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

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.

In early 2020, Sri Lanka’s authorities officially adopted a , 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.

Without high levels of PCR testing for symptomatic people in local health facilities, however, lapses in adherence to isolation policies led to . 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  did not include pooled or saliva testing). 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.

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.”, 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.”

. 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). 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.

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

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.

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.

Effect on essential health service delivery in Sri Lanka: Phases 1 and 2 (2020)

Early in the pandemic, Sri Lanka’s effective control of COVID-19 transmission ensured that most health institutions were not overburdened or overwhelmed.

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.  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.

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, .

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. 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 , friendly havens for survivors of gender-based violence, which operated during hospitals’ usual working hours. Additional guidance was issued in May 2020 for the proprietors of safe homes for survivors of gender based violence.

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.

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.

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.

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.

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.

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.

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.  (For further information, read more in section on service delivery adaptations made for the delivery of medicines for noncommunicable diseases during the pandemic).