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Moving toward a common goal via cross-sector collaboration: lessons learned from SARS to COVID-19 in Singapore

Moving toward a common goal via cross-sector collaboration: lessons learned from SARS to COVID-19... Background: The spread of COVID-19 has taken a toll on many countries and its healthcare system over the last two years. Governments have sought to mitigate the repercussions of the pandemic by implementing aggressive top- down control measures and introducing immense fiscal spending. Singapore is no exception to this trend. Owing to a whole-of-society approach, Singapore is still being lauded globally for its relatively successful record at controlling both community and trans-border spread. One notable effort by the Singapore government has taken place through its cross-sectoral collaborative partnerships with the private stakeholders behind the success. Methods/results: In an attempt to better explain Singapore’s robust yet strategic response to COVID-19, this study focuses on how the experience of the SARS outbreak has informed the government’s collaborative efforts with other stakeholders in society, beyond mere transnational cooperation. Taking a comparative case study approach in the specific context of Singapore, we perform a content analysis of related government documents, mainstream news- paper articles, and academic journal articles in an inductive manner. By closely comparing two global healthcare outbreaks, we note four differences in approach. First, during the COVID-19 pandemic, Singapore has focused on securing sufficient essential healthcare resources with contingency plans to strengthen preparedness. Second, the government has actively harnessed the capacity of private entities to promote the resilience of the healthcare system and the community. Third, Singapore’s management policies have been made not only in a top-down, centralized style during the initial response stage, but also with a greater proportion of bottom-up approaches, particularly as the pandemic trudges on. More interestingly, the multi-faceted repercussions of COVID-19 have gradually opened the door to a greater variety of collaborative partnerships in sectors beyond healthcare services. The participating stake- holders include, but are not limited to, local and international business actors, non-profit organizations, academia and other countries. Lastly, as the pandemic has continued, the Singapore government has managed outward to tap the expertise and knowledge of the private sector, in particular leveraging science and technology to improve control measures and putting supportive programs into practice. Conclusion: The evidence from our focused analyses demonstrates that the nature and scale of the COVID-19 pandemic produced more collaborative partnerships between the public and private sectors in Singapore as com- pared with the SARS outbreak. What is more, our findings offer evidence that through adaptive learning from the prior global healthcare outbreak, plus some trial and error during the initial phase of the ongoing pandemic, public- and *Correspondence: sjkim@ntu.edu.sg Public Policy and Global Affairs Programme, School of Social Sciences, Nanyang Technological University, 48 Nanyang Avenue, HSS-05-02, Singapore 639818, Singapore © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kim et al. Globalization and Health (2022) 18:82 Page 2 of 18 private-sector partners, both in and outside of the healthcare service sector, have tended to “act alike,” working together to achieve a common goal. Both have been socially responsible, providing public services to people in need to promote the rapid resilience of the community, and sharing the associated risks. Overall, this study has deep and wide implications for other governments and policy makers who are still struggling to maximize essential resources and minimize the negative impacts of the healthcare crisis. Keywords: COVID-19, Health Crisis, Cross-Sector Collaboration, Partnerships, Singapore Introduction Emergency Risk Management for Health (ERMH) Over the past two years, we have witnessed unprec- which has identified multi-sectoral approach as a guid - edented impacts of the COVID-19 pandemic on global ing principle for managing health crises [85]. These col - health and the global economy. First discovered in 2019 laborations may take the form of a multi-ministry-centric in Wuhan, China following a cluster of unidentified hybrid organization that plays a leading role in prevent- pneumonia cases, the novel coronavirus spread rapidly ing and controlling disease spread within a community not only in Wuhan but also worldwide [69], and has since by investing in sustainable diagnostic solutions and digi- undergone several waves of mutations (such as the Delta tal solutions to current and future needs. For this, diverse and Omicron variants). As of August 10, 2022, more than industries such as medicine, education, science and tech- 580 million COVID-19 cases have been reported around nology may produce these solutions together with policy the globe. Cases peaked at over 3,800,000 in a single day support from the government. in January 2022, and over 6 million people have died of Singapore is no exception to this trend. Unlike other COVID-19 [87]. As COVID-19 rages on, many health- Asian countries such as South Korea or Taiwan that faced care systems worldwide are on the brink of collapse, in upticks in COVID-19 cases after initially containing the some cases due to a lack of medical facilities or profes- spread of the virus, Singapore is still being lauded glob- sionals. Consequently, the estimated cost of the pan- ally for its relatively successful record at controlling both demic has added $24 trillion to the collective global debt community and trans-border spread. It has also main- as of February 2021, bringing it to a whopping $281 tril- tained a lower mortality rate than much of the world lion [36]. [1]. Given its small geographic size and high population Given this, recent scholarship has highlighted the density, the city-state has adopted a so-called “a defensive importance of collaboration across all sectors of society pessimism stance,” remaining vigilant and preparing for as a way forward out of the pandemic and toward a more worst-case scenarios [82]. Notably, during the COVID-19 resilient healthcare system, a full economic recovery, and pandemic, Singapore’s government has demonstrated its continued long-term growth (e.g., [12, 63, 80]. This is readiness and agility, taking more proactive and strategic reminiscent of Bryson and colleagues’ (2015) definition action than it did during previous health crises (e.g., the of cross-sector collaboration as “the linking or sharing Severe Acute Respiratory Syndrome (SARS) outbreak of information, resources, activities, and capabilities by in 2003). The government’s initial policies to contain organizations in two or more sectors to achieve jointly an COVID-19 were “top-down” in style. It managed down- outcome that could not be achieved by organizations in ward at the initial response stage, but since then has also one sector separately” [10], p. 44 as cited in [11], p. 648). managed outward, forming collaborative partnerships In this vein, it can reasonably be argued that by effec - with other stakeholders over time, including the private tively mobilizing stakeholders and resources, multisector healthcare and economic sectors (including local and collaborative partnerships can help alleviate the strain international businesses), non-profit organizations, aca - on public finance, especially for governments, and can demia and other countries (e.g., see [42]). provide cost-efficiency gains and drive appropriate and Some scholarship has compared Singapore’s response satisfactory essential services to the most disadvantaged to the COVID-19 pandemic with its response to the people [52, 66]. SARS outbreak in 2003, as both diseases were caused by Over the past two years of the global health crisis, stra- coronaviruses. However, most research on Singapore’s tegic multisectoral collaboration efforts have been put The last time the world witnessed an influenza pandemic on the scale of into practice in many developed countries, including the COVID-19 was the Spanish Flu of1918. Yet, in the existing research, COVID- United States, Australia, Canada, and Japan, to ensure 19 has more often been compared to the 2003 SARS outbreak, since both diseases emerged in the modern era and were causedby viruses in the coro- the timely and continuous delivery of essential goods naviridae family. In addition, given that the SARS outbreak was the first epi - and services, including medical assistance [66]. This is demic since Singapore became a developed country, aswith Chen et  al. [18], in line with the World Health Organization’s (WHO’s) this study posits that SARS is the optimal case for comparison. K im et al. Globalization and Health (2022) 18:82 Page 3 of 18 Table 1 Comparison between the SARS and COVID-19 Outbreaks in Singapore SARS COVID-19 Outbreak period (Global) November 2002 to July 2003 November 2019 to present Outbreak period (Singapore) March 2003 to June 2003 January 2020 to present First reported case in Singapore March 1, 2003 January 23, 2020 Total confirmed cases 238 1,773,386 Local Death toll 33 1543 (Case fatality rate) (14%) (0. 09%) Rapid diagnostics RT-PCR/reverse transcription polymerase reaction RT-PCR/reverse transcription polymerase reaction/Antigen-rapid test (ART ) Medical prevention Not available (No FDA-approved vaccination) Available (FDA-approved vaccines and antiviral pills) Governance Structure From the Operations Group Multi-Ministry Taskforce (MTF) (Led by the MOH) to the three-tiered taskforce (Led by the (Currently led by the Minister for Health MHA): and the Minister for Finance together) Inter-Minister Committee (IMC), Core Executive Group (CEG) and Inter-Ministerial SARS Operation Committee (IMOC) In the case of COVID-19 outbreak, total confirmed cases and local death toll were calculated as of August 10, 2022 Source: Compiled from various sources [39, 49] success against COVID-19 has tended to describe chron- unexplained pneumonia. However, China did not pro- ological, medical data (e.g., the death toll); the country’s ceed with state-level control measures nor report the in-house capacity resulting from its enhanced healthcare cases to the World Health Organization until February system; its early response and disease surveillance efforts 11, 2003 [45]. The virus later spread to 29 other countries (e.g., [17, 47], or public sentiments about the related poli- including Singapore [35]. Globally, 8422 confirmed and cies (e.g., [71, 82]. Little attention has been paid to cross- probable cases were reported. A total of 916 deaths from sector collaboration, particularly related to the role of SARS were reported by the end of the pandemic in June private actors in and outside of the healthcare service 2003 [14]. arena. In response to this gap in the existing literature, Singapore recorded its first case of SARS on March this study aims to closely map the extent of the multisec- 1, 2003, when a traveler returning from Hong Kong tor collaboration efforts that have been implemented by was admitted into Singapore’s Tan Tock Seng Hospital Singapore’s government during the ongoing COVID-19 (TTSH). Her case was linked to a superspreading event pandemic. In the focused analyses, we use Singapore’s at Metropole Hotel [18]. Singapore soon saw an exponen- experience during the SARS outbreak as a point of ref- tial increase in cases following outbreaks in several pub- erence as we evaluate and discuss the progress made in lic settings such as hospitals [24]. Crucially, 41% of the governmental partnerships with other stakeholders. cases were healthcare workers due to the multiple hos- pital-related outbreaks that took place at TTSH, National Background: the SARs and COVID‑19 outbreaks University Hospital (NUH), and Singapore General Hos- in Singapore pital (SGH) [18, 35]. Singapore became one of the top 5 Given that coronaviruses have been responsible for both most affected countries, recording a total of 238 cases outbreaks, this study posits that reviewing Singapore’s and 33 deaths, resulting in a case fatality rate of 14% [57]. experience with SARS and COVID-19 and comparing the The epidemic ended in Singapore in June 2003 after the government’s response to the two outbreaks can reveal WHO declared Singapore SARS-free on May 30, 2003. the adaptive learning that has taken place over time. The SARS outbreak was initially and directly man - Table  1 provides some basic details as to how Singapore aged by Singapore’s Ministry of Health (MOH). The was affected by the SARS and COVID-19 global health Operations Group by the MOH, announced in the mid- crises. dle of March 2003, was led by the Director of Medical Services and comprised on senior doctors and admin- The SARS outbreak in 2003 istrators from various public hospitals. The Group was In November 2002, the first ever reported case of SARS in control of all the medical resources and served as the occurred in Foshan, China, when patients presented link between the MOH and all healthcare providers [39]. clinical flu-like symptoms such as high fever with But later, as the government realized that resources from Kim et al. Globalization and Health (2022) 18:82 Page 4 of 18 Fig. 1 SARS Governance Structure. Source: Adapted from Tay & Mui (2004, p. 35) [76] other ministries were required to combat the outbreak, dormitories for foreign workers and accounted for the a three-tiered national control structure was created spike in cases early in April 2020. This led to a nation - to strongly control the spread of the virus. As shown in wide lockdown known as “the circuit breaker,” which Fig. 1, the three tiers included the Inter-Ministerial Com- lasted from April 7 to June 1, 2020. The circuit breaker mittee (IMC), the Core Executive Group (CEG) and the largely contained the initial outbreak within the foreign Inter-Ministerial SARS Operation Committee (IMOC) workers’ dormitories and minimized the spread to the [76]. The IMC was chaired by the Minister for Home community. However, Singapore experienced two more Affairs and comprised of ministers from other ministries, massive outbreaks in the community in the latter half of including the MOH, the Ministry for Education (MOE 2020/first half of 2021 and in the first half of 2022, which and the Ministry for National Development (MND. were primarily attributed to the spread of the Delta and This committee served to: (i develop strategic decisions Omicron variants, respectively [2]. As of August 10, to design policies,(ii approve major decisions; and (iii 2022, Singapore had recorded a total of 1,773,386 cases implement control measures [39]. Meanwhile, the CEG and 1543 fatalities [61]. The case fatality rate is therefore was led by the Permanent Secretary for Home Affairs and around 0.09%, much lower than the rate with SARS cases directed valuable resources at the ministry level to key (See Table 1). areas during the outbreak, whereas the IMOC carried In terms of the government decision-making of health out the health control measures issued by the IMC, coor- emergencies, the Singapore government established an dinating interactions between the MOH and healthcare inter-departmental organization named the Homefront providers and frontline workers [39, 76]. Crisis Executive Group (HCEG) prior to 2004. HCEG is chaired by the Permanent Secretary of the Ministry of The COVID-19 pandemic from 2020 to the present Home Affairs (MHA) and comprises senior representa - COVID-19 emerged in Wuhan, China in November 2019 tives from all ministries but the major role of the HCEG and was reported to the WHO on the last day of 2019 was to provide the strategic and political guidance dur- [16]. On March 11, 2020, the WHO officially declared ing the health crisis (e.g., the endorsement of MOH’s COVID-19 a pandemic. The virus has spread to more recommendations for the suitable Disease Outbreak than 150 countries around the world. COVID-19 has Response System Condition (DORSCON) level). Dur- similar clinical features to the flu, but the incubation ing the COVID-19 pandemic, although essential medical period for COVID-19 before symptoms are developed resources are mainly controlled by the MOH, there was may be as long as 14 days. These features have made the an urgent need to coordinate health (control) measures virus difficult to contain, and as of August 10, 2022, the across governmental sectors as well as across the com- WHO has reported close to 580 million confirmed cases plete society. In turn, to facilitate inter-departmental and 6,418,958 deaths globally [86]. communication in setting priorities into action, the The first case in Singapore was reported on January 23, 2020 when a 66-year-old Wuhan resident tested positive for COVID-19 while traveling in Singapore [26]. Singa- This is a color-coded framework that highlights Singapore’s  health crisis pore has experienced multiple outbreaks over the last two (disease) condition. There arefour colors—green (the lowest), yellow, orange, years of COVID-19. The first major outbreak occurred in and red (the highest) that represent each alert level of Singapore’s pandemic preparedness plan dependingon the level (nature) of disease [1]. K im et al. Globalization and Health (2022) 18:82 Page 5 of 18 Fig. 2 COVID-19 Governance Structure. Source: Adapted from Low (2020) [50] government has become to set up a Multi-Ministry Task- to the public [23, 82]. All in all, the MTF has actively sup- force (MTF) which was jointly led by the Minister for ported the HCEG to effectively deliver their plans and Health and the Minister for National Development in the decisions to the elected leadership for political direction initial phase [1]. Interestingly, the number of ministries and ensure subsequently confirmed actions to be taken in participating in the MTF has been more than doubled practice (See Fig. 2) [50, 51]. compare to the SARS outbreak. The MTF on COVID-19 consists of the Ministry of Communication and Informa- Methods and analyses tion (MCI), the Ministry of Trade and Industry (MTI), During the SARS outbreak and the ongoing COVID-19 the Ministry of the Environment and Water Resources pandemic, the Singapore government has embarked on (MEWR), the National Trade Union Congress (NTUC), multiple service delivery projects in collaboration with pri- the Ministry of Education (MOE), the Ministry of Man- vate actors to manage, pre-empt and mitigate challenges power (MOM), the Ministry of Social and Family Devel- associated with the outbreaks. In order to scrutinize and opment (MSF), and the Ministry of Transport (MOT) compare Singapore’s response to the two global health- [41]. The main tasks of the MTF have been not only to care crises, this study uses inductive conventional content direct the national whole-of-government response to analysis based on secondary data obtained through major COVID-19 outbreak, but also to work with the interna- local newspaper articles, related government agency and tional community to respond to the outbreak. For exam- industry reports, and academic journal articles describing ple, this taskforce has focused on border controls, the how Singapore responded to each outbreak. Specifically, as circuit breaker (lockdown), and addressing the outbreak with Berg and Lune [9] and Hsieh and Shannon [32], we in the migrant worker dormitories. In addition, in order attempted to identify and cluster evidence-based themes to continue to prevent the public from underestimating derived directly from the text data in a document and then the risks of COVID-19 and the mitigation policies from discover hidden meaning of the related content. backfiring, the MTF has tried to coordinate the commu - Building on Baxter and Casady’s [12] so-called recovery nity response by carrying out weekly press conferences framework model, we discuss the Singapore government’s to convey critical information (e.g., daily contact-tracing specific milestones related to multisectoral collaborative reports or stepwise criteria for reopening the economy) partnerships during the two global health crises (See Tables 2 Kim et al. Globalization and Health (2022) 18:82 Page 6 of 18 Table 2 SARS: Multisector Collaboration Healthcare Non-Healthcare Short-term, • Diversion of non-flu cases away from TTSH to be Reactive handled by general practitioners (GPs) Response • Development of Infrared Thermal Fever Scanner by ST Electronics with DSTA Medium-term, • Bilateral arrangements with Malaysia and Indonesia • Monitoring of employees’ temperatures by major Proactive to facilitate contact-tracing and quarantine hoteliers in cooperation with the Singapore Tourism Response • Joint Declaration of the Special ASEAN Leaders Board (STB) Meeting on SARS 2003 • STB launch of ‘Cool Singapore Awards’ to acknowledge major hoteliers and tourist facilities Table 3 COVID-19 Multi-Sector Collaboration Healthcare Non-Healthcare Short-term, • Public Health Preparedness Clinics (PHPCs) were activated • Temasek Foundation provided reusable masks Reactive • Private hospitals cared for well and stable COVID-19 patients and hand sanitizers Response • Masks were produced locally by Innosparks and ST Engineering • Migrant Workers Center and Alliance for Guest • Surbana Jurong constructed Community Care Facilities (CCFs) Workers Outreach delivered food and provided • Staff from private hospitals provided medical care in CCFs support for migrant workers in isolation • TvVax, made up of healthcare professionals from the private sector, secured • VisualAid provided cards with translations of vaccines for the population healthcare terms to improve healthcare workers’ • Duke-NUS medical school developed serological test kits to boost contact- communication with migrant workers tracing efforts • Joint statement of ASEAN Defence Ministers on Defence Cooperation against Disease Outbreak (ASEAN, 2020) • Grab offered GrabCare catered to the transport needs of healthcare workers Medium-term, • Hotels were converted into isolation and quarantine facilities • Private firms provided training and partially Proactive • SIA and DHL were tasked with the handling and delivery of vaccines funded trainees’ allowance under SG United Response • Private healthcare providers ran the vaccination centers set up by the MOH Traineeship program • Ramatex worked with A*STAR to develop more effective masks suited for Sin- • Ministry of Health, SG United, and Nanyang gapore’s climate Polytechnic worked with GovTech Singapore together to improve the effectiveness of a new app called TraceTogether Long-term, • Private telemedicine providers offered enhanced home recovery programs Future-oriented • ASEAN Strategic Framework for Public Health Emergencies and ASEAN Response Regional Reserve of Medical Supplies and 3 below; for more detailed information, see Appendi- anticipate the challenges of the pandemic. The responses ces A and B). It should be noted that while Baxter and Cas- may include product development or the strengthening ady [12] focused on healthcare policies alone, our analysis of existing healthcare services. Long-term responses are expanded the model to include non-healthcare policies. those aimed at pre-empting future outbreaks, and they As seen in Fig.  3, the responses of a government fac- require careful planning for the future based on adaptive ing a healthcare crisis can be divided into three different learning. It is expected that these responses will emerge broad timeframes. In terms of short-term response, a from one month after the initial phase of virus transmis- government is expected to respond promptly to an exist- sion to beyond a year, depending on when an outbreak ing outbreak or an unanticipated new wave of a disease. ends and how serious its transmission is. In the post- Such reactive responses are likely to emerge between outbreak period, the government may consider continu- the start of a new wave of the outbreak and about one ing its collaborative partnerships with actors including month into an outbreak. Crisis-driven government-led private firms, non-governmental organizations (NGOs), collaborative management is meant to meet the imme- academia and even international organizations of a diate needs of the healthcare system and society. In the medium term, responses are more proactive and are Given that government-linked companies (GLCs) in Singapore such as Temasek Holdings and Singapore Airlines are subject to thediscipline of the expected to emerge anywhere from a few weeks after the stock market and investors, it can reasonably be argued that they function in line initial outbreak to one year into the outbreak. During this with a profit-maximizing objective, thereby acting morelike private firms than period, cross-sector collaboration can help governments state-owned enterprises [5]. Thus, this study treats GLCs as private entities. K im et al. Globalization and Health (2022) 18:82 Page 7 of 18 Fig. 3 Relative Timeframes of Healthcare Crisis Responses. Source: Authors modified Baxter and Casady’s (2020) PPP-based analytical approach transnational nature to strengthen the existing healthcare In turn, at first, TTSH was designated as a SARS hospital system and other service industries and reduce the sever- by the MOH on March 22, 2003 [35, 39]. That is, the “all- ity of future pandemics. in-one” approach required all suspected and confirmed cases of SARS were sent only to TTSH. Restrictions were Results also imposed on the movement of healthcare workers Short-term reactive response and patients among hospitals [35]. Meanwhile, all elec- In response to the extreme uncertainty brought about by tive procedures in other public hospitals were placed on a global health crisis, as mentioned above, governments hold as the MOH redirected non-flu illness cases (that initially tend to behave reactively to meet the immedi- is, non-SARS related emergency patients) to other public ate demands not only of the healthcare system, but also hospitals and local general practitioners (GPs) [39]. The of the community. In practice, as seen in Tables  2 and 3, Singapore Armed Forces (SAF) were also activated to collaborative partnerships among public agencies and/or provide manpower support to public hospitals [54]. All between the public and private sectors can meet press- these efforts were intended to prevent the overstraining ing needs of a community in a state of agitation (e.g., by of hospitals and to prevent cross-contamination. ensuring the resilience of the food and essential medical In addition, during the SARS outbreak, to curb trans- equipment/devices supply chains) [12]. border spread of the disease, a mandatory health declara- In the early stages of the SARS outbreak, the Singapore tion was imposed on travelers to Singapore. The Defence government was not adequately prepared to deal with Science and Technology Agency (DSTA) under the Min- the infectious disease that was fluid and unprecedented istry of Defence collaborated with Singapore Technol- [39]. Due to the initial lack of dedicated testing and iso- ogy (ST) Electronics to develop a temperature scanner, lation facilities and on-going contact-tracing effort, the the Infrared Thermal Fever Scanner (Defence Science & first patient who had contracted SARS was only hospi - Technology Agency, 2003) [21]. This cross-sectoral col - talized and isolated after five days upon her return from laboration, which capitalized on the thermal imagers Hong Kong, during which she had spread the virus to commonly used in the military, led to the rapid deploy- 22 other individuals [24]. Given this, the MOH initiated ment of the scanner within one week at immigration a SARS taskforce to study and manage the unexpected checkpoints at Changi Airport to prevent the entry of spread of the virus throughout the community, focus- suspected SARS patients [44]. ing on collaboration within the public sector that could During the COVID-19 pandemic, the Singapore gov- better serve the public [35]. However, in practice, the ernment has moved in a timely way to roll out preventive presence of the first confirmed SARS cases within one strategies intended to control the spread of the disease in public hospital––Tan Tock Seng Hospital (TTSH)–– the community, across borders, and in hospitals. Nota- highly influenced the condition of other patients in the bly, there has been an increase in collaborative partner- same hospital and caused the further spread of SARS ships to meet the needs of the healthcare industry as well to other healthcare institutions such as Singapore Gen- as society—the general populace, healthcare workers eral Hospital and National University Hospital [24]. In and foreign workers—and such partnerships have been response, to effectively contain the spread among various found not only in the healthcare arena but also in non- healthcare workers, institutions, and patients, the gov- healthcare fields (e.g., IT, R&D, and the economic sec - ernment tapped into the so-called “all-in-one” approach tor). As indicated in Table 3, for example, as the first line which has been considered as a unique Singapore term. of defense, Public Health Preparedness Clinics (PHPCs) Kim et al. Globalization and Health (2022) 18:82 Page 8 of 18 were activated in February 2020, within a few weeks of on every continent, it was able to procure reusable masks the first COVID-19 case in Singapore. GPs enrolled in the that were new innovations and of better quality [79]. PHPC scheme underwent courses on the importance of Some of the masks distributed utilized technology by infection control and were trained on the use of personal Swiss-based Livinguard and UK-based DET30. Temasek protective equipment (PPE) [15]. Because patients with Holdings’ distribution of essential items ensured that the respiratory illnesses were offered subsidized treatment at MTI could divert their resources to the procurement of PHPCs, these patients were diverted away from hospitals other items such as food while ensuring that the populace to clinics, and only suspected positive cases of COVID- received better quality masks [50]. 19 were referred to hospitals for further diagnostics [29]. Apart from the Temasek Foundation’s procurement of Additionally, in contrast to Singapore’s SARs response, masks from overseas suppliers, there have also been local in March 2020, private hospitals in the city-state were efforts to restart the domestic production of masks amid allowed to collaborate with public ones to better accom- worries of future supply chain shortages as the demand modate stable patients, preventing a hospital bed crunch for masks increases globally. The domestic produc - and ensuring that public hospitals had enough capacity tion of surgical masks, overseen by the MTI, was aided to deal with more severe cases of COVID-19 [19]. by Innosparks at ST Engineering, which had experience Despite these timely response efforts, within a few producing N95 masks [4]. These masks were meant to be months, confirmed positive cases of COVID-19 in local distributed to healthcare workers amidst a market short- communities had increased substantially, and Singa- age of medical-grade masks. Meanwhile, the shortage of pore’s government faced the simultaneous challenge of masks meant for the general public was also addressed by a massive outbreak of new cases in the foreign workers’ private firms such as Razer, which set up an automated dormitories where daily cases reached the thousands [1, manufacturing line that has been able to produce up to 5 89]. This was largely attributable to the cramped living million masks per month (CNA, 2020b) [20]. arrangements therein and residents’ lack of access to pro- Furthermore, the government noted the importance tective supplies such as masks and hand sanitizers [89]. of securing vaccines early on to reduce the death toll In response, the Singapore government required foreign and curb the spread of COVID-19. This led to the for - workers’ dormitories to be isolated and to undergo mass mation of a Therapeutics and Vaccines expert panel testing. What is more, to ensure that patients including (TxVax) that included 18 scientists and clinicians across foreign workers in critical condition received immediate hospitals, research groups, and the private sector in attention and treatment with enough medical manpower, April 2020 [30, 83]. While the approval of vaccines was the government engaged Surbana Jurong, a private con- eventually done by the Health Sciences Authority (HSA) sultancy firm, to convert exhibition centers into Com - like a normal medication approval process, the panel munity Care Facilities (CCFs). The CCFs were used to played an additional yet a critical role in recommending accommodate individuals with mild symptoms that it is the more promising vaccines directly and swiftly to gov- not required to have extensive medical treatment [51]. ernment planners and the MOH for early procurement These were similar to the temporary hospitals, such as logistics after examining and discussing the results of Huoshenshan Hospital, that were constructed in a mat- the clinical trials of prospective vaccines [83]. In addi- ter of days in China. Given Surbana Jurong’s expertise tion to increasing the healthcare sector’s capacity and and networks in the construction industry, they were well procuring vaccines, there were also efforts to improve equipped to overcome the logistical issues posed by dis- contact-tracing, which was the bedrock of containment ruptions to the supply chain [51]. Meanwhile, the medi- of the disease in its initial phases. The MOH engaged cal care in CCFs was provided by personnel deployed a research team from Duke-NUS Medical School to from private hospitals [51]. conduct serological tests during the early phases of The imposition of mandatory wearing of face masks in COVID-19, in which serological tests were limited Singapore coincided with a massive supply chain short- [20]. Serological testing allowed for the detection of age as countries that were major producers of such masks past infections even after an individual had recovered, were in lockdown and people worldwide were scrambling allowing for more precise contact-tracing [65]. In prac- for masks. The Ministry of Trade and Industry (MTI) tice, the development of the test helped contact-tracers initially distributed masks from their stockpiles, but this detect the source of a cluster of 23 COVID-19 cases was unsustainable. The Temasek Foundation, a subsidi - in the initial phase of the epidemic in Singapore and ary of Temasek Holdings, later became the main distribu- stemmed further outbreaks in the community [65]. The tor of masks and other precautionary items such as hand incident was the world’s first successful use of the sero - sanitizers in Singapore [78]. Given Temasek Holdings’ logical test kit [65]. broad networks due to its diverse investment portfolio K im et al. Globalization and Health (2022) 18:82 Page 9 of 18 Aside from healthcare policies, multi-sector collabo- arenas, given the economic repercussions a prolonged ration on non-healthcare policies was intended to meet pandemic can have on society. In short, governments can other needs of society. During the outbreak in the foreign use this strategy to work toward an economic recovery, workers’ dormitories which led to the isolation or hospi- thereby further stabilizing and strengthening the econ- talization of many foreign workers in CCFs, NGOs such omy against the backdrop of an ongoing pandemic. as Healthserve, Transient Workers Count Too (TWC2), Because the SARS outbreak was over in 3  months, Singapore Migrant Friends, and the Alliance of Guest it resulted in minimal healthcare partnerships. Nev- Workers Outreach worked with the inter-agency task ertheless, the outbreak had longer-term economic force to cater meals suited to the tastes of foreign work- repercussions in Singapore, particularly for the tour- ers and provided psychological support to those in isola- ism industry. The Ministry of Trade and Industry tion [13, 67, 81]. Additionally, given the language barrier (MTI) reduced its GDP growth forecast from 3% to between local healthcare workers and foreign workers, a 0.5% after the initial outbreak of SARS [40, 55]. In addi- volunteer project, VisualAid, was also rolled out to pro- tion, the unemployment rate reached a peak of 4.8% vide informational cards containing terms translated into (higher than during the 2007–2009 Global Financial six different languages to help healthcare workers com - Crisis) for a few months after the end of the SARS out- municate more effectively with foreign workers [43]. break in September 2003 [68]. These signals of an eco - Healthcare workers meanwhile faced discrimination nomic downturn prompted the government to work from the general public while using public transport due with the private sector to revitalize the economy and to the public’s fear of contracting the mysterious new reduce retrenchment. For instance, as seen in Table  2, virus [74]. Such discrimination resulted in difficulties for one notable initiative was the collaboration between healthcare workers looking for a ride home from hospi- the public sector Singapore Tourism Board (STB) and tals after their shifts. Grab, one of the top-ranked mobile major private sector hoteliers. While Singapore’s bor- app–based private transport service companies in South- ders remained partially open to travelers, foreigners east Asia, stepped in to resolve the challenge by launch- were wary of visiting Singapore due to the rapid spread ing GrabCare. GrabCare is similar to the company’s of the virus and the country’s strict quarantine orders. ride-hailing services, but caters specifically to healthcare Singaporeans were also reluctant to staycation at hotels workers traveling to and from their workplaces with the and instead chose to stay home to avoid contracting the fixed fare for all 24 h, and employs only those drivers who disease during that period. This situation led to the col - voluntarily sign up for the service. laborative partnership between the STB and hoteliers Aside from domestic multisector collaboration, the to provide travelers and Singaporeans assurance that Singapore government has also signaled its commit- hotels were safe environments by monitoring the tem- ment to transnational collaboration at the Association of peratures of hotel employees [31]. The initiative later Southeast Asian Nations’ (ASEAN’s) Defence Ministers’ expanded into a full-fledged certification system known meeting (ADMM) on February 19, 2020 where the man- as the ‘Cool Singapore Awards,’ which were awarded to agement of COVID-19 was discussed. The joint state - hotels and other tourist attractions. The certification ment issued on Defence Cooperation against Disease worked as a motivator to participants to ensure their Outbreak emphasized the importance of information complete adherence to government health advisories sharing to facilitate domestic contact-tracing and quar- and the disinfection of their facilities during the SARS antine efforts [6]. outbreak [31]. Aside from its efforts to prop up the local economy, Mid-term proactive response the Singapore government also engaged in transnational In line with Baxter and Casady’s [12] typology of short- cooperation to mitigate the cross-border spread of SARS. term, medium-term, and long-term governmental For instance, beginning with bilateral arrangements with responses, we note that medium-term partnerships neighboring countries such as Malaysia and Indone- between the public and private sectors represent a shift sia, Singapore has sought to exchange the information away from reactive responses to proactive responses required for contact-tracing and quarantine to ensure and anticipation of potential challenges in a pandemic. that visitors are safe [35]. Later, through the Joint Dec- Multisectoral collaborative partnerships may, for exam- laration of the Special Meeting by ASEAN Leaders on ple, facilitate product development, strengthen existing SARS 2003 and an ASEAN + 3 summit involving ASEAN healthcare services, or repurpose existing facilities to leaders, China, Japan and South Korea, Singapore further improve society’s resilience to potential outbreaks. But collaborated with other countries to facilitate informa- notably, during the COVID-19 pandemic, such partner- tion-sharing and pre-departure screenings to reduce the ships have progressively expanded into non-healthcare cross-border transmission of SARS [31]. Kim et al. Globalization and Health (2022) 18:82 Page 10 of 18 The longer duration of the COVID-19 pandemic has roll-out of the first doses of the vaccines started on Feb - illustrated the need to increase the resilience of the ruary 22, 2021 [59]. The government aimed to complete healthcare system to battle the next outbreak while also COVID-19 vaccinations by the third quarter of 2021 to ensuring that the economy recovers. The summer of keep the virus under control. It strongly encouraged res- 2020 saw massive outbreaks on every continent while idents to get the jab and first made vaccines available to Singapore was barely able to control the spread in for- Singapore Armed Forces personnel, then workers in the eign workers’ dormitories [90]. The need for stronger land transport sector, seniors aged 70 and above, seniors measures to mitigate community outbreaks that could aged 60 to 69, and each progressively younger age group bog down the healthcare infrastructure and to reduce in a timely sequence. In order to ensure the seamless and mortality rates led to closer partnerships between the efficient roll-out of vaccines as planned, the MOH set up government and hotels. One of the control measures 36 vaccination centers including public general hospitals was an issuance of stay-home notice (SHN), a form of (e.g., for frontline healthcare workers), community cent- individual quarantine orders for all travelers. The gov - ers, and 10 mobile vaccination teams island-wide. The ernment prevented travelers and returning Singaporeans tender to run these vaccination centers, worth a total of from completing SHN at their place of residence in order $38 million, was awarded to 17 healthcare providers in to prevent household spread, but for the measure to be February 2021 [92]. The main service providers from the effective, more dedicated SHN facilities were needed. private sector have been Raffles Medical and Fullerton More than half of the hotel rooms in Singapore were put Health. Although the vaccination dosage interval was ini- to this use through July 2020 [77]. While some hotels tially increased from 6 to 8 weeks due to a supply crunch, have reopened to accommodate staycationing Singapo- it was later shortened to 4 weeks to ensure that the popu- reans, these hotels remain ready to be converted back to lation could be vaccinated quickly [60]. quarantine facilities if required [88]. The local production of masks in the short-term was In addition to expanding Singapore’s healthcare facili- accompanied by ongoing innovations to increase the ties, the private sector has also made significant contri - efficiency of production lines. In particular, the Agency butions to Singapore’s vaccine roll out. In a bid to achieve for Science, Technology and Research (A*STAR) collabo- herd immunity by vaccinating the population as quickly rated with Ramatex to design more effective masks [4]. as possible, the Singapore government started its national Through the combination of A*STAR’s scientific knowl - vaccination drive in January 2021, accompanied by rigor- edge and Ramatex’s expertise in textiles, the collabo- ous public outreach and media coverage (e.g., TV and ration was able to produce a reusable mask that was as radio spots, personal SMS from the MOH, social media effective as medical masks, as shown in Fig. 4. campaigns, and printed brochures). In addition, the gov- Aside from increasing the resilience of the health- ernment prepared financial assistance and insurance care sector, the government also sought to reduce youth packages (e.g., on-time pay-out) for cases with serious unemployment brought about by the pandemic through side effects. Given the temperature-sensitive nature of the SG United Traineeship program, which works with the vaccines, air transportation business partners includ- private organizations to provide traineeships to recent ing Singapore Airlines (SIA) and DHL Global Forwarding graduates. Participating companies ranged from finan - played a critical role in delivering the vaccines from over- cial institutions such as DBS Bank, to telecommuni- seas [91]. As a result, Singapore became the first Asian cations and event management firms such as Singtel country to receive the Pfizer-BioNTech shots from Brus - and Kingsmen, respectively. As part of the program, sels, Belgium in December 2020, and Moderna’s COVID- Workforce Singapore (WSG), a government agency (a 19 vaccines arrived in Singapore in February 2021 once statutory board) under the Ministry of Manpower, has they were approved by the government. funded about 80% of the training fees while the partici- Even after the delivery of the vaccines, the vaccination pating private companies have agreed to pay the remain- programs were conducted jointly by the two sectors— ing costs. the MOH and private medical providers. Community Another major impact of COVID-19 was the closure of borders, which was extremely detrimental to Singa- pore’s small and open economy. Singapore’s government The SHN is a legally binding document promulgated under the Infectious has continued to strive to open its borders safely once Diseases Act that requires travelers to remain in a dedicated facility for the stipulated duration. Failure to do so may be punishable under the Singapore law [34]. 5 6 While DHL ensured that the cargo was successfully delivered from vac- Covid-19 vaccines have been free for all Singaporeans and long-term resi- cine production facilities overseas to airports, SIA was tasked with ensuring dents, including those on an employment or S-pass, as well as work permit that aircraft carriers were equipped with temperature-monitoring capabili- holders, foreign domestic workers, and holders of dependent passes, long- ties and cool boxes to transport the vaccines. term visit passes, and student passes. K im et al. Globalization and Health (2022) 18:82 Page 11 of 18 Fig. 4 Details of mask produced by Ramatex and A*STAR. Source: A*STAR [3] pandemic situations in its key partners stabilize. One key collaboration. In contrast, in its response to COVID-19, pillar in this initiative is to ensure that travelers are vac- Singapore’s government has shifted from a pandemic cinated or test negative for COVID-19 pre-departure. To response to an endemic one, suggesting that it intends facilitate information sharing about vaccination status, to maintain and expand such collaborative partnerships. technologies such as Israel’s Green Pass and the European Domestic policies that emphasize living with the virus, Covid Digital Certificate have been used. Building on the as we do with influenza, and eventually easing con - Open Attestation Framework developed by the Govern- trol measures, can be considered a long-term, strategic ment Technology Agency (GovTech), private companies response to COVID-19. such as Accredify and Trybe.ID helped to amplify the Singapore’s population is highly vaccinated, with 90% reach of HealthCerts in other countries through their having received the full regimen as of March 2022. Thus international networks [28]. The private companies have the government has increasingly strived to transition therefore enabled HealthCerts to be used in 9 countries toward treating COVID-19 as endemic [70]. As with and 420 medical facilities [28]. Foreign buy-in to Health- influenza or dengue, when COVID-19 is considered Certs for the storage of digital records of COVID-19 tests endemic, occasional outbreaks will be expected, but a has been critical to the reopening of borders in Singapore shift will be seen to home recovery over hospitaliza- and elsewhere. tion [37]. Given that the virus is still prevalent in many Another instance of Singapore’s government capital- other countries and that there are wide disparities in izing on digitalization is the collaboration between the vaccination rates internationally, the Singapore govern- MOH, SG United, GovTech Singapore and Nanyang Pol- ment has needed to ensure that healthcare policies and ytechnic to develop and further enhance the effectiveness related infrastructure are in place for home-based treat- of an app called TraceTogether across different models of ment and focused care. For example, private telemedi- phones [72]. The collaboration capitalized on the latter cine enterprises such as CommCare, Doctor Anywhere, two’s existing facilities to accurately measure the signal Fullerton Health, and HiDoc were brought in to reinforce strength between two phones [42]. the MOH’s home recovery program by providing virtual consultation to COVID-19 patients including children. Long-term future prevention-oriented response Their services have also included delivery of medications According to Baxter and Casady [12], in the long-term, and in-person swabbing that can accommodate home governments may continue their multisectoral partner- recovery. Later, general practitioners (GPs and dentists in ships and/or trans-national partnerships to ensure suf- a voluntary manner have stepped into this telemedicine ficient service delivery to the people. Yet it should be care for their own patients [62, 75]. noted that relative to COVID-19, the short timeframe of In addition, looking to the future, Singapore has SARS reduced the possibilities for long-term cross-sector actively sought to prevent or at least mitigate the impacts Kim et al. Globalization and Health (2022) 18:82 Page 12 of 18 of a future global pandemic by building up its interna- as the main hospital to treat patients who were criti- tional cooperation and collaboration chains. One nota- cally ill with COVID-19 [33]. Given the general under- ble effort by the government has taken place through lying expectation that healthcare resources can be easily the ASEAN member states. The ASEAN Strategic overwhelmed in the short term due to the transnational Framework for Public Health Emergencies was final - nature (spread) of the infectious disease via human-to- ized in late 2020. It provides for a multilateral approach human contact, the special designation of NCID by the to public health emergencies and increases the capacity government was a crisis prevention strategy to reduce of ASEAN’s public health networks [56]. In particular, an the burden that had been placed on public hospitals such ASEAN Regional Reserve of Medical Supplies was cre- as TTSH during the SARS outbreak and to strengthen ated to enhance the region’s ability to stockpile essential preparedness via medical-capacity building that could be medical items such as PPE to protect healthcare workers activated during another SARS-like crisis [84]. and prevent a shortage as seen during the initial phase of the COVID-19 outbreak, when countries had to scramble Harnessing private sector capacity to develop to obtain PPE and oxygen ventilators [7]. a whole-of-society response Interestingly, beginning in the middle phase of the Discussion: evolution of collaborative partnerships COVID-19 pandemic, the reliance on the NCID alone from SARS to COVID‑19 turned out to be insufficient to withstand several sharp Although Singapore was out of the woods within a few spikes in local COVID-19 transmission and subsequent months of the outbreak of the SARS virus, given that surges in hospitalizations. Thus, to rapidly strengthen SARS was the first major communicable disease chal - its operational capacity and to reduce further strain lenge of its kind, the government took away critical les- on public hospitals, Singapore’s government started to sons that informed its policy responses to the COVID-19 develop collaborative partnerships with private hospi- pandemic [73]. Singapore maintained the key tenets tals in a whole-of-society approach [38, 84]. For instance, learned from SARS and also managed to fight COVID-19 through the activation of the Public Health Preparedness more effectively, not only by increasing its cross-sector Clinic (PHPC) scheme, the MOH encouraged private collaborations, but also by mobilizing partnerships with clinics and hospitals to work as government partners to private entities such as NGOs, academia, and neighbor- help patients with emergency health needs and provide ing governments and expanding these beyond the tradi- financial and material support (e.g., medications, swab tional arenas of the healthcare and economic sectors. The tests, vaccines and professional training for healthcare following four emerging themes demonstrate how Singa- workers). The establishment of PHPCs was in line with pore learned from the prior outbreak and has responded ERMH’s recommendations for governments to make differently to the recent global healthcare emergency. advanced arrangements with private companies to ensure access to medical facilities during a health emer- Ensuring sufficient essential healthcare resources gency [85]. As a result, acting as the first line of defense, and developing contingency plans PHPC-affiliated private actors have played an important In order to manage a health emergency effectively, it is role in reducing the burden on the operational capaci- important to maintain access to and ensure sufficient ties of public hospitals dealing with unconfirmed cases of infrastructure and logistics, including the stockpiling and COVID-19 [48]. distribution of healthcare resources and the establish- Along with transferring medically stable COVID-19 ment of temporary medical facilities [85]. One of the key patients to private hospitals for continued recovery, takeaways of the SARS outbreak for Singapore was the another notable strategy in the healthcare arena geared at importance of having excess capacity and contingency accommodating more patients and providing enhanced plans during a healthcare crisis, such as available hospi- medical support within a short time was to increase the tal beds and medical resources for emergency cases (e.g., number of newly-built CCFs, especially massive-scale infected patients) to receive professional attention imme- facilities (e.g., about 10,000 beds at the Singapore EXPO diately [24, 84]. When the COVID-19 pandemic began, and Changi Exhibition Centre) staffed with private just as TTSH had been designated as the public hospi- healthcare workers and even volunteers [27, 51, 58]. This tal for SARS patients, the Singapore government swiftly represents a fundamental change from Singapore’s SARS confirmed the National Centre for Infectious Diseases response in that the MOH showed reluctance to use pri- (NCID), equipped with high-level isolation units, its own vate hospitals to fight the virus when SARS hit Singapore in-house laboratories, and technological features of a hard in 2003. Indeed, it suggests that the Singapore gov- wearable tag-based real-time locating system for contact- ernment has made extensive efforts to enable the contin - tracing among healthcare workers, patients, and visitors, uous deliverance of healthcare services even as demand K im et al. Globalization and Health (2022) 18:82 Page 13 of 18 increased to a great extent. This was to strengthen lower the morale of frontline healthcare workers, put- and sustain the resilience of public health security of ting greater strain on the healthcare system as health- communities. care workers battled mental health problems [53]. As In a similar vein, there was a shift in quarantine prac- large clusters began to rapidly form in a community tices from the SARS outbreak to the COVID-19 pandemic. and many people feared such evolving local transmis- During the SARS outbreak, individuals identified as close sion scenarios, the Singapore government’s ability to contacts of sick individuals served out their quarantine at address this discrimination was limited, since a behav- home with minimal private resources utilized, except when ioral change among residents to show social acceptance enforced by private security agencies [35]. In contrast, dur- of healthcare workers (e.g., avoiding the use of public ing the COVID-19 pandemic, a large volume of private transport or ride-sharing) seemed to involve a substan- resources have been employed, particularly in the form of tial commitment of time and effort. In turn, a bottom- government-designated facilities such as affiliated hotels up approach was more suitable. By the end of February and makeshift convention halls operated by private organi- 2020, about 50% of Grab’s driver pool had joined the zations. Food providers have also played a peripheral role program [74]. While Grab’s actions did not ignite the assisting with isolation and quarantine orders [58]. behavioral change required to eliminate discrimination Moreover, the dramatic shortage of face masks dur- against healthcare workers, it can reasonably be argued ing the initial outbreak of COVID-19 made clear the that the initiative has helped resolve the challenge, at importance of procuring essential resources. The govern - least during the initial peak of the pandemic, ensur- ment initially released 5 million masks from its stockpile ing that essential healthcare workers have been able to to retailers, but these were snapped up in a matter of a carry out their duties efficiently. few hours by zealous Singaporeans [25]. Given the high It is also notable that the Singapore government has demand for masks and the export bans in major mask- formed partnerships with NGOs to help migrant work- production countries like Taiwan, the Singapore govern- ers, something that did not occur during the SARS out- ment turned to domestic mask production, which had break. NGOs that frequently interacted with foreign been non-existent, as well as relying on private procure- workers provided expertise at responding to their par- ment by Temasek Holdings. ticular circumstances and needs during the COVID- Lastly, following breakthroughs in vaccine research, Sin- 19 pandemic (e.g., by providing translation services to gapore’s government aimed to vaccinate the entire popu- facilitate communication or catering food that would lation against COVID-19 as quickly as possible. As noted appeal to this population) [67]. For instance, Visu- earlier, private sector healthcare organizations played a alAid was another prominent bottom-up approach that leading role in operating vaccination facilities across the occurred during the height of the outbreak in the for- region and providing vaccine services to the public. eign workers’ dormitories. The volunteer project was aimed at improving communication between health- care workers and foreign workers, a topic of second- Allowing more bottom-up approaches together ary importance to the government relative to ensuring with top-down approaches that foreign workers were treated promptly and that the During the SARS outbreak, Singapore’s government outbreak was stemmed. VisualAid created information managed downward, using top-down approaches to cards with translations of medical terms, which were directly manage the public health crisis. However, dur- distributed to healthcare workers to help them commu- ing the COVID-19 pandemic, these government-led nicate with foreign workers [43]. Indeed, the collabora- top-down approaches have been accompanied by soci- tion between NGOs and the government’s inter-agency ety-driven bottom-up (ground-up) approaches involv- taskforce ensured that foreign workers, who were not ing collective actions and public–private partnerships. explicitly included in the national crisis response plan, More notably, in an effort to achieve a common goal to received equal treatment and essential services for their return Singapore to normal conditions, through tap- healthcare and welfare [13]. ping on the bottom-up approaches, the government could embrace a variety of private actors and volun- Leveraging science, research and digital technology teers beyond the healthcare service sector. Taking a long-term view, as COVID-19 shifts from pan- For example, as noted earlier, one crucial bottom- demic to endemic in Singapore, the government might up approach was the GrabCare initiative led by Grab, be prepared to cope with uncertainties as future pub- a private transportation and food delivery company, lic-health outbreaks unfold. Arguably, as COVID-19 to offer dedicated rides for healthcare professionals becomes endemic, more patients will likely be required who faced discrimination on other forms of transpor- to recover at home to prevent excess strain on the tation [8, 74]. This discrimination had the potential to Kim et al. Globalization and Health (2022) 18:82 Page 14 of 18 healthcare system. Given this expectation, in conjunc- produced more collaborative partnerships between the tion with the home recovery program, the government’s public and private sectors in Singapore as compared partnerships with private telemedicine providers could with the SARS outbreak. First, during the COVID-19 have made a difference. Specifically, they could help pandemic, the government has focused on securing suf- ensure that patients receive the primary care they need ficient essential healthcare resources with contingency at home and even in quarantine without needing to seek plans to strengthen preparedness. Second, the govern- treatment at hospitals, for example, via virtual consulta- ment has actively harnessed the capacity of private tion by the healthcare professionals and supervised self- entities (e.g., private healthcare providers and manu- swab COVID-19 Antigen Rapid Test (ART) over video facturers of medical products) to promote the resilience call [46, 62, 75]. of the healthcare system and the community. Third, the Not only did academia and the tech industry acceler- government has proceeded with control measures and ate innovations based on their pre-existing knowledge in related management policies not only in a top-down, specific areas, these sectors also helped develop diagnos - centralized style, especially during the initial response tic solutions, contact-tracing, and vaccination status digi- stage, but also with a greater proportion of bottom-up talization with the help of their state-of-the-art facilities approaches, particularly as COVID-19 cases have con- and information technology (IT). For example, as men- tinued to rage on in the community. In other words, the tioned earlier, the joint development of the cPass test COVID-19 pandemic sparked more government-led col- kit by A*STAR and Duke-NUS Medical School shows laborative partnerships and further led the government how multi-sector collaboration can produce results to embrace the ideas of community-based organiza- quickly based on participants’ existing troves of knowl- tions. Notably, most collaborations led by private actors edge and the research circulating in the academic sector (e.g., GrabCare and VisualAid) have been voluntary, [22. In addition, the collaboration between the MOH, and their underlying goals have been to help vulner- SG United, GovTech Singapore and Nanyang Polytech- able and at-risk groups (e.g., foreign workers and front- nic helped ensure community-wide surveillance via the line healthcare workers). It can be argued that so-called development of apps such as TraceTogether, even in the community-based private organizations have played a initial phase of the COVID-19 outbreak [72]. Further, fundamental role in alleviating the government’s burden during the mid-term phase of the pandemic, the Singa- through strong collaborative partnerships that have pro- pore government continued to use digital transformation vided integrated care for the community (Yi et al., 2021) to improve the government’s COVID-19 response [42]. [89]. More interestingly, the multi-faceted repercus- One notable example is the cross-sectoral collaborative sions of COVID-19 have gradually opened the door to partnerships between GovTech and private organizations a greater variety of collaborative partnerships in sectors including Accredify and Trybe.ID to develop health pass- beyond healthcare services. The participating stakehold - ports that could ascertain the validity of travelers’ pre- ers include, but are not limited to, the private healthcare screening details such as their vaccination status or the and economic sectors (such as local and international results of their COVID-19 tests, allowing Singapore to business actors), non-profit organizations, academia and reopen its borders safely. other countries [42]. Lastly, as the pandemic has contin- ued, the Singapore government has managed outward Conclusion to tap the expertise and knowledge of the private sector In an attempt to better explain Singapore’s whole-gov- (e.g., its R&D capacity), in particular leveraging science ernment approach to tackling the spread of COVID- and technology to improve control measures and putting 19, this study has focused on how the experience of the supportive programs into practice (e.g., social distanc- SARS outbreak has informed the government’s collabo- ing, diagnostic solutions and the digitalization of vacci- rative efforts with other stakeholders in society, beyond nation records) [23]. mere transnational cooperation. Taking a comparative This paper makes several contributions to the literature. case study approach, we performed a content analysis First, in the specific context of Singapore, which has been of related government documents, mainstream newspa- globally applauded for its successful control of the spread per articles, and journal articles in an inductive manner. of COVID-19, comparing the government’s management We were able to closely compare two global healthcare of the SARS outbreak with its management of COVID- outbreaks and note both importance differences in their 19 has allowed us to delineate what the government contexts and the government’s progress in terms of its learned and how cross-sector collaboration expanded more robust response to COVID-19. during the current pandemic. Second, this study provides The evidence from our focused analyses demonstrates a practical, chronological analysis of the implementation that the nature and scale of the COVID-19 pandemic of related policy prescriptions to combat the pandemic, K im et al. Globalization and Health (2022) 18:82 Page 15 of 18 with a particular focus on how COVID-19’s larger scale authoritarian state or an illiberal democracy [1, 64]. has brought about an evolution in cross-sector col- These characteristics could result in a more straightfor - laboration since SARS (also see Appendices A and B). ward management method during SARS and COVID- Specifically, by categorizing the various collaboration 19, relative to other countries. However, policies with efforts into healthcare and non-healthcare service areas, different characteristics including varying fiscal capac - and by closely examining Singapore’s response during ity and different political and cultural environments three different timeframes (here, the short-term reactive may not diffuse along the same lines. Given this, we response, the mid-term proactive response, and the long- believe the findings of this study can provide a point of term future-oriented response), this study has provided comparison for future work (e.g., cross-national case a detailed discussion of the topic. In addition, our find - studies). In other words, future studies may continue ings offer evidence that through adaptive learning from to uncover additional points of evidence (practices) in the prior global healthcare outbreak, plus some trial and different contexts. This is especially so given that the error during the initial phase of the ongoing pandemic, widespread and flexible cross-sector collaboration that public- and private-sector partners, both in and out- have sprung up during the pandemic in various coun- side of the healthcare service sector, have tended to “act tries are likely to ignite better ways of collaboration in alike,” working together to achieve a common goal. Both the future [63]. We also expect that collective planning have been socially responsible, providing public services and action will continue even in the post–COVID- to people in need to promote the rapid resilience of the 19 era through partnerships across various public and community, and sharing the associated risks. private organizations. Thus, it may be worthwhile for As the war against COVID-19 continues around the focused research to employ more varied interpre- world, Singapore’s strategic response against the pan- tive approaches, including survey questionnaires or demic can serve as a point of reference for other like- focus group interviews with healthcare providers and minded nations to cultivate a sustainable and effective workers. long-term response against the pandemic. The lessons learned in Singapore have proved that as the short-term Abbreviations reactive response, public health measures implemented A*STAR : Agency for Science, Technology and Research, Singapore; ADMM: by the government alone could be effective, but they ASEAN’s Defence Ministers’ Meeting; ART : Antigen-Rapid Test; ASEAN: Asso- ciation of Southeast Asian Nations; CCFs: Community Care Facilities; CEG: turned out to be unsustainable, especially as the world Core Executive Group; CNA: Channel News Asia; DSTA: Defence Science and prepares to deal with an endemic disease like COVID- Technology Agency, Singapore; EG: Executive Group; FDA: Food and Drug 19. Collaboration between the government agencies Administration; GDP: Gross Domestic Product; GLCs: Government-Linked Companies; GovTech: Government Technology Agency, Singapore; GP: General and a variety of private actors thus can help prevent our Practitioner; HCEG: Homefront Crisis Executive Group; IMC: Inter-Minister Com- public healthcare system from being overwhelmed and mittee; IMOC: Inter-Ministerial SARS Operation Committee; IT: Information Tech- ensure that the public continues to benefit from higher nology; MCI: Ministry of Communication and Information, Singapore; MEWR: Ministry of the Environment and Water Resources, Singapore; MHA: Ministry of quality of healthcare services in a sustainable and feasi- Home Affairs, Singapore; MND: Ministry of National Development, Singapore; ble manner. Given this, other governments and policy MOE: Ministry of Education, Singapore; MOH: Ministry of Health, Singapore; makers who are still struggling to maximize essential MOM: Ministry of Manpower, Singapore; MOT: Ministry of Transport, Singapore; MSF: Ministry of Social and Family Development, Singapore; MTF: Multi-Ministry resources and minimize the negative impacts of the Taskforce; MTI: Ministry of Trade and Industry, Singapore; NCID: National Centre healthcare crisis may need to consider adjusting their for Infectious Diseases; NGO: Non-Governmental Organization; NTUC: National response stance from managing downward to inviting Trade Union Congress, Singapore; NUH: National University Hospital, Singapore; PHPC: Public Health Preparedness Clinic; PPE: Personal Protective Equipment; more participation from private-sector entities and capi- R&D: Research and Development; RT-PCR: Reverse Transcriptase Polymerase talizing on innovation to gain wisdom from their exper- Chain Reaction; SAF: Singapore Armed Forces; SARS: Severe Acute Respiratory tise and knowledge. At the same time, through closely Syndrome; SGH: Singapore General Hospital; SHN: Stay-Home Notice; SIA: Singapore Airlines; ST Electronics: Singapore Technology Electronics; STB: Singa- working with voluntary organizations and civil society pore Tourism Board; TTSH: Tan Tock Seng Hospital; TWC2: Transient Workers groups in a community, a nation’s social security net can Count Too; TxVax: Therapeutics and Vaccines expert panel; WHO: World Health be further complemented especially in times of crisis. Organization; WSG: Workforce Singapore. One limitation of this study is that it focuses only on the Singapore context, and readers should bear this Supplementary Information in mind and take care when generalizing its results. The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12992- 022- 00873-x. Notably, Singapore is a small-sized city state in which neither subnational structures (e.g., federal-state rela- Additional file1: Appendix A. Timeline of Collaborative SARS Response. tions) nor the rural-versus-urban continuum exist and Appendix B. Timeline of Collaborative COVID-19 Response. its political system has been known as a competitive Kim et al. Globalization and Health (2022) 18:82 Page 16 of 18 Acknowledgements 8. Baharudin H. Coronavirus: New Grab service dedicated to taking health- This work was based on Undergraduate Research Experience on CAmpus care workers home. The Straits Times; 2020. Retrieved from https:// www. (URECA) program during the 2021-22 academic year of Nanyang Technologi-strai tstim es. com/ singa pore/ coron avirus- new- grab- servi ce- dedic ated- to- cal University, Singapore. The related project titled exploring public-private taking- healt hcare- worke rs- home partnerships for effective management of public health and economic crises 9. Berg BL, Lune H. Qualitative research methods for the social sciences. 8th includes SSS21011 and SSS21072. ed. Boston: Pearson; 2012. 10. 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Moving toward a common goal via cross-sector collaboration: lessons learned from SARS to COVID-19 in Singapore

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Springer Journals
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Copyright © The Author(s) 2022
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1744-8603
DOI
10.1186/s12992-022-00873-x
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Abstract

Background: The spread of COVID-19 has taken a toll on many countries and its healthcare system over the last two years. Governments have sought to mitigate the repercussions of the pandemic by implementing aggressive top- down control measures and introducing immense fiscal spending. Singapore is no exception to this trend. Owing to a whole-of-society approach, Singapore is still being lauded globally for its relatively successful record at controlling both community and trans-border spread. One notable effort by the Singapore government has taken place through its cross-sectoral collaborative partnerships with the private stakeholders behind the success. Methods/results: In an attempt to better explain Singapore’s robust yet strategic response to COVID-19, this study focuses on how the experience of the SARS outbreak has informed the government’s collaborative efforts with other stakeholders in society, beyond mere transnational cooperation. Taking a comparative case study approach in the specific context of Singapore, we perform a content analysis of related government documents, mainstream news- paper articles, and academic journal articles in an inductive manner. By closely comparing two global healthcare outbreaks, we note four differences in approach. First, during the COVID-19 pandemic, Singapore has focused on securing sufficient essential healthcare resources with contingency plans to strengthen preparedness. Second, the government has actively harnessed the capacity of private entities to promote the resilience of the healthcare system and the community. Third, Singapore’s management policies have been made not only in a top-down, centralized style during the initial response stage, but also with a greater proportion of bottom-up approaches, particularly as the pandemic trudges on. More interestingly, the multi-faceted repercussions of COVID-19 have gradually opened the door to a greater variety of collaborative partnerships in sectors beyond healthcare services. The participating stake- holders include, but are not limited to, local and international business actors, non-profit organizations, academia and other countries. Lastly, as the pandemic has continued, the Singapore government has managed outward to tap the expertise and knowledge of the private sector, in particular leveraging science and technology to improve control measures and putting supportive programs into practice. Conclusion: The evidence from our focused analyses demonstrates that the nature and scale of the COVID-19 pandemic produced more collaborative partnerships between the public and private sectors in Singapore as com- pared with the SARS outbreak. What is more, our findings offer evidence that through adaptive learning from the prior global healthcare outbreak, plus some trial and error during the initial phase of the ongoing pandemic, public- and *Correspondence: sjkim@ntu.edu.sg Public Policy and Global Affairs Programme, School of Social Sciences, Nanyang Technological University, 48 Nanyang Avenue, HSS-05-02, Singapore 639818, Singapore © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kim et al. Globalization and Health (2022) 18:82 Page 2 of 18 private-sector partners, both in and outside of the healthcare service sector, have tended to “act alike,” working together to achieve a common goal. Both have been socially responsible, providing public services to people in need to promote the rapid resilience of the community, and sharing the associated risks. Overall, this study has deep and wide implications for other governments and policy makers who are still struggling to maximize essential resources and minimize the negative impacts of the healthcare crisis. Keywords: COVID-19, Health Crisis, Cross-Sector Collaboration, Partnerships, Singapore Introduction Emergency Risk Management for Health (ERMH) Over the past two years, we have witnessed unprec- which has identified multi-sectoral approach as a guid - edented impacts of the COVID-19 pandemic on global ing principle for managing health crises [85]. These col - health and the global economy. First discovered in 2019 laborations may take the form of a multi-ministry-centric in Wuhan, China following a cluster of unidentified hybrid organization that plays a leading role in prevent- pneumonia cases, the novel coronavirus spread rapidly ing and controlling disease spread within a community not only in Wuhan but also worldwide [69], and has since by investing in sustainable diagnostic solutions and digi- undergone several waves of mutations (such as the Delta tal solutions to current and future needs. For this, diverse and Omicron variants). As of August 10, 2022, more than industries such as medicine, education, science and tech- 580 million COVID-19 cases have been reported around nology may produce these solutions together with policy the globe. Cases peaked at over 3,800,000 in a single day support from the government. in January 2022, and over 6 million people have died of Singapore is no exception to this trend. Unlike other COVID-19 [87]. As COVID-19 rages on, many health- Asian countries such as South Korea or Taiwan that faced care systems worldwide are on the brink of collapse, in upticks in COVID-19 cases after initially containing the some cases due to a lack of medical facilities or profes- spread of the virus, Singapore is still being lauded glob- sionals. Consequently, the estimated cost of the pan- ally for its relatively successful record at controlling both demic has added $24 trillion to the collective global debt community and trans-border spread. It has also main- as of February 2021, bringing it to a whopping $281 tril- tained a lower mortality rate than much of the world lion [36]. [1]. Given its small geographic size and high population Given this, recent scholarship has highlighted the density, the city-state has adopted a so-called “a defensive importance of collaboration across all sectors of society pessimism stance,” remaining vigilant and preparing for as a way forward out of the pandemic and toward a more worst-case scenarios [82]. Notably, during the COVID-19 resilient healthcare system, a full economic recovery, and pandemic, Singapore’s government has demonstrated its continued long-term growth (e.g., [12, 63, 80]. This is readiness and agility, taking more proactive and strategic reminiscent of Bryson and colleagues’ (2015) definition action than it did during previous health crises (e.g., the of cross-sector collaboration as “the linking or sharing Severe Acute Respiratory Syndrome (SARS) outbreak of information, resources, activities, and capabilities by in 2003). The government’s initial policies to contain organizations in two or more sectors to achieve jointly an COVID-19 were “top-down” in style. It managed down- outcome that could not be achieved by organizations in ward at the initial response stage, but since then has also one sector separately” [10], p. 44 as cited in [11], p. 648). managed outward, forming collaborative partnerships In this vein, it can reasonably be argued that by effec - with other stakeholders over time, including the private tively mobilizing stakeholders and resources, multisector healthcare and economic sectors (including local and collaborative partnerships can help alleviate the strain international businesses), non-profit organizations, aca - on public finance, especially for governments, and can demia and other countries (e.g., see [42]). provide cost-efficiency gains and drive appropriate and Some scholarship has compared Singapore’s response satisfactory essential services to the most disadvantaged to the COVID-19 pandemic with its response to the people [52, 66]. SARS outbreak in 2003, as both diseases were caused by Over the past two years of the global health crisis, stra- coronaviruses. However, most research on Singapore’s tegic multisectoral collaboration efforts have been put The last time the world witnessed an influenza pandemic on the scale of into practice in many developed countries, including the COVID-19 was the Spanish Flu of1918. Yet, in the existing research, COVID- United States, Australia, Canada, and Japan, to ensure 19 has more often been compared to the 2003 SARS outbreak, since both diseases emerged in the modern era and were causedby viruses in the coro- the timely and continuous delivery of essential goods naviridae family. In addition, given that the SARS outbreak was the first epi - and services, including medical assistance [66]. This is demic since Singapore became a developed country, aswith Chen et  al. [18], in line with the World Health Organization’s (WHO’s) this study posits that SARS is the optimal case for comparison. K im et al. Globalization and Health (2022) 18:82 Page 3 of 18 Table 1 Comparison between the SARS and COVID-19 Outbreaks in Singapore SARS COVID-19 Outbreak period (Global) November 2002 to July 2003 November 2019 to present Outbreak period (Singapore) March 2003 to June 2003 January 2020 to present First reported case in Singapore March 1, 2003 January 23, 2020 Total confirmed cases 238 1,773,386 Local Death toll 33 1543 (Case fatality rate) (14%) (0. 09%) Rapid diagnostics RT-PCR/reverse transcription polymerase reaction RT-PCR/reverse transcription polymerase reaction/Antigen-rapid test (ART ) Medical prevention Not available (No FDA-approved vaccination) Available (FDA-approved vaccines and antiviral pills) Governance Structure From the Operations Group Multi-Ministry Taskforce (MTF) (Led by the MOH) to the three-tiered taskforce (Led by the (Currently led by the Minister for Health MHA): and the Minister for Finance together) Inter-Minister Committee (IMC), Core Executive Group (CEG) and Inter-Ministerial SARS Operation Committee (IMOC) In the case of COVID-19 outbreak, total confirmed cases and local death toll were calculated as of August 10, 2022 Source: Compiled from various sources [39, 49] success against COVID-19 has tended to describe chron- unexplained pneumonia. However, China did not pro- ological, medical data (e.g., the death toll); the country’s ceed with state-level control measures nor report the in-house capacity resulting from its enhanced healthcare cases to the World Health Organization until February system; its early response and disease surveillance efforts 11, 2003 [45]. The virus later spread to 29 other countries (e.g., [17, 47], or public sentiments about the related poli- including Singapore [35]. Globally, 8422 confirmed and cies (e.g., [71, 82]. Little attention has been paid to cross- probable cases were reported. A total of 916 deaths from sector collaboration, particularly related to the role of SARS were reported by the end of the pandemic in June private actors in and outside of the healthcare service 2003 [14]. arena. In response to this gap in the existing literature, Singapore recorded its first case of SARS on March this study aims to closely map the extent of the multisec- 1, 2003, when a traveler returning from Hong Kong tor collaboration efforts that have been implemented by was admitted into Singapore’s Tan Tock Seng Hospital Singapore’s government during the ongoing COVID-19 (TTSH). Her case was linked to a superspreading event pandemic. In the focused analyses, we use Singapore’s at Metropole Hotel [18]. Singapore soon saw an exponen- experience during the SARS outbreak as a point of ref- tial increase in cases following outbreaks in several pub- erence as we evaluate and discuss the progress made in lic settings such as hospitals [24]. Crucially, 41% of the governmental partnerships with other stakeholders. cases were healthcare workers due to the multiple hos- pital-related outbreaks that took place at TTSH, National Background: the SARs and COVID‑19 outbreaks University Hospital (NUH), and Singapore General Hos- in Singapore pital (SGH) [18, 35]. Singapore became one of the top 5 Given that coronaviruses have been responsible for both most affected countries, recording a total of 238 cases outbreaks, this study posits that reviewing Singapore’s and 33 deaths, resulting in a case fatality rate of 14% [57]. experience with SARS and COVID-19 and comparing the The epidemic ended in Singapore in June 2003 after the government’s response to the two outbreaks can reveal WHO declared Singapore SARS-free on May 30, 2003. the adaptive learning that has taken place over time. The SARS outbreak was initially and directly man - Table  1 provides some basic details as to how Singapore aged by Singapore’s Ministry of Health (MOH). The was affected by the SARS and COVID-19 global health Operations Group by the MOH, announced in the mid- crises. dle of March 2003, was led by the Director of Medical Services and comprised on senior doctors and admin- The SARS outbreak in 2003 istrators from various public hospitals. The Group was In November 2002, the first ever reported case of SARS in control of all the medical resources and served as the occurred in Foshan, China, when patients presented link between the MOH and all healthcare providers [39]. clinical flu-like symptoms such as high fever with But later, as the government realized that resources from Kim et al. Globalization and Health (2022) 18:82 Page 4 of 18 Fig. 1 SARS Governance Structure. Source: Adapted from Tay & Mui (2004, p. 35) [76] other ministries were required to combat the outbreak, dormitories for foreign workers and accounted for the a three-tiered national control structure was created spike in cases early in April 2020. This led to a nation - to strongly control the spread of the virus. As shown in wide lockdown known as “the circuit breaker,” which Fig. 1, the three tiers included the Inter-Ministerial Com- lasted from April 7 to June 1, 2020. The circuit breaker mittee (IMC), the Core Executive Group (CEG) and the largely contained the initial outbreak within the foreign Inter-Ministerial SARS Operation Committee (IMOC) workers’ dormitories and minimized the spread to the [76]. The IMC was chaired by the Minister for Home community. However, Singapore experienced two more Affairs and comprised of ministers from other ministries, massive outbreaks in the community in the latter half of including the MOH, the Ministry for Education (MOE 2020/first half of 2021 and in the first half of 2022, which and the Ministry for National Development (MND. were primarily attributed to the spread of the Delta and This committee served to: (i develop strategic decisions Omicron variants, respectively [2]. As of August 10, to design policies,(ii approve major decisions; and (iii 2022, Singapore had recorded a total of 1,773,386 cases implement control measures [39]. Meanwhile, the CEG and 1543 fatalities [61]. The case fatality rate is therefore was led by the Permanent Secretary for Home Affairs and around 0.09%, much lower than the rate with SARS cases directed valuable resources at the ministry level to key (See Table 1). areas during the outbreak, whereas the IMOC carried In terms of the government decision-making of health out the health control measures issued by the IMC, coor- emergencies, the Singapore government established an dinating interactions between the MOH and healthcare inter-departmental organization named the Homefront providers and frontline workers [39, 76]. Crisis Executive Group (HCEG) prior to 2004. HCEG is chaired by the Permanent Secretary of the Ministry of The COVID-19 pandemic from 2020 to the present Home Affairs (MHA) and comprises senior representa - COVID-19 emerged in Wuhan, China in November 2019 tives from all ministries but the major role of the HCEG and was reported to the WHO on the last day of 2019 was to provide the strategic and political guidance dur- [16]. On March 11, 2020, the WHO officially declared ing the health crisis (e.g., the endorsement of MOH’s COVID-19 a pandemic. The virus has spread to more recommendations for the suitable Disease Outbreak than 150 countries around the world. COVID-19 has Response System Condition (DORSCON) level). Dur- similar clinical features to the flu, but the incubation ing the COVID-19 pandemic, although essential medical period for COVID-19 before symptoms are developed resources are mainly controlled by the MOH, there was may be as long as 14 days. These features have made the an urgent need to coordinate health (control) measures virus difficult to contain, and as of August 10, 2022, the across governmental sectors as well as across the com- WHO has reported close to 580 million confirmed cases plete society. In turn, to facilitate inter-departmental and 6,418,958 deaths globally [86]. communication in setting priorities into action, the The first case in Singapore was reported on January 23, 2020 when a 66-year-old Wuhan resident tested positive for COVID-19 while traveling in Singapore [26]. Singa- This is a color-coded framework that highlights Singapore’s  health crisis pore has experienced multiple outbreaks over the last two (disease) condition. There arefour colors—green (the lowest), yellow, orange, years of COVID-19. The first major outbreak occurred in and red (the highest) that represent each alert level of Singapore’s pandemic preparedness plan dependingon the level (nature) of disease [1]. K im et al. Globalization and Health (2022) 18:82 Page 5 of 18 Fig. 2 COVID-19 Governance Structure. Source: Adapted from Low (2020) [50] government has become to set up a Multi-Ministry Task- to the public [23, 82]. All in all, the MTF has actively sup- force (MTF) which was jointly led by the Minister for ported the HCEG to effectively deliver their plans and Health and the Minister for National Development in the decisions to the elected leadership for political direction initial phase [1]. Interestingly, the number of ministries and ensure subsequently confirmed actions to be taken in participating in the MTF has been more than doubled practice (See Fig. 2) [50, 51]. compare to the SARS outbreak. The MTF on COVID-19 consists of the Ministry of Communication and Informa- Methods and analyses tion (MCI), the Ministry of Trade and Industry (MTI), During the SARS outbreak and the ongoing COVID-19 the Ministry of the Environment and Water Resources pandemic, the Singapore government has embarked on (MEWR), the National Trade Union Congress (NTUC), multiple service delivery projects in collaboration with pri- the Ministry of Education (MOE), the Ministry of Man- vate actors to manage, pre-empt and mitigate challenges power (MOM), the Ministry of Social and Family Devel- associated with the outbreaks. In order to scrutinize and opment (MSF), and the Ministry of Transport (MOT) compare Singapore’s response to the two global health- [41]. The main tasks of the MTF have been not only to care crises, this study uses inductive conventional content direct the national whole-of-government response to analysis based on secondary data obtained through major COVID-19 outbreak, but also to work with the interna- local newspaper articles, related government agency and tional community to respond to the outbreak. For exam- industry reports, and academic journal articles describing ple, this taskforce has focused on border controls, the how Singapore responded to each outbreak. Specifically, as circuit breaker (lockdown), and addressing the outbreak with Berg and Lune [9] and Hsieh and Shannon [32], we in the migrant worker dormitories. In addition, in order attempted to identify and cluster evidence-based themes to continue to prevent the public from underestimating derived directly from the text data in a document and then the risks of COVID-19 and the mitigation policies from discover hidden meaning of the related content. backfiring, the MTF has tried to coordinate the commu - Building on Baxter and Casady’s [12] so-called recovery nity response by carrying out weekly press conferences framework model, we discuss the Singapore government’s to convey critical information (e.g., daily contact-tracing specific milestones related to multisectoral collaborative reports or stepwise criteria for reopening the economy) partnerships during the two global health crises (See Tables 2 Kim et al. Globalization and Health (2022) 18:82 Page 6 of 18 Table 2 SARS: Multisector Collaboration Healthcare Non-Healthcare Short-term, • Diversion of non-flu cases away from TTSH to be Reactive handled by general practitioners (GPs) Response • Development of Infrared Thermal Fever Scanner by ST Electronics with DSTA Medium-term, • Bilateral arrangements with Malaysia and Indonesia • Monitoring of employees’ temperatures by major Proactive to facilitate contact-tracing and quarantine hoteliers in cooperation with the Singapore Tourism Response • Joint Declaration of the Special ASEAN Leaders Board (STB) Meeting on SARS 2003 • STB launch of ‘Cool Singapore Awards’ to acknowledge major hoteliers and tourist facilities Table 3 COVID-19 Multi-Sector Collaboration Healthcare Non-Healthcare Short-term, • Public Health Preparedness Clinics (PHPCs) were activated • Temasek Foundation provided reusable masks Reactive • Private hospitals cared for well and stable COVID-19 patients and hand sanitizers Response • Masks were produced locally by Innosparks and ST Engineering • Migrant Workers Center and Alliance for Guest • Surbana Jurong constructed Community Care Facilities (CCFs) Workers Outreach delivered food and provided • Staff from private hospitals provided medical care in CCFs support for migrant workers in isolation • TvVax, made up of healthcare professionals from the private sector, secured • VisualAid provided cards with translations of vaccines for the population healthcare terms to improve healthcare workers’ • Duke-NUS medical school developed serological test kits to boost contact- communication with migrant workers tracing efforts • Joint statement of ASEAN Defence Ministers on Defence Cooperation against Disease Outbreak (ASEAN, 2020) • Grab offered GrabCare catered to the transport needs of healthcare workers Medium-term, • Hotels were converted into isolation and quarantine facilities • Private firms provided training and partially Proactive • SIA and DHL were tasked with the handling and delivery of vaccines funded trainees’ allowance under SG United Response • Private healthcare providers ran the vaccination centers set up by the MOH Traineeship program • Ramatex worked with A*STAR to develop more effective masks suited for Sin- • Ministry of Health, SG United, and Nanyang gapore’s climate Polytechnic worked with GovTech Singapore together to improve the effectiveness of a new app called TraceTogether Long-term, • Private telemedicine providers offered enhanced home recovery programs Future-oriented • ASEAN Strategic Framework for Public Health Emergencies and ASEAN Response Regional Reserve of Medical Supplies and 3 below; for more detailed information, see Appendi- anticipate the challenges of the pandemic. The responses ces A and B). It should be noted that while Baxter and Cas- may include product development or the strengthening ady [12] focused on healthcare policies alone, our analysis of existing healthcare services. Long-term responses are expanded the model to include non-healthcare policies. those aimed at pre-empting future outbreaks, and they As seen in Fig.  3, the responses of a government fac- require careful planning for the future based on adaptive ing a healthcare crisis can be divided into three different learning. It is expected that these responses will emerge broad timeframes. In terms of short-term response, a from one month after the initial phase of virus transmis- government is expected to respond promptly to an exist- sion to beyond a year, depending on when an outbreak ing outbreak or an unanticipated new wave of a disease. ends and how serious its transmission is. In the post- Such reactive responses are likely to emerge between outbreak period, the government may consider continu- the start of a new wave of the outbreak and about one ing its collaborative partnerships with actors including month into an outbreak. Crisis-driven government-led private firms, non-governmental organizations (NGOs), collaborative management is meant to meet the imme- academia and even international organizations of a diate needs of the healthcare system and society. In the medium term, responses are more proactive and are Given that government-linked companies (GLCs) in Singapore such as Temasek Holdings and Singapore Airlines are subject to thediscipline of the expected to emerge anywhere from a few weeks after the stock market and investors, it can reasonably be argued that they function in line initial outbreak to one year into the outbreak. During this with a profit-maximizing objective, thereby acting morelike private firms than period, cross-sector collaboration can help governments state-owned enterprises [5]. Thus, this study treats GLCs as private entities. K im et al. Globalization and Health (2022) 18:82 Page 7 of 18 Fig. 3 Relative Timeframes of Healthcare Crisis Responses. Source: Authors modified Baxter and Casady’s (2020) PPP-based analytical approach transnational nature to strengthen the existing healthcare In turn, at first, TTSH was designated as a SARS hospital system and other service industries and reduce the sever- by the MOH on March 22, 2003 [35, 39]. That is, the “all- ity of future pandemics. in-one” approach required all suspected and confirmed cases of SARS were sent only to TTSH. Restrictions were Results also imposed on the movement of healthcare workers Short-term reactive response and patients among hospitals [35]. Meanwhile, all elec- In response to the extreme uncertainty brought about by tive procedures in other public hospitals were placed on a global health crisis, as mentioned above, governments hold as the MOH redirected non-flu illness cases (that initially tend to behave reactively to meet the immedi- is, non-SARS related emergency patients) to other public ate demands not only of the healthcare system, but also hospitals and local general practitioners (GPs) [39]. The of the community. In practice, as seen in Tables  2 and 3, Singapore Armed Forces (SAF) were also activated to collaborative partnerships among public agencies and/or provide manpower support to public hospitals [54]. All between the public and private sectors can meet press- these efforts were intended to prevent the overstraining ing needs of a community in a state of agitation (e.g., by of hospitals and to prevent cross-contamination. ensuring the resilience of the food and essential medical In addition, during the SARS outbreak, to curb trans- equipment/devices supply chains) [12]. border spread of the disease, a mandatory health declara- In the early stages of the SARS outbreak, the Singapore tion was imposed on travelers to Singapore. The Defence government was not adequately prepared to deal with Science and Technology Agency (DSTA) under the Min- the infectious disease that was fluid and unprecedented istry of Defence collaborated with Singapore Technol- [39]. Due to the initial lack of dedicated testing and iso- ogy (ST) Electronics to develop a temperature scanner, lation facilities and on-going contact-tracing effort, the the Infrared Thermal Fever Scanner (Defence Science & first patient who had contracted SARS was only hospi - Technology Agency, 2003) [21]. This cross-sectoral col - talized and isolated after five days upon her return from laboration, which capitalized on the thermal imagers Hong Kong, during which she had spread the virus to commonly used in the military, led to the rapid deploy- 22 other individuals [24]. Given this, the MOH initiated ment of the scanner within one week at immigration a SARS taskforce to study and manage the unexpected checkpoints at Changi Airport to prevent the entry of spread of the virus throughout the community, focus- suspected SARS patients [44]. ing on collaboration within the public sector that could During the COVID-19 pandemic, the Singapore gov- better serve the public [35]. However, in practice, the ernment has moved in a timely way to roll out preventive presence of the first confirmed SARS cases within one strategies intended to control the spread of the disease in public hospital––Tan Tock Seng Hospital (TTSH)–– the community, across borders, and in hospitals. Nota- highly influenced the condition of other patients in the bly, there has been an increase in collaborative partner- same hospital and caused the further spread of SARS ships to meet the needs of the healthcare industry as well to other healthcare institutions such as Singapore Gen- as society—the general populace, healthcare workers eral Hospital and National University Hospital [24]. In and foreign workers—and such partnerships have been response, to effectively contain the spread among various found not only in the healthcare arena but also in non- healthcare workers, institutions, and patients, the gov- healthcare fields (e.g., IT, R&D, and the economic sec - ernment tapped into the so-called “all-in-one” approach tor). As indicated in Table 3, for example, as the first line which has been considered as a unique Singapore term. of defense, Public Health Preparedness Clinics (PHPCs) Kim et al. Globalization and Health (2022) 18:82 Page 8 of 18 were activated in February 2020, within a few weeks of on every continent, it was able to procure reusable masks the first COVID-19 case in Singapore. GPs enrolled in the that were new innovations and of better quality [79]. PHPC scheme underwent courses on the importance of Some of the masks distributed utilized technology by infection control and were trained on the use of personal Swiss-based Livinguard and UK-based DET30. Temasek protective equipment (PPE) [15]. Because patients with Holdings’ distribution of essential items ensured that the respiratory illnesses were offered subsidized treatment at MTI could divert their resources to the procurement of PHPCs, these patients were diverted away from hospitals other items such as food while ensuring that the populace to clinics, and only suspected positive cases of COVID- received better quality masks [50]. 19 were referred to hospitals for further diagnostics [29]. Apart from the Temasek Foundation’s procurement of Additionally, in contrast to Singapore’s SARs response, masks from overseas suppliers, there have also been local in March 2020, private hospitals in the city-state were efforts to restart the domestic production of masks amid allowed to collaborate with public ones to better accom- worries of future supply chain shortages as the demand modate stable patients, preventing a hospital bed crunch for masks increases globally. The domestic produc - and ensuring that public hospitals had enough capacity tion of surgical masks, overseen by the MTI, was aided to deal with more severe cases of COVID-19 [19]. by Innosparks at ST Engineering, which had experience Despite these timely response efforts, within a few producing N95 masks [4]. These masks were meant to be months, confirmed positive cases of COVID-19 in local distributed to healthcare workers amidst a market short- communities had increased substantially, and Singa- age of medical-grade masks. Meanwhile, the shortage of pore’s government faced the simultaneous challenge of masks meant for the general public was also addressed by a massive outbreak of new cases in the foreign workers’ private firms such as Razer, which set up an automated dormitories where daily cases reached the thousands [1, manufacturing line that has been able to produce up to 5 89]. This was largely attributable to the cramped living million masks per month (CNA, 2020b) [20]. arrangements therein and residents’ lack of access to pro- Furthermore, the government noted the importance tective supplies such as masks and hand sanitizers [89]. of securing vaccines early on to reduce the death toll In response, the Singapore government required foreign and curb the spread of COVID-19. This led to the for - workers’ dormitories to be isolated and to undergo mass mation of a Therapeutics and Vaccines expert panel testing. What is more, to ensure that patients including (TxVax) that included 18 scientists and clinicians across foreign workers in critical condition received immediate hospitals, research groups, and the private sector in attention and treatment with enough medical manpower, April 2020 [30, 83]. While the approval of vaccines was the government engaged Surbana Jurong, a private con- eventually done by the Health Sciences Authority (HSA) sultancy firm, to convert exhibition centers into Com - like a normal medication approval process, the panel munity Care Facilities (CCFs). The CCFs were used to played an additional yet a critical role in recommending accommodate individuals with mild symptoms that it is the more promising vaccines directly and swiftly to gov- not required to have extensive medical treatment [51]. ernment planners and the MOH for early procurement These were similar to the temporary hospitals, such as logistics after examining and discussing the results of Huoshenshan Hospital, that were constructed in a mat- the clinical trials of prospective vaccines [83]. In addi- ter of days in China. Given Surbana Jurong’s expertise tion to increasing the healthcare sector’s capacity and and networks in the construction industry, they were well procuring vaccines, there were also efforts to improve equipped to overcome the logistical issues posed by dis- contact-tracing, which was the bedrock of containment ruptions to the supply chain [51]. Meanwhile, the medi- of the disease in its initial phases. The MOH engaged cal care in CCFs was provided by personnel deployed a research team from Duke-NUS Medical School to from private hospitals [51]. conduct serological tests during the early phases of The imposition of mandatory wearing of face masks in COVID-19, in which serological tests were limited Singapore coincided with a massive supply chain short- [20]. Serological testing allowed for the detection of age as countries that were major producers of such masks past infections even after an individual had recovered, were in lockdown and people worldwide were scrambling allowing for more precise contact-tracing [65]. In prac- for masks. The Ministry of Trade and Industry (MTI) tice, the development of the test helped contact-tracers initially distributed masks from their stockpiles, but this detect the source of a cluster of 23 COVID-19 cases was unsustainable. The Temasek Foundation, a subsidi - in the initial phase of the epidemic in Singapore and ary of Temasek Holdings, later became the main distribu- stemmed further outbreaks in the community [65]. The tor of masks and other precautionary items such as hand incident was the world’s first successful use of the sero - sanitizers in Singapore [78]. Given Temasek Holdings’ logical test kit [65]. broad networks due to its diverse investment portfolio K im et al. Globalization and Health (2022) 18:82 Page 9 of 18 Aside from healthcare policies, multi-sector collabo- arenas, given the economic repercussions a prolonged ration on non-healthcare policies was intended to meet pandemic can have on society. In short, governments can other needs of society. During the outbreak in the foreign use this strategy to work toward an economic recovery, workers’ dormitories which led to the isolation or hospi- thereby further stabilizing and strengthening the econ- talization of many foreign workers in CCFs, NGOs such omy against the backdrop of an ongoing pandemic. as Healthserve, Transient Workers Count Too (TWC2), Because the SARS outbreak was over in 3  months, Singapore Migrant Friends, and the Alliance of Guest it resulted in minimal healthcare partnerships. Nev- Workers Outreach worked with the inter-agency task ertheless, the outbreak had longer-term economic force to cater meals suited to the tastes of foreign work- repercussions in Singapore, particularly for the tour- ers and provided psychological support to those in isola- ism industry. The Ministry of Trade and Industry tion [13, 67, 81]. Additionally, given the language barrier (MTI) reduced its GDP growth forecast from 3% to between local healthcare workers and foreign workers, a 0.5% after the initial outbreak of SARS [40, 55]. In addi- volunteer project, VisualAid, was also rolled out to pro- tion, the unemployment rate reached a peak of 4.8% vide informational cards containing terms translated into (higher than during the 2007–2009 Global Financial six different languages to help healthcare workers com - Crisis) for a few months after the end of the SARS out- municate more effectively with foreign workers [43]. break in September 2003 [68]. These signals of an eco - Healthcare workers meanwhile faced discrimination nomic downturn prompted the government to work from the general public while using public transport due with the private sector to revitalize the economy and to the public’s fear of contracting the mysterious new reduce retrenchment. For instance, as seen in Table  2, virus [74]. Such discrimination resulted in difficulties for one notable initiative was the collaboration between healthcare workers looking for a ride home from hospi- the public sector Singapore Tourism Board (STB) and tals after their shifts. Grab, one of the top-ranked mobile major private sector hoteliers. While Singapore’s bor- app–based private transport service companies in South- ders remained partially open to travelers, foreigners east Asia, stepped in to resolve the challenge by launch- were wary of visiting Singapore due to the rapid spread ing GrabCare. GrabCare is similar to the company’s of the virus and the country’s strict quarantine orders. ride-hailing services, but caters specifically to healthcare Singaporeans were also reluctant to staycation at hotels workers traveling to and from their workplaces with the and instead chose to stay home to avoid contracting the fixed fare for all 24 h, and employs only those drivers who disease during that period. This situation led to the col - voluntarily sign up for the service. laborative partnership between the STB and hoteliers Aside from domestic multisector collaboration, the to provide travelers and Singaporeans assurance that Singapore government has also signaled its commit- hotels were safe environments by monitoring the tem- ment to transnational collaboration at the Association of peratures of hotel employees [31]. The initiative later Southeast Asian Nations’ (ASEAN’s) Defence Ministers’ expanded into a full-fledged certification system known meeting (ADMM) on February 19, 2020 where the man- as the ‘Cool Singapore Awards,’ which were awarded to agement of COVID-19 was discussed. The joint state - hotels and other tourist attractions. The certification ment issued on Defence Cooperation against Disease worked as a motivator to participants to ensure their Outbreak emphasized the importance of information complete adherence to government health advisories sharing to facilitate domestic contact-tracing and quar- and the disinfection of their facilities during the SARS antine efforts [6]. outbreak [31]. Aside from its efforts to prop up the local economy, Mid-term proactive response the Singapore government also engaged in transnational In line with Baxter and Casady’s [12] typology of short- cooperation to mitigate the cross-border spread of SARS. term, medium-term, and long-term governmental For instance, beginning with bilateral arrangements with responses, we note that medium-term partnerships neighboring countries such as Malaysia and Indone- between the public and private sectors represent a shift sia, Singapore has sought to exchange the information away from reactive responses to proactive responses required for contact-tracing and quarantine to ensure and anticipation of potential challenges in a pandemic. that visitors are safe [35]. Later, through the Joint Dec- Multisectoral collaborative partnerships may, for exam- laration of the Special Meeting by ASEAN Leaders on ple, facilitate product development, strengthen existing SARS 2003 and an ASEAN + 3 summit involving ASEAN healthcare services, or repurpose existing facilities to leaders, China, Japan and South Korea, Singapore further improve society’s resilience to potential outbreaks. But collaborated with other countries to facilitate informa- notably, during the COVID-19 pandemic, such partner- tion-sharing and pre-departure screenings to reduce the ships have progressively expanded into non-healthcare cross-border transmission of SARS [31]. Kim et al. Globalization and Health (2022) 18:82 Page 10 of 18 The longer duration of the COVID-19 pandemic has roll-out of the first doses of the vaccines started on Feb - illustrated the need to increase the resilience of the ruary 22, 2021 [59]. The government aimed to complete healthcare system to battle the next outbreak while also COVID-19 vaccinations by the third quarter of 2021 to ensuring that the economy recovers. The summer of keep the virus under control. It strongly encouraged res- 2020 saw massive outbreaks on every continent while idents to get the jab and first made vaccines available to Singapore was barely able to control the spread in for- Singapore Armed Forces personnel, then workers in the eign workers’ dormitories [90]. The need for stronger land transport sector, seniors aged 70 and above, seniors measures to mitigate community outbreaks that could aged 60 to 69, and each progressively younger age group bog down the healthcare infrastructure and to reduce in a timely sequence. In order to ensure the seamless and mortality rates led to closer partnerships between the efficient roll-out of vaccines as planned, the MOH set up government and hotels. One of the control measures 36 vaccination centers including public general hospitals was an issuance of stay-home notice (SHN), a form of (e.g., for frontline healthcare workers), community cent- individual quarantine orders for all travelers. The gov - ers, and 10 mobile vaccination teams island-wide. The ernment prevented travelers and returning Singaporeans tender to run these vaccination centers, worth a total of from completing SHN at their place of residence in order $38 million, was awarded to 17 healthcare providers in to prevent household spread, but for the measure to be February 2021 [92]. The main service providers from the effective, more dedicated SHN facilities were needed. private sector have been Raffles Medical and Fullerton More than half of the hotel rooms in Singapore were put Health. Although the vaccination dosage interval was ini- to this use through July 2020 [77]. While some hotels tially increased from 6 to 8 weeks due to a supply crunch, have reopened to accommodate staycationing Singapo- it was later shortened to 4 weeks to ensure that the popu- reans, these hotels remain ready to be converted back to lation could be vaccinated quickly [60]. quarantine facilities if required [88]. The local production of masks in the short-term was In addition to expanding Singapore’s healthcare facili- accompanied by ongoing innovations to increase the ties, the private sector has also made significant contri - efficiency of production lines. In particular, the Agency butions to Singapore’s vaccine roll out. In a bid to achieve for Science, Technology and Research (A*STAR) collabo- herd immunity by vaccinating the population as quickly rated with Ramatex to design more effective masks [4]. as possible, the Singapore government started its national Through the combination of A*STAR’s scientific knowl - vaccination drive in January 2021, accompanied by rigor- edge and Ramatex’s expertise in textiles, the collabo- ous public outreach and media coverage (e.g., TV and ration was able to produce a reusable mask that was as radio spots, personal SMS from the MOH, social media effective as medical masks, as shown in Fig. 4. campaigns, and printed brochures). In addition, the gov- Aside from increasing the resilience of the health- ernment prepared financial assistance and insurance care sector, the government also sought to reduce youth packages (e.g., on-time pay-out) for cases with serious unemployment brought about by the pandemic through side effects. Given the temperature-sensitive nature of the SG United Traineeship program, which works with the vaccines, air transportation business partners includ- private organizations to provide traineeships to recent ing Singapore Airlines (SIA) and DHL Global Forwarding graduates. Participating companies ranged from finan - played a critical role in delivering the vaccines from over- cial institutions such as DBS Bank, to telecommuni- seas [91]. As a result, Singapore became the first Asian cations and event management firms such as Singtel country to receive the Pfizer-BioNTech shots from Brus - and Kingsmen, respectively. As part of the program, sels, Belgium in December 2020, and Moderna’s COVID- Workforce Singapore (WSG), a government agency (a 19 vaccines arrived in Singapore in February 2021 once statutory board) under the Ministry of Manpower, has they were approved by the government. funded about 80% of the training fees while the partici- Even after the delivery of the vaccines, the vaccination pating private companies have agreed to pay the remain- programs were conducted jointly by the two sectors— ing costs. the MOH and private medical providers. Community Another major impact of COVID-19 was the closure of borders, which was extremely detrimental to Singa- pore’s small and open economy. Singapore’s government The SHN is a legally binding document promulgated under the Infectious has continued to strive to open its borders safely once Diseases Act that requires travelers to remain in a dedicated facility for the stipulated duration. Failure to do so may be punishable under the Singapore law [34]. 5 6 While DHL ensured that the cargo was successfully delivered from vac- Covid-19 vaccines have been free for all Singaporeans and long-term resi- cine production facilities overseas to airports, SIA was tasked with ensuring dents, including those on an employment or S-pass, as well as work permit that aircraft carriers were equipped with temperature-monitoring capabili- holders, foreign domestic workers, and holders of dependent passes, long- ties and cool boxes to transport the vaccines. term visit passes, and student passes. K im et al. Globalization and Health (2022) 18:82 Page 11 of 18 Fig. 4 Details of mask produced by Ramatex and A*STAR. Source: A*STAR [3] pandemic situations in its key partners stabilize. One key collaboration. In contrast, in its response to COVID-19, pillar in this initiative is to ensure that travelers are vac- Singapore’s government has shifted from a pandemic cinated or test negative for COVID-19 pre-departure. To response to an endemic one, suggesting that it intends facilitate information sharing about vaccination status, to maintain and expand such collaborative partnerships. technologies such as Israel’s Green Pass and the European Domestic policies that emphasize living with the virus, Covid Digital Certificate have been used. Building on the as we do with influenza, and eventually easing con - Open Attestation Framework developed by the Govern- trol measures, can be considered a long-term, strategic ment Technology Agency (GovTech), private companies response to COVID-19. such as Accredify and Trybe.ID helped to amplify the Singapore’s population is highly vaccinated, with 90% reach of HealthCerts in other countries through their having received the full regimen as of March 2022. Thus international networks [28]. The private companies have the government has increasingly strived to transition therefore enabled HealthCerts to be used in 9 countries toward treating COVID-19 as endemic [70]. As with and 420 medical facilities [28]. Foreign buy-in to Health- influenza or dengue, when COVID-19 is considered Certs for the storage of digital records of COVID-19 tests endemic, occasional outbreaks will be expected, but a has been critical to the reopening of borders in Singapore shift will be seen to home recovery over hospitaliza- and elsewhere. tion [37]. Given that the virus is still prevalent in many Another instance of Singapore’s government capital- other countries and that there are wide disparities in izing on digitalization is the collaboration between the vaccination rates internationally, the Singapore govern- MOH, SG United, GovTech Singapore and Nanyang Pol- ment has needed to ensure that healthcare policies and ytechnic to develop and further enhance the effectiveness related infrastructure are in place for home-based treat- of an app called TraceTogether across different models of ment and focused care. For example, private telemedi- phones [72]. The collaboration capitalized on the latter cine enterprises such as CommCare, Doctor Anywhere, two’s existing facilities to accurately measure the signal Fullerton Health, and HiDoc were brought in to reinforce strength between two phones [42]. the MOH’s home recovery program by providing virtual consultation to COVID-19 patients including children. Long-term future prevention-oriented response Their services have also included delivery of medications According to Baxter and Casady [12], in the long-term, and in-person swabbing that can accommodate home governments may continue their multisectoral partner- recovery. Later, general practitioners (GPs and dentists in ships and/or trans-national partnerships to ensure suf- a voluntary manner have stepped into this telemedicine ficient service delivery to the people. Yet it should be care for their own patients [62, 75]. noted that relative to COVID-19, the short timeframe of In addition, looking to the future, Singapore has SARS reduced the possibilities for long-term cross-sector actively sought to prevent or at least mitigate the impacts Kim et al. Globalization and Health (2022) 18:82 Page 12 of 18 of a future global pandemic by building up its interna- as the main hospital to treat patients who were criti- tional cooperation and collaboration chains. One nota- cally ill with COVID-19 [33]. Given the general under- ble effort by the government has taken place through lying expectation that healthcare resources can be easily the ASEAN member states. The ASEAN Strategic overwhelmed in the short term due to the transnational Framework for Public Health Emergencies was final - nature (spread) of the infectious disease via human-to- ized in late 2020. It provides for a multilateral approach human contact, the special designation of NCID by the to public health emergencies and increases the capacity government was a crisis prevention strategy to reduce of ASEAN’s public health networks [56]. In particular, an the burden that had been placed on public hospitals such ASEAN Regional Reserve of Medical Supplies was cre- as TTSH during the SARS outbreak and to strengthen ated to enhance the region’s ability to stockpile essential preparedness via medical-capacity building that could be medical items such as PPE to protect healthcare workers activated during another SARS-like crisis [84]. and prevent a shortage as seen during the initial phase of the COVID-19 outbreak, when countries had to scramble Harnessing private sector capacity to develop to obtain PPE and oxygen ventilators [7]. a whole-of-society response Interestingly, beginning in the middle phase of the Discussion: evolution of collaborative partnerships COVID-19 pandemic, the reliance on the NCID alone from SARS to COVID‑19 turned out to be insufficient to withstand several sharp Although Singapore was out of the woods within a few spikes in local COVID-19 transmission and subsequent months of the outbreak of the SARS virus, given that surges in hospitalizations. Thus, to rapidly strengthen SARS was the first major communicable disease chal - its operational capacity and to reduce further strain lenge of its kind, the government took away critical les- on public hospitals, Singapore’s government started to sons that informed its policy responses to the COVID-19 develop collaborative partnerships with private hospi- pandemic [73]. Singapore maintained the key tenets tals in a whole-of-society approach [38, 84]. For instance, learned from SARS and also managed to fight COVID-19 through the activation of the Public Health Preparedness more effectively, not only by increasing its cross-sector Clinic (PHPC) scheme, the MOH encouraged private collaborations, but also by mobilizing partnerships with clinics and hospitals to work as government partners to private entities such as NGOs, academia, and neighbor- help patients with emergency health needs and provide ing governments and expanding these beyond the tradi- financial and material support (e.g., medications, swab tional arenas of the healthcare and economic sectors. The tests, vaccines and professional training for healthcare following four emerging themes demonstrate how Singa- workers). The establishment of PHPCs was in line with pore learned from the prior outbreak and has responded ERMH’s recommendations for governments to make differently to the recent global healthcare emergency. advanced arrangements with private companies to ensure access to medical facilities during a health emer- Ensuring sufficient essential healthcare resources gency [85]. As a result, acting as the first line of defense, and developing contingency plans PHPC-affiliated private actors have played an important In order to manage a health emergency effectively, it is role in reducing the burden on the operational capaci- important to maintain access to and ensure sufficient ties of public hospitals dealing with unconfirmed cases of infrastructure and logistics, including the stockpiling and COVID-19 [48]. distribution of healthcare resources and the establish- Along with transferring medically stable COVID-19 ment of temporary medical facilities [85]. One of the key patients to private hospitals for continued recovery, takeaways of the SARS outbreak for Singapore was the another notable strategy in the healthcare arena geared at importance of having excess capacity and contingency accommodating more patients and providing enhanced plans during a healthcare crisis, such as available hospi- medical support within a short time was to increase the tal beds and medical resources for emergency cases (e.g., number of newly-built CCFs, especially massive-scale infected patients) to receive professional attention imme- facilities (e.g., about 10,000 beds at the Singapore EXPO diately [24, 84]. When the COVID-19 pandemic began, and Changi Exhibition Centre) staffed with private just as TTSH had been designated as the public hospi- healthcare workers and even volunteers [27, 51, 58]. This tal for SARS patients, the Singapore government swiftly represents a fundamental change from Singapore’s SARS confirmed the National Centre for Infectious Diseases response in that the MOH showed reluctance to use pri- (NCID), equipped with high-level isolation units, its own vate hospitals to fight the virus when SARS hit Singapore in-house laboratories, and technological features of a hard in 2003. Indeed, it suggests that the Singapore gov- wearable tag-based real-time locating system for contact- ernment has made extensive efforts to enable the contin - tracing among healthcare workers, patients, and visitors, uous deliverance of healthcare services even as demand K im et al. Globalization and Health (2022) 18:82 Page 13 of 18 increased to a great extent. This was to strengthen lower the morale of frontline healthcare workers, put- and sustain the resilience of public health security of ting greater strain on the healthcare system as health- communities. care workers battled mental health problems [53]. As In a similar vein, there was a shift in quarantine prac- large clusters began to rapidly form in a community tices from the SARS outbreak to the COVID-19 pandemic. and many people feared such evolving local transmis- During the SARS outbreak, individuals identified as close sion scenarios, the Singapore government’s ability to contacts of sick individuals served out their quarantine at address this discrimination was limited, since a behav- home with minimal private resources utilized, except when ioral change among residents to show social acceptance enforced by private security agencies [35]. In contrast, dur- of healthcare workers (e.g., avoiding the use of public ing the COVID-19 pandemic, a large volume of private transport or ride-sharing) seemed to involve a substan- resources have been employed, particularly in the form of tial commitment of time and effort. In turn, a bottom- government-designated facilities such as affiliated hotels up approach was more suitable. By the end of February and makeshift convention halls operated by private organi- 2020, about 50% of Grab’s driver pool had joined the zations. Food providers have also played a peripheral role program [74]. While Grab’s actions did not ignite the assisting with isolation and quarantine orders [58]. behavioral change required to eliminate discrimination Moreover, the dramatic shortage of face masks dur- against healthcare workers, it can reasonably be argued ing the initial outbreak of COVID-19 made clear the that the initiative has helped resolve the challenge, at importance of procuring essential resources. The govern - least during the initial peak of the pandemic, ensur- ment initially released 5 million masks from its stockpile ing that essential healthcare workers have been able to to retailers, but these were snapped up in a matter of a carry out their duties efficiently. few hours by zealous Singaporeans [25]. Given the high It is also notable that the Singapore government has demand for masks and the export bans in major mask- formed partnerships with NGOs to help migrant work- production countries like Taiwan, the Singapore govern- ers, something that did not occur during the SARS out- ment turned to domestic mask production, which had break. NGOs that frequently interacted with foreign been non-existent, as well as relying on private procure- workers provided expertise at responding to their par- ment by Temasek Holdings. ticular circumstances and needs during the COVID- Lastly, following breakthroughs in vaccine research, Sin- 19 pandemic (e.g., by providing translation services to gapore’s government aimed to vaccinate the entire popu- facilitate communication or catering food that would lation against COVID-19 as quickly as possible. As noted appeal to this population) [67]. For instance, Visu- earlier, private sector healthcare organizations played a alAid was another prominent bottom-up approach that leading role in operating vaccination facilities across the occurred during the height of the outbreak in the for- region and providing vaccine services to the public. eign workers’ dormitories. The volunteer project was aimed at improving communication between health- care workers and foreign workers, a topic of second- Allowing more bottom-up approaches together ary importance to the government relative to ensuring with top-down approaches that foreign workers were treated promptly and that the During the SARS outbreak, Singapore’s government outbreak was stemmed. VisualAid created information managed downward, using top-down approaches to cards with translations of medical terms, which were directly manage the public health crisis. However, dur- distributed to healthcare workers to help them commu- ing the COVID-19 pandemic, these government-led nicate with foreign workers [43]. Indeed, the collabora- top-down approaches have been accompanied by soci- tion between NGOs and the government’s inter-agency ety-driven bottom-up (ground-up) approaches involv- taskforce ensured that foreign workers, who were not ing collective actions and public–private partnerships. explicitly included in the national crisis response plan, More notably, in an effort to achieve a common goal to received equal treatment and essential services for their return Singapore to normal conditions, through tap- healthcare and welfare [13]. ping on the bottom-up approaches, the government could embrace a variety of private actors and volun- Leveraging science, research and digital technology teers beyond the healthcare service sector. Taking a long-term view, as COVID-19 shifts from pan- For example, as noted earlier, one crucial bottom- demic to endemic in Singapore, the government might up approach was the GrabCare initiative led by Grab, be prepared to cope with uncertainties as future pub- a private transportation and food delivery company, lic-health outbreaks unfold. Arguably, as COVID-19 to offer dedicated rides for healthcare professionals becomes endemic, more patients will likely be required who faced discrimination on other forms of transpor- to recover at home to prevent excess strain on the tation [8, 74]. This discrimination had the potential to Kim et al. Globalization and Health (2022) 18:82 Page 14 of 18 healthcare system. Given this expectation, in conjunc- produced more collaborative partnerships between the tion with the home recovery program, the government’s public and private sectors in Singapore as compared partnerships with private telemedicine providers could with the SARS outbreak. First, during the COVID-19 have made a difference. Specifically, they could help pandemic, the government has focused on securing suf- ensure that patients receive the primary care they need ficient essential healthcare resources with contingency at home and even in quarantine without needing to seek plans to strengthen preparedness. Second, the govern- treatment at hospitals, for example, via virtual consulta- ment has actively harnessed the capacity of private tion by the healthcare professionals and supervised self- entities (e.g., private healthcare providers and manu- swab COVID-19 Antigen Rapid Test (ART) over video facturers of medical products) to promote the resilience call [46, 62, 75]. of the healthcare system and the community. Third, the Not only did academia and the tech industry acceler- government has proceeded with control measures and ate innovations based on their pre-existing knowledge in related management policies not only in a top-down, specific areas, these sectors also helped develop diagnos - centralized style, especially during the initial response tic solutions, contact-tracing, and vaccination status digi- stage, but also with a greater proportion of bottom-up talization with the help of their state-of-the-art facilities approaches, particularly as COVID-19 cases have con- and information technology (IT). For example, as men- tinued to rage on in the community. In other words, the tioned earlier, the joint development of the cPass test COVID-19 pandemic sparked more government-led col- kit by A*STAR and Duke-NUS Medical School shows laborative partnerships and further led the government how multi-sector collaboration can produce results to embrace the ideas of community-based organiza- quickly based on participants’ existing troves of knowl- tions. Notably, most collaborations led by private actors edge and the research circulating in the academic sector (e.g., GrabCare and VisualAid) have been voluntary, [22. In addition, the collaboration between the MOH, and their underlying goals have been to help vulner- SG United, GovTech Singapore and Nanyang Polytech- able and at-risk groups (e.g., foreign workers and front- nic helped ensure community-wide surveillance via the line healthcare workers). It can be argued that so-called development of apps such as TraceTogether, even in the community-based private organizations have played a initial phase of the COVID-19 outbreak [72]. Further, fundamental role in alleviating the government’s burden during the mid-term phase of the pandemic, the Singa- through strong collaborative partnerships that have pro- pore government continued to use digital transformation vided integrated care for the community (Yi et al., 2021) to improve the government’s COVID-19 response [42]. [89]. More interestingly, the multi-faceted repercus- One notable example is the cross-sectoral collaborative sions of COVID-19 have gradually opened the door to partnerships between GovTech and private organizations a greater variety of collaborative partnerships in sectors including Accredify and Trybe.ID to develop health pass- beyond healthcare services. The participating stakehold - ports that could ascertain the validity of travelers’ pre- ers include, but are not limited to, the private healthcare screening details such as their vaccination status or the and economic sectors (such as local and international results of their COVID-19 tests, allowing Singapore to business actors), non-profit organizations, academia and reopen its borders safely. other countries [42]. Lastly, as the pandemic has contin- ued, the Singapore government has managed outward Conclusion to tap the expertise and knowledge of the private sector In an attempt to better explain Singapore’s whole-gov- (e.g., its R&D capacity), in particular leveraging science ernment approach to tackling the spread of COVID- and technology to improve control measures and putting 19, this study has focused on how the experience of the supportive programs into practice (e.g., social distanc- SARS outbreak has informed the government’s collabo- ing, diagnostic solutions and the digitalization of vacci- rative efforts with other stakeholders in society, beyond nation records) [23]. mere transnational cooperation. Taking a comparative This paper makes several contributions to the literature. case study approach, we performed a content analysis First, in the specific context of Singapore, which has been of related government documents, mainstream newspa- globally applauded for its successful control of the spread per articles, and journal articles in an inductive manner. of COVID-19, comparing the government’s management We were able to closely compare two global healthcare of the SARS outbreak with its management of COVID- outbreaks and note both importance differences in their 19 has allowed us to delineate what the government contexts and the government’s progress in terms of its learned and how cross-sector collaboration expanded more robust response to COVID-19. during the current pandemic. Second, this study provides The evidence from our focused analyses demonstrates a practical, chronological analysis of the implementation that the nature and scale of the COVID-19 pandemic of related policy prescriptions to combat the pandemic, K im et al. Globalization and Health (2022) 18:82 Page 15 of 18 with a particular focus on how COVID-19’s larger scale authoritarian state or an illiberal democracy [1, 64]. has brought about an evolution in cross-sector col- These characteristics could result in a more straightfor - laboration since SARS (also see Appendices A and B). ward management method during SARS and COVID- Specifically, by categorizing the various collaboration 19, relative to other countries. However, policies with efforts into healthcare and non-healthcare service areas, different characteristics including varying fiscal capac - and by closely examining Singapore’s response during ity and different political and cultural environments three different timeframes (here, the short-term reactive may not diffuse along the same lines. Given this, we response, the mid-term proactive response, and the long- believe the findings of this study can provide a point of term future-oriented response), this study has provided comparison for future work (e.g., cross-national case a detailed discussion of the topic. In addition, our find - studies). In other words, future studies may continue ings offer evidence that through adaptive learning from to uncover additional points of evidence (practices) in the prior global healthcare outbreak, plus some trial and different contexts. This is especially so given that the error during the initial phase of the ongoing pandemic, widespread and flexible cross-sector collaboration that public- and private-sector partners, both in and out- have sprung up during the pandemic in various coun- side of the healthcare service sector, have tended to “act tries are likely to ignite better ways of collaboration in alike,” working together to achieve a common goal. Both the future [63]. We also expect that collective planning have been socially responsible, providing public services and action will continue even in the post–COVID- to people in need to promote the rapid resilience of the 19 era through partnerships across various public and community, and sharing the associated risks. private organizations. Thus, it may be worthwhile for As the war against COVID-19 continues around the focused research to employ more varied interpre- world, Singapore’s strategic response against the pan- tive approaches, including survey questionnaires or demic can serve as a point of reference for other like- focus group interviews with healthcare providers and minded nations to cultivate a sustainable and effective workers. long-term response against the pandemic. The lessons learned in Singapore have proved that as the short-term Abbreviations reactive response, public health measures implemented A*STAR : Agency for Science, Technology and Research, Singapore; ADMM: by the government alone could be effective, but they ASEAN’s Defence Ministers’ Meeting; ART : Antigen-Rapid Test; ASEAN: Asso- ciation of Southeast Asian Nations; CCFs: Community Care Facilities; CEG: turned out to be unsustainable, especially as the world Core Executive Group; CNA: Channel News Asia; DSTA: Defence Science and prepares to deal with an endemic disease like COVID- Technology Agency, Singapore; EG: Executive Group; FDA: Food and Drug 19. Collaboration between the government agencies Administration; GDP: Gross Domestic Product; GLCs: Government-Linked Companies; GovTech: Government Technology Agency, Singapore; GP: General and a variety of private actors thus can help prevent our Practitioner; HCEG: Homefront Crisis Executive Group; IMC: Inter-Minister Com- public healthcare system from being overwhelmed and mittee; IMOC: Inter-Ministerial SARS Operation Committee; IT: Information Tech- ensure that the public continues to benefit from higher nology; MCI: Ministry of Communication and Information, Singapore; MEWR: Ministry of the Environment and Water Resources, Singapore; MHA: Ministry of quality of healthcare services in a sustainable and feasi- Home Affairs, Singapore; MND: Ministry of National Development, Singapore; ble manner. Given this, other governments and policy MOE: Ministry of Education, Singapore; MOH: Ministry of Health, Singapore; makers who are still struggling to maximize essential MOM: Ministry of Manpower, Singapore; MOT: Ministry of Transport, Singapore; MSF: Ministry of Social and Family Development, Singapore; MTF: Multi-Ministry resources and minimize the negative impacts of the Taskforce; MTI: Ministry of Trade and Industry, Singapore; NCID: National Centre healthcare crisis may need to consider adjusting their for Infectious Diseases; NGO: Non-Governmental Organization; NTUC: National response stance from managing downward to inviting Trade Union Congress, Singapore; NUH: National University Hospital, Singapore; PHPC: Public Health Preparedness Clinic; PPE: Personal Protective Equipment; more participation from private-sector entities and capi- R&D: Research and Development; RT-PCR: Reverse Transcriptase Polymerase talizing on innovation to gain wisdom from their exper- Chain Reaction; SAF: Singapore Armed Forces; SARS: Severe Acute Respiratory tise and knowledge. At the same time, through closely Syndrome; SGH: Singapore General Hospital; SHN: Stay-Home Notice; SIA: Singapore Airlines; ST Electronics: Singapore Technology Electronics; STB: Singa- working with voluntary organizations and civil society pore Tourism Board; TTSH: Tan Tock Seng Hospital; TWC2: Transient Workers groups in a community, a nation’s social security net can Count Too; TxVax: Therapeutics and Vaccines expert panel; WHO: World Health be further complemented especially in times of crisis. Organization; WSG: Workforce Singapore. One limitation of this study is that it focuses only on the Singapore context, and readers should bear this Supplementary Information in mind and take care when generalizing its results. The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12992- 022- 00873-x. Notably, Singapore is a small-sized city state in which neither subnational structures (e.g., federal-state rela- Additional file1: Appendix A. Timeline of Collaborative SARS Response. tions) nor the rural-versus-urban continuum exist and Appendix B. Timeline of Collaborative COVID-19 Response. its political system has been known as a competitive Kim et al. Globalization and Health (2022) 18:82 Page 16 of 18 Acknowledgements 8. Baharudin H. Coronavirus: New Grab service dedicated to taking health- This work was based on Undergraduate Research Experience on CAmpus care workers home. The Straits Times; 2020. Retrieved from https:// www. (URECA) program during the 2021-22 academic year of Nanyang Technologi-strai tstim es. com/ singa pore/ coron avirus- new- grab- servi ce- dedic ated- to- cal University, Singapore. The related project titled exploring public-private taking- healt hcare- worke rs- home partnerships for effective management of public health and economic crises 9. Berg BL, Lune H. Qualitative research methods for the social sciences. 8th includes SSS21011 and SSS21072. ed. Boston: Pearson; 2012. 10. 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Yi H, Ng S, Farwin A, Pei Ting Low A, Chang C, Lim J. Health equity considerations in COVID-19: geospatial network analysis of the COVID- At BMC, research is always in progress. 19 outbreak in the migrant population in Singapore. J Travel Med. Learn more biomedcentral.com/submissions 2021;28(2):1–8.

Journal

Globalization and HealthSpringer Journals

Published: Sep 21, 2022

Keywords: COVID-19; Health Crisis; Cross-Sector Collaboration; Partnerships; Singapore

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