social impact of covid 19 in sri lanka essay

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Sri Lanka's fight against COVID-19: a brief overview

Sri Lanka was endorsed by the World Health Organization as a country that made immense progress in controlling the COVID-19 pandemic. This chapter focuses on the health-care structure, strategic use of Police, Tri-forces, and other government entities, media support, traditional social practices, the public responsiveness, and even the geographic location of the country that contribute to the overall control of the pandemic and management of the disease plausibly. Despite the nearly successful achievement, the country has faced economic, political, and social challenges during this critical period, through which many lessons are learnt. Sri Lanka has had few H1N1 outbreaks in the recent past. However, till the spread of COVID-19, the current population had not experienced the spread of a highly contagious disease in the country. Therefore, this chapter aims to share the novel experience, strategies used, challenges faced, and ways adapted in confronting COVID-19 as a country.

1. Introduction

The pandemic, Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2 virus) is among the deadliest events happened to the humankind in the recent history. The pandemic has triggered devastating effects on economic and sociopolitical conditions of tens of millions of people. Owing to the novelty of the virus, the development of remedial measures including vaccines posed many challenges. Thus, people had to adhere to many, mostly previously unpracticed precautionary measures including extensive hand washing, wearing masks, and social distancing. The spread of the disease was rapid and exponential in many regions severely affecting the day-to-day lives of people.

Sri Lanka is a tropical island in the Indian Ocean with an estimated population of 21,919,000 ( Department of Census and Statistics, Sri Lanka, 2020 ). Population density is highest in the Western Province of the country, especially concentrated in and around the capital city, Colombo. Large crowds enter Colombo on a daily basis or seek temporary accommodation in Colombo or suburbs as many government and private offices, best hospitals, leading schools, several large state universities, free trade zones, the main seaport, and the prime airport of the country are situated in the Western Province. Sri Lanka being a popular tourist destination, earns a large amount of foreign exchange from the tourism industry; thus, its economy relies heavily on tourism ( Ranasinghe & Sugandhika, 2018 ). The apparel industry also contributes largely to export income catering to the high-end US and European markets. The livelihood of a substantial portion of the population hence depends directly or indirectly on tourism and the apparel industry. Yet another considerable majority depends on agricultural industries, as producers, processors, retailers, or at a different scale in the market chain.

The main economic challenges faced by Sri Lanka as a country in the past few decades were the civil war, the tsunami, and the most recent Easter Sunday attack in 2019. COVID-19 pandemic hit Sri Lanka at a time the country was grappling to recover from the loss of the Easter Sunday attack in April 2019. The health sector of Sri Lanka is at a reasonably plausible level for a middle-income country. Sri Lanka ranked 73 rd among 195 countries for personal health-care access and quality, being fairly ahead of other South Asian countries ( Barber et al., 2017 ). Therefore, the state health sector was vigilant and ready to take up the health challenge of COVID-19. The Tri-forces, the Police, and government administrative workers are other main forces that strengthen and support the health-care sector in Sri Lanka throughout this mission. The cooperation and the commitment of the private sector and the public also play a pivotal role in succeeding the COVID-19 battle.

The very first COVID-19 case from a Sri Lankan citizen was reported on March 11, 2020 ( Ediriweera et al., 2020 ), and the second after 2 weeks. Since then, the number of cases increased very slowly, not more than 10 patients on most days up to mid-April 2020. Besides the three to four spikes reported due to clusters from quarantine centers, a Navy base, and a rehabilitation center, the numbers remained in a range of 0–30 up to early October 2020 ( Epidemiology Unit, 2020a ). This period was considered the first COVID-19 wave in the country. The second COVID-19 wave hit the country harder than the first, just when the society was adopting the “New normal” life. The disease pattern and the trend were dissimilar to the first wave, where the daily numbers became 10–20 times higher by December 2020 ( Epidemiology Unit, 2020b ), supposedly due to different strategies adopted by the Government keeping in line with new global knowledge about the pandemic. Despite the recent increase in positive cases, the death rate of Sri Lanka is at 0.48% which is considerably lower than the global rate: 2.14% ( Sri Lanka Health Promotion Bureau Website Dashboard, 2021 ). Several factors such as the robust health-care structure, strategic use of Police, Tri-Forces and other government entities, media support, traditional social practices, the public responsiveness, and the geographic location of the country have contributed largely for the control of the pandemic and management of the disease in the country.

2. The health-care structure of Sri Lanka

Sri Lanka's health-care system comprises allopathic, traditional, Ayurveda, Yunani, Siddha, homeopathy, and acupuncture practices ( Ministry of Health and Indigenous Medical Services, 2020a ). Allopathic or Western medical service is largely available via public and private sector service providers. Public allopathic care is provided by a robust network spanning across the country. Most importantly the public health-care sector is commonly accessible for the entire population free of charge. Private allopathic services provided at a cost are concentrated in metropolitan areas, enhanced by modern equipment and facilities ( Perera & Perera, 2017 ). They attract the more modernized and economically sound fraction of the public. Nevertheless, the majority of the population seeks inpatient care primarily in the public sector. Twenty four million patients have been implicated to benefit through routine health clinics conducted at these facilities in 2014 ( Perera & Perera, 2017 ). Moreover, the public sector offers Ayurvedic care free of charge to the public through regional Ayurveda hospitals/centers although the network is as not as much expanded as of the Western health-care structure. The private sector is also involved in providing Ayurveda, traditional Sri Lankan, and other conventional medical care. Most importantly, the private health-care institutions in Sri Lanka are regulated by the Private Health Regulatory Council (PHRC) while the conventional medical services are also regulated under different authorities to a great extent.

2.1. The state health sector

The state health sector caters to the nation in two main aspects; a) providing curative care services ranging from nonspecialized primary care to specialized care delivered through hospitals of different grades, and b) providing community health services focusing on promotive and preventive health. The curative care institutions are of three levels: tertiary care institutions (National Hospital of Sri Lanka, Teaching Hospitals, and Provincial General Hospitals), secondary care institutions (District General Hospitals and Base Hospitals (Type A, B)), and primary care institutions (Divisional Hospitals (Type A, B, C)) and primary medical care units ( Ministry of Health and Indigenous Medical Services, 2020a ). The management of the National Hospital and 21 teaching hospitals is driven by the Ministry of Health while the provincial councils are given the authority to manage other hospitals.

An excellent set of community health services are offered to the public through the Medical Officer of Health (MOH) offices, which are divisional health units, formed to reach almost all families throughout the country ( Perera & Perera, 2017 ). Their prime focus is on maternal and child health, followed by communicable and noncommunicable diseases. As of 2018, 353 MOH offices have been functioning across the country ( Ministry of Health and Indigenous Medical Services, 2020a ). These units are managed by a medical doctor and supported by public health field staff, mainly consisting of Public Health Inspectors (PHIs) and Public Health Midwives (PHMs). The central authority of all public health services, however, lies on the Ministry of Health, and it is responsible for the provision of trained human resources, drug supply, and major infrastructure developments for all hospitals in the country. The effectiveness of this well-structured health-care system is clearly evident by its credible health indicators ( Ministry of Health and Indigenous Medical Services, 2020a ).

2.2. Excellence in disease management and surveillance

Before the emergence of COVID-19, Dengue was the most challenging public health concern in Sri Lanka ( Tissera et al., 2020 ). Due to the high receptivity and the vulnerability to the disease, and the major Dengue outbreak in year 2004, Sri Lanka has established a dedicated unit for Dengue control: the National Dengue Control Unit, and a Presidential task force on dengue control headed by the President. Despite the lapses in vector control, disease management is well under control having skilled practitioners in the state hospitals and elaborate disease management guidelines set up by the authorities. Sustaining the Malaria-free status since 2012 further explains the strong and continuous disease surveillance system in Sri Lanka. However, Sri Lanka had not experienced any pandemic in the recent past.

2.3. Initial responses to COVID-19 disease management

The first COVID-19 patient, a foreign national, was reported from Sri Lanka in late January 2020 at the departure terminal of the main international airport of the country. The patient was treated at the National Institute of Infectious Diseases (Infectious Diseases Hospital – IDH) in Colombo and discharged mid-February after full recovery. Sri Lanka's preparedness for COVID-19 prevention and cure was well displayed through the prompt detection and successful management of this first patient. The first Sri Lankan patient was reported in early March, more than a month apart from the first patient diagnosis, followed by a slow daily rise in the numbers, establishing the first COVID-19 wave in the country. Based on the global disease trends and patterns, the health authorities paid much attention to strengthen the hospital emergency preparedness and response plans of all health-care institutions. The needs were addressed by the Government using a three-tier approach as shown in Fig. 10.1 ( Ministry of Health and Indigenous Medical Services, 2020b ).

The three-tier approach used by the Ministry of Health of Sri Lanka to immediately address the need of strengthening the hospital emergency preparedness and response plan of all state health-care institutions of the country.

Initially only three hospitals—the IDH, Colombo East Base Hospital, and the Welikanda Base hospital in the North Central Province of Sri Lanka—were designated as COVID-19 treatment facilities. IDH was immediately designated to treat COVID-19 positive individuals and its infrastructure was rapidly developed. By mid-March the Welikanda Base hospital was converted to a fully equipped COVID-19 treatment center. Personnel from the Tri-forces were deployed in rapid construction activities where facilities were uplifted. By April 2020 just as the total number of COVID-19 patients was reaching 700, the authorities designated the Defence University (Kotelawala Defence University) hospital as a treatment center and 30 other hospitals as isolation centers to house suspected patients. They included tertiary as well as secondary care institutions covering most districts in the island. This was an important measure to ensure local preparedness to respond to a large number of suspected and confirmed cases as was reported in China and Europe during that period.

Hospitals with isolation centers, however, continue to provide the usual diverse health-care services, other than routine clinics, to the general public. Patients at risk, i.e., those with noncommunicable diseases, elderly patients, and pregnant women, are discouraged to attend the clinics. As many of these patients depend on freely issued medication, they are given options to get their prescribed medicine delivered to their residence or to be issued to a relative visiting the clinic. This arrangement was possible as the hospitals have well-maintained clinic registers with patient information. COVID-19 surveillance was expanded using existing respiratory disease surveillance systems and hospital-based surveillance. Heads of all the state health-care institutions were strongly advised by the health authorities not to deprive any patient of their usual standard of care due to their COVID-19 status. Such directions are vital to ensure the general well-being of the majority while caring for the directly affected, as the general public highly depends on state hospitals for any medical emergency and inpatient care.

The central health-care authority further advised and guided all the tertiary and secondary care hospitals including those with isolation centers to make arrangements to immediately scale up their COVID-19 preparedness as and when necessitated, based on the crisis status. The preparedness plan of the said hospitals included the establishment of a COVID-19 operational cell, outpatient and emergency department care, establishment of a designated COVID-19 suspected section/ward, provision of critical care for non-COVID and COVID suspected patients, safe transferring of patients to a COVID-19 designated/isolation hospital, ensuring safety of health-care staff, and managing COVID-19 cured patients ( Ministry of Health and Indigenous Medical Services, 2020b ). The COVID-19 operational cell is established with the expectation to ensure effective and collective decision-making at the hospital level at a critical time, and it consisted of the Head of the Institution, relevant consultants, and persons in-charge of other staff. The authorities had identified that ensuring the safety of staff is crucial in effectively managing the pandemic. Thus, supply of personal protective equipment (PPE), provision of required infrastructure and transport, continuous education and awareness programs, provision of psychological support, and ensuring surge capacity by deploying an adequate number of staff from other units of the hospital if needed were considered as essential steps to be taken at all hospitals to ascertain safety and well-being of the staff.

The Ministry of Health in no time published the guidelines for clinical management of COVID-19 ( Ministry of Health and Indigenous Medical Services, 2020b ). These guidelines, compiled by a group of expert medical practitioners in the country, highlight the importance of early case detection, prompt isolation of ill people, appropriate and timely management of patients, comprehensive contact tracing, and immediate quarantine of all possible contacts to minimize widespread community transmission to mitigate a major outbreak and associated mortality. The guidelines have even provided insight to develop the capacity of the health sector to be prepared to successfully handle any outbreak. Uniform and systematic management of all COVID-19 patients is ensured by the guideline, which is strictly followed at all state hospitals, where COVID-19 patients are managed. The private sector was not permitted to manage COVID-19 patients initially.

Disease diagnosis was limited to PCR tests during the first wave. Majority of the tests were done by the Medical Research Institute (MRI). With the rise in patient numbers during the first wave, the PCR testing facilities were established in state hospital laboratories and other government institutions, viz. universities in parallel to upgrading hospital facilities, as the authorities foresaw the need of bulk testing. In order to prevent over burdening of the laboratories, the treatment and isolation hospitals were assigned with specific laboratories for diagnostic testing.

2.4. COVID-19 community health services

The MOHs providing community health services are effectively utilized in engaging the public in quarantine and self-isolation activities where necessary. The close contacts of COVID-19 positive persons are quarantined at home or specially designated quarantine centers for 14 days irrespective of their initial PCR results. When people are home quarantined, the PHIs of the relevant MOH area is made responsible to ensure, the people under quarantine are made aware of the need to quarantine, and their basic needs such as food and other medical needs are fulfilled. The PHIs are the ideal resource persons that could be deployed to ensure the quarantine process is proper and adequate because they are the field health officers who are familiar with the neighborhood and the general requirements of the people in the area. The first wave of the pandemic halted the services of field clinics for pregnant women and the child immunization program, which are otherwise successfully handled by the PHMs in the country. However, their well-established communication network with the public has enabled them to continuously support and guide women in pregnancy-related matters and childcare. The Family Health Bureau functioning under the Ministry of Health released specific guidelines to ensure uninterrupted field maternal and child health-care services for lockdown areas and quarantined families. Safety of both the health-care workers as well as the community is given attention while guidance on field care and hospital care is provided in the instructions to field workers ( Adikari et al., 2020 ). The need of continuous therapeutic communication was also highlighted to assure that necessary mental and emotional support is extended to the community as domestic violence is inevitable at a time when people are struggling to make a living while surviving a pandemic.

3. The public responsiveness

COVID-19 pandemic has created anxiety and uncertainty, worsening the economic crisis globally, in a similar or worse manner than other pandemics have. However, it is the worst and possibly the first pandemic that the current population is experiencing during their lifetime. In that light, the current Sri Lankan population has not even experienced an epidemic that is slightly in par with the COVID-19 pandemic. The worst epidemic faced by Sri Lankans in the recent past was the Dengue epidemic in 2017. A few H1N1 outbreaks in the recent past raised the alertness of the health sector, but the risk was not sensed significantly by the general public. Thus, similarly to the majority of the world's population, the COVID-19 pandemic is a novel experience to Sri Lankans.

Although the authorities imposed restrictions on overseas visitors in a gradual manner at the emergence of the first wave, i.e., over more than 6 weeks from the first patient being reported, a public holiday was declared abruptly overnight with a slight rise of the number of patients. The holiday was extended for several days and curfew was imposed on the entire country which lasted for 52 days. This unexpected sudden lockdown immensely affected the lives of general public. The fundamental challenge for the urban population was to secure their food and medical needs. The government authorities worked out to allow essential services to function under special permission and extremely high restrictions. Mobile vending was encouraged and well guided. The postal service workers were deployed to deliver medicine to patients being followed up at state hospital clinics. The public was very much enthusiastic to grow their own vegetables and cooking their own meals during the curfew period. Gardening and cooking became good hobbies for many people who used to work strenuously at offices. Many people made use of such opportunities to rebond with families which they had missed due to their hectic lifestyles. On the contrary, another portion of the society who depends largely on daily wages lost their livelihood due to the lockdown. Challenges faced by them are discussed in a later section in this chapter.

The Sri Lanka COVID-19 Healthcare and Social Security Fund was introduced by the President. The general public, government servants, and private entrepreneurs contributed generously in different scales to the fund. In addition, they assured direct donations of medical equipment, food, and other necessities to other needy entities. Many garment factories ran out of their regular orders. However, they started producing face masks and other PPE in large scales to meet the increasing demand in the country.

4. Traditional social practices

Sri Lanka is a multiethnic country with different cultures, practices, and beliefs. The current generation is often criticized by the older generation for ignoring the rich traditional cultures and practices and embracing more of western practices. The COVID-19 pandemic has now granted an opportunity for Sri Lankans to apply such cultural practices in the day-to-day lives. The traditional way of greeting in Sri Lanka is to join the palms together and to wish “ Ayubowan ” (“may you live longer!”). At a time when hand shaking is discouraged globally to avoid physical contact with outsiders, Sri Lankans found it intriguing to readopt their own way of greeting which does not involve physical contact. More fascinatingly the greeting gives out an energetic vibe when people wish good health and long life at a time they need it the most.

Quarantining became a new term for the general public. But the concept is not. Sri Lankans get self-isolated for 14–21 days when they contract contagious diseases such as chicken pox, measles, and mumps. Although curative allopathic medicine for such diseases is available currently, patient isolation and warning of visitors by hanging Neem leaves at the entrance to the house are still practiced by many. The health promotion workers used this traditional practice to make the public aware and understand the requirement of home quarantining.

One other strong advice given to the general public is that, before entering the house after being outside they should remove all clothing and footwear and shower outside if possible. The older generations in Sri Lanka have long been practicing such manners, or at least are familiar with such practices. Hence people are not reluctant to adhere to similar advice by the health authorities. Sri Lankans frequently consume ginger, coriander, and many other spices. There is belief that such spices can boost immunity, and thus play a protective role against the Coronavirus. Therefore, with the onset of the pandemic, the use of such home remedies has increased. Steam inhaling, another practice of traditional household to ease the sinuses, and upper respiratory tract infections, has lately become a common practice among many.

Having a Buddhist majority, Buddhist temples started enchanting the Ratana sutta (Jewel discourse) with belief that it protects a person or society from evil influences and pestilences. Similarly, there have been many religious rituals carried out by others including the Christian churches and Hindu temples. Such religious practices close to the people's heart may help to uplift the spiritual well-being of the public.

5. The geographic location of the country

There is evidence that countries closer to the equator have lower COVID-19 fatality rates than those that are away from the equator ( Whittemore, 2020 ). Having exposed to optimum levels of sunlight prevents vitamin D deficiency, a reason associated with COVID-19 deaths ( Whittemore, 2020 ). Moreover, sunlight can be used as a disinfectant of the SARS-CoV-2 virus as it is known to be inactivated in 30 min at 56°C ( Eslami & Jalili, 2020 ; Whittemore, 2020 ). Being closer to the equator, Sri Lanka has a hot climate year around and can be considered a blessing in mitigating the effects of the virus.

Sri Lanka encompasses a limited number of ports to enter the country. The main international airport is the Bandaranayake International Airport among four other airports with less international functioning. There are seven seaports in the country, the Colombo port being the largest and busiest. As one of the very first precautionary actions against COVID-19 spread, the airports started monitoring the temperature of the passengers. It is undoubtedly an important step as the first COVID-19 patient was identified at the departure terminal when under surveillance ( Sri Lanka Tourism Development Authority, 2020 ). From the first week of March 2020, passengers arriving from high-risk countries were sent for 14 days essential quarantine at centers specifically set up by the Sri Lanka Army to control the entry of COVID-19 patients to the country. The government decided to totally suspend all passenger flight and ship arrivals into Sri Lanka from third week of March 2020, with the gradual increase of patients reported in the country ( Sri Lanka Tourism Development Authority, 2020 ). Being an island placed Sri Lanka in an advantageous position in controlling and surveillance of patients entering the country.

6. The role of military and police on COVID-19 management in Sri Lanka

As a country, Sri Lanka took strong measures to manage and mitigate the crisis at the initial stages of the pandemic and continue with the same. The government deployed the Tri-forces—Army, Navy, and the Air force—as well as the Police in different activities related to the management of the pandemic. Among the key activities are facilitating quarantine/isolation services, services at the COVID-19 intermediate care centers for nonsymptomatic patients, and community behavior control. Society believes that the proactive contribution of health professionals and the military personnel in battling against COVID-19 is the major reason for keeping the pandemic under control. When compared to some countries with a similar socioeconomic setting, Sri Lanka so far has successfully managed the pandemic while minimizing deaths. According to the report on combating COVID-19 Sri Lankan approach by the State Intelligence Service, the first line of the operations of preventing the spread of COVID-19 is through the military, police, and Intelligence sector of the country ( State Intelligence Service, 2020 ). The major task of this line of operations was to sustain the magnitude of the pandemic into a manageable scale for the medical and health-care sectors. There are three major components of this process, i.e., detection, isolation, and tracing ( Fig. 10.2 ). The Ministry of Defense has taken the lead in coordinating between all these agencies in this first line of operations in Sri Lanka. In addition, the forces are at the forefront of border management to control the entry of infected persons from overseas.

Major components of the operations undertaken by the military, police, and intelligence sector of Sri Lanka to prevent the spread of COVID-19.

Roping the military in community behavior control could restrict the public freedom; nevertheless, the military has been one of the key supporters of crisis assistance and thus of humanitarian aid ( Jayasena & Chinthaka, 2020 ). In this regard, as the first line of operations, members of the military built a national resilience against the pandemic situation.

7. The role of media on COVID-19 management in Sri Lanka

Dissemination of accurate, reliable, and useful information to the public is crucial for any disaster management effort. Mass media acts as a powerful force in shaping people's attitudes and ideas. Publishing the right information regarding the pandemic situation in the country to the local and international community is critical to keep them well-informed. In this regard, there are different types of sources of information in operation. Presidential Media Division acts as the official source of information for all the initiatives, actions, and progress regarding the process of combating the COVID-19 pandemic by providing the right information to the public through its website and social media. During this crisis period, traditional media including television (TV) channels, radio channels, and newspapers, in addition to social media forums, contribute significantly to the dissemination of correct information to the community ( Hettiarachchi et al., 2020 ). Positive health practices are well promoted by the mass media via different advertisements to increase public awareness and control the spread of the disease in the country. For instance, for groups with inadequate literacy rates such as younger children (e.g., preschool level) and adults who are less conversant with reading, pictorial or video messages are the best source of information, especially on disease preventive measures such as wearing masks and washing hands. Experts from different fields have extensively used state and private media (both TV and radio channels), social media platforms to share the correct information with the general public through discussions and programs. Many TV commercials appeared with creative messages that encompass essential information to reduce exposure, social distancing, hand washing, face protection etiquette, etc.

However, since the recent past, there is an increasing concern about the misinformation spread especially by social media. There have been reports on unethical behavior of local media who had reported recognizable personal information, publishing the ethnicity of the COVID-19 patients which leads to stigmatization in the society ( Ayub, 2020 ). On the other hand, the spread of fake news via social media platforms has significantly risen which mislead the community perception regarding COVID-19 spread, its causes, and prevention ( Limaye et al., 2020 ). Many social media groups target providing “hot news” without verifying the sources and reliability.

7.1. Official COVID-19 information websites in Sri Lanka at a glance

As the COVID-19 outbreak is considered a health emergency in Sri Lanka, the government websites, especially the website of the Ministry of Health, are the official sources of information. The Ministry of Health website provides essential information on summary statistics including active cases and number recovered as well as deaths by each district. In addition, details on hospital admissions and tests carried out (PCR) are included. A Presidential Taskforce hotline is available on the Ministry of Health website for any emergency information ( Ministry of Health, Sri Lanka, home page ). Other important information including notices, guidelines, letters, and circulars are displayed on the website and these are updated frequently to provide the latest information ( Figure 10.3 , Figure 10.4 ).

Guidelines on general preventive measures for work settings.

Preventive measures for special settings. The specific settings identified are displayed.

8. Risk communication plan

In any disaster, risk communication plays a crucial role in the management and reducing impacts. The risk communication framework and risk communication plan for COVID-19 in Sri Lanka were developed by the Health Promotion Bureau of the Ministry of Health in January 2020. Accordingly, the risk communication plan consists of four phases ( Health Promotion Bureau, 2020 ) ( Table 10.1 ).

Table 10.1

Four phases of the COVID-19 risk communication plan in Sri Lanka.

However, the control strategies implemented in the country have been reported to be effective with at least 50% contact rate reduction or with at least 40% isolation of the contact history of infected population ( Erandi et al., 2020 ).

9. Challenges faced

COVID-19 pandemic is not only affecting physical and mental health but also disrupting lives and livelihoods. Many pressing concerns and challenges are being increasingly appearing in the “new normal” status of the pandemic. New problems have emerged in economic development at both local and national levels and beyond as “business as usual” scenarios have changed. In times of uncertainty and with a plethora of regulations to manage the pandemic many vulnerable groups including poor and marginalized communities, part-time and temporary workers, low-income households, fishery and agricultural workers, and self-employed individuals are severely affected ( Deyshappriya, 2020 ). Hospitality, apparel, and other export-oriented industries on which a considerable portion of the country's economy rely on are facing the greatest challenges. The exceptional and sudden increased costs of health care and safety management have taken the country's focus away from some essential developmental activities.

The interruption caused to the social structure is formidable. As Sri Lanka is a country with a social fabric of interconnected societal segments of family members, relatives, and friends, social isolation, quarantine, and lockdowns have affected psychosocial health. Among the most vulnerable groups are the poor, women, children, sick, and elderly. Restrictions on social gatherings that include religious rituals, cultural events, functions, sports, and leisure activities have hit the society badly. The virtual work environment has resulted in individuals being restricted to their homes and weakened social cohesion and discontent.

10. Conclusion

COVID-19 is still spreading globally at an alarming rate. While some countries that were fortunate to fully or nearly fully vaccinate their populations fight to restore health and normal life, some countries are still far from coming out of the COVID-19 disaster. Even though with unprecedented challenges, Sri Lanka's struggle to control the emergency situation which is basically managed by the health authorities and supported by other agencies has been successful to date. Specifically, the three-tier approach adopted has generated fruitful results. Public responsiveness to successful containment of the disease is increasingly evident. The media and the armed forces extend help in managing the pandemic situation. Yet, the pandemic has necessitated the need for a broader and integrated attempt to understand and act on many pressing socioeconomic concerns and as issues that are growing day by day.

Acknowledgment

We profoundly thank Dr. Sachini Amarasekara of the Department of Zoology and Environment Science, University of Colombo, Sri Lanka, for the English Language check.

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Ethical Responses to the COVID-19 Pandemic—Lessons from Sri Lanka

• Perspective
• Published: 03 November 2020
• Volume 13 , pages 225–233, ( 2021 )

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• Dineshani Hettiarachchi   ORCID: orcid.org/0000-0002-1732-7339 1 ,
• Nafeesa Noordeen 2 ,
• Chanpika Gamakaranage 3 ,
• E. A. Rumesh Buddhika D. Somarathne 1 &
• Saroj Jayasinghe 3  

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The COVID-19 pandemic has undoubtedly become an era-defining challenge for the entire world. It has implications not only in the public health sector but also in the global economy and political landscape. The prevention strategy that has been followed in Sri Lanka is unique. Early action taken by the government and the ministry of health, being one of pre-emptive quarantining and isolation of suspected contacts even before they developed symptoms, was vital to contain the spread of the disease. During the early phase, a nationwide lockdown in the form of a curfew was imposed which helped mitigate the spread of the virus. However, due to several lapses, there was a threat of community transmission; this was swiftly brought under control through ongoing government interventions. Thus, strict social/physical distancing measures enforced by the government, together with an increase in testing capacity, prevented widespread community transmission. Strictly containing the outbreaks as and when they were identified made it easier to bring the spread under control through contact tracing. In this article, we give an account of the strategy taken by Sri Lanka to mitigate the pandemic and comment on the lessons learned concerning the ethical responses to the COVID-19 crisis.

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Introduction

The COVID-19 pandemic has spread alarm and panic the world over, with many countries unprepared to respond quickly, and sometimes ethically, to the disease outbreak. Even counties that had faced pandemics such as influenza in the past failed in the face of the COVID-19. Hence, the current pandemic has demonstrated unequivocally that every country should have a plan that can be executed effectively during future pandemics. In response to this public health emergency, the World Health Organization (WHO) has put forth best practice guidelines (World Health Organization 2020 ). The importance of recent changes in international health regulations was emphasized by the WHO, which included that all public health emergencies of international concern should be notified without delay. Furthermore, there needs to be a national focal point to respond in such a situation. Having core capacities that are urgently needed, and recommended measures to implement without delay to safeguard the public, is of paramount importance (Ferhani and Rushton 2020 ). In this article, we outline the strategy that has been adopted by Sri Lanka, which at the time of writing has only 13 reported deaths (i.e. 0.6 per 1 million people) attributable to COVID-19. Against this apparent public health success story, we assess the ethical lessons to be learned from adopting a strategy such as that deployed by Sri Lanka.

Sri Lanka’s Strategy

Sri Lanka took strong measures to manage and mitigate the crisis at the initial stages of the pandemic. Since the first local case of COVID-19 was confirmed in March 2020, the country went into extremely stringent lockdown within days. This curfew style lockdown adopted by Sri Lanka is different from the lockdown that was seen in many other countries, such as the UK, many European countries and America. The curfew and lockdown began on the 20th of March 2020, with complete restrictions on people’s movements and prohibition of social gatherings. Unlike the lockdowns seen in other countries, where citizens were able to drive to the grocery store or a walk in the park, the curfew imposed by the Sri Lankan authorities ensured that people stayed at home. This was mainly to prevent non-essential travel those who were essential workers or had a valid reason to leave their homes required a curfew pass from the area police. Workplaces, schools and businesses were unexpectedly closed. Only private sector, government, grocery and food retailers and essential service providers were given permission to continue services and make deliveries to residential areas. The new regulations caused major disruptions of lives and income of the Sri Lankan people. A COVID-19 task force was immediately implemented under the leadership of the president which consisted of a team of multidisciplinary experts such as epidemiologists, medical administrators, infectious disease specialists, military teams, police, social workers, politicians and media teams. The military played a leading role in response to the crisis, from overseeing quarantine centers to contact tracing, while the police managed the curfew, responding to reports of violations and arresting suspected violators. According to some media outlets quoting police reports, “more than 56,000 curfew violators have been arrested after curfew was imposed on March 20 th 2020” (News 1st  2020 ). Even though having armed forces involved in the mitigation strategy may not seem ethically sound, this move was seen as an institutional strategy for crisis management. Sri Lanka being a low-middle income country had no option but to use all available resources to tackle and prevent the epidemic. The use of the military could be seen as restricting individual freedom and autonomy. However, that had to be balanced with the effects of COVID-19. Military involvement differs in terms of their tasks, their mission and the force used in any given situation. In this instance, it was to build national resilience against the pandemic and hence was seen in a positive light.

The government implemented further strict measures, including a temporary suspension of inbound flights and on-arrival visas, mandatory quarantine of travelers arriving from high-risk countries in special quarantine centers and regularly disinfecting marketplaces and public transport stations, all of which have successfully reduced the rate of disease transmission. Major celebrations, such as the Sinhala and Tamil New Year, and Vesak, which is the most important period in the Buddhist calendar, were confined to the households. Subsequently, during July 2020, Sri Lanka rapidly increased its testing, and the number of confirmed cases reached 3363 as of September 2020, with more than 3230 recoveries and only 13 deaths (Epidemiology Unit 2020a , b , c , d ). Therefore, we believe there are lessons to be learned from Sri Lanka’s mitigation strategy.

Lessons Learned

Policy and regulations.

In Sri Lanka, we have learned many lessons as policymakers, healthcare workers and a community. The international health regulations are implemented under the Quarantine and Prevention of Disease Ordinance Act & Public Security Ordinance (Section 16 - Curfew subject to Gazette of Sri Lanka ( http://www.documents.gov.lk/en/gazette.php ). Through the ordinance which is updated from time to time via gazette notifications, a mandatory 14-day quarantine at a center and further 14 days of self-quarantine for all inbound passengers were imposed. This further reduced the likelihood of the disease spreading in the community. The strict adherence to the measures enforced through the Quarantine and Prevention of Disease Ordinance Act could be further strengthened by making the wearing of face masks, mandatory quarantine and social distancing which are considered only as guidelines issued on COVID-19 prevention, legally binding, at least during an outbreak, so that more citizens follow these measures stringently.

Maintaining a Steady Supply Chain

In the face of rapidly escalating cases, even the most developed countries went short of medical facilities, including intensive care beds, face masks, personal protective equipment, sanitizers, intubation and ventilation equipment and lab facilities to screen and confirm cases (Mikhael and Al-Jumaili 2020 ). Therefore, surveillance of these capacities at timed intervals to face future situations should be emphasized. Particularly as a developing nation, we felt the need to establish a mechanism to manufacture laboratory and medical equipment and to ensure a continuous food supply chain in the face of the closure of ports and airports.

A Phased Lockdown

During the past few months, many Sri Lankans faced economic hardships due to a long lockdown period, which commenced on the 20th of March in Colombo and Gampaha districts, until the middle of May. An early and very strict lockdown was essential in the name of public health and to prevent limited health resources from being overwhelmed. However, as this was not sustainable in ethical or economic terms, a phased lockdown was implemented in mid-May, where there was a slow easing of restrictions. This phased return to a more open society, as opposed to a strict and complete lockdown for a long period, is ethically viable as it does not disproportionately restrict civil liberties and economic freedom. Another feature of Sri Lanka’s unique strategy was that not all districts experienced lockdown to the same degree. While the districts of Colombo and Gampaha experienced the most stringent lockdown, the other districts were relatively less strict. Furthermore, even though the strict lockdown did not seem ethically sound, given the number of ICU beds available in Sri Lanka, it was the opinion of the public health experts that we employ a method known as “the hammer and the dance”. This method involved a two-phase strategy (Assenza et al. 2020 ), where an initial strong confinement stage (the hammer), was followed by a more relaxed phase (the dance). The relaxed phase was implemented once the local transmission reached a point that could be curtailed with community measures such as wearing a facemask, good hand hygiene practices and social distancing.

The government’s preventative measures, while indispensable, have led to the economy taking a major downturn, particularly as the pandemic comes in the wake of the 2019 Easter bomb attacks (United Nations Sri Lanka  2020 ). The disruption of livelihoods has caused concern in some communities, particularly among daily wage earners, who felt the effects of the pandemic the most. The Sri Lankan Government struggled to support these people economically, and although the government has expressed concern for the low-income earners, emergency food relief and other basic support were delayed. By mid-April, the government had arranged for financial support to those citizens whose livelihoods had come to a standstill, and a sum of Rs 5000 was granted to each person. Many local charities collaborated with the authorities to supply dry rations and other essential items to those who had fallen on hard times. We must, therefore, have a plan to support the daily wage earners and small businesses until the country returns to normalcy. Locking down a country and exiting the lockdown is a difficult process and it is therefore imperative to have a pre-prepared plan for future pandemics. As stated above, the public health measures implemented by the Sri Lankan Government could have been argued by some as non-ethical as it could be seen as an undue infringement on an individual’s autonomy as well as an interference with civil liberty. However, in a broader context, preventing death due to the lack of resources if the number of cases of COVID-19 reached overwhelming figures, as seen in our neighboring country India, would have outweighed the ethical concerns pertaining to the enforced lockdown.

Free Healthcare for All

The most important asset for Sri Lankans was the free healthcare system, which enabled the country to face a public health problem of such magnitude with confidence. Both curative and preventive healthcare systems are free in Sri Lanka. The private healthcare system mainly works in the curative aspect with some contribution to preventive care as well, like cancer screening and screening for non-communicable diseases. The strength of our preventive health system is one key determinant behind the success in facing the epidemic. It was therefore vital that this resource was protected from being overwhelmed during the pandemic crisis as mentioned above. Due to the curfew and strict lockdown measures imposed by the government, our healthcare system was thus protected.

In the context of healthcare workers, the importance of continued medical education with concepts of good medical practices was felt more than ever before. An example is the skill of intubation, which was deemed to be crucial in the management of severe cases. Every healthcare worker should have sound knowledge regarding notification and surveillance systems of a specific disease. To this end, responsible authorities need to organize awareness programs for healthcare workers. This is also a good opportunity to educate medical practitioners on medical ethics, especially as it was found that in a recent survey 81.2% of doctors did not have sufficient knowledge of medical ethics. However, most (> 90%) of the participants had expressed their willingness to learn (Ranasinghe et al. 2020 ).

Procedures for handling an emerging/re-emerging infection, including evidence-based clinical practice, epidemiological surveillance, investigation and control measures, implementing preventive measures with behavioural, environmental changes, laws and regulations, monitoring and evaluation and research should also be streamlined (World Health Organization 2018 ). In Sri Lanka, when suspected COVID-19-positive cases were admitted to the hospital, the hospital ward setting was changed to prevent the spread of the disease. Guidelines were issued early on from respective professional colleges, with guidance from the WHO, to enable a quick response. These guidelines were readily accessible via the Ministry of Health Epidemiology Unit website www.epid.gov.lk (Epidemiology Unit 2020a , b , c , d ). The importance of a global partnership in handling a pandemic was felt very strongly in this instance.

Accountability of Citizens and Community Awareness

Taking into account the experiences and lessons learned from the COVID-19 pandemic, not only is the government’s response vital but every citizen should have a plan to prepare for and respond to future pandemics. Many Sri Lankans started home gardening to face problems with food supply; thus, the importance of being self-sufficient was strongly felt among the citizens (Rodrigo  2020 ). The majority of Sri Lankans have a high literacy rate owing to the free education system and hence, they were equipped with basic skills to understand and implement necessary preventive strategies such as wearing a face mask, hand hygiene measures and social distancing, all of which were strictly enforced by the government. Adherence to directed self-discipline either volunteered or forced (in some instances) is one other key determinant to the success in fighting this crisis. “Vidya dadathi vinayang”, a saying by Lord Buddha, means “being informed or knowledgeable, generates discipline”. Furthermore, we did not have people overtly objecting to or flouting the rule of mask wearing, as seen in America, Australia and Europe. Literacy in information and communications technology was also vital, with the concept of working from home and homeschooling children during the lockdown period. Due to the feasibility and convenience of working from home, some companies decided to continue this concept indefinitely, even after the pandemic settled with time. In the face of such a pandemic, the Sri Lankan people understood that the suffering caused by being irresponsible affects everyone in society, including oneself and one’s family.

Local governments, while providing fundamental facilities, should under the directive of the provincial director of health services arrange awareness programs with the help of the area medical officer of health (MOH) and public health inspectors (PHI), to increase awareness at a community level, thus promoting autonomy and preparedness at a micro-level in case of a future pandemic.

Role of the Media

The mass media in collaboration with the Sri Lankan Government was an important aspect of our fight against COVID-19. Media support was vital for the dissemination of correct information, de-stigmatization and myth-busting efforts executed by the government. A substantial amount of funding, donated by various organizations, was spent on media advertisements to control the spread of the disease. Positive health behaviour was greatly advocated through the mass media as it played a major role in preventing COVID-19 (Health Promotion Bureau 2020 ). However, the issue of false or misleading news was also strife in the media, and as citizens, we learned that getting updated with accurate information from responsible parties was vital to prevent unnecessary panic caused by fake news. There have been instances of unethical behaviour by the local media, who had reported identifiable personal information about COVID patients as well as publicizing the ethnicity of the patients who died due to COVID-19. This leads to the stigmatization of these persons and their families in society (Ayub  2020 ). Some international media outlets also picked up and reported on this unethical reporting by local media, urging Sri Lankan authorities to act (Mukhopadhyay 2020 ). The International Press Institute has reported 426 media freedom violations during the COVID-19 pandemic, and nearly half of these violations were reported from Asia (International Press Institute 2020 ).

While the crisis strengthened the society and improved social cohesion, as shown by examples of social solidarity and community initiative from all parts of the country, at the same time, incidences of stigmatization and exclusion counter these positive narratives. For example, there were media reports that when a person was found to be tested COVID positive in the community, not only the individuals’ family but the whole street was quarantined. However, the regional epidemiologist claimed that they took an evidence-based approach towards controlling clusters, stating in an article “first-line contacts are the immediate home contacts of the index case. These contacts undergo mandatory testing and immediate isolation as they are at an increased risk of contracting COVID-19 and are most likely to spread it to others. The second and third contacts are kept under the radar and closely monitored” (Hettiarachchi 2020 ).

Ethics of Care in Sri Lanka’s Response

The ethics of care, which emphasizes solidarity, care and responsibility to the most vulnerable people in society, was important in Sri Lanka’s successful response to the pandemic. The phrase “ethics of care” was initially coined by psychologist Carol Gilligan ( 1982 ) and has its origins in feminist theory. Gilligan studied how little girls looked at ethics and found that in relation to boys, the moral development of girls usually came from compassion instead of being justice based. Her theory proposed that ethics should be focused on relationships and dependent on the context of the situation, instead of emphasizing autonomy and rules. The philosopher Nel Noddings ( 1984 ) further contributed to the theory by considering that values such as justice, equality and individual rights should operate together with values such as care, trust, mutual consideration and solidarity. In a recent paper describing Vietnams successful response to the COVID-19 pandemic, which attributed Vietnams success partly to the ethics if care prevalent in Vietnamese society, Ivic ( 2020 ) stated that “In light of ethics of care, the requirement for practicing social distancing for the good of vulnerable groups (elderly, ill, and so forth) represents the social responsibility towards our shared communities”. Similarly, in Sri Lanka during the COVID-19 pandemic, care ethics was seen in several different scenarios. It was manifested in the way people adhered to social distancing rules and the wearing of face masks, to protect the vulnerable groups. Peaceful and amicable adherence to the stringent curfew and lockdown by most citizens was also an example of care ethics. As seen in Vietnam (Ivic 2020 ), the ethics of care overcame binary oppositions: we/they, young/old, public/private, wealthy/poor; this is observed in Sri Lanka’s successful response as well. Many private sector companies offered their hotels and services for quarantine purposes and well-to-do citizens gave charitable donations of food to the needy and less fortunate. Furthermore, the ethics of care justifies an initial curfew-like lockdown to get the pandemic under control and was vital in the initial few weeks of the pandemic. However, if a resurge in COVID-19 cases occurs, this might prove not to be the case.

The decision by the government to open the country’s main international airport was primarily to prevent the economy from sinking further and salvaging the jobs and livelihoods of many citizens. In this context, it does not infringe upon the ethics of care principle. When considering preparedness in the context of care ethics, it is vital that essential health services must be freely available to all citizens to minimize COVID-19-related fatalities as well as additional deaths from the pandemic, especially with respect to chronic diseases. Free access to infection prevention, control, testing and treatment is vital to protect communities. Crucially, controlling a pandemic—disease detection, communication and containment efforts—all depend upon community engagement in terms of public cooperation, solidarity and responsibility.

Conclusions

The strategy employed by Sri Lanka, where an initial stringent lockdown period of 8 weeks was followed by the gradually easing of the lockdown, a phased approach, is an example of an ethically sound measure. This method can be further justified as one that would prevent our health system from being overwhelmed, thus saving many lives. The Buddhist teachings of self-discipline that prevails within Sri Lankan society have likely played a role in the adherence to the strict rules set by the government during the curfew and lockdown periods.

As the number of fatalities from the COVID-19 pandemic is low in Sri Lanka, many lessons can be learned from the country’s response to the crisis, from an ethical perspective. The way forward would be to have, firstly, ethics of care and self-discipline among the majority of people in society. The early strict curfew and lockdown followed by a phased out easing of the lockdown were necessary. Even though there are ethical concerns with this approach, it was vital in Sri Lanka’s successful response to the pandemic. However, this is a good lesson for future pandemics and an opportunity to establish an ethically sound system with broader dissemination of ethical practices among all healthcare works. Secondly, due to the issue of fake news being spread by social and mass media, it is important to use reliable sources of information. Thirdly, a strong and free healthcare system and a robust public health and community care system, such as that which is present in Sri Lanka, are important to combat a health crisis. Finally, to have a plan in place for disaster preparedness and especially to financially support people who have fallen on hard times is important. Having overcome past crises such as the civil war and the Easter attacks of 2019, Sri Lanka will no doubt find a way to renewed prosperity in the aftermath of the COVID-19 storm.

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Hettiarachchi, D., Noordeen, N., Gamakaranage, C. et al. Ethical Responses to the COVID-19 Pandemic—Lessons from Sri Lanka. ABR 13 , 225–233 (2021). https://doi.org/10.1007/s41649-020-00153-z

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Research Article

Initial response to SARS-CoV-2 (COVID-19) outbreak in Sri Lanka; views of public health specialists through an International Health Regulations lens

Contributed equally to this work with: Amandhi Caldera, Rajitha Wickremasinghe

Roles Conceptualization, Data curation, Formal analysis, Writing – original draft, Writing – review & editing

Affiliation Department of Public Health, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Roles Writing – original draft, Writing – review & editing

Affiliation Malaria Elimination Initiative, Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States of America

Roles Data curation, Writing – original draft, Writing – review & editing

Affiliation Department of Parasitology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka

• Amandhi Caldera, 
• Rajitha Wickremasinghe, 
• Gretchen Newby, 
• Ruwanthi Perera, 
• Kamini Mendis, 
• Deepika Fernando

• Published: November 10, 2023
• https://doi.org/10.1371/journal.pone.0293521
• Reader Comments

The COVID-19 pandemic affected Sri Lanka despite having developed an International Health Regulations (IHR) steering committee in 2016 and a national action plan for health security following the Joint External Evaluation in 2018. Many steps were taken to improve the disaster management skills of healthcare workers even before the COVID-19 outbreak. We interviewed seven public health specialists to obtain their views on the country’s response to the pandemic. A thematic analysis was conducted, leading to the emergence of three major themes and seven subthemes. The major themes included health security preparedness; COVID-19 management; and effects of COVID-19. The subthemes were; preparedness prior to pandemic and gaps in the preparedness (under health security preparedness); dual burden for the curative sector, strategies to reduce transmission and barriers to managing COVID-19 (under COVID-19 management) and negative and positive effects of COVID-19 (under effects of COVID-19). When COVID-19 reached Sri Lanka, healthcare workers, border control authorities and those involved with infectious disease control were overwhelmed by the magnitude of the pandemic. Healthcare workers’ hesitation to work amidst the pandemic due to fear of infection and possible transmission of infection to their families was a major issue; the demand for personal protective equipment by health workers when stocks were low was also a contributory factor. Lockdowns with curfew and quarantine at government regulated centers were implemented as necessary. Perceptions of the public including permitting healthcare workers to perform field public health services, logistical barriers and lack of human resources were a few of the barriers that were expressed. Some persons did not declare their symptoms, fearing that they would have to be quarantined. The pandemic severely affected the economy and Sri Lanka relied on donations and loans to overcome the situation. Pandemic also brought about innovative methods to maintain and upgrade health service provision. Individuals with non-communicable diseases received their regular medications through the post which reduced their risk of being infected by visiting hospitals. Improvement of laboratory services and quarantine services, a reduction of acute respiratory infections and diarrhoeal diseases, improved intersectoral coordination and public philanthropic response were other positive effects.

Citation: Caldera A, Wickremasinghe R, Newby G, Perera R, Mendis K, Fernando D (2023) Initial response to SARS-CoV-2 (COVID-19) outbreak in Sri Lanka; views of public health specialists through an International Health Regulations lens. PLoS ONE 18(11): e0293521. https://doi.org/10.1371/journal.pone.0293521

Editor: Khin Thet Wai, Freelance Consultant, Myanmar, MYANMAR

Received: November 7, 2022; Accepted: October 13, 2023; Published: November 10, 2023

Copyright: © 2023 Caldera et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The qualitative study that we are reporting is based on in-depth interviews, the release of which could identify the interviewee as some questions were specific to the role of the organization the person was working for. The study was approved by the Ethics Review Committee of the Faculty of Medicine, University of Kelaniya, Sri Lanka. The contact details of the Ethics Review Committee are given below: Ethics review committee, Faculty of Medicine, University of Kelaniya. Telephone no: 0112961267 Email: [email protected] .

Funding: We acknowledge the financial assistance provided by the Bill & Melinda Gates Foundation, through a grant to the Malaria Elimination Initiative at the University of California, San Francisco (OPP1160129). The funders had no role in study design, data collection or analysis, or the preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The International Health Regulations (IHR) is a legal framework to assist the international community to prevent or respond to acute public health risks. The responsibility of implementing IHR at national level lies with governments and all countries are required to have the ability to detect, assess and report and respond to public health risks and emergencies thereby limiting the spread of health risks to neighboring countries through travel and trade. In compliance with IHR, International Health Regulations are implemented in the Sri Lanka through the Quarantine Unit of the Ministry of Health with its offices located at ports of entry. Sri Lanka, a South Asian country, has a population of approximately 21.5 million. Over half of the population is concentrated in the Western, Central and Southern provinces which jointly covers less than one fourth of the total land area of the country. Government’s spending on health was 5.92% of the total government expenditure [ 1 ].

Sri Lanka took active steps prior to the pandemic to strengthen preparedness against a potential threat towards public health. Following the establishment of the IHR steering committee in Sri Lanka in 2016, the Ministry of Health and the World Health Organization (WHO) continued to take active steps to ensure preparedness. A five-year National Action Plan for Health Security was developed following the Joint External Evaluation in 2018. There were many steps taken to improve the skills of healthcare workers on disaster management even before the COVID-19 outbreak. In addition, training of security personnel at points of entry and securing a supply of Personal Protective Equipment (PPE) were steps taken towards preparedness prior to the pandemic. The Ministry of Health also had a pandemic preparedness plan that specifically focused on preparing for pandemics. Despite these efforts, however, there were gaps in the preparedness plan that were identified due to the overwhelming demands of the pandemic that put an enormous strain on the Sri Lanka’s health system.

The 2019 novel coronavirus, or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), known as COVID-19, has rapidly spread from its origin in Wuhan City of China’s Hubei Province to the rest of the world [ 2 ]; China reported the first case of COVID-19 in response to abide by International Health Regulations. Since the origin of the virus, it has spread across the world with the emergence of new variants having varying degrees of virulence and transmissibility in many waves with more than 475 million cases and over 6 million deaths been reported by end March 2022 ( https://www.worldometers.info/coronavirus/#countries ).

The first confirmed COVID-19 case was reported in Sri Lanka on the 27 th January 2020 in a 44-year-old Chinese national from Hubei province, China. On 10 th March 2020, with the first local case being reported from a 52-year-old tour guide working with a group of Italian tourists the country went into an extremely stringent, curfew-type lockdown that imposed complete restrictions on people’s movements and prohibited social gatherings from 17 th March 2020 [ 3 ]. A COVID-19 task force was immediately established under the leadership of the country’s President which consisted of multidisciplinary experts such as epidemiologists, medical administrators, infectious diseases specialists, military personnel, police officers, social workers, politicians and media personnel. The military played a leading role in responding to the crisis, from overseeing quarantine centers to contact tracing, while the police managed the curfew [ 3 ].

Upon intensification of the health crisis, the government implemented further restrictions, including a temporary suspension of all inbound flights and on-arrival visas, mandatory quarantine of travelers arriving from high-risk countries in special quarantine centers, regular disinfection of market places and public transport stations, and wearing of face masks and sanitizing or handwashing when entering any facility, all of which contributed to the successful reduction of the disease transmission rate over the initial months of the epidemic by mid-September 2020 [ 3 ].

Since the inception of the epidemic in Sri Lanka in March 2020, three waves of infections have originated from six distinct clusters which erupted in different parts of the country although some of the clusters no longer exist with the emergence of new variants. Because of its commitment to preparedness under the IHR, Sri Lanka was relatively successful in controlling the first wave, from March to October 2020. The second wave, from October 2020 to April 2021, took a much longer time to control, probably due to control measures not being as stringent as during the first wave. The Sinhala New Year celebration in mid-April 2021, during which many travelled to their homes, led to the third wave of the epidemic which was not investigated in this study as the third wave was in progression at the time of our interviewing public health specialists. The aim of this study was to understand the views of public health specialists on COVID-19 control in Sri Lanka during the second wave of the infection in the country which was highly commended as part of a broader investigation of the effect of the pandemic on prevention of re-establishment of malaria in Sri Lanka.

Materials and methods

This qualitative study was carried out in two phases; a key informant interview guide schedule addressing the research questions was developed and interviews were conducted during the first phase. In the second phase, the interview transcripts underwent thematic analysis. Patterns were identified through a rigorous process of data familiarization, data coding, and theme development and revision. Themes were derived after identifying patterns of meaning across the transcribed interviews. The study was carried out between November 2021 and March 2022. Ethics clearance was obtained from the Ethics Review Committee of the Faculty of Medicine, University of Kelaniya, Sri Lanka (ref. No: P/201/12/2021). The details of each phase are given below.

Interview guide development.

The semi structured interview guide was developed, reviewed, and edited by the research team. The interview guide was then tailored to reflect the specific role and expertise of each key informant to better capture their unique perspectives and experiences with COVID-19.

Participant identification and recruitment.

Through a purposive sampling approach, as described by Green and Thorogood (2018), representatives of seven organizations that were intensely involved with COVID-19 management were selected as interviewees [ 4 ]. Seven key informant interviews were conducted from November, 2021 to March, 2023 comprising four Directors of units of the Ministry of Health, two specialists from international organizations and a Deputy Regional Director of Health Services who was on the ground managing and directing healthcare services, all of whom were medical doctors who were public health specialists.

Data collection.

The identified key informants were contacted via phone, their cooperation sought and a suitable time for the interview via zoom was obtained. All key informants were mailed the participant information sheet. All key informant interviews were conducted over zoom; at the commencement of the interview, verbal consent to conduct the interview and permission to record the interview were obtained by the principal investigator. The principal investigator and another investigator were the interviewers in all key informant interviews. The research assistant was also present at all the interviews. Each interview was approximately 40 minutes in length.

Interview transcription.

After the research assistant listened to the interviews conducted in English for the purpose of familiarization, the interviews were transcribed. Almost all the interviews contained a few short sections of conversation that were not related to the interview questions and these sections of the interview were not included in the transcribed document. Furthermore, fillers in speech (e.g.- ummm, ugh…ah) and false starts were also not included in the transcribed and translated document unless it was essential to the context of what was stated.

On average, a 40-minute recording required about 3 hours to be transcribed. The transcribed interviews were approximately 6–8 single spaced pages in length.

Process of thematic analysis.

The transcribed interviews were analyzed using Thematic Analysis described by Braun and Clark (2006) [ 5 ]. The six phases of thematic analysis were carried out to arrive at the themes. During the initial stage of the thematic analysis process, the research assistant familiarized herself with the data by reading the transcribed data 1–2 times. Preliminary codes were identified, paying close attention to recurring ideas in the interviews. These recurring ideas comprised themes. The themes were closely examined by the research assistant and the principal investigator to ensure that the responses were categorized under the most appropriate theme. Finally, sub-themes were identified within the main themes.

Results and discussion

Three prominent themes were derived from the transcribed data. A summary of themes and the sub themes are included in Table 1 .

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https://doi.org/10.1371/journal.pone.0293521.t001

Theme 1: Health security preparedness

Subtheme 1: preparedness prior to pandemic..

Representatives of the Ministry of Health and international organizations had several insights regarding the steps taken to strengthen preparedness prior to the pandemic based on the National Action Plan for Health Security. However, the preparedness plan that existed could not cope with the COVID-19 pandemic.

“We were prepared for a similar outbreak at any time… through the disaster unit, we organized preparedness awareness programs focused on CBRNE (Chemical, Biological, Radiological, Nuclear, and Explosive) management…At trainings we spoke mainly about how to manage chemical and biological hazards … We also have a disaster preparedness diploma program … we strengthened the capacity of health workers especially at the National Institute of Infectious Diseases, Infectious Diseases Hospital, National Hospital and several other places so they will be able to handle some kind of biological hazard.” (Director from Ministry of Health) “We also trained the security forces to handle them (chemical and biological hazards). we provided initial supply of PPEs and similar items for those places…so therefore , when COVID hit , the initial procurement of such items was not a major issue . (Director from Ministry of Health) “it was only a just nominal services that we were having.. We had the pandemic influenza preparedness plan when the COVID-19 came, I think that helped a lot to face this pandemic.” (Director from Ministry of Health) “The ministry also had a specific pandemic preparedness plan which was done in 2012… that was developed after the SARS, MERS and the other influenza epidemics we have been experiencing globally… So, under that, we also meet once a month as a part of this influenza and preparedness plan” (Representative from an international organization)

After COVID-19 started spreading globally, the Ministry of Health along with the WHO took active steps to ensure monitoring of different viral strains coming through ports of entry into Sri Lanka.

“In the meantime, luckily on the 2nd of January 2020 we had this influenza meeting and we tabled the COVID matter with all the virologists and at that time it was identified as a zoonotic disease in Wuhan and not much of a threat to global issues. But still we activated the pandemic preparedness plan so that we make sure that the points of entries are checked and to ensure that we don’t have any of these viral strains coming through the border… because that’s the only way that viruses can come to the country… Sri Lanka took a proactive role to control the threat” (Representative from an international organization)

Subtheme 2: Gaps in preparedness.

Although the Ministry of Health and other organizations continuously worked in line with the National Action Plan for Health Security, when the pandemic hit Sri Lanka, the healthcare workers, border control authorities and those involved with infectious disease control were overwhelmed by the magnitude of the COVID-19 pandemic.

“We never expected a condition like this. That means to this magnitude … no no…no way… Because of that, there were so many gaps we had… so we had to start from the beginning … and the disease condition was entirely different to the other things we had encountered or prepared for and rapidly spreading.” (Director from Ministry of Health) “Now if you look at that plan, our maximum thinking was influenza level and dengue. We never thought of a pandemic of this magnitude globally and that is why we struggled… not only developing countries, but developed countries are also struggling too.” (Representative from an international organization)

The Ministry of Health identified many gaps in the preparedness plan that mainly occurred because of the high demand for services that COVID-19 exerted on the health system. One of the main areas of difficulties was the lack of preparedness of health care workers to work amidst the pandemic. Interviewees spoke about the general fear of the COVID-19 pandemic among healthcare workers and how that affected d the commitment to their work. This, in turn, affected the efficiency of management during the early stages of the pandemic. The staff were demanding personal protective equipment which were in short supply. There was also misuse of personal protective equipment due to lack of knowledge of their use initially.

“The health system was overwhelmed. So, we had to dedicate wards, and on top of that, entire hospitals were closed for other services…other health services were compromised” (Director from Ministry of Health) “Even though people were competent to handle the situation, most of our people were not ready to handle this situation. They were running. For instance, I had trained people in disaster management where you are supposed to go to the frontline in case an emergency… they were ready to go to landslide areas …they were ready to go to flood areas. camps and everywhere they were ready … but when they were asked to go to the airport, they were not willing. when we wanted them to enter some data from the declaration form from the airport, they didn’t even want to touch the declaration form …even though the form also comes 10 hours after the passenger has actually touched it. But still they did not want to touch it. Someone else has to scan and mail them to the other side of the room to get the data entered. So, you can see that they were so scared.” (Director from Ministry of Health) “So once lockdown was lifted in May, what we found was that because of these public health measures that have been enforced and recommended by the Government there was a lot of phobia… not only among the general public but also among health workers. they were reluctant to move out and start working” (Representative from an international organization) “For example, the consultant physicians and several others who were supposed to be working very closely in emergency situations were so reluctant to see the patients without ensuring the patient was free from COVID which is an impossible task in an emergency … I saw that the readiness of the health system was very poor at the beginning…. Now it is gradually picking up … up to now the readiness is something I am concerned about.” (Director from Ministry of Health) “Staff wants to kind of get protected from the patient, then they wanted to have a personal protective equipment … this was a huge challenge, because they were not freely available …the personal protective equipment were kind of misused at the early stage” (Director from Ministry of Health)

Even though the facilities increased with greater investments to accommodate more patients, the human resources did not increase leaving the existing work force exhausted.

“The other thing is the exhaustion of the health staff because of that people were not well and could not cope up work with all the work, … the preventive health sector was the most affected as they had to do COVID monitoring, home quarantining, doing PCR and RAT antigen tests etc.” (Deputy Regional Director of Health Services from Ministry of Health)

While some healthcare workers showed a lack of readiness to provide services, there were other gaps in preparedness that were noted during this time. Sri Lanka had originally planned to conduct a parliamentary election in June 2020 but it had to be postponed to mid-August 2020 due to the COVID-19 pandemic. During elections, some government services are restricted according to election law prohibiting insinuations that such services are used for election propaganda. Therefore, some proactive government services were curtailed during this time, which further affected COVID-19 control.

“Regular services were provided as much as possible till election time… And health systems were working… but the implementation was slowed down because of this election mode … because once you get into the declaration of election most government servants actually take a step back without being proactive.” (Representative from an international organization)

Initially, testing facilities available in the Ministry of Health was limited. There was a shortage of test kits and a dearth of places to carry out the tests. Testing facilities were slowly expanded in the country with purchase of needed equipment.

“Initially it was only MRI (Medical Research Institute) doing PCR testing …then it was expanded slowly to hospitals in Kandy, Karapitiya and Anuradhapura and then Ragama, and then to other places in many general hospitals … at the beginning the testing facilities were limited. So, because of that, the samples had to be transported a very long distance. And then there’s a waiting list for testing. And because of that, the results were not immediately available.” (Director from Ministry of Health)

The Ministry of Health also faced barriers in training personnel to conduct laboratory testing during the pandemic. Initially, the Ministry decided to train many categories of employees in rapid antigen testing to ensure that a higher number of tests could be carried out within the country. However, the designated employees who routinely conduct diagnostic tests were unhappy with other groups of employees being trained to perform the test, as they felt that this was a skill that should be given only to people with their particular job role.

“You know the rapid antigen test can be done by a trained laborer …but a certain category of people say that it should be done by them and no one else …these kinds of bottle necks should be eased out. If not in future also this can happen … trade unions involvement in this kind of activity should be handled in a very serious way…” (Director from Ministry of Health)

Access to data was another gap in the preparedness plan that was identified. Many departments under the Ministry of Health did not have access to data obtained from airports, isolation or quarantine facilities. They felt making decisions without data was dangerous and ineffective.

“The issue is that the data is not in the form that will be available to a third party. That is one of the most important aspects to strengthen the response” (Director from Ministry of Health) “At present someone will stay at a government quarantine center for fourteen days but what is the risk of them coming to the community and spreading the disease. We don’t know. Because when they leave the quarantine center, we don’t do another PCR test on them… So, we don’t actually have any data on how many have got the disease after coming from a quarantine center back to their homes. In Sri Lanka, still this data is not available. We are taking those decisions without scientific data. That part is a major issue.” (Director from Ministry of Health)

Theme 2: COVID-19 management

There were a number of strategies implemented to manage the spread of COVID-19 in Sri Lanka. Some of the strategies were based on research outcomes available on the effect of COVID-19 on vulnerable groups. The Ministry of Health also observed the steps taken by other countries to control the spread of COVID-19 and made calculated decisions based on their observations and findings.

Subtheme 1: Dual burden for the curative sector.

The curative sector had to manage both COVID-19 patients and non-COVID patients. Hence, there was a compromise of services. For the non-COVID patients, issues were experienced for both inward patients and outpatients. For inward patients, space was a problem as priority was given to COVID-19 patients and the two types of patients could not be mixed. For outpatients, a triage system had to be developed and implemented.

“Then the curative sector had to manage both COVID-19 and other non-COVID patients … so, there was a kind of compromising of certain services to a certain extent …for inward care again, there was the problem of the space, because we can’t keep both patients together … space was a problem in almost all hospitals” (Deputy Director from Ministry of Health) “Now in outpatient care there was a huge challenge whether patients coming into hospital are positive or not … then the a patient triage system was implemented, to identify whether patients were infected or not” . (Deputy Regional Director of Health Services from Ministry of Health)

Subtheme 2: Strategies to reduce transmission.

To reduce transmission of COVID-19, a lockdown was implemented in densely populated areas where the risk of transmission was high. As many studies had found that COVID-19 resulted in fatalities in individuals with non-communicable diseases (NCDs), the Ministry of Health ensured that individuals with non-communicable diseases continued to receive their medication despite the lockdown regulations. The public who attended government clinics for prevention of NCDs were asked to register by phone with the institute and the medicines were distributed to ensure an uninterrupted supply. This was carried out under the supervision of the nearest Post Office. This was a strategy the Ministry of Health took to reduce the risk of fatalities amongst the public.

“We tried our best to make sure that their co-morbidities are under control all the time wherever possible. That is how we tried to reduce complications despite the spread of COVID… we did this by visiting lockdown areas and distributing drugs to those who need. That is how we tried to assist the communities affected especially the vulnerable groups. In some situations, we also posted the medications to the people. Our morbidity and mortality were reduced to a great extent … not transmission but the number of severe cases and the number of deaths were reduced to a great extent after starting this process.” (Director from Ministry of Health)

Quarantining was another method that was used to reduce COVID-19 transmission within the country. All citizens and expatriates who had permission to enter Sri Lanka were brought back through repatriation flights and were quarantined either in government facilities at no cost or at a hotel with self-paid quarantine facilities. In addition, if someone from the community was diagnosed with COVID-19, the first contacts of this person had to be quarantined while the COVID-19 infected person was treated at the Infectious Diseases Hospital or any other designated institution.

“So, mandatory quarantine was brought in. So, any person entering Sri Lanka had to go to this government quarantine center… So, through this actually we basically were able to prevent this COVID disease coming to our community… A few months back about fifty thousand people had registered to come. So, there was an issue…we did not have enough quarantine centers to put them. So, then the government took a policy to basically involve the private sector that means the hotels. They introduced the hotel quarantine… here people were able to pay and go and stay in hotel quarantine. Although it is run by the private sector, the access control and other control measures are done through the army.” (Director from Ministry of Health) “Then the government took a decision to quarantine the first contacts at their homes. That means home quarantine. But there were certain instances, all people didn’t have the facility to home quarantine. So, in those instances they were taken to government quarantine centers. Other than that, at present mainly the first contacts are home quarantined.” (Director from Ministry of Health)

Subtheme 3: Barriers to managing COVID-19.

There were a number of barriers that healthcare workers encountered when managing the spread of the virus. Perceptions of the public, logistical barriers and lack of human resources were a few of the barriers that were identified by the interviewees.

The perceptions of the public on the virus were extremely negative. The public followed the guidelines laid down by the government. However, they feared the fact that health care workers visited their areas for COVID-19 related work, in the belief that the workers may be infected with the virus. Many people also did not declare their symptoms, fearing that they would have to be quarantined. There were a lot of negative messages through the media regarding the quarantine facilities and this discouraged people from receiving the treatment and management they required.

“Basically, there was a resistance from the people… people thought that this quarantine was the huge harassment for them. basically mandatory quarantine for fourteen days then again another fourteen days of home quarantining, total twenty-eight days, when someone in the community was detected with COVID the media came… the police came … the inspectors came… COVID was feared like leprosy and became a stigmatized disease. Then the people basically did not want to come out with their disease condition. That is happening. They are not coming for PCR testing. They hide their symptoms…This resulted in the disease spread also.” (Director from Ministry of Health) “General public also had certain reservations about public health persons visiting their homes. Like midwives coming home. There was a lot of tension in the sense that they were not sure whether our health workers were affected and that they will bring the virus to their homes. So, there was a little bit of hesitancy” (Representative from an international organization)

The Ministry of Health experienced many logistical barriers. Organizing transport services for infected persons to quarantine centres and clearing intensive care beds for COVID-19 were extremely challenging logistical issues that had to be attended to during the management process. The interviewees also mentioned how exhausting the entire process has been for the people working to manage the effect of COVID-19.

“Sending people to hospital… sending them back after discharging, these were all major operations that we had to undertake. It was highly challenging but because of a few people who were really committed to do it we managed. Now these people are also exhausted. We need more committed people for these kinds of activities.” (Director from Ministry of Health) “We had about 500 intensive care beds …we ear marked 146 beds for this activity to be specific, but when comes to the real utilization of intensive care beds it was another challenge, because we cannot keep intensive care beds vacant … if one person is there in the intensive care then we cannot keep COVID patients there … clearing beds was another very challenging part. At present we are managing by clearing around 25 beds for COVID management.” (Director from Ministry of Health)

There was also a lack of human resources. Although Sri Lanka has encountered and managed many crisis situations, COVID-19 stretched the human resources of the healthcare system. Unlike other crisis situations, the entire country needed to be monitored and therefore, it was not possible to mobilize human resources from one province to another. Furthermore, volunteer opportunities could not be encouraged under these circumstances because of the social distancing guidelines that were implemented by the Government.

“But it was challenging to bring even one or two public health inspectors to the Colombo Municipality area because the services of these people are needed elsewhere also. As a result, the system did not permit to mobilize human resources from other areas …” (Director from Ministry of Health) “We had to monitor the entire geographic area of the island in different ways to make sure things are happening in a proper way… that was the major challenge…even if people wanted to help, they couldn’t come because of the social distancing guidelines.” (Director from Ministry of Health)

The pandemic also adversely affected the national economy. Due to the limited availability of emergency funds within the country, Sri Lanka was unable to cover the costs of the required interventions to control the spread of the virus. Expenses related to establishing and maintaining quarantine facilities, providing meals and other services to each person at these facilities, cost for disinfection activities, transport costs of patients to quarantine facilities were additional costs for the government. Construction of isolation rooms and conversion of outpatient service centers to COVID-19 wards were also tasks that required funding.

Sri Lanka received donations and loans to combat the virus. The WHO invested USD 5million to strengthen Sri Lanka’s response. The World Bank also provided a 3-year loan of USD 217 million, allocated to the Ministry of Health and the Ministry of Social Services.

“More than fifteen-thousand rupees for one person when you consider the food and other things… Apart from these we have to spend on the salaries of the army, the facilities and everything… it was like around fifteen-thousand to twenty-thousand rupees for fourteen days per person. Then there is a transport cost as well… for example we will assume you are going from here to Kandakadu… the vehicles are going, the army guards are going… when returning also they have to transport all those people.” (Director from Ministry of Health) “The maintenance of the quarantine centres are also supported by this loan (World Bank loan)… from the electricity bills, the food, the equipment the furniture … the maintenance costs of 30–40 quarantine centers was managed by using this money…” (Representative from an international organization)

Polymerase Chain Reaction (PCR) and antigen testing, which were the diagnostic tests used in Sri Lanka, were other significant expenditures. In addition to the costs of these tests, the swab taking process, transportation and laboratory-related work were all additional expenses. Personal protective gear had to be provided for each healthcare worker carrying out tests. Furthermore, viral transport media had had to be purchased.

“Assuming that the basic cost of a PCR test is six thousand rupees… ten thousand tests a day…you can imagine the amount of money we have to spend in one day… we had to buy PPE, test kits, the viral transport mediums, swabs and other type of sample taking items … “ (Director from Ministry of Health)

The external funding was also used to strengthen contact tracing. When a patient is diagnosed with COVID-19 in Sri Lanka, Public Health Inspectors (PHI) identify and notify their contacts and ensure they are home quarantined. For this purpose and for other transportation needs, a portion of the World Bank loan was used to purchase vehicles for public health inspectors and public health midwives. The Ministry of Social Services used USD 89 million of the World Bank loan to provide money for vulnerable groups.

“Ministry of Social Services used the money to support the cash transfers for elderly care program as well the cash transfers for this chronic kidney disease people… and to support the low-income families . (Representative from an international organization)

Theme 3: Effects of COVID-19

COVID-19 has affected many areas of functioning in Sri Lanka, both positively and negatively. Many of these changes are likely to have long term repercussions in the country.

Subtheme 1: Negative effects.

While the economic burden is an obvious disadvantage that arose due to COVID-19, there are other negative effects that this virus brought about such as monitoring other conditions and regular follow up of patients. As a result of lockdowns and social distancing guidelines, the management of other public health programmes were neglected. There is minimal focus on other public health activities as a result of the current situation as some personal were redeployed. Professional trainings are now being conducted virtually, and this may not be the most effective method to acquire new skills. If these trends continue, it will have a negative effect on the quality of life of people in Sri Lanka.

“…there were other problems as well. For example, checking of blood pressure was not happening for some patients, even for a one-year period. And patients who needed to get laboratory investigations like patients having kidney disease. investigations were not done and they were just giving the drugs without checking the routine investigations.” (Deputy Regional Director of Health Services from Ministry of Health) “I don’t think other public health programmes have been implemented to the scale expected because with the indicators being mapped till 2025 and SDG indicators till 2030, we had given the targets… reduction of child infant mortality was also one … all those projects will have to definitely be rethought with this COVID situation… if COVID continues till 2021 there is going to be a huge impact on all public health programmes which includes nutrition, NCDs and also the non-health areas like education and environment … all those sectors are going to be affected. I think the entire SDG targets will have to be looked at again…” (Representative from an international organization) “You can’t have physical meetings…you can’t have trainings… except online. Online trainings work for some but for skilled trainings like what we do in the health sector, it’s a challenge. So, likewise all the programmes are affected due to this situation and we being the health sector, we don’t want to violate the guidelines that we developed… because if we violate our own guidelines then there is no way where the other departments and general public will have faith in our system.” (Representative from an international organization)

Another consequence of COVID-19 was a drop in the attendance at most health clinics and an overall decline in demand for health services, with some exceptions.

“Two weeks into lockdown, mothers were asking for the vaccination. Because there was a demand created by the people… they knew the value of child vaccinations. Now likewise we did not see much of a demand from the general public regarding other services except for NCD medication.” (Representative from an international organization)

Subtheme 2: Positive effects.

Some positive developments have taken place due to COVID-19. For instance, the capacity of laboratory services has been improved in terms of ability to perform a wider range and greater volume of investigations, and better equipment. One interviewee stated that there is also a reduction in acute respiratory infections and diarrhoeal diseases because of practices such as handwashing and wearing face masks.

“During 2020 we have been able to strengthen the COVID response including laboratory strengthening … it is a part of our mandate … . 4 million dollars plus closer to 5 million was actually invested to strengthen the Sri Lankan situation … I think the positive side is that we were able to strengthen laboratories from what we had …now be able to detect the viruses using PCR” (Representative from an international organization)

The development of quarantine facilities within the country has been expanded exponentially. Transport facilities for field health services also have been improved.

“30-bed isolation facility at Infectious Disease Hospital (IDH) was newly constructed. 6 provincial hospitals were identified and upgraded to mini IDH to have a center for disease control in those hospitals… They used some funds to refurbish some of those hospitals to convert into isolation rooms and OPDs to patient centres in selected hospitals… for example in Warakapola and Matale…” (Representative from an international organization) “They purchased 930 motor cycles for the PHI… also the government procured 21 cabs for Medical Officers of Health (MOHs) … this was done to strengthen the mobility support at grassroot level. Now we’re in the process of procuring 1000 scootys [a two wheeled mode of transport] for PHMs …” (Representative from an international organization)

A feature especially during the second wave was the development of innovative solutions. Various individuals and organizations including the armed forces came up with novel sanitizer dispensers, remote communication systems to communicate with and monitor the condition of isolated patients.

“There were some innovations as well. So, this is a positive thing during the second wave… there were a lot of innovations from other sectors as well like sanitizer machines and some remote communication systems” (Deputy Regional Director of Health Services from Ministry of Health)

Lastly, coordination among inter-governmental organizations and across many governmental sectors commenced or increased due to the pandemic. In addition, with increasing number of cases the public and other well-wishers also contributed significantly.

“Without the army logistic support, definitely we would not have been able to manage this. For example, when we initially decided to quarantine the flights, at the time we only had the Hendala Leprosy hospital to quarantine…two wards were selected. But only one hundred persons could be kept there. Basically, with half a flight it will be filled. Then only the President instructed the army to put up these quarantine centres. Definitely without those quarantine centres we would not have been able to do this quarantine operation.” (Director from Ministry of Health) “Donations were received from in-country people as well as the foreign people. Now, I know many instances when we received calls asking whether the we want money and so on” (Deputy Regional Director of Health Services from Ministry of Health)

Sri Lanka is currently experiencing tremendous challenges as a result of the COVID-19, pandemic. Recent studies on pandemic response show that the earlier a country took active steps to control the spread of COVID-19, the more effective the strategies were in containing and slowing down the crisis [ 6 , 7 ]. Although Sri Lanka took early steps to curb the spread of the virus during the first wave and, to a lesser extent, during the second wave, the virus has still adversely affected the economy, health system, education and wellbeing of citizens.

Health security preparedness.

Sri Lanka had an emergency preparedness plan but the demand of COVID-19 was overwhelming and beyond the capacity the country had prepared for. A strengthened emergency preparedness plan is a need for many countries across the world. Many studies point out that mitigating stockouts of medical supplies such as PPE is an area that must be addressed in the emergency preparedness plans [ 8 , 9 ]. Although Sri Lanka had an initial stock of PPE, there were other gaps within the preparedness plan that needed to be addressed.

Educating the public on emergency preparedness is an area that must be included in Sri Lanka’s emergency preparedness plan. It was evident that the public had difficulty adhering to guidelines put forward by the government during the pandemic. For instance, there were patients who absconded treatment or did not cooperate with contact tracing due to the public fear about the virus and the conditions in quarantine centers. Therefore, empowering the public on mitigating emergency situations is likely to reduce such issues in the future [ 10 , 11 ].

Training and educating healthcare staff to work under high-risk conditions while ensuring personal safety has also been identified as an area that must be included in the emergency preparedness plans. For instance, a study conducted in Pakistan showed that 33% of healthcare workers showed a high level of anxiety to directly care for patients during the pandemic period [ 12 ]. Negative effects on mental wellbeing of healthcare workers have also been reported [ 13 , 14 ]. As revealed by the interviewees in this study, some healthcare workers in Sri Lanka were reluctant to work in high-risk situations and displayed a high level of anxiety. This, in turn, caused delays in the delivery of required health services. Often, the fears and anxiety of family members further exacerbated the anxiety of the frontline workers regarding COVID-19 [ 15 ] similar to that observed among the healthcare workers in Sri Lanka. The concerns of family regarding the spread of the virus were affecting their productivity at work.

COVID-19 management.

The management of non-communicable diseases to reduce mortality using evidence-based strategies [ 16 – 18 ] was implemented by healthcare workers in Sri Lanka. Interventions provided for sexual and reproductive health, maternal and child heath, and non-communicable diseases were negatively affected in multiple countries through lockdowns [ 17 , 19 , 20 ] based on the excerpts of the interviews we carried out, similar views were expressed. Mustafa et al (2022) highlight the need for establishing concrete plans to ensure health systems resilience for non-emergency health services [ 21 ]. The findings from this study point out that national authorities and partners—including academia, international organizations and donors—need to work together on health emergency planning to cater to population health needs and thereby improve available emergency and non-emergency health services. Therefore, Sri Lanka requires a system that pays equal focus to emergency and non-emergency health services during a pandemic situation.

The establishment of quarantining facilities within the country was another strategy used to reduce the rate of COVID-19 transmission in Sri Lanka. However, some interviewees were concerned that COVID-19 was being transmitted amongst the occupants in quarantine facilities. Studies show that such transmission occurs through asymptomatic patients at quarantine centers [ 22 ]. As suggested by the interviewees, it would be beneficial to systematically monitor the health of occupants after leaving the quarantine center to reduce potential risk of community transmission.

Changes in health system operations due to COVID-19.

There were major negative effects of the pandemic that affected all aspects of society in Sri Lanka. Economic disruptions have impacted every community. Schools have been closed for almost the entirety of the pandemic, interrupting education programs for students of all ages. In the health sector, training programs, sexual and reproductive health, maternal and child health and other environmental health programs were neglected.

Health system operations . The pandemic has impacted the health system and its operations in both negative and positive ways. The aggressive spread of the disease demanding more focus on COVID-19 management in terms of human and other resources, hampered other activities like blood pressure monitoring of the patients, routine laboratory investigations of patients with chronic kidney disease etc. This has also increased the number of dropouts from clinics, the effect of which we may see long after the pandemic has been declared over. Similar findings have been reported from Northern Italy where emergency department visits for non-COVID-19 patients decreased with increased out-of-hospital mortality [ 23 ]. Comparable findings have been reported by others [ 24 – 26 ]. Although most studies have reported that online training of staff was a positive outcome, our interviewees felt that online training is likely to be ineffective due to other constraints such as online connectivity and lack of devices. All of the above were the negative effects of COVID-19 pandemic on the health system. The collective impact of all of these factors on sustainable SDG targets is yet to be reviewed.

There were indirect benefits that resulted from the pandemic. Laboratory facilities were upgraded in all major hospitals to conduct PCR testing. Hospitals, intensive care units and high dependency units were upgraded to accommodate the growing number of patients. Ventilators, high flow oxygen delivery systems and other equipment were provided by the government as well as through generous donations by well-wishers. Quarantine centers were established and today the country has sufficient quarantine capacity to meet any situation. The nature of the response to the pandemic has strengthened inter-sectoral coordination and action. In addition, given the travel restrictions, authorities resorted to online systems for communication. If maintained, these improvements will equip Sri Lanka to better respond to potential future waves of COVID-19 and other pandemic threats. Similar effects on the health system have been reported by other countries where the pandemic had acted as an eye opener as well as a driving force in bringing about improvements to the existing system [ 27 ]. There were reports of adaptation of health systems to meet the emergency; in some countries, ICU bed capacity was increased, adaptations in emergency and outpatient departments. There was expansion of many public health laboratories globally [ 28 , 29 ].

Economic effects of COVID-19

The pandemic contracted the global economy and the impact was particularly experienced by low- and middle-income countries, including Sri Lanka. A study conducted in four sub-Saharan African countries showed that 77% of the population (256 million individuals) had lost their income during the pandemic [ 30 ]. A large proportion of Sri Lanka’s working population belongs to the informal sector comprising daily wage earners [ 31 ]. Similar to the findings of Josephson and colleagues, many families in Sri Lanka lost their modes of income, especially those engaged in the tourism industry, due to the restrictions imposed by the government to control the spread of the virus. The impact of the pandemic on the informal sector has not been estimated as yet. The Sri Lankan government therefore, took steps to provide financial assistance, though a very small amount, to low-income families. However, the provision of relief packages given to the public in need maybe difficult to continue on a regular basis due to the severe strain on the economy.

Limitations

This study is based on interviews with seven high ranking personnel directly involved in the control of the pandemic and who are familiar with IHR. The interviews were conducted in November/December 2021 about six months after the evolution of the third wave. It is likely that some of the interviewees may have forgotten some facts. It was difficult to interview healthcare personnel holding senior administrative grade posts during this time given their heavy workload. However, we believe that the ideas expressed by the interviewees are representative of the situation during the first and second waves of the epidemic in the country.

We were mindful of reflexivity where preconceived ideas about the area of study or the participants whom we are studying may affect the conduct of the study or the interpretation of the results. During analysis, the team assumed that their different backgrounds and experiences might influence the perspective, and subsequently, the analysis. As the analysis was conducted by the research assistant, an independent evaluator, the analysis is likely to have delivered unbiased efficient results.

Conclusions

Although Sri Lanka had difficulties in managing the epidemic, pandemic preparedness as a result of IHR training helped in mitigating the spread of COVID-19 during the first and second waves of the pandemic. The report of the Joint External Evaluation was endorsed by the Ministry of Health and implemented; the Quarantine Unit of the Ministry of Health, the focal point for IHR, develop protocols and standards. However, the magnitude of the pandemic was too great and many lessons have been learned where improvement is required.

A larger proportion of the effects of the pandemic has influenced badly on the healthcare system exposing its weaknesses and highlighting where new systems and protocols should be established to handle future calamities. However, it has also had some positive influence by way of capacity building among health staff, improving awareness of infections and prevention methods among the general public, encouraging innovations and improved facilities such as transportation for field staff in order to carry out their duties effectively.

The economic impact of the pandemic in a LMIC such as Sri Lanka affected low-income families to a great extent; national budgets should consider having allocations for substantial social benefits during emergencies, particularly to low-income families as an integral part of the disaster preparedness plan. But, for Sri Lanka which is in a severe debt crisis, this would be a distant dream.

Acknowledgments

We thank the interviewees for sparing their time to be interviewed despite their busy schedules.

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• 27. OECD. Strengthening the frontline: How primary health care helps health systems adapt during the COVID 19 pandemic. In: OECD Policy Responses to Coronavirus (COVID-19) [Internet]. 2021 [cited 26 Jun 2023]. Available: https://www.oecd.org/coronavirus/policy-responses/strengthening-the-frontline-how-primary-health-care-helps-health-systems-adapt-during-the-covid-19-pandemic-9a5ae6da/#section-d1e1822
• 29. Llamas A, McClurg A, LaRosa J, Nuzum R. Bolstering the Public Health Infrastructure in the Wake of COVID-19 | Commonwealth Fund. In: The Commonwewalth Fund [Internet]. 2023 [cited 17 Jul 2023]. Available: https://www.commonwealthfund.org/blog/2022/bolstering-public-health-infrastructure-wake-covid-19
• 31. Department of Census and Statistics. Sri Lanka Labour Force Survey -Annual Report 2019. Ministry of Finance; 2020.

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COVID-19 pandemic

Covid-19 pandemic response.

Humanity needs leadership and solidarity to defeat the coronavirus

The Coronavirus pandemic is the defining global health crisis of our time. Since its emergence late last year, the virus has spread to  every continent  except Antarctica.  

What is COVID-19?

COVID-19 is an infectious disease caused by the most recently discovered coronavirus. This new virus and disease were unknown before the outbreak began in Wuhan, China, in December 2019.

Countries are racing to slow the spread of the disease by testing and treating patients, carrying out contact tracing, limiting travel, quarantining citizens, and cancelling large gatherings such as sporting events, concerts, and schools.

The  UN’s Framework for the Immediate Socio-Economic Response to the COVID 19 Crisis  warns that “The COVID-19 pandemic is far more than a health crisis: it is affecting societies and econ­omies at their core. While the impact of the pandemic will vary from country to country, it will most likely increase poverty and inequalities at a global scale, making the achievement of SDGs even more urgent.

UNDP response

Every country needs to act immediately to prepare, respond, and recover. The UN system will support countries through each stage, with a focus on the most vulnerable.

Drawing on our experience with other outbreaks such as Ebola, HIV, SARS, TB and malaria, as well as our long history of working with the private and public sector, UNDP will help countries to urgently and effectively respond to COVID-19 as part of its mission to eradicate poverty, reduce inequalities and build resilience to crises and shocks.

“We are already hard at work, together with our UN family and other partners, on three immediate priorities : supporting the health response including the procurement and supply of essential health products, under WHO’s leadership, strengthening crisis management and response, and addressing critical social and economic impacts.” UNDP Administrator, Achim Steiner

UNDP in Sri Lanka 

UNDP Sri Lanka recognises that COVID-19 is much more than a health crisis. Drawing on our experience with combatting other outbreaks such as Ebola, HIV, SARS and Malaria, as well as our long history of working with the private and public sector, UNDP stands ready to help Sri Lanka to urgently and effectively respond to COVID-19 as part of its mission to eradicate poverty, reduce inequalities and build resilience to crises and shocks.

To help Sri Lankans make informed decisions about the safety of themselves and their families, an automated service by UNDP in Sri Lanka and 99X Technology was launched via  Facebook Messenger . 

You can now get the latest information, news, statistics, travel advice & FAQ's answered about  #COVID19  in සිංහල, தமிழ் & English 

An automated service by UNDP in Sri Lanka and 99X Technology

Like all hospitals around the world, hospitals in Sri Lanka also faced shortages of medical supplies, specifically Personal Protective Equipment (PPE) kits during the height of the COVID-19 pandemic. At a critical time where community effort was needed the most, UNDP was able to support the need of the hour through its Climate Change Adaptation Project (CCAP II) by teaming up with Green Coop. Through this initiative, garment factories established through the project in the Polonnaruwa area were approached, seeking a solution to address the shortage of Personal Protective Equipment (PPE) by exploring methods of local production.

From their hard work, 500 PPE kits for healthcare workers, 250 patient safety kits and 1,400 masks were donated to healthcare workers in the frontlines in Colombo and Polonnaruwa.  The safety kits were handed over to the Governor of the Western Province Mr. Roshan Goonatileke and Provincial Director of Health Western Province Dr. Damayanthi Jayathilaka. 

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The Lingering Economic Consequences of Sri Lanka’s Civil War

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A lack of justice following Sri Lanka’s Civil War has compounded the economic crisis in the North-East.

Sri Lankan Tamil civil war survivors perform rituals in memory of their deceased family members on a small strip of land where civilians were trapped during the last stages of the war in Mullivaikkal, Sri Lanka, May 17, 2024.

This year marks 15 years since the end of the Civil War in Sri Lanka. The armed forces carried out an avalanche of atrocities during the conflict: they bombed No Fire Zones, shelled hospitals, fired on Liberation Tigers of Tamil Eelam (LTTE) combatants that surrendered, carried out enforced disappearances, and denied humanitarian aid such as food and medicine to civilians in camps. An International Crisis Group report in 2010 noted that the “the Sri Lankan option” set a precedent for the elimination of dissent. In fact, close parallels can be seen in Gaza today.

Fifteen years later, the Tamil people have not received a solution to the National Question, be it a political solution – such as the complete devolution of authority from a centralized state to the provincial councils, a solid accountability mechanism, or personalized reparations – or an economic solution. 

Research has revealed a number of obstacles to economic development in the North-East: militarization, unsustainable infrastructure projects, a lack of viable livelihoods in the area, the lack of a macro-economic vision that prioritizes local people’s autonomy over land, and the absence of ports. 

The diminished civic space and lack of economic development are closely connected. This can be seen in the state-sponsored colonization that has restricted people’s access to their land and resources, and militarized capitalism, that has acutely reinforced the military’s ability to act as a capitalist hand. 

State-sponsored Colonization 

“It is only the armed conflict that is over. The civil conflict is very much alive,” said Shanakiyan Rasamanickam, an MP and member of Illankai Tamil Arasu Kachchi (ITAK). “The oppression still exists and the land issues are the topmost issue.”

In Sri Lanka, the majority of land is under the state’s control. Land is distributed under various ordinances to farmers as annual or extended permits. Grants exist but they have specific stipulations. In the North-East, most citizens had access to private lands. Faced by violence from the armed forces, the Indian Peace Keeping Forces, and other paramilitary troops, many people had to leave their lands and in the process lost their deeds. At the end of the Civil War, the army released the majority of land but the state used various departments to reoccupy them. 

The state has three primary motivations for this. First, the extensively centralized state is paranoid that the complete devolution of authority to the provincial councils could loosen their control over the land. Second, colonization shapes the ethnic makeup of an area. With land occupation, the number of Sinhala voters increases and there is a greater likelihood of a Sinhala representative elected into Parliament. Finally, when the state occupies land, they could use it to complete their political project, be it Sinhalization or neoliberalization. 

“Land is power. The state needs to control land to implement its political project,” said Sandun Thudugala, a member of People’s Alliance for Right to Land. This can be seen in former President Gotabaya Rajapaksa’s allocation of land to the military and current President Ranil Wickremesinghe’s allocation of land for market liberalization (i.e. private investment). 

Under British rule, the state occupied land for tea plantations. These schemes displaced Sinhala peasants and confined them to the periphery of these areas. In the post-independence period, many politicians had to meet the demands of these constituencies and expanded colonization schemes into the Dry Zone. D. S. Senanayake, the first prime minister of Sri Lanka (then known as Ceylon), set up the Gal Oya project for rural development during 1948-1952. The project built a dam in the Gal Oya Basin and used it to cultivate paddy, chilies, and potatoes. The need for labor led to the violent displacement of Tamil and Muslim farmers to make space for Sinhala settlements. The Gal Oya riots in 1956 exploded as a result of these schemes. 

Water diversification for Sinhala farmers was the primary aim of the Accelerated Mahaweli Development Program in the 1970s. In the next decades, Sinhala farmers did not have a base in the North-East, so the state continued the project. These development projects led to tensions in rural areas like Batticaloa’s Mayilathamaduva. Tamil cattle farmers were threatened by Sinhala paddy farmers and many times their livestocks were harmed or killed.

In the Civil War, the military occupied land for security reasons and maintained its establishments. No one could enter these areas except for military personnel. After the conflict ended, the military released most of the land, but certain lands such as Mullikullam in Manner are still occupied. The military also runs tourism sites such as the Thalsevana Holiday Resort and Restaurant in Valikamam. Some families were provided alternate lands, but other families continue to protest for their private land. Despite pressure from the international community, some of these lands have been reoccupied by other departments.

The Department of Archeology (DOA)’s main mandate is the restoration and preservation of Sinhala Buddhist culture, but they use this to colonize lands in the Tamil homeland. When the DOA identifies ruins (i.e. ancient stones or broken statues), they demarcate the land under their department. The entrance is closed and all productive activities are ceased. A Buddhist monk enters the area and a temple is built around him. He opens the space up to devotees, usually family members from the South, to clean the premises and cook. Once a number of families have been settled, the area becomes a Sinhala-Buddhist community. Kurunthurmalai temple is an example of a temple’s construction under the premise of archaeological restoration, despite the presence of a court order. 

The DOA’s narrative only promotes Sinhala Buddhism. So only Sinhala people can enter these areas and pray. Tamil historians have pointed to the presence of Tamil Buddhists in the North but these nuanced identities are unable to fit into the state’s definition of a fixed Sinhala Buddhist identity. Land colonization by the DOA, as a result, upends and fractures the complexity of identity in the island. 

Similarly, the Department of Wildlife Conservation (DWC) declares land to be under its authority for conservation purposes. Once land is allocated to the DWC, people cannot enter unless they have permission. Land allocated under the DWC in the Civil War naturally turned into forests. When the state mapped the area, they demarcated occupied private land as forest cover. 

“We have certain places where the house is owned by a private individual and the toilet is owned by the DWC,” Sandun said. “Conservation is important but this is an arbitrary declaration of zones. We have asked for a proper mapping of the area for environmental conservation and private lands. This can help the release of lands to citizens.” 

Despite their mandate for conservation, DWC-held land has also been used to set up cultivation projects. In 2015, the president claimed demilitarized land to be forest cover. The DWC set up elephant fences as borders, initiated reforestation projects, and the Civil Defense Forces (CDF) occupied these areas. In 2021, former Wildlife Conservation Minister Wimalaweera Dissanayake asked 600 CDF members to cultivate nut trees in the 300 acres allocated to each of them. Subsequently, the CDF members erected fences and claimed to be involved in a reforestation scheme, despite it being a cultivation scheme.

Another example is the occupation of the coastal belt. Coastal land in Sri Lanka is common land and in the past fishermen used this land to host their shelters, boats, and nets. After the tsunami in 2004, the state prevented construction in a 100 meter area that separated coast and land. When the Civil War ended in 2009, the state decided to allocate this land for tourism. In the Eastern Province, in particular, land has been sold to hotels. 

The occupation of land by various state departments denies people access to the land, natural resources, and local infrastructure. Land that could potentially be used to stimulate the local economy is held by the state. The state is able to occupy, appropriate, and extract the lands for its benefit at the expense of the people it belongs to. 

“If land is not prioritized, who are the beneficiaries of a political solution?” Rasamanickam asked. 

The release of private land is just a start. There are a number of people that relocated from the plantations to the North and members of oppressed castes that never had land. 

“There is a large section of society in the North that is landless. They never had land to start. This requires a much broader scheme for land alienation and land redistribution,” said Ahilan Kardirgamar, a lecturer at the University of Jaffna. 

Militarized Capitalism 

A study published in 2017 touched on the concept of militarized capitalism in the North-East. The idea is that militarization intersected with capitalism, in the form of apparel factories set up in former LTTE-occupied areas. The military helped these factories secure property, production sites, and a labor force in 2009. They also built infrastructure such as roads to increase connectivity. The factories set up training centers to indoctrinate the labor force into the rules of capitalism, namely technical skills, presentation and interpersonal skills. At this point, civilians still employed the labor force. 

Over time, the intersection of capitalism and militarization coalesced into one form: militarized capitalism. In Mullaitivu alone, there are a number of military-run businesses (i.e. farms, hotels, and factories), recruitment of civilians into the military-run Civil Security Department (CSD) and interference by the military in the private sector. People are stuck in a cycle of control, dependence, and debt. As a result, the military, as a hand of capitalism, has a monopoly over the local economy and local political activity. 

“The local people cannot access their land, natural resources, and markets. They are denied opportunities,” Sandun said. “Smallholder businesses and SMEs are supposed to compete. This is not a fair or equal competition. This bodes badly for the entire economy. It provides control of the economy to a limited group of people. 

“Look at Myanmar and Pakistan. The authority of the military has been built through economic exercises. In those countries, the military controls the economy,” he continued.

The structural dependence of local livelihoods on the military means that they are instrumentalized for political purposes. CSD employees were used to campaign for former President Mahinda Rajapaksa’s re-election in 2015. Workers had been told to protest the transfer of the CSD to civilian authorities in 2017. 

With the end of the Civil War, repression became normalized in Sri Lanka’s North-East. In 2017, the district of Mullaitivu had 60,000 troops – 25 percent of the approximately 243,000 active military personnel in the entire country. For every two citizens, there was one soldier. 

In 2024, over a decade since the war ended, Tamil people are haunted by surveillance, harassment, and intimidation. Women, in particular, have not received justice for the sexual violence they experienced in 2009. They encounter armed men in mundane situations: as they purchase food, enter schools, and access resources. Female-headed households are particularly culpable to violence. Those who protest have received visits from armed men at late hours, sources have disclosed. 

Research from 2020 mapped out diminished civic space for minorities across Sri Lanka. While this space briefly opened up in the 2022 protests in the South, activists have encountered a climate of repression in events that remember Tamil people, such as the Mullivaikkal remembrance event in 2023 in Borella Cemetery and 2024 in Wellawatte Beach. Similarly, protests for Palestine are accompanied by a police force and water cannons.

“Tamils in the North-East have fought for the right to commemorate for many years prior, facing severe repression from the state. While commemoration events marking the Tamil Genocide Remembrance Day and Maaveerar Naal happen, the participants and organizers continue to face harassment from the state,” said Mario Arulthas, a Ph.D. candidate at SOAS, University of London. “The people organizing Tamil remembrance events in Colombo only started in recent years and are in a space that the state is not used to and therefore faced some backlash. Tamils have shown that these spaces, while contested, must be fought for.” 

The deprivation of economic and civic rights has left the North-East vulnerable to external shocks. Sri Lanka’s poverty rate increased from 4 to 7 million during 2019-2023. While the economic crisis hit the entire island, the impact is compounded in the Tamil homeland. Research from 2019 revealed that multidimensional poverty had declined from 2007-2013, but existed in pockets in the North-East. In 2023, a UNDP report identified 55.7 percent of the country to be multidimensionally vulnerable, mostly from areas in the North, North-Central, and Eastern provinces. Many people have been forced into debt to secure basic necessities such as food and medicine. Reports by the World Food Program and U.N. Food and Agricultural Organization in 2023 exposed the acute food insecurity in districts in the North-East. 

Tamil Vote 

The Tamil people’s choice is crucial for the upcoming presidential election because no party is likely to secure a majority in the first round. Data from 2019 revealed that the North-East has exceptional voter turnout. These votes helped Sajith Premadasa and his party become a contender in the 2019 presidential election. The upcoming election is a three-horse race run by three candidates. As the Sinhala vote is likely to be split into three, the minority Tamil votes are essential for a party to secure a victory. 

Tamil nationalist parties have announced a number of options: a boycott of the elections, support for a candidate in the South, or a common candidate for the Tamil vote. While some feel that the common candidate is an opportune moment to further Tamil demands, others are critical of it. 

“The common candidate is a distraction. The Tamil nationalist parties have distorted the entire project. They remain on this one-track, polarizing ethnic project but this does not help the Tamil people,” Kardirgamar observed. 

In a local paper, leader of ITAK, M. A. Sumanthiran said that presidential elections are not the time to make statements about Tamil demands. 

“No party or a candidate is likely to receive 50 percent in the first count. So the president is likely to focus on the second preference. He could rely on SLPP members for the Southern votes and CWC for the Hill Country Tamil votes,” said Shreen Saroor, an activist and member of the Women’s Action Network.

“The Cabinet recently issued a statement about burial rites and an apology for forced cremation done during the pandemic, probably for the Muslim votes. It is also speculated that the president and the Tamil common candidate have a deal to further split the Tamil votes.”

Despite the importance of the Tamil vote, apart from lip service about the provincial councils, none of the candidates has proposed a radical solution to either the national question or the economic crisis. In the North-East, they manifest as one crisis. 

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