COVID-19 and developing countries: lessons learnt from the Sri Lankan experience

The COVID-19 pandemic is the defining global health crisis of our time. Although it was forecast that developing nations will struggle, Sri Lanka has so far coped reasonably well with the pandemic in comparison to more advanced healthcare systems in the world. It is safe to say that Sri Lanka would have been facing a different reality, had it not been for the early tough restrictive measures taken by the government, and the dedication and strive of the military and health professionals in battling COVID-19. However, with neighbouring countries posting high numbers of COVID-19 cases, many questions remain regarding the future effects of the early tough efforts taken to control the spread of COVID-19.

The Sri Lankan response

Following the first reported case of COVID-19, island-wide health educational programmes using social, print and mass media were commenced. Moreover, health facilities and testing methods were identified and readied for possible community spread. Contact tracing was instituted with broad screening methods at the international airports to identify and quarantine those passengers with COVID-19 symptoms. The early identification of such patients was further facilitated by the availability of locally developed rapid tests, with results issued within 24 h. The government took early, decisive social measures such as the mandatory use of facemasks in public and limiting of public gatherings. Most COVID-19 cases were reported in quarantine centres with intermittent clusters noted in densely populated areas. In an attempt to curtail the spread of COVID-19, an island-wide curfew was instituted with the country in lockdown for two months with severe movement restrictions in place. During this period, stringent contact tracing and isolation of suspected patients was done by the community health teams with the support of the military intelligence units. The community health teams worked tirelessly to conduct random polymerase chain reaction (PCR) testing in areas of dense populations, to check for possible community spread. The Sri Lankan Military played a pivotal and commendable role in lessening the burden placed on the overstretched community teams, by establishing and managing quarantine centres. Sri Lanka was also among the first countries to arrange repatriate missions to bring back its citizens stranded abroad. While these aggressive measures directly contributed to keeping case fatalities and numbers low, has Sri Lanka increased its chances of a second wave of COVID-19 by acting too fast, too soon?

Problems facing Sri Lanka

The health sector has been previously recognised as providing good healthcare at a low cost.¹ It boasts of achievements such as 100% vaccination coverage and elimination of measles, polio and malaria. Improvements in lifestyle, economy and quality of health services have resulted in a much healthier ageing population. Sri Lanka is seeing an epidemiological transition from infectious and deficiency diseases to that of non-communicable diseases such as diabetes and ischaemic heart disease. The absence of an effective, cheap vaccine for COVID-19 puts Sri Lanka’s growing elderly population at grave risk of succumbing to a second wave of the disease.

Additionally seasonal monsoon has brought about heavy rainfall, which inadvertently contributed to a rise in Dengue fever and Leptospirosis cases in the country. There is much concern among health professionals that the rising numbers of COVID-19 cases will take much-needed attention away from routine communicable disease surveillance, since the overstretched public health teams are expected to accommodate these activities, while juggling the needs of the current pandemic.

Sri Lanka was one of the earliest countries to respond to the calls to bring back its citizens stranded abroad. With more than 45 quarantine facilities in place, there is increased welfare expenditure on maintaining and facilitating suspect patients in such centers. A mandatory period of 14–21 days in quarantine with regular medical review and polymerase chain reaction testing has led to an increasing burden on the health budget and resources. In keeping with the World Health Organization’s ‘Test, Test and Test’ strategy, Sri Lanka has yet to do more to improve its testing policy as overall testing numbers remain low. Additionally, a major challenge to the existing system will be a shortage of intensive care beds, ventilators, oxygen supplies and other necessities required to care for patients with severe respiratory failure. With severe cuts in expenditure, Sri Lanka may not be able to prepare its health facilities on time to face a second wave of COVID-19 cases.

In the midst of it all, undoubtedly Sri Lanka will face severe economic repercussions in the long term. With the economy frozen during lockdown, the entire economic mechanism involving agriculture, manufacturing and service sectors were drastically affected.² Additionally, with big-player global economies struggling, the demand for imported luxury goods from Sri Lanka such as tea and cinnamon has reduced significantly. The unprecedented cost of the pandemic management will take Sri Lanka’s focus away from much-needed development in infrastructure and strengthening of the economy. The sudden economic down turn means that Sri Lanka is likely to face high unemployment, inflation and poverty rates in the future.

Conversely, the pandemic has sparked a growing sentiment that Sri Lanka must use this as an opportunity to be self-sufficient and reduce its reliance on foreign aid or markets. Hence, local produce and enterprises are championed, with curtails on importing foreign goods been introduced. As a result, it has reinvigorated the nationalistic interest in building and expanding knowledge through research and innovation. This boom in research and innovation has paved the way to design and manufacture low-cost, local solutions to aid combat the needs of the pandemic such as rapid test kits and personal protective equipment. It remains to be seen, however, if continued support can be provided to further develop such innovations in the face of low investment capacity of the country.

Since Sri Lanka did not follow the ‘herd immunity’ route as some western countries have, the consequences would be devastating should a second wave return. With neighbouring India experiencing a large surge in numbers, it is proving to be a difficult task ahead for Sri Lanka. The close proximity and the trade links between the two countries pose a huge risk of the disease re-emerging in Sri Lanka.

Tourism remains the main contributor to the country’s income. Sri Lanka remains a popular travel destination, and with gradual, step-wise lifting of the restrictions in place, it is expected that tourism will help reinvigorate the country’s economy. However, tourists are expected to strictly adhere to several measures introduced by the government. These include higher visa processing fee, a negative polymerase chain reaction test before and on arrival in the country as well as mandatory 14–21 days in quarantine for anyone with symptoms.³ With global travel at a standstill together with such strict screening measures in place, it is unlikely that Sri Lanka will achieve the high number of visitors as it did pre-COVID era.

As a middle-income country, Sri Lanka has its own socioeconomic problems, having to deal with limited resources and funding. Add a global pandemic into the mix, it was expected that Sri Lanka would sink. At the moment, Sri Lanka is managing to keep its head just above the water. The fight against COVID-19 is far from over.