Middle East respiratory syndrome coronavirus (MERS-CoV) causes a potentially fatal respiratory disease. Although it is most common in the Arabian Peninsula, it has been exported to 17 countries outside the Middle East, mostly through air travel. The Risk Assessment Guidelines for Infectious Diseases transmitted on Aircraft (RAGIDA) advise authorities on measures to take when an infected individual travelled by air. The aim of this systematic review was to gather all available information on documented MERS-CoV cases that had travelled by air, to update RAGIDA. The databases used were PubMed, Embase, Scopus and Global Index Medicus; Google was searched for grey literature and hand searching was performed on the EU Early Warning and Response System and the WHO Disease Outbreak News. Forty-seven records were identified, describing 21 cases of MERS that had travelled on 31 flights. Contact tracing was performed for 17 cases. Most countries traced passengers sitting in the same row and the two rows in front and behind the case. Only one country decided to trace all passengers and crew. No cases of in-flight transmission were observed; thus, considering the resources it requires, a conservative approach may be appropriate when contact tracing passengers and crew where a case of MERS has travelled by air. A novel coronavirus was discovered in 2012 after a patient in Jeddah, Saudi Arabia, died from a severe respiratory disease [Coronaviridae are widely distributed among mammals and birds [The nd birds , and thend birds . This fand birds , a betacThe origin and the transmission of MERS remain poorly understood; however, coronaviruses have been isolated from bats worldwide and MERS-CoV has been detected in camels throughout the Middle East and Africa , 7. IdenR0) during this outbreak was estimated to be 8.1 before measures were undertaken to control the spread of the disease [Around 84% of all MERS cases have been reported from Saudi Arabia , and all disease . However disease .Table 1et al. [The clinical presentation of MERS extends from a mild respiratory disease to a fatal lower respiratory tract infection and the incubation period ranges between 2 and 14 days (average 5 days). Asymptomatic infections have been identified through contact tracing investigations  and seroet al.  suggest et al. , 26. Theet al. . Most MEet al. .The diagnosis of the disease should be performed by using reverse transcription PCR, real time or conventional, targeting either the upstream of the gene E (UpE gene) or the gene N (UpN gene) as an initial screening test. For confirmation, ORF1b or ORF1a are used , 27. TheIn 2007, the European Centre for Disease Prevention and Control (ECDC) initiated RAGIDA (Risk Assessment Guidance for Infectious Diseases transmitted on Aircraft) to assist national public health authorities in the EU in the evaluation of the risks associated with the transmission of infectious agents on board aircraft and to advise on measures for containment . This prIn-flight transmission has been documented for several diseases. The systematic review in 2009 identified 18 cases of on-board transmission from tuberculosis infected persons; 81 infections resulted from influenza infected travellers; 26 passengers were infected during flight by persons with SARS; one person got meningococcal infection; and six people had been infected with measles , 31, 32.One of the in-flight transmission events of influenza  occurredThe most important public health intervention carried out after a case of any infectious disease with person-to-person transmission potential travels on board aircraft is contact tracing. Contact tracing is the process of identifying people who may have encountered an infected individual, to alert them about the possibility of infection, offer testing for diagnosis and provide prophylactic care, when available. The goal of contact tracing is to interrupt the transmission of the disease and reduce the spread of the infection.This review aims to gather the available evidence needed to guide health interventions, such as contact tracing, in the event of a case of MERS travelling on aircraft, and to provide a thorough description of cases on aircraft, interventions undertaken, and, if any, in-flight transmission events.Is there any evidence that MERS-CoV has been transmitted to passengers and/or crew on aircraft?Have any interventions been taken after a case of MERS-CoV travelled on aircraft? What were they and what were the outcomes?We aim to answer the following primary and secondary questions:This systematic review was conducted following the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines , and theFor the primary question, the study population was defined as all aircraft passengers and crew exposed to a case of MERS on board aircraft. The outcome sought was whether any in-flight transmission to passengers or crew had occurred.For the secondary question, the study population was defined as all aircraft passengers and crew exposed to a case of MERS on board aircraft, with intervention defined as contact tracing, laboratory testing or authorities informing the study population about the exposure to a MERS case. The outcome sought was a description of the interventions that took place in an attempt to alter the risk of onwards transmission of the disease.For this review, a ‘case’ refers to a passenger on board aircraft who was diagnosed with MERS-CoV infection (using molecular methods as stated in the WHO case definitions ) and whoA possible event of in-flight transmission was defined as the detection of any person on board aircraft where a case of MERS had been present, and who was diagnosed with MERS after the flight, who had no other known previous exposure to the virus or risk factors (i.e. direct or indirect contact with camels), and with symptom onset within 14 days of the flight.All reports describing a case of MERS who had travelled on aircraft while symptomatic were included in this review. Reports where no public health measures are described after a case of MERS had travelled by aircraft were also included. A report was excluded if the case was asymptomatic during the flight, or if it described an importation or exportation of MERS-CoV between countries, but without specifying that the case had travelled by aircraft. Other exclusion criteria included the setting not being an aircraft, or the disease not MERS.The electronic literature databases used for retrieval of peer-reviewed articles were Medline (PubMed), Embase, Scopus and Global Index Medicus. Google was used to search for grey literature. Additionally, hand searching was performed on relevant events reported in the EU Early Warning and Response System (EWRS), a communication tool between health authorities in the EU; and on the WHO Disease Outbreak News (DON) section for MERS-CoV. Public health officers were contacted by email to complete information missing from sources.Keywords from natural and controlled vocabulary (MeSH terms and Emtree terms) were identified for each component of the study questions, to be used in the electronic literature search. The specific search strategy was created with input from all authors and with support of a Medical Library Specialist, and subsequently peer-reviewed by a second Medical Library Specialist.No limits were set regarding time coverage, language, type of study design or publication status.Forward and backward reference checking of the articles selected and all systematic reviews, literature reviews and modelling studies was performed to ensure the identification of all relevant studies.The initial search was carried out on 18 February 2019, and an alert was set up for all database searches, so notifications of new search results were received up until the final analyses were complete, on 31 May 2019, and eligible studies were retrieved for inclusion.The search was broadened by including terms related to SARS-CoV on board aircraft to ensure misclassified articles about MERS-CoV were captured, or to gather indirect information on transmission if the number of MERS-CoV-related articles was too low to perform an analysis.An example of the search strategy, used for PubMed, is included in the All results from the database search were uploaded to Endnote v7.8; this tool was used for de-duplication of references, for the initial title and abstract screening process, and for full text retrieval of relevant articles.For each of the references resulting from the search strategy, an initial title and abstract screening was performed to identify articles relevant to answer the review questions. Titles and abstracts were assessed independently by two reviewers to increase the reliability of the inclusion and exclusion process. For records lacking abstracts, the full text of articles with relevant titles were considered.At this step, all systematic reviews, literature reviews and modelling studies were included to perform a reference cross-check to validate our search and prevent omissions, even if they were later excluded upon evaluation of the full texts.For all sources passing the initial abstract screening process, a copy of the full text was retrieved and evaluated by the two reviewers.Articles were included when both reviewers determined that the article met the inclusion criteria. All disagreements were resolved by consensus.Data about the flight, the confirmed MERS case on board, the contact tracing investigation of the flights and any additional public health interventions implemented were extracted using pre-designed tables to systematise the data collection and evaluation. Explicit descriptions of each item were formulated before the extraction. All items retrieved are listed in When information between different sources regarding the same case conflicted, the information on the source with the highest quality of evidence score  was considered.WHO DON reports that only provided an update of a previous mentioned case, but did not report a new case, were regarded as duplicates of the first, but data were updated.When not reported, flight times were estimated by using Google Maps. When no city of departure/destination was available, capital cities were used. For all MERS cases that travelled by flight while symptomatic, country of flight origin was considered the country of probable exposure.Risk of bias assessments were performed on all included records using a modified version of the Bias Assessment Tool  developeAll data were collected, summarised and analysed using Microsoft Excel (2016).A total of 47 records  describing 21 cases of MERS who had travelled on aircraft while symptomatic were identified for inclusion in this review. The search of online medical databases provided a total of 729 references, plus 49 additional records obtained by the set-up alerts. Another 240 records were identified through hand searching, Google searching and reference checking, for a total of 1018 records. After de-duplication, 728 records remained for title and abstract screening. Of these, 635 records were discarded because they did not meet the inclusion criteria. The full text of the 93 remaining records was evaluated in more detail, and 47 were deemed relevant for this review. Reasons for exclusion are described in None of the records included described all items sought. All records reported country of flight origin and destination, although 28 (60%) did not report city of departure and 17 (36%) did not report city of destination. None of the records mentioned any ground delay or the HEPA filter function.One article mentioned the type of aircraft, one mentioned the exact total flight duration, two mentioned the total number of passengers and crew members on board and one mentioned the sitting characteristics of the case on board. Twenty-nine records mentioned a contact tracing investigation was done on the case's flight. Communication with three public health officers did not reveal new information regarding the included cases.Of the 47 records, 26 were classified as having a low level of evidence, most of which were WHO DON reports and EWRS notifications, due to the limited amount of information contained in them; 17 records obtained a medium score, and four peer-reviewed articles got a high score (Appendix 1).The 21 cases described boarded 31 flights while symptomatic. Three of the cases were transported to another country by air ambulances. No secondary cases of in-flight transmission were identified.Eighteen cases were male (86%). The median age was 57.5 years (range 18–85 years) . ThirteeEight cases were residents of Saudi Arabia. Other countries of residence included Qatar, United Arab Emirates, United Kingdom, Italy, Netherlands, South Korea, Oman, Kuwait and Malaysia. Six cases travelled with family members.The most common symptoms present during flight were fever and respiratory symptoms other than cough . The thrThe outcome of the disease was not mentioned for all cases (70.2% of the 47 records had no information), however, at least three died and nine were discharged from the hospital as cured. The observed case fatality rate among the 12 cases with known outcome was 33%, and among all 21 cases was 14%.Out of the 47 records included in the review, 29 stated that a contact tracing investigation had been carried out on the case's flight, and of those, 19 described the contact tracing results. Contact tracing of the passengers and crew on board the aircraft was carried out for at least 17 cases and 24 flights; it was not mentioned whether contact tracing had been carried out for the remaining four cases. At least 18 countries are mentioned to have been involved in a contact tracing investigation: Austria, China, Germany, Greece, Italy, Malaysia, the Netherlands, Oman, Philippines, Poland, Qatar, Saudi Arabia, South Korea, Taiwan, Thailand, Turkey, the United Kingdom and the United States of America.Cases were diagnosed an average of six days after they had travelled on aircraft. Contact tracing investigations were initiated an average of 0.5 days after the case was diagnosed with MERS, that is, either on the same day of diagnosis or just before, when MERS-CoV infection was suspected . The ave‘Contacts’ for contact tracing investigations were most commonly defined as the passengers sitting in the same row as the case and in the two rows in front and behind (known as the two-row rule). Contact definitions for passengers and crew per country performing the investigation are described in more detail in The most widely used method for identifying contacts was requesting the passenger manifest and contact details from the airline. Contacts were most commonly reached by phone . Some coThe median and the mean number of contacts identified per flight were 24 and 109.9, respectively. This varied widely between cases (range 9–561), depending on the contact definition used  and on the number of flights boarded by each case. In most contact tracing investigations, more than 50% of the identified contacts were reached and followed for the 14-day maximum incubation period of MERS-CoV. This again was dependent primarily on the definition of contacts used; the most successful interventions (records that mention that 100% of the contacts were reached and followed for 14 days) were observed when a two- or three-row approach was taken, and was the least successful when more complicated definitions were used, such as dividing contacts into several categories . ContactCases 1−3 in this review  were traThe most important factor that delayed the possibility of conducting an adequate contact tracing of the flight mentioned by authors, was the unavailability of all passengers' contact details, since many airlines do not demand these details in all situations for booking tickets.The most common additional health intervention described in the reports included contact tracing of healthcare workers, family members and other contacts of the case not present on the flight, such as co-workers or bus passengers, which was mentioned in 21 records.Other additional or alternative interventions carried out by national public health authorities included: press releases to alert passengers and crew about a possible exposure to MERS-CoV and to inform on what measures to take, such as going to a health care professional if they develop any symptoms (mentioned in eight reports); setting up a hotline for passengers on the flight to be able to reach authorities (one report); and communication with international public health authorities of countries whose nationals had been on board the flight (seven reports). One of the countries also decided to evaluate the psychological stress generated by the contact tracing investigation on the passengers of the flight, and concluded that contact tracing seems to be a stressful event for passengers.During the screening process, 16 additional records were found describing eight cases of MERS that had travelled by aircraft before symptom onset. For two of these cases, contact tracing of the flights was carried out and no secondary cases related to these flights have been reported by any of the involved countries (Appendix 2).In this review, no evidence of secondary transmission of MERS-CoV on board aircraft was found among the 21 cases included in the study. To the authors' knowledge, there have been no secondary cases reported from flights worldwide, in contrast with at least 26 secondary in-flight transmission events documented during the multi-state outbreak of SARS, and multiple reports of SARS-CoV-2 transmission. MERS-CoV seems to not have acquired the ability of sustained transmission between humans outside of healthcare settings or households – situations where close contact or aerosol generating procedures are frequent.The demographic characteristics of the reported cases who had travelled on board aircraft  were not markedly different from those of all globally reported cases. Most cases were probably exposed in Saudi Arabia, the country with the highest number of MERS-CoV cases worldwide. The finding that most cases travelled during 2014 also coincides with an outbreak in Saudi Arabia during that period [An important factor to consider when deciding who to trace, is the movement of passengers around the aircraft. Any passenger that changed seats may therefore have to be included (or excluded) in the contact tracing investigation. The case may also have interacted with passengers sitting on further rows during the flight, and proximity during boarding or disembarking, while hard to ascertain, may be relevant.It was encouraging to find that most contact tracing investigations were initiated soon after the cases were diagnosed with MERS-CoV. This highlights that countries involved in the reported events have appropriate guidelines in place and have the capacity to respond timely to these events. From this review we cannot conclude if this is the case for other countries.The aim of this review was to gather all available information on MERS-CoV cases that have travelled by aircraft and any evidence of in-flight transmission events, with the goal of producing an update of the RAGIDA project including a chapter on MERS-CoV. Having no transmission events during any flight hinders the possibility of making an assertive recommendation on whether to trace a limited number of rows or the whole plane when a case of MERS-CoV travels by aircraft. Since no transmission has been observed either on rows around the case or on further rows, it is not possible to know how far away from the case the infection is likely to spread. The lack of in-flight transmission observed in this study suggests that a more conservative approach, with fewer rows traced, may be adequate, also considering the large resources needed for conducting contact tracing investigations , 39.The most significant limitation was the scarce amount of data regarding the flights and the contact tracing investigations from many of the records included. However, records were not excluded based on the quality or quantity of the information given in order to extract the largest possible amount of information and to avoid any omissions. Although experts were contacted regarding missing data, no further information that could have improved the analysis was obtained.Furthermore, for 15 of the 21 cases included more than one source of information was identified. Two cases were mentioned each in six different records. Incorporating all the information from several sources into one set of results, while avoiding making incorrect assumptions, was challenging but has, in our opinion, resulted in the best available evidence.Although it was not expected that every record identified would report all items sought in the review, none of the sources mentioned whether there was any ground delay of the flights, or whether it was known if the HEPA filter was functioning adequately. Since these factors have been important in previous in-flight transmission, future case reporting should consider them to support learning and decision making regarding contact tracing. Similarly, only two records mentioned the total number of passengers and crew members on board; one mentioned the exact duration of the flight, and one mentioned the seating characteristics of the case. We consider the items used for the review to be useful for future contact tracing data collection and reporting shown in .On 26 November 2019, ECDC organised a meeting to discuss the results of this systematic review and determine the most adequate course of action to take whenever a case of MERS-CoV has travelled by aircraft. The guidance has been published online . In the


Negotiation scoring systems are fundamental tools used in negotiation support to facilitate parties searching for negotiation agreement and analyzing its efficiency and fairness. Such a scoring system is obtained in prenegotiation by implementing selected multiple criteria decision-aiding methods to elicit the negotiator’s preferences precisely and ensure that the support is reliable. However, the methods classically used in the preference elicitation require much cognitive effort from the negotiators, and hence, do not prevent them from using heuristics and making simple errors that result in inaccurate scoring systems. This paper aims to develop an alternative tool that allows scoring the negotiation offers by implementing a sorting approach and the reference set of limiting profiles defined individually by the negotiators in the form of complete packages. These limiting profiles are evaluated holistically and verbally by the negotiator. Then the fuzzy decision model is built that uses the notion of increasing the preference granularity by introducing a series of limiting sub-profiles for corresponding sub-categories of offers. This process is performed automatically by the support algorithm and does not require any additional preferential information from the negotiator. A new method of generating reference fuzzy scores to allow a detailed assignment of any negotiation offer from feasible negotiation space to clusters and sub-clusters is proposed. Finally, the efficient frontier and Nash’s fair division are used to identify the recommended packages for negotiation in the bargaining phase. This new approach allows negotiators to obtain economically efficient, fair, balanced, and reciprocated agreements while minimizing information needs and effort. Negotiation is a complex process in which two or more parties with mixed interests resolve their common decision-making problem . It invoFor this reason, the theory of negotiation analysis offers a series of support protocols, algorithms and methods that facilitate the negotiators in their prenegotiation activities . The resThis paper aims to present a novel framework for preference declarations, scoring negotiation offers, and identifying efficient solutions based on a fuzzy clustering model. First, the general method for representing the preferences in negotiations by triangular fuzzy numbers is proposed. Next, the model of preferences is built that derives from the notion of fuzzy clustering. It assumes that, instead of a tiresome evaluation of all elements of the negotiation template, negotiators declare their preferences holistically in terms of complete packages that can be considered as limiting profiles of predefined categories. For such a definition of the preferences, the scoring rules are proposed to cluster any feasible negotiation offer. Some mechanisms for increasing the scoring granularity are also suggested, which reduce the number of offers considered indifferent but simultaneously resign from defuzzification that would question the use of the fuzzy approach at the initial preference elicitation stages. Finally, the methods for searching the Pareto optimal and fair solution in bilateral negotiation are described for our fuzzy clustering model. The usefulness of the proposed approach is shown using a typical example of supply negotiations.By proposing our framework, we contribute to the theory of negotiation analysis with a novel approach that can be used to organize the prenegotiation preparation activities and the process of suggesting efficient and fair solutions to the negotiating parties. It: (1) accepts uncertainty in the evaluation of negotiation offers that are considered as the limiting profiles in the preference model; (2) reduces the cognitive demand imposed on the parties, not requiring a precise evaluation of all atomic elements of the negotiation template, but operating with a holistic approach and comparisons of complete packages; (3) allows to increase the scoring precision without additional interaction with the negotiator; (4) implements the mechanisms for recommending efficient and fair solutions that may ease the problem of searching of a mutually acceptable agreement.The paper consists of seven sections. The second section presents an overview of the literature on the fundamental issues related to the decision support in negotiations, i.e., the definition of the negotiation template, its evaluation, determination of the scoring systems, and their use to support the parties in finding the satisfying agreements. ith issue, and Negotiation analysis aims at providing the negotiators with tools that facilitate the entire negotiation process and support them in decision making as well as achieving a mutually satisfying agreement see ,12). The. The12])Such a definition of the negotiation template assumes the discrete representation of the negotiation problem. This is, however, a technical simplification only, which does not collide with the continuous nature of some issues . In the case of continuous issues or issues with numerous feasible resolution levels, sets  options . TechnicThe aforementioned definition of template ith issue, and With the definition of the negotiation space, a problem of supporting negotiators in finding the agreement is technically reduced to the problem of searching space The entire negotiation space The negotiators may use the individual scoring system to analyze the profitability of concessions, track the negotiation progress by analyzing the concession paths, visualize the negotiators’ moves on the negotiation history graphs, etc. see ,15,16). ,16. 15,1In this paper, we consider bilateral negotiation only; therefore, the negotiation space d F2 see .In the search for reasonable compromise recommendations, the entire space is limited to the efficient frontier only, i.e., to the subset of Pareto-efficient packages  efficient frontier to be subject of renegotiation. If the parties are unable to find the compromise themselves, some notion of fair solutions may be applied to find one for them, such as classic Nash fair bargaining solution or other similar see ,18,19). ,19. 18,1Since the scoring systems are used to support negotiator individually and jointly (as described in The SMARTS (Simple Multi-Attribute Ranking Technique) method  represenTherefore, alternative approaches are designed to reduce the cognitive burden. They implement holistic judgments that use the principle of preference aggregation–disaggregation and require negotiators to declare their preferences over some subset of complete packages only  . This inanalysis ,35. The analysis ,37. Hencanalysis ,21. Simianalysis , which hanalysis .A few problems with implementing holistic approaches in prenegotiation may occur. First, taking into account the imprecise nature of holistic declarations, it may be unjustified to derive the crisp ratings for options and issues out of them, especially when one realizes that they may depend on some technical parameters of linear programming models required to decompose the preferential information. Second, such a holistic approach requires a predefined subset of alternatives (packages) to be evaluated by the negotiator, and inventing such a subset may be a cognitively demanding task itself. Some experimental studies show that leaving this issue to an inexperienced user may result in quite poor results . This isAll the classic approaches described in In real life, negotiation is usually a complex and ill-structured problem, e.g., the information available to negotiators and their preferences are incomplete or imprecisely defined . Moreover, both parties have limited information about the preferences of each other. For modelling uncertainly and impression in decision-making problems, several theories offered useful tools, including fuzzy sets ,42, inteA variety of fuzzy support negotiation models have been proposed in the literature. The fuzzy set concept in determining the negotiators’ preferences was applied in a multi-attribute utility model in a bilateral Negotiation Support System (NSS) by Bui and Sivasankaran . Matos aIn another paper, Kim  describeRoszkowska and Wachowicz  proposedAs defining preferences over the template or negotiation space elements may be cognitively demanding , the linIn this paper a novel framework of scoring negotiation offers based on a fuzzy clustering model, were the negotiation option as well as negotiation packages are represented by triangular fuzzy numbers is proposed. Although the negotiation analysis currently offers a variety of decision support approaches to facilitate the prenegotiation preparation and evaluation of the negotiation template, they still reveal some shortages. Some of them enforce the negotiators to operate with precise declarations of the strength of preferences for the disaggregated templates, which is time-consuming and unnatural to many negotiators, as they are forced to evaluate the options regardless of the potential offers they constitute. Some others allow for holistic declarations but require series of countless and tiresome comparisons of ample reference sets to define the preferences at acceptably accurate level. Alternatively, they allow using imprecise preference declarations employing linguistic scales and accompanied grey or fuzzy numbers, but operate with the numerical equivalents a priori defined for these scale without any reflection on how the negotiators may perceive these scales and how they interpret the verbal etiquettes from these scales in terms of quantitative relationships. Additionally, when the imprecision of evaluation is allowed, and fuzzy numbers are used to describe the preferences, they are eventually very often defuzzified to allow for comparisons between the offers and provide the negotiators with a univocal recommendation regarding the offer quality and the scale of concessions it requires. Therefore in this paper, we propose an alternative approach that, on the one hand, would allow negotiators to imprecisely and holistically declare their preferences over the subset of feasible negotiation space, but simultaneously will allow expanding this preference information over the entire negotiation space and use these imprecisely preferences to measure the differences between the quality of the offer and suggest the potential agreement’s improvements or fair compromises without any unjustified aggregations to their scalar and crisp form. The underlying element of this approach is a change in the perception of the problem under considerations, i.e., it replaces the problem of ranking the alternatives with the problem of their sorting . In this approach, it is assumed that instead of determining the ratings of alternatives, they need to be assigned to the predefined categories of quality. Hence, instead of defining the set of reference alternatives out of the ranking of which the value functions are determined, it is enough to define the examples of offers that will be considered as the limiting profiles of the predefined categories. Such an approach seems quite universal, as it may be applied to basically any core MCDA technique used later to assign the offers into the classes see ,74,75). ,75. 74,7Despite the fact that the sorting-based approach seems promising in prenegotiation offer evaluation , some issues should be addressed and solved before applying it to the process of scoring the negotiation template. Two issues are the most important. First, how to increase the granularity of the evaluation of the offers, here limited to some (at most a few only) ordered categories that would allow differentiating among all (or at least the majority of) the offers within Let us assume that for negotiation space ue G see .Using the aforementioned definition of categories and profiles, the classification rule may be defined, which will allow to assign any offer However, to be able to provide the negotiators with mutual support as described in Hence, no scoring system as defined by Naturally, the small number of categories results in the narrow evaluation scale and may make many offers to be indistinguishable in the sense of preferences. We may, however, increase the evaluation scale in our approach by implementing the same notion of interpolation that is classically used to determine the scores for options other than salient in traditionally defined template The only remaining issue that should be considered now is how the preferences of the negotiators should be captured to allow the classification rule (5) to assign each offer into a corresponding category and sub-category. In the following subsection, the issue of implementing the linguistic scales to define the categories decoding them into fuzzy numbers describing the performance of each limiting profile within each issue is introduced.The preliminary definitions of fuzzy sets, fuzzy numbers, fuzzy operations and fuzzy preferences are presented below.Fuzzy number. A fuzzy number is defined as a fuzzy subset of the universe of discourse ℜ that is both convex and normal. The most commonly used form of fuzzy numbers is Triangular Fuzzy Numbers (TFNs).Triangular fuzzy number. Triangular fuzzy number Then, TFN Operations on TFNs. For any given two TFNs The fuzzy weights and normalization formula. We adopt the notion of fuzzy weights proposed by Wang and Elhag  for supplier (N2). for recipient  it was possible to choose the best package. The article presents a new fuzzy multi-criteria decision model for comprehensive negotiation support. The developed model can be a useful tool for the so-called third party in determining a set of effective and fair negotiation proposals. Thanks to the model, it is possible to take into account a wide variety of proposals while minimizing the information requirement. Moreover, the main advantage of the proposed model is that it can process linguistic information to minimize cognitive effort.The main contribution of the authors relates primarily to three elements. Firstly, with the development of a new method of generating a set of negotiation issues on the basis of the sparse information obtained from negotiators expressed in fuzzy numbers. Secondly, with proposing a new scoring system for negotiation issues, and thirdly, with presenting a new method of generating reference set of limiting profiles. Our contribution is therefore both theoretical—in terms of developing a new model based on fuzzy numbers and practical—by developing a useful tool for managers to support the negotiation process. A limitation of the developed model is its bilateral nature. At this stage of the research, the authors did not assume the possibility of more than two parties to the negotiation. Another limitation of the model concerns the use of only triangular fuzzy numbers. Further research by the authors of the article will concern, on the one hand, the reduction of the current limitations of the model, i.e., the development of a new method by including the possibility of modeling the negotiation process in which more than two parties are involved. Moreover, it is assumed that fuzzy number concepts other than triangular ones can be used in the model. In addition, the authors plan to improve the determination of criteria weights in further studies. Currently, the model is based on simple linguistic scales. An interesting idea is to use other advanced weight determination methods such as Best Worst Method (BWM), Level Based Weight Assessment (LBWA), or Stepwise Weight Assessment Ratio Analysis (SWARA). Regarding the measurement scales used in the proposed model, it is important to investigate other types of measurement scales. This could be conducted using simulations. It would allow us to determine the relationship of the effect of a measurement scale on information granularity. It will also be a good idea in further research to compare the proposed model with methods based on rough theory, soft sets, or grey sets. Another important issue is that only a numerical example is shown in this paper. It is therefore advisable in the near future to study the use of the proposed method in the context of real negotiation problems. Real application of the model will allow us to validate its usefulness not only on the level of mathematical correctness but also in the context of business pragmatics.


Thailand is a popular host nation for international migrant workers, particularly those from Cambodia, Lao PDR, and Myanmar. Thailand has introduced approaches to protect their rights for health and social welfare, using various mechanisms over many years. However, the implementation of these policies is dynamic and has been influenced by national security, economic necessity, and public health concerns. The aim of this study was to explore how Thailand designs and implements health and social welfare policies for migrants in Thailand, both before and during COVID-19. A qualitative analysis was used alongside interviews with 18 key informants in various sectors in this field. Thematic coding was applied. Results show that there were seven key themes emerging from the analysis, including: (i) sustainability of the HICS; (ii) people dropping out from the Social Security Scheme (SSS); (iii) quality of health screening in the Memorandum of Understanding (MOU) migrants; (iv) health screening problems and state quarantine management in response to COVID-19; (v) managing the migration quota and dependency on migrant workers; (vi) influx of migrants in the backdrop of COVID-19; and (vii) poor living conditions of migrants and the impact of COVID-19. The majority of interviewees agreed that undocumented migrants is a critical concern that impedes access to migrants’ health and social welfare. This situation was especially pronounced during the second wave of COVID-19 in Thailand, which took hold in migrant communities. In the short term, the poor living conditions of migrants urgently need to be addressed in order to contain and mitigate this crisis. In the long term, there needs to be an improved health system design that includes migrants, regardless of their immigration status. This requires intersectoral policy coherence, including the hastening of nationality verification to sustainably mitigate undocumented migrants. Southeast Asia is one of the world’s most dynamic regions, with a substantial volume of migrant workers moving within the region, as well as between the region and the rest of the world . DestinaGlobally, it is estimated there are over 20 million migrants from ASEAN member states, about seven million of whom have migrated within the region . By usinNet-sending or net-receiving countries are identified according to migrant profiling. Cambodia, Indonesia, Lao PDR, Myanmar, the Philippines, and Vietnam are net-sending countries, while Brunei, Malaysia, Singapore, and Thailand are net-receiving countries of labour migration . While iOf course, all these migrants have healthcare needs to varying extents. A large amount of literature explores the health system function of providing care for migrants from the perspectives of receiving countries. For example, Guinto et al.  investigIn addition, the unforeseen arrival of the coronavirus disease 2019 (COVID-19) has left migrant workers especially vulnerable and susceptible to the crisis . They arThailand is the most significant host among ASEAN members, being the prime destination for many migrant workers over many years. Most of the inflow migrants are from neighbouring countries, namely, Cambodia, Lao PDR, and Myanmar (CLM) . In 2018In Thailand, financial protection for migrant workers is separate from that of the Thai population. Due to the successful implementation of universal health coverage (UHC), in 2015, 98.5% of the Thai population was insured by three public health insurance schemes, including the Universal Coverage Scheme (UCS), the Civil Servant Benefit Scheme (CSMBS), and the Social Security Scheme (SSS) . HoweverDue to the fact that Thailand shares a very long border with its neighbouring countries, the influx of undocumented migrants still continues . AlthougTherefore, a better understanding on the policy design to facilitate access to healthcare and address the challenges in utilizing health services among cross-border migrants is imperative, and Thailand can serve as a good case study. We hope that this study will provide insights to improve policy coherence and shared responsibility among member states in the ASEAN. The objective of this study was to investigate how Thailand designs and implements policies to protect the health of migrants living on their soil during COVID-19. The challenges of care faced by migrant workers against the backdrop of COVID-19 were also examined. Note that the concept of health encompasses many aspects of wellbeing, not just physical health.A qualitative cross-sectional study was employed. A health systems framework, adapted from Abubakar et al.  and LeveA purposive sampling method was used to target interviewees who had experience working to support migrants’ access to healthcare. Experts in the field of migrant-related policies suggested potential professionals in different governmental and nongovernmental agencies. The target migrant population, as the focus of the interview, was low-skilled migrant workers from neighbouring countries including CLM nations as these migrant workers are considered to be the majority of the overall migrant worker population in Thailand and have been the main target of migrant policies of the government . Cross-bA total of 18 key participants were included in the first phase of the interview, including those from the health sector, nongovernmental organisations, international organisations, and academic institutions see . All of Inductive and deductive thematic coding was applied in the data analysis. The interviews were audiotaped and transcribed verbatim and then manually coded in an Excel programme for thematic analysis. The themes were broadly classified into four areas. These included health insurance and financial protection for migrant workers; healthcare services; factors and challenges affecting health services; and legal mechanisms to protect the migrants’ right to health. However, for the health determinants of migrants, the focus was on clean environments, living conditions, and basic sanitation as part of occupational health and safety, which are significantly linked to the spread of COVID-19. After that, open coding was performed based on inductive thematic analysis, and the findings were categorised into subthemes emerging from the deductive coding. The interviewees were coded as letters to maintain anonymity. Document reviews on grey literature and online documents were undertaken to explore more relevant information, such as updates on health insurance arrangements, the impact of COVID-19 on migrants’ health and wellbeing, and the recent notifications of the MOL and MOI. This approach was part of triangulation to check the validity of the study results.Ethics approval was obtained from the Institute for the Development of Human Research Protections in Thailand (IHRP 340/2562). All participants were asked to sign a consent form on a voluntary basis. The interviewees were free to stop the interview at any time if they felt uncomfortable or unable to participate in the discussion. Individual identification was kept anonymous.Seven key themes emerged from the analysis. The key themes included: (i) sustainability of the HICS; (ii) people dropping out from the SSS; (iii) quality of health screening in MOU migrants; (iv) health screening problems and state quarantine management in response to COVID-19; (v) managing the migration quota and dependency on migrant workers; (vi) influx of migrants in the backdrop of COVID-19; and (vii) poor living conditions of migrants and the impact of COVID-19. Key findings for each subtheme are described as follows.Some interviewees suggested that the concept of the HICS itself might contradict fund management by using the provider–purchaser split, as the MOPH acts as the insurer and the provider at the same time. It is obvious that there are different structural mechanisms in the SSS, which is run by the MOL, in comparison to the HICS, which is managed by the MOPH. Some interviewees suggested that for the HICS, an independent body could be established to manage the HICS funding separately in order to avoid a conflict of interest (COI). However, currently, the MOPH acts as a provider of health services and runs the health system supporting migrants. At the same time, it is also a manager in the operation of the HICS funding.I think there should be an independent body to manage the HICS funding which is not the MOPH. We should separate a provider from the funding manager (to prevent COI). The MOPH can be a provider to manage health care services and the health systems overall.”“—Public Health Officer PA-5A concern about the smaller pooled funding of the HICS was raised (the number of the HICS beneficiaries is about one million). One participant mentioned the sustainability of the HICS funding, where other beneficiaries of highly skilled workers might be included in the scheme in order to have greater pooled funding at the central authority. In comparison with private health insurance, the MOPH can communicate advantages of the HICS benefits to these beneficiaries, including better health promotion and chronic disease packages.As the HICS funding is not that big, we can include more beneficiaries of high-skilled workers to maintain the sustainability of this funding pool. We can also inform them about advantages of HICS packages that cover health promotion and non-communicable diseases in order to compete with private health insurance.”“—NGO PA-2In addition, some participants mentioned the idea of integrating the HICS (for migrants) with the UCS (for Thais). Some participants referred to the United Kingdom (UK) health insurance scheme and the National Health Service, which is the only organisation responsible for all beneficiaries or ordinary residents in the UK . OrdinarTo set up on a single health insurance system like the UK can be a way to improve health and social equity. For the operational cost, I think this approach could save more money too as the management of different health insurance schemes will become less complex. However, it can be difficult in practice because the UHC law includes only beneficiaries with Thai nationality only.”“—Public Health Officer PA-5All employees who are working in the formal sector regardless of their nationality are insured by the SSS. The SSS benefits cover nine areas of health and social welfare. These include medical care, sickness, unemployment, old age, employment injury, family maternity, invalidity, and survivors’ benefit ,22. HoweSome migrant workers stay in Thailand for a short period of time, and some of them often change their employers. So migrants’ employers would not be satisfied once their migrant workers move away and they do not want to pay for the SSS fund because somehow it is not cost effective .”“—Public Health Officer PA-5There is inequity of access to the SSS information between migrant workers and the Thais. Some migrants they do not know once their payment will be sent to the SSS or not. And it is too late that they can use this SSS when they get sick and want to do medical reimbursement. So I would like to see the proper SSS information system to help them track their payment and know their right.”“—NGO PA-7During the COVID-19 crisis, the MOL announced a financial relief for migrant workers who were forced into unemployment. However, the criteria for receiving this benefit were quite strict: (i) migrants needed to contribute to the SSS fund for at least six months prior to the unemployment condition; (ii) they needed to complete self-quarantine as a result of the closure of their workplace; and (iii) their prior employment must have been part of the list announced by the government that dictated the organisations they believed to have been affected by COVID-19. Once all criteria were met, migrant workers received the 50% subsidy of their daily wages, but only for 90 days after the initiation of their unemployment condition .Some participants suggested that, under the MOU policy, there should be an effort to work with the migrants’ countries of origin in order to establish proactive health screening and surveillance programs in those settings before their arrival. This approach can improve control measures for infectious diseases, in particular HIV and syphilis, and mitigate transmission risk along the border of Thailand. However, in practice, efforts to strengthen the health check mechanism at the country of origin were not well-structured. As such, strong preventive measures, such as health screening and surveillance and treatment before cross-border travel, should be well-established in neighbouring countries. Although both public and private health facilities had a role in health examinations as part of the NV process, the national policy message about the validity of health examinations was unclear.The prevalence of HIV and syphilis is more intense in cross-border migrants. It will be more problematic if they get infected from their countries. Also, it means that its transmissibility will be greater in Thailand. Additionally, surveillance system for these infectious diseases is critical and it should be more proactive.”“—Health Professional PA-5We have already had the health checks from migrant workers’ countries of origin but practically the implementation is not good enough although this is a condition under the MOU. Sometimes our MOL does not care about the health check results. They try to urge them to have work permits at first and then the health check.”“—Health Professional PA-17The demand for importing MOU migrant workers to Thailand still continued during COVID-19. To prevent the spread of COVID-19, the MOL asked the private sector to be responsible for the cost of health screening and quarantine for imported migrants . It was Some interviewees suggested that the Social Security Office (the governing body of the SSS) or the DHEHS of the Thai MOPH (the governing body of the HICS) should take care of the cost for state quarantine. In the meantime, there was a contrasting view about whether it would be difficult for the HICS funding to be utilised for such costs. The reason being that this expense would affect the sustainability of the HICS fund in the future. Moreover, as the purpose of the HICS is specifically reserved for medical treatment, the cost of health screening and state quarantine for COVID-19 was unlikely to be valid for HICS fund utilisation . One of There is a gap in the financial policy to identify who should be the key player responsible for the cost of COVID-19 screening. Currently, the Department of Disease Control is bearing this cost but some told us that the DHEHSF has a direct mission to take care of migrant people. However, the HICS reimbursement does not cover COVID-19. I am so worried about this situation as now the Department of Disease Control and some health facilities have to use their own finances for the screening during this crisis.”“—Health Professional PA-17One of the interviewees said he was not sure that a shorter quarantine period could be implemented to reduce the cost. It was estimated that the average cost of quarantine for one migrant worker was about THB 1500 (USD 50) . HoweverIt is unclear about the appropriate settings for the state quarantine. Some people suggested that migrants can be quarantined at the factories but we cannot ensure the quality of that. Now there is a negotiation to reduce the cost of state quarantine with a shorter period.”“—Health Professional PA-5According to the regulations on MOU migrant workers, employers can request a quota to import migrant workers to Thailand. In this process, they need to identify the number of migrant employees and the information related to the type of work. However, some participants mentioned that at the macro level they did not realise the actual demand for migrant workers . They also suggested that the Office of the National Economic and Social Development Council (NESDC) should be a national leader in developing this framework and set up a quota for importing migrants within a specific timeframe. This idea would help create a sound balance between labour demand and national security. At present, there is an effort to identify the ceiling for imported migrants in each business sector to prevent an excessive migrant import . HoweverThe NESDC should speak out about how many low-skilled migrants should be imported from neighbouring countries within 5 years. This number needs to be identified, along with how many of them can boost the national economy.”“—Health Professional PA-1In fact we should accept that there are many undocumented migrants in Thailand. We need to know who they are, where they live, and how we can deal with them. The government needs to have a plan and policy to address this issue and report the accurate number of undocumented migrants. Big data system is absent in Thailand which is a way to report and track some personal information systematically such as their ID.”“—International Organisation Officer PA-10The social discourse during early 2021 claimed that the undocumented status of migrants was one of the main reasons for the second wave of COVID-19 in Thailand. A quick survey reported that the majority of Thai participants perceived that the superspreading event was caused by the irresponsibility of government authorities in dealing with undocumented migrants . Some paCOVID-19 is an opportunity to revise the regulation on undocumented migrants. Though this crisis remains in the country, we still need migrant workers. A long-term plan for addressing undocumented migrants should be developed, and it should be not only a 5-year plan but rather 10 years.”“—International Organisation Officer PA-10In addition, due to the protest against the military regime in Myanmar, there was a huge influx of migrant workers and refugees crossing the border to Thailand . The ThaOpponents of the military regime will definitely come to Thailand. I am not sure how the local health authorities could deal with it. Actually, there should be temporary camps to help people fleeing from Myanmar but I am not sure whether now it is in place.”“—Government Officer PA-15The second wave of COVID-19 in late 2020 originated in Samut Sakhon, a provincial vicinity of Bangkok and one of the most densely migrant-populated areas in the country. This situation caught the wider public’s attention, raising awareness about the poor working and cramped living conditions of migrants. One participant suggested that poor living conditions were a critical factor that facilitated disease transmission. The crowding in migrant communities caused significant difficulties in maintaining physical distancing, and a significant number of migrants were still in need of basic support during the COVID-19 crisis. A rapid assessment by the International Organisation for Migration (IOM) in Samut Sakhon found that about 12% of migrants needed food assistance, and the same proportion (12%) were unable to access basic healthcare .Our concern is about their poor living conditions. Actually, food and housing are even worse than for Thais. The Ministry of Interior needs to take action to improve their quality of life. Employers have to take care of them. However, many employers, I have heard, also seek decent rooms for their migrant workers. Many of them are living in a small room, and the water quality is also poor.”“—Health Professional PA-5Seven key themes emerged from the analysis through the inductive and deductive thematic coding. Regarding the themes of financial systems for migrants, the issue of the sustainability of the HICS funding was raised; integrating the HICS with the UCS was considered a policy option. Low utilisation of the SSS fund was found amongst migrant workers, especially for the additional benefits beyond medical treatment. In terms of access to health services, the quality of health screening and state quarantine was also points of contention. Although the government encouraged the private sector to take care of the quarantine expense in order to maintain the labour demand, the high cost of the process prohibited the involvement of the private sector. Although COVID-19 was perceived as the crisis, it could be seen as an opportunity to reorientate the Thai health system to be more inclusive for migrants regardless of their immigration status.The healthcare policy for migrants is very complex as it is hugely influenced by the concept of national security and economic necessity . AlthougDue to the structural mechanism of the HICS, the institutional capacity of the HICS is limited compared with the SSS because the MOPH was not set up to be the fund manager (or the insurer) from the outset. The direction of migrant policy is dynamic, especially for the categories of adult dependents . As suchFor undocumented migrants, facilitating the process of the NV and MOU is recognised as the first step to deal with precarious status and accelerate the uptake of health insurance . Such prChallenges in the number of undocumented and documented migrants and migrant health insurance are also pronounced in ASEAN countries, including Malaysia and Singapore, two of the most important destination countries in the region. In Malaysia, documented migrants account for 15% of the total domestic labour force ,45. All It is undeniable that COVID-19 massively impacts the health and wellbeing of populations with higher vulnerabilities. Migrant workers are disproportionately affected by COVID-19. Challenges were more pronounced, in particular inaccessibility to health and social services and crowded living conditions. During this crisis situation, strengthening the inclusiveness of public health efforts is key to containing and mitigating the outbreak and accelerating recovery across all populations . During The COVID-19 crisis in the ASEAN countries is critical, and its impact is evident among migrant workers. In Singapore, this pandemic has widened health disparities in comparison with general populations . Many miAlthough the purpose of this study was to gather opinions from stakeholders in the field of migrant health policy, ranging from local actors to policymakers, some limitations remain. First, as there were difficulties due to travel restrictions during the study period, the information from the demand side, including from the migrant workers and their employers, was absent. However, interviews of representatives of the NGO organisations, who are key informants, were performed. Although these persons may not directly reflect the view of migrants themselves, only this option was available during the time of travel restriction, and they were able to share their insights about their extensive experience in working with migrants in the local context. Second, due to the changing COVID-19 situation and the dynamics of the policy response, this analysis captured only a snapshot of interviewees’ views, while the impact of COVID-19 on migrants’ health and wellbeing should be regularly monitored, including long-term consequences. Third, our analysis was mainly based on the public health lens and therefore insights into social and political dimensions as a whole were not comprehensively analysed in the findings. Rather, the challenges in healthcare faced by migrant workers were central to the analysis. It would be of great value to rethink the inclusion of the HICS in the Thai UHC with more comprehensive policies for COVID-19 and emerging diseases. Moreover, studies on the revision of MOUs for a labour force between Thailand and migrants’ country of origin and COVID-19 need to be considered with a broader scope including economic necessity and national security.Multidimensional effects of COVID-19 have been confirmed worldwide. In this study, all participants agreed that COVID-19 affected migrant policies across the country. Due to a rapid increase in the confirmed cases, infection among undocumented migrants is of great concern, and the numbers tend to be underestimated. Regarding policy implications, in the short term, housing measures to avoid the overcrowded and unhygienic living conditions of migrant workers need to be addressed. In the long run, inclusiveness in social protection and public health policies needs to be enhanced to cover all vulnerable populations regardless of their nationality or status. A long-term plan at the national level is required for tackling the undocumented status of migrants, rather than just treating infected migrants as part of the immediate response during the crisis. Multisectoral coordination and collective actions within government agencies and between the government and other non-state actors, including civic groups, the business sector, and migrant communities themselves, are crucial. To improve implications of these findings, further studies should engage more stakeholders beyond the health sector and migrants themselves. This will provide deeper insights into the link between health and social policies for migrant communities, especially during the global crisis.