How did Sri Lanka respond to the COVID-19 pandemic?

Social distancing

From the beginning of the COVID-19 pandemic until early 2022, Sri Lanka’s government employed a range of social distancing measures to reduce transmission of the novel coronavirus. These measures included school and university closures and limitations on gatherings such as weddings.²⁶ Officials also imposed a nationwide curfew on March 20, 2020, although they did not declare a state of emergency. Over the next few months, officials eased and adjusted the curfew from place to place according to risk.²⁷

Public messaging—via video, leaflets, stickers, posters, and pictograms in Sinhala, Tamil, and English—also emphasized the importance of maintaining distance from others in public spaces.³

When curfews and lockdowns were lifted, officials released guidelines on safety in workplaces and on public transport. Working with the World Health Organization (WHO), they devised a marketing campaign called DReAM:

• D – Distancing
• Re – Respiratory etiquette (cough/sneeze using the inner side of your elbow and not directly in front of you)
• A – Aseptic techniques (handwashing, using hand sanitizer, avoiding touching your face)
• M – Mask (proper wearing of a face mask and its proper disposal)³

School closures

Schools, universities, and other training facilities were closed from mid-March to August 2020, and twice during the pandemic waves in 2021.³ Schools reopened in January 2022, but fuel shortages and power outages associated with economic crisis soon closed them again.^28,29

During these school closures, efforts were made to continue education through special television programs and the internet, but these would have had limited reach for lower-income students without internet connections and other key supplies. A 2020 survey showed that only 48% of households with children had a computer or smartphone and only 34% had an internet connection. Among the lowest-income group, only 21% had an internet connection.³

At some private schools, typically attended by children from high-income families, children benefited from relatively well-organized internet-based teaching during most shutdowns.³⁰

School Closures in Sri Lanka from March 2020 to March 2022

Other social distancing measures limited the maximum number of people allowed to congregate in public and at large gatherings such as weddings and funerals.³¹ These limits were relaxed or tightened throughout 2021 depending on case counts across the country.³ Efforts were also made to encourage public- and private-sector office workers to work from home, particularly during the delta wave, but most of Sri Lanka’s workers are not office workers and could not work from home.

In general, these efforts waned as the pandemic continued. For example, efforts to maintain social distancing in public transport were often undermined by efforts to save money and boost efficiency by reducing the number of buses and trains in service at one time.³² Additionally, many offices were exempt from the delta wave lockdowns, including public offices.³³ Enforcement of social distancing regulations, which critics claimed were sometimes selectively enforced against minority populations such as Muslims and Tamils, also became less intensive over time.³⁴

Lockdowns

Lockdowns also reduced population mobility in Sri Lanka. In March 2020, officials imposed seven weeks of lockdown, enforced by the military and police, that required everyone in the country except essential workers to stay home.³ This early lockdown successfully reduced population mobility in most places; however, residents of low-income, high-density urban settlements sometimes struggled to comply, making it difficult to eliminate local transmission in those areas.

As sustained local transmission began in July 2020, health authorities attempted to control the spread of the novel coronavirus by establishing local lockdowns in which travel across district borders was often prohibited.³

Mobility in Sri Lanka from March 2020 to December 2021

Political authorities concerned about the perceived economic and political costs of national lockdowns, particularly among low-income households who depended on daily wage labor, pushed health officials to avoid subsequent national lockdowns. Two additional national lockdowns were imposed, from May–June 2021 and August–October 2021; however, large numbers of exemptions appear to have undermined their effectiveness in reducing mobility.³⁵ The Sri Lanka Health and Ageing Study Wave 2 survey during the August–September 2021 lockdown found that the public—including low-income respondents—strongly supported the lockdown and believed it should have been imposed earlier and more stringently.²⁵

At the beginning of the pandemic, health authorities recommended that people wear masks when in public. Because supplies were limited, however, health authorities initially avoided imposing a mask mandate.³⁶

According to key informant interviews, the government provided guidance on when to wear face masks in 2020, requiring them in public settings where a minimum of about 3 feet (1 meter) of physical distancing is difficult to maintain, on public transport, and for those at high risk of severe illness from COVID-19.

Starting in October 2020, mask wearing in public was mandated.³⁷ The mandate was lifted in June 2022. Facebook survey data suggested high public compliance with the mandate.³⁸ However, people often wore masks incorrectly, reducing or even eliminating their protective effect—despite an investments in explanatory television and radio advertisements sponsored by governmental authorities; online webinars organized by community organizations; and billboards, posters, and stickers displayed at public places and transportation modes.^39,40

Mask Use in Sri Lanka from March 2020 to December 2021

Social and economic support was a key part of Sri Lanka’s pandemic response from the beginning of 2020. In fact, the presidential vision strategy issued in May 2020 explicitly named it as one of four key domains of action.¹ A range of economic and social support measures were targeted at both businesses and households—but even so, overall public spending on pandemic-related economic support was comparatively low. Among the primary reasons for this low spending may have been the lack of fiscal capacity stemming from the tax cuts implemented at the start of the pandemic and the high levels of public debt, which constrained the government’s ability to borrow.

Aid to businesses

Businesses received tax subsidies in the form of exemptions, waived penalty fees, and extended deadlines for tax payments; tax exemptions on imports of pharmaceutical and medical goods and personal protective equipment; and pauses on loan repayments.⁴⁶ The Central Bank also relaxed prudential requirements for banks and developed a refinancing facility to provide small and medium enterprises with concessional working-capital loans. The government did not implement measures that would have helped workers maintain their employment, such as direct subsidies to firms to pay wages or increase government spending to maintain domestic demand.³

Aid to households

Support measures for households primarily consisted of cash grants, including one-off or monthly grants of 5,000 Sri Lankan rupees (US$27) to low-income earners, older adults, and households most affected by COVID-19 or lockdown from April through December 2020^3,47; 10,000 Sri Lankan rupees (US$55) interest-free advances to some welfare (Samurdhi) recipients⁴⁸ ; and dry ration packs for some families.⁴⁹ Officials also waived fees for late credit card payments⁵⁰ and increased insurance benefits for health care workers, police, the military, and other government employees.⁵¹ Several NGOs, such as Sarvodaya, also organized relief efforts to assist households in isolation or lockdown.⁹

Cash transfers to households in response to COVID-19 was small in comparison with other Asian developing countries,⁵² amounting to only 0.5% of GDP in 2020 and 0.1% of GDP in 2021.⁴⁵

Data from the Sri Lanka Health and Ageing Study Wave 2 in mid-2022 indicates that only 5.4% of households received any cash or food assistance because of COVID-19 from the start of the pandemic, and only 2.9% of these reported receiving food or cash assistance from NGOs.⁵² However, government assistance benefited low-income households more than high-income households, whereas most of the NGO assistance appears to have benefited more high-income households. This may reflect barriers NGOs face in reaching the lowest-income community members and the greater intensity of NGO activity in areas of higher social capital.

Despite these interventions, in 2021 the World Bank estimated that 500,000 Sri Lankans fell into poverty during the COVID-19 pandemic.⁴⁹

Hospitals shared all COVID-19 statistics with the Ministry of Health coordinator in charge of COVID 19 operations, who then shares them with the Epidemiology Unit. The Epidemiology Unit, in turn, publicly shares the data (including a daily situation report, epidemiological summary, vaccination summary, and confirmed deaths weekly analysis) on its website.⁵³

Since March 2020, the Department of Government Information also released daily press announcements on case counts and deaths.⁵⁴ The Health Promotion Bureau likewise provides a daily dashboard of key COVID-19 statistics on its website, including confirmed cases, deaths, recoveries, PCR and antigen test numbers, fatality and recovery rates, and comparisons with other countries.⁵⁵

Nevertheless, key informants reported some controversy around data transparency, accessibility, and validity.⁵⁶ For example, because the official methodology for identifying and counting pandemic deaths changed over time,^57,58 it is possible that deaths from COVID-19 were underreported.

While the 2017 Joint External Evaluation showed that Sri Lanka had strengthened its testing capacity, some researchers argue Sri Lanka had insufficient testing capacity that limited its ability to detect and eliminate community transmission of the novel coronavirus. At the beginning of the pandemic, Sri Lankan health authorities increased PCR testing to under 250 tests per million a day⁵⁹   but did not invest in ramping up testing capacity or implementing a system for symptomatic testing at the primary care level.

Between March and June 2020, health authorities rejected offers by private donors and suppliers to obtain the larger testing machines required to sustain testing at the high levels necessary for the success of their elimination strategy. They also resisted implementing widespread symptomatic testing of patients with acute respiratory infection symptoms, focusing instead on symptomatic testing of hospital patients and random testing in the community, according to key informant interviews.

According to key informants, including political officials and high-level members of the COVID-19 Task Force, the task force was never advised that the level of testing was inadequate to maintain the declared strategy. Other local experts—including many of the most senior members of Sri Lankan’s medical profession—repeatedly raised the need to increase testing, but officials rejected these calls.⁶⁰

Several factors likely contributed to these problems. First, key decision makers had a sense of complacency due to Sri Lanka’s early success at containing the virus and did not act on outside experts’ calls to take testing more seriously; instead “groupthink” was reinforced by not incorporating alternate viewpoints and advice from WHO and other international agencies. Second, health authorities did not seek to determine how much testing it should be doing, despite that many researchers outside the government had the capacity to conduct such an analysis. Third, the deteriorating fiscal environment following the 2020 tax cuts may have bolstered the widely held belief that testing was a waste of money. Fourth, according to key informant interviews, Sri Lankan medical culture was inherently resistant to spending more on laboratory testing, an attitude that served Sri Lanka well in keeping health care costs low during nonpandemic times, but not when faced with COVID-19.

Consequently, although Sri Lanka’s Ministry of Health (MOH) established PCR testing capacity for COVID-19 within two weeks of China’s release of the SARS-CoV-2 genome, the country was slow to expand its testing capacity. Sri Lanka’s testing capacity in terms of monthly PCR tests per 1,000 people at the end of early 2021 was equivalent to testing capacity in other lower-middle-income countries, but substantially lower than in upper-middle-income countries. These testing limitations subsequently became the major factor constraining the country’s efforts to control pandemic transmission.

The initial expansion of PCR testing for COVID-19 involved repurposing an existing pool of PCR machines, many of which were part of the national tuberculosis program. In April 2020, private laboratories were also authorized to undertake PCR testing for paying patients, according to key informant interviews. Antigen testing was introduced in December 2020 to supplement PCR testing, mainly for clinically suspected cases. To help control transmission inside hospitals and other health facilities, hospitals also started testing all inpatients and some outpatients using antigen tests. In June 2021, MOH guidance instructed clinicians to reduce the use of scarce PCR tests and rely instead on rapid diagnostic tests.⁶¹ Rapid diagnostic tests became the main method for testing contacts, and PCR tests were reserved for symptomatic first contacts with negative antigen tests.

Rapid diagnostic tests were not licensed for sale directly to consumers, but large private-sector employers such as factories were encouraged to use rapid diagnostic tests for routine testing. In October 2021, this routine asymptomatic testing at workplaces was discontinued.⁶²

Officials established a system to coordinate Sri Lanka’s testing laboratories, transfer samples to different laboratories based on need, and report daily results to the MOH, according to key informants. It also set up a centralized procurement system for purchasing and distributing reagents and supplies to all government laboratories. Private laboratories, on the other hand, purchased PCR test kits (approved by the National Medicines Regulatory Authority, or NMRA) from suppliers on their own and established their own teams of sample collectors and vehicles to transport samples from any location on the island while maintaining cold chain conditions.

Some public health authorities were initially reluctant to involve the private sector in testing, but the overwhelming need to expand testing capacity in 2020 changed their minds. Private laboratories were used for testing travelers and handling samples from workplace screening; between March 2020 and December 2021, they handled about 40% of all PCR tests. To improve access, the MOH imposed a price ceiling on private-sector PCR tests, set at 6,500 Sri Lankan rupees in August 2021 (equivalent to US$33 at the time).⁶³ Even so, survey data suggests that lower-income people were less likely to get tested than their higher-income counterparts, especially in the private sector, indicating that making test access depending on ability to pay worsened inequity.²⁵

Due to concerns about private laboratories abusing sample pooling to save costs, the MOH eventually prohibited sample pooling at private laboratories altogether, although it could have helped expand overall testing capacity considerably. MOH laboratories were authorized to do limited sample pooling, but they never adopted it (or saliva testing) on a scale large enough to reduce barriers to outpatient testing.²⁵

Further limiting capacity in Sri Lanka was that most testing was done using small- and medium-sized machines with laboratory staff manually extracting and preparing samples. Although donors had offered to help the MOH fund the purchase of large, automated testing systems, officials believed Sri Lanka’s testing capacity was adequate, as confirmed by key informant interviews, and repeatedly turned down donor offers. This belief may have been due to Sri Lanka’s early success in building out testing capacity in January 2020, a wider phenomenon of “groupthink” (conformity and consensus in decision-making) observed among official decision-making bodies, which prevented consideration of alternative views on testing and disregarded technical expertise from outside the government. Additionally, the assessment from the 2017 Joint External Evaluation also suggested that the country had strong preexisting testing and surveillance capacity, which may have led to a false sense of security.

For all these reasons, Sri Lanka’s testing capacity continued to fall behind.

Building on its strong preexisting competencies in infectious disease control, particularly for malaria, and with the support of the military and state intelligence services, Sri Lanka maintained an unusually aggressive contact tracing and isolation strategy from the start of the pandemic until early 2021.⁶⁴ As health authorities gradually gave up the idea of stopping local transmission (even though it remained the country’s official strategic goal), contact tracing was relaxed until it resembled practices in other countries that had never pursued a COVID-19 elimination strategy.

Sri Lanka’s early contact tracing and isolation efforts were supervised and coordinated by the MOH Epidemiology Unit.⁶⁵ More than 3,000 public health inspectors across the island performed the actual contact tracing with the help of the police.⁶⁶ They also managed quarantine facilities for identified cases.

From the beginning of the pandemic until January 2021, Sri Lanka’s contact tracing strategy was to trace all first- and second-level downstream and upstream contacts of each identified case.² Through most of 2020, public health inspectors placed all identified cases and contacts into institutional isolation or quarantine. In October 2020, this policy changed to allow home quarantine of contacts for 14 days with supervision by village committees and public health inspectors.⁶⁷ Institutional quarantine only applied to vulnerable individuals, those living in boarding places, and airline crew.⁶⁸

Contact tracing relied on traditional face-to-face interviews supported by state intelligence services who used “big data”—including location data from mobile-phone towers—to identify and locate additional contacts.⁶⁹ Additionally, the Information and Communication Technology Agency launched a mobile-phone app, MyHealth Sri Lanka, that checked individuals in and out of public places and alerted others who had been in those locations at the same time.⁷⁰

By August 2021, key informants reported that contact tracing and isolation efforts had essentially stopped. Health authorities relied mostly on vaccination to mitigate the impact of infections.

The Sri Lankan government initiated its COVID-19 vaccination campaign in January 2021.^18,71   The campaign’s goals were to minimize illness and death, slow viral transmission, and boost the economy.⁷² Epidemiologists outside Sri Lanka began to conclude by early 2021 that herd immunity was unachievable with available COVID-19 vaccines because they had a limited ability to block transmission of the pandemic pathogen.⁷³ Despite this, key informants reported that Sri Lankan health authorities’ political and media messaging focused on achieving herd immunity through vaccination into 2022.

Initially, Sri Lanka’s targets for vaccine coverage were based on WHO global guidance and expected supplies from COVAX.²⁰ In November 2020, the MOH established the National Coordination Committee for COVID-19 Vaccines, whose membership included MOH officials, health experts from the public sector (such as the College of Community Physicians of Sri Lanka), and partner organizations such as WHO, the United Nations Children’s Fund, Asian Development Bank, and the World Bank.⁷⁴ The committee’s role was to design the country’s vaccination campaign, and it issued a detailed national plan in January 2021⁷⁵   covering regulation, financing, vaccine prioritization (of health care workers, border security and frontline essential workers, and older adults), and service delivery.

When COVID-19 vaccines began to be available for purchase on the global market, health officials in the new State Ministry of Primary Health Care, Epidemics and COVID Disease Control⁷⁶ pivoted to a more aggressive strategy: purchasing enough vaccines, first from India and then from China, to vaccinate the entire adult population as soon as possible. The World Bank and the Asian Development Bank eventually provided grants and loans, but the Sri Lankan government also spent substantial funds of its own on vaccine procurement: through 2021, the government spent US$328 million,⁷⁷ or 0.4% of the GDP, on COVID-19 vaccines.⁴⁵ By late 2021, most adult Sri Lankans had been vaccinated and focus shifted to vaccinating children and covering the adult population with boosters.⁷⁸

Timeline of eligibility for COVID-19 vaccination:

• January 2021: Health care workers
• March 2021: Ages 60 years and older
• May 2021: Ages 30–59 years
• September 2021: Ages 20–29 years
• October 2021: Ages 15–19 years
• January 2022: Ages 12–14 years

Sri Lanka started its COVID-19 vaccination campaign in late January 2021 by inoculating frontline health care workers with Covishield shots from India.^18,71 After large supplies of Sinopharm vaccines became available in July 2021, Sri Lanka’s vaccination coverage rapidly increased, with over 60% of the total population fully vaccinated (i.e., receiving all doses prescribed by the initial vaccination protocol) by December 31, 2021.⁷⁹

Vaccination centers, managed with logistical support from the military,⁸⁴ were set up at government hospitals, clinics, and eventually large workplaces such as garment factories, religious institutions, schools, and other public spaces.⁸⁴

Vaccination was typically given on demand if the individual met the eligibility criteria, but online and other systems were eventually set up to enable people to prebook appointments.⁸⁵ Mobile vaccination drives targeted individuals who were unable to travel to vaccination centers.⁸⁶

The COVID-19 vaccination campaign benefited from Sri Lanka’s preexisting and extremely well-organized immunization services, as well as high levels of public acceptability for vaccination in general. However, it also exposed a neglected area of development in Sri Lanka’s routine immunization program: the MOH’s information system was built for health service managers to track vaccine delivery by public-sector providers, not for individual citizens to use as an electronic vaccine registry. Eventually, army personnel developed a digital system92 to track COVID-19 vaccination at the individual level: military personnel entered data at vaccination sites or from paper records generated by MOH staff. In the future, this immunization system could be modernized to track all vaccinations for individual users.^88,89,90

Based on an analysis of the Sri Lanka Health and Ageing Study data, Sri Lanka’s COVID-19 vaccine rollout was highly—and unusually—equitable in its reach.²⁵ Controlling for differences in eligibility dates, which were mostly related to age or district, researchers found negligible differences in coverage associated with gender, ethnicity, urban or rural residence, or socioeconomic status. This equitable distribution of COVID-19 vaccines throughout the country was a unique strength of the Sri Lankan vaccination program enabled by public financing and delivery of the vaccines, as well as by the mobilization of military support in expanding coverage.

Much of the task shifting and additional workforce deployment was in support of the COVID-19 vaccination effort. In Sri Lanka, the military played a uniquely crucial role in supporting the vaccination effort. Although the country’s strong immunization system typically delivers routine vaccinations to more than 97% of children, the scale and pace of the push for COVID-19 vaccinations overwhelmed this preexisting capacity. The need to deploy staff at health facilities to vaccination duties resulted in them being pulled from testing and contact tracing work and other preventive work such as dengue control. As the vaccination campaign expanded, the military increased its support, assisting public vaccination clinics and setting up and running its own clinics for the public. Some of these were open 24 hours a day in the early part of the vaccination campaign, and some had drive-through facilities. According to key informants, by the end of 2021, military-operated vaccination centers had delivered 2.4 million doses with a total deployment of 5,200 personnel.

The military also set up mobile vaccine units that went from house to house in some regions, targeting people in the community with restricted mobility, such as older adults or disabled community members. The National Operational Centre for Prevention of COVID-19 Outbreak established a number to text and an email address for the public to arrange this service.¹⁰⁹

At first, Sri Lanka’s MOH prohibited the private sector from managing COVID-19 patients,⁹⁴ and only three hospitals—the National Infectious Disease Hospital, Colombo East Base Hospital, and the Welikanda Base Hospital—were designated as COVID-19 treatment facilities. In April 2020, authorities designated the Kotelawala Defence University as a treatment center and turned other public hospitals and health facilities into pandemic isolation and treatment centers.⁹⁴

As case counts increased and hospital beds were filled in November and December 2020, authorities moved to enable facilities in the private sector to care for stable and asymptomatic COVID-19 patients and establish intermediate-care centers, often in hotels, to manage mildly symptomatic cases. Private hospitals and intermediate-care centers charged patients directly for their care and shared revenue with the hotel operators. The military also established intermediate-care centers for patients in the public sector and organized patient transportation from hospitals to intermediate-care centers.⁴⁰

As COVID-19 became more prevalent in Sri Lanka, officials and clinicians introduced a range of protocols to minimize COVID-19 infection in health care settings, including requiring antigen testing for inpatients. The MOH also issued and regularly updated a range of clinical guidelines for managing patients that were developed through expert consultations and the experience of clinicians at facilities such as the National Hospital for Infectious Diseases.¹¹⁰