Readiness, Responses, and Resilience & Recovery.In this viewpoint, we present public policies and public health strategies for a gradual lockdown lifting during the coronavirus disease (COVID-19) crisis in two country cases, Jordan and the United Arab Emirates. While managing pandemics is critical in terms of preparedness, response, and recovery, it is equally vital to ensure that the measures for a lockdown exit are both efficient and effective. It is critical to learn from first-wave lessons to systematize responses during times of crisis and execute appropriate public policies and public health strategies. This viewpoint highlights the importance of the following during lockdown lifting: pandemic control, health care capacity, training, scaling up of resources and systems, and priority setting of public policies by acknowledging challenges, developing policy insights, and setting the policy direction. The systematic approaches and leadership thinking required for lifting lockdowns during a crisis include the three Rs:  About 5 million people have been infected with coronavirus disease COVID-19) worldwide, with over 324,000 deaths as of May 20, 2020 [9 worldwiAccording to the Ministry of Health in Jordan, the first confirmed case was reported on March 2, 2020 . The numIn the UAE, the current widespread physical distancing and lockdown measures taken and the ramping up of testing have been successful in identifying new cases of COVID-19. However, the average number of new cases (from April to May) is estimated at 300-500 per day and rising ,7; it maIn an ideal situation, the requirements for lifting the lockdown would include the following:Control the spread of the virus in a way that ensures a continuous reduction in new cases and a decrease in reproduction rate (R0) to less than one  Preparedness of public health and curative services to contain all new cases and the contact spread chain, whether from a local source or for those who come from abroad, through the following measures :The ability to epidemiologically detect suspected cases within 48 hours of the appearance of symptomsThe ability to effectively isolate all diagnosed cases in hospitals or identified facilitiesThe ability to detect, trace, quarantine, and monitor the close contacts of suspected or confirmed COVID-19 casesThe reduction of the potential spread of COVID-19 in congregated settings with a large number of people that are in close contact in the most vulnerable populations and areas such as nursing homes, nurseries, kindergartens, schools, universities, restaurants, religious or entertainment events The ability to manage evacuated returnees and those crossing the border  to minimize the risk of spreading the epidemic (importation risk management)The community and citizens should be aware of the measures to be taken when responding to the lockdown lifting; commitment and collaboration by identifying and reporting any new cases and cooperating to prevent the spread of the disease in large numbers is needed .It is paramount to consider the notions of priority setting of public policies when it comes to lifting the lockdown via acknowledging the challenges, developing policy insights, and setting the policy direction ,10.Jordan and the UAE have already started the gradual lifting of the lockdown for private businesses and in some industries and local communities. The timing of movement regulations during the lockdown implementation is a critical element since access to public services and offices were restricted. As an effort to partially lift the lockdown measures, movement was allowed during specific times in both countries. During the lockdown, there were restrictions in terms of moving to and from public sector offices; only essential employees were permitted to move during the usual working hours of the public sector. In Jordan, the public sector lockdown exit began by permitting citizens to leave homes between 10 AM to 6 PM for reasons including visits to essential public offices . Meanwhile, in the UAE residents are allowed to leave their homes between 6 AM and 10 PM without a permit, which includes visits to essential public offices .It may not be necessary to wait for all the ideal requirements for lifting the lockdown to exist to open up public sector institutions. Accordingly, we provide our perspective on the most important strategies that may enable the opening process to achieve the overall goal of continuous reduction in the spread of the disease (case incidence) while gradually restoring normal life for society and the economy. The proposed strategies should be implemented slowly in stages, and an epidemic situational assessment should be completed at each stage to ensure there are no new cases detected. Once the stage proves successful, the next step can be implemented. If the epidemic situation were to worsen, it will be possible to resume lockdown measures.The lockdown, which was initiated around mid-March and has lasted strictly until about the end of April, has caused much economic and social suffering, especially for the self-employed sector, big businesses, private clinics, and disadvantaged groups. Many have demanded a rapid lifting of the lockdown, which was considered and done gradually. However, the public sector, including health, higher education and vocational training, transport, etc, remained almost completely inaccessible. This viewpoint addresses the public health strategies and recommendations for the gradual lifting of the lockdown in these sectors.Readiness, Responses, and Resilience & Recovery Scale up and continue contact tracingCarry out random testing of communities, industries, and institutions to detect asymptomatic casesConduct sentinel surveillance of the workforce at different workplacesThese measures aim to ensure that the spread of the virus is under control and that there is an ability to detect and isolate new cases that may arise due to rapid reopening and to quarantine their contacts. It also will provide insight into how much herd immunity has been achieved. The most important criteria that should be monitored while applying this strategy are:The occurrence of an unexpected spike in new casesContinued reduction in the number of cases from unknown sourcesRapid identification and control of hot spots and proper control of cases and their contactsThis involves raising the preparedness of available public laboratories and their technical and working staff and, when necessary, train and seek assistance from the private sector, retirees, and relevant, unemployed laboratory science graduates to accommodate the expected increasing number of COVID-19 polymerase chain reaction (PCR) diagnostic tests needed. The customary protocol requires conducting 152 screening tests per 100,000 people daily ,13, whicProviding large numbers of test kitsTraining the field infection investigation team staff on COVID-19 field sample collection protocol and other laboratory technicians on the procedures associated with running COVID-19 test in laboratoriesEnsuring safety and personal protection measures for staffThis entails increasing the preparedness of hospitals and other curative service delivery posts by at least 20% to accommodate possible increases in the number of new cases requiring medical care at the national level. The construction of field hospitals is evident with a bed capacity of up to 3000 in the case of the UAE .This involves managing reopening at the provincial level by promoting the activation of the Decentralization Law or any relevant local government legislation. The experience of Jordan in managing the COVID-19 crisis in some governorates such as Irbid and Alaqaba was proven to be successful through contact tracing. This experience can be expanded to delegate the management of the opening-up measures at local levels to the local government and local executive boards. A thorough involvement of local community stakeholders who know which sectors have the highest priority to be opened is needed. Depending on the situation in each province, brigade, and locality in Jordan, and with continuous daily coordination at the national level, a more community-oriented lifting strategy may need to be achieved. Therefore, the roll-out strategy is to gradually increase the percentage of employees returning to public offices. Recently, in the UAE, a small number of public sector staff were allowed to work from the office, but this should not exceed 30% of the total number of employees .The effective involvement of the communities, stakeholders, and individuals in the opening-up strategies across the public sectors is paramount. This strategy will encourage their serious buy-in commitment to reduce the number of new cases. They can be empowered to be actively involved in monitoring the case incidence by providing and encouraging innovative methods to report on suspected cases in person through private electronic platforms or to report on suspected cases in the workplace or among friends and family via other methods such as social media communication and different modes (event-based surveillance) and public information . It is paramount to effectively communicate with the public about the situation and policy measures in a timely manner to raise awareness levels. In addition, increasing health awareness by providing health education and public safety information to the public is needed. This responsibility falls on public, private, and civil society institutions alike (a holistic government-society approach) . While iThis consists of involving civil society institutions in all phases of the opening process. The public sector is an essential partner in this crisis either in terms of raising awareness and field education for families and local communities or by involving them in infection field investigation measures. However, in the latter, they should receive adequate training in reporting suspected cases and in tracing their contacts. Civil society can also contribute to providing essential services to vulnerable populations in Jordan and the UAE, such as refugees, people with special needs, the elderly, orphanages, and other workers. According to the latest reports from the UAE’s Ministry of Health & Prevention , more thThis involves activating the role of the “judicial police” and giving them the authority to refer establishments, institutions, or individuals who do not comply with personal protection measures and social distancing to the relevant authorities under the activated emergency legislation. Strict government policy adherence in Jordan and the UAE is vital, especially those related to school closures, workplace closures, cancellation of public events, restrictions on public gatherings, closures of public transport, stay-at-home requirements, general information campaigns, restrictions on internal movements, and international travel bans . For insThis step involves taking advantage of the comprehensive database found in some public and private institutions that show population data at the level of neighborhoods to document lessons to be learned . In addiThis strategy involves restarting the provision of public services at the national and local levels. This will decrease the burden on the secondary care level, which needs to be ready for a possible increase in the number of COVID-19 cases .This involves setting criteria for lifting the lockdown beginning with vital public sectors such as health and food security followed by other sectors in a gradual manner that provides enough time after reopening to detect any new or suspected cases and their contacts ,9. The sThe contact intensity and density; that is, either high-risk exposure contacts who have spent 15 minutes or more in close proximity (≤2 meters) or in a closed environment; or low-risk exposure contacts who are still at risk but who have not been exposed to a confirmed case for as long;The number of persons or crowd number (contact number), which is given a value that ranges between high, medium, and low ,21; and Crowd reduction (risk modifying likelihood ability), which describes the institution’s ability to introduce measures such as spatial or physical distancing into a space that will control the number of people in contact within a distance of 2 meters. These criteria are also given a value that ranges between high, medium, or low.Based on the assessment of these three criteria and consensus on the value, vital sectors can initiate reopening while active monitoring and case detection are continuously exercised and kept in line with the criteria mentioned above.It is critical to reinforce the notions of priority setting of public policies and public health strategies when it comes to lockdown lifting nationwide and keep in mind the challenges that may lie ahead. Thus, it is important to have mobilized teams in place for developing policy insights and setting the policy direction  and exec


To accomplish this objective, and to link the relationships under analysis to the level of development, a comparison between a group of developing countries and a group of developed ones was performed. The results confirm the suitability of the division of the countries by revealing various effects. This analysis was conducted from 1996 to 2017 and by recurring to the Autoregressive Distributed Lag model. This study proves that foreign investors play a vital role in reaching sustainable development. Measures must be implemented to eliminate the distortions that cause a company based in a country with strict environmental regulations to relocate its production to one with lax environmental regulations. However, these measures need to be combined with complementary measures that encourage developing economies to agree to a possible slowdown in their economic growth if sufficiently compensated for this reduced growth.Can globalisation and foreign direct investment shape sustainable development? Foreign direct investment is one of the main drivers for the transfer of polluting industries. With this in mind, the main objective of this research is to identify the role played by foreign direct investment (flow and stock), globalisation ( GlobaliGlobalisation  provides an effective framework for the transfer of polluting industries from developed to developing countries. The relocation of dirty industries phenomenon clashes with the sustainable development goals of the United Nations . The greatest concern is that emissions from polluting industries are transferred to the host country (commonly developing countries), maintaining, or even increasing, the global level of environmental degradation. Considering that the literature points to the relocation of pollutant industries to developing countries with permissive environmental regulation and weak exigence of governance , an empiEven though some researchers are investigating the role of FDI and globalisation on environmental degradation, few are using empirical evidence directed to sustainable development. Sustainable development (measured in this study by the Index of Sustainable Economic Welfare) has been a topic of discussion in diverse fields for several years. However, measuring sustainable development is quite difficult, as it must be measured by incorporating three main dimensions: social, economic and environmental  and FDI (inward and outward FDI flow and stock) on environmental degradation and sustainable development for two groups of countries: developed and developing. In light of this, the central question is “Are globalisation and FDI contributing to environmental degradation, thus compromising sustainable development?” In order to answer the central research question, this paper analyses the role of each dimension and measure of globalisation and inward and outward FDI, flow and stock, on a group of 17 developed countries and a group of 14 developing ones, by performing a comparison between them. Moreover, this paper analyses the role of corruption and regulatory quality on the relocation of polluting industries. These governance indicators were chosen as they are considered in the literature as motivation for the transfer of polluting industries. In a context of energy sources substitution and taking into account the resources widely used by FDI, the sources composition is analysed by considering both fossil fuels and renewable energy sources. This analysis is performed from the longest time period available from 1996 to 2017. Although FDI is considered a long-run phenomenon [2 emissions and sustainable development in both groups of countries. Furthermore, governance indicators expose a relevant and distinct role in the countries under analysis, by analysing the regulatory quality and the control of corruption.This study aims to provide measures to combat environmental degradation without compromising sustainable development. Overall, this research innovates by providing an all-embracing analysis of the role of globalisation   is predicted to increase emissions in developing countries while decreasing it in developed ones, thus sustaining the Pollution Haven Hypothesis.Increasing Gross Domestic Product (GDP) is one of the main goals of countries worldwide, but this objective may hamper sustainable development targets. Besides being powerless to measure welfare and sustainability ,59,60,61The ISEW was introduced in the literature not as a substitute for GDP, but as an additional indicator to complement any analysis of the state of an economy . Lawn 7 providesBriefly, the ISEW allows current and future wellbeing analysis, which is the keystone to sustainable development, ensuring the satisfaction of future generations’ necessities. To the best of our knowledge, the ISEW is considered a useful measure of sustainable development . This in2 emissions as the dependent variable are estimated from 1996 to 2017, while the models with ISEW as the dependent variable are estimated from 2000 to 2017. The relocation of polluting industries is associated with contrasting features among the home and the host country. In light of this, this research aims to analyse two groups of countries with distinct features, such as level of development, income, globalisation and regulatory quality. The countries under analysis are categorised as developed and developing countries by the United Nations . CategorThe FDI is measured as inward and outward, both stock and flows. Based on the FDI stock definition, it measures the total level of FDI at a given point in time, while FDI flows mean the value of FDI transactions during a given period. As such, it may provide an in-depth analysis of the impacts of FDI on the environment. Both the corruption index and regulatory quality index are used following the definition provided by the World Bank proposed by Kaufmann et al. . The conIn contrast to GDP, the ISEW is an indicator that aims to measure sustainable economic welfare. This indicator is used as a proxy of sustainable development, see, e.g., in ,78. BaseS measures the unpaid work benefit, N consists of the depletion of the natural environment and The ISEW calculation process employed in this research is adopted from studies such as Menegaki et al., Marques et al., and Menegaki and Tsagarakis ,78,82. ESome limitations were faced during the ISEW calculation process, such as the lack of social costs data, as handled by Menegaki et al. and Marques et al. ,78. TherOwing to a lack of observations in the GINI coefficient data for a small number of countries, the missing values were calculated through the trend of the available years, see, e.g., in . For exaGDP, 2CO and ISEW were transformed into per capita (pc), and FF and RES were transformed into a percentage of primary energy consumption. Descriptive statistics of the variables under analysis for both groups of countries and both time periods are displayed in A preliminary analysis to evaluate the data features was conducted. Correlation is a common concern in panel data analysis. In light of this, the coefficients of the correlation matrix were assessed. Therefore, in order to avoid correlation between the variables, specific transformations were performed, namely, Panel data specification tests were performed, such as the cross section dependence test (CD-test). Cross-sectional dependence is a common phenomenon in panel data settings, and it can lead to inconsistent outcomes once the presence of cross section dependence can bias the results of the first-generation unit root tests. Introduced by Pesaran , the CD-As displayed in Considering the time periods under analysis, over which diverse events could have occurred, the suspicion of the existence of structural breaks arises in the series. In light of this, the assessment of the variables unit root was taken further and as commonly used in energy economics research, see, e.g., in ,85,86,87Introduced in the literature by Pesaran and Smith  and PesaThe general ARDL model is provided in Equation (2):Following the general ARDL model structure, Equation (3) represents the models estimated with the ISEW:2 emissions as a dependent variable:Equation (4) represents the models estimated with COIn these equations, prefix D indicates first differences, FDI_si and FDI_so in the models of the developed countries. Therefore, these two variables were not estimated simultaneously, and two separate models were estimated for FDI_si (models I and III) and for FDI_so (models II and IV). Furthermore, a high correlation between KOFSODF and KOFSODJ in the model of the developing countries was noticed. Consequently, two separate models were estimated for KOFSODF (models V and VII) and for KOFSODJ (models VI and VIII). Furthermore, in the developing countries’ models, a high correlation between 2_pcCO and GDP_pc was reversed through estimation the model with 2CO instead of 2_pcCO.The estimation of models with diverse explanatory variables could raise the suspicion of multicollinearity among them and consequently raise concerns regarding the confidence in the results and variables’ significance. In light of this, the variance inflation factor (VIF) statistics were assessed, revealing potential multicollinearity among The Hausman test was employed to choose the most appropriated estimator to use. The null hypothesis under this test is that the random effects are appropriate, and the results are presented in The rejection of the null hypothesis displayed above supports that the fixed effects estimator is the most appropriate estimator to use. Considering that, some specification tests were conducted to assess the presence of contemporaneous correlation, namely, Pesaran , Frees  and FrieThe results from the previous tests emphasise that the Driscoll–Kraay  estimatoISEW and 2CO as dependent variables and for both groups of countries are displayed in 2 models of developed and developing countries reflects a decline in CO2 emissions provoked by a decrease in economic activity during the financial crisis (2008−2009) [n component of the ISEW computation) and, on the other hand, through defensive costs (N component of the ISEW computation). In developed countries, this effect was immediate, and the dummy variable was included in 2009 in the ISEW model of developed countries. While in developing countries, the effect was more evident in 2010.The estimations of the ARDL model and Driscoll–Kraay estimator for both the 08−2009) . In turnBesides the conducted analyses of FDI in the disaggregated form (inward and outward FDI flow and stock) provided in 2 emissions damage costs  on the ISEW computation). In the developing economies, the stock of FDI also increases sustainable development through inward FDI; however, it increases environmental degradation as well. In these economies, inward FDI flow is the one that produced an effect on the environment contrary to the effect produced on sustainable development, reducing environmental degradation and improving sustainable development.The analysis of FDI in the developed economies reveals that FDI stock affects the environment contrary to the effect produced on sustainable development. Both inward and outward FDI stock produced mitigation of environmental degradation and an improvement of sustainable development, suggesting that the improvement in the ISEW occurs through the reduction of the COde jure raises environmental degradation and reduces sustainable development in both groups of countries. Contrasting, social globalisation improves sustainable development in both groups of countries, together with political globalisation de jure, while political globalisation de facto is harmful to it. Concerning governance, regulation quality mitigates environmental degradation, meanwhile, corruption, which can be a business enabler and consequently increases GDP, benefits sustainable development by increasing capital growth (Kn of ISEW computation) in both groups of countries. It is worth highlighting that the Error Correction Model (ECM) of all models is highly significant and discloses a moderate speed of adjustment to the long-run equilibrium.The analysis of globalisation through each dimension and measure proved to be useful as well. It showed an effect on the environment contrary to the effect on sustainable development in both groups of countries. Economic globalisation 2 emissions as the dependent variable, estimated from 2000 to 2017. Overall, these results are similar to the results presented in The estimations shown in The achievement of sustainable development goals is a global objective, but some countries could be facing more barriers than others to reach this. In developing countries, renewable energy consumption is not adequate enough to shrink environmental degradation as its use remains statistically insignificant, which is also found with sustainable development. Both of these outcomes are entirely predictable. As announced by Zaidi and Saidi , developThe impact of corruption could depend on the objectives of the investor. Indeed, Barassi and Zhou  consider2 emissions: it contributes to a sharp reduction in investments in developing countries, as they are frequently chosen as recipient countries for polluting industries.Regulatory quality, on the one hand, stimulates sustainable development in developed countries. On the other hand, regulatory quality diminishes sustainable development in developing countries. As a result, regulatory quality in developed countries incites sustainable development, perhaps due to the reduction in defensive costs (N component of ISEW computation), as the regulatory quality reduces environmental degradation. However, while regulatory quality reduces environmental degradation in developing countries, the negative impact on investment level seems larger than the relevance of reducing defensive costs. As stated by Dartey-Baah , the accde jure is related to trade taxes and investment restrictions, and as stated by Rudolph and Figge [de jure increases environmental degradation and simultaneously reduces sustainable development in both groups of countries. By increasing environmental degradation, the defensive costs (N component of ISEW computation) will consequently increase, suggesting that any decrease in sustainable development could be due to an increase in defensive costs. Regarding developing economies, this effect could be explained by investment restrictions which cause the continued use of older and more polluting technologies, consequently increasing environmental degradation.Focusing on globalisation, the results obtained provide evidence that globalisation measures can have distinct effects on environmental degradation and sustainable development, in both nature and/or magnitude. Globalisation revealed some opposite effects on environmental degradation compared with the effects on sustainable development in both groups of countries. Economic globalisation nd Figge , high ecde jure and de facto measures contribute to increasing sustainable development and environmental degradation in the developing economies. A possible cause for that could be explained by the fact that these countries are an international tourism destination and trade in cultural goods recipients [de facto mitigates environmental degradation. This could be explained by the easier access to information components such as the use of internet and access to reliable media that could enhance environmental awareness, as stated by Ahmed et al. [de facto provokes in sustainable development might come from the reduction in the defensive costs (damage from CO2 emissions (N)) reflected in lower emissions.Regarding social globalisation, both cipients . Despited et al. . The impde facto contributes to environmental quality improvement, political globalisation de jure increases environmental degradation in the developing economies under analysis. As referred by Leal et al. [de facto measures could be explained by the dissemination of environmental policies among countries, while the positive effect of de jure measures could provide evidence of a lack of success on global environmental management. In developed countries, political globalisation de facto reduces sustainable development, while political globalisation de jure improves it, which could be explained by the international treaties that prompt economic development. In short, sustainable development in developed countries is prompted by social globalisation de facto, as it shrinks CO2 emissions, and by political globalisation de jure. In developing countries, social globalisation, both de jure and de facto, is also contributing to sustainable development, but contrary to the effect on developed countries, in developing ones, social globalisation increases environmental degradation as political globalisation de jure. However, political globalisation de facto mitigates environmental degradation in developing countries.Last, while political globalisation l et al. , the mitLooking carefully at the FDI stock definition, it measures the total level of FDI at a given point in time, while FDI flows mean the value of FDI transactions during a given period. As expected, FDI behaves differently in the groups of countries under analysis. The stock of FDI both inward and outward revealed opposite effects on environmental degradation compared with the effects on sustainable development in the developed economies. Regarding the mitigation of environmental degradation, inward and outward FDI stock reduce emissions and increase sustainable development in developed countries. The effect of inward FDI stock reflects more environmental awareness and that these countries are receiving environmentally friendly FDI with the transfer of efficient technologies. This is also supported by the mitigating effect of inward FDI flow on environmental degradation in the developed countries. Consequently, one observes a decrease in defensive costs (N component of ISEW computation); inward FDI stock contributes to an increase in sustainable development. In turn, the outcome of outward FDI stock is anticipated and could suggest that polluting industries have been relocated from developed countries to developing countries, transferring emissions. Nonetheless, it is also important to consider that outward FDI could represent a production transfer, thus reducing energy consumption and environmental degradation.2 emissions and be environmentally conscious in the long-run in developing countries, thus contributing to environmental preservation. The greater the gap between the technological level in the source country of FDI and the recipient ones, the greater the effect of the introduction of technological processes [Inward FDI stock is damaging the developing countries’ environment, which could mean that these countries are receiving polluting industries, thus supporting the Pollution Haven Hypothesis. Therefore, inward FDI stock induces environmental degradation as it considers the industries already relocated and installed. This means that the effect of inward FDI measured as stock represents the accumulation effect of FDI on the environment . Thus, trocesses . This ouRegarding sustainable development in developing countries, it has been positively affected by inward FDI both as a flow and stock. Following the assumption that FDI induces economic growth, this outcome is expected. As FDI increases income and the rate of employment, then the social consequences are reduced while FDI is increasing . This meThe main findings expose a potential new paradigm under the analysis of the relocation of polluting industries. While inward FDI stock supports the transfer of polluting industries, inward FDI flow uncovers the indirect role of the investment in innovation in developed countries. Besides, this result also reveals the crucial role of energy consumption. Although the adoption of energy-efficient techniques through FDI could be considered as crucial to reduce emissions , the eneThis investigation is developed under the objective of filling some gaps found in the literature. Indeed, each dimension and measure of globalisation is considered. The results reveal the suitability of conducting this disaggregation as it could have different impacts in nature and/or magnitude. Furthermore, to better discern the transfer of polluting industries from developed to developing countries, inward and outward FDI are analysed, both as flow and stock. Besides, the measurement of sustainable development by the ISEW is innovative in this subject. By analysing and comparing developed and developing countries, it was fulfilled a gap in the literature by analysing whether globalisation and FDI are harming environmental degradation and compromising sustainable development.Environmental degradation has become one of the biggest challenges facing the planet. Resources are scarce, and the environment is considered within this scarcity. The fight against climate change is urgent, and although some countries are taking significant steps towards environmental degradation mitigation, others are ignoring this urgency. The Glasgow summit (26th United Nations Climate Change Conference of the Parties (COP26) in Glasgow), originally scheduled to take place in November 2020, has been rescheduled to November 2021 as a consequence of the current COVID-19 pandemic situation. The Paris Agreement (COP21) outlined the necessity to meet every five years to re-evaluate the current state of climate change. COP26 is the first time that parties are expected to commit to enhancing the ambition to tackle climate change. A key topic of discussion at the Glasgow summit should be the transfer of pollutant industries to developing countries. It is in these countries that the transfer has the greatest repercussions, and as a driver of environmental degradation, mechanisms to discourage it and/or compensate those host countries receiving it should be a focus.This study suggests that future lines of research could involve conducting a similar analysis to the present one by considering other indicators of sustainable development, including social, economic and environmental aspects of sustainability. Furthermore, the use of ecological footprint as a proxy for environmental degradation could bring an interesting discussion to compare results with a sustainable development indicator, as it is used in the literature as a proxy for both environmental degradation, see, e.g., in , and susThis research was undertaken with the objective of evaluating the nature of polluting industries transfer from developed to developing countries. To do that, this study analyses the influence of FDI (measured as inward and outward FDI flow and stock) on environmental degradation. This study also aims to analyse the consequences of the phenomenon of industry relocation on sustainable development (measured through the ISEW) for both home and host countries. This research goes beyond innovating through analysing the specific effect of inward and outward FDI flow and stock on developed and developing economies; the influence of each dimension and measure of globalisation is considered as well. Additionally, governance indicators were included in the analysis. The analysis of both inward and outward FDI flow and stock, and the analysis of globalisation through the three dimensions and two measures, make it possible to go deeper into the study of the complexity of globalisation and FDI on the environment, and to the best of our knowledge, this approach is innovative.When looking for governance indicators, the effect of corruption seems to be helpful to reach sustainability. Corruption may speed bureaucratic processes and assumes the role of business facilitator. However, corruption can represent long-term adverse effects that could be undermining the growth of economies. Regarding regulatory quality, it reduces environmental degradation in both groups of countries, which helps countries to reach sustainable development goals. In developed countries, this beneficial environmental effect is reflected in an increase in sustainable growth through the reduction of environmental costs. In the developing ones, the loss of capital growth is not offset by the reduction in environmental costs, thus reducing sustainable development. These effects evidenced the lax and undemanding environmental regulation in the developing countries analysed in the study.2 emissions (N)) results in improved sustainable development. On the one hand, inward FDI flow and stock suggest that the investments received by developed economies have an environmental awareness background. On the other hand, the environmental mitigation effect of outward FDI stock in developed countries might suggest that emissions have been transferred through the relocation of pollutant industries to developing countries. As a result, inward FDI stock in both the short- and long-run increases environmental degradation in developing countries.The analysis of inward and outward FDI flow and stock in developed countries reveals that both improve environmental quality and sustainable development. In these countries, the reduction in emissions that consequently leads to a reduction in defensive costs (damage from COThe undemanding environmental regulation in developing countries adds to the defensive costs that are subsequently offset by capital growth. Inward FDI stock provokes an improvement in sustainable development. As is evidenced by the effects of regulatory quality in developing countries, this research maintains that it is necessary to implement measures that encourage these countries to improve their environmental regulation. Notwithstanding, it is essential to compensate recipient countries for the loss of investment that may result from tightening environmental legislation.


This paper examines racial science and its political uses in Southeast Asia. It follows several anthropologists who travelled to east Nusa Tenggara , where Alfred Russel Wallace had drawn a dividing line between the races of the east and the west of the archipelago. These medically trained anthropologists aimed to find out if the Wallace Line could be more precisely defined with measurements of the human body. The paper shows how anthropologists failed to find definite markers to quantify the difference between Malay and Papuan/Melanesian. This, however, did not diminish the conceptual power of the Wallace Line, as the idea of a boundary between Malays and Papuans was taken up in the political arena during the West New Guinea dispute and was employed as a political tool by all parties involved. It shows how colonial and racial concepts can be appropriated by local actors and dismissed or emphasised depending on political perspectives. In the course of the nineteenth and twentieth centuries, insular Southeast Asia attracted natural historians, medical experts, physical anthropologists and (more recently) geneticists, each hoping to explain the supposed variety in human types. They were, in a region that until 1945 (New Guinea 1962) was for the most part under the control of the Dutch Empire, an international, mostly European, group of scientists, including – among others – French craniologists, British and German naturalist travellers and Dutch anthropologists.One important structuring concept for the human diversity in this region was the difference between people with frizzy hair and darker skins in the east and light brown people with straight hair on the western islands. The difference between these two people had already been noticed by early European travellers, together with the difference in flora and fauna. After extended travels in the region, the British naturalist explorer Alfred Russel Wallace – better known as the co-discoverer with Darwin of evolution by natural selection – proposed in the 1860s that the region could be divided into two biological zones, separated by what came to be known as Wallace’s line.This paper analyses the anthropological Wallace Line and its political afterlife. It starts with the work of the early naturalist travellers who conceptualised the line and continues with the engagement of a generation of physical anthropologists with the line in the late nineteenth and early twentieth centuries. Educated in medical schools, these physical anthropologists considered themselves experts in the human body, and this included the body in racial terms. Physical anthropology as a discipline had crystallised within medical departments in Europe, where encounters with unfamiliar bodies had led medical scholars to rethink both medical theories and the nature of human diversity. For those medically trained anthropologists who travelled overseas, racial differences and evolutionary hierarchies were an essential part of how they understood individual bodies and society.From the 1880s onwards, physical anthropologists were eager to measure the physical differences between Malays and Papuans and hoped to provide a line that was drawn even sharper and more objectively. Several anthropologists in this period travelled to the Timor archipelago or east Nusa Tenggara – the eastern part of the Lesser Sunda Islands, including the islands of Flores and Timor and the adjacent smaller islands, crossed by the anthropological Wallace Line – and did fieldwork among the Atoni, Manggarai or Savunese. This paper shows that even though this generation of anthropologists failed to substantiate their claims, the idea of a boundary between Malays and Papuans persisted. The human Wallace Line became salient, especially during the West New Guinea dispute, and was employed as a political tool by all parties involved to further their goals.Exploring the making and afterlife of the Wallace Line, this paper follows historians of medicine, race and geography who have shown how the idea of a boundary line was an important organising principle in the making of  conceptions of the word and how it shaped realities.cordons sanitaires.Wallace’s maps, both the faunal and the human, were important scientific tools, but the reproduction of the Wallace Line consisted of more than maps. The idea of a human line was mobilised in academic texts and in the speeches of politicians, so it was the spatial imagery in a broader sense, rather than the cartography, that proved to be influential.This paper follows the most recent scholarship in colonial science and medicine that explores how colonial subjects ignored or resisted Western medicine, how they integrated it with their own health practices and, similarly, how they created alternative versions of racial ideas.2The idea of a contrast between the eastern and western peoples of the region and of a boundary line or region between them was first conceived by the generations of naturalist travellers that preceded Wallace. Father and son Johann Reinhold and Georg Forster, for example, naturalists who travelled with James Cook on his second voyage to the Pacific, observed ‘two great varieties’, one ‘more fair, well limbed athletic, of a fine size and a kind benevolent temper; the other blacker, the hair just beginning to become woolly and crisp, the body more slender and low, and their temper, if possible more brisk, though somewhat mistrustful’.The Malay Archipelago (1869), in which he recounts his travels and biogeographical theory, includes a map with both lines , nasal index, height, skin colour and eye colour were essential measurements. If there was time for more extensive research, ten Kate used the dynamometer to test muscular strength, and he also tested sight, sense of colour and skin sensitivity. He concluded that the Timorese were relatively immune to physical pain.That one can find fine observers full of humour among the Sumbanese sometimes became apparent when, late in the afternoon, a man held an anthropometric séance in his own way and copied all my manipulations of that morning to another subject, with a wooden stick and a long blade of grass giving me questioning looks repeatedly.The local audience laughed out loud about this performance.To decide where a racial boundary line could be drawn, ten Kate sought the westernmost influence of Papuan physical features. Timor, he concluded, was very mixed. He wrote that the autochthonous ‘wild’ population was generally rather small in size (men measured on average 1.597 m and women 1.496 m) and had a warm dark-coffee skin colour  and ‘Negroid’ foreheads. Cranial indices showed that the population was neither particularly brachycephalic nor dolichocephalic.Attentive to the extent of Papuan influence in the boundary area, ten Kate encountered what he saw as the as the purest representatives of the ‘negro race’ in the highlands of the island of Flores. He based this on his quick observation of skin colour and hair form but also on the noisy clatter and chatter of the locals, so his personal impressions here carried more weight than his measurements. His servants, likely Malay carriers, confirmed his opinion. Ten Kate wrote that his opinion was confirmed by anthropometric measurements (of six men): four of them were quite tall and several were very long-headed, so ten Kate defined that as their Papuan element.Two decades later, anthropometry in the Dutch Empire had taken off with studies all over the region. In the Timor archipelago, Hendrik Bijlmer, Doeke Brouwer and Wilhelmina Keers all took measurements in the region in the wake of ten Kate, again hoping to bring more clarity in the case of the Wallace Line but finding instead a complexity that defied easy categorisation. Bijlmer would be better known for his anthropological work on New Guinea, but he started his anthropological work as a military medical officer in the Timor archipelago. The appeal of the region had not changed: in the words of Bijlmer, ‘the so-called Malays from the Western part of the Indian Archipelago met here with the off-shoots of the Oceanic Negroes whose birth-place is commonly said to have been somewhere in Melanesia, New Guinea included’.Bijlmer measured hundreds of people at eight different places on Timor, Flores and Sumba. His wife accompanied him and was responsible for the photography. He decided not to measure ‘anything that the compasses can grasp’ but those human dimensions where he expected to find racial difference, such as stature, distance between the corners of the eyes, length and width of the head  and length and width of the nose , and he focused on the face with four indices and the interorbital breadth.Bijlmer had hoped that clear influences of each dimension would be traceable in the Timor archipelago. ‘No greater difference is imaginable,’ he wrote, ‘between the brown straight-haired, slightly Mongoloid Malay and the dark, frizzy-haired, absolutely non-Mongoloid Papuan.’According to Bijlmer, however, the line crossed the island of Flores, but it was difficult to know where. ‘We have been accustomed,’ Bijlmer wrote, ‘to consider the frontier between Ngada and Manggerai as the Western limit of the Melanesian element.’ So when Bijlmer crossed from the Ngada region to the neighbouring Manggarai, he was full of expectation, even though Wallace had not conceptualised a sharp line but a region in which different features blended. For Bijlmer, it turned out to be a disappointment in terms of physical features. Instead, he resorted to thinking in terms of civilisational hierarchy: ‘there is certainly a great difference between the fierce-looking unwashed and roughly clothed Ngadanese and the better groomed Manggerai, mostly in Malay dress’.On eastern Timor, according to Bijlmer, Melanesian influence was most prominent. The inhabitants of this region were ‘[m]ore uniform, more true to type’, as they showed ‘great mutual resemblance’, which suggested to anthropologists that they were of a pure kind. Unfortunately for Bijlmer, they included both long-skulled and short-skulled individuals. This meant he had to conclude that both represented a specific Melanesian type and that skull type could not be a marker for difference between Malays and Melanesians. Bijlmer decided not to differentiate between these two groups, showing that he attached greater importance to the characteristics he observed than to skull shape. Similarly, as he had already decided on the basis of his impressions that Sumba was fully (pre-) Malay, he linked the medium-length skull type he found there to a pre-Malay strain.Several other doctors and anthropologists added their measurements to those of ten Kate and Bijlmer. In the 1930s, Doeke Brouwer, a military doctor on the island of Alor, east of Flores, studied the inhabitants of Alor and the smaller nearby Pantar. Measuring twenty different dimensions and indices, he divided the population on the two islands into seven groups and classified them generally as Melanesians with mostly Papuan but also pre-Malay influence. According to his findings, then, western influences were traceable even east of the line.4If anything can be concluded from the politics and non-politics of the racial Wallace Line, it is that they became active at a politically opportune moment. For the Dutch colonial government, a dividing line between Malays and Papuans did not fit the image they wanted to create. Until the independence of Indonesia, the government preferred that of a patchwork of different ethnic and racial groups under one Dutch umbrella.For the Portuguese colonisers of East Timor, on the other hand, the Wallace Line, if redrawn slightly to the east, supported Portuguese colonial claims perfectly, as Ricardo Roque has shown in a relevant recent article. Ten Kate, Bijlmer and other Dutch anthropologists found that, surprisingly, the island of Timor, the western part of Dutch Timor, seemed more Melanesian than the east, which went against the wider picture of a Papuan east versus a (pre-) Malay west. The Belu of the eastern highlands were also the main ethnic group in Portuguese East-Timor, which was considered advantageous by the Portuguese, because by defining Portuguese subjects as more Malay and less Papuan, they could be portrayed as evolutionarily more advanced. In 1916, the Portuguese anthropologist António Mendes Correia suggested that East-Timor be placed west of the Wallace Line, giving the line an extra loop around East-Timor that neatly followed the border between Dutch and Portuguese Timor.In the first half of the twentieth century, Papuans had a different experience from many other colonised people of the archipelago, as the Dutch started to invest heavily in the region only after 1949, when it was their last remaining colony in the east. Papuans also played only a small role in the independence struggle of Indonesians. However, Indonesian nationalists had included West New Guinea in their discussions about territory since the early twentieth century, when they conceptualised the future Indonesia as a continuation of the current Dutch Empire rather than a racial community.Indonesia proclaimed independence in 1945, but after the war that followed and the negotiations with the Dutch, West New Guinea was not part of the transfer of sovereignty and continued to be contested terrain. The Dutch concentrated all their colonial efforts on New Guinea, with the aim of uplifting the population from their primitive state. Because of the continuing presence of the Dutch in New Guinea while the Indonesian government claimed it was part of Indonesia, relations between Indonesia and the Netherlands soured until the situation escalated in 1962. The administration of West New Guinea was then transferred to the United Nations Temporary Authority and less than a year later, in 1963, to Indonesia.The Dutch defended their prolonged presence in New Guinea with, among other things, the argument that the Papuans were racially  different from Malays in Indonesia. A New Guinea Committee in 1950 was supposed to prepare for negotiations but only revealed irreconcilable differences, especially on the question of whether West New Guinea belonged to Indonesia. The final, Dutch report of the Committee argued thatto elaborate on the anthropological difference between Indonesians and Papuans is  flexible enough to be invoked time and again.In the period of decolonisation, the Timor archipelago and the Moluccas were generally seen as part of Indonesia, hence the line was moved further eastwards. The discussions surrounding the transfer of sovereignty of West New Guinea from the Dutch to the Indonesians show that the idea of the human Wallace Line was there to be called on when the argument was advantageous for one of the groups involved: ‘no one can draw a distinct dividing line between the so-called Papua and Malay areas!’, said an Indonesian pamphlet in 1956, invoking it.


The coronavirus disease COVID-19) pandemic started in late 2019 in Wuhan, China before spreading globally in the following months, first in Asia and Europe, followed by the Americas, Africa and Oceania 9 pandemi. In counSurveillance of COVID-19 in Europe started on 27 January 2020 when the European Centre for Disease Prevention and Control (ECDC) and the World Health Organization (WHO) Regional Office for Europe asked countries to report all cases meeting the WHO case definition . The iniCountries also report their cases to The European Surveillance System (TESSy)–which is mostly case based– with a set of variables including importation status (i.e. case travelled outside the reporting country in the 14 days before symptom onset) and geographical information (i.e. place of residence and place of infection). Provided that these variables have a good completeness, it is theoretically possible to distinguish locally acquired infections from those that were imported. However, it remains to be determined whether this distinction makes sense and if it does, how to best use this information to meet the surveillance objectives.There are a number of challenges related to both the definition and the classification of travel-associated infections.An imported case is usually defined as any case with a travel history outside of the reporting country in a specified number of days before onset of symptoms, i.e. 14 days for COVID-19 surveillance in Europe. Since most Europeans travel domestically, a substantial proportion of travel-associated COVID-19 will not be captured . This maImported cases are usually included when calculating the notification rate, even when there are few autochthonous cases, such as in the case of dengue . This heAside from the impact of imported cases on the notification rate, another challenge is to determine the population under surveillance, which is crucial when selecting the denominator used for calculating notification rates. As for many other diseases under comprehensive surveillance, the population under surveillance is the general population. Countries report cases of residents present in the country and of visitors who have fallen ill and been diagnosed during their stay. The inclusion of cases among non-residents could lead to an overestimation of the notification rate if only residents are counted in the denominator. This is generally not problematic, since visitors usually account for only a small proportion of all reported cases. Yet, in countries with a small population, large numbers of tourists or commuters testing positive for the disease under surveillance could impact the overall notification rate substantially, especially if the disease is associated with large outbreaks in specific settings, such as holiday resorts, seasonal worker accommodations or migrant reception centres. Although it may be possible to identify and exclude those diagnosed by entry testing from the numerator (provided that they remain in strict quarantine), most travellers, migrants living in the country or transients would be included. Moreover, people staying for longer periods or with multiple re-entries (e.g. commuters) will be contributing to community transmission regardless of their residency status. For all these reasons, it appears important to include all cases in notification rate calculations. If estimating very precise rates is necessary, adding non-residents to the denominator can be considered for a short period of time (e.g. in the summer months for regions with large numbers of tourists).The underlying assumption for classifying a case as imported or travel associated is that the probable place of infection can be easily determined, or at least that it is possible to eliminate the reporting country as the probable place of infection. If testing is done upon entry, one could reasonably assume that the case was indeed imported. The predictive value of the definition for importation is unknown for COVID-19 and depends on the current transmission intensity in both the reporting country and the visited country, as well as the length of stay. Since cases may have travelled in more than one country, the ascertainment of the place of infection may be even more challenging. Without sound epidemiological investigation of imported cases and clusters around them, classification of COVID-19 as imported or not will remain unreliable in many instances. There is also a risk that cases may withhold their travel history because of possible inconvenience, such as quarantine .The impact of the inclusion of imported COVID-19 cases in the calculation of the notification rate will depend greatly on the surveillance system in place. Therefore, it is essential to describe the surveillance system as accurately as possible, using surveillance descriptors . These dThe collection, analysis and sharing of comprehensive data at national and international levels is essential to allow for appropriate, evidence-based public health action. Particularly in the context of an evolving pandemic, detailed information may have important implications for response. The choice of surveillance indicators, such as the notification rate, should be determined by the surveillance objectives. The inclusion or exclusion of imported cases in these indicators will depend on the objectives. It is of utmost importance that countries report all cases diagnosed in their territories, regardless of their residence or importation status. The inclusion of imported cases should not provide disincentives to test or report and surveillance data should be interpreted by taking into account surveillance system descriptors.


Saudi Arabia is considering increasing the role of the private sector’s participation in financing and delivering healthcare services through the adoption of Public-Private Partnerships (PPPs). However, the adoption and successful implementation of PPPs in the Saudi healthcare sector requires careful attention to overcome potential obstacles.This study investigates and identifies potential barriers to the successful implementation of PPPs in the Saudi healthcare sector.A pre-tested interviewer-administered questionnaire was used to collect data from 72 respondents over a two-month period. Respondents were asked to rate the degree of influence of potential key barriers using a five-point Likert scale. The collected data was analysed using descriptive and inferential statistics.The evidence showed that the top three barriers, as rated by the respondents, were legal barriers, including delays in receiving approval and permits and law and regulation changes, environmental barriers, including lack of transparency and accountability and technological barriers, including a shortage of professionals qualified to handle PPP projects.The barriers identified suggested that the government should ensure that PPPs are implemented in a timely manner to ensure that private sector involvement yields the intended benefits. Furthermore, a stable legal and regulatory framework must be established that is properly and easily enforced to avoid confusing stakeholders with too many changes. It is also important to ensure that transparency and accountability measures are strengthened. One of the main duties of governments is to provide essential public services. The provision of such services, including education, transport infrastructure and healthcare, requires adequate resources, including financial resources. Governments provide these services by building infrastructure and financing projects delivering other services to the citizenry. When providing these services, governments face many constraints, including technical challenges  and financial challenges (because they do not have unlimited budgets) ,2. It isPPPs have received much attention in the context of the development and financing of public infrastructure facilities and services in the last decade due to their inherent advantages. This approach has been adopted by many countries for several reasons, including the need to address fiscal deficits, budgetary pressure and demand-supply gaps . PPPs arPPP adoption in the healthcare sector has increased due to the many benefits that are associated with them, both in healthcare development and management . The benThe Kingdom of Saudi Arabia (KSA) is a high-income, developing country . Its ecoIn KSA, healthcare services are provided through the Ministry of Health (MOH), other government agencies and private healthcare providers. The KSA government is responsible for operating, financing and managing the public healthcare sector, which delivers 80% of all healthcare services, free of charge at the point of use, to Saudi citizens . The priDespite the substantial resources that the government is currently able to allocate to it, the healthcare system, like most publicly funded healthcare systems is increasingly under strain, caused by rapid increases in expenditure and demand while resources remain finite. Hence, as has been recognised by both academics and international health organizations, relying solely on oil revenues to finance public healthcare services is unsustainable in the medium to long term –18.Recently, the Saudi Government initiated a major economic reform and adopted “Vision 2030” as a roadmap for economic development. Vision 2030 is a strategic plan aimed at reducing Saudi Arabia’s reliance on oil revenue and its priorities have been identified in all economic sectors. It has been implemented with the aim of identifying the general direction, policies, goals and objectives of KSA . One of The adoption of PPPs in the Saudi healthcare sector, therefore, requires caution in identifying and attempting to overcome obstacles to their successful implementation in the long term. Hence, it is worth investigating and understanding how to successfully implement PPP in healthcare. This study aims to identify and classify the perceived obstacles and barriers to the successful implementation of PPPs, so that policymakers can take them into consideration as KSA implements the Vision 2030 program. This will allow the government and other stakeholders to recognize the barriers and develop plans and solutions that will prevent them from consistently besetting progress in the healthcare sector. This research adds to the existing body of knowledge on barriers to the implementation of PPPs in the healthcare sector.Cooperation between the public and private sectors in healthcare infrastructure construction and maintenance and healthcare services delivery has been longstanding and takes various forms, from outsourcing to almost complete privatisation of services . PPPs inThere is no single precise definition of PPPs –25. AccoPPPs have been used to encourage and facilitate innovations in many healthcare fields. PPPs in public health research  have incThere are several advantages of PPPs in healthcare, including increasing efficiency, allocating risk, reducing the cost of delivery quality services, increasing accessibility, delivering services on time, adopting new technology and management, solving public sector capital shortages and reducing fiscal and public pressures ,34.For the sake of efficiency, it is estimated that the optimal solution is where a private entity is responsible for a healthcare facility’s design, construction and continuing maintenance . It is eA great advantage of PPPs is proper risk-sharing between the partners. There are many types of risks in healthcare contracts, including demand, demographic change, health changes, epidemiological trends, long-term healthcare demands, infrastructure construction risks, operational risks, and financial risks . Proper In spite of the advantages of PPPs, their implementation still suffers from several disadvantages and impediments, including higher costs of providing goods and services, difficulty in specifying services  resulting in difficulty in quantifying the cost of PPP projects, political risks associated with long-term cooperation between public and private sectors, volatile and often unpredictable external conditions , difficult and often inappropriate infrastructure maintenance and service delivery pricing, lengthy procurement processes, lack of appropriate skills, unattractive financial markets and incomplete risk transfer and higher end user charges –44.PPPs in healthcare projects also experience many impediments that characterise other PPP investments, including lack of suitable skills and experience, lengthy bidding and negotiation processes, lack of well-established legal framework, legal risks, unfavourable economic and commercial conditions, inefficient public procurement frameworks, lack of mature financial engineering techniques, public opposition, delays because of political debate and lack of competition ,45.Both public and private partners in PPP arrangements should work to overcome the barriers and try to ensure that such issues do not hinder the proposed projects’ progress . One of The Saudi MOH is committed to providing healthcare services that meet the needs of the citizenry and has made a commitment to achieve this objective, in part, by empowering the private sector to participate in the healthcare sector’s transformation through partnerships in the financing of capital and realisation of operational projects . It is aThese two projects are currently at the pilot stage and limited information about them is available. The radiology project is extremely ambitious and is planned for a 10 year period. It will cover demand for radiology services from seven hospitals, as well as nuclear medicine services, serving 1 million beneficiaries. The private partner will get, on a “right of use” basis, the existing infrastructure and qualified staff. The private partner will be responsible for replacing equipment over the project term, for investing in IT infrastructure and networks to set up a tele-radiology solution and any required refurbishment. The payment mechanism will be based on ongoing payments by the MOH and will be on a per-scan basis .Because PPPs have only recently been introduced and the MOH has committed to utilising this model until 2030, KSA provides a unique case in which barriers to the utilisation of PPPs can be studied as they arise, allowing the policies to be reviewed and feedback to be provided during the project’s implementation. Such data will be extremely helpful when the MOH expands the implementation of PPPs in the healthcare sector in the future.We conducted a descriptive study to identify and map barriers to the implementation of PPPs in the Saudi healthcare sector. A pre-tested interviewer-administered questionnaire was used to collect data from 72 stakeholders involved in PPPs in the Saudi healthcare sector over a two-month period (June-July 2019). The target respondents included various stakeholders from both the public and private sectors, i.e. those knowledgeable about the implementation of PPPs in this context. They included government leaders, public sector officials, private investors, consultants, lenders and representatives from contractors involved in PPP projects. Interviewer-administered questionnaire was used in order to accurately record responses, to make the most efficient use of time, and to avoid any missing data. The sample was purposively selected to gather the insights of a varied group of people. The study participants’ main characteristics are presented in The questionnaires were administered in the Arabic language by the author (SA). The interviewer read, managed and completed the questionnaire based on the answers provided by the participants to record responses accurately and make the most efficient use of time. The interviews lasted between 15–30 minutes, with an average length of 21 minutes. The interviewer-administered questionnaire guide was adapted from the validated questionnaires developed by Babatunde et al.  and Li .The questionnaire included two main sections. The first section asked the respondents for general information related to their demographic characteristics and PPP project knowledge and experience. The second section was designed to investigate barriers to the successful implementation of PPPs in the Saudi healthcare sector. Forty-six pre-identified barriers were divided into six categories using the SLEEPT approach . Written consent to participate was secured from all respondents who participated in the study.The ranking of the barriers to the implementation of PPPs are presented in For each category of barriers, several statements were used (detailed barriers) to assess the barrier’s importance. Details of the statements and their ranking list  are presented in The analysis of the rankings based on the barriers’ mean values, as rated by the respondents, showed that they ranged from 2.77 to 3.85 . Legal bDelays in approval were considered the biggest legal barrier, with a mean value of 4.06, then law and regulation changes, with a mean value of 3.97. Among environmental barriers, lack of transparency and accountability and lengthy delays in negotiations were considered the leading environmental barriers. The shortage of professionals qualified to handle PPP projects and lack of clarity in the process of implementing PPPs were identified as the two biggest technological barriers, with mean values of 3.78 and 3.69 respectively. Issues with delays in receiving payments and the inability of local institutions to provide long-term financing ranked as the biggest economic barriers, with mean values of 3.64 and 3.53 respectively. Potential conflicts of interests among stakeholders had the highest mean value, 3.81, of the social barriers. Inadequate experience with PPPs and poor understanding of PPPs by decision-makers were the biggest political barriers, with mean values of 3.29 and 3.22, respectively.This study’s findings showed how the respondents ranked the various barriers and that different stakeholders perceive different barrier categories as having different degrees of impact on the success of PPP projects in the healthcare sector in KSA. The evidence showed that the top three barriers, as rated by the respondents, were legal barriers such as delays in receiving approval and permits and law and regulation changes; environmental barriers such as lack of transparency and accountability; and technological barriers such as a shortage of professionals qualified to handle PPP projects.Our findings related to the legal barrier agree with those of other studies that have showed that the lack of adequate legal and regulatory frameworks pose a challenge to the successful implementation of PPPs ,56–58. AWeak/poor regulatory frameworks and enforcement, problems with administrative procedures and guidelines and weak institutional capacity and PPP strategies were identified as strong legal barriers in KSA. Well prepared institutions and a strong legal framework will mitigate delays in approvals and permits, which are the most highly ranked barriers in our study. A well-designed institutional support, the Private Infrastructure Investment Management Center (PIMAC), was introduced in Korea and it would be beneficial to take advantage of its experience. Its functions include (a) provision of advice on structuring PPPs; (b) appraisal of government-sponsored PPP projects and (c) provision of assistance to government agencies in negotiation with private sector PPP developers . It is vEnvironmental issues were ranked as the second-highest barriers to the successful implementation of PPPs, with lack of accountability and transparency being the highest-ranked environmental barrier to the success of PPPs in the healthcare sector in KSA, which is not the case in other countries . ConcernPPPs are like all businesses; they thrive in regions where the laws, regulations and business climate are favourable. In the case of KSA, this study’s results imply that KSA should devise standards that ensure that all parties concerned with the implementation of PPPs are accountable and transparent, both to the public and to each other, so that trust can be established. In addition, laws and policies should be created to facilitate private-sector engagement with the government, with the goal of implementing PPP projects in the healthcare sector.This study’s results also showed that, in KSA, technological barriers are an important element affecting the success of PPPs in the healthcare sector. It is suggested that a lack of professionals with the right experience and skills and project-preparation capacity are obstacles to the successful implementation of PPPs ,62. SimiIn addition, the KSA government should work to improve the capacity of the stakeholders involved in the implementation of PPPs so that the government officials handling such projects can acquire the necessary skills and ability to negotiate proper contracts and become more accountable and transparent. Furthermore, the government can facilitate the process by streamlining such projects into programs, so that they can be prioritised and the private sector will not become overwhelmed by a multiplicity of projects. A good example of a matured user of PPP in healthcare in another country, from which we can learn, is Moheb Hospitals in Iran .The results also showed that there are important political barriers that hinder the successful implementation of PPPs in the healthcare sector. Our study found that the most important barriers are inadequate experience with PPPs and poor understanding of PPPs by decision-makers. Both these barriers in KSA were confirmed by findings from another study that found that the resistance stems from top government officials, who still think that PPP is synonymous to privatization which entails a full divestiture of assets to the private sector . SimilarIn addition, there are economic barriers that make it difficult to implement PPPs. Our findings are similar to those of another study, which suggested that high bidding and transaction costs are also obstacles to the implementation of PPP projects ,68. To eSocial barriers were another factor hampering the effective implementation of PPPs. Because PPPs call for close interaction and discussion between the government and the private sector, such barriers are likely to lead the parties to distrust the processes and, therefore, challenge their acceptance by society at large. In the case of multinational engagements, it has been suggested that cultural impediments can pose serious challenges, especially when cultural competence is lacking ,70,71. TBearing in mind all the potential barriers already mentioned, it should be noted that, for PPPs in healthcare in Islamic countries to succeed, they should be analysed in the context of shari'ah. An example of a pilot PPP in healthcare is the Konya Integrated Health Campus, which was followed by a very similar shari'ah-compliant PPP, the Manisa Hospital in Turkey .Our work analysed the potential barriers proposed by Babatunde et al.  and Li . It woulA few limitations should be considered when interpreting this study’s findings. The study used a purposive sample that was relatively small but suitable for the purpose of the study. The study is, therefore, limited by the sample size, and any future study aiming to corroborate these results should employ a larger sample. Moreover, KSA only has limited experience in PPPs in healthcare because projects have just started. Hence, the different stakeholders’ views presented in this study might be limited by their current experiences. With more experience following the implementation of some projects in KSA, in-depth investigations and further research will be warranted.The authorities in KSA should benefit from the good practices in regulating the procedures of introducing PPPs, including the preparation of PPPs and procurement and contract management, found in other developing countries ,72. It iShould PPPs be more common in healthcare in KSA? If so, then on what scale and which model should be used first? What should be done to ensure that the implementation of projects is successful, thereby contributing to an increase in the level of healthcare services provided? Will their wider application support the efforts made towards Universal Health Coverage? In order to find answers to these questions, one can draw on the experiences of other countries. However, it is necessary to consider each country’s peculiarities and its inhabitants, which might make the copying of solutions effective in certain legal and cultural systems, while, in a different environment, copying might prove useless. The public management models functioning in individual countries are shaped by local, cultural, institutional and legal conditions. An attempt to create a model without considering internal and external conditions is doomed to failure. Whether a PPP can prove to be a useful tool for the socio-economic policy pursued by the Saudi Arabian authorities can only be determined by a careful attempt to put this model into practice, prepared carefully, with an understanding of the essence of the partnership and, above all, according to local conditions.


For a more efficient system of radiation emergency medicine, licensee workers prioritized the workforce, whereas inspectors favored laws and regulations for safety. The survey results show different perspectives between inspectors and licensee workers, which stem from the actual properties of each occupational role in the regulatory system for radiation medical emergency. These data could be utilized for communication and interaction with relevant people to improve the medical response preparedness against radiation accidents.Radiation emergency medicine systems are operated around the world to provide special care for the injured that require immediate medical attention in accidents. The objective of this survey was to evaluate people’s perception of those who design the emergency medical plan for radiation accidents and those who supervise it in Korea. A questionnaire survey was conducted on the people involved in a regulatory system for medical response in a radiation emergency. Of 150 survey recipients, 133 (88.7%) completed the survey, including 92 workers and 41 inspectors. The respondents expressed the view that the national emergency medical plan is prepared above the average level using a Likert-style scale of 1 to 5 . Interestingly, using the Mann–Whitney U test, it could be shown that inspectors evaluated the emergency medical system for radiation accidents more strictly in all of the questions than the licensee workers, especially on radiation medical emergency preparedness  After the Fukushima nuclear power plant (NPP) accident in Japan in March 2011, the public was overwhelmed by severe anxiety about radiation exposure in Korea, which resulted in temporary closures of schools, massive selling of masks against radioactive dust, and a higher distrust of the health and safety of agricultural and marine products from Japan . The peoAs stated in the legal Article 45 of the Act on Measures for the Protection of Radiation Disasters in Korea, all nuclear licensees, such as companies and institutes having nuclear or radiation facilities, should establish medical preparedness plans for protection and human care in a radiation emergency, and implement drills at their facilities following the plan. This is in accordance with the international recommendation for safety requirements assigned by International Atomic Energy Agency (IAEA) as emergency preparedness categories I, II, III, and IV . The emeTo strengthen the medical care for worker victims of occupational radiation exposure due to accidents, a unique regulatory system for radiation emergency medicine was legally introduced to all of the companies and institutes with nuclear/radiation facilities in Korea. They should prepare the emergency medicine plan for nuclear/radiological accidents, including the rescue of the injured, first aid, and transfer of patients to hospitals. The plan should be designed taking into account the scale, structure, and number of workers of each facility, according to references such as the IAEA guidance ,10. SpecThe companies and institutes with radiation facilities should prepare their own emergency medical plans, which should be examined by law. The NREMC has investigated the individual emergency plans for each facility and assessed whether they could be appropriately executed under a radiation emergency. The emergency medicine plans are not identical, and can be very complicated, depending on the scale of the facilities, the structure of the building, and the number of workers. This survey aimed to evaluate the perception of people involved in the execution and examination of the emergency plan of medical preparedness for a radiation emergency. This kind of survey study of the perception of societal issues is usefully applied to investigate the gap-filling of perspectives that are different between interested stakeholders, including the public ,12. PrevA questionnaire  was devip-value < 0.05 was considered to be statistically significant.Statistical analysis was performed using SPSS software . Univariate and multivariate linear regression was performed to explore variables related to the answer to “Do you agree that the national plan of emergency medicine is well-prepared for nuclear or radiation accidents?” A Mann–Whitney U test was used to compare the question #8–#11 score of inspectors with licensee workers. Pearson’s chi-square analysis was used to analyze the difference in the proportion of medical emergency work between inspectors and licensee workers. A One-hundred thirty-three of the participants in the workshop for radiation emergency medicine replied to the survey; 150 questionnaire sheets were distributed (88.7% collection rate). Radiation emergency medicine (REM) staff in our survey of the workshop are representative workers entrusted by each company and institute with the license. In total, 689 persons have been enrolled as REM staff and affiliated with various companies and institutes, including a nuclear power plant, nuclear fuel manufacturing company, large-scale irradiation facility, radio waste disposal company, and R&D institute in Korea (as of 19.03.31). We believed that the survey results showed the representative opinion of the REM staff, considering the response ratio (133/689). Our study subjects consist of workers with various occupations with different affiliations. They are radiation safety officers, administrators, medical doctors, and medical researchers, including health physicists, radiation biologists, and medical specialists. Approximately 70% of the respondents were radiation workers affiliated with companies and institutes undergoing a revision and inspection of the emergency medicine plan, and 43% of them worked for a nuclear power company. Based on the score of five questions assessing the knowledge of radiation, they had the basic knowledge necessary for radiation safety, given that 90.4% answered more than three questions correctly. Over half of them had more than six years of experience with radiation emergency preparedness .p = 0.043). None of the other variables were statistically correlated with evaluation results.People related to medical preparedness of radiation emergencies were asked to evaluate the medical preparedness status of the radiation emergency plan, and the responses were investigated depending on the respondents’ characteristics . They pep = 0.007 in Mann–Whitney U test). Furthermore, they also had different views on the important items of radiation emergency medicine  has entrusted NREMC with the role and responsibilities regarding the examination of the emergency plans. This could produce the perception gap in the evaluation of the licensee emergency plans for radiation accidents, even if the independent assessment is guaranteed, as mentioned above. Expansion of inspectors to other independent institutes may lead to different assessment results. Second, our survey data explained that the current level of national plans in radiation emergency medicine was estimated to be above average without a comparison of previous survey data immediately after the construction of the regulatory system. In other words, this kind of study should be performed repeatedly every two or three years to get more valuable information to produce a well-made emergency plan, regarding communication between inspectors and workers.Based on our survey, we showed differences in opinions of inspectors and licensee workers in the assessment of an emergency medicine system for radiation accidents. Different views seem to come from the actual properties of each occupational role for the regulatory system. It is not easy to determine which one is more important in radiation emergency medicine. Both inspectors and licensee workers should recognize their different perceptions and exchange ideas to find a reasonable and consensual way to improve the regulatory system for radiation emergency medicine. To accomplish the accurate judgment on the emergency medical plan, a regular survey should be implemented and analyzed periodically.


Current understandings of the etiology of traumatic brain injury (TBI) and the trajectory of care significantly lack consideration for the inclusion of Black populations. The global prevalence of TBI is increasing, particularly in North America and Europe where approximately 65 million people are affected every year. Although community integration is an ultimate goal of rehabilitation post injury, persons with TBI, particularly Black populations continually face challenges with regards to unmet needs along the continuum of care including meaningful participation and vocation, resulting in occupational deprivation. While integrated care is seen as an appealing approach to service delivery, little is known about what this means for Black people with TBI. This protocol produces the first critical transdisciplinary (CTD) scoping review mapping the extent, range, and nature of integrated care pathways for Black people experiencing TBI.CTD provides an analytical tool with a health equity lens that will be applied as both a methodology and theory for undertaking this review. Under the methodological guidance of Arksey and O’Malley, CTD will be used to map the literature and better understand the elements of integrated care pathways for Black people experiencing TBI. To identify the published literature, several databases will be searched including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, and Sociological Abstracts.The application of CTD compels health-care providers, administrators, clinician-scientists, rehabilitation specialists, and scholars in the field of TBI and integrated care to re-examine hidden assumptions about racism, racialization, and Blackness that are often embedded in current visions of health for all. The health equity lens of CTD asks about who is accounted for in the research and clinical literature and who is absented. It is anticipated that applying the health equity lens of CTD will provide a critical examination of the literature and illuminate significant implications for integrated care for Black persons experiencing TBI.Not applicable. Wilson  describeThe U.S. Center for Disease Control and Prevention (CDC) defines TBI as a disruption or change in brain function “that can be caused by a bump, blow, or jolt to the head” . TBI canThe consequences of TBI may involve an assemblage of changes with physical, psychosocial, cognitive, behavioral, and emotional states , 11. TheIn 2016, the World Health Organization (WHO) released the “Framework on Integrated People-Centered Health Services,” which promotes a vision whereby “all people have equal access to quality health services that are co-produced in a way that meets their life course needs coordinated across the continuum of care” . The WHOIntegrated care can also be described as integrated care pathways, coordinated care pathways, care maps, connected care pathways, or predicted recovery pathways . These sRacism stems from a historically constructed position of whiteness and embodies a social location of power that marks the social category of white as the locus of social privilege . Racism Race is a socially created category of identity with no biological basis . The conBlackness, and anti-Black racism, are an important part of this picture. Richard Iton  describeCurrent understandings of mechanisms of injury and community integration in integrated care fail to question the existence of racialized social systems and how anti-Blackness operates in a particular geographical context to consciously produce and perpetuate adverse and differential effects. It is difficult to understand how and what community integration means for Black populations without broader discussions of how whiteness, geography, racism, and racialization have shaped the contexts that Black populations inhabit. Community integration is defined by Sander et al.  as sociaThe practice of transdisciplinarity offers a holistic and coherent approach to research, which Pohl  argues sA one-size-fits-all approach that attempts to see the struggle of all minorities as a single and isolated operation to address health inequalities is harmful. For this reason, it is important to classify anti-Black racism as separate from the experiences of other racialized groups. The extent, nature, and range of integrated care pathways for persons with TBI have never been comprehensively reviewed with a health equity lens and, in particular, for the purposes of illuminating how Black people are presented in the literature.It is important that health-care professionals, rehabilitation clinicians and scientists, and policy makers apply a health equity lens to illuminate how health-care systems operate and are structured, including examing the purpose that care pathways and integrated care serves, and for whom. To help close the equity gap, this paper outlines the first protocol of a CTD scoping review that will interrogate and map the field of integrated care and Black populations experiencing a TBI. This review seeks to map the scope of the field in the literature that explicitly examines integrating care with respect to racialization, racism, and Blackness. This CTD scoping review will use a holistic and critical approach to explore the state of the literature regarding the sequencing of care and what happens to Black people as they enter the health-care system, rehabilitation care, and health-related research. This review of the literature will identify knowledge gaps and areas of future exploration, and will contribute to the long-overdue review of the breadth and nature of the literature on integrated care for Black persons experiencing TBI.When appraising the various systematic approaches to reviewing the literature, the scoping review methodology was selected as the best method to map the literature on integrated care for Black persons with TBI. Scoping reviews offer an opportunity for critical examination. Critical transdisciplinarity/CTD operates from a realist onto-epistemological worldview. The ontological tenants of the realist paradigm articulate that “the structures creating the world cannot be directly observed” . RealismThe application of CTD is both a rigorous methodology and theory. Brink  defines This CTD scoping review protocol was developed under the methodological guidance of Akrsey and O’Malley , later rThe current standard for scoping reviews  often inHow are Blackness, race, and racism conceptualized in the literature on integrated care for Black people experiencing TBI?How are the concepts of sex and gender positioned in relation to Black people generally and integrated care for Black people experiencing TBI specifically within the included texts?How do Black people experiencing a TBI come to access integrated care pathways?How do integrated care pathways for Black persons experiencing a TBI take into account the mechanism of injury  and the implications for occupation?In accordance with CTD and to best meet the objectives of this scoping review, the following primary research question is asked: what is the extent, nature, and range of the literature on integrated care for Black people experiencing TBI? The research sub-questions are:To identify relevant studies for this CTD scoping review, the following electronic databases of the published peer-reviewed literature will be systematically searched including MEDLINE (In-Process and Other Non-Indexed Citations), EMBASE, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Sociological Abstracts. This study will not include books or grey literature.The search strategy for this review was developed through an iterative process in collaboration with an Information Specialist. The search strategy included the application of text words and subject headings  in congruence with the following concepts: TBI, integrated care, and Black populations. The terms used for this review were informed based on other reviews on integrated care , 67–74, The complete and final search strategy in MEDLINE can be found in Additional file Given the above operationalization of integrated care pathways, the following inclusion and exclusion criteria will be used:All texts must include a description of an “integrated care pathway” or integrated care, which may be a plan, model, protocol, or intervention that maps onto the pre-identified definition, integrated care pathways refers to, “the tasks to be carried out together with the timing and sequence of these tasks and the discipline for a specific clinical condition”  across aThe integrated care pathway must be considered in the context of persons with a primary diagnosis of TBI of any level of severity.The persons with TBI must include Black persons in the sample or as part of the text for non-empirical articles and/or any of the words race, racism, racialization, and Blackness.The text must be published in English.The text must be peer-reviewed literature.Other neurological conditions that are not indicated as being a sequelae of TBIThe review process in this scoping review will consist of two levels of screening: (1) a title and abstract review and (2) full-text review. Prior to commencing the first level of screening, two independent reviewers will screen a sample of 20 abstracts against the criteria to compare and discuss any discrepancies, to increase consistency. The two reviewers will independently review the first level of screening against the inclusion and exclusion criteria. All articles that meet the criteria above will be included for the second level of screening which will consist of full-text review of the selected articles against the predetermined inclusion criteria. Where differences or any discrepancies arise after discussion between the two reviewers, a third reviewer will be consulted to reach consensus.Please see Fig. After consensus is reached on which articles will be included in the review, the relevant information will be abstracted. To assist with data charting, a form has been designed a priori for this CTD scoping review and will be used to abstract data. The goal is to extract information that will help address the objectives and research questions for this review which have been highlighted in the protocol. Yet, current conventions on conducting scoping reviews often lack detail in their data charting forms and mainly abstract summary characteristics such as the author information, variables, and central findings. CTD is a comprehensive, holistic, and transformative tool that allows individuals to rigorously engage with the literature in a more detailed manner to improve the quality of work. As such, in creating the data charting form, the various elements of CTD including critical political ecology, political economy, critical race theory, and intersectionality were used to comprehensively inform the information required to answer the research questions. Please see Table Where possible, the extracted data will be reported using descriptive statistics. For example, frequency tables may be used to provide a comparative analysis between study locations, and to better understand the representation of Black populations reported in integrated care pathways for persons with TBI. Scoping reviews often include an additional analysis piece that provides a qualitative analysis that reports about themes and patterns . Rather Integrated care has become an attractive “solution” to health-service delivery that has been explored in many chronic conditions. A current challenge of integrated care/integrated care pathway is the lack of consideration for Black lives. This makes it increasingly challenging to understanding what integrated care means for Black people experiencing TBI. In keeping with the current vision of equity and health for all , this prThis review will only examine literature published in English. Unfortunately, the vast majority of reviews exclude literature due to language barriers  and thisA known limitation to scoping reviews is the lack of critical appraisal . The appAdditional file 1. PRISMA-P Checklist.Additional file 2. Medline search strategy.