As of March 5, 2020, there has been sustained local transmission of coronavirus disease
2019 (COVID-19) in Hong Kong, Singapore, and Japan.
Containment strategies seem to have prevented smaller transmission chains from amplifying
into widespread community transmission. The health systems in these locations have
generally been able to adapt,2, 3 but their resilience could be affected if the COVID-19
epidemic continues for many more months and increasing numbers of people require services.
We outline some of the core dimensions of these resilient health systems
and their responses to the COVID-19 epidemic.
First, after variable periods of adaptation, the three locations took actions to manage
the outbreak of a new pathogen. Surveillance systems were readjusted to identify potential
cases while public health staff identified their contacts. National laboratory networks
developed diagnostic tests once the COVID-19 genetic sequences were published
and laboratory testing capacity was increased in all three locations, although expansion
of the diagnostic capacity to university and large private laboratories in Japan is
still ongoing. In Hong Kong, initially, only pneumonia patients without a microbiological
diagnosis were tested, but surveillance has been broadened to include all inpatients
with pneumonia and a purposively sampled proportion of outpatients and emergency attendees
totalling about 1500 per day (Leung GM, unpublished). Japan's testing strategy has
also evolved with diagnostic tests now offered to all suspected cases irrespective
of their travel history; however, there are reports of cases that should have been
tested but were not.
Different strategies were used to selectively control travellers entering these locations.
In Singapore, there was a stepwise series of decisions to restrict entry for anyone
from mainland China and, more recently, from northern Italy, Iran, and South Korea.
Hong Kong has imposed mandatory 14-day quarantine for everyone who enters from the
mainland, and denies entry to non-local visitors from South Korea and Iran as well
as the most affected parts of Italy. In Japan, there were travel restrictions on citizens
from Hubei and Zhejiang provinces, and cruise ships with cases of COVID-19 were quarantined.
Second, intragovernmental coordination was improved because health authorities drew
on their experiences of severe acute respiratory syndrome during 2002–03 in Hong Kong
and Singapore, H5N1 avian influenza in 1997 in Hong Kong, and the 2009 influenza H1N1
pandemic in all three locations. Hong Kong and Singapore began interministerial coordination
within the first week, whereas Japan did this in early February when the operation
to quarantine passengers on the Diamond Princess cruise ship was heavily criticised
as inadequate, resulting in the widespread infections among crew and passengers.
Third, all locations adapted financing measures so that all direct costs for treating
patients are borne by the governments. In Singapore, the government pays the cost
of hospitalisation, irrespective of whether the patient is from Singapore or abroad.
In Japan, funding has been provided through routine financing and contingency funds.
Meanwhile, Hong Kong is using routine financing that already pays for all such care.
Fourth, the three health systems developed plans to sustain routine health-care services,
but the integration of services has been problematic. In Japan, as the capacity at
designated hospitals becomes overstretched, the coordination between hospitals and
local government will be a major challenge. In Singapore, at the beginning of the
outbreak, there were difficulties with disseminating information to the private sector.
In all locations, intensive-care unit bed capacity is limited.
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Fifth, in all locations, critical care treatment and medicines have been available
for patients with COVID-19, but adequate supplies of personal protective equipment
in hospitals and face masks in the community are a key concern. In Japan and Hong
Kong, hospital supplies are running low but have not yet impacted clinical management.
In all locations, pressure on critical care treatment is likely if there is a sustained
increase in cases of COVID-19.
Sixth, in all three locations training and adherence to infection prevention and control
measures in hospitals have largely been appropriate, but Japan could face a shortage
of infectious disease specialists. Health-care staff are stretched in all localities,
especially in selected designated hospitals. Long-term escalation in the need for
health services will place pressures on health-care workers, and could at some point
compromise the clinical management of people with COVID-19 and other patients.
Seventh, management of information systems is comprehensive in all locations. In Singapore,
there are almost daily meetings between Regional Health System managers, hospital
leaders, and the Ministry of Health. However, in Japan information sharing across
prefectures could be improved. The interoperability of systems between the government
health department and public hospitals in Hong Kong is not optimal.
Timely, accurate, and transparent risk communication is essential and challenging
in emergencies because it determines whether the public will trust authorities more
than rumours and misinformation.
Singapore health authorities provide daily information on mainstream media, the Ministry
of Health has Telegram and WhatsApp groups set up with doctors in the public and private
sectors where more detailed clinical and logistics information is shared, and authorities
use websites to debunk circulating misinformation. Risk communications to establish
trust in authorities has been less successful in Japan and Hong Kong.
Finally, the political environment and differences in communities and their moods
and values are important. The ongoing social unrest in Hong Kong has led to a breakdown
of public trust with the government
and affected front-line health-care staff and the reception and acceptance of government
In Hong Kong and Singapore, rumours led to panic purchasing to the extent that shops
ran out of some food and supplies.
In Japan, concerns related to the Diamond Princess cruise ship and the sudden announcement
of school closures fuelled increased public anxiety.
The three locations introduced appropriate containment measures and governance structures;
took steps to support health-care delivery and financing; and developed and implemented
plans and management structures. However, their response is vulnerable to shortcomings
in the coordination of services; access to adequate medical supplies and equipment;
adequacy of risk communication; and public trust in government. Moreover, it is uncertain
whether these systems will continue to function if the requirement for services surges.
Three important lessons have emerged. The first is that integration of services in
the health system and across other sectors amplifies the ability to absorb and adapt
The second is that the spread of fake news and misinformation constitutes a major
unresolved challenge. Finally, the trust of patients, health-care professionals, and
society as a whole in government is of paramount importance for meeting health crises.