Leadership and governance

The national strategy for pandemic in Singapore emphasised preparedness through a whole-of-nation approach. Since the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak, nationwide efforts were implemented to prepare institutions and individuals for pandemic response. Organisations simulated possible scenarios of pandemics and developed corresponding outbreak management plans.6 A multiministry government taskforce was convened to coordinate actions between clinical and non-clinical stakeholders, centralise efforts and disseminate information.7 The taskforce, comprising heads of ministries, led and coordinated actions between different agencies. For example, Ministry of Health (MOH) worked closely with academic institutions to provide timely epidemiological and clinical data about COVID-19 in the population. The taskforce designed and implemented measures which were guided by scientific evidence.

Risk communication

Clear communication channels between the government and all sectors are essential to translate policy into intended actions. The taskforce was transparent and frequent in providing situational updates, as well as new guidance and its associated rationale through traditional and social media channels, and regular press conferences. These nationwide communication channels were vulnerable to misinformation. MOH regularly clarified misinformation, encouraging the public to follow accurate and reliable information on official channels.

Public health outbreak containment measures

Singapore adopted a three-pronged approach to contain COVID-19: (1) reducing spread from imported cases; (2) detecting and isolating cases early; and (3) emphasising and supporting social responsibility.8

Health systems financing and economic issues

It is vital to reduce financial barriers to healthcare and encourage care-seeking behaviours during disease outbreaks if infection is suspected. When the outbreak started, the government declared that it would finance treatment costs incurred by COVID-19 patients in public hospitals.29 Most private insurers have also extended coverage for hospitalisation due to COVID-19. To deter non-compliance with guidelines, residents and long-term pass holders who disregarded travel advisories would not be subsidised at public hospitals, if admitted as suspected or confirmed COVID-19 patients within 14 days on return.30 From June 2020, all travellers entering Singapore were required to self-fund their COVID-19 tests and stay at dedicated facilities if necessary.

This pandemic threatened not only the health but also the livelihood of many. The government has committed 60 billion Singapore Dollars (SGD) (~42.4 billion USD, 12.2% of Singapore’s gross domestic product) to help businesses stay viable, preserving jobs and protecting livelihoods.31 The Quarantine Order Allowance Scheme allowed self-employed individuals or employers whose employees were serving Quarantine Orders to claim 100 SGD per day, while the Temporary Relief Fund and COVID-19 Support Grant helped low-to-middle-income Singaporeans tide through the crisis. For example, low-income workers who have lost jobs were entitled to 800 SGD monthly for 3 months.

Health service delivery

Following the SARS outbreak, Singapore prioritised building a specialised infectious disease centre for outbreak management.12 The National Centre for Infectious Diseases (NCID), inaugurated in 2019, is a 330-bed purpose-built infectious diseases management facility with integrated clinical, laboratory and epidemiologic functions. It houses a screening centre, isolation and cohort wards, ICUs, laboratories, imaging facilities and operating theatres.

Human resources

In Singapore hospitals, mask fitting sessions and structured training were organised to ensure appropriate handling of PPE for all deployed healthcare workers (HCWs).40 HCWs changed PPE in between care for each isolated patient, as well as during movement between a COVID-19 cohort ward and a designated clean area. Innovative solutions were developed, including the ‘Swab Assurance For Everyone’ (SG SAFE) booth for large-scale screening of potential COVID-19 patients to protect HCWs behind the booth while reducing PPE utilisation.43 To maintain full crisis capability, team segregation within each discipline was practised, ensuring provision of continued care in the event a team was quarantined due to suspected exposure to COVID-19. Movement of HCWs between hospitals was limited to reduce cross infection. As of 4 May 2020, there were 66 COVID-19 cases among HCWs.44 Although these cases, except for one, had no established epidemiological link to indicate nosocomial transmission, and vulnerabilities of HCWs in this health crisis were clear from the experiences of other countries.45 Timely, accurate and honest reporting from hospital leadership helped alleviate concerns among HCWs. This, together with messages of support and gratitude from the community, helped boost resolve and morale of HCWs.

Legal foundation

The COVID-19 (Temporary Measures) Act and COVID-19 (Temporary Measures) (Control Orders) Regulations 2020 was enforced to complement policy measures in managing the outbreak.46 This legislation allowed the government to requisition any land, undertaking or other resources for the purpose of control order. It also provided legal basis to enforce social distancing measures, such as a limitation on mass gatherings, and hold individuals as well as business owners accountable for violation.

Political environment and values of the community

Initial success for COVID-19 containment was attributed to Singapore’s dexterous political environment, which allowed the government space to swiftly institute measures.47 The Disease Outbreak Response System Condition (DORSCON) framework, which was part of the standing national pandemic preparedness plan, was adopted for the COVID-19 outbreak. The colour-coded framework provided guidance on outbreak severity and on the required public response to prevent and reduce impact of infections.48 The taskforce stepped up risk assessment from DORSCON Yellow to DORSCON Orange on 7 February 2020. This led to sporadic instances of public panic purchasing essential supplies.49 The prime minister made national addresses to assure Singapore residents of sufficient medical supplies and daily necessities, provide an assessment of the COVID-19 situation and urge strict adherence to containment measures. These national addresses were followed by press conferences to reinforce specific adjustments to guidelines.

Experience from previous SARS outbreak has prepared Singapore residents on what to expect and how to react. Some similar measures implemented before included school closures, temperature checks, screening for fever and travel history to affected countries and home quarantine, although at a smaller scale. In addition, Singapore residents’ respect for authority, coupled with stringent regulations, has allowed smooth implementation of governmental measures. The advent of social media allowed faster information dissemination while providing a platform for community and emotional support. It has also allowed online vigilantism to become more prevalent.50 While this could aid compliance to rules, reporting potential infringements directly to the authorities have been recommended.

Rise in cases from April 2020

A timeline of significant events and implementations is shown in figure 1. Despite rigorous containment and mitigation efforts, there was a sharp rise in local transmissions, likely due to imported cases, from early April 2020. On 7 April 2020, the government initiated a 1-month ‘circuit breaker’ measure, which was later extended for another month.51 Most workplace premises were closed, and the public were asked to stay home and avoid unnecessary outings. Schools migrated to HBL. Only essential services, including pharmacies, hospitals, clinics, supermarkets, food establishments, banking services and transport, could operate. All public gatherings were prohibited during this period. The government escalated efforts to protect the vulnerable, particularly seniors, during the ‘circuit breaker’ period. Volunteers were deployed to educate seniors who lived by themselves about these precautionary measures. Those who required additional support were identified and connected with relevant service providers.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Timeline of significant COVID-19 events and implementations in Singapore updated to June 2020. Source: Ministry of Health, Singapore. DORSCON, Disease Outbreak Response System Condition.

A large portion of the increase was attributed to rapid transmission within migrant worker dormitories. In response, a second taskforce was set up to support this outbreak.52 Various measures were implemented to interrupt transmission in this community, including: (1) active testing of potential cases in dormitories and provision of good medical care;53 (2) identifying new housing areas to accommodate healthy workers;54 and (3) providing translated health information to empower self-protection. By the time of writing, these measures have contained further spread of virus within the dormitories and in the community.55 However, conditions in these dormitories must be improved to prevent similar outbreaks. The government announced short-term and long-term plans for improvement. Migrant workers were housed temporarily in unused state properties, while the upcoming quick-build dormitories were being developed.56 These temporary accommodations were proposed to be replaced by permanent and less dense purpose-built dormitories once ready.

Singapore embarked on a planned three-phased approach to resume activities safely once the ‘circuit breaker’ ended on 1 June 2020.57 Phase 1 involved allowing household visits of up to two immediate family members and reopening of workplaces and schools. Those who could telecommute had to continue working from home, while students had to rotate between HBL and returning to school. Phase 2 involved resumption of most businesses that ceased operations during the ‘circuit breaker’ and small-group gatherings of up to five people. Phase 3 would involve resumption of higher-risk activities with larger numbers of people including religious services and entertainment venues. There was no fixed duration for each phase and transition between phases was determined by community transmission rates and the testing, contact tracing and healthcare capacity.

Lessons learnt from Singapore

Four important lessons from the Singapore experience could inform future strategies in managing pandemics in other high-income countries. First, consistency and transparency in information communicated by a trusted figure and team promotes acceptability of policy measures. Concise public messages tailored to the community and cultural norms accelerate public awareness of health crises. These, in turn, facilitate public trust in leadership and cooperation in containment efforts. Next, an established and clear legal framework reduces the possibility of misinformation during crisis and enhances clarity in risk communication. Third, vigorous testing and contact tracing to identify and isolate cases promptly are important for outbreak containment. Technology helps facilitate contact tracing efforts. However, more work needs to be done to mitigate potential issues such as privacy concerns, and to design methods to improve uptake of information technology (IT)-based contact tracing tools. Providing reassurance on how contact tracing personal data will be collected, used and stored could strengthen public support. Lastly, greater emphasis on dense or at-risk populations, for example, migrant workers living in dormitories, was vital to curb community transmission of COVID-19. More efforts are required to prevent potential recurrence, including dormitory housing expansion and enhancement of migrants workers’ social cohesion with the rest of the society.55 An equitable and inclusive response that protects the health and rights of all individuals, especially the most vulnerable, is necessary to overcome such crises.