## 4 Discussion
### What Policymakers Should Be Aware of When Considering a \"Green Pass Policy\"  
COVID-19 has been changing the way vaccine certificates are used; there has been great debate on their advantages and disadvantages and the ethical considerations surrounding them. Recently, GPPs have become an increasingly accepted concept, particularly because restrictions on fundamental civil rights are less justifiable from a public health rationale for those who are already protected from the pandemic [27, 28, 29]. The Israeli experience highlights issues not yet explored in the literature (for a summary of the issues policymakers should consider when shaping a vaccine certificate policy, see Conclusions below). Figure 2: COVID-19 morbidity, vaccination rollout, public health responses, and the Green Pass. (Note: CR = COVID restrictions. Sources: Authors’ own compilation based on [[https://datadashboard.health.gov.il/COVID-19/general](https://datadashboard.health.gov.il/COVID-19/general)]([https://datadashboard.health.gov.il/COVID-19/general](https://datadashboard.health.gov.il/COVID-19/general)), accessed on 18 October 2021 and [12]). Any GPP must be implemented in a timely manner. In Israel, it was developed and put into practice in a record time of two months, in part because the four health plans operating in Israel covering the entire population have standardised, universal electronic medical records with the information about the vaccine or recovery status of all residents. These records were easily compiled into one single database created by the MoH for the GPP, as privacy and data protection laws in Israel allow the sharing of this data [25]. To ensure data privacy and protection, any data related to the vaccine or recovery was only transferred if a person requested the GPP or vaccine/recovery certificate. Data was encrypted during the entire process. The GPP raises equity concerns due to the fragmented recovery of civil rights within a country (those unvaccinated remain restricted) and the exclusion of those who cannot get the vaccine, including children, and those who cannot prove that they have recovered [27; 28; 29]. Israel has attempted to mitigate these equity concerns first by implementing the GPP only after the prioritisation of the vaccine was opened to all eligible populations (illustrated in Figure 1). This meant that all residents eligible and willing (in light of FDA and MoH approval, at the time, ages 16+) to receive the vaccine had the option to do so (or not), and no resident aged 16+ would be denied a GPP due to ineligibility or a lack of supply of the vaccine. Second, Israel only implemented the system after the vaccination rate was already high (about 45% of the aged 16+ fully vaccinated and 65% with the first dose). By August 2021, most high-income countries had opened eligibility to the vaccine to all age groups (older than 12, the age for which the vaccine was subsequently approved), yet middle- and low-income countries were still facing supply limitations and retained prioritisation policies. As long as not all population groups are eligible or have access to the vaccine, a GPP may not be an equitable tool [30]. In this case, negative tests were temporary solutions for the unvaccinated, granting them a temporary GPP. It is also important to include children younger than 12, who currently cannot be vaccinated, into the GPP. However, this solution is only relevant if tests are widely available and free of charge. Those who cannot get the vaccine are registered at the MoH and can receive antigen or PCR tests free of charge and a temporary GPP. Since the objective of the GPP is to reduce transmission of the virus, and those who cannot get vaccinated are more likely to transmit it more than those who are vaccinated, this cohort is treated as unvaccinated. Nevertheless, there are very few people (about 2000) within this group, and they receive their exemption on a case-by-case basis. A second caveat is that essential activities should be excluded from the GPP requirement.