COVID-19 and Singapore’s Health Diplomacy

ETHOS Issue 22, June 2021

Introduction

Even before the global pandemic, global health has had a place at the diplomatic table alongside health security, humanitarian affairs, and social and economic development, as a significant component of foreign policy.¹  And as the COVID-19 outbreak has shown so vividly, viruses do not recognise national borders. Singapore, having faced the dire effects of the SARS epidemic first-hand, has long been aware of the need for multilateral cooperation on global health issues—including the prospect of a pandemic.

Accordingly, Singapore has been an active participant in multilateral efforts—such as the US-led Global Health Security Agenda—to bolster the pandemic preparedness and response of low- and middle-income countries. It has contributed to international programmes to provide technical and medical assistance, and helped promote global health security as a national and global priority.² This is a reason why, despite being a small state, Singapore has come to play a significant role in global health, as a knowledge and innovation hub for the control of infectious and chronic diseases.³

Since the outbreak of the COVID-19 pandemic, a number of small states and Asian societies have demonstrated best practices in managing the pandemic compared to many larger countries—particularly in areas such as diagnosis, contact tracing and health surveillance. For instance, Singapore’s rapid development of test kits for COVID-19 in the early days of the pandemic, subsequently shared globally, demonstrates how even a little red dot can contribute to countering a pandemic of unprecedented scale.

Singapore’s participation in global health diplomacy in the current pandemic can be noted on four broad fronts: (1) bilateral assistance for ASEAN member states and beyond; (2) participation in multilateral mechanisms through the ASEAN Plus platforms; (3) participation in international efforts (G20, Belt and Road Initiative) on COVID-19; and (4) contributions to the World Health Organization's (WHO) Strategic Preparedness and Response Plan, and UN mechanisms and processes for COVID-19 response.

Figure 1. Singapore’s Global Health Diplomacy in Context

Four Fronts of Global Health Diplomacy

As a responsible small power, Singapore’s participation in multilateral and international mechanisms contributes to what Alan Chong has called “virtual enlargement”.⁴ This is a strategy in which small states enlarge their importance to the international community, enhancing their influence and prospects for survival and success.

Bilateral health assistance: “Test-kit diplomacy”

Singapore’s health diplomacy includes engaging in bilateral health assistance. Home to more than 50 biomedical companies, Singapore’s strategic investment in biomedical manufacturing has provided ballast in an economy battered by the impact of COVID-19.⁵ It also afforded the city-state the infrastructure and capacity to rapidly develop diagnostic test kits in the early days of the pandemic, and then to help fulfil international demand for kits to detect the novel virus, especially in low- and middle-income countries.

Fortitude Kit 2.0 was the first complete diagnostic kit to be approved and produced at scale in Singapore, and is also the most common test kit donated by Singapore’s Temasek Foundation.⁶ Developed by the Agency for Science, Technology and Research (A*STAR), Tan Tock Seng Hospital and Diagnostics Development (DxD) Hub, Fortitude Kit 2.0’s technology can be transferred through a non-exclusive license for manufacturing to meet local and regional demands.⁷

Such bilateral technology transfers engender goodwill for Singapore, at a time of uncertainty in which most high-income countries with similar capacities had been slow to act. This is part of what Foreign Minister Vivian Balakrishnan in March 2020 termed “test-kit diplomacy”.⁸ While Singapore, recognising its own vulnerabilities as a small island state, is reliant on and advocates multilateral cooperation, it is in turn also ready to share its homegrown technological know-how for a good global cause.

Accurate and rapid detection of the virus helps everyone: by facilitating the global fight to detect, treat and protect against the virus, Singapore also serves to protect its own population and accelerate an eventual return to the normalcy of open borders and trade that it thrives upon. Notably, Temasek Foundation, the philanthropic arm of Temasek, one of Singapore’s two sovereign wealth funds, has earmarked S$800 million (US$563 million) for COVID-19 response, with at least S$250 million of the earmarked funds redirected to COVID-19-related therapeutics and vaccines research and development.⁹

In addition to test kits, Singapore’s bilateral health assistance to support the pandemic response has also included polymerase chain reaction machines, oxygen and ventilation equipment, personal protection equipment, and hand sanitisers. While these have mostly gone out to the nine fellow ASEAN member states, Singapore has also provided assistance to countries in Asia, Oceania, Africa, and Europe.¹⁰

These assistance efforts have also been bolstered by public-private partnerships. One such initiative was between Temasek Foundation, Singapore Airlines and the World Food Programme.¹¹ With global travel at a standstill because of the pandemic, the freight and flight capabilities of Singapore’s national air carrier were redirected to help deliver bilateral health assistance globally.

Non-government organisations based in Singapore have also stepped in. The Singapore Red Cross channelled the Singapore Government’s seed donation of S$1 million to provide assistance to communities affected by COVID-19 in China;¹² it also contributed more than S$800,000 of support for COVID-19 response to all ASEAN member states and other countries in Asia, including Timor Leste, India, Sri Lanka, Nepal, and Maldives.¹³

Maintaining relationships through bilateral health assistance enables Singapore to stay relevant and preserve goodwill at a challenging time. Many of the countries that received bilateral health assistance from Singapore are source countries of its migrant worker communities, as well as important suppliers of essential goods to Singapore. China is also one of Singapore’s key bilateral partners particularly in terms of trade and investment. Indeed, the global health-science diplomatic relations between Singapore and China has fed into a partnership in the development of COVID-19 vaccines, treatment and diagnostics.

While there has been multilateral cooperation in infectious disease control and response between China and ASEAN in the past, Singapore and China have also signed bilateral MOUs and agreements related to global health amid COVID-19, including health cooperation, food safety cooperation, health policy fellowship exchange, biomedical cooperation and scientific research cooperation through the Sino-Singapore International Joint Research Institute.^{14, 15} Such bilateral commitments further galvanise Singapore-China global health cooperation, on top of other socio-cultural and economic ties.

ASEAN matters: Participation in ASEAN and ASEAN Plus platforms

During the SARS and H1N1 epidemics, Singapore was active in engaging regional platforms to enact coordinated, cross-border responses. With the outbreak of COVID-19, Singapore has again been actively participating in ASEAN and the ASEAN Plus mechanisms to develop and implement a regional response to the latest pandemic.

For instance, in the crucial early stages of the outbreak, Singapore was able to quickly share technical protocols and guidelines on the clinical management of COVID-19 cases (based on its global health expertise and experience of past epidemics) at the ASEAN Emergency Operations Centre Network for Public Health Emergencies Special Video Conference in February.¹⁶

With the pandemic shutting borders and placing strain on global supply lines, Singapore has reaffirmed the ASEAN framework as vital in promoting regional cooperation to “keep trading routes and supply lines open”, particularly for essential goods, including medical supplies and food.¹⁷ With trade being necessary for food security, Singapore has also encouraged the region to support related regional platforms like the ASEAN Plus Three Emergency Rice Reserve to bolster the region’s food security.¹⁸

As one of the high-income countries in ASEAN, Singapore has also shown that it can be a dependable source of contributions for regional initiatives like the COVID-19 ASEAN Response Fund, to which the city-state contributed US$100,000 in November 2020.¹⁹ Singapore has also pushed for regional cooperation in the production and distribution of vaccines, citing the November 2019 ASEAN Leaders’ Declaration on ASEAN Vaccine Security and Self-Reliance.²⁰

Multilateralism matters

Singapore’s active participation in multilateral, cross-border efforts to contain COVID-19 is consistent with its core principles of foreign policy— promoting friendly relations to protect and advance its own interests—in both global health and economic fronts.²¹

At the global level—including platforms such as the G20, the Forum of Small States and the Global Governance Group (3G)—Singapore has consistently expressed its commitment to the principles of multilateralism, cooperation and interdependence in controlling the pandemic. ^{22, 23} Singapore along with other members of the 3G have strongly supported the UN as a central driver in “intensified global action, cooperation and solidarity that puts people at the core of the COVID-19 response.”²⁴ Singapore has also advocated the key role of the WHO in directing and coordinating multilateral cooperation “to ensure that extensive immunisation against COVID-19 remain a global public good for health”.²⁵

A multilateral and broad-based approach to vaccination remains the best prospect for the world to be able to gradually reopen its borders to international travel—vital to Singapore’s economic interests as an open economy and travel hub. Notably, while there have been efforts to establish safe travel bubbles (such as between Singapore and Hong Kong), implementation has been delayed by sudden surges of infections.

At the 75th UN General Assembly, despite scathing criticisms of the WHO and the UN from the United States, Singapore expressed its support of the WHO’s efforts in responding to COVID-19 and in facilitating vaccine development, while also acknowledging the need to evaluate the WHO and its processes.²⁶ Such support reflects Singapore’s prevailing stake in multilateral institutions that are “open, inclusive and fit for purpose” in tackling global problems.²⁷ Singaporean leaders have urged the international community to give multilateral institutions such as the UN and WHO the “commensurate latitude, resources and mandate” to carry out their mission for the global public good.²⁸ Issuing a statement on behalf of ASEAN at the 75th session of the UN General Assembly in October 2020, Singapore also stated that the pandemic was the time for countries “to double down on multilateralism” and “reaffirm commitment to a rules-based international system”, which includes supporting the UN and providing it with adequate financial resources by paying assessed contributions in full.²⁹

Contributions to Global Health and Pandemic Governance

As a responsible member of the global health community, Singapore has walked the talk by keeping up with its funding dues to the WHO. Singapore also increased its assessed contributions from US$4.227 million (for 2018–2019) to US$4.641 million (for 2020–2021)— and more than doubled its voluntary contributions from US$548,000 in 2014 to US$1.125 million in 2020—to support WHO health emergencies programmes and help strengthen its capacities in the Southeast Asia region.³⁰ In March 2020, Singapore announced a contribution of US$500,000 to the WHO’s Strategic Preparedness and Response Plan for COVID-19 response.^{31, 32} This is beyond its assessed and specified voluntary contributions to the WHO, which amount to US$ 6.538 million for 2020-2021.

As one of very few high-income small states that can make a contribution on international platforms through global health and science diplomacy, Singapore was one of the early supporters of the Access to COVID-19 Tools (ACT) Accelerator and the COVID-19 Vaccines Global Access (COVAX) Facility.³³ It also co-chairs, with Switzerland, the Friends of the COVAX Facility network of supporting countries.³⁴ In December 2020, Singapore committed to contributing US$5 million to the COVAX Advance Market Commitment mechanism, to help 92 low- and lower-middle-income countries including six ASEAN member states (Cambodia, Indonesia, Lao PDR, Myanmar, the Philippines and Vietnam) to access 2 billion doses of COVID-19 vaccines by the end of 2021.³⁵ Singapore is also participating in the WHO-led multi-country Solidarity Vaccine Trials, slated to begin in 2021.

A significant aspect of Singapore’s global health-science diplomacy is the engagement of infectious disease experts in Singapore. These include Dr Dale Fisher of the National University of Singapore, who sits on the Steering Committee of the WHO Global Outbreak Alert and Response Network (GOARN). Medical and public institutions in Singapore have been actively engaged not only in research and development for treatment, vaccines and diagnostics for COVID-19 but also in health communication, battling the infodemic that has spread with COVID-19.³⁶

Singapore has also shown solidarity with the international scientific community, by implementing pandemic response measures based on the scientific data it has contributed to building up.

Prospects for Singapore and the Role of Small States in Global Health and Global Health Diplomacy

Lingering Impact on Foreign Relations

COVID-19 is likely to have a lasting impact on regional and global relations. The pandemic could prompt governments to reflect on the need to incorporate a health-in-all-policies approach, and accelerate a shift towards a global health paradigm that acknowledges and moves beyond state-centric notions of global governance. In the Southeast Asia region, the pandemic will test the ASEAN way of working through consensus and consultation, and it will retune the balance to be struck between state-led health diplomacy and the role of non-state actors in addressing global health needs. For Singapore, health aid and cooperation will remain critical components of foreign policy for some time to come: as was the case in the aftermath of the 2003 SARS epidemic.

Singapore’s four-frontal approach to global health diplomacy during this unprecedented pandemic balances between two main principles. It recognises health issues as a vanguard of regional and global governance, and it harnesses strengths in health and science to enhance regional and global influence.³⁷ With COVID-19, Singapore has shown how a small city-state can take on effective global health diplomacy with bilateral health assistance and multilateral cooperation, while battling a pandemic, at home and abroad.

Singapore does not act alone however. It recognises that there is power in numbers and that a global pandemic needs global action. No one country can be said to have conquered the outbreak; it is only through solidarity in global action that the virus and its impacts might be overcome.

Singapore’s actions for global health are made in cooperation with other small states and neighbouring states, both developed and developing. It demonstrates how small states can contribute and pool their convening power, political will, leadership and resources to address a global crisis—in the process undergoing a “virtual enlargement” of its international influence and relevance as a responsible, valuable member of the global community.

Need for a More Deliberate Health Diplomacy Agenda

It is hard to compare Singapore’s global health diplomacy with that of other relatively small developed countries. For example, New Zealand and Qatar might be comparable to Singapore in terms of economic power, population and size, but while New Zealand and Qatar have dedicated aid agencies (New Zealand Aid and Qatar Fund for Development, respectively), Singapore does not. Despite this, Singapore coordinates and distributes health aid for COVID-19 response in a strategic and systematic manner, comparable to developed countries with a vast network of distribution hubs for international health assistance. Singapore’s test-kit diplomacy, for example, was done through a whole-of-government approach, and unprecedented cooperation with the private sector and non-profit and philanthropic organisations.

The need for an ongoing global health and humanitarian response could be cause for Singapore to consider developing a specific, if evolving, health diplomacy agenda. One aspect of this might be the establishment of its own aid agency. This could allow Singapore to comprehensively respond not only to humanitarian crises in the region but also global health emergencies.

Cultivating Tomorrow's Global Health Diplomats

COVID-19 has illustrated how global health challenges can have a profound, cross-border impact on any country’s wellbeing. Increasingly, the public sector at large will need to be able to discern and understand how global health issues (beyond pandemics) inform their country’s ability to pursue security, trade, development and social progress.

If global health concerns are to be embedded as part of public policy and foreign policy going forward, a new set of diplomatic and public sector skillsets will be needed. These should embrace, and also go beyond, both foreign policy and global health expertise. For instance, expertise in areas such as global health ethics, global health communication and global health policy analysis will be critical for risk communication, infodemic management and global health negotiations.

To stay relevant to the international community, Singapore should have tangible mechanisms to systematically nurture young professionals trained in global health diplomacy—not only in Singapore but also among its Asian neighbours. This will build mutual trust and shared expertise: enhancing the region’s propensity for and capacity to cooperate for mutual benefit, in a world increasingly beset by challenges that transcend national boundaries and capabilities.

NOTES

1. This was particularly the case with the widespread adoption of the UN Millennium Development Goals (and now the Sustainable Development Goal on health and wellbeing). See Tikki Pang, “Singapore Should Play a Strong Leadership Role in Global Health”, Lancet 391, no. 10116 (January 2018): 120, https://doi.org/10.1016/S0140-6736(18)30013-8; Tommy Koh, “Medicine and Diplomacy”, Singapore Medical Journal 57, no. 11 (2016): 641–643,
   http://www.smj.org.sg/article/medicine-and-diplomacy.
2. Hsu Li Yang and Jeremy Lim, “Beyond a Scorecard Index: Relooking Singapore’s Global Health Security”, Saw Swee Hock School of Public Health Perspective, November 15, 2019, accessed September 30, 2020,
   https://sph.nus.edu.sg/featured-content/beyond-a-scorecard-index-relooking-singapores-global-health-security/.
3. Tikki Pang, “Singapore Should Play a Strong Leadership Role in Global Health”, Lancet 391, no. 10116 (January 2018): 120, https://doi.org/10.1016/ S0140-6736(18)30013-8.
4. Alan Chong, “Small State Soft Power Strategies: Virtual Enlargement in the Cases of the Vatican City State and Singapore”, Cambridge Review of International Affairs 23, no. 3 (September 2010): 383–405, doi: 10.1080/09557571.2010.484048.
5. Audrey Tan, “Coronavirus: Biomedical Manufacturing a Bright Spot for Singapore”, The Straits Times, June 6, 2020, accessed September 30, 2020,
   https://www.straitstimes.com/singapore/health/biomedical-manufacturing-a-bright-spot-for-spore.
6. Temasek Foundation, “Temasek Foundation Report 2020”,
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7. Economic Development Board, “Mission Possible: Singapore Players Do Their Part to Combat COVID-19”, EDB Singapore, April 29, 2020, accessed September 30, 2020,
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8. Ministry of Foreign Affairs, “Minister for Foreign Affairs Dr Vivian Balakrishnan’s Live Interview on CNBC Asia’s Squawk Box Asia, 11 March, 2020”, March 12, 2020, accessed September 30, 2020,
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9. “Temasek CEO Says S$800 Million Earmarked for Coronavirus Fight”, Bloomberg, April 27, 2020, accessed September 30, 2020,
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10. See Note 6.
11. World Food Programme, “Singapore Airlines and Temasek Foundation Partner to Support WFP and the Global COVID-19 Response”, August 11, 2020, accessed September 30, 2020,
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12. Asyraf Kamil, “Government Donates S$1 Million to Singapore Red Cross to Aid Communities in China Stricken by Coronavirus”, Today, February 4, 2020, accessed September 30, 2020,
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13. Singapore Red Cross, “COVID-19: Singapore Red Cross Rolls Out More Support for Communities in Singapore and the Asia Pacific”, April 3, 2020, accessed September 30, 2020,
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14. Linette Lai, “Singapore, China to Deepen Collaboration on Public Health, including Development of COVID-19 Vaccines and Treatments”, The Straits Times, July 31, 2020, accessed September 30, 2020,
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15. Ministry of Foreign Affairs, “Minister for Foreign Affairs Dr Vivian Balakrishnan’s participation in the ‘High-Level Videoconference on Belt and Road International Cooperation: Combating COVID-19 with Solidarity’”, June 19, 2020, accessed September 30, 2020,
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16. Ferdinal Fernando, Jennifer Frances E. de la Rosa, Mary Kathleen Quiano-Castro and the ASEAN Editorial Team, “Shifting Current: COVID-19: A Collective Response in ASEAN”, The ASEAN, no. 1 (May 2020): 30–35, accessed September 30, 2020,
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17. Prime Minister’s Office Singapore, “Intervention by PM Lee Hsien Loong for the 36th ASEAN Summit (June 2020)”, June 26, 2020, accessed September 30, 2020,
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18. Prime Minister’s Office Singapore, “Intervention by PM Lee Hsien Loong at the Special ASEAN Plus Three Summit on COVID-19 on 14 April 2020”, April 14, 2020, accessed September 30, 2020,
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19. Linette Lai, “ASEAN Summit: Singapore Calls for Equitable, Steady, Affordable Supply of COVID-19 Vaccines to Region”, The Straits Times, November 13, 2020, accessed January 31, 2021,
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20. ASEAN Secretariat, “ASEAN Leaders’ Declaration on ASEAN Vaccine Security and Self-Reliance (AVSSR)", November 2, 2019, adopted in Bangkok, Thailand.
21. Vivian Balakrishnan, “Five Core Principles of Singapore’s Foreign Policy”, The Straits Times, July 17, 2017, accessed January 31, 2021,
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22. Prime Minister’s Office Singapore, “Written Statement by PM Lee Hsien Loong at the Extraordinary Virtual G20 Leaders’ Summit on 26 March 2020”, March 26, 2020, accessed September 30, 2020,
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23. Ministry of Foreign Affairs, “Minister for Foreign Affairs Dr Vivian Balakrishnan’s Participation at the Extraordinary G20 Foreign Ministers’ Meeting, 3 September 2020”, September 3, 2020, accessed September 30, 2020,
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24. Ministry of Foreign Affairs, “Press Statement by the Global Governance Group (3G) on its Thirteenth Ministerial Meeting on 23 September 2020”, September 23, 2020, accessed September 30, 2020,
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25. Ibid.
26. Ministry of Foreign Affairs, “Minister for Foreign Affairs Dr Vivian Balakrishnan’s National Statement at the General Debate of the 75th United Nations General Assembly, 26 September 2020”, September 27, 2020, accessed September 30, 2020,
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27. Ministry of Foreign Affairs, “PM Lee Hsien Loong’s Statement at the High-level Meeting to Commemorate the 75th Anniversary of the United Nations, 21 September 2020”, September 22, 2020, accessed September 30, 2020,
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28. Ibid
29. Ministry of Foreign Affairs, “Statement on Behalf of the Association of Southeast Asian Nations by H.E. Burhan Gafoor, Permanent Representative of Singapore to the United Nations, on the Organisation of Work of the Fifth Committee at the Main Part of the 75th Session of the General Assembly, New York, 5 October 2020”, October 5, 2020, accessed October 10, 2020,
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30. World Health Organization, “The WHO Programme Budget Portal”, accessed January 31, 2021,
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31. “Singapore Contributes US$500,000 to Support WHO Efforts against COVID-19”, CNA, March 23, 2020, accessed September 30, 2020,
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32. World Health Organization, WHO COVID-19 Preparedness and Response Progress Report: 1 February to 30 June 2020, (Geneva: World Health Organization, 2020), accessed September 30, 2020,
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33. Launched in April 2020 by the WHO and its international partners, the ACT Accelerator is a framework for collaboration towards the development, production and equitable access to COVID-19 tests, treatments and vaccines. The COVAX Facility is one of the pillars of the ACT Accelerator, offering a global risk-sharing platform to pool procurement and equitably distribute COVID-19 vaccines to low-and middle-income countries. See: World Health Organization, “Statement from the First ACT-Accelerator Facilitation Council Meeting”, September 10, 2020, accessed October 10, 2020,
    https://www.who.int/news-room/detail/10-09-2020-statement-from-the-first-act-accelerator-facilitation-council-meeting.
34. Ministry of Foreign Affairs, “Statement by Friends of the COVAX Facility (FOF)”, September 21, 2020, accessed January 31, 2021,
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35. “Singapore to Contribute US$5 million to COVAX, to Help Less Wealthy Countries Access COVID-19 Vaccines”, CNA, December 4, 2020, accessed January 31, 2021,
    https://www.channelnewsasia.com/news/singapore/covid-19-vaccine-5-million-covax-fair-distribution-13697806; Gavi, “Commitment Agreements”, COVAX, October 9, 2020, accessed October 10, 2020, https://www.gavi.org/sites/default/files/covid/pr/COVAX_ CA_COIP_List_COVAX_PR_09-10-2020.pdf.
36. These institutions include: the Ministry of Health Singapore, National University of Singapore, Singapore General Hospital, Tan Tock Seng Hospital, Regional Emerging Diseases Intervention (REDI) Centre, the Programme in Emerging Infectious Diseases at the Duke-NUS Graduate Medical School.
37. Kelley Lee, Tikki Pang, and Yeling Tan, eds., Asia’s Role in Governing Global Health (Routledge, 2013).