reduce the risk of
wastage. Bespoke training of vaccinators was potentially more expensive and time-
consuming, but it reflected the importance of administering the vaccine safely.
Vaccinators were required who were not just technically competent, but could give
people accurate and appropriate information. This was critical, as highlighted by
the rare but devastating cases where things went wrong and people suffered as a
result.42 Guidance from the World Health Organization’s Strategic Advisory Group
of Experts on Immunisation notes that myocarditis (inflammation of the heart) is
a ‘rare adverse event’ that can occur following administration of mRNA COVID-19
vaccines, including the Pfizer vaccine.43
See discussion of international assessments of vaccine effectiveness

and safety in section 7.2.2.
7.3.1.3
Hesitancy and misinformation challenged vaccine uptake
The rollout was challenged by growing vaccine hesitancy – that is, when
people delayed or declined getting vaccinated because they lacked confidence,
motivation and/or ease of access.44 This became a major global challenge in the
COVID-19 pandemic as vaccine messaging was complicated by the rapid spread
of misinformation and disinformation.45 (Misinformation and disinformation
are also discussed in Chapters 2 and 8.) We heard from several stakeholders
that lower vaccine uptake among younger people was at least partly driven by
their greater exposure to misinformation by the time they were eligible to be
vaccinated. This was a particular issue for Māori and Pacific communities given
their younger age structure and historically lower trust of mainstream health
providers.46 As one senior Māori health official told us, ‘We gave too much of
a run-in for misinformation to get out there and take hold … We missed an
opportunity to vaccinate our people early, and as a result we saw resistance
come in’.
Efforts to boost vaccine uptake included the use of vaccine incentives (such as
food or petrol vouchers) by health providers and the introduction of vaccine
requirements (such as passes) by the Government (discussed in Chapter 8).
Other countries used similar ‘carrot and stick’ approaches to maximise
COVID-19 vaccine coverage, with positive impacts on uptake.
We heard mixed views on the use of vaccine incentives. While generally
viewed as effective in the short term, some people felt they were unfair or
inappropriate, and we heard anecdotal accounts of people receiving expensive
items (such as laptops) or delaying or repeating vaccination in order to receive
incentives. But others argued that incentives addressed underlying needs in
these communities: in the words of one Māori leader, ‘Some people called it a
bribe; we call it manaakitanga’.
The Inquiry notes that the use of direct incentives raises complex ethical
challenges. Material ‘rewards’ for vaccination can create perverse incentives
– meaning people may delay vaccination (waiting for incentives to be offered
before presenting) or seek vaccination when they are not eligible. We also
heard from health providers who were concerned that use of incentives for
COVID-19 vaccination might create expectations that would impact future
vaccination programmes, leading to lower vaccination coverage unless people
were offered ‘rewards’ for vaccine uptake. The Inquiry notes that maximal effort
should be put into reducing barriers to vaccine access in order to reduce the
need for direct incentives.
We heard from many people about the importance of engaging with community
leaders as ‘trusted voices’ who could encourage and reassure people in relation
to vaccination. The Ministry of Health’s communications team identified this as
an important part of their strategy to counter misinformation and disinformation
about the vaccine. They also noted that the introduction of vaccine mandates
(discussed in Chapter 8) made it more difficult to maintain a positive framing
around vaccination. This point was echoed in engagements with other health
stakeholders, who felt the use of mandates had a negative effect on trust in
many communities and even reduced some people’s willingness to be vaccinated.
The issue of vaccine hesitancy is linked with – and
complicated by – the fact that vaccines (like most
medicines) are not entirely without risk. Where
We heard mixed views on
the use of vaccine incentives. a vaccine has been used for many years, these
While generally viewed as risks are usually well understood. But COVID-19
effective in the short term, vaccines were very new at the point they were
some people felt they were
unfair or inappropriate.
rolled out, and – while evidence on their safety
was available from clinical trials – it was not
possible to fully understand the risk of very rare
adverse effects (such as might occur with only
one in a million doses) until the vaccine had been administered to much larger
groups of people. As this occurred, it became apparent that mRNA COVID-19
vaccines such as the Pfizer vaccine are linked with a small but potentially serious
risk of myocarditis, particularly in young men (see section 7.2.2).
The evolving nature of this evidence is likely to have been a contributing
factor in vaccine hesitancy, as it may have created the impression that
experts and officials were withholding information from members of the
public. In practice, both Medsafe and the Ministry of Health issued several
communications (from June 2021 onwards) advising vaccinators and the
public about the potential risk of myocarditis following vaccination with the
Pfizer vaccine.47 While the frequency and changing content of these updates
reflected a desire to communicate the most current evidence, it was challenging
for people to keep on top of and process this information. The Health and
Disability Commissioner noted the desirability of having stronger mechanisms
for providing clear and consistent advice on vaccine risks – a recommendation
our Inquiry supports.48
7.3.2 Despite an in-principle focus on equity of coverage,
vaccination uptake and access were lower for Māori and
Pacific peoples than for other groups
As noted earlier, the existence of wide disparities in health and wellbeing was
well-known before COVID-19 reached Aotearoa New Zealand. Māori, Pacific
peoples, disabled people, people living in poverty, some rural communities
and people experiencing mental illness were all known to have poorer health
outcomes than the general population. The health and disability system
therefore understood that ‘existing health inequities would result in the
pandemic having a disproportionate impact on these people without equity-
focused response measures’.
There were compelling public health reasons for putting equity at the centre
of the response (beyond the pragmatic argument that individuals are better
protected in a pandemic if all members of society are protected). Memories
of the 1918 influenza pandemic’s devastating and disproportionate impact on
Māori remained front of mind for many communities, officials and Members
of Parliament. Prioritising equity was also consistent with the Crown’s te Tiriti o
Waitangi responsibilities. A commitment to equity was thus prominent in many
aspects of the pandemic response, including the decision to adopt an elimination
approach and the immunisation strategy – the purpose of which, as we have
already noted, was to support the ‘best use’ of vaccines ‘while upholding and
honouring te Tiriti o Waitangi obligations and promoting equity’.49 The COVID-19
Health and Disability System Response Plan warned of the ‘potential for equity
failure with the exacerbation of existing inequities and the creation of new
inequities’ and devoted several pages to the need to embed the equity principle
in pandemic decision-making.50
The evidence we have reviewed suggests the Government was committed in
principle to equity and upholding te Tiriti. In designing the vaccination rollout,
the Ministry of Health paid particular attention to supporting access for older
people, for Māori and Pacific people, and for people with disabilities. These
groups were highlighted in advice on the vaccine sequencing framework, and
district health boards were encouraged to work closely with Māori, Pacific and
disability healthcare providers on plans for the vaccination rollout.51 Keeping
Māori health equity at the heart of the vaccination rollout was also the aim of the
COVID-19 Māori Vaccine and Immunisation Plan, which the Ministry of Health
released in March 2021.52 It set out how the vaccination rollout would give effect
to the Crown’s te Tiriti obligations to ensure equitable health outcomes, including
by working closely with iwi and Māori representatives. The plan emphasised the
important role of Māori health providers, who had proved critical to the success
of the COVID-19 response so far. The recent influenza vaccination programme
had shown that more equitable outcomes were possible when Māori providers
delivered services to Māori in a Māori way. The Ministry had therefore ring-fenced
funding for Māori vaccination providers and for a service to ‘support and empower
whānau’ through vaccine information and access.53
Particularly after the Delta outbreak, the Ministry of Health, district health boards
and providers expanded options for accessing COVID-19 vaccinations, including
via general practices and pharmacies (as agreed by Cabinet on 23 August 2021).
As part of this expansion, the Ministry of Health contracted Māori and other
community providers, seeking to implement what it described as a ‘whānau-
centred approach’ in Māori communities ‘so whānau could be vaccinated in
groups, for multiple things at the same time where appropriate and in a range of
locations to suit [them], including at home and on marae’. Similarly, from August
2021 vaccinations were offered to Pacific communities in places such as churches
and community centres. Pacific peoples had been disproportionately impacted
by COVID-19 from the start, accounting for 75 percent of active cases linked
to community transmissions by August 2020. The Ministry also set up mobile
outreach and pop-up sites to meet the needs of remote rural communities.
While evidence from our engagements showed such initiatives were effective in
reaching relevant communities, it appears these efforts occurred too late in the
rollout to deliver more equitable vaccination rates across the population. As shown
in Figure 3, by August 2021, vaccination among Māori and Pacific populations was
already substantially lower than for people who were neither Māori or Pacific,
and the gap was never closed. It is likely that in the absence of efforts to expand
reach to these communities, the disparities in vaccine uptake would have been
even worse. It is important to recognise the significant effort invested in improving
vaccine reach, and the benefits gained in terms of vaccination uptake in vulnerable
communities. But it is equally important to recognise that even greater equity
gains could have been achieved by starting the outreach to Māori, Pacific peoples
and disadvantaged and rural communities earlier.xi
xi In December 2021, the Health Quality and Safety Commission reported that ‘once supported to lead their
own approaches, significant increases in vaccination rates for both Māori and Pacific peoples have been achieved’.
See A window on quality 2021: COVID-19 and impacts on our broader health system (Part One), p 32, https://www.hqsc.
govt.nz/assets/Our-data/Publications-resources/COVID-Window-2021-final-web.pdf Health Quality and Safety
Commission review).
Figure 3: Receipt of COVID-19 vaccine (1st dose and 2nd dose) by ethnicity
among population aged 15 years and over, March–December 2021
Coverage
for 15+
population
(1st dose)
Coverage
for 15+
population
(2nd dose)
Dark blue = Māori, Green = Pacific, Light blue = Other (non-Māori non-Pacific)
The 2024 modelling study published in Vaccine offered further insights into how
their lower vaccination coverage affected Māori mortality. It estimated that if Māori
vaccination rates had been the same as non-Māori, between 11 and 26 percent
of the 292 Māori COVID-19 deaths recorded between January 2022 and June 2023
could have been prevented.54 The authors noted that other factors – such as poor
access to healthcare, lower quality housing and higher rates of co-morbidities –
also contributed to the higher Māori hospitalisation and mortality rates.
That up to a quarter of Māori deaths could have been avoided if vaccination rates
had been equal is a stark demonstration of the meaning of health equity and what
happens in its absence.
This disparity – and likely inequity – is particularly salient given that concerns about
equity were raised with decision-makers even before vaccination had started. It
also reinforces that the initial approach to the rollout did not facilitate sufficient
involvement of Māori, Pacific and other community providers. The Auditor-General’s
review of preparations found that, as early as February 2021, officials had expressed
concern that ‘equitable access to the vaccine was not being properly incorporated
into the immunisation programme’ and that it was unclear where responsibility
and accountability for equity lay.55 The Auditor-General noted that changes to the
programme’s structure and staffing had since improved matters. Even so, he found
evidence of ongoing delays in funding and vaccine supplies for Māori and Pacific
providers, noting that much still needed to be done to ensure equity:56
“ District health boards are still working out how they will organise aspects of the vaccine
roll-out in their communities. Some are well-positioned, but others have a lot of work to
do. … Although a lot of thought has been given to ensure that everyone (Māori and Pasifika
communities in particular) can access the vaccine in a way that meets their social, linguistic,
and cultural needs, it is not yet clear whether this will be fully achieved. At the time this audit
was completed, many in the wider health and disability sector were still not clear about what
their role will be or when they will know.”
The Auditor-General’s report recommended that the Ministry of Health keep working
with district health boards and Māori, Pacific and disability healthcare providers ‘to
make sure equity considerations are fully embedded in delivery plans’.57
Ministry of Health officials had sought to place equity at the centre of the COVID-19
immunisation programme. In March 2021, the COVID-19 Vaccine Technical Advisory
Group advocated prioritising Māori and Pacific peoples (and some other vulnerable
groups) for vaccination at a younger age than the rest of the population since they
were at greater risk of serious illness.58 This advice was included in the Ministry
of Health’s briefing to Cabinet, which recommended including Māori and Pacific
peoples over 50 years of age in Group 3 of the sequencing framework.59 (The
proposed approach was referred to as an ‘age adjustment’ since it sought to ‘adjust’
the Group 3xii age-threshold for Māori and Pacific peoples in recognition of their
higher risk of severe outcomes from COVID-19 infection.)
Cabinet did not follow officials’ advice to use a younger age threshold for
Māori and Pacific peoples in the vaccine rollout. Instead, they sought to
ensure equitable vaccine access via other mechanisms – including promoting
a ‘whānau-centred’ approach to the vaccine rollout, enabling household members
to be vaccinated alongside older Māori and Pacific people and prioritising of
people with co-morbidities (noting co-morbidities are more common, by age,
among Māori and Pacific peoples). District health boards were also given a degree of
flexibility in how they decided to prioritise the vaccine rollout in their area.60
xii Group 3 described those in the general population who were first in line to receive the COVID-19 vaccine.
This included older adults (aged 65 years and over) and people with an underlying health condition that
placed them at increased risk of severe outcomes from COVID-19 infection.
The intention behind Cabinet’s decision was to ensure Māori and Pacific peoples
were appropriately prioritised in the vaccine rollout. Unfortunately, this intention
was not consistently reflected in the implementation of the complex immunisation
programme. As discussed previously, pressure to deliver a fast vaccine rollout
while managing scarce vaccine supply initially (and understandably) resulted in
a centralised approach. Vaccination centres were strongly focused on careful
stewardship of vaccine doses – an approach that was sometimes in tension with
equity considerations. As a result, involvement of Māori and Pacific providers was
limited until August 2021. This created unintended barriers to vaccine access –
and hence an inequity – for many Māori and Pacific communities.
Cabinet’s decision not to follow officials’ advice in relation to the vaccine sequencing
framework was heavily criticised in the Waitangi Tribunal’s priority report Haumaru,
released at the end of 2021. The New Zealand Māori Council, supported by a several
Māori health providers, lodged a claim with the Tribunal asserting that the Crown’s
vaccination strategy and plan (and the COVID-19 Protection Framework, introduced
later in the pandemic) were inconsistent with te Tiriti. The Tribunal upheld the claim
on several counts. It found that Cabinet’s decision to reject advice from officials
to adopt an age adjustment for Māori in the vaccine rollout breached the treaty
principles of active protection and equity. It also found the Crown breached the
principle of partnership and the guarantee of te tino rangatiratanga by failing to
jointly design the vaccine sequencing framework with Māori, while its inconsistent
engagement with Māori more generally was another breach of partnership.61
Haumaru criticised delays in provision of funding to Māori health providers,
which it said had contributed to lower vaccine uptake among Māori, while poor
communication and mixed messaging had undermined the potential for a ‘whānau-
centred’ vaccine rollout. These actions and others occurred despite advice that
Māori health leaders and iwi leaders were giving the Government, the Tribunal said.62
The Government undertook several measures in response to the Haumaru report,
including providing an additional $140 million for Māori and Pacific providers to support
the health response to Omicron and targeted support to improve vaccination uptake
for Māori.63 It also committed to improved monitoring of Māori health outcomes,
including through the establishment of the Māori Health Authority | Te Aka Whai Ora.
Since Haumaru was released, other equity-related reviews of the Government’s
pandemic response have highlighted inequities in the vaccination strategy and
rollout. One review (commissioned by the Ministry of Health and based on interviews
with mostly Māori and Pacific whānau, stakeholders and service providers) concluded
that equity had been ‘actively discarded as an objective’ in the vaccination strategy
and that the Ministry needed to do better in any future pandemic response.64
It is clear that the Government understood the importance of protecting Māori interests
in the vaccination strategy and rollout: the many references to its te Tiriti obligations
in guiding documents speak to this. Unfortunately, this clear intention to protect Māori
failed to translate into equitable implementation of the COVID-19 vaccine rollout. This
implementation risk was flagged by the Auditor-General when the rollout was still in
its early stages and later confirmed by the Waitangi Tribunal.65
We note that the Ministry of Health sought to respond to the Waitangi Tribunal’s
findings by working with Māori providers to improve vaccine access for Māori and
by strengthening its ability to monitor vaccine uptake by ethnicity. It is not our role to
identify breaches of te Tiriti. However, the general thrust of the Waitangi Tribunal’s
findings are consistent with evidence we reviewed from many sources, showing
the significant benefits that were achieved when the Government did undertake
genuine te Tiriti-based engagement with iwi and Māori; when it trusted them to lead,
organise and deliver vaccination in ways that responded to local needs and barriers
and resourced this accordingly. In our view, when responding to a future pandemic,
the Government must not only document its responsibility to ensure equitable
outcomes for Māori in policy statements, but also give effect to this responsibility
in implementation. This comment is not intended to dismiss the significant efforts
that were made to ensure the vaccine rollout reached everyone, but to note the
opportunity to do better in future by trusting and resourcing community expertise.
We return to this in the lessons for the future and recommendations set out later
in our report.
The vaccination rollout also fell short of delivering equitable outcomes for Pacific
peoples. Like Māori, they too were affected by Cabinet’s decision not to adjust
the vaccination age threshold for those ethnic groups at greatest risk of severe
outcomes from COVID-19 infection. Pacific health providers experienced delays in
receiving funding and vaccine supplies, and some told us they were often blocked
when they tried to lead or organise vaccination in ways they knew would work for
their communities. We do not have quantitative evidence of the likely impact on
Pacific COVID-19 mortality (unlike the impact of lower vaccine uptake on Māori
mortality, which has been modelled). But as Pacific peoples suffered the highest
mortality risk of all ethnic groups (see Figure 3), it is only logical that inequities
in vaccine access and uptake contributed to this outcome.
It is a human right to refuse medical treatment such as vaccination, and not all
people will be willing or feel able to be vaccinated. There will therefore be variation
in vaccine uptake across the population, due in part to differences in people’s
preferences and beliefs. This variation is not regarded as an inequality if it reflects
genuine choice based on sound information. However, vaccine coverage is also
impacted by factors other than personal or whānau choice – including geographical
barriers, lack of cultural alignment between providers and those receiving vaccines,
and historical breaches of trust. It is the Inquiry’s view that lower vaccine coverage
among Māori and Pacific peoples is primarily due to these broader factors. For
example, while lower coverage in Māori partly reflected higher vaccine hesitancy
in Māori communities, this was itself driven by delays in bringing Māori providers
into the rollout, greater exposure to misinformation and disinformation, and
higher mistrust of government.66 The Inquiry therefore regards lower vaccine
coverage in Māori and Pacific peoples as an inequality.
Spotlight:
Māori and Pacific vaccine providers |
Ngā kaiwhakarato rongoā āraimate Māori me Ngā Uri Moutere
“ When you left us to deliver the services ourselves, we did an exceptional job.”
Pacific community healthcare provider
“ We were getting reports about vaccination rates and seeing there were problems
with Māori uptake... In the end, we just … gave the money to Iwi and community groups,
and that worked.”
Cabinet Minister
The effectiveness of Māori and Pacific health providers in the vaccine rollout –
supported by strong national and community leadership – was a recurrent
theme in our Inquiry.67
Government agencies acknowledged the value these providers brought. In
October 2021, Te Puni Kōkiri told ministers that Māori providers, iwi groups and
organisations ‘have deep connections and networks into their communities that
can reach whānau often on the margins of government responses. Importantly,
these providers, groups and organisations are often highly trusted by those
whānau in need’.68 District health boards too highlighted the impact of Māori
providers on vaccination rates. Clinical leaders at the former MidCentral District
Health Board, where Māori vaccination coverage exceeded the national average,
described ‘an amazing Māori response… the Māori nurses that worked with them,
the iwi, the NGO providers… just the way te Ao Māori engaged with their people’.
It was a similar story with Pacific providers, whom the Ministry of Health later
praised for providing ‘flexible, adaptive, by-Pacific-for-Pacific’ vaccination delivery
that met the needs of their communities.
For providers at the front line of the vaccination rollout, there was a mix of
successes and frustrations. In Ōtautahi, Te Rūnanga o Ngāi Tahu told us of a
long wait before the district health board gave their vaccinators the mandate
they needed to start ‘vaccinat[ing] our communities, in our way, in our spaces’.
But once they were up and running, the impact was immediate:
“ Our health and social service organisations stepp[ed] up, our marae stepp[ed] up and
work[ed] together… Our Papatipu Rūnanga, we run community vaccinations, kaumātua
and whānau from all around the area, no matter what iwi, we just contact everyone in
our community and run big vaccination days at our marae, utilising local Māori health and
social service agencies to provide support, but also staff from the PHO would come in.”
At the other end of the country, Māori health provider Hauora Hokianga said
their COVID-19 response was hampered by funding limitations and uncertain
availability. Government and district health board funding became available with
little notice or discussion about what was needed most on the ground. ‘Putea
bombs … came out of the sky’, they said, along with an expectation that they
would be able to deliver at pace, especially during the Delta outbreak. The
pressure took a heavy toll on health workers. On the other hand, the pandemic
environment made it possible to secure some long-needed resources, including
funding for a van to provide mobile healthcare and vaccinations.
347
According to Hauora Hokianga, some Ministry of Health directions for the
rollout – especially the phased approach to vaccination – simply didn’t work for
their communities, which were rural, widely dispersed and had a younger age
profile than the general population. Older family members were often brought to
vaccination sites by younger whānau who weren’t yet eligible under the sequencing
framework.69 But as providers told us: ‘We weren’t going to turn whānau away
who came to get vaccinated as they wouldn’t come back. We had a little mantra …
“one more is one more than we had before”.’ When vaccinators ran out of supplies,
‘we just winged it and other providers supported us with their excess vaccines’.
Good relationships and communications with other providers (‘the kūmara vine’)
helped them get through.
In Tāmaki Makaurau, Ngāti Whātua Ōrākei, Whai Māia – which provides cultural and
social support for the people of Ngāti Whātua Ōrākei, including through healthcare
services – also described developing a bespoke ‘outreach’ approach. ‘[That’s] when
it took off for Māori vaccination rates and it [was] all about engagement. The centre
does not attract Māori – you have to go out to the community.’ They used five
camper vans (adapted to keep the vaccine at the required temperature) and a team
of seven vaccinators who could deliver 300–500 vaccinations in a three-hour stint.
Ngāti Whātua Ōrākei played a key role in a rangatahi-led mass vaccination weekend
held at Eden Park| Ngā Ana Wai in November 2021, targeting young people.70
Vaccination clinic run by Ngāti Whātua Ōrākei (Photo supplied by Ngāti Whātua Ōrākei)
348
In Kaitaia, Māori primary healthcare providers emphasised the need
to tailor the rollout for their local communities, where many lacked
trust in Government and anti-vaccination sentiment was high. They
developed their own resources, interpreting Government requirements
and guidance for the local context. The ANT Trustxiii – which set up the
border control and other protective strategies for the community during
COVID-19 – used monetary vouchers to incentivise vaccination uptake. It
was effective in the short term, although they considered that ‘incentives
shouldn’t be necessary if whānau were better connected with [the] health
system’. Far North providers were generally frustrated by what they saw
as a lack of trust and resourcing from central government during the
pandemic response; it was very ‘top-down’, they felt, with few ways for
providers to give feedback or contribute to decisions.
Many Māori and Pacific providers were frustrated at not being enabled
to lead the vaccination drive for their communities earlier. There were
various barriers, including the Ministry of Health’s initial preference
for centralised vaccination sites. ‘[Pacific community providers] knew
the models that were going to work… family-centred, drive-throughs,
community pop-ups and outreach… these were the approaches that
we put forward. But they were pushed back because the focus was on
setting up fixed vaccination sites.’ According to the National Hauora
Coalition, the country’s largest Māori-led primary health organisation,
‘the system didn’t give permission or provide for different access options
for vaccinations – after hours, drive through or whole whānau. We had
to battle the political arguments about mass vaccination sites’.
Others shared providers’ frustration at not being brought into the vaccine
rollout earlier. Sir Brian Roche, a key independent advisor to ministers
and officials throughout the pandemic response, was one.xiv He described
a failure to unleash ‘the power of the community to respond and to lead’
– backed by resourcing – as a weakness of the pandemic response overall.
In relation to vaccination specifically, he said: ‘What a wasted opportunity.
When they finally began to use the community to vaccinate, the rates
went up exponentially.’
xiii Aupōuri Ngāti Kahu Te Rarawa (ANT) Trust

xiv Among other responsibilities, Sir Brian Roche led the first rapid review of all-of-
government arrangements (April 2020) and chaired the COVID-19 Independent
Continuous Review, Improvement and Advice Group from April 2021 to June 2022.
This group provided regular advice to the Minister for COVID-19 Response.
349
7.3.3 The procurement process balanced the principles
of prudent investment with the need to obtain an effective
COVID-19 vaccine in a context of uncertainty
We have already set out the key steps in the vaccine procurement process the
Government embarked on in 2020. The portfolio approach (used by many countries)
was an appropriate investment that resulted in the purchase of an effective
vaccine. As the vaccine taskforce advised ministers in July 2020, ‘traditional vaccine
procurement approaches are not suitable for securing a product that does not yet
exist’ and for which global demand would be fierce.71
While the possibility of domestic production was initially presented as one of three
potential routes to obtaining a vaccine (alongside multilateral agreements such
as COVAX and direct purchase from global manufacturers), limited experience
with human vaccine production meant local manufacturing was an unlikely option.
Aotearoa New Zealand eventually obtained COVID-19 vaccines by entering directly
into advance purchase agreements with international pharmaceutical companies.
The vaccine taskforce was supported in this endeavour by the provision of high-
quality scientific advice to inform decision-making on which vaccine candidates
were the most promising.72
It took time for vaccine doses to reach Aotearoa New Zealand, adding to the
challenge of organising the national immunisation programme. While some accounts
suggested New Zealand received lower priority by vaccine manufacturers and
distributors in the vaccine supply chain, others rejected this suggestion, and we
found no evidence to support it. When potential supply shortages emerged at
a critical point in the vaccine rollout, alternative supplies were secured through
agreements with other countries (supported by effective relationships at the
leadership level). These findings illustrate the importance of international
relationships and forward planning in securing essential supply chains in the
context of a pandemic.
7.3.4 The regulatory approval process for COVID-19 vaccines

was accelerated but still ensured their safety and efficacy
were properly assessed
Before any vaccine can be used in Aotearoa New Zealand, it must be approved for
use by Medsafe under the Medicines Act 1981. The approval process is intended to
be objective and transparent, and to give the public confidence that medicines meet
acceptable standards of safety, quality and efficacy, taking into account the specific
New Zealand context and population.73
Given the urgent need to secure a safe and effective COVID-19 vaccine, Medsafe
streamlined its administrative processes so that vaccine candidates could be assessed
‘at the earliest possible time’, without compromising the integrity of the approval
process.74 Pfizer applied for Medsafe approval for its vaccine in October 2020.
As usual, Medsafe undertook expert review of evidence that Pfizer provided – albeit
on a rolling basis, for speed – about the vaccine’s efficacy and safety in clinical trials.
Again, as it normally does, Medsafe also assessed the vaccine’s expected benefits
and risks. It granted the vaccine provisional approval on 3 February 2021, three
months after Pfizer had applied.
We received a small number of public submissions from people who cited a lack
of adequate testing and trialling as the reason they opposed the COVID-19 vaccine
(though not necessarily other vaccines): ‘I am not against jabs as I have so many but
I am against getting the covid jab as it didn’t have all the safety stages complete’.
Few commented specifically on Medsafe’s approval process. One submitter who
did said the regulator should ‘be free of government and big pharma influence,
to enable an unbiased and professional assessment of any future vaccines and
medicines’. However, many submitters appreciated that the Government obtained
the vaccine it found to be the most effective and safe, and were impressed at the
level of research that went into the choice of vaccine.
The evidence we considered indicates Medsafe followed its usual process to
properly assess the efficacy and safety of COVID-19 vaccines, albeit on an expedited
timeline. Arguably, its review of the Pfizer vaccine was even more rigorous than
those of regulators in other countries. At the time, Pfizer had already been approved
for use in the United Kingdom, United States and Australia, meaning Medsafe
was able to review the most up-to-date evidence on vaccine efficacy and safety –
including recent data that had not been available to regulators in other countries.
This provided an extra level of reassurance that was welcome, given this was an
entirely new product that was developed and trialled under urgency. At the same
time, Medsafe’s approval process did not delay either procurement or rollout of the
vaccine, with immunisations starting as soon as practicable after the first vaccine
doses arrived in the country.75
We also note that in March 2021, the High Court rejected an application for an
interim injunction that would have halted the vaccine rollout.76 The applicants
argued that provisional approvals under section 23 of the Medicines Act 1981
were intended only for new medicines used on a ‘limited number of patients’; this
provision did not apply to the Pfizer vaccine since the Government intended rolling
it out to the entire adult population of Aotearoa New Zealand. In her decision,
the judge observed ‘it is difficult to see how the assessment process could, in the
circumstances, have been more thorough’ and that the evidence showed ‘a number
of layers of reflection and review in addition to those that would ordinarily be
expected in a provisional consent assessment’.77 Parliament later passed an urgent
update to the Medicines Act 1981 to remove the legal risk. While the judgment
affirmed the integrity of Medsafe’s approval process, it also highlighted what we
consider a recurrent problem in the response to COVID-19: the risks of applying
existing legislation to new and unanticipated circumstances arising in a pandemic.
We return to this issue in our lessons for the future.
1. In combination with the elimination strategy, vaccination

was fundamental to the effectiveness of the country’s
COVID-19 response.
1a, From the first weeks of the pandemic response, vaccination was recognised as
the likely key measure that would allow Aotearoa New Zealand to reconnect
with the rest of the world while protecting the population from the levels of
COVID-19 illness and death seen in other countries.
1b, While Aotearoa New Zealand’s vaccination programme started slightly later
than those in some other countries, it quickly achieved very high coverage:
more than 80 percent of adults had received two vaccine doses by the end
of 2021. This meant the vast majority of New Zealanders had been fully
vaccinated before they were exposed to COVID-19 infection.
1c, The vaccination programme was also successful in ensuring people at highest
risk received a third ‘booster’ dose within a few months of their original
vaccination. This meant they benefited from high levels of protection at the point
New Zealand experienced its first COVID-19 ‘peak’ with Omicron in early 2022.
1d, In addition to the protective effect of the elimination strategy, vaccination
is estimated to have saved more than 6,500 lives and prevented more than
45,000 hospitalisations from COVID-19 in Aotearoa New Zealand.
2. The vaccine procurement process was appropriate and

effective. International relationships were important in
securing timely vaccine supplies to support the rollout.
2a, Aotearoa New Zealand used a portfolio approach that appropriately invested
in several potential vaccine sources to be confident of securing an adequate
supply. While this approach eventually resulted in surplus vaccine doses
(donated to Pacific countries), it represented a prudent ‘insurance’ policy given
the historical expectation that only one in five candidates being developed
results in an effective vaccine.
2b, Advance purchase agreements were obtained for enough doses to immunise
the entire population with a single vaccine – the Pfizer vaccine. While other
vaccines were subsequently purchased, Pfizer remains the country’s first-line
vaccine option for COVID-19.
2c, Good relationships with other countries (particularly Spain and Denmark)
were important in addressing supply challenges and ensuring Aotearoa
New Zealand had sufficient vaccine to support the national rollout.
3. The Pfizer vaccine underwent full assessment and
received provisional regulatory approval prior to being
rolled out.
3a, Pfizer underwent independent assessment and received provisional
approval by Medsafe before being rolled out in Aotearoa New Zealand.
3b, The Medsafe assessment process provided assurance about the quality,
safety and efficacy of the vaccine for the New Zealand population. The
process also allowed regulators to review the most up-to-date evidence,
including data not available to regulators in other countries. An expedited
review process meant Pfizer received approval before the first doses
arrived in the country.
4. An enormous effort underpinned the vaccine rollout,

which achieved very high levels of population coverage.
At the same time, some opportunities were missed to
ensure the vaccine reached vulnerable people as equitably
as desirable.
4a, The COVID-19 immunisation programme was very effective in quickly
delivering high levels of vaccine coverage at an overall population level.
4b, The rollout of the vaccine involved difficult trade-offs between the need
to manage operational constraints, the desire to vaccinate the population
as quickly as possible, and recognition that more tailored approaches
would be needed to reach some population groups (including Māori and
Pacific communities, and people living in more rural areas). With hindsight,
opportunities to ensure more equitable vaccination uptake were missed
by not involving Māori, Pacific and community-based providers earlier, in
parallel to the main vaccination programme.
4c, Once Māori, Pacific and other community-based providers were brought
into the vaccine rollout, they were highly effective in supporting vaccine
uptake within their communities.
4d, Faster vaccine rollout and uptake among Māori and Pacific people would
have resulted in fewer hospitalisations and deaths during the Auckland
Delta outbreak and likely shortened the final Auckland lockdown.
5. Vaccine hesitancy emerged as a growing challenge
to the rollout, fed by exposure to misinformation and
disinformation and declining trust in government within
some communities.
5a, The vaccine rollout was challenged by declining trust and confidence in
parts of the population, exacerbated by a proliferation of misinformation
and disinformation. The influence of these factors was particularly
apparent among younger people, in some Māori and Pacific communities
and in rural areas.
5b, Providing direct ‘rewards’ (such as vouchers) to encourage vaccination
was effective in the short term, but raises ethical challenges – including
the impact of perverse incentives and the risk that future vaccination
programmes may be less successful if they do not provide such
rewards. A better approach is to improve vaccine access and address
the root causes of vaccine hesitancy in vulnerable communities. In
a future pandemic, direct incentives to boost vaccination should be
used with caution.
5c, All vaccines have the potential to cause harm to a small number of
individuals. While Medsafe and the Ministry of Health sought to keep
people up to date with emerging evidence of rare complications, the
Inquiry understands there is potential to strengthen the communication
of risk at the time people are vaccinated. Doing so would support both
informed consent and awareness of any subsequent symptoms that
require medical attention.
Endnotes |
7.5
0.0 Tuhinga āpiti
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2022/23-0915, obtained under Official Information files/2021-05/february_2021_update_on_the_covid-19_
Act 1982 request to Department of the Prime Minister immunisation_strategy_and_programme.pdf
and Cabinet, https://www.dpmc.govt.nz/sites/default/ 75. Rt Hon Jacinda Ardern and Hon Chris Hipkins, ‘First
files/2023-09/dpmc-roia-oia-2022-23-0915.pdf batch of COVID-19 vaccine arrives in NZ’, media
67. Te Puni Kōkiri and Te Arawhiti, Briefing: Supporting release, 15 February 2021, https://www.beehive.govt.
Māori communities through the COVID-19 transition, nz/release/first-batch-covid-19-vaccine-arrives-nz
21 October 2021, p 4, https://www.tpk.govt.nz/docs/ Ministry of Health, Pfizer agreement, COVID-19 cases,
covid19/tpk-211021-brief-phase1-estab-mccf-2022.pdf deaths and vaccinations, H202117875, obtained under
68. Te Puni Kōkiri and Te Arawhiti, Briefing: Supporting Official Information Act 1982 request to Ministry of
Māori communities through the COVID-19 transition, Health, 3 February 2022, https://www.health.govt.nz/
21 October 2021, p 4, https://www.tpk.govt.nz/docs/ system/files/2022-02/h202117875_response.pdf
covid19/tpk-211021-brief-phase1-estab-mccf-2022.pdf 76. Courts of New Zealand, In the High Court of
69. Office of the Auditor-General, Preparations for the New Zealand Wellington Registry, Nga Kaitiaki
nationwide roll-out of the Covid-19 vaccine (May 2021), Tuku Iho Medical Action Society Inc v Minister of
p 64, https://oag.parliament.nz/2021/vaccines/docs/ Health & Ors: Judgment of Ellis J, CIV-2021-485-181
vaccines-roll-out.pdf [2021] NZHC 1107 (Wellington, 18 May 2021),
https://disasterlaw.ifrc.org/sites/default/files/media/
70. Adam Pearse, ‘Covid 19 Delta outbreak: Got ya
disaster_law/2021-09/1107.pdf
Dot – Rangatahi Māori driving Auckland vaccination
evolution’, The New Zealand Herald, 5 November 77. Courts of New Zealand, In the High Court of
2021, https://www.nzherald.co.nz/nz/covid-19- New Zealand Wellington Registry, Nga Kaitiaki
delta-outbreak-got-ya-dot-rangatahi-maori-driving- Tuku Iho Medical Action Society Inc v Minister of
auckland-vaccination-evolution/2C7BULKHCIX2ZJYEJK Health & Ors: Judgment of Ellis J, CIV-2021-485-181
6ZEV23HQ/ [2021] NZHC 1107 (Wellington, 18 May 2021), [70],
https://disasterlaw.ifrc.org/sites/default/files/media/
disaster_law/2021-09/1107.pdf
New Zealand Foreign Affairs and Trade, and Ministry
of Health, Briefing: COVID-19 Vaccine Strategy –
Purchasing Strategy and funding envelope, MBIE:
2021-0139, 10 July 2020, pp 4-5, https://covid19.govt.
nz/assets/Proactive-Releases/proactive-release-2020-
october/HR28-2021-0139-COVID-19-Vaccine-Strategy-
Purchasing-Strategy-and-funding-en....pdf
72. Cabinet Paper and Minute, COVID-19 Vaccine Strategy:
Early Progress, SWC-20-MIN-0098, 22 July 2020,
https://covid19.govt.nz/assets/Proactive-Releases/
proactive-release-2020-october/HR40-Minute-and-
Cabinet-Paper-COVID-19-vaccine-strategy-early-
progress.pdf
73. Cabinet Paper, February 2021 update on the COVID-19
Immunisation Strategy and Programme, 3 February
2021, p 26, https://www.health.govt.nz/system/
files/2021-05/february_2021_update_on_the_covid-19_
immunisation_strategy_and_programme.pdf
CHAPTER 8:
0
8 Mandatory measures |
Ngā whakaritenga
whakature
Introduction |
8.1
0.0 Kupu whakataki
Each of the chapters so far in this ‘looking back’ section of our report has covered
a key element of the COVID-19 response in Aotearoa New Zealand: strategy
and decision-making, the use of lockdowns, border restrictions and quarantine,
economic and social supports, the health response, and the vaccine rollout.
In each of these areas, the Government took extraordinary steps. Requiring
everyone to stay at home, spending unprecedented amounts on wage subsidies,
quarantining new arrivals in hotels, rapidly rolling out a new vaccine to the entire
population: all of these would have seemed unthinkable prior to the pandemic.
For many people, the most unsettling of the extraordinary steps taken in
response to COVID-19 were those that restricted people’s freedoms (including
their freedom of movement and ability to congregate) or strongly directed
them to undergo testing and vaccination. We have already discussed several
mandatory measures that formed a key part of Aotearoa New Zealand’s
COVID-19 response, including the use of lockdowns (in Chapter 3) and border
and quarantine restrictions (in Chapter 4). In this one we consider the use of
mandates and orders to make public health measures – testing, contact tracing,
mask wearing and vaccination – compulsory under certain circumstances.i
In considering whether to make certain measures mandatory, ministers (and
their advisors) had to weigh up the need to protect the public from the worst
impacts of the virus (especially vulnerable population groups), the available
evidence about whether each measure would be effective at doing so, and the
fundamental importance of upholding individual freedoms and rights. These
were not easy decisions. In relation to each of these measures, at some point
in the pandemic, ministers judged that the additional protection offered by
making them compulsory under certain circumstances justified the temporary
curtailment of individual freedoms. They also empowered others to make
similar judgements in certain contexts, for example by enabling employers to
set workplace-specific vaccine requirements. Many governments around the
world reached similar conclusions.
i To compel someone is to oblige, force, or irresistibly urge them to do something; a mandate is a judicial or legal
command issued by a superior or ordered by a legislative body. In common usage, terms like ‘mandatory’ and
‘compulsory’ are often used interchangeably to describe something that somebody has to do, whether because
it is a legal requirement, or because there is no alternative. In the context of the COVID-19 response in Aotearoa
New Zealand, the term ‘mandate’ was used to describe a range of public health measures that people were
obliged to undertake under certain circumstances, including testing, contact tracing, mask wearing, vaccination,
and showing proof of vaccination before entering a venue. These may not have met the formal definition of
‘compulsion’, since in each case, individuals retained the ability to decline, but the consequences of doing so (such
as having their employment terminated or not being able to enter a public space) made some affected individuals
feel that they had no meaningful ‘choice’. In this chapter, we tend to use ‘compulsory’ and ‘mandatory’ in line with
this common usage, in the same way that we use ‘lockdown’ throughout the report even though it was never an
official term. When we are referring to a specific mandate or legal requirement, we make this clear.
It was clear from our public submissions that the rules and mandates
promulgated during COVID-19 (particularly vaccination requirements) were
among the most controversial aspects of the pandemic experience, and prompted
a strong response from many people. While many opposed the imposition of
masking and vaccine requirements, others were in favour of what they saw as
necessary measures to protect public health and safety, particularly in workplaces.
Many public submitters expressed concern about the long-term impact this
period may have had on social cohesion, trust and community solidarity in
Aotearoa New Zealand.
In Aotearoa New Zealand – as in many
other countries – resistance to mandatory
COVID-19 measures dovetailed with
Pandemic responses are
more effective where there
broader anti-vaccine and anti-government
is high social cohesion. sentiments, prompted in part by rising levels
of misinformation and disinformation and
the proliferation of COVID-19 related
conspiracy theories on social media.1
These distinct but overlapping groupings culminated in the 28-day occupation
of Parliament grounds in early 2022ii – the most significant instance of civil
unrest in New Zealand since the 1981 Springbok tour.
These are important issues for an inquiry like ours focused on future pandemic
preparedness. There is sound evidence that during a pandemic, high levels of
social cohesion support greater social licence for action, effective community-
led responses, and are associated with lower infection and death rates. Indeed,
Aotearoa New Zealand’s relatively strong levels of social cohesion and trust prior
to the COVID-19 pandemic have been cited as a key factor in the success of the
elimination strategy.2
However, pandemics (and some of the measures taken in response to them)
can damage and erode social cohesion and trust. Having just weathered one,
Aotearoa New Zealand (and many other countries) would start from a different
place if another pandemic broke out next week – an observation also made
by the Australian COVID-19 Inquiry.3 Fostering trust and cohesion will therefore
be an important part of future pandemic preparedness, as will thinking ahead
about how to balance the use of ‘compulsion’ to protect public health against the
need to uphold individual rights and avoid marginalising people. Understanding
the role of mandatory measures during COVID-19, and why they proved controversial,
is a good place to start. There is much to learn.
ii The Inquiry acknowledges that those at the occupation raised a wide range of issues, not only
concerns about the response to COVID-19.
There are three main sections in this chapter. In the first, we look together
at compulsory testing, contact tracing and mask wearing, and consider
how these measures were mandated, how these requirements were
implemented, and what the effects were.
The second section considers the most controversial measures –
vaccination requirements – of which there were three categories:
Government-issued vaccine mandates for certain occupations, workplace-
specific vaccine policies (enabled by legislation but set by employers),
and vaccine passes for entry to certain locations and social gatherings.
We consider the case for such measures, the evidence available to
decision-makers, how this changed over time, and some of the direct
social and economic consequences.
In the third section, we look at how controversy about these matters
played out, including a condensed account of the Parliamentary protest
and occupation in early 2022.
We conclude with some comments about the impact of these events –
and the pandemic in general – on social cohesion and trust in Aotearoa
New Zealand, and what this might mean for future preparedness.
What happened: testing, contact tracing,
and masking requirements | I aha: ngā
8.2
0.0 whakaritenga whakamātautau, whaiwhai
i te pātanga, me te mau ārai kanohi
During an infectious disease outbreak, testing, contact tracing, and the use of
masks in high-risk environments are useful public health tools that can often be
deployed – depending on the specific nature of the pathogen – to help reduce the
spread of infection. In the case of the COVID-19 pandemic, all three were important
components of the response that contributed to the overall success of the
elimination strategy.
Throughout much of 2020 and 2021, testing at the border (together with mandatory
quarantine of overseas arrivals) reduced the risk of new COVID-19 cases entering
Aotearoa New Zealand; routine testing of wastewater and of people in the
community at higher risk of infection provided assurance that the virus had not
entered the country; rapid contact tracing of confirmed cases stopped potential
chains of transmission from taking hold; and mask wearing in public spaces made
it less likely that any undetected cases would result in an outbreak. For each of
these measures to be effective at providing population-level protection, they
needed to be taken up on a large scale.
Encouraging widespread uptake was therefore very important. This was largely
achieved via effective public messaging encouraging people to voluntarily take
up these measures, both from official channels via the ‘Unite Against COVID-19’
campaign, and within communities to their own members (see Chapter 2 on
public communications).
At certain points though, for each of these measures, the Government determined
that an extra ‘push’ was required to achieve uptake of the encouraged behaviour
(none of which was common or established practice in Aotearoa New Zealand
prior to the pandemic) at the scale required for them to be effective. They were
therefore each – at different times, and for different groups – made compulsory
under certain circumstances.
For each of these measures to be

effective at providing population-
level protection, they needed to
be taken up on a large scale.
8.2.1 Testing requirements
The overall role of testing during the COVID-19 response – including the types
of tests used, procurement matters, and laboratory capacity to process results –
have already been discussed in Chapter 5. Here, we focus on how testing was
made compulsory for some groups of people, which began from mid-2020.
Mandatory testing – primarily regulated via the COVID-19 Public Health Response
(Required Testing) Order 2020, which first came into force from 30 August 20204 –
was seen as a key control measure in the broader COVID-19 Surveillance Strategy.
Such testing was intended to detect and isolate any cases of COVID-19 infection
to prevent further seeding of transmission in the community.
8.2.1.1
Overseas arrivals
As outlined in Chapter 4, ‘closing’ Aotearoa New Zealand’s borders, testing travellers
and border workers for COVID-19, and requiring all international arrivals to
quarantine were important components of New Zealand’s COVID-19 response and
elimination strategy. Compulsory testing at the border began early in the pandemic.
From April 2020, it was required of all international arrivals under section 70 of
the Health Act 1956.5 Once the COVID-19 Public Health Response Act was in place,
bespoke Air and Maritime Border orders were enacted requiring compulsory testing
of anyone arriving in the country by air or sea.6
Air arrivals
From June 2020, anyone entering the country by air had to test on arrival and to
undergo further testing during a 14-day quarantine period.7 From early 2021, an
additional requirement was added for travellers from the United Kingdom and the
United States to undergo a pre-departure test.8 From March 2022, when managed
isolation and quarantine (MIQ) requirements began to be lifted, post-arrival testing
remained compulsory. All incoming travellers were required to undergo a rapid
antigen test (RAT) on the first/second and fifth/sixth day after arrival and report the
results online. Any positive RAT results had to be followed up with a PCR test.9
Maritime arrivals
With 99 percent of Aotearoa New Zealand’s trade transported by sea,iii continuing
safe maritime operations during the pandemic was seen as very important.
The Maritime Border Order restricted which vessels could arrive in Aotearoa
New Zealand and established isolation, quarantine and testing requirements for
anyone arriving by sea, disembarking temporarily, or transferring between ships.10
Existing requirements for vessels arriving in Aotearoa New Zealand to provide
health declarations were extended to include pre-departure testing of people
on board and reporting of any symptomatic or confirmed COVID-19 cases.
iii By volume; 90 percent by value.
8.2.1.2
Border workers
During the pandemic, the New Zealand Customs Service estimates that
approximately 20,000 people were working at Aotearoa New Zealand’s air and
sea borders, and a further 4,500 at managed isolation and quarantine facilities.11
These workers routinely encountered people arriving in from countries where
COVID-19 was circulating widely. They were therefore considered a potential vector
by which the virus could enter the community. To reduce the risk of this happening,
a majority of these ‘border workers’iv were required to undergo routine COVID-19
testing (as well as regular symptom checks) as a condition of their work between
late August 2020 and late June 2022.12
Initially, this mandatory testing was targeted at workers considered to be at ‘high
risk’ at Auckland International Airport, the ports of Auckland and Tauranga, and in
MIQ facilities. These workers were all required to have weekly nasal or oral swab
tests, temperature tests and other symptom checks. Later, mandatory testing was
extended to all border workers.
The initial testing order placed primary responsibility on the worker to be tested.13 In
November 2020 this was amended to place responsibility on the owners/managers
of border-related businesses or organisations (known as ‘persons conducting a
business or undertaking’) to ensure their workers were regularly tested.14 These
people were expected to identify workers subject to the order, notify them, ensure
they were able to meet their testing requirements within working hours, and keep
records of the test results.
The Ministry of Health developed an online tool called the Border Workforce Testing
Register to help the responsible parties meet their record-keeping requirements.
The system matched workforce data (from business owners/managers) with
National Health Identifier numbers, allowing the Ministry to check that the required
testing had been completed and reported. The register went live in November
2020,15 sending automated text reminders about upcoming and overdue tests.
In response to some ministerial concerns about compliance with the order, a
Monitoring and Compliance Framework was introduced in May 2021 to help give
assurance that workers were being tested regularly in accordance with the order.16
While the online register supported this assurance function, it had initial limitations
which frustrated some businesses and organisations – including delays in recording
of test results, the need to manually resolve cases of duplicate identification
numbers, and some business owners/managers being unable to make changes to
the system.17 A review of border testing arrangements in December 2021 noted
that these issues improved over time as the systems matured.18
iv ‘Border workers’ included customs workers, biosecurity and aviation security staff, frontline port workers and other
‘border facing’ workers (as defined in Cabinet papers about the COVID-19 Surveillance Plan and Testing Strategy).
8.2.1.3
Health workers
After community transmission of COVID-19 became established in August 2021,
the risk of health workers being exposed to the virus substantially increased. While
hospitals and other healthcare settings had been following strict infection control
procedures since early in the pandemic (see Chapter 5), the near absence of
community transmission had meant the actual risk of health workers contracting
and spreading the virus was very low. But with the virus now circulating in the
community, health workers were much more likely to encounter positive cases in
the course of their work. Health workers were therefore made subject to the same
testing, symptom checks and record-keeping requirements as border workers.
These requirements remained in place until the Required Testing order was revoked
on 30 June 2022.19
8.2.1.4
People crossing regional boundaries
The first regional lockdown occurred in August 2020 when community transmission
was detected in Auckland. Auckland was put into Alert Level 3 lockdown while the
rest of the country was moved to Alert Level 2. This created a regional boundary
for the first time, but this lockdown was of such a short duration that the issue of
mandating testing for people crossing the regional boundary did not arise.
The story was different a year later, however, during the Delta outbreak. Auckland
spent several months in a regional lockdown from August 2021, while other regions
had several shorter localised lockdowns; these necessitated processes to manage
boundary crossings. Public health officials thereby hoped to prevent Delta from
spreading beyond Auckland (then at Alert Level 4) and the other affected regions
into the rest of Aotearoa New Zealand (then at Alert Level 2).20
To this end, mandatory testing was introduced for workers crossing regional
boundaries in September 2021. People crossing boundaries for personal travel were
also required to provide evidence of testing (a saliva test within the last seven days),
where practicable.21 The boundary testing requirement was modified in December
2021 to require evidence of either vaccination or a negative test, before being lifted
in early 2022.
All COVID-19 testing requirements were lifted from 30 June 2022.22
8.2.2 Contact tracing requirements
During an infectious disease outbreak, ‘contact tracing’ is the process of identifying
and notifying people who may have been in contact with an infected person. The
aim is twofold. First, contact tracing aims to identify anyone else who has been
infected so they can be offered treatment and advice; and second, to locate people
who have been exposed to the disease and may be incubating infection, so that
they can isolate (technically quarantine) and thus prevent further onward
transmission of infection.23
The broader role of contact tracing in the pandemic response is addressed in
Chapter 5. Here we focus on the aspects of contact tracing that were mandatory
during Aotearoa New Zealand’s COVID-19 response. There were two categories:
• pre-existing requirements (under the Health Act 1956) for people to provide
information for public health contact-tracing purposes, and
• new requirements introduced during the COVID-19 pandemic for people to
register attendance at various locations, and for business owners to collect
customer information and display QR codes.
8.2.2.1
Pre-existing contact-tracing requirements
Prior to the COVID-19 pandemic, it was already compulsory for people to supply
information for contact tracing in certain situations. These requirements are set
out in the Health Act 1956 (Part 3A, subpart 5).24 The purpose is to protect the
population from the spread of notifiable diseases by empowering public health
officers to collect information from people who have been in close contact with
someone known to be infected. If an authorised contact tracerv deems it necessary,
they may require someone diagnosed with a notifiable disease to provide
information about what they have been doing and who they have been in contact
with (including personal information and contact details). If appropriate, they may
also go around the person in question to obtain information directly from their
employer or an event organiser. Failure to comply with a contact-tracing request or
provision of false information can result in a fine of up to $2,000.
There are some caveats around how contact tracing can be done, including
obligations on contact tracers to provide reasons, take account of someone’s ability
to comply, and deal with the parents or legal guardians of people under 16. Under
the Privacy Act,25 contact tracers also have a duty of confidentiality not to disclose
the names of people who may have been a vector of transmission, and not to use
the information gathered for any other purpose than for public health.
Since COVID-19 was made a notifiable disease in late January 2020, the above
requirements for members of the public to comply with contact-tracing requests
applied throughout the pandemic response.26
v Namely, a medical officer of health, health protection officer, or person suitably qualified in health or community work
who is nominated to undertake contact tracing by Health New Zealand or medical officer of health (see s92ZZA(1) of
the Health Act 1956).
8.2.2.2
COVID-19-specific requirements
The methods and systems used for contact tracing evolved considerably during the
COVID-19 pandemic. ‘Manual’ contact tracing (that is, direct questioning of people
diagnosed with COVID-19 and their identified contacts) remained the key approach
throughout the pandemic. It was supplemented by other methods, however,
including publication of ‘sites of interest’ and the development of digital tools.
Additional requirements to support contact tracing for COVID-19 were enacted
under the COVID-19 Public Health Response Act 2020, which created an order-
making power to require people to ‘provide, in specified circumstances or in any
specified way, any information necessary for the purpose of contact tracing’.27 Such
orders were used to make it mandatory for businesses, event organisers and public
transport operators to display QR codes (for contact-tracing purposes), and for
businesses and event-organisers to ensure records were kept of people who had
attended their premises.
Displaying a QR code
The NZ COVID Tracer smartphone app was initially developed as a voluntary
contact-tracing measure (see section 5.3.2.1 in Chapter 5). In August 2020, with
Auckland back in lockdown, the COVID-19 Public Health Response (Alert Levels
3 and 2) Order 2020 made it compulsory for businesses to display QR codes at
Alert Level 2 or higher.28 Later that same month the COVID-19 Public Health
Response (Alert Level Requirements) Order 2020 extended this requirement to
all levels.29 In September 2020, it was also made compulsory for all public
transport vehicles to display QR codes.30
Compulsory scanning?
In 2021, the Government was seeking ways to strengthen the available tools for
contact tracing. Consideration was given to making it mandatory for members of the
public to record their presence at indoor public and business locations using the NZ
COVID Tracer app or other means (paper records).
A briefing from senior officials indicates the Government initially favoured a ‘dual
obligation’ system where both businesses and individuals attending them would
be required to ensure their presence there was recorded.31 However the Privacy
Commissioner – when consulted about the possible measures – had indicated he
had ‘significant concerns’ about the privacy impacts of mandating record-keeping for
contact-tracing purposes.
Officials subsequently advised ministers that an obligation on individuals ‘would
create significant privacy, compliance monitoring and enforcement issues’.32
Cabinet therefore chose to locate responsibility for record-keeping with business
owners and event organisers, but not with individual members of the public.33 In
presenting advice on these options, officials were aware that ministers would need
to consider the benefits of making record-keeping mandatory against any perceived
encroachment on people’s right to privacy and any potential risk to the maintenance
of social licence for the COVID-19 response overall.34
While Cabinet responded to the Privacy Commissioner’s concerns by not requiring
individuals to scan into premises or otherwise record their presence, this distinction
may not have been well understood by members of the public. There was also very
limited capacity to enforce record-keeping requirements on the part of business
owners and event organisers (see section 8.3.2.2). Again, it is unlikely that most
members of the public were aware of this, feeding a perception by some that
scanning-in or recording their details was ‘compulsory’ at this time.
Paper-based records
As well as displaying a QR code, businesses and organisers of events where people
gathered in close-confined settings were now required to actively keep records of
attendees for contact-tracing purposes. Such businesses included indoor public
and event facilities, aged care and health facilities (for visitors), exercise facilities,
hairdressers, hospitality venues and social gatherings (including weddings, funerals,
faith-based services and gatherings held at marae, but not at private residences).35
8.2.2.3
Lifting of requirements
The first case of the Omicron variant was detected at the Aotearoa New Zealand
border in December 2021,36 and the first community transmission of Omicron
was reported on 18 January 2022.37 Omicron was more infectious than previous
strains, and by December 2021, international evidence was starting to emerge that
vaccines were less effective at preventing its spread (see also section 8.4.5).38 With
this evolving situation came the realisation that Aotearoa New Zealand’s ‘opening up’
might not involve stamping out a series of localised outbreaks as anticipated in late
2021, but rather a large wave of infection across the whole country. Indeed,
that is what occurred. By early February 2022, case numbers had surged into the
hundreds, and by March 2022 there were thousands of new cases every day.39
Omicron was now firmly established as the dominant COVID-19 variant circulating
in New Zealand.
This had many implications. One was that the intensive approach of actively
tracing the contacts of all cases was no longer feasible: Aotearoa New Zealand’s
contact-tracing capacity, despite having recently been significantly expanded, would
quickly be overwhelmed. Over the first quarter of 2022, the approach therefore
shifted to a more ‘hands-off’ model in which people who had tested positive for the
virus were encouraged to alert potential contacts themselves.40 From 4 April 2022,
all requirements to keep records of attendance or display QR codes were lifted.41
The NZ COVID Tracer app was eventually removed from smartphone app stores
in August 2023.
8.2.3 Mask requirements
It took some time for a scientific consensus to emerge and for consistent
guidance to be issued from the World Health Organization about the effectiveness
of masks at reducing the spread of COVID-19 (see Chapter 5). Mask mandates
therefore did not feature prominently in the early stages of Aotearoa New Zealand’s
pandemic response.vi
By August 2020, however, it was well-established that COVID-19 was spread by
airborne particles, and that mask wearing was an effective tool for reducing its
spread. That month, Cabinet considered advice from the Ministry of Health to
include mandatory mask wearing in the response to the next outbreak. Masks
were subsequently required for all passengers on public transport and domestic
air travel at Alert Level 2 and above.42
Mask requirements were expanded in the second half of 2021 in response to the
Delta outbreak. Mask wearing was required for a wide range of indoor settings
at Alert Level 2 or above.43 Although businesses were never legally tasked with
enforcing mask wearing on their premises, many chose voluntarily to make mask
wearing a condition of entry as a way of supporting the public health response
and protecting their staff and customers.
8.2.3.1
Mask requirements under the COVID-19 Protection Framework
Under the COVID-19 Protection Framework or ‘traffic light’ system (in place from
December 2021), mask requirements varied at the different levels.
• At ‘Red’, masks were required for everyone at most indoor places including
flights, public transport, at retail, events, schools (years 4 to 13), tertiary
education, close-proximity businesses, food and drink businesses (except
when eating or drinking), and in public facilities.44
• At ‘Orange’, masks were required in many indoor locations including on
flights, public transport, retail, public facilities and for workers at gatherings,
events, and other hospitality businesses including cafes and restaurants.45
• At ‘Green’, masks were not required except on flights. However, masks
were encouraged indoors along with maintaining healthy habits such
as handwashing and staying at home when sick to keep whānau and
others protected.46
The entire country was at ‘Red’ from 23 January 2022 until 13 April 2022, and then
at ‘Orange’ until 12 September 2022.47
vi It is possible that this made the imposition and tightening of later mask mandates more challenging, because there was
a perception among some members of the public that advice and evidence about mask use had been inconsistent.
8.2.3.2
Mask exemptions
Some people could not wear facemasks for reasons of physical or mental
impairment or illness. This was recognised in the orders mandating their use,
which allowed anyone who had a physical or mental illness or disability that
made wearing a face covering unsuitable to be exempt from the requirement
to do so.48 The Government implemented a facemask exemption scheme in late
2020, which was coordinated by disability providers.
On 31 May 2022, the Government launched a new process for providing evidence
of a person’s facemask exempt status.49 This involved the person making an
online self-declaration that they met one or more of the criteria for exemption.
The downloadable digital exemption card was personalised so that it could not
be used by someone other than the person to whom it was issued, and the
corresponding COVID-19 Order made it a requirement for businesses to accept
these exemption cards.
By August 2022, there were 45,363 people with facemask exemptions.
8.2.3.3
Lifting of requirements
On 12 September 2022, the Government retired the COVID-19 Protection
Framework, removing most facemask requirements.50 However, many people
remained vulnerable to severe impacts of a COVID-19 infection. Accordingly,
facemask requirements were retained for healthcare settings, including for
in-home and disability support and aged residential care. These were eventually
revoked on 15 August 2023.51
By August 2022, there were
45,363 people
with facemask exemptions.
Our assessment: testing, contact tracing and
mask requirements | Tā mātau arotake: ngā
8.3 whakaritenga whakamātautau, whaiwhai
i te pātanga, me te ārai kanohi
During the pandemic, routine COVID-19 testing, extensive contact tracing and
widespread mask use were all important tools used to mitigate the spread of the
virus. The combination of testing and contact tracing ensured that positive cases
and their close contacts could be identified, then isolated or quarantined until
they were no longer contagious or at risk. Mask use reduced the likelihood of a
community outbreak from cases that had not been detected by these methods.
There is good international evidence

that testing, contact tracing and
mask wearing all reduce the risk of
Making testing, contact tracing and
COVID-19 transmission.52 It is more masking compulsory resulted in
difficult to quantify the benefit of meaningful benefit that outweighed
making these measures mandatory, the ‘cost’ to New Zealanders.
although cross-jurisdictional
comparisons show that protection
from infection is greater where
mask wearing is compulsory (rather
than voluntary).53 Nevertheless, given the effectiveness of these measures depends
on them being widely adopted, we are confident that making them compulsory
contributed usefully to the success of the elimination strategy during 2020 and 2021.
In our view, making testing, contact tracing and masking compulsory resulted in
meaningful benefit that outweighed the ‘cost’ to New Zealanders (e.g. the discomfort
of wearing masks and impingements on individual human rights and privacy).
While we are satisfied that these requirements were reasonable, we identified
some practical issues with their implementation that provide useful learning
opportunities for future pandemics.
8.3.1 Testing requirements
8.3.1.1
Compulsory border testing was useful for keeping COVID-19 out
of the community
Mandatory testing for groups at higher risk of exposure made it more likely that
cases would be detected and could be isolated. This was particularly relevant at the
border and in MIQ, to reduce the risk of the virus spreading from overseas arrivals
to border workers, their families and the wider community. It appears to have been
effective. Between June 2020 and September 2021, a small but steady stream of
positive COVID-19 cases were detected at the border. The vast majority of these
cases did not result in, or coincide with, any community transmission.
8.3.1.2
Compulsory testing orders were challenging to implement
Operational realities at the border
While the mandatory testing system provided assurance, some government
agencies were reluctant to implement mandatory testing for people working at the
border and did not know how best to do so, as was noted in a 2020 review.54 Further,
there were practical issues in some cases with mandatory testing, especially when
testing could not be performed onsite.55
The 2020 review of the implementation of the COVID-19 surveillance strategy,
including mandatory testing, found that there was ‘a lack of appreciation of
operational implications of directives’, leading to border directives that were difficult
to understand and implement.56 The review also suggested that testing regimes
were poorly targeted in terms of which workers were at highest risk of COVID-19
exposure, especially at the border.57
The view that central government lacked operational awareness about how such
requirements would work in practice was echoed by some stakeholders the Inquiry
engaged with directly. One major port company criticised what they regarded as
‘unworkable instructions’ for testing of border workers:
“ There was an order for immediate testing […] issued Friday 9am with a deadline for midnight
the following Monday. Every person had to be tested in that time. It covered 5,500 people
who worked at our port. MoH had no idea about the number of people and the practicalities
of testing. […] People showed up at the testing facility which could not cope. The timeframe
was eventually amended to focus on those with higher risk (720 workers) [...] It impacted
workers locally – there were unworkable instructions with the threat that if they didn’t follow
them, they were breaking the law.”
‘Testing fatigue’
Nasal swabbing – the principal method used in mandatory testing for COVID-19 – is an
unpleasant and somewhat invasive procedure.58 Some public submitters who were
subject to frequent testing requirements found these intrusive and unpleasant.
“ Expecting people to have their nasal passage scratched every day they worked is cruel
and should be illegal.”
“ Crossing the [Auckland] border I was subjected to regular PCR tests so I could cross the
imaginary ‘border’ that separated my home from my work. I still feel sick in my stomach
every time I come up to that bit of the road that marked the ‘border’.”
There was some concern that ‘testing fatigue’ could undermine the effectiveness
of the regime. In April 2021, ministers were briefed about reports of increasing
resistance to repeated nasal swab testing among border workers, noting:
“ There is a risk that ongoing use of invasive testing methods could create testing reluctance
or fatigue, and compliance with the testing regime could reduce given this.” 59
Border workers were subsequently given the option of saliva testing in recognition
of the challenges of taking frequent nasal tests.60
Record-keeping and assurance

The mandatory testing regime placed significant requirements on people running
border-related businesses or activities to ensure staff were being tested as required.
An online register helped with record-keeping requirements, but had some
significant limitations. It was not a real-time system; there was a lag between when
swabs were taken and when results appeared in the register.61 There were also
issues with duplicate health identification numbers, which meant the system might
struggle to match border workers with their test results, exacerbated in cases where
businesses were unable to correct errors in the system.62 A submission from an
organisation working at the air border highlighted these challenges:
“ Managing testing mandates was resource intensive and system poor… 14,000 records were
uploaded into BWTR [the Border Worker Testing Register], every person who had ever worked
in the facilities from inception. There was little consultation with PCBUs [persons conducting
a business or undertaking], and current staffing lists were not sought. This created significant
discrepancies in the records, names spelt wrong, incomplete, and incorrect records, multiple
records for one person, and in one instance, a […] staff member had five records with five
different NHI numbers. His tests were assigned to multiple records […] this created ongoing
noncompliance [issues] for this staff member when in fact he was compliant.”
From February 2021, the Ministry of Business, Innovation and Employment rolled
out a visitor management system for staff at MIQ facilities that improved and
automated the register and addressed some of these issues. Despite this, concerns
remained about the quality of data the system generated,63 as well as more general
concerns about the level of compliance with the border testing regime.64
8.3.2 Contact-tracing requirements
8.3.2.1
Mandatory contact tracing was an important element of
Aotearoa New Zealand’s COVID-19 response
Requiring people to comply with contact tracing is a key element of infection
control, particularly during a pandemic. International evidence shows that contact
tracing reduces the risk of COVID-19 transmission.65 As noted in Chapter 3, contact
tracing in Taiwan was so effective in identifying cases that – together with isolation
and widespread masking – it enabled Taiwan to successfully eliminate COVID-19
transmission in 2020 without the need for lockdowns.66
Details of contact tracing and how this was carried out are discussed in more detail
in Chapter 5. Mandatory contact tracing was an important component of Aotearoa
New Zealand’s COVID-19 response – particularly during the early stages of the
elimination strategy, when it successfully enabled chains of COVID-19 transmission
to be identified and closed down (through quarantine of people with infection and
isolation of their close contacts).
While the discussion here focuses on implementation challenges with the NZ
COVID Tracer app, the Inquiry is confident that contact tracing more broadly was an
important and necessary part of Aotearoa New Zealand’s COVID-19 response.
8.3.2.2
The NZ COVID Tracer app made contact tracing easier, but it was
not as effective as hoped at identifying contacts of cases
During COVID-19, many countries introduced digital technology to supplement
‘manual’ (person-based) contact tracing. Digital apps allowed people to record or
scan their location while out and about, creating a database that could be used to
inform people if it became apparent they had been in proximity to someone who
was subsequently diagnosed with COVID-19.
User experiences with the NZ COVID Tracer app

Some people found the NZ COVID Tracer app useful and reassuring. There were
positive comments about the app in our public submissions, generally expressing
views that it was easy to use and had a beneficial impact.
“ The use of the Covid app was fantastic and provided a degree of comfort knowing your
potential exposure would be notified to you.”
“ I think the app was a great idea – allowing people to scan into various locations and it meant
you got a warning when you might have been in contact with someone else. This information
allowed people to make informed decisions e.g. not visiting a newborn baby or grandparent
if there is risk of covid. The main goal should be keeping people safe.”
However, others found the app inaccessible or confusing, as the following
quotes indicate. It may have been particularly challenging for older or
disabled people.
“ Many elderly or those without smartphones couldn’t use COVID tracing app.
Businesses often didn’t have log in sheets.”
“ I wanted to follow the rules but wasn’t able to do so. How could they help?
Could they design alternative systems and still ensure privacy? They tried
but I don’t think they succeeded.”
These concerns were later reinforced in academic research exploring barriers

to digital contact tracing in Aotearoa New Zealand. Focus group participants
pointed out how older people, lower socio-economic groups, and some disabled
people encountered barriers in using or accessing smartphones. Disability sector
participants pointed out that the app could have been improved by following
smartphone accessibility guidelines and noted many issues that prevented
disabled people from scanning in (for example, QR posters located too high
for people in wheelchairs).67
Privacy concerns
Some people held strong privacy concerns about the NZ COVID Tracer app,
despite the Privacy Commissioner’s supportive assessments.68 Discomfort about
the Government’s ability to ‘track’ people’s movements via the app was one of
the main objections to its use expressed by public submitters to our Inquiry.
Some felt this was government overreach – or worse, a ‘hidden agenda’ to
gather and exploit data about individual citizens’ movements.
An academic study of barriers to the uptake of digital contact tracing also
identified privacy as a common concern. Such concerns were particularly
evident in population groups with low historical trust in government, the study
found. Māori participants expressed distrust of the Government’s motivation
for gathering data about people’s contacts and movements, reflecting Aotearoa
New Zealand’s history of colonisation, and in particular, the disproportionate
number of tamariki Māorivii being taken into state care.69 Similarly, a Pacific
community participant noted that:
“ Some of our community don’t have permanent residency … [They] weren’t

comfortable in disclosing or downloading anything like that [app] as much
as they wanted to, because they’re scared for their immigration status.” 70
vii An issue that was prominent during the COVID-19 response and subsequently raised by the Royal Commission
of Inquiry into Abuse in State Care.
Some of the stakeholders we engaged with reflected on the impact of such
privacy concerns. One senior official involved with commissioning and rolling out
the app told us that a key lesson from the pandemic was to think carefully about
privacy concerns and keep data from contact tracing separate from other parts
of the health system:
“ People generally don’t trust the government, or are not comfortable with tracing
functionality … when we talked to people, understood what’s worrying people in the
community… this [lack of trust] was a big lesson. So I think it [tracing function]
needs to be kept separate from apps that are used in peacetime, but be kept ready.”
Impact of mandatory QR codes on uptake of the app

Use of the NZ COVID Tracer app rose considerably in August and September 2020
following the re-emergence of community transmission and the Government’s
decision to make the display of official QR code posters mandatory.71 After this
decision, the number of users grew from about 600,000 to 2.2 million, while the
number of posters displayed rose from 87,000 to 381,000 by late September 2020.
A later review of the NZ COVID Tracer app’s effectiveness suggested around 45
percent of the population used it to scan their locations (considered a high rate
of uptake for a tool of this nature).72
Effectiveness of the app at identifying contacts of cases

Unfortunately, the app wasn’t as effective as hoped as a public health tool. The
same review that found uptake to be ‘high’ at 45 percent also found that the QR
function of the app was not effective in detecting close contacts of cases (though
it was good at identifying casual contacts). The authors concluded that the app
‘likely made a negligible impact on the COVID-19 response in relation to isolating
or testing potential contacts of cases’.73
Challenges with enforcement

Evidence suggests it was challenging to ensure that members of the public
participated in record-keeping activities (such as QR scanning) without placing
impossible or unworkable requirements on business owners or enforcement
agencies. An internal report indicates the New Zealand Police saw their role
as one of supporting businesses to implement record-keeping rather than
attempting to enforce compliance.
8.3.3 Mask requirements
8.3.3.1
Mask requirements provided actual and perceived protection
from COVID-19
The evidence that mask wearing decreases the rate of transmission of COVID-19 (and
other airborne respiratory viruses) is substantial (see Chapter 5).74 However, for masks
to have a significant impact on community transmission, they need to be both worn
correctly, and used by most people. Making masks compulsory in a wide range of
public and high-risk settings at different stages of the pandemic was an effective – if
blunt – tool to encourage their use at the scale required.
Many of our public submitters supported the use of masks as a protective measure.
We heard that they made people feel safe, by providing a perceived added layer of
protection for themselves, their family, or for others who were immunocompromised.
Some told us that they have continued to use masks, and expressed a view that they
should be used more as a tool for general health management.
“ The lockdowns, mask usage and vaccine passes made me and my family feel as safe as we
could do under the circumstances, especially with immune compromised family members.”
“ That masking does work and should be practised when sick regardless of pandemics and
encouraged. This should be normalised so it isn’t pushed against so hard.”
Some submitters who were immunocompromised or had other medical vulnerabilities

described feeling ‘relieved’ that mask measures were enforced to help them feel safe.
“ As someone with chronic medical conditions, I was grateful for the mask and vaccine mandates
as the pandemic progressed, as this meant I felt more safe as I carried out my daily living.”
Some submitters expressed the view that mask mandates should have been
introduced earlier.
“ My only concern, being a nurse was how long it took the MOH to realize that masks should
be mandated. In the beginning they even said they weren’t required.”
8.3.3.2
But mask mandates were challenging for some
Mask requirements were also criticised by a substantial number of submitters, many
of whom questioned the rationale for mask mandates. These submitters tended
to cite the changing evidence about mask use over the course of the pandemic as
proof that masks ‘did not work’ against COVID-19 and found the evolving guidance
about mask use confusing.
Particular frustrations were expressed about the perceived illogic of mask
requirements in enclosed spaces such as cafes, restaurants, on flights and in cars.
“ The idiocy of having to wear a mask into a cafe and then take it off when you sat to eat
was nonsensical.”
“ Why did we have to wear masks on a plane but then it was ok to take them off to eat.
Did the COVID hide in the toilet while we were eating?”
Some submitters shared negative personal experiences of wearing masks, and
expressed concerns that masks caused social harms, including fear, isolation,
impeding socialising and making it difficult to read facial expressions.
“ This has caused damage to those wearing them.”
“ The mask mandates making you feel trapped and silenced, a useless piece of cloth covering
your mouth to keep you quiet, to stop you speaking out, giving people anxiety and [making
them] feel like they couldn’t reach out at the risk of being disowned by family and friends.”
The compulsory use of masks may have created difficulty for some disabled people,
including deaf and hard of hearing people, who rely on lip reading to communicate.
A 2021 report on the impact of the COVID-19 response on disabled people’s rights
outlined the negative experiences of some disabled people who rely on lip-reading
to communicate. Some reported that health workers refused to remove their masks,
even at a distance, and refused to try alternative ways of communicating (such as
writing) to convey important information.75
We also heard that mask requirements were difficult to carry out in practice in
some settings, particularly in schools. While some public submitters expressed
distress about children having to be masked at school, we heard in direct
engagements that obtaining sufficient masks to uphold these requirements was
also difficult. An education union told us that it took ‘far too long for masks to
arrive, and when they did, they were no longer needed’.
Issues with exemptions

Mask exemptions caused ongoing issues for some members of the disability
community. We heard in direct engagements that the process for issuing mask
exemptions was poorly managed, and that some of the disability organisations
contracted to issue mask exemption certificates had minimal notice about
taking on this function and were overwhelmed with requests.
We also heard that many businesses did not trust the integrity of mask exemption
certificates, and that the purpose and criteria for these were not well-communicated
to the general public. This led to some disabled people who could not wear masks
feeling subjected to discrimination and abuse.
“ We had calls from people who were being arrested for trespass in their local supermarket
because the police were refusing to acknowledge the exemption tool that had been provided
by the Ministry of Health. The situation was denying disabled people access to essential
services and food, and our reputation was negatively impacted.”
Some retail workers and members of the public found it difficult to distinguish
between people who were legitimately exempt from mask requirements, and
people who refused to wear a mask for other reasons, including as a point of
protest. In attempting to verify whether people were genuinely exempt, some
workers, especially in retail settings such as supermarkets, experienced
escalating and unsafe behaviour from some customers.
What happened: Vaccination
8.4 requirements | I aha: Ngā
whakaritenga rongoā āraimate
Many countries began to introduce vaccine requirements for certain workforces as

part of their COVID-19 responses during 2021. For example, the Italian government
made it mandatory for healthcare workers to be vaccinated from April 2021, while
Australia introduced a vaccine mandate for residential aged care workers in
September 2021.
In Aotearoa New Zealand, the term ‘vaccine mandate’ was mostly used to describe
this same type of occupational mandate, specifically government orders that
required people working in certain professions (such as education and healthcare
workers) to be vaccinated against COVID-19 if they wanted to continue working
in those roles.76 Several Government-issued occupational vaccine mandates were
introduced in New Zealand between May and November 2021, using order-making
powers under the COVID-19 Public Health Response Act 2020.
As well as mandating COVID-19 vaccination for certain occupations, the Government
also introduced a Vaccination Assessment Tool to assist employers with the health
and safety assessments required to introduce their own workplace vaccination
policies. While not set by central government, these policies operated as de facto
vaccine ‘mandates’ within certain workplaces or sectors. Finally, in December
2021, Aotearoa New Zealand introduced a series of more stringent restrictions
for people who were not vaccinated against COVID-19. These included additional
masking and physical distancing requirements, and stricter limits for gatherings with
unvaccinated people.77 Such restrictions were able to be implemented and enforced
by the introduction of government-issued COVID-19 vaccination certificates,
commonly referred to as ‘vaccine passes’.78 These were in place from late 2021
until April 2022.
The term ‘vaccine mandate’ was commonly used to describe workplace-specific
vaccination policies and vaccine pass requirements, as well as the Government-
issued occupational mandates. For ease of reference, when we use the term
‘vaccine mandates’ in this section, we are referring mainly to Government-issued
occupational mandates (and we try to make this clear in the text of this report).
We refer separately to ‘workplace-specific policies’ and ‘vaccine passes’, and when
a catch-all term is helpful, we use ‘vaccine requirements’.
Many countries introduced

vaccine mandates for certain
workforces as part of their
COVID-19 response.
8.4.1 The case for requiring vaccination
Much of the rest of this section documents what vaccine requirements were
introduced, and when, as part of the COVID-19 response. It is also important
to understand why such requirements were considered necessary, if we are to
draw lessons for future pandemics. We begin, therefore, by setting out what
we understand to have been the overarching rationale for introducing various
vaccine requirements, based on the evidence available to our Inquiry.
Decisions about vaccine requirements involved complex trade-offs. Decision-
makers were aware of the need to protect vulnerable population groups from the
virus, but were also under pressure in late 2021 to reduce reliance on stringent
public health measures after the long regional lockdown in Auckland. They
needed to balance the public health benefits of higher vaccination coverage, the
social and economic imperative to return to something like ‘normal’ life, and
the importance of upholding people’s individual rights and medical autonomy.
Cabinet decisions to issue occupational vaccination mandates, simplify the
process for employers to set workplace-specific vaccine policies, and require
vaccine passes for certain locations and gatherings were all attempts to strike
an acceptable balance between these arguably competing imperatives.
8.4.1.1
Reducing COVID-19 transmission
Until November 2021, the rationale for making vaccination compulsory in a
range of settings was usually described in terms of its potential to reduce
transmission of COVID-19. This is a very significant benefit, as it means
vaccination can reduce the size of outbreaks and the speed at which they
spread, as well as protecting vulnerable people from infection. This rationale
was evident in early advice to Cabinet from February 2021, which discussed
the need to balance the anticipated benefits of requiring vaccination in certain
settings against the constraint this would place on individual freedoms and
human rights. The expectation that vaccinating one person would provide
protection for other people (including vulnerable individuals) was an important
consideration when imposing constraints on individuals that would not have
been considered justifiable under ‘normal’ circumstances.
Decision-makers had to balance the

benefits of vaccine mandates (such
as preventing spread of infection
and protecting vulnerable people)
against the limitation these placed
on people’s individual freedoms.
8.4.1.2
The New Zealand Bill of Rights Act and the right to refuse
medical treatment
In weighing up the public and personal health benefits of making vaccination
compulsory in certain settings, ministers needed to consider whether any of the
rights and freedoms affirmed by the New Zealand Bill of Rights Act 1990 would be
engaged. One potentially applicable provision is ‘the right to refuse to undergo any
medical treatment’.79 Another potentially applicable provision is the right to freedom
from discrimination ‘on the grounds of discrimination in the Human Rights Act 1993.’
Importantly, however, the New Zealand Bill of Rights Act also recognises that the
rights and freedoms it affirms may be subject ‘to such reasonable limits […] as can
be demonstrably justified in a free and democratic society.’80 Ministers therefore
needed to consider whether any interference with fundamental rights and
freedoms was ‘demonstrably justified’ despite the elementary principles of
freedom and democracy under which we normally live in Aotearoa New Zealand.
The risk of legal challenge

Decisions and actions of Government that are in breach of the New Zealand Bill of
Rights Act can be subject to judicial review. Cabinet’s decisions about the use of order-
making powers under the COVID-19 Public Health Response Act 2020, to introduce
vaccine mandates, would have taken Bill of Rights Act compliance into consideration.
The Minister would need to be satisfied that the introduction of vaccine mandates
represented a justified limit on individual rights and freedoms.
Justification for infringement

Cabinet received detailed advice on the conditions that would need to be met for
vaccine mandates to be justified under the New Zealand Bill of Rights Act. This
advice recognised vaccination as a medical treatment and set out the basis on which
the Government could be ‘demonstrably justified’ in requiring people to undergo
vaccination in order to work in certain roles. The original wording of the COVID-19
Public Health Response Act 2020 linked the use of such orders with preventing the
spread of COVID-19.
From the evidence we have reviewed, it seems clear that – for the introduction of
most vaccine requirements – the basis on which ministers were satisfied that they
were justified in limiting people’s right to refuse medical treatment was that these
requirements would substantially reduce community transmission. This is evident
from one briefing we have seen – concerning the extension of vaccination mandates
to cover booster doses on 22 December 2021 – in which health officials gave the
following advice:
“ Vaccination plainly constitutes medical treatment and therefore engages the right of every
person to refuse it if they choose. Compulsory vaccination of whatever sort, and by whatever
means will be inconsistent with that right unless it can be demonstrably justified. The state
has a legitimate interest in impeding community transmission of the virus. If the Minister of
COVID-19 Response is satisfied on the basis of credible evidence that compulsory vaccination
of affected workers will have that effect or make a substantial contribution to it that cannot
be otherwise achieved, it will be justified.”
8.4.1.3
The importance of emerging evidence
Early advice to ministers on the use of vaccine requirements acknowledged that
scientific evidence about the effectiveness of COVID-19 vaccination would continue
to evolve. Officials advised ministers that they would need to monitor evidence on
the effectiveness of vaccines at preventing COVID-19 transmission when considering
the ongoing appropriateness of requiring vaccination in certain settings:
“ The Ministry of Health will continue to monitor emerging evidence on the effectiveness of
COVID-19 vaccines at preventing transmission to ensure that any options appropriately
respond to the most recent scientific evidence. Up to date scientific evidence will provide
a good foundation for any changes in approach to the public.”
The implication was that policies might change in response to ‘emerging evidence’,
and that health officials would proactively update advice on the use of vaccination
mandates and requirements in response to such evidence.
8.4.1.4
Te Tiriti | Treaty of Waitangi and equity considerations
The same early advice noted that mandatory vaccination might undermine the
Crown’s obligations in relation to te Tiriti, with respect to both self-determination
and equity of treatment, noting:
“ if a decision to mandate vaccination was not made in partnership with Māori this would
mean that Māori would not be supported to self-determine whether to undergo this medical
treatment, which is likely contrary to the Te Tiriti principle of Tino rangatiratanga (which in
a health context, provides for Māori self-determination and mana motuhake in the design,
delivery and monitoring of health services).”
The advice also noted that Māori (and Pacific peoples) would be ‘more likely to be
adversely impacted by compliance measures, such as redeployment and dismissal’
given their greater likelihood of not receiving a COVID-19 vaccine – reflecting higher
rates of underlying health conditions (which might preclude vaccination) and their
historically lower vaccination coverage.
Later, the potential for disproportionate impacts on Māori was specifically
acknowledged in advice on use of vaccine pass requirements (where people
were required to show evidence of vaccination to access certain venues and
events). A Ministerial briefing described Māori as having ‘higher levels of structural
disadvantage’, noting:
“ … there are ongoing and increased concerns and anxieties among some Māori and other
population groups around surveillance and low trust in government agencies… This is why
transparent and outward facing engagement is likely to be critical to successful adoption
of [vaccine passes].” 81
8.4.2 Occupational vaccine mandates
8.4.2.1
Early mandates for specific workers
Border workers were the first group for whom vaccination was made a requirement
of their employment. These workers had been prioritised for vaccination since
February 2021 due to their role on the ‘front line’. At that time, officials presented
Cabinet with a range of options for encouraging border workers to get vaccinated,
ranging from paid time off to attend vaccination to directly issuing vaccine
mandates.82 At that early stage, encouragement was preferred over compulsion,
but Cabinet requested further advice on legislative or regulatory levers that might
be needed if a mandatory approach was favoured in future.
Even at that early stage, it is clear that officials and ministers were aware of the
potential for mandatory vaccination to have unintended impacts, including a
potential loss of trust among some members of the public:
“ Mandating vaccination for particular workforces will likely have flow on impacts on
the perception of the COVID-19 Immunisation Programme and may have unintended
consequences, such as reducing trust in the Programme among some groups…”
“ The precedent impacts of a decision to make vaccination mandatory for specific workforces
is most likely to have an impact on the health workforces and other frontline public sector
workforces in the future.”
Section 11 of the COVID-19 Public Health Response Act 2020 contained a broad
power allowing the relevant minister to issue orders that could ‘require persons
to take any specified actions, or comply with any specified measures, that
contribute or are likely to contribute to preventing the risk of the outbreak or
spread of COVID-19’.83 This was the mechanism by which the Government issued
occupational vaccine mandates.
The COVID-19 Public Health Response (Vaccinations) Order 2021 came into force in
May 2021, stipulating that specified high-risk roles should be undertaken only by
vaccinated individuals.84 From May 2021, it applied to a small group of border workers;
from July, it was extended to most maritime and aviation workers.85 The order also
applied to Police and Defence staff working in border or quarantine settings.
According to the Ministry of Health, the rationale for these early mandates was to
reduce the risk of COVID-19 entering Aotearoa New Zealand through the border.
The expectation was that vaccination would reduce the chance of border workers
and their families catching the virus and in turn passing it onto others.86
8.4.2.2
Widening of mandates to health, disability, education and
prison workers
The emergence of the Delta variant precipitated a widening of occupational
vaccine mandates to include health, disability, education and prison workers.
This was intended to reduce the risk of COVID-19 transmission, particularly to
vulnerable groups, as reflected in a 2022 letter from the Strategic COVID-19
Public Health Advisory Group to the Associate Minister of Health:
“ The main purpose of these mandates has been to reduce the risk of workers becoming
infected and transmitting the virus to groups of people who may be either unable to be
vaccinated themselves (e.g. young children), particularly vulnerable to infection (e.g. sick
patients or residents in aged care), or at risk of large outbreaks (e.g. inmates in prisons)’.” 87
By August 2021, most health workers had already been vaccinated, but some had
not. The emergence of the Delta variant, which began to circulate in Auckland
that month, refocused attention on the potential for the healthcare system to be
overwhelmed. Health workers were at greater risk of being infected and of passing
COVID-19 on to patients. There were also potential system capacity implications if
health workers had to isolate in large numbers. The Minister of Health directed the
Ministry to start working on extending the vaccination order to certain groups of
health workers.
In October 2021, Cabinet duly agreed to extend the vaccination order to workers
in the health and disability sector. (The order also applied to Police and emergency
services staff working as or alongside health staff.) Cabinet also agreed to apply the
order to aged care workers, prison staff, and teachers and other education workers.88
The Ministry of Business, Innovation and Employment estimated that Government-
issued vaccine mandates for workers in border, health, education and correctional
settings would cover roughly 15 percent of the country’s total workforce.89
Again, the rationale for extending the order to these other sectors appears to have
been to prevent the spread of infection. A Cabinet briefing from the time emphasises
the importance of vaccination in the prevention of COVID-19 transmission –
particularly in ‘high-risk settings’ such as prisons:
“ Mandating vaccination for work that takes place in prisons is an important step to protect the
health of workers and people in prison. People in prison are some of the most vulnerable
to COVID-19, due to the ease of transmission that COVID-19 can have in prisons, and the
existing health vulnerabilities of the prison population.” 90
We have not seen direct evidence on the specific rationale for applying vaccination
orders to teachers and other education workers. However, a subsequent High Court
ruling (in response to a legal challenge to the mandates) described the purpose
of these mandates as preventing schools from becoming a source of community
transmission that might pose a risk to vulnerable people (including parents and
grandparents of students).91 We also heard from education stakeholders we engaged
with directly that schools wanted stronger guidance from government on whether
staff should be required to be vaccinated, and how to keep teachers employed.
Affected workers who were likely to have contact with children were required to
have their first vaccine by 15 November 2021 and be fully vaccinated (i.e. two doses)
by 1 January 2022. Subsequent decisions and orders in late 2021 and early 2022
extended the requirement for MIQ, border and health workforces to include booster
doses within six months of their second primary dose.
It was possible for workers to obtain a medical exemption from the vaccine
requirement, but access to these was highly restricted. Those who were eligible
included people already infected with COVID-19, people who had had a serious
adverse reaction requiring hospitalisation (such as anaphylaxis and myocarditis)
to a previous dose, and people with pre-existing heart conditions or who had
experienced inflammatory cardiac illness in the previous six months. Otherwise,
it was expected that most people could be safely vaccinated, although some might
require extra precautions.92
While exemption certificates could initially be issued by any registered medical
practitioner, there were concerns that exemptions were being granted in situations
where they were not warranted on clinical grounds. From November 2021,
such exemptions were issued centrally under the authority of the Director-General
of Health.93
The decision to apply vaccine mandates to health and education workers occurred
at a difficult period in the pandemic response when there was ‘confusion [… over
the] ambiguity of what New Zealand’s overall COVID-19 strategy is’.94 Ministers
were aware of ‘mixed reactions’ to the mandate announcement, with some
people reassured by their introduction – and the prospect of further vaccination
requirements – while others saw their introduction as a breach of trust:
“ Some people expressed happiness and a desire for the mandate to be expanded
to other sectors, with others perceiving the decision as a backtrack on Government’s
word not to mandate vaccinations in New Zealand. At the same time, others are
discussing vaccination [passes], with some noting that they booked their vaccination
in anticipation of their introduction.” 95
8.4.2.3
Broadening the potential basis for future mandates
As set out in section 8.4.2.1, the original wording of the COVID-19 Public Health
Response Act 2020 allowed ministers to make orders requiring people to comply
with specific measures, if these would contribute (or be likely to contribute) to
preventing the spread of COVID-19. That is, premised on vaccines reducing the
risk of between-person transmission, and not premised on vaccines protecting
against serious illness. This was the basis on which the earlier Government-issued
occupational mandates were set.
In October 2021, Cabinet agreed to amend the COVID-19 Public Health Response
Act 2020 to expand the basis on which workers could be required to undergo
vaccination.96 The changes allowed Government to introduce vaccine mandates (via
Section 11AA and Section 11AB orders) on ‘public interest’ grounds. Public interest
was defined as ‘ensuring continuity of services that are essential for public safety […]
supporting the continued provision of lifeline utilities and other essential services:
maintaining trust in public services: [and] maintaining access to overseas markets’.97
These changes came into force on 25 November 2021,98 having been passed under
urgency and without referral to a Select Committee.
Cabinet papers recommending these changes noted that several government
agencies wanted to ensure ‘key public services and essential services should only
be delivered by vaccinated workers’ and made the case that mandatory vaccination
would help ensure continuity of essential services, critical national infrastructure,
and access to overseas markets.99 The changes were recommended to:
“ enable Government to mandate vaccination for these categories of work in future,

particularly if public interest arguments are stronger than public health reasons
for requiring vaccination.” 100
This shift in the grounds for requiring vaccination is subtle but important. It meant
that the Government could require vaccination on the grounds that it would help
prevent workers in essential services from becoming sick (whereas before they
could only require vaccination on the grounds that it would help limit transmission
of COVID-19). This might be helpful if it substantially increased vaccination rates
among essential workers, notably reducing the number of staff sick and off work
due to sickness from the pandemic pathogen and compromising the delivery of key
public and essential services.
Government powers to issue orders on public interest grounds were eventually
repealed on 26 November 2022.101
8.4.2.4
Inclusion of paid and volunteer firefighters
According to the Ministry of Health, Fire and Emergency New Zealand considered
their frontline to be covered by the vaccine mandates for health workers since they
were frequently in direct contact with patients and other health staff (as firefighters
are often involved as first responders in emergency situations).102
This took some time to confirm, meaning there was a delay between vaccine
mandates for health workers being announced, and firefighters (both paid staff and
volunteers) being informed that it applied to them. The Vaccination Order therefore
was amended on 12 November 2021 to extend the dates which by which firefighting
personnel had to comply. Firefighters were required to have their second vaccination
by 14 January 2022 in order to continue in their roles.103
8.4.2.5
New mandates for Police and Defence Force staff
As noted previously, many Defence Force staff were covered by mandates requiring
vaccination of staff working in border settings; while many Police were covered by
mandates for staff in border, health and education settings. Occupational mandates
covering remaining Police and Defence Force staff were issued on 16 December
2021.104 A month before, Cabinet had agreed to apply vaccine mandates to these
roles in line with the expanded ‘public interest’ grounds introduced via changes
to the COVID-19 Public Health Response Act 2020.105 The case was made that
mandatory vaccination would ensure continuity of the ‘essential services’ provided
by these workforces in relation to public safety, national defence and crisis response.
8.4.2.6
Removal of occupational vaccine mandates
Most government-ordered COVID-19 vaccination mandates were in place for
between six and 12 months in 2021 and 2022.viii Ministers requested periodic
reviews of the advisability of continuing vaccine mandates during this time, and
officials and expert groups provided advice in response to these requests.106
In March 2022, the Strategic COVID-19 Public Health Advisory Group told the
Associate Minister of Health that the case for retaining occupational vaccine
mandates was now:
“ more finely balanced, because of our relatively high vaccination coverage and increasing
natural immunity, as well as the apparent lowering of vaccine effectiveness against
transmission of the Omicron variant.” 107
The Government-issued vaccine mandates for workers in education, Police and the
Defence Force were accordingly revoked in April 2022. However, other occupational
mandates remained in place beyond this time. Advice to Cabinet suggests there was
a particular desire to maintain vaccine mandates for workers who were in contact
with vulnerable people (including people in healthcare settings, aged care residents
and those in prison facilities), and for border workers who were at risk of exposure
to new COVID-19 variants.108
The remaining occupational vaccine mandates were removed progressively
from July (border workers, workers in prisons, and Fire and Emergency staff) to
September 2022 (workers in health, disability and aged care settings) in accordance
with advice from officials.109
We return to how the Omicron variant changed the case for vaccine requirements
in Aotearoa New Zealand in section 8.4.5.
viii Though the mandates for Police and Defence were in place for less than four months.
8.4.3 Workplace-specific vaccination requirements
8.4.3.1
Expectations around workplace vaccination policies
Once vaccines were readily available in Aotearoa New Zealand, some businesses
and unions sought clarity over the circumstances in which workplaces could – or
should – require staff to be vaccinated.110 In April 2021, the Institute of Directors
published an article by MinterEllisonRuddWatts which showed the situation was
complicated. From an employment law perspective:
“ Whether an employer could lawfully compel an existing employee to be vaccinated (or

redeploy them or take disciplinary action if they refuse) does not have a clear-cut answer.” 111
The advice noted that in most situations, it would not be permissible to introduce
a workplace vaccination requirement under existing legislation (‘because it would
amount to the employer unlawfully imposing a new employment condition without
the employee’s agreement’). However, the Health and Safety at Work Act 2015
created an obligation for an employer or business ‘to ensure as far as reasonably
practicable the health and safety of its workers’. In the context of COVID-19, the
article advised that this obligation required employers or business owners to
carry out ‘a careful risk assessment and [ensure that] reasonable safeguards are
in place to reduce the risk of exposure to COVID-19’. In certain circumstances, as
a result of this assessment, the employer could require that a specific role had
to be undertaken by a vaccinated person.112
8.4.3.2
Enabling workplace COVID-19 vaccination policies
The issue of workplace vaccination requirements became more salient in late
2021 as the country began transitioning away from the elimination strategy and it
became inevitable that COVID-19 would start to circulate in the general population.
This was quite a challenging idea for many people, having just spent almost two
years successfully keeping COVID-19 out of the country. Against this backdrop, many
employers, workers and members of the public were concerned about potential
exposure to COVID-19 in the workplace and in wider social life.
Workplace-specific vaccine requirements offered one option for employers to
assuage some of these fears. Employers already had the ability under employment
law to terminate an employee’s employment (following a procedurally fair process)
where that employee failed to comply with a vaccination requirement.113 But many
employers were concerned that they might be exposed to legal challenge if they
attempted to require staff to be vaccinated under existing regulations.114 The
workplace health and safety regulator, WorkSafe, told us there were ‘high levels’
of community expectation in late 2021 and early 2022 that employers would set
workplace-specific vaccination requirements and that WorkSafe – with the Health
and Safety at Work Act 2015 as a ‘backstop’ – would enforce them.
In October 2021, the Minister responsible for the Ministry of Business, Innovation
and Employment proposed changes to existing legislation to support the
introduction of broader vaccination requirements in the workplace.115 Advice
to Cabinet emphasised the need to ‘provide a much greater degree of certainty
and support to employers’ who were struggling to determine whether they had
grounds to introduce vaccine requirements for their staff, and cited ‘widespread
and persistent calls from employers, sector groups and unions for greater clarity’ on
workplace vaccination requirements.116
In response to these concerns, the Government introduced a regulatory framework
(aligned with the Health and Safety at Work Act 2015) that simplified the process
for employers and business owners to assess the risk of COVID-19 in the workplace
and require workers to be vaccinated to continue working there.117 The Act also
amended the Employment Relations Act 2000 to provide those employees who were
terminated in these circumstances with a minimum of four weeks’ paid notice.118
In line with the Minister’s proposal, WorkSafe was empowered and funded to both
support businesses with these activities, and enforce any resulting requirements.
The changes were supported by the Council of Trade Unions and Business NZ.119
The new regulatory framework was introduced in late November via the COVID-19
Response (Vaccinations) Legislation Act 2021, which also amended the COVID-19
Public Health Response Act 2020 to broaden the range of reasons for which the
Government could issue occupational vaccine mandates (see section 8.4.2.3).120
The new Vaccination Assessment Tool was introduced on 15 December 2021.121
This significantly simplified the process by which employers could introduce a
requirement for workers to be vaccinated in line with the Health and Safety
at Work Act 2015.
The Vaccination Assessment

Tool simplified the process for
employers to require workers
to be vaccinated.
8.4.3.3
Demand for and uptake of work-related vaccination requirements
The new regulatory arrangements achieved what was perhaps their main purpose:
making it easier to ensure that workers in settings where members of the public
were required to show a pass for entry would also be vaccinated themselves.122
The Ministry of Business, Innovation and Employment estimated that this would
represent around 25 percent of the country’s workforce.123
The regulatory changes simplified the health and safety risk assessment that
employers were required to undertake to make vaccination a requirement for their
staff. We do not have information on how many employers set such policies for their
workers. But based on accounts from the businesses and employers we engaged
with directly, and evidence that there was strong demand for such policies, it appears
some business and other organisations did take up the option to set such policies.
Many public sector agencies placed a strong emphasis on vaccination. In November
2021 the Public Service Commission issued guidance to agencies (including Crown
entities and a variety of other Crown organisations) noting ‘an expectation that
all employees in the public service should be vaccinated’. Agencies with ‘at-risk
workforces’ were encouraged to ‘consider introducing a requirement for new
employees to be vaccinated into employment agreements’.124 While many agencies
followed suit, others resisted or sought to delay finalising requirements.
8.4.3.4
Removal of workplace-specific vaccine requirements
In April 2022, WorkSafe issued updated guidance for employers regarding risk
assessments in relation to COVID-19 transmission in their workplaces.125 This
guidance noted that setting vaccination requirements might be justified for health
and safety purposes but that such requirements ‘should be used carefully and are
not a suitable first response for managing COVID-19 in most workplaces’. WorkSafe’s
senior leaders told us that the organisation now sees vaccination primarily as a
public health issue rather than a workplace safety issue.
Regulations allowing employers to introduce workplace vaccination policies based
on the Vaccination Assessment Tool were revoked in May 2022.126 Advice to the
Cabinet Legislation Committee noted that ‘the risks of contracting and transmitting
COVID-19 have materially shifted… [and] the factors in the [Vaccination Assessment]
Tool are no longer an appropriate reflection of the current public health advice’.127
Public health advice was cited as stating that ‘vaccination requirements may
continue to be appropriate in some circumstances’ but that such requirements
should be ‘specific to roles and the organisation’s circumstances’.128 The paper
noted that employers could continue to require staff to be vaccinated but would
‘now need to undertake a full work health and safety risk assessment to determine
whether this is an appropriate COVID-19 control for their circumstances’.129 In other
words, the expedited process offered via the Vaccination Assessment Tool was no
longer in place.
8.4.4 Vaccine passes
The population-wide vaccination rollout was well underway by the time
Government-issued occupational vaccine mandates were being developed and
announced. Once vaccination had been offered to everyone aged 65 and over, it
was made available to the wider population (in descending age cohorts) from
August and September 2021. Various initiatives were undertaken to encourage
uptake, such as a ‘National Day of Action’ (including several mass vaccination events
and a ‘Vaxathon’ broadcast) on 16 October 2021 (see Chapter 6 for more on the
vaccine rollout).
8.4.4.1
Initial policy work on vaccine passes
By August 2021, a growing number of countries were investigating or implementing
COVID-19 vaccination certificates (also known as vaccine passes) to support
international travel, restrict access in domestic settings, or both. Around this time,
Ministry of Health officials started work on a digital certificate for people vaccinated
in Aotearoa New Zealand, primarily to support international travel. Relevant
ministers were kept informed.
In September 2021, policy work on COVID-19 vaccination certificates was extended
to include the possible domestic use of certificates to make vaccination a condition
of entry for certain settings.130 Advice from the Ministry of Health and Department of
the Prime Minister and Cabinet appeared to focus on their potential role in reducing
the risk of COVID-19 transmission, but other benefits were also suggested.131 While
vaccination rates were not yet optimal, the rationale given for vaccine passes was that:
“ requiring proof of vaccination using a certificate for large high-risk events would support
the public health response to COVID-19 by reducing the risk of super spreader events and
potentially encouraging those not yet vaccinated to get vaccinated.” 132
Officials recommended the ‘targeted application of vaccine certificates to high-risk

events and venues’ as providing the ‘best balance of risk mitigation, public acceptability,
and feasibility to implement’.133 It was proposed that vaccine certificates should be
required at ‘large high-risk events’ such as music festivals and concerts.134 Officials also
recommended prohibiting the use of vaccination certificates for other types of venues
– including essential businesses and life-preserving services, schools and community
facilities – so as to ensure unvaccinated people could retain access to essential services.135
Ministers were aware of the risk to social licence and cohesion

from the use of vaccine passes
In developing advice for senior ministers, the Department of the Prime Minister
and Cabinet had undertaken consultation with a range of other agencies.136 In
response, several government agencies raised concern about the potential risks
associated with domestic use of vaccine certificates (or ‘passes’). Some agencies
noted the potential for such a system to cause unintended harms – including further
marginalisation of some groups, adverse impacts on vaccine uptake, and erosion
of social cohesion.
On 16 September 2021, in feedback on the inter-agency consultation, Treasury
officials questioned the rationale for introducing a vaccine pass system if vaccine
coverage was already high, noting that – in this case – the public health benefits
would be smaller and likely outweighed by the costs.137
Advice to senior ministers emphasised several of these concerns – including
potential impacts on equity, social licence and cohesion, and the risk that vaccine
pass requirements were inconsistent with the Crown’s obligations to uphold self-
determination, partnership and equity for Māori.138 The paper noted that targeting
vaccination pass requirements at high risk events could ‘provide sufficient public
health benefits while balancing human rights, equity, social licence and cohesion
and operational considerations’.139 In September 2021, ministers were advised that:
“ …the introduction of [vaccine certificates] will have an impact on social cohesion that will
need mitigation... There is also a risk that restrictions on where unvaccinated people may go
could negatively impact the trust that has been built around the COVID19 vaccination rollout
and to address vaccine hesitancy that is linked to a wider mistrust of the health system.” 140
An appendix to this paper noted that the introduction of vaccine pass systems
in other countries (including Canada, France and Finland) had been associated
with public protests, although they were also credited with helping to increase
vaccination rates in France.141
Subsequent work focused on the use of vaccine pass requirements in ‘high-risk’
settings – where people would be in close proximity to one another – on the basis
that this provided an appropriate balance between public health benefit and
risks around equity, social division and compliance.142 Officials identified the need
to continue weighing the potential benefits of vaccine requirements against the
potential damage they could cause to social licence, noting that:
“ The more that vaccination is seen as mandatory, for example by requiring [vaccine passes]
for access to a wide range of venues (even if considered high risk by public health officials)
the greater the risk of loss of social license for vaccination overall.” 143
These issues were much less prominent in the initial advice that went to Cabinet
on vaccine passes.144 This advice considered the vaccine pass system as part of
the new COVID-19 Protection Framework and envisaged their use in fairly limited
settings (such as gatherings of 500 or more people at the lowest setting, entry to
cafes and restaurants at the highest setting). Cabinet was advised that vaccine pass
requirements ‘could exacerbate existing inequities in the coverage of vaccination
among different groups’ – particularly Māori and Pacific peoples.
At the point Cabinet was asked to approve their implementation (in late October 2021),
the proposed use of vaccine pass requirements had been expanded to a much broader
range of settings (gatherings of 100 people or more at the lowest settings, and entry to
cafes and restaurants at any other setting).145 Cabinet was advised that the introduction
of these requirements was ‘likely’ to have an impact on social cohesion since:
“ … those without [vaccine passes] will potentially be excluded from a much wider range of
social settings. This risks isolating the unvaccinated and increases the likelihood that we will
see large-scale protests similar to those experienced in other countries that have introduced
vaccine requirements.”
“ There is also a risk that restrictions on where unvaccinated people may go could negatively
impact the trust that has been built around the COVID-19 vaccination rollout and to address
vaccine hesitancy that is linked to a wider mistrust of the health system. Targeted funding,
programmes, communication and education could be important in mitigating this risk…” 146
The paper also acknowledged that vaccine pass requirements could exacerbate lower
vaccination levels for Māori, noting the risk that they ‘could negatively impact the trust
that has been built for the COVID-19 vaccination rollout and could enhance vaccine
hesitancy’.147 It noted that a communication strategy could help reduce this risk.
Note that the above advice to Cabinet preceded any knowledge of Omicron, and
in particular preceded the realisation in late 2021 and early 2022 that vaccines
offered poor protection against getting infected by Omicron; the policy was made
with Delta in mind.
8.4.4.2
Vaccine pass requirements under the ‘traffic light’ system
Domestic use of vaccine passes was introduced as part of the new COVID-19
Protection Framework. This followed the Prime Minister’s announcement on 4
October 2021 that the country would move out of the elimination strategy. The
Delta outbreak was in full swing, Auckland’s lockdown had not been successful at
eliminating community transmission, and officials were working at speed to devise
new settings that could allow Aucklanders to come out of lockdown while continuing
to protect public health as much as possible.
In this context, the Government decided to move ahead with the domestic use
of vaccine passes. People would be required to have proof-of-vaccination when
entering settings in which they would be in close proximity to others and where
face coverings and social distancing might be impractical or difficult to enforce.148
The specific rationale for this requirement (as outlined by officials) was ‘to reduce
the risk of super-spreader events, at least until vaccination rates are well over
90 percent across all (eligible) age and ethnic groups)’.149 That is, the rationale was
based on the vaccine’s ability to reduce transmission – which it did reasonably
well for Delta. In a briefing to Cabinet on the introduction of this requirement,
the Minister for COVID-19 Response described it as:
“ a tool to help support the broader public health response to COVID-19… and an additional
measure to ensure people in certain settings can demonstrate that they are either fully
vaccinated, or medically exempt from vaccination.” 150
Vaccine passes were introduced as part of the new COVID-19 Protection Framework
(or ‘traffic light’ system) on 3 December 2021.151 In this context, vaccine pass
requirements were seen as part of a suite of public health measures that would
help contain COVID-19 transmission without resorting to lockdowns.152 This might
have been a plausible expectation pre-Omicron: in early December, the world was
only just becoming aware of Omicron (the first global cases were reported in South
Africa on 24 November 2021)153 and knowledge about its notable escape from
vaccine protection against infection was nascent at best. Exemptions from vaccine
passes were made only on medical grounds, and to children under 12 years and
3 months of age.
The introduction of vaccine passes as part of the ‘traffic light’ system created what
was effectively a dual system, under which people who did not have a pass were
subject to stricter limitations than those who had one (or an exemption). Specific
restrictions varied by both traffic light level, and vaccination status, as summarised
in Figure 1.154
Figure 1: Restrictions based on traffic light settings

and vaccination status
Traffic light With vaccination Without vaccination pass

setting pass
Green No gathering limits Gathering limits of 100, mandatory face
or mask mandates coverings and physical distancing in close
(except on flights) contact settings
Orange No gathering limits Gathering limits of 50 at private gatherings;

not able to attend close contact businesses,
events or gyms
Red Gathering limits Gathering limits of 25 at private gatherings;

of 100 and physical not able to attend close contact businesses,
distancing in most events or gyms
settings outside
the home
Source: Adapted from Department of the Prime Minister and Cabinet, 2021, COVID-19: Implementing the
COVID-19 Protection Framework [CAB-21-MIN-0497], https://www.dpmc.govt.nz/sites/default/files/2023-01/
COVID-19-Implementing-the-COVID-19-Protection-Framework.pdf
‘My Vaccine Pass’
To support these dual requirements, the Government needed a practical system
by which people could easily identify who had been vaccinated (or had a medical
exemption). Vaccination certificates – formally known as ‘My Vaccine Pass’ or just the
‘vaccine pass’ – were issued by the Ministry of Health in a digital format that people
could download and display on their phones (non-digital options were also available).
My Vaccine Pass was rolled out during the first week of the transition to the traffic
light system. By 9 December 2021, the Ministry of Health had issued more than
four million passes (representing about 90 percent of people who had been double
vaccinated by that point) and just under 100,000 temporary exemptions.
The ‘traffic light’ system remained in place until 12 September 2022, but the vaccine
pass system was retired on 4 April 2022.155
8.4.5 Changing evidence and its impact on the case for

vaccine requirements
As discussed in section 8.4.1 above, the original case for introducing vaccine
mandates was based on their ability to reduce COVID-19 transmission and thus
confer broader protection.
Officials sought to keep updated on the effectiveness of COVID-19 vaccines and to
reflect this information in their advice to decision-makers. International evidence
on vaccine effectiveness was continually evolving, complicated by the emergence
of new variants. Given the evolving nature of this evidence, it is difficult to pinpoint
exactly what information officials were aware of, and when this information was
presented to decision-makers.
By September 2021 officials were aware that vaccine-induced protection against
COVID-19 infection – and thus transmission – declined over time (in other words,
waning immunity). In a September 2021 memo, the COVID-19 Vaccine Technical
Advisory Group noted that the Pfizer vaccine was less effective in preventing
COVID-19 transmission than in protecting people from severe disease or
hospitalisation.156 On 10 November 2021, the group noted that vaccine-induced
protection from infection waned over time, ‘particularly from 6 months after a
primary vaccination course’, referencing studies from the United States, Israel
and Qatar.157 They recommended the introduction of a third ‘booster’ vaccine
dose 6 months following the primary vaccination course.
This evidence was referenced in a 22 December 2021 briefing recommending that
border and healthcare workers receive a third ‘booster’ vaccine dose four months
following their initial vaccine course. Officials noted that:
“ Current evidence… indicates the antibody levels against COVID-19 wane over time following a
second dose of the Pfizer COVID-19 vaccine. There is a reduction in protection against infection
from the Delta variant, particularly from six months after a primary vaccination course.”
The potential for vaccines to reduce COVID-19 transmission was substantially
reduced once Omicron became the dominant variant in Aotearoa New Zealand.
Community transmission of Omicron was first detected in January 2022. By
February, Omicron was sweeping through the population and causing hundreds
and then thousands of new COVID-19 infections every day (as shown in
Chapter 1).
There was growing international evidence that vaccination was less effective
in preventing transmission of Omicron compared with previous variants. In
December 2021, a preprintix version of a United Kingdom study reported that
– following two doses of the Pfizer vaccine – protection against infection from
Omicron fell from 88 percent in the first few weeks to around 35 percent at 15
weeks post vaccination.158 This was around half the level of protection observed
for Delta. The full version of this study (published in the New England Journal
of Medicine in early March 2022) gave even lower figures, with protection from
infection dropping from 66 percent at 2–4 weeks to 8.8 percent at 25 weeks
following vaccination.159
A Cabinet briefing from 22 January 2022 suggested officials were aware
that vaccination offered lower protection against transmission of Omicron
compared with Delta. The briefing summary notes that ‘vaccines show reduced
effectiveness against the Omicron variant compared to Delta. This means that
more vaccinated people are likely to become infected and that the number of
COVID-19 cases occurring each day will be far greater than at any other time
during the pandemic’.160 From this point on, advice to ministers and Cabinet
made frequent reference to vaccination providing reduced protection against
Omicron transmission.161 However, protection was generally characterised as
‘reduced’ rather than minimal or absent. For example, a Cabinet paper from 16
March162 refers to evidence from the
United Kingdom showing that protection
against symptomatic infection was over
The potential for vaccines 50 percent following two doses of the
to reduce COVID-19
Pfizer vaccine and ‘remain[ed] above
transmission was
substantially reduced 50 percent in those that had received a
once Omicron became booster more than 10 weeks prior’.x
the dominant variant.
ix That is, an early version of a research article that is made available online ahead of going through full checks
(including peer-review) and being formally published in an academic journal.
x The Inquiry is not aware of the specific study to which the Cabinet paper refers. The footnote expands on the
evidence as follows: ‘Vaccine effectiveness (VE) against infection with Omicron is around 55 percent or more soon
after two doses of Pfizer, which represents an epidemiologically important reduction in transmission. VE against
infection with Omicron wanes to levels unlikely to reduce transmission within 5–6 months of the second dose. VE
against infection with Omicron is around 55–69 percent after a booster dose of Pfizer. This also represents an
epidemiologically important reduction in transmission’.
Our assessment: Vaccination requirements |
8.5 Tā mātau arotake: Ngā whakaritenga
rongoā āraimate
We start our assessment of vaccination requirements with an overview of the basis

on which the Government introduced them, including the central trade-off between
protecting and looking after the public (by advancing the goals of the pandemic
response) and infringing people’s right to refuse medical treatment.
We set out the Inquiry’s assessment of whether the Government got this balance
right overall and in some specific instances in section 8.5.1. We try to make these
assessments based on knowledge that was available at the time.
In section 8.5.2 we extend our assessment to consider the impact of vaccine
mandates – including evidence on their effectiveness in increasing vaccine coverage
and public health protection, challenges in their implementation, and the wider
social and economic impacts of requiring people to be vaccinated. The Inquiry
acknowledges that the discussion in section 8.5.2 draws on material and evidence
that was not always available to decision-makers at the time. The purpose of this
discussion is to draw out lessons to help inform future pandemic responses where
use of vaccine mandates may be considered.
The purpose of this discussion

is to draw out lessons to help
inform future pandemic responses
where use of vaccine mandates
may be considered.
8.5.1 Assessment of the case for vaccination requirements
Requiring people to be vaccinated in order to work or be present in particular
settings is a significant decision. The Government recognised that such a
requirement represented a limitation on people’s right to refuse medical treatment,
and that any benefits needed to be carefully weighed against this infringement.
It was also advised about the wider risks of requiring vaccination and the potential
for discrimination, erosion of trust and social cohesion, and disproportionate
impacts on Māori.
There are two benefits of vaccination invoked to justify vaccine requirements.
First, vaccination reduces transmission of COVID-19 from one person to another.
This means that:
i) for a highly effective vaccine, one may achieve herd immunity – meaning
only sporadic outbreaks occur among unvaccinated pockets of the population.
Herd immunity was most unlikely for Delta (due to incomplete and waning
protection against infection), and impossible for Omicron;
ii) partial or moderate vaccine protection against transmission, and moderate
to high vaccine coverage, will dampen transmission, and reduce the peak of
waves (in a mitigation strategy) and make it easier to contain any outbreaks
(in a suppression strategy); and
iii) other people, particularly those with co-morbidities and who were medically
vulnerable, would be protected from becoming infected with COVID-19.
Second, vaccination protects the vaccinated person from illness (even if it does not
reduce the risk of them passing the virus on to others). This is a weaker ground
for vaccine requirements than the above transmission rationale, as one is now
compelling people to be vaccinated for their own benefit against their own
judgement, not for the benefit of others. However, in the peak of a serious wave of
infection, a requirement of people in public and essential services to be vaccinated
may reduce the number off sick at any one time, with a ‘spill over’ benefit to others.
Indeed, from November 2021, legislative changes broadened the legal grounds on
which vaccination could be required to include such ‘public interest’ goals such as
to assist continuity of essential services.
Requiring people to be
vaccinated in order to work
or be present in particular
settings is a significant decision.
Embedded in this reasoning is the assumption that making vaccination mandatory
(or requiring it for people to work or be present in particular settings) will result in
a meaningful increase in the number of people being vaccinated, over and above
what would be achieved via voluntary vaccination. To put it another way, the benefit
of requiring people to be vaccinated depends on people taking up vaccination
who otherwise would not have done so. Turning to our assessment, given the
importance of keeping COVID-19 out of the country, there was a strong case in 2021
for requiring border workers to be vaccinated (in the same way that they were the
first group to be prioritised in the vaccine rollout). With the Delta outbreak proving
hard to contain, there was also a good case for mandating vaccination for those
working with vulnerable people or in high-risk settings – including health, aged care
and disability settings and prisons.
It was also reasonable for the government to introduce a simplified health and
safety risk assessment tool in late 2021 that employers could use if they were
intending to introduce workplace specific vaccination requirements as the country
moved away from use of lockdowns and sought to find a way of ‘living with’
established COVID-19 transmission.
Similarly, we consider it was sensible to introduce a vaccine pass system in
December 2021 with the intention of reducing the risk of Delta ‘superspreader’
events and protecting vulnerable groups, while reducing reliance on more stringent
public health and social measures. These decisions were made in a difficult context
where people were having to shift their understandings of risk and adjust to a very
different approach to that of the elimination strategy.
The case for requiring vaccination became less clear in 2022 with Omicron. The
public health benefit of most vaccine mandates depended on vaccination
meaningfully reducing transmission of COVID-19 from one person to another. By
late 2021, it was clear that protection against transmission waned in the weeks and
months following vaccination. By early 2022, there was evidence that vaccination
offered significantly lower protection against transmission of Omicron (now the
dominant COVID-19 variant in Aotearoa New Zealand) and that this more modest
protection also waned in the weeks following vaccination.
The addition of a booster dose to occupational vaccine requirements arguably
meant there was still some potential benefit from requiring people to be vaccinated
in order to work in certain settings. But this benefit was smaller than previously
since vaccination offered lower protection from transmission with the Omicron
variant, although boosting certainly helped. Vaccination rates were also now very
high in relevant occupations. The added benefit of vaccination being mandatory
in these groups was therefore smaller, given there was little scope for additional
people taking up the vaccine who had not already done so.
In section 8.4.5, we established that health officials would have been aware
of emerging evidence that vaccination offered very low protection against
transmission of the Omicron variant.163 While this evidence weakened the case for
vaccine requirements, officials are likely to have been cautious in recommending
the removal of vaccine requirements that might offer even modest additional
protection. This is illustrated in a High Court ruling from February 2022 concerning
occupational mandates.164 An expert witness expressed the opinion that vaccination
did not prevent transmission of the Omicron variant. In contrast, the Chief Science
Advisor for Health, Dr Ian Town, was more circumspect in his assessment of
the evidence, noting that – in relation to Omicron – vaccination was thought to
provide ‘some protection against symptomatic disease’, albeit at lower levels than
for previous variants.165 Dr Town noted that officials were cautious about placing
too much emphasis on early studies, but were continuing to monitor the evolving
evidence in this area:
“ The information in respect of Omicron is still in its infancy and is evolving. Many of the
studies are either in pre-print (have not yet been subject of peer review) or have significant
limitations. The Ministry of Health constantly reviews and makes publicly available on its
website the most up to date and relevant scientific information.” 166
Based on the evidence provided in this case, Justice Cooke concluded (on
25 February 2022) that ‘vaccination may still have some effects in limiting
infection and transmission, but at a significantly lower levels [sic] than was the
case with the earlier variants’.167
The March 2022 Cabinet paper we discussed in section 8.4.5 stated that the
Pfizer Comirnaty vaccine provided ‘an epidemiologically important reduction in
transmission’ of Omicron.168 Referencing advice from the Ministry of Health and
the Strategic COVID-19 Public Health Advisory Group, the paper took a mixed view
on continuing vaccine requirements, recommending the retirement of some (the
vaccine pass system, workplace vaccine requirements for staff in associated venues,
and occupational mandates for teachers and educators) and the retention of others
(occupational mandates for border workers, health workers and prison staff).
As noted previously, by March 2022, the Strategic COVID-19 Public Health Advisory
Group assessed the case for vaccine mandates as ‘more finely balanced’ due to a
combination of high vaccination coverage and ‘the apparent lowering of vaccine
effectiveness against transmission of the Omicron variant’.169 The Group advised
the Government to remove vaccine mandates for workers in Fire and Emergency
services, the Police, the Defence Force and educational settings, but to retain those
for workers in border, healthcare and prison settings. It seems that advisors felt
that even a small potential gain in protection from vaccination warranted the
retention of mandates in these settings.
A precautionary approach to removing mandates is understandable in the context
of growing rates of infection from Omicron after previously stringent public health
and social measures were removed. Nevertheless, the case for retaining vaccine
mandates became less clear once the peak of Omicron infection had passed (in
March 2022), when it was apparent that measures under the COVID-19 Protection
Framework were sufficient to manage infection peaks and prevent the health
system from being overwhelmed. While many occupational mandates were rolled
back in April 2022, mandates for prison staff and border workers were retained
until July 2022, and those for workers in high-risk settings (healthcare and prisons)
remained in place until September 2022.
The decision to require vaccination involved a careful weighing up of people’s right
to refuse medical treatment against the benefits decision-makers believed would
result from making vaccination mandatory. This is a judgement call. Decision-
makers may reach different views on the most appropriate balance at different
times and in different contexts, particularly as evidence of both the costs and
benefits of mandates becomes clearer.
It is the view of this Inquiry that the retention of many occupational vaccine
mandates until well into 2022 was too long. Once the peak of Omicron had passed,
in March 2022, the Government could have confidence that the new COVID-19
Protection Framework was effective in preventing the health system from being
overwhelmed and protecting vulnerable groups as far as was possible. It was also
becoming clear that vaccination offered limited protection against transmission
of Omicron, and that – rather than seeking to control COVID-19 outbreaks – the
approach going forward would rely on other measures (including the development
of stronger or ‘hybrid’ immunity from people getting infected on top of already
being vaccinated) to reduce the severity of infection.
The Inquiry is also of the view that the extension of vaccination requirements into a
broad range of workplaces went too far – although we also acknowledge that these
requirements were introduced by employers and businesses (under regulatory
guidance) rather than the Government, and that many of these employers were
responding to expectations on the part of their staff.
It is the view of this Inquiry

that the retention of many
occupational vaccine
mandates until well into
2022 was too long.
On vaccine passes, our Inquiry’s assessment is that there was a case for
using passes in the context of Delta infection (in late 2021) as they would have
helped lessen superspreader events and outbreak frequency and severity.
In practice, however, Omicron was the dominant COVID-19 variant when
Aotearoa New Zealand ‘opened up’ in early 2022. Epidemiologically, vaccine
passes in the face of Omicron provided only marginal benefit in terms of
reducing the spread of infection – although they may have helped somewhat
to reduce the peak of the first wave of Omicron infection.xi Those making
decisions in January and February 2022 would have had considerable
uncertainty about how big the first wave of Omicron infection was going to
be and whether it would put pressure on health services. It is understandable
that vaccine passes were left in place for the first Omicron wave, albeit it was
a decision that could reasonably have gone either way. Notably, vaccine passes
were removed promptly after the peak of the first Omicron wave.
The move from encouraging to compelling vaccination was a significant one
that affected how many people felt about the pandemic response overall.
While vaccination requirements offered a level of reassurance to many in the
short term, the long-term impacts of these decisions had negative social and
economic impacts (discussed further in section 8.5.2) which – for many people –
have been deep and lasting.
The Inquiry notes that vaccine requirements were used in many other countries
as part of their COVID-19 responses.170 Decision-makers in these countries would
also have considered the trade-off between the increased protection gained from
vaccine mandates and the associated constraints on personal freedom. Many of
them judged the cost to be ‘worth it’, although some did not. This was a difficult
judgement to make. As one summary of international experience notes:
“ It is hard to accurately quantify the consequences [of vaccine mandates] such as [loss of]
social exclusion, loss of public trust, or inequitable outcomes. Numerous other factors
are at play, such as the way a government handled the pandemic overall, wider political
campaigns against vaccination or mandates, or frustrations with the way that a mandate
was implemented. Another crucial aspect of whether mandates are successful is the
political skill and messaging used to introduce them.” 171
Many of these factors are discussed further in following sections.
xi There was also a positive synergy from vaccination that was theoretically known at the time. In addition to providing
a modest reduction in a person’s chance of becoming infected with Omicron (as was shown in studies available in
early 2022), vaccination was also likely to modestly reduce the chance of an infected person passing the virus on to
someone else (a benefit that was expected at the time, but not demonstrated until later in 2022). The combination of
these two mechanisms meant that vaccination would still have had some impact in dampening Omicron transmission.
8.5.2 Assessment of vaccination requirements – impacts
and implementation
8.5.2.1
Effectiveness of vaccination requirements in protecting
public health
Having reflected on the justification for vaccination requirements (in terms of
whether the Government had sufficient grounds for limiting people’s right to
refuse medical treatment), we now turn to the impacts of these requirements –
including their effectiveness in supporting the COVID-19 response, issues with
their implementation, and their broader social and economic impacts.
Vaccination requirements had limited impact on vaccination coverage

Aotearoa New Zealand was one of at least 75 countries to use vaccine mandates
as part of its COVID-19 response.172 How far these were applied, and to which
workforces, varied widely around the world. For example, while in New Zealand
it was seen as important to mandate vaccination for the health workforce to
protect both workers and patients, in the United Kingdom, frontline health
workers were not required to be vaccinated, due to concerns that this would
deplete the workforce to critical levels.173
International evidence suggests COVID-19 vaccine mandates had a small positive
impact on population-wide vaccination coverage, although this varied widely from
country to country and depended on a many factors such as the level of voluntary
vaccine coverage achieved without mandates.174 In Canada, where population-
wide vaccination mandates were introduced when voluntary coverage was already
over 80 percent, they are estimated to have boosted first-dose coverage by 2.9
percentage points, which the researchers call a ‘sizeable increase […] considering
the relatively short period in which it was achieved’.175
A 2024 evaluation concluded that Aotearoa New Zealand’s occupational vaccination
mandates are likely to have had limited impact on population protection from
COVID-19.176 The authors noted that vaccination levels in relevant workforces were
already very high at the point the mandates were introduced. While vaccination
levels continued to rise, the relevant increase appeared as ‘a continuation of an
[existing] upward trend rather than a jump in uptake’ as shown on Figure 2.177
Figure 2. Proportion of relevant workforces that had received two doses
of COVID-19 vaccine
Source: Dewar J, Wilson D, Pacheco G, Meehan L, 2024, Unintended consequences of NZ’s COVID vaccine
mandates must inform future pandemic policy – new research, https://theconversation.com/unintended-
consequences-of-nzs-covid-vaccine-mandates-must-inform-future-pandemic-policy-new-research-222989
The report concluded that – since the vaccination mandates had little
discernible impact on vaccine coverage – they would not have meaningfully
increased population protection from COVID-19:xii
“ Overall, the results suggest that in the context of already-high vaccination rates,
workforce vaccine mandates may not have provided much benefit in terms of
increasing vaccination rates among mandated workers.” 178
Specific to the health workforce, the review further found that Aotearoa
New Zealand’s vaccination mandates negatively impacted healthcare workers’
employment, and that this may have had wider consequences by exacerbating
existing skills shortages in the health sector.179 We discuss workforce implications
further in section 8.5.2.3.
xii For some infectious diseases (such as measles), even a modest increase in vaccination coverage can
significantly reduce the risk of sustained community transmission and prevent outbreaks from occurring.
Unfortunately this is not the case for COVID-19 since immune protection (from either vaccination or previous
infection) wanes fairly quickly. This means a proportion of the population will be susceptible to infection at
any given point in time, even if total vaccine coverage is high.
Vaccine requirements supported the elimination strategy and protected
vulnerable people from COVID-19
While there is limited evidence that vaccination requirements produced
substantial increases in vaccination coverage, the Inquiry recognises that – in
2021 – it made sense to require vaccination for workers at higher risk of being
exposed to or passing on COVID-19.
The rationale for requiring vaccination was particularly strong in the case of
border and health workers. For the first group, the rationale was similar to
that for mandatory COVID-19 testing. Border workers were at higher risk of
being exposed to COVID-19 – including new variants – due to their contact with
people arriving from overseas. As long as Aotearoa New Zealand was pursuing
an elimination strategy, requiring border workers to be vaccinated made sense
in terms of reducing the risk of new chains of COVID-19 transmission entering
the population. We cannot know how many ‘breaches’ of New Zealand’s border
may have been prevented through such requirements, so it is not possible to
evaluate the effectiveness of this measure.
Similarly, there is a clear case for requiring vaccination for workers interacting
with medically vulnerable people – including those working in health and
disability care and in residential aged care facilities. Again, it is not possible
to assess how many cases of COVID-19 may have been prevented by these
requirements. But it is clear that a key part of the rationale for health worker
mandates was to protect vulnerable people from COVID-19 infection – including
those who may not have been able to receive the vaccine themselves (due to
medical contraindications).
8.5.2.2
Implementation issues
Medical exemptions to vaccination requirements were difficult to obtain
When occupational vaccine mandates were introduced in early 2021, workers
could be exempted from the requirement on the basis of a certificate from a
registered medical practitioner. This meant workers could continue to work in
a role covered by a Government-issued vaccine requirement providing they
presented a letter from their GP stating that there were valid medical reasons
for them not being vaccinated.
This situation changed in early November 2021, when access to medical
exemptions was tightened considerably. By this time vaccination mandates
had been extended to the education and health and disability sectors, as well
as frontline Police, Defence, and Fire and Emergency staff. From 7 November
2021 onwards, medical exemptions were issued centrally, under the authority
of the Director-General of Health, on the basis of very limited criteria.180
Health officials recommended the exemption process be centralised in order to
avoid people obtaining or demanding exemptions from healthcare practitioners
in situations where they did not meet the relevant criteria.181 A small proportion of
medical practitioners were known to have concerns about the safety of COVID-19
vaccines, and a group called New Zealand Doctors Speaking Out on Science
(NZDSOS) had been vocal on this issue since April 2021.182 In August 2021 a general
practitioner had contacted their patients noting that they did not support COVID-19
vaccinations (the doctor’s actions were found to be in breach of professional
standards183). In the absence of a centralised system, it was not possible to monitor
how many medical exemptions (appropriate or otherwise) were being granted, but
the Ministry of Health had received complaints about practitioners allegedly issuing
inappropriate exemptions.
It is possible that officials underestimated the scale of demand for medical
exemptions that would arise with the expansion of vaccine requirements. A Cabinet
briefing from October 2021 discusses the possibility of applications for vaccine
exemptions being processed centrally by the Ministry of Health. The briefing states
that ‘Provided the total number of exempted persons in the country remains in the low
hundreds, the processing of the exemptions would not be overly administratively
burdensome’ [italics added].184
In practice, 6,410 individual temporary medical exemptions were granted from
vaccination requirements between 15 November 2021 and 26 September 2022.185
A considerable number of public submitters to our Inquiry expressed frustration
about being denied a medical exemption, either on their own behalf, or
someone else’s.
“ I have two sisters that have health conditions and should not under any circumstance
receive the vaccine, they were denied an exemption and told they should get their jab
at the hospital in case they react and need to be revived. This is totally unacceptable from
our government.”
“ I worked in a school office and lost my job because I wouldn’t take the vaccine. […]
I got a medical exemption only for the government to change the law on exemptions.”
Exemptions to prevent ‘significant service disruption’ were also possible,

but controversial
Along with medical exemptions in very limited circumstances, it was also possible
for employers to obtain temporary exemptions from vaccination mandate
requirements on behalf of their staff. This measure was intended to prevent
‘significant service disruption’ to a critical health service where there were
insufficient vaccinated workers available to allow the service to continue.
These temporary exemptions were applied for by employers (mostly district
health boards), who had to show that a critical health service would not be
provided unless they employed unvaccinated staff; that no alternative option
was available; and that the organisation had done all they could to mitigate
the risk of COVID-19 transmission from having unvaccinated staff.
According to information released by the Ministry of Health under the Official
Information Act, a total of 478 applications for significant service disruption
exemptions were received by the Ministry. Of these, only 103 were granted,
covering approximately 11,005 workers.186 These were all for health services,
and were temporary, the longest lasting eight weeks.187
This ‘11,000 exemptions’ figure featured prominently in the minds of some
public submitters, perhaps reflecting a misconception that exemptions had
been granted selectively, or a misunderstanding that these exemptions were
some form of ‘medical’ exemption:
“ I read that he [the Director-General of Health] thought there were less than 100
people in the whole of NZ that may be eligible for an exemption YET he approved
11,000 fellow MOH workers from it – how is this justified? ”
It fell to employers in affected sectors to uphold Government-issued

vaccine mandates
While central government issued occupational vaccination mandates by public
health orders for border, education, health and disability, and frontline Police
and Defence workers, it fell to employers in these sectors to enforce them.
This involved notifying staff of the requirement, obtaining proof of vaccination
from those who met it, and entering into an employment review process with
any who did not.
While it is likely that some employers reached an accommodation with
unvaccinated staff members through this process (such as keeping them on
but requiring them to work from home), in many instances this would not
have been possible. For example, with students back to full-time, in-person
learning, it would not have been practical to ask teachers to work from home;
nor was it feasible for frontline health or Corrections staff to work remotely.
Many employers in these sectors were ultimately required to terminate
the employment of unvaccinated staff. The Inquiry has not seen figures
on how many employees lost their jobs because of vaccine mandates, but
representatives from many organisations and sectors told the Inquiry they
had lost staff because of the vaccine mandate. This was challenging for many,
as we heard from some of the stakeholders we engaged with directly. School
principals and boards (usually made up of parent volunteers) may have found
this particularly challenging.
“ It came up often in peak body meetings. Many times we were asking for central
direction because every individual school was having to interpret, based on often
quite scant knowledge and limited understanding of compliance. Principals felt really
vulnerable in that space because beholden to their communities, wanting to support
workers, but equally keep their school operating. Quite big decisions.”
Occupational mandates were the subject of several High Court challenges

in 2021 and 2022.188 While the Court upheld the mandates (except in the
case of Fire and Emergency, New Zealand Police and New Zealand Defence
Force staff), one of the judgments noted that ‘a more flexible approach to
exemptions under employment arrangements may be more appropriate’.189
Arguably, some of the unintended social and economic harms arising from
the Government’s occupational mandates (as detailed in the following
sections) might have been reduced had the mandates allowed a ‘more
flexible approach’ (for example, to reassign roles or grant extended periods
of unpaid leave) as suggested by the Court.
8.5.2.3
Social and economic impacts
Some people lost income or employment as a result of vaccination mandates
We are not aware of any comprehensive data quantifying how many people
lost their jobs because of non-compliance with a vaccination requirement
(whether Government-issued or workplace-specific) during the COVID-19
response. However, a study undertaken by the New Zealand Work Research
Institute in 2024 found workplace mandates had negative labour market
impacts, including on unvaccinated workers’ overall employment rates and
their earnings.190
Although the number cannot be quantified, people did lose employment
due to vaccine mandates. A substantial number of public submitters to our
Inquiry addressed this topic. Some shared first-hand experiences, while
others talked about the impacts of mandate-related job losses more broadly.
Many felt it was unfair and unnecessary for people to lose their jobs because
they chose not to get vaccinated:
“ I lost two jobs I loved, one being in healthcare and the other in hospitality. The stress
and anxiety was very debilitating and not knowing what was going to happen as it
progressed was so unsettling I nearly broke.”
“ Devastation does not begin to cover what these people went through. The stories of
loss were overwhelming. I spoke with couples who faced both earners losing their
employment, rendering them unable to afford the basics, including food on the
table and a roof over their children’s heads.”
Others did not have their employment fully terminated but still faced mandate-
related consequences, such as being assigned different work or losing
relationships with colleagues.
“ My job was put at risk and I had a tense meeting with the directors and was no longer
allowed onsite or to associate with my colleagues of 6 years.”
“ I was reinstated in my job for a Government ministry, but the treatment by them has
meant [I] no longer feel loyal or valued.”
Vaccination mandates exacerbated staff shortages for some sectors

We are not aware of any sources documenting how many people lost their jobs
as a direct result of vaccination mandates. Nevertheless, we heard in many direct
engagements that occupational mandates exacerbated existing staffing shortages
in several key areas – including healthcare.
One district health board told us they had ‘lost 38 staff, including two doctors’, as
well as ‘the only qualified audiologist’ they had. Following that person’s departure,
a trainee audiologist saw patients, supervised remotely by a qualified audiologist
based overseas. Similarly, a nursing organisation told us they had lost ‘about 35
people’ as a result of the mandates, noting ‘we couldn’t shift them to backroom
functions as they still needed the vaccine […] there was nowhere for them to go’.
Other health sector bodies talked about the disproportionate impact of vaccine
mandates on small and remote communities, if the sole practitioner in that area
was unable to work. We heard similar reports from other sectors, including
early childcare.
Some of our public submitters also claimed particular sectors and professions –
in health and education especially – had been damaged as a result of mandate-
related job losses. Workers with much-needed skills had been ‘mandated out …
at the very time when the country needed all hands on deck’, one wrote. We
heard a number of direct accounts from submitters who were affected:
“ I was mandated out of my 30 year nursing career, which led to the sale of my home.”
“ My wife worked for [an ambulance service] and was mandated out of her job as she did
not want to take a vaccine. This put further stresses on us financially, our family life, and
I suspect pressure on the already understaffed [ambulance] service.”
Some submitters felt the mandates had undermined their long-term employment
prospects. We heard from people who had undergone mandate-enforced
termination and been re-employed once the mandate was lifted, but who now
felt disillusioned and socially ostracised from their workplace.
Vaccine requirements provided assurance to some members of the public,
although this reassurance may not always have been well founded
Aside from any impact on COVID-19 transmission or illness, vaccine mandates may
have been seen as supporting the country’s economic recovery and a return to
something approaching daily normalcy. In information supplied to our Inquiry about
the evolution of the public health response, the Ministry of Health pointed out that
one of the key benefits of vaccination certificates (and, by extension, other vaccine
requirements) was the reassurance they provided to members of the public that
it was relatively safexiii to return to indoor venues like bars and restaurants, hold
gatherings of more than 100 people, and make use of close-proximity businesses
like hairdressers and gyms. (We note, however, that from early 2022 this perception
did not strongly align with the reality that vaccination offered limited protection
from transmission, given Omicron was now the dominant variant.)
Some public submitters to our Inquiry supported this view:
“ I supported having vaccines and agreed with the mandates, although I acknowledge the
difficulties faced by those who chose not to be vaccinated and were unable to work. However,
I was concerned for my own health and safety, so did not want an unvaccinated person to be
at my place of work or at any of the services that I required (e.g. hairdresser, bus driver).”
Public reassurance may have been seen as particularly important during Aotearoa
New Zealand’s transition away from an elimination strategy and towards the
‘minimisation and protection’ (suppression and mitigation) strategy. Given the
scale of public concern at that time, it is understandable the Government sought
to use vaccination requirements as a form of insurance as the country ‘opened up’.
It is also understandable that the Government wanted to support employers in
responding to staff concerns and managing the risk of COVID-19 transmission in
the workplace.
At the same time, the justification for introducing vaccine mandates, and the
associated limiting of people’s right to refuse medical treatment, focused on the
role of vaccination in reducing COVID-19 transmission. While vaccination offered
meaningful protection against transmission of Delta, protection was much weaker
for Omicron. It seems likely that public understanding of this distinction was
limited at the time, which may have contributed to the expectation that workplace
vaccination requirements were protecting people from infection with COVID-19.
Some stakeholders felt that vaccine messaging was slow to explain the evolving
evidence (i.e. that vaccination was no longer particularly effective in limiting
COVID-19 transmission), and told the Inquiry that this ‘disconnect’ fuelled distrust
in Government. The Inquiry notes that – should a similar situation arise in a future
pandemic (i.e. that vaccines become less effective in reducing transmission) – it will
be important for public messaging to be agile in reflecting the changing science.
xiii We say ‘relatively’ safe because it was clear from early in the rollout that the available vaccines could not eliminate
the risk of contracting or passing on COVID-19, nor guarantee that a vaccinated person would not become seriously
unwell if they contracted the virus. They could – and did – however, reduce the risk on both scores (waning
effectiveness against the Omicron variant notwithstanding).
Some unvaccinated people felt ostracised, lost relationships and/or
were unable to access certain locations and services, including some
types of healthcare
The public submissions we received gave an insight into the experience of being
unvaccinated during the pandemic. As well as being unable to use many public
places and services, submitters described unvaccinated people feeling shunned
by their communities, workplaces and even their families due to their
unvaccinated status.
“ It was ridiculous to not be able to take my grandchildren to the public library as well
as other places. I was definitely discriminated against for not being vaccinated.”
“ [Vaccine mandates] destroyed the latter years of my family’s life. Mandated out of RSA.
Bars, Car and Motorcycle clubs, visit to retirement homes and family around country.
Can’t even get coffee and cake at cafe in town...”
In some cases, submitters said unvaccinated people were effectively ostracised

by society – treated as if they were selfish, responsible for spreading COVID-19,
and to be avoided. At a personal level, being unvaccinated could strain and even
destroy family relationships. Submitters described couples divorcing, unvaccinated
grandmothers being prevented from seeing their grandchildren, and lifelong
friends who would no longer speak to them.
“ Due to mandates I was excluded from my family Xmas, not allowed to attend my sisters
50th or my father’s 80th birthday. This has had a devastating and lasting effect on my
relationship with my family.”
Other submitters reported difficulty accessing healthcare during the

pandemic because they were not vaccinated.xiv It is important to note that it was
not permitted for essential services (including primary healthcare) to require
vaccination certificates for entry. However, the strict protocols adopted by many
services, such as seeing unvaccinated patients in their cars or delaying routine
visits, made some people feel as though they could not access basic services.
“ I was basically trespassed from my doctor’s office which meant I was not able to receive
my healthcare needed for my own disability. I was told that face to face was impossible
because of my decision. I was denied healthcare. When I did see someone it was in the
car park. I pay for these visits I am entitled to healthcare.”
“ Unable to have a breast ultrasound [and] checkup with my private surgeon. Nevertheless
2 months later, she saw me in the public hospital! What was the difference?”
xiv Most were commenting on primary healthcare (GP visits or routine screening) or dental care.
For some, the consequences of not being vaccinated or having a vaccine pass –
threatened or actual job loss, social ostracism, being unable to enter certain places
– left them feeling they were being coerced (by employers or the Government) to
get vaccinated. While vaccination was voluntary (in that people had to consent to
receive it), some submitters clearly felt as though this ‘choice’ was not a real one.
“ I felt bullied into taking the COVID 19 vaccine in order to keep my job and to be treated like
a sensible, law abiding, caring, normal person in NZ society and to be able to receive and
use basic services.”
“ When the previous Prime Minister Chris Hipkins said recently ‘there was no compulsory
vaccination, people made their own choices’ is an absolute insult. My husband’s choice
was to resign as he was forced out of his employment.”
“ I felt pressured in to getting the vaccine even though I didn’t feel comfortable […] For a long
period of time [it] felt like our country was and government was a dictatorship.”
While many public submissions describing the negative impacts of vaccine

mandates were from people who told us they had chosen not to get vaccinated,
we also heard from people who had themselves been vaccinated but who
lamented the harm the mandates had caused by stigmatising others and
damaging relationships. Many people who submitted to the Inquiry expressed
grief and anger over divisions they said the mandates had caused, describing
families and friends who were ‘torn apart’ or ‘split’ over the issue, and strained
relationships that had never been repaired.
“ I found the division between my friends and colleagues astounding.”
“ It caused fractures between our families and friends that have yet to mend.”
“ The division created between vaccinated and non-vaccinated was cruel and unusual […]
There is anger and trauma still remaining to this day and distrust in authority is evident.”
Workplace specific vaccination policies caused some confusion
We saw evidence suggesting employers were concerned about their legal risk if
employees were exposed to COVID-19 in the workplace and were inclined to put
vaccination policies in place as a result.191 Some businesses (as well as unions) were
also concerned about the risk to other employees who might be obliged to work
alongside unvaccinated colleagues.
All this led to considerable uncertainty about what employers – and public
sector agencies that had not been deemed essential services – should do. In our
engagements, some said they wanted directives and clarity from Government,
rather than guidance that put the onus on them to make their own assessments
and policies. We also heard that some employers and governance bodies were
concerned about their exposure to potential litigation if they did (or didn’t) require
employees to be vaccinated, and sought legal advice.
Vaccination mandates contributed to a loss of trust in some communities

The Inquiry heard from a range of stakeholders that vaccine mandates had
undermined trust in some communities, particularly among Māori. Many
stakeholders (including health and education providers) spoke about how they
were ‘still feeling the effects of the mandate’ in terms of a loss of engagement and
trust among whānau.
Health providers felt the mandates had caused many people to disengage from
the system and had even decreased the likelihood that some groups would take
up vaccination. Several spoke of Māori experiencing this as a loss of their agency,
exacerbating mistrust of the health system:
“ We need to rebuild trust between Māori and the health service... People were wanting to
maintain mana Motuhake and self-determination. The vaccine mandate meant people left
the health sector and some people are reluctant to re-engage with health services. We need
to create and rebuild trust with communities, trust with services.”
Several stakeholders linked the vaccine mandate with decreased uptake of

childhood vaccinations since the pandemic. A member of a hospital senior
leadership team said:
“ The COVID vaccination journey has left an enduring bruise on vaccination for New Zealand,
moving forward… [the result of people] being forced to [undergo vaccination], versus
“let’s have a conversation”. There was a loss of trust. The vaccine mandates caused
lasting harm.”
Another member of the same leadership team talked about the ‘unintended cost’
of vaccine mandates in terms of decreased uptake of key childhood vaccines and a
consequent increase in the risk of diseases such as measles and whooping cough.
The team made a direct link between the vaccine mandate and a loss of social
cohesion and trust within the community they served, particularly among Māori.
Other team members talked about a ‘huge erosion of trust’ among many whānau
that would continue for years to come:
“ There’s a whole generational impact. A whole generation that won’t trust [the health
service], as a result of the mandates.”
Official data confirms a drop-off in childhood vaccination levels since the pandemic,
with pronounced declines among Māori and Pacific children – for whom vaccination
coverage at 2 years has declined from over 90 percent in the pre-pandemic period
to 80 percent (for Pacific) and 68 percent (for Māori)xv (see Figure 3). These changes
reflect several pandemic-related factors, including decreased access to WellChild
visits during the pandemic. Other countries have also experienced declines in
uptake of childhood immunisations, due in part to reduced healthcare contact
during the pandemic.192 There is global evidence of falling public confidence
in vaccines, which may be linked to the spread of vaccine misinformation and
disinformation during the COVID-19 pandemic.193
Figure 3: Immunisation coverage by 24 months of age, by ethnicity
Source: Based on data from Immunisation Advisory Centre
We note there are particular risks to social cohesion and trust from the use of
vaccine passes that create a ‘dual system’ of entry to spaces and social gatherings.
While these risks were known and communicated to decision-makers at the time,
they were perhaps even more pronounced than was understood prior to the
COVID-19 response. We return to these matters in the next section.
xv The most recent estimates of coverage are from September 2023
Controversy over compulsory measures |
8.6 Te wenerau mō ngā whakaritenga
whakahauanga
As noted in the introduction to this chapter, the use of mandates and orders to
make various public health measures compulsory under certain circumstances
were among the most controversial aspects of the COVID-19 response, in
Aotearoa New Zealand and elsewhere – particularly vaccination requirements.
In this final section, we depart from our standard ‘What Happened’ and ‘Outcomes
and Impacts’ format and take a step back to consider how this controversy played
out over the course of the pandemic, culminating in the 28-day occupation of
Parliament grounds by a broad coalition of anti-mandate protestors in early 2022.
Dramatic images from those events – and in particular the scenes that unfolded
on 2 March 2022 during the Police operation to end the protest – remain etched
in the minds of many people almost three years later. Many of our public
submitters expressed concern about the protest, the divisions that emerged
between many people over COVID-19-related matters, and the potential long-
term consequences of these. While the full legacy of these events will not be
known for some time, we offer some reflections on them here.
The use of mandates and other

compulsory public health
measures were among the
most controversial aspects
of the COVID-19 response.
8.6.1 The Parliamentary occupation
8.6.1.1
Protest activity began to cohere from mid-2021 around
mandatory COVID-19 response measures
Opposition and disquiet about elements of the response had been present
throughout the pandemic, but began to cohere from about mid-2021 in the second
half of the year. Several groups formed to organise protest activities focused on
aspects of the Government’s response:
• The Freedom Alliance was a coalition of Wellington-based groups that believed
‘the Government’s COVID-9 response was never designed to protect the health
of New Zealanders, but rather to push a global political agenda’.194 It carried out
protest activity focused on use of mandates in the COVID-19 response.
• The Freedom and Rights Coalition formed in September 2021 in response
to perceived government ‘overreach’ in the COVID-19 response. It began to
organise protest actions around the country from October 2021.
• Voices for Freedom, a not-for-profit advocacy organisation, was founded in
December 2020, focused on the view that ‘all freedoms (were) under attack
from an overzealous and oppressive Covid-19 response’ (particularly freedom
of speech and health and medical freedom).195
8.6.1.2
A ‘Freedom Convoy’ converged on Parliament on 8 February 2022
In late January 2022, a ‘Freedom Convoy’ formed in Canada in opposition to
vaccination mandates and other aspects of the Canadian government’s COVID-19
response. This protest attracted considerable international attention and emulation.
On 29 January 2022, a ‘Convoy 2022 NZ’ Facebook page was created. It proposed
a New Zealand-based protest convoy, modelled on the Canadian one, with the
following objectives:
• ‘Stop all mandates and end all COVID-19 imposed restrictions,
• Reverse COVID-19 introduced legislation and cease proposed legislation,
• The immediate restoration of our universal inalienable human rights,
• Medical professionals to follow the Principals [sic] in the NZMA Code of Ethics, and
• All media to have freedom without censorship.’
In the first week of February, the New Zealand Police became aware of a plan for
two convoys – one from Cape Rēinga and one from Bluff – to converge in Wellington,
culminating in a potential occupation at Parliament.196 The two convoys set out on
Sunday 6 February 2022 – Waitangi Day.197
The ‘Freedom Convoy’ arrived at Parliament on Tuesday 8 February 2022. More than
150 convoy vehicles blocked streets around Parliament and approximately 2,000
protestors had assembled on Parliament grounds by midafternoon. More than
50 tents were erected that day on Parliament’s lawn. Parliament’s Speaker, Trevor
Mallard, asked for Police assistance to remove these, but was advised that Police did
not have the resources available to take enforcement action that evening. Around
500 protestors stayed on Parliament grounds overnight.198
8.6.1.3
Initial attempts to disperse the protestors were unsuccessful
The occupation lasted 23 days, attracting a range of people with diverse views
that loosely coalesced around a distrust of government. Protestors blockaded
the surrounding area with their vehicles and covered Parliament lawn with tents,
portaloos, and other temporary structures. At peak times, there were up to 3,000
people in attendance – the highest estimated day being Monday 14 February. Because
there were so many people, the occupation spread beyond Parliament grounds to
cover a large part of the surrounding Thorndon and Pipitea areas, and some also
camped on private property such as the driveways and gardens of nearby homes.199
In the first few days, the Speaker, Parliamentary security, and Police attempted to
disperse the protestors. On 9 February, Speaker Trevor Mallard asked for Police
to accompany Parliamentary staff to issue trespass notices to protestors, but they
were only able to approach three tents before Police assessed that the situation
had become unsafe.200 The next day, on 10 February, he officially closed Parliament
grounds, and loudspeaker announcements informed protestors that they must
leave. One hundred and fifty Police officers were deployed to enforce this, and
made more than 100 arrests, but the next morning a second wave of protestors
arrived, including more children and young people. That night, the Speaker activated
Parliament’s lawn sprinklers and played music and COVID-19 vaccination messages
over a loudspeaker until 10pm in an attempt to disperse the protestors. This was
done against Police advice.201
A severe weather event – Cyclone Dovi – hit Wellington on 12 February. Protestors
dug trenches and laid out straw to deal with the combination of rain and sprinklers.
They arranged security, a medical tent and food distribution, forced open the gates
of Parliament, and cut power to the electronic bollards that had been preventing
vehicle access to the grounds themselves.202
At the end of the first week of occupation, six protest groups associated with the
occupationxvi sent a letter to ministers outlining their objective:
“ Until the end of the mandates, participants are determined to maintain their presence.” 203
Prime Minister Jacinda Ardern refused the letter’s request ‘for an urgent meeting
with senior cabinet ministers to start a conversation’, pointing out that some of
their signs called for the ‘death of politicians.’204 She solidified this position on 16
February when she formally advised the Police Commissioner that she would not
meet or engage with the protestors.205 While some other politicians did engage
with protestors at this time, a few days later on 17 February, leaders of all the
Parliamentary political parties signed a statement indicating that they would not
engage further with the protestors until they stopped breaking the law.306
xvi These groups were the three already mentioned – the Freedom Alliance, Freedom and Rights Coalition, and Voices for
Freedom – along with Convoy 2022NZ, The Outdoors Freedom Movement, and NZ Doctors Speaking out with Science.
8.6.1.4
Significant Police resource was required to manage and
contain the protest
Throughout the 23-day occupation, significant Police resource was required to
manage – and ultimately disperse – the protest.
On 13 February, a specialist Police negotiation team started work to liaise with the
protestors. At that stage, around 200–300 protestors remained, amid torrential
rain and gale-force winds.207 Numbers surged again early in the second week of the
occupation. On 15 February, Police began a national operation to respond to the
protest, establishing a Major Operations Centre to support the Wellington District’s
local response.208
Police presence peaked in the weekend of 19–20 February, when 600 officers were
rostered on in three shifts over a 48-hour period, with 200 more on standby. Around
this time, an increased gang presence was observed at the occupation. Also at this
time, Police officers who had been deployed at the protest began to test positive for
COVID-19. Police were now of the view that de-escalation was the only safe way to
deal with the protest.209 On 21 February they began a two-day workshop to plan a
response to end the occupation.210
8.6.1.5
City leaders, Police, mana whenua, and the Human Rights
Commission met with protestors to hear their concerns
On 22 February, the Chief Human Rights Commissioner met with several protest
group leaders to listen to their concerns and discuss ‘rights and responsibilities’.
The next day, the Mayor of Wellington and Deputy Police Commissioner also met
with several protestors.211
On 23 February, some protestors forced entry to nearby Pipitea Marae and
attempted to ‘trespass’ tangata whenua there. On 24 February the Deputy Police
Commissioner again met with protestors at the marae, along with two church
leaders, to try to reach a resolution.212
There was increasing sickness among protestors, as the conditions in the
encampment became increasingly unsanitary, with reports of sewage from
portaloos being discharged directly into stormwater drains. On 23 February,
a confirmed COVID-19 case was reported among protestors for the first time.
By 24 February, Police had serious concerns for the health and wellbeing of
about 30 children at the protest.213 They were also observing increased discord
between different groups of protestors.214
On Monday 28 February, Taranaki Whānui ki Te Upoko o Te Ika led a dawn
ceremony at Pipitea Marae to deliver a unified message from North Island iwi
condemning the aggressive and violent behaviour of some protestors.
Significant numbers of protestors, tents and structures, and vehicles remained
in place up to the end of the protest.
8.6.1.6
On Wednesday 2 March 2022, Police undertook a large-scale
operation to end the protest
Early in the morning of Wednesday 2 March 2022, Police began a large-scale
operation to clear protestors, vehicles and structures from the protest site. This
was brought forward by one day due to concerns about available Police resource
(including having many officers unwell with COVID-19).215 The graduation of recently
trained Police officers was brought forward by several days to enable the new
recruits to be deployed in the operation.216
In total, around 600 officers were involved.217 Starting at the outer edges of the
occupation, they worked progressively to remove vehicles, arrest protestors, and
establish a progressively tighter Police line around the core location of Parliament
grounds itself.
The operation was successful, but dramatic and volatile scenes played out over the
course of the day and late into that evening. There were many instances of violence.
Protestors lit fires, set explosives, and used bricks and fire extinguishers as weapons
against Police.218 The slide in Parliament’s relatively new playground was burnt down.219
By 10pm, Police had established a cordon close to Parliament. Around 40 protestors
remained, and about 40 officers held the line into the early hours of the morning.
The remaining protestors either dispersed or were arrested. In total Police made
95 arrests on 2 March, predominantly for trespass and obstruction, and later
charged 54 more people after further investigation.220 Ambulance staff ended up
treating 82 Police officers for injuries and six required hospital treatment.221 Some
protestors and bystanders were also injured in the operation. An extensive clean-up
operation began the next day. Public areas that had been cleared in the operation,
particularly Parliament grounds, were treated as a crime scene.222
8.6.2 Impacts of opposition on trust in institutions and
social cohesion
The occupation of Parliament grounds – prompted by disaffection over the
introduction of vaccine mandates (and to some extent, other pandemic
measures), combined with the increasing circulation of false and misleading
information about the pandemic and response – was perhaps the most visible
expression of the pandemic’s impact on social cohesion and trust. However, the
challenges to trust, social licence and social cohesion were recognised by some
senior decision-makers from at least the second half of 2021.
During a pandemic, high levels of social cohesion support greater social
licence for action, effective community-led responses, and are associated with
lower infection and death rates.223 Conversely, pandemics can also damage
social cohesion and trust in ways that – at their most extreme – threaten the
rule of law, public safety and provision of essential services.224 This meant
social cohesion and licence were salient factors for decision-makers when
considering whether to implement mandatory measures. While the purpose of
such measures was to increase the uptake and effectiveness of public health
measures like vaccination, contact tracing and masking, use of mandates
could actually undermine these goals if they resulted in decreased trust in
government or eroded goodwill for the response.
Many public submitters and stakeholders we engaged with felt that aspects
of the pandemic response – particularly mandatory measures – had damaged
social cohesion. We heard, for example, about breakdowns of personal, family/
whānau, community and employment relationships over vaccine mandates and
vaccination status, and increased public anxiety, antisocial behaviour, stress
and violence.225 The Department of the Prime Minister and Cabinet has also
reflected that the damage to social cohesion and spread of misinformation and
disinformation during the pandemic may have impacted the effectiveness of
the public health response over time.226
Looking to the future, many stakeholders commented that the loss of social
licence and breakdown of social cohesion that occurred during this pandemic
may shape how the population is likely to respond to public health responses
like lockdowns and vaccine requirements in any future pandemics. Some
stakeholders also reported increased hesitancy about non-COVID-19 vaccines,
consistent with evolving international research.227
The evidence we heard from experts on the role of misinformation and
disinformation was mixed. While agreeing that misinformation and
disinformation are a significant global issue which the pandemic has exacerbated,
experts we engaged with differed on the extent to which they saw it as an
ongoing risk to trust and social cohesion. Some thought Aotearoa New Zealand
had largely reverted to pre-pandemic trust levels, while others were more
concerned that trust levels would continue to decline.
Regardless, all agreed that misinformation and disinformation present an
increasing global challenge, and that those who are already marginalised and
with low trust in government (including Māori) are most susceptible. This
evidence, as well as reports by multiple government agencies, supports a
continued focus on the risk of misinformation and disinformation.228 Repairing,
fostering and maintaining trust and social cohesion will be key to both countering
the impacts of COVID-19-related misinformation and disinformation, and
ensuring Aotearoa New Zealand is in a good position to respond effectively to
a future pandemic.
Repairing, fostering and

maintaining trust and social
cohesion will be key to ensuring
Aotearoa New Zealand is in
a good position to respond
effectively to a future pandemic.
1. The use of compulsion was one of the most controversial

aspects of the COVID-19 response.
• In deciding whether to mandate various public health measures, ministers
weighed up the need to protect public health (especially for vulnerable
populations) and individual freedoms and rights. These were not easy decisions,
and ministers were aware they would carry a social and economic cost.
• In addition to restrictions on movement and gatherings (such as ‘lockdowns’)
and quarantine and isolation requirements, ministers judged it necessary
to mandate COVID-19 testing, contact tracing, masking and vaccination in
particular circumstances at various points in the COVID-19 response.
• Vaccine requirements were a major source of tension and social division,
and there were strongly held views both for and against their use.
• Organised opposition to mandatory measures contributed to the 28-day
occupation of Parliament grounds in February and March 2022.
2. Testing, contact-tracing and masking requirements were

reasonable, but their implementation could be improved
in a future pandemic.
• Testing, contact tracing and mask wearing were all important components of the
COVID-19 response. Given the need for widespread uptake and how they were
mandated (i.e. in limited circumstances), we consider it appropriate that these
measures were compulsory for periods during the pandemic response.
• There were practical issues with the implementation of testing, contact tracing
and mask mandates that could be improved on if similar requirements are
deemed necessary in a future pandemic.
3. It was reasonable to introduce some targeted vaccine

requirements based on information available at the time.
• Based on the information available at the time (in 2021), it was reasonable for
the Government to issue orders making vaccination mandatory for specific
occupations (for example, border and health workers).
• It was also reasonable in late 2021 (when Delta was the dominant variant)
to design a system where people were required to show a vaccine pass
as a condition of entry to spaces and events where they would be in close
proximity with others in confined conditions, because of the high risk of viral
transmission. Having done so, it was logical to ensure that workers in such
spaces were also vaccinated.
• Based on information available in late 2021, it was reasonable for the Government
to introduce a simplified health and safety risk assessment tool to support
employers who wanted to consider setting workplace-specific vaccine policies
in contexts where people would be in close proximity in confined conditions.
4. Some vaccine requirements were applied more
broadly than originally envisaged.
• Vaccine requirements were initially targeted and based on a clear
expectation of public health benefit.
• However, over time, widespread concern about the risks of COVID-19
fuelled expectations that a wide range of settings and workplaces would
be subject to vaccination requirements.
• This led to some vaccine requirements being applied more broadly than
originally envisaged.
5. The case for vaccine requirements became weaker in 2022

once Omicron became the dominant COVID-19 variant.
• The case for vaccine requirements of all kinds weakened in early 2022 with
the arrival of the Omicron variant since vaccination was now much less
effective in preventing COVID-19 transmission and immunity waned over
time. While beneficial to the individual concerned, vaccination now offered
less protection to others and the public health case for requiring it was weak.
• In our view, some workplace, occupational and other vaccine requirements
were applied too broadly and remained in place for too long, which caused
harm to individuals and families and contributed to loss of social capital.
6. While some people found vaccine requirements reassuring,

they had wider social and economic consequences.
• Vaccine requirements may have helped facilitate a return to in-person
work and social activities, by making people feel safe. Many workers were
also in favour of vaccine requirements and made strong demands for
employers to introduce them.
• However, vaccine requirements also had significant negative impacts,
including exacerbating workforce issues and shortages in some sectors.
• Some people who chose not to get vaccinated lost employment, and
many experienced stigma, or were unable to access important places and
events. There were also difficult social consequences for some people
who did choose to get vaccinated, such as the breakdown of family, work
and personal relationships.
• Vaccination requirements (occupational mandates, workplace
requirements and vaccine passes) reduced trust in government for some
and probably contributed to lower uptake of other vaccines (such as
childhood immunisations) in some communities, particularly among Māori.
• In hindsight, vaccine requirements had substantial long-lasting impacts –
particularly for Māori and Pacific peoples – that would need to be taken into
account in any future decisions around their use in a pandemic response.
7. The use of mandatory measures – and other aspects
of the COVID-19 pandemic – affected trust and social
cohesion in ways that may make future pandemic
responses more difficult.
• The occupation of Parliament grounds in protest against a range of
matters, including mandatory measures (especially vaccine requirements),
represented the most significant civil unrest in Aotearoa New Zealand for
some time. It is likely to have far-reaching social consequences.
• The COVID-19 pandemic was associated with declining levels of public
trust in government (as occurred in other countries), particularly in some
communities. Many of our public submitters expressed concern about
the ongoing effects of the pandemic period on social cohesion, trust and
collective identity in Aotearoa New Zealand.
• These are important matters for our Inquiry, because during a pandemic,
high levels of trust and social cohesion support greater social licence for
action, effective community-led responses, and are associated with lower
infection and death rates.
• Pandemics can also damage social cohesion and trust in ways that – at
their most extreme – threaten the rule of law, public safety, and provision
of essential services.
• Fostering, rebuilding and enhancing trust and social cohesion following
the unsettling events of the COVID-19 pandemic should be a key part of
preparing for any future pandemic.
Endnotes |
0.0
8.8 Tuhinga āpiti
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testing-phase-one.pdf
LMS400302.html
Clause 10, COVID-19 Public Health Response
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15. Venter Consulting, Rapid Review of Border Worker
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6. Clause 12, COVID-19 Public Health Response testing-phase-one.pdf
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16. Ministry of Health, Briefing: Enhancing compliance
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22 April 2021, https://www.health.govt.nz/system/
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files/2022-06/20210915_briefing.pdf
(Air Border) Order 2020, version 22 June 2020,
https://www.legislation.govt.nz/regulation/ 17. Venter Consulting, Rapid Review of Border Worker
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Roberto Bertollini, and Laith J. Abu-Raddad, ‘Waning
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162. Nick Andrews, Julia Stowe, Freja Kirsebom, Samuel 171. Thomas Hale, Anna Petherick, Toby Phillips, Jessica
Toffa, Tim Rickeard, Eileen Gallagher, Charlotte Gower, Anania, Bernardo Andretti de Mello, Noam Angrist,
Meaghan Kall, Natalie Groves, Anne-Marie O’Connell, Roy Barnes, Thomas Boby, Emily Cameron-Blake,
David Simons, Paula B. Blomquist, Asad Zaidi, Sophie Alice Cavalieri, Martina Di Folco, Benjamin Edwards,
Nash, Nurin Iwani Binti Abdul Aziz, Simon Thelwall, Lucy Ellen, Jodie Elms, Rodrigo Furst, Liz Gomes
Gavin Dabrera, Richard Myers, Gayatri Amirthalingam, Ribeiro, Kaitlyn Green, Rafael Goldszmidt, Laura
Saheer Gharbia, Jeffrey C. Barrett, Richard Elson, Hallas, Nadezhda Kamenkovich, Beatriz Kira, Sandhya
Shamez N. Ladhani, Neil Ferguson, Maria Zambon, Laping, Maria Luciano, Saptarshi Majumdar, Thayslene
Colin N.J. Campbell, Kevin Brown, Susan Hopkins, Marques Oliveira, Radhika Nagesh, Annalena
Meera Chand, Mary Ramsay, and Jamie Lopez Bernal, Pott, Luyao Ren, Julia Sampaio, Helen Tatlow, Will
‘Covid-19 Vaccine Effectiveness against the Omicron Torness, Adam Wade, Samuel Webster, Andrew
(B.1.1.529) Variant’, New England Journal of Medicine Wood, Hao Zha, Yuxi Zhang, and Andrea Vaccaro,
386, no. 16 (2 March 2022), 1532-1546, ‘Variation in government responses to COVID-19,
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Zealand Wellington Registry, Yardley v Minister for ox.ac.uk/research/publications/variation-government-
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165. Courts of New Zealand, In the High Court of New 174. Alexander Karaivanov, Dongwoo Kim, Shih En Lu, and
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and-restrictions/10-Dec-2021/Vaccine-Certificates- Samir V. Sodha, Christine Prosperi, Joshua Wunderlich,
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domestic-use.pdf Marta Gacic-Dobo, Katherine L. O’Brien, and Ann
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Ranasinghe, Shyam Sundar Budhathoki, Helen
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‘Reasons for reductions in routine childhood
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14 October 2023, https://www.pressreader.com/new- journal.pgph.0001415, https://journals.plos.org/
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202. McGuinness Institute, COVID-19 Nation Dates (1st ed.) download/164247/20%20APRIL%202023%20IPCA%20
(Wellington, 2023), p 123, https://nationdatesnz.org/ PUBLIC%20REPORT%20-%20Review%20of%20
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the%20Policing%20of%20the%20Protest%20and%20 the%20Policing%20of%20the%20Protest%20and%20
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213. Independent Police Conduct Authority, The Review: 222. Sophie M. Rose, Michael Paterra, Christopher Isaac,
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2022 (20 April 2023), p 20, https://www.ipca.govt.nz/ Tyrrell, Michael Guterbock, and Jennifer B. Nuzzo,
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2022 (20 April 2023), p 164, https://www.ipca.govt.nz/ Background paper to Te Tai Waiora: Wellbeing in
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the%20Policing%20of%20the%20Protest%20and%20 treasury.govt.nz/publications/ap/ap-22-01
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215. Independent Police Conduct Authority, The Review: (November 2021), p 7, https://www.police.govt.nz/
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2022 (20 April 2023), p 177, https://www.ipca.govt.nz/ New Zealand Police, Briefing to the Incoming
download/164247/20%20APRIL%202023%20IPCA%20 Minister of Police (July 2023), https://www.police.govt.
PUBLIC%20REPORT%20-%20Review%20of%20 nz/about-us/publication/briefing-incoming-minister-
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the%20Policing%20of%20the%20Protest%20and%20 Heidi J. Larson, and Alexandre de Figueiredo, ‘Global
Occupation%20at%20Parliament%202022.pdf Declines in Vaccine Confidence from 2015 to 2022:
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2022 (20 April 2023), p 11, https://www.ipca.govt.nz/ Classification Office, The Edge of the Infodemic:
download/164247/20%20APRIL%202023%20IPCA%20 Challenging Misinformation in Aotearoa (Wellington,
PUBLIC%20REPORT%20-%20Review%20of%20 June 2021), https://www.classificationoffice.govt.nz/
the%20Policing%20of%20the%20Protest%20and%20 resources/research/the-edge-of-the-infodemic/
CHAPTER 9:
9 Taking stock |
Te whakaaroaro: he
kōrero mō te urupare
ki te mate urutā
Introduction |
9.1
0.0 Kupu whakataki
At the start of this ‘Looking Back’ section, we said it would not be a detailed
chronological account of the entire pandemic and the Government’s response.
Instead, it has focused on some elements of both that affected people
particularly deeply, presented the biggest challenges to decision-makers,
and had lasting consequences (both unavoidable and avoidable) for
individuals, whānau, society and the economy.
We have therefore assessed the use of lockdowns, the closing of the border
and the introduction of compulsory quarantine and isolation. We have
examined how the health system functioned throughout the pandemic, and
the care available to those affected by (or vulnerable to) COVID-19 as well as
people needing treatment or services for other health issues. We have looked
at the acquisition and rollout of vaccines, and the use of compulsory measures
to achieve public health benefits. We have assessed the management of
the economy and the provision of economic and social supports, as well as
the engine that drove the entire response: the Government’s pre-pandemic
preparations and the plans, systems and strategies it formulated over time.
These are the areas where we think we can most usefully put our insights
to work, in the form of the lessons for the future and recommendations set
out in the next section. While consistent with our overall assessment that
Aotearoa New Zealand’s response (enabled by the hard work and sacrifice
of many individuals) was among the best in the world, they also reflect our
conviction that the response to the next pandemic must be even better.
But before turning to the future, we want to take stock of our learnings
looking back. Our analysis and assessment of what happened in the period
2020–2022 has – inevitably, but artificially – uncoupled the elements of the
pandemic response from one another. But if we consider them collectively,
what are they telling us? If we were to explain Aotearoa New Zealand’s
pandemic response to a future generation who did not live through it, what
story would we tell? We think it would unfold something like this.
The story of the response |
9.2 He kōrero mō te urupare: te ohorere,
te angitu me ngā whakawhitinga uaua
Although the rapid spread of COVID-19 around the world had caused concern
since the start of 2020, the magnitude and pace of events in March shocked
Aotearoa New Zealand. The global pandemic was no longer happening
elsewhere and to other people: it had reached our doorstep. Things that
had been unimaginable only a few weeks earlier quickly became reality –
international borders were effectively ‘sealed’, businesses and schools closed,
and the nation was locked down.
Initially, it was thought Aotearoa New Zealand’s best hope was to try delaying
COVID-19’s arrival and suppress any outbreaks for as long as it could – a goal
made more achievable by the country’s natural advantages as an island nation
distant from its nearest neighbours. Delay and suppression would give the
country time to prepare, especially the health system which (as had happened
in Europe) would otherwise be rapidly overwhelmed.
But, encouraged by the example of countries like Singapore, Aotearoa
New Zealand instead chose a more aggressive path: a complete national
lockdown accompanied by stringent public health measures, with the possibility
of eliminating the virus until a vaccine was available. Early signs of success
prompted decision-makers to move away from suppression as the backstop
strategy and instead fully embrace the elimination strategy. With the initial shock
passing, Aotearoa New Zealand resolved to keep going hard.
9.2.1 The pursuit of elimination

Once the elimination strategy was formalised in early April 2020, it provided
a coherent, easily understood national goal that was clearly communicated
and found widespread acceptance. So too did the ground-breaking Alert Level
System supporting it, which set out four levels of increasingly restrictive public
health measures. At Alert Levels 3 and 4, when ‘soft’ and ‘hard’ lockdowns were
required, these measures were undoubtedly stringent and created significant
stresses that escalated over time. But – in combination with border restrictions
and other tools – they were highly effective at preventing the virus from entering
the country and, when it did, stamping out chains of transmission. By the start
of June 2020, community transmission had been eliminated, at least for the time
being. This was a remarkable achievement.
People took heart from this initial success. And, despite the difficulties of
lockdown, they drew a sense of common purpose and collective achievement
from the knowledge that – by complying with the restrictions until most of the
population was vaccinated – Aotearoa New Zealand could return to normality
more quickly. This community solidarity was one factor in the effectiveness of
the elimination strategy throughout 2020 and much of 2021. Strong leadership
was another. Ministers and public health officials, most notably Prime Minister
Jacinda Ardern and Director-General of Health Ashley Bloomfield, were
exceptional in their public communications, something that was acknowledged
domestically and internationally.
The success of Aotearoa New Zealand’s elimination approach during 2020 and
into 2021 has earned global praise, and deservedly so. It stopped widespread
COVID-19 infection until most of the population was vaccinated and the virus
became less deadly. It prevented the premature deaths of thousands of
New Zealanders and ensured the health system was never swamped.
Importantly, the response’s benefits
went beyond public health. Holding
The success of Aotearoa fast to the elimination strategy allowed
New Zealand’s elimination Aotearoa New Zealand to spend
approach during 2020 and into less time in lockdown than many
2021 has earned global praise.
other parts of the world. It allowed
society and the economy to function
comparatively well at a time when
many other countries were facing
extreme disruption. The elimination approach was buttressed by economic
and social support measures that were rolled out quickly, generously and on a
‘least regrets’ basis, effectively cushioning many people and businesses from the
pandemic’s worst impacts while normal life remained on hold. These supports
meant that, once the initial shock had passed, economic activity and growth
bounced back quickly. There was no large-scale unemployment and workers
largely stayed connected to their jobs and workplaces, despite the lockdowns.
The potentially devastating effects of the pandemic on individuals and families
– both those already facing significant disadvantage and others who had never
needed to rely on social services before – were mitigated by government-funded
supports and services, and by the efforts of the network of agencies, non-
governmental and local organisations, iwi and Māori groups, volunteers and
many others who took them out into their communities. There is much to be
proud of.
However, as we discuss further, the longer-term human, social and economic
cost of pursuing elimination was high. With the benefit of hindsight, it is possible
to see that some harm might have been avoided or at least reduced if things
had unfolded differently. While of course we cannot be certain how other
response scenarios would have played out, they are worth reflecting on as we
look to the future. For example, had there been a higher level of preparation
before the pandemic, the goal of elimination might still have been achieved
without such a long and stringent initial lockdown.
9.2.2 The all-of-government response
Before COVID-19, Aotearoa New Zealand had a well-established civil defence
and emergency management system, led by the National Emergency
Management Agency. The Officials’ Committee for Domestic and External Security
Coordination could be activated in an event where all-of-government coordination
was required, and legislation was in place that gave the Government appropriate
powers to respond to an emergency.
However, while in principle this system was capable of managing the response to
a pandemic, in practice most agencies’ previous experience, tools and plans were
geared towards natural disasters and were not suitable for a national emergency
of the scale or duration of COVID-19. At the start of the pandemic it quickly
became apparent that the crisis was too big and multi-faceted for the Ministry of
Health to manage as the lead agency, and that a new all-of-government response
structure would be needed.
Ministers and officials, working at pace to put in place an all-of-government
response to COVID-19 in March 2020, described feeling as if they were flying a
plane at the same time they were building it, at speed and under extraordinary
pressure. While the pre-existing influenza pandemic plani had some useful
elements, there was no manual for dealing with something like COVID-19, and
little in the way of ‘muscle memory’ that could be activated.
Despite this, officials and agencies were remarkably quick in standing up the
systems, services and supports that would allow Aotearoa New Zealand to pursue
elimination. This is a particularly impressive achievement given that before
2020 New Zealand had not fully prepared all the measures that would be needed
for responding to something like COVID-19. For example, New Zealand lacked
large-scale contact-tracing and testing capacity, options for quarantining and
isolating large numbers of people, adequate building ventilation standards,
and sufficient capacity in hospitals to care for many sick people and patients
on ventilators. While some economic and social support schemes had been
set up for previous crises, they were not sufficiently developed – especially in
terms of targeting, delivery and accountability – for a response on the scale
the COVID-19 pandemic required.
i The New Zealand Influenza Pandemic Plan 2017.
In the event, the Government succeeded in maintaining the supplies and services
needed for life in lockdown. A generous wage subsidy scheme was announced
even before the borders closed. The first managed quarantine facility opened
within hours of compulsory quarantine for air travellers being ordered. The
contact-tracing workforce – from a low starting point – was rapidly scaled-up into
a national operation, equipped with a digital contact-tracing system, database
and trained staff.
Throughout the pandemic, decisions had to be made and implemented at pace,
in rapidly-changing and stressful circumstances, often with limited information
and little time to consult stakeholders and other agencies. In ensuring decisions
were informed by the latest public health intelligence, there was often limited
time to integrate other perspectives into advice. Agencies that needed to operate
collectively did not always have strong pre-existing relationships and had to
build these as the response was underway. Responding to COVID-19 required
ministers and officials to draw on unprecedented levels of commitment, effort
and fortitude – not just once, but repeatedly over many months.
The quality of agencies’ relationships with groups outside government was also
critical. The effectiveness of the response depended not only on public servants
and politicians, but on the private sector, iwi and Māori, Pacific and other ethnic
communities, non-government social service and health providers, volunteers
and many more. They could often do what central government could not. They
were known and trusted; they understood local or sector-specific needs; they
could reach individuals and families who might otherwise be overlooked. Yet
these groups were not always adequately consulted or relied on by government,
especially early on. The strength, leadership and capacities found within these
groups cannot be over-stated as prime enablers of the ‘government’ response.
The effectiveness of the response

depended not only on public
servants and politicians, but on
the private sector, iwi and
Māori, Pacific and other ethnic
communities, non-government
social service and health providers,
volunteers and many more.
9.2.3 Human impacts
A pandemic like COVID-19 affects everyone and every aspect of life in some way.
Negative consequences can never be entirely avoided, although their impacts
may be anticipated and mitigated to some degree.
Aotearoa New Zealand’s pandemic experience bore this out. Despite the
success of the elimination strategy, despite the evident effort within and
beyond government, and despite the introduction of measures to cushion the
pandemic’s effects, there was undoubted harm. In the first two years when
COVID-19 infection rates were low, this harm came less from the virus than from
the pandemic response itself. While delivering many benefits, the response had
negative impacts on the economy, society, individuals and families that were
significant, cumulative and unevenly distributed.
The pandemic had different impacts for different groups of people. Some
were impacted unequally and in ways that have been deep and lasting. Those
who went into the pandemic already experiencing health, economic or other
inequities were often disproportionately affected, such as Māori and Pacific
peoples. Others, were impacted in unique ways or suffered specific disruptions
to their life plans, such as essential workers, New Zealanders overseas or people
needing treatment for non-COVID-19 medical conditions. Some people fell into
multiple of these groups, such as those living in South Auckland, working in
essential industries (including managed isolation and quarantine (MIQ) and the
border), and with higher co-morbidities. Groups such as children and disabled
people were particularly impacted by certain restrictions. Aucklanders did it
particularly tough, spending more than twice as long in lockdowns as the rest of
the country.
The elimination strategy was the best way to protect all New Zealanders and
look after those at highest risk from a pandemic. By delaying widespread
transmission until most people had been vaccinated, the elimination strategy
prevented thousands of premature deaths from COVID-19 – particularly
among the elderly, those with existing health problems and those living in
disadvantaged circumstances.
9.2.4 Challenging transitions
The elimination strategy was one of the major strengths of the pandemic response,
and moving away from it was one of the biggest challenges. Once Aotearoa New
Zealand reached the point when elimination was no longer required or viable –
because the population was largely vaccinated, and the arrival of more easily spread
variants made elimination infeasible – a new strategy and set of public health
measures was needed. However, in the event, developing and communicating a
new goal post-elimination, and transitioning to a new way of managing COVID-19
that did not involve a ‘zero-risk’ approach to transmission, was not discussed or
‘socialised’ early or well enough. This proved to be one of the most challenging
periods of the pandemic.
For much of 2020/21, planning for recovery, preparing exit strategies and
considering possible future scenarios received less attention than they should have.
Complex and urgent operational decision-making absorbed the time and energy
of ministers and officials. The focus on ensuring the most up-to-date public health
intelligence and processes for providing advice under urgency meant there was less
scope for Cabinet to consider the trade-offs and longer-term impacts that would
normally form a key part of the decision-making process, or to consider possible
new pandemic and response scenarios.
The health system experienced similar challenges. The need to preserve capacity
in case of a surge of COVID-19 cases – and the increased demands of new infection
control measures – made it difficult to judge when there was scope to resume more
non-COVID-19 services (surgeries, other planned care, screening). In managing the
risk posed by COVID-19, the health system reduced provision of services for other
health issues – with consequences for those whose care was delayed or missed.
Once the more virulent Delta strain reached Aotearoa New Zealand in August 2021,
the country returned to lockdown. In most regions, it lasted a matter of weeks. But
Auckland (and sometimes neighbouring regions) stayed locked down for months.
In a city with the largest Polynesian population in the world, Māori and Pacific
peoples were hit especially hard. They were more likely to live in overcrowded
housing and work in essential industries (including MIQ), and they had lower
vaccination rates than other groups – all factors that increased their vulnerability
and made it hard to eliminate Delta transmission by means of the usual public
health measures. The decision to keep Auckland locked down until all population
groups had adequate vaccination coverage was laudable in intent, but the costs
(individual, social, economic, educational) were high and they were borne by all
Aucklanders and some in neighbouring regions.ii In addition to thinking about
coverage as a target for ending lockdowns, decision-makers needed to be
considering other matters at the same time – including waning immunity and
what that meant for average immunity across the population, and the impact
of time lags (given vaccination coverage can still be increasing once a lockdown
finishes and ‘catch’ any resurgence of infection rates).
ii Continuing Auckland’s lockdown until 90 percent vaccine coverage was reached was not necessary
on epidemiological grounds, although other considerations were also relevant.
As the economic and social costs mounted across the country, community
support for continuing restrictions began to wane. Businesses and families were
struggling, children’s learning was impacted, and people’s mental health was
affected. Many who had been quick to get vaccinated and had always complied
with restrictions now felt their efforts counted for nothing: they were still in
lockdown and a return to normal life seemed as far away as ever.
Even though the pandemic response was losing social licence, and eliminating
transmission of the virus was becoming more challenging, the Government
remained publicly committed to the elimination strategy. The discussion
started to change in early October 2021 when the Prime Minister suggested the
elimination strategy might be phased out – although without indicating what
could replace it or when. Then on 22 October, the Government announced that
Aotearoa New Zealand would shift to a suppression strategy in December, which
it described as ‘minimisation and protection’. Alert levels would be replaced by
a traffic light system.
This unheralded announcement was contentious, for many reasons. People felt
unprepared to start moving in a new direction, and the goals of the new strategy
were less clear (unsurprisingly, as suppression is an inherently messier strategy
than elimination). Many people who had felt protected by the elimination
strategy were now anxious about the health risks if COVID-19 was allowed to
become established, and there was not good information about what ‘living
with’ the virus might look like for people. Some criticised the timing of the shift.
Vaccination coverage among Māori and Pacific peoples was still below the 90
percent level which the Government’s health advisers had recommended should
be reached before adopting the ‘traffic light’ system.
After the transition to the suppression strategy, the pandemic response never
regained its initial clarity of purpose or the public support it had earlier enjoyed.
There was also increasing resistance to compulsory public health measures – face
masks, vaccine passes and especially the Government-issued occupational vaccine
‘mandates’ and employer-issued vaccine rules. These rules were expanded to
cover more categories of workers, with new guidance assisting employers in
setting their own workplace vaccination policies. Earlier in the pandemic, there
had been clear public health reasons for making certain measures compulsory
for specific settings or occupations, even though doing so constrained individual
rights. But vaccination was now being required in sectors or workplaces where the
public health benefit was less clear but where many employers and employees
considered them necessary for workplace health and safety.
The case for vaccine requirements (employer policies, vaccine passes and
some Government-issued mandates) became more finely balanced once
the highly transmissible Omicron variant became New Zealand’s dominant
COVID-19 strain in early 2022. International evidence was starting to show that
vaccination, including the Pfizer Comirnaty vaccine specifically, was considerably
less effective in preventing transmission of Omicron compared with previous
variants, meaning it was unclear how much vaccine requirements were
increasing people’s protection from being infected with COVID-19.
In light of this evidence, the Government might have considered removing
vaccine passes and mandate requirements in January and February 2022.
However, like most decisions made in a pandemic, this move would not have
been risk-free. Even if vaccines were not as good at stopping the transmission of
Omicron as other variants, it is likely they would have helped to flatten the first
wave to some degree. Vaccine requirements would also have helped dampen
down any outbreaks of the Delta variant, which it was feared could return.
Occupational vaccine mandates were updated to include a third dose, in line
with the Government’s decision to rapidly roll out vaccine boosters as Omicron
was arriving – a decision that saved many lives and relieved pressure on the
health system.
While some people were anxious about ‘living with’ the virus, for others the
persistence of measures such as vaccine requirements had a corrosive effect.
People became increasingly outspoken about the consequences they or others
were suffering – unemployment, loss of income, fractured relationships and
more. For some, the requirements became a symbol of a pandemic response
that had lost its way, becoming increasingly heavy-handed and devoid of
compassion. These sentiments partly fuelled the Parliamentary occupation
that ended violently in March 2022.
By this stage, core measures that had long scaffolded the pandemic response
were already being dismantled. Border restrictions and MIQ were gradually
reduced starting in February 2022. Employer vaccine policies, vaccine passes
and occupational vaccine mandates were progressively rolled back from
April 2022.
9.2.5 The long tail
By the time most pandemic response measures were removed, Aotearoa
New Zealand was in a significantly different place from where it had started
in March 2020. Collectively, the global pandemic and additional shocks like the
war in Ukraine left a legacy of economic, health and social after-effects, many
of which remain with us – cost increases, global supply chain problems, the high
cost of living, loss of learning, long COVID, poor mental health, loss of income,
business failures, broken relationships and widening inequalities among them.
From an international perspective, Aotearoa New Zealand’s pandemic response
was comparatively a positive one. New Zealand had one of the lowest health
losses from COVID-19 and fared comparatively well economically and socially,
at least in the short term. But the response could have been better still, thereby
preventing or lessening some of the long tail of consequences which this
country is still reckoning with. This provides the impetus for the lessons for
the future and recommendations we set out in Part Three Moving Forward.
New Zealand had one of the lowest

health losses from COVID-19 and
fared comparatively well economically
and socially, at least in the short term.
But the response could have been
better still.
Moving on |
9.3 Te neke whakamua
The story we have just sketched out is not simply a recital of events: like all
narratives, it invites us to draw meaning from what happened, to see patterns
and themes, and to recognise the significance of things that may not have been
noticed at the time. As commissioners charged with understanding the past so
the country is better prepared for the future, we have been immersed in this
story for the past two years. In essence, this is what it tells us should happen in
an effective pandemic response:
• put people at the centre of the response, protecting them as much as
possible from the pandemic’s direct harms while also minimising negative
impacts on other aspects of their lives;
• make good decisions that look after people – while also weighing up
different options, considering a range of factors, and being transparent
about necessary trade-offs;
• build resilience into the country’s health, economic and social systems to
ensure there is sufficient capacity to respond to the increased demands
of a pandemic;
• work in partnership – build, nurture and deploy strong relationships
and partnerships that make the best use of diverse skills, experience,
leadership and connections;
• get the fundamentals in place – ensuring there is effective all-of-
government preparation and planning for responding to pandemics
and other national risks.
With these high-level ‘takeaways’ in mind, we turn to the lessons for the future
and the recommendations which give effect to them.
Contents |
Ngā Kaupapa
Chapters
10 Lessons for the future 2
10.1 Overview 3
10.2 he context for our lessons for the future
T 5
10.3 Lessons for the future 15
10.4 Endnotes 69
11 Recommendations 71
11.1 verview of the recommendations
O 72
11.3 In brief: what the recommendations say 77
11.4 Complete table of recommendations 84
Appendices 104
A: An overview of legislation, emergency plans, systems
and structures supporting the COVID-19 response 104
B: An epidemiological overview of COVID-19 in Aotearoa New Zealand 129
C: Pandemic scenarios 164
D: Vaccine coverage and population immunity –
key considerations for lifting pandemic measures 178
Glossary 193
AOTEAROA NEW ZEALAND ROYAL COMMISSION COVID-19 LESSONS LEARNED • MAIN REPORT: PART 3 – MOVING FORWARD 1
CHAPTER 10:
10 Lessons for the future |

Ngā akoranga mō ā
muri ake
Overview |
10.1 Tirohanga whānui
Having reflected on what can be learned from looking back at

Aotearoa New Zealand’s response to the COVID-19 pandemic,
we now turn to the future. This chapter outlines six thematic
lessons that we believe should be learned from and acted on
before the next pandemic.
Before outlining these lessons in detail, it is worth pausing to reflect on how much
the global context from which they are drawn has been fundamentally shaped by
the events of the COVID-19 pandemic itself. The pandemic was a transformative and
disruptive worldwide event. It expanded what the world knows about pathogens,
their origins and spread, and how science and data can help us prepare for and
combat future pandemics. It graphically demonstrated the extraordinary reach
pandemics can have in a highly mobile and connected world. COVID-19 touched
nearly every aspect of people’s lives, producing social and economic effects of
great breadth, severity and duration. And it also brought home the challenges of
responding well to such an event.

This chapter consists of two sections. In the first, we make eight big-picture
observations about how the global context has shifted as a result of the
COVID-19 pandemic, shaping the context for the lessons we draw for the future.
These observations, in brief, are:
COVID-19 expanded international understanding

of pandemic pathogens.
Pandemics require a different kind of response from most

other emergencies because of their scale and duration.
Resolute, clear and strategic leadership is a formidable asset during a

pandemic emergency, coupled with strong social cohesion and trust.
The increasing challenge of misinformation and disinformation

is an issue for pandemic responses.
Pandemics require anticipatory governance, and long-term

planning and investment.
A highly connected world has changed how pandemics are experienced;

this creates both risks and opportunities when managing them.
COVID-19 expanded the strategic response options that can be

deployed in a pandemic.
There are many ways to respond to a pandemic, even within

a single strategy.
In the second section, we present these six thematic lessons for the future. These
describe the high-level elements we think are necessary to ensure Aotearoa New
Zealand is better prepared for the next pandemic ahead of time, and ready to respond
in ways that take care of all aspects of people’s lives. These lessons, in brief, are:
Lesson 1: Manage pandemics to look after all aspects of people’s lives.

In practice, this means:
1.1 Put people at the centre of any future pandemic response.
1.2 Consider what it means to ‘look after all aspects of people’s
lives’ from multiple angles.
Lesson 2: Make good decisions. In practice, this means:

2.1 Maintain a focus on looking after all aspects of people’s
lives in pandemic preparedness and response.
2.2 Follow robust decision-making processes (to the extent
possible during a pandemic).
2.3 U
se appropriate tools when developing and considering
policy response options.
2.4 Be responsive to concerns, clear about intentions and
transparent about trade-offs.
Lesson 3: Build resilience in the health system. In practice, this means:

3.1 Build public health capacity to increase the range of
options available to decision-makers in a pandemic.
3.2 Enhance the health system’s capacity to respond to
a pandemic without compromising access to health services.
Lesson 4: Build resilience in economic and social systems. In practice, this means:
4.1 Foster strong economic foundations.
4.2 Use economic and social support measures to keep
‘normal’ life going as much as possible.
4.3 Ensure continuous supply of key goods and services.
Lesson 5: Work together. In practice, this means:

5.1 Work in partnership with Māori.
5.2 Work in partnership with communities.
5.3 Work closely with the business sector.
Lesson 6: Build the foundations. In practice, this means:

6.1 Anticipate and manage the risks posed by a future
pandemic (alongside other risks).
6.2 Have key components of an effective national response
in place and ready to be activated
These lessons for the future lay the groundwork for our final recommendations,
which follow in the next chapter.
4 AOTEAROA NEW ZEALAND ROYAL COMMISSION COVID-19 LESSONS LEARNED • MAIN REPORT: PART 3 – MOVING FORWARD
The context for our lessons for
10.2 the future | Te horopaki mō ngā
akoranga mō ā muri ake
Our collective experience of COVID-19 may have brought

challenges and loss, but it also gave us some valuable
resources – new knowledge and tools, a renewed awareness
of the things we value most as individuals and societies,
deeper understanding of the systems and services we will
rely on in a crisis, and a broader portfolio of response and
support options.
As a result, the national and international context within which the next pandemic
arises will be different from the start of 2020. In particular:
COVID-19
expanded international understanding
of pandemic pathogens.
We may never know the source of the COVID-19 virus. Whether it arose from the
virus spilling over from bats or another mammal to humans, or – less likely but still
possible – from a pathogen leaking from a virus research facility.
Both scenarios can be prevented – or at least the probability of either occurring
again can be reduced. Prevention is the best form of pandemic preparedness, and
Aotearoa New Zealand actively supports many of the key international pandemic
prevention efforts now underway. They range from reducing risks at wet markets
and discouraging incursions of human settlement into high-risk areas, to improving
global surveillance systems so cross-species jumps can be stamped out as early
as possible. Work is also underway to build strong and effective mechanisms
that encourage countries to report worrying outbreaks early, and fully, to the World
Health Organization (WHO) and the global community.
COVID-19 also significantly changed the world’s understanding of how respiratory
viruses spread. Before COVID-19, it was not entirely certain which of the three
main forms of transmission (droplet, aerosol and fomite or surface transmission)i
was the most significant. But definitive evidence emerged during the pandemic
that SARS-CoV-2 (and probably other respiratory viruses as well) is mostly spread
through aerosol transmission. Aotearoa New Zealand and Australia played an
important role in demonstrating this phenomenon, providing compelling evidence
from MIQ facilities of international arrivals in hotel quarantine becoming infected by
‘air’ wafting from one room to another via hotel corridors when doors were opened.
This knowledge underscores the critical role of ventilation and air flow in a
pandemic and has implications for the design of many indoor environments
– including schools, hospitals and quarantine facilities. It demands that more
attention is given to limiting aerosol transmission in high-risk settings, from
doctors’ waiting rooms to hospitality venues.
i Fomite transmission occurs when someone touches a surface on which particles have been deposited; droplet
transmission is when a large infectious particle is expelled directly from one person’s airway into that of another in
close proximity, and aerosol transmission occurs when small infectious particles ‘float’ in the air after being expelled
until they are inhaled by another person (who may have been some time or distance away).
Here again, COVID-19 reinforced the growing understanding that, if worn
properly, masks are effective in limiting the spread of respiratory viruses. Even
if the next pandemic pathogen has a shorter incubation period (making contact
tracing less effective), decision-makers now know that masking, ventilation and
air filtration will go a long way towards dampening transmission. Much can be
done ahead of time to ensure these measures are in place and ready to use.
Finally, the pandemic was a powerful reminder of the ability of pathogens to
change their stripes. What we saw from 2020 onwards was a virus being constantly
selected for a fitter variant that could infect people more easily, spread faster
and evade immunity (due to previous infection or vaccination). The extraordinary
capacity of the COVID-19 virus to mutate had consequences; the arrival of the highly
transmissible Omicron variant saw immunity from vaccination begin to wane just as
high levels of population coverage were achieved. Luckily the Omicron variant was
less virulent than earlier strains. But Aotearoa New Zealand should not rely on lucky
breaks in the next pandemic: we need to be prepared for a similarly sophisticated
future pathogen, and one that is more deadly.
The mutability of the COVID-19 virus points to the importance of scenario
thinking in pandemic preparations and response. Drawing on all the new and
enhanced knowledge about pathogens now available, experts need to identify
a range of potential pandemic scenarios and their likelihood so decision-makers
can consider the implications and possible mitigations. In addition, there must
be open public discussion of possible pandemic scenarios, what response
options are feasible and cost effective – and what trade-offs may be required.
Our lessons draw on this insight.
andemics require a different kind of response from most

P
other emergencies because of their scale and duration.
Aotearoa New Zealand is well practised in responding to natural disasters
like earthquakes or severe weather events. Our civil defence and emergency
management system has been designed to provide an integrated approach
to managing emergency events at any local or regional size. The system is
underpinned by the Coordinated Incident Management System (CIMS), allowing
all those involved to use a common tool and ‘speak the same language’.
But responding to a global pandemic has differences, in terms of both scope
and scale. While a pandemic may present as a public health crisis, it has ripple
effects across many aspects of society that the response needs to address. In
Aotearoa New Zealand, this meant the response involved a much broader
range of agencies, non-governmental and community groups than was typical
of other emergencies; including many people who were unfamiliar with CIMS
and other practices.
Moreover, unlike other emergencies, people are usually the vector in a pandemic.
As we saw with COVID-19, stopping the spread of an infectious disease may require
protective measures that affect the whole population – whether or not they are sick
or symptomatic yet. A precautionary approach in the next pandemic may require
blanket restrictions to be put in place before fuller information about how the virus
spreads becomes available.
This situation puts decision-makers in something of a bind. Successful pandemic
responses rely on high levels of social trust and cohesion. When they are present,
people are more likely to comply with public health measures, trust decision-makers
and evolving scientific evidence, support each other through lockdowns and other
challenges, and accept their own freedoms being restricted in order to protect others.
Yet if a pandemic response requires measures that are all-encompassing and drastic,
these are likely to erode trust and cohesion over time. During COVID-19, Aotearoa
New Zealand experienced both high social cohesion and then its gradual erosion.
The country’s starting point for a future pandemic will be different as a result.
It is important to act fast at the start of a pandemic and adopt a ‘least

regrets’ approach – but it is also important to keep an eye on the long-term
social and economic consequences of decisions.
Throughout a pandemic response, governments must constantly balance
the short- and long-term effects of their actions and policies. Keeping people
employed and maintaining their incomes so they can feed and house their
families is obviously an immediate goal in a people-centred pandemic response.
Underdoing initial economic and social support can impose unnecessary costs and
losses that risk creating longer-term harms for people, business and communities:
at this stage, a ‘least regrets’ approach is justified.ii However, overdoing the level
of support will create long-term costs (in the form of debt, cost of living increases
and productivity losses), and may require longer-term consolidation or even
austerity – with all their associated hardships. In the early days of a pandemic,
it is hugely challenging to make the right decisions that ensure the response is
neither underdone nor overdone.
Governments will be judged not only on how many lives they save in a pandemic
or how well they achieve their initial strategic objectives (very well, in the case of
the early success of New Zealand’s elimination strategy) but also on the country’s
long-term economic and social health – including whatever scars the response may
have caused (or exacerbated). Decision-makers must therefore distinguish between
short-term and long-term priorities when formulating policies; they should not let
the urgent and immediate undermine the important and long-term.
ii As we explained in Chapter 6, a ‘least regrets’ approach is one that aims to minimise the risk of the worst possible
outcomes.
Decision-makers should also be prepared to adjust their thinking about risk as
the pandemic response evolves. As the initial uncertainty diminishes, it makes
sense to move away from a default precautionary and near-zero risk tolerance for
infection to a more balanced approach to risk. Knowledge about the characteristics
and risks of the pathogen (for example, how easily it transmits through the air, or
who is most at risk of dying if infected) will continuously evolve. This will change
how the effectiveness of potential policy response options is assessed (for example,
whether masks and ventilation reduce transmission risk, or whether contact tracing
will be effective). As more time passes, the risks associated with the supporting
economic and social measures will start to increase. Even in the shorter term,
various ‘non-essential’ activities – such as horizontal construction, certain outdoor
activities and access (albeit regulated) to a wider range of retail outlets – may be
able to operate in relative safety as more is learned about managing the
risk for a new pandemic pathogen.
It is of course important that the pandemic response avoids causing harm to key
areas of the economy and society. This makes good long-term sense. Similarly, as
the pandemic and the response evolve, some adjustments should be considered
to reduce potential harms including, for example, impacts on productivity and
disengagement of learners from the education system.
Resolute, clear and strategic leadership is a formidable

asset during a pandemic emergency, coupled with strong
social cohesion and trust.
Aotearoa New Zealand’s unified collective response to COVID-19, especially
in the first year, was a source of strength and a significant factor in the success
of the elimination strategy. It was made possible by strong, consistent and
clear leadership, combined with deep reservoirs of social cohesion and trust
in government and experts that had built up over time. Other countries that
lacked this kind of social capital and trust in institutions did not fare as well.
Our country’s experience of COVID-19, and the international evidence available,
together suggest that going into a pandemic with high stocks of trust and social
cohesion may be just as important as large stockpiles of PPE and a strong national
balance sheet. But equally, the New Zealand experience showed the extent to
which a pandemic can erode trust in institutions within sections of society, and
cause polarisation. The extent and speed of that erosion could be held in check if
decision-making during the response is transparent, seen to be fair by the majority,
and respectful and accommodating of the minority. This is where strong leadership
and effective communication – about decisions, their objectives and the trade-offs
involved, as well as listening carefully to those affected – is paramount.
Even so, leaders and decision-makers everywhere face real challenges when
it comes to establishing and maintaining social trust and cohesion. Unsurprisingly,
the COVID-19 pandemic confirmed the extent to which societies have changed
since the last major global pandemic in 1918. Attitudes to authority, public trust
in governments and public institutions, faith in science and religious institutions,
the proliferating sources of information people rely on, and even the fundamental
concept of truth – all have been shaken or changed profoundly.
Populations are now vastly more diverse and heterogenous, meaning one
message or form of communication may work well for one group but not for
another. Trust levels vary hugely between population groups, as do attitudes
to compliance. Some people like to be told precisely what to do, while others
want to know the desired outcome and find their own way to best achieve it.
Such factors have major implications for regulation and sequencing.
The increasing challenge of misinformation and

disinformation is an issue for pandemic responses.
The way that people share and consume information has been transformed
over the past 20 years. While the rise of digitalised media has offered considerable
benefits, it has also propelled the spread of false or misleading information across
the world. This comprises both misinformation (incorrect information which
is shared by those who honestly believe it is factual) and disinformation (false
information which is deliberately shared, sometimes by state actors, to cause
harm or achieve a particular aim). In Aotearoa New Zealand, the circulation of
false information – whether on direct pandemic matters such as vaccines, or other
societal issues – added to the social fractures we saw developing over the course
of the pandemic.
Of course, this dynamic is not unique to pandemics. The contexts in which it
occurs, and the underlying causes are many and varied.1 So too are potential
ways to counter it, and technology companies, the education system (which
can equip citizens to be more discerning) and experts all have roles to play.
At the same time, it is vital to preserve freedom of speech – including the
freedom to express views that may run counter to what the Government of the
day is proposing – and the ability to robustly critique knowledge. The value of
both was repeatedly underlined throughout the COVID-19 pandemic. For
example, it was important for experts and citizens to ‘speak up’ on issues like
vaccine mandates, which were opposed by some school principals and healthcare
providers. Similarly, it was vital for experts to help inform the public on important
issues relating to COVID-19.
No society has yet ‘solved’ the problem of misinformation and disinformation.
In our Inquiry, we discussed the issue with many people and heard a wide
range of views. We have no definitive solutions to propose. But we do think it is
important that society keeps working to tackle the issue – including by listening
empathetically to those who take this information seriously and by disagreeing
respectfully if others hold to different views from ourselves. In another pandemic,
it is also important that decision-makers balance whatever response measures
and restrictions they are considering against the value of free speech and valid
scientific and expert debate.
andemics require anticipatory governance,
P
and long-term planning and investment.
Like climate change, a pandemic is an example of what is sometimes called a ‘wicked’
policy problem: unclear, complex, cutting across different systems, underpinned by
unclear causal relationships, and liable to result in unanticipated consequences.
COVID-19 amply demonstrated the difficulties of responding to problems like these.
The lack of straightforward (and politically palatable) solutions is perhaps one reason
why so many countries were ill-prepared. Before 2020, many countries had already
categorised pandemics as a highly probable risk. Yet, globally, there had been little
consideration of plausible scenarios or the potential ripple effects that restrictive
public health measures could have across wider society and the economy.2
Responding better to the ‘wicked’ problems which pandemics raise will require
a shift in thinking towards what the OECD terms ‘anticipatory innovation
governance’ – taking a proactive approach that embeds foresight, innovation
and continuous learning into policy and investment decisions.3 Such an approach
means decision-makers preparing for a range of future pandemic, economic
and social scenarios, helping to stress-test response options, identifying
vulnerabilities and opportunities, investing wisely and cost-effectively for the
long term, and being prepared to respond swiftly and flexibly as required.
Tools are available to help decision-makers make these difficult judgements –
particularly scenario thinking, planning and modelling. Before and during the
next pandemic, we think these should play a much stronger role in preparation
and decision-making.
We also believe we need to shift the default thinking (among experts and across
society more broadly) from ‘we do not know when the next pandemic will occur
and what it will be like’ to ‘we can assign probabilities to future pandemic scenarios
and the frequency with which they might occur; therefore we can quantitatively
prioritise investment and planning before the next pandemic and optimal response
options during it.’ While there will always be uncertainty about the next pandemic
– where it will come from, how severe it will be – we can still quantify scenarios,
response option costs and consequences, and therefore manage risk.
One tenet of anticipatory governance which is especially relevant for future
pandemics is the value it places on managing crisis and strategy in tandem:
“ One excellent technique is to manage chaos and innovation in parallel:

The minute you encounter a crisis, appoint a reliable manager or crisis management
team to resolve the issue. At the same time, pick out a separate team and focus
its members on the opportunities for doing things differently. If you wait until the
crisis is over, the chance will be gone.” 4
Elsewhere in this report (see especially Chapter 2), we have described what this
‘separate team’ would look like in a pandemic response. We envisage a strong,
strategically-focused group which – while others deal with immediate and
operational matters – is thinking ahead, considering scenarios, and developing
options to respond to them. It will also be using dynamic learning techniques,
and documenting response lessons as it works. The need to have and protect this
strategic function has been highlighted in other countries’iii COVID-19 inquiries.5
highly connected world has changed how pandemics

A
are experienced; this creates both risks and opportunities
when managing them.
As we have already acknowledged, since the world last experienced a pandemic
on a similar scale to COVID-19, global connections between people, institutions
and markets have grown exponentially. We have become accustomed to living
in a world in which capital, goods, knowledge, people, cultures and trends cross
borders at dizzying speed – even for countries like Aotearoa New Zealand, which
are geographically isolated.
The COVID-19 pandemic confronted us with a virus that could travel round the
world far faster than ever before. This brought home to us the many consequences,
positive and negative, of New Zealand’s isolation and reliance on international
connections. We also saw the importance of connectedness at a national level, and
what could happen when vital connections were disrupted. For example, an industry
not designated as essential may have to stop making a by-product required by
another industry that is considered essential, significantly affecting that industry’s
ability to operate until a solution can be found.iv
Our size and geographic isolation were undeniable assets when it came to
stopping the virus, giving us response options that were not available to other
countries. However, the same factors also created vulnerabilities. The pandemic
exposed Aotearoa New Zealand’s heavy reliance on international supply chains
that were long, thin and complex. New Zealand has a small, open economy that
depends on trade and the easy movement of people (workers, students and others)
and goods and (increasingly) services in and out of the country. We are often at
the furthest end of the supply chain: something we use every day might have been
designed in Italy, funded in London or New York, machined in Thailand and finished
in Australia before it reaches New Zealand. With borders effectively closed, and
delays to ships being able to unload their cargo and manufacturing scaled back or
completely halted, we saw the fragility of that chain. Disruption to just one part was
shown to have consequences for the whole.
iii This includes, for example, the Dutch Safety Board (which emphasised the need to take a broad approach and invest
in scenario-based thinking) and the UK COVID-19 Inquiry (which has recommended the development of a UK-wide
whole-system civil emergency strategy and the adoption of new scenario-based approaches to risk management).
iv In Chapter 6, we described what happened when the Kinleith Mill’s forestry and wood processing operations were
not initially considered essential, despite the fact the mill is Aotearoa New Zealand’s only supplier of chlorine (which it
produces as a by-product) for drinking water.
Aotearoa New Zealand’s supply chain vulnerability was heightened by its use of
‘just in time’ delivery which, though efficient in normal times, meant goods that
were essential in the pandemic (PPE, for example) were sometimes in dangerously
short supply or had to be used past their expiry date. We return to the challenges of
maintaining strong supply chains in a pandemic in Lesson 4.
People’s ability to move freely across international borders – a routine expectation
in our highly-connected world – was also a casualty of the pandemic. In 2021,
only 800,000 traveller movements were recorded across New Zealand’s border,
the lowest in 50 years, and only around 5 percent of the 14.2 million movements
in 2019. The curtailment of international travel inflicted considerable damage
on sectors like tourism and hospitality, and highlighted New Zealand’s economic
reliance on the international trade in services. Moreover, it exposed the fragility
of the rights of New Zealanders living overseas to return home, and the ability of
foreign nationals in this country to return to their country of origin.
On the plus side, however, it was thanks to greater global connectedness that
the latest scientific knowledge and research about COVID-19 became available
almost immediately. The speed with which it was disseminated meant it could
inform countries’ pandemic responses and planning, while also helping to counter
misinformation and disinformation. In addition, international relationships
and collaboration were instrumental in the development and distribution of
effective vaccines. And since the worst of the pandemic has passed, we have seen
multilateral efforts to better prepare the world for future pandemics – such as the
revised International Health Regulations, ongoing work to forge a global pandemic
accord and various initiatives to improve poorer countries’ access to vaccines.
Developments like these demonstrate how international connectedness can be a
force for good when it comes to building resilience to future pandemic shocks.
COVID-19 expanded the strategic response options that

can be deployed in a pandemic.
COVID-19 demonstrated that countries – especially island states, which enjoy the
additional benefit of geographic isolation – have options about how to respond to
pandemics, including pursuing elimination (‘stamp it out’) or exclusion (‘keep it out’)
strategies. Until COVID-19, it was assumed that in a global pandemic, the pathogen
would inevitably sweep through all countries and could not be kept at bay. ‘Keep
it out’ was a relatively short-term tactic to buy time to plan and prepare for the
inevitable, and not envisaged as a strategy to create enough time for the population
to be vaccinated before opening up. This assumption was reflected in New Zealand’s
pandemic plan,6 similar plans in other countries, and in WHO guidance. But the
COVID-19 experiences of Aotearoa New Zealand and some other countries, such as
Australia and Taiwan, showed otherwise. Providing they act early and fast enough,
countries can opt to keep the pathogen out or (repeatedly) stamp it out. They can
keep doing so until they are ready to let the virus in and exit from an elimination
strategy on their own terms and at the time of their choosing.
This option is especially feasible when the pathogen in question sits in what might
be called the ‘goldilocks’ zone – when it is sufficiently virulent and infectious to have
major adverse effects if a country aims only to mitigate or suppress it, but not so
infectious that it cannot be eliminated or stamped out when outbreaks occur. The
COVID-19 virus was in that goldilocks zone.
However, such an approach comes with costs – particularly the economic and
social impacts of shutting down or severely restricting the flow of people across
borders, which need to be carefully weighed up when deciding to pursue either
elimination or exclusion approaches. Nonetheless, the COVID-19 experience has
empowered governments to at least consider the option of imposing tight border
restrictions. Not only was that prospect almost unimaginable before COVID-19 –
it also contrasted sharply with WHO’s initial view that keeping border restrictions
in place for the medium term was unfeasible and too much of a barrier to
international trade and mobility.
Is it really feasible to exclude a pandemic pathogen like the COVID-19 virus by
effectively closing the borders before any infection has the chance to become
established? We argue ‘yes’, if it has been carefully considered and planned for
in advance. Aotearoa New Zealand’s experience in 2020 and for much of 2021
demonstrated that an elimination strategy is an effective medium-term strategic
option for pandemic pathogens of sufficient severity; with the right combination
of public health measures, and high levels of public support, we saw that such
pathogens can be eliminated even after they have gained a foothold in the country.
From there, it is only a small step in counterfactual thinking to consider what could
have happened if we had restricted entry at the international border earlier and
more stringently. If the WHO’s declaration of the novel coronavirus as a ‘public
health emergency of international concern’v on 31 January 2020 had come a week
earlier, and if Aotearoa New Zealand had planned for the possibility of closing
borders faster, the COVID-19 virus might not have entered New Zealand at all
in February and March – and we could have avoided the first national lockdown
entirely. Even if we did not completely stop the virus from arriving, with well-
prepared contact tracing, quarantine and isolation systems in place, it would have
been possible to ‘stamp out’ the odd outbreak (though the occasional soft or hard
lockdown might still have been needed).
v Note that the WHO has now defined a pandemic emergency within the International Health Regulations that will
trigger more effective international collaboration in response to events that are at risk of becoming, or have become,
a pandemic. This change was agreed on 1 June 2024.
In the next pandemic, rapidly deploying an exclusion strategy early on may well
be a viable option for Aotearoa New Zealand – providing the necessary plans and
investment decisions are made in advance. Implementing such a strategy in the
uncertain initial days of a pandemic would not be easy. There is inherent risk in
deciding to close the border swiftly – namely, that the pandemic pathogen turns
out to be less severe than originally thought, and neither exclusion nor elimination
strategies are warranted. But such risks do not lessen the need to engage in
scenario thinking, planning and modelling before the next pandemic. Decision-
makers need to be better-equipped to gauge the likely balance of benefits and
harms of such a strong precautionary approach.
There are many ways to respond to a pandemic, even within

a single strategy
The tools and tactics at Aotearoa New Zealand’s disposal in a pandemic include
vaccines, therapeutics, public health and social measures (ranging from encouraging
physical distancing through to mandating hard lockdowns), masks, contact tracing,
isolation of cases, quarantine of contacts and international (and even inter-regional)
arrivals, regional borders, school closures, restricted gathering sizes, and better
ventilation and filtration of air in buildings. The global experience of COVID-19
showed that the better these tools and tactics are prepared – and the greater the
willingness of the population to collectively implement them – the more likelihood
that our chosen strategy will succeed and deliver greater benefits with less harm.
For example, if excellent contact-tracing, isolation and quarantine capacity and
capability are in place before the next pandemic (providing the virus in question
is amenable to such things), there will be less need for New Zealand to use
measures such as lockdowns that people found more unpalatable or were more
harmful in the COVID-19 pandemic. Likewise, decision-makers may choose next
time to prioritise people attending tangi and funerals – which we know was a
contentious and distressing issue for many during COVID-19 – and ‘offset’ that
risk via another response measure (such as encouraging and requiring more
high-quality mask wearing). Or they may choose to take a little more risk by
allowing schools to stay open more and offset it by encouraging as many adults
as possible to work from home.
Given the array of tactical choices which leaders can use in various combinations to
achieve their chosen strategy, the challenge will be to arrive at the ‘sweet spot’ that
maximises the benefits and minimises the costs. Developing better understanding
of the choices to be made, the impacts of each and the settings required to
implement them should be part of Aotearoa New Zealand’s preparations for
the next pandemic (see also our discussion of anticipatory governance).
Lessons for the future |
10.3 Ngā akoranga mō ā muri ake
Overview | Tirohanga whānui

With the fundamental global observations and context from the previous section
in mind, we now turn to the specific lessons Aotearoa New Zealand can learn for
the future. These lessons describe the high-level elements we think are necessary
to ensure the country is fully prepared for the next pandemic ahead, and ready to
respond in ways that take care of all aspects of people’s lives. In our earlier chapters
and reflections, we have been looking at COVID-19 through the rear-view mirror.
Now we turn our attention to the road ahead.
The overarching lesson from COVID-19 (Lesson 1) is that we need to manage
pandemics to look after all aspects of people’s lives. This means recognising the
broad range of impacts that a future pandemic may have on all aspects of people’s
lives in Aotearoa New Zealand – and balancing the responses to minimise both
immediate and long-term harms. The remaining five lessons for the future flow
from the first. Figure 1 shows how the lessons work together.
Figure 1: Lessons for the future and how they fit together
Lessons 2 to 6 reflect what we have learned about what it would mean to
prepare for and respond to a future pandemic in a way that looks after all
aspects of people’s lives.
Lesson 2: Make good decisions. In order to look after people in a pandemic,
decision-makers need to keep sight of the overall purpose of the response while
being adaptable in how this is achieved. They also need advice and evidence that
helps them weigh up different options and strike a balance between different
priorities and values. What is needed to ‘look after people’ will change as the
pandemic evolves and the balance of benefits and harms of various policy
options shifts over time.
Lesson 3: Build resilience in the health system. Looking after people’s health
is a core part of any pandemic response. Strengthening public health capacity will
expand the tools available to reduce the risk of pandemic infection. This can reduce
their reliance on more restrictive measures (such as lockdowns). Capacity is also
needed in the healthcare system so this can meet the demands of safely caring for
those who become infected while also delivering other essential health services.
Lesson 4: Build resilience in our economic and social systems. Any pandemic
response needs to look after the social, economic and cultural aspects of people’s
lives. In order to do this, New Zealand’s social and economic systems need to be
resilient and have the capacity to ‘step up’ during a crisis. People are the most
important resource, but we also need tools and processes for identifying and
reaching those who need support during a pandemic.
Lesson 5: Work together. Looking after people in a pandemic means all parts
of society need to be involved. Communities, businesses, faith groups, NGOs
and tangata whenua are able to reach people and do things beyond the scope of
government agencies. Building relationships and recognising the value of others’
approaches are important preparation for working together in a pandemic.
Lesson 6: Build the foundations for future responses. Looking after people
means thinking about what would be needed in a future pandemic response and
acting now to ensure this is in place ahead of time. It’s not possible to predict the
exact nature of the next pandemic, or the economic and social situation in which it
might occur, but there are tools (such as scenario planning) that can give a sense
of the range of challenges a future government might need to respond to. These
should inform what’s prioritised in the work of pandemic preparation and where
Aotearoa New Zealand should focus its resources – including the tools and systems
needed to look after all aspects of people’s lives.
Lesson 1: Manage pandemics to look after all aspects of
1 people’s lives | Akoranga 1: Te whakahaere mate urutā hei
tiaki i ngā āhuatanga katoa o te ao o te tangata
In brief: What we learned for the future about looking after

all aspects of people’s lives
In preparing for and responding to the next pandemic:

• Lesson 1.1 Put people at the centre of any future pandemic response
• Lesson 1.2 Consider what it means to ‘look after all aspects of people’s
lives’ from multiple angles
Overview
While pandemics are first and foremost public health emergencies, Aotearoa
New Zealand’s COVID-19 experience demonstrated that managing a pandemic
is also about much more than controlling an infectious disease. The pandemic –
and the Government’s response to it – affected every part of people’s lives – health,
social, economic and cultural. Preparing effectively and responding well to a future
pandemic will therefore require involvement from across both sectors and society.
The COVID-19 pandemic was also a reminder of what matters most for people.
Humans are social beings whose lives are made meaningful by the strength and
value of our relationships and connections. Physical health and wellbeing matters,
of course, but so do whānau and family, friendships, livelihoods and the freedom
for individuals and communities to choose and pursue what is important to them,
even during a crisis like a pandemic.
These insights are an important reminder of the core purpose of pandemic
preparedness and response – looking after all aspects of people’s lives. In practice,
this means:
• Looking after all aspects of people’s health – protecting them from infection,
while also looking after their wider physical, mental and emotional health.
• Looking after the broader aspects of people’s lives – looking after their
social, economic and cultural interests.
• Looking after people in the future as well as the present – making sure
that actions and decisions in the moment take account of what may be
needed in times to come.
What’s needed to ‘look after people’ may change over time. Sometimes, multiple
objectives may be in tension with each other. Recognising and responding to this
will require decision-makers to weigh up different options and balance potentially
competing priorities and values. This is covered in more detail in Lesson 2.
When it is understood that the purpose of pandemic management is looking
after all aspects of people’s lives, it becomes clear that pandemic preparedness
and response need to take a broad approach. The centrality of this purpose was
encapsulated by the Chair of our counterpart inquiry in the United Kingdom,
Rt Hon Baroness Hallett DBE, in the introduction to her Inquiry’s first report: ‘The
primary duty of the state is to protect its citizens from harm’.7 While it will be up
to future governments to determine exactly how to prepare for, approach and
respond to a future pandemic, and what weight to put on different forms of harm,
it is hard to imagine any pandemic scenario in which protecting and supporting
people through the crisis is not the primary focus.
Lesson 1.1 Put people at the centre of any future

pandemic response
Many people, groups and organisations in Aotearoa New Zealand draw
inspiration from the well-known whakataukī: He aha te mea nui o te ao? He tangata,
he tangata, he tangata (What is the most important thing it the world? It is people, it
is people, it is people). Embedded in this whakataukī is a challenge – before taking
an irreversible action, consider: what will it mean for people?
Early in the COVID-19 pandemic, many people in Aotearoa New Zealand had a
strong sense that the response was intended to look after them. While daily life was
fundamentally changed by the introduction of border restrictions and lockdowns,
strong messaging to ‘Unite against COVID-19’ and ‘be kind’ gave many people a
sense that the Government was acting in their best interests. Many of our public
submitters expressed gratitude for this decisive and empathetic approach, drawing
attention to the contrast between the quiet streets in Aotearoa New Zealand
during the first Level 4 lockdown in 2020, and images of the devastating impact
of COVID-19 in parts of Europe and North America.
Over time, however, this sense of being looked after began to fade for some
people. Measures such as gathering restrictions that were intended to keep
people safe from the virus became a cause of distress and harm. We heard from
some submitters that, in minimising the risk of infection, it sometimes felt as
though people were being denied the things that made their lives worthwhile.
Some New Zealanders who were overseas felt forgotten or abandoned by their
home country.
The challenge for future governments will be to ensure that people – and all
the things that make their lives meaningful – are kept at the centre of any
pandemic response. Pandemic policies and measures should be evaluated not
only for their efficacy in minimising infection, but also for the impacts they have on
people’s lives. There will be times when it is necessary to use measures that come
with significant costs or restrictions. But COVID-19 has underscored the importance
of fully considering the impacts of pandemic response measures on all aspects of
people’s lives – both short- and long-term – and taking this into account as much
as possible when deciding when and for how long to deploy such measures.
Lesson 1.2 Consider what it means to ‘look after all aspects
of people’s lives’ from multiple angles
It is important to take a broad perspective on what looking after all aspects of
people’s lives means during a pandemic, and to embed this across all elements
of the response. This is partly acknowledged in the recent interim update to
New Zealand’s Pandemic Plan, which sets the following ‘key objective’:
“ The key objective of this plan is to minimise deaths, serious illness and significant
disruption to communities, the health system and the economy arising from a
pandemic associated with a respiratory infection.” 8
As we learned during COVID-19, people’s lives and quality of life can be

threatened not only by a pandemic pathogen, but by the response itself. Mental
health may be challenged by long periods in lockdown. Jobs and incomes may
be lost. Families may be painfully separated or exposed to damaging stress and
violence. Delays in accessing ‘business as usual’ healthcare may lead to people
dying or becoming seriously unwell from other illnesses. There may even be
longer-term, intergenerational impacts, such as loss of learning from school
closures, or lack of housing affordability from response measures accelerating
existing economic trends.
There are numerous models and frameworks that future decision-makers and
officials can use to inform their understanding of what matters to people and
what it means to look after all aspects of their lives during a pandemic. These
include (but are not limited to):
• Aotearoa New Zealand’s human rights framework, comprised of a
mix of domestic laws and various United Nations treaties and rights
declarations which New Zealand has ratified. Te Tiriti o Waitangi is
also part of this framework.
• Outcomes frameworks developed by agencies to inform their work,
such as Treasury’s Living Standards Framework.
• Models developed for specific population groups, such as children and young
people, Māori, Pacific peoples and other ethnic communities.
• Holistic models of mental and physical health, such as the outcomes
framework developed by Mental Health and Wellbeing Commission |
Te Hiringa Mahara.
Using such models and frameworks can give decision-makers confidence that
they have identified a wide range of potential impacts from various pandemic
response measures and support sound decision-making about which measures
to use and in different circumstances.
Aotearoa New Zealand’s COVID-19 experience demonstrated that a pandemic’s
impact will be unevenly distributed – especially if efforts to mitigate unequal impacts
are insufficient. As set out in the ‘Looking Back’ section of the report, especially
in Chapter 6, even with a proactive policy response, the COVID-19 pandemic and
associated response measures disproportionately affected Māori, Pacific people,
women, disabled people and others, even with a proactive policy response.
Many actions by policy makers and communities helped to reduce these impacts.
For example, food parcels and other forms of grassroots support were part of
the tremendous wraparound support provided to many communities during
the first lockdown. But some efforts could have been more effective through, for
example, earlier engagement of Māori and Pacific providers in the vaccine
rollout (see Chapter 7).
Making use of the kinds of models and frameworks set out in this lesson can also
help to flush out how different individuals and groups may experience a pandemic
differently. Recognising that it will never be possible to completely mitigate every
potential negative or unequal impact with an optimal policy response package, a
people-centred future pandemic response should nevertheless aim to anticipate
these were possible, consider the overarching purpose of the response, apply
ethical principles to guide decision-making including trade-offs, and augment
population-wide or universal policies with targeted policies as appropriate. Making
use of a wide range of models and tools can inform effective planning for how
to do this in a way that looks after all aspects of life for a wide range of people
– recognising a pandemic is still going to see ‘losses’ in many domains. This will
also help to ensure that underlying inequities and existing disadvantages are not
exacerbated during a future pandemic.
Aotearoa New Zealand’s COVID-19

experience also demonstrated
that a pandemic’s impact will
be unevenly distributed.
Lesson 2: Make good decisions |
2 Akoranga 2: Te tuku whakatau pai
In brief: What we learned for the future about making

good decisions

Lesson 2.1 Maintain a focus on looking after all aspects of people’s
lives in pandemic preparedness and response. In practice, this means:
2.1.1 Consider and plan for multiple time horizons simultaneously
2.1.2 Make more explicit use of ethical frameworks to balance different
rights, values and impacts over time
Lesson 2.2 Follow robust decision-making processes (to the extent possible
during a pandemic). In practice, this means:
2.2.1 Seek out a range of advice and perspectives
2.2.2 Make use of times when the situation is stable to look
ahead and plan for what might come next
2.2.3 Anticipate and plan for burnout
Lesson 2.3 Use appropriate tools when developing and considering
policy response options
2.3.1 Identify a wide range of possible policy response options
2.3.2 Compare the impacts of different policy response options
to make good decisions
2.3.3 Use modelling and scenarios to inform decision-making
Lesson 2.4 Be responsive to concerns, clear about intentions and
transparent about trade-offs
2.4.1 Engage stakeholders, partners and the public in key
decisions, to the extent possible in the circumstances
2.4.2 Be transparent about how different considerations have
been weighed against one another.
2.4.3 Clearly signal in advance where the response is heading,
to help people navigate periods of uncertainty and transition.
Overview
In the early days of the COVID-19 pandemic, the Government made many hard
decisions (such as imposing border restrictions and quarantine requirements)
quickly and under pressure. The elimination strategy, once adopted, provided a clear
purpose and touchstone for such urgent decisions. However, as the pandemic wore
on – especially in the second half of 2021 – the goal of (re)eliminating community
transmission began to move out of reach. This made pandemic decision-making
more challenging, especially because there had been limited capacity to consider
and plan for other options and scenarios (including how to move on from a
zero-transmission target).
Good pandemic decision-making must be responsive to changing circumstances
and take account of cumulative effects. In a future pandemic, it will be important
for decision-makers to keep sight of the overall purpose of the response, while
also having a degree of flexibility about how this is achieved.
Depending on the situation and context, the decisions necessary to look after all
aspects of people’s lives may need to shift over the course of a pandemic response.
For example, the kinds of actions taken in a situation where no vaccine is available
will differ from those required in a situation in which nearly everyone is fully
vaccinated. Good decision-making processes that can anticipate and accommodate
a changing context, lead discussions with the public to keep them abreast of likely
scenarios, and maintain focus on people’s economic, social and cultural interests
become crucial in such situations.
The role of a lessons-focused Inquiry such as ours is not to stipulate exactly
what decisions should be made in a pandemic (either in the now-past COVID-19
pandemic, or in any future pandemics). Rather, our role is to identify factors and
processes that will ensure strong options and robust analysis and advice are
available to future decision-makers.
A critical tool in the pandemic decision-
making toolkit is identifying and planning
Good pandemic decision-making for a range of likely pandemic scenarios.-
must be responsive to changing This can support good decision-
circumstances and take account of making before a pandemic by helping
cumulative effects. governments prioritise investment to
manage the most likely pandemic-related
risks (discussed further in Lesson 6), and
during a pandemic by helping decision-
makers predict how the pandemic
Depending on the situation may evolve and plan for changes or
and context, the decisions transitions in the response. It can also be
necessary to look after all used to estimate the impact of different
aspects of people’s lives may
measures or policy responses at specific
need to shift over the course
of a pandemic response.
points in the pandemic, helping decision-
makers evaluate different options and
their likely benefits and harms.
Lesson 2.1 Maintain a focus on looking after all aspects
of people’s lives in pandemic preparedness and response
Consider and plan for multiple time horizons simultaneously
At the start of any future pandemic, decision-makers will need to react to the
immediate threat and do whatever is necessary to protect people from imminent
harm. At the same time, however, they should ensure that planning for the longer
term – including for the recovery phase – gets underway as soon as possible.
Without this dual focus on both the immediate situation and the longer-term
picture, there is a risk that the response remains in a reactive mode for too long,
or fails to effectively identify, anticipate or mitigate wider impacts.
An effective pandemic response requires dedicated, future-focused planning to
be carried out separately from (but in parallel with) the immediate operational
response. Our ‘Looking Back’ analysis suggests that a separate strategic function
responsible for keeping the evolving ‘big picture’ in mind as the COVID-19 pandemic
evolved would have strengthened Aotearoa New Zealand’s response. This needs
to be staffed by people with the right skills and attributes – preferably identified
in advance.
Both before and during a future pandemic,
there may be value in mapping out the
overall pathway the Government expects to An effective pandemic response
follow in managing the response. Achieving required dedicated future focused
the goals of the response is likely to involve planning to be carried out separately
several distinct phases, each with its own from (but in parallel with) the
strategy and specific aims. Mapping the immediate operational response.
likely stages on this pathway ahead of time
may help decision-makers to prepare to
transition between response phases. Such
mapping could also help to identify potential indicators or targets that might trigger
a change in strategy (see Figure 2 for an indicative example for COVID-19), and
help the public, stakeholders and experts to understand the overall direction of the
response and prepare accordingly.
Of course, such mapping needs to be alive to the possibility that the anticipated
trajectory of the pandemic may change – due (for instance) to changes in the
pathogen, shifts in public compliance with control measures, or the early, late or
unexpected arrival of a new tool to combat the virus. In Aotearoa New Zealand’s
COVID-19 response, for example, the Government had to adapt its strategy when
it became apparent that the Delta variant was unlikely to be eliminated. Continually
adjusted scenario planning will help the strategic part of the response consider
and plan for the medium- and long-term time horizon.
Figure 2: An indicative pathway through the pandemic response
(based on COVID-19 experience)
Make more explicit use of ethical frameworks to balance different rights,

values and impacts over time
In our view, Aotearoa New Zealand’s leaders generally did well at juggling the
ethical complexities during the COVID-19 response. It was clear from our
engagements and evidence that ministers and officials were aware when ethical
principles were at play and took a thoughtful approach to considering and
balancing them. However, it seems the use of ethical principles to inform
decisions during the COVID-19 response was largely intuitive.
We think there is value in making more explicit use of ethical principles that
can consistently and transparently guide decision-makers. These principles could
be applied at all levels of the response – from the allocation of clinical resources
to individual cases, through to Cabinet level decisions about prioritising vaccination
rollouts, or balancing public health measures, such as lockdowns, against their wider
impacts. While the same principles apply to both pandemic planning and pandemic
response, the relative importance of each principle may shift. For instance, greater
weight may be placed on protecting health and wellbeing in the early stages where
there is less information about the virus.
It is generally much easier for people to accept difficult decisions when they
understand (or even endorse) the principles and values that sit behind them
and see how they have been used to arrive at a decision. As the World Health
Organization (WHO) has commented, without such discussion response efforts
could be hampered:
“ A publicly-discussed ethical framework is essential to maintain public trust, promote

compliance, and minimize social disruption and economic loss. As these questions
are particularly difficult, and there will be insufficient time to address them effectively
once a pandemic occurs, countries must discuss them now while there is still time for
careful deliberations.”9
Several existing ethics frameworks have been specifically designed for this purpose.
One of the most globally influential is promoted in the Oxford Handbook of Public
Health Policy.10 Based on a Canadian model,vi the guiding values from this framework
are intended to be useful in any jurisdiction. As this was published pre-COVID-19,
and has a strong focus on healthcare settings, it is likely that it will soon be updated
to reflect learnings from COVID-19, including the much wider range of impacts
a pandemic can have. This approach distinguishes between substantive values
(values that guide what decisions are made during a pandemic) and procedural
values (values that guide how decisions are made during a pandemic).
Table 1: Values to guide ethical decision-making in a pandemic
Substantive values (values that guide what decisions are made in a pandemic)
• Individual liberty • Reciprocity
• Protection of the public from harm • Equity
• Proportionality • Trust
• Privacy • Solidarity
• Duty to provide care • Stewardship
Procedural values (values that guide how decisions are made during a pandemic)
• Reasonable • Responsive
• Open and transparent • Accountable
• Inclusive
Source: Based on Oxford Handbook of Public Health Policy, 2019 and University of Toronto Joint Centre for
Bioethics, 2005, A report of the University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group,
https://jcb.utoronto.ca/wp-content/uploads/2021/03/stand_on_guard.pdf
In 2007, the National Ethics Advisory Committee had also published a set of
ethical guidelines for epidemics and pandemics for use in Aotearoa New Zealand.11
After COVID-19, the National Ethics Advisory Committee began updating its
pandemic guidance, holding extensive public consultations in 2022.12 There
was strong support for a pandemic response that prioritised people’s health
and wellbeing, and moderate support for efforts to protect the most vulnerable
– including by providing greater support to those with greater needs (such as
disabled people, older people and Māori). Submissions highlighted the public’s
strong expectation that, in a pandemic, freedoms should be protected as much
as possible, and the Government should justify the use of restrictive measures.
Responses also emphasised the importance of transparent decision-making and
clear communication about the principles and evidence used in making decisions.
The National Ethics Advisory Committee’s guiding principles for a pandemic
(shown in Figure 3) are specific to Aotearoa New Zealand and offer localised and
culturally relevant guidance. At the time this report was completed, an updated
(post-consultation) version of the Committee’s pandemic guidance was due
to be published (Figure 3 reflects this latest version).
vi Published in 2005, the Canadian framework was developed by researchers at the University of Toronto following
the Severe Acute Respiratory Syndrome (SARS) outbreak in 2002-2003. The table produced here is a summary only.
For a full version including a description of each value, see the sources listed in endnote 10.
Figure 3: National Ethics Advisory Committee’s updated guiding principles
for an epidemic or pandemic
Manaakitanga: implementing measures that are intentioned, respectful, and demonstrate

caring for others. Establishing mutually beneficial communication and collaboration pathways.
Tika: implementing measures that are ‘right’ and ‘good’ for a particular situation, through being
open and transparent. Cultivating trust between decision-makers and the people they impact.
Liberty: implementing measures that uphold human rights, including liberty and privacy.
Equity: implementing measures that eliminate or reduce unjust inequities in health outcomes
for different groups of people and achieve Pae Ora for all.
Kotahitanga: implementing measures that strengthen social cohesion through

empowering local government, leaders and communities to be active participants
in the planning and response.
Promoting health and wellbeing: implementing measures that protect and uplift the four
cornerstones of Te Whare Tapa Whā health model: whānau health, mental health, physical
health and spiritual health. Healthy individuals and whānau turn into healthy communities
and a healthy population.
Source: Based on information from the National Ethics Advisory Committee (Ministry of Health), 2022, Ethical Guidance
for a Pandemic (Draft report) https://neac.health.govt.nz/
Both the Oxford Handbook and the New Zealand frameworks set out core values
and principles that can guide decision-makers towards a people-centred
pandemic response. It is important that the principles and processes used by
decision-makers during the crisis are visible to the public, both before the next
pandemic for discussion and input, and during the next pandemic as a framework
to progress decisions. It will be important for future governments to regularly
engage with the public about what it is that they value, to ensure that decision-
makers explicitly consider and communicate these trade-offs in an empathetic
and accessible manner.
Lesson 2.2 Follow robust decision-making processes

(to the extent possible during a pandemic)
An emergency response often requires decisions to be made quickly and with
limited information or consultation. Normal decision-making processes may need
to be modified, abbreviated or (in situations of extreme urgency) temporarily set
aside to enable a rapid response. For example, in urgently deciding to introduce
very tight border restrictions to prevent or exclude the arrival of a new pandemic
agent, decision-makers may need to act without receiving comprehensive advice
on alternative options or hearing from a broad range of stakeholders.
But there are risks to suspending these processes, and these risks increase over
time. Without comprehensive advice and consideration of diverse perspectives,
decision-makers may become overly focused on a particular set of objectives.
They may also be less aware of changing public concerns and expectations, or the
unanticipated consequences of the decisions they make. This narrowing in focus
and awareness is often referred to as ‘group think’ – a situation in which alternative
options or important evidence may be overlooked.
A key lesson from the COVID-19 response is therefore the importance of following
robust decision-making processes and actively encouraging the expression of diverse
points of view, to the extent that circumstances and time allow. When decisions must
be made quickly, the range of processes and tools will be limited to those that can
be employed by a small group of decision-makers and advisors. Whenever possible,
however, more comprehensive consultation, advice and discussion should be brought
to bear. What this looks like will depend on the urgency of the situation and is likely
to require a degree of pragmatism. But decision-makers must be aware there may be
a trade-off between speed and robustness. More comprehensive consultation and
advice takes time, but also protects against the risks of poor decision-making, group
think and loss of social licence.
While they may sometimes feel slow, the decision-making processes normally
followed within Government – including the time needed for comprehensive
consultation and the development of
advice – are designed to support good
decisions. They should be truncated Whenever possible more
during a crisis only to the extent necessary, comprehensive consultation, advice
and resumed as early and fully as possible and discussion should be brought
to ensure decision-makers have the best to bear in decision-making.
advice to inform their decisions.
Seek out a range of advice and perspectives

While the breadth of input will be determined by the time available, Governments
should still seek out advice and perspectives on what is happening, what might
happen and how they might adjust their approach to meet changing pandemic
circumstances. It is important to create a culture where both advisors and decision-
makers feel empowered to contest the advice and present different views on how to
achieve the best outcomes.
In both preparing for and responding to a future pandemic, decision-makers
(and their advisers) should therefore actively seek out:
• Advice from different public sector agencies, including local government,
on policy options for dealing with a range of plausible scenarios.
• Data and intelligence (including emerging scientific evidence, modelling,
qualitative and quantitative data, and international experience and insights).
• Wide-ranging expertise from many disciplines and sectors – biomedicine,
science, economics, behavioural and social sciences, Te Ao Māori, businesses,
human rights organisations and more.
• Input from stakeholders and key partners, including iwi and Māori and
other community groups who play key roles in designing, operationalising
and delivering the response.
• Public opinion data which tracks people’s attitudes to the pandemic and
response and indicates how they may respond to future decisions.
Make use of times when the situation is stable to look ahead and plan
for what might come next
In the early stages of a pandemic response, when little is known about the
pandemic pathogen, a precautionary and risk-averse approach is likely to be the
most appropriate. But once the immediate threat has been addressed, and as more
information becomes available, decision-makers may find some breathing space
where they can consider if the initial approach is still appropriate – and what might
come next.
Such a breathing space was available to New Zealand decision-makers in
mid-2020, when the combined effect of national lockdowns, border restrictions,
quarantine requirements and other public health measures eliminated COVID-19
transmission in the community for 100 days. This was a significant opportunity
to regroup, take stock and look ahead – but (as set out in Chapter 2) it may
not have been used to full effect.
While it is important to keep the possibility of changing scenarios in mind all
the time, in a future pandemic, decision-makers should be alert to opportunities
presented by periods of relative stability and ensure they are used well. At these
times, decision-makers have more opportunity to take in the ‘big picture’, and
review the medium- to long-term strategy to check that the response is still on
track to achieve its overall goals.
Anticipate and plan for burnout

Throughout our Inquiry, we were constantly reminded of the extraordinary
effort and commitment of leaders, officials and others who – under great pressure
– set up the initial response to COVID-19 and enabled the success of the elimination
strategy. However, they paid a heavy price. As we saw in Chapter 2, the pressure
was relentless, the situation was constantly changing, and people were working
for long stretches in unfamiliar and sometimes difficult environments. Burnout
was common.
It is difficult for decision-makers to remain adaptable and innovative – and to juggle
managing the day-to-day pandemic response with planning for the next phase –
when they are exhausted. Based on our findings, this was one reason why leaders
struggled to develop and communicate a forward-looking plan for moving on from
the elimination phase, despite the breathing space that opened up in mid-2020
when Aotearoa New Zealand was COVID-19-free.
The next pandemic response is likely
to be no less challenging and the
Decision-makers should be alert demands on decision-makers will be
to opportunities presented by similarly unrelenting. For this reason, it
periods of relative stability and is vital to embed workforce resilience
ensure they are used well. and sustainability, and plan workforce
capacity ahead of time.
Lesson 2.3 Use appropriate tools when developing and
considering policy response options
The COVID-19 pandemic presented complex and dynamic problems, and
the possible policy responses were numerous. For decision-makers in Aotearoa
New Zealand and elsewhere, coming up with bespoke policy options under
pressure, and then understanding and comparing the costs, benefits and
trade-offs between these options was a constant challenge. Much can be done
now to ensure this process is easier in the next pandemic.
Identify a wide range of possible policy response options

Having just experienced the COVID-19 pandemic, we expect many agencies
will be better prepared with a set of potential response options ahead of a
future pandemic. It is important not to be complacent about this, and to ensure
that the lessons learned and future policy options developed in response to
COVID-19 are well-documented and regularly reviewed and updated. Preparing
options for a future pandemic should be part of the ongoing work of all
government agencies, including:
• identifying potential policy and response options (for example, are contact
tracing, isolation and mask wearing sufficient to eliminate transmission or do
we need to impose lockdowns?)
• anticipating design and implementation considerations (for example, how
should geographical boundaries be determined and implemented if regional
lockdowns are used?)
• considering the potential flow-on implications for other systems (for example,
what implications will border restrictions have for New Zealanders overseas,
the labour market and supply chains?)
• estimating the potential impacts on people (for example, what are the health
benefits of lockdowns versus the impacts on other aspects of people’s lives –
employment, relationships, education, mental health?), and
• identifying potential vulnerabilities and gaps that should also be addressed
(for example, how will supply chains for essential medicines and products
be maintained in the context of dramatically limited global transportation?).
This work should draw from a range of policy tools and frameworks, including
human rights frameworks and te Tiriti o Waitangi. It is important to prepare options
with reference to multiple potential pandemic scenarios (considering factors related
to the pathogen, as well as economic and social factors), to test how they may
perform under different circumstances.
Compare the impacts of different policy response options to make
good decisions
With a clear and comprehensive list of options available, it is important to then
consider the relative impacts of each option against the goals sought – just like
any other business case. Two common tools for systematically weighing up the
costs and benefits of different options are:
• Cost Benefit Analysis (CBA) which offers a structured approach to evaluate
the economic pros and cons of various options. By quantifying benefits and
costs, it supports informed decisions to achieve agreed objectives.
• Multi-Criteria Analysis (MCA) which can accommodate a wider range of
criteria, making it suitable for complex decisions involving diverse factors. This
method can help to make trade-offs between the different visible outcomes
and support options being explicitly assessed against ethical principles.
These tools – and others – can support decision-makers to select optimal
combinations of policies by weighing the financial investment in a policy against
its likely success at reducing harmful impacts of the pandemic, while also
considering the risk of new or ‘unintended’ consequences of the policy itself.
Such tools require good data inputs and integrated epidemiological, social and
economic modelling alongside expert analysis and advice on qualitative aspects
like the impact on people’s freedom and human rights, or likely outcomes for
specific groups.
Spotlight:
Making complex decisions in a pandemic |
Te whakatau tikanga matatini i tētahi mate urutā
While more than 80 percent of people in Aotearoa

New Zealand had received two doses of the COVID-19
vaccine by November 2021, it was known that protection
from vaccination generally waned over time.
Cabinet was therefore asked to consider rolling out COVID-19 booster doses
alongside the continuing drive to get more people to have the initial course.
Since the pandemic began, the Government had been clear that maximising
vaccine uptake was essential to allow the country to move on from repeated
lockdowns and stringent public health measures.
Ministers had to weigh up multiple factors – including the cost of administering
additional doses, evidence of booster effectiveness, whether requiring the
vaccination programme to roll out booster doses might detract from its efforts
to maximise overall vaccination coverage, and the possibility that new COVID-19
variants might emerge just as the country was beginning to open up. Ministers
were also conscious that Māori and Pacific people had lower vaccination coverage
and were at higher risk of severe COVID-19 disease compared with other groups.
Cabinet received advice from the Ministry of Health, the Treasury, and the Ministry
of Foreign Affairs and Trade on the complex factors they needed to weigh up.
The advice included explicit consideration of vaccine supply issues and of the
implications for Māori, children and young people and older people if boosters
were rolled out.
Cabinet ultimately decided to proceed with a targeted booster rollout which
prioritised those at highest risk of exposure and illness (including health workers,
everyone aged 65 years or over, Māori and Pacific people aged 50 years or over,
and people especially at risk from the virus due to other health conditions). It
began in late November 2021. The booster rollout accelerated in the new year as
Omicron got closer, with the required time to wait between having the second dose
and the booster reducing to five months, and then four months, and becoming
available to a wider age range. This successful booster rollout ensured those groups
most vulnerable to the virus had high levels of protection when the country’s first
substantive COVID-19 ‘wave’ arrived in March 2022. This probably saved hundreds
of lives and reduced pressure on the health system.
31
This example illustrates many of the elements of good
decision-making we consider essential in the next
pandemic response:
• Leaders remained committed to the objective of maximising
vaccine-related protection while adapting how this was achieved
as the situation changed.
• With support from advisors, they reviewed evolving evidence (on
levels of primary vaccination, the duration of protection and groups
at greater risk from COVID-19 infection) and weighed up potentially
competing objectives (maximising overall population coverage,
compared with optimising protection for the most vulnerable).
• While the extent of broader consultation is unclear, as is the use
of tools such as cost-benefit analysis, input was sought from several
government agencies and explicit attention was paid to the needs of
particular groups.
• Finally, the decision to proceed with the booster programme,
and the reasons for it, were communicated to the public clearly
and transparently.
32
Use modelling and scenarios to inform decision-making
Modelling and scenario thinking can be particularly useful tools to support good
decision-making in a pandemic response. Indeed, they will likely be essential to
underpin the tasks set out in this lesson. Modelling can be used to indicate how
key indicators (such as rates of infection or hospitalisations) are likely to evolve
in response to specific interventions or policy options, helping decision-makers
evaluate different options and weigh up the trade-offs involved. The World Bank,
OECD and WHO have all recently emphasised the importance of modelling
that integrates epidemiology, health and economic domains as part of future
pandemic preparedness.13
Modelling was a useful input in many key decisions during Aotearoa New Zealand’s
COVID-19 response. Modelled projections of COVID-19’s health impacts under
different approaches were a key catalyst for the initial decision to ‘close the border’
and place the country in lockdown, while later decisions about moving up and down
alert levels were also informed by modelling. The Inquiry heard that modelling
evidence was particularly helpful when it combined projected impacts across
multiple domains (for example, economic as well as health indicators). The potential
uses of modelling are also expanding rapidly as technology advances, making it
faster and easier to test sensitivity to different inputs.
While modelling is a useful input, it is not a panacea for selecting optimal policy
responses. Models rely on assumptions about the impact of particular measures
and can only give an approximation or estimate of what may happen if they are
implemented. Moreover – and especially in the context of a pandemic – the sheer
complexity of many policy options and their associated trade-offs cannot be
captured in a single quantitative framework. It is therefore important that modelling
is treated as a guide and considered alongside other inputs, including the views of
key partners, stakeholders, experts and the wider public.
While modelling is a useful input,

it is not a panacea for selecting
optimal policy responses.
Spotlight example:
Responding to changes in risk and vaccine-related protection |
Te urupare ki ngā huringa o te mōrea me te ārai ā-rongoā āraimate
A key consideration in any pandemic response is the

availability and impact of vaccines.
Based on experience with COVID-19, vaccination rates are likely to be an important
consideration in decisions about if and when to use and/or relax strict measures
such as lockdowns. But it will be critical to monitor emerging scientific evidence
on the effectiveness of vaccination, especially if the pandemic pathogen mutates
frequently and/or protection from vaccination wanes over time (as was
the case with COVID-19 on both counts).
In situations where the protection from vaccination does wane over time, it is
not vaccine coverage that should be the ‘target’ for when to loosen public health
measures, but the estimated immunity in the population (see Appendix D). As such
evidence on waning emerges, it should be factored into any modelling alongside
other variables as soon as possible.
Time lags also matter for decisions about when to introduce or stand down public
health restrictions. Experience during COVID-19 in a range of jurisdictions is
that it can take several weeks – if not months – for a new epidemic wave to gain
momentum after restrictions are relaxed.
While information about vaccination levels often informed decisions about when
to end stringent COVID-19 public health measures, different jurisdictions used this
information in different ways. In Australia, for example, the states of New South
Wales (NSW) and Victoria both moved out of lockdowns when their populations
reached 70 percent vaccination coverage on 11 and 22 October 2022, respectively14
– about six weeks before the Auckland Delta lockdown ended. Daily case numbers
for Victoria and NSW are shown in Figure 4, and demonstrate that case numbers did
not surge following the lifting of restrictions.
34
Figure 4: Daily cases of Delta in New South Wales and Victoria,
and end dates of their lockdowns
Source: Based on data from COVID LIVE Australia, 2024, COVID LIVE, https://covidlive.com.au/
Deciding when to relax public health restrictions is a delicate balancing

act. The experiences in New South Wales and Victoria suggest it is
possible to remove lockdown restrictions before completing a vaccination
rollout without this leading to an immediate resurgence of cases. While
there is some risk involved with lifting lockdowns at lower levels of
vaccine coverage, relying on a lag in case rate resurgence to ‘bridge over’
to higher vaccination coverages is something that could be considered in
a future pandemic response. Appendix D provides further analysis of how
consideration of such factors could provide evidence to support decisions
about lifting stringent public health measures in future.
35
Lesson 2.4: Be responsive to concerns, clear about intentions and
transparent about trade-offs
While an effective pandemic response requires strong leadership, it also requires
a high degree of confidence and trust in public institutions and decision-makers
from the general public, Māori, communities of all kinds, businesses, and key
partners and stakeholders the Government works with. Decision-makers are more
likely to retain this kind of confidence and trust when the reasoning behind their
decisions is transparent and clearly communicated, when their decisions are open
to scrutiny and debate, and when they demonstrate willingness to revisit and (if
necessary) modify decisions as circumstances change. It is important for people to
see leaders being responsive to their needs, concerns and recognising the impact
of decisions on people’s health, social, economic and cultural interests.
Engage stakeholders, partners and the public in key decisions, to the extent
possible in the circumstances
As COVID-19 demonstrated, opportunities for direct discussion are often limited
during a pandemic for logistical reasons. This makes it more difficult and
time-consuming for government to undertake meaningful engagement with
stakeholders, partners and the public. While urgent pandemic decisions can (and
often should) be made quickly without broad consultation or engagement, in the
longer-term this approach can create the impression that decision-makers are
unaware of – or unresponsive to – people’s concerns. It also increases the risk
that decision-makers and advisers may misread public sentiment, underestimate
the strength of feeling around particular issues, or lapse into ‘group think’.
Taking time to engage the public, Māori, communities, businesses and key
partners ensures decision-makers are aware of important concerns and receptive
to suggestions about how they might be addressed. It also helps build trust in
government and can support better public understanding of the need for decision-
makers to balance potentially competing objectives or values. This is likely to be
particularly important in a pandemic, when the needs and priorities of different
groups must sometimes be explicitly weighed against each another.
Meaningful engagement is more likely to occur when the Government has
already built relationships and processes for dialogue. Decision-makers and
advisors should draw on these established connections as much as possible
to support decision-making in a pandemic. Lesson 5 explores wider lessons
about working together with Māori, communities and business to achieve
shared goals.
Aotearoa New Zealand’s COVID-19 experience showed that when decisions need
to be made quickly, pre-existing approaches to engagement might not be suitable.
In such instances, it may be necessary to develop more rapid and pragmatic forms
of engagement such as the creation of advisory panels (including representatives
from relevant groups). In periods of greater stability, more comprehensive forms
of engagement should be undertaken ahead of major decisions, such as changes
in public health strategy and longer-term recovery options.
In our engagements with groups who felt alienated by the Government’s
response, or who had major concerns with some of the approaches taken
during COVID-19, we encountered a wide range of views and some common
themes. Some of the points raised with us seemed reasonable (such as calls for
greater consideration of and engagement with New Zealanders finding it difficult
to return home). In future situations, there could be opportunities to avoid or
mitigate some of these concerns.
In our view, some more direct government engagement with groups voicing
disquiet at aspects of the response would be valuable during a future pandemic.
Perspectives should be listened to openly as this can help with weighing up the
benefits and harms of policy options. Even when agreement cannot be reached
about the preferred overall policy response, such engagement can give people
confidence that their point of view or opposing position has at least been listened
to, and that their concerns are being considered when weighing up trade-offs
as part of the decision-making process. This can in turn reinforce and support
social cohesion to some degree. However, such engagements should be carefully
considered on a case-by-case basis – we are not advocating that busy leaders
should meet with groups that have no real interest in being constructive.
In other jurisdictions, innovative approaches such as citizens’ juries and other
deliberative formats are being used to engage members of the public on complex
policy issues. Ireland, for example, uses Citizens’ Assemblies to help the government
address important challenges. Approaches like these can allow decision-makers
to take account of public views and values when assessing options and considering
trade-offs.15 However, they take considerable time (including for preparing and
selecting participants) and for this
reason are unlikely to be feasible
during the emergency phase of a
pandemic response. As part of the
More direct government engagement
Government’s preparation for a
with groups voicing disquiet at aspects
pandemic, such approaches could of the response would be valuable
offer useful insights into how the during a future pandemic. Perspectives
public want their leaders to make should be listened to openly as this
decisions in an emergency. can help with weighing up the benefits
and harms of policy options.
Be transparent about how different considerations have been weighed
against one another
During the COVID-19 response, governments around the world had to repeatedly
weigh up different objectives and values, and then judge how best to balance
them. This was especially important when making decisions that placed constraints
on people’s human rights (such as restricting the return of citizens from overseas,
limiting domestic movement, and using vaccine mandates). In Aotearoa New Zealand
– as in other countries16 – the judgements underpinning these decisions were not
always made public (or done so explicitly and with clarity). This meant people did
not always understand why particular decisions were made, or how introducing
or removing measures might affect the risks facing specific groups.
Decision-makers often had good reasons for not wanting to advertise how they
were choosing to balance different priorities in the COVID-19 response. For
example, the decision to protect Pacific communities and Māori – who were at
greater risk from the Delta variant – was a key factor in the decision to maintain
the Auckland lockdown in late 2021; however, leaders were reluctant to make
this reasoning public in case of a public backlash against these communities. But
deciding not to share the reasons behind such decisions came at a cost. Over time,
some people lost trust in the Government or felt it didn’t care about the harm
caused by restrictive public health and social measures. Others started to feel
the Government was withholding information from them or making decisions
based on a hidden agenda.
COVID-19 showed us that governments need to be willing to share information
with the public, however difficult or uncomfortable, in order to retain their trust in
government, public institutions and the response. This means being upfront with
people about the level of risk different groups may face, and why this may influence
certain trade-offs. It also means acknowledging that decisions may change or be
reversed as the situation evolves and relevant trade-offs are revisited. In the longer
term, it is essential for maintaining social licence as the response, and the process
of balancing objectives and risks, continues to evolve.
COVID-19 showed us that

governments need to be willing
to share information with the
public, however difficult or
uncomfortable, in order to retain
their trust in government, public
institutions and the response.
Clearly signal in advance where the response is heading, to help people
navigate periods of uncertainty and transition
Experience with COVID-19 – in Aotearoa New Zealand and elsewhere – shows how
challenging it is for leaders to retain public confidence through difficult transitions
in the pandemic response. While such transitions and changes of direction due
to new events – such as a new variant – cannot be avoided, it is easier to retain
people’s confidence when they have had prior warning and understand why
they are necessary. Failure to do so risks undermining people’s confidence in
government in the longer term.
It is important that, at regular intervals, leaders describe their long-term response
plans and the steps they anticipate as the country moves towards a new post-
pandemic ‘normal’. This involves being honest about the challenges to be navigated
in likely future phases of the response (such as learning to live with the virus), and
proactively outlining new scenarios that might arise. While noting their intention to
carefully plan and manage the transition between these phases, leaders should be
clear that the exact timing will depend on many factors and will therefore require a
degree of flexibility.
Communicating changes in direction during a pandemic response can be difficult.
This is especially true if they involve reintroducing restrictive measures such as
lockdowns, or accepting risks that were previously presented as unacceptable.
But despite the communication challenges, it is important that leaders move quickly
to change direction when circumstances require it. Being transparent about the
rationale for a change will help people accept and support it, as will explaining
that – even though some may experience temporary hardship or inconvenience
as a result – the decision will ultimately support the overall goal of the response:
looking after all aspects of people’s lives as much as possible.
Lesson 3: Build resilience in the health system |
3 Akoranga 3: Te whakatipu kia tū pakari te pūnaha hauora
In brief: What we learned for the future about building

resilience in the health system

Lesson 3.1 Build public health capacity to increase the range of options
available to decision-makers in a pandemic. In practice, this means:
3.1.1 Make scaling-up effective testing and contact tracing part
of core public health capability
3.1.2 Plan for a flexible range of quarantine and isolation options
3.1.3 Be ready to quickly implement infection prevention and
control measures
Lesson 3.2 Enhance the health system’s capacity to respond to a pandemic
without compromising access to health services. In practice, this means:
3.2.1 Build the capability of the healthcare workforce
3.2.2 Strengthen intelligence, monitoring and coordination of
healthcare to enable adaptability
3.2.3 Improve health system infrastructure
3.2.4 Strengthen resilience in primary healthcare
Overview
Before COVID-19, Aotearoa New Zealand’s public health system was assessed as
moderately well-prepared for a pandemic. With the arrival of the virus, however, it
became clear that greater public health capacity was needed. Thanks to impressive
effort and innovation, key tools such as contact tracing and testing were quickly
scaled-up. But capacity limits remained a challenge, and systems for large-scale
isolation and quarantine had to be developed from scratch.
Aotearoa New Zealand’s health system was never overwhelmed by COVID-19,
thanks to the success of the elimination strategy (and a degree of good luck).
However, the pandemic highlighted and exacerbated the health system’s
underlying fragility, with long-standing capacity constraints affecting core areas,
including workforce, physical infrastructure, supply chains. These long-standing
and underlying issues should be addressed before the next pandemic, as much
as it is possible to do so.
A key aspect of pandemic preparation is to build resilience into Aotearoa
New Zealand’s health system. The OECD describes resilience as:
“ the ability of systems to prepare for, absorb, recover from, and adapt to major
shocks. It is not simply about minimising risk and avoiding shocks: resilience is also
about recognising that shocks will happen.” 17
Having better public health capacity will enable a rapid initial response to any
future pandemic, increasing the likelihood that the pandemic virus (or other
infectious agent) can be excluded or eliminated before it becomes established.
The ability to rapidly scale-up key public health functions such as contact tracing
will also give decision-makers more options, potentially reducing the need to use
blunt measures like lockdowns.
A resilient health system is one equipped with a strong workforce, secure supply
chains (including for medicines and medical equipment) and good infection
prevention and control processes (which require well-maintained stocks of PPE and
excellent ventilation systems). Having these resources in place before a pandemic
arrives will better enable the health system to continue meeting other health needs
during a pandemic response, ensuring support for all aspects of people’s health.
Lesson 3.1: Build public health capacity to increase the range

of options available to decision-makers in a pandemic
COVID-19 demonstrated the importance of core public health functions such as
testing and contact tracing, isolation and quarantine, and infection prevention and
control measures. These will provide the first line of defence in the next pandemic,
preventing or slowing transmission of the virus and protecting people from serious
illness and death.
Importantly, the greater the capacity to deliver these tools and functions (especially
at the start of a pandemic), the more options decision-makers will have at their
disposal. For example, if testing and tracing systems are ready to be rapidly scaled-
up when the first cases of a new pandemic disease are detected, it may be possible
to eliminate chains of transmission without the need for national lockdowns. Higher
uptake of infection control measures (such as masks) in public spaces may also
reduce the need to restrict people’s movement.
The public health response to a pandemic is interconnected with its economic
and social impacts. Building public health capacity in key areas can create options
for mitigating the health impacts of a pandemic without having to resort to more
stringent measures that have high economic and social costs. For example, Taiwan
was able to eliminate COVID-19 transmission in 2020 without using lockdowns, due
to its well-developed testing and contact-tracing capacity and very high levels of
mask wearing in its population.
Of course, even the best-prepared country may need to resort to lockdowns in a
future pandemic, and we cannot rule out their use in Aotearoa New Zealand again.
However, our analysis of the response to COVID-19 has shown that the need to
use more stringent measures such as lockdowns may be reduced by building the
capacity and resilience of core public health services and tools.
Make scaling-up effective testing and contact tracing part of core
public health capability
Testing and contact tracing are core functions that form part of the day-to-day
toolkit used by public health services in Aotearoa New Zealand. In a pandemic
response to a pathogen that is amenable to contact tracing, these functions will
need to be rapidly expanded to detect and contain new chains of transmission
across the population.
For these capabilities to be ‘kept warm’ in case of a future pandemic, planning
and investment is needed so they can be rapidly and effectively scaled-up when
needed. This includes:
• Investing in the public health workforce, including training and capacity
building for the specific skill of contact tracing.
Contact tracing requires a skilled workforce, experience in interacting with
members of the public to obtain potentially sensitive information and
familiarity with digital record-keeping platforms. COVID-19 showed how
contact-tracing capacity can be quickly expanded via recruitment and short-
course training of non-public health personnel – but provision of training,
oversight and quality control all rely on existing expertise, especially for the
core team that will train others.
• Enabling public health services to develop and maintain relationships
with local communities.
Contact tracing is most effective where public health workers have good
relationships with the communities they serve. People can be reluctant to
discuss where they have been, and who they have been with, particularly in
stressful circumstances such as having been exposed to a virus. Navigating this
requires skill on the part of the contact tracers, and trust on the part of those
they are speaking with. COVID-19 demonstrated the importance of effective
relationships between public health services and the communities they serve –
including different ethnic minorities, faith groups, business leaders and Māori.
• Maintaining digital platforms, information systems and supporting
capability.
The development of effective digital platforms to support contact tracing
was one of the successes of the COVID-19 response. It will be important to
maintain and strengthen this capacity so that health information can be safely
coordinated and shared, both in the context of normal public health activities
as well as in a pandemic. Investing in digital and data capacity is a key form of
insurance in case of future public health crises.
• Establishing mechanisms to facilitate rapid scaling-up of testing capacity.
Testing is an essential complement to contact tracing. It enables people who are
infected to be isolated – preventing further spread – and allowing those without
infection to go about their daily lives. COVID-19 showed the importance of being
able to rapidly scale-up testing capacity but also the difficulties encountered
when access to testing is limited. With most of the country’s testing capacity
located in private laboratories, it will be important for government to consider
how to ensure it has access to additional testing when needed.
Plan for a flexible range of quarantine and isolation options
Border restrictions and quarantine, lockdowns (national and regional) and
home isolation were core parts of Aotearoa New Zealand’s response to COVID-19.
However, a more flexible range of quarantine and isolation options could give
decision-makers more choices for using these measures effectively, while
minimising negative impacts – for example, when someone with a right to
enter the country struggles to do so because of a shortage of quarantine
capacity. Flexible options could include allowing low-risk travellers the possibility
of isolating at home, if feasible.
While officials and agencies learned a lot during COVID-19 about how to make
hotels work as quarantine facilities, they were not ideal sites for infection control
or isolation of community cases. Memoranda of understanding and other
arrangements are required to ensure ventilation is of high quality and that
facilities can easily be reconfigured to keep cohorts and people separate in hotel
facilities. Other options – ranging from a blend of facilities and home-based
quarantine, to bespoke facilities and more hospital-level care facilities – should
be investigated ahead of the next pandemic so that decision-makers have a
flexible range of quarantine and isolation approaches to consider, depending
on the nature of the pandemic.
Be ready to quickly implement infection prevention and control measures

Infection control measures such as the use of PPE, masks and physical
distancing were often highly effective in responding to COVID-19. However,
Aotearoa New Zealand’s ability to use these measures quickly and to good
effect was constrained by shortcomings in procurement and distribution
systems, infrastructure and information and advisory systems.
These problems were not confined to this country. Globally, the COVID-19
pandemic created both a supply and demand shock for key equipment and
materials essential to the response. It created urgent, worldwide demand for
things like PPE, tests, medical devices and vaccines, but at the same time,
disrupted the national and international supply chains and workforces that
provided those goods and services.
As the next pandemic may well be very different from COVID-19, different
infection prevention and control measures may be needed. However, some
key equipment is always likely to be required – such as PPE – whatever the next
pandemic’s characteristics. Ideally, Aotearoa New Zealand would secure, distribute
and manage (for example, by rotating) sufficient stocks of such equipment ahead
of time so it is ready to use as soon as required.
The need for other equipment and tools such as bespoke tests and specific
vaccines cannot be determined in advance as that will be dictated by the specific
pathogen. Therefore, ensuring Aotearoa New Zealand has access to what it
needs will depend on having established networks of advice and expertise,
strong international relationships and good procurement processes in place.
Lesson 3.2: Enhance the health system’s capacity to respond
to a pandemic without compromising access to health services
COVID-19 revealed the intense pressure a pandemic can exert on the health
system and its resources. It also demonstrated the importance of maintaining non-
pandemic health services while simultaneously responding to both the immediate
and long-term effects of a virus or other pathogen. Aotearoa New Zealand needs
its health and disability system to be sufficiently resilient to meet both of these
competing demands.
Building resilience ahead of a pandemic will ensure that, during the response,
decision-makers can be more confident in the ability of the health system to cope
with the demands placed on it. This gives them more response options, including
adopting a different risk tolerance when it comes to using public health measures
such as lockdowns and gathering limits. It will also probably provide substantial
benefits for non-pandemic health services. What this might mean in practice is
addressed further in our recommendations.
Priority areas that should be addressed are:
• Building the capability and flexibility of the workforce so health workers can
be more readily redeployed in a pandemic while other health services are
kept going.
• Strengthening the systems that allow for services to be prioritised if necessary.
This includes the data, intelligence and monitoring systems that enable
decision-makers to understand what capacity is available, and the governance
and coordination mechanisms needed to make decisions and ensure capacity
is utilised as effectively as possible.
• Improving infrastructure so that the health system can continue safely caring
for patients during a pandemic (for example, by improving building ventilation
and ensuring capacity to separate potentially infectious from non-infectious
patients) and can surge additional capacity where needed (for example, by
repurposing facilities for pandemic-specific services or by increasing capacity
to care for patients needing ventilation).
• Strengthening resilience in primary health care (that is, general practice and
community-based care). Discussion of health system capacity often focuses on
specialist services such as intensive care and surgery, but primary health care –
while less easily measured – is the foundation of the system and the first line of
delivery. During the COVID-19 response, primary care was essential in both the
vaccine rollout and dispensing antivirals during the Omicron waves, which likely
saved many lives. Strengthening the primary health care workforce, data and
intelligence systems and other infrastructure, including building design and
ventilation, will enhance Aotearoa New Zealand’s ability to respond well
to a future pandemic.
Lesson 4: Build resilience in economic and social systems |
4 Akoranga 4: Te whakakaha i te pakaritanga o ngā pūnaha
ōhanga me te pāpori
In brief: What we learned for the future about building

resilience in the economic and social systems

Lesson 4.1 Foster strong economic foundations. In practice, this means:
4.1.1 Continue to build strong relationships between
economic agencies
4.1.2 Prepare better for economic shocks
4.1.3 Strengthen fiscal reserves and maintain fiscal discipline
Lesson 4.2 Use economic and social support measures to keep ‘normal’
life going as much as possible. In practice, this means:
4.2.1 Deploy economic and social measures to support key
health measures
4.2.2 Design key tools in advance to save time and resources
4.2.3 Build on the improvements to social sector contracting
and partnership
4.2.4 Maintain well-functioning labour markets, including by providing
financial support to workers
Lesson 4.3 Ensure continuous supply of key goods and services.
In practice, this means:
4.3.1 Build greater resilience into supply chains
4.3.2 Maintain food security for a future pandemic
4.3.3 Maintain access to government and community
services throughout a pandemic
4.3.4 Allow the ‘essential’ category to change over time
Overview
The COVID-19 pandemic and associated policy measures impacted all sectors and
parts of society, over a prolonged period. This created demands beyond what could
be managed via ‘business as usual’. Thanks to extraordinary effort, innovation and
investment – and the success of the elimination strategy – Aotearoa New Zealand
did not face the kinds of crises experienced in many other countries. But while the
country avoided such predicaments as fuel shortages or running out of essential
equipment, the stark risks posed by a pandemic (or other emergency that exceeds
the limits of essential systems and infrastructure) were very much apparent.
There were also some positive lessons. Overall, Aotearoa New Zealand’s
pandemic experience underscored the importance of strong economic and
social institutions that have built up reserves and capacity during ‘normal’ times.
This gives decision-makers much better options for responding to a crisis.
Because Aotearoa New Zealand went into the COVID-19 pandemic in a relatively
strong economic position built up over a number of years, the Government was
able to provide swift and generous supports that helped with the success of the
elimination strategy and protected many people from the pandemic’s worst
impacts. Among other things, the Government funded vaccines, provided generous
wage and business support subsidies, arranged short-term accommodation
support for people who had been homeless or in unstable housing, and ensured
air freight capacity was maintained so that time-sensitive and essential goods
could still arrive in the country. Where capacity and infrastructure were already
in place, it was easier to manage pandemic risk while minimising disruption to
essential activities. The reasonably good availability of internet access across
most of the country, for example, made it possible for many people to shift to
online learning and working.
The interconnected nature of people’s economic, social, physical and mental
health means resilience in any one area will have benefits in others. A prepared
and resilient education system, for example, that enables children and young
people to continue to attend school in person as much as possible, will be
protective of their mental health and social development. Avoiding or minimising
the use of lockdowns will reduce people’s exposure to stress, loneliness and –
for some – violence. Ideally, in a future pandemic, better overall preparation
will mean decision-makers have more options that reduce the need for more
restrictive measures such as lockdowns and school closures.
A resilient economy and social support systems are important to reduce
disruptions to ‘normal’ life as much as possible, during and after a pandemic.
These sectors provide essential scaffolding of daily life that becomes even more
critical – and comes under greater pressure – in times of crisis. Building resilience
into this scaffolding is a key part of future pandemic preparedness. While some
degree of disruption and adverse impact is inevitable in a large-scale crisis, this
can be lessened if core systems and infrastructure are more robust. This can
also act as insurance against other types of shocks and stressors.
A resilient economy and social

support systems are important to
reduce disruptions to normal life
as much as possible, during and
after a pandemic.
Lesson 4.1: Foster strong economic foundations
Ensuring the economy is sufficiently resilient to handle major shocks is critical
for looking after people through a pandemic. Strong economic foundations and
institutions will enable a greater range of options to respond to a future pandemic
and reduce the risks of pandemics causing other crises – in the financial sector,
for example.
Continue to build strong relationships between economic agencies

The COVID-19 response benefited from the prior existence of strong working
relationships between the main economic agencies. These agencies responded
promptly and effectively as developments unfolded although – like their overseas
counterparts – they were clearly not prepared for the economic implications
of an all-of-society crisis on the scale of a global pandemic.
While respecting the Reserve Bank’s independence in the operation of monetary
policy and the Treasury’s ability to provide ministers with fiscal and economic
advice in reasonable confidence, the two agencies have developed useful forms of
collaboration over many years which serve them well in normal times and up to a
point proved valuable during the pandemic. We suggest building and strengthening
these key relationships, as well as those with other agencies as appropriate, such
as the Ministry of Business, Innovation and Employment, Inland Revenue, the
Ministry of Transport and the Financial Markets Authority. Good and well-directed
engagement can ensure access to a wider range of data, insights and skills when
they are most needed.
Having these agencies work collaboratively on preparing possible economic
response options based on different pandemic scenarios would be valuable. This
would pick up on and capture accumulated experience gained through past crises
(such as the Global Financial Crisis, earthquakes, floods and now COVID-19). As
such experiences are documented and developed, they help to build ‘muscle
memory’ for effective response design in the future.
Prepare better for economic shocks

Determining the appropriate initial macroeconomic response to a pandemic
is extremely challenging. As the COVID-19 experience demonstrated, it is not
safe to assume that the economic shock from a pandemic primarily works
through demand. The economic shock associated with the advent of COVID-19
has emphasised the importance of developing greater understanding of
supply shocks and how to respond to them. In this and other areas, Aotearoa
New Zealand is not alone. Both the Reserve Bank and the Treasury have
built up their relationships with international counterparts and institutions.
Continuing to share information and experience on these matters should
help us to understand better how to respond.
On the demand side, judging the mix, size and duration of any expansionary
policies is an extraordinarily sensitive matter – undershooting can result in
lasting damage to people’s and business wellbeing, while overshooting can lead
to a long tail of economic aftereffects, including cost of living and inflationary
pressures and expanding national debt. Complicating this is the fact that demand
is influenced by both the Government (acting on advice from the Treasury) and
the Reserve Bank (operating monetary policy independently). Developing a
shared understanding or ‘playbook’ between the two agencies of when and how
different fiscal and monetary interventions might best be deployed in a pandemic
(or similar crisis) would enable them to collaborate effectively while safeguarding
their separate roles and accountability. We understand that the two agencies
have already embarked on this process and we are confident that this will not
compromise either Reserve Bank independence or the Treasury’s ability to provide
advice confidentially to government when this is needed (for example, during a
Budget process).
Strengthen fiscal reserves and maintain fiscal discipline

Because Aotearoa New Zealand went into the COVID-19 pandemic with low
levels of public debt (by international standards) and a strong national credit
rating, decision-makers had options to finance a range of health, social and
economic measures. Providing a fiscal buffer is one of the intended benefits of
running responsible fiscal policies over time, and its use in a pandemic is entirely
appropriate, but building fiscal resilience in preparing for future pandemics goes
beyond simply building a buffer. Prudent levels of net debt need to be backed up
by a strong balance sheet, a sound financial sector and economic settings that
encourage productivity and efficient investment – including in research, science
and infrastructure that produces positive social returns.
The fiscal reserves that provided important support during COVID-19 now need
to be restored. This should be achievable at a sensible pace that does not drive
the economy into negative territory.
Some experts we spoke to commented on the current strength of Aotearoa
New Zealand’s fiscal responsibility institutions. We heard that a range of
proposals for strengthening these have been discussed in policy circles for some
time. These matters go beyond our terms of reference, except to suggest that
if consideration is given to these proposals at some stage, the implications for
pandemic readiness should be factored in.
A pandemic also carries the risk of generating a financial crisis. Keeping relevant
financial markets operating smoothly during the COVID-19 pandemic was a
direct objective of some of the Reserve Bank’s policy moves. Authorities were
generally alert and well-prepared to respond to any looming crises of this sort.
This responsiveness illustrates the value of the sort of preparation this report
argues for more generally.
Lesson 4.2: Use economic and social support measures
to keep ‘normal’ life going as much as possible
Deploy economic and social measures to support key health measures
Mitigating the pandemic’s potential social and economic impacts was a significant
component of the COVID-19 response from the start. Similarly, the public health
response to any future pandemic will need to be supported by a suite of economic
and social support measures. Such measures seek to reduce disruption to people’s
lives and to enable compliance with public health measures. This includes specific
pandemic tools and support measures developed in advance and ready to use when
the situation demands, as well as broader economic and welfare support to keep
‘normal’ life and activity going as much as possible. This will be challenging, because
– as occurred with COVID-19 – a future pandemic is also likely to generate an initial
and ongoing shock to Aotearoa New Zealand’s economy and society. The best way
to deal with the shock is to prepare for it in advance.
A key benefit of financial support for workers, whānau and households and
businesses is that they help keep a semblance of daily life going as much as
possible. These schemes, appropriately targeted and designed, can substantially
assist with living costs, keep people attached to the labour force, and help otherwise
viable businesses to continue to operate (or at least survive in the meantime).
A strength of the schemes initiated during the COVID-19 response is the positive
effect they had on confidence (both personal and business).
Economic and social supports can make the implementation of public health
measures more bearable, while public health measures ultimately work to support
a healthy economy. The longer a pandemic persists, however, the greater the
economic and social costs and the more the costs of financial support accumulate.
It is impossible, as time progresses, to avoid significant trade-offs between economic
costs and the full suite of pandemic responses, and these trade-offs therefore need
to be constantly re-evaluated (see Lesson 2).
Design key tools in advance to save time and resources
It is essential to think in advance about how to ensure economic and social
support measures will reach everyone they need to, and that their effects will be
fair and proportionate. Viable compliance frameworks and exit strategies should be
developed for various measures that are likely to be deployed in a future pandemic,
to avoid the risk of them being mis- or over-used, and to ensure reasonable levels
of cost-effectiveness. Good use can be made of existing knowledge from previous
crises about where impacts are most likely to fall. Such information can support the
development of options that target known needs early in a future pandemic and
may help to more accurately anticipate wider social and economic challenges that
the pandemic may exacerbate.
COVID-19 demonstrated that setting up programmes and initiatives under urgency
can sometimes lead to less efficient or effective spending of limited resources.
For example, there were limited options for rapidly rolling out the Wage Subsidy
Scheme in a more targeted way, because Inland Revenue did not have the systems
functionality at the time to deliver it (see Chapter 6). The ability to target funding
to different groups, or have a more tailored approach to timing, is dependent on
having suitably flexible payment and delivery systems.
Resolving in advance the delivery agency and system requirements required for
the range of policy options being developed for delivering support could save
considerable time and money in the future and serve the fundamental purpose
of looking after people in a crisis. For example, a prepared and resilient education
system should have methods and tools in place to deliver effective online education,
if necessary, alongside measures that can be implemented to help keep schools
open as much as possible, such as improved classroom ventilation, mask wearing
protocols and flexible classroom desk arrangements.
Part of designing good tools and options in advance is learning from past
experiences. For example, the evidence we reviewed suggests that some, but not
all, of the sectoral business assistance provided during the COVID-19 response
represented reasonable value-for-money. Relevant agencies should thoroughly
review the various supports provided during the COVID-19 pandemic, including
sectoral business support, the Wage Subsidy Scheme, and social support packages
such as Care in the Community. Based on analysis of what worked well and what
could be improved, agencies should identify and develop a range of options that
would support a future pandemic response.
Resolving in advance the delivery

agency and system requirements
needed for the range of policy
options for delivering support
could save considerable
time and money in the future.
Build on the improvements to social sector contracting and partnership
A critical element of Aotearoa New Zealand’s COVID-19 response was the work
done by various community groups, service providers, iwi and Māori organisations
and social sector agencies to respond to emerging needs in communities. Many
government agencies adapted their operating and contracting practices to enable
delivery organisations to focus on flexibly meeting the needs people presented
with. Generally, these changes were viewed positively. Agencies identified that they
should still be in a position to manage appropriate oversight of this more flexible
outcomes-based contracting, and the flexibility improved the ability of providers
to respond and adapt to the changing needs in their communities.
These adaptations and other positive experiences can be built on in a future
pandemic. Agencies contracting in the social sector should review their approaches
to cross-agency coordination and governance, and standardise more streamlined
contracting arrangements so that these can be put in place quickly. A key
improvement would be to ensure that all contracting agencies adjust their reporting
requirements at the same time, to reduce confusion and burden on providers
who need to focus on demand for their services during a prolonged crisis. This will
ensure the good practices developed during COVID-19 can easily be continued or
improved, while maintaining effective oversight.
Maintain well-functioning labour markets, including by providing financial

support to workers
It is in the shared interests of government, employers and workers to minimise
disruption to employment and working conditions caused by a pandemic and its
restrictions. The COVID-19 experience highlighted the importance of maintaining
depth and flexibility in labour markets for both economic and social reasons. The
potential impact on labour markets was a major driver of the economic response to
the pandemic and should also be a major focus of future pandemic preparedness.
Minimising disruption allows people to maintain their employment and wellbeing,
while ensuring workforce supply. However, there is also a downside to this
necessary support, beyond the fiscal cost. Labour mobility is likely to reduce as
people hold on tightly to their means of support in very uncertain times. Long
periods of subsidisation carry a risk of maintaining unproductive businesses and
can reduce the natural forces of change within the economy, gradually eroding
productivity. This reinforces the need to adapt over time to ensure shorter-term
benefits are balanced against longer-term risks.
Financial support for workers, whānau, households and businesses is critical
for the overall success of public health measures. These supports can be very
expensive fiscally, depending on the extent to which border measures, lockdowns
or other highly impactful measures are implemented and for how long.
Nevertheless, international evidence suggests that the economic (and possibly
financial) costs of not deploying such measures could be even greater.18
Lesson 4.3: Ensure continuous supply of key goods and services
Build greater resilience into supply chains
Despite the very challenging circumstances, Aotearoa New Zealand was able to
sustain domestic and international supply chains and ensure continued access to
necessary goods and services for its citizens and to international markets during
the COVID-19 pandemic. The government and private sector worked collaboratively
to enable this and to respond and adapt to changing circumstances. There were
of course still some shortages and disruptions to supply chains but despite early
fears, these limits did not have systemic consequences.
The evidence we reviewed on this matter indicated a widely held view (outside
of government, at least) that central government agencies did not have a strong
understanding of how key supply chains work, prior to the pandemic. COVID-19
highlighted how vulnerable Aotearoa New Zealand is to disruptions in international
supply chains (for example, the potential loss of international shipping services, or
the reduction in passenger flights reducing light cargo options).
Knowledge was also variable in the private sector, and we heard evidence of a
wider lack of thinking about security of supply chains and how this could be
strengthened. Domestically, the use of regional boundaries during the Auckland
lockdowns also had unintended impacts, reducing the flow of some goods across
the boundaries to and from the rest of the country.
Overall, Aotearoa New Zealand was relatively fortunate in terms of supply chain
disruptions during the COVID-19 response but should not rely on the same
happening again. Government cannot build resilience to these potential disruptions
by itself and, in relation to international supply chains, may have limited direct
influence. Joint work by government and the private sector to understand and
reduce supply chain risks will be
an important part of strengthening
economic foundations ahead of a future
Overall Aotearoa New Zealand was pandemic or other national crisis.
relatively fortunate in terms of
supply chain disruptions during the
COVID-19 response but should not Maintain food security for a future
rely on this happening again. pandemic
Food is a critical good that people need
daily, and it was a topic of great interest
during the COVID-19 response. Retailers
did a good job of managing hoarding and panic buying, and while there were
queues and some people faced challenges in getting their groceries, overall, there
were no food shortages. The food supply chains held.
But food security means more than simply maintaining commercial food supply.
During the pandemic, there was a significant increased demand for food parcels
and food grants. In our view, ensuring widespread food security in the face of
these pressures was one of the success stories of the pandemic response.
This was achieved through the combined efforts of government agencies
and community organisations and providers. First, the Ministry of Social
Development provided some foodbanks with emergency funding so they could
stay open. Later, Civil Defence and Emergency Management groups stepped up
to support foodbanks and other community food services to meet the demand
for food from the community. As the pandemic progressed, the Government also
invested strategically in building the capacity and capability of the non-commercial
food recovery and distribution network (see Chapter 6). This enabled certainty
of supply and a more flexible and sustainable approach to the distribution of
emergency food to the social services sector.
Maintaining capability for this support for food security infrastructure will be
of significant benefit in a future pandemic (or other crisis). It is important,
therefore, that the Government maintains good engagement with and support
for the charitable sector which provides the bulk of services in this area.
Maintain access to government and community services throughout a pandemic

As well as access to essential goods and services, such as food, housing and
lifeline utilities, a good pandemic response needs to maintain people’s access
to government and community services as much as possible. During COVID-19,
lockdowns, gathering limits and physical distancing all disrupted people’s ability
to access some government and community services, including services that
have a significant impact on people’s lives, such as court processes, education
and healthcare.
Maintaining accessibility to critical services and supports during a future pandemic
will be an ongoing challenge. We heard many examples where the efforts of a few
individuals were critical to ensure the continuity of essential services and functions.
This worked, but in future such responses should not be reliant on individuals.
Key government delivery agencies, such as the Ministries of Social Development
and Justice, should review their operational responses to COVID-19 and develop
plans and processes based on potential pandemic scenarios, to ensure that they
can shift approach and maintain services during a future crisis.
The ability for many sectors, services and communities to switch to remote and
online operations was an impressive aspect of the COVID-19 experience. There
were many examples of innovation and adaptability in moving the provision of core
education, health and justice services
online, among others. But we also
heard concerns about inequitable
access to devices, connectivity and
We heard many examples where the
capability being barriers to some efforts of a few individuals were critical
people’s participation in these to ensure the continuity of essential
activities. Continual efforts to reduce services and functions. This worked but
the digital divide will be important in future such responses should not be
considerations for a future pandemic. reliant on individuals.
Allow the ‘essential’ category to change over time
The COVID-19 pandemic highlighted that the delineation between activities that
are ‘essential’ and those that are not, is seldom clear. A key lesson is that the
passage of time significantly impacts what is considered necessary and/or essential.
For example, during a crisis of a few days or weeks duration, replacement parts
and repairs for plant and machinery may not be considered essential, but over
the course of months or years, some equipment will begin to wear out and fail.
Without changes to the ‘essential’ category to enable repair or replacement, some
businesses may not be able to operate.
The temporary closure of businesses and services during a pandemic can also
cause long-term social and economic damage. There are some activities where
closure – even for a short period of time – will make it very difficult to recommence
business. The costs of preventing businesses from operating can mount up quickly,
as can the social costs of missing access to education, childcare and mental health
support. These difficulties reinforce the desirability of limiting the use and extent of
more restrictive measures such as lockdowns, as much as possible. However, it is
likely that some use of the ‘essential’ services category will be necessary in a future
serious pandemic.
We think there is scope in future (and depending on the nature of the pathogen)
to designate some activities (such as civil construction or outdoor activities in the
primary sector) as ‘safe enough to continue’ rather than ‘essential’. These may well
be able to operate safely in a future pandemic (with appropriate requirements in
place), reducing some of the social and economic costs of public health restrictions,
such as the triggering of force majeure provisions.
Similarly, some of the requirements set by Health Orders during the COVID-19
pandemic were very prescriptive and impractical to apply in the workplace. We
suggest agencies give consideration, in advance of a future pandemic, to how
principles-based settings that provide for greater flexibility could be used in some
cases as an alternative to prescriptive operational settings.
The ‘everything everywhere all at once’
aspect of the COVID-19 pandemic
The temporary closure of businesses
also reinforced that some sectors
and services during a pandemic can make a crucial contribution to a well-
also cause long-term social and functioning society both during and after
economic damage. a pandemic, for example mental health
services, childcare and construction.
In a future response, deliberate steps
should be taken to ensure these
services can operate effectively to
The costs of preventing businesses
from operating can mount up quickly the greatest extent possible.
as can the social costs of missing
access to education, childcare and
mental health support.
Lesson 5: Work together |
5 Akoranga 5: Mahi ngātahi
In brief: What we learned for the future about

working together

Lesson 5.1 Work in partnership with Māori
Lesson 5.2 Work in partnership with communities. In practice this means:
5.2.1 Work with the community to deliver necessary supports
5.2.2 Make use of both locally-delivered initiatives and standardised
national approaches
5.2.3 Ensure public information is accessible and use trusted networks
to help deliver key messages
Lesson 5.3 Work closely with the business sector
Overview
Everyone has a role to play in responding to a pandemic, and success will rely
on people’s collective commitment to each other to get through it together. An
effective response therefore needs strong and trusting relationships that bring
together the diverse skills, experience, leadership and connections needed to
generate collective action. These relationships need to be built and fostered
during quiet times so that they can be quickly activated in a crisis.
Government agencies of course have overall responsibility for the oversight
and delivery of a pandemic response. To do this well, they need to have established
strong external relationships in advance, particularly with the community and
business sectors, and to collaborate effectively with each other.
Aotearoa New Zealand’s COVID-19 experience reinforced the critical role of
relationships and a culture of collaboration in a successful pandemic response.
Time and time again, the evidence we gathered showed that the quality of
working relationships at all levels was central to ensuring an effective, efficient
and equitable response.
Before and during another pandemic, government agencies need to strengthen
and maintain their relationships with communities, iwi and Māori, businesses,
researchers, experts and non-governmental organisations – and also with one
another. Not having established such relationships in advance will mean the
response to another pandemic will start on the back foot and may delay effective
action in those crucial first days.
The Government should also ensure that it upholds te Tiriti o Waitangi in
preparing for and responding to another pandemic. This requires enabling Māori
to participate in decisions consistent with the exercise of tino rangatiratanga, with
potential benefits as well to wider communities beyond those in Te Ao Māori.
Lesson 5.1: Work in partnership with Māori
In Lesson 1, we emphasised that the core purpose of pandemic preparedness and
response is to look after all aspects of people’s lives. In addition to this overarching
responsibility to the whole population, central government also has distinct
obligations to Māori under te Tiriti o Waitangi. Indeed, the Waitangi Tribunal has
observed that the relationship considerations and partnership responsibilities
flowing from te Tiriti were actually heightened during the pandemic:
“ given the expansive kaawanatanga powers exercised in this emergency and the
need for agile decision-making by the Executive, the Crown’s obligation to actively
protect tino rangatiratanga and partner with Maaori is, in fact, intensified.”19
In addition, pandemics – which are known to exacerbate pre-existing inequities20

– have historically had a greater impact on Māori. This was true of the COVID-19
pandemic, although the elimination strategy and a range of deliberate policies
mitigated its unequal impacts to a large extent, and represented a significant
improvement from previous pandemics and epidemics. Minimising disproportionate
impacts on Māori during a future pandemic will require nuanced understanding
of likely impacts, and for the response to be designed accordingly. Supporting iwi
and Māori organisations to deliver tailored responses in their communities helped
reduce the impact on whānau during the COVID-19 response and is an example
of practice that is consistent with te Tiriti o Waitangi.
The National Ethics Advisory Committee has described te Tiriti partnership in a
pandemic context as ‘ensur[ing] iwi, hapū, whānau, and Māori communities are
active partners in preventing, managing, and recovering from the impacts of an
epidemic or pandemic’.21 Working closely with iwi and Māori is the best way for
the Crown and its agencies to enact this vision of partnership. In planning for and
responding to a future pandemic then, government should:
• Work in partnership with Māori in the development, design and delivery
of any response.
• Enable iwi and Māori to exercise tino rangatiratanga in both preparing
for and responding to a future pandemic (while recognising the right of
the Crown to govern).
• Work towards equitable outcomes for Māori as part of an effective
pandemic response for everyone in Aotearoa New Zealand.
• Ensure the national pandemic plan, and any future pandemic response,
is delivered in a culturally appropriate way.
One important way of ensuring any future pandemic response is consistent
with te Tiriti will be ensuring that any ethical principles and decision-making tools
used in the response (as discussed in Lesson 2) are developed with Māori so
that such tools and principles are applied in ways that help the Crown uphold
its te Tiriti obligations.
Lesson 5.2: Work in partnership with communities
Responding effectively to a pandemic (and keeping people safe during any type
of national emergency) is a critical function of central government. But – as the
COVID-19 response clearly demonstrated – government cannot and should not
do this alone. Delivering the range of supports and services people need during
a pandemic requires close partnership between government agencies and
communities of all kinds. And clearly communities and whānau will draw on their
own relationships and partnerships to support people through a pandemic.
During COVID-19, we saw that when strong, trusting relationships were already in
place before the pandemic, things worked well. When relationships were patchy, or
had to be developed fresh, this often impeded the effectiveness of the response.
One way to maintain and strengthen good working relationships is through
joint participation in pandemic exercises and other civil defence and emergency
management activities.
COVID-19 highlighted how reaching, looking after and communicating with
people – including those in the ‘hard-to-reach’ category – requires a wide network
of trusted community groups and organisations that are ready and able to respond
in a pandemic. This network will include iwi and Māori organisations, community
groups, NGOs and business networks. To muster collective action in a future
pandemic, the government will need to know this network well.
Work with the community to deliver necessary supports

Most social support services in Aotearoa New Zealand are delivered by tens of
thousands of non-government service providers and community organisations.
Delivering social supports during the COVID-19 response required government
to trust and flexibly resource community providers. This trust and flexibility
should be maintained for the future, and will enable providers to be confident
that resources will be available when required in an emergency.
Building and maintaining strong relationships between government and
communities for a future crisis also requires system oversight by the lead social
sector agencies. These agencies can identify gaps in the network to be addressed in
advance of an emergency, including funding to local organisations that face ongoing
challenges. Trying to address those gaps during a pandemic risks delaying the
response and compromising delivery. There were examples where this was done
well during the COVID-19 response: when it became clear that some ethnic minority
(including migrant) communities were
not receiving important information
and support, social agencies worked
through the Ministry for Ethnic
Delivering the range of supports and
Communities to support community services people need during a pandemic
leaders and groups and ensure support requires close partnership between
reached those who needed it. government agencies and communities
of all kinds.
Make use of both locally-delivered initiatives and standardised
national approaches
People and groups working in local communities generally have better
understanding than central government of what those communities need, want
and are likely to struggle with in an emergency. This means they are mostly better
placed to design and deliver support. Community-led approaches using local
knowledge and leadership often delivered the most effective local solutions during
the COVID-19 response. As the Ministry of Social Development has observed:
“ A locally-led, regionally-enabled, and nationally supported approach is emerging

as a valuable framework for supporting community wellbeing and recovery.”22
Some of the most remarkable success stories of Aotearoa New Zealand’s COVID-19
response involved iwi and Māori organisations exercising tino rangatiratanga as
well as Te Ao Māori values like whakapapa, manaakitanga and kaitiakitanga to
support not only their own people but the community at large. Many iwi and Māori
organisations were well-placed to respond to their communities’ needs and could
draw on their cultural protective factors. For example, in Northland, we learned how
Māori health providers used their existing knowledge and relationships to meet the
unique challenges whānau in rural and remote areas faced during the pandemic.
The key lesson then is that ahead of the next pandemic that strong relationships are
fostered, embedded or built and that options for how to respond reflected in sector
plans should be developed in partnership or consultation with the community sector.
Ensure public information is accessible and use trusted networks to help

deliver key messages
During a pandemic, it is vital that accurate information about what people need
to do reaches as wide an audience as possible. This is a significant challenge; the
forms of communication that work for some groups will not work for others, and
information needs to be culturally appropriate, accessible and rapidly translated
into multiple languages. As we discussed in section 10.2, a particular challenge
during the COVID-19 response was the rise of misinformation and disinformation,
and – among some groups – an accompanying drop in trust in government and
willingness to comply with public health measures.
The key lesson then is that

ahead of the next pandemic that
strong relationships are fostered,
embedded or built and that options
for how to respond reflected in
sector plans should be developed
in partnership or consultation with
the community sector.
The COVID-19 pandemic demonstrated the importance of working with
trusted intermediaries to translate, interpret and disseminate vital information
in ways that would work best for their communities. These communication
channels should be two-way, allowing questions and feedback to be brought back
to government agencies as well as information being pushed out. One example
from the COVID-19 pandemic that showed the benefits of trusted organisations
relaying important information to their communities was ‘Malu’i ma’a Tonga’ – a
vaccination drive set up by the Tongan Health Society and the local community, located
on church grounds, attended by prominent Tongan leaders and delivered in the
Tongan language. Identifying and working with trusted individuals and organisations
should be an element of planning and preparation for a future pandemic.
Lesson 5.3: Work closely with the business sector

When government agencies worked closely with the business sector during the
COVID-19 response, this allowed important aspects of ‘normal life’ to continue –
in particular, the flow of essential goods and services (including lifeline utilities),
ongoing employment and economic activity.
As we saw during COVID-19, businesses were affected differently depending on
many factors. In another pandemic, government decision-makers will need to
understand the potential impacts on businesses for different-sized operations
and various sectors. Business can also have information and networks that are
very useful to public servants, if used with discernment.
At several times during the COVID-19 pandemic, Aotearoa New Zealand was short of
the skills and capabilities needed for various economic and other activities to keep
going. The shortages included some highly specialised engineering skills, many kinds
of health workers, primary sector seasonal workers and more. While it is of course
essential to ensure appropriate health safeguards are followed in a pandemic,
immigration procedures need to be well-tuned, efficient and responsive – without
imposing too heavy a compliance burden.
The key lesson then is that ahead of the next pandemic, it is important to look
back at the role of partnerships between the public and private sector in the
COVID-19 response and reflect on what worked well and what did not. Reviewing
what worked well in the past is the starting point for developing effective strategies
and understanding needed for the future. There are also opportunities for further
learning by looking at sectors that were particularly impacted by the pandemic
(such as international education, tourism and hospitality) to better understand
the pressure points and problems they faced – and how they could be avoided
in the future.
Lesson 6: Build the foundations |
6 Akoranga 6: Hangaia ngā tūāpapa
In brief: What we learned for the future about the

foundations of a sound pandemic response

Lesson 6.1: Anticipate and manage the risks posed by a future pandemic
(alongside other risks). In practice, this means:
6.1.1 Establish an effective national risk management system
6.1.2 Ensure central oversight of pandemic preparation across
the whole of government
6.1.3 Base planning on robust pandemic scenario planning
and modelling
Lesson 6.2: Have key components of an effective national response
in place and ready to be activated. In practice, this means:
6.2.1 Establish an effective all-of-government national
response mechanism
6.2.2 Ensure strong cross-agency leadership
6.2.3 Prepare fit-for-purpose legislation
6.2.4 Build strong international connections
Overview
Aotearoa New Zealand delivered one of the most successful COVID-19 responses
of any country. Like most of the world, however, the country was not ready for
an event of the scale, complexity and duration of the COVID-19 pandemic, and
notwithstanding the successes, there was harm and distress for a significant range
of people, some of which may be possible to avoid in the future.
The need for more purposeful pandemic preparation and risk management was
a recurring theme in our engagements and evidence. The strong global emphasis
on influenza as the likely cause of the next pandemic meant that, prior to COVID-19,
the preparation that was in place did not consider all options that might be relevant
for responding to a different type of infection. The fact that pre-existing emergency
response models were not suitable for a crisis of the scale and duration of COVID-19
meant that much of the all-of-government response had to be built while also
responding to the crisis. The lesson from these experiences is that more robust
foundations of preparedness and resilience need to be in place before the arrival
of the next pandemic.
Usefully, the COVID-19 experience has provided specific, real-life examples of
where Aotearoa New Zealand can enhance its preparedness by building stronger
foundations for assessing, planning for, and managing the risks associated with
pandemics and other national crises. COVID-19 highlighted the importance of having
a range of options and tools decision-makers might want to reach for in future
to keep people safe while minimising disruption to daily life as much as possible.
It also highlighted the need for investment in preparation – and governance and
accountability mechanisms to ensure this – to mitigate the risks posed by future
pandemics. While significant work is needed to increase the capability and resilience
of key agencies and sectors, investment made in preparing for a pandemic will
also be valuable in relation to other national risks.
Lesson 6.1: Anticipate and manage the risks posed by a future

pandemic (alongside other risks)
Establish an effective national risk management system
Pandemics require a highly coordinated approach to preparedness and risk
reduction. Just as many businesses and organisations maintain hazard and risk
registers as part of ongoing governance, central government needs to strengthen
its preparation for pandemic risk – and other national risks – ahead of time. Once
such risks are identified, they need to be managed and mitigated with appropriate
plans and policy options, and there should be accountability mechanisms in place
to ensure this takes place.
While our brief as an Inquiry was to consider future pandemic preparedness, in
practice, it makes sense to consider and address the risks of a future pandemic
alongside other national risks. To prepare better for future pandemics and other
types of emergencies, current and future governments should therefore invest in
a strong national risk management system.
Ensure central oversight of pandemic preparation across the whole

of government
We learnt that in an ‘all of everything’ crisis, responsibility should be allocated
centrally to oversee, coordinate and evaluate ongoing pandemic planning and
preparedness across all relevant government agencies. This will not only ensure
that pandemic plans are in place where they are needed, but also that they are
coordinated, and that any gaps in pandemic preparedness within or between
agencies are identified and addressed. As part of this oversight, scenario planning
and pandemic modelling should be used to guide and regularly test Aotearoa
New Zealand’s readiness for a future pandemic, including by undertaking regular
cross-agency practice exercises, evaluating these, and building key learnings into
both national and sector-specific pandemic plans.
Base planning on robust pandemic scenario planning and modelling
The next pandemic Aotearoa New Zealand faces might be nothing like COVID-19.
We do not know when the next pandemic will occur, what the characteristics of that
pandemic pathogen will be (such as its infectiousness and virulence), or what the
social and economic context will be at the time of the next pandemic. However, as
outlined in Lesson 2, governments can use a range of evidence and estimates to
model what a future pandemic might look like in terms of both the behaviour and
impacts of the infectious agent and the social and economic context in New Zealand
at the point a pandemic occurs. They can also assess which of these potential
pandemic scenarios are more likely, and what specific risks they pose.
In addition to anticipating the range of pandemic scenarios the country may need
to respond to, scenario planning helps to ascertain the optimal mix of preparation
and response options, so that governments can prioritise investment and capacity-
building accordingly. For example, consideration of potential pandemic scenarios
will help future decision-makers identify what should be prioritised in terms of
preparatory investments (such as strengthening the ventilation of buildings,
stockpiling PPE, ensuring standing laboratory and testing capacity and the best mix
of quarantine facilities, including whether to invest in purpose-built facilities).
This kind of modelling and scenario planning has been used by the Treasury,
the Reserve Bank23 and the Ministry for Primary Industries24 to inform preparation
for an outbreak of Foot and Mouth disease (an infection affecting cows, sheep
and pigs), which could have serious impacts on Aotearoa New Zealand’s economy.
Modelling work helped demonstrate the importance of prevention and the scale
of investment that would be needed to support New Zealand’s farmers, rural
communities and primary industries if such an outbreak occurred. Despite this,
the use of modelled scenarios was not a key input in New Zealand’s pandemic
preparedness prior to COVID-19.
Ongoing investment in modelling capacity across multiple disciplines – coupled with
the development of pandemic scenarios – is essential to building the foundations
for a future pandemic response. See Appendix C for a more detailed discussion of
the potential uses of pandemic, economic and social scenarios.
Investment in pandemic preparation:
an example from South Korea
Aotearoa New Zealand’s state of preparedness can be usefully compared
with South Korea’s. Unlike New Zealand – which, before COVID-19,
had not encountered a major pandemic since 1918 – South Korea had
dealt with significant outbreaks of severe acute respiratory syndrome
(SARS) in 2003 and Middle East respiratory syndrome (MERS) in 2015.
Following the MERS outbreak, South Korea reformed the way it
prepared for and responded to pandemics.25
South Korea learnt from MERS the importance of having strong
national leadership and coordination models ready to go. Between the
2015 MERS outbreak and the emergence of COVID-19, South Korea
made significant changes to its national infectious disease prevention
and management system.26 Key changes included: amending legislation
to set out coordination models; improving early detection systems;
and investing in their public health system capacity, infection control and
public health tools, and surge capacity to handle outbreaks. Pandemic
legislation was also amended to provide for stronger governance
arrangements, with clear roles and responsibilities across all levels of
government and private institutions.27
South Korea’s preparedness activities and investment helped to slow
the spread of COVID-19 when it arrived, despite the country’s
high-density cities and proximity to China. For example, the availability
of universal testing and contact tracing enabled health officials to
identify clusters, ensure infected persons isolated and maintain a low
rate of infection within hospitals.
Lesson 6.2: Have key components of an effective national

response in place and ready to be activated
Establish an effective all-of-government national response mechanism
At the beginning of 2020, Aotearoa New Zealand did not have an all-of-government
emergency response mechanism that was suitable for a crisis of the nature, scale
and duration of COVID-19. A key learning from this experience is the need to have a
structure in place that can be quickly activated to provide oversight, leadership, and
coordination of the response. For some types of emergencies, such as earthquakes
or floods, this leadership function may be best undertaken locally, or by a specific
relevant agency. A pandemic response, however – as we learned during COVID-19
– is likely to require an all-of-government approach, because of the wide range
of social, economic and cultural impacts that can occur beyond the pandemic
pathogen’s immediate health impacts.
When the next severe pandemic occurs that requires more than just a
health-led response, a pre-agreed all-of-government coordination and leadership
mechanism should be ready to be activated. Key roles and responsibilities of
different agencies should be identified ahead of time, along with appropriate
governance arrangements.
The immediate function of this mechanism during the early days of a pandemic
should be to lead and coordinate the response and provide immediate intelligence
and advice during a fast-moving and evolving situation. Critically, it should lead
and coordinate the multi-agency response, and coordinate provision of advice to
decision-makers on the impacts of policy response options across multiple criteria
(see Lesson 2). At the same time, it should also be prepared to provide long-term
strategic analysis and advice on matters such as how a pandemic could evolve over
time, and how and when a response might adapt or change course. Even from the
early stages of a future response, the coordinating body should have an eye on
long-term recovery, how and when the response will end, and possible exit
strategies. As we heard regularly during our engagements with stakeholders, those
coordinating the response to a future pandemic need to be able to give decision-
makers both the detailed view of what is happening on the ground now, as well
as the big picture scenarios that may play out in the future.
Ensure strong cross-agency leadership

As COVID-19 made clear, responding to a pandemic requires effective leadership
and coordination across government agencies. Core aspects of the response – such
as managing international borders, securing vaccine doses, and providing social
and economic support – require agencies to work together. While officials worked
hard to do what was needed, Aotearoa New Zealand’s ability to quickly stand-up key
pillars of a pandemic response would be substantially strengthened if agency leads
worked together ahead of time to collectively plan for, coordinate and lead an all-of-
government response.
A recurring theme in the Inquiry’s engagement was the value of trust in a crisis
response. By engaging in cross-agency dialogue and preparation for a pandemic
response, agency leads have the opportunity to build trust with one another.
Clarity around roles and responsibilities, and an understanding of how different
agencies will work together, will help enable an effective and coordinated all-of-
government response. The importance of working together is discussed in Lesson 5.
When the next severe pandemic

occurs that requires more than just
a health-led response, a pre-agreed
all-of-government coordination and
leadership mechanism should be
ready to be activated.
Prepare fit-for-purpose legislation
At the start of the COVID-19 pandemic, standing response legislation (the
Health Act 1956, Epidemic Preparedness Act 2006 and Civil Defence Emergency
Management Act 2002) was sufficient to provide an initial response. This legal
framework was supplemented with bespoke COVID-19 legislation, developed at
pace and passed under urgency in May 2020, and other legislative changes to
mitigate and address the COVID-19 experience.
In a 2022 Law Commission assessment of the legal framework for emergencies,
Professor Janet McLean KC noted a number of areas where improvements to
the Health Act 1956 and other emergency legislation should be factored into a
review of the legislation to respond to a pandemic.28 The Law Commission’s report
notes, for example, that the operation of the Epidemic Preparedness Act 2006
should be assessed for its effectiveness and to determine whether more provisions
should be embedded in advance to be activated by an epidemic notice.
We agree with the need to refresh aspects of legislation to respond to a
pandemic. While the legislation in place in March 2020 was sufficient to support
the initial response, a key lesson arising from our Inquiry is that there is value in
developing an improved legal framework ahead of time to cater for a national public
health emergency. Any work to improve the legislative framework should specifically
address lessons learned from using the legislation during the COVID-19 response.
Given the likely wider-ranging impacts of a future pandemic, in our view it is key
that there is central oversight to ensure the readiness of emergency pandemic
legislation based on the experiences of COVID-19. In particular, any future work
should review or modernise the Health Act 1956 and the Epidemic Preparedness
Act 2006 to ensure they are fit-for-purpose in supporting the immediate response
to an emerging pandemic in the future.
For example, and based on the
experience during COVID-19, it would
be useful to consider the overarching Given the likely wider-ranging impacts
principles in Part 3A of the Health Act of a future pandemic, in our view it is key
that there is central oversight to ensure
1956 as part of this review. A review of
the readiness of emergency pandemic
the Health Act should also determine legislation based on the experiences of
any changes required to the powers COVID-19.
of medical officers of health to deal
with an immediate threat from an
unknown virus and to act on a quickly
emerging pathogen that has not yet
been identified. The appropriateness of officials exercising powers to make orders
that affect national populations, essential services and enforcement provisions
should be a focus, to ensure relevant powers are available given the circumstances
and timeframes, with the appropriate accountability arrangements. Another
aspect for review is the thresholds for modification orders under the Epidemic
Preparedness Act 2006.
We recognise that it will be difficult to ensure public health legislation can be
refreshed and reformed to address all possible eventualities for a future pandemic,
given the way pathogens, public health measures and treatments evolve. It is
neither possible nor desirable to try to comprehensively legislate for every future
pandemic scenario – this risks legislation that is too wide-ranging and complex
and insufficiently flexible to accommodate the ‘unknown unknowns’.
In its 2022 study, the Law Commission noted in relation to writing emergency
law that:
“ Ensuring that legal frameworks provide governments with sufficient powers to cope
with future emergencies while at the same time including effective political and legal
constraints on such powers is a difficult balance to achieve.” 29
It is important that the existing legislation be updated to provide sufficient legal

grounds to enable a speedy and effective immediate response to a pandemic,
thus providing adequate time for any bespoke pandemic legislation or legislative
amendments to be developed and considered by Parliament. It was beyond
the scope of Phase One to identify a comprehensive, specific set of legislative
amendments to the existing standing pandemic provisions in the Health Act and
Epidemic Preparedness Act, or to the legislation of other agencies who have to
modify their operations, or put in place measures, to support a pandemic response.
In addition to updating existing standing legislation, the Inquiry heard evidence
that it would be useful for ‘model’ pandemic legislation to be developed and
consulted on, but not enacted. This ‘model’ legislation would set out key safeguards,
checks and balances for implementing and reviewing the use of various public
health measures and ensuring that any limitations on human rights are
proportionate and support the rule of law (by providing clear, accessible and
enforceable laws). This ensures there is ready-to-go ‘model’ legislation available,
which can be modified to ensure it meets the bespoke needs of an emerging
future pandemic.
There is an alternative view, however, that such ‘model’ pandemic legislation
should in fact be considered by Parliament and enacted. If a future pandemic
required specific new bespoke powers or provision because of the nature of the
new pathogen, the legislation could be quickly amended at that time to address
the emerging pandemic. Ultimately the choice between an enacted or ‘ready-
to-go’ model pandemic legislation will be a political decision, but as a first step,
development and consultation on potential pandemic legislation should begin
right away.
One issue with the bespoke COVID-19 Public Health Response Act 2020 was
the number of COVID-19 orders and how often they were changed. Trying to
ensure guidance aligned with orders proved challenging, limiting the ability
of the public, businesses and even the legal profession to keep up-to-date with
their understanding of the emerging law.
It will be important for the development of ‘model’ pandemic legislation to carefully
consider which aspects of future pandemic management should be in primary
legislation (for example, key health response measures or border restrictions,
vaccine or treatment mandates, isolation and quarantine requirements) and what
should be in more flexible and nimble secondary legislation (for example, where and
how roadblocks would operate, which and how essential businesses will operate,
use of mask wearing, and requirements for contact tracing). For example, with
regards to border restrictions, the primary legislation needs to provide the ability to
quickly restrict the movement of people or craft from particular locations to address
the immediate risks of a pandemic or an infectious disease outbreak. In addition,
the grounds for longer term, ongoing restrictions governing the movement of craft
and/or people across the border should be set out in primary legislation alongside
built-in review mechanisms or relevant restrictions incorporated.
Regulatory stewardship means that each agency needs to take responsibility for
ensuring their own emergency response legislative frameworks and existing key
statutory legislation are fit-for-purpose to meet the challenges of a future pandemic.
There is an ongoing need for agencies to continue to consider the application of
existing legislation to new and unanticipated circumstances that may arise during
a future pandemic. For example, an urgent amendment to the Medicines Act 1981
in 2021 was required relating to ministers’ provisional consent for approval of
new medicines such as vaccines.
While individual agencies are responsible for keeping their legislation up-to-date
for a future pandemic (or other emergency), there is a role for central oversight
and coordination — for example, supporting an omnibus bill for changes across
multiple legislation relating to facilitating electronic and online activities that may
be necessary during a pandemic.
There is also a role for central coordination to support agencies to reconcile
the interface between their key foundational legislative frameworks and the use
of public health measures and policies that supported those measures (such as
the wage subsidy). For example, determining the extent that legislative change or
improved guidance may be needed to clarify the interaction between employment
law and public health, or wider fiscal support measures such as the payment of
wage subsidies in an emergency, or how sick leave provisions are used when
public health requires individuals to self-isolate. Another example is the degree
of separation that should be maintained between the health and safety legislative
framework (performance-based regime that is flexible and tailored to individual
circumstances of risk) and public health legislation in managing a pandemic
(rule-based system that sets clear requirements for managing evolving risks across
a multitude of settings).
Build strong international connections
The pandemic showed the importance of developing and maintaining strong
international connections, not only at the ministerial and official level, but also
with (and between) businesses, scientists, policy advisors and academics.
During the COVID-19 pandemic, Aotearoa New Zealand was able to leverage
existing international connections and alliances in several important ways. Early
in the response, strong diplomatic relationships helped with the repatriation of
New Zealand citizens from overseas. Later, health officials and politicians were
able to liaise with drug manufacturers and other countries to ensure a continued
supply of medicines and secure timely and stable supplies of COVID-19 vaccines.
Scientists and academics drew on collegial networks with international colleagues
to ensure their advice on the virus and the public health response was accurate
and up-to-date. Economic advisors and operatives had international relationships
they were able to leverage off effectively. Many New Zealand businesses, despite
travel restrictions, maintained strong trade and commercial relationships with
overseas partners and suppliers.
International connections were also useful for maintaining key supply chains.
Trade officials engaged with other governments, for example Singapore, to remove
trade blockages for several essential products. Aotearoa New Zealand’s strong
Pacific relationships meant the New Zealand Government was able to provide
concrete support for Pacific nations before and during COVID-19.
As these examples from COVID-19 show, many of the foundations are already
in place to enable Aotearoa New Zealand to draw on strong international
connections in a future pandemic. It is important that these are maintained and,
in some areas, they need to be strengthened. In particular, New Zealand should
build on the Indo-Pacific Economic Framework for Prosperity initiative as part of
broader efforts to improve international and domestic supply chain resilience.
Ministry of Foreign Affairs and Trade officials should also explore opportunities to
work with other countries (such as Australia and Singapore) to improve collective
capacity to respond to the needs of a future pandemic. This could include research
partnerships or collaborating on the production of vaccines. In particular, as
Australia establishes its new Centre for Disease Control, there will almost certainly
be opportunities for New Zealand public health officials to collaborate across
the Tasman on pandemic preparedness activities that are mutually beneficial
to both countries.
Aotearoa New Zealand should also look to support multilateral efforts to strengthen
global pandemic preparedness
and responsiveness. This includes
initiatives led by the WHO to improve
The pandemic showed the importance
of developing and maintaining strong intelligence and technology sharing, to
international connections, not only at build international coordination and
the ministerial and official level, but collaboration and to promote global
also with (and between) businesses, equity in protecting people from the
scientists, policy advisors and academics. impacts of pandemics.
Endnotes |
10.4 Tuhinga āpiti
1. Atsuyoshi Ishizumi, Jessica Kolis, Neetu Abad, 10. Maxwell Smith and Ross Upshur, ‘Pandemic Disease,
Dimitri Prybylski, Kathryn A. Brookmeyer, Christopher Public Health, and Ethics’, in The Oxford Handbook of
Voegeli, Claire Wardle, and Howard Chiou, ‘Beyond Public Health Ethics, ed. Anna C. Mastroianni, Jeffrey P.
misinformation: developing a public health prevention Kahn, and Nancy E. Kass (Oxford Handbooks, 2019;
framework for managing information ecosystems’, online edn, Oxford Academic, 8 Jan. 2019), https://doi.
The Lancet Public Health 9, no. 6 (2024), e397-e406, org/10.1093/oxfordhb/9780190245191.013.69
https://doi.org/10.1016/S2468-2667(24)00031-8, See also the Canadian model on which the Oxford
https://www.thelancet.com/journals/lanpub/article/ Handbook framework was based: University of
PIIS2468-2667(24)00031-8/fulltext Toronto Joint Centre for Bioethics Pandemic Influenza
2. Bruno Monteiro and Rodrigo Dal Borgo, Supporting Working Group, Stand on Guard for Thee: Ethical
decision making with strategic foresight: An emerging considerations in preparedness planning for pandemic
framework for proactive and prospective governments, influenza (14 November 2005), https://jcb.utoronto.ca/
OECD Working Papers on Public Governance, wp-content/uploads/2021/03/stand_on_guard.pdf
No. 63, OECD Publishing (Paris, 11 September 2023), 11. National Ethics Advisory Committee, Getting Through
https://doi.org/10.1787/1d78c791-en Together: Ethical values for a pandemic, Ministry of
3. Piret Tõnurist and Angela Hanson, Anticipatory Health (Wellington, 10 July 2007), https://neac.health.
innovation governance: Shaping the future through govt.nz/assets/Uploads/NEAC/publications/getting-
proactive policy making, OECD Working Papers on through-together-jul07.pdf
Public Governance, No. 44, OECD Publishing 12. National Ethics Advisory Committee, ‘Ethical Guidance
(Paris, 24 December 2020), https://doi.org/10.1787/ for a Pandemic: Whakapuāwaitia e tatou kia puāwai
cce14d80-en tātou’, updated 22 August 2023, https://neac.health.
4. David J. Snowden and Mary E. Boone, ‘A Leader’s govt.nz/consultations/past-consultations/ethical-
Framework for Decision Making’, Harvard Business guidance-for-a-pandemic-whakapuawaitia-e-tatou-kia-
Review, November 2007, https://hbr.org/2007/11/a- puawai-tatou
leaders-framework-for-decision-making 13. World Health Organization, Organisation for Economic
5. Chris van Dam (Chairman of Dutch Safety Board) Co-operation and Development, and International
and Erica Bakkum (Member of Dutch Safety Board) Bank for Reconstruction and Development/The
to The Cabinet and the House of Representatives World Bank, Strengthening pandemic preparedness
of the States General, Overarching lessons of and response through integrated modelling (Geneva,
COVID-19 investigation, 25 October 2023, 8 May 2024), https://www.who.int/publications/i/
https://onderzoeksraad.nl/wp-content/ item/9789240090880
uploads/2023/12/Letter-Overarching-lessons-of- 14. Elias Visontay, ‘NSW’s lockdown lifts on Monday.
COVID-19-investigation.pdf What Covid restrictions change after the 70%, 80%
The Rt Hon the Baroness Hallett DBE, Module 1 vaccination milestones and beyond?’, The Guardian,
Report – The resilience and preparedness of the United 10 October 2021, https://www.theguardian.com/
Kingdom, UK Covid-19 Inquiry (UK, 18 July 2024), australia-news/2021/oct/07/nsw-lockdown-will-soon-
recommendations 3 and 4, https://covid19.public- lift-what-covid-restrictions-change-at-the-70-vaccine-
inquiry.uk/wp-content/uploads/2024/07/18095012/ milestone
UK-Covid-19-Inquiry-Module-1-Full-Report.pdf Premier of Victoria, ‘Victorians’ Hard Work Means
6. Ministry of Health, New Zealand Influenza Pandemic Hitting Target Ahead Of Time’, updated 17 October
Plan: A framework for action (2nd edn) (Wellington, 2021, https://www.premier.vic.gov.au/victorians-hard-
2017), https://ndhadeliver.natlib.govt.nz/delivery/ work-means-hitting-target-ahead-time
DeliveryManagerServlet?dps_pid=IE53291176 15. An Tionól Saoránach The Citizens’ Assembly,
7. The Rt Hon the Baroness Hallett DBE, Module 1 ‘About Ireland’s Citizens’ Assemblies’,
Report – The resilience and preparedness of the https://citizensassembly.ie/about/
United Kingdom, UK Covid-19 Inquiry (UK, 18 July 2024), 16. Dutch Safety Board, Summary – Approach to
p viii, https://covid19.public-inquiry.uk/wp-content/ COVID-19 Crisis Part 3: January 2020 through to
uploads/2024/07/18095012/UK-Covid-19-Inquiry- September 2022 (The Hague, 25 October 2023),
Module-1-Full-Report.pdf https://www.onderzoeksraad.nl/wp-content/
8. Ministry of Health, New Zealand Pandemic Plan: A uploads/2023/12/approach_to_covid_19_crisis_
framework for action, Ministry of Health (Wellington, part_3_summary.pdf
July 2024), p 3, https://www.health.govt.nz/system/ 17. OECD, Ready for the Next Crisis? Investing in
files/2024-07/interim_nz_pandemic_plan_v2.pdf Health System Resilience (OECD Health Policy
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health response to pandemic influenza (29 July 2007), https://doi.org/10.1787/1e53cf80-en
https://www.who.int/publications/i/item/WHO_CDS_
EPR_GIP_2007.2
18. The Australian Government the Treasury, Economic 24. Rod Forbes and Andre van Halderen, Foot-and-
Impact Analysis: National Plan to Transition to Australia’s Mouth Disease Economic Impact Assessment: What
National COVID 19 Response (2021), https://treasury. it means for New Zealand, Ministry for Primary
gov.au/sites/default/files/2021-08/PDF_Economic_ Industries (August 2014), https://www.mpi.govt.nz/
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Haumaru%20W.pdf (6 August 2024), 2126, https://doi.org/10.1186/s12889-
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compass.onlinelibrary.wiley.com/doi/full/10.1111/ Cheong, and Woo Joo Kim, ‘How lessons learned from
soc4.12080 the 2015 Middle East respiratory syndrome outbreak
United Nations Office for Disaster Risk Reduction affected the response to coronavirus disease 2019 in
(UNDRR), ‘Poverty and inequality’, updated 18 April the Republic of Korea’, The Korean Journal of Internal
2024, https://www.preventionweb.net/understanding- Medicine 36, no. 2 (5 February 2021), 271-285, https://
disaster-risk/risk-drivers/poverty-inequality doi.org/10.3904/kjim.2020.371 https://www.kjim.org/
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Understanding Social Recovery (1 April 2016), 27. Katelyn J Yoo, Soonman Kwon, Yoonjung Choi,
https://quakestudies.canterbury.ac.nz/store/ and David M Bishai, ‘Systematic assessment of
object/524767?search=understanding%2520 South Korea’s capabilities to control COVID-19’,
social%2520recovery Health Policy 125, no. 5 (May 2021), 568-576,
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Resource Allocation and COVID-19, Ministry of Health https://www.sciencedirect.com/science/article/pii/
(Wellington, 16 February 2021), p 5, https://neac. S0168851021000543?via%3Dihub
health.govt.nz/publications-and-resources/neac- 28. Janet McLean, The Legal Framework for Emergencies
publications/ethics-and-equity-resource-allocation- in Aotearoa New Zealand (NZLC SP23), Law Commission
and-covid-19 (11 November 2022), https://www.lawcom.govt.nz/our-
22. Ministry of Social Development, Care in the Community work/emergency-powers-for-pandemics-and-other-
(CiC) welfare response – Lessons from a real-time threats/tab/study-paper
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lessons-learned.pdf other-threats/tab/study-paper
23. Reserve Bank of New Zealand and The Treasury,
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14 February 2003, https://www.rbnz.govt.nz/hub/
research/additional-research/the-macroeconomic-
impacts-of-a-foot-and-mouth-disease-outbreak
CHAPTER 11:
11 Recommendations |
Ngā tūtohutanga
Overview of the recommendationsi |
11.1 Tirohanga whānui o ngā whakaaturanga
Group 1: Strengthen all-of-government coordination and accountability

for pandemic preparedness
Establish a central agency function to coordinate all-of-government preparation

and response planning for pandemics and other national risks.
Strengthen oversight and accountability for pandemic preparedness.
Central agency function Oversight and accountability

• Lead all-of-government • Chief Executives Group
pandemic planning • Ministerial oversight
• Coordinate and drive preparation activities • Parliamentary scrutiny
across agencies • Public transparency
Group 2: Ensure an all-of-government pandemic plan, response structure

and supporting processes are developed and ready for a pandemic response
Planning Response structure

Develop and practise an all-of-government Ensure an all-of-government response
response plan for a pandemic, covering the structure is ready to be activated if
national-level response and integrating needed in a pandemic, supported by
sector-specific plans. adequate staffing and the provision of
comprehensive advice under urgency.
Group 3: Strengthen the public health measures that may be required

in a pandemic
Health system pandemic planning Plans in place for scaling-up and

Refine the health system pandemic implementing significant public health
plan and link it with the all-of-government measures in a pandemic:
pandemic plan. • future options for quarantine
and isolation
• plans for rapidly scaling-up
testing and contact tracing
• implementing border
restrictions and lockdowns,
and managing impacts
• vaccination.
i
i This overview provides a summary of the high-level recommendations included in the table of recommendations
(see section 11.4). It does not include the supporting detail, and the table itself should be regarded as the definitive
statement of the Phase One recommendations
Group 4: Ensure all sectors are prepared for a pandemic and are ready
to respond
Ensure each sector Health Economic

has a pandemic plan Build resilience to Ensure plans are in place
and considers what ensure continuity to address the way that
they would need of non-pandemic the economy functions
to do to support health care. during a pandemic –
activity within their Improve ventilation including economic and fiscal
sector to keep in hospitals and policy, the labour market,
going safely in a other public spaces. management of supply
pandemic. chains, the operation of
lifeline utilities, and the
provision of financial support.
Social sector Justice sector Education

Strengthen Maintain access Plan to keep educational
coordination at to services and facilities open as much as
local, regional and ensure the rights possible.
national levels. and wellbeing Maintain access to
Ensure access to of prisoners education through remote
welfare support, are protected. learning.
food and housing.
Group 5: Ensure enablers are in place
Improve the way public sector agencies work with iwi and Māori during
a pandemic, to support the Crown in its relationship with Māori under te Tiriti.
Review legislation to ensure it is fit for purpose for a future pandemic.
Ensure core infrastructure is fit for purpose to support each sector’s pandemic response.
Group 6: Implement these recommendations
Assign a minister to lead the response to the recommendations, ensure

six-monthly progress reports, and report to Parliament within 12 months of
this report being completed.
Introduction |
11.2
0.0 Kupu whakataki
This chapter sets out what we recommend the

government and its agencies do to ensure Aotearoa
New Zealand is pandemic-ready and resilient.ii
The Looking Back chapters of this report demonstrate that the challenge of
responding well to a pandemic does not fall on central government alone –
communities, iwi and Māori, non-governmental organisations, local government
and the private sector all contributed enormously to the COVID-19 response and
will doubtless do so again in another pandemic. These groups and others may
well find aspects of our recommendations relevant to their own pandemic
planning. However, our recommendations are directed at central government.iii
The recommendations give practical effect to the lessons learned from the
COVID-19 pandemic, but they are not specific to that event. As we know, the
next pandemic could well originate from a different pathogen that spreads and
affects people quite differently, and it could require other response measures
altogether. Our recommendations have therefore been designed to meet a
range of possible pandemic scenarios. Some are also relevant to other kinds
of national risks and emergency situations.
Like the lessons from which they arise, our recommendations are grounded in
the evidence gathered during the Inquiry, including what we learned about other
countries’ COVID-19 responses. The recommendations take account of what
worked well and also what did not. Some recommendations reflect the views and
suggestions of stakeholders we engaged with directly or who provided submissions.
When we heard good ideas for improving pandemic preparedness and resilience,
we took note and used them to inform our recommendations.
Our Inquiry confirmed the extent to which Aotearoa New Zealand is still reckoning
with the impact of COVID-19. Regardless of its continuing shadow, the country may
need to respond to another global pandemic at any moment; just in the period
spent preparing this report, we have seen growing fears of avian flu pandemic
and the spread of mpoxiv to countries with no previous documented transmission
(including Aotearoa New Zealand).
ii See section 5 of the Terms of Reference: ‘Matters upon which recommendations are sought: The inquiry should
make recommendations on the public health strategies and supporting economic and other measures that
New Zealand should apply in preparation for any future pandemic, in relation to the principal matters within the
inquiry’s scope, by applying relevant lessons learned from New Zealand’s response to COVID-19 and the response
from comparable jurisdictions.’
iii We have used the term central government as the decisions and actions associated with the recommendations will
require ministerial or Cabinet decisions and do not sit solely with officials to implement.
iv Avian flu (or ‘bird flu’) is an illness caused by an influenza virus that normally affects birds but can cross over to infect
humans (as in the case of the H5N1 influenza virus). Mpox (previously known as monkeypox) is an illness caused by
the monkeypox virus, a type of Orthopoxvirus.
We cannot predict whether the next pandemic will be triggered by a virus known
to us or by an entirely new pathogen, whether it will be more deadly than COVID-19
or less, and whether it will be short-lived or protracted. What we can do is be ready
for a range of possible pandemic scenarios. We therefore urge the Government to
consider and implement these Phase One recommendations as soon as practicable.
The minister charged with leading this work should receive regular progress reports
on how the recommendations are being implemented at the all-of-government level
and by individual agencies, and keep Parliament informed.
Readers can engage with the recommendations in two ways.

For those wanting a general overview of their intent and scope,
section 11.3 groups and summarises the recommendations
under six thematic headings.
Readers wanting to review the recommendations in full should
consult the complete table of recommendations provided in section
11.4. This should include the officials who will need to consider,
implement or monitor them. That table should be regarded as
the definitive statement of the recommendations arising from
Phase One of this Inquiry.
In brief: what the recommendations say |
11.3
0.0 Te kōrero poto: he aha ngā tūtohutanga
The 39 recommendations set out in the definitive table of recommendations

at the end of this chapter call for action across many areas of government
(see section 11.4). All support a common overall objective: ensuring pandemic
preparations and the response itself have a clear purpose and are people-centred.
As we commented in our lessons for the future (Chapter 10), such an objective
should be adopted and regularly articulated throughout any pandemic response.
Doing so will give the Government and the people of Aotearoa New Zealand a
clear sense of direction, a benchmark against which response decisions can be
measured and decision-makers held accountable, and a lodestar when the going
gets especially tough.
Our recommendations are organised into six groups. The broad intention behind
each group is described below.
Group 1: Strengthen all-of-government coordination

and accountability for pandemic preparedness | Rōpū 1:
Te whakakaha i te whakariterite o te kāwanatanga whānui
me te noho haepapa mō te takatū mō te mate urutā
This first group of recommendations aims to strengthen the coordination of, and
accountability for, all-of-government pandemic preparedness. Our analysis of
the response to COVID-19 showed that Aotearoa New Zealand – like many other
countries – would benefit from stronger assessment of the risks posed by a future
pandemic (and potentially other national risks), and stronger coordination of
government preparedness to mitigate that risk.
The scale, complexity and duration of COVID-19 reinforced the need for all-of-
government coordination of and support for pandemic preparedness and response.
We therefore recommend that a specific function be established within a central
agency to carry out this role. The term ‘central agency function’ is used because,
while it is clearly a function that needs to be carried out by a central agency in
government (with assistance from other agencies), we see the breadth and capacity
of this function as extending beyond the role of any one existing agency. Something
new and expanded is needed. Its functions should include considering the risks
posed by a future pandemic (using tools such as scenario planning), evaluating
potential options for mitigating those risks, supporting cross-agency preparations
for a pandemic response and coordinating pandemic response exercises.
This new centralised function needs to be supported by relevant expertise and
capacity. Both scenario planning and modelling (not only epidemiological modelling,
but also health, social and economic) should be routinely used to support decision-
making, planning and all other preparedness activities. So too should specialist
advice on issues including safeguarding human rights and democratic principles in a
pandemic response, and the Crown’s te Tiriti obligations. External expertise should
also inform pandemic preparations and response.
As we set out in Chapter 2, the risk management system in place ahead of
the COVID-19 pandemic had limitations. In particular, it had few formal oversight
or accountability mechanisms for ensuring adequate planning and preparation
was underway across government. As was the case in many countries, Aotearoa
New Zealand’s risk management system lacked real ‘bite’ – a factor that we consider
affected national preparedness for an event of the scale, duration and complexity
of COVID-19.
This group of recommendations also therefore sets out how the Government
can ensure stronger oversight and accountability for the preparation for pandemics
and other national risks. As we conducted the Inquiry, it became clear that it would
be both illogical and inefficient to consider pandemics in isolation from other
national risks. Evidence presented to us reinforced the need for a broad approach.
Our recommendations therefore situate pandemics within the broader context of
national risks. We recommend actions that will improve oversight at many levels –
by Parliament, at the all-of-government level, by the public sector collectively and
within government agencies. Their scrutiny should include what actions are being
taken to address national risks and how gaps in preparedness are being addressed.
Group 1 recommendations at a glance

Strengthen all-of-government coordination and accountability for
pandemic preparedness.
• Establish a central agency function to coordinate all-of-government
preparation and response planning for pandemics and other national
risks, supported by strengthened scenario planning, modelling
capability, and external expertise.
• Strengthen oversight and accountability for pandemic preparedness,
and make it more publicly transparent, with preparedness being
sustainably funded.
Group 2: Ensure an all-of-government pandemic plan,
response structure and supporting processes are developed
and ready for a pandemic response | Rōpū 2: Te whakarite
ka hangaia tētahi mahere mate urutā, anga urupare me ngā
hātepe tautoko i te kāwanatanga whānui, ā, e rite ana mō
tētahi urupare mate urutā
An all-of-government pandemic plan is an essential element of a coordinated and
effective response. It should integrate the individual response plans prepared by
sector groups (for example, justice or social sector agencies) and also align closely
with the pandemic plan produced by the Ministry of Health, the agency with core
competency in public health emergencies.
We saw early on in the response to COVID-19 that the pre-existing ‘lead agency’
model, supported by Officials Committee for Domestic and External Security
Coordination (ODESC), was not adequate for the scale of the pandemic.
An all-of-government response structure was needed. While arrangements were
quickly established, they had to be modified several times during 2020. Things
might have been different if an all-of-government response structure had been
developed and practised in advance. To ensure the all-of-government approach
works effectively, there should be processes in place to quickly secure adequate
staffing and rotate staff to prevent burnout. Processes for developing advice
under urgency, while still taking account of critical considerations such as human
rights issues, are also needed. Strengthening decision-making will be particularly
important in relation to public health measures, like lockdowns and vaccine
mandates, which involve careful weighing of competing considerations.

Ensure an all-of-government pandemic plan, response structure
and supporting processes are developed and ready for a
pandemic response.
• Develop and regularly practise an all-of-government
response plan for a pandemic, covering the national-level
response and integrating sector-specific plans.
• Ensure an all-of-government response structure is ready
to be activated if needed in a pandemic, supported by
adequate staffing and the provision of comprehensive
advice under urgency.
Group 3: Strengthen the public health measures that may be
required in a pandemic | Rōpū 3: Te whakakaha i ngā whakaritenga
hauora tūmatanui ka hiahiatia pea i tētahi mate urutā
The Influenza Pandemic Plan that Aotearoa New Zealand had before COVID-19 had
some useful elements but was inadequate for COVID-19. A more comprehensive
pandemic plan is needed for the health system that sets out how public health
measures can be used to respond to a range of pandemic scenarios. The Ministry of
Health has developed a health system pandemic plan since the COVID-19 pandemic,
and we make recommendations for how this should be refined. These refinements
include plans for health communication, which is critical in any pandemic.
There is a core set of public health measures that need to be part of the available
toolkit given the range of potential pandemic scenarios. Along with the health sector
pandemic plan, specific plans should be made for how this set of public health
measures can be rapidly implemented and scaled-up as required. These include
quarantine and isolation, national or regional lockdowns, testing, contact tracing,
border restrictions and vaccination.
Lockdowns are measures of last resort, and our view is that with better preparation
of other core tools, the likelihood that they will be needed again can be reduced.
However, they should stay as part of the toolkit, as a scenario involving a virus that is
even more infectious or deadly than the COVID-19 virus is possible; even with good
preparation and a good policy response we may still need to reach for lockdowns.
Government-issued occupational vaccination requirements should similarly stay
in the toolbox, though the bar for their use should be very high. Employer-set
vaccination policies for staff under occupational safety and health legislation should
only be used with caution, with good information available to employers and
employees on the likely benefits and harms. Vaccination certificates or passes – for
example, for incoming travellers – cannot be ruled out either, but should only be
used when the marginal benefits relative to other policy responses such as mask
wearing outweigh the potential harms.
Our groups of recommendations work together. Good decision-making about
when to use lockdowns and vaccination requirements will be strengthened by
recommendations in Group 2. The recommendations in Group 3 and Group 4
then strengthen our ability to use such tools in a way that minimises their negative
consequences, when it is decided they are needed.

Strengthen the public health measures that may be required in a pandemic.
• The Ministry of Health should refine the health system pandemic plan
and link it with the all-of-government pandemic plan.
• Plans in place for scaling-up and implementing significant public health
measures in a pandemic.
Group 4: Ensure all sectors are prepared for a pandemic and
are ready to respond | Rōpū 4: Te whakarite kei te takatū ngā
rāngai katoa mō tētahi mate urutā, ā, e rite ana ki te urupare
The COVID-19 pandemic and associated response measures impacted all
sectors and parts of society over a prolonged period, to a degree that had not
been anticipated. Wide ranging impacts are inevitable in a future pandemic too,
given the interconnectedness of our economic, social, health and government
systems, and the range of possible responses that might be needed. This group
of recommendations is aimed at lessening the breadth, severity and duration of
those impacts to the greatest extent possible next time.
Aotearoa New Zealand has learned that being prepared for a pandemic is not just
a matter for the emergency management system, or for the health system, the
responsibility falls on all sectors to be ready to respond and remain resilient, for
however long the response is needed. We therefore recommend that each sector
has its own pandemic plan which aligns with the overall all-of-government
pandemic plan.
Agencies must invest in and maintain working relationships and partnerships with a
broad range of stakeholders in their sectors. They should seek to develop a shared
understanding of the likely impacts of another pandemic and what preparations are
required. Regional and international relationships that will be beneficial next time
(for example, by ensuring access to vaccines and essential products like personal
protective equipment (PPE)) should also be fostered.
We also include specific recommendations for the health, economic, social,
education and justice sectors. For each, we set out how these sectors can prepare
and build the resilience needed to keep necessary goods and services going as
efficiently as possible in a pandemic and beyond.
In the health system, we recommend taking steps to strengthen its resilience and
readiness to deal with the multiple demands of a national pandemic: it needs access
to a greater capacity to treat a possible surge in pandemic-related illness without
compromising non-pandemic health and disability services. We also recommend
that health and other agencies investigate ways to improve ventilation and airflow
in buildings which we now know play a significant role in limiting the transmission
of respiratory viruses.
In other sectors, we make recommendations aimed at ensuring they can play
their role in responding to a pandemic. These include minimising disruption to
supply chains, making sure that households have sufficient income and food
security, and ensuring access to services like courts and education is maintained
as much as possible.
Ensure all sectors are prepared for a pandemic and are ready to respond.
• Ensure each sector has a pandemic plan and consider what they would
need to do to support activity within their sector to keep going safely in
a pandemic.
• Ensure the health, economic, social, education and justice sectors
are prepared to keep necessary goods and services going as much as
possible in a pandemic, without compromising the long-term capability
to continue delivering these services in the future.
Group 5: Ensure enablers are in place | Rōpū 5: Te whakarite

kua rite ngā kaihāpai
This group of recommendations focuses on the enablers that must be in
place to underpin any future pandemic response. Government agencies and
appropriate iwi and Māori organisations should review successful examples
of Crown-Māori partnerships in the COVID-19 response – some of which are
documented throughout this report – and make any changes that will embed te
Tiriti relationships, frameworks and partnerships in a future pandemic response.
It is also essential that fit-for-purpose legislation is in place, and that all
agencies have the core infrastructure they need to carry out their role in any
pandemic response.

Ensure enablers are in place.
• Improve the way public sector agencies work with iwi and Māori during
a pandemic to support the Crown in its relationship with Māori under
te Tiriti.
• Review legislation to ensure it is fit for purpose for a future pandemic.
• Ensure core infrastructure is fit for purpose to support each sector’s
pandemic response.
Group 6: Implement these recommendations | Rōpū 6:
Whakatinanahia ēnei tūtohutanga
Almost two years have passed since the COVID-19 pandemic response formally
ended, and the risk of a future pandemic remains high. While this Inquiry will
not be complete until the Phase Two report is presented in early 2026, the lessons
and recommendations in this Phase One report have been drafted with an eye
to their immediate applicability and implementation.
We therefore recommend that a minister should be appointed to lead the
response to, and implementation of, the Phase One recommendations.
Responsible agencies should report to this minister every six months on
their progress towards implementing the recommendations, and a report
summarising all agencies’ progress should be tabled in Parliament within
12 months of the Phase One report being released.

Implement these recommendations
• Consider and implement Phase One recommendations as
soon as practicable.
Complete table of recommendations |
11.4
0.0 Te tūtohi me ngā tūtohutanga katoa
This section has a complete list of the Inquiry’s

recommendations.
To avoid repetition in the recommendations themselves, we note that:
• Unless otherwise stated, all recommendations are directed at central
government and public sector agencies.
• While our recommendations focus on pandemic preparedness, they
should also be read as applying to other national risks and emergencies
as appropriate.
• In developing the plans and advice set out in the recommendations, we
expect that agencies will work in collaboration (including with population
agencies where relevant), carry out appropriate consultation and engagement
(including with iwi and Māori, community groups, businesses, local and
regional government, and internationally) and consider how their plans give
effect to te Tiriti.
• Pandemic response planning should be informed by scenario planning
and modelling.
Group 1: Strengthen all-of-government coordination and
accountability for pandemic preparedness
A central agency function should be established to coordinate

all-of-government preparation and response planning for
pandemics and other national risks, supported by strengthened
scenario planning, modelling capability, and external expertise.
Recommendations Responsible
agency / agencies
Central governmentv
1 Establish a central agency function to coordinate all-of-
government preparedness to respond to pandemics (and
other national risks). The function should:
a. Develop, monitor and produce reports on the National
Risk Register (see also Recommendation 5a).
b. Support the Chief Executives Group (see also
Recommendation 4) to oversee a cross-agency work
programme to prepare for and respond to pandemics.
c. Coordinate the development of a range of pandemic
scenarios to guide preparedness and response planning
(see also Recommendation 2).
d. Develop an all-of-government response plan (see
also Recommendation 7) and lead associated
preparatory work.
e. Coordinate national pandemic response exercises at least
once every three years and report on those exercises to
the Chief Executives Group and ministers.
Central government
2 Ensure the central agency function has access to appropriate
scenario planning and modelling capability to support
pandemic preparedness and response. That capability should:
a. Be drawn from public sector agencies, non-government
institutions and the international community.
b. Include health, economic and social modelling to allow
for the interaction of these components.
c. Determine the data and monitoring systems that are
needed over the longer term.
d. Be able to be surged during a pandemic response.
The central
3 Establish a pandemic expert advisory group, including
expertise from both the public and non-government sectors, agency function, in
to support pandemic preparedness and provide strategic consultation with the
advice during a pandemic response. Ministry of Health and
other relevant agencies
v We have used the term central government as the decisions and actions associated with the recommendation will
require ministerial or Cabinet decisions and are not something that sit solely with officials to implement.
Oversight and accountability for pandemic preparedness should
be strengthened, and made more publicly transparent, with
preparedness being sustainably funded.
agency / agencies
• Central government
4 To strengthen oversight and accountability for public
sector agencies’ preparedness for pandemics (and other • Te Kawa Mataaho/
national risks): Public Service
a. Establish a Chief Executives Group to have strategic Commission
oversight of national preparedness for pandemics for part of
(and other national risks) and associated cross-agency Recommendation 4e
work, including the development and delivery of a work
programme to address gaps in preparedness.
b. Create an oversight mechanism such as a Cabinet
Committee or Ministerial Group chaired by a senior
minister to proactively review national preparedness for
pandemics (and other national risks) and oversee a work
programme to address gaps in preparedness.
c. Require the Chief Executives Group to regularly update
the Cabinet Committee or Ministerial Group on the
extent of preparedness.
d. Invite Parliament to establish a mechanism to proactively
review national preparedness for pandemics and other
national risks, on a regular basis.
e. Set expectations for pandemic preparedness via public
service chief executive performance agreements, and
via Ministerial direction to Crown entities, including a
requirement to work collectively on preparedness.
f. Invite the Office of the Auditor-General to establish
a review and a public reporting programme on the
public sector’s readiness to respond to pandemics
(and potentially other national risks), that includes how
they would deliver business-as-usual activity during a
pandemic of extended duration.
Central government
5 To ensure public transparency:
a. Publish the National Risk Register and report on actions
being taken to address risks, every three years.
b. Require public sector agencies to include an assessment
of pandemic preparedness in their annual reports.
The Treasury
6 Provide advice on options for sustainably funding the
necessary preparation activities and associated systems
improvements, as outlined in the recommendations in
this report.
Group 2: Ensure an all-of-government pandemic plan,
response structure and supporting processes are developed
and ready for a pandemic response
An all-of-government response plan for a pandemic, covering

the national-level response and integrating sector-specific plans,
should be developed and regularly practised.
agency / agencies
The central
7 Develop an all-of-government pandemic response
agency function
plan that includes:
a. A statement of the overarching objective of a pandemic
response (to be adapted as appropriate depending on
the nature of the pandemic).
b. Roles and responsibilities for delivering an all-of-
government pandemic response.
c. Criteria, thresholds and processes for when an all-of-
government response will be triggered, instead of a
health-led response.
d. Key considerations to guide the initial and urgent
response, including whether/when to introduce stringent
measures that may be required urgently.
e. Guidance on how to develop and ensure there are
pathways and transitions through all stages of the
response through to exit.
f. Mechanisms for communication with different
communities (including Māori, Pacific and other ethnic
communities, disabled people and other groups with
specific communication needs).
g. Mechanisms for monitoring the social, economic and
cultural impacts of a pandemic response, and feeding this
back into advice on policy responses.
h. A statement of how the pandemic response plan will
support the Crown to meet its te Tiriti o Waitangi
obligations.
i. An explanation of how individual sector plans will work
together to ensure a comprehensive response.
The central agency

8 Update the all-of-government pandemic plan following
function with input
each national pandemic response exercise (see also
from other agencies
Recommendation 1e).
as required
An all-of-government response structure should be ready to be
activated if needed in a pandemic, supported by adequate staffing
and the provision of comprehensive advice under urgency.
agency / agencies
The central
9 Develop an all-of-government response structure that can
agency function
be quickly stood up in a pandemic where the lead agency
does not have the capacity and capability to coordinate
the response. Its functions and capabilities when activated
should include:
a. Leading the all-of-government response.
b. Coordinating the development of new legislation.
c. Coordinating the provision of expert advice.
d. Information systems and processes to support the
development of advice to decision-makers (see also
Recommendation 11).
e. Public communication and engagement during
the response.
f. Processes to rapidly review and strengthen key response
arrangements to ensure they remain fit for purpose and
can be adjusted to changing circumstances, including
operational issues.
g. A separate strategy function that has the capacity to lead
high-level planning for different phases of the response,
including planning for transition and exit.
Te Kawa Mataaho/
10 Develop a plan to enable the movement of public
Public Service
sector capability and capacity during a pandemic
Commission
response, including bringing in specific expertise where
needed and ensuring that staff can be rotated to reduce
the risk of burnout.
The central
11 Prepare guidance and templates for producing advice under
agency function
urgency that takes account of:
a. The overarching strategic purpose of the response and the
ethics frameworks that will be used to balance different
rights, values and impacts in decisions.
b. The impacts on the wider health system and
non-health sectors.
c. The cumulative impacts of decisions to limit the New
Zealand Bill of Rights Act 1990 rights and other human
rights over time, and how those impacts are assessed.
d. How long-term implications are considered.
e. The Crown’s obligations under te Tiriti o Waitangi.
f. The use of tools such as multi-criteria analysis, value for
money, and cost benefit analysis to weigh up the relative
costs and benefits of choices in a consistent manner.
• Central government
12 Establish processes and accountability mechanisms to for Recommendations
protect democratic and human rights during a pandemic
12a and 12c
response, including:
• The central agency
a. Enabling cross-party consultation and input, as well as
function on
mechanisms that ensure parliamentary scrutiny during
Recommendation 12b
a pandemic.
b. Balancing quick decision-making with transparency,
accountability, and maintaining trust and social licence.
c. Inviting entities with oversight and accountability
responsibilitiesvi to develop, after consultation with
relevant public sector agencies, processes that will enable
them to exercise their functions during a pandemic
of extended duration.
vi Including the Offices of Parliament (the Office of the Auditor-General, the Office of the Ombudsman and the
Parliamentary Commissioner for the Environment), the Electoral Commission, and entities identified as designated
National Preventative Mechanisms under the Optional Protocol to the UN Convention Against Torture (listed on
www.justice.govt.nz as the Human Rights Commissioner (oversight responsibilities for the National Preventative
Mechanisms), Independent Police Conduct Authority, Mana Mokopuna|Children and Young People’s Commission,
Inspector of Service Penal Establishments and Office of the Ombudsman).
roup 3: Strengthen the public health measures that may
G
be required in a pandemic
The Ministry of Health should refine the health system pandemic

plan and link it with the all-of-government pandemic plan.
agency / agencies
Ministry of Health
13 Refine the current health system pandemic plan so that it:
a. Complements the all-of-government plan (see also
Recommendation 7) and other public sector agencies’
planning, and helps identify some of the requirements
for both.
b. Sets out a range of public health strategies (such as
elimination, suppression, mitigation), objectives and
associated public health and social measures that can be
used in responding to a pandemic and provides guidance
on how they might be deployed.
c. For the initial response, identifies key public health
considerations to guide advice on whether or when to
introduce border restrictions and other strict measures
aimed at excluding or eliminating the infectious agent.
d. Identifies indicators of capacity and mechanisms for
surging capacity when needed (in areas such as testing
and quarantine).
e. Provides for pandemic preparedness and resilience
in the wider health system, including plans for
maintaining access to non-pandemic healthcare (see
also Recommendation 22).
f. Includes plans for health communications in a
pandemic response – including communication with
the government, other government agencies, across
the health system (such as healthcare providers) and
with healthcare users. These plans should consider
mechanisms for communicating effectively with different
communities (including Māori, Pacific and other ethnic
communities, people with disabilities, and other groups
with specific communication needs), as well as business
groups and not-for-profit bodies.
g. Indicates how the health system will support the Crown
to meet its te Tiriti obligations in a pandemic response,
consistent with the existing frameworks and policies of
health agencies, services and providers.
Plans should be in place for scaling-up and implementing significant
public health measures in a pandemic.
agency / agencies
Ministry of Health
14 Develop a comprehensive plan for quarantine and isolation
together with
measures, that includes:
Health New Zealand |
a. Identifying a range of quarantine and isolation options,
Te Whatu Ora
including a cost-effective and scalable mix of purpose-
built, hotel contracts and other facilities, the associated
investment required, and how different approaches
could work together as an integrated system.
b. Options for the allocation of quarantine and isolation
capacity in case of limited supply that take account of
need and legal rights, and provide for user-friendly and
compassionate processes.
c. How current and new technology, such as location
monitoring of people in home isolation and quarantine,
could be used, including as a complement to facility-
based quarantine.
d. Information-sharing protocols.
e. Alignment and integration with the financial support
measures to meet welfare and business support needs
(see also Recommendation 30).
Ministry of Health,
15 Ensure the health system can rapidly scale-up key public
together with
health functions in line with the health system pandemic
plan. This includes preparedness to deliver contact tracing,
Te Whatu Ora
testing, vaccination and guidance on infection prevention
and control measures.
Ministry of Health,
16 Ensure the health system has the information and data
together with
capability to deliver a pandemic response by prioritising
work to implement the recommendations of the Health and
Te Whatu Ora
Disability System Review (March 2020) calling for connected
and shared health systems, data and information.vii
vii See pp 227-228, https://www.health.govt.nz/publications/health-and-disability-system-review-final-report
Border Executive
17 Develop a comprehensive plan for the use of international
Board and Ministry of
border restrictions which includes consideration of how
Social Development
to manage the impacts on people affected by border
restrictions, including:
a. Any necessary changes to immigration settings to
support foreign nationals in New Zealand.
b. Provision of timely social, welfare and financial support
to foreign nationals in New Zealand and New Zealand
citizens offshore.
c. Provision of relevant social, financial and health support
to the New Zealand Government’s offshore workforce in
a future pandemic.
Ministry of Health,
18 Develop a comprehensive plan for the use of national and together with other
regional lockdowns which includes consideration of:
relevant agencies
a. The thresholds and circumstances that might justify
their use.
b. How the impacts on people can be managed, including
the work done under Recommendations 30 and 32.
c. A process for establishing and managing regional
boundaries, if required.
Ministry of Health
19 Identify the circumstances in which vaccination
requirements (such as occupational requirements,
mandates, vaccine certificates or passes) might be
recommended as part of a package of public health
measures, and key considerations for how the negative
impacts of the requirements might be mitigated.
Group 4: Ensure all sectors are prepared for a pandemic
and ready to respond
Each sector should have a pandemic plan and consider what they
would need to do to support activity within their sector to keep
going safely in a pandemic.
agency / agencies
All public
20 Develop and maintain sector pandemic plans that: sector agencies
a. Complement other sector plans and the all-of-
government pandemic response plan (see also
Recommendation 7).
b. Incorporate input from sector stakeholders on gaps or
vulnerabilities that need to be addressed ahead of a
future response.
c. Identify sector-specific key considerations that need
to be taken into account when making decisions on the
initial response.
d. Set out the strategies and options that can be used
over the short and longer term, including how they might
be deployed.
e. Identify roles and responsibilities within each sector for
responding to a pandemic.
f. Provide mechanisms for surging capacity when needed.
g. Identify the workforce needed to support a pandemic
response, within a specific sector.
h. Include mechanisms to allow sector stakeholders’
connections, intelligence and ideas to feed into
any response.
i. Enable communication with different communities during
a pandemic response (including Māori, Pacific and other
ethnic communities, disabled people, and other groups
with specific communication needs), as well as with
business groups and not-for-profit bodies.
j. Indicate how they will support the Crown to meet its te
Tiriti obligations in a pandemic response.
All sectors
21 Alongside the development of their pandemic plans, each
sector should consider what activities within their sector
might be able to be kept going in a safe way even when
public health restrictions are in place, and how such safe
activities could be enabled. They should also consider:
a. What activities might in limited circumstances need to be
designated ‘essential’ during a pandemic response, and
what would need to be in place to enable these activities
to continue.
b. How the right balance might be struck between
prescriptive rules and flexibility for devolved decision-
making for the agencies, businesses and other bodies
within their sector, and what guidance and safeguards
would be needed to support this.
The health, economic, social, education and justice sectors should
be prepared to keep essential services going as much as possible in
a pandemic, but without compromising the long-term capability to
continue delivering these services in the future.
Health
agency / agencies
• Ministry of Health,
22 Plan and ensure system resilience and readiness for together with
continuity of health and disability services during a
Health New Zealand
pandemic, including through:
| Te Whatu Ora,
a. Guidance on how to prioritise non-pandemic health
Ministry of Social
services in a pandemic and mechanisms to regularly
Development as
review prioritisation decisions during a pandemic.
required
b. Mechanisms for monitoring and reporting on health
• Ministry of
system performance and capacity to inform decisions
Health, Health
during a pandemic.
New Zealand |
c. Planning for, and investment in, workforce capability Te Whatu Ora,
and resilience for a pandemic. Pharmac and
d. Building health system resilience into operational Ministry of Business,
policy, commissioning frameworks, service contracting, Innovation and
monitoring and reporting. Employment on
e. Planning for how providers can be supported to adapt Recommendation 22f
their service delivery models in a pandemic to minimise
disruption to the ongoing provision of healthcare.
f. Identifying possible supply chain issues for key pandemic-
related products (such as reagents, ventilators, medical
products, personal protective equipment) and medicines
or medical products, that might arise during a pandemic
and prepare a plan that addresses sources of supply,
procurement mechanisms, management protocols and
contingency measures.
g. Planning for how to secure adequate physical capacity to
meet healthcare needs in a pandemic (such as through
the allocation of public hospital capacity, the use of ad
hoc and private facilities, management protocols, and
other contingency measures).
Ministry of Health,
23 Determine the costs and benefits (and associated funding Health New Zealand
priorities) of improving ventilation in all or parts of hospitals
| Te Whatu Ora and
and other healthcare facilities, alongside other interventions
Ministry of Business,
designed to manage infection risk in those facilities.
Innovation and
Employment
24 Review and develop options for improving ventilation and Innovation and
filtration in buildings generally accessed by the public, other
Employment
than healthcare facilities. This work should consider:
a. The relative priority and costs and benefits for improving
ventilation in different building types (or parts of buildings)
– for example, schools, prisons, aged care facilities.
b. The costs and benefits of improving ventilation across
existing buildings, compared to new buildings.
c. The incremental costs and benefits of improving
ventilation over and above alternative interventions that
may be cheaper and easier (such as masking).
d. The use of standards, guidance and voluntary codes.
e. The benefits that accrue outside pandemics (such as
reduced respiratory disease transmission, and improved
workforce productivity and student performance) because
of improved air quality.
f. Reviewing and improving building standards and codes,
given the above considerations.
Economic
agency / agencies
• All economic
25 Determine appropriate governance arrangements and sector agencies on
responsibilities for a coordinated economic response to a
Recommendations
pandemic, in both short- and long-term scenarios, by:
25a and 25b and 25g
a. Clarifying relevant principles and the respective roles
• The Treasury and
and responsibilities of economic agencies to ensure the
Reserve Bank on
coordinated delivery of an economic and fiscal response.
Recommendations
b. Ensuring a forward-looking view during a pandemic on
25c and 25d
likely evolving scenarios and exit strategies.
• Reserve Bank,
c. Developing a shared Treasury and Reserve Bank of
Financial Markets
New Zealand playbook aimed at obtaining a common
Authority and
understanding on how the appropriate level, sequencing
the Treasury on
and composition of monetary and fiscal support might
Recommendation 25e
play out in a pandemic, and the arrangements needed
• The Treasury on
to ensure appropriate monetary and fiscal policy
Recommendation
collaboration in an emergency.
25f and oversight
d. Ensuring that principles of sustained good fiscal, and
of 25g
sound monetary and financial system management
are not compromised when implementing
Recommendation 25c.
e. Ensuring the ongoing supply of essential financial
services.
f. Providing, and publishing, advice on prudently rebuilding
fiscal buffers to ensure that there is fiscal headroom for
responding to future emergencies.
g. Establishing mechanisms that can fast-track effectiveness,
‘reach’, and value-for-money assessments to ensure high
quality and targeted public expenditure.
• Ministry of Business,
26 Develop a labour market plan for responding to a Innovation and
pandemic that:
Employment
a. Identifies possible labour market gaps and vulnerabilities
• Ministry of Business,
that might arise during a pandemic, and which skill and
Innovation and
labour shortages are likely to need prioritising to maintain
Employment and
necessary goods and services.
Ministry of Health on
b. Explores how these gaps and vulnerabilities might be
Recommendation
addressed, including through training settings; identifies
26c
the key skills that might need to be sourced from
overseas; and proposes how these skills can be obtained.
c. Identifies how quarantine and isolation management and
allocation systems can assist in meeting urgent labour
market needs.
27 To ensure ongoing operation of supply chains: Innovation and
a. Continue to work with international partners to develop
Employment
ways of minimising future supply chain disruptions during
with Ministry of
a pandemic, including through the Indo-Pacific Economic
Transport and other
Framework work on supply chains.
relevant agencies
b. Build on existing work programmes to improve the
government’s knowledge of domestic and international
supply chains (including through improved government
data collection and use of international and domestic
supply chain information) and the inputs Aotearoa
New Zealand manufacturers and producers rely on and
how these could be affected in a pandemic.
c. Improve and maintain relationships and information-
sharing between government agencies, shippers and
supply chain operatives, with the aim of increasing
resilience and enabling better preparation against supply
chain threats.
d. Establish a programme to improve private sector
knowledge of supply chain trends and practices, and
how to mitigate performance problems to improve
commercial resilience to a pandemic.
Ministry of Transport
28 Assess what steps are needed prior to and during a
pandemic to maintain port performance, and assess trends
in international trade, aviation and shipping leading to a plan
to mitigate the risk of transport shortages or bottlenecks.
29 Ensure the ongoing functioning of lifeline utilities, and Innovation and
continued provision of necessary goods and services during
Employment
a pandemic, by:
a. Working with providers to assess and understand the
risks that both short-lived and protracted pandemics pose
for the lifeline utilities they are responsible for.
b. Considering what measures the government should take
to ensure the continued provision of necessary goods
and services.
The Treasury, Inland

30 Develop a comprehensive plan for financial assistance Revenue, Ministry of
schemes during a pandemic to support people and
Social Development,
businesses and maintain employment. It should include:
a. Options that are proportionate, suitably targeted, and
Innovation and
take account of the needs of different people (with
Employment and other
particular regard to those groups that are already
agencies if required
most vulnerable).
b. Clear agency responsibilities.
c. Where pre-existing economic and social supports may be
inadequate in a pandemic, and options to address gaps.
d. How measures would be monitored, reviewed and
assessed for quality and effectiveness of spend, and
could be adapted over different phases of a pandemic.
e. Indicative exit strategies.
f. Compliance systems to ensure the effectiveness of
support measures.
Social sector
agency / agencies
Ministry of Social
31 Determine appropriate governance arrangements and Development with
allocation of responsibilities for a coordinated welfare
response in both short- and long-term pandemic
scenarios, including:
a. Identifying agencies that need to be involved and the
leadership and governance mechanisms to enable a
collective response that is ready to be activated urgently
at the start of a pandemic.
b. Strengthening regional structures to ensure improved
coordination among agencies and between agencies and
local delivery organisations.
c. Building internal capability to partner effectively with
community agencies and iwi.
Ministry of Social
32 In any future pandemic, ensure policy response options Development, Ministry
and funding mechanisms are in place to:
of Housing and Urban
a. Address the housing, income, food security and safety
Development and the
needs of people and households to enable them to
Ministry of Health with
manage through a pandemic.
b. Target the needs of people who are hardest hit after engagement with
during emergencies. emergency services
c. Address additional mental health issues that arise and other providers
during and after a pandemic.
Ministry of Social
33 Plan and coordinate cross-sector approaches to Development
commissioning delivery of community services in a
with relevant social
pandemic so that:
sector agencies
a. Mechanisms are in place to allocate and distribute
funding quickly and efficiently in a future pandemic or
emergency to ensure providers have the resources to
respond to immediate community needs.
b. Any gaps in coverage are identified and addressed
(including by developing new capability and relationships
in underserved communities).
c. Flexibility in delivery approaches is supported, balanced
with appropriate accountability arrangements.
d. There are clear processes and communications
for winding down resources so this is signalled to
service providers and community organisations
receiving funding.
Justice
agency / agencies
Department of
34 Develop a sector pandemic plan that balances the need to Corrections|Ara
maintain a functioning prison system with the wellbeing and
Poutama Aotearoa
human rights of the prison population, including:
working with other
a. Identifying and anticipating the range of options, tools,
relevant justice
and settings that could be applied in a pandemic, and
sector agencies
ensuring that operational implementation is consistent
with human rights and te Tiriti compliance across all sites.
b. Having plans to maintain staffing during a pandemic, to
mitigate as much as possible restrictions such as reduced
outdoor and physical activity time.
c. Providing mitigations to lessen the impact of necessary
restrictions, support technology and transportation
options, ensure transparency and enable the role of
oversight bodies.
Education
agency / agencies
Education agencies
35 To ensure access to education can be maintained during
a pandemic:
a. Continue to coordinate planning work within the
schooling sector (including peak bodies) which will allow
schools and places of education to remain open as much
as possible in a pandemic – by, for example, pivoting to
remote learning, flexibility of the curriculum, teacher
capability for teaching in online and hybrid learning
environments, and planning for student access to digital
devices and connectivity.
b. Plan support for the early childhood sector which can
be urgently activated, so that early childhood education
can continue as much as possible in a pandemic of
extended duration.
c. Plan support that can be urgently activated for the
international education sector, including consideration
of financial implications and pastoral care for
international students.
Group 5: Ensure enablers are in place
Public sector agencies need to improve the way that they work with
iwi and Māori to support the Crown in its relationship with Māori
under te Tiriti.
agency / agencies
Public sector agencies,

36 Review how public sector agencies supported the Crown in in conjunction with
its relationship with Māori under te Tiriti in the COVID-19
Te Puni Kōkiri and
pandemic. This should include:
Te Arawhiti, and in
a. Identifying good experiences and practices in the use
partnership with
of existing te Tiriti frameworks and partnerships in the
appropriate Māori
COVID-19 response and considering how these can be
organisations
supported to continue.
b. Identifying and changing any structures, behaviours and
practices that prevented existing te Tiriti relationships,
frameworks and partnerships from being used in the
COVID-19 response or might prevent them being used in
another pandemic.
c. Using the results of reviews to establish better
relationships, protocols and partnerships with iwi and
Māori to work towards outcomes for Māori that are
equitable, culturally appropriate and consistent with
te Tiriti.
Legislation should be reviewed to ensure it is fit for purpose for a
future pandemic.
agency / agencies
• The central agency

37 Ensure all relevant legislation is fit for purpose in a function and Ministry
pandemic, including:
of Health with other
a. Ensuring the Health Act 1956 and other relevant
relevant agencies
health legislation provide sufficient powers for an
• The Treasury on
initial response to a pandemic, including updating
Recommendation
the definitions to include the provision for a quickly
37e
emerging and unidentified pathogen, modernising
language, ensuring the appropriateness of powers for
the enforcement and making of orders, and ensuring
the legal framework for large-scale, centralised contact
tracing is appropriate.
b. Reviewing the Epidemic Preparedness Act 2006, including
the threshold for modification orders.
c. Developing ‘model’ bespoke pandemic legislation that
considers the strengthening of standing legislation (as
per Recommendations 37a and 37b) and the provisions
provided by the COVID-19 Public Health Response Act
2020 framework, as well as feedback from relevant
consultation with stakeholders. This should include
consideration of what should be in primary and
secondary legislation, and whether the model legislation
should be left dormant or enacted as soon as possible.
d. Any legislative changes arising from policy reviews by
individual agencies which identify changes in legislation
needed to effectively respond to a future pandemic and/
or ensure they can continue to provide services.
e. Reviewing Aotearoa New Zealand’s fiscal responsibility
policies and legislation (within the Public Finance Act
1989) to identify whether further measures are required
to protect our fiscal resilience and ability to respond as
the need arises to future pandemics (as well as other
potential crises with a significant fiscal impact).
Core infrastructure should be fit for purpose to support each
sector’s pandemic response.
agency / agencies
All agencies
38 Provide for the management and review of the infrastructure
needed to support each sector’s response to, and specific
role in a pandemic, such as information communication
technology, data systems, payment systems, contracting and
operational systems, to ensure they are fit for purpose and
ready for deployment.
Group 6: Implement these recommendations
The Phase One recommendations should be considered and

implemented as soon as practicable.
agency / agencies
Central government
39 Ensure timely implementation of the recommendations of
Phase One of this Royal Commission of Inquiry, by:
a. Assigning a minister to lead the response to, and
implementation of, the recommendations arising from
Phase One as soon as practicable.
b. Requiring progress against the Phase One
recommendations to be reported to the responsible
minister, at least every six months. This should
include an overall view of progress against all
recommendations by the central agency function, as
well as reporting by individual agencies on applicable
recommendations. A summary of these reports should
be made publicly available.
c. Tabling a report in Parliament on progress against the
Phase One recommendations within 12 months of this
report being completed.
APPENDIX A:
A An overview of
legislation, emergency
plans, systems and
structures supporting
the COVID-19 response |
Āpitihanga A He
tirohanga whānui o
te ture, ngā mahere
ohotata, ngā pūnaha
me ngā hanganga
tautoko i te
urupare ki te
KOWHEORI-19
This appendix supports and
expands on the material and
analysis presented in Chapter 2
on the all-of-government
pandemic response.
A.1
0.0 Legislation
1.1 The first legislative framework

Acts of Parliament that could be used to manage a pandemic were already in
place well before COVID-19: the Health Act 1956, the Civil Defence Emergency
Management Act 2002 and the Epidemic Preparedness Act 2006.i
While some new legislation and amendments were needed later as the response
evolved (see section 1.2), the combination of the following three statutes broadly
gave the Government the key initial legislative powers it needed.
1.1.1
Public health legislation
Health Act 19561
The Health Act 1956 sets out the public health functions of the Ministry of Health,
its officials and other parts of the health system. Between 1956 and the outbreak
of the SARS-Cov-2 virus here in 2020, several amendments were made to the 1956
Act,ii including some that were made in conjunction with the enactment of
the Epidemic Preparedness Act 2006 (discussed in section 1.1.2).
One of the most significant sets of provisions in the Health Act 1956 is Part 3,
in particular section 70, which gives medical officers of health broad powers to
manage infectious and notifiable diseases, including:
• Requiring people to ’report themselves’ or submit for medical examinations
at specified times and places;
• Requiring persons, places, buildings, ships, aircraft, animals and things to
be isolated, quarantined or disinfected;
• Forbidding people, ships, vehicles, aircraft, animals, or things to come or be
brought to any port or place in a health district from any port or place which
is, or is supposed to be, infected with any infectious disease;
• Requiring people to remain in a health district or the place in which they are
isolating or quarantining until they have been medically examined and found
to be free from infectious disease, or have undergone preventive treatment
that may have been prescribed;
• Closing any premises within a health district; and
• Forbidding the congregation of people at various outdoor places of
amusement or recreation.
Part 6 section 117 (1) provides for the introduction of public health regulations to
manage people who have (or are thought to have) an infectious disease; for the
vaccination of people to prevent quarantinable diseases; the contacts of infected
people to be identified; and for a range of other purposes important in a pandemic.
i All three Acts are still in effect at the time of writing, although some provisions were repealed or amended during
and after the pandemic.
ii It is beyond the scope of this report, and unnecessary, to traverse the various amendments made during this period
except to record that some significant amendments were made in this period including in 1988 and 1993.
These special powers of section 70 of the Health Act 1956 were activated in
early March 2020 when COVID-19 was formally recognised as a quarantinable
disease giving rise to an epidemic.iii The Prime Minister issued an Epidemic
Preparedness (COVID-19) Notice 2020 on 25 March 2020, which was repeatedly
renewed and remained in force until October 2022. It enabled medical officers
of health to use section 70 and 71iv powers throughout this period and authorised
the New Zealand Police to enforce those powers to control the virus’s spread.2
Part 4 of the Health Act 1956 also provides extensive statutory powers in
relation to subjecting ships and aircraft (and people on board) to quarantine and
inspection requirements.
Section 70 was amended in 2006 as part of the wider package of legislation
reform in response to concerns of a pandemic. This package also included what
became the Epidemic Preparedness Act 2006. The Minister of Health’s first
reading speech noted:
“ The primary amendments in the bill are to the Health Act. The amendments clarify,
modernise, and, where necessary, close gaps in the law relating to public health
emergencies and quarantine powers. The current provisions are old and were made
in the days when ship travel was the most common way in which people arrived in
New Zealand. The amendments will ensure that the Act is more responsive to current
epidemic and pandemic influenza scenarios.”3
The Health (Protection) Amendment Act 2016

The Health (Protection) Amendment Act 2016 originated from a Bill first introduced
in 2014. A key concern at the time was the emergence of infectious diseases that
were not sufficiently catered for in the Health Act 1956. The amendments increased
the range of infectious diseases that would be notifiable, improved management of
individuals with infectious diseases that put other people at risk, and strengthened
contact-tracing provisions. As the then-Minister of Health, Dr Jonathan Coleman,
said in the first reading debate: ‘[The Health Act 1956] is a very longstanding piece of
legislation, but, although excellent in many respects, in some areas it has not kept
up with the times’. 4
iii Some initial measures – such as quarantine of incoming travellers – were initially activated via ministerial
authorisation. The first was used to legally require passengers who had been onboard a flight from Wuhan on
5 February to quarantine for 14 days on arrival in Auckland. Subsequent orders were made under an epidemic
notice. On 30 January 2020 an Order in Council was made to add ‘Novel coronavirus capable of causing severe
respiratory illness’ but it was in March 2020 that an Order was added specifically for COVID-19.
iv Under section 71 of the Health Act 1956, a medical officer of health has powers to requisition premises, land or
vehicles, including for the purpose of disposing of bodies, which can only be exercised for managing an outbreak.
The main amendment to the Health Act 1956 was the enactment of a new
Part 3A which concerned the management of infectious diseases (with a focus
on improving the measures to manage and protect the public from sexually
transmitted diseases). The amendment also established a clear legal basis for
the principles applying to medical officers of health and the courts in exercising
their disease management powers, as well as providing for:
• Overarching human rights principles to be taken into account by
decision-makers.
• Directions that could be given to individuals who pose a public health risk
(and others).
• Directions to undergo medical examinations.
• Directions to close educational institutions.
• Offences for failing to comply with directions.
• Authority to make public health and medical examination orders,
including orders relating to contacts of infected persons, as well as
procedural provisions for court hearings and appeals; and
• Provisions authorising contact tracing and imposing duties on people
involved in that process.
The amendments sought to recognise and balance the tension between disease
surveillance and prevention on the one hand and human rights on the other.
However, the focus of the amendments was the control of infected or potentially
infected individuals and their contacts, particularly for sexually transmitted diseases.v
While efforts were made to anticipate governance requirements of the kind that
might arise in a future public health emergency, the need to provide for broadscale
governance measures was not the focus at the time.
1.1.2
Civil defence legislation
Overlapping with the development of public health legislation was the incremental
development of civil defence legislation in Aotearoa New Zealand.vi The Civil Defence
Act 1962 and Civil Defence Act 1983 provided public protection in civil emergencies –
definitions were sufficiently broad to include epidemics and pandemics, but they
did not purport to address exigencies of that kindvii and sections 70 and 71 of the
Health Act 1956 were not affected.
v The Middle East respiratory syndrome (MERS) epidemic is not mentioned in the Parliamentary debates, despite a
Ministry warning about MERS being issued in 2015, while the Bill was still before Parliament. However the Ebola virus
outbreak in West Africa, an issue in the media at the time, was mentioned in a number of first reading speeches in
November 2014.
vi For a more in-depth discussion of the history of civil defence in New Zealand see: https://www.civildefence.govt.
nz/assets/Uploads/documents/publications/reports/Short-History-of-Civil-Defence.pdf. Evident from this historical
analysis is that civil defence was not originally conceived as a form of protection in relation to public health, in general,
or epidemics/pandemics in particular.
vii There is, of course, an inevitable overlap between emergencies that engage civil defence arrangements and those
that engage public health arrangements. Both can involve large numbers of people requiring medical and/or hospital
treatment. The overlap can be observed in various amendments made to s 71 of the Health Act 1956 over the years:
the power to requisition property for medical and hospital purposes might arise from civil defence emergencies or
from medical emergencies or both.
This changed, however, with the enactment of the Civil Defence Emergency
Management Act 2002 (CDEM Act) which replaced the older civil defence
legislation. In the CDEM Act, an ‘emergency’ was broadly defined to include those
emergencies arising from ‘infestation, plague or epidemic’, thus falling within the
scope of both the civil defence legislation and the public health legislation. The
link between civil defence and public health legislation was strengthened with the
CDEM Act amending the Health Act 1956 to allow the powers under section 70
to be activated by a declaration of a state of emergency under the CDEM Act.viii
Civil Defence Emergency Management Act 20025

This Act sets out a hazard risk framework encompassing all ‘4 Rs’ – reduction,
readiness, response and recoveryix – to enable emergencies to be managed at
the local, regional and national level (using a devolved accountability approach).
The Act encompasses emergencies caused by hazards such as earthquakes,
weather events as well as epidemics, chemical leakages, technological failures and
more. For this reason, the Act is said to take an ‘all hazards’ approach to emergency
management and the recovery from local, regional and national emergencies.
The Act authorises the Minister for Emergency Management to declare a state of
national emergency in situations where:6
• An emergency has occurred or may occur (this could be due to a natural
hazard or something else like a technological failure); and
• The emergency is, or is likely to be, ‘of such extent, magnitude, or severity’
that the civil defence emergency management necessary or desirable is likely
to be beyond the resources of the Civil Defence Emergency Management
Groups whose areas may be affected.
For a declaration to be made, certain legal tests must be met – such as the
definition of emergency which includes that the emergency causes or may cause
‘loss of life, injury, illness or distress or in any way endangers the safety of the
public or property …’ and ‘cannot be dealt with by emergency services, or otherwise
requires a significant and co-ordinated response under this Act [the Civil Defence
Emergency Management Act 2002]’.7 Parliament must meet whenever a state of
national emergency is declared. Declarations can be extended for as long as the test
in the Act can be met and is required. Once a state of emergency ends, the minister
can then put in place a national transition period to support recovery activities, and
this too can be extended if necessary. In some circumstances, powers in the Act
can be used to support emergencies, such as a pandemic, as long as they are not
in substitution for powers in other enactments (e.g. the Health Act 1956).
viii A similar amendment was made to section 71 of the Health Act 1956.
ix For more on the ‘4 Rs’ approach to emergency management, see the Schedule to the National Civil Defence Emergency
Management Plan Order 2015, especially section 2.
The Act sets out the duties and planning obligations of central government
agencies, local authorities, the emergency services, and lifeline utility providers.
Section 39 of the Act provides for a national civil defence emergency management
plan that addresses ‘the hazards and risks to be managed at the national level’
(we describe the plan more fully in section 2.2).
After the Canterbury earthquakes in 2010/2011, Parliament’s Regulations Review
Committee had examined what kind of legislative response was best suited to
dealing with national emergencies. Its 2016 report found that the Civil Defence
Emergency Management Act 2002 was sufficient, supplemented by bespoke
legislation that could be developed if necessary: generic national emergency
legislation was not needed.8 In 2023, an Emergency Management Bill was drafted
to replace the 2002 Act and introduced to Parliament in June 2024. After the
general election, the incoming Government decided not to proceed with it and
to introduce a new Bill later.9
Epidemic Preparedness Act 200610

This Act was introduced to give the Crown adequate statutory powers to
‘properly respond to and manage a major public health emergency, such as the
threat or actual outbreak of a highly infectious disease, whether occurring in
Aotearoa New Zealand or overseas’.11 Developed amid growing concerns about
an imminent bird flu epidemic, it addressed gaps that had been identified in the
Crown’s powers under the Health Act 1956.12 It had become clear that the machinery
of government in Aotearoa New Zealand, including a wide range of statutory
powers, might need to be modified in an epidemic or pandemic. The purposes
of the Epidemic Preparedness Act 2006 were summarised as follows:
The principal purpose of this Act is to ensure that there is adequate statutory
power for government agencies: a) to try to prevent the outbreak of epidemics
in New Zealand; and b) to respond to epidemics in New Zealand; and c) to
respond to certain possible consequences of epidemics (whether occurring in
New Zealand or overseas).
This Act also has the following purposes:
a) to ensure that certain activities normally undertaken by people and agencies
interacting with government agencies can continue to be undertaken during
an epidemic in New Zealand;
b) to enable the relaxation of some statutory requirements that might not be
capable of being complied with, or complied with fully, during an epidemic.13
The machinery by which the legislative purposes were intended to be effected
was found difficult to follow at the time.x It is beyond the scope of this report, and
unnecessary for present purposes, to deconstruct the Epidemic Preparedness
Act in granular detail.xi
The Act allows the Government to use special powers in the event of a
quarantinable disease outbreak likely to significantly disrupt essential
government and business activity. To activate these powers, the Act requires
the Prime Minister to first issue an epidemic notice, in the following terms:
“ With the agreement of the Minister of Health, the Prime Minister may, by notice
in the Gazette, declare that he or she is satisfied that the effects of an outbreak
of a stated quarantinable disease (within the meaning of the Health Act 1956)
are likely to disrupt or continue to disrupt essential governmental and business
activity in New Zealand (or stated parts of New Zealand) significantly (section 5,
Epidemic Preparedness Act).”
The notice is effective for three months and renewable if required. If necessary,
it can be supported by an epidemic management notice, enabling provisions
in existing laws to be modified if the epidemic makes complying with them
impossible or impractical. However, modifications can go no further than what
is reasonably necessary in the circumstances. Core constitutional legislation such
as the New Zealand Bill of Rights Act 1990 and Electoral Act 1993 cannot be
modified. No modification can be made to a person’s custody or detention, and
under section 12 of the Act, the minister with responsibility for the legislation being
modified has to recommend the change to be made.
Section 15 of the Epidemic Preparedness Act authorises the Governor-General
to make secondary legislation (Order in Council) to amend an Act of Parliament
(an Immediate Modification Order), with some exceptions (for example, as noted
above, the Bill of Rights Act cannot be modified). The ability to amend or suspend
primary legislation by an Order in Council,xii allows the Governor-General (on
recommendation of a minister of the Crown) to override Parliament and is therefore
subject to strict controls (for example, by ensuring epidemic notices are self-
terminating or subject to ongoing review, and that any immediate modification
orders are presented to the House as soon as practicable and can be disallowed).
x This is reflected in some of the speeches in the House of Representatives during the passage of the legislation.
For example, National MP Brian Connell said: ‘The Law Reform (Epidemic Preparedness) Bill is complex legislation,
and it has been quite difficult for colleagues to navigate their way through the bill to put in place something that
is meaningful and pragmatic. I say it is complex legislation because it is part crystal-ball gazing – what if scenario
planning – and part pragmatism and plain old common sense’.
xi For an analysis of the Epidemic Preparedness Act, see the Court of Appeal’s judgment in Idea Services Ltd v Attorney-
General [2022] NZCA 470, @ justice.govt.nz/courts/decisions/jdo/).
xii Commonly referred to as a Henry VIII clause – for discussion of this type of clause see the Court of Appeal’s judgment
in Idea Services Ltd v Attorney-General [2022-NZCA 470 @ justice.govt.nz/courts/decisions/jdo/) and High Court
[2022-NZHC-308.pdf (courtsofnz.govt.nz)].
The triggering of special powers in the Health Act 1956 to address an epidemic in
Aotearoa New Zealand could be authorised by three different mechanisms:
• Authorisation by the Minister of Health;
• A state of emergency has been declared under the Civil Defence Emergency
Management Act; or
• An epidemic notice (declared by the Prime Minister) under the Epidemic
Preparedness Act.
A combined legislative approach for civil defence and public health emergencies
results in statutory provisions that must necessarily cater for a vast array of
inherently unpredictable exigencies.
1.1.3
Other Acts of Parliament
The COVID-19 Response (Urgent Management Measures) Legislation Act 2020
was passed on 25 March 2020, the same day it was introduced to Parliament.14
It was an ‘omnibus’ bill which amended the Education Act 1989, the Epidemic
Preparedness Act 2006, the Local Government Act 2002, the Local Government
Official Information and Meetings Act 1987, and the Residential Tenancies Act
1986. These amendments were needed so that COVID-19 Alert Level 4 measures
could be implemented, or to make the response more effective – for example,
the amendment to the Epidemic Preparedness Act 2006 added district court judges
to the list of those who could modify court rules when an epidemic notice was
in force, while the change to the Residential Tenancies Act 1986 introduced rent
freezes and restricted the termination of tenancies.15
Other statutes that were subsequently used or amended to support the
COVID-19 response were the Immigration Act 2009 (for example, regulations
were added making it easier for Immigration New Zealand to refuse entry to cruise
ship passengers and crew) and the Medicines Act 1981 (one amendment, for
example, allowed a fourth dose of the Pfizer vaccine to be administered without
prescription). The COVID-19 response was subject to both the New Zealand Bill
of Rights Act 1990 and the Privacy Act 2020.
Other legislation was relevant to the pandemic response because it contained
provisions enabling the government to quickly activate or modify certain processes
in an emergency.xiii For example, Section 13A of the Parole Act 2002 allowed the
Parole Board to follow different procedures than usual when an epidemic notice
was in place – such as determining whether to release an offender on parole
solely on the basis of documents rather than through a hearing.
xiii The triggers for such provisions were generally a state of emergency, an epidemic notice, or the authorisation of the
relevant minister or the Prime Minister.
The COVID-19 Response (Further Management Measures) Legislation Act 202016
was another omnibus bill that made amendments to a wide range of personal,
property, commercial, construction, insolvency, gambling, financial services, food,
waste disposal, local government, fire and emergency and other legislation. The
Act sought to enable businesses, local government and others to manage the
immediate impacts of the response, and to mitigate unnecessary and potentially
longer-term impacts on society. Among other things, it provided for existing statutes
to be amended to overcome ‘impracticability issues’ to address situations where
legislative compliance was difficult because of public health measures in place,
and to extend access to mechanisms for financial support.17
1.1.4
Secondary legislation
An array of secondary legislation – Orders in Council, regulations, rules, notices
and other instruments – was used to implement public health measures at
different times during the pandemic. The measures applying during the first
national lockdown were individually introduced by means of orders made under
section 70 of the Health Act 1956 (section 70 orders). But from late April 2020,
combinations of infection control measures or powers started being collectively
introduced via single orders, which simplified the process of getting Cabinet
agreement to changes.
Between January and May 2020, three significant section 70 orders affected the
general public:
• Order 1 (25 March 2020), which closed premises and forbade ‘people
to congregate in outdoor places of amusement or recreation’.
• Order 2 (3 April 2020), which required all people to isolate or quarantine
at home and to maintain physical distance from others.
• Order 3 (27 April 2020), which revoked and reissued Orders 1 and 2 and
added clarifications.
Later in 2020, the legality of the early lockdowns was challenged in the
High Court (Borrowdale v Director-General of Health).18 The Court found that,
for the 9-day period between 26 March and 3 April 2020, the Government’s
requirement that New Zealanders stay at home and in their bubbles was ‘justified,
but unlawful’.19 However, the Court ruled that Order 2, which came into effect
on 3 April 2020, provided for the legality of the lockdown. It also found that
the Orders 1 to 3 were lawful.
The quantum of Orders was high (over 230 Orders in total) and during the alert
level phases Orders were being regularly adjusted to reflect the evolving risk.
When looked at by topic and considering the timeframe of the pandemic, the
orders are spread across a range of areas. There were 195 COVID–19 Orders
made over the period 2020-2022, covering:
Table 1: COVID-19 orders made during 2020–22
Orders and Notices 2020 2021 2022 Total

Alert Levels 9 37 46
Protection Framework 4 12 16
Air Border 4 15 7 26
Maritime Border 3 3 2 8
Quarantine Free Travel 18 18
Quarantine and Isolation 6 11 5 22
Self Isolation and Permitted Work 8 8
Testing 6 6 1 13
Vaccination 14 6 20
Masks 1 1
Contact Tracing 2 2
Infringement Offences 1 1 1
Exemption for RSE workers 2 2
Election and Referendum 1 1
Miscellaneous (revocation and

1 3 7 11
commencement orders)
Total 30 114 51 195
Source: Based on secondary legislation orders and Royal Commission staff calculations, https://www.legislation.govt.nz/
In addition, 24 Orders were made under Health Act 1956 (section 70)20 and
12 Orders were made under the Epidemic Preparedness Act 2006.
There has been some commentary on the urgency and pace of some of the orders
(often associated with alert level changes or border management) that raised
challenges for implementation and enforcement (as noted in Chapter 2).
1.2 The second legislative framework: the COVID-19
Public Health Response Act 2020
In May 2020, Parliament passed the COVID-19 Public Health Response Act 2020
(CPHRA) under urgency. It became the new linchpin of the pandemic response,
replacing the Health Act 1956 as the primary legal basis for the Government’s use
of mandatory public health measures. The Bill’s Explanatory Note indicated the
Government’s rationale for developing this bespoke piece of legislation to establish
a ‘fit-for-purpose legal framework for managing the unprecedented circumstances
of the COVID-19 epidemic in a coordinated and orderly way, even if there is no
longer a national state of emergency’. It would also establish ‘decision-making
processes that are more modern and consistent with recommended practice by
legal academics and others’.21
The Act’s purpose was to support a public health response that prevented and
limited the risk of outbreak or spread of COVID-19; avoided, mitigated or
remedied the adverse effects of an outbreak; and was ‘coordinated, orderly, and
proportionate’ and had ‘enforceable measures, in addition to the relevant voluntary
measures and public health and other guidance that also supported that response’.
An amendment made in August 2020 acknowledged that the public health response
the Act supported would also ‘allo[w] social, economic, and other factors to be
taken into account where it is relevant to do so’ and be ‘economically sustainable’
(section 4).
Sections 9 and 10 of the Act gave the Minister of Health and the Director-General
of Health (with some limitations) the ability to make orders on a wide range of
infection control measures, subject to prerequisites and requirements being
met.xiv The range of orders could cover isolation and quarantine, travel restrictions,
COVID-19 testing and reporting, masking requirements, physical distancing
and closure of businesses and services.xv The subsequent COVID-19 Response
(Vaccinations) Legislation Act 2021 broadened the scope of these section 11 orders
so that people could be required to produce a vaccination certificate to enter
certain premises. Section 70 orders, made under the Health Act 1956, continued
to be used occasionally.22
xiv An order can only be made if either an epidemic notice is in force for COVID–19, a state of emergency in respect of
COVID–19 is in force (or a subsequent transition period); or the Prime Minister has authorised the use of COVID–19
orders (if satisfied there is a risk of an outbreak or spread of COVID–19). In addition, the minister must have regard to
advice from the Director-General of Health and may have regard to any decision by the Government; be satisfied that
the order does not limit, or is a justified limit, on the New Zealand Bill of Rights Act 1990 rights and freedoms; and that
the order is appropriate to achieve the purpose of the Act; and consult the Prime Minister, Minister of Justice, Minister
of Health (and may consult any other minister) before making the order.
xv The Director-General could only make orders that applied to a single territorial authority district and were, in the
Director-General’s opinion, ‘urgently needed to prevent or contain the outbreak or spread’ and were the most
appropriate way of addressing those matters (section 10).
Section 13(1) of the CPHRA provided that a section 11 order could not be held
invalid for specified reasons. Significantly, though, section 13(2) provided that
section 11(1) did not limit or affect the application of the Bill of Rights and section
13(3) provided that nothing in the Act prevented the filing, hearing or determination
of any legal proceedings in respect of the making or terms of any section 11 order.
This meant courts expressly retained their inherent supervisory jurisdiction to rule
that the exercise of a statutory power, seemingly conferred by section 11(1), could
be invalid if it was not ‘demonstrably justified in a free and democratic society’.
The CPHRA had built-in Parliament scrutiny of any Orders made under the Act
with section 16 of the Act providing that a COVID-19 order was revoked if not
approved by the House of Representatives within the longer of 10 sitting days
of Parliament or 60 days after the Order was made.
Courts expressly retained their

inherent supervisory jurisdiction
to rule that the exercise of a
statutory power, seemingly
conferred by section 11(1),
could be invalid if it was not
‘demonstrably justified in a
free and democratic society’.
A.2 Emergency plans
Generic (function based) emergency management plans and specific plans

for public health emergencies were in place at the start of 2020. In theory, the
emergency management plans addressed all kinds of potential hazards and risks.
They had been shaped largely by Aotearoa New Zealand’s history of emergencies
resulting from natural hazards, which had recently included frequent flooding and
two large earthquakes. Health emergency plans included the New Zealand Influenza
Pandemic Plan 2017, the result of what the Ministry of Health called a period of
‘accelerated’ pandemic planning that had begun in 2005 when global outbreaks
of new infectious diseases (such as severe acute respiratory syndrome (SARS),
avian influenza (bird flu), and Middle East respiratory syndrome (MERS) were
recognised as potential threats to this country).23 The key plans which decision-
makers relied on in early 2020 are set out in the following sections.
2.1 National Civil Defence Emergency Management Plan

Order 201524
Section 39 of Civil Defence Emergency Management Act 2002 provides for the
development of a National Civil Defence Emergency Management Plan by Order
in Council.
This plan sets out the hazards and risk to be managed at a national level. At its
broadest level the plan sets out how the civil defence emergency management
sector will coordinate in a national emergency. The plan is supported by a detailed
guide setting out the arrangements, roles and responsibilities of agencies involved
in the national management of emergencies, or supporting local management.
They include the National Emergency Management Agency, Civil Defence Emergency
Management Groups, Police and the Defence Force, health and disability services,
lifeline utilities and others.
Consistent with the ‘all-hazards, all-risks approach’ to emergency management
which Aotearoa New Zealand adopted in 2002, the plan applies regardless of
the hazard or threat causing the emergency. It lists eighteen hazards and risks
that ‘either singularly or in combination, have the potential to cause emergencies
that may require coordination or management at the national level’ – including
‘infectious human disease pandemics’.25
The plan also addresses the responsibilities of government departments and
other organisations in the National Civil Defence Emergency Management Plan
2015 in an emergency, in addition to whatever hazard-related activities their own
legislation might require of them. The Civil Defence Emergency Management Act
2002 requires departments and other organisations to ensure business continuity
by ‘functioning to the fullest extent possible during and after an emergency to
meet their statutory responsibilities’.xvi
xvi This requirement reinforces section 58 of the Civil Defence Emergency Management Act, which says departments
and interdepartmental ventures must prepare plans to continue functioning during and after an emergency (an
interdepartmental venture is a distinct organisation within the Public Service, much like a department, but rather than
a chief executive at the head, it has a board of chief executives – see https://www.publicservice.govt.nz/guidance).
The plan also described the crisis management responsibilities of the Officials
Committee for Domestic and External Security Coordination (ODESC) and the
National Security Committeexvii – the groups responsible for governance and
decision-making within central government – and the lead agencies mandated
to head emergency responses. Which agency leads the response is determined
by the nature of the emergency itself. The plan names the Ministry of Health
as the lead agency in the event of a pandemic.
2.2 National Health Emergency Plan (2015)26

The Ministry of Health developed this plan as a strategic framework to guide the
health and disability sector ‘in its approach to planning for, responding to and
recovering from health-related risks and consequences of significant hazards in
New Zealand’. When it was released in 2015, it was seen as an important step in
the ongoing development of the sector’s emergency management capability and
capacity. It was supported by several guidance documents and actions, which in
2020 included the New Zealand Influenza Pandemic Plan 2017 (described in
section 2.3).
Echoing the language of the Civil Defence and Emergency Management Act, the
plan addressed the sector’s role in leading or supporting the ‘4 Rs’ of emergency
management: reduction of risks, readiness, response and recovery. The specific
risks it focused on were the same as those identified in the National Civil Defence
Emergency Management Plan and the National Hazardscape Report (2007),27
including pandemics. The plan defined and described the Ministry of Health’s all-
of-government coordination role as the national lead agency in such emergencies.
It also set out a formal structure for liaison between the Ministry, district health
boards, and national and local response agencies in emergencies.
xvii Although this Committee was not being used at the time of COVID-19.
2.3 New Zealand Influenza Pandemic Plan 201728
This was Aotearoa New Zealand’s sole pandemic-specific response plan at the
time COVID-19 emerged, and it served as the guiding document in the first weeks
of the response. It set out the all-of-government measures to be taken before,
during and after a pandemic in order ‘to protect New Zealand’s people, society and
economy’. While focused explicitly on an influenza pandemic – considered at the
time to be the most likely event to cause a large-scale public health emergency –
the approach underpinning the plan was said to be applicable to ‘other respiratory-
type pandemics’ whether mild or severe.
The plan focused on containing or suppressing infection, although it also referred
to social and economic goals. It described an influenza pandemic consisting of six
sequential phases, which the country would move between according to changes
in cases and transmission rates: ‘Plan for it’, ‘Keep it out’, ‘Stamp it out’, ‘Manage
it’, ‘Manage it: Post-Peak’ and ‘Recover from it’. The plan specified public health
measures and other actions to be taken in each phase. As with most countries’
pre-COVID-19 pandemic plans, the approach taken in the Influenza Pandemic Plan
was consistent with guidance from the World Health Organization’s 2017 Pandemic
Influenza Risk Management document.29
A large part of the Influenza Pandemic Plan was devoted to describing key
public agencies and their responsibilities in a pandemic response. It emphasised
the importance of regular inter-agency exercises and training to test the plan,
to integrate the efforts of individual agencies, and to ensure staff could function
effectively in an emergency (see section 3.4 for more on these exercises).
The plan noted the very significant impact of the 1918 influenza pandemic on
Māori (who died at between five and seven times the rate of non-Māori) as
well as the 2009 influenza A (H1N1) pandemic, which hit both Māori and Pacific
people very hard.30 The plan emphasised the need for effective communication
of key messages to Māori and Pacific communities, the inclusion of Māori in
district, regional and national pandemic planning, and other forms of ‘active
engagement’.31 District health boards were also urged to engage with Māori
and Pacific communities in their regions to understand their priorities. The plan
noted that ‘Māori communities often [had] important resources to contribute
in terms of health emergency planning for a pandemic’.32 It did not refer to
te Tiriti o Waitangi or address the Crown’s te Tiriti obligations in a future
pandemic response.
A.3 All-of-government systems and structures
At the start of 2020, responsibility for preparing for and responding to national
emergencies lay with multiple systems, entities, functions and teams across
central and local government. They were:
3.1 The civil defence emergency management system

This system sets the framework to reduce risk, prepare for, respond to and
recover from national and local emergencies and is part of the wider national
security system (see section 3.2). It is led by the National Emergency Management
Agency (NEMA), whose role is to support the Director of Civil Defence Emergency
Management to carry out the functions and duties required of them under the
Civil Defence Emergency Management Act 2002. NEMA oversees the ‘4 Rs’ of
emergency management – reduction, readiness, response and recovery. It is an
autonomous agency hosted by the Department of the Prime Minister and Cabinet.
While NEMA provides leadership and stewardship, the civil defence
emergency management system is a devolved accountability model. There are 16
regionally-based Civil Defence Emergency Management Groups (collectives of local
and/or unitary authorities within each region with membership made up of elected
officials) that provide the most visible face of the system on-the-ground. Because
they are usually required to swing into action quickly, and sometimes to take life-
saving measures, they operate with a degree of autonomy; for example, they can
appoint someone to declare a state of emergency or a mayor can. All parts of the
system use a common operating framework (Coordinated Incident Management
System or CIMS) to ensure they work consistently and effectively. Civil Defence
Emergency Management Groups are supported and advised by a group of senior
representatives from the local authorities, emergency services and health and
disability service providers in their region.xviii
xviii These groups are known as Civil Defence Emergency Management Coordinating Executive Groups.
Figure 1: Structure and key relationships of the Civil Defence
Emergency Management system
Source: Adapted from National Emergency Management Agency (NEMA), 2024, Guide to the National CDEM Plan
2015 Section 6, pp 4-5, https://www.civildefence.govt.nz/assets/Uploads/documents/publications/guide-to-the-
national-cdem-plan/Guide-to-the-National-CDEM-Plan-2015-Section-06.pdf
Even though the civil defence emergency management system was set up to
address ‘all-hazards, all-risks’, its experience has been largely with natural hazard
events. More than 100 state of emergency declarations have been made since
2002, and the COVID-19 pandemic declaration is the only one to have been
triggered by something other than a natural hazard or fire.33
3.2 The national security system and its supporting

structures34
The national security system deals with all risks to national security, ranging from
terrorism incidents to natural hazards and public health emergencies, and has a
strategic and coordinating role across government. It is led by the Department of
the Prime Minister and Cabinet.
When events occur that require strategic all-of-government coordination in
line with pre-identified triggers, the ODESC system is activated alongside the
emergency management system. This was the case with the COVID-19 pandemic.
The national security system has both a response role and a strategic/governance
role. The arrangements for the first are well-established, remaining essentially
unchanged since 1987. When the national security system is in response mode,
the key players are:
• The Officials Committee for Domestic and External Security Coordination
(ODESC) chaired by the Chief Executive of the Department of the Prime
Minister and Cabinet, the committee comprises chief executives from a range
of relevant agencies who work together as a collective. ODESC’s role is to
provide strategic direction and coordination for the all-of-government response
to an emergency or security event, and to advise the Prime Minister, Cabinet,
and Cabinet’s External Relations and Security Committeexix (when activated).
It ensures the lead agency has the resources and capabilities it needs and
gives advice on risks outside the lead agency’s control.35 ODESC meets only
during an emerging or actual emergency or event.
• Red Teams, which can be established by the chair of ODESC to carry
out ‘semi-independent real-time review[s]’ of specific response activities.
These short, focused reviews are intended to ‘assure ODESC that the full
range of actions is being considered for a response’ and to identify
‘undetected vulnerabilit[ies]’.36
• Watch Groups which are formed to monitor potential, developing or
actual crises. They usually comprise officials from relevant agencies with
sufficient seniority to commit resources and agree actions on behalf of
their organisations. Watch Groups are responsible for ensuring ongoing
high-level coordination between agencies, and for the provision of
assessments and advice to ODESC.37
• The lead agency (see section 3.3).
xix In 2024, this committee was renamed the Cabinet Foreign Policy and National Security Committee.
The national security system’s strategic/governance role is concerned with risk
management and building national resilience across government, comprising:
• The Security and Intelligence Board (now the National Security Board),
another grouping of agency chief executives which focuses on external
threats to national security and intelligence issues.
• The Hazard Risk Board (now the National Hazards Board), chaired by the
Department of the Prime Minister and Cabinet’s Deputy Chief Executive for
Security and Intelligence. It includes the Department’s Chief Executive and the
Chief Executives of New Zealand Police, the Ministry of Health, the Ministry
for Primary Industries, the Ministry of Transport, the New Zealand Defence
Force, the Ministry of Foreign Affairs and Trade, the New Zealand Fire Service,
and the Ministry of Civil Defence and Emergency Management. The National
Security System Handbook (2016) described the Board’s purpose as building ‘a
high performing and resilient National Security System able to manage civil
contingencies and hazard risks through appropriate governance, alignment,
and prioritisation of investment, policy and activity’.38
• The Strategic Risk and Resilience Panel, an independent group whose
members have expertise in many areas and are drawn from both the public
and private sectors. Its role is ‘to provide a rigorous and systematic approach
to anticipating and mitigating strategic national security risks’.39
3.3 The lead agency model

This is a common international model whose use in Aotearoa New Zealand is
set out in the National Civil Defence Emergency Management Plan 2015 and
accompanying guide. Under this model, the lead agency’s role in emergencies
at the national level is to:40
• Monitor and assess the situation.
• Plan for and coordinate the national response.
• Report to ODESC and provide policy advice.
• Coordinate the dissemination of public information.
Agencies that have lead agency responsibilities are required to develop and
maintain the necessary capability and capacity to undertake the role.41
As noted earlier, the National Civil Defence Emergency Management Plan lists
the agencies that are ‘mandated through legislation or expertise’ to carry out the
role of lead agency, according to the hazard involved. NEMA is the lead agency for
emergencies involving meteorological or geological hazards and infrastructure
failures. The Ministry of Health is the lead agency for emergencies arising
from infectious human diseases under the National Civil Defence Emergency
Management Plan.42
Although the lead agency has the ‘primary mandate’ for managing the response,
it does not work alone. NEMA has specific responsibilities, and other government
and non-government agencies may be expected to provide support. The lead
agency reports to ODESC and provides policy advice.
Figure 2: The relationship between the lead agency and ODESC in a

national emergency
Source: Adapted from National Emergency Management Agency (NEMA), 2024, Guide to the National CDEM
Plan 2015 Section 3, p 3, https://www.civildefence.govt.nz/assets/Uploads/documents/publications/guide-to-the-
national-cdem-plan/Guide-to-the-National-CDEM-Plan-2015-Section-03.pdf
3.4 The risk management system
3.4.1
National Risk Register
Government’s primary tool for helping inform the management of nationally
significant hazards and risks is the National Risk Register, which is led and
maintained by the Department of the Prime Minister and Cabinet.43 The register
lists the most significant risks that Aotearoa New Zealand faces at any given
time, identified on the basis of evidence and expert advice.
In 2020, the register listed both ‘threat-type’ risks (such as terrorism and cyber
security) and a larger group of ‘hazard-type’ risks, including the risk of a pandemic.
All risks on the register were overseen by either the Security and Intelligence Board
(threats) or the Hazard Risk Board: the latter oversaw 30 hazard risks, including
pandemics. Individual agencies were expected to support the work of these two
governance boards, alongside managing specific risks in their areas of operation.
3.4.2
Emergency Exercises
The Hazard Risk Board (now the National Hazards Board) is responsible for
oversight of the National Exercise Programme – this includes monitoring the
results of mock ‘system readiness’ exercises aimed at building capability across
government by bringing agencies together to respond to various simulated
emergency scenarios (hazard and threat-based). Three all-of-government national
pandemic exercises had taken place before 2020; Exercise Virex in 2002, Exercise
Cruickshank in 2006-2007 and Exercise Pomare in 2017-2018. All were based
on influenza infection scenarios. Such exercises provided opportunities to build
public sector capability and test emergency plans for a national pandemic. Exercise
Pomare had a specific goal of familiarising senior leaders and managers with
long-term emergencies, and was also intended to inform ongoing work on the
Influenza Pandemic Plan.44 The Hazard Risk Board was to consider the outcomes
and any lessons to be learned from such exercises.
3.4.3
National Security Intelligence Priorities
First developed in 2012 and subsequently updated on several occasions, this
list of Cabinet-approved priorities provided another national risk management
mechanism. It was intended to help agencies involved in the national security
system focus their risk-monitoring and intelligence-gathering efforts; however,
it was not designed to guide day-to-day operational or longer-term strategic
decisions. At the start of 2020, the National Security Intelligence Priorities
comprised 16 equally-weighted priorities. One was ‘threats to biosecurity and
human health’, including pandemics.
A.4 Human rights frameworks
As the human, environmental and economic costs of

large-scale natural disasters have grown in recent times,
so too has awareness of the significant human rights
issues they can create or reveal.
The Human Rights Commission described the Canterbury earthquakes of 2010
and 2011, for example, as not just an unprecedented natural catastrophe but ‘one
of New Zealand’s greatest contemporary human rights challenges’.45 Similarly,
public health crises can also result in people’s human rights being impacted, both
by the event itself and by the response.
Whatever their cause, it was known prior to the pandemic that national emergencies
test not only the laws, institutions and mechanisms designed to protect people’s
lives but also those intended to safeguard their human rights. Typically, the rights
of the most vulnerable members of society are especially challenged. As the Human
Rights Commission said of natural disasters, although they are ‘indiscriminate in the
devastation they cause to whole populations, […] the poor, the vulnerable and the
marginalised suffer most.’46
A number of key principles, which were part of Aotearoa New Zealand’s existing
human rights framework, were impacted by new enactments and the exercise
of statutory powers during the COVID-19 pandemic. The general human rights
landscape has recently been painted in Ko tō tātou kāinga tēnei: Report of the Royal
Commission of Inquiry into the terrorist attack on Christchurch masjidain on 15 March
2019.47 While the ultimate focus of the Christchurch terrorist attack report was
very different from this one, the underlying human rights framework is essentially
the same for both inquiries, and we respectfully agree with and adopt the outline
of Aotearoa New Zealand’s international and domestic human rights framework
provided by the Commissioners for that Inquiryxx in Part 2 of their report.
Aotearoa New Zealand’s human rights framework before COVID-19 looked much
as it does today – a mix of domestic laws (with supporting regulations), international
laws, and United Nations human rights treaties, declarations, resolutions and other
instruments which New Zealand has adopted. Te Tiriti o Waitangi also forms part
of the framework, and the Human Rights Commission has stated that te Tiriti is
‘New Zealand’s original human rights declaration’.48 Encompassing both universal
and indigenous rights, te Tiriti aligns with many of the international human rights
instruments that bind Aotearoa New Zealand.
xx Hon Sir William Young KNZM, former president of the New Zealand Court of Appeal and, more recently, a judge of the
New Zealand Supreme Court together with Jacqui Caine (Ngāi Tahu, Kāti Māmoe, Waitaha), formerly New Zealand’s
Ambassador to Chile, Colombia, Peru, Ecuador and Bolivia.
As Ko tō tātou kāinga tēnei observes, the New Zealand Bill of Rights Act 199049
was a vital part of the legal context in which the events in question took place.
The same point applies to the management of the COVID-19 pandemic in Aotearoa
New Zealand. Fundamental rights and freedoms affirmed by the Act were engaged
in a variety of ways in the period under inquiry, including:
• The right not to be deprived of life (section 8), not to be subjected to medical
or scientific experimentation (section 10), and to refuse to undergo medical
treatment (section 11).
• Freedom of expression (section 14) and the right to manifest religion and
belief in community with others (section 15).
• Freedom of peaceful assembly (section 16), freedom of association
(section 17), and freedom of movement (section 18).
• The right to be secure against unreasonable search or seizure (section 21),
and the right not to be arbitrarily detained (section 22).
Each of these rights has its own sometimes complex jurisprudence and caselaw.
It is beyond the scope of this report to delve into the detail. A point of vital
significance, though, is that the rights and freedoms affirmed by the New Zealand
Bill of Rights Act 1990 are not absolute. They may be subject to other Acts of
Parliament (section 5) and ‘such reasonable limits prescribed by law as can be
demonstrably justified in a free and democratic society’ (section 5). And, unlike
rights protected by the constitutions of certain other countries,50 the rights and
freedoms affirmed in New Zealand’s Act can be overridden by ordinary laws passed
by a simple majority in the House of Representatives. In this sense, New Zealand’s
Bill of Rights is not ‘entrenched’xxi and can be modified with relative ease by a
simple parliamentary majority. Whether this is a strength or a weakness in our
constitutional arrangements may legitimately be the subject of debate; but that
is the situation under our current law. With only a few exceptions,xxii Aotearoa
New Zealand’s human rights framework is therefore moderately flexible.
xxi See: Barber, Why Entrench? International Journal of Constitutional Law, Volume 14, Issue 2, April 2016, Pages 325–350,
https://doi.org/10.1093/icon/mow030
xxii Some rights are said to be so fundamental they cannot be subject to derogation, for example the right to life and the
right to a fair trial.
A.5 Endnotes
1. Health Act 1956, version 30 June 2024, 14. COVID-19 Response (Urgent Management Measures)
https://www.legislation.govt.nz/act/ Legislation Act 2020, https://www.legislation.govt.nz/
public/1956/0065/206.0/DLM305840.html act/public/2020/0009/latest/LMS326982.html
2. New Zealand Government, ‘Epidemic Preparedness 15. COVID-19 Response (Urgent Management Measures)
(COVID-19) Notice 2020’, updated 24 March 2024, Legislation Bill, https://www.legislation.govt.nz/bill/
https://gazette.govt.nz/notice/id/2020-go1368 government/2020/0239/latest/096be8ed81960b9a.pdf
3. Law Reform (Epidemic Preparedness) Bill 16. COVID-19 Response (Further Management Measures)
— First Reading, 4 May 2006, https://www. Legislation Act 2020, https://www.legislation.govt.nz/
parliament.nz/en/pb/hansard-debates/rhr/ act/public/2020/0013/latest/LMS339370.html
combined/48HansD_20060504_00001119 17. COVID-19 Response (Further Management Measures)
4. Health (Protection) Amendment Bill — First Legislation Bill, https://www.legislation.govt.nz/bill/
Reading, 6 November 2014, https://www. government/2020/0244/latest/096be8ed81980f81.pdf
parliament.nz/en/pb/hansard-debates/rhr/ 18. Courts of New Zealand, In the High Court of
combined/51HansD_20141106_00000028 New Zealand Wellington Registry, Borrowdale v Director-
5. Civil Defence Emergency Management Act 2002, General of Health: Judgment of the Court, CIV-2020-
version 1 July 2024, https://www.legislation.govt.nz/act/ 485-194 [2020] NZHC 2090 (Wellington, 19 August
public/2002/0033/latest/DLM149789.html?search=ts_ 2020), https://www.courtsofnz.govt.nz/assets/cases/
act%40bill%40regulation%40deemedreg_ Borrowdale-v-D-G-of-Health-V_1.pdf
Civil+Defence+and+Emergency+Management+Act+_ 19. The High Court of New Zealand, ‘Andrew Borrowdale
resel_25_a&p=1 v Director-General of Health and Attorney-General’,
6. See Section 66 of the Civil Defence Emergency media release, 19 August 2020, https://www.
Management Act 2002, version 1 July 2024, courtsofnz.govt.nz/assets/cases/Borrowdale-v-D-G-of-
https://www.legislation.govt.nz/act/ Health-Media-Release-19.8.20.pdf
public/2002/0033/latest/DLM149789.html?search=ts_ 20. McGuinness Institute, COVID-19 Nation Dates
act%40bill%40regulation%40deemedreg_ (2nd ed.) (Wellington, 2024), Table A2.18 p 399-402,
Civil+Defence+and+Emergency+Management+Act+_ https://nationdatesnz.org/2ndedition/
resel_25_a&p=1
21. COVID-19 Public Health Response Bill 246-1 (2020),
7. National Emergency Management Agency, Briefing: Government Bill Explanatory note – New Zealand
Declaring a National State of Emergency, 24 March Legislation https://www.legislation.govt.nz/bill/
2020, p 3, https://www.dpmc.govt.nz/sites/default/ government/2020/0246/latest/d12844704e2.
files/2020-04/covid-19-sone.pdf html#LMS344133
8. Regulations Review Committee, Inquiry into 22. Ministry of Health, ‘COVID-19 Section 70 orders’,
Parliament’s legislative response to future national updated 31 August 2023, https://www.health.govt.
emergencies (1 December 2016), https:// nz/strategies-initiatives/programmes-and-initiatives/
selectcommittees.parliament.nz/v/2/55b0aae0-d8ef- covid-19/legislation-and-orders/section-70-orders
4b75-b55f-2dd72122bca0
23. Ministry of Health, New Zealand Influenza Pandemic
9. Hon Mark Mitchell, ‘Release of North Island Severe Plan: A framework for action (2nd edn) (Wellington,
Weather Event Inquiry’, media release, 23 April 2024, 2017), p 18, https://ndhadeliver.natlib.govt.nz/delivery/
https://www.beehive.govt.nz/release/release-north- DeliveryManagerServlet?dps_pid=IE53291176
island-severe-weather-event-inquiry
24. Schedule to the National Civil Defence Emergency
10. Epidemic Preparedness Act 2006, version 3 Management Plan Order 2015, version 5 April
November 2021, https://www.legislation.govt.nz/act/ 2023, https://www.legislation.govt.nz/regulation/
public/2006/0085/latest/DLM404459.html public/2015/0140/latest/DLM6486453.html
11. Law Reform (Epidemic Preparedness) Bill 25. Clause 10(2), Schedule to the National Civil Defence
— First Reading, 4 May 2006, https://www. Emergency Management Plan Order 2015, version 5
parliament.nz/en/pb/hansard-debates/rhr/ April 2023, https://www.legislation.govt.nz/regulation/
combined/48HansD_20060504_00001119 public/2015/0140/latest/DLM6486453.html
12. Law Reform (Epidemic Preparedness) Bill, https://bills. 26. Ministry of Health, National Health Emergency Plan:
parliament.nz/download/Bill/d46a4f9b-c085-4f1f-b5ff- A framework for the health and disability sector
fff99ac6168d (Wellington, 15 October 2015), https://www.health.
13. Food and Agriculture Organization of the United govt.nz/publications/national-health-emergency-plan-
Nations, ‘FAOLEX Database: New Zealand’, updated a-framework-for-the-health-and-disability-sector
25 March 2020, https://www.fao.org/faolex/results/ 27. Officials Committee for Domestic and External
details/en/c/LEX-FAOC152706/ Security Coordination, National Hazardscape Report,
Department of the Prime Minister and Cabinet
(Wellington, September 2007), https://www.
civildefence.govt.nz/assets/Uploads/documents/
publications/national-hazardscape/national-
hazardscape-report-sept-2007-complete.pdf
28. Ministry of Health, New Zealand Influenza Pandemic 41. The Guide to the National Civil Defence Emergency
Plan: A framework for action (2nd edn) (Wellington, Management Plan 2015, Department of the Prime
2017), https://ndhadeliver.natlib.govt.nz/delivery/ Minister and Cabinet (Wellington, 2015), Section 3,
DeliveryManagerServlet?dps_pid=IE53291176 p 4, https://www.civildefence.govt.nz/assets/Uploads/
29. World Health Organization, Pandemic influenza documents/publications/guide-to-the-national-cdem-
preparedness and response: a WHO guidance document plan/Guide-to-the-National-CDEM-Plan-2015.pdf
(France, 3 March 2009), https://www.who.int/ 42. National Civil Defence Emergency Management
publications/i/item/9789241547680 Plan Order 2015, version 5 April 2023, https://www.
30. Ministry of Health, New Zealand Influenza Pandemic legislation.govt.nz/regulation/public/2015/0140/latest/
Plan: A framework for action (2nd edn) (Wellington, DLM6486453.html, Appendix 1 Lead agencies.
2017), p 6, https://ndhadeliver.natlib.govt.nz/delivery/ 43. Department of the Prime Minister and Cabinet,
DeliveryManagerServlet?dps_pid=IE53291176 ‘National Risk Framework’, updated 13 March 2024,
31. Ministry of Health, New Zealand Influenza Pandemic https://www.dpmc.govt.nz/our-programmes/risk-and-
Plan: A framework for action (2nd edn) (Wellington, resilience/national-risk-framework
2017), pp 17-19, https://ndhadeliver.natlib.govt.nz/ 44. Office of the Auditor-General, Co-ordination of the
delivery/DeliveryManagerServlet?dps_pid=IE53291176 all-of-government response to the Covid-19 pandemic in
32. Ministry of Health, New Zealand Influenza Pandemic 2020 (December 2022), p 23, https://oag.parliament.
Plan: A framework for action (2nd edn) (Wellington, nz/2022/covid-19
2017), p 18, https://ndhadeliver.natlib.govt.nz/delivery/ 45. New Zealand Human Rights Commission, Monitoring
DeliveryManagerServlet?dps_pid=IE53291176 Human Rights in the Canterbury Earthquake Recovery
33. National Emergency Management Agency, ‘Declared (2013), p 7, https://tikatangata.org.nz/cms/assets/
States of Emergency’, updated 26 June 2024, https:// Documents/OPCAT-Files/Monitoring-Human-Rights-in-
www.civildefence.govt.nz/resources/previous- the-Canterbury-Earthquake-Recovery.pdf
emergencies/declared-states-of-emergency 46. New Zealand Human Rights Commission, Monitoring
34. This description of the national security system is Human Rights in the Canterbury Earthquake Recovery
drawn from: Office of the Auditor-General, Governance (2013), p 22, https://tikatangata.org.nz/cms/assets/
of the National Security System (November 2016), pp 12- Documents/OPCAT-Files/Monitoring-Human-Rights-in-
16, https://oag.parliament.nz/2016/national-security the-Canterbury-Earthquake-Recovery.pdf
35. Department of the Prime Minister and Cabinet, ‘The 47. Royal Commission of Inquiry into the Terrorist
Officials Committee for Domestic and External Security Attack on Christchurch Mosques on 15 March 2019,
Coordination (ODESC)’, updated 27 October 2020, Ko tō tātou kāinga tēnei: Report of the Royal Commission
https://www.dpmc.govt.nz/our-programmes/risk-and- of Inquiry into the terrorist attack on Christchurch
resilience/odesc-system-during-crisis/odesc masjidain on 15 March 2019 (26 November 2020),
https://christchurchattack.royalcommission.nz/the-
report/
2020 (December 2022), p 72, https://oag.parliament. 48. New Zealand Human Rights Commission, ‘75 years
nz/2022/covid-19 on from the Universal Declaration of Human Rights,
Aotearoa has work to do’, updated 10 December 2023,
https://tikatangata.org.nz/news/75-years-on-from-the-
‘Watch Groups’, updated 27 October 2020,
universal-declaration-of-human-rights-aotearoa-has-
https://www.dpmc.govt.nz/our-programmes/risk-and-
work-to-do
resilience/odesc-system-during-crisis/watch-groups
49. New Zealand Bill of Rights Act 1990, version 30 August
2022, https://legislation.govt.nz/act/public/1990/0109/
latest/DLM224792.html
para 34-35, https://ndhadeliver.natlib.govt.nz/delivery/
DeliveryManagerServlet?dps_pid=IE39987621 50. USA, Canada, Germany and South Africa for example:
see Emily Haves and Sarah Tudor, National Bills of
Rights: International Examples, House of Lords Library
(19 February 2016), https://researchbriefings.files.
para 36, https://ndhadeliver.natlib.govt.nz/delivery/
parliament.uk/documents/LLN-2016-0010/LLN-2016-
DeliveryManagerServlet?dps_pid=IE39987621
0010.pdf
40. Clause 14, National Civil Defence Emergency
Management Plan Order 2015, version 5 April
Appendix B
B An epidemiological
overview of COVID-19
in Aotearoa New Zealand |
He tirohanga mātai
tahumaero whānui
mō te KOWHEORI-19
i Aotearoa
B.1 Introduction
The purpose of this appendix is to present an

epidemiological overview of COVID-19 and its health
impacts in Aotearoa New Zealand, focusing on the
period from 2020 to 2022.
This overview illustrates the trajectory and evolution of the pandemic in
Aotearoa New Zealand and the timing of key policy interventions, including the
application of major public health and social measures (such as lockdowns) and the
rollout of the national COVID-19 vaccination programme. Several figures from this
appendix are also presented in the findings section of the main report. The account
here provides greater technical detail and a more comprehensive range of figures
and tables to complement the evidence used in the main report.
A note on the graphs: The terms of reference for this Royal Commission of
Inquiry are for the decisions, actions, policies and programmes to October 2022.
However, it takes time for the impact of decisions up to October 2022 to play
out in terms of health and social impacts. Therefore, where possible, the timeline
for these graphs extends to the end of 2023.
B.2 Data and methods
The majority of data used in this appendix was provided to the Inquiry on
an anonymised and aggregated basis by the Ministry of Health and Health
New Zealand | Te Whatu Ora. Key measures included in these datasets – and their
sources – are outlined in Table 1.
Table 1. Key measures used in epidemiological overview

Measure Data source Notes
Population Health Service This dataset includes all people enrolled with a primary
User 2022 healthcare provider or who received services from a
population healthcare provider in New Zealand in 2022. While it
covers a very high proportion of the population living in
the country at that time, it does not include individuals
who had no contact with the health system in that year.
It may also have included some people who were not
living in New Zealand but who had received healthcare
in the country at some point during the year.1
COVID-19 cases EpiSurv Until February 2022, new cases of COVID-19 infection
(national were detected via PCR tests conducted by health workers.
notifiable From late February 2022, most new COVID-19 cases were
disease detected through self-administered rapid antigen tests
surveillance (RAT tests) with members of the public asked to self-report
database), any positive test via an online portal. The proportion of
National COVID-19 infections being detected and reported declined
Contact under the new testing regime – meaning new cases are
Tracing likely to be underestimated from March 2022 onwards,
Solution with possible differences in detection by age, ethnicity,
deprivation and other characteristics.
COVID-19 National Hospitalisation for COVID-19 was determined

hospitalisations Minimum retrospectively based on the diagnostic codes relating
Dataset to the specific hospital admission. It does not include
(hospital people admitted to hospital for other reasons who
events) were found to also have COVID-19 infection, unless that
infection subsequently became a contributing reason
for their hospital stay.
COVID-19 National Deaths attributed to COVID-19 are deaths where

deaths Health Index COVID-19 was listed as either the underlying or a
database, contributing cause of death.
national
mortality data
COVID-19 National While eligibility for COVID-19 vaccination was initially

vaccination Immunisation limited to those aged 16 and older, the age-threshold
Register had been expanded to include 12–15-year-olds by the
time the vaccine rollout had reached younger age-
groups (in the latter part of 2021). Calculating vaccination
coverage is complicated by younger individuals becoming
eligible during the period under study (so moving from
outside to inside the eligible population). For this reason,
vaccination coverage in this appendix is usually calculated
for the population aged 15 years and older, based on
the age people were at the beginning of 2022.
Categorisation of demographic factors (age, sex, ethnicity and socio-economic
deprivation) is based on information recorded in the National Health Index dataset.2
Age was calculated at 1 January 2022, based on a person’s date of birth. Sex is
recorded as male or female.i Ethnicity is self-identified and has been categorised
as prioritised ethnicityii (Māori, Pacific and non-Māori non-Pacific or ‘Other’) for
consistency with analyses undertaken by the Ministry of Health.3 Deprivation refers
to neighbourhood socio-economic deprivation, based on a person’s residential
address (on 1 January 2022) linked to the 2018 New Zealand socio-economic
deprivation index.4 For presentation purposes, deprivation is categorised in
three groups (least deprived/New ZealandDep deciles 1–3, mid-range deprivation/
deciles 4–7, most deprived/deciles 8–10) or as quintiles (from quintile 1/least
deprived to quintile 5/most deprived).
Data on COVID-19 cases detected at the border versus in the community were
sourced from the Ministry of Health’s public COVID-19 data website.5 Dates of
policy changes regarding border restrictions and application of ‘lockdowns’ (that
is, settings-based restrictions) were sourced from the official COVID-19 timeline
developed by the Department of the Prime Minister and Cabinet.6
Data for cross-national comparisons (of COVID-19 deaths, excess mortality and
the stringency of policy measures) was obtained from Our World in Data.7 Data
on other major causes of death in New Zealand was obtained from the Global
Burden of Disease Study 2021.8
Most figures present numbers (of COVID-19 cases, hospitalisations or deaths)
as an incidence rate or numbers per head of population for a given time period.
Where incidence rates are compared between population groups (defined by
ethnicity or deprivation), the data is standardised for age. (This is in order to
filter out any differences due to the different age-structures of the groups being
compared.) Rates were standardised to the World Health Organization World
Standard Population. The majority of data visualisations presented in this
appendix were undertaken by the Inquiry secretariat using R statistical software.
i The National Health Index records sex with categories limited to male, female, unknown and indeterminate (this last is
largely used in relation to newborn babies). At the time of writing, it does not include a category for gender.
ii ‘Prioritised ethnicity’ means that – for presentation of data on ethnicity – people are assigned to a single ethnic group
in a given order of priority, even if they identified with more than one ethnic group. The priority commonly used in
Aotearoa New Zealand is Māori, Pacific Peoples, New Zealand European and other ethnic groups.
Comparison of Years of Life Lost (YLL) to different diseases / under different
counterfactuals (Figure 7) was undertaken by Professor Tony Blakely using
Microsoft Excel. YLLs to different diseases for the population of Aotearoa
New Zealand were taken from the Global Burden of Disease Study 2021.9 YLLs for
COVID-19 deaths were estimated based on Datta et al (2024)10 and Milkovska et
al (2024).11 For the counterfactual scenario of New Zealand having no vaccination,
figures generated by Datta et al (2024) from standard lifetables were used to
estimate that each person dying from COVID-19 would have had an average of
11.2 years of remaining life had they not become infected with COVID-19 (i.e. 74,500
YLL divided by 6,650 deaths).12 We scaled this estimate to account for the greater
prevalence of co-morbidities in people dying from COVID-19 – meaning they would
have fewer years of remaining life expectancy compared with the average person
of the same age. Milkovska et al (2024)13 estimated that a person dying of COVID-19
had on average 30 percent fewer remaining expected years to live compared with
someone of the same age who did not die from COVID-19. Based on this estimate,
we adjusted Datta et al’s estimate of 11.2 years down to 7.8 YLLs per COVID-19
death. The burden of morbidity due to COVID-19 in New Zealand was estimated
using the ratio of YLDs to YLLs from Howe et al (2023),14 who estimated the burden
of disease from COVID-19 in an Australian study. Findings from Datta et al (2024)
were also used to estimate YLL under the counterfactual of New Zealand having
had no COVID-19 vaccination but otherwise the same strategy and timeline for
moving out of elimination and removing border restrictions.
Comparison of risk for COVID-19 hospitalisation and death (Tables 2 and 3)
was undertaken by the Public Health Agency, Ministry of Health. Risk ratios and
95 percent CIs were estimated using Poisson regression with robust standard
errors. Analyses were undertaken using STATA MP/18.0 (StataCorp, LLC) statistical
software. Data presented here is preliminary but was shared with the Inquiry
in order to inform its findings.
Cases, hospitalisations and
B.3 deaths across 2020 to 2022
In big-picture terms, Aotearoa New Zealand’s COVID-19 experience was one

of very limited viral transmission or disease in 2020 and 2021, followed by
significant waves of transmission from the Omicron variant in 2022 (Figure 1).
This trajectory reflected the success of the elimination strategy in successfully
keeping case rates (and thence hospitalisations and deaths) as low as possible,
and often zero, through 2020 and most of 2021. Thus New Zealand did not
experience substantial COVID-19 transmission until 2022, by which time the
population had very high levels of protection from vaccination coverage.
In 2020 and for much of 2021 we did not know what the circulating pandemic
virus variant would be when Aotearoa New Zealand opened up to the rest of the
world. One plausible scenario was that the pandemic agent would not mutate much,
and that vaccines afforded strong and enduring protection not only against severe
illness but also against the chance of getting infected – meaning that we would
have experienced much lower case, hospitalisation and death rates than we
actually did. Another plausible scenario was similar to what transpired, but that
the circulating variant in 2022 was just as infectious as Omicron but with the
virulence of Delta or worse, meaning we would have experienced much higher
hospitalisation and death rates in 2022 than we actually did – but still, in all
likelihood, a considerably lower cumulative morbidity and mortality burden over
the whole 2020 to 2022 period compared to a scenario where we had not used
an elimination strategy with SARS-CoV-2 freely circulating in New Zealand from
2020. A third plausible scenario – if we were in 2020 and thinking ahead – was
that the vaccines would have offered less protection than they did against
Omicron, and the morbidity and mortality burden would have been worse.
The scenario we actually experienced, as shown in Figure 1 – whilst not the
best scenario we might have hoped for – was a pretty good one. Namely, the
elimination strategy worked to keep the virus largely out of Aotearoa New Zealand
in 2020 and 2021, and due to widespread vaccination a much lesser cumulative
mortality burden than we would have experienced had we allowed the virus
in during 2020. (Note, here, we are just considering the health impacts of the
pandemic – we consider social and economic impacts in depth elsewhere in
the Report.)
Figure 1 shows two major waves in 2022, one peaking in March, the other
around July. The second peak features higher hospitalisation and death rates
relative to case rates compared to the first wave. This reflects decreasing case
ascertainment (as ‘pandemic fatigue’ resulted in fewer people getting tested for
COVID-19 and thus lower case reporting) as well as the higher likelihood that
people in the second wave would have more severe disease (since the second
wave featured higher case rates in older age groups). We now examine outbreaks
in 2020 and 2021 in detail.
Cumulatively, Aotearoa New Zealand had 2168, 12,032 and 2,101,473 COVID-19
cases in 2020, 2021 and 2022, respectively. The total number of infections would
have been somewhat greater in 2020 and 2021 due to ‘missed’ asymptomatic
cases, and considerably greater in 2022 due to ‘pandemic fatigue’ and incomplete
reporting of cases (and many more asymptomatic or mild cases that people hardly
registered, due to both vaccination and the less virulent nature of Omicron.)
No seroprevalence survey was conducted in New Zealand in late 2022 or early
2023, but we know from many such surveys internationally that most of New
Zealand’s population would have been would have been infected by late 2022, due
to the partial-only and waning protection vaccines offered against infection.
Regarding hospitalisations, Aotearoa New Zealand had 95,851, and 20,920 hospital
admissions for COVID-19 in 2020, 2021 and 2022, respectively. And New Zealand
had 26, 24 and 2,776 deaths from COVID-19 in 2020, 2021 and 2022, respectively.
Figure 1: Case notifications, hospitalisations and deaths
The 3,276 COVID-19 deaths in Aotearoa New Zealand from 2020 to 2022 equated
to about 3 percent of all deaths in that period – a burden that would have been
substantially higher if New Zealand had not followed an elimination strategy.
These deaths tended to be among older people. Thus, thinking of these deaths
in terms of years of life lost (YLL) is useful, whereby we tally up the expected
remaining life expectancy for all people dying. The YLLs due to COVID-19
across 2020 to 2022 were about 1.3 percent of all YLLs from all other deaths
in that period.
YLLs only measure the mortality burden of COVID-19. There is also substantial
health loss due to morbidity, including symptoms at the time of initial infection,
any long COVID, and any sequelae (such as possible increased rates of other
diseases after SARS-CoV-2 infection). The morbidity for the acute illness and
long COVID components, quantified in years lived with disability (YLDs), might
be about 20 percent of the magnitude of the YLL loss.
Aotearoa New Zealand compared favourably with other countries on confirmed
COVID-19 death rates (Figure 2).
Because public health and social measures are effective in preventing a range
of infectious diseases, and death rates from other diseases can also change in a
pandemic (e.g. fewer injury-related deaths during lockdowns), another useful way
to look at the death burden of the pandemic is excess mortality. Here one uses
death rates in the years leading up to the pandemic, and ‘predicts’ what they will
be in 2020, 2021 and 2022. These predictions are then compared to the actual total
number of deaths occurring. Compared to other countries, Aotearoa New Zealand
experienced lower than expected death rates in 2020, and only saw a ‘kick up’
in excess death rates in 2022 (when Omicron washed through), such that by the
end of 2022 New Zealand had one of the lowest cumulative excess mortality
rates of any country (Figure 3).
Figure 2: Cross-national comparison of total confirmed
COVID-19 death rates
Source: Our World in Data, Edouard Mathieu, Hannah Ritchie, Lucas Rodés-Guirao, Cameron Appel, Daniel
Gavrilov, Charlie Giattino, Joe Hasell, Bobbie Macdonald, Saloni Dattani, Diana Beltekian, Esteban Ortiz-Ospina,
and Max Roser, 2024, https://ourworldindata.org/covid-deaths
Figure 3: Cross-national comparison of cumulative excess

mortality rates per million people
Excess deaths were found to be a more reliable indicator of the total COVID-19 burden, due to under
ascertainment of COVID-19 caused deaths and knock on effects of the pandemic onto other service provision
and other disease and death rates. However, for countries like New Zealand the recording of COVID-19
deaths was reasonably reliable
Source: Our World in Data, 2024, Data Page; Excess mortality: Cumulative deaths from all causes compared to
projection based on previous years, per million people. Data adapted from Human Mortality Database, World
Mortality Database, Karlinsky & Kobak. Retrieved from https://ourworldindata.org/grapher/cumulative-excess-
deaths-per-million-covid
Stringency of public health
B.4 and social measures
What we experienced, whilst low in terms of morbidity and mortality impacts

through 2020 and 2021, was not without costs. International borders were closed –
other than arrivals through managed isolation and quarantine (MIQ). Liberties
were curtailed and lockdowns were used. The Oxford Stringency Index was
developed during the pandemic to compare levels of restriction (e.g. closure of
schools and workplaces, limits on gatherings) across countries and over time.
Where a country (or a region within a country) is in ‘lockdown’, the stringency
index is higher. Figure 4 shows the stringency index for Aotearoa New Zealand and
comparator countries through 2020–2022. New Zealand stands out in two ways.
First, New Zealand had notably high stringency when lockdowns were in place
(national lockdowns in March/April 2020, and August 2021 and regional (mostly
Auckland) lockdowns in August 2020, February 2021 and August to December
2021iii). That is, New Zealand took a ‘go hard’ approach to enacting an elimination
strategy. Second, New Zealand had long periods of very low stringency between
lockdowns. Moreover, compared to all other jurisdictions except Taiwan the average
level of stringency over time, and the amount of time at high stringency, was less
in New Zealand. This lesser overall stringency for New Zealand was even more the
case outside of Auckland.
Figure 4: Oxford stringency index for New Zealand and comparator

countries, 2020 to 2022 inclusive
The stringency index is a composite measure based on nine response indicators including school closures,
workplace closures and travel bans, rescaled to a value from 0 to 100 (100 = strictest).15 Stringency index data at
Our World in Data is not available beyond 2022.
Source: Blavatnik School of Government, University of Oxford – with minor processing by Our World in Data,
(2023), COVID-19: Stringency Index (New Zealand, Australia, Taiwan, United Kingdom, United States and Sweden),
https://ourworldindata.org/metrics-explained-covid19-stringency-index
iii For convenience, we equate the Alert Levels 3 and 4 that New Zealand used as equivalent to soft and hard
lockdowns, respectively.
B.5 Vaccination rates
Aotearoa New Zealand’s vaccine coverage for first, second and third doses is shown
in Figure 5, and cross-national comparisons of completion of the (usually) two
dose primary course is shown in Figure 6. We consider vaccination in depth, from
many perspectives, elsewhere in the Report. Suffice to say here:
• New Zealand achieved high vaccination rates, but rollout started a bit later
than in many comparator countries.
• Whilst New Zealand’s vaccine levels initially lagged behind some other
countries, coverage levels eventually exceeded those of countries such as
Sweden and the United Kingdom.
• New Zealand achieved 60 percent coverage of completed vaccination
(that is, two doses of Pfizer) on 29 Oct 2021. (The population denominator is all
ages, so 60 percent coverage here – for New Zealand – is equivalent
to 74 percent coverage among 15+ year olds.) The equivalent coverage was
achieved 88 days earlier in Singapore, 76 days earlier in the United Kingdom,
40 days earlier in Sweden, 17 days earlier in South Korea, 4 days earlier in
Australia – but 38 days later in Taiwan.
• New Zealand’s rollout of the third dose (first booster) was very rapid, going
from 10 percent to 80 percent of 65+ year olds in 64 days, from 20 Dec 2021
to 22 Feb 2022. This rapid rollout was enabled by reducing the time that
citizens had to wait after their second dose to receive their third dose, from
six to four months, in early 2022 as the Omicron wave was approaching and
hitting. This rapid rollout of a third booster dose – boosting people’s immunity
to overcome waning after the second dose – undoubtedly saved many lives
and reduced the morbidity impact of the Omicron wave.
Figure 5: Cumulative vaccine coverage 2020 to 2022 (all of New Zealand)
Figure 6: Vaccine coverage by time for New Zealand and

comparator countries
protocol. Data adapted from Official data collated by Our World in Data, World Health Organisation, Various
Additional COVID-19 deaths and YLLs had
B.6 New Zealand not pursued an elimination
strategy, or not vaccinated
It is conceptually challenging to understand COVID-19 health loss, whether it is small

or large, and how it compares to other causes of health loss.
Moreover, many early models of COVID-19 estimated the deaths that might occur
for a completely unmitigated pandemic, compared to no pandemic. Neither
scenario is plausible: all countries employ measures to mitigate or reduce deaths
compared to an unmitigated ‘let it rip’ pandemic, and no country could avoid
COVID-19 entirely.
One useful thought experiment is to ask, ‘What would have been the
additional health loss for Aotearoa New Zealand if the country had followed the
approach the United Kingdom took (a mix of suppression and mitigation), compared
to the elimination strategy New Zealand actually took?’ An approximate estimate
of the increased deaths that New Zealand might have experienced is to apply the
difference in cumulative COVID-19 death rates for 2020 to 2023 inclusive for the
United Kingdom compared to New Zealand and multiply that into the New Zealand
population. Using numbers from Our World in Data,16 this calculation gives 14,000
additional deaths in New Zealand, or about 41 percent additional deaths, for the
four year period (2020-2023). This equates to approximately 10 percent additional
deaths in each of the four years from 2020 to 2023, which is sizeable.
However, these deaths are more likely to be among the elderly and the frail,
meaning a conversion of these deaths to years of life lost may be more meaningful.
When we do this, we estimate that the United Kingdom’s approach applied to
Aotearoa New Zealand, compared to the New Zealand experience as it actually
happened, might have resulted in an additional 110,000 years of life lost over the
four-year period 2020 to 2023. This equates to about 4 percent of all years of life
lost from other deaths over the 2020 to 2023 period.
Another way to understand the health gains of an elimination strategy as run
in Aotearoa New Zealand, compared to the suppression or mitigation strategy as
run in the United Kingdom, is to compare the additional YLLs New Zealand would
have incurred if it had run the United Kingdom strategy (dark red bar, Figure 7) to
the top ten ranking non-COVID-19 YLLs in 2021 (grey bars). The YLLs from COVID-19
deaths over the four years 2020 to 2023 exceed the top cause of death, ischemic
heart disease. But once annualised and spread over the four years (light red bar),
the YLLs reflecting the United Kingdom versus New Zealand’s experience rank
between the sixth (Alzheimer’s disease and other dementias) and seventh (self-
harm, suicide) causes of annual YLLs.
Figure 7: Comparison of years of life lost (YLL) for different conditions
and COVID-19 scenarios
Bars show YLL for New Zealand population for different conditions and COVID-19 scenarios – including if
New Zealand had the same COVID-19 mortality rate as the United Kingdom (red) and if New Zealand had no
COVID-19 vaccination (blue). Error bars for YLL due to specific condition are 95 percent uncertainty intervals
as published by the GBD study. Estimates for counterfactual scenarios (red and blue bars) have considerable
uncertainty but this has not been quantified.
Source: Based on data from Institute for Health Metrics and Evaluation, Global Health Data Exchange: Global
Burden of Disease Study 2021 (GBD 2021) Data Resources, https://ghdx.healthdata.org/gbd-2021
How does one judge whether the health gains from running an elimination
strategy, versus having run a suppression or mitigation strategy (as in the United
Kingdom), were worth it? This is a challenging question to answer as we must
weight differential impacts across health, economic and social domains – and such
weighting is inherently value-based, with no technocratic ‘right’ answer. What we can
say, here, is that:
• An elimination strategy, compared to a suppression or mitigation strategy
used in the United Kingdom, gains a substantial amount of health as
measured by metrics such as excess deaths (Figure 3) or YLLs (Figure 7).
• Some of the social impacts of Aotearoa New Zealand’s strategy were less
than the United Kingdom’s strategy if we use the PHSM stringency index
as a metric (Figure 4). However, this is just one of many social impacts. For
example, international border closures in New Zealand kept family and loved
ones separated for two years unless they went through MIQ. New Zealand’s
elimination strategy was also accompanied by vaccine mandates that the
United Kingdom did not have (although New Zealand could have run its
elimination strategy with lesser mandates), with resultant breakdown in
social cohesion and marginalisation for many. There are many other such
social considerations we cover in this report.
• The economic impacts were variable. The initial GDP impact in New Zealand
was less than in the United Kingdom, but the fiscal cost to the New Zealand
Government of wage subsidies to allow stringent lockdowns was large and
the long tail of harder to quantify economic costs due to border closures
was substantial.
Timing also matters. Counterfactually, it’s possible that Aotearoa New Zealand
could have opened up earlier (or later) with little impact on net health loss – but
with marked differences in social and economic impacts.
It is beyond the scope of this report, and our terms of reference, to undertake
full-blown cost-benefit analyses for alternative ways Aotearoa New Zealand could
have managed COVID-19. But these types of thinking – weighing up health, social
and economic impacts of policy choices, considering small or large changes that
could have been made to New Zealand’s approach to COVID-19 – imbue our report.
And we apply this type of thinking not only to COVID-19, but to scenarios of what a
future pandemic might look like.
Also shown in Figure 7 are the additional YLLs for another counterfactual,
namely if Aotearoa New Zealand had not administered any vaccine but run the
same elimination strategy and border reopening timing as actually occurred.iv
Datta et al (2024) undertook modelling of this very question and estimated that
74,500 YLLs were gained by vaccination. Their YLL estimate is likely to be somewhat
generous since it assumed that people dying of COVID-19 had the same remaining
life expectancy as other people of the same sex and age who did not die of
COVID-19. This is unlikely since deaths from COVID-19 were more likely where the
infection occurred in people with co-morbidities who would therefore have lower
remaining life expectancy than healthy people of the same age. We therefore
discounted Datta et al’s YLL estimates by 30 percent, based on Milkovska et al’s17
estimate that – on average – YLLs due to COVID-19 are about 30 percent less than
estimates derived from standard lifetables. This gives an estimated additional
52,150 YLL if New Zealand had not administered any vaccine (dark blue bar). If we
annualise the YLLs prevented by vaccination over the 18 months of 2022 to mid-
2023 (34,767 YLL – light blue bar), we can see that the vaccine gains ranked between
the third (stroke) and fourth (chronic obstructive pulmonary disease) leading annual
causes of YLL health loss in New Zealand.
iv While such a counterfactual is somewhat unlikely – i.e. New Zealand would probably not have continued running an
elimination strategy through to late 2021 if vaccines were not forthcoming – it does help to answer the question
‘what was the impact of vaccines?’
Close ups of 2020 and 2021: cases and
B.7 hospitalisations, alert levels and key
policy events
There were three notable outbreaks in New Zealand in 2020 and 2021.
The first of these was in early 2020 (when SARS-CoV-2 first arrived in Aotearoa
New Zealand) and involved cases throughout the country (initially, mostly people
who had recently travelled overseas). The second occurred in Auckland and was
focused on a group of cool store workers; this outbreak was stamped out with the
assistance of genomic sequencing supporting contact tracing which helped identify
linked cases. The third was the Delta variant outbreak of late 2021, which was
mostly confined to the Auckland region (with some reported cases in Northland
and the Waikato) and was primarily concentrated among Pacific and Māori
communities. The Delta variant is more virulent than the SARS-CoV-2 strains that
came before it and the Omicron variants that followed it, which is why the Delta
outbreak is more easily visible in the hospital admission and death trends in
Figure 1 than the case trends.
B7.1 March to May 2020 outbreak

Figure 8 shows the case numbers by day with superimposed policy events (coloured
vertical lines; AL = alert level). There was a total of 1,505 cases between February
28 (the first case in Aotearoa New Zealand) and May 22 (the last known community
acquired case in the tail of the first outbreak). Of these cases, 38 percent were
detected at the border or among recent international arrivals (detected in home
isolation that was in place from 16 March to 9 April, and after that detected in
MIQ facilities). The border cases were – as expected – dominant at the beginning
of the outbreak.
The first reported case on 28 February was a recent arrival from Iran, precipitating
an extension of the ban on arrivals from China (instituted on 3 February) to also
include arrivals from Iran – although New Zealand citizens could return from either
country with self-quarantine. This ban was extended on 2 March to include non-
New Zealand citizens having travelled in northern Italy and South Korea.
Aotearoa New Zealand’s second, third and fourth notified cases were reported
on 4, 5 and 6 March, respectively.
From 16 March, all international arrivals (except from Pacific Island countries
and territories) were required to self-isolate/quarantine for 14 days. Gatherings
were limited to a maximum of 500 people, excluding schools and universities.
On 19 March, total notified cases were 28, spread across Aotearoa New Zealand.
Indoor events were limited to a maximum of 100 people.
On Saturday 21 March, the Alert Level System was introduced, and Aotearoa
New Zealand set at Alert Level 2. The alert level was escalated to Alert Level 3 on
Monday 23 March, and Alert Level 4 on Wednesday 25 March, putting New Zealand
in an unprecedented ‘lockdown’.
Figure 8: March to May 2020 outbreak community and border cases,
and key policy events
Source: Based on data from Ministry of Health GitHub data, 2024, covid-case-counts,
https://github.com/minhealthnz/nz-covid-data/blob/main/cases/covid-case-counts.csv
Alert levels were unwound to Level 3 on 27 April, Level 2 on 14 May and Level 1
on 8 June. The last case was on 22 May 2020, with a cumulative total of 930
community cases by that date – and nil further community cases for the next
81 days. The successful stamping out of the first outbreak was a joint function
of targeted measures like contact tracing, isolation of cases, and quarantine of
close contacts, through to the ‘blunt’ population-wide lockdown measures.
Figure 9 shows the case rates across 2020 by ethnicity. Rates at the outset of
the first outbreak were highest among non-Māori and non-Pacific people, a result
of most early cases being among recent arrivals to Aotearoa New Zealand and their
contacts. Rates by ethnicity in the tail of the first outbreak were roughly equivalent,
other than a late small peak among Pacific people.
Figure 9: 2020 case rates by ethnicity (all of New Zealand)
B7.2 August 2020 South Auckland outbreak
The second outbreak was quite different, with the highest rates among Pacific
people (Figure 9), consistent with the origin of this outbreak among workers at
a cool store in Mount Wellington, Southeast Auckland. The outbreak comprised
179 known community acquired cases between 11 August and 11 September
(Figure 10). Presumably this outbreak was seeded from an international arrival
somewhere, but the source was never identified. The outbreak was stamped
out with the assistance of genomic sequencing supporting contact tracing and
helping identify linked cases.
Figure 10: August 2020 South Auckland outbreak community and

border cases, and key policy events
B7.3 August to December 2021 Delta outbreak
A total of 11,280 Delta cases occurred nationally from August 17 (when the first
community cases were detected) to December 31, 2021, of which 84 percent were
in Auckland and 44 percent (of the 11,280) were in South Auckland. There were
843 hospitalisations in the same period, and 22 deaths – crudely, a case fatality
of 0.2 percent. By ethnicity, the rates were initially highest among Pacific people,
then among Māori (Figure 12).
Delta was substantially more infectious than previous variants, making it difficult
to stamp out – and indeed it was never fully stamped out before Omicron arrived
in 2022. Without the measures in place (Alert Levels 3 and 4; contact tracing,
testing and isolation; mask wearing; growing vaccination coverage), Delta
would have spread through Aotearoa New Zealand resulting in much greater
morbidity and mortality.
Figure 11: Whole of 2021 community and border cases (all of New Zealand),
and key policy events
Figure 12: 2021 Delta outbreak cases and hospitalisations
(Auckland region) by ethnicity, and key policy events
B7.4 Aotearoa New Zealand opens up to Omicron: 2022
Figure 13 shows the case, hospitalisation and death rates for late 2021 through
2022, and key policy events overlaid. In anticipation of opening (both ending
lockdowns and opening international borders), Aotearoa New Zealand moved from
the Alert Level System to the COVID-19 Protection Framework (also known as the
‘traffic light’ system) on 3 December 2021. The COVID-19 Protection Framework
placed a large emphasis on people having vaccination certificates in order to enter
public premises or participate in larger gatherings. It also included some PHSMs
such as gathering sizes and physical distancing. The idea of the traffic light system
was to provide a framework for containing COVID-19 transmission without having
to resort to full lockdowns. The higher settings (orange and red) were to be
used initially as a brake on infection rates while the country emerged from the
elimination phase and accepted that COVID-19 transmission was now established
in the population. These higher settings provided a safeguard against COVID-19
cases growing too rapidly and overwhelming the health system (and society
more generally).
Accordingly, all of Aotearoa New Zealand was set to Orange or Red in December
2021. The whole country was at Orange for three days from 20 January 2022
before moving back to Red on 23 January, following the first detected community
transmission of Omicron. The country remained at Red through all of February
and March 2022. Cases and hospitalisations fell from late March and by April 13
had halved from their peak, precipitating a decision to move down to the
Orange traffic light setting. New Zealand remained at Orange through the next
6 months (traversing the second July wave) until the COVID-19 Protection
Framework was finally retired on 12 September 2022.
Daily hospitalisation admissions for COVID-19 peaked at nearly 3 per 100,000

(or 150 actual hospitalisations a day) in the first Omicron wave, and at 2 per
100,000 in the second wave. Of note, the mortality rate was higher in the second
wave due to older people being more impacted in this wave (see section B8.2).
Figure 13: Late 2021 through 2022 cases, hospitalisation and death rates
(all of New Zealand), and key policy events
B.8 Case, hospitalisation and death rates by
socio-demographic groups
B8.1 Summary of health outcomes (2020–2022 inclusive)

Reported case rates were higher among people less than 60 years old, but
hospitalisation rates increased steeply with age above 60 years and death
rates even more so (Figure 14). Compared to people aged less than 60, the
hospitalisation rates among 60–69, 70–79, 80–89 and 90+ year olds were 1.87,
3.38, 7.13 and 10.6 times greater (respectively), and the death rates were 8.95,
32.5, 135 and 509 times greater (respectively), based on age-standardised rate
ratios. Considering absolute numbers, 20 percent of hospitalisations and 66
percent of deaths were among people aged 80 years and over.
Case rates over the full 2020–2022 period did not differ too much by
deprivation and ethnicity. (Case rates were much higher among Māori and
Pacific populations in the second half of 2020 and 2021, although case numbers
were low overall during these periods.) In 2022, case rates were initially higher
among Māori, Pasific peoples and people living in more deprived neighbourhoods,
although these differences disappeared by the end of 2022 as shown in Figure 15).
However, hospitalisation and death rates were considerably higher among Māori
and Pacific people over the 2020–2022 period, and among those living in more
deprived areas – in part due to their higher rates of infection in 2020 and 2021
(that is, pre-Omicron) with more virulent viruses (such as Delta) and before the
protection of vaccinations was available.
Figure 14: Case, hospitalisation and death rates 2020 to 2022.
First row: by age and sex; second row: by ethnicity and
deprivation (age-standardised)
B8.2 Trends throughout 2022
Widespread transmission of SARS-CoV-2 in Aotearoa New Zealand occurred in 2022
with the arrival of the Omicron variant. The pandemic spread through different
groups with different phasing through 2022:
• Case notification rates were initially much higher amongst people less than
60 years of age in the first quarter of 2022, but much the same by age by the
fourth quarter (Figure 15). Some of this change might be due to a greater
drop-off in testing and self-notification among younger people, as testing
shifted from PCR to RAT tests and some people became more ‘relaxed’ about
COVID-19 infection.
• Case rates were initially higher among Māori, Pacific peoples and those
living in more deprived areas (see Q1). This trend then reversed in quarter 2
(Q2) and quarter 3 (Q3) of 2022; i.e. case rates were higher among non-Māori
non-Pacific (Other) ethnic groups and among those living in the least deprived
areas. By the end of 2022 (Q4), case rates appeared much the same by
ethnicity and area-level deprivation.
• Hospitalisation rates were consistently higher among older age groups, a
trend that became more pronounced from quarter 2 onwards (Figure 16) as
older age groups were less protected from infection and started to experience
a similar case rate to younger age groups (Figure 15).
• Hospitalisation rates were consistently higher among Māori, Pacific peoples
and those living in more deprived areas (Figure 16).
Figure 15: Case rates across 2022. First row: by sex and age (crude);
second row: by ethnicity and deprivation (age-standardised)
Figure 16: Hospitalisation rates across 2022. First row: by sex and age
(crude); second row: by ethnicity and deprivation (age-standardised)
Hospitalisation trends approximately follow the shape of case trends, but the
inequities between groups are more pronounced. Māori and Pacific people
have substantially elevated relative hospitalisation rates despite their younger
population structure, and this becomes more pronounced once age is adjusted for.
There is also a clear and consistent pattern of higher hospitalisation rates for
people living in higher deprivation areas.
Figure 17: Death rates across 2022. Top row: by sex and age (crude);
second row: by ethnicity and deprivation (age-standardised)
Figure 17 shows both crude and age-adjusted death rates from COVID-19 as they
changed across the four quarters of 2022. At all time-points the risk of
dying from COVID-19 was strongly patterned by age, with people in older age groups
(80-89 years and 90 years and over) much more likely to die from COVID-19.
The risk of dying from COVID-19 was also consistently higher for Māori and Pacific
peoples. Higher death rates for Māori and Pacific in quarter 1 of 2022 are partly
a reflection of their higher case rates at that time. As the year progressed, the
pandemic spread more to the rest of the population (non-Māori non-Pacific or
‘Other’), which is older on average than Māori and Pacific populations. In the
latter part of 2022, a majority of COVID-19 deaths were occurring in non-Māori non-
Pacific (‘Other’) ethnic groups, predominantly New Zealand European or Pākehā.
The age-standardised death rates can be understood as showing how the risk
of dying from COVID-19 compared for people of the same age who belonged to
different ethnic groups or who lived in areas of greater or lesser deprivation. The
younger age structure of Aotearoa New Zealand’s Māori and Pacific populations
means their crude death rates from COVID-19 are lower than that of non-Māori non-
Pacific (or ‘Other’) ethnic groups, but their age-standardised death rates are much
higher. People living in areas of higher socio-economic deprivation had higher death
rates than less deprived people throughout the course of the pandemic. This trend
is particularly clear and consistent in the age-adjusted rates.
8.3 Multivariable regression analyses for 2022 to

determine total and mediated effect for ethnicity,
deprivation and co-morbidity
For 2022 there were sufficient numbers of hospitalisations and deaths to
undertake multivariable regression modelling. The purpose of these analyses
was to determine:
• The ethnicity rate ratio (RR) differences, adjusted for sex and age (which should
align closely with the above age-standardised analyses)
- How much of this ethnic difference was due to mediation by
deprivation, and by deprivation and co-morbidity
• The deprivation RR differences, adjusted for sex and age, and adjusted
for ethnicity (which is a prior determinant of deprivation)
- How much of the deprivation difference was due to mediation
by co-morbidity
• The co-morbidity RR difference, adjusted for sex, age, ethnicity and deprivation.
8.3.1
Hospitalisations
Rate ratios from the Poisson regression for hospitalisations are shown in Table 2.
Māori and Pacific people had a 74 percent and 140 percent increased rate of
hospitalisation respectively compared to non-Māori non-Pacific and non-Asian
people respectively, adjusted for sex and age. About a third of these elevated risks
for Māori and Pacific people were attributable to differing levels of deprivation
(excess risks reducing from 70 percent to 45 percent for Māori, and from 140
percent to 100 percent for Pacific people). Another third (Māori) and 16 percent
(Pacific) was due to differences by ethnicity in co-morbidities. Thus, the ethnic
differences adjusted for both deprivation and co-morbidity reduced to RRs of 1.31
and 1.84 for Māori and Pacific people, respectively.
There was a deprivation gradient in hospitalisations (adjusting for sex, age
and ethnicity), that monotonically increased from 16 percent to 31 percent to
51 percent to 79 percent higher hospitalisation rates for quintiles 2, 3, 4 and 5
(the most deprived) each compared to the least deprived. These deprivation
differences reduced by about a third when adjusting for co-morbidity.
Having any co-morbid conditions, compared to nil, adjusted for sex, age, ethnicity
and deprivation, was associated with a 4.58-fold increased rate of hospitalisation.
Sex+Age+Ethnicity
160
Sex+Age+Ethnicity
Sex+Age+Ethnicity +Deprivation+Co-
+Deprivation
morb
Hospitalisations Popn Incidence
Rate Ratio 95% CI Rate Ratio 95% CI Rate Ratio 95% CI
n N (per 10k)
Total 2,883 5,279,183 (37.4)
Sex
Male 9,488 2,611,562 (36.3) 0.99 (0.96–1.02) 0.99 (0.96–1.02) 1.00 (0.98–1.03)
Female 10,207 2,660,073 (38.4) Baseline Baseline Baseline

in New Zealand in 2022
Age group
<20 3,222 1,339,719 (24.0) 1.17 (1.11–1.23) 1.20 (1.14–1.26) 1.37 (1.30–1.44)

(years)
20-39 2,815 1,459,251 (19.3) Baseline
40-59 3,624 1,309,742 (27.7) 1.49 (1.42–1.57) 1.52 (1.44–1.60) 1.28 (1.22–1.35)
60-79 5,894 960,504 (61.4) 3.47 (3.31–3.63) 3.28 (3.32–3.65) 2.14 (2.04–2.25)
80+ 4,169 209,967 (198.6) 11.85 (11.27–12.46) 11.66 (11.08–12.28) 5.00 (4.73–5.29)
Prioritised
Māori 3,411 823,353 (41.4) 1.70 (1.63–1.77) 1.45 (1.39–1.52) 1.31 (1.26–1.37)
ethnicity
Pacific 2,351 398,516 (59.0) 2.40 (2.29–2.51) 2.00 (1.91–2.11) 1.84 (1.75–1.93)
Asian 1,981 844,255 (23.5) 0.94 (0.89–0.98) 0.93 (0.88–0.98) 1.01 (0.96–1.06)
Other 11,938 3,177,450 (37.6) Baseline Baseline Baseline
Deprivation
least 2,580 1,032,923 (25.0) Baseline Baseline
(quintiles)
Table 2: Multivariable regression results for hospitalisations
Quintile 2 3,074 1,008,474 (30.5) 1.16 (1.10–1.22) 1.11 (1.06–1.17)
AOTEAROA NEW ZEALAND ROYAL COMMISSION COVID-19 LESSONS LEARNED • MAIN REPORT: PART 3 – MOVING FORWARD
Quintile 3 3,531 1,011,426 (34.9) 1.31 (1.24–1.38) 1.22 (1.16–1.28)
Quintile 4 4,231 1,023,503 (41.3) 1.51 (1.44–1.59) 1.35 (1.29–1.42)
most 5,349 1,053,471 (50.8) 1.79 (1.70–1.88) 1.54 (1.47–1.62)
Co-
No 9,488 2,611,562 (36.3) Baseline
morbidity
Yes 10,207 2,660,073 (38.4) 4.58 (4.43–4.73)

8.3.2
Deaths
Rate ratios from the Poisson regression for hospitalisations are shown in Table 2.
Māori and Pacific peoples had a 74 percent and 100 percent increased rate of
death from COVID-19 compared to people in non-Māori, non-Pacific ethnic groups.
(People of Asian ethnicity had a 40 percent lower death rate.) About a third of the
elevated mortality risk for Māori and Pacific peoples was linked with their greater
likelihood of living in a socio-economically deprived area. And roughly a further
quarter of their increased risk could be linked with their higher level of co-morbidity.
After adjustment for deprivation and co-morbidity (in addition to age and sex), the
risk of COVID-19 mortality remained 38 percent higher in Māori and 55 percent
higher in Pacific peoples, respectively.
There was a strong deprivation gradient in COVID-19 mortality (adjusting for sex,
age and ethnicity) whereby the death rate from COVID-19 increased monotonically
by quintiles of area-level deprivation. Compared with people living in the least
deprived quintile (quintile 1), the COVID-19 death rate increased by 47 percent to
83 percent to 111 percent to 125 percent for people living in quintiles 2, 3, 4 and
5 (the most deprived) respectively. These differences by deprivation reduced by
about 20 percent following adjustment for co-morbidity.
Having any co-morbid conditions (compared with none) was associated with
a 4.25-fold increased risk of COVID-19 death independent of any effect from age,
sex, ethnicity or deprivation.
Sex+Age+Ethnicity
162
Sex+Age+Ethnicity
Sex+Age+Ethnicity +Deprivation+Co-
+Deprivation
morb
Deaths Popn Incidence
Rate Ratio 95% CI Rate Ratio 95% CI Rate Ratio 95% CI
n N (per 10k)
Total 2,883 5,279,183 (54.6)
Sex
Male 1,506 2,611,562 (57.7) Baseline Baseline Baseline
Female 1,365 2,660,073 (51.3) 0.68 (0.63–0.73) 0.65 (0.60–0.70) 0.68 (0.63–0.73)
in New Zealand in 2022
Age group
<20 174 4,108,712 (4.2) 0.10 (0.08–0.13) 0.10 (0.08–0.13) 0.15 (0.12–0.18)

(years)
20-39 225 573,326 (39.2) Baseline Baseline Baseline
40-59 564 387,178 (145.7) 3.87 (3.31–4.52) 3.79 (3.23–4.45) 3.10 (2.64–3.64)
60-79 1,062 172,444 (615.9) 17.03 (14.73–19.69) 16.49 (14.21–19.14) 11.04 (9.46–12.87)
80+ 858 37,523 (2286.6) 66.78 (57.58–77.45) 64.07 (55.00–74.64) 37.31 (31.77–43.81)
Prioritised
Māori 256 823,353 (31.1) 1.74 (1.53–1.98) 1.51 (1.32–1.73) 1.38 (1.20–1.59)
ethnicity
Pacific 156 398,516 (39.1) 2.00 (1.70–2.35) 1.71 (1.44–2.02) 1.55 (1.31–1.84)
Asian 112 844,255 (13.3) 0.60 (0.49–0.72) 0.60 (0.50–0.73) 0.66 (0.54–0.80)
Other 2,343 3,177,450 (73.7) Baseline Baseline Baseline
Deprivation
least 267 1,032,923 (25.8) Baseline Baseline
(quintiles)
Quintile 2 472 1,008,474 (46.8) 1.47 (1.27–1.71) 1.40 (1.20–1.63)
Table 3: Multivariable regression results for COVID-19 deaths
Quintile 3 615 1,011,426 (60.8) 1.83 (1.58–2.11) 1.70 (1.47–1.96)
Quintile 4 730 1,023,503 (71.3) 2.11 (1.83–2.43) 1.90 (1.65–2.19)
most 638 1,053,471 (60.6) 2.25 (1.95–2.61) 1.99 (1.72–2.30)
Co-
No 632 4,527,583 (14.0) Baseline
morbidity
Yes 2,251 751,600 (299.5) 4.25 (3.81–4.74)

B.9 Endnotes
1. Laura Cleary, The Health Service Utilisation Population 11. Elena Milkovska, Bram Wouterse, Jawa Issa, and
(HSU): Estimates of the NZ Population using health data, Pieter van Baal, ‘Quantifying the Health Burden of
Ministry of Health (June 2019), https://population.org. Covid-19 Using Individual Estimates of Years of Life
nz/wp-content/uploads/2019/07/4D-Laura-Cleary- Lost Based on Population-Wide Administrative Level
MoH-Health-Service-Utilisation-population.pdf Data’, (18 March 2024), https://doi.org/10.2139/
2. Ministry of Health, National Health Index Data ssrn.4754930, https://papers.ssrn.com/sol3/papers.
Dictionary (Version 5.3), 1 July 2009, https://www. cfm?abstract_id=4754930
tewhatuora.govt.nz/assets/Our-health-system/Data- 12. Samik Datta, Giorgia Vattiato, Oliver J. Maclaren,
and-statistics/NZ-health-stats/Data-references/Data- Ning Hua, Andrew Sporle, and Michael J. Plank,
dictionaries/nhi-data-dictionary-v5.3.doc ‘The impact of Covid-19 vaccination in Aotearoa
3. Ministry of Health, Covid-19 Mortality in Aotearoa New Zealand: A modelling study’, Vaccine 42, no.
New Zealand: Inequities in Risk (Wellington, 6 (2024), 1383-1391, https://doi.org/10.1016/j.
30 September 2022), https://www.health.govt.nz/ vaccine.2024.01.101, https://pubmed.ncbi.nlm.nih.
publications/covid-19-mortality-in-aotearoa-new- gov/38307744/
zealand-inequities-in-risk 13. Elena Milkovska, Bram Wouterse, Jawa Issa, and
4. Clare E. Salmond and Peter Crampton, ‘Development Pieter van Baal, ‘Quantifying the Health Burden of
of New Zealand’s Deprivation Index (NZDep) and Its Covid-19 Using Individual Estimates of Years of Life
Uptake as a National Policy Tool’, Canadian Journal of Lost Based on Population-Wide Administrative Level
Public Health / Revue Canadienne de Sante’e Publique 103 Data’, (18 March 2024), https://doi.org/10.2139/
(2012), S7-S11, http://www.jstor.org/stable/41995682, ssrn.4754930, https://papers.ssrn.com/sol3/papers.
http://www.jstor.org/stable/41995682 cfm?abstract_id=4754930
5. Ministry of Health, COVID-19 data, 2021, 14. Samantha Howe, Joshua Szanyi, and Tony Blakely,
https://github.com/minhealthnz/nz-covid-data ‘The health impact of long COVID during the 2021–
2022 Omicron wave in Australia: a quantitative burden
of disease study’, International Journal of Epidemiology
Timeline of Significant COVID-19 Events and Key
52, no. 3 (3 April 2023), 677-689, https://doi.
All-of-Government Response Activities (Version
org/10.1093/ije/dyad033, https://academic.oup.com/
1), September 2023, https://www.dpmc.govt.nz/
ije/article/52/3/677/7100842
publications/proactive-release-timeline-aotearoa-
new-zealands-significant-events-and-key-all- 15. Thomas Hale, Noam Angrist, Rafael Goldszmidt,
government-activities Beatriz Kira, Anna Petherick, Toby Phillips, Samuel
Webster, Emily Cameron-Blake, Laura Hallas, Saptarshi
7. Our World in Data, COVID-19 Data Explorer, 2024,
Majumdar, and Helen Tatlow, ‘A global panel database
https://ourworldindata.org/explorers/coronavirus-
of pandemic policies (Oxford COVID-19 Government
data-explorer
Response Tracker)’, Nature Human Behaviour 5, no. 4
8. Institute for Health Metrics and Evaluation, Global (2021), 529-538, https://doi.org/10.1038/s41562-021-
Health Data Exchange: Global Burden of Disease 01079-8, https://www.nature.com/articles/s41562-021-
Study 2021 (GBD 2021) Data Resources, https://ghdx. 01079-8
healthdata.org/gbd-2021
16. Our World in Data, COVID-19 Data Explorer, 2024,
9. Institute for Health Metrics and Evaluation, Global https://ourworldindata.org/explorers/coronavirus-
Health Data Exchange: Global Burden of Disease data-explorer
Study 2021 (GBD 2021) Data Resources, https://ghdx.
17. Elena Milkovska, Bram Wouterse, Jawa Issa, and Pieter
healthdata.org/gbd-2021
van Baal, ‘Quantifying the Health Burden of Covid-19
10. Samik Datta, Giorgia Vattiato, Oliver J. Maclaren, Ning Using Individual Estimates of Years of Life Lost Based
Hua, Andrew Sporle, and Michael J. Plank, ‘The impact on Population-Wide Administrative Level Data’, (18
of Covid-19 vaccination in Aotearoa New Zealand: A March 2024), https://doi.org/10.2139/ssrn.4754930,
modelling study’, Vaccine 42, no. 6 (2024), 1383-1391, https://papers.ssrn.com/sol3/papers.cfm?abstract_
https://doi.org/10.1016/j.vaccine.2024.01.101, https:// id=4754930
pubmed.ncbi.nlm.nih.gov/38307744/
Appendix C:
C Pandemic scenarios |
Ngā āhuatanga o te
mate urutā
C.1 Purpose and audience
This appendix is intended for people interested in thinking

in more depth about pandemic scenarios – for example,
those who might be responsible for working through and
then implementing this report’s recommendations on
scenario thinking, planning and modelling.
We discuss scenario thinking, anticipatory governance, and using scenario planning
and modelling to inform policy response options in Chapter 10 of the main report.
Here we focus in more depth on the core aspect of pandemic scenarios, with
examples relating to characteristics of potential pandemic agents.
This appendix builds on a growing body of work about the role of scenario
planning for future pandemics. We also commend to interested readers a report
published in 2023 by Te Niwha: Likely future pandemic agents and scenarios: An
epidemiological and public health framework.1 Discussions about the Te Niwha
report helped inform the work of this Inquiry.
C.2 Generic or ‘Agent X’ pandemic scenarios
How a future pandemic will play out in Aotearoa New Zealand is a function
of three factors:
1. Pathogen and host: Specifically, the virulence and infectiousness of
the pandemic agent (likely a virus), and the immunological and general
susceptibility (such as age and co-morbidities) of the people it infects.
2. Response: That is, the actions we take collectively and individually to
respond, selecting from the ‘tools’ we have in the ‘toolbox’. (This in turn is
influenced by what pandemic preparation has occurred in the past.) The
response options are wide-ranging, including: public health and social measures
(PHSMs), ranging from voluntary physical distancing to lockdowns; vaccines –
both the quality of what is in the vial, and when and how we deploy or roll it
out in society; treatments that might be generic for any serious viral illness
(such as ICU care) through to bespoke pharmaceuticals developed in response
to the new pandemic agent; testing including the actual test itself through
to how it is deployed and used; contact tracing; isolation and quarantine;
and border controls.
3. Contextual factors: Social cohesion and trust (in government, science,
each other) are important preconditions for a coordinated response that
requires solidarity or kotahitanga to execute (such as an elimination
strategy that occasionally requires working from home or even lockdowns).
The range of possibilities under each of these three domains is large. It is not
possible to conceptualise and work through all possible scenarios. However, the
backbone of future pandemic preparedness will involve developing scenarios that in
turn inform preparedness activities. We also recommend that modelling – including
economic and social inputs and impacts – of many scenarios is performed to help
guide that process going forward. A combined WHO, OECD and World Bank report
has eloquently made the case for integrated epidemiologic and economic modelling
capacity to be built before the next pandemic.2
But for this appendix, we flesh out a handful of scenarios – the objectives being:
• To highlight that the next pandemic will likely be different from COVID-19.
• To highlight that the impact of the next pandemic will likely depend on
what preparation is done in advance.
• To demonstrate how outlining scenarios can assist prioritisation of
preparedness activities.
For our scenario thinking, we consider component scenarios as follows:
Figure 1: Scenario Components
1. Pathogen characteristics:
a) four combinations of infectiousness (measured by R0i) and visibility

for case detection, contact tracing, isolation and quarantineii
(i) low infectiousness (R0 = 2.0) and high visibility
(ii) moderate infectiousness (R0 = 3.0) and low visibilityiii
(iii) high infectiousness (R0 = 6.0) and high visibility
(iv) high infectiousness (R0 = 6.0) and low visibility
b) virulence of infection fatality risk (IFRiv; low=0.5 percent/high=7.5 percentv)
= 8 scenarios
2. Societal preparation: good versus poorvi

= 2 scenarios
i The R0 is the basic reproductive number – or the number of people each infected person infects on average, early in
the outbreak when there is no immunity among the population. It is also a social construct, in that the R0 depends on
contact patterns and facilitation of transmission in the society. For the purposes of these scenarios, we assume this
R0 applies to a pathogen ‘dropped into New Zealand in 2019’ before it was detected. If in the future people congregate
in buildings with much improved ventilation (and possibly filtration), the R0 of a given pathogen will be reduced.
Likewise, the R0 will be less in the future if people work and study more from home.
ii High visibility for contact tracing would be a long incubation period (allowing more time for people to quarantine
effectively and be contact traced); little if any pre-symptomatic infectious period (meaning people do not circulate
for long in the community before self-isolating when they become symptomatic – assuming they comply); and few
if any people getting asymptomatic infection (yet still being infectious to others). Low visibility is the converse. For
additional discussion and consideration of ‘visibility’ of a pandemic pathogen, including social factors that influence
visibility and detectability, see J.M. McCaw, K. Glass, G.N. Mercer, and J. McVernon, ‘Pandemic controllability: a
concept to guide a proportionate and flexible operational response to future influenza pandemics’, Journal of Public
Health 36, no. 1 (3 June 2013), 5-12, https://doi.org/10.1093/pubmed/fdt058, https://academic.oup.com/jpubhealth/
article/36/1/5/1572791.
iii It seems unlikely for a low infectiousness virus (R0 = 2.0) to also be low visibility, so we set a moderate infectiousness
(R0 = 3.0) as the ‘best’ scenario with a low visibility pathogen.
iv The infection fatality risk (IFR) is the proportion of people infected who die (in the absence of more than supportive
care, before any specific treatments for the pandemic pathogen are available). It is less than the case fatality rate (CFR),
which has symptomatic and detected people as the denominator. Thus, if two thirds of people are symptomatic and
classified as a case (for example, because they are captured by surveillance systems), then a 10 percent IFR equates to
a 15 percent CFR. For these scenarios, we assume the IFR and CFR vary by age, being greater among older age groups.
The 1918 influenza epidemic had a notably high CFR among young adults, probably due to some immune memory
from an influenza virus that circulated in the late 1800s and secondary bacterial infection on top of the 1918 influenza
virus that actually resulted in most of the deaths. A high CFR among young adults relative to older adults in a future
pandemic is possible but seems unlikely.
v The IFR will almost certainly vary by age, perhaps greater than 100 fold. But here we just consider the ‘crude’ IFR across
all ages combined.
vi A well-prepared society might have these features: improved ventilation and filtration of public buildings (especially
healthcare settings), leading to a 5 to 10 percent reduction in the R0 of any respiratory-borne pathogen; be digitally
enabled allowing easy work and study from home; deploy effective digitally enhanced contact tracing and surveillance;
have a strong public health workforce that is able to surge for contact tracing and supporting cases and contacts, with
excellent connections into and collaborations with diverse communities; have strong health systems that are able to
surge to meet community, secondary and tertiary care demands in a pandemic; have strong testing strategy and capacity
that can be surged rapidly; have strong IT systems in health, to provide for situational awareness surveillance, and
prioritisation of activities; maintain large well-managed stockpiles of personal protective equipment (PPE) and medicines;
have onshore manufacturing capacity for PPE and masks that can be surged; have a comprehensive quarantine system that
can surge to provide a mix of strict facilities through to supported home quarantine; have predetermined governance and
decision-making structures, supported by strong legislation, policy workforce capacity and with engagement and liaison
arrangements with Māori and other community groups, that can all be surged in a coordinated manner; have strong
wage and business support systems that can be turned on and off rapidly, and targeted as required; maintain strong
border systems and workforce that can rapidly move up levels of stringency for international arrivals; and have strong
social support and welfare sector that can reprioritise and surge to support people.
3. Strategy:
a) Immediate: There will be an initial and urgent decision required as to

whether to use an exclusion strategy and minimise the possibility of the
pathogen entering the country at all (or at least delaying its arrival). The
exclusion strategy would be used with a pathogen with obvious major
potential health and social impact due to its combination of infectiousness,
virulence, visibility – and the societal preparedness and response capacity
in place. It would also be used when there was a high degree of uncertainty
requiring time to rule out the likelihood of the pandemic pathogen being
‘bad’ (in other words, applying the precautionary principle).
b) If the pathogen is within New Zealand: If an exclusion strategy is not
taken, or it is taken then a pivot to more open borders is pursued with the
inevitability of onshore transmission occurring, or exclusion fails, despite
rigorous international border quarantine, with incursion of the pathogen
into New Zealand, the strategy choices are broadly two-fold:
(i) Elimination or aggressive suppression (keep stamping it out, aiming for
zero within-country transmission most of the time; may even revert to
exclusion strategy, emphasising that strategies sit on a spectrum); versus
(ii) Loose suppression of mitigation (that is, let the pathogen wash through
until something like herd immunity is achieved, using ‘flattening the
curve’ activities if peak healthcare demand exceeds system capacity).
= 2 scenarios
4. Vaccine:
a) Good scenario of vaccines with high vaccine effectiveness (including

against transmission), rapid development and rollout (for example,
starting within six months of the pathogen being identified and
completed within another six months), and high vaccine uptake (for
example, 90 percent or more of the eligible population); versus
b) Bad scenario of vaccines with only moderate vaccine effectiveness
(protection) against death (for example, a 90 percent reduction in risk) and
hospitalisation (for example, an 80 percent reduction in risk) and poor
vaccine effectiveness against transmission (for example, a 30 percent
reduction in risk of vaccinated person being infected, and a 50 percent
reduction in risk of a vaccinated person with infection passing it on to
others – meaning a hypothetical 1 – ((1–30 percent) × (1–50 percent)) = 65
percent reduction in transmission in society if everyone was vaccinated),
and only 60 percent vaccine uptake in the eligible population.vii
= 2 scenarios
vii A 60 percent uptake, with the vaccine effectiveness against transmission as stated in this paragraph, would lead to a 60 percent
× 65 percent = 39 percent ≈ 40 percent (assuming homogeneous population mixing, and 60 percent uptake is for all ages as
the denominator). Assuming no waning, and no immune escape from new variants, the effect of this vaccine scenario alone
(with no other changes in society) would be enough to achieve an effective reproductive rate (Reff) of 1.0 for a pathogen with an
R0 of 1.67. It would still be helpful in combination with other measures to reduce transmission for pathogens with an R0 > 1.67.
Another key consideration is uncertainty – which will likely be high initially.
Uncertainty may be explicitly included in frameworks for deciding on the optimal
pandemic strategy (see, for example, Kvalsvig and Baker, 20213). There is also likely
to be uncertainly in relation to the initial decision about whether to immediately
impose strict national border restrictions and keep the pathogen out (exclusion
strategy above). We refer to these dimensions occasionally, but do not explicitly
include them in our framework.
These component scenarios come together as 64 different combinations (8×2×2×2).
This is far too many to expound in depth, but we will select from them
to demonstrate possible futures.
Next, the pathogen characteristics are considered in more detail. Table 1 shows
the expected deaths in an unmitigated pandemic in a population of 6 million. The
lower bound is given, assuming the proportion infected is determined by the herd
immunity threshold (R0 – 1)/R0), which will require strong controls as the pandemic
progresses to ensure infection rates are kept low as the herd immunity threshold
is approached. The upper bound is that for a completely unmitigated epidemic,
whereby there are many people infected when the population reaches the level
of infection required to achieve herd immunity (meaning there is still some way to
go before wave of infection fades away). Note that these numbers are theoretical,
assuming homogenous mixing and no societal or individual measures to reduce
the risk of transmission. In reality this is an unlikely situation since – even in the
absence of a coordinated government response – people are likely to take voluntary
measures to ‘shield’ the vulnerable (such as elderly people avoiding social gatherings
and people wearing masks), meaning death counts would likely be lower than
those projected here.
Table 1 also shows in parentheses the likely time-specific occurrence (return period)
for such a pandemic, using the work of Madhav et al (2023)4 and assumptions as per
the footnotes to Table 1.
Table 1: Excess deaths by pandemic scenario in an unmitigated pandemic
with no societal or behavioural change † for a country of 6 million (return
period in backets derived from Madhav et al, 2023 ‡)
Virulence
Low, IFR = 0.5% High, IFR = 7.5%
15,000 to 27,000 £ 225,000 to 400,000 £

Low, R0 = 2
Infectiousness
(1 in 25 yr) (1 in 100 yr to 1 in 200 yr)
20,000 to 28,000 £ 300,000 to 425,000 £

Moderate, R0 =3
(1 in 25 yr) (1 in 100 yr to 1 in 200 yr)
25,000 to 30,000 £ 375,000 to 450,000 £

High, R0 = 6
(1 in 25 yr) (1 in 200 yr)
† For illustrative purposes (in reality there will be behavioural changes, although the extent is unclear).
‡ Madhav et al compiled a historical record of pandemics. They created an approximate excess death rate
corresponding to how often a pandemic of that severity occurred. Those excess death rates are ‘observed’
and therefore mitigated to some extent. Further, and assuming the IFR is higher among older ages, then the
‘completely unmitigated’ excess death rate in contemporary society would be more than in historical records
due to older populations. These factors are allowed for in the (very) approximate assigning of 1 in 25-year
and 1 in 100-year to 1 in 200-year pandemics.
£ Lower bound is for the herd immunity threshold (HIT) of infection ((1 – R0)/R0) multiplied by the IFR by 6 million.
For the proportion of the population to be infected to equal the HIT requires homogenous mixing and (critically)
that the epidemic is controlled so that it approaches the HIT with low infection rates – that is, there would need
to be considerable flattening of the curve and mitigation activities. The upper bound is that for an unmitigated
epidemic (‘let it rip’, no dampening of transmission whatsoever) that means the epidemic still has many people
infected at the HIT, and whilst each infected will pass it on (on average) to less than one other person, there is still
much more momentum to run out. Using formulas derived for a SIR model5 (Susceptible, Infectious and Removed
individuals) model, an unmitigated epidemic for a pathogen with R0 of 2.0 will see 79.7 percent of the population
infected (c.f. HIT = 50 percent), and R0 6.0 will see 99.7 percent infected (c.f. HIT = 83.3 percent).
Rather soberingly, the current H5N1 strain of avian influenza (‘bird ‘flu’) has a
recorded case fatality rate (CSR) of about 50 percent among people infected via
animal-to-human transmission. (The virus has not yet mutated to allow human-to-
human transmission, which could potentially precipitate another pandemic.) Based
on experience with previous influenza viruses, we assume that – should human-to-
human transmission occur, the infection fatality risk (IFR) for H5N1 will be much
less than the case fatality rate (CFR).viii This is likely for two reasons: firstly, many
cases of H5N1 influenza infection from animal-to-human transmission are likely
to have remained undetected due to mild or absent symptoms (that is, IFR < CFR);
and secondly, if mutations occur to allow human-to-human transmission, the
virus is likely to simultaneously become less virulent (although this second
assumption is not certain). Thus, our worst case of an IFR of 7.5 percent should
not be discounted as impossible.
viii See footnote iv for an explanation of IFR and CFR.
C.3 Examples of future pandemic scenarios
Below we give a narrative description of four stylised scenarios. For readers

interested in a more comprehensive overview, Tables 2 and 3 will be of
interest – and some readers may want to start with those tables before
reading the following narratives.
(1) Good scenario: Low R0 = 2.0, low virulence with

IFR = 0.5 percent, highly visible (and therefore amenable
to self-isolation, contact tracing and quarantine measures)
This scenario is a bit better than initial SARS-CoV-2 both in terms of R0
(the ancestral variant of SARS-CoV-2 had an R0 of about 2.5) and IFR.
With good preparation and good anticipated vaccines (in terms of both coverage
and effectiveness) that can be rolled out in six months, this scenario looks ideally
manageable with an elimination strategy (Table 2).
However, the situation might evolve differently. For example, if vaccines were
likely to be delayed and there was pressure from citizens to keep borders open,
mitigation might offer an alternative route. This would be more feasible and
acceptable if those most vulnerable to serious illness (such as people who were
older, frail and/or with co-morbidities) could be ‘shielded’ through measures
such as distancing and masking, allowing others at low risk of serious illness to
become infected and develop something like herd immunity that is later topped
up through vaccination.
Another option would be to use elimination initially, hoping for effective vaccines
to become available in a short timeframe. But if in the first few months it became
clear that vaccines were a way off, or would likely be of low effectiveness, it may
make sense to pivot to suppression or mitigation.
All options would be easier to navigate with better preparation. For example:
• Greater built-in ventilation of public buildings would ‘take the edge’ off the
R0 (although we do not yet fully understand by how much), probably making
it less likely for outbreaks to occur, and – where outbreaks do occur – a bit
easier to stamp out.
• A stronger public health workforce with greater capacity to surge contact-
tracing and isolation functions would make it easier to control outbreaks
without having to resort to more stringent public health and social measures
such as lockdowns.
• Greater laboratory capacity and ability to surge testing rapidly would enable
faster identification and isolation of cases, and quarantine of contacts.
• A fine-tuned system that can deliver wage subsidies rapidly to regional
employers and employees in a targeted manner would assist any need
(if at all) for short, sharp regional lockdowns.
(2) Not quite so good scenario: Low R0 = 3.0, low virulence
IFR = 0.5 percent, poorly visible (and therefore less amenable
to self-isolation, contact tracing and quarantine measures)
Imagine, now, that the pathogen is essentially the same, except that it has
some mix of a shorter incubation period, greater infectivity before symptoms,
and more asymptomatic infection (Table 2). An elimination or exclusion strategy
might still work well, especially if borders are moved rapidly to (good) quarantine
systems before any infection takes hold onshore. But if outbreaks occurred,
they would be harder to stamp out given less visibility of early infection.
This more challenging set of circumstances might prompt a pivot to mitigation,
especially if social licence for an elimination strategy was low, vaccines seemed
a long way off, and the vaccines in the pipeline did not appear to have high
effectiveness.
As with all the possibilities outlined, better preparation would give decision-makers
more options in such a scenario.
(3) Bad scenario: high R0 = 6.0, high virulence with
IFR = 7.5 percent, but high visibility
This scenario is in Table 2. Because of the high R0, stamping out or keeping low
transmission will be challenging. (An early exclusion response might be ideal,
preventing any onshore transmission – or at least holding it off as long as possible
until a breach in international quarantine occurs.) But with such a high IFR, there
would be a strong incentive to keep transmission low – meaning society would
likely be willing to forego liberties to lessen health loss and health system pressure.
Better preparation would make an elimination strategy easier. International
borders would probably need to be strictly managed with quality quarantine of
international arrivals.
Even if vaccines appeared to be a long way off, if an elimination strategy was
holding and transmission within the country was very low or at zero, an ongoing
elimination approach would probably be better than pivoting to mitigation (which
would be likely to bring tens to hundreds of thousands of deaths, and substantial
health system and social disruption).
If an elimination strategy failed (from one or a combination of one too many
outbreaks, infection taking off, societal fatigue with restrictions, or societal
pressure to open up borders), the pivot to a suppression or mitigation strategy
would be extremely challenging for health systems with substantial loss of life –
unless those most vulnerable could be effectively protected and shielded through
measures like masking and distancing.
If an elimination strategy was retained, its true success would likely be a
function of vaccines – both uptake and effectiveness. If those factors were poor,
health loss would still be substantial over the whole pandemic – better than
if the government pursued a suppression or mitigation strategy (rather than
an initial elimination strategy) from the outset, but still far from good.
(4) Really bad scenario: high R0 = 6.0, high virulence with
FR = 7.5 percent, but low visibility
This scenario is the same as the last, but for a pathogen that has some mix
of short incubation period, infectiousness before symptoms and moderate to
high asymptomatic infection (but still infectious). Contact tracing and citizen self-
isolation upon becoming symptomatic are unlikely to be very effective in this
scenario. Unless borders were shut before infection arrived (that is, an immediate
exclusion strategy), stamping out incursions and outbreaks would be difficult –
requiring luck, an extremely good public health workforce with strong surveillance
and contact-tracing systems and likely repeated stringent population-wide
PHSMs to help stamp out outbreaks.
Under this scenario, the likelihood of losing control and infection taking off
requiring a mitigation strategy is high – but that mitigation strategy would still
require stringent PHSMs to protect health services during waves of infection.
It would be very challenging if elimination failed, with substantial health, societal
and economic loss.
An early and effective vaccine would be desperately sought; countries that
had invested in vaccine production and access schemes in advance would
be advantaged.
T
R0 = 2.0 and High Visibility (long incubation, R0 = 3.0 and Low Visibility (short incubation,
low asymptomatic, low infectiousness before symptoms) high asymptomatic, high infectiousness before symptoms)
Good societal preparation Poor societal preparation Good societal preparation Poor societal preparation
Vaccine: Good Elimination 1st 12 months (i.e. to the end of the As per left, but likely 1st 12 months: Uncertain if As per left, but likely more deaths
6 months till or aggressive vaccine rollout): Very low deaths. If more deaths, likely more difficulty elimination strategy will work in first (as more people infected before
rollout, rollout suppression international border quarantine then controlling outbreaks, somewhat 6 mnths – more likely to work with vaccine rollout), more difficulty
completed in modest only PHSMs likely needed; wider community transmission, international border quarantine and controlling outbreaks, more societal
6 months, high if open borders outbreaks perhaps likely more societal and (stringent) PHSMs to give chance for and health system disruption.
coverage controllable with standard public health system disruption. standard public health response to
and vaccine health response and some population work, level of disruption to health
effectiveness wide PHSMs. Low demands on health sector and society hard to predict. As
sector, low societal disruption. vaccine rollout occurs, control becomes
After vaccine rollout: very low deaths, notably easier.
negligible societal and health system After rollout: very low deaths,
disruption. negligible societal and health system
Good (comparatively) outcome
disruption.
Loose 1st 12 months: 1000s of deaths, As per left. 1st 12 months: Many 1000s of As per left, but likely more
suppression or health system stretched, sporadic deaths, health system stretched, societal and health system disruption
mitigation † disruption to business and society sporadic disruption to business and (including possible lockdowns) as
from sickness. society from sickness. flattening the curve harder.
After rollout: very low deaths, negligible After rollout: very low deaths,
societal and health system disruption. negligible societal and health system
disruption.
Vaccine: Bad Elimination 1st 24 months: Very low deaths. If As per left, but likely more deaths 1st 24 months: Uncertain if 1st 24 months: As per left, but with
12 months till or aggressive international border quarantine then and disruption earlier (may be less elimination strategy will work – more more likelihood of elimination strategy
rollout, rollout suppression modest only PHSMs likely needed; disruption and deaths later as ‘washes likely to work with international border struggling (meaning more stringent
completed in if open borders outbreaks perhaps through’ quicker to something like quarantine and (stringent) PHSMs to PHSMs, or even pivot to mitigation).
12 months, controllable with standard public health herd immunity ‡ within the first year). give chance for standard public health (May be less disruption and deaths
low coverage response and some population wide response to work, level of disruption later as ‘washes through’ quicker to
and vaccine PHSMs. Low demands on health to health sector and society hard to something like herd immunity ‡ within
effectiveness sector, low societal disruption. predict. the first year.)
† Assumed no international border quarantine in loose suppression or mitigation.

After rollout: probably low infection After rollout: probably low infection After rollout: probably low infection
as even though vaccine poor, with as even though vaccine poor, with as even though vaccine poor, with
high rates of natural infection hybrid high rates of natural infection hybrid high rates of natural infection hybrid
immunity good enough to achieve immunity good enough to achieve immunity good enough to achieve
something like herd immunity. ‡ something like herd immunity ‡. something like herd immunity ‡.
(R0 = 2.0 or 3.0) and low virulence (IFR = 0.5 percent) pathogen
Loose 1st 24 months: 1000s of deaths, As per left, but likely more deaths 1st 24 months: Many 1000s of As per left, but likely more
able 2: Pandemic scenarios for low or moderate infectiousness
suppression or health system stretched, sporadic and disruption earlier (may be less deaths, health system stretched, societal and health system disruption
mitigation † disruption to business and society disruption and deaths later as ‘washes sporadic disruption to business and (including possible lockdowns) as
from sickness – all more concentrated through’ quicker to something like society from sickness – all more flattening the curve harder.
in first 12 months as something like herd immunity ‡ within the first year). concentrated in first 12 months
herd immunity ‡ already in place as something like herd immunity ‡
‡ Assumes strong immunity from natural infection that neither wanes nor is ‘broken through’ by new variants.
by start of vaccine rollout. already in place by start of vaccine
After rollout: very low deaths, rollout.
negligible societal and health system After rollout: very low deaths,
disruption. negligible societal and health system
disruption.
175
Moderate (comparatively) outcome Too uncertain to predict
T
R0 = 6.0 and High Visibility (long incubation, R0 = 6.0 and Low Visibility (short incubation,
176
low asymptomatic, low infectiousness before symptoms) high asymptomatic, high infectiousness before symptoms)
Good societal preparation Poor societal preparation Good societal preparation Poor societal preparation
Vaccine: Good Elimination st st

1 12 months: Uncertain. Perhaps Uncertain. As per left, but likely 1 12 months: Very uncertain. As per left, but likely more deaths
6 months till or aggressive low deaths, if stringent international more deaths, likely more difficulty Elimination strategy might work if (as more people infected before
Bad outcome
rollout, rollout suppression border quarantine and stringent controlling outbreaks, wider stringent international border quarantine vaccine rollout), more difficulty
completed in PHSMs in place during outbreaks (due community transmission, likely more and only occasional outbreaks requiring controlling outbreaks, more societal
6 months, high to high R0; open borders unlikely to societal and health system disruption. (very stringent) PHSMs with intense and health system disruption, even
coverage work), moderate demands on health public health response to work, level of more likely than left elimination
and vaccine sector, moderate societal disruption disruption to health sector and society strategy will fail.
effectiveness (but uncertain and elimination hard to predict. As vaccine rollout occurs,
could fail). control becomes notably easier. (Very
After rollout: very low deaths, uncertain and elimination could
negligible societal and health system easily fail.)
disruption. After rollout: very low deaths, negligible
societal and health system disruption.
Loose 1st 12 months: Tens to As per left, but likely more deaths 1st 12 months: Tens to 100s of As per left, but likely more deaths
suppression or 100s of 1000s of deaths, health system and disruption. 1000s of deaths, health system over- and disruption.
mitigation † over-run, massive disruption to run, massive disruption to business
business and society from repeated and society from repeated lockdowns
lockdowns (more so 1st 6 months). (more so 1st 6 months).
After rollout: very low deaths, After rollout: very low deaths,
negligible societal and health negligible societal and health
system disruption. system disruption.
Vaccine: Bad Elimination 1st 24 months: Uncertain. Perhaps As per left, but likely more deaths, 1st 24 months: Very uncertain. As per left, but likely more deaths
12 months till or aggressive moderate deaths, if stringent likely more difficulty controlling Elimination strategy might work (as more people infected before
rollout, rollout suppression international border quarantine outbreaks, wider community if stringent international border vaccine rollout), more difficulty
completed in and stringent PHSMs in place during transmission, likely more societal and quarantine and only occasional controlling outbreaks, more societal
12 months, outbreaks (due to high R0; open health system disruption. outbreaks requiring (very stringent) and health system disruption,
able 3: Pandemic scenarios for high infectiousness
low coverage borders unlikely to work), moderate PHSMs with intense public health even more likely than left that
(R0 = 6.0) high virulence (IFR = 7.5 percent) pathogen
† Assumed no international border quarantine in loose suppression or mitigation

and vaccine demands on health sector, moderate response to work, level of disruption elimination strategy will fail.
effectiveness societal disruption (but very uncertain to health sector and society hard to
and elimination could fail). predict. As vaccine rollout occurs,
After rollout: ongoing outbreaks and control becomes notably easier. (Very
deaths, ongoing societal and health uncertain and elimination could easily
system disruption until herd immunity ‡ fail.)
reached through natural infection. After rollout: very low deaths, negligible
societal and health system disruption.
Loose 1st 12 months: Tens to 100s of 1000s As per left, but likely more deaths 1st 24 months: Tens to 100s of 1000s As per left, but likely more deaths
suppression or of deaths, health system over-run, and disruption. of deaths, health system over-run, and disruption.
mitigation † massive disruption to business and massive disruption to business and
society from repeated lockdowns society from repeated lockdowns
(more so 1st 12 months). (more so 1st 12 months).
After rollout: ongoing outbreaks and After rollout: ongoing outbreaks and
deaths, ongoing societal and health deaths, ongoing societal and health
Too uncertain to predict [might be good or moderate, or bad if elimination
system disruption until herd immunity ‡ system disruption until herd immunity ‡
fails with massive social and economic disruption and/or pivot to mitigation]
reached through natural infection. reached through natural infection.

C.4
0.0 Endnotes
1. Nigel French, Howard Maxwell, Sue Huang, Fiona 3. Amanda Kvalsvig and Michael G. Baker, ‘How Aotearoa
Callaghan, Kristin Dyet, Jemma Geoghegan, David New Zealand rapidly revised its Covid-19 response
Hayman, Amanda Kvalsvig, Michael Plank, and Pippa strategy: lessons for the next pandemic plan’, Journal of
Scott, Likely future pandemic agents and scenarios: An the Royal Society of New Zealand 51, no. sup1 (9 March
epidemiological and public health framework, Te Niwha 2021), S143-S166, https://doi.org/10.1080/03036758.20
(November 2023), https://www.teniwha.com/research- 21.1891943, https://www.tandfonline.com/doi/full/10.1
projects/likely-future-pandemic-agents-and-scenarios 080/03036758.2021.1891943
2. Gabrielle Bonnet, Carl A. B. Pearson, Sergio Torres- 4. Nita K. Madhav, Ben Oppenheim, Nicole Stephenson,
Rueda, Francis Ruiz, Jo Lines, Mark Jit, Anna Vassall, Rinette Badker, Dean T. Jamison, Cathine Lam, and
and Sedona Sweeney, ‘A Scoping Review and Amanda Meadows, Estimated Future Mortality from
Taxonomy of Epidemiological-Macroeconomic Models Pathogens of Epidemic and Pandemic Potential, Center
of COVID-19’, Value in Health 27, no. 1 (2024), 104-116, for Global Development (13 November 2023),
https://doi.org/10.1016/j.jval.2023.10.008, https://www.cgdev.org/publication/estimated-future-
https://www.valueinhealthjournal.com/article/S1098- mortality-pathogens-epidemic-and-pandemic-potential
3015(23)06154-5/fulltext?_returnURL=https%3A%2F%2 5. Maximilian M. Nguyen, Ari S. Freedman, Sinan A.
Flinkinghub.elsevier.com%2Fretrieve%2 Ozbay, and Simon A. Levin, ‘Fundamental bound on
Fpii%2FS1098301523061545%3Fshowall%3Dtrue epidemic overshoot in the SIR model’, Journal of The
World Health Organization, Organisation for Economic Royal Society Interface 20, no. 209 (6 December 2023),
Co-operation and Development, and International 20230322, https://doi.org/10.1098/rsif.2023.0322,
Bank for Reconstruction and Development/The https://royalsocietypublishing.org/doi/abs/10.1098/
World Bank, Strengthening pandemic preparedness rsif.2023.0322
and response through integrated modelling (Geneva,
8 May 2024), https://www.who.int/publications/i/
item/9789240090880
Appendix D
D Vaccine coverage and

population immunity
– key considerations
for lifting pandemic
measures | He mea nui
te whai whakaaro ki te
awhikiri o te taupori –
kaua ko te tokomaha
anake kua whiwhi
rongoā āraimate –
i te hōrapa i te
rongoā āraimate
ina ngoikore
haere te kaha o
tētahi rongoā
āraimate
D.1 Purpose
In Lesson 2 of Chapter 10, we included a ‘spotlight’ on

responding to changes in risk and vaccine-related
protection, drawing on examples from the Australian
states of New South Wales and Victoria.
This PHMS appendix is intended to support that lesson: if vaccine effectiveness
wanes, population immunity is perhaps more important than vaccine coverage
when it comes to making decisions about when to ease restrictions. This appendix
is also intended to demonstrate how – in the next pandemic – the monitoring and
forecasting of population immunity from vaccines could be undertaken.
It is not the purpose of this appendix to focus on what happened during
COVID-19 in Aotearoa New Zealand and the decisions taken at that time. Rather,
we seek to pull out what we think is an important lesson. We use the population
of South Auckland in mid- to late 2021 to illustrate what the likely population
immunity probably was week by week. Taking the Auckland lockdown during 2021
as our example, we consider how this sort of analysis might be included (alongside
other factors) in decision-making on when to ease public health and social measures
(PHSMs) in a future pandemic.
To put this in context, decisions about when to ease PHSMs such as lockdowns
are based on multiple criteria and can be very challenging to make. There are
social considerations (such as the general population’s loss of liberty, and the
educational and social impacts for children and young people of not being able
to attend school in person), economic considerations (including the impacts on
small businesses in the locked down area, and spillover effects for the wider
economy), and health impacts (both direct effects of getting infected, and indirect
mental health and other effects of long lockdowns). In the case of the Auckland
lockdown in 2021, a key focus was the extent of protection for Māori and Pacific
populations, who had lower levels of vaccine coverage and higher risk of overall
negative health outcomes.
This appendix is designed to help future officials and decision-makers think about
one criterion (protection against infection, symptomatic illness and hospitalisation
or death) in one domain (health) as an important input into the range of factors
involved in deciding when to ease PHSMs.
What do we mean by population immunity?
D.2 And why does it matter?
In a population that so far has had negligible natural infection,

we define population immunity as the ‘average vaccine
effectiveness (VE) by time, allowing for the number of people
vaccinated and the time since they were each vaccinated’.
This definition might be for the average VE protection against death, against
hospitalisation, against symptomatic disease or against getting any infection (be
that asymptomatic or symptomatic). These distinctions are important because:
• VE immediately after completing the primary course (or booster) can differ
for protection against death through to that against any infection; and
• VE can wane by time since completion of the primary course (or booster).
Consider a simple example of a vaccine that gives (on expectation) a 90 percent
reduced risk of being hospitalised one month after completion of the primary
course, 80 percent protection two months later, 70 percent protection three months
later, and 60 percent four months later. Imagine a country of ten people in which
three were vaccinated one month ago, three were vaccinated two months ago,
three were vaccinated three months ago, and one is unvaccinated. The average
VE is (3×90 percent + 3×80 percent + 3×70 percent) / 10 = 72 percent. If this country
opened to the world at this point, and the entire population was infected quickly
(putting aside protection against any infection for now), we would expect
a hospitalisation rate 72 percent lower than if no one had been vaccinated.
Now imagine that the tenth and last citizen has decided to get vaccinated. The
primary course is just one dose, and it takes one month to get their immunity or
VE of 90 percent. After that month, the average VE of population immunity will be
(1×90 percent + 3×80 percent + 3×70 percent + 3×60 percent) / 10 = 72 percent.
That is, no difference from a month ago, because the gain of the one person getting
vaccinated is offset by the loss of immunity among the nine vaccinated people after
another month of waning. Accordingly, this nation of ten people could have lifted
its restrictions a month earlier: there is no difference in expected health loss
from having one month less of isolation.
This simple example was just for protection against hospitalisation. The situation
becomes more complex if we factor in protection against any infection, since the
health loss is a function of both the reduced transmission risk and infection level,
and the reduced risk of being hospitalised among those infected (both unvaccinated
and vaccinated if there is less than 100 percent protection against any infection).
D.3 Data inputs to estimate population immunity
To demonstrate the value of this approach we have prepared an example analysis

based on real data from the COVID-19 pandemic, which required the following
three data inputs:
1 Vaccine coverage by time;
2 VE after completing the primary course; and
3 How much VE wanes by time after the primary course.
For this appendix, we want to demonstrate how this sort of analysis could be
undertaken in a future situation. We have used vaccine coverage data for South
Auckland in 2021 provided to our Inquiry by the Ministry of Health and Health
New Zealand I Te Whatu Ora. We have also drawn on vaccine effectiveness data
after the primary course was taken from analyses of United Kingdom data
published in early October 2021. For details on the level and timeline of vaccine-
induced protection see Figure 3 in the supplementary material section, which
provides further details on the methods for this appendix.
3.1 Modelling example

Figure 1 shows the estimated average VE for South Auckland, by ethnic group,
age and severity. Figure 2 pulls out findings for what we think are two more
important considerations, namely protection against hospitalisation among people
aged 65 and over, and protection against any infection among 15- to 64-year-olds
(that helps dampen transmission). Vaccine coverage is shown superimposed to
help see the difference between coverage and average VE as time progresses.
Key findings from these two figures include:
• Peak VE occurs earliest in non-Māori, non-Pacific people
(predominantly European New Zealanders or Pākehā) and latest
in Māori – a function of the sequencing of the of vaccine rollout
and the different age-distribution of these populations.i
• The average VE peaks first for protection against any infection (because
it wanes the fastest, it peaks the earliest), then for protection against
symptomatic disease, and finally for protection against hospitalisation.
• Given that the majority of hospitalisations and deaths occur among
people aged 65 and over, the average VE against hospitalisation in the
65+ age group is important (see Figure 2a). This analysis suggests that
– among those 65 years and older – peak immunityii was reached in
the week of:
- 10 October 2021 for non-Māori, non-Pacific people; and
- 31 October 2021 for Māori and Pacific peoples.
• Regarding the ability for the virus to spread in the community, the
VE against any infection among 15–64-year-olds is most important
(see Figure 2b). This analysis suggests that peak immunity was
reached in the week of:
- 31 October for non-Māori, non-Pacific people;
- 21 November for Pacific peoples; and
- 12 December for Māori.
i The vaccine rollout was sequenced by age so that – in the general population – people aged 65 and over became
eligible for vaccination before those in younger age groups. Because Māori and Pacific populations have younger
age-structure (that is, a greater proportion of their population is in younger age groups), a majority of Māori and
Pacific people became eligible for vaccination later than most non-Māori and non-Pacific people.
ii We define ‘peak immunity’ as when the average VE is within 5 percent points of the peak average VE attained.
Figure 1: Average VE by age, ethnic group and severity, in Counties
Manukau or South Auckland. In parentheses in the legend of each
sub-figure is the week when the average VE exceeds 95 percent of
the future ‘peak’ VE
Figure 2: Average VE and vaccine coverage by ethnic group for protection
against COVID-19 hospitalisations, in Counties Manukau or South
Auckland. Fig 2a is for people aged 65 and over; Fig 2b is for people
aged 15-64 years
a) 6
5+ VE against hospitalisation b) 1
5 to 64 VE against any
and vaccine coverage transmission and vaccine coverage
By way of a sensitivity analysis, Table 1 shows the week at which each
population group would reach 95 percent of peak VE against infection for different
levels of VE (at two weeks post vaccination) and different rapidity of waning.iii
The date when peak immunity is achieved is not particularly sensitive to these
alternative values (as it is more driven by the vaccine rollout itself).
Table 1: Sensitivity analysis about the week that Vaccine Waning

against any infection among 15- to 64-year-olds reached 95 percent of
its peak, for low, medium and high scenarios of: VE at two weeks post
second-dose, and rapidity of waning
VE at 2 weeks Waning Māori 15–64 Pacific 15–64 nMnP 15–64
Low VE = 60% Low waning 12-Dec-21 28-Nov-21 31-Oct-21
Med Waning 05-Dec-21 21-Nov-21 24-Oct-21
High waning 05-Dec-21 07-Nov-21 24-Oct-21
Med VE = 70% Low waning 19-Dec-21 05-Dec-21 07-Nov-21
High VE = 80% Low waning 26-Dec-21 05-Dec-21 07-Nov-21
iii Low and high waning of any infection VE was 50 percent or 150 percent of that derived from Andrews et al
(on logit scale).
D.4 In summary
For a vaccine with waning immunity, average VE across

the populationiv will peak before vaccine coverage peaks –
assuming the uptake of vaccination slows down toward
the end of the rollout (as would normally be expected)
Exactly when peak immunity occurs will vary by the level of protection being
considered (from protection against any infection through to protection against
death) if either the initial VE, or the amount of waning, varies by severity.
For a future pandemic, therefore, evidence on when peak immunity is reached
will be a key consideration in when to end or ease PHSMs.
There is no ‘magic’ answer as to when to lift PHSMs, but the example provided
here may provide additional evidence to assist decision-making alongside a range
of other criteria. For example, if a decision-maker in the future was aiming to lift
restrictions in accordance with ‘peak immunity’, anticipating it might take several
weeks for any uptick in infection to occur, it would make sense to aim to make
significant relaxations of PHSMs a few weeks before 95 percent of peak immunity
was achieved. This would mean peak immunity could occur at the same time as
any resurgence in infection is happening. For the example of South Auckland in
2021 used in this appendix, peak immunity would have occurred in late September
(for non-Māori, non-Pacific people) to early October (for Māori and Pacific peoples),
from the perspective of protection against serious illness or hospitalisation, and
early October (for non-Māori, non-Pacific people) to mid-November (for Māori)
for younger adult protection against any Delta infection.
This appendix takes data on vaccine coverage one step further, combining this
with evidence on the timing of vaccine waning to consider what this means for
population immunity. As stated at the outset of this appendix, the actual impact
of easing PHSMs on population infection and disease rates depends upon the
interplay of population immunity against disease transmission and the protection
against serious illness in vulnerable people (which in COVID-19 was the elderly,
immunocompromised and those with co-morbidities).
Therefore, we strongly encourage full epidemiological modelling to be undertaken
(with waning included) in such a circumstance in any future pandemic. The ‘average
population immunity’ can be generated in real-time and forecast, both in advance
of fuller simulation modelling outputs and to assist understanding such simulation
modelling once it has been conducted.
iv Also known as ‘population immunity’ if the population has not yet had any consequential exposure to
natural infection.
D.5 Implications for the next pandemic
As stated at the outset of this appendix, decision-making

on when to loosen PHSMs is extremely challenging and
requires the balancing of many criteria. This appendix outlines
one additional – albeit important – criterion that should
be considered in the next pandemic, if the vaccines have
notable waning
Our analyses and modelling for this paper has used New Zealand vaccine
coverage data to illustrate the methodology and the value of undertaking such
analysis during an evolving pandemic. In the next pandemic, real-time analysis
would need to include an additional step of forecasting the likely administration of
vaccines over eight or so weeks to be able to forecast forward population immunity
and assist decision-making. This additional forecasting need not be difficult. For
example, for COVID-19 in New Zealand, the time gap between first and second
dose was four weeks up to 12 August 2021, then six weeks. Thus, it would be
straightforward to use first dose receipt to forecast second dose receipt in four
to six weeks with high accuracy, and then to forecast further weeks based on
trends in first dose administration and second dose conversion.
D.6 Supplementary information
To ensure a robust analysis is undertaken, it is important

that there is sufficient data available to use
For the example undertaken here, the VE estimates we used (from Andrews et
al, 20211) are listed in Table 2. For this example we ‘smoothed’ the Andrews et al
VE estimates using a log odds VE method developed by Blakely and colleagues in
2021 and published as a peer reviewed publication in 2022 (Szanyi et al (2022)).2
Figure 3 presents the vaccine waning on both the untransformed and logit scale for
Comirnaty and Delta, using the data reported by Andrews et al (2021)3 fitted to our
logit regression model.v The regression analysis predicting VE for Comirnaty against
Delta, back on the non-transformed scale that is easier to interpret, are shown in
Figure 4. Also shown is the estimated VE against any infection (which is what matters
more for transmission in the population than protection against symptomatic
illness), assuming the average VE for both the 20–64 age group and the 65 and over
age group is 70 percent at two weeks following the second dose, and otherwise
the same age difference and waning (on logit scale) as per the above regression
equation. The value of this data is that it shows the decreasing impact of the vaccine
on protection against becoming ill and against hospitalisation with increased time
post vaccination. Similar data would need to be used to undertake this analysis in
a future pandemic.
Estimating the average VE by sex, age and severity (namely, any infection,
symptomatic illness, hospitalisation or death) was a matter of working out the
average VE for every person by week, allowing for time since they were vaccinated.
v Here we have used the logit of VE, generating coefficients (or differences on the logit scale) of -0.48441 for 65+ year
olds compared to 40 to 64 year olds (standard error 0.06256), 2.23616 for protection against hospitalisation compared
to protection against symptomatic illness (s.e. 0.11681), -0.06041 for week (s.e. 0.00418; that is, with each extra week
since vaccination, the VE is exp(-0.06041) = 0.941 that of a week ago on the odds ratio scale), and an intercept of
2.04799 (s.e. 0.04944).
Table 2: Estimates of Comirnaty vaccine effectiveness against Delta
symptomatic illness and hospitalisation from Andrews et al (2021
preprint), on both the non-transformed and logit scales
Weeks post second dose

(assumed mid-point for modelling)
2 to 9 (5.5) 10–14 (12) 15–19 (17) 20+ (22)
VE (95% confidence interval)
84.9 78.2 74.2 75.7

15-64 years
Symptomatic (84.3 to 85.4) (77.5 to 78.9) (73.1 to 75.3) (71.1 to 79.5)
illness 80.1 69.1 62.1 55.3
65+ years
(77.5 to 82.4) (66.2 to 71.8) (58.6 to 65.4) (50.2 to 60)
98.5 97.5 96.2 95.7

15-64 years
(97.7 to 99) (96.7 to 98.2) (94.1 to 97.5) (69.5 to 99.4)
Hospitalisation
97.9 95.7 93 90.7
65+ years
(95.9 to 99) (94.3 to 96.8) (90.9 to 94.6) (86 to 93.8)
Logit VE = ln[VE/(100-VE)] (standard error †)
1.727 1.277 1.056 1.136

15-64 years
Symptomatic (0.022) (0.021) (0.029) (0.116)
illness 1.393 0.805 0.494 0.213
65+ years
(0.078) (0.067) (0.074) (0.101)
4.185 3.664 3.231 3.103

15-64 years
(0.216) (0.159) (0.228) (1.093)
Hospitalisation
3.842 3.103 2.587 2.278
65+ years
(0.368) (0.154) (0.143) (0.230)
† Calculated as the difference in logit of upper and lower 95 percent confidence limits, divided by 3.92.
The inverse of square of this, being the inverse variance, was use as to weight the regression model.
Source: Based on data from Andrews N, Tessier E, Stowe J, Gower C, Kirsebom F, Simmons R, Gallagher E,
Chand M, Brown K, Ladhani SN, Ramsay M, Lopez Bernal J, 2021, Vaccine effectiveness and duration of protection
of Comirnaty, Vaxzevria and Spikevax against mild and severe COVID-19 in the UK,
https://www.medrxiv.org/content/10.1101/2021.09.15.21263583v2
Figure 3: The logit of Andrews et al VE, and the predicted logit
based on regression
of Comirnaty, Vaxzevria and Spikevax against mild and severe COVID-19 in the UK, https://www.medrxiv.org/
content/10.1101/2021.09.15.21263583v2
Figure 4: Our VE estimates for Comirnaty against Delta by time since
second dose, on non-transformed scale, out to 9 months post dose
(or 39 weeks)
of Comirnaty, Vaxzevria and Spikevax against mild and severe COVID-19 in the UK, https://www.medrxiv.org/
content/10.1101/2021.09.15.21263583v2
D.7 Endnotes
1. Nick Andrews, Elise Tessier, Julia Stowe, Charlotte

Gower, Freja Kirsebom, Ruth Simmons, Eileen
Gallagher, Meera Chand, Kevin Brown, Shamez N.
Ladhani, Mary Ramsay, and Jamie Lopez Bernal,
‘Vaccine effectiveness and duration of protection
early/2021/10/06/2021.09.15.21263583.abstract
2. Joshua Szanyi, Tim Wilson, Nick Scott, and Tony
Blakely, ‘A log-odds system for waning and boosting
of COVID-19 vaccine effectiveness’, Vaccine 40 (20
May 2022), 3821–3824, https://doi.org/10.1016/j.
vaccine.2022.05.039, https://www.sciencedirect.com/
science/article/pii/S0264410X2200634X
3. Nick Andrews, Elise Tessier, Julia Stowe, Charlotte
Gower, Freja Kirsebom, Ruth Simmons, Eileen
Gallagher, Meera Chand, Kevin Brown, Shamez N.
Ladhani, Mary Ramsay, and Jamie Lopez Bernal,
‘Vaccine effectiveness and duration of protection
early/2021/10/06/2021.09.15.21263583.abstract
Glossary |
Rārangi kupu
Term Definition
ACC |Te Kaporeihana Accident Compensation Corporation – the New Zealand public
Āwhina Hunga Whara service agency that administers the no-fault accidental injury
compensation scheme.
aiga A Samoan language term for family unit, household. In

Samoan culture, aiga consists of a wide family group of blood
and marriage or even adopted connections who all
acknowledge the matai (head of the family).
Alert Level System The sliding scale of public health and social measures used in
Aotearoa New Zealand’s COVID-19 response from March 2020
to November 2021. The sliding scale used 4 levels, called alert
levels.
all-of-government A term used to describe issues, rules or processes that apply

to, or involve, all the agencies and organisations that make up
Aotearoa New Zealand’s public service. It denotes unified and
joined-up processes involving many government agencies.
Auditor-General | Tumuaki An independent officer of the New Zealand Parliament

o te Mana Arotake responsible for auditing public sector spending and
performance.
Aviation Security Service The operational arm of the New Zealand Civil Aviation
Authority responsible for aviation security at security-
designated airports.
booster An extra dose of a vaccine administered some time

after the initial course to renew or increase immunity.
Border Executive Board An interdepartmental executive board established to deliver

an integrated and effective New Zealand border system.
Members of the Board were made jointly accountable to
the Minister for COVID-19 Response for delivering strategic
improvements to the border system.
bubble A concept used to describe small groups of people who were

(‘extended bubble’, permitted to interact with one another during the COVID-19
‘household bubble’) lockdowns.
Cancer Control Agency | Te The New Zealand public service agency responsible for
Aho o te Kahu providing leadership and oversight of cancer control and
uniting efforts to deliver better cancer outcomes for Aotearoa
New Zealand.
Care in the The name given to the programme set up to support people
Community (CiC) with COVID-19 who were directed to isolate at home.
Term Definition
Caring for A governance mechanism, established in July 2020, to ensure

Communities (C4C) coordination of the COVID-19 welfare response across social
sector government agencies.
Chief Human Rights The Chair of the Human Rights Commission, alongside up
Commissioner to four other Commissioners.
Chief Science Advisor An individual appointed to independently provide scientific

advice to the Government, and to comment on and contribute
to scientific issues and debates of public importance. Chief
Science Advisors are appointed to specific agencies and to the
Prime Minister.
Civil Defence A statutory joint standing committee that is made up

Emergency of mayors or chairs of member local authorities, or a
Management Group committee set up by a unitary authority that has governance
responsibilities for emergency management.
civil defence emergency Refers to the system, led by National Emergency Management
management system Agency and including regional Civil Defence Emergency
Management Groups, that manages the response to national
and local emergencies.
Classification Office | The independent Crown entity that provides ratings for films,
Te Mana Whakaatu videos and publications to protect people from harmful
content.
Commissioner of Police The Chief Executive of the New Zealand Police, who is
accountable to the Minister of Police for the administration
of police services but acts independently in carrying out law
enforcement decisions.
community isolation The term used to refer to the policy of requiring people with
(see also home isolation) COVID-19, and their close contacts, to isolate/quarantine in
their place of residence.
Community Panel A group of community leaders / representatives from across

the country and different communities, established by the
COVID-19 All-of-Government Response Group in 2021, to
ensure advice to government had input from communities.
community When a disease is spreading in the community and is not

transmission linked to a known international or border source (such as
a recent traveller from overseas).
co-morbidities Other diseases or health conditions a person has (besides

any COVID-19 infection).
Term Definition
contact tracing Where a person has been diagnosed with an infectious

disease, identifying that person’s contacts (downstream) and
index or source person (upstream) in order to contain the
spread of infection.
Coordinated Incident A framework to coordinate the management of incidents

Management System across agencies involved. It includes principles, structures,
(CIMS) functions, processes and terminology that agencies can apply
in both emergency and non-emergency incidents.
coronavirus A group of viruses that cause respiratory infections in

humans, other mammals and birds. Coronaviruses can cause
mild disease, such as a cold, or more serious disease such
as SARS, MERS and COVID-19.
COVID-19 The disease caused by the coronavirus SARS-CoV-2. COVID-19

(see also coronavirus) is also widely used to refer to the virus (e.g. ‘COVID-19
transmission’) and to the pandemic caused by the virus
(e.g. ‘our COVID-19 experience’).
COVID-19 All-of- A group established on 1 July 2020 to oversee and coordinate

Government Response New Zealand’s response to COVID-19. The Group took over
Group (also known from the ‘Quin’ and the National Crisis Management Centre
as COVID-19 Group) (which had led the response from mid-March 2020). The
Group operated under the Department of the Prime Minister
and Cabinet and was staffed mainly from other agencies
across the public service.
COVID-19 The Government’s approach to delivering COVID-19 vaccine

immunisation strategy to all eligible New Zealanders – including infrastructure,
logistics, training and administration. Unlike the COVID-19
Vaccine Strategy, the immunisation strategy comprised a
series of decisions and was not clearly set out in a single
document.
COVID-19 Protection The sliding scale of public health and social measures used in
Framework (the Aotearoa New Zealand’s COVID-19 response from December
‘traffic light’ system) 2021 to September 2022. The sliding scale used 3 levels, called
‘traffic lights’ – green, orange and red.
COVID-19 Response A funding envelope established in Budget 2020 as a temporary

and Recovery Fund fiscal management tool to support Aotearoa New Zealand’s
response to and recovery from COVID-19.
COVID-19 The Government’s approach to identifying and procuring

Vaccine Strategy a suitable COVID-19 vaccine or vaccines.
Term Definition
COVID-19 Wage Financial assistance provided by the Government to employers

Subsidy Scheme to enable them to continue to pay their staff when they were
unable to perform their normal duties due to public health
measures, such as lockdowns.
Crown Law (Office) | The New Zealand public service department that provides
Te Tari Ture o te Karauna legal advice and representation services to the government
in matters affecting the executive government, particularly in
the areas of criminal, public and administrative law.
Delta A variant of the COVID-19 virus (SARS-CoV-2) that became

the dominant form globally in the second half of 2021. Delta
was more transmissible (easier to catch) and more virulent
(causing more severe disease) than earlier variants.
Department of Corrections The New Zealand public service department responsible

| Ara Poutama Aotearoa for managing prisons and offenders in the community.
Department of The New Zealand public service department responsible

Internal Affairs | for issuing passports, administering applications for
Te Tari Taiwhenua citizenships and lottery grants, enforcing censorship,
anti-money laundering, gambling and digital security laws,
registering births, deaths, marriages and civil unions,
and supplying support services to ministers. It includes
New Zealand Archives and the National Library.
Department of the Prime A central public service department of New Zealand,

Minister and Cabinet responsible for providing support and advice to the
(DPMC) | Governor-General, the Prime Minister and Ministers
Te Tari o te Pirimia with responsibilities relating to national security, risk and
me te Komiti Matua resilience, and the regeneration of greater Christchurch.
diagnostic testing A test used to confirm or rule out the presence of a particular
disease (e.g. COVID-19), usually in a person with symptoms.
Director-General The Chief Executive of the Ministry of Health. While this

of Health role is not necessarily occupied by a medical doctor or public
health specialist, the Director-General of Health during
Aotearoa New Zealand’s COVID-19 response had both
these qualifications and took on a prominent role in public
communication – similar to that of chief medical officers (in
the United Kingdom) or chief health officers (in Australia).
Director of Civil A statutory role under the Civil Defence Emergency

Defence Emergency Management Act 2002. The Director has responsibility for
Management providing advice and monitoring the performance of the
civil defence emergency management system at a national
level and with powers in a national state of emergency
or national transition period.
Term Definition
Director of A senior government advisor with a statutory advisory

Public Health role to the Director-General of Health on matters relating
to public health. The Director of Public Health may also,
following consultation with the Director-General,
independently give advice or report on any matter of public
health to the Minister. This role is normally occupied by a
public health medicine specialist.
district health boards The 20 regional bodies that were responsible for provision of
(DHBs) publicly-funded health and disability services throughout
Aotearoa New Zealand, including funding and provision of
hospital-based services and funding and coordination of
primary and community-based healthcare. On 1 July 2022, the
district health board system was replaced by a single national
agency responsible for funding and coordinating publicly-
funded healthcare – i.e Health New Zealand | Te Whatu Ora.
elimination strategy A pandemic response strategy with the goal of eliminating

infection from within the population whenever it occurs and
preventing new cases of infection from entering.
epidemic An increase in the incidence of a disease that is higher than

expected in the population in question.
epidemiology The study of the occurrence, distribution and causes of health

and disease conditions in populations.
ERO | Te Tari Education Review Office – the public service agency that
Arotake Mātauranga evaluates the quality of, and facilitates improvement in,
education and the care of learners in schools, kura, kōhanga
reo and early childhood services.
ESR Institute of Environmental Science and Research – a Crown

Research Institute specialising in science that safeguards
the health and wellbeing of New Zealand’s people and
natural environment.
essential services A term used to refer to businesses that were classified as

essential to the provision of necessities, and those businesses
that supported them, during the COVID-19 pandemic.
ethnic minority People of the Middle Eastern, Latin American, African and
communities Asian communities experiencing greater cultural and language
barriers in Aotearoa New Zealand.
excess mortality The difference between the number of deaths observed in a

population during a given period and the number that would
normally be expected based on recent years’ experience.
Term Definition
exclusion strategy Where a jurisdiction (usually an island nation) responds to

a pandemic by applying very tight restrictions to its borders
with the aim of preventing the infectious agent from reaching
the population via inward travel. This can be thought of as a
form of elimination strategy where border restrictions are
applied very early, before any infection has entered the
relevant jurisdiction.
financial policy The actions taken by the Reserve Bank of New Zealand, under
the Financial Policy Remit issued by the Minister of Finance, to
protect and promote the stability of the financial system, in a
way that also ensures the efficiency and inclusiveness of the
system.
Financial Markets The New Zealand public service agency with responsibility
Authority | Te Mana Tātai for regulating New Zealand’s financial markets.
Hokohoko
Fire and Emergency The national firefighting and emergency services agency
New Zealand of Aotearoa New Zealand.
fiscal policy One tool a government has to achieve its economic and
social objectives. The operation of fiscal policy is governed
by the Public Finance Act 1989. It refers to how a government
manages its revenue, expenses, assets and liabilities to
manage these objectives.
GDP Gross domestic product – the total monetary or value of

all the goods and services produced in a country in a specific
time period (e.g. a year), regardless of who made them.
A broad measure of the size of a country’s economy.
Governor-General The representative of the monarch of Aotearoa New Zealand

responsible for carrying out the monarch’s constitutional
and ceremonial duties.
Hazard Risk Board The board of central government agency leaders established
to oversee and govern management of New Zealand’s national
risks and provide advice to the Government.
Health and Disability The New Zealand public service agency responsible for
Commissioner | Te Toihau promoting and protecting the rights of those using health
Hauora, Hauātanga and disability services in Aotearoa New Zealand.
Health New Zealand | The New Zealand public service agency that is the primary
Te Whatu Ora provider of New Zealand’s healthcare system from 1 July 2022.
health order An Order in Council created under health-related legislation.
Term Definition
health protection A role in New Zealand’s public health service with a focus on
officer communicable disease control and health protection. Health
protection officers have statutory powers under the Health Act
1956 to require members of the public to comply with contact
tracing, quarantine, isolation or other activities to support
the control of infectious diseases (such as COVID-19).
Health Quality and Independent Crown entity that monitors the quality, safety
Safety Commission | and accessibility of New Zealand’s healthcare services and
Te Tāhū Hauora works with healthcare providers and consumers to improve
service quality and safety.
home isolation A term used to refer to people who had either been
diagnosed with COVID-19, or were close contacts, isolating
(or quarantining) themselves from others in their place
of residence.
Human Rights Commission The Human Rights Commission works with the Government
| Te Kāhui Tika Tangata and civil society to advocate and promote respect for human
rights, and to promote harmonious relations in Aotearoa
New Zealand. The Commission is made up of the Chief Human
Rights Commissioner, and at least three (but no more than
four) other Commissioners.
Immigration The operational processing arm of New Zealand’s immigration

New Zealand system. The immigration system regulates the entry and stay
of foreign nationals in Aotearoa New Zealand.
Incident A team established in an emergency to coordinate

Management Team and communicate between the respective emergency
management functions and organisations involved in
managing an incident.
Independent Panel for A panel of international experts established by the World

Pandemic Preparedness Health Organization to develop recommendations on
and Response how to improve capacity for global pandemic prevention,
preparedness and response. It was co-chaired by the Right
Honourable Helen Clark.
Indo-Pacific Initiated in May 2022, the Indo-Pacific Economic Framework

Economic Framework for for Prosperity (IPEF) is an economic and trade framework
Prosperity involving 14 countries (including Aotearoa New Zealand).
Inland Revenue | The New Zealand public service agency responsible for
Te Tari Taake collecting most of the government revenue (most of which
comes from tax), and collecting and disbursing payment
for social support programmes.
Term Definition
intensive care A hospital unit or ward where critically ill patients receive
unit (ICU) specialised care, usually including mechancial ventilation
(machine-supported breathing) and one-on-one nursing care.
isolation Separating people who have a contagious disease from

(see also self-isolation and people who are not infected, to prevent transmission.
quarantine)
Justice Sector Leadership A cross-agency board of justice sector leaders to increase

Board collaboration on system-wide issues, govern significant
cross-agency work programmes and lead agencies with united
purpose. The Board consists of leaders from the Ministry
of Justice, New Zealand Police, Department of Corrections,
Oranga Tamariki, the Serious Fraud Office and the Crown
Law Office.
Kāinga Ora Kāinga Ora – Homes and Communities; the New Zealand
public service agency that provides rental housing for
New Zealanders in need.
lead agency The public service agency with the primary mandate for
managing the response to an emergency.
LGBTQIA+ (see also An acronym which stands for Lesbian, Gay, Bisexual,
Rainbow community) Transgender, Queer, Intersex, Asexual or Ace. The + recognises
there are further identities not listed.
lifeline utilities Entities defined under the Civil Defence Emergency

Management Act 2002 that provide essential infrastructure
services to the community, such as water, wastewater,
transport, energy and telecommunications.
lockdown A mandatory stay-at-home order, a legal prohibition

placing blanket restrictions on the whole population (apart
from specified activities) for the purpose of limiting the
spread of a disease. In Aotearoa New Zealand’s COVID-19
response, the term ‘lockdown’ was used for situations where
the population was under Alert Level 3 or 4 restrictions (see
Alert Level System).
Managed isolation The government-run system of quarantine and isolation

and quarantine (MIQ) facilities used to accommodate incoming travellers undergoing
a period of mandatory isolation or quarantine before being
able to enter Aotearoa New Zealand, and community cases
who could not safely isolate at home.
Māori Council (In full: New Zealand Māori Council.) A statutory representative
body that advocates Māori policy and supports community
initiatives that contribute to Māori self-determination.
Term Definition
Māori Health Authority| An independent Crown entity that was to be the lead
Te Aka Whai Ora commissioner of Māori health services and lead on health
policy, strategy and service coordination to ensure the
New Zealand health system met the needs of Māori. Te Aka
Whai Ora was established in July 2022 and disestablished
in the first half of 2024.
Maritime New Zealand | The New Zealand public service agency that regulates the
Nō te rere moana Aotearoa safety, security and environmental protection of New
Zealand’s coastal and inland waterways.
mandatory measures A range of government-imposed restrictions on people’s

actions and activities intended to achieve specified goals
in the management of the impact of COVID-19.
Medical Officer A statutory role in New Zealand’s public health service

of Health that is accountable to, and subject to direction from the
Director-General of Health in providing oversight of public
health regulatory functions. Medical Officers of Health are
public health physicians (doctors) who specialise in improving,
protecting and promoting the health of the population.
Medsafe (In full: the New Zealand Medicines and Medical Devices
Safety Authority.) The agency responsible for regulation of
medicines and other therapeutic products in Aotearoa
New Zealand.
Mental Health and An independent Crown entity that monitors the performance
Wellbeing Commission | of health and addiction services and advocates for people
Te Hiringa Mahara who experience mental distress, substance harm, gambling
harm or addiction.
Middle East respiratory A viral respiratory infection caused by a type of coronavirus

syndrome / MERS (MERS-CoV). Outbreaks of MERS have occurred in several
countries – mainly in the Middle East – since 2012, but to date
the World Health Organization has not designated MERS a
Public Health Emergency of International Concern (a
designation that often precedes the declaration of a global
pandemic).
minimisation and The official name of the pandemic strategy adopted in

protection strategy Aotearoa New Zealand following the elimination strategy.
The ‘minimisation and protection’ strategy was effectively a
suppression strategy, at least in the first few months, with
some experts describing it as a mitigation strategy thereafter.
It lasted from December 2021 to September 2022.
Ministry of Disabled People The New Zealand public service agency responsible for
| Whaikaha policy advice in relation to disabled people and for providing
disability support services.
Term Definition
Ministry for Ethnic The New Zealand public service agency responsible for policy
Communities | advice on ethnic diversity and inclusion and administering
Te Tari Mātāwaka funds to support community development and social
cohesion.
Ministry of Housing and The New Zealand public service agency responsible for policy
Urban Development | advice on, and overseeing, housing and urban development.
Te Tūāpapa Kura Kāinga
Ministry for Pacific Peoples The New Zealand public service agency responsible for
| Te Manatū mō Ngā Iwi ō policy advice on wellbeing and development of Pacific peoples
te Moana-nui-ā-Kiwa in Aotearoa New Zealand.
Ministry for Primary The New Zealand public service agency that provides
Industries (MPI) | Manatū policy advice and some regulatory functions across
Ahu Matua agriculture, biosecurity, food safety, fisheries and forestry.
Ministry of Business, The New Zealand public service agency responsible for
Innovation and providing policy advice, services, and regulatory functions
Employment (MBIE) | across a range of business and enterprise-related sectors
Hīkina Whakatutuki to build a strong economy.
Ministry of Civil Defence See National Emergency Management Agency, which replaced
Emergency Management the Ministry of Civil Defence Emergency Management in 2019.
Ministry of The New Zealand public service agency responsible for

Defence | Manatū strategic defence policy advice, acquiring military equipment
Kaupapa Waonga and building international defence relationships.
Ministry of Education | The New Zealand public service agency responsible for
Te Tāhuhu o te education policy. It supports, funds, licenses and regulates
Mātauranga schools, kura and early childhood education.
Ministry of Foreign Affairs The New Zealand public service agency responsible for
and Trade | Manatū Aorere foreign and trade policy and promoting New Zealand interests
in trade and international relations.
Ministry of Health | The New Zealand public service agency responsible for
Manatū Hauora the health and disability system. Its functions include health
policy, legislation, regulation and monitoring. Prior to July 2022
the Ministry of Health was also responsible for planning and
allocating funding for national healthcare services through
the 20 district health boards and public health services
through the 12 regional public health units.
Ministry of Justice | The New Zealand public service agency responsible for
Te Tāhū o te Ture the judiciary and for administering the court and legal aid
systems, and the Public Defence Service.
Term Definition
Ministry of Social The New Zealand public service agency responsible for
Development | social policy advice and providing social services.
Te Manatū
Whakahiato Ora
Ministry of Transport | The New Zealand public service agency responsible for
Te Manatū Waka transport policy advice.
Ministry of Youth The New Zealand public service agency that encourages
Development | and supports the use of a positive youth development
Te Manatū approach to help support young people, aged between
Whakahiato Taiohi 12 and 24 years, to increase their overall wellbeing.
mitigation strategy A pandemic response strategy with the goal of protecting

vulnerable groups from infection while minimising disruption
to normal social and economic activities. A mitigation
strategy tolerates higher levels of infection and illness than
a suppression strategy.
monetary policy The actions the Reserve Bank of New Zealand takes,
primarily by adjusting the Official Cash Rate, to achieve and
maintain low inflation (and, at the time of the COVID-19
pandemic), to support maximum sustainable employment.
Monetary Policy A committee of the Reserve Bank of New Zealand that is

Committee responsible for setting and implementing monetary policy
in Aotearoa New Zealand to maintain low inflation. It does
so primarily by setting the official interest rate – the Official
Cash Rate.
mRNA vaccine A type of vaccine that uses mRNA to evoke an immune

response in the person to whom it is administered (see
vaccine). While most vaccines contain proteins that imitate
the relevant pathogen or infectious agent, these vaccines
contain mRNA (or messenger RNA) which the body then
uses to build proteins that evoke an immune response.
myocarditis Inflammation of the heart muscle. Myocarditis can be

caused by infection (e.g. a virus) but can also occur as a
reaction to a medicine (e.g. a vaccine). It can affect the heart’s
ability to pump blood around the body which – if severe – can
cause serious illness or death.
My Vaccine Pass The vaccination certificate issued by the New Zealand

Government that enabled easy verification of whether a
person had been vaccinated against COVID-19 (or had a
medical exemption). Often used to verify eligibility to work
in a particular role, to enter specified locations, or to attend
specified gatherings.
Term Definition
National Crisis A secure all-of-government facility maintained in a state

Management Centre of readiness for central government to manage the national
response to emergencies. It is housed under the Beehive
in Wellington.
National Emergency The New Zealand public service department that leads and
Management Agency coordinates the emergency management system.
(NEMA) | Te Rākau
Whakamarumaru
National A Māori-led charity and primary health organisation

Hauora Coalition that delivers health and social programmes that improve
outcomes for families.
National Health A crisis management centre that coordinates the national

Coordination Centre health and disability sector response to health-related
emergencies.
National Health Identifier A unique identifier assigned to each person who receives
(NHI) healthcare in Aotearoa New Zealand.
National Hospital A framework aimed at supporting DHBs to safely deliver

Response Framework healthcare and maximise patient access to non-COVID-19
services (such as in-patient care, surgeries and specialist
appointments), while also protecting healthcare capacity
to deal with COVID-19-related demand as it arose.
National Risk Register A system for identifying nationally significant hazards and
risks, such as earthquakes, cyber attacks and pandemics.
NCEA National Certificate of Education Achievement – the main

qualification for secondary school students in Aotearoa
New Zealand.
New Zealand Customs The New Zealand public service agency responsible for
Service | Te Mana national border control.
Ārai o Aotearoa
New Zealand Defence The three branches of New Zealand’s military – army, navy
Force (NZDF) | Te Ope and air force.
Kātua o Aotearoa
New Zealand Police / The national police service and principal law enforcement
Police | Ngā Pirihimana o agency of New Zealand.
Aotearoa
New Zealand Security New Zealand’s domestic security agency and lead
Intelligence Service | organisation for human intelligence.
Te Pā Whakamarumaru
Term Definition
New Zealand Trade The New Zealand government agency responsible for
and Enterprise | international business development. Its role is to
Te Taurapa Tūhono support exporters to grow a productive, sustainable
and inclusive economy.
NGOs Non-governmental organisations. In this report, NGOs are

mainly referred to in their role as deliverers of health and
social services and community-based support. This includes
voluntary and not-for-profit organisations through to social
enterprises and can include for-profit commercial enterprises
operating in the social services space.
notifiable disease A disease or injury for which health professionals are required
to report confirmed or suspected cases to the local Medical
Officer of Health or the public health service.
Nursing Council | Te Nursing Council of New Zealand – the regulatory authority

Kaunihera Tapuhi o responsible for the registration of nurses.
Aotearoa
Office of the Inspectorate / An operationally independent office within the Department

the Inspectorate | of Corrections that inspects prisons, undertakes thematic
Te Tari Tirohia reviews, investigates complaints from prisoners and offenders
and investigates deaths of people in Corrections’ custody.
Office of the Privacy The independent Crown entity that protects and
Commissioner | promotes privacy in Aotearoa New Zealand.
Te Mana Mātāpono
Matatapu
Official Cash Rate The interest rate the Reserve Bank of New Zealand charges
banks when they borrow money from the Reserve Bank. It is
the main policy lever used to keep inflation low and stable. It
affects the interest rates that registered banks charge on loans
and deposits. This in turn affects the costs and earnings of
banks, which influences the interest rates they charge
customers.
Officials Committee A committee of senior officials (normally chief executives)

for Domestic and External from the New Zealand public service to coordinate an all-
Security Coordination of-government response to an emergency or crisis. The
(ODESC) Committee provides support to ministers in developing
the high level strategic direction, policy, and priorities for a
response.
Ombudsman | A government-appointed role that investigates complaints

Tari o te Kaitiaki about government agencies.
Mana Tangata
Term Definition
Omicron A variant of the COVID-19 virus (SARS-CoV-2) that was first

detected in November 2021 and rapidly became the dominant
form globally, including in Aotearoa New Zealand in early
2022. Omicron was highly transmissible (very easy to catch)
compared with previous variants but was also less virulent
(causing milder infection) than Delta.
Oranga Tamariki Oranga Tamariki – Ministry for Children; the New Zealand
public service agency responsible for the wellbeing of children
and young people, specifically children at risk of harm, youth
offenders and children in the care of the state.
order / Order Refers to an Order in Council.
Order in Council A type of secondary legislation that is made by the Executive

Council (the part of the executive branch of government that
carries out formal acts of government, usually comprising all
Ministers) presided over by the Governor-General.
pandemic An infectious disease epidemic occurring across multiple

geographical regions, and affecting a large number of people.
A pandemic is usually caused by a new infectious agent (for
example, a new form of a virus for which people do not have
immunity) that transmits readily between people.
pathogen An infectious organism, such as a virus, bacteria or parasite,

that can produce a disease.
PCR test (In full: Polymerase Chain Reaction test.) A laboratory

technique that detects the presence of an organism by
copying tiny amounts of genetic material from a sample.
PCR tests for the COVID-19 virus were carried out on nasal
or throat swabs or saliva, and typically took around 8 hours
to process (not counting the time needed for the sample
to reach the laboratory or for the results to be checked
and reported).
peak body An advocacy group, sector or trade organisation with allied

interests, widely accepted as the legitimate ‘voice’ of the
community, sector, profession or industry it represents.
Peak bodies are key stakeholders in lobbying, and being
consulted by, government on policy or policy implementation.
persistent disadvantage Disadvantage that is ongoing, whether for two or more

years, over a life course or intergenerationally. It has three
domains: being left out (excluded or lacking identity, belonging
and connection), doing without (deprived or lacking the
means to achieve their aspirations), and being income poor
(income poverty or lacking prosperity).
Term Definition
Pharmac | Te Pātaka (In full: the Pharmaceutical Management Agency.) A

Whaioranga New Zealand Crown entity that makes decisions on which
medicines and pharmaceutical products receive public
funding for use in healthcare. Pharmac purchases and
maintains a stock of all funded vaccines (unlike other
medicines). Management of COVID-19 vaccines transferred
to Pharmac from Ministry of Health on 1 July 2023.
primary health Not-for-profit organisations that provide primary health

organisation (PHO) services (e.g. general practice) within a certain geographical
area. PHOs provide health services themselves or through
a network of member healthcare providers.
planned care Medical and surgical care for people who don’t need
to be treated right away.
PPE Personal protective equipment – that is, equipment worn

by a person to minimise risks to their health and safety. In
the context of an infectious disease, PPE may refer to face
masks or visors, protective clothing (e.g. plastic aprons or
suits) and/or medical gloves.
primary care The first point of contact between a person and the health
system for most health issues, from prevention to treatment.
In Aotearoa New Zealand, primary care is often provided by
teams of general practitioners (that is, medical doctors
specialising in providing community-based care), practice
nurses, paramedics and other health professionals.
public health The science and art of preventing disease, prolonging life
and promoting health through organised efforts of society.
public health and social A range of controls on people’s actions and activities,
measures (see also imposed by the Government with the intention of reducing
mandatory measures) the risk of transmission of an infectious disease.
public health emergency An official declaration that a disease or disorder poses

a serious threat to public health.
public health unit (PHU) Public health service teams that provide communicable
disease control, environmental health and health prevention
services to the population in each of the 12 regions
throughout Aotearoa New Zealand. Since 2022, PHUs are
organised into four Regional Public Health Servies within a
National Public Health Service.
Term Definition
Public Service Commission The New Zealand public service agency responsible for
| Te Kawa Mataaho overseeing, managing and improving the performance of
the public service.
Public Service Appointed by the Governor-General, the Public Service

Commissioner Commissioner provides leadership to the public service.
Public Service Leadership A team of Chief Executives from all government departments,
Team and, at the Public Service Commissioner’s discretion, the
Commissioner of Police, the Chief of the Defence Force, and
Chief Executives of Crown agents and departmental agencies.
The team provides strategic leadership to achieve cross-
agency effectiveness and a cohesive public service.
quarantine Separating people who may have been exposed to a

(see also isolation contagious disease from others until it is confirmed that they
and self-isolation) are not infected. Quarantine – either at a border or as part
of contact tracing – is an essential and long-standing tool
in public health to slow, or even stop, the spread of
communicable diseases.
(the) Quin A leadership group set up in response to COVID-19 that

was in place between March and June 2020. Members
were the All-of-Government Controller and four key response
leaders – Director-General of Health, Director of Civil Defence
Emergency Management, head of Strategic Operations
Command Centre and the All-of-Government Strategy and
Policy Lead. The group’s role was to oversee and provide
direction to cross-agency activities.
Rainbow community (see An umbrella term that covers all sexual and gender
also LGBTQIA+) minorities, and people with variations of sex characteristics
and avoids the acronym LGBTQIA+. This can be used
to identify communities as well as an individual.
rapid antigen testing / RAT A technique used to detect COVID-19 infections by analysis
tests of a nasal swab or saliva sample in a chemical solution.
Tests could be self-administered and results were available
in 10-20 minutes.
Recognised Seasonal A government initiative enabling horticulture and viticulture

Employer scheme industries to bring workers (Recognised Seasonal Employees)
into New Zealand from overseas.
Term Definition
Regional Each of New Zealand’s 16 local government regions has a

Leadership Group cross-agency and cross-organisation leadership group that
works to support regional social and economic outcomes.
Groups consist of regional leads from the Ministry for Social
Development and a range of public sector agencies, and
regional local government and iwi representative leaders.
Regional Public A statutory role appointed to a region, that strengthens

Service Commissioner regional system leadership by coordinating and aligning
central government decision-makers and regional
wellbeing outcomes.
Reserve Bank of Aotearoa New Zealand’s central bank, responsible for

New Zealand | maintaining
Te Pūtea Matua a sound and efficient monetary and financial system by
giving people, communities and businesses the confidence
to spend, borrow and save money.
Reserve Bank Governor A role with statutory responsibilities for all New Zealand
monetary policy decisions.
saliva test A technique used to detect COVID-19 infections by analysis

of a saliva sample.
SARS-CoV-2 The strain of coronavirus that causes COVID-19.
self-isolation Staying at home, isolated from other people, because of a

(see also isolation suspected or confirmed infection to prevent transmission.
and quarantine)
sequencing framework (see The prioritisation framework used to determine the order
also vaccine rollout) in which groups of people would become eligible for the
COVID-19 vaccine in Aotearoa New Zealand.
severe acute respiratory A viral respiratory disease caused by a type of coronavirus

syndrome (SARS) (SARS-CoV-1). In 2003, SARS caused a regional epidemic in East
Asia and had the potential to become a global pandemic, but
infection was contained by a rapid and coordinated response.
Serious Fraud Office | The New Zealand public service agency with responsibility
Te Tari Hara Tāware for preventing, detecting, investigating and prosecuting
financial crimes.
social distancing A public health measure to prevent the spread of an infectious

disease by maintaining a physical distance between people.
Term Definition
social cohesion Generally refers to the tendency for a group of people to be

in unity while working towards a goal; the degree to which
bonds link members of a social group together. Important
in the context of a pandemic for the overall success of the
response.
social licence The amount of acceptance or approval the general public

has in government or a private organisation’s activities. In
the specific context of a pandemic, refers particularly to the
degree of public acceptance of public health and other
measures deployed in the response.
social sector Government agencies and a diverse collection of

non-governmental organisations delivering and funding social
services and supports across the country with a goal of
improving wellbeing and equity of outcomes for New
Zealanders. This includes income and welfare support, health,
housing, justice, education and community services.
state of national A declaration by a Minister, under the Civil Defence Emergency

emergency Management Act 2002, where an emergency is of such a
magnitude that it is likely to be beyond the resources of the
Civil Defence Emergency Management Groups in the affected
areas. It provides for the civil defence system roles at national,
regional and local levels to be activated and emergency
powers to respond to a national emergency.
State Services Commission The precursor organisation to the Public Service Commission.
State Services A statutory officer responsible for appointing top officials,

Commissioner issuing a code of conduct and investigating poor performance
in the New Zealand public service.
Statistics NZ | Tatauranga The New Zealand public service agency responsible for the
Aotearoa collection of statistics related to the economy, population
and society of Aotearoa New Zealand.
Strategic COVID-19 Public A group of experts appointed by the Associate Minister of

Health Advisory Group Health (Public Health) in 2021 to provide independent advice
(SPHAG) on COVID-19 vaccination, public health protections and
border settings.
super-spreader (event) A large gathering of people resulting in transmission of

infection among attendees and subsequently multiple chains
of transmission into the wider community.
suppression strategy A pandemic response strategy with the goal of suppressing

rates of transmission within the population in order to
prevent the health system from becoming overwhelmed.
Term Definition
telehealth Delivery of healthcare services remotely using information

and communication technologies (e.g. telephone).
Te Puni Kōkiri The New Zealand public service agency responsible for
policy advice on Māori wellbeing and development.
Tertiary Education A New Zealand Crown agency that leads the Government’s
Commission | relationship with the education sector, invests Government
Te Amorangi Mātauranga funding in tertiary education organisations and provides
Matua career services from education to employment.
Te Tiriti o Waitangi / The treaty signed in 1840 by iwi, hapū and representatives
the Treaty of Waitangi of the British Crown. Often referred to as Aotearoa
New Zealand’s founding document.
The Treasury | The New Zealand public service agency responsible for
Te Tai Ōhanga providing economic and financial advice to the Government.
traffic light system See COVID-19 Protection Framework.
transmission The passing of an infectious disease from an infected

individual to another individual or group.
transmission chain The transmission of infection from one person to others

via a sequence of connections. A transmission chain can
consist of multiple links, all starting from the one original
source.
Unite Against The public information campaign which supported

COVID-19 Campaign the Government’s communication efforts by providing
New Zealanders with a trusted source of information about
COVID-19, the Government’s response and responsibilities
of individuals, businesses and organisations.
vaccination The administration of a vaccine as a means of protection

against a disease.
vaccination hub A location for administering vaccinations to a large number

of people.
vaccination rates Strictly speaking, vaccination rates refer to the number of

vaccine doses delivered in a specific time-frame (e.g. per
day). However this term is more often used to describe the
proportion of a particular population (by age, geography,
ethnicity or some other category) who have received the
relevant vaccine (i.e. vaccine coverage).
Term Definition
vaccine A type of medicine designed to evoke an immune response

in the person to whom it is administered. Vaccines train the
body’s immune system to recognise a pathogen and to defend
the body from it at the next encounter.
vaccine certificate See vaccine pass.
vaccine coverage The proportion of a particular population (by age,

geography, ethnicity or some other category) who have
received the relevant vaccine. Vaccine coverage may refer
to receipt of a single dose or of a course of vaccination
(e.g. the two initial doses of COVID-19 vaccine).
vaccine hesitancy When people delay or decline getting vaccinated (for

themselves or for their children) because they lack
confidence, motivation, ease of access or trust in those
providing the vaccine.
vaccine pass An official certificate verifying that someone has received

a vaccine (or is exempt). See also My Vaccine Pass.
vaccine rollout Implementation of New Zealand’s COVID-19 vaccination

(see also sequencing programme in which the first two doses of the vaccine
framework) were administered to the entire eligible population (aged
12 and over).
vector (of transmission / of Living organisms (including people) that can transmit
infection) infectious pathogens between humans or from animals
to humans, i.e. carriers of infectious pathogens.
ventilation 1. Building ventilation refers to the process of introducing

fresh air into indoor spaces while removing stale air.
Ventilation lowers the concentration of any infectious
particles or droplets (aerosols) that may have been
introduced by the presence of a person with a respiratory
infection.
2. Ventilation of a person refers to the use of mechanical
support to help them breath (see ventilator). Ventilation
may be needed for people who become seriously unwell
from a respiratory infection such as COVID-19.
ventilator A life-support machine used to mechanically support a

person’s breathing by pushing air into their lungs.
virologist A person who specialises in the study of viruses.
Term Definition
virulence The relative capacity of a pathogen (such as a virus) to

cause severe disease. Virulence may be quantified using
indicators such as infection fatality rate, case fatality rate,
or hospitalisation rate.
virus A tiny infectious agent that reproduces itself within the

cells of the infected person, animal or ‘host’.
wage subsidy scheme See COVID-19 Wage Subsidy Support Scheme.
Waitangi Tribunal The permanent commission of inquiry that considers claims

of contemporary and historical breaches of te Tiriti o Waitangi
| the Treaty of Waitangi.
Whānau Ora A programme of family-centric care in Aotearoa New Zealand,

driven by Māori cultural values and delivered by specialist
Whānau Ora providers, to empower Māori communities
and families to achieve better outcomes for families (and
extended families) in areas such as health, education, housing,
employment, improved standards of living and cultural
identity. It is funded by the Government, managed through the
Whānau Ora Commissioning Agency and delivered through
community-based NGO partners.
welfare response The welfare services delivered to individuals, families and

communities affected by an emergency.
WHO See World Health Organization.
WorkSafe New Zealand New Zealand’s primary work health and safety regulator.
(Worksafe) | Mahi
Haumaru Aotearoa
World Health Organization The United Nations agency that leads multilateral efforts to
(WHO) promote and protect health, including via coordination of
global preparation and response to pandemics.
Glossary of te reo Māori terms
hapori Part of a kinship group, family or community.
hapū A section of a large kinship group and primary

political unit in traditional Māori society (subtribe).
hauora Health.
Term Definition
iwi A large group of people (or tribe) descended from a

common ancestor and associated with a distinct territory.
kai Food or a meal.
kaumātua An adult or elder who is a person of status within the whānau.
kawa Protocol or etiquette, particularly in a Māori meeting place.
kūmara Sweet potato.
kura School.
mahi tahi Working together, collaboration, cooperation, or teamwork.
manaakitanga The act of showing kindness, respect, generosity, care for

others and reciprocity.
mana motuhake Enabling the right for Māori to be Māori (Māori self-
determination); to exercise their authority over their lives,
and to live on Māori terms and according to Māori
philosophies, values and practices.
mana whenua The power associated with possession and occupation

of tribal land.
marae The open area in front of the wharenui where formal

greetings and discussions take place. It is also often used to
include the complex and building around the marae. The
marae is the hub of a Māori community, the place where
people gather in times of joy and celebration, and times of
stress and sadness. (A wharenui is a meeting house; the main
building of a marae where guests are accommodated.)
Ōtautahi Christchurch.
Pākehā A New Zealander of European descent.
papakāinga The original home, village, or communal Māori land.
putea A fund or sum of money.
rāhui Temporary prohibition, closed season, ban or reserve.
rangatahi Young people.
Term Definition
rohe Area of land e.g. district, region, territory.
Tairāwhiti The East Coast (of the North Island).
takatāpui Māori who identify as LGBTQIA+. A traditional word

meaning ‘intimate friend of the same sex’. It includes all
Māori who identify with diverse sexualities, gender
expressions, and/or variations of sex characteristics.
Tāmaki Makaurau Auckland.
tamariki Children and young people.
tangata whenua A term that refers to the ‘people of the land’. It can refer to
either a specific group of people with historical claims to a
district, or more broadly the Māori people as a whole.
tangihanga The grieving and burial rites for the dead – one of the most
important institutions in Māori society, with strong cultural
imperatives and protocols.
Te Tai Tokerau Northland.
Te Ao Māori The Māori world.
te tino rangatiratanga See tino rangatiratanga.
tikanga The customary system of values and practices that

have developed over time and are deeply embedded
in the social context.
tino rangatiratanga Sovereignty and self-determination.
tupāpaku A deceased person’s body.
whānau The immediate and extended family group.
whanaungatanga A relationship through shared experiences which provides

people with a sense of belonging. It grows from kinship rights
and obligations, which also serve to strengthen each member
of the kin group. It also extends to others to whom one
develops a close familial, friendship or reciprocal relationship.
Find the full suite
of documents at:
3
For more information visit:
www.covid 19Iessons.roya lcommission.nz
ISBN: 978-1-0670514-9-5 (digital)

ISBN: 978-1-0670514-7-1 (print)

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Whītiki Aotearoa:

Lessons from COVID-19 to

2024 – Phase One

Part One: Part Two: Part Three:

Experiences Summary Consolidated

2026 – Phase Two

The COVID-19 pandemic impacted everyone in Aotearoa New Zealand and

“ I sincerely hope that our Phase One

Part One: Preliminaries

02 Summary – our lessons and recommendations 10

03 About the Inquiry 16

04 About the report 28

05 Pre-pandemic Aotearoa New Zealand: an overview 29

How can we do better next time?

Kāore i roa ka pā mai te māramatanga e urutā whakataurite o Aotearoa). Kāore i

We set out to establish:

What How the response What could

We also considered how the pandemic was managed in other international

Chapters 1 to 8 provide an overview of some key pandemic events, impacts,

Overall, compared to other jurisdictions, The initial success of the elimination

After reflecting on what can be learned from looking back at Aotearoa

• One critical overall observation • Our overarching high-level lesson

Build the foundations for

Why and how the Inquiry was established

Throughout Phase One, our approach has been:

Non-adversarial: Under the Inquiries Act 2013, a Royal Commission must

Scenario-focused: Our work has been informed by scenario thinking – a way

Exploratory, Rather than undertaking an overly forensic analysis

The views, suggestions and

ii A complete list is available at https://www.covid19lessons.royalcommission.nz/the-inquiry/record-of-inquiry-engagements.

We issued three procedural Minutes confirming our approach:

Minute 1 – Interim Minute 2 – Inquiry Minute 3 – Inquiry

Of course, maintaining confidentiality cited, unless we sought and received

This report comprises three parts:

broad reflections on what the country’s

In Aotearoa New Zealand,

As an island nation, Aotearoa Aotearoa New Zealand’s

The issues highlighted in this brief overview, and how they

v Further detail is provided in Appendix A.

2 All-of-government preparations and response 28

4.1 Introduction 146

5 The health system response 180

6 Economic and social impacts and responses 241

8 Mandatory measures 360

9 Taking stock 440

How well did Aotearoa New Zealand emerge from

In the face of the (initially unknown) threat that COVID-19

What part was played in the response by groups outside

What were the effects of the response – positive and

What did decision-makers do to prevent or reduce the

In considering such questions, we are aware of the huge advantage we have

December 2019 – March 2020 April 2020 – July 2021

2019 2020 2021

17/8/2021 1/11/2021 29/11/2021 2/3/2022 12/9/2022

1.2.1 Overall, Aotearoa New Zealand’s COVID-19 response

1.3.1 Low COVID-19 case numbers, hospitalisations and deaths

Aotearoa New Zealand’s COVID-19 case numbers were much

Figure 1: COVID-19 cases (confirmed) per million people, 2020–2021

Aotearoa New Zealand’s peak COVID-19 hospitalisation rate was

Aotearoa New Zealand’s COVID-19 hospitalisations peaked in March 2022, at