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Context

The Exemplars in COVID-19 conceptual framework outlines key factors that could help explain countries’ COVID-19 burden and outcomes. These key factors are divided into two categories: (1) contextual and system factors (i.e., demographic, geographic, or environmental) and (2) policies and interventions. Contextual and system factors cannot easily be influenced in the near term, whereas policies and interventions factors can.

Although our research focuses primarily on the policy choices made by officials during the early phases of the pandemic, a country’s ability to limit COVID-19 transmission and related deaths could also be attributed to contextual factors, including those below.

Exemplars in COVID-19 conceptual framework for assessing epidemic preparedness and response

Contextual factors

Demographic indicators and pre-pandemic health context

IHME, World Bank

Underlying population-level health characteristics that shaped Sri Lanka’s experience in the early months of the COVID-19 pandemic include the following.

Age structure

Sri Lanka’s population is aging—in 2011, more than 25% of Sri Lankans were 0 to 14 years of age, 67% were 15 to 64, and nearly 8% were 65 and older (compared with just 4% in that age group in the 1960s and 1970s). In 2021, about 23% of Sri Lankans were 0 to 14 years of age, 65% were 15 to 64, and nearly 12% were 65 and older.1,2 Researchers expect the shares of the population 65 and older and 85 and older to increase to 20% and 3%, respectively, by 2050.

Elderly adults are significantly more likely to die from COVID-19 than younger adults and children.3 Countries around the world vary widely in their age structures: in some African countries, fewer than 2 percent of the population is 70 years or older, while in some European countries that share is more than 15 percent.4 Some research suggests that accounting for variation in age structure between countries may explain nearly 50 percent of the variation in COVID-19 mortality.5

 

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Chronic health conditions

Since the 1960s, Sri Lanka’s disease burden has shifted away from infectious diseases and maternal and child health conditions. By the 1990s, noncommunicable diseases accounted for much of the country’s disease burden, although age-specific mortality rates for several of these have been declining since the 2010s. Sri Lanka has eliminated several major infectious diseases, including polio (in 1993) and malaria (in 2016); others, such as HIV/AIDS and tuberculosis, are at low levels of prevalence. The infectious disease of most notable public concern is dengue, which is endemic in Sri Lanka (as in much of Southeast Asia). Cardiovascular disease and diabetes are the leading causes of death: the prevalence of adults with diabetes (23%) is among the highest in the world, and 28% of adults suffer from hypertension.6

A variety of chronic health conditions like high blood pressure, diabetes, and cardiovascular disease are associated with greater rates of mortality from COVID-19.3 HIV can make individuals susceptible to infectious diseases because of how it impacts the immune system. Similarly, cancer and cancer treatments like chemotherapy frequently disrupt the immune system, leaving individuals vulnerable to severe infection.7

 

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Smoking prevalence and ambient air pollution

According to the World Health Organization, there were 2.1 million tobacco users in Sri Lanka in 2018. Nearly half of all men between the ages of 18 and 69 used tobacco (29% were smokers, and 26% used smokeless tobacco) compared with just 5% of women (nearly all of whom used smokeless tobacco). About 24% of adults and 13% of children were exposed to secondhand smoke at home.8 In Sri Lanka, smokers tend to be less educated, lower income, and more rural than their nonsmoking counterparts.9

Sri Lanka’s air is moderately polluted (the average annual concentration of PM2.5 was 25.2 µg/m³ in 2019). Experts attribute the country’s air pollution to emissions from older vehicles, agricultural by-products, and petroleum refining.10

Fine particulate matter, especially matter small enough to reach the deepest part of the lungs, causes chronic pulmonary injury and inflammation.3,11 Individuals exposed to these particles may be more likely to be infected with respiratory pathogens and to have more severe outcomes.

Sri Lanka is a multiethnic, multilinguistic, and multireligious lower-middle-income country dominated by its Sinhalese Buddhist majority. In 1931, when Sri Lanka was a British colony known as Ceylon, the Donoughmore Constitution provided for self-rule with universal adult suffrage making it the first predominantly nonwhite colony to achieve self-rule on this basis.12 In 1948, Ceylon gained independence as the Dominion of Ceylon within the British Commonwealth and adopted the Soulbury Constitution. This constitution provided for minority rights but fatally undermined them by adopting a system that did not have proportional representation—which made it relatively easy for political parties to achieve parliamentary supermajorities and encouraged pursuit of ethnic majoritarianism. This led to growing ethnic tensions in the 1950s and open conflict and terrorism in the 1970s. Subsequent constitutional reforms in the 1980s—proportional representation in elections, devolution, and official language status for both Sinhala and Tamil—came too late to prevent the growing unrest. Since the 1950s, political power in Sri Lanka has alternated between two major parties that have shared a practical commitment to promoting the interests of the Sinhala Buddhist majority.13

Sri Lanka’s military has played a crucial role in the country’s political history, defeating three insurgencies against the country’s democratic system, while always remaining subservient to Sri Lanka’s elected civilian leaders. It stopped two insurrections (in 1971 and in 1987–1989) by the predominantly Sinhala and Maoist Janatha Vimukthi Peramuna, and the decades-long violent campaign (1975–2009) by the Liberation Tigers of Tamil Eelam for a separate Tamil ethnic state.14

Much of the differences in social, health, and development outcomes between Sri Lanka and the rest of South Asia can be traced to Sri Lanka’s long history of self-governance and democracy. From the 1930s, the country has prioritized health and education, establishing an extensive network of free hospitals and clinics that delivered curative and preventive care.15

During the British occupation, Ceylon was a major exporter of tea, rubber, and other plantation crops,16 and taxes on these goods helped finance its initial investment in health and other social infrastructure. From the 1970s to the 1990s, Sri Lanka expanded the production and export of manufactured goods.17 Since the 1990s, tourism and remittances from people who travel abroad to work have also become substantial economic engines.18,19

Since the 1970s, Sri Lankan policymakers have reduced tax revenues as a share of national income, relying instead on deficit spending and foreign borrowing.20 According to the World Bank, tax revenue was 19% of Sri Lanka’s gross domestic product (GDP) in 1990 and just 8% of GDP in 2020.21

After the elections in 2019, the new government cut taxes further: it reduced the VAT from 15% to 8% and abolished others altogether, including a 2% Nation Building Tax on businesses. These tax cuts came even though the Sri Lanka Health and Ageing Study Wave 1 survey in late 2019 found that just 4% of respondents thought taxes were too high, and most supported tax increases to pay for higher social spending.22 As a result, Sri Lanka’s credit rating was downgraded, and it lost access to the international financial markets it relied on. In 2020, the government started dipping into its foreign reserves to meet debt obligations.23,24

Sri Lanka has a long history of experience managing infectious disease. During the British occupation through 1948, colonial health authorities developed systems for quarantine and surveillance reporting to prevent the importation and spread of infections, especially among plantation laborers.25

For centuries, and through the first decade of the 20th century, malaria was a major cause of death in Sri Lanka. In the 1930s, a major malaria epidemic killed hundreds of thousands of people and shaped Sri Lanka’s official commitment to establishing an extensive network of free public health facilities, particularly in rural areas.26 After a century-long campaign of disease surveillance, reporting, and health education, which shifted from large-scale vector control to intensive case detection—and in spite of the three-decade civil war—in 2016 the World Health Organization declared that Sri Lanka had eliminated malaria.27,28 Since then, the Anti-Malaria Campaign has maintained an effective apparatus for surveillance and rapid response, which has kept imported cases from leading to local transmission.29,30

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Sri Lanka has successfully eliminated other major communicable diseases, including lymphatic filariasis and maternal and neonatal tetanus.31 Since the 2000s, however, the country has experienced large-scale dengue outbreaks every few years. The most recent, in 2017, resulted in more than 186,000 reported cases and 440 deaths.32,33 Sri Lanka was relatively less affected by Ebola, SARS, MERS-CoV, and influenza A.

System factors

Beyond policy interventions, other modifiable factors under the short-term control of countries and governments that can help shape countries’ pandemic outcomes (such as testing strategies, disease surveillance, laboratory capacities, contact tracing programs, case management, mobility restrictions, and surge response coordination), it is also important to consider preexisting system factors, such as the strength and structure of a country’s health care system and supply chains, in any analysis of a country’s COVID-19 preparedness and response.

Sri Lanka’s strong capacity for securing and distributing medicines, vaccines, and medical supplies predated the COVID-19 pandemic.34 Its centralized public sector procures these goods in bulk via the State Pharmaceutical Corporation, typically for much lower prices than private importers pay, and distributes items to government patients free of charge through Ministry of Health care facilities.35 The private sector also imports medicines and other key supplies, which it distributes through private retailers and medical providers.36 This combined public-private system achieves a high level of supply of medicines at a relatively low cost to government and individuals.

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Typically, Sri Lanka imports about 85% of its medicines.37 The rest are locally produced, typically by formulating imported active pharmaceutical ingredients, by the Sri Lanka State Pharmaceutical Manufacturing Corporation and sold to the State Pharmaceutical Corporation and private distributors.38 Sri Lanka lacks substantial local vaccine manufacturing capacity, requiring them to procure vaccines from outside of the country.

Sri Lanka has a large and cost-competitive garment-manufacturing sector, which means it had substantial capacity to produce masks and medical clothing from the start of the pandemic.39,40

Medical supplies donated from other countries require two separate approval processes: regulatory approval if the item is not licensed for medical use in Sri Lanka, and a separate approval for exemption from customs taxes. According to key informant interviews, this is a key weakness in Sri Lanka’s supply chain for pandemic preparedness because it causes delays in accepting and distributing critical medical donations in emergency situations.

Sri Lanka has two parallel health systems that are largely independent from one another. The taxpayer-funded public health system, managed by the Ministry of Health and provincial departments of health, is an integrated system that delivers a comprehensive range of services including preventive care, maternal and child health care, heart surgery, and even liver transplants (although access to costly treatments may be limited and rationed by waiting lists). Services in this public health system are essentially free to all. Underfunding is most apparent in the supply of medicines and laboratory tests; high-income patients often buy these from private pharmacies or providers.41

All Sri Lankans have universal access to public facilities, but high-income patients often seek care in private hospitals and clinics on a fee-for-service basis.41 Private insurance in the formal sector accounted for 10% of overall private spending in 2019.42 Government doctors are permitted to engage in private practice outside their duty hours.43

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Sri Lanka’s public delivery system achieves high levels of access, efficiency, and quality of care despite relatively low spending (perhaps due to intense physician training among other factors).44,45 Consequently, use of medical services by the average Sri Lankan is comparable to that of Organisation for Economic Co-operation and Development (OECD) countries.46 It is also generally equal across income levels. In 2019, the public sector accounted for 55% of outpatient and 96% of inpatient episodes, half of all medicines supply, and almost all preventive care.41

For decades, Sri Lanka has achieved exemplary universal health care outcomes: high life expectancy, a low under-five mortality rate, and utilization rates for medical care that match OECD countries.47 In 2019, Sri Lanka’s Ministry of Health released the Sri Lanka Essential Health Service Package,48 a list of services typically provided by lower-level primary care facilities, as a planning tool to expand coverage and guide investment.

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Universal Health Care Coverage Index for Sri Lankan health services

GBD 2019 Universal Health Coverage Collaborators

 

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Most public facilities provide a comprehensive list of essential health services, including almost all preventive services; family planning; facility-based childbirth; maternal and child care; and nonspecialized treatment of infections including tuberculosis and HIV/AIDS, and common noncommunicable diseases such as diabetes, hypertension, and accidents.41

Health care financing in Sri Lanka

The two major sources of health financing in Sri Lanka are the government budget and out-of-pocket payments. In 2018, out-of-pocket spending accounted for 42% of current health expenditure, government spending 48%, employer spending 5%, and voluntary health insurance 4%.49

In Sri Lanka, contributions by nonprofit institutions or nongovernmental organizations to health care is minimal (1% of total spending). External development assistance accounted for only 0.2% of total health care spending in 2019. Most of this money was channeled to the public sector.49

In 2018, Sri Lanka’s total health expenditure per capita was US$170, or 4.4% of GDP.50 Although total health expenditure is the standard metric for global health spending comparisons, Sri Lanka shifted to using current expenditure on health, according to the Organisation for Economic Co-operation and Development System of Health Accounts 2011 revision.51In 2018, Sri Lanka’s per capita current expenditure on health was US$122, or 2.9% of GDP.49 This is relatively low compared with countries of the same income level.42

Current Expenditure on Health (CEH) across sources of financing, 1990-2018

Institute for Health Policy

In theory, all services provided at public facilities are free to patients. However, public-sector patients can be directed to private pharmacies and diagnostic services to obtain medicines and laboratory tests if they are not available in a public facility.

Shifting the burden of out-of-pocket spending to higher-income people who choose to use private services minimizes that spending for those who use free public services. This was accomplished through policy changes that have ultimately increased financial protection for lower income populations.

Even before the COVID-19 pandemic began, Sri Lanka’s strong health system had substantial experience and competency in disease surveillance, contact tracing, and handling of infectious disease outbreaks, honed from over a century of experience in eliminating malaria and other diseases.44 In addition, it has a technically competent, efficient national immunization program that achieved coverage levels for child immunization better than most high-income countries. Its system of hierarchical control and management of public health services facilitated rapid, uniform response across the whole island. Finally, close alignment at the district management level between preventive health services and the public sector’s curative services dates back to health reforms in the 1960s.

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The health system also enjoyed high levels of public trust. Doctors, ministries of health, and the overall health system have high favorability ratings compared with other countries, in part because health services have high rates of contact with the population: more than 90% of mothers use public-sector maternal and child health services, and 97% of adults report using a public-sector health facility in the past year.6,52,53,54,55 The World Health Organization’s 2017 Joint External Evaluation of Sri Lanka’s International Health Regulations core capacities found that Sri Lanka had strengthened its capacities in laboratory testing, surveillance systems, and human resources for health—all of which would be essential to the country’s response to the COVID-19 pandemic.56 However, Sri Lanka struggled to sufficiently ramp up its testing capacity to adequately match increasing demand in COVID-19 waves past mid-2020.

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Key recommendations from the Joint External Evaluation for Sri Lanka include:

  • Fostering a true One Health approach through increased multisectoral engagement
  • Establishing integrated surveillance across animal and human health sectors, and across all levels of government
  • Ensuring improved documentation of national plans, memoranda of understanding, and standard operating procedures to ensure sustainable and scalable health security

Sri Lanka’s 2021 Global Health Security Index score ranked 105th out of 195 countries.57 However, research by Sri Lankan investigators and others has shown that the Global Health Security Index measure performed poorly in predicting performance in controlling COVID 19.58,26

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Outbreak factors

Daily new confirmed COVID-19 cases per million people in Sri Lanka, Asia and the World

Our World in Data

Time series of COVID-19 mortality rate in Sri Lanka, Asia and the World

Our World in Data

The COVID-19 pandemic in Sri Lanka had five phases: 

Phase 1: Initial Outbreaks (January–June 2020)

In the first phase, sustained local transmission was prevented and the government pursued a successful zero-COVID strategy.

Sri Lanka quickly set up border screening of arrivals from China and PCR testing facilities after China shared the SARS-CoV-2 genetic sequence and the World Health Organization announced the possibility of human-to-human transmission in January 2020. On January 27, 2020, PCR testing confirmed the country’s first case: a Chinese tourist who had come to the country two weeks earlier. This first case was isolated and did not lead to further transmission.

No new cases were detected that February, and travel restrictions, screening, and mandatory quarantine of arrivals were intensified in early March. Temperature and symptom screening were imposed on all arrivals, but restrictions focused on arrivals with a travel history to Italy, Korea, and Iran. Health authorities were slow to react to information in early March that COVID-19 transmission in Europe—Sri Lanka’s major tourist market—and the United States was higher than in China. The first case of local transmission, a tour guide working with Italian tourists, was confirmed on March 11. Other case detections in the community followed. It was only after public and private appeals by the Government Medical Officers Association, Institute for Health Policy, and others59 that Sri Lankan officials took steps to secure the country’s borders. All passenger arrivals by air were suspended on March 19, and arrivals by sea were suspended on March 22.

From March to September 2020, the spread of COVID-19 was controlled by the mix of border closures, quarantine, and intensive contact tracing and isolation following detection of new cases in the community. This response was relatively successful in suppressing local transmission except for repeated, localized outbreaks seeded by the initial virus entry in March 2020. The government also imposed an island-wide lockdown in March and April 2020, which was followed by several localized lockdowns in response to new outbreaks.

Phase 2: Continuous Local Transmission (July–December 2020)

This phase marks the start of sustained local transmission, which for several months remained undetected, but eventually manifested in rising case numbers.

As the initial outbreaks were controlled and new local case detection fell to zero, the government adopted a zero-COVID strategy.60,61 This strategy resembled the approach adopted by China, Taiwan, Australia, and New Zealand. The philosophy was to minimize entry of the virus through effective border security, and to take aggressive actions to stop any new local outbreaks so that transmission was brought to manageable levels—effectively zero cases—and citizens could live their normal lives.

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From April to October 2020, the government’s approach appeared to be effective: much of the country was able to function for long periods of time without lockdowns or fear of infection. The strategy faltered as early as June 2020, however, when (according to subsequent genomic and epidemiological analyses) the virus entered the country and began a chain of continuous local transmission.62   This transmission remained undetected until October 2020, when it emerged as a large outbreak, known as the Brandix cluster, in and around a garment factory on the outskirts of Colombo. From that point on, Sri Lanka experienced continuous, visible local transmission of the virus.

Phase 3: The Alpha Wave and the Start of Vaccination (January–June 2021)

The national strategy unraveled as health authorities effectively gave up trying to prevent local transmission and attention switched to vaccination and opening borders in response to business interests.

In late 2020, the Sri Lankan government implicitly abandoned its original COVID-19 strategy. Borders were reopened to tourists from the end of 2020.

In early 2021, as evidence grew that this was leading to entry of the more infectious COVID-19 alpha variant, the government ignored calls by health officials and other experts to tighten border security, to intensify other public health and social measures, and to step up genomic sequencing to track the new variant. At this point, the interests of the tourism industry seemed to have taken precedence, and government ministers increasingly discussed the need to live with COVID-19.

Phase 4: Delta Wave (July–December 2021)

The country was hit by the delta variant, which resulted in the most severe wave of infections with thousands of deaths and eventually forced a two-month national lockdown.

Starting in January 2021, the official strategy shifted to mass vaccination and reliance on herd immunity63; efforts to control viral transmission through border security, testing and isolation, and other public health and social measures waned, as did efforts to use testing and isolation to control transmission.

The delta variant entered Sri Lanka in January 2021 and displaced the alpha variant in July. This led to a new surge in case numbers and the fourth delta wave from July to October 2021.64 This wave was much more serious than the preceding alpha wave: confirmed deaths peaked at more than 200 a day in early September. From August 16 through October 1, officials imposed a nationwide lockdown—although surveys showed that most of the public (66%), and especially lower-income Sri Lankans, thought the lockdown was too late.65 In fact, many had voluntarily curtailed their mobility before the lockdown was imposed. However, there was no effort to ramp up testing to help control the virus. Officially, the delta wave caused 11,588 deaths between July 9 and December 31, but researchers believe these deaths were substantially undercounted because of limited PCR testing.

Phase 5: Omicron (January 2022–ongoing)

The country has been hit by successive, lower-mortality omicron waves and attention has shifted to the consequences of economic collapse.

As the delta wave subsided in September 2022, the nationwide lockdown was lifted, and the economy gradually shifted back to normal until the arrival of the omicron variant started a series of waves that continued into the middle of 2022. The combination of immunity from previous natural infection and vaccination largely blunted the worst effects of this wave, and limited testing further reduced the number of official deaths. By this point, anxiety about and fear of COVID-19 had dissipated.66 From the beginning of 2022, a growing economic crisis stole much of the public’s attention.

Based on reported data from Our World in Data, which are influenced by low levels of testing and changing testing strategies, the COVID-19 pandemic resulted in 587,245 cases and 14,979 deaths by December 31, 2021.67 It is likely that most Sri Lankans had been infected at least once by early 2022, and actual deaths were more than 20,000 by the end of 2021. According to projections from the Institute for Health Metrics and Evaluation, excess mortality due to COVID-19 from January 1, 2020, to December 31, 2021, was 12,900 in Sri Lanka.68

 

The relative importance of the drivers of outcomes of interest during an epidemic or pandemic will depend on the nature of the specific pathogen. In the case of the COVID-19 pandemic, the SARS-CoV-2 virus is characterized by respiratory transmission by both symptomatic and asymptomatic individuals. The virus disproportionately impacts older adults and those with compromised immune systems and comorbidities. Although vaccines and therapies to reduce severe disease and fatal outcomes from SARS-Cov-2 were developed relatively quickly, this is not always the case for other pathogens with epidemic and pandemic potential.

For more information, please see How Does COVID-19 Compare with Past Epidemics and Pandemics?

 

Global and regional factors

Sri Lanka is an island nation, which means its COVID-19 response benefited from relatively easy border control, though its strong economic and commercial ties to India may have contributed to potential cross-border transmission.69 About 99% of all arrivals to the island came through the international airport in Colombo.70 It is not possible to conclude whether these conditions played a role in the spread of COVID-19 in Sri Lanka.

Sri Lanka has one of the highest average temperatures in the world, with two main seasons centered around the northeast monsoon season from September to March and the southwest monsoon season from May to August.71 While the majority of Sri Lanka’s topography is flat, there is a mountainous region in the southcentral region of the island, which affect patterns of rainfall and relative humidity throughout.

Respiratory viruses spread more easily through thin, dry air (and consequently at higher elevations) than through humid air.72 In different climates, outdoor temperature ranges can lead to increased congregating in climate-controlled indoor settings that can increase viral transmission potential.3 All these factors may influence how rapidly COVID-19 spreads in different countries and at different times of the year.

As climate change worsens, the risk of infectious disease outbreaks has increased, with climatic conditions becoming increasingly fertile ground for pathogenic transmission.73 Research has shown that many infectious diseases are susceptible to climate variability, flooding, droughts, and the animal and human migratory impact of a changing climate, leading to a rise in vector, food, and water-borne illness.74

 

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  1. 1
    Statista. Sri Lanka: age structure from 2011 to 2021. Accessed January 3, 2023. https://www.statista.com/statistics/728538/age-structure-in-sri-lanka/
  2. 2
    World Bank. Population ages 65 and above (% of total population) – Sri Lanka [data set]. Accessed January 3, 2023. https://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS?locations=LK
  3. 3
    COVID-19 National Preparedness Collaborators. Pandemic preparedness and COVID-19: an exploratory analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1, 2020, to Sept 30, 2021. Lancet. 2022;399(10334):1489-1512. https://doi.org/10.1016/s0140-6736(22)00172-6
  4. 4
    Ritchie H, Roser M. Age structure. Our World in Data. Accessed February 6, 2023. https://ourworldindata.org/age-structure
  5. 5
    COVID-19 Forecasting Team. Variation in the COVID-19 infection-fatality ratio by age, time, and geography during the pre-vaccine era: A systematic analysis. Lancet. 399(10334):1469-1488. https://doi.org/10.1016/s0140-6736(21)02867-1
  6. 6
    Rannan-Eliya RP, Wijemunige N, Perera P, et al.; SLHAS Collaborators 2022. Prevalence and associations of hypertension in Sri Lankan adults: estimates from the SLHAS 2018–19 survey using JNC7 and ACC/AHA 2017 guidelines. Glob Heart. 2022;17(1):50. https://doi.org/10.5334/gh.1135
  7. 7
    Bollyky TJ, Tohme S, Kiernan S. Noncommunicable diseases kill slowly in normal times and quickly in COVID-19 times. Council on Foreign Relations. Last updated September 10, 2021. Accessed February 6, 2023. https://www.cfr.org/article/noncommunicable-diseases-kill-slowly-normal-times-and-quickly-covid-19-times
  8. 8
    World Health Organization (WHO). Tobacco Factsheet 2018, Sri Lanka. Geneva: WHO, 2018. Accessed January 3, 2023. https://apps.who.int/iris/bitstream/handle/10665/272688/wntd_2018_srilanka_fs.pdf?sequence=1
  9. 9
    Madurawala S, Karunanayake C, Thilanka C. Tobacco Smoking in Sri Lanka: Identifying and Understanding the Last Mile Smokers. Sri Lanka: Institute of Policy Studies of Sri Lanka; 2023. Accessed January 10, 2023. https://think-asia.org/bitstream/handle/11540/12603/Tobacco-Smoking-in-Sri-Lanka-Identifying-and-understanding-the-last-mile-smokers.pdf?sequence=1
  10. 10
    IQAir. Air quality in Sri Lanka. Accessed January 3, 2023. https://www.iqair.com/us/sri-lanka
  11. 11
    Wu X, Nethery RC, Sabath MB, Braun D, Dominici F. Air pollution and COVID-19 mortality in the United States: Strengths and limitations of an ecological regression analysis. Sci Adv. 2020;6(45):eabd4049. https://doi.org/10.1126/sciadv.abd4049
  12. 12
    Barron TJ. The Donoughmore commission and Ceylon’s national identity. J Commonw Comp Polit. 26(2):147-157. https://doi.org/10.1080/14662048808447539
  13. 13
    Waidyatilake B, Sivaloganathan M. Can Buddhist values overcome nationalism in Sri Lanka? Published July 25, 2018. Accessed January 3, 2023. https://carnegieindia.org/2018/07/25/can-buddhist-values-overcome-nationalism-in-sri-lanka-pub-76922
  14. 14
    Anandakuygan N. The Sri Lankan Civil War and its history, revisited in 2020. Harvard International Review. August 31, 2020. Accessed January 3, 2023. https://hir.harvard.edu/sri-lankan-civil-war/
  15. 15
    Jones M. The Sri Lankan path to health for all from the colonial period to Alma-Ata. In: Medcalf A, Bhattacharya S, Momen H, et al., ed. Health for All: The Journey of Universal Health Coverage. Hyderabad, India: Orient Blackswan; 2015. https://www.ncbi.nlm.nih.gov/books/NBK316260/
  16. 16
    McCune S. Sequence of plantation agriculture in Ceylon. Econ Geogr. 1949;25(3):226-235. https://doi.org/10.2307/141335
  17. 17
    Ross RR, Matles Savada A, ed. Industry. In: Ross RR, Matles Savada A, ed. Sri Lanka: A Country Study. Washington, DC: GPO for the Library of Congress, 1988. https://tile.loc.gov/storage-services/master/frd/frdcstdy/sr/srilankacountrys00ross/srilankacountrys00ross.pdf
  18. 18
    World Bank. International tourism, receipts (current US$) – Sri Lanka [data set]. Accessed January 3, 2023. https://data.worldbank.org/indicator/ST.INT.RCPT.CD?locations=LK;
  19. 19
    World Bank. Personal remittances, received (% of GDP) – Sri Lanka [data set]. Accessed January 3, 2023. https://data.worldbank.org/indicator/BX.TRF.PWKR.DT.GD.ZS?locations=LK
  20. 20
    Mashal M, Schmall E. Showdown at the mansion gates: how Sri Lankans rose up to dethrone a dynasty. New York Times. August 12, 2022. https://www.nytimes.com/2022/08/12/world/asia/sri-lanka-rajapaksa.html
  21. 21
    World Bank. Tax revenue (% of GDP) – Sri Lanka [data set]. Accessed January 3, 2023. https://data.worldbank.org/indicator/GC.TAX.TOTL.GD.ZS?locations=LK
  22. 22
    Rannan-Eliya R. Sri Lankan thinking on national issues, spending and taxes. Institute for Health Policy blog. Published March 13, 2020. Accessed January 6, 2023. https://www.ihp.lk/blogs/ravi/2020/134/
  23. 23
    Timeline: Sri Lanka’s economic crisis was in the making from November 2019. Firstpost. April 4, 2022. https://www.firstpost.com/world/timeline-sri-lankas-economic-crisis-was-in-the-making-from-november-2019-10515461.html
  24. 24
    Bhowmick S. How Sri Lanka’s tax cuts crippled its economy. Observer Research Foundation. Published August 6, 2022. Accessed January 3, 2023. https://www.orfonline.org/expert-speak/how-sri-lankas-tax-cuts-crippled-its-economy/
  25. 25
    Meegama SA. Cholera epidemics and their control in Ceylon. Popul Stud (Camb). 1979;33(1):143-156. https://doi.org/10.2307/2173871
  26. 26
    Rannan-Eliya RP, Sikurajapathy L. Sri Lanka: “Good Practice” in Expanding Health Care Coverage. Colombo, Sri Lanka: Institute for Health Policy; 2009. Accessed January 10, 2023. https://www.ihp.lk/publications/docs/RSS0903.pdf
  27. 27
    World Health Organization. WHO certifies Sri Lanka malaria-free. Published September 5, 2016. Accessed August 20, 2022. https://www.who.int/southeastasia/news/detail/05-09-2016-who-certifies-sri-lanka-malaria-free
  28. 28
    Ahmed A, Hounsell KG, Sadiq T, et al. Eliminating malaria in conflict zones: public health strategies developed in the Sri Lanka Civil War. BMJ Glob Health. 2021;6(12):e007453. https://doi.org/10.1136/bmjgh-2021-007453
  29. 29
    Datta R, Mendis K, Wikremasinghe R, et al. 2019. Role of a dedicated support group in retaining malaria-free status of Sri Lanka. J Vector Borne Dis. 2019;56(1):66-69. https://doi.org/10.4103/0972-9062.257778
  30. 30
    Ranaweera P, Wickremasinghe R, Mendis K. Preventing the re-establishment of malaria in Sri Lanka amidst the COVID-19 pandemic. Malar J. 2020;19(1):386. https://doi.org/10.1186/s12936-020-03465-5
  31. 31
    World Health Organization (WHO). WHO Sri Lanka Annual Report 2016: A Journey of Commitment, Passion and Dedication. Geneva: WHO; 2017. https://apps.who.int/iris/handle/10665/254823
  32. 32
    Tissera HA, Jayamanne BDW, Raut R, et al. Severe dengue epidemic, Sri Lanka, 2017. Emerg Infect Dis. 2020;26(4):682-691. https://doi.org/10.3201/eid2604.190435
  33. 33
    Malavige GN, Jeewandara C, Ghouse A, Somathilake G, Tissera H. Changing epidemiology of dengue in Sri Lanka—challenges for the future. PLoS Negl Trop Dis. 2021;15(8):e0009624. https://doi.org/10.1371/journal.pntd.0009624
  34. 34
    Guyer AL. Procurement of Medicines in Sri Lanka: A Case Study. India Health Systems Project, Working Paper #4. Cambridge, MA: Harvard T.H. Chan School of Public Health, Department of Global Health and Population; 2021. Accessed January 10, 2023. https://sites.sph.harvard.edu/india-health-systems/2021/06/04/wp4-medicines-sri-lanka/
  35. 35
    State Pharmaceuticals Corporation of Sri Lanka. About SPC. Accessed January 3, 2023. https://www.spc.lk/about-spc.php
  36. 36
    Govindaraj R, Navaratne K, Cavagnero E, Seshadri SR. Health Care In Sri Lanka: What Can the Private Health Sector Offer? New Delhi: World Bank; 2014. Accessed January 3, 2023. https://documents1.worldbank.org/curated/en/423511468307190661/pdf/899540WP0Box380th0Care0in0Sri0Lanka.pdf
  37. 37
    Health crisis looms as Sri Lanka medicines run out. France 24. April 22, 2022. https://www.france24.com/en/live-news/20220422-health-crisis-looms-as-sri-lanka-medicines-run-out
  38. 38
    Sri Lanka Chamber of the Pharmaceutical Industry (SLCPI). The Future of Pharmaceutical Manufacturing in Sri Lanka: Final Report. Colombo, Sri Lanka: SLCPI; 2020. Accessed January 10, 2023. https://www.slcpi.org/wp-content/uploads/2020/10/Stax-Report-for-SLCPI_Local-Pharma-Manufacturing_FINAL_08252020.pdf
  39. 39
    Sri Lanka opens its first automated mask manufacturing plant. Xinhua. March 17, 2021. http://www.xinhuanet.com/english/asiapacific/2021-03/17/c_139816917.htm
  40. 40
    Rajapaksa L, De Silva P, Abeykoon A, et al. Sri Lanka Health System Review. New Delhi: World Health Organization Regional Office for South-East Asia; 2021. Accessed January 10, 2023. https://apo.who.int/publications/i/item/sri-lanka-health-system-review
  41. 41
    Rajapaksa L, De Silva P, Abeykoon A, et al. Sri Lanka Health System Review. New Delhi: World Health Organization Regional Office for South-East Asia; 2021. Accessed January 10, 2023. https://apo.who.int/publications/i/item/sri-lanka-health-system-review
  42. 42
    Amarasinghe SN, Fonseka HSH, Dalpatadu KCS, Rannan-Eliya RP. Sri Lanka Health Accounts: National Health Expenditure 1990-2019. Colombo, Sri Lanka: Institute for Health Policy; 2021. Accessed January 10, 2023. http://www.ihp.lk/publications/docs/HES2106.pdf
  43. 43
    Rannan-Eliya RP, Jayawardhane P, Karunaratne L. Private primary care practitioners in Sri Lanka. In: Yazbeck AS, Peters DH, ed. Health Policy Research in Asia: Building Capacity for Reform. Washington, DC: World Bank; 2003: 279-303. https://web.worldbank.org/archive/website00811/WEB/PDF/11_YAZBE.PDF
  44. 44
    Dalpatadu S, Perera P, Wickramasinghe R, Rannan-Eliya RP. The Sri Lankan Model of Public Hospital Governance: A Case Study. Sri Lanka: Institute for Health; 2016. Accessed January 10, 2023. https://l4uhc.world/wp-content/uploads/2019/11/ANHSS-Public-Hospitals-Sri-Lanka.pdf
  45. 45
    Rannan-Eliya RP, Wijemanne N, Liyanage IK, et al. Quality of inpatient care in public and private hospitals in Sri Lanka. Health Policy Plan. 2015;30(suppl 1):i46-58. https://doi.org/10.1093/heapol/czu062
  46. 46
    Smith OK. Sri Lanka: Achieving Pro-Poor Universal Health Coverage without Health Financing Reforms. Universal Health Coverage Study Series No. 38. Washington, DC: World Bank Group; 2018. Accessed January 3, 2023. https://documents.worldbank.org/en/publication/documents-reports/documentdetail/138941516179080537/sri-lanka-achieving-pro-poor-universal-health-coverage-without-health-financing-reforms
  47. 47
    Leadership for Universal Health Coverage. Sri Lanka. Accessed January 3, 2023. https://l4uhc.world/countries/countries-sri-lanka/
  48. 48
    Sri Lanka Ministry of Health (MOH). Sri Lanka Essential Health Services Package. Colombo, Sri Lanka: MOH; 2019. Accessed January 3, 2023. http://www.health.gov.lk/moh_final/english/public/elfinder/files/publications/2019/SLESP-2019.pdf
  49. 49
    De Alwis SS, Fernando T, Rannan-Eliya RP. Sri Lanka Health Accounts: National Health Expenditure 1990-2008. Health Expenditure Series No.2. Colombo, Sri Lanka: Institute for Health Policy; 2011. Accessed January 3, 2023. https://www.ihp.lk/publications/docs/HES1102.pdf
  50. 50
    Institute of Health Metrics and Evaluation. Flows of development assistance for health. Accessed January 3, 2023. https://vizhub.healthdata.org/fgh/
  51. 51
    Organisation for Economic Co-operation and Development (OECD). A System of Health Accounts 2011. Paris: OECD; 2017. Accessed January 10, 2023. https://www.oecd.org/publications/a-system-of-health-accounts-2011-9789264270985-en.htm
  52. 52
    Institute for Health Policy. Analysis by authors of SLHAS Wave 1 & Wave 2 data collected from Nov. 2018 to Nov. 2019. Colombo, Sri Lanka: Institute for Health Policy; 2022. https://r4d-ncd.org/2020/06/10/sri-lanka-health-and-ageing-survey/
  53. 53
    Rannan-Eliya RP, De Mel N. Resource Mobilization for the Health Sector in Sri Lanka. Boston, MA: Harvard School of Public Health; 1997. http://koha.ips.lk/cgi-bin/koha/opac-detail.pl?biblionumber=693
  54. 54
    Narayan D, Chambers R, Shah MK, Petesch P. Voices of the Poor: Crying Out For Change. Washington, DC: World Bank Group; 2000. Accessed January 3, 2023. http://documents.worldbank.org/curated/en/501121468325204794/Voices-of-the-poor-crying-out-for-change
  55. 55
    Bhatia M, Rannan-Eliya R, Somanathan A, Huq MN, Pande BR, Chuluunzagd B. Public views of health system issues in four Asian countries. Health Aff (Millwood). 2009;28(4):1067-1077. https://doi.org/10.1377/hlthaff.28.4.1067
  56. 56
    World Health Organization (WHO). Joint External Evaluation of IHR Core Capacities of the Democratic Socialist Republic of Sri Lanka. Geneva: WHO; 2017. Accessed January 2, 2023. https://www.who.int/publications/i/item/WHO-WHE-CPI-REP-2017.33
  57. 57
    Global Health Security Index. 2021 GHS Index Country Profile for Sri Lanka. Accessed January 3, 2023. https://www.ghsindex.org/country/sri-lanka/
  58. 58
    Haider N, Yavlinsky A, Chang YM, et al. The Global Health Security index and Joint External Evaluation score for health preparedness are not correlated with countries’ COVID-19 detection response time and mortality outcome. Epidemiol Infect. 2020;148:e210. https://doi.org/10.1017/S0950268820002046
  59. 59
    Padeniya AB. 2020. GMOA Proposes drastic measures to control COVID19 pandemic. Letter. 16 March 2020. https://www.facebook.com/login/?next=https%3A%2F%2Fwww.facebook.com%2Fgmoasl%2Fphotos%2Fa.1640552802880194%2F2594134874188644%2F%3Ftype%3D3
  60. 60
    Government of Sri Lanka. Combatting COVID-19 Sri Lankan Approach. Colombo, Sri Lanka: Government of Sri Lanka; 2020. Accessed January 3, 2023. https://www.chamber.lk/images/COVID19/pdf/conceptpapergovt.pdf
  61. 61
    Pueyo T. Coronavirus: the hammer and the dance. Medium. March 19, 2020. https://tomaspueyo.medium.com/coronavirus-the-hammer-and-the-dance-be9337092b56
  62. 62
    Jeewandara C, Jayathilaka D, Ranasinghe D, et al. Genomic and epidemiological analysis of SARS-CoV-2 viruses in Sri Lanka. Front Microbiol. 2021;12:722838. https://doi.org/10.3389/fmicb.2021.722838
  63. 63
    President of Sri Lanka. President Gotabaya Rajapaksa’s special address to the nation. Published 2022. Accessed August 10, 2022. https://web.archive.org/web/20220320024835/https://www.president.gov.lk/president-gotabaya-rajapaksas-special-address-to-the-nation-2/
  64. 64
    Ranasinghe D, Jayathilaka D, Jeewandara C, et al. Molecular epidemiology of AY.28 and AY.104 delta sub-lineages in Sri Lanka. Front Public Health. 2022;1811:873633. https://doi.org/10.3389/fpubh.2022.873633
  65. 65
    Rannan-Eliya RP. Increasing Numbers of Sri Lankans Want to Migrate, Especially Youth and Disenchanted Government Voters. Colombo, Sri Lanka: Institute for Health Policy; 2021. Accessed January 4, 2023. https://www.ihp.lk/publications/publication.html?id=956
  66. 66
    Rannan-Eliya RP, Selvaratnam A, Dananjana T, Wisidagama N, Kapuge Y, Weerawardena N. Consumer Confidence Collapses Despite Waning Omicron Wave as Economic Disruption Hits. Colombo, Sri Lanka: Institute for Health Policy; 2022. Accessed January 4, 2023. https://www.ihp.lk/publications/docs/SLOTSReport202202.pdf
  67. 67
    COVID-19 Data Repository by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. Our World in Data. Accessed February 14, 2023. https://ourworldindata.org/coronavirus#explore-the-global-situation
  68. 68
    COVID-19 Excess Mortality Estimates 2020-2021. Institute for Health Metrics and Evaluation (IHME). 2022. https://ghdx.healthdata.org/sites/default/files/record-attached-files/IHME_EM_COVID_19_2020_2021_INFO_SHEET_Y2022M03D10.PDF
  69. 69
    India-Sri Lanka Economic and Trade Agreement. High Commission of India – Colombo, Sri Lanka. Updated January 2023. https://hcicolombo.gov.in/Economic_Trade_Engagement#:~:text=India%20has%20traditionally%20been%20among,US%24%205.45%20billion%20in%202021.
  70. 70
    Sri Lanka Tourism Development Authority (SLTDA). Annual Statistical Report 2020. Colombo, Sri Lanka: SLTDA; 2020. Accessed January 4, 2023. https://sltda.gov.lk/en/annual-statistical-report
  71. 71
    Climate Change Knowledge Portal – Sri Lanka. World Bank Group. https://climateknowledgeportal.worldbank.org/country/sri-lanka/climate-data-historical#:~:text=Sri%20Lanka%20has%20two%20main,hottest%20countries%20in%20the%20world.
  72. 72
    Khan AJ, Hussain H, Omer SB, et al. High incidence of childhood pneumonia at high altitudes in Pakistan: a longitudinal cohort study. Bull World Health Organ. 2009;87(3):193-199. https://doi.org/10.2471/blt.07.048264
  73. 73
    Mora C, McKenzie T, Gaw IM, et al. Over half of known human pathogenic diseases can be aggravated by climate change. Nat Clim Chang. 2022;12(9):869-875. https://doi.org/10.1038/s41558-022-01426-1
  74. 74
    The Lancet Microbe. Climate change: fires, floods, and infectious diseases. Lancet Microbe. 2021;2(9):e415. https://doi.org/10.1016/s2666-5247(21)00220-2
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