Challenges

Key challenges

Sri Lanka faces many pressing political concerns that have limited the resources available for sustaining pandemic prevention and response interventions. Challenges associated with the country’s COVID-19 response include the following.

Sri Lankan health authorities adopted a COVID-19 elimination strategy that echoed Australia’s and New Zealand’s.^1,2 However, it focused on the first two elements—effective border control and intensive contact tracing, and isolation in response to outbreaks—without enough attention to the third element, high levels of symptomatic testing at the primary care level. Starting in April 2020, the country did not invest in strengthening its testing capacity or setting up a systematic effort to test acute respiratory infection symptoms in the community.

Low levels of testing meant that sustained local transmission went undetected for months in mid-2020. By that time, community transmission was so extensive in relation to the country’s test-and-trace capacity that health authorities were unable to stop transmission.³ Instead of tightening control measures, authorities gradually reopened borders and reduced efforts to detect new cases or trace and isolate contacts of confirmed cases. Successive COVID-19 waves resulted in high infection rates and substantial disruption to essential health services in 2021.

Because the country did not invest more aggressively in expanding PCR testing capacity, despite World Bank funds for testing equipment and supplies becoming available in May 2020, it could not sustain necessary levels of daily testing even as cases mounted in the second half of 2020 and into 2021. Consequently, and ironically, many health officials and experts rejected calls for increasing testing as a tool to control transmission. Health authorities did not communicate the need for increased testing to political authorities, in part because of the “groupthink” observed in key decision-making bodies. This desire for conformity and consensus led to alternative views on testing not being seriously considered, failure to seek technical expertise from scientists outside the government, complacency following the initial success at controlling COVID-19, a medical culture that was generally averse to testing in clinical practice, and an environment of fiscal scarcity that worsened in 2020 following substantial tax cuts.

In Sri Lanka, routine preventive public health activities were disrupted from the start of the pandemic, typically because core public health staff were mobilized as frontline workers—first to contain COVID-19 transmission, then to provide vaccinations. Routine surveillance for other infections, such as leptospirosis and dengue, was most affected.

Mosquito control activities, which are crucial for preventing dengue, were undermined by the diversion of field staff for COVID-19 control, COVID-19 safety regulations prohibiting field staff from undertaking routine inspections of house interiors, and shortages of chemicals for fogging. Reduced mobility, social distancing, and masks reduced the transmission of many infectious diseases during the first two years of the pandemic—likely including dengue, which fell to one-quarter of predicted levels between March 2020 and April 2021 despite the pause in dengue control activities.⁴ Dengue vector breeding sites are also concentrated in workplaces—such as factories, construction sites, and schools—and not households.⁵ As mobility increased and other public health and social measures were relaxed, there was a surge in dengue cases beginning in December 2021.

As COVID-19 transmission increased, especially during the delta wave from August to December 2021, data from the Sri Lanka Health and Ageing Study (SLHAS) Wave 2 suggested considerable distrust in the government’s reporting on the pandemic. Inconsistent and inaccurate messaging about risk may have reduced the effectiveness of official communication. As the government reopened borders and reduced mitigation efforts, health officials increasingly understated the risk of COVID-19. For example, the MOH insisted there was no community transmission in early 2021, despite evidence that local transmission was both well-established and increasing. This message was rationalized based on a narrow World Health Organization definition of community transmission, but it did not correctly communicate the true situation and led many to question the credibility of health officials. It is unclear whether this messaging reflected the beliefs of health officials or whether it was an effort to align with the official desire to open borders, give up attempts to control the virus, and persuade the public to adjust to living with COVID-19.

Health officials were inadequately trained in public communication during a health crisis of the scale and nature of COVID-19. They often resorted to lecturing the public without conveying what they did not know or the underlying uncertainties given the novel and evolving nature of the pandemic. Health officials also often failed to communicate risks and uncertainties to political authorities, and at times suppressed information-sharing despite statutory obligations for transparency.

In 2022, Sri Lanka underwent a political and economic crisis, which likely further eroded public trust in the government.⁶ The president of Sri Lanka resigned following protests on July 9, 2022, and the Ministry of Health experienced continuous turnover throughout the year. The World Bank estimated that the poverty rate in the country doubled between 2021 and 2022.⁷

Throughout 2021, health officials and political authorities conveyed the message that vaccination would protect people and largely end the problem of COVID-19, without accurately conveying the inability of the vaccines to prevent most transmission or to prevent all serious morbidity. Uptake of the initial first two doses was high, but the public did not rush to get booster vaccinations when they were provided—a possible consequence of the earlier miscommunication of risks and benefits.