The COVID-19 pandemic sweeping the globe has led to a frantic search of a model for which the coronavirus can be effectively contained. I am a Singaporean living in Taiwan, and both these countries have managed to keep the coronavirus at bay with minimal community transmission thus far since recording their first cases in late January, though they have seen their cases rise more rapidly in recent days due to a second wave of infections stemming from imported cases originating in other areas, including the United States and Europe, which have seen outbreaks in March.
Several articles have been written about the effectiveness of the approaches in both countries. In this article, I explore in more detail the strategies both Singapore and Taiwan are using in their health containment system to restrain the virus’s tentacles, as well as compare their social protection policies for workers during this coronavirus to look at the strengths in each model, and what we can learn from them. I also outline here Taiwan’s very effective face mask provision and rationing strategy that has provided another line of defense for the country, as well as how Singapore’s foresight planning has helped play a role in preparing it for this outbreak.
In short, both countries conducted very early risk assessment of the reality of COVID-19 very early on and decided to take very stringent measures to prevent the virus from spreading across their island states.
As you can see from the chart below, Taiwan has managed thus far to flatten the curve of confirmed cases, well below that of most other countries, which is quite a feat for a country which has seen confirmed cases since January.
Singapore has similarly managed to flatten the curve enough for its healthcare system to cope, though both countries have had to contend with a sudden increase in imported cases in recent days.
Data source: Our World in Data (Taiwan’s and Singapore’s figures are updated until March 22)
Stringent Testing Protocol and Constant Refinement
The key reason why both Singapore and Taiwan have been able to successfully contain the local transmission of COVID-19 is largely attributed to their strong health systems and COVID-19 testing regimes. Not only have both countries been performing stringent testing and contact tracing, they also conducted a systemic and retrospective testing of people with relevant symptoms to try to arrest any possible spread in the community right from the beginning, so as to contain it within the community at the very first instance.
Starting in late January 2020, Singapore’s Ministry of Health started testing all patients with pneumonia in its public hospitals. Singapore sees 500 to 600 cases of patients with pneumonia each week, and from this, it was able to identify six COVID-19 cases in the first week it started the mass screening of pneumonia patients.
In Taiwan, the authorities also looked through the country’s National Health Insurance Administration (NHIA) database to identify patients from January 31 reporting with severe respiratory symptoms but had tested negative for influenza, and then tested them for COVID-19. Of the 113 people tested, one person was identified positive. By the end of January, Singapore had 13 confirmed cases, and Taiwan had nine.
While both countries had managed to largely keep the number of new cases low for the next month, they began to see sudden surges from the middle of March due to an increase in imported cases, leading both countries to expand and revise their testing strategies to expand screening to their checkpoints, with hopes of containing the disease at arrival point before it spreads into the community.
Between March 14 and March 22, Singapore saw its confirmed cases jump by more than double, from 200 to 455, while Taiwan saw its cases jump by more than three times, from 50 to 169. Of the 255 cases confirmed in Singapore between March 14 and March 22, 190 or nearly 75% of them, were imported; and of the 119 cases confirmed in Taiwan during the same period, 106, or nearly 90% of them, were imported.
Since March 4, Singapore started conducting nasal swab tests for travelers who have fever or display signs of respiratory illness, and later on expanded it to include those asymptomatic as well. On March 15, Taiwan similarly announced that it was testing travelers with pneumonia and other respiratory symptoms. Of the 23 confirmed cases on March 18, 11 were detected via this newly-announced measure. Taiwan also started conducting retrospective testing on travelers from Europe who had arrived between March 3 and March 14 who had sought treatment locally for respiratory symptoms. Of the 513 people identified as of March 17, 136 people had been tested with three positives, while 426 had been instructed to also go for testing. On March 21, the government also announced that travelers who entered Taiwan from the U.S. and East Asian countries from March 8 to March 18 would also have to undergo testing and quarantine. 3,000 people would have to do so.
However, with there not yet being an end in sight to the second wave, both these countries would need to prepare for whence their defenses are broken as import cases keep escalating, at which time they would undoubtedly have to adopt broader community measures. Health Minister Chen Shih-chung 陳時中 has said that he was anticipating the number of cases to increase rapidly in the two weeks starting March 18 when Taiwan saw a spike in import cases (more than 90% of cases were imported on that day). Taiwan President Tsai Ing-wen 蔡英文 has also said that “the next 14 days will be a critical second stage in the epidemic response effort.”
The efficacy of both approaches in Singapore and Taiwan can be seen in how they have been able to keep their COVID-19 cases relatively low thus far, though both have seen increasing numbers of cases due to import cases in recent days. However, it is difficult to have a full appraisal of the veracity of Singapore’s testing strategy due to a lack of data on its testing figures.
Taiwan (and countries like South Korea) have provided daily counts of the number of tests conducted on a daily basis, but the figures for Singapore are a mystery. Fortune was able to locate a figure of 1,300 tests conducted as of February 27 (with 96 confirmed cases) from the Singapore Ministry of Health website, but a search I conducted on the ministry’s website turned out nothing. However, National University Hospital Infection Control Committee Chair Dale Fisher said in The Conversation that of the tests Singapore has conducted, less than 1% have been positive, which would suggest that as of the time of writing, the confirmed 345 cases would mean more than 34,500 tests have been conducted. Thss would be a massive disparity from the 1,300 tests conducted just less than a month ago which has a positive rate of 7%—again, a considerable gap from the claim of less than 1%. Moreover, as of March 21, Singapore had only quarantined 7,533 people.
On the other hand, Taiwan is very transparent with its testing data, and all data is publicly available on its Centers for Disease Control website. It has also conducted 23,805 tests at the time of writing with 169 confirmed cases, which puts Taiwan among the 15 countries which have conducted the most COVID-19 tests globally. Taiwan’s positive rate is also lower than Singapore, at 0.7%.
At the time of writing, Taiwan has developed the capacity to conduct 3,200 COVID-19 tests a day, while Singapore has increased its capacity to more than 2,000.
Taiwan Health Minister Chen Shih-chung has also been asked if general population COVID-19 testing will be conducted in Taiwan, or if individuals could be allowed to go for testing at their own expense. However, Chen explained that Taiwan does not currently have a need to conduct community testing, as the virus is still being contained in Taiwan. Chen also explained that doing so might lead to more false negatives, pointing to how there were people on the Diamond Princess cruise ship who were tested negative even as they had been infected, but the viral load was too low to yet be detected, thereby resulting in them becoming vectors of transmission.
I spoke to Dr. Wu Yu-Hsin from Linkou Chang Gung Memorial Hospital who explained that currently, “the prevalence of the disease and the sensitivity of the test kits are not high enough for mass screening to be considered.” He added that disease prevalence needs to be high enough for mass screening to be cost effective. In addition, sensitivity refers to “the ability of a test to correctly identify patients with a disease,” thus Dr. Wu explained that, if the sensitivity of the test is not high enough and someone tests negative, it would not mean that they are not negative, and they would need to be repeatedly tested.
Decentralized Health Systems Approach to Prepare for Community Transmission
In addition to a well thought-out testing regime, both countries have also developed decentralized systems to tackle COVID-19. On the basis that there were a number of confirmed COVID-19 cases who had continued to work even when they had respiratory symptoms, the Singapore government started re-activating its network of 900-odd Public Health Preparedness Clinics (PHPCs) from February 18, with special guidance provided for the doctors: In order to prevent the spread of COVID-19 even among those with mild symptoms, the government drew up guidelines for doctors to provide five days of sick leave for patients with respiratory symptoms (such as fever, cough, sore throat and runny nose), and “urged” those individuals and their employers to cooperate with the guidelines. Patients who do not recover within five days were also advised to visit the same doctor for further treatment. In cases where patients were suspected to have pneumonia, they would be referred to the hospitals for further testing and treatment.
PHPCs are set up by the Singapore government to be activated during public health emergencies, and would be provided protective equipment at no cost as well as receive prioritization for “antivirals [such as Tamiflu], antibiotics, and/or vaccines from the national stockpile.” However, clinic visits in Singapore are expensive, with a 2013 survey showing average fees to be S$35 (US$24.14) per visit, and which can go up to as high as S$141.67 (US$97.73), so it is a relief and somewhat surprising that the government decided to implement a flat rate during this COVID-19 period, of S$10 (US$6.90) for people who visit the PHPCs for respiratory illnesses, and S$5 (US$3.45) for those born before 1960, with those on public assistance not required to pay
However, public assistance is provided only to a small group of people who due to old age, illness or disability are unable to work, and have a household income of less than S$1,900 (US$1,311). People on public assistance also only receive S$600 (US$414) a month.
A more affordable healthcare system needs to be looked into after the pandemic is over, though the business-oriented government in Singapore has been very reluctant to adopt the single-payer system used in other advanced countries. Moreover, workers are only entitled to 14 days of paid outpatient sick leave, and while the suggestion by the Ministry of Manpower is that “employers can also treat the 5-day MC [medical certificate] as part of their paid hospitalization leave entitlements,” which amount to 60 days including the 14 days of sick leave, this is only an advisory and it is unclear whether employers would actually force workers to take unpaid leave instead.
In Taiwan, the Ministry of Health and Welfare (MOHW) also announced a list of 167 clinics on March 12 which would provide testing for COVID-19, with the aim of decentralizing the testing of COVID-19, so as not to overwhelm major hospitals which have thus far spearheaded the coronavirus efforts. Chen, the health minister, explained that while Taiwan has managed to defend itself well from the first wave of the coronavirus infections, it would be naive to believe that Taiwan would be able to avoid community infections due to the severity of the pandemic on a global scale. The network of 167 smaller hospitals was therefore developed with the objective of enabling testing to be more accessible to people. Based on this format, people should seek testing at the designated 167 smaller hospitals and, if tested positive, would then be sent to negative pressure isolation wards at the major hospitals. In the event that the wards become unavailable, patients would instead be transferred to the 50 medical centers in Taiwan which are equipped to handle critical cases.
Taiwan, however, has not developed similar guidelines as Singapore on the amount of sick leave doctors should provide for patients who present with respiratory symptoms. In a culture where workers are afraid to request for sick leave due to company pressure, doctors do not usually automatically provide sick leave unless patients ask for it. In addition, workers in Taiwan, while being entitled to 30 days of sick leave a year, are only paid half their wages if they call in sick, which acts as a deterrent for workers to stay home even if they are unwell. These then become loopholes in Taiwan’s COVID-19 strategy when people who feel unwell continue to go to work. This is particularly concerning as people infected with COVID-19 can be asymptomatic and still be infectious.
In this way, both Singapore and Taiwan have seen their COVID-19 health containment strategy evolve from one initially focused at the hospital setting during the first wave, to one that is decentralized to designated clinics or smaller hospitals to prepare for anticipated community infections during the second wave. The clinics and smaller hospitals therefore act as the first line of defense in the health system strategies of both countries, while the major hospitals act as the second line of defense to oversee critical cases. To arrest community transmission, both countries have also conducted sweeping tests on high-risk cases (i.e. those with pneumonia and severe respiratory symptoms) and commenced testing at their borders to catch such cases before the virus reaches the community at greater scale. It is therefore also due to the success of Singapore’s and Taiwan’s health and testing strategies that have managed to contain this coronavirus thus far, and has not yet required them to take even more drastic social distancing strategies at this point, such as by closing down schools or workplaces.
Singapore’s and Taiwan’s containment approach therefore highlights how early and stringent testing can effectively curb the spread of new viruses. This is a lesson that countries need to take heed.
Taiwan Vice President Chen Chien-jen 陳建仁 has his temperature checked. (Photo via Taiwan Presidential Office, CC BY 2.0)
All-Rounded Health Systems Preparedness and Capabilities
In addition, the existing strength of the healthcare systems of both Singapore and Taiwan also go some way in ensuring the resilience of their systems in coping with the new coronavirus.
In Asia, Taiwan ranks as having the most number of critical care beds per 100,000 population, with 28.5 beds (also one of the highest in the world), while Singapore ranks slightly lower with 11.4 beds, above South Korea with 10.6 beds, Japan with 7.3 beds and Hong Kong with 7.1 beds. Iran and China have 4.6 and 3.6 beds, respectively. Taiwan also has 1,100 isolation negative-pressure beds (for 169 confirmed cases, of which 28 have been released from isolation) that can be used for the isolation of patients, compared to 330 in Singapore’s National Centre for Infectious Diseases (NCID) (for 455 confirmed cases of which 144 have “fully recovered”). Taiwan’s 46 beds per million population and Singapore’s 58 beds therefore exceed Japan’s capacity of only 15 beds.
In Singapore, patients are tested on two consecutive days to make sure they are free of the coronavirus before they are discharged. Patients are also tested two weeks after they are discharged. Tests are conducted using nasal or throat swabs, and might include tests on their urine or feces, and even breast milk.
But there are mixed messages coming out from Singapore. Its ministry of health also contradicted itself by saying that “whether or not a patient is discharged is a decision solely taken at the discretion of doctors on a hospital-by-hospital basis.” In Taiwan, patients are tested three times before they are considered cured.
Very importantly, right from the start, both governments decided to provide free testing and treatment, albeit in different formats. While in the United States, the debate was still raging on as to whether free COVID-19 testing and treatment should be provided even as the virus was starting its exponential spread in the U.S. in early March, the Singapore government had said early on that it would “pay the hospital bill in full for such [COVID-19] admissions in public hospitals” based on “public health reasons,” though this would only cover inpatient treatment but not outpatient ones, and also not for general practitioner clinics, polyclinics or private hospitals.
Nonetheless, such a move is especially important in Singapore because healthcare is known to be exorbitant when paid for out-of-pocket: in 2012, there were more than 2,400 people who had to pay more than S$10,000 (US$6,900 / NT$208,950) out-of-pocket on their hospital bills. In 2017, Singapore’s out-of-pocket health expenditure was also the third highest in the world, based on purchasing power parity—even higher than the United States. In Taiwan, on top of the already affordable healthcare system, the government also announced in January that due to COVID-19, it would provide “free antiviral drugs to patients with flu-like symptoms, regardless of their nationality.” In addition, hospital bills are already capped at NT$39,000 (US$1,290 / S$1,870) per visit and for NT$65,000 in a year for any one particular condition. It should also be noted that healthcare is completely free for people with catastrophic illnesses.
However, both countries have recently changed their stance towards paying for foreign visitors due to having to conserve their resources. Singapore announced that from March 7, while testing would still be free for all visitors on short-term visit passes, these visitors would have to pay for their own treatment if tested positive. In Taiwan, the government also announced that from March 17, foreign travelers who arrived from countries on its highest-tier alert would have to pay for their own testing and treatment, though the country has since raised all countries to the third tier while also banning all foreign nationals from entering the country from March 19.
As an interesting comparison, South Korea has said it would still continue to pay for the testing and treatment of both locals and foreigners, and not only that, but for undocumented immigrants as well. Hospitals are also not required to inform the authorities of the immigrant’s status.
In Taiwan, however, a debate had ensued as to whether undocumented immigrants should be granted amnesty, after the Ministry of Labor instructed the New Taipei City local government to investigate the 32nd case of an undocumented immigrant, leading to fears that a crackdown on these workers could result from it. However, Health Minister Chen has said that he opposes any crackdown for public health reasons, stating that many of these workers actually work as caregivers, which would result in a shortage of workers to look after patients and thereby putting more strain on healthcare workers. Chen therefore made the clinical assessment that the key concern should be whether a “person has any questionable travel history, or illnesses, and if he or she knows how to look after the patient,” and to also train all caregivers to ensure they would not place themselves at risk of “catching or spreading the disease.”
Taiwan’s government announced on March 20 that it will reduce penalties for three months to all foreign nationals who overstayed their visas with a reduced penalty of NT$2,000 (down from NT$10,000), and the mandatory detention and re-entry ban will be removed during this period.
However, this measure still requires overstayers and undocumented workers to self-report, or else they can face the usual penalties. Even those who self-report to immigration authorities still face deportation. Unlike South Korea, whose hospitals have stopped collecting information on undocumented visitors, those who visit hospitals in Taiwan to get tested will still be deported.
There’s a curious case in Singapore as well. A 64-year-old Indonesian man with pneumonia actually managed to pass Singapore’s border screening on March 13, and then went straight to a private hospital where he was diagnosed with COVID-19 and passed away a few days later on March 21, but not before infecting a Singaporean under unknown circumstances and a family member who came with him from Indonesia.
The focus and pressure put on the health systems of both countries to rein in COVID-19, however, do put a strain on the healthcare workers, especially for those at the frontline. Of course, the alternative is to adopt an unbridled approach, which would then create an even greater burden on the health system when more people become critically ill and in need of care, and eventually risk collapsing the health system—as is the case in Italy. The stringent testing protocol in Singapore and Taiwan therefore has to be followed to a tee, at least for the time being if the aim is to reduce the burden that would otherwise come, but this comes at the expense of healthcare workers at the frontline. This also means both governments have seen the need to provide additional forms of compensation to healthcare workers. In Singapore, public healthcare officers at the frontline will be given a one month bonus and a one-off grant will be given to the 900-odd PHPCs, though it is not stated how much the grant for each PHPC is.
In Taiwan, medical workers and disease-prevention effort workers would also receive subsidies and provided additional compensation if they fall sick or pass away due to work, and subsidies will also be provided for their children’s education in case of their unfortunate passing. When three nursing staff and a cleaning staff were infected earlier this month, Health Minister Chen said that they would be compensated a minimum of NT$350,000 (US$11,563).
Existing Biotechnological Capabilities to Create Health Innovations
Some new innovations in both Singapore’s and Taiwan’s COVID-19 testing capabilities also shone through during this coronavirus episode. In Singapore, the Ministry of Health revealed on February 25 that it managed to use a new serological test developed by the Duke-NUS Medical School in Singapore to identify the missing link between two clusters of infections. Current laboratory tests for SARS-CoV-2—the virus that causes COVID-19—uses polymerase chain reaction (PCR) tests to detect genetic material from a patient though such a test would not work if patients are recovered. However, the new test developed in Singapore was able to detect the antibodies produced as a response to the infection inside one recovered case and therefore helped identify the connection between two church clusters—Singapore claimed this to be “likely a world first.”
However, just a few days before Singapore’s discovery, on February 20, Taiwan had also used antibody testing to help trace back the source of an infection—a research team at Academia Sinica managed to use molecular biology and genetic engineering to produce antigens for the coronavirus, which was then used to test for the antibodies, and similarly helped to link a confirmed case with a recovered individual. I find that Taiwan tends to be overly humble when it comes to its achievements. Therefore, both Taiwan and Singapore have made breakthroughs in identifying new testing methods for contact tracing—feasible in part because they managed to keep caseloads low.
On top of that, both countries have also been developing their own test kits and vaccines to combat the COVID-19. Since early February, public hospitals in Singapore have been using diagnostic test kits developed locally by the Agency for Science, Technology and Research (A*Star)’s Experimental Drug Development Centre and Bioinformatics Institute. The test kits shorten the time taken for testing by pre-packing the reagent mix instead of having technologists mix it, which the researchers say can shorten the time preparing the reagents by about 30 percent. It was not reported how long results would take. When the test kits were launched, 5,000 kits were sent to local hospitals while Singapore also sent 10,000 of the kits to China, with another 10,000 thereafter. Another test kit, the HTX COVID-19 test kit, developed by Singapore’s Home Team Science & Technology Agency (HTX) and Veredus Laboratories can apparently obtain results within three hours with 99% accuracy and is currently being used at Singapore’s checkpoints, after obtaining provisional authorization from the country’s Health Sciences Authority in early March.
In Taiwan, the Centers for Disease Control’s (CDC) Center for Research, Diagnostics and Vaccine Development, or the Kunyang Lab, has as early as January 13 developed its own test to test for the coronavirus within four hours, just a few days after the genome sequence of COVID-19 was released on January 10, which allowed it to conduct the tests for identifying the virus in humans. Academic Sinica also announced in early March that with the help of the Ministry of Economic Affairs, it “has synthesized monoclonal antibodies that are able to identify the protein of SARS-CoV-2,” which would enable it to produce a rapid screening reagent that would shorten the time for testing time from about four hours to only 15 to 20 minutes, and it aims to mass produce these test kits within the next three to four months after the reagent is verified and approved by the Ministry of Health and Welfare.
Meanwhile, Singapore’s Duke-NUS Medical School is working with Norway’s Coalition for Epidemic Preparedness Innovations (CEPI) to develop a vaccine within four months, while in Taiwan, the National Health Research Institutes under the Ministry of Health and Welfare expects to develop a peptide vaccine within three months. Academia Sinica also announced the development of a vaccine and said it would work with the European Union to do so. Both Singapore and Taiwan are also conducting clinical trials to see if the antiviral drug remdesivir can be used effectively for COVID-19 treatment.
Finally, in spite of the comprehensive health and testing protocol Singapore and Taiwan have systematically put in place, the containment strategies they have developed are not foolproof—whether COVID-19 cases are caught and treated accordingly are also dependent on the judgment of doctors at the frontline who have to decide if patients who, for example, present with mild symptoms should be tested even if they have no travel history or contact with prior cases, or if doctors might not test suspected cases for fear of having to shut down their operations for two weeks and therefore incurring losses to their business.
Nonetheless, if community infections were to occur because they were not initially detected, the number of people with pneumonia and severe respiratory symptoms would also spike, especially among the elderly and those with existing complications, which should allow the systems in both countries to detect such cases based on their current testing protocol of testing people with pneumonia or severe respiratory symptoms. The methodical and clinical approach to the testing regimes in both countries therefore act to ring-fence their societies from the coronavirus and try to contain the spread as far as possible.
Taiwan has also closed off its borders from March 19 in a bid to prevent its lines of defense from being broken through. Singapore followed suit by banning all short-term visitors from March 23. Nonetheless, there is still the fear that community spread is going around, to which Taiwan’s system offers another line of defense—its face masks act both to reduce transmission especially from asymptomatic cases, and importantly, as psychological defense. However, this coronavirus episode has also exposed some of the gaps in the countries’ healthcare systems—in how there is inadequate medical leave and compensation support for workers, and the lack of policy initiatives to address them.
A mask factory in Taiwan. (Photo via Taiwan Presidential Office, CC BY 2.0)
Systematic Upscaling of Face Mask Production and Provision
One thing the Taiwan government understood very early on is how face masks can act as a lever to calm social anxieties during times of an epidemic, which was why right from the onset of this coronavirus—even before it was named COVID-19—the government decided to ensure a steady stream of surgical masks in order that the safety and confidence of citizens can be procured as an effective partner to fight the disease, and to act as a secondary defense measure to complement its strict testing regime.
It has largely worked. Taiwan confirmed its first COVID-19 case on January 21 and, on the same day, Premier Su Tseng-chang 蘇貞昌 came out to assure Taiwanese that the government has reserve surgical masks numbering 45 million and that it had the capacity to produce another 1.88 million masks daily, which could be increased to 2.44 million if necessary. The government later released 23 million masks onto the market and even managed to increased daily production to 3.2 million by the first week of February, 3.9 million in the second week and 4.6 million in the third week. The increase in mask production was made possible because Taiwan’s cabinet approved the construction of 60 additional production lines led by what has been termed a “national team” of 30 machinery companies and three research institutes. Instead of taking the usual four to six months to build these lines, it managed to do so within a month.
By the end of February, Taiwan was producing 6.6 million masks, which increased to 8.2 million in the first week of March, 9.2 million masks by the second week, and would have increased to 10.3 million by the third week. The government then announced that it would invest another NT$200 million (US$6.607 million) to construct another 32 production lines to increase production to 13 million by early April, and 15 million in the near future. Through these efforts, Taiwan has today become the second largest manufacturer of face masks.
To ensure an adequate supply of masks for all residents, Taiwan also instituted a mask rationing system at the end of January to limit purchases of masks to three per customer made available only at specific outlets such as convenience stores, medical supply stores and drug stores, at NT$6 per piece. This was later amended in early February to two masks a week per person at NT$5 per piece, which could only be obtained at pharmacies and public health centers to better control supplies. As Taiwan’s mask production increased in early March, the rationing was then loosened to allow adults to purchase three masks a week since the start of March. As Taiwan began to produce adequate masks for its residents, it has also started selling the masks at duty free stores at five designated airports in Taiwan from March 21, and is also exploring providing masks for its citizens overseas. However, some migrant workers still face difficulties getting the masks, and undocumented migrant workers have also been left out.
An online system was also set up on March 12 to trial run allowing people to preorder face masks online for a week, for collection at convenience stores—intended for office workers and students who might not have the time to go to the pharmacies and public health centers to purchase masks. Seven million masks were allocated for the trial, meant to be provided for an estimated 2.33 million, though there were only 1.178 million people who eventually preordered. A second trial would run from March 25 for another week to further assess demand and test the ordering system. The ease at which Taiwan’s government was able to integrate its National Health Insurance database with the mask rationing system is attributed to “the infrastructure upgrades and data management experience accumulated over the years in Taiwan,” NHIA Information Management Division chief Chang Lin-chih 張齡芝 explained. Minister without Portfolio Audrey Tang 唐鳳, in charge of digital technology development in Taiwan, also worked with IT experts to create online maps allowing individuals to look for the pharmacies and health centers nearest to them for the purchase of face masks, as well as the quantities left, so that they would not need to make a wasted trip.
The government also prioritized mask allocation to targeted groups, such as medical workers, drivers and schools. As of early March, about 3 million masks are being allocated to medical workers every day, while bus drivers, taxi drivers, delivery drivers, and Uber drivers are also able to purchase one mask a day. 6.45 million surgical masks, 250,000 forehead thermometers and 84,000 liters of alcohol-based sanitizers were also distributed to schools before the new semester began at the end of February, to be used for “backup” purposes as children are already entitled to buy five masks a week.
To prevent price gouging and the hoarding of masks, the government also instituted fines of up to NT$50 million (US$1.65 million). The government also announced on January 24 a ban on the export of disposable surgical masks until February 23, and later extended the ban to the end of April, although it has begun allowing limited mask exports. The export of digital thermometers was also banned for March. As of February 14, 148,733 face masks have been confiscated, and violators were fined up to three times the value of the masks or thermometers.
There are other innovations too. Taiwanese startup Yallvend developed a smart vending machine with fellow Taiwanese startups Biilabs, Drippp and AuthMe to test-run the provision of face masks alongside the government’s program so that people need not go down to pharmacies and health centers for their purchases so as to limit their exposure to infection. Vending machines were also installed in some cities in Taiwan to provide free hand sanitizer for residents. A mask disinfection machine using atmospheric pressure plasma has also been invented by the National Taiwan University of Science and Technology (Taiwan Tech) to extend the life span of masks. Following the success of Taiwan’s face mask production, Taiwan has also formed another “national team,” this time to produce protective and isolation gowns. To do so, Taiwan will also be collaborating with the U.S. to obtain raw materials for the production of 300,000 medical protective suits, in exchange for providing 100,000 medical face masks to the U.S. once a week once the production of masks is stabilized.
In Singapore, on the other hand, there is currently a lack of masks for members of the public. In flyers distributed by cadres from the ruling party, people are being told that they should not wear a mask unless they have a fever, cough or runny nose. The sense is that the government hasn’t been able to procure adequate masks for public consumption and has therefore resorted to telling people that mask use is not necessary, though people on the ground would prefer if the government could be upfront about it.
Moreover, an article published in Lancet just this month points out that surgical masks are actually effective in protecting against COVID-19 via “source control,” and Professor Yuen Kwok-yung from the University of Hong Kong also explained that because asymptomatic transmission can occur with COVID-19, “wearing a mask [therefore] not only protects yourself, but also protects others in case you are an asymptomatic patient.” The lack of masks in Singapore thus means that Singapore has had to ensure that the strength of its health system and contact tracing is top-notch in order to compensate for its lack of masks. There have been at least two articles that have covered Singapore’s contact tracing strategy in detail (here and here), so I will not discuss them in this article. Taiwan’s contact tracing efforts have also been discussed in CommonWealth Magazine.
A point to note is how both Singapore and Taiwan have turned to digital means to monitor people during these times of the coronavirus. Singapore has launched a smartphone application, TraceTogether, which uses Bluetooth to track the proximity of people to one another, so that in the event contact tracing needs to be done, the government could seek the compliance of users to determine if they have been in close contact with confirmed cases. Users who do not share their data with official contract tracers could be prosecuted under the country’s Infectious Diseases Act.
In Taiwan, people in mandatory quarantine will be given smartphones with GPS which will be used to track their locations, where government officials will receive daily reports via this monitoring system, such that if people were to break their quarantine, a warning message will be sent to them via the LINE messaging chat application.
But such invasive tracking methods have given rise to privacy concerns. In the longer term, a discussion needs to be undertaken as to how, if digital and data tools are to effectively aid in situations like disasters, how the transparency over their usage can be legislated into law.
Policies to Mitigate Social and Economic Disruptions
One way to understand a society’s strength is to look at whether there are policies to protect its citizens and how government officials respond to their concerns, and studying the policy measures both governments have introduced to address social concerns arising from COVID-19 allows us to understand the comprehensiveness of the coronavirus response in both countries. In Singapore, news headlines reported that S$100 (NT$2,100 / US$69.38) a day would be provided for individuals quarantined, but if you look at the details, this money actually goes to the individual only if he or she is self-employed. For salaried workers, the money goes instead to their bosses on the basis that the money is intended to compensate the employer since “the quarantine period will not come from their annual leave.”
Meanwhile, in Taiwan, individuals who have to undergo home isolation or quarantine for 14 days would be compensated with NT$1,000 (US$33.04) a day, while for individuals who require caregivers such as for children under the age of 12, one caregiver for each person would also be compensated NT$1,000 a day. Singapore’s compensation is therefore geared towards the compensation for losses incurred due to business operations being disrupted while Taiwan’s program is better geared towards protecting worker well-being.
Both Taiwan and Singapore have also announced measures to protect workers who become unemployed or have their work hours reduced due to COVID-19. For Singapore, it was reported that to help workers stay employed, the government would subsidize the wages of local workers by offsetting 8% of the wages of each Singaporean or permanent resident-employee for three months, for a cap of up to S$3,600 a month. However, this money would again go directly to employers, which means that it is unclear if workers will actually benefit from it.
In addition, Singapore does not have unemployment benefits which places workers at risk of income insecurity due to COVID-19-related job losses. However, when opposition member of parliament Sylvia Lim from the Worker’s Party suggested just last month about implementing unemployment benefits again (this is not the first time she has asked about them in parliament—she did so in 2011 and 2016 as well), in order to “provide a stabilizer to workers, [and] to soften the cliff-edge that they face with job disruption.” Singapore’s Minister for Manpower Josephine Teo rejected the proposal and said instead that “most people do not expect to need it and they also have other buffers, for example, a working spouse or child.” Teo also made the claim that, “that countries that provide unemployment insurance usually have persistently high unemployment,” in spite of the evidence pointing to the contrary.
Compare this with a country like Denmark which has a similar GDP per capita as Singapore, where the government has said that it would cover for 75% of employees’ salaries if companies promised not to lay off their workers—though employees would have to cut five days from their annual leave, which is five weeks (25 days) long, by the way—already one of the highest among the developed countries. This is also on top of the unemployment benefits in Denmark which pays up to 90% of the salary before unemployment, and up to 19,083 kr (US$2,735 / NT$83,750 / S$3,960) a month, and a coverage of nearly 70%—or almost 70% of unemployed workers who are able to obtain unemployment benefits.
In Taiwan, the government also provides subsidies for companies during this coronavirus—employers that hire a person unemployed for more than 30 days would receive a subsidy of NT$5,000 for each new person hired for up to a period of six months, while companies which hire a person who has been unemployed for more than three months would allow the company to receive a subsidy of NT$9,000 for up to 12 months. Hiring a senior or disadvantaged worker would net a higher amount of up between NT$11,000 and NT$13,000 a month for up to 12 months as well.
But not only are companies given subsidies, workers are too. In Taiwan, unlike in Singapore, workers who work reduced hours or go on unpaid leave are already required by law to be paid the minimum wage of NT$23,800 a month, but during this coronavirus the government has also introduced additional wage subsidies to increase this to half the salary of the worker, to be provided for three to six months, thereby allowing workers to receive up to an additional NT$11,000 monthly (based on the highest wage bracket of NT$45,800 for which the subsidies would be provided). For unemployed workers, current unemployment benefits already provide for 60% of a worker’s wages six months prior to unemployment, to be paid for six months, but the Workforce Development Agency Deputy Director-General Shih Chen-yang 施貞仰 has said that this could go up to nine months.
Not only that, for parents who become unemployed during this COVID-19 episode, the government will also provide a subsidy of between NT$4,000 and NT$6,000 for each child while parents with children in university would also be able to receive between NT$13,600 and NT$24,000 in subsidies for each child. Nonetheless, there are still gaps—companies have avoided reporting to the Ministry of Labor about putting their workers on reduced work hours so as not to compensate them, and Taiwan’s unemployment benefits provide one of the lowest coverage among advanced economies—less than 20% of unemployed workers actually end up receiving unemployment benefits. But on the whole, workers in Taiwan still benefit more than those in Singapore.
Planning Ahead for Risks with Strategic Foresight Planning
As many observers have noted, both Taiwan and Singapore are well-prepared to handle COVID-19 because of their experiences with the SARS virus. SARS, or the Severe Acute Respiratory Syndrome, hit both countries particularly hard. Taiwan had the third highest number of reported cases (346) and deaths (73), while Singapore was at Number 5 with 238 cases and 33 deaths.
In fact, SARS was called a black swan by Singapore’s Centre for Strategic Futures (CSF)—a foresight research department under the Prime Minister’s Office. The term, “black swan” was popularized by author and risk analyst Nassim Nicholas Taleb in his book ‘The Black Swan: The Impact of the Highly Improbable’, and defined by the CSF as “rare, hard-to-predict events with a large impact”. Singapore surmised from its lesson in SARS that, “there will be more of such crises, [and that] when the normal flow of life is disrupted, societies will need resilience to cope.” The CSF also pointed out that, “to deal with disruptions, governments must go beyond an emphasis on efficiency [because] lean systems that focus exclusively on efficiency are unlikely to have sufficient resources to deal with unexpected shocks and volatility”. This perhaps explains why Singapore pretty much threw the kitchen sink into ensuring that its health system had sufficient resources to manage the COVID-19 coronavirus.
Singapore’s foresight planning for this coronavirus also shows in the speech its prime minister Lee Hsien Loong made early on, on February 8. Even as Singapore saw only 40 cases at that time, Lee was already discussing the long-term strategy. He explained that Singapore would need to reconsider its strategy if cases kept growing because by then, the virus would become widespread and it would be “futile” to trace every contact, and hospitals would be overwhelmed if every case were to be hospitalized and isolated. Assuming fatality rate remains low, Lee said that Singapore should shift its approach to encourage people with mild symptoms to go to general practitioners at clinics, with hospitals being focused on the most vulnerable patients. In parliament, Minister of Health Gan Kim Yong also explained that the Singapore government was planning for three potential scenarios: for when community spread widens to more cities in China and other countries, for when community spread takes place in Singapore, and if the virus mutates and results in a pandemic.
While Lee was praised for his speech—senior lecturer at the University of Sydney’s Center for Values, Ethics and the Law in Medicine Claire Hooker said that the speech “was a pretty outstanding example of very good risk communication”—there is the question of the timing of the speech. Lee’s speech came a day after Singapore saw a bout of panic buying due to Singapore raising its Disease Outbreak Response System Condition (Dorscon) alert level to the second-highest Orange level. To a populace unnerved by their concerns over their immediate needs, it might not be the most appropriate time to inform them of the government’s long-term approach to decentralizing COVID-19 treatment to localities, as it did little to address their immediate concerns, which at that time was about the availability of face masks, toiletries and food supplies.
But to Singapore’s decision-makers, it is clear their concern is less about what citizens are worried about but more about business continuity. “If (we do not respond) collectively, we will undermine the international confidence in our system and in our society, and that will have long-term ramifications,” its Trade and Industry Minister Chan Chun Sing said two days after the panic buying episode. In a leaked recording to a group of local business leaders, Chan also referred to people who panic-buy as “stupid,” “suckers,” an embarrassment and a disgrace. He said: “So some of us, just a small group behaving like idiots will kill all of us. It will kill our current price negotiation strategy, it will kill our future business opportunity.” He added that only if Singaporeans “behave[d] properly,” would people “have confidence” in Singapore. “Every country can behave like idiots, Singaporeans must not behave like idiots,” he said. In fact, in an interview with Bloomberg, Chan also said of Singapore’s coronavirus response: “We must constantly plan on this basis that we want to be the first one off the blocks [once global economies begin to rebound from the effects of the virus] beyond just handling the crisis well.”
While Singapore is clearly planning ahead in tackling COVID-19, it is clear that its strategy is geared towards an economic focus—about business confidence and continuity, which nonetheless (fortunately) also means ensuring an effective health system which would protect their investments. However, as can be seen from its social policies (e.g. unemployment benefits) and the way citizens were chided, the Singapore government places little focus on providing social assurances.
But the weak, or even lack of, understanding of the social and psychological aspects among Singapore’s decision-makers present as a loophole in its coronavirus response strategy. A few days after the first panic buying, National Development Minister Lawrence Wong admitted that a “lack of clarity” in its messaging could have led to the panic buying. Wong said: “When we went around asking, there was some misunderstanding, or even a lack of clarity” around what Dorscon Orange meant. At that point, Wong revealed a hint of humility not usually seen among Singapore’s decision-makers—he admitted that the government “[did] not know everything,” especially with the “rapidly evolving” situation of the coronavirus.
Taiwan Premier Su Tseng-chang has won praise for his effective and lighthearted communication. In this image, Su warns against non-essential travel abroad. (Photo via Su Tseng-chang / Twitter)
Early Risk Assessment and Honest Critical Appraisals
Now, compare this with how Taiwan managed it: when the number of COVID-19 cases reached 100 last week due predominantly to import cases, it also sparked a mini panic-buy episode. President Tsai came out the next day to give a speech, and the first thing she did was to give credit to the Taiwanese people. She said: “The ability of the Taiwanese people to come together to fight COVID-19 and their commitment to protect Taiwan were crucial to our success in the first stage of preventing an outbreak.”
Premier Su Tseng-chang, who has become a ‘grandfather’ of sorts to the Taiwanese—he actually used a pointer stick to give presentations on Taiwan’s successes during the election rallies early this year, to great enjoyment and amusement—also shared on his Facebook a poster using his trademark humorous style to even urge Taiwanese to buy more food and eat healthy to protect themselves during this coronavirus—a great use of reverse psychology here to try to calm people. He also reminded people of Taiwan’s role as a food producer—and of toilet paper—thereby adding another layer of calm.
Pingtung mayor Lin Ya-chun 林亞蒓 and Tainan mayor Huang Wei-cher 黃偉哲 also got on the act to promote the local food produce in their cities and counties. Indeed, a huge part of why Taiwan has been able to successfully keep the coronavirus under control as well as tide through it, is because of Taiwan’s manufacturing ability to produce face masks on its own, and its food producing ability—both of which Singapore lacks at scale due to a shift towards the service and financial sector.
Taiwan’s ability to produce its own supplies should therefore not be underestimated—its economic affairs ministry was even able to get local manufacturers to increase their production of basic necessities such as toilet paper in response to the panic buying. President Tsai herself said: “The power of Taiwan’s SMEs never ceases to amaze me.” Moreover, Taiwan’s willingness to ban exports of essential items such as face masks and thermometers and enact heavy penalties for price inflation and hoarding stands in contrast with some other countries which have not adopted such a proactive approach towards rationing its resources.
Most important of all is how Taiwan took the pandemic seriously right from the start from whence it spotted the signs. If we were to use the Risk Governance Framework developed by the International Risk Governance Council, it could be seen that as early as 31 December last year when public confirmation of a new type of pneumonia was announced in Wuhan, Taiwan immediately held an inter-ministerial meeting to conduct a risk assessment of the situation, from which it decided to implement stricter border controls straight away, including testing travelers coming into Taiwan with fever. A series of more than 100 measures were also implemented as Taiwan’s authorities continued framing and re-framing the problem, including refining the testing criteria and expanding it to travelers at the checkpoints.
Taiwan’s government also conducted an appraisal of the possible social concerns right from the start, and just before Taiwan saw its first confirmed case, it set up the Central Epidemic Command Center (CECC) to coordinate its risk management strategies—the very next day, when Taiwan saw its first case, a risk communication plan kicked in to assuage people’s concerns on the availability of masks and a plan to increase the number of masks via local production and corresponding rationing was carried out speedily. Within a month, Taiwan was able to increase mask production from slightly more than a million to more than 10 million, exceeding the domestic needs of 9 million a day.
The constant risk evaluation the authorities conducted therefore allowed it to constantly adjust their plans, and Taiwan (as well as Singapore) have thus not needed to adopt shutdowns or more intensive measures at this point due to how the risk reduction measures implemented are still tolerable enough to deal with the pandemic, though things may change anytime soon. Taiwan’s Department of Medical Affairs director Shih Chung-liang at the ministry of health says that it has also come out with five different scenarios of how COVID-19 will continue to develop and the adjustments that will be adopted—if the pandemic worsens, there will be 21 hospitals which will be activated solely as isolation hospitals to handle the coronavirus; and if it continues to become more widespread, more than 100 hospitals would be activated with non-emergency surgeries postponed; and finally, when the hospitals reach tipping point, patients with mild symptoms would be sent to quarantine facilities outside of the hospitals instead.
It is therefore due to a strict risk assessment approach, including early assessment from the start, identifying the toxicity of the hazard and characterizing its threat clearly, as well as having a clear assessment of Taiwan’s vulnerability (due both to its proximity to China as well as having to live with constant threats from China’s government of its sovereignty), that has enabled the Taiwanese government to develop a response and governance system that has enabled Taiwan to counteract the force of COVID-19’s impact for now.
Taiwan’s high press freedom rankings (Taiwan ranks 42nd on the Reporters Without Borders’ 2019 World Press Freedom Index while Singapore ranks 151st) also enables the citizenry and civil society to partake in a vibrant discourse surrounding the coronavirus, thereby helping them stay aware and vigilant.
Developing Transparent and Social-Based Systems to Tide Through COVID-19
While criticisms have been levied on authoritarian regimes like China and Iran for their non-transparent modi operandi thereby suppressing news of the virus and allowing it to spiral out of control—at least for the beginning in China if the data is to be trusted, the criticism against neoliberal economic models such as the United States is how their focus on wealth generation resulted in a neglect of the institutional investment necessary to strengthen the healthcare and testing facilities to fight a new coronavirus like COVID-19.
However, while Singapore is an authoritarian regime functioning on a neoliberal model, it has not let itself be crippled by the pitfalls of such “models”. Singapore’s decision-makers come from a legacy of networked Chinese businessmen linked both in pedigree and economic interests in the financial and governance sector since the 1920s and 1930s, and it is this history that has enabled them to intertwine their business interests together with the nation state, which means that while other neoliberal models might divert investments to prop up business interests at the expense of medical institutional infrastructure, Singapore’s decision-makers on the other hand look at Singapore as an entire business case where institutional risk assessment of business viability therefore necessitates strengthening the healthcare infrastructure if their business interests are to be secured. Being able to develop an effective health system to fight COVID-19 is therefore not viewed as a waste of resources, rather it is appreciated as a means to protect investments in the country-business. It also explains the lack of social investment because labor is dispensable to Singapore’s profit-making strategy—the country’s porous borders allow for labor to be easily replaced.
The Singapore government has boasted about its efforts to international media using platforms such as Bloomberg to highlight its COVID-19 response with a very specific aim of signaling to businesses it should have their full confidence—Bloomberg is an economically-geared media platform. But Taiwan’s response does not pale in comparison, and in fact takes a somewhat more holistic approach in not only ensuring critical health infrastructures have the strength to resist this new coronavirus, but the whole-of-government approach Singapore champions is clearly in operation in Taiwan as well, in the coordination between government agencies and even local businesses to not only partake in the health response but also consolidate local production for surgical masks and gowns. However, the lack of coordination between the health and labor ministries vis-à-vis the management of undocumented workers do expose gaps in Taiwan’s inter-ministerial cooperation.
Nonetheless, Taiwan’s approach goes beyond the narrow business interest-strategy supported by healthcare infrastructure that has come to define Singapore’s strategy—its face mask response and its direct investment in the social protection of workers affected by COVID-19 are all superior to Singapore, and this is not accounting for the existing social institutions Taiwan already has in place—affordable healthcare, unemployment benefits and adequate pension protection—all of which do not exist in Singapore. (Singapore does not have unemployment benefits, its out-of-pocket healthcare aside from COVID-19 is one of the most expensive in the world while it is also ranked by the OECD as having one of the least adequate pension replacement.) Even so, Singapore is already announcing to the world that it is ready to move beyond COVID-19 to welcome investors when the time comes, and there is no reason why Taiwan cannot show an equal or even stronger level of confidence in its own capabilities. As President Tsai said, “Our country deserves our confidence.”
Indeed, both Taiwan and Singapore has handled the COVID-19 coronavirus admirably and while both countries have adopted strong health systems approach to containing the virus, Taiwan’s comparatively more socially-minded current ruling party has come out with more all-rounded policies.
While Taiwan still has some way to go before it can reach the social protection level of some Western European and Nordic countries—the coverage of unemployment benefits for workers is still dismal, for example—at the very least, Taiwan’s social infrastructure is in place to enable it to progress further on this front. In fact, the major pitfall about Singapore’s approach is because Singapore is not the democracy Taiwan is. It requires the compliance of citizens to abide by its top-down measures for the protection of its own business interests. But this also breeds resentment towards what is perceived as a government that despises its citizens—they were called “idiots” and an embarrassment. The resultant distrust among some also resulted in panic buying due to a lack of reassurance from Singapore’s heavy-handed decision-makers. The protection of citizens are a byproduct of a nonetheless effective health strategy. Taiwan instead prioritized both its citizens and the economy.
Credit should be given where credit is due but unless a society is run by such a business-government integration model, following in Singapore’s strategy is not possible. The transparent, open and socially-minded approach that Taiwan uses is a more fair-minded and balanced approach if citizens in other countries are hoping to find inspiration during this coronavirus outbreak.
(Cover photo via Taiwan Presidential Office, CC BY 2.0)
