If countries invest in information and communications technology (ICT), could that that improve their ability to protect public health during a crisis like the COVID-19 pandemic? How have Singapore, Taiwan and South Korea leveraged their IT infrastructure and capabilities to deal with the crisis? What could other governments learn from their experience? Is it possible to develop a framework for the public administration of health that can be amplified by ICT-related capabilities? Ravi Aron addresses these questions and more in this opinion piece. A professor at the Johns Hopkins Carey Business School who studies information technology strategy, healthcare strategy and healthcare information systems, Aron has several research projects underway in some ASEAN countries.
Newspapers, television, and social media have been awash with reports about COVID-19 developments. Country after country watches these updates, riveted with fear and anxiety. Little wonder that three developments at the policy level in the U.S. were barely noticed, reduced to the status of footnotes in the main storyline.
First, the Federal Communications Commission (FCC), the country’s communication regulator, gave temporary access to the 5.9GHz spectrum for rural wireless broadband. Temporary access was granted to 33 fixed-wireless internet service providers (WISPs), marking the first steps towards giving rural Americans more reliable access to broadband. The agency’s stated aim behind this move was to bring access to telehealth, distance learning and telework to rural communities in several states. Second, Ajit Pai, the FCC chairman, came up with a proposal for the COVID-19 Telehealth Program. This offers financial assistance to healthcare providers to pay for telehealth services, including the cost of devices and broadband. And finally, in a bold legislative move, Congress relaxed several restrictions on the use of telemedicine to treat people covered under the Medicare program.
Taken together, these three policy developments are the harbingers of an emergent paradigm: a health technology ecosystem that enables better public administration of health. Indeed, deep and mutually reinforcing connections exist between the elements of a health technology ecosystem and population health delivery capabilities that countries may seek to develop. These are best understood in terms of the complementarity lens that is used to understand the impact of information and communication technologies (ICT) on firms.
What is the complementarity lens? Many researchers have shown that the value of ICT goes beyond the goals of cost savings and higher online sales. Researchers have adopted a complementarity perspective — in which gains from one capability such as, say, manufacturing efficiency amplify the gains from another, say, marketing effectiveness – to analyze the strategic role of ICT in a firms’ strategy. In a seminal study, Sundar Bharadwaj, a professor of marketing at the University of Georgia and his co-authors showed that for manufacturing firms, enterprise level ICT management capabilities result in complementarities between manufacturing, marketing and supply chain functions to drive enhanced performance.
Other studies have tackled the complex nature of complementarities between health information technologies and other external economic factors. A similar approach to studying the complementarities between the health technology ecosystem and the public administration of health would greatly demystify both the role of ICT in health care delivery and how this ecosystem comes into play when swift and large scale responses are called for while facing pandemics and other perils to population health.
Adopting such a complementarity lens is stymied by two problems: first, unlike in the world of business, there are no unambiguously measurable financial targets — such as profits, market share, unit costs and market capitalization – in the public administration of health. Second, there is no framework that delineates what other capabilities in the public administration of health are amplified by ICT related capabilities. We remedy these two related deficits in this article and propose a framework for identifying the complementarities between ICT capabilities and administration capabilities in population health. We base this on our extensive research into health care delivery and current research projects that we have underway in ASEAN countries.
We begin by asking the question, what elements of public administration are complementary to technological capabilities? To answer this question, we investigate how Singapore, Taiwan and South Korea overcame daunting challenges and deployed technology to combat the COVID-19 pandemic.
The Singapore government’s investments in rapid and effective delivery of care were enhanced by the strategic use of ICT.
There is perhaps no better example than that of Singapore when it comes to using ICT for rapid, large-scale social orchestration. The Singapore government’s investments in rapid and effective delivery of care were enhanced by the strategic use of ICT. Singapore, which has a population density as well as a population comparable to that of New York City, reported its first case of COVID-19 on January 23, while New York confirmed its first case on March 1. Singapore had 9,125 cases on April 21, compared to New York’s 251,720 (and 11 deaths to NYC’s 14,828 on April 21).
At the heart of Singapore’s response to the pandemic is contact tracing, a process by which every newly discovered infected case (person) is mapped on to all the people that might have been potentially infected by that person. Within 24 hours of each new infection being discovered, more than 100 contact tracers working around the clock put together the contact map for that person. This map estimates the nature and extent of contact between that person and others who came in contact with him or her.
To assemble a complete contact map of the person spanning 14 days, the tracers use several digital footprints. They look at video tapes of businesses as well as the public and private venues that the person visited; they track digital signatures of activities at ATM machines as well as electronic records of credit card transactions. These highly developed digital capabilities of the country are complementary to the capabilities of the administrative state. As quoted in a recent report, Clarence Tam, at the Saw Swee Hock School of Public Health at the National University of Singapore observed that “Singapore invested heavily in developing capacity and an infrastructure to deal with these types of outbreaks over the past 10 to 15 years, including increasing capacity for intensive care and patient isolation facilities, building expertise in infectious disease.” Singapore’s digital technological capabilities paid off. They enabled the state to take extraordinarily thorough and swift measures at scale in the face of the pandemic.
South Korea provides another example of how the administrative state’s investments in effective response to disasters has been enhanced by its ICT management capabilities. Facing the sudden and massive outbreak of the virus in the country, South Korea orchestrated a massive response. The country installed drive-through tests for the COVID-19 virus. Exhibition halls and public venues installed body sterilizers to spray on visitors passing through malls, and other venues used thermal scanners to test visitors’ body temperature. The government developed and distributed a self-health check mobile app to track the movements of overseas visitors; the ministry of health reports usage rates of the app in excess of 90%. Health administration authorities have developed mobile apps to track and monitor those under quarantines as well as the capabilities to use drones to disinfect large public areas.
South Korea’s administrative capabilities were developed in part because of the country’s sensitive geopolitical location and its fraught history with North Korea. The Korea Centres for Disease Control and Prevention (KCDC) first proposed the drive-through clinic as a research project years ago in response to anti-terrorism drills that involved distribution of medicines in large scale to the public. The capabilities that South Korea developed to fight disaster stemming from geopolitical conflicts were amplified by its use of digital technologies to orchestrate a swift and cohesive response at scale to the pandemic.
The capabilities that South Korea developed to fight disaster stemming from geopolitical conflicts were amplified by its use of digital technologies to orchestrate a swift and cohesive response at scale to the pandemic.
A recent report in the medical research journal JAMA highlighted Taiwan’s exceptional digital technological capabilities in its campaign to create a credible response to COVID-19. Ever since the SARS epidemic of 2003, Taiwan has been in a state of constant readiness to combat epidemics arising from China, given the deep and extensive contact between the two countries. As many as 2.71 million visitors from China entered Taiwan in 2019. After the virus emerged just before the Chinese lunar new year, Taiwan moved swiftly to contain the fallout and make appropriate resource allocations to its healthcare system.
Taiwanese authorities started collating data from two disparate sources – the immigration and customs database and the national insurance database – to create a unified big data platform for analytics. They were able successfully to identify cases based on clinical visits, travel history, and symptom patterns to provide real-time alerts to targeted population segments about possible infected persons.
After the SARS outbreak in 2002, Taiwan had created a disaster management and recovery center — National Health Command Center (NHCC) – which focused on large disease outbreaks and served as the operational command for a coordinated response across multiple agencies and regions. In the face of the rapidly escalating pandemic, Taiwan was able to calm its citizens and convince them that the government was in control of several critical tasks. These ranged from border control, quarantine monitoring and resource mobilization to the effective management of logistics and operations. Careful and accurate communication helped Taiwan keep its citizenry well informed and fight misinformation. The vice president of Taiwan, an epidemiologist by training, led the public information campaign from the office of the president.
The vice president of Taiwan, an epidemiologist by training, led the public information campaign from the office of the president.
In the same way, Singapore used digital media capabilities to assure the population that its administrative machinery was in control of the situation. A recent report noted the Singapore’s Prime Minister Lee Hsien Loong’s use of Facebook to reach out to the citizens. The PM posted “…Once a case is confirmed, within two hours [contact tracers] create a detailed activity log of the patient’s movements and interactions in the 14 days before admission….” The ministry of health also provided regular and consistent WhatsApp group updates of what was happening in the country and the extent to which the virus had spread. The government opted for transparency and people were told in stark terms what could happen next. Not only did the delivery of information on social media channels help control panic, it also strengthened the credibility of the public administration in the eyes of its citizens.
The administrations of Taiwan, Singapore, and South Korea won the trust of their citizens in the campaigns to combat the pandemic. In each case, the investment in administrative capabilities in public health was strengthened by its digital technology capabilities and vice versa.
South Korea’s KCDC had in place contingency plans that were put into action effectively and rapidly because of its effective use of digital technology. The use of the self-health check app and the quarantine tracking app acted as enforcers of the controls and preventive measures that KCDC had put in place. South Korea’s high tele-density enabled the rapid capture of emerging patterns and the dissemination of information to targeted population subgroups. As a result, when a new COVID-19 case was found in a neighborhood, people within that geography were alerted by information sent to their mobile phones. The alert provided information about the patient’s demographic details as well the patient’s travel history.
Sharing of aggregate population trends and tracking of events in real-time are possible even in regimes that have stringent privacy laws. South Korea’s Personal Information Protection Act (PIPA) provides for comprehensive safeguards for the protection of citizens’ privacy. Taiwan, too, has very strict data protection and privacy legislation including the Personal Data Protection Act, which regulates collection, processing and use of personal data. These laws have not restricted these countries from using information effectively when a swift response was called for in an emergency. Researchers have proposed guidelines for creating data sharing frameworks in the U.S. and abroad that will bring together telecom firms and other tech companies to create data and analytics platforms that support accurate pattern identification and prediction modeling.
Singapore’s use of social media, with the highest officer of the government directly reaching out to the citizens, the use of frequent and consistent WhatsApp notifications created and fostered an environment of trust. Singapore possibly offers the canonical example of using ICT to implement an adage of public administration – trust but verify. The ministry of health uses data from multiple formats and sources to track the movement of possibly infected people and determine their contagion footprint. These real-time data feeds, including multimedia data streams, are then combined with a tracking mechanism developed by the Government Technology Agency (GovTech). The ministry of health uses a contact-tracing smartphone app – TraceTogether – developed by GovTech that identifies people that have been within two meters of a patient for at least 30 minutes for follow up action by contact tracers.
The same principle of trust but verify is implemented using ICT to varying degrees in other countries. South Korea has created a customized app to alert officials and sound an alarm if home quarantine measures are violated. Taiwan tracks quarantined peoples’ cell phone signals for possible violation of quarantine requirements. Texts to those found outside the quarantine zone as well alerts to enforcement authorities are sent by the automated system. Taiwan imposes a fine on people who leave quarantine without a phone. South Korea levies large fines for violating the conditions of the quarantine. Singapore, South Korea, and Taiwan all made a distinction between the use of data to advance commercial objectives and the use of data to protect the well-being of citizens in an emergency. In all three cases, the use of data was restricted to narrowly defined and specific usage contexts that were only related to responding to the contagion.
The authority that moves large numbers of people to cohesive action is not the coercive power of the state as much as the authority of specialists and the credibility that they command.
A misleading narrative that often appears in the popular media is that these states were able to achieve impressive results because of their authoritarian nature. While authority certainly plays a role, it is important to investigate its provenance: Exactly what is the nature of the state’s authority and where does it originate? The authority that moves large numbers of people to cohesive action is not the coercive power of the state as much as the authority of specialists and the credibility that they command. As stated above, the vice president of Taiwan is an epidemiologist who leads by example in making public service announcements and informing the public about the state of the pandemic and the government’s response.
Singapore’s citizens have always been led by a technocratic government often praised for its efficiency. Within a week of China’s lock down of Wuhan, the government of Singapore closed its borders, set up a virus fighting task force and imposed stringent home quarantine measures. The initial response was led by Vernon Lee, director of the communicable diseases division at Singapore’s Ministry of Health, who said his goal was to get ahead of the pandemic rather than to chase it and fall behind.
Trust in the government’s capabilities and competence brought forth volunteer efforts by citizens with ICT expertise. In South Korea, a college student created the website Coronamap to create heatmaps of the virus spread across the country. Another map developed by four students at Korea University – called Corona-Nearby – allowed users to create their own maps of virus-affected regions in their vicinity. Taiwan’s Central Epidemic Command Center (CECC) communicated with the public in a manner that built confidence in the administration’s capabilities.
Taiwan’s big data efforts coopted the public as collaborative partners. Rather than treat patients as careless offenders, the CECC took the view that the population faced a looming peril which was best combatted using collective measures. Balaji Padmanabhan, director of the Center for Analytics & Creativity at the Muma College of Business at the University of Southern Florida, observes that Taiwan’s approach was not only ‘big data’ but also ‘big tent’ – which means Taiwan did not seek to assign blame or take punitive measures against those infected and/or quarantined. This helped legitimize efforts to fight disinformation by getting several agencies to collaborate and share information. In a public poll conducted by the Taiwan Public Opinion foundation in mid-February, the approval ratings of the president and premier were about 70% and the minister of health and welfare was over 80%.
Taiwan’s investment in technological capabilities were complementary to its public health campaign; it has 420 cases and 6 deaths with a mortality rate of 0.25 per million people (the U.S. has a mortality rate of about 85 per million people). It experienced a surge in cases starting March 12 and within a month it had first flattened the curve and then brought the contagion under control by reducing the number of new cases per day to fewer than 10 by April 12. In contrast, a month after the surge in new cases, New York City reported about 7,500 new cases a day.
Taiwan’s investment in technological capabilities were complementary to its public health campaign.
In each case, Singapore, South Korea and Taiwan learned from the past and put in place a set of competencies and response capabilities. These capabilities required effective communication techniques, rapid dissemination of information, the ability to recognize emerging patterns and act on them, and finally, the ability to reach the individual citizen and orchestrate cohesive group action.
Any large-scale deployment of an information network will of course carry with it the hazards of cyber-attacks. Such hazards are no different from those faced by financial systems, public transportation systems, and indeed the power grid. For this reason, robust protections are needed both for the physical security of the information processing network as well as the privacy of individuals from overreach by commercial entities and bureaucrats. These information networks can be made less vulnerable by building in resiliency and redundancy and highly distributed processing capabilities. Indeed, the internet itself was first designed with the objective being able to withstand just about any catastrophe.
Winston Churchill once reportedly said that one should never let a good crisis go to waste. We may well be seeing the first signs of a technology ecosystem emerging in the U.S. There should never be any doubt about the benefits of such an ecosystem and its ability to enable, sustain, and reinforce the public administration of health.
(The author gratefully acknowledges research support from the Sasin School of Management at the Chulalongkorn University, Thailand.)