How has Taiwan navigated the pandemic?

Taiwan has fared better than many other countries during the Covid-19 crisis. Political leadership, early action, a national plan, strong information and communications technology infrastructure and a cooperative public have all contributed.

At the end of December 2019, when public health officials in Taiwan learned of an outbreak of infections caused by a then unknown pathogen in Wuhan, China, the government wasted little time preparing for the disease’s arrival on the island. The 2003 SARS crisis had taught Taiwan to be vigilant and prepared for the next pandemic, particularly given its geographical proximity and close economic and cultural ties to China.

To date, Taiwan has gone through two phases of its Covid-19 crisis, with somewhat different outcomes for each; and it is currently in the middle of a third phase. Overall, the country has fared well as a result of its planned and methodical response to the pandemic. As of October 2021, it ranked lowest in total number of Covid-19 cases and second lowest in deaths per 100,000 population among comparable OECD countries (see Figures 1 and 2).

Figure 1: Covid-19 cases and deaths per 100,000 population

Source: Johns Hopkins University Center for Systems Science and Engineering

Figure 2: Covid-19 deaths per 100,000 population

Source: Johns Hopkins University Center for Systems Science and Engineering

During the first 16 months of the pandemic in particular, Taiwan experienced minimal casualties as a result of Covid-19, while many countries suffered much higher numbers of cases and deaths.

At the same time, Taiwan’s economy grew in both 2020 and 2021. This continued, and even outpaced, the growth seen in preceding years. The economy is also projected to grow in 2022 (see Figure 3). In contrast, the world’s real GDP declined by 3.4% in 2020, with the G20 countries, members of the euro area and comparable OECD countries had negative growth ranging from -1% to -11% (see Figure 4).

Figure 3: Economic growth in Taiwan 2013-20 and forecast 2021-22

Source: Directorate-General of Budget, Accounting and Statistics, Republic of China, Taiwan and Statista

Figure 4: Economic impact of Covid-19, percentage change in GDP

Source: OECD Economic Outlook, Interim Report March 2021

Data for Taiwan from the Directorate-General of Budget, Accounting and Statistics, Executive Yuan, ROC (Taiwan), updated 20 February 2021 (in Chinese)

Other neighbouring Asia-Pacific countries, including Australia, New Zealand, Japan and South Korea, also succeeded in limiting Covid-19 cases and deaths (see Figures 1 and 2). But in economic terms, they did not perform as well as Taiwan. In fact, each of their economies shrank in 2020 (see Figure 5).

Figure 5: Economic growth during the pandemic, 2021 and projected 2022

Source: International Monetary Fund, Regional Economic Outlooks: Asia and Pacific and Directorate-General of Budget, Accounting and Statistics, Executive Yuan, ROC (Taiwan)

Phase I: January 2020 to mid-May 2021

For 16 months from January 2020, when the pandemic first emerged, Taiwan sustained very few cases and deaths. According to the country’s Centers for Disease Control (CDC), as of 13 April 2021, Taiwan had a cumulative 1,057 confirmed cases and 11 deaths. In the same period, much of the rest of the world was reeling from heavy casualties (see Table 1).

Table 1: Covid-19 cases and deaths in selected OECD countries and Taiwan as of 13 April 2021

	No. of confirmed cases	Deaths
Global	137,034,950	2,951,332
United States	31,311,046	563,027
France	5,167,253	99,639
United Kingdom	4,390,797	354,617
Germany	3,040,326	78,924
Taiwan	1,057	11

Source: Taiwan CDC and John Hopkins CSSE

That Taiwan escaped heavy casualties in this period was the result of a set of measures that the government took early on. As soon as it learned what was happening in Wuhan, the government immediately activated a national strategic response plan prepared in the years after the country’s 2003 SARS crisis.

The government adopted a two-pronged approach: ‘keep the virus out’ – prevent the virus from entering Taiwan in the first place – and ‘prevent and control community spread’. It was concerned about the healthcare system being potentially overwhelmed in the event of a large outbreak, which did happen to many healthcare systems around the world. Indeed, this also occurred to some extent in Taiwan for a brief time in the next – small outbreak -- phase of the crisis.

The immediate response of the government in Taiwan – as early as 1 January 2020 – was to impose stringent cross-Taiwan Strait travel restrictions. Essentially, the country closed its borders to flights between the island and China except flights from four designated Chinese cities to allow Taiwanese citizens living in China to return home. In the days that followed, the government also imposed travel restrictions to and from other countries.

By mid-January 2020, Taiwan had established the Central Epidemic Command Center (CECC) to lead on all Covid-19 related matters. Headed by health minister Shih-chung Chen, it works closely with Taiwan’s CDC, the National Health Insurance Administration (NHIA) – the government agency that administers Taiwan’s single payer health insurance system – the immigration authority and the private sector.

Recognising the crucial importance of transparency, the CECC held daily news conferences, personally chaired by Minister Chen, to keep the public and media fully informed. These reported on cases and deaths, new developments and any measures introduced to prevent and control Covid-19. Measures implemented included strict travel advisories and entry protocols tiered by the risk levels of countries, 14-day home quarantine protocols according to individuals’ risk levels, contact tracing, mask wearing, social distancing and hand hygiene.

Contact tracing and quarantine in Taiwan have been highly effective and instrumental in preventing large-scale community spreading of the disease, thanks to the country’s advanced information and communications technology (ICT) infrastructure. Taiwan’s interoperable ICT platform enables various government agencies – the CECC, CDC-Taiwan, the NHIA and the immigration authorities – access to real-time big data. Using these data, they are able to monitor the situation, plan next steps and adjust or change any anti-Covid-19 measures. The system also enables close real-time interactions between government agencies and Taiwan’s private sector, such as pharmacies, convenience stores and the predominantly private healthcare delivery system; and facilitates real-time communications with the public.

Throughout this first phase (and subsequent phases) of the pandemic, Taiwan’s public cooperated closely with the government, for example, in contact tracing and quarantine. These measures can only be carried out effectively with a public willing to cooperate. This differs from the country’s experience during the 2003 SARS crisis, when the public did not trust the government and often evaded contact tracing and hid from authorities.

The set of measures implemented by the government was successful in preventing the spread of Covid-19, such that Taiwan did not (and arguably didn’t need to) resort to costly measures used in other countries, such as large-scale testing or closing of schools and businesses.

Another consequence was that Taiwan’s population was not widely vaccinated when vaccines became available in December 2020. A combination of extremely limited access to vaccines and vaccine hesitancy resulted in extremely low vaccination rates in this period. As of 13 April 2021, just 27,113 Taiwanese (0.001% of the population) had received one dose of the only vaccine available to them at that time, AstraZeneca.

Phase II: Mid-May 2021 to July 2021

True to the Chinese saying that ‘all feasts under the heaven come to an end’, in mid-May 2021, the number of Covid-19 cases in Taiwan suddenly jumped for a number of days before declining again (see Figure 6). On 11 May, Chen declared that Taiwan had officially entered the phase of community spread that policy-makers had feared, and moved the Covid-19 emergency alert from level 1, the lowest, to level 2 (of four levels).

Figure 6: Trend in the number of confirmed cases from domestic transmission

Source: Central Epidemic Command Center (CECC)

The CECC reported 1,290 new cases and 12 deaths on 14 May, and a further 953 in the following five days. As of 22 May 2021, the CECC reported a cumulative total of 3,862 cases and 17 deaths. These numbers caused great concern among Taiwan’s policy-makers, as there was a sense of being underprepared. The Financial Times said of the situation: ‘[Taiwan] was not prepared for a surge of infection[…] Infectious diseases experts say health authorities have squandered the chance to learn from the experiences that other countries had while going through outbreaks.’ As mentioned earlier, vaccination rates at this time were extremely low due to both supply issues and vaccine hesitancy, and wide testing capacity was limited. In addition, there was a shortage of special intensive care beds and medical personnel.

The vast majority of these cases were concentrated in the two major population centres in Taiwan’s north: Taipei City and New Taipei City. This turned out to be, perhaps, the silver lining in the outbreak crisis, for it allowed the government time to implement a rapid response as cases and deaths climbed, by declaring, on 15 May, a level-3 emergency alert for the two cities. This move prevented a large-scale spread to the rest of Taiwan.

To be on the safe side, the level-3 emergency alert was extended to all of Taiwan on 19 May. Emergency measures included closing all recreational establishments (for example, cinemas, swimming pools and public libraries), elementary and middle schools, day care centres for children and the elderly; banning of large national and religious gatherings and indoor dining; a mask mandate; and social distancing. Family and social gatherings were limited to five people and outdoor gatherings to ten. Border controls remained in effect, with the number of flights allowed to land in Taiwan pegged to the country’s healthcare delivery system capacity at the time to avoid overwhelming the system.

The NHIA – the single payer government agency that administers Taiwan’s mixed private-public healthcare delivery system – made preparations for a large influx of patients. Still, demand for hospital beds exceeded available spaces and there were reports of long waits for beds and of Covid-19 patients being treated outdoors on hospital grounds.

The situation, tense as it was at the height of the outbreak, came under control within weeks. Figure 7 shows changes in cases and government response during the period of the outbreak. New cases came down drastically by the end of June, and by mid-July, Minister Chen declared the situation ‘very stable’ and began, on 13 July, to loosen certain restrictions On 27 July, the CECC downgraded the emergency alert to level 2.

Figure 7: Changes in the number of confirmed cases and government response (May-October 2021)

Source: Taiwan Centers for Disease Control

Although short-lived, the outbreak took a toll on Taiwan’s economy. Exports continued to enjoy unprecedented growth – first quarter growth of 12.1% – thanks to economic recovery and re-opening and increased consumer spending in Europe and the United States. But consumer spending in Taiwan declined for the duration of the outbreak, resulting in a fall of 4.2% in the second quarter of 2021. Hardest hit was the services industry, with many businesses cutting workers’ hours to save costs. Unemployment reached a ten-year high – at an average of 4.3% between May and August 2021. But projected overall growth for 2021 remains a robust 5.9%.

Phase III: August 2021 to October 2021

The situation has remained stable since the government lowered the emergency alert from level 3 to level 2 on 27 July. Since September, new cases of domestic transmission have been at either zero or in the low single digits. Deaths have also remained very low. For nine successive days between 29 September and 8 October, Taiwan reported no deaths. This was at a time when the average daily deaths in the United States stood at 1,867, with most days exceeding 2,000 deaths per day.

Schools in Taiwan are open and other restrictions are gradually being relaxed, such as the permitted size of gatherings and re-opening of certain sports and recreational facilities. Throughout October, 14-day quarantine and facemask mandates remain. When the government might downgrade the emergency alert to level 1 depends on the vaccination coverage rate and compliance with mask wearing and social distancing, according to Chen.

The current thinking is that if Taiwan records no new cases of domestic transmission for 28 consecutive days and vaccination rates for at least one dose reach 70% and 60% for the second dose by the end of October 2021, the government might downgrade to a level-1 alert. This extra caution aims to minimise potential community spread of the Delta variant, which constitutes at least 25% of the new ‘imported’ cases from overseas.

Taiwan is also making good progress on vaccinations. As of 21 October, 65% of the population had been vaccinated with at least one dose of several vaccines now available, including a vaccine produced domestically.

Lessons

As of 25 October 2021, Taiwan’s CECC reported a cumulative total of 16,376 Covid-19 cases and 847 deaths since January 2020. These are extremely low numbers compared with many other countries. To date, total cases in the United States alone have exceeded 45 million and deaths are over 730,000.

What was different about Taiwan’s approach and experience? In particular, what enabled the country to limit cases of Covid-19 in the first 16 months of the pandemic and then to control the outbreak quickly in May 2021?

First, Taiwan was prepared and acted at the first signs of the virus in early 2020. Policy-makers had learned lessons from the 2003 SARS crisis and made plans to prepare for future pandemics.

To that end, the government strengthened Taiwan’s CDC and healthcare delivery system, and taught the public the importance of face masks, hand hygiene and temperature checks. In addition, a 2011 constitutional ruling granted the government power to do all that is necessary in national public health emergencies, including ‘temporarily removing personal freedom of movement’. This made mandatory quarantine possible during the Covid-19 crisis.

The CECC and Taiwan’s state-of-the-art ICT infrastructure have also played crucial roles. The CECC exercises central command and oversight for all policies and measures concerning Covid-19 control and prevention. Advanced ICT infrastructure drives government and private sector Covid-19 related operations, including data collection, which helps the government with data-driven decision-making.

For example, through the interoperable ICT infrastructure, the NHIA works closely with the healthcare delivery system, Taiwan-CDC, immigration control and other government agencies as well as the private sector. The government knows in real time all arriving passengers’ travel and immediate prior health histories and enforces quarantine through effective tracking of movements of people under quarantine.

The NHIA IC-card, which every Taiwanese person carries to access medical care anywhere in the country, lets doctors and hospitals see the cardholder’s travel history (domestic and overseas), health records, quarantine status, based on which providers make triaging and treatment decisions. The NHI IC-card also makes access to PPE such as facemasks equitable as it keeps track of when the cardholder last bought PPE supplies. This eliminates hoarding, which happens frequently in many countries when cases spike.

Taiwan’s ICT infrastructure also makes it easy for the public to work closely with the government. For example, residents can check, using their mobile phones, real-time availability of PPE at any pharmacies and convenience stores, and reserve pick-up times. Residents can also see, on their phones and in real time, government notifications of new cases found and their precise locations so that residents, and through them their families and friends, can avoid those hot spots.

Finally, the cooperation of Taiwan’s public also plays an important role. Like the country’s government, the public also learned important lessons from the 2003 SARS crisis, such as basic public health practices like hand hygiene, wearing facemasks and social distancing. More importantly, the experience from this earlier pandemic changed the public’s attitude from distrusting the government to cooperating.

Difficulties frequently encountered in many Western countries with vaccine hesitancy, contact tracing, quarantine and facemask resistance have not generally been problems in Taiwan. The public regards cooperating with the government in national emergencies as a civic responsibility and shares the recognition that everyone is in this together. The importance of these two attributes cannot be overstated in Taiwan’s highly successful Covid-19 outcomes to date.