key: cord-0780132-id9jg6v4
authors: Fouda, Ayman; Mahmoudi, Nader; Moy, Naomi; Paolucci, Francesco
title: The COVID-19 pandemic in Greece, Iceland, New Zealand, and Singapore: Health Policies and Lessons Learned
date: 2020-08-28
journal: Health Policy Technol
DOI: 10.1016/j.hlpt.2020.08.015
sha: ee107ef5740d8605deb69f8714daa45365f37dea
doc_id: 780132
cord_uid: id9jg6v4

OBJECTIVE(S): This paper aims at providing an overview of the COVID-19 situation, health policies, and economic impact in Greece, Iceland, New Zealand, and Singapore. The four countries were chosen due to their ability to contain the spread and mitigate the effects of COVID-19 on their societies. METHOD(S): We use document analysis based on the available national reports, media announcements, official coronavirus websites and governmental decrees in each of the four countries starting from the 1(st) of January o the 9th of August announcements. We apply a policy gradient to compare and examine the policies implemented in the four countries. FINDING(S): The four countries have different demographic, epidemiological, socioeconomic profiles but managed to control the pandemic at an early stage in terms of total number of positive cases. The four countries managed to absorb the health system shock and decrease the case fatality ratio of COVID-19. Early interventions were crucial to avoid expected life lost in case of no early lockdown. The pandemic triggered several economic stimulus and relief measures in the four countries; the impact or the economic rebound is yet to be fully observed. CONCLUSION(S): We conclude that early, proactive and strict interventions along with leveraging previous experience on communicable diseases and the evolution of testing strategies are key lessons that can be synthesized from the interventions of the four countries and that could be useful for a potential second wave or similar pandemics.

In a space of three months, the world has changed quickly as a result of the spread of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus reported in the final days of 2019. To date, only a few countries reported no positive cases within their borders. Due to rapid spread and the uncertainty regarding the nature, pathology, prognosis, spread of the virus, and day of confirmed positive cases between different countries, there was no unified regimen to deal with the pandemic on a clinical, social, or economical scale. Different countries adopted different measures for detection, treatment, mitigation, and elimination of the virus within their borders.

A number of the measures taken are influenced by the existing health care system and its ability to respond to an influx of COVID-19 cases. As a respiratory disease, patients with severe COVID-19 are likely to require intensive care and use ventilators. In addition to focusing on the virus, many countries have considered the societal and economic repercussions of the pandemic and therefore, have provided several economic initiatives to relieve those who are affected and to stimulate the affected sectors.

In this paper, we document and compare four countries with different demographic characteristics, health systems, and different varying timelines to combat COVID-19. The countries Greece, Iceland, New Zealand and Singapore have been chosen due to their ability to mitigate the effects of COVID-19 at an early stage and, in the case of one, eliminate community transmission of SARS-CoV-2; their similar geographic nature as islands and peninsulas; and their economies which mainly rely on service producing industries. The first confirmed cases of COVID-19 in all four countries have varied, Singapore reported its first case on the 23rd of January, whereas the first confirmed cases were almost a month later for New Zealand (26th of February), Greece (26th of February), and Iceland (28th of February). The main objective of this paper is to investigate the health policies implemented by the four countries and to provide insights on the resulted health outcomes and the economic and fiscal impact. We explore the footprints of escalation and de-escalation of measures and policies to contain the pandemic in financial markets as well as macroeconomic indicators.

After this brief introduction, the second section provides a country description for the four countries in hand where we look at the demographic profile, health system, healthcare resources, and potential risk factors associated with COVID-19. The third section describes the methods.

The fourth section delves into the results and findings divided as the different trends of COVID-19 in the four countries and policy; technology roadmap based on the available data till the 9 th of August 2020; the healthcare response data; and the economic and financial indicators and measures. The fifth section is the discussion and conclusion.

Not only are each of the countries geographically different, but they differ culturally, economically and on a health system level. All of which are likely to have had an influence on how well its population has responded to the spread of SARS-CoV-2. Out of the four countries, Iceland has the smallest population (352,721 citizens), whilst Greece is the largest (10, 731, 726 citizens) [1] . In terms of population size, none of these countries reach the top 100 in the world [1] . Referring to Table 1 , Greece has the highest population density and old age dependency percentage, the Greek population also has the lowest life expectancy at birth however it is above the European average [1, 2] . On the other hand, Iceland has the smallest population and density with 4 people per km 2 of land, as well as the highest life expectancy at birth. Compared to the other countries, Singapore has the lowest percentage of old age dependency and the highest population density per km2 [1] . 10 .73 0.36 [3] 4.95 [4] 5.7 [5] Population There are different typologies of health systems between the four countries. For instance, the

Greek system is a mixed system that includes a predominant social health insurance (SHI) system and a supplementary Voluntary Health Insurance (VHI) market. On the other hand, both the New Zealand and the Icelandic systems are tax-based systems. Table 2 shows that New

Zealand has the highest percentage of health expenditure as a percentage of GDP (9.3%) while Iceland and Greece have a similar percentage, they differ in terms of health expenditure per capita. Singapore has the least health expenditure percentage (4%). Greece has the highest out of pocket percentage expenditure and the lowest percentage of insured population (75%). Service provision in the four countries are mainly from public and also private providers. Evidence from countries who have experienced the Sars-CoV-2 outbreak for longer suggests that those who have chronic conditions or engage in riskier health behaviors are more at risk from severe consequences of COVID-19 [16] . In terms of risk factors that might be correlated with the prognosis of the COVID-19 active cases, we look at the prevalence of chronic conditions, tobacco use and alcohol consumption. Table 4 shows that Greece has the highest percentage of +15-year-old population who are daily smokers (27%), while Iceland has the least (8.6%). As for alcohol consumption, New Zealand has the highest number of yearly liters per capita consumed (8.8) . [18, 19] Tobacco use 27% 12.4% 13.1% 13% [20] Percentage of obesity in adults 2016 [21] 21.9% 24.9% 30.8% 6.1%

Top three conditions as proportion of mortality [22, 25] Sources: (4)- (25) Containing the spread of SARS-CoV-2 has meant implementing a number of initiatives that support the existing healthcare systems within a country. In terms of pre-existing healthcare resources, Table 4 shows different parameters to compare the four countries. For example, in terms of number of beds per 1,000 of the population, Greece has the highest number of hospital beds (4.2). The severity of COVID-19 will mean that a number of intensive care unit beds will be required, out of the four nations Iceland has the highest number of beds with 9.1 per 100,000 people and the highest number of ICU beds/100,000 populations. New Zealand has the highest ratio of general practitioners compared to specialists, while Greece is the opposite. Iceland has the highest number of nurses per 1,000 populations. Greece has an understaffing issue; the lowest number of nurses per 1000 population and the highest number of physicians per 1,000 populations; while Singapore has the least number of physicians per 1,000 populations (2.5/1,000). [6] GPs to Specialist ratio 1:16 1:6 1:3 1:0.7 [16] No. of Nurses (per 1,000 people) approx. 3.31 lowest in EU approx. 14. 8 10.29 7.5 [16] No. of Physicians around 6.2/1000 population Highest in EU Around 3.8/1000 population 3.5/1000 population 2.5 [16] No. of ICU beds 6/100k population in 2012 Lower than average 9.1/100k 5.1/100K [26] 11.4/100K [17] Sources: (4)-(17), (26) 3. Methods

The case definition for COVID-19 in New Zealand is a person who is unwell with an acute respiratory infection and has at least one symptom of coughing, sore throat, head cold or a loss of the sense of smell. While in Iceland, symptoms of COVID-19 are described to be cough, fever, cold-like symptoms, muscle pain, fatigue or sore throats, there have been some instances of abdominal pain and loss of smell and taste. In Greece, a case definition for testing if someone shows symptoms such as a fever, cough and difficulty breathing. It is also advised that COVID- 19 can present with symptoms of muscle pain, fatigue, and difficulty breathing. At the current stage, testing in Greece is restricted to patients with severe acute respiratory illness who are or need hospitalization, as well as patients in hospitals, elderly (>70) care or chronic care, and health staff who develop respiratory infections with fever, coughs or dyspnea [27] .

Testing in New Zealand can occur through a septum test or nasal swab, and all are expected to self-isolate until the results are confirmed. It is possible that a small number may not be tested and those that are not are still expected to self-isolate. In Iceland, initially testing was conducted on residents returning from high risk areas and contacts of confirmed cases. This was widened to include the general community who presented with symptoms, in addition a private testing agency has collaborated with the Directorate of Health to randomly sample the population.

Singapore has not released detailed information about the country's testing strategy, in fact the number of tests were released twice in April and have since been reported on a weekly basis. None of the nations have reported an overview of the epidemiology data related to COVID-19

deaths, some of this information is provided in respective nation's media releases however comorbidity information is not included. New Zealand, Singapore, Greece and Iceland report information on whether the confirmed cases are in the community or were imported (contracted overseas). New Zealand provides information on the flights that the individuals came on, while

Singapore reports the residency status of confirmed cases. All but Singapore are currently reporting information on confirmed cases at a regional level, while confirmed deaths are reported at a national level. There are four periods where Greece does not report the daily testing information, the 26th of March, 19th of April, 3rd of June, 5th to 7th of June and 15 th of July.

The next reported day includes the data for the missing period, for example the 8th of June reports a 35,590 new test increase.

To examine the impact of policy interventions on COVID-19 related outcomes, we use the policy categorization process and gradient proposed by Moy et al. (2020) . [33] This categorization process groups policy interventions for those that contain the spread of a virus, interventions for the prevention and care, policies to reduce the economic impact, as well as a categorization for measures taken by private sectors without government intervention and health technology interventions used for treating, testing and tracing cases of a virus. From these categorizations, it is possible to apply a gradient that represents the strictest or most dominant policy being used. To examine the impact of the most dominant policy on outcomes such as the daily rate of cases, we incorporate the gradients into each of the figures in the following sections.

4.1.1. Daily data COVID-19 cases, deaths, recoveries As of the 9 th of August 2020, Greece, Iceland, New Zealand and Singapore had reported 20,440 laboratory confirmed cases of SARS-CoV-2 between them, accounting for 0.6% of the world's confirmed cases [34] . Out of the four nations, Singapore has the most cases with 55,104, whilst New Zealand had reported the least with 1,219 (see Table 5 ). Whilst Iceland has reported the lowest number of deaths (7), and Greece the highest with 213 COVID-19 related deaths.

However, there are numerous differences between the four countries, such as the health systems, interventions put in place and size of the country, that may influence the overall rate and impact of SARS-CoV-2. In order to compare the rates of growth of SARS-CoV-2, and the daily and cumulative trend over the course of the pandemic we revert the date of the first confirmed case to day one. As such we observe that Greece, New Zealand and Iceland are at 106 and 104 days, whilst Singapore has reached its 140th day. The daily number of cases in Greece, New Zealand and Iceland show a fairly normal distribution (see Figure 1 ), indicating that the nations are past the peak. In fact, New Zealand has announced that it has eradicated the virus from its shores. However, the daily confirmed cases of Singapore show a left skewed distribution, as the country had maintained a low number of cases for the majority of the period observed but the number of cases has recently increased.

All four countries implemented medium level interventions to contain the spread relatively soon after the first case. Containment measures increased in strictness for New Zealand at the peak of daily cases, while Singapore escalated measures as the daily cases began to increase. Economic interventions began to be introduced approximately 20 days after the first case for New Zealand, Greece, Iceland and Singapore.

It is evident that all countries were experiencing a different daily rate of the virus as the pandemic progresses. To determine the daily rate of change in cases, we divided the daily new cases by the daily new cases from the day before. If the growth rate is higher than one, then the number of cases is increasing and if the rate of growth continues to increase then it could indicate that the policy interventions are not mitigating the spread of SARS-CoV-2. In Figure 2 , it is clear that each of the four countries has maintained relatively low daily growth rates, with the biggest spikes in growth occurring in Greece towards the beginning of the pandemic, and most recently at the 56 th day. These spikes in Greece are likely to be driven by clusters of COVID-19 being discovered.

Both Singapore and Iceland have maintained growth rates between zero and three for the duration of pandemic so far. For the last seven days, the average rate of growth for Greece, Table 1 ). The country with the lowest number of confirmed cases per 100,000 was New Zealand with 22 per 100,000, however Greece also reported 29 cases per 100,000.

As observed in Figure 3 , the majority of Iceland's daily cases were in its fifteenth to fortieth days, whereas Singapore's picked up pace towards the seventy-fifth day. Despite delaying the number of cases in the wider community in Singapore, there was a breakout of cases in the dormitories that house migrant workers. As a result, authorities increased testing in the dormitories and implemented dormitory wide quarantine to stem the spread. Note: Singapore does not report the daily testing numbers.

Hospitalization information provides an overview of how 

Note: around the 90 th day Singapore reclassified its categorization of hospitals, and a number were moved into isolation.

Although SARS-CoV-2 virus is indiscriminate in those that can catch it, COVID-19 appears to severely affect those over the age of 60 more than other age groups, whilst children seem less likely to catch the virus. Each of the four countries provide data on the distribution of COVID-19 by different age groups and gender, although Singapore stopped providing age and gender for confirmed cases from the 19th of April. As of the 9 th of August (see Table 2 ), more females (males) were confirmed with SARS-CoV-2 than males (females) in New Zealand (Greece). This equates to 478 male confirmed cases per 100,000, with 22 and 25 confirmed male cases per 100,000 and 30 and 23 confirmed female cases per 100,000 in New Zealand and Greece, respectively. [35] In terms of the distribution of laboratory confirmed cases by age group, all but Singapore have released up to date information. However, as each country uses different age group scales the following section reports the total counts for the 10 th of June and does not convert to a comparable population level. Referring to Figure 5 , the majority of cases in all three countries are in the working population (considered the 18-64 age group). Whilst the least number of confirmed cases appears to be in children and youth. Each nation has reported a number of cases in the over 65 age group, who are considered to be the most at risk.

Note: Singapore has not released a breakdown of deaths, although some information is released in the Singapore Government's daily media releases. This figure demonstrates the associated deaths, as such this figure refers to the associated deaths and reports more for Iceland.

All four countries have reported information on the number of deaths and the corresponding ages of the deceased. Whilst this is not necessarily released on the dashboards, government media releases specify the ages (or age group) of those who have passed and tested positive for Finally, whilst research has indicated that pre-existing morbidities are related to increased severity of symptoms and higher probabilities of death, limited information has been reported by each country on the pre-existing health status of those who test positive for COVID-19. A limited amount of health-related information is available on the deceased based on media announcements by the Ministry of Health in Singapore. It was reported that ten of the COVID-19 related deaths had pre-existing conditions that were related to cancer, chronic heart disease, diabetes, hypertension, hyperlipidemia, isometric heart disease and kidney disease. Seven of the associated cases had multiple morbidities [23] .

In order to estimate changes in mortality risk determine the benefits of public health and environments policies, the estimates of life-years saved by these policies is used as a measure of mortality risk. [ [33] . In panel B of Figure 6 , we see the distribution of government intervention based on the Government Response index created by [37] . Both demonstrate the increased government activity used to control or stop the spread of the virus.

Referring to panel A, we see that a majority of interventions are observed after the 100 th case for New Zealand, Greece and Iceland. However, Singapore implemented hygiene and border control measures swiftly, before focusing on tracing contacts of confirmed cases. In addition, Singapore implemented fines up to $10,000 and 6 months in prison for breaking quarantine. In comparison to the other three nations, Singapore has focused on the use of technology to help manage the spread and increase citizens' awareness of crowded places and social distancing measures.

Whilst New Zealand and Greece locked down earlier than most nations relative to the amount of cases (see Figure 7) , Iceland never declared a full lockdown instead the number of people able to meet was restricted (maximum of 20). Rather there was a focus on containment and protecting health systems before implementing stimulus packages. Iceland utilized private industry and created a testing policy for anyone to be tested free of charge, providing the most detailed spread of the disease outside of the Diamond Princess case study [40, 41] . 

In all nations, the number of hospitalized cases has not overwhelmed the existing health care system, however there are a number of healthcare workers being affected by the virus in terms of confirmed cases and self-isolation as a result of being in contact with confirmed cases. Singapore has reported a number of confirmed cases of healthcare staff through their media announcements, with 66 confirmed cases amongst their health staff as of the 26 th of April [48] .

New Zealand reported on the 18 th of April that 131 healthcare staff members were isolating and a further 43 had recovered. However, Iceland is the only country out of the four that has provided daily updates on the number of staffs in self-isolation and quarantine (see Figure 8 ) [49] .

Whilst all four countries' health systems have responded well to the virus, all are preparing for potential increases in cases that are beyond their existing health systems capacity. In fact, in response to the COVID-19 outbreak, the Greek government announced an increase in the number of permanent medical staff and the intention to reach 12 intensive care unit beds per 100,000 of the population [50] . The government has aided this goal by providing 15 million euros for health resources, and an additional 70 million euros to hire additional health staff.

Since then, almost 3,000 medical staff have been made permanent [51] . Greece has also begun to reduce the lockdown measures and allow certain systems to reopen, at the same time the nation is also preparing resources for an eventual surge of COVID-19 and influenza cases in the fall of 2020.

In Singapore, the government is increasing its ability to bring online additional ICU beds if they become needed. At present, Singapore has 150 vacant ICU beds, with an additional 300 able to be brought online. There are additional plans in place to bring another 450 online within the next few weeks [52] . In addition, general isolation beds have increased from 550 to 1,500 beds since January and the National Centre for Infectious Diseases has increased their negative pressure isolation beds from 100 to over 500 [52] . To increase the health staff capacity of the public health system, the government launched the SG Healthcare Corps on April 7 th for private healthcare professionals to sign up. As of the 28 th of April, an additional 3,000 health care professionals had registered [53, 54] .

Those who show milder symptoms and are on the path of recovery from more severe symptoms of COVID-19 are placed in community care facilities in Singapore. To care for these individuals, Singapore created 10,000 beds in a number of facilities across the country. For those individuals who are recovering well and are healthy at the 14-day mark of the course of COVID-19, they are moved to a community recovery facility to stay where they are then assessed for discharge [54] .

Singapore has 2,000 recovery beds and will be expanding it to more than 10,000 beds by the end of June [54] . As well as these facilities, Singapore has created swab isolation facilities (totaling 4,000 beds) where those who are unable to self-isolate can stay whilst they wait for their test results to come back [54] .

Other measures have been taken by the four countries to help facilitate the movement of medical resources, such as the easing of importers licenses for medical protective gear in Singapore [53-55]. We can also observe that the consumer confidence indices in these countries have hit their lowest since the beginning of 2019. Similarly, business confidence indices in these countries decreased during the pandemic given the COVID-19 outbreak has brought the economy across the four countries to a standstill. In Figure 11 , we see the impact that the pandemic has had on the retail and tourism industries. Except supermarkets and consumable sectors, the turnover in other sectors has fallen since February 2020. This is explained by the majority When it comes to discretionary spending, it is clear that individuals have reduced their purchases throughout the pandemic as a result of the high level of uncertainty and unemployment rate.

Tourism has been heavily impacted by government interventions causing an incredibly low number of foreign visitors, with more than 50% decrease compared to the same period in 2019.

Such a drop in a sector clearly indicates there is a need for continuous support for the workers and business in the tourism industry. As a part of this, job keeper and job seeker support packages should be fairly distributed among the hardest hit businesses such as the tourism industry. Figure 12 demonstrates weekly job seeker support or the cumulative wage subsidy as well as the community activity of New Zealand. Due to the easing in the restrictions, where the majority of businesses have started opening, we see that the subsidies provided by the New Zealand government flatten during May 2020. In addition, we can see that various activity indices, including card transaction spending, electricity grid demand, and traffic indices, have been normal after re-opening the economy. The only noticeable exception is in Singapore where the curve of the total positive cases showed an exponential pattern from day 80 onwards. This is due to the outbreaks in the country's migrant dormitories, which are densely populated and difficult to socially distance in. In addition, Greece has seen a steady although small increase in numbers which may be due to the increase in testing and a more widespread testing strategy. Iceland also announced plans to implement nationwide testing which is easier to implement in Iceland due to the small population number.

The four countries maintained a low case fatality ratio (CFR) with Singapore having the lowest CFR of 0.09%. It is noticeable how Singapore has the lowest CFR and the lowest deaths per 100,000 regardless of the fact that it has the least health expenditure as percentage of GDP. This might be primarily attributed to the readiness of the health system for such events based on the experience with previous pandemics like SARS and H1N1. Additionally, this low CFR could be attributed to early intervention by the Singaporean government. As shown in Figure 6 , Singapore initiated its response 21 days prior to the detection of the first positive case; the response included advice for Wuhan-bound travels and a temperature check in sea checkpoints and airports.

Greece has the highest CFR with 5.30% but compared to other European Mediterranean countries such as Italy, Spain, France, and Turkey, the Greek CFR remains relatively lower.

Compared to the four countries, the high CFR could reflect the high old age dependency as shown in Table 1 and could also reflect the fact that the positive cases are higher in older age groups compared to the other three countries as shown in Figure 5 . Additionally, the high CFR in Greece could be related to the testing strategy, which focuses on severe cases. Iceland has the highest number of deaths per 100,000 populations among the four countries and this is mainly due to the small population number and the fact that the number of confirmed cases is concentrated in the younger age groups as shown in Figure 5 .

The mitigation policy interventions as shown in Table 3 and Figures 8, 9 , 10, and 11, show that the early policy interventions as seen in Singapore and the strict early policies as seen in Greece,

Iceland and New Zealand might also be correlated to the relative low number of positive cases and deceased cases at early stage of COVID-19. This is also reflected in the low number of hospitalizations and ICU admissions in the four countries in Figure 4 . This indicates that the health systems of the respective countries managed to absorb the influx of new cases without reaching full capacity/saturation. In addition to the pandemic's impacts on health systems, the economic and financial impact in the four countries is ostensible. Several measures and policies implemented by the four countries along with their economic and fiscal responses in order to contain the pandemic. The economic and fiscal measures implemented by the four countries resulted in immediate relief for relevant stakeholders however, the assessment of the full effect will need a longer time period to observe amidst the COVID-19-related economic hardships. Despite all economic and fiscal support packages provided by these countries, we can observe that the major market indices have recently started moving smoothly across four countries. However, we see a significant drop in exports and imports by the four countries that signals the break in the global supply chain. If this continuously happens, we will ultimately see the increase in unemployment and inflation rates and GDP will collapse.

The COVID-19 pandemic has also hit the consumer and business confidence indices, thus, neither consumers nor businesses feel safe during such a tough period. Due to the high level of uncertainty amid the COVID-19 pandemic, the local exchanges have depreciated compared to the US$ dollar, which can be related to the boost in the demand for US$ given its safe-haven status. On the other hand, short-and long-term government bond yields have hit their lowest in spite of their lower risk compared to other securities such as equity stocks. However, these countries hope to recover the damage by providing continuous support and implementing existing policies. These measures will get employees back to their jobs, guarantee their wages and salaries, and boost the economy.

Important lessons can be learned from the management of the COVID-19 pandemic in the four countries. Firstly, building upon previous experience and capacity to respond to future pandemics as shown in the Singaporean experience. Secondly, the early and strict policy interventions to combat the spread of the pandemic within borders as seen in the Greek and New

Zealand case. Thirdly, the proactive and responsive policy intervention since day one of the infection globally as seen in Singapore. Fourthly, the evolution of the testing strategy to a nationwide approach to detect cases at an earlier stage and prevent serious complications.

Regardless of the differences in the demographic, epidemiological, health system profile, some of these lessons can be applied even in countries with larger borders, bigger populations, or less stable economy. As the four countries have unfolded their exit strategy to the new normal, ongoing/future research should observe the developments and the indicators for a potential second wave and the concurrent health system and economy performance.

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