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Health System Resilience in Managing the COVID-19 Pandemic: Lessons from Singapore

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Health System Resilience in Managing the COVID-19 Pandemic: Lessons from Singapore Practice Health system resilience in managing the COVID-19 pandemic: lessons from Singapore 1 1 1 Alvin Qijia Chua , Melisa Mei Jin Tan , Monica Verma , 1 1 1 1 Emeline Kai Lin Han, Li Yang Hsu , Alex Richard Cook , Yik Ying Teo, 1,2 1 Vernon J Lee, Helena Legido- Quigley To cite: Chua AQ, Tan MMJ, ABSTRACT Summary box Verma M, et al. Health Singapore, one of the first countries affected by COVID-19, system resilience in adopted a national strategy for the pandemic which ► Singapore was among the first countries affected by managing the COVID-19 emphasised preparedness through a whole- of- nation pandemic: lessons from COVID-19. Its health system resilience was tested as approach. The pandemic was well contained initially Singapore. BMJ Global Health the pandemic continued to spread following a surge until early April 2020, when there was a surge in cases, 2020;5:e003317. doi:10.1136/ in the number of infected people in early April. attributed to Singapore residents returning from hotspots bmjgh-2020-003317 ► The strength in the response of Singapore to the overseas, and more significantly, rapid transmission COVID-19 pandemic was in part due to coordination locally within migrant worker dormitories. In this paper, Handling editor Seye Abimbola between government agencies. However, we iden- we present the response of Singapore to the COVID-19 tified a few areas of improvement that may provide pandemic based on core dimensions of health system Received 1 July 2020 important learning points for other countries. Revised 23 August 2020 resilience during outbreaks. We also discussed on the ► Understanding reasons for poor uptake of initiatives, Accepted 24 August 2020 surge in cases in April 2020, highlighting efforts to mitigate such as the mobile application for contact tracing, it. There was: (1) clear leadership and governance which may help design of future initiatives that garner adopted flexible plans appropriate to the situation; (2) more public support. timely, accurate and transparent communication from ► Adopting a more inclusive response that protects the government; (3) public health measures to reduce all individuals, including at-risk populations such as imported cases, and detect as well as isolate cases early; migrant workers living in dormitories, is vital to curb (4) maintenance of health service delivery; (5) access to community transmission of outbreaks. crisis financing; and (6) legal foundation to complement policy measures. Areas for improvement include understanding reasons for poor uptake of government initiatives, such as the mobile application for contact and more substantially, rapid transmission tracing and adopting a more inclusive response that locally within migrant worker dormitories. protects all individuals, including at- risk populations. The Singapore received initial recognition from experience in Singapore and lessons learnt will contribute WHO for its approach in COVID-19 contain- to pandemic preparedness and mitigation in the future. ment.3 However, its health system resilience was tested as the pandemic continued to infect more people. Health system resilience is the ability of populations to prepare for and INTRODUCTION effectively respond to crises, by reorganising © Author(s) (or their On 30 January 2020, WHO declared corona- systems to manage the new conditions while employer(s)) 2020. Re- use 4 permitted under CC BY- NC. No virus disease 2019 (COVID-19) as an interna- maintaining core functions. In this paper, commercial re- use. See rights tional public health emergency. Singapore, a we present the COVID-19 pandemic response and permissions. Published by city state of 5.7 million people, densely popu- of Singapore based on core dimensions of BMJ. lated at 7866 people per square kilometre, health system resilience during outbreaks, as 1 Saw Swee Hock School was among the first countries affected.1 Since elaborated by Nuzzo et al4 and Legido- Quigley of Public Health, National 5 University of Singapore, then, progressive measures were in place to et al. We have adapted the core dimensions Singapore detect and contain the disease. As of 20 August into eight critical functions for our paper, 2Communicable Diseases 2020, Singapore has 56 099 confirmed cases, including leadership and governance, risk Division, Ministry of Health, reflecting more than 50-fold increase since communication, public health outbreak Singapore April, but has kept case fatality rate lower than containment measures, financing, health 2 Correspondence to 0.1% (27 deaths). The surge in cases started service delivery, human resources, legal Alvin Qijia Chua; in early April and was attributed to Singapore foundation, as well as political factors and alvin. chua@ nus. edu. sg residents returning from hotspots overseas, values that shape the response, experiences Chua AQ, et al. BMJ Global Health 2020;5:e003317. doi:10.1136/bmjgh-2020-003317 1 BMJ Global Health and behaviours of individuals and communities during members. Progressive reopening in June 2020 allowed the outbreak. Considering the surge of cases since April returnees from selected countries to serve their SHN at 2020, we also reviewed its significance and highlighted home if they remained in those countries the last consec- interventions to contain it. utive 14 days.11 Deferment of outbound travel was still advised. Short- term visitors were still not allowed entry, except for official travel permitted under special arrange- LEADERSHIP AND GOVERNANCE ments. The national strategy for pandemic in Singapore empha- sised preparedness through a whole-of- nation approach. Detecting and isolating cases early Since the 2003 Severe Acute Respiratory Syndrome Singapore employed complementary detection methods (SARS) outbreak, nationwide efforts were implemented when the outbreak started.12 Case definitions were based to prepare institutions and individuals for pandemic on clinical and epidemiological data, updated regu- response. Organisations simulated possible scenarios larly according to evolving global situations. There was of pandemics and developed corresponding outbreak 6 enhanced surveillance for patients with pneumonia or management plans. A multiministry government task- prolonged acute respiratory symptoms and patients in force was convened to coordinate actions between clin- intensive care units (ICUs). Physicians were given discre- ical and non- clinical stakeholders, centralise efforts and 7 tion to test patients for COVID-19 based on clinical suspi- disseminate information. The taskforce, comprising cion even if case definition was not fulfilled. Laboratory heads of ministries, led and coordinated actions between testing capacity was scaled up in phases, expanding to different agencies. For example, Ministry of Health all public hospitals and major private laboratories. As (MOH) worked closely with academic institutions to of 1 June 2020, more than 408 000 tests were conducted provide timely epidemiological and clinical data about (71 700 tests per million population), with plans to COVID-19 in the population. The taskforce designed and increase testing capacity from 8000 to 40 000 tests per implemented measures which were guided by scientific day.13 evidence. Individuals who tested positive were immediately isolated and interviewed for contact tracing. Contact RISK COMMUNICATION tracing operations led by MOH were aided by dedicated contact tracing teams at the hospitals, the Singapore Clear communication channels between the govern- Armed Forces (SAF) and the Singapore Police Force.14 ment and all sectors are essential to translate policy into Hospital contact tracers interviewed confirmed cases to intended actions. The taskforce was transparent and map their activity history over the last 14 days prior to frequent in providing situational updates, as well as new onset of symptoms, until diagnosis and isolation. This guidance and its associated rationale through traditional information was passed to MOH where their contact and social media channels, and regular press confer- tracers called people whom the patient had interacted ences. These nationwide communication channels were with, to fill information gaps, and to identify close vulnerable to misinformation. MOH regularly clarified contacts. Close contacts and lower- risk contacts identi- misinformation, encouraging the public to follow accu- fied were placed under quarantine and phone surveil- rate and reliable information on official channels. lance, respectively. More than 1300 personnel from SAF and Ministry of Defence helped trace and monitor all PUBLIC HEALTH OUTBREAK CONTAINMENT MEASURES contacts via phone during the 14-day period, referring 15 Singapore adopted a three-pronged approach to contain those who reported symptoms to hospitals. Importantly, COVID-19: (1) reducing spread from imported cases; (2) cases were isolated at hospitals or community isolation detecting and isolating cases early; and (3) emphasising facilities, akin Fangcang hospitals in China, rather than 16 and supporting social responsibility.8 at home where they might infect household members. More than 800 Public Health Preparedness Clinics Reducing spread from imported cases (PHPCs) were activated to enhance detection and Since identification of the first imported case in Singa- management of potential cases. PHPCs were private pore, various phases of travel restrictions were imple- primary care clinics responsible for screening and refer- mented as the global situation worsened. Starting from ring severe cases
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