The following section covers the interventions that were deployed in Sri Lanka to respond to COVID-19 and maintain essential health services (EHS). Unlike context and systems factors which cannot easily be changed when an outbreak occurs, policies or interventions can. Interventions during the early months of the coronavirus pandemic in Sri Lanka fell into three main categories: national, governmental, and population-level measures, health system-level measures, and patient-level measures.
Exemplars in COVID-19 conceptual framework for assessing epidemic preparedness and response
In early 2020, Sri Lanka’s authorities officially adopted a zero-COVID strategy,1 which had two prongs:
- Preventing entry of the novel coronavirus via effective border security
- Acting aggressively to stop any local outbreaks by implementing strict contact tracing and isolation
The goal of the strategy was to bring local transmission to zero, enabling communities to return to normal life behind protected borders.2
Sri Lanka’s Strategy for Eliminating COVID-19 at the Population and Patient Levels
Read more
Without high levels of PCR testing for symptomatic people in local health facilities, however, lapses in adherence to isolation policies led to widespread community transmission that went undetected for months.3 By the end of 2020, this transmission overwhelmed the country’s capacity for testing, tracing, and isolation. Soon it was clear that the testing rates necessary to sustain the COVID-19 elimination strategy would be impossible to attain (especially because the country’s testing approach did not include pooled or saliva testing).4 In the face of this impossibility, political and health authorities implicitly abandoned the pandemic elimination strategy. They lifted border controls and slowed efforts to detect new cases and contacts.5
Read more
Sri Lanka’s COVID-19 response was coordinated from the top down. On March 16, 2020, the president established a National Operations Centre for Prevention of COVID-19 Outbreak, headed by Army Commander General Shavendra Silva, to “coordinate preventive and management measures to ensure that health care and other services are well-geared to serve the general public.”6,7 Shortly thereafter, the president established a Presidential Task Force for the COVID-19 response to “direct, coordinate and monitor delivery of continuous services and for the sustenance of overall community life.”8
Nongovernmental entities and civil society organizations were not involved in Sri Lanka’s COVID-19 response.8 One exception was the nongovernmental organization (NGO) Sarvodaya, which coordinated and managed a collective of civil society organizations providing food security and meeting the hygiene and medical needs of vulnerable groups (in homes for children and older adults, rehabilitation centers, safe houses for women, and probation centers).9 It also mobilized and trained community and religious leaders on COVID-19 prevention and control. In general, however, the government did not seek, and often did not recognize, civil society contributions to the country’s pandemic response.
“The government didn’t want to involve civil society organizations, no one was invited to be part of the response. None of the committees that were appointed including Presidential Task Force included any civil society organizations.”
- Key informant
Read more
Financing Sri Lanka’s COVID-19 response Because of Sri Lanka’s ballooning deficit and limited ability to borrow internationally, its pandemic response spending was relatively low. It did receive some international loans and donations:
Sri Lanka’s president also established the “ITUKAMA – COVID 19 Healthcare and Social Security Fund” in March 2020 to collect local donations aimed at controlling COVID-19 and boosting social welfare programs.23 However, spending from this fund was limited. By September 2021, it had collected about US$10 million from organizations and individuals for advocacy, PCR testing, vaccines, quarantine facilities, and intensive care unit beds.24 |
read more
read more
Interventions to limit the spread of COVID-19 and maintain essential health services during the early months of the pandemic in Sri Lanka fell into three main categories:
- National, governmental, and population-level measures
- Health system–level measures
- Patient-level measures
National, governmental, and population-level measures
Building on its existing National Risk Communication Plan for Avian Influenza, Sri Lanka’s Health Promotion Bureau began to develop a risk communication plan for COVID-19 in early January 2020.3
Daily official briefings delivered by the director-general of health services, the army commander general, and a police spokesperson updated the public on Sri Lanka’s COVID-19 response. These briefings were widely covered by television, radio, and the print and social media, and they were the primary source of information for most of the media and public.3
Many of these government representatives had no public health training or expertise and some minimized the dangers of COVID-19 in their public briefings. The Sri Lanka Health and Ageing Study Wave 2 data also indicated that the public supported more aggressive pandemic interventions that could have reduced case counts and deaths.25
read more
The Sri Lanka Health and Ageing Study (SLHAS) is an ongoing national phone survey that has monitored information on population-level behavior and changes since 2019. The SLHAS is a Ministry of Health-approved, national longitudinal cohort study with two nationally representative sample surveys: Wave 1, which included data from 2018 and 2019 just before the pandemic started, and Wave 2, which included data from 2021 and 2022. The SLHAS provided crucial data on topics including the use of health services, health care access, public opinion, and vaccine uptake.
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
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.
read more
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
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
read more
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
Economic impact of the COVID-19 pandemic in Sri Lanka The economic effects of the COVID-19 pandemic in Sri Lanka were widespread: agriculture, forestry, fishing, industry, and the services sector all contracted in 2020 from the previous year, and unemployment increased from 4.8% in 2019 to 5.5% in 2020.41 Experts believe these effects were due, in part, to the curfews and lockdowns officials imposed to halt the spread of COVID-19.42 These measures, especially lockdowns and border closures, harmed Sri Lanka’s tourist economy. In 2019, some 1.8 million people arrived in the country, compared with 508,000 in 2020, a 73.5% decline. As a result, the tourism sector comprised only 3.3% of total foreign exchange earnings (profits from services exchanged in a global marketplace), compared with 13.7% in 2019.43 Read more: Sri Lanka Tourism Development Authority – 2020 Annual Statistic Report Remittances from migrant workers, which are Sri Lanka’s largest single source of foreign exchange, fell during the first year of the pandemic, and factory closures slowed textile and garment exports. The COVID-19 pandemic exacerbated economic struggles that had been mounting from previous government policies, such as large tax cuts, and in December 2021 Fitch Ratings downgraded Sri Lanka’s long-term foreign currency issuer default rating.44 Although GDP growth improved in 2021, public debt rose to 119% of GDP, inflation rose, and the foreign currency shortage continued.45 |
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 20203,47; 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
read more
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
read more
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.
read more
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
Vaccine procurement challenges in Sri Lanka In Sri Lanka, procurement regulations prevented officials from ordering vaccines until the National Medicines Regulatory Authority had given local approval for each one—a process which key informants report effectively delayed the procurement of vaccines from China and Russia.80 WHO’s Emergency Use Listing process, which only enabled Western regulatory agencies to fast-track approval, caused additional delays.81 When the delta wave paused the supply of Covishield (AstraZeneca vaccine produced at the Serum Institute of India) vaccines from India in mid-2021, political authorities pressured the National Medicines Regulatory Authority to speed up its approval process for Chinese vaccines.82 Eventually, Sinopharm and Sputnik vaccines were approved for use in Sri Lanka,83 and the government purchased a large supply of Sinopharm from China using World Bank funds in 2021.80 Officials later supplemented this supply with directly purchased Pfizer vaccines and Moderna vaccines obtained through COVAX.80 |
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
read more
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
Addressing vaccine hesitancy in Sri Lanka Despite the quick and comprehensive rollout of vaccine coverage among the eligible adult population, health officials and mass-media reports (possibly influenced by policy debates in other countries) anticipated high levels of vaccine hesitancy among young people and some religious groups. Survey data, however, showed comparatively negligible opposition to COVID-19 vaccines in Sri Lanka, and less opposition among younger people than older people. Most hesitancy was associated with a strong public preference for the Pfizer shot, which only became available at volume in late 2021.91 The belief that difference vaccines varied in quality was treated as a problem of misinformation by some health officials who felt that a stronger public communications effort should have eradicated it, according to a key informant interview. On the other hand, there was some evidence that Pfizer vaccines were more effective, so the official reaction was somewhat unwarranted.
Researchers found in late 2021 that unvaccinated adults accounted for a disproportionate share of COVID-19 deaths, leading to intensified efforts to reach unvaccinated adults. However, these efforts did not include making vaccines widely available through the private sector, which might have increased the number of delivery points accessible to the population. In late 2021, as concerns grew over the omicron wave, Sri Lankan officials decided to offer booster vaccinations—first to older adults, then to all adults who requested it. Lower rates of booster uptake may have reflected reduced public anxiety about COVID-19 after November 2021.92 |
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.
Health system–level response measures
In the early months of the pandemic, Sri Lanka’s response measures at the health system level fell into two main categories: direct responses to COVID-19 and interventions for the maintenance of essential health services despite pandemic-related disruptions.
Essential health service maintenance in Sri Lanka during the COVID-19 pandemic
In many countries around the world, the COVID-19 pandemic and efforts to mitigate it caused supply- and demand-side barriers to essential health service delivery. In Sri Lanka, the pandemic did not have a major effect on essential health services until 2021, when sustained local pandemic transmission overwhelmed the COVID-19 elimination strategy and undermined access to routine care across the board. Data show that unmet health care need in late 2021 was two to three times higher than before the pandemic.93
It is also plausible that later pandemic waves have left a long-term burden for Sri Lanka’s health services—in the form of an increased prevalence of noncommunicable diseases such as diabetes and cardiovascular disease, as well as long COVID—but researchers do not yet have the data they would need to assess this.
In terms of routine vaccination, there was a decline in routine immunization coverage early in the pandemic (from March to May 2020), but it recovered to pre-pandemic levels by June 2020. The figure below shows the ratio of the monthly number of doses of DTP3 vaccine (third dose of diphtheria, tetanus, and pertussis vaccine) given to children younger than one year old in 2020 as it compares with the same month in 2019. A value of 1 represents no change and values less than 1 indicate delivery disruption.
DTP3 Routine Vaccination Coverage in Sri Lanka Through 2020
Early in the pandemic, Sri Lanka’s effective control of COVID-19 transmission ensured that most health institutions were not overburdened or overwhelmed.2
Read more
The island-wide lockdown and disruption of transportation services during Phase 1 affected the delivery of some routine health services, mainly by making it more difficult for both health care workers and the public to reach health facilities. Authorities minimized the impact by announcing in March 2020 that all public clinics would continue to deliver routine health services in addition to COVID-19 care.94 Health care workers and people seeking medical care were exempted from the lockdown, registered clinic patients were allowed to use their clinic records as a curfew pass, and special transportation arrangements were provided for many health care workers. These policies were extended in April 2020 to allow health care workers and patients to cross district borders.95
Testing all inpatient admissions became routine to address worries about potential transmission in health care facilities. To mitigate impacts on access and eliminate delays to urgent care, the MOH issued guidelines in late May 2020 for testing elective and surgical emergency patients.96
Recognizing the potential for disruption, the MOH took proactive measures to ensure maintenance of maternal and child health services. Officials instructed all clinics to remain open and revised procedures with this goal in mind.97 They also introduced COVID-19 safety protocols to enable home visits to continue.
When concerns arose about escalating domestic violence during the lockdown, the MOH issued guidelines for hospitals to expand availability of Mithuru Piyasa, friendly havens for survivors of gender-based violence, which operated during hospitals’ usual working hours.98 Additional guidance was issued in May 2020 for the proprietors of safe homes for survivors of gender based violence.99
Read more
As the country emerged from the first lockdown, the MOH issued guidelines to restart suspended maternal and child health services, such as vaccinations in May 2020 and school dental services in September 2020.100
Effect on essential health service delivery in Sri Lanka: Phases 3 and 4 (2021)Increased local transmission of the virus had a substantial impact on the provision of routine health services. During the delta wave in particular, pressure on routine health services was acute and at times overwhelming, leading to the suspension of many routine services and nonemergency care. Large numbers of health workers were also infected during this period.101
Data from the Institute for Health Policy’s regular private hospital survey in 2022 indicates that there was a 20% to 25% reduction in both inpatient and outpatient service delivery at private hospitals during the two waves in 2021, compared with 2019.102
Inpatient and Outpatient Visits in Sri Lanka Pre-Pandemic and During the COVID-19 Pandemic
In addition, increasing numbers of adults did not access services in the previous 12 months. Adults who did not access needed medical care increased from 4% to 17%, dental care 4% to 14%, and medicines 5% to 20%, between 2019 and 2022.93
Analysis of the Sri Lanka Health and Ageing Study Wave 2 data indicates that the end of the August–October 2021 lockdown and the waning of the delta wave led to rapid improvements in unmet need for medical care.25
Except during the delta wave, the main drivers of reduced health care access in Sri Lanka were not supply constraints, but demand-side factors—especially public fear of catching or being diagnosed with COVID-19 and mobility restrictions and transport barriers during lockdowns.25
Although some adults who reported unmet need for care cited cost as a major barrier, lower-income Sri Lankans reported smaller increases in unmet need (higher-income people were more likely to avoid seeking care because they were afraid of contracting COVID-19 in health facilities). On the other hand, patients with chronic noncommunicable diseases were much more likely to report unmet need, indicating that efforts to improve the distribution of medicines were not completely successful.93 (For further information, read more in section on service delivery adaptations made for the delivery of medicines for noncommunicable diseases during the pandemic).
Sri Lanka’s health authorities acted quickly to enable the maintenance of routine service delivery. The service delivery adaptations they introduced proved especially necessary in 2021, when severe pandemic waves caused large numbers of deaths, increased hospital admissions, overwhelmed health facilities and staff, and disrupted health service delivery across the country.
Maintaining access to medicines
Starting in March 2020, senior health officials began to implement service delivery adaptations aimed at maintaining access to necessary medicines for patients with noncommunicable diseases during lockdowns. In the public sector, service providers revised regulations to extend the duration of prescriptions from one month to two months. They also organized home delivery of medicines via mail and courier.103 This system was formalized during the October 2020 COVID-19 outbreak in factory workers at the apparel manufacturer Brandix.104 Health officials, the police, and the postal service arranged to deliver up to two months of routine medications to patients in public clinics in the Western Province and Kurunegala districts.105 Additionally, officials allowed patients to make appointments to pick up their medication from pharmacies and health facilities, minimizing contact with others. Starting in November 2020, noncommunicable disease patients in the private sector were allowed to get their medications from government hospitals if necessary.106
Health officials also worked with the private sector, including private pharmaceutical firms, importers, distributors, and retailers, to troubleshoot and maintain key supplies of medicines. For instance, they relaxed regulations to enable pharmacies to accept digital prescriptions and deliver medicines directly to patients’ homes.107
read more
Public awareness of (and uptake for) these new distribution mechanisms was high. Estimates using the Sri Lanka Health and Ageing Study Wave 2 data (August 2021–August 2022) indicate that of the 30% of adults who needed a regular medication refill, 85% were aware of the MOH program to deliver medicines by mail and 33% of them had used it.25 About 90% of users reported being satisfied with the service. Smaller numbers of people knew of and used other MOH arrangements, such as scheduling medication pickups at government hospitals and alternative locations such as government offices or public health inspector and maternal and child health offices. Awareness of the liberalized private-sector delivery options was also high. An estimated 40% of adults who needed regular prescription refills were aware that private pharmacies could deliver medicines to their doorstep, although just 5% of them had used this option.
Most people who used these novel arrangements did so during the lockdown periods. According to survey data, rates of uptake for government medication-delivery innovations declined after the end of the last national lockdown.25 Approximately 10% of the lowest-income tertile of adults reported having used these services, compared with just 5% of the highest-income tertile.
Telehealth
In both the public and private sectors, clinicians substantially expanded their use of remote consultations. New MOH guidelines supported telephone consultations, even for remote screening of possible COVID-19 cases.108 Primary care doctors at the University of Kelaniya developed a system to facilitate teleconsultations by phone and WhatsApp, which other public-sector facilities later adopted.108,3 Public facilities also made efforts to increase their internet bandwidth to support teleconsultations, according to key informants.
read more
The better-resourced private hospital sector expanded access to teleconsultation services: patients were able to consult most specialists through video or audio consultations, and many private hospitals invested in additional hardware to facilitate this remote care.
According to key informants, telecommunication providers also took several initiatives to support the health sector by providing equipment and additional bandwidth to public-sector institutions.
Many patients took advantage of these options for remote consultation, especially during the national lockdowns. The MOH does not collect data on remote consultations, so public-sector statistics are not available, but key informants indicated that teleconsultations booked through their platforms grew from essentially zero before the pandemic, peaked at 35% of all consultations in March 2020, and subsequently averaged 5% to 10% of consultations from October 2020 to October 2021. Key informants from private hospitals suggested that teleconsultations accounted for about 10% of consultations during 2020–2021 and dropped off after the July–September 2021 lockdown. In the private sector, teleconsultations were used mainly for postsurgical follow-ups after cesarean sections and other procedures. According to survey data, 7% of all outpatient visits were remote consultations between September 2021 and August 2022.25
Surprisingly, given that rates of internet access increase with income, both public and private consultations were equally likely to involve remote methods and there was no evidence of any socioeconomic gradient in their use. Lower-income adults made more use of public-sector remote consultations, and higher-income adults used mostly private-sector remote consultations.25
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
Patient-level measures
From March 2020 until the end of that year, Sri Lanka enforced a mandatory 14-day quarantine and PCR testing for people entering the country to minimize COVID-19 transmission.111 At the end of 2020, authorities boosted the struggling tourist industry by lifting border controls. Tourists were allowed to visit Sri Lanka if they began their trip by isolating at approved hotels before traveling to other approved hotels, without direct contact with the public.112 These were known as “bio-bubbles.”113 The country piloted the project in late 2020 with a group of Ukrainian tourists, then expanded it to all entering travelers the next month.114
Between April and June 2021, border controls for nontourists were incrementally relaxed, starting with residents traveling on official business.115 New policies reduced the length of quarantine and substituted home isolation for quarantine for arrivals who were vaccinated and had negative PCR tests on arrival. Eventually, in mid-October 2021, officials lifted rules for quarantine and isolation completely for arrivals who were vaccinated with two doses and had a negative PCR test just before arrival.116
-
1
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
-
2
Arambepola C, Wickramasinghe ND, Jayakody S, et al. Sri Lanka’s early success in the containment of COVID-19 through its rapid response: clinical & epidemiological evidence from the initial case series. PLoS ONE. 16(7):e0255394. https://doi.org/10.1371/journal.pone.0255394
-
3
Rajapaksa LC, de Silva P, Abeykoon P. COVID-19 Health System Response Monitor: Sri Lanka. New Delhi: World Health Organization Regional Office for South‐East Asia; 2022. Accessed January 4, 2023. https://apo.who.int/publications/i/item/covid-19-health-system-response-monitor-sri-lanka
-
4
Epidemiology Unit of the Ministry of Health and Indigenous Medical Services. COVID-19 Laboratory Test Strategy in Sri Lanka, Version 02. Colombo, Sri Lanka: Epidemiology Unit of the Ministry of Health and Indigenous Medical Services; 2020. Accessed January 4, 2023. https://www.epid.gov.lk/web/images/pdf/Circulars/Corona_virus/final_draft_of_testing_strategy_v_2.pdf
-
5
The country will be fully opened in two months—head of NOCPCO. ColomboPage. July 14, 2021. http://www.colombopage.com/archive_21A/Jul14_1626281492CH.php
-
6
Presidential Secretariat. Army Commander Shavendra Silva heads National Operation Center for Prevention of COVID-19 Outbreak. Published March 17, 2020. Accessed January 4, 2023. https://www.presidentsoffice.gov.lk/index.php/2020/03/17/army-commander-shavendra-silva-heads-national-operation-center-for-prevention-of-covid-19-outbreak/
-
7
Farzan Z. NOPCO will disintegrate from COVID related activities—army commander. News 1st. December 9, 2021. https://www.newsfirst.lk/2021/12/09/nocpco-will-disintegrate-from-covid-related-activities-army-commander/
-
8
Centre for Policy Alternatives. Statement on the Presidential Task Forces. Published June 15, 2020. Accessed January 4, 2023. https://www.cpalanka.org/statement-on-the-presidential-task-forces/
-
9
Sarvodaya Sri Lanka. Let’s extend our compassion to thousands of children, youth, women and elders living in homes/institutional care around the country. Posted April 16, 2020. Accessed January 4, 2023. https://www.facebook.com/SarvodayaSriLanka/photos/lets-extend-our-compassion-to-thousands-of-children-youth-women-and-elders-livin/3389270557754198/
-
10
China extends concessionary loan to Sri Lanka to combat COVID-19. News 1st. March 18, 2020. https://www.newsfirst.lk/2020/03/18/china-extends-concessionary-loan-to-sri-lanka-to-combat-covid-19/
-
11
EU provides EUR 22 million grant to Sri Lanka to support COVID-19 response. Ada Derana. April 9, 2020. http://www.adaderana.lk/news/62435/eu-provides-eur-22-million-grant-to-sri-lanka-to-support-covid-19-response
-
12
Japan grants USD 1.2 million to combat COVID-19 in Sri Lanka. Ada Derana. April 21, 2020. http://www.adaderana.lk/news/62880/japan-grants-usd-12-million-to-combat-covid-19-in-sri-lanka
-
13
US Embassy in Sri Lanka. United States commits $5.8 million in COVID-19 assistance to Sri Lanka. Published May 6, 2020. Accessed May 16, 2022. https://lk.usembassy.gov/united-states-commits-5-8-million-in-covid-19-assistance-to-sri-lanka/
-
14
World Bank. Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project. Accessed July 29, 2022. https://projects.worldbank.org/en/projects-operations/project-detail/P173867
-
15
World Bank. Stakeholder Engagement Plan (SEP) Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project (P173867). Washington, DC: World Bank Group; 2021. Accessed January 4, 2023. https://documents.worldbank.org/en/publication/documents-reports/documentdetail/578671614887470900/stakeholder-engagement-plan-sep-sri-lanka-covid-19-emergency-response-and-health-systems-preparedness-project-p173867
-
16
World Bank. Sri Lanka, World Bank sign agreement for COVID-19 vaccine deployment. Published May 13, 2021. Accessed July 20, 2022. https://www.worldbank.org/en/news/press-release/2021/05/13/sri-lanka-world-bank-sign-agreement-for-covid-19-vaccine-deployment
-
17
Asian Development Bank. Sri Lanka: Health System Enhancement Project- additional financing. Accessed July 15, 2022. https://www.adb.org/projects/51107-003/main
-
18
Asian Development Bank. $150 million loan to help Sri Lanka purchase COVID-19 vaccines. Published July 8, 2021. Accessed May 15, 2022. https://www.adb.org/news/150-million-loan-help-sri-lanka-purchase-covid-19-vaccines
-
19
Presidential Secretariat. China donates another 1.6 million doses of Sinopharm to Sri Lanka. Published July 27, 2021. Accessed January 4, 2023. https://www.presidentsoffice.gov.lk/index.php/2021/07/27/china-donates-another-1-6-million-doses-of-sinopharm-to-sri-lanka/#
-
20
World Health Organization. First batch of COVID-19 vaccines from the COVAX Facility arrive in Sri Lanka. Published March 7, 2021. Accessed May 17, 2022. https://www.who.int/srilanka/news/detail/07-03-2021-first-batch-of-covid-19-vaccines-from-the-covax-facility-arrive-in-sri-lanka
-
21
United Nations Children’s Fund. Sri Lanka received over 1.5 million doses of COVID-19 vaccines from COVAX. Published July 15, 2021. Accessed May 17, 2022. https://www.unicef.org/srilanka/press-releases/sri-lanka-receives-over-15-million-doses-covid-19-vaccines-covax
-
22
United Nations Children’s Fund. Sri Lanka receives a large consignment of AstraZeneca vaccines from Japan via the COVAX Facility. Published July 31, 2021. Accessed May 17, 2022. https://www.unicef.org/srilanka/press-releases/sri-lanka-receives-large-consignment-astrazeneca-vaccines-japan-covax-facility
-
23
Ministry of Mass Media. COVID-19 Healthcare and Social Security Fund continues with ITUKAMA brand name. Published May 20, 2020. Accessed January 4, 2023. https://www.media.gov.lk/media-gallery/latest-news/2471-covid-19-healthcare-and-social-security-fund-continues-with-itukama-brand-name
-
24
PublicFinance.lk. The government spent only 10.6% of the Itukama COVID-19 Fund balance. Accessed May 17, 2022. https://publicfinance.lk/en/topics/the-government-spent-only-10-6-of-the-itukama-covid-19-fund-balance-1641814589
-
25
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.
-
26
Hewage S, Wickramasinghe N, Jayakody S, Samaranayake D, Prathapan S, Arambepola C. Social distancing and its impact on flattening the COVID-19 curve in Sri Lanka. J College Commun Physic Sri Lanka. 2020;26(1):65-70. https://doi.org/10.4038/jccpsl.v26i1.8314
-
27
Amaratunga D, Fernando N, Haigh R, Jayasinghe N. The COVID-19 outbreak in Sri Lanka: a synoptic analysis focusing on trends, impacts, risks and science-policy interaction processes. Prog Disaster Sci. 2020;8:100133. https://doi.org/10.1016/j.pdisas.2020.100133
-
28
Mallawarachi B. With no fuel and no cash, Sri Lanka keeps schools closed. US News & World Report. July 3, 2022. https://www.usnews.com/news/world/articles/2022-07-03/with-no-fuel-and-no-cash-sri-lanka-keeps-schools-closed
-
29
Save the Children. Sri Lanka closes schools for fourth time this year amid worsening fuel shortage. June 22, 2022. Accessed January 4, 2023. https://www.savethechildren.net/news/sri-lanka-closes-schools-fourth-time-year-amid-worsening-fuel-shortage
-
30
Liyanagunawardena TR, Williams SA. Emergency remote education: experience from Sri Lanka during COVID-19. Asian J Distance Educ. 2021;16(1):207-229. https://files.eric.ed.gov/fulltext/EJ1303575.pdf
-
31
Erandi KKWH, Mahasinghe AC, Perera SSN, Jayasinghe S. Effectiveness of the strategies implemented in Sri Lanka for controlling the COVID-19 outbreak. J Appl Math. 2020;2954519. https://doi.org/10.1155/2020/2954519
-
32
Updated announcement on travel restrictions. Ada Derana. July 4, 2021. http://www.adaderana.lk/news.php?nid=75143
-
33
Updated announcement on travel restrictions. Ada Derana. July 4, 2021. http://www.adaderana.lk/news.php?nid=75143
-
34
Kumarasinghe K. Sri Lanka teaches the world how not to respond to COVID-19. The Diplomat. May 18, 2021. https://thediplomat.com/2021/05/sri-lanka-teaches-the-world-how-not-to-respond-to-covid-19/
-
35
Sri Lanka announces lockdown as coronavirus cases surge. Reuters. August 21, 2021. https://www.reuters.com/world/asia-pacific/sri-lankans-seek-full-covid-lockdown-ahead-presidents-address-2021-08-20/
-
36
Sri Lanka Ministry of Health (MOH). General Guidance for the Public on COVID-19 Prevention. Colombo, Sri Lanka: MOH; 2020. Accessed January 4, 2023. http://www.health.gov.lk/moh_final/english/public/elfinder/files/feturesArtical/2020/46/GENERAL%20GUIDANCE%20FOR%20THE%20PUBLIC%20ON%20COVID-19%20PREVENTION-E.pdf
-
37
Sri Lanka makes masks mandatory under new quarantine laws; to impose fine if rule violated. The New Indian Express. October 16, 2020. https://www.newindianexpress.com/world/2020/oct/16/sri-lanka-makes-masks-mandatory-under-new-quarantine-laws-to-impose-fine-if-rule-violated-2211071.html
-
38
Face mask rule in Sri Lanka lifted. Ada Derana. June 9, 2022. http://www.adaderana.lk/news/82958/face-mask-rule-in-sri-lanka-lifted
-
39
Magedaragamage C. Face mask usage and disposal practices among adults at selected market places in Gampaha district, during COVID-19 pandemic. Disaster Preparedness and Response Division of the Sri Lanka Ministry of Health. Published 2021. Accessed January 4, 2023. http://dprd.health.gov.lk/index.php/repository/24-face-mask-usage-and-disposal-practices-among-adults-at-selected-market-places-in-gampaha-district-during-covid-19-pandemic-dr-c-c-magedaragamage
-
40
Sri Lanka Ministry of Health (MOH). Guidance for Intermediate Care Centers on Management of COVID-19 Positive Individuals. Colombo, Sri Lanka: MOH; 2020. Accessed January 28, 2023. https://www.epid.gov.lk/web/images/pdf/Circulars/Corona_virus/Guidance_for_intermediate_care_centers_on_management.pdf
-
41
Central Bank of Sri Lanka. Annual Report 2020. Colombo, Sri Lanka: Central Bank of Sri Lanka; 2021. Accessed January 4, 2023. https://tamilguru.lk/central-bank-annual-report-2020/
-
42
KPMG. Sri Lanka banking report: about the report. Accessed August 15, 2022 https://web.archive.org/web/20211202181156/https://home.kpmg/lk/en/home/insights/2020/11/sri-lanka-banking-report-november-2020.html
-
43
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
-
44
FitchRatings. Correction: Fitch downgrades Sri Lanka’s long-term foreign currency IDR to ‘CC’. Published January 17, 2022. Accessed July 25, 2022. https://www.fitchratings.com/research/sovereigns/correction-fitch-downgrades-sri-lanka-long-term-foreign-currency-idr-to-cc-17-01-2022
-
45
International Monetary Fund (IMF). Sri Lanka: 2021 Article IV Consultation – Press Release; Staff Report; and Statement by the Executive Director for Sri Lanka. IMF Country Report No. 22/91. Washington, DC: IMF; 2022. Accessed January 4, 2023. https://www.imf.org/en/Publications/CR/Issues/2022/03/25/Sri-Lanka-2021-Article-IV-Consultation-Press-Release-Staff-Report-and-Statement-by-the-515737
-
46
Ministry of Finance (MOF). Ministry of Finance Annual Report 2020: Sri Lanka. Colombo, Sri Lanka: MOF; 2021. Accessed January 4, 2023. https://publicfinance.lk/en/report/annualreport-2020-mof
-
47
United Nations Children’s Fund (UNICEF). Sri Lanka’s Initial Social Protection Response to COVID-19: An Assessment of the Value of the COVID-19 Support to Sri Lankan Households. New York: UNICEF; 2020. Accessed January 4, 2023. https://www.unicef.org/srilanka/media/1651/file/An%20assessment%20of%20the%20value%20of%20the%20COVID%2019%20support%20to%20Sri%20Lankan%20households.pdf
-
48
Govt.’s failure to reimburse COVID-19 relief triggers possible Samurdhi Bank crash. The Sunday Times. February 13, 2022. https://www.sundaytimes.lk/220213/business-times/govt-s-failure-to-reimburse-covid-19-relief-triggers-possible-samurdhi-bank-crash-471759.html
-
49
Bandara T. Equity in recovery: addressing Sri Lanka’s social protection and food security needs. Institute for Policy Studies: Talking Economics. Published October 25, 2021. Accessed January 4, 2023. https://www.ips.lk/talkingeconomics/2021/10/25/equity-in-recovery-addressing-sri-lankas-social-protection-and-food-security-needs/
-
50
Central Bank of Sri Lanka. Debt moratorium and financial sector regulatory measures. Accessed January 4, 2023. https://www.cbsl.gov.lk/en/covid-19-debt-moratorium-and-banking-sector-regulatory-measures
-
51
Asian Disaster Reduction Center. COVID-19 response and counter measures in Sri Lanka. April 24, 2020. Accessed January 30, 2023. https://www.adrc.asia/publications/disaster_report/pdf/covid19/LKA_eng.pdf
-
52
Asian Development Bank (ADB). Asian Development Outlook 2022 Mobilizing Taxes for Development. Manila, Philippines: ADB; 2022. Accessed January 4, 2023. https://www.adb.org/publications/asian-development-outlook-2022
-
53
Sri Lanka Ministry of Health (MOH). Progress Report of COVID-19 Immunization. Colombo, Sri Lanka: MOH; 2022. Accessed May 28, 2022. https://epid.gov.lk/web/index.php?option=com_content&view=article&id=231&lang=en
-
54
Sri Lanka Department of Government Information. Three more test positive for Corona. Published March 13, 2020. Accessed January 4, 2023. https://www.dgi.gov.lk/news/press-releases-sri-lanka/1944-press-release-13-03-2020-three-more-test-positive-for-corona
-
55
Government of Sri Lanka, Health Promotion Bureau. COVID-19- Live situational analysis dashboard of Sri Lanka. Accessed May 20, 2022. http://web.archive.org/web/20220531130455/https:/hpb.health.gov.lk/covid19-dashboard/
-
56
Jayasinghe C. “Doubtful” data has led to diminished public concern over COVID-19 in Sri Lanka: GMOA. EconomyNext. July 16, 2021. https://economynext.com/doubtful-data-has-led-to-diminished-public-concern-over-covid-19-in-sri-lanka-gmoa-84081/
-
57
Sri Lanka Ministry of Health (MOH). Certification of Death During Current Pandemic of COVID-19 for All Deaths (Institutional Deaths Where Death Declaration Form Is Filled or Deaths Subjected to Inquests and Autopsies) and Reporting of COVID-19 Deaths. Colombo, Sri Lanka: MOH; 2021. Accessed January 28, 2023. https://www.epid.gov.lk/web/images/pdf/Circulars/Corona_virus/certification_of_death_and_reporting.pdf
-
58
Sri Lanka Ministry of Health. Update on post-mortem diagnosis, disposal and reporting of COVID-19 related deaths. Accessed January 4, 2023. https://mfa.gov.lk/update-on-post-mortem-diagnosis-disposal-and-reporting-of-covid-19-related-deaths-02-03-2022/
-
59
Institute for Health Policy. COVID Database. 2021.
-
60
Doctors call for more PCR tests, random sample testing. ColomboPage. November 2, 2022. http://www.colombopage.com/archive_20B/Nov02_1604257083CH.php
-
61
Sri Lanka Ministry of Health (MOH). Revised Guidelines on Laboratory Testing Strategy for COVID-19. Colombo, Sri Lanka: MOH; 2021. Accessed January 28, 2023. https://www.epid.gov.lk/web/images/pdf/Circulars/Corona_virus/laboratory_testing_strategy.pdf
-
62
Sri Lanka Ministry of Health (MOH). Screening and Testing Strategy for COVID-19 for Employees in Workplaces. Colombo, Sri Lanka: MOH; 2021. Accessed January 28, 2023. https://www.epid.gov.lk/web/images/pdf/Circulars/Corona_virus/testing_strtergy_15.10.2021.pdf
-
63
Nilar A. Maximum price for PCR and antigen tests declared. News 1st. August 11, 2011. https://www.newsfirst.lk/2021/08/11/maximum-price-for-pcr-antigen-tests-declared/
-
64
Test, trace, treat—putting Sri Lanka’s pandemic management mantra into practice. World Bank. Published January 15, 2021. Accessed January 4, 2023. https://www.worldbank.org/en/news/feature/2021/01/13/test-trace-treat-putting-sri-lanka-pandemic-management-mantra-into-practice
-
65
Sri Lanka Ministry of Health, Epidemiology Unit. Accessed January 4, 2023. https://www.epid.gov.lk/web/
-
66
Sri Lanka eyes coronavirus home management, COVID-19 deaths rise to 22. EconomyNext. May 9, 2021. https://economynext.com/sri-lanka-eyes-coronavirus-home-management-covid-19-deaths-rise-to-22-81663/
-
67
Sri Lanka Ministry of Health (MOH). Guideline for the Home Quarantine. Colombo, Sri Lanka: MOH; no date. Accessed January 4, 2023. https://www.epid.gov.lk/web/images/pdf/Circulars/Corona_virus/guidelines-ofhome-quarantine.pdf
-
68
Sri Lanka Ministry of Health (MOH). Preventive Measures for Airline Crew Members. Colombo, Sri Lanka: MOH; 2021. Accessed January 4, 2023. https://www.epid.gov.lk/web/images/pdf/Circulars/Corona_virus/preventive_measures_for_airline_crew_members.pdf
-
69
World Health Organization. COVID-19 case surveillance app: Suwapetha. Published December 8, 2020. Accessed January 4, 2023. https://www.who.int/srilanka/news/detail/08-12-2020-covid-19-case-surveillance-app-suwapetha
-
70
Information and Communication Technology Agency of Sri Lanka. Initiatives embarked and facilitated by ICTA for government of Sri Lanka during the COVID19 outbreak. Accessed January 4, 2023. https://www.icta.lk/covid19-response/
-
71
India’s Serum Institute to raise AstraZeneca COVID-19 vaccine output in June. Reuters. May 30, 2021. https://www.reuters.com/business/healthcare-pharmaceuticals/indias-serum-institute-raise-astrazeneca-covid-19-vaccine-output-june-2021-05-31/
-
72
Asian Development Bank (ADB). Summary of the National Deployment and Vaccination Plan. Manila, Philippines: ADB; 2021. Accessed January 5, 2023. https://www.adb.org/sites/default/files/linked-documents/55085-001-sd-03.pdf
-
73
Reaching ‘herd immunity’ is unlikely in the U.S., experts now believe. The New York Times. July 21, 2021. https://www.nytimes.com/2021/05/03/health/covid-herd-immunity-vaccine.html
-
74
Sri Lanka Ministry of Health (MOH). COVID-19 Sri Lanka Strategic Preparedness and Response Plan 2021. Colombo, Sri Lanka: MOH; 2021. Accessed January 28, 2023. http://www.health.gov.lk/moh_final/english/public/elfinder/files/publications/2021/Edited%20Final%20SPRP%20on%2015th%20May%202021%20.pdf
-
75
Sri Lanka Ministry of Health (MOH). National Deployment and Vaccination Plan (NDVP) for COVID-19 Vaccines. Colombo, Sri Lanka: MOH; 2021.
-
76
Sri Lanka State Ministry of Primary Health Care, Epidemics and COVID Disease Control. Accessed January 9, 2023. http://web.archive.org/web/20220619080635/https://www.statehealth.gov.lk/
-
77
Govt. spent over Rs. 66 billion to import COVID vaccines so far. Ada Derana. December 2, 2021. http://www.adaderana.lk/news/78859/govt-spent-over-rs-66-billion-to-import-covid-vaccines-to-sri-lanka
-
78
IHP analysis of SLOTS survey data to 17 August 2022 and published MOH statistics.
-
79
Sri Lanka had little choice except China’s Sinopharm: Weeratunga. EconomyNext. July 29, 2021. https://economynext.com/sri-lanka-had-little-choice-except-chinas-sinopharm-weeratunga-84413/
-
80
World Bank. Project Paper on a Proposed Restructuring and Additional Loan in the Amount of US$100 Million to the Democratic Socialist Republic of Sri Lanka for a Sri Lanka COVID-19 Emergency Response and Health Systems Preparedness Project. Washington, DC: World Bank; 2021. Accessed January 5, 2023. https://documents1.worldbank.org/curated/en/702871635172673879/pdf/Sri-Lanka-COVID-19-Emergency-Response-and-Health-Systems-Preparedness-Project-Third-Additional-Financing-and-Restructuring.pdf
-
81
British Columbia Centre for Disease Control (BCCDC). World Health Organization (WHO) Emergency Use Authorization (EUA) Qualified COVID-19 Vaccines. Vancouver, Canada: BCCDC; no date. Accessed January 5, 2023. http://www.bccdc.ca/Health-Info-Site/Documents/COVID-19_vaccine/WHO-EUA-qualified-covid-vaccines.pdf
-
82
Delay prompts Sri Lanka to look for AstraZeneca vaccines outside India. Deccan Herald. May 1, 2021. https://www.deccanherald.com/international/world-news-politics/delay-prompts-sri-lanka-to-look-for-astrazeneca-vaccines-outside-india-981218.html
-
83
Amnesty International. Sri Lanka Struggles to Respond Effectively to COVID-10 Third Wave. London, UK: Amnesty International; 2021. Accessed January 5, 2023. https://www.amnesty.org/en/wp-content/uploads/2021/07/ASA3742622021ENGLISH.pdf
-
84
Farzan Z. COVID-19: Army-manned vaccination centers for AstraZeneca and Sinopharm. News 1st. August 8, 2021. https://www.newsfirst.lk/2021/08/08/covid-19-army-manned-vaccination-centers-for-astrazeneca-sinopharm/
-
85
World Health Organization. Putting women and children first: immunization resumes in Sri Lanka amidst the COVID-19 pandemic. Published July 4, 2020. Accessed January 5, 2023. https://www.who.int/southeastasia/news/feature-stories/detail/putting-women-and-children-first-immunization-resumes-in-sri-lanka-amidst-the-covid-19-pandemic
-
86
Presidential Secretariat. Mobile vaccination service to administer booster dose. Published November 26, 2021. Accessed January 5, 2023. https://www.presidentsoffice.gov.lk/index.php/2021/11/26/mobile-vaccination-service-to-administer-booster-dose/
-
87
Sri Lanka Ministry of Health. COVID-19 immunization tracker: request for Smart Vaccination Certificate. Accessed January 11, 2023. https://covid-19.health.gov.lk/certificate/
-
88
World Health Organization. WHO Dialogues: Sri Lanka shares digital innovations made during pandemic. Published December 7, 2021. Accessed January 5, 2023. https://www.who.int/southeastasia/news/feature-stories/detail/who-dialogues-sri-lanka-shares-digital-innovations-made-during-pandemic
-
89
Sri Lanka starts issuing digital vaccination certificates. South Asia Monitor. July 11, 2021. https://www.southasiamonitor.org/sri-lanka/sri-lanka-starts-issuing-digital-vaccination-certificates
-
90
DHIS2. Innovative management of COVID-19 vaccine delivery in Sri Lanka. Accessed January 5, 2023. https://dhis2.org/sri-lanka-covid-vaccine/
-
91
Wijesekara N, Kodituwakku K, Bulathsinghe B, Sachinthani J, Lakshani M. Eighty-six percent of Sri Lankans wish to receive COVID-19 vaccine: a window of opportunity for rolling out a successful vaccination campaign. Int J Commun Res. https://www.researchgate.net/publication/348902715_Eighty-six_percent_of_Sri_Lankans_Wish_to_Receive_COVID-19_Vaccine_A_Window_of_Opportunity_for_Rolling_Out_a_Successful_Vaccination_Campaign
-
92
Jayasinghe C. Health officials urge Sri Lankans to get COVID-19 booster as expiration dates draws nearer. EconomyNext. March 26, 2022. https://economynext.com/health-officials-urge-sri-lankans-to-get-covid-19-booster-as-expiration-dates-draws-nearer-92096/
-
93
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.
-
94
Wickramasinghe D, Fernando VK. Sri Lanka’s fight against COVID-19: a brief overview. In: Shaw R, Pal I, ed. Pandemic Risk, Response, and Resilience: COVID-19 Responses in Cities Around the World. Amsterdam, Netherlands: Elsevier; 2022: 129-142.
-
95
Sri Lanka Ministry of Health (MOH). Guidelines to Get Essential Workers to Work During Curfew. Colombo, Sri Lanka: MOH; 2020.
-
96
Sri Lanka Ministry of Health (MOH). Interim Guidance for Surgical and Medical Procedures in Relation to COVID-19. Colombo, Sri Lanka: MOH; 2020. Accessed January 28, 2023. https://www.epid.gov.lk/web/images/pdf/Circulars/Corona_virus/guidance_for_medical_and_surgical_procedures.pdf
-
97
Sri Lanka Ministry of Health (MOH). Interim Guidelines on Maternal and Child Health Services During Curfew Period During Outbreak of COVID-19 Infection. Colombo, Sri Lanka: MOH; 2020. Accessed January 28, 2023. https://www.epid.gov.lk/web/images/pdf/Circulars/Corona_virus/gosl-hospital-guidelines-27-03-2020.pdf
-
98
Sri Lanka Ministry of Health (MOH). National Supplementary Guideline for Mithuru Piyasa/Natpu Nilayam Staff to be Adopted During COVID-19 Pandemic. Colombo, Sri Lanka: MOH; 2020. Accessed January 28, 2023. https://drive.google.com/file/d/1VmnoSBV4yNJGkr6fTHnDULDWy2I11n3K/view
-
99
Sri Lanka Ministry of Health (MOH). Interim Guidance During COVID-19 Pandemic Outbreak for Service Providers of Safe Homes/Temporary Shelters Intended for Survivors of Gender Based Violence. Colombo, Sri Lanka: MOH; 2020. Accessed January 28, 2023. https://drive.google.com/file/d/1sgVrp64l2eZ6jBa-IXNsYVNeRIIUPufE/view
-
100
Sri Lanka Ministry of Health (MOH). Interim Guideline on School Dental Services in the New-Normal Phase of COVID-19 Pandemic. Colombo, Sri Lanka: MOH; 2020. Accessed January 28, 2023. https://covidlawlab.org/wp-content/uploads/2021/01/Sri-Lanka_2020.02.09_School-Dental-Services-in-the-New-Normal-Phase-Covid-19_EN.pdf
-
101
Samaranayake WAMP, Jayawardena GPC, Roshan ALL, Wijewardene MAM, Siraj MI. COVID-19 infection among health care workers: experience in Base Hospital Wathupitiwala, Sri Lanka. Preprint. August 29, 2021. medRxiv. https://doi.org/10.1101/2021.08.28.21262733
-
102
IHP analysis of data from the IHP Private Hospitals Survey 2022.
-
103
Sri Lanka Ministry of Health (MOH). Purchase and Get Medicine Delivered at Your Door Step. Colombo, Sri Lanka: MOH; 2020.
-
104
Garment workers on front line of Sri Lanka coronavirus outbreak. Reuters. November 3, 2020. https://www.reuters.com/article/us-health-coronavirus-sri-lanka-workers/garment-workers-on-front-line-of-sri-lanka-coronavirus-outbreak-idUSKBN27K08Z
-
105
Sri Lanka Ministry of Health (MOH). Supply of Pharmaceuticals for Clinic Patients During COVID-19 Outbreak Period. Colombo, Sri Lanka: MOH; 2020.
-
106
Sri Lanka Ministry of Health (MOH). Provision of Medicines for Patients with Non-Communicable Diseases (NCDs) Taking Treatment From the Private Sector. Colombo, Sri Lanka: MOH; 2020.
-
107
Wickramasighe C, Kumarapeli V, Wickramasinghe A, et al. Web-based mechanism for door-step delivery of medicines to patients with Non-Communicable Diseases (NCDs) using the state and private pharmacy network during the COVID-19 outbreak in Sri Lanka. Paper presented at: Annual Academic Sessions of College of Community Physicians of Sri Lanka 2020; Colombo, Sri Lanka. Accessed January 5, 2023. https://www.researchgate.net/publication/346378400_Web-based_mechanism_for_door-step_delivery_of_medicines_to_patients_with_Non-Communicable_Diseases_NCDs_using_the_state_and_private_pharmacy_network_during_the_COVID-19_outbreak_in_Sri_Lanka
-
108
Primary Health Care Performance Initiative. Ensuring access to routine and essential services during COVID-19 through utilizing telehealth in Sri Lanka. COVID-19 promising practices. Colombo, Sri Lanka: Primary Health Care Performance Initiative; 2020.
-
109
Jayasinghe C. Sri Lanka army deploys mobile vaccination fleet for elderly and disabled. EconomyNext. August 12, 2021. https://economynext.com/sri-lanka-army-deploys-mobile-vaccination-fleet-for-elderly-and-disabled-84801/
-
110
Provisional Clinical Practice Guidelines on COVID-19 suspected and confirmed patients. Ministry of Health Sri Lanka. March 2020. https://www.hpb.health.gov.lk/media/pdf/provisional-clinical.pdf
-
111
Sri Lanka Ministry of Health (MOH). Release of Persons who Have Quarantined From the Quarantine Centers. Colombo, Sri Lanka: MOH; 2020. Accessed January 28, 2023. http://www.health.gov.lk/moh_final/english/public/elfinder/files/feturesArtical/2020/Release%20of%20persons%20who%20have%20quarantined%20from%20the%20quarantine%20centers.pdf
-
112
Sri Lanka Tourism Development Authority. Important notice to international travelers. Accessed January 28, 2023. https://srilanka.travel/image/helloagain/Notice/importantNoticeInternationTraveller.jpeg
-
113
Sri Lanka Tourism Development Authority. Sri Lanka tourism gears up to welcome international visitors. Published January 17, 2021. Accessed January 28, 2023. https://srilanka.travel/image/helloagain/Notice/PR-SRILANKATOURISMGEARSUPTOWELCOMEINTERNATIONALVISITORS.pdf
-
114
Pitrelli M. Sri Lanka is now open to travelers—no quarantine, but no mingling with locals too. CNBC. February 17, 2021. https://www.cnbc.com/2021/02/17/where-can-i-travel-in-asia-without-quarantining-sri-lanka-is-now-open.html
-
115
Sri Lanka Tourism Development Authority. https://srilanka.travel/image/helloagain/Notice/importantNoticeInternationTraveller.jpeg
-
116
Sri Lanka Ministry of Health. Quarantine measures for travellers arriving from overseas during the pandemic of COVID-19. September 28, 2021. http://web.archive.org/web/20220213183853/https://srilanka.travel/helloagain/documents/Quarantine-Measures-for-Travellers.pdf