Country responses to COVID-19 pandemic: Success stories and key lessons

Cross-country experience is enriched with lots of potential for learning lessons primarily because of the tremendous diversity of the countries affected by the disease as well as the differences in the approaches used to combat the spread of the disease – Pic by Shehan Gunasekara 

By Dr. Nimal A. Fernando

Writing about success of country responses to COVID-19 (coronavirus disease 2019) pandemic is a high-risk task.

Before I begin my essay proper on this subject I must divulge few reasons for the uneasiness I felt about whether to write on this subject. First, I read few days ago that President Donald Trump’s senior adviser and son-in-law, Jared Kushner has praised the (US) administration’s response to the coronavirus pandemic as a “great success story”. He had made this remark, less than a day after the number of confirmed COVID-19 cases in the US surpassed one million. According to many commentators, the US was and is nowhere near a success story. Hard data available tend to support that position. But I told myself may be he might have his own definition of success and reasons to justify his conclusion, and he was not telling that just because he was President Trump’s son-in-law.

Second reason: Things may look rosy this morning and suddenly become terribly disappointing this afternoon. We are talking about an ongoing virus with immense potential for exponential spread and for which there is no vaccine yet. (The virus took less than 100 days to shut the entire world). Remember the case of Singapore. In mid-April, most commentators were praising Singapore as a model case of ‘success’. But with the discovery of thousands of new infections among migrant workers housed in crowded dormitories with inadequate facilities, the story has become gloomy.

Third reason for my apprehension about writing on success stories relates to data on various facets of COVID-19. There is a trove of data on multiple dimensions of the disease at country, regional and global level. However, the truth is, as one expert pointed out, “no country knows the total number of people infected with COVID-19. All we know is the infection status of those who have been tested”. All those who have a lab-confirmed infection are counted as confirmed cases. 

Then there remains serious unresolved issues as well of the quality of available data. Their reliability, coverage, consistency, etc. Substantial differences can be found across countries and even within countries in units in testing data, for example. Amidst these quality problems, making sense of the data is a formidable task. One country’s data may be less complete or less accurate than others. Time series data of a given country may also have many issues in part due to changes in collection and reporting practices. Writing about relative success invariably involves cross- country comparisons. But to what extent we can be sure we are comparing apples with apples?

Fourth reason is that country context matters in a variety of ways to shape up the outcomes. Differences in population density and age distribution of the population, for example, are crucial factors in the spread of the virus.

But comparisons are important.

Cross-country experience is enriched with lots of potential for learning lessons primarily because of the tremendous diversity of the countries affected by the disease as well as the differences in the approaches used to combat the spread of the disease. A systematic comparison of the diverse experience hence is likely to provide valuable insights and enables identification of good, if not best, practices. This learning is important for all those who are involved in addressing the pandemic-related issues including finding right approaches to implementation. Peer learning adds a great deal to the knowledge also because expertise involved in the task is also diverse across countries.

What are the success stories?

Now to my success stories.

In some countries the pandemic has turned into a massive disaster. Yet, some countries have done comparatively much better than others and achieved impressive outcomes. They have effectively limited the spread of this deadly disease and prevented escalation of the deaths. They have also been successful in treating the infected as indicated by the high ratio of the number of diseased people who eventually recovered. Some of these countries have achieved these with relatively less restrictions imposed on the people in terms of the severity or the duration of such restrictions. 

Mainly on the basis of these criteria at least 10 countries may be listed as relatively successful cases: Vietnam, Taiwan, South Korea, Australia, New Zealand, Iceland, Israel, Slovakia, Jordan and Costa Rica. 

Take Vietnam, a country with over 97 million population, and South Korea, a country with over 51 million people. The first confirmed case of COVID-19 in Vietnam was reported on 23 January 2020 while South Korea reported its first case on 20 January. Despite this, Vietnam managed to limit the number of confirmed cumulative cases to 285 while South Korea reported only 10,810 as of 7 May 2020. The cases per one million population were 2.9 in Vietnam and 51.3 in South Korea. Given the fact that Vietnam shares an 800-mile-long border with China, it could have easily been a hotspot of COVID-19. In South Korea, relatively high population density at 527 people per square kilometre could have helped the spread of the disease. But these countries did not allow those to happen.

In the other eight countries the cases per one million population varied from a high of 5272 in Iceland and 1875 in Israel to a low of 18.4 in Taiwan. For Jordan and Costa Rica comparative figures were 46.4 and 149.2, respectively as of 8 May 2020. Iceland’s figure was unusually high because its population is only 341,243 people.

More importantly, the death rate (deaths per 100,000 population which in general is considered as an indicator of the overall performance effectiveness of a country’s healthcare system) in these ten countries remain at relatively low levels. Excluding Vietnam, which reported zero deaths, Taiwan reported the lowest rate of .03 and Costa Rica’s rate was .12. Two countries that reported the highest death rates are Iceland (2.93) and Israel (2.75), all as of 7 May 2020. To put these in perspective, the world average was 3.4 while the rates in France, USA and Germany were, respectively 38.3, 22.2 and 8.5, as of the same date. 

Recovery rates and new cases

The recovery rate (defined as the percentage of the total number recovered out of the total number of confirmed cases) was highest in Iceland at 98%, followed by 91.7% in New Zealand. The rate for other eight countries varied in the range of 59.6% in Costa Rica to 88.4% in Australia as of 7 May. In comparison the global recovery rate was about 36% while the rate in USA was 18%. Germany reported a high rate of 84%.

The number of daily new confirmed cases reported by most of these countries has been on a declining trend for some time and suggests how far they have been successful in flattening the curve. For the 10 consecutive days up to 7 May, Vietnam reported a total of only one new case, Iceland seven and Taiwan, New Zealand and Jordan 10, 15 and 24, respectively. These were followed by Slovakia with 48 new cases, South Korea with 58 and Costa Rica with 64 cases. Australia’s number stood at 150, a bit disappointing. Israel reported the highest number of 844 new cases during the same period of 10 days, creating some doubts about the sustainability of its previous achievements.

Factors behind the successes

The overall picture looks impressive. Of course this is in relative terms. But what is more important from a policy and learning point of view is the multitude of factors that contributed to the achievements in these countries. There is some similarity in the factors but there are important differences too.

Most countries in our chosen group acted fast and decisively and were strictly guided by the principle that “nothing is a better substitute for speed and aggressive action” to contain the spread of the virus. Michael Ryan, the executive director of the WHO’s health emergency program also emphasised in March: “Be fast. Have no regrets. You must be the first mover. The virus will always get you if you don’t more quickly… if you need to be right before you move, you will never win…speed trumps perfection”. 

Vietnam

The Vietnam government started to act even before the WHO announced that the outbreak was a global health emergency. The Prime Minister Nguyen Xuan Phuc sealed off the border with China by 1 February, closed all schools, locked down the population. The country’s textile industry was immediately mobilised to produce the much needed face masks. Wearing of face masks was made obligatory in all public places. The infected and those who were found to have been in contact with the infected were admitted to quarantine facilities managed by health authorities.

 Vietnam did not allow self-quarantine at home. The communist party’s country-wide network was used to police each neighbourhood. Its approach focused on rapid identification and isolation of infected people and tracking their contacts to prevent socialisation of the disease. The government was open and transparent with people in its communication about the pandemic. And people trusted the government. All of these enabled effective containment of the spread of the virus. The leadership of the country is praised for “doing ordinary things extraordinarily well” to manage the COVID-19 pandemic effectively. With some previous experience relating to SARS outbreak in 2003, it seems to have been shoe-leather public health for Vietnam.

Taiwan

Taiwan also achieved its success through early and rapid action. These were driven partly by its suspicion of China and information coming out of China and the fear of being in close proximity to China. From the very beginning the policymakers there were of the view that this could be a massive threat to the country and risks were extraordinarily high. Thus in January Taiwan’s leader introduced 124 measures to block the spread of the virus but did not resort to lockdowns. Flights from China were stopped first and then those from other countries too. Quarantine directives were issued and a heavy penalty of $30,000 was imposed on the violators. According to some, this heavy fine helped in limiting the new cases reported in the island.

Taiwan used military selectively in the implementation. The government took control of all existing stocks of masks in the country in late January, army was mobilised to make millions of additional masks, introduced a ceiling price on masks and made sure that every citizen of the country gets a mask. Digital technology was used extensively for some time to track people’s movements and assist those engaged in the efforts to curb the spread of the virus. 

South Korea

Although COVID-19 was new to South Korea, pandemics were not new. South Korea has learned from the MERS outbreak in 2015 that led to 186 cases and 38 deaths in the country. As a result there was a greater political will in the country to deal with the COVID-19. South Korea’s approach was somewhat similar to that of Taiwan; it was never under a major lockdown. 

Shops, restaurants and many leisure facilities remained open. Many companies and institutions did not change their working arrangements in the office. The Government Response Stringency Index (see note at the end of the essay) was only 31.35 on 20 February and rose to 83.46 on 6 April and came down to 46.16 on 20 April indicating that most of the time restrictions remained at a low level. South Korea acted to prevent the spread of the virus rather than follow it.

Self-discipline and vigilance of people, high degree of voluntary compliance of people with government instructions on measures such as social distancing and wearing of face masks to curb the spread of the virus, and testing and widespread contact tracing were among the other factors that contributed to the containment of the virus. Also, easy availability of accurate information was a big plus.

According to a UNDP staff based in Seoul, “this inundation of real-time public information is what has really helped South Korea throughout the crisis”. And South Korea’s approach focused not on single actions but on the package of actions. This reinforced the strength and effectiveness of each action in the package. As some analysts have pointed out the virus containment required “a war-like mobilisation” that ensured mobilisation and coordination. South Korea met these requirements effectively.

Story of other seven countries

The other seven countries also adopted effective approaches. Early action and efficient implementation have been common. 

Take Jordan, for example. The Government appointed a National Epidemic Committee in late January to prepare to meet the COVID-19 challenge systematically. The Committee prepared plans and finalised the necessary protocols well in advance to deal with the disease, before the first case was detected on 2 March. On 19 March State of Emergency was declared. The government entrusted the army to implement a number of actions introduced. A strict curfew was used selectively and effectively to restrict peoples’ movements. 

A fine of $ 30 was introduced on violators of safety and quarantine regulations. And many other measures such as closing of schools and banning public gatherings used by most other countries were also introduced. The government’s package of response measures was highly restrictive. The Government Response Stringency Index for Jordan remained at the maximum level of 100 consecutively for 45 days from 18 March to 1 May, 2020.

Israel also took decisive actions to prevent the spread of the virus. Standard measures included border closures and suspension of flights to control travel. What is different in Israel was the major role of the security forces which bypassed the Knesset (national assembly). In the country context this turned out to be a wise move partly because people had more trust in the security forces. The counterfactual would have been disastrous. The military production facilities worked to increase the supply of face masks wearing of which had been made compulsory in all public places. A fine was in effect for the violators. Israel not only used a contamination-tracing app but also employed sophisticated tracking tools commonly used in counter-terrorism effectively to trace the spread of the virus. People put in quarantine were monitored; those who disrespected the quarantine directives were fined.

Iceland, realising that the virus is faster than the bureaucracy, adopted an approach to stay ahead of the curve: quick introduction of the measures needed to identify the infected and prevent the spread of the disease and efficient implementation produced results. According to some commentators, Iceland with the private sector involvement “has turned testing into a new pastime”, reporting more tests per 1,000 people than most other countries in the world. 

Slovakia also took decisive actions in a not so conducive political environment because when the virus started to spread in Europe the country was in the middle of a general election (29 February) and the new Prime Minister of the four party coalition government assumed office with his cabinet only on 21 March. Despite this political situation, the pandemic control program continued. Given the location of the country sharing borders with such countries as Austria and Hungary, the country could have become, according to a Slovak daily newspaper, a “sea of mortality” but smart policies and effective implementation turned it into “an island in the sea of mortality”.

Costa Rica reported the first COVID-19 confirmed case in Latin America on 6 March. But quick response and effective measures contained the outbreak to become one of the most successful nations in the fight against the pandemic. The case density and death rates of Costa Rica are much lower than those of New Zealand, a country often praised as a model. The Health Minister of Costa Rica (Daniel Salas) attributed the success to two main factors: “actions taken at the moment” and “very favourable response from a population that understand the challenge the country is faced with”. Costa Rica’s universal healthcare system was a big plus. The seriousness with which the government deals with the pandemic and its realistic approach is reflected in Costa Rican President Carlos Alvardo’s statement: “We have had a relative and fragile success, but we cannot let our guards down”.

Both Australia and New Zealand achieved success on the basis of six shared factors: strong leadership, plans formulated and implemented based on scientific evidence; high level of inter-agency and intra-agency coordination; decisive actions; effective communication strategy; and high level of public trust in the government actions. In addition, the structural capacity of the healthcare systems of each country was high. 

In the case of New Zealand its geographical location and low population density also helped a great by providing an element of natural protection to achieve impressive results. New Zealand Prime Minister Jacinta Arden was very clear about her strategy: “We must go hard and we must go early”. She took a bold decision to announce a harsh lockdown but it paid-off. People’s compliance was high. The citizens’ trust in the government was also high. According to one poll, 88% of Kiwis trust their government to make the right decisions about COVID-19. To strengthen and sustain the trust the Prime Minister communicated with the people very smartly: through frequent, clear, consistent messages.

Australia also had well-formulated plans and, they were implemented efficiently. The Prime Minster quickly activated the Emergency Response Plan for COVID-19. The government response was based on scientific evidence and up-to-date data. What is more remarkable about the Australian story is the high level of coordination between the central government and state and territorial governments and exclusion of politics from the entire process. The high level of vertical and horizontal coordination ensured that the government response was consistent and integrated across the country. An effective communication strategy improved coordination efficiency. The high level of structural capacity of the healthcare system also figured high in the Australian success story.

Key lessons

The COVID-19 pandemic is global crisis. It has affected more or less all countries across the globe. Some have faced the daunting challenge better than others and come out with a degree of success in relative terms. Our sample of ten countries discussed above illustrates the diversity of the success countries to-date. A number of key lessons can be drawn from this diverse set.

First, is the importance of leadership with an unwavering commitment to achieve results, as I have stressed in a previous article (see http://www.ft.lk/columns/Sri-Lanka-s-response-to-COVID-19-Factors-underpinning-relative-success/4-699278) in the Daily FT. Second, it is absolutely important to respond quickly with a systematic plan and decisive actions in close coordination with all key stakeholders within the country. Third, the measures and the process must be underpinned by scientific and reliable evidence. 

Fourth, keeping politics out of the whole process is vitally important. COVID-19 pandemic does not mix well with politics although the political economy of the pandemic may be extremely appealing to some. Fifth, a smart communication strategy is critically important. Poor, unclear, inconsistent communication leads to erosion of people’s trust in the government response and undermine the effectiveness of the whole process. Sixth, learning lessons along the process from within the country and rest of the world (from both successes and failures) can enrich the entire program and improve the quality of implementation to meet the challenge more effectively. 

Seventh lesson is that policymakers have to be realistic: until an effective vaccine becomes widely available, most countries will have to live with the virus to some extent; and we have to admit that potential is there for it to come back and haunt us from time to time. That should not be interpreted as a government failure. Both governments and citizens have to face this reality. 

Be cautious and be prepared.

[Note: 1.The coronavirus Government Response Stringency Index is prepared by a team at the Blavatnik School of Government at the University of Oxford. The team collects information from publicly available sources on common policy responses, scores the stringency of such measures as school closures, travel bans and aggregates them into a Stringency Index. The Index value of 100 indicates the strictest response. This index simply records the number and strictness of government policies, and should not be interpreted as “scoring” the appropriateness or effectiveness of a country’s response. A higher position in the Index does not necessarily mean that a country’s response is “better” than others lower on the index (https://covidtracker.bsg.ox.ac.uk/).

Note: 2. Given that the COVID-19 pandemic is on-going, the numbers used in this essay may not reflect the current situation at the time of the publication of the essay.]

(The writer is a development economist and former Associate of the Kuala Lumpur-based global organisation, Alliance for Financial Inclusion. He can be reached at [email protected].)