On 7 December 2022, the National Health Commission of China released the “Notice on Further Optimising and Implementing the Prevention and Control Measures of the COVID Outbreak”. The notice marked a turning point in China’s strict zero-COVID policy as it is intended to relax the numerous regulations that had slowed the spread of the virus but, at the same time, also stifled the world’s second-largest economy and generated civil unrest.

The implementation of the new rules introduces many challenges to the country and its people as China has little experience in dealing with the virus in nearly three years of strict control. One reassuring sign is that China can learn some lessons from other countries in managing the recent surge of COVID cases: China’s rural and countryside areas with insufficient medical supplies can look to the Indian case; on the other hand, China’s urban and first-tier cities, which have adequate healthcare facilities, may find a model in Singapore.

Lessons from India: Irony of Lockdown amid Lack of Resources

India spends a small share of its budget on healthcare. In 2019, India’s expenditure on healthcare was only US$231 per capita, while China’s was US$307 per capita. Although China’s healthcare expenditure is slightly higher than that of India, the relatively low expenditure on healthcare in both countries has left their medical infrastructures underdeveloped. The rather short-sighted way the Indian government tackled a series of COVID waves provides valuable lessons for Chinese rural areas in terms of healthcare reallocation and protection from emerging variants of the virus.

On 24 March 2020, India issued a 3-week nationwide lockdown to control the spread of the virus. The lockdown did effectively stem the rise of positive cases. Ironically, however, the success of the lockdown left the Indian government with little motivation to increase its healthcare spending. For example, India built thousands of cardboard beds at hospitals and clinics as a temporary measure. Yet, the government did not upgrade those stopgap facilities on the naïve anticipation that COVID would come to an end. As a result, India has suffered from a persistent shortage of beds. To prevent a similar crisis, Chinese rural areas should continue to train medical personnel and invest in healthcare facilities even without a major spike in the number of infections.

The main challenge for rural China is that it lacks the resources to invest in healthcare systems. Currently, China’s healthcare infrastructure is not allocated according to population density. For example, the intensive care unit (ICU) occupancy rate is below 10% in metropolitan cities, whereas that in rural areas is already over 50% on average. The scarcity of medical resources in rural areas may result in the collapse of the entire system. To avert such a possibility, the Chinese government should rebalance its medical capacity from relatively affluent urban regions to vulnerable rural regions before the next wave of COVID.

The emergence of new variants of the virus will be another threat to rural China. Some 70–80% of the positive cases in India in 2021 were from new variants. India is a continent-size country, where multiple variants are expected to emerge from countless transmissions. During the lockdown in the first wave in 2020, the Indian government decided to send internal migrant workers back to their hometowns. These travellers disseminated the virus across the country. China is in a similar situation now. In about a week’s time, the people will begin celebrating the lunar new year. After three years of the strict COVID policy, internal migrants have a high motivation to return to their hometowns. As millions of people are likely to travel across the country, rural areas will face the risk of exposure to multiple variants like India did in 2020 and 2021.

Medical facilities in rural China cannot be compared with those in urban areas in terms of quantity and quality. Since rural regions have limited capacity to distinguish between COVID variants, it is more challenging for Chinese local governments to tailor their policies according to variants of differing virulence. During the second wave, India was struggling to identify COVID variants by their virulence and transmission rates and to conduct research on the effectiveness of various vaccines. There is an urgent need for rural China to be ready for virus detection and investigation by creating fast lanes to city areas to allow timely tracking and countering of variants.

Lessons from Singapore: Self-tracking and Gradual Reopening

As a developed country, Singapore’s circumstances are different from that of India and rural China. In 2019, Singapore spent US$1,441.27 per capita on healthcare. But China’s urban and first-tier areas are comparable to Singapore in terms of medical infrastructure. For instance, in 2021, Singapore had only 2.15 hospital bedsper 1,000 people while Beijing had 5.95 beds per 1,000 people, almost three times more.

During the first wave of COVID in 2020, Singapore implemented a strict COVID policy, where residents who tested positive to the virus must self-isolate at home immediately or face serious penalties. For those whose homes did not have the facility for self-isolation, the Singaporean government offered a subsidised quarantine space. In urban China, it is difficult for most patients to self-isolate in their own homes as these are shared with family members. When the Omicron variant of COVID hit Beijing, a saying that was circulating widely was: “Omicron is merciful because it at least leaves one family member uninfected to cook for the rest.” Before the next wave strikes, Chinese authorities should prepare facilities to minimise transmission among family members in small residential spaces in urban China.

Singapore has used technology to promote individual awareness and responsibility in controlling the spread of the virus. In mid-2021, before the reopening of its borders, Singapore distributed a wearable pocket-sized Bluetooth device to residents for contact tracing. Thus, instead of restricting the movement of the people, the government incentivised them to be more conscious of their health and social responsibility.

After the first wave of COVID infection, it was reported that the tracking devices had helped reduce positive cases and delay the emergence of a second wave. Chinese first-tier cities with relatively abundant resources may be able to achieve a similar goal by developing technologies to help individuals with self-tracking. While open borders and free movement of residents may make it hard to keep track of positive cases in populous cities, especially when cases go unreported, the authorities could use the tracking data at least to trace contacts of severely ill patients who require hospitalisation.

However, more than contact tracing, China should focus on inoculating the people. To promote vaccination among the elderly, who are more vulnerable and often tend to be more suspicious of the efficacies of vaccines, the Singaporean government made a bigger push to reach out to them. Ong Ye Kung, Singapore’s health minister, said that authorities might even resort to “knocking on their [seniors’] doors if necessary”.

Indeed, high vaccination rates played an important role in controlling the pandemic. By the end of 2021, the vaccination rate in Singapore was as high as 87%, with more than 40% of the population having had booster shots as well. Among those who had been vaccinated, the death rate from COVID was 0.9 per 10,000 people, while the death rate among the unvaccinated was 10 times higher, with 9 out of 10,000 dying. With adequate resources, Singapore was able to prepare for a spike in infections by administering vaccines, stockpiling antiviral drugs, and expanding the number of ICUs. A lesson for China is that the country should adopt a more active stance in encouraging the elderly to be vaccinated and in improving medical facilities.

Conclusion

China can learn lessons from both Singapore and India in managing its reopening. Rural China, with limited resources and a high rate of internal migration, should swiftly prepare robust medical infrastructure to defend against sequential waves and to track COVID variants. This would involve reallocating the country’s healthcare investment from urban to rural regions. Urban China, with adequate medical resources, can improve citizens’ self-awareness by providing tracking devices and quarantine facilities.

Both Singapore and India have gone through large-scale outbreaks; China is now about to face the first round of mass infections. Since the notion of natural herd immunity is tenuous in the case of COVID, given that reinfection is highly possible after one to three months, China should prepare for herd immunity through high vaccination rates; otherwise, the consequences of reopening can be serious.