Where does Sri Lanka stand in the global pandemic?

In the wake of the COVID-19 outbreak in Sri Lanka and subsequent implementation of a nation-wide curfew on 20 March 2020, the Citra team identified countries that followed similar trajectories to that of Sri Lanka and conducted a comparative analysis of the measures that were implemented in these countries. The original report explored measures that appeared to have been successful in other countries and attempted to draw parallels where possible to Sri Lanka’s context. Examining the different pathways of countries that were more successful in ‘flattening their curves’ (such as Taiwan and Vietnam) vs. countries that had recovered (China) vs. countries that were experiencing an exponential increase in confirmed cases and deaths was a useful exercise in identifying what measures may have worked and why, as a first step to determining if they can be replicated elsewhere, while, of course, bearing in mind differences in economic, social, political and cultural contexts.

The report was maintained as a live document, and the Citra team updated the data and evolution of the countries’ pathways from mid-March up until 10 May 2020. The initial report and updated versions were maintained as an internal resource and were directly shared with decision-makers from the government, private sector, UN agencies, NGOs, civil society and the diplomatic community, to support measures being taken at all levels to combat the spread of COVID-19 in Sri Lanka. The following is a summary of the team’s analysis as of 10 May 2020.

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At the beginning of the spread of COVID-19, no streamlined instruction manual was available for countries to follow in combating it. This resulted in different countries embarking on their own approaches while looking to borrow best practices from others and adapting measures to suit their own contexts.

As the virus spread with uneven patterns across nations, there were multiple factors, such as population density, the proportion of urban and rural communities, host immune systems, and low levels of existing diseases etc. that may have contributed to differences in transmission and death rates. However, the focus of this paper is to compare the primary containment and mitigation measures put in place and to understand how they may have helped in different contexts, while also identifying certain practices that may not have been common across the board.

PATHWAY #1 — BEST-CASE

SUMMARY ANALYSIS

Out of the pool of countries displaying similar timelines to that of Sri Lanka, Taiwan and Vietnam were identified as countries presenting what we believe to be a best-case pathway, given that (as of 10 May 2020) they had managed to contain the number of cases to less than 500 and/or under 10 deaths and/or more than 100 recovered patients. While the number of confirmed cases increased beyond 500 in Sri Lanka, it seemed to be following a similar trajectory to these two countries until 13 April, as illustrated in the graph below — for instance, interestingly, all three countries experienced sudden jumps in the number of cases within 7–8 weeks of the first case.

Detailed analysis of Pathway #1

While we observed some differences in the approaches adopted by Taiwan and Vietnam, some commonalities emerged:

• Social distancing and quarantining were strictly observed in both countries. Taiwan took the additional step of identifying at-risk cases through big data and technology, but both countries took the need for social distancing and staying at home seriously and maintained strict enforcement. Similarly, Sri Lanka also took steps to establish over 45 quarantine centres, enforced an island-wide curfew, and encouraged citizens to practice social distancing during breaks in curfew and if they feel unwell.
• Entry restrictions, with both countries imposing mandatory medical checks and quarantining for all visitors from high-risk areas. Sri Lanka, too, imposed a travel ban and requires any citizens travelling in to undergo mandatory quarantine for a period of 14 days.
• Transparent, detailed and unified communication on COVID-19.
• Institutional coordination and planning and rapid policy implementation. Taiwan began preparing for the virus as early as 31 December 2019, and subsequently released a 124-point list of policy measures, going beyond border control.
• Understanding the strengths and weaknesses of their healthcare systems and manoeuvring accordingly. For instance, Taiwan immediately tackled the size of working groups in medical facilities and hospital layouts and facilities, such as isolation rooms, while Vietnam developed and leveraged low-cost testing kits, given its limited healthcare infrastructure.
• It is not surprising that the countries that exhibited the greatest success in containing it were those that went through SARS in 2002–03. This led to greater government and citizen commitment and willingness to comply with restrictions, as well as greater preparedness. It is also worthwhile noting that perhaps both countries have benefited from socio-political systems and cultural contexts where citizens are more likely to comply with expert opinions and government policies. It should also be highlighted that both countries did not need to enforce a nationwide lockdown/curfew to curb the virus, due to the measures detailed above.

PATHWAY #2 — SECOND BEST CASE

SUMMARY ANALYSIS

Cyprus, Albania and Panama were identified as countries experiencing a second-best pathway, as each of these countries were spurred into enforcing stringent measures to control and mitigate the spread of the virus, while containing confirmed cases between 500–10,000, deaths between 5–200 and >100 recoveries.

While each of the three countries adopted a range of strategies, there were some commonalities:

• The implementation of early travel bans and the early imposition of curfew
• Enforcing social distancing measures.
• Panama and Albania also took measures to pass or amend legislation and establish control centres to manage and monitor the spread of Covid-19.
• Efforts were also taken to support businesses and supplement people’s income.

It should also be noted that each of these countries took pre-emptive steps to manage the spread of COVID-19 — for instance, imposing a travel ban when only one case had been reported or establishing a control/command centre prior to any reported in-country cases. Sri Lanka’s response to managing the spread of COVID-19 has many parallels to the approaches adopted by each of these countries — for instance, early restriction of travel, the imposition of a lockdown, and the mandatory quarantine of travellers from COVID-19 hotspots. In addition, the social distancing tactics adopted in Sri Lanka mirrored those adopted in Cyprus with the closure of all schools and work from home arrangements being made.

It should also be noted that Panama and Albania were able to quickly respond to the impending crisis by adapting previous response mechanisms to crises to manage the outbreak. Also, while the number of cases in some of these countries were much higher than those reported in Sri Lanka, as of 10 May, they had succeeded to an extent in containing the spread of the virus and had made some progress towards flattening the curve.

Detailed analysis of Pathway #2

PATHWAY #3 — LEAST BEST-CASE

SUMMARY ANALYSIS

Under this pathway, we considered countries that reported more than 50,000 confirmed cases. Further, countries showing a rapid increase in confirmed cases and deaths were also taken into consideration. Hence, we selected Italy, Iran and Spain based on the number of confirmed cases and the United States (US) and the United Kingdom (UK) based on their increasing rates at the time. Although each country has taken different measures to prevent / mitigate the effects of COVID-19, there were commonalities among these countries.

• Lack of unified communication to the public on the gravity of the situation.
• Lack of (immediate or timely) operationalisation of existing plans or procedures.
• Trying to maintain business as usual with minimal interruptions.
• Neglecting the community spread of the asymptotic carriers of the virus.
• No proper plans or procedures in place to avoid community spread.
• Lack of government enforced quarantine or home quarantine measures.
• People not complying with the rules and regulations in place.

Detailed analysis of Pathway #3

PATHWAY #4 RECOVERING

SUMMARY ANALYSIS

As per the timeline being considered in this study, the Hubei Province reported 444 confirmed cases on 22 January 2020. Since then, the numbers of confirmed cases increased drastically every 24 hours, with its most prominent spike on 26 January. However, China — Hubei province is ‘flattening its curve’ as depicted in the above graph. As of 8 April, the city had also lifted the lockdown that had been in place for over 70 days. Hence, we will consider China, or specifically, Wuhan, as a ‘recovering’ case, in recognition that while there is always a possibility of a further wave, it has successfully flattened the curve thus far.

Containment and Mitigation

China utilised a differentiated risk-based containment strategy to manage the outbreak in order to ensure a sustainable approach that minimized the socio-economic impact. Ports across the country implemented emergency plans and the health declaration card system was restarted for movements between cities. Mobile phone apps, AliPay and WeChat also helped enforce restrictions by allowing the government to keep track of people’s movements and even stop those with confirmed infections from traveling.

Institutional response

Response structures were based on existing emergency plans with prevention and control mechanisms initiated immediately with 9 working groups and a ministerial leader to coordinate the response. Payment of health insurance was taken over by the state, along with improved accessibility to medical materials and basic living materials for those affected. The government also restored production, expanded production capacity and supported the expansion of imports using e-commerce platforms to help import medical materials.

Communication and Community Engagement

China’s experience was made possible by a deep commitment of citizens to collective action. The National Health Commission provided a daily review to citizens, and the government enabled experts with scientific knowledge to address public concerns. Government institutions at all levels, NGOs and all sectors of society also developed guidelines for emergency psychological crisis intervention and guidelines for public psychological self-support and counselling.

As of 10 May 2020, Sri Lanka had reached 863 confirmed cases, with 9 reported deaths. On the one hand, we can make a case for Sri Lanka falling under the ‘best-case’ scenario, as, having initially reported cases in late January, there are less than 10 reported deaths and more than 100 recovered thus far (similar to Taiwan and Vietnam), although the number of confirmed cases has now exceeded 500.

However, if looking at the timeline from the second reported case onwards, the best fit is the ‘second best case’ scenario. While many of the countries in the ‘second best scenario’ category have a much higher number of recorded cases, there are similarities to Sri Lanka in terms of the reported timeline of the first and second cases, as well as in the trajectory of a rapid increase in the number of cases thereafter.

These countries also employed stringent containment and mitigation measures in order to contain the spread of the disease, similar to Sri Lanka. If we consider both the best-case and second-best case scenarios as a wider cluster that has taken positive steps towards preventing COVID-19 rapidly, we are confident that Sri Lanka falls under this bigger group. Our country is chartering a unique approach to managing the spread of COVID-19 and its consequences in a manner which best suits our context. Furthermore, looking very closely into the measures that have taken place so far (as of 10 May), it is our opinion that Sri Lanka constitutes a unique case study that currently lies in between the best-case and second-best case scenarios.

GLOBAL BEST PRACTICES IN COVID-19 RESPONSE EFFORTS FOR THE SRI LANKAN CONTEXT

The sections above have explored the key mitigation, containment, communications-related and institutional measures and responses taken across a spectrum of countries. Accordingly, the team extracted certain measures that appear to have contributed towards countries’ successes in managing the crisis, that may be useful to apply to Sri Lanka’s context going forward:

Healthcare: Strengthen our free public healthcare system.

• Ensure that health personnel and field officers involved in contact tracing are continuously supplied with PPE for their safety and to minimize further spread.
• Facilitate an increase in the number of tests performed to utilise the full capacity of the existing system.
• Increase hospital capacities to include isolation wards, ventilators and test equipment that will enable the country to face further waves after opening the country back up.
• Research and development of local testing kits.

Communications:

• Ensure that all public communications on COVID-19 are in all local languages and expressed very simply and in a straight-forward manner, such that all citizens understand the gravity of the situation and what must be done to contain the virus.
• Continue advocacy programs on personal hygiene and social distance, even as the country reopens.
• There should be a single/few established channels of communication between the government and citizens, which will be treated as the only source of official information. This source should also ensure the accuracy and validity of the data it is sharing with citizens and ensure that the frequency of information-sharing is in line with the urgency of the situation.
• Strengthen mechanisms to trace, track and stop infected cases, and take action against the spread of false/misleading information through social media channels.

Containment:

• Take necessary measures to ensure all cases are identified, controlled and isolated while minimizing the economic impact on the country — for instance, developing and using data and digital solutions effectively for contact tracing, as was carried out in Taiwan. Develop or use technological apps, such as social distance alarms that can detect if people are closer than 1m distance, as seen in China.
• More widespread use of thermal checks at the entrance and exit of establishments.
• Create isolation units within establishments to quickly isolate people with symptoms and transport them to nearest COVID treatment places.
• Have clear SOPs in place in all three languages to enable better social distancing and personal hygiene practices going forward.
• Ensure strict safety protocols are in place for people coming into the country for the foreseeable future, to avoid further waves.
• The government to work with the private sector and SMEs to focus on increasing the domestic production of facemasks and other sanitization and PPE products, while ensuring price ceilings are maintained, if implemented, to ensure accessibility to all citizens.

Mitigation:

• Use daily sterilization methods on mass transit and public transportation systems as well as public institutions once reopened.
• Have mechanisms in place to home deliver pensions for older people to avoid community exposure.
• Combining safety protocols and precautionary measures with a mass testing approach, even as cases to dwindle, to ensure the continuation of case identification and isolation.