Hermoso C, Tsagkaris C, Laguilles E, Vaghela G, Mastropieri D, Ganzon J, Bernardino G, Panaligan N, Oruga M, Ahmadi A, Lucero-Prisno D. Taiwan model to COVID-19 response. HPHR. 2021;29.
This paper discusses the key elements of Taiwan’s approach in mitigating the impact of the COVID-19 pandemic. Extensive public health infrastructure established in the country pre-COVID-19 enabled a rapid and coordinated response which included meticulous border control measures, distribution of medical resources, effective quarantine and isolation methods, digital technologies, and mass mask use. Several components of Taiwan’s model could be adapted by other countries for halting and controlling the dissemination of the agent of the current pandemic and may contribute to preparedness for eventual future outbreaks.
On 23 December 2020, Taiwan reported its first local COVID-19 transmission in more than eight months. Taiwan’s world-leading 253-day streak ended with a woman who was a close contact of a foreign pilot who travelled while infected. The pilot, an employee of a Taiwanese airline, is thought to have been infected during a flight to the United States (US) in November 2020. Despite Taiwan’s strict mandatory 14-day quarantine for most of its arrivals, pilots are only required to isolate for three days and are not tested if they are asymptomatic.1 In this case and during the previous months, a robust track-and-trace program along with its proactive testing enabled Taiwanese authorities to effectively contain the infection with only a total of 942 confirmed cases equivalent to daily confirmed cases of 39 per million population as of 21 February 2021. Taiwan has achieved one of the lowest mortality burdens among high-income territories and achieved elimination by April 2020 without a lockdown. Its success in keeping the virus out has enabled the country to open its borders and return to relative normality in recent months.2 This paper aims to discuss the key elements of success in Taiwan’s approach, highlighting lessons applicable in the time being and in the post-COVID-19 era.
Technology has been one of Taiwan’s strongest frontline tools in responding to COVID-19. Digital governance helped improve disease detection through an integrated database of people’s health records and travel history. The government linked individual international travel history to the national health insurance system to create big data for analytics.3 Along with mobile phone tracking systems, Quick Response (QR) codes, and online case identification based on symptoms and travel history, big data paved the way to effective and efficient digital quarantine systems. Thermometers and video monitors were placed in public transportation to ensure that people with fever will not enter and passengers will not violate sanitary measures in fear of being fined. Open data and open source movement modalities amplified Taiwan’s technological armory.4 A testing robot, the QVS-96 robot, was developed which can process more than 2,000 COVID-19 test results a day. This helped testing capacity and accurate determination of positivity rate, which is 0.5% as of 22 February 2021.
Taiwan’s experience and lesson with the 2003 SARS-CoV-1 outbreak led to the establishment of various collective government efforts such as the formation of Taiwan’s Central Epidemic Command Center (CECC). Provisions such as Health Care Smart Card project wherein important health data of the citizens are digitally recorded, mask rationing system, active contact tracing, and transparent and open communication were implemented highlighting Taiwan’s resiliency from previous experience.4 As a result, Taiwan was able to proactively respond and alleviate the deleterious effects of COVID-19 despite its close proximity to mainland China where the outbreak started.
Taiwan’s success against COVID-19 can be attributed to the collaboration between the government and the citizens. Civilians saw this as an opportunity to unite and protect others by following community guidelines. They understand the fact that COVID-19 pandemic is not a matter of one’s self anymore. Transparency and open communication from the side of Taiwan’s government undoubtedly enhanced the compliance of citizens to the aforementioned policies and protocols. The government centralized a mask rationing system and controlled isopropyl alcohol supply and cost to prevent panic buying. Informative briefings kept all the citizens on the same page at the peak of the pandemic. Authorities worked for financial stabilities offering subsidies to jobless people or carers, who were not able to work in their usual occupation. Loan and debt policy became more flexible in terms of extending or deferring payment time without extra commission.5
Despite being a model for the rest of the world to emulate in terms of COVID-19 response, Taiwan faces a challenge wherein its participation in World Health Organization (WHO) meetings is opposed because it is not recognized as a sovereign state. Due to its intricate sovereignty, Taiwan was less likely to receive international aid, if the pandemic escalated. Hence the authorities took nationwide measures early enough to avoid this situation. This strategy led the US to issue the Taipei Act to support Taiwan’s formal participation in international institutions.
Even though hindered by sovereignty issues which compromised its participation in WHO meetings, Taiwan still emerged to be a successful model country in terms of COVID-19 response. As a non-WHO member deprived of access to relevant WHO documents, Taiwan managed to combat the spread of COVID-19 virus by strengthening the foundation of its response through high-tech contact tracing and quarantine system, proactive government, compliant citizens and fitting application of its prior epidemic experience. The spike in COVID-19 cases during Spring 2021 put Taiwan in a difficult situation with regards to vaccine delivery. Due to its political status , Taiwan faces obstacles in procuring vaccines from foreign manufacturers. The delivery of 1.24 million doses of AstraZeneca vaccines from Japan 750,000 doses of Pfizer vaccines from the US provided Taiwan with some relief. However, these doses are still not sufficient for Taiwan’s population of 23 million. In response to this deficiency, Taiwan’s authorities cooperate with two local companies, Medigen Vaccine Biologics Corp and United Biomedical Inc., which are expected to finalize the development of local COVID-19 vaccines, obtain emergency use authorization in Taiwan and deliver 20 million doses of the authorized vaccines within the following months. These domestic vaccines are said to have completed the second phase of clinical trials near the end of May 2021. Public vaccination is awaited to begin by July 20217. Taiwan’s persistent response to the recent crisis (despite its major disadvantage as a non-WHO member-state) proves its competence in handling complex healthcare crises.
Reflecting on the case of Taiwan can provide other countries with valuable lessons for the time being and for the post-COVID-19 era.
Taiwan’s public health response was based on robust real-time surveillance methods pre-COVID-19 and already had a national alert system in place similar to Korea.8 Thermal Imaging Systems (Infrared Thermographic Systems/Thermal Imaging Cameras) in public grounds and public transportation were used combined with an effective fining policy. Taiwan also used digital name-based mask rationing, centralized distribution, and sales controls to avoid hoarding and enable distribution to those most in need.
Taiwan’s strict and smart border control can be valuable for countries welcoming large numbers of migrants and tourists. That includes symptom-based surveillance before travelers board flights and digital fence tracking via cellular signals to ensure a coherent 14-day quarantine.9 Contact tracking with smart apps monitoring transportations and facilitating timely action in case of positive COVID-19 tests would be necessary in summer 2021 worldwide due to increased mobility during this season. On top of these, in the post-covid era, cancer screening and cardiovascular health monitoring could be organized likewise.
Taiwan’s authorities have managed to reduce the fear in the general population. The aftermath of this is the need to include psychosocial aspects in disease control policy worldwide. By increasing health literacy, governments can lower the stigma and anxiety associated with COVID-19. Updates on the latest undertakings by the government as well as other concerns are vital because when people are uninformed, they tend to rely on false pieces of information that impact their well-being. Through this, the people are not unaware of the unknown and the public will not be in trepidation. It is worth taking note that at times, how people react to things are more detrimental than the happening of the real event.10
Taiwan was one of the few countries where medical education activities resumed soon. The Ministry of Education (MOE) of Taiwan issued guidelines for the establishment of COVID-19 Campus Task Force at each University, ensuring the safety of all staff and students. The guidelines emphasized on hygiene and sanitation, wearing masks indoors, ventilation, quarantine protocols and reporting of suspected cases. Many universities and institutes were also required to measure the daily temperature of the students in dormitories, twice a day. The school officials were aware and cautious about the increased risk of infection spread in this large setting.11
When it comes to policy, Taiwan resembles navigating a labyrinth leading to an exit. Taiwan manifested a set of good practices with the transparent collaboration between the authorities and the citizens. Financial support partially relieved the socioeconomic burden of the pandemic enabling individuals to adhere to preventive measures.12 Taiwan’s approach to subsidies, debt and loan policies were in line with the International Monetary Fund13. Transparent governance persuaded the citizens to entrust sensitive personal data to their government for the sake of public health. This bidirectional equation, where authorities may violate what is known as GDPR in Europe and confidential information in the US as long as they are held accountable,14 could lead to a pandemic-friendly social contract.
However, the extrapolation of Taiwan’s good practices may not be possible due to its intricate sovereignty. For effective exchange of practices, Taiwan needs the endorsement of the United Nations (UN) and the World Health Organization (WHO) and the capacity to establish diplomatic relations with individual states. In the past, Taiwan has been excluded from those institutions on the grounds of politics and finance. The current crisis has re-prioritized health and science. In this frame, we may suggest the establishment of a temporary scheme of collaboration between Taiwan and the UN, the WHO or independent states with regard to health and science, until issues related to sovereignty are resolved.
Taiwan’s past experience with epidemics has proven the need of an early intervention to contain COVID-19. The government’s proactivity using disruptive technology, effective contact tracing, border control, and fair distribution of essentials played key roles in preventing high infection and death rates seen in many parts of the world. Taiwanese residents also adapted to the situation by wearing masks, practicing physical distancing, and washing hands among others. They resumed their regular lives and economic activities a few months after the outbreak. Taiwan maintains these strict defenses while waiting for evidence about vaccines. It is set to vaccinate 60% of its population. The case of Taiwan indicates that when the government invests in its public health system and rationally makes evidence-based decisions, it can yield optimal results. Taiwan’s experience has been an example on how democratic governance is compatible with crisis prevention and pandemic control.
Catherine Hermoso is with Bicol University.
Christos Tsagkaris is a final year medical student at the University of Crete in Greece. He is a Youth Ambassador of the European Code Against Cancer, the Vice President for Events of the European Student Think Tank and one of the co-founders and core facilitators of #Students_Against_COVID.
Elaine May Laguilles is with the College of Medicine, Bicol University.
Gladson Vaghela is with GMERS Medical College.
Donnatella Mastropieri is with the National Defense Medical Center.
Jerome Ganzon is with the School of Pharmacy, College of Pharmacy, Taipei Medical University.
Gilbert Bernardino, Jr. is with the College of Nursing, University of the Cordilleras.
Nenita Panaligan is with Cavite State University.
Myra Oruga is with University of the Philippines Open.
Attaullah Ahmadi is with Medical Research Center, Global Health Focus Asia.
Don Eliseo Lucero-Prisno, III is with the London School of Hygiene and Tropical Medicine and University of the Philippines Open University.