Introduction

COVID-19 has seriously impacted a large number of countries globally. The response of different countries to its onslaught has, however, varied. Different responses—epidemiological and political—to the pandemic have resulted in varied consequences. Policies and actions by governments, including their ability to promote the engagement of communities, have impacted outcomes.

Some countries in Asia have successfully contained the epidemic. It is important to study and analyze the measures they employed in order to draw lessons for countries that are still struggling to counter the health and economic impacts of COVID-19. This chapter is focused on drawing the learnings from countries from Asia that have successfully contained the epidemic. These learnings could be adapted by countries that are in the throes of the epidemic and are, as yet, unclear about the strategies they might employ in their contexts to diminish serious negative health and economic impacts of the pandemic including increased morbidity and mortality and loss of livelihoods.

Learnings from the Experience of Asian Countries

A comprehensive review and analysis of the experiences (successful and unsuccessful) of countries in Asia was undertaken. This review provided the following learnings:

  1. 1.

    Competent leadership is essential for an agile and effective response to the pandemic.

  2. 2.

    The presence of a robust public health system that provides quality services is an essential prerequisite for effectively implementing policies and programs to combat the epidemic.

  3. 3.

    The presence of strong national institutions that have the authority and autonomy to respond to emergencies and, more specifically, to infectious disease prevention and control is important to enhance preparedness for implementing early and sustained interventions for combatting the pandemic.

  4. 4.

    An early and sustained response to the crisis is effective in halting the spread of the infection.

  5. 5.

    Partnerships of the government with the private sector and with other relevant institutions expand medical capacities to respond to national emergencies.

  6. 6.

    Overhauling regulatory systems to enable fast-track approvals to undertake safety measures provides an agile and effective response for managing a national crisis.

  7. 7.

    Engagement of the public through effective ongoing communications by the government that keep people informed of developments is critical for the success of the program.

  8. 8.

    Addressing equity and the social dimensions by ensuring the inclusion of marginalized and vulnerable populations is important for program success.

  9. 9.

    Policies are more likely to succeed and have an enduring impact when they are compatible with the culture of the country as they are then more likely to elicit public cooperation and voluntary compliance over the long term.

  10. 10.

    The provision of accurate, honest, complete, and unambiguous messages to the public debunking misinformation is critical for ensuring that the people are fully informed about the program as well as about their responsibilities to comply.

The experiences of different countries in Asia that are combatting the COVID-19 pandemic have provided the above-mentioned learnings. It is, however, important to underscore that to be effective and have a sustainable response there is a need to combine some or all of these learnings within a judicious mix. To illustrate this point, it may be noted that while competent leadership is necessary to confront an unprecedented crisis, it is not by itself sufficient. The country must also have an adequate infrastructure in place when the crisis strikes. Policies are more likely to succeed when an infrastructure exists to support their effective implementation. In order to be effective, policies and programs must address equity issues by reaching marginalized and vulnerable communities. In addition, these policies must be compatible with the existing culture. It is important to understand how government leadership, policies and programs, and cultural predispositions relate to each other.

Several Asian countries that have performed well have had prior experiences with epidemics in the past, including severe acute respiratory syndrome (SARS) and Middle Eastern respiratory syndrome (MERS). Based on these experiences, governments overhauled their health systems and put in place a relevant institutional infrastructure which prepared them for the COVID-19 onslaught.

Preparedness of Countries: Infrastructure for Infection Control and Health Service System

South Korea, Taiwan, Vietnam, and Singapore had established initial warning systems and had put in place an institutional infrastructure before they were attacked by COVID-19. Taiwan, Vietnam, and Singapore were hardest hit by SARS in 2003. Vietnam also experienced the Avian Influenza in 2004–2010. South Korea was less affected by SARS but was second to Saudi Arabia in terms of total MERS cases in 2015 [1]. After their experiences with SARS and MERS, these countries overhauled their health systems and so were better prepared when they were hit by COVID-19.

Infrastructure for Infection Control

More importantly, all these countries set up emergency institutions equivalent to the Centers for Disease Control (CDC). These centers were equipped with adequate staff, budgets, specialties, and autonomy to issue emergency guidelines to the public and policy advice to the government. The CDC in South Korea was upgraded to a deputy ministerial-level agency and expanded its professional specialties and autonomy. The Chair of the Central Epidemic Command within the CDC in Taiwan has the rank of a government minister [2].

Public–private partnerships were forged to enhance health capacity [2]. In addition, approval processes for developing test kits and undertaking clinical trials were defined.

Health Service System

Learnings from the SARS and MERS epidemics enabled Singapore, Taiwan, Vietnam, and South Korea to identify and fill infrastructure gaps [3, 4]. The program in Vietnam presents a successful low-cost model unlike Taiwan, South Korea, and Singapore that undertook mass testing, Vietnam implemented a proactive prevention strategy which was feasible given its limited resources.

During the 2000 and 2016, Vietnam’s preventive health expenditure increased by 9% per year [5]. Having learnt from the SARS epidemic, the government strengthened its public health program by including a national public health surveillance system. It built on its already data robust system and established a nearly real-time, Web-based system in 2009. A system of reporting notifiable diseases, that is now in place, enables the Ministry of Health to track epidemiological developments in the country in real time [6]. This system empowers community members to report health problems and enables the government to detect emerging outbreaks of infectious diseases [7].

Leadership: Rapid Response, Evidence-Based Strategies, and Partnerships

The role of leadership in the pandemic response remains undeniable [8]. Strong examples of countries in Asia where swift and decisive action helped allay the impact of the virus and unite nations include South Korea, Taiwan, and Timor-Leste. These examples of effective leadership witnessed a swift and agile response, strong coordination, an evidence-based approach that was well communicated, and partnership spirit [9].

Rapid Response

A well-recognized characteristic of decisive leadership is rapid response, based on a clear understanding of the threat presented by COVID-19, and that delayed action could lead to worse outcomes [8]. In a study of national responses, there was significant variation in the rate and speed at which strict measures were employed [10]. Earlier implementation was associated with better outcomes [11]. In Taiwan, leadership has been praised for its decisive action. Some have attributed Taiwan’s success to its female leadership [12]. Effective leaders ensure strong and rapid coordination, given the socioeconomic and health dimensions of the pandemic. Learning from previous disease outbreaks, Singapore established a multi-ministry task force to centrally coordinate a whole-of-government response which means the movement from isolated silos in public health administration to formal and informal networks that call for collaborative responses, increase demand on the part of citizens; and for more personalized and accessible public services to transform the way the government works for the people [13].

Evidence-Based Approaches

It is very important to make decisions based on scientific evidence. Leaders who deferred to scientists and medical experts for making decisions were successful. Those who based their decisions on short-term economic or political gain lost valuable time in a situation where there was exponential growth of the pandemic. They were, therefore, not able to contain the pandemic. As the pandemic is continually evolving and knowledge about COVID-19 is increasing, it is important to based decisions on the latest available scientific information.

Partnerships

It is important to ensure that there is effective coordination between the central and provincial governments. This is critical in determining successful outcomes. Public trust and subsequent compliance were possible in the case of countries that implemented holistic programs which succeeded in mitigating economic slowdown through broad-based stimulus packages.

Leaders who adhered to the measure prescribed by the International Health Regulations (2005) were more successful [8, 14]. South Korea showed that it is essential to share data in a transparent way. It provided WHO with information on its very first case [15]. It is important for countries to collaborate and form partnerships in order to develop treatment regimens and undertake vaccination trials. WHO is supporting global partnerships through its Solidarity Fund, COVID-19 Supply Chain System, and Solidarity Trial [16, 17]. A pandemic that presents a global threat requires all leaders to step up, collaborate, and cooperate in decisive action [8].

Equity and Social and Cultural Dimensions

The experience of Asian countries with COVID-19 illustrates the importance of incorporating equity and related societal considerations within policies and programs. Preventive strategies should be implemented to reach everyone regardless of citizenship, age, gender, and class.

Equity and Society

A policy focus on mainstream societal groups could mask simmering problems among marginalized groups and ultimately ruin early progress in the fight against COVID-19. In Singapore, for example, major outbreaks emerged among migrant workers after the country’s initial success in containing the spread of the virus. It was estimated that migrant workers living in government-run dormitories accounted for 88 percent of the increased cases [18]. This experience resonates with the argument that social equity should be a major pillar of public administration not only for normative values but also for practical ones [19, 20].

An early response with solidarity of citizens and care for the vulnerable social groups was a key factor in Vietnam’s successful response to COVID-19. The ethics of care in the response of Vietnam to the COVID-19 pandemic included care of the vulnerable, social groups [21].

Cultural Dimension

Citizen’s compliance with the government’s policy measures is essential even when some measures impose heavy demands on them. For example, in Singapore and Taiwan, there was heavy police enforcement of quarantine rules and heavy penalties if these were not adhered to. Public cooperation and voluntary compliance are needed for the government’s policies to succeed.

In the Asian collective culture, individuals are willing to sacrifice their freedom during a crisis for the collective good [22]. Communities in Asia have a long history of threats from wars, natural disasters, and diseases, which have shaped strong social norms and strict principles governing social behavior [23]. In South Korea strong actions were undertaken such as using government apps for quarantine and mandating rule-breakers to wear wristbands, that are supported by its collectivist culture.

Communications

It is evident that a successful COVID-19 response demands the need for trusted public communication. Although government action is necessary to implement wide-scale measures, individual behavior is important in limiting the spread of COVID-19, with emphasis on the importance of ensuring individual rights [8, 24, 25]. In Vietnam and South Korea, for example, the governments harnessed the potential of information technology to set up Web sites and apps for epidemiological information and surveillance. Building trust requires clear and consistent communication based on reliable and credible sources, thus promoting transparency and accountability. Political partisanship adversely affects health behaviors and policy preferences, thus determining success or failure of the COVID-19 response [8, 26]. Factors that undermine trust such as political polarization should be overtly and deliberately addressed by leaders. Effective communication needs to emphasize a shared identity against the COVID-19 threat.

Governments that used COVID-19 to accumulate power, target the media, and silence critics fared poorly. Using emergency powers in such ways only serves to propagate mistrust. If authoritarian leaders look at a pandemic as a political opportunity instead of a public health crisis, their priorities are terribly misplaced, and lives are lost as a result. Governments that communicated with their publics in a transparent manner tended to quickly win the confidence of their people.

Furthermore, governments that acknowledged the problem, communicated the risks, outlined effective mitigation efforts, and spoke with one voice fared much better than governments that had multiple speakers or leaders who down-played the threat, publicly reversed their stand, denied the science, identified scapegoats, and fueled conspiracy theories. Greater trust led to much greater support, social engagement, and compliance when it came to wearing face masks and social distancing. Singapore and Vietnam are models of effective communication and transparency. While Vietnam is a fully authoritarian state, and Singapore is quasi-authoritarian, regime types that are not always cited as transparent but both know that in public health matters transparency and communication are key. Vietnam, in particular, deserves credit for its transparent communication strategy, TikTok dances, and a catchy hand-washing campaign. This has been a course reversal since SARS hit in 2003. Today, the Vietnamese government has become a model of transparency and effective communication [27].

Box 1: Vietnam’s patriotic communication campaign

One of the ways in which the Vietnamese pandemic response differed from other countries is that the government relied heavily on the power of communication to engage its people—from all walks of life—to join the government-led fight against COVID-19. ‘Early, decisive, and transparent actions by the country’s leadership, along with the engagement and solidarity of citizens, have been a key to Vietnam’s success in combating COVID-19 to date’ [28]. This strategy aimed at increasing solidarity and care for oneself and one’s fellow citizens. The Government of Vietnam employed the war rhetoric from the beginning of its pandemic response emphasizing solidarity in winning the war over the virus. ‘In Vietnam, news coverage was marked by a prominent narrative: Every citizen is a soldier fighting the disease’ [29]. The Prime Minister of Vietnam, Nguyen Xuan Phuc, represented the pandemic as a battle and called on the citizens to unite in the fight [28]. The communication strategy portrayed the COVID-19 pandemic as the enemy in Vietnam. Social distancing and hand-washing were identified as a matter of patriotism, and this message resounded through all information campaigns and popular art [28]. For example, a famously cited viral poster communicated the message ‘to stay home is to love your country’ [29]. The Prime Minister’s unified message ‘Every business, every citizen, every residential area must be a fortress to prevent the epidemic’ echoed throughout the pandemic’s communication campaign [21, 30].

At the start of the outbreak, the communication to Vietnamese citizens was centrally led. It focused on communicating about the spread of the virus and its potential impact on local lives and livelihoods. At this stage, communication was necessarily centralized, implying that information was vertically communicated starting from the central government down to citizens. This approach leveraged national television, which played the primary role. However, as the pandemic continued and its risks increased, the communication strategy also changed. Soon communication reached the most remote communities as a result of the country’s nationwide, public loudspeaker system, and network of mass organizations. While vertical communication through national television remained, horizontal and informal channels were subsequently adopted. For example, a door-to-door method was employed, with leaflets being provided. Of these latter methods, what has been most interesting is the application of the public loudspeaker system that is available in all cities, provinces, and rural areas across the country. The loudspeaker was accompanied by innovative mobile communications, for example, communication mini-trucks and motorbikes, which travel to the country’s remote areas.

Vietnam’s strong network of mass organizations, including the Women’s Union, Farmers’ Association, and the Youth Union across the country have been central to two-way communication regarding the pandemic. These networks reach every neighborhood and suburb. Most people in communities are members of one or another mass organization that proactively communicates the decisions of the government nationwide. In response to the rapid spread of COVID-19, these organizations were a key task force in supporting information spread and securing active citizen engagement during the pandemic response.

Country Policies and Strategies

The strategies employed by Taiwan, South Korea, Vietnam, and Singapore are discussed in the next section.

Taiwan

Decisive, Rapid Response

Taiwan responded rapidly and efficiently and was successful in combating the pandemic even though it is located geographically close to China and does not have WHO membership. With 446 cases and seven deaths as of the June 22, 2020, in a population of 23.8 million, Taiwan has remained relatively unscathed despite its proximity to the epicenter [31]. The government responded speedily and decisively. Taiwan began to screen arrivals from Wuhan immediately after the first report from China on December 31, 2019. The Central Epidemic Command Center, which had operated well in combatting the outbreak of SARS in 2003, became functional in January 2020.

Health Insurance, Emergency Funding, and Capacity Strengthening

The lack of health insurance for large parts of the population is a major barrier in mounting an effective outbreak response [32]. In Taiwan, more than 99% of the population was covered by health insurance. Emergency funding was also approved to support COVID-19 prevention efforts and affected industries [33].

Taiwan invested in additional capacity at the CDC, hospitals, and infectious disease laboratories after the SARS pandemic. Once China released the genetic sequence of COVID-19, Taiwan developed a test kit and expanded diagnostic capacity by engaging 37 laboratories that could perform 3900 tests per day [34]. A critical component was integrating the National Health Insurance database with its immigration database, which enabled the healthcare providers to access patients’ travel histories and generates real-time alerts to facilitate early detection of cases. Innovative technology forecasted detection including quick response (QR) code scanning and online reporting of travel history, contact history, and symptoms was used. High risk was subject to 14-day home quarantine with phone monitoring of compliance and health status [35].

Robust Health System

After the SARS epidemic, Taiwan’s government built a robust health system that was well-equipped and well-prepared to handle the COVID-19 epidemic. The SARS experience also prepared the people for the pandemic as they engaged in social distancing and mask-wearing [33]. Thus, the public was a close partner of the government in the fight against COVID-19.

South Korea

Hospital-Based Care

Compared to other high-income countries, the number of hospital beds per capita in South Korea is much higher at 12.3 beds per 1000 population. This is over two times the average of Organization of Economic Cooperation and Development (OECD) [36]. Although some critics suggest that South Korea’s health system is over-indexed on hospitals—often sources of secondary or tertiary care—to the detriment of primary care, this increased capacity-enabled hospitals to respond quickly to COVID-19 without sacrificing care for non-COVID-19 patients [37]. Despite its robust health system, South Korea struggled to respond to the 2015 outbreak of MERS, with nearly 17,000 suspected cases and 38 deaths. During the six months of that outbreak, Koreans lived in fear, and the government lost an estimated USD 2.6 billion in tourism revenue while spending almost USD 1 billion on diagnosis, treatment, and other response activities.

Pandemic Preparedness

After MERS, the country made a series of policy changes to improve pandemic preparedness and response. When COVID-19 struck, the painful memory of MERS inspired an early government response as well as a willingness among people to wear masks, cooperate with contact tracers, and listen to public health officials. A recent poll showed that more people adhered to public prevention protocols during the COVID-19 outbreak than during the MERS outbreak [37]. After the peak of 900 cases on February 29, 2020, the number of cases fell rapidly in the following two weeks until it hovered below 200 daily confirmed cases by March 12, 2020. Daily cases steadily declined to nearly zero, although there was a minor resurgence in mid-May (about 30 cases per day), as the country started to reopen.

Improving Epidemic Intelligence Service

The government transformed public facilities owned by private corporations into temporary isolation wards. This prevented transmission within households and also relieved hospitals of bed shortages. Healthcare workers regularly monitored and quarantined clinically stable patients who did not warrant in-patient treatment [38]. South Korea expanded its usual workforce of Epidemic Intelligence Service (EIS) officers quickly by training staff at local public health centers, hiring 300 private epidemiologists and leveraging staff at 11 non-governmental organizations that train and support EIS officers. These efforts led to earlier case detection, kept the rate of new infections low, and potentially reduced fatality rates by preventing hospital overcrowding [37].

During a shortage of hospital beds in the epicenter of Daegu, health officials developed a triage system using a severity scoring system to classify patient illnesses as mild, moderate, severe, and critical. Mildly ill patients were sent to community treatment centers where they were closely monitored. Moderately ill patients were sent to community hospitals, and severe or critically ill patients were hospitalized at tertiary hospitals equipped to provide intensive care [38]. Also, 2400 additional healthcare workers were spread out among these institutions.

The population in South Korea is highly urbanized with over 80% living in urban areas [39]. Culturally and legally South Korea is more tolerant of personal data sharing, and its success has been heavily dependent on its ability to rapidly scale up technological solutions. Countries with less technology and where citizens do not have smart phones or are not willing to share their data may experience difficulties adopting such strategies. Despite these differences, many of South Korea’s strategies, including its investments in preparedness, decisive, and data-drive leadership, strategic clarity, and willingness to be innovative can be adapted in other countries. South Korea showed that it is possible to contain the coronavirus without shutting down the economy [40, 41].

South Korea’s Fast Intervention

The government began to act within a week of the diagnosis of its first case. Approvals for developing test kits were followed by thousands of test kits shipped daily. South Korea now produces 100,000 kits per day and plans to export them. Furthermore, South Koreans were primed to treat the coronavirus as a national emergency, after a 2015 outbreak of MERS in the country, which killed 38 persons.

Test Early, Often, and Safely

Initially, the South Korean government was accused of complacency. Its testing campaign, however, was successful in sparing hospitals from being overwhelmed. Testing centers were set up to screen as many people as possible in the shortest possible time. Drive-through stations tested people in their cars. This procedure was completed in 10 minutes. And test results were available within hours.

About a week after the first COVID-19 case, the Korean CDC directed private companies to produce a diagnostic reagent [42]. Within two weeks of the first case, thousands of test kits were shipped daily with the numbers reaching up to 100,000 kits in March [41]. By April 24, 2020, 118 institutions were available to run diagnostic tests. Collectively, these institutions have the capacity to run an average of 15,000 tests (up to 20,000) per day. COVID-19 screening clinics were set up. Those flagged by the screening were tested and told to return home and self-quarantine. By late March, the country had performed over 300,000 tests, which were more than 40 times per capita than in the United States at that time.

Full and Transparent Messaging

Relentless public messaging urged South Koreans to seek testing if they or someone they know developed symptoms. Visitors from abroad were required to download a smartphone app that guided them through self-checks for symptoms. Offices, hotels, and other large buildings often used thermal image cameras to identify people with fever. Many restaurants checked customers’ temperatures before accepting them. This allowed health workers to identify networks of possible transmission early, carving the virus out of society.

South Korea developed tools and practices for aggressive contact tracing during the MERS outbreak. Health officials retraced patients’ movements using security camera footage, credit card records, and even GPS data from their cars and cellphones. ‘We did our epidemiological investigations like police detectives’, according to Dr. Ki, epidemiologist advising the government’s coronavirus response. ‘Later, we had the laws revised to prioritize social security over individual privacy at times of infectious disease crises’. [41, 43].

People’s cellphones received emergency alerts when a new case was discovered in the district. The movements of the people were tracked through smart phone apps and Web sites. These movements were tracked hourly or even minute-to-minute. Loss of privacy has been a trade-off in implementing this system.

Community Engagement

Leaderships kept the public informed and saught its active cooperation. Reminders were continuously sent to smart phones, and mass media was also used. These messages asked people to wear face masks and maintain social distancing. The public responded well. Polls showed high confidence and low panic. The messaging generated a war-time sense of purpose. Officials also credit the country’s nationalized healthcare system, which guarantees care and special rules covering coronavirus-related costs, giving even people with no symptoms greater incentives to get tested.

Vietnam

Effective Testing and Contact Tracing

Vietnam’s first case of COVID-19 was reported on January 23, 2020. A week after the first case was confirmed, Vietnam formed a national steering committee to coordinate the program. A second wave of cases was discovered on March 6, 2020. These cases were imported from new hot spots including Europe, Great Britain, and the United States. On May 1, 2020, a hundred days into the outbreak, Vietnam had confirmed just 272 cases despite extensive testing.

Starting in early February 2020, publicly funded institutions in Vietnam developed at least four locally made COVID-19 tests validated by the Ministry of Defense and the National Institute of Hygiene and Epidemiology. Subsequently, private companies also manufactured test kits. Testing capacity was also ramped up quickly, from just two testing sites nationwide in late January to 120 by May 2020. When community transmission was detected (even just one case), the government reacted quickly with contact tracing, community-level lockdowns, and widespread local testing to ensure that no case was missed. This helps explain why Vietnam has performed more tests per confirmed cases than any other country in the world—by a longshot—even though testing per capita remains relatively low.

Vietnam’s contact tracing strategy stands out as uniquely comprehensive. It is based on testing degrees of contact from F0 (the infected person) though F1 (those who have had close contact with F0 or are suspected to be infected), F2 (close contact with F1), and all the way up to F5. A noteworthy aspect of Vietnam’s approach is that identified and quarantined suspected cases are based on their epidemiological risk of infection (if they had been in contact with a confirmed case or traveled to a COVID-19 infected country), not whether they exhibited symptoms. The high proportion of cases that never developed symptoms (43%) suggests that this approach may have been a key contributor to limiting community transmission at an early stage [44].

On March 10, 2020, the Ministry of Health worked with telecom companies to launch NCOVI, an app that helps citizens put in place a ‘neighborhood watch system’ that complements official contact tracing efforts and may have helped to slow transmission of the disease. NCOVI includes a map of detected cases and clusters of infections and allows users to declare their own health status, report suspected cases, and watch real-time movements of people placed under quarantine [45]. In mid-April 2020, a Bluetooth-enabled mobile app was developed. It notifies users if they have been within approximately six feet of a confirmed case within 14 days. When users are notified of exposure, they are encouraged to contact public health officials immediately [46].

Improved Hospital Infection Control

During the SARS epidemic in 2003–2004, a number of Vietnamese healthcare workers were infected. Apart from the index patient, everyone in Vietnam who died from SARS was a doctor or a nurse [47]. Over the past ten years, Vietnam significantly improved hospital infection control. In preparation for the COVID-19 pandemic, Vietnam further strengthen hospital procedures to prevent infections in healthcare settings.

Although most COVID-19 patients in Vietnam were hospitalized at specialty hospitals in Hanoi and Ho Chi Minh City, healthcare facilities at all levels were prepared to receive them to avoid overwhelming the acute care system. Although Vietnam has not enough cases to overload hospitals, it is worth noting that only four healthcare workers were infected up to June end.

Transparent and Proactive Communications

The Vietnamese government positioned itself as an effective leader during the pandemic by providing information with transparency. The Ministry of Health took the initiative to launch a Web site and a mobile application not only to ease the medical process but also to disseminate accurate information quickly. The digital apparatus helped stem the spread of rumors and fake news, in addition to legal enforcement against people who spread inaccurate information or engage in profiteering. State media constantly covered the hot spots of the pandemic to raise public awareness about the seriousness of COVID-19 and to demonstrate that robust government intervention is essential. By being transparent and proactive in communicating with the public, the government was able to gain and maintain public confidence [27, 48].

The Prime Minister declared war on the virus. He mobilized the nation by imploring to their civic duties. As a result, this relatively poor, one-party state was able to contain the pandemic. It should also be noted that Vietnam was the first country to contain the SARS outbreak—in just 20 days.

Large-scale monitoring and testing and regular temperature scans at airports and other public places resulted in very few cases (about 267) and no deaths as of April 15, 2020. Vietnam also set up infection chambers at clinics to eliminate the transmission of infection. Vietnam is exporting masks to USA and Europe [49, 50].

Singapore

Prompt and Comprehensive Approach

Singapore is a city-state within South-East Asia with a multiethnic population. With high levels of travel and connectivity to the world, it was a key location of the SARS outbreak in 2003. Experience with SARS significantly influenced the country response to COVID-19. Singapore was one of the first countries outside China to identify, document, and diagnose SARS-CoV-2 infections including local transmission [51, 52]. The first case was confirmed on January 23, 2020, and by February 4, 2020, local transmission was reported.

Singapore was ready when WHO declared COVID-19 as a public health emergency at the end of January. Singapore implemented an early and whole-of-government approach to direct public health measures. It restricted in-bound air travel to reduce imported cases. There was extensive testing and meticulous contract tracing and ensuring proper quarantine and/or isolation in Singapore. Clear and consistent public messaging regarding policy was timely, evidence-based, and trusted. And, a clear mandate to promote innovation and research was implemented. There was preparedness for the pandemic because of Singapore’s experience with the SARS epidemic. The National Center for Infectious Diseases (NCID) and a National Public Health Laboratory were set up to specifically tackle emerging infectious diseases and potential pandemics.

Every national hospital quickly and seamlessly transited to a state of operational readiness. The 3-P approach (planning, preparedness, and protective equipment) was successful in flattening the curve and ensuring that healthcare facilities did not become overwhelmed despite the higher-than-usual caseloads, while strictly adhering to the fundamentals of high quality and accessible medical care.

Research and Education

In its response to COVID-19, Singapore prioritized clinical, translational, and basic science from the early stages of the pandemic. National funding schemes such as COVID-19 Research Fund were launched through the National Medical Research Council.

Finally, education and training strategies for medical students and practicing residents were restructured quickly to include required assessments and examinations in line with Singapore’s digital SMART nation evolution. Contract tracing, temperature monitoring, and even the robotic delivery of meals to patients isolated in community build facilities were undertaken. While COVID-19 presented a complex and wide range of clinical, research, and logistical challenges to which Singapore responded promptly. The country is now undergoing a carefully calibrated and phased return to a new ‘post-COVID’ normal [53].

Box 2: Timor-Leste’s success despite a fragile healthcare system and limited resources

Timor-Leste, an island nation of 1.3 million people, responded swiftly and effectively in dealing with the COVID-19 pandemic, despite a fragile healthcare system and limited resources. As soon as WHO warned the world of the threat of COVID-19 and subsequently declared a Public Health Emergency of International concern on January 30, 2020, the Prime Minster along with parliament and senior government officials raised the alarm for urgent action. The Prime Minister set up a crisis management center and a multi-sector task force, which then developed the National COVID-19 Preparedness Action Plan with support from WHO and other partners.

Even before the first confirmed case in the country, as immediate assistance, WHO prioritized availability of essential medical supplies and testing kits to Timor-Leste. Given the importance of timely and quality testing, WHO provided the National Health Laboratory (NHL) primers and probes to carry out 1000 COVID-19 tests. Personal protective equipment (PPE), including gloves, gowns, goggles, and masks, was also made available. Support included numerous technical guidelines adapted to the Timor-Leste context, laboratory support, training of health workers, and surveillance capacity. In addition to activating the Incident Management System (IMS), WHO provided support to the Ministry of Health to conduct training sessions for health workers, point of entry staff, emergency responders, and rapid response teams. A Web-based COVID-19 surveillance portal was created, and national staff were trained in active surveillance and contact tracing.

A country with no testing capacity, no identified isolation and quarantine facility, and limited surveillance capability was transformed into one with in-country testing, functional COVID-19 facilities, staff rapidly trained in infection control and case management, a gradual increase in PPE stocks, capacity for an expanding testing strategy, and active surveillance capabilities over a relatively short period of 4–6 weeks.

Timor-Leste has been a close partner of WHO. WHO advises the government on quality standards and quarantine facilities. WHO also provides advice on health and social interventions as well as monitoring and evaluation.

The country is currently under a State of Emergency, with no new cases reported for over five months. There have been 27 confirmed cases, 25 recovered cases, and no deaths, so far. Almost all cases are linked to well-defined clusters in government quarantine facilities. The expanded testing strategy in health facilities has not identified any signs of community transmission as yet [54].

Box 3: Mongolia’s success story

Mongolia has achieved notable success in protecting the health of its people by preventing the community spread of COVID-19. As of mid-August 2020, Mongolia had experienced no deaths from COVID-19 and had 300 cases, all of which were imported. The COVID-19 outbreak was declared a pandemic by WHO on March 11, 2020. In recognition of the severity of the outbreak, the Government of Mongolia activated the State Emergency Committee (SEC) in January 2020, on the basis of the 2017 Disaster Protection Law. As a result, various public health measures were undertaken, which led to delaying the first confirmed case of COVID-19 until March 10, 2020. These measures include promoting universal personal protection and prevention such as the use of face masks and hand-washing, restricting international travel, suspending all training and educational activities from kindergarten to universities, and banning major public gathering such as the celebration of the national New Year holiday. These measures were accompanied by active infection surveillance and self-isolation recommendations [55].

For a low–middle-income country, Mongolia has a remarkably high literacy rate. Female literacy rate is 96.4%, and male literacy rate is 93%. A high literacy rate has notable implications for public education and understanding of public health initiatives. In Mongolia, 2.5 million people use mobile telephones of which 70% are smartphones, thus providing a valuable opportunity for the dissemination of public messages [56].

Mongolia is currently undergoing a health system reform nationally with primary care and secondary care centers well established. There are approximately 12,000 doctors nationwide, translating into one physician for 283 people, and more than 20,000 mid-level health workers of which more than 12,000 are nurses. Although the general infrastructure and facilities are inadequate and not well-equipped, Mongolia’s ICU capacity is remarkably high. There are 349 intensive care beds and 443 critical care ventilators in 70 ICUs countrywide, which translates to approximately 11 ICU beds per 100,000 population. In late January 2020, based on the SEC risk assessments, initial travel bans were introduced by the government to prevent the importation of COVID-19 [57].

From early on, the public were engaged and kept up-to-date through public information provision and action, coordinated by the SEC and organized by government agencies. Predominantly spreading health promotion messages via public media, the SEC initiated a one-window policy to provide accessible and reliable information from only one source. Although no general lockdown was imposed on all Mongolian citizens, some businesses in which physical distancing was not possible, such as the entertainment industry, including nightclubs and bars were closed [57].

Before the end of February, a structured surveillance system for contact tracing was put in place to enable the required observation and isolation of contracts to contain the spread of the disease. Suspected cases and their contacts were identified with the use of case-definition-derived criteria. COVID-19 healthcare and quarantine services were free of charge, except for three meals at a cost of USD 20 per day, during mandatory quarantine [58].

The Mongolian case shows that with advanced preparedness and robust preventive systems, an effective response to a pandemic is indeed possible for a low–middle-income country.

Concluding Comments

The success of Taiwan, South Korea, Vietnam, and Singapore in combating COVID-19 demonstrates the importance of strong leadership in mitigating the pandemic by harnessing the power of rapid response, evidence-based approaches, transparent communication, and partnerships in building a sustainable and successful pandemic response. Founded on principles of participation, transparency, and accountability, lessons from these examples in Asia are spread open for the world to learn from and emulate. These experiences shift the process of generating and enforcing top-down policies to multi-stakeholder, participatory approaches by leveraging swift action and opportunities. Strong and compassionate leadership is undoubtedly the defining trait of nations to navigate time-sensitive issues in today’s pandemic era. Leaders must act decisively to the COVID-19 response with a whole-of-government approach. The presence of robust public health systems along with strong national institutions that can respond swiftly to prevent the spread of infection is an essential prerequisite for containing the epidemic. Policies that address equity issues and are compatible with the cultural context have an enduring impact. Engagement of the public through effective communications is critical for public cooperation and voluntary compliance over the long-term. In countries where large numbers of infections are still being reported, it is time that leaders acknowledge the importance of acting rapidly on the best available evidence with transparency, a responsibility that is particularly critical in low-income and fragile settings.