Sri Lanka’s response to COVID-19: Factors underpinning relative success

Yes, Sri Lanka has achieved relative success. But there is no room for complacency. Sri Lanka’s COVID-19 response agenda still remains unfinished business and a significant challenge – Pic by Shehan Gunasekara

By Dr. Nimal A. Fernando

By now a vast number of countries across the globe have been affected by the COVID-19 pandemic. Its spread across the globe, its severity, the damage it has already inflicted upon people and most dismally the large number of deaths in addition to the immediate adverse socio-economic consequences and the potential for far-reaching medium and long-term adverse impact, all these factors taken together, tell us that there has been no comparable pandemic in recent history. 

Most recent data reveal that some 210 countries in six continents are facing the crisis, more than 2.3 million confirmed cases (WHO defines a confirmed case as “a person with laboratory confirmation of COVID-19 infection”) have been reported globally while approximately 160,000 people had died after contracting the disease, as of 18 April. 

Pandemic has impacted countries differently

However, the pandemic has impacted different countries differently. The severity of the crisis, individual country responses and the results achieved so far also show a marked variation across countries. What is remarkable is the presence of many so-called well developed, First World countries with modern healthcare systems in the worst affected lot and are included in the category of countries poorly responding to the crisis. Most glaring examples include the United States of America, Belgium, Spain, Italy, France and United Kingdom.

The top 17 countries( each with over 15,000 confirmed cases) in the number of confirmed cases as o 18 April 2020 are: USA (734,969), Spain (194,416), Italy (175,925), France (152,978), Germany (143,724), United Kingdom (115,314), China (83,804), Turkey (82,329), Iran (80,868), Belgium (37,183), Russia (36,793), Brazil (36,760), Canada (34,386), Netherlands (31,766), Switzerland (27,404), Portugal (19,685) and India (15,723). 

However, despite reporting the highest number of confirmed cases, some of these countries have managed to achieve relatively high recovery rates (number recovered as a percentage of number of confirmed cases). China is outstanding in this respect with a reported recovery rate of 92.6%, followed by Iran with a rate as high as 69.2%, Switzerland with 62.4%, Germany with 59.4% and Spain with 38.5%, as of 18 April. 

The worst five countries (in the lot with more than 15,000 confirmed cases) with regard to recovery rate include the United Kingdom (0.4%), Netherlands (1.0%), Portugal (3.1%), Russia (8.0%) and the USA (9.0%). It is worth noting that the global recovery rate as of the same date was 25.6%.

A variety of indicators may be used to look at individual country performance. Owing to many problems associated with COVID-19 data, some consider data on deaths are a more dependable indicator. In terms of death rate (reported deaths as a % of confirmed cases), Belgium (14.7%), United Kingdom (13.4%), Italy (13.2%), France (12.6%) and Spain 10.6%), respectively reported the highest death rates while the death rates in Iran (6.2%), China (5.5%), USA (5.3%) have been relatively moderate. Germany and Turkey reported relatively low rates of 3.2% and 2.3%, respectively. 

It is worth highlighting that although the US has come under severe criticisms on many counts in regard to the response to COVID-19, it has managed so far to keep the death rate close to 5.0 %, despite having the highest number of confirmed cases. (One reason that it remains at relatively low levels is statistical because the rate of increase in the number of confirmed cases has been much higher than the rate of increase in the number of deaths.)

Relatively better performing countries

As noted, amidst remarkable diversity in individual country performance, some countries have done remarkably well overall. The category of relatively better performing countries, according to the Global Response to Infectious Diseases (GRID) index-based analysis commissioned by the Institute of Certified Management Accountants (Australia) include New Zealand (COVID-19 response rank 1), Singapore (2), Iceland (3), Australia (4), Finland (5), Norway (6), Canada (7), South Korea (7), Hong Kong (9), Sri Lanka (9), UAE (9), Japan (9) and Taiwan (9). This ranking is based on the efficient and effective leadership of the country and the preparedness of its health system in tackling the COVID-19 pandemic. 

However, in terms of death rate, there is a degree of diversity even within this category of countries: for example, the death rate in Canada is 3.97% and 2.87% in Sri Lanka. Finland, Norway and South Korea reported 2.22%, 2.20% and 0.16% respectively. In this category the lowest death rate was reported by Singapore (0.23%) while Hong Kong reported 0.39%, Iceland 0.46%, New Zealand 0.78% and Australia 0.97%. One might be tempted to point out that some of these countries such as Sri Lanka (244) and New Zealand (1,409) had low number of confirmed cases (as of 17 April) and that must have contributed to better performance. However, the counter argument could be that the low case numbers themselves may be a reflection of the effectiveness and high quality of the national responses to the outbreak.

As has been done in the GRID index-based analysis, it is possible to identify in general a number of factors underpinning relatively better performance. ICMA Australia paper highlighted leadership as one of the most critical factors. Strong leadership is the foundation behind a good national strategy. Great leaders not only have a clear vision but also a remarkable capacity and skill to quickly put in place a pragmatic and smart program in line with local context in consultation with all key agencies while taking cognizance of key external factors as well. 

Leaders of both New Zealand and Australia have been able to achieve success in controlling the virus as measured by “flattening the curve” (when a country has fewer new COVID-19 confirmed cases emerging today than it did on a previous day, that is a sign that the country is flattening the curve. Often a five-day moving average is used to visualise the number of new cases and compute the rate of change. Flattening the curve is critically important partly because health system of any country operates subject to capacity constraints). 

Pragmatic responses of Sri Lanka’s leadership

The ICMA (Australia) paper elaborates farsighted pragmatic responses of Sri Lanka’s leadership and notes: “As the origin of the novel coronavirus in Wuhan was announced, Sri Lankan authorities started to take vigilance in stopping the potential danger. The military forces and the national intelligence service were put on high alert. The government created specialised aviation and border control expert teams, to track the movement of all inbound tourists and with a potential threat. Sri Lanka was one of the first countries to send rescue missions to Wuhan to evacuate 33 Sri Lankan families. The families were brought down via an exclusive carrier and quarantined in a unique military facility. All potential contacts were observed continuously under quarantine. Those in the military facility were given full access to information; and there was no government control of information, hence increasing its reliability.”

Good leaders not only take timely actions but also make a concerted effort to cultivate a strong commitment across a diverse range of stakeholders. And they are able to put the issue at the top of the national policy agenda and garner broad support. They ensure effective coordination among critically important agencies at the national level and below including those at the community level and are able to sustain unwavering commitment to the cause until the target is fully achieved. This is exactly what countries such as Australia, Iceland, Sri Lanka, New Zealand and Finland had done in a multitude of ways. 

National coordinating bodies mobilised the broad support and commitment under national leadership and sustained these over time. Sri Lanka’s political leadership at the very early stages correctly identified national coordination as the most daunting challenge to implementation of responses to the COVID-19. This led them to give it the highest priority in the process from the outset. The mechanisms put in place ensured not only inter-agency coordination but also intra-agency coordination covering all key agencies including health care agencies in the public sector. 

In Sri Lanka it was remarkable that the leaders made a smart decision at early stages to use the military forces and the national intelligence service extensively to trace the contacts of the infected persons as quickly as possible and manage the process efficiently and effectively. The armed forces not only quickly built new facilities for quarantine but also immensely assisted the national health system to operate these in an efficient and effective manner. Often they did these at the expense of the welfare of their members. The rank and file of the forces extended their full support to these operations.

It was, for example, the continuous high quality of the national intelligence services that enabled the health system staff to limit the number of tests to a relatively low level without compromising the overall quality and effectiveness of the efforts to contain the spread of the virus within the broader society. Had it not been for the stellar services rendered by the armed forces to the dedicated and efficient health care staff who was working tirelessly round the clock as well as the political leadership, Sri Lanka’s COVID-19 story would have been different, most probably dismal. 

Participatory and consultative approach

Leadership is undoubtedly critical, but how committed are the leading institutions of the country and how these institutions organise themselves to execute a strategy are equally important. Evidence indicates that institutions organise themselves to execute a strategy in remarkably diverse ways. This is what we can observe across different countries in the responses to COVID-19. 

Sri Lanka’s leadership was well positioned to take leadership, systematically drive the process with the highest level of commitment to overcome barriers on the way and steer the entire gamut of activities in the right direction to achieve the shared goal of wiping out the pandemic from the country. In passing it must be noted that the fact that the Parliament remained dissolved during this period was a blessing in disguise. One could argue that this helped in many ways to take and implement timely decisions to tackle COVID-19.

Although the Parliament remained dissolved during this period, evidence suggests that it did not act as a serious constraint on adoption of a participatory and consultative approach. The participatory and consultative approach adopted by the national leadership has been much broader and of higher quality than what could have been realised within the parliamentary assembly boundaries. The leaders ensured that broad and in-depth consultations with relevant stakeholders are carried out throughout the process. This was done with a genuine commitment to gain insights from key persons and agencies. That process enriched the quality of the responses. 

While there was room for opposition leaders to make a positive contribution to further refine the process in some instances and improve the quality of implementation, it remains an open question whether they made a genuine effort to make a positive contribution. There was lots of noise but little substance in their views most of the time. 

The responses of the leaders were as much as possible formulated based on hard data and frequently updated diagnostic studies from the health sector as well as other line agencies. Apparently, partisan politics played no significant role in the entire process, although there was some evidence of efforts to mix politics with the process at some localities in distributing relief support. 

As noted in the recent ICMA (Australia) paper on COVID-19, “Popularity and populism will not win the battle against the pandemic. The true test of (his) leadership will be how well he manages the fallout from this pandemic, irrespective of his popularity.” In general, Sri Lanka’s leaders acted in line with this and were bold enough to take and implement tough policy decisions. At the heart of these decisions and actions have consistently been the health and welfare of the people of the country.

Learning and applying lessons

The leaders did not overlook the importance of learning lessons and applying those to refine the implementation process. Also, responses were fine-tuned based on the changing local contexts to ensure better outcomes. Quick lessons from implementation experience of many measures put into practice were used to refine those measures to achieve better results and minimise the potential adverse consequences on the people.

This could be seen in the way how quarantine systems were organised and operated and also how curfew was introduced and enforced throughout the country. For example, the initial decision (announced on 18 April) to lift the curfew in the four mostly affected districts (Colombo, Gampaha, Kalutara and Puttalam) with effect from 22 April was revised on 20 April. The new date for lifting the curfew in these four districts was announced as 27 April. This revision was done partly taking account of the potentially high risks associated with an early lifting. 

Also flaws in the systems put in place to ensure distribution of essential food and other items to improve access of both rural and urban people were addressed in a similar manner over time. These measures were designed, refined and executed to achieve the twin objectives of effective control of the pandemic and minimising the potential adverse impact on welfare of the vast majority of people in the country. 

There were some implementation issues and there still are. But when cognisance is made of the size of the problem and absence of comparable previous experience on a national issue of health of this magnitude, it is not difficult to realise the impossibility of putting in place perfectly and smoothly functioning procedures and systems on a nation-wide scale. In this context, emergence of implementation issues at various level is natural. What is significant is to point out is that those were not big enough issues to derail execution of the overall strategy. And the leadership demonstrated a genuine commitment to speedily address those issues as and when they cropped up. 

Initial institutional conditions and country context

In addition to the leadership factor what may be termed as “initial institutional conditions and country context” factors also played a significant role in the relative success achieved so far. The ICMA (Australia) paper explained these briefly:

“The reason Sri Lanka responded so well is because Sri Lanka has a public health system which is free for all citizens. Going hand in hand. Sri Lanka has had a free education system until graduate school for the last 60 years; thanks to which it has trained thousands of well-qualified healthcare professionals and paramedical workforce or many decades through well-regulated and state of the art medical faculties covering all regions of the country; all free of charge. The doctors and paramedical staff receive post graduate training and continuous medical education throughout their career.

“The island nation also has a robust century-old community health program. Health statistics such as maternal and child mortality rates are the lowest in the region. In fact, comparable to the western world. The life expectancy is highest in the region. The nation is 100% vaccination covered, and all treatments under the extended program of immunisation are administered free of charge.”

No room for complacency

Yes, Sri Lanka has achieved relative success. But there is no room for complacency. Sri Lanka’s COVID-19 response agenda still remains unfinished business and a significant challenge. Tremendous diversity in individual country responses provide a fertile ground for cross-country learning for the leadership in addition to the potential for learning lessons from within the country to address the remaining challenges.

Our success also depends in part on the success of other countries in and outside the region. Leadership will be able to do even better if a cautious approach is pursued in learning and making use of the lessons to ensure that the COVID-19 is wiped out of the country in toto. Keeping politics out of the program particularly in the design and execution of the exit strategy will be crucial in achieving the desired final outcome at minimum cost to the society and the economy. At the same time we have to work in close cooperation with the rest of the world to see a happy and lasting outcome in this daunting task.

Note: Most of the data used for the paper is extracted from the data base of the Johns Hopkins University’s Coronavirus Resource Center. However, given that the COVID-19 outbreak is ongoing, the numbers used for this paper may not reflect the current situation at the time of publication of the paper.

(The writer is a development economist and former Associate of the Kuala Lumpur-based Alliance for Financial Inclusion.)