In April 2022, Sri Lanka suspended repayment on its foreign debt, cutting off access to most of the medicine and medical supplies needed by its 22 million citizens. Seventeen months later, while the medical situation has improved relative to the worst of the crisis, people across the country are still struggling to get access to the medicine and medical supplies needed to treat chronic diseases and to conduct surgeries and medical procedures.

Before the crisis, Sri Lanka relied on imports for about 85% of its pharmaceutical needs and about 80% of its medical supplies. Sri Lanka imported $815 million in medicine in 2021, but by May of 2022 it had only about $25 million in foreign reserves to pay for imports, so the vast majority of medicines became scarce or completely unavailable.

With hospitals lacking anesthesia, most general surgeries in the country ceased. Life-extending kidney transplants were performed at a significantly lower rate, while cancer patients couldn’t get the chemotherapy agents to treat their deadly disease. Hospitals ran out of stents and guide wires for heart procedures, and common supplies like bandages and cotton balls became unobtainable.

Hundreds of widely used drugs become extremely scarce. For example, there was a severe shortage of the immunosuppressant drug cyclophosphamide, without which a transplanted kidney’s lifetime can be cut in half. Currently, there are shortages of intravenous basiliximab, intravenous methylprednisolone, antithymocyte globulin (equine), and dialysis filters.

Hence, it’s a dynamic situation, said Dr. Mathu Selvarajah, President of the Sri Lanka Society of Nephrology. “With a disease like lupus nephritis, if you don’t treat it aggressively, there is irreversible kidney damage. The sooner we treat it, the sooner you’ll stop the ongoing damage.”

For cardiac care, early in the crisis, the country ran out of the most effective thrombolytics, which dissolve blood clots, and “we had virtually no medicine to give for heart attacks,” said Dr. Chandrike Ponnamperuma, president of the Sri Lanka College of Cardiology. “There is a severe shortage of cath lab consumables like stents, guide wires, balloons, and catheters,” he said.

“Sri Lankan patients who are relying on free medicines through the government hospitals in many cases seem to not have most simple consumables items or the essential medicines in some of the peripheral hospitals in this dynamic situation Sri Lanka is in,” said Ayusha Amarakone, a Sri Lankan-American who is Executive Director of Medical Help International-USA, which works closely with Direct Relief to identify needs and direct donations.

Other Sri Lankan medical leaders Direct Relief has spoken with report shortages of widely needed medicines, including insulin and supplies, such as plasters and suture materials.

Sri Lanka has an especially high need for dialysis fluids due to a high prevalence of chronic kidney disease. One study among a rural population in Sri Lanka found that 58% of individuals with hypertension also had chronic kidney disease, a rate 1.6 and 3.4 times that found in Bangladesh and Pakistan, respectively.

Direct Relief has been the largest charitable donor of medicine and medical supplies in Sri Lanka since the financial crisis began, securing and delivering donations of insulin, oncology medicine, dialysis fluid, and much more. Between April 2022 and August 2023, Direct Relief shipped 41.5 million daily defined doses of medicine (weighing 221 tons) with a wholesale value of $126.9 million.

In its response, the organization has worked closely with Sri Lanka’s Ministry of Health, the Prime Minister’s Office, the Ministry of Foreign Affairs, the Medical Supplies Division, the National Medicines Regulatory Authority, the College of Endocrinologists, the Government Medical Officers’ Association, Sri Lanka’s Embassy in Washington and its Los Angeles Consulate.

“Direct Relief has been strategically positioned to respond to this crisis, largely due to the commitment from our pharmaceutical company partners willing to support the people of Sri Lanka,” said Chris Alleway, Direct Relief’s manager of emergency response & new initiatives. “Our goals are to maintain the close working relationships with the Ministry of Health, the Government Medical Officers Association, the College of Endocrinologists, and the individual health facilities that have helped us to continue the flow of aid. As Sri Lanka strives for stability, Direct Relief will remain a resource during this difficult time.”

“I would like to express appreciation on behalf of the Sri Lanka Medical Association to Direct Relief,” said Dr. Vinya Ariyaratne, President of the Sri Lanka Medical Association, in a recent meeting with Direct Relief.

While the International Monetary Fund in March approved $3 billion in loans to help restore financial stability, the funds are being released only slowly, starting with $333 million in March, and the medicine shortages are expected to persist. In June, the World Bank approved $700 million in budgetary and welfare support for Sri Lanka.

“Sri Lanka has been facing tremendous economic and social challenges with a severe recession amid high inflation, depleted reserves, an unsustainable public debt, and heightened financial sector vulnerabilities,” the IMF said upon approving its package in March. It recommended that “social safety nets should be strengthened and better targeted to the poor.”

In addition to shortages of medical supplies, Sri Lankans also are losing many experienced healthcare providers to emigration. “The migration of health care workers due to increased living expenses and having to struggle with basic commodities like fuel and electricity is another reason that causes a crisis in the health care system in the country these days,” said the Ministry of Health, Nutrition & Indigenous Medicine in a January report. “The huge demand created for healthcare professionals in other countries has encouraged healthcare worker migration even more.”

Sri Lanka’s economy continues to shrink while costs soar. Consumer prices are projected to rise 28% in 2023, after a 46% spike last year, while the economy is projected to contract 3% this year, after an 8.7% fall in GDP in 2022, according to the IMF. Sri Lanka’s poverty rate nearly doubled from 13% to 25% between 2021 and 2022 and is projected to increase by another 2.4 percentage points in 2023, the World Bank said in June.

Fuel shortages have also shaken the economy. By mid-2022, fishing boats lacked the fuel to go to sea, slashing the availability of seafood, a major protein source for Sri Lanka.

Overall, the food insecurity situation has improved. In March 2023, about 3.9 million people (17% of the population) were estimated to be “moderately acute” food insecure, down from 6.2 million in that condition in May 2022, according to a joint FAO/WFP Crop and Food Security Assessment Mission report published in May 2023. However, the same report forecasts a 14% drop in aggregate cereal production in 2023, “mainly affected by the inadequate availability of fertilizers” due to high prices and low supplies. Chicken meat and egg production, “vital for local protein intake, is forecast to drop substantially in 2023,” and fish production is also projected to decline.

“Sri Lanka’s journey to recovery has just started,” the Asian Development Bank said in an April announcement.

The financial crisis came after two crucial sectors of the country’s economy were disrupted. Spending by foreign international tourists – which brought in foreign currency and accounted for the equivalent of 24% of Sri Lanka’s total exports in 2019 – plunging 93% between 2019 and 2021 amid the Covid crisis, according to the World Travel & Tourism Council. Tourist arrivals in 2021 amid the Covid crisis were down 92% from their 2018 peak. Meanwhile, the country’s agricultural production dropped sharply when the government suddenly banned the use of agricultural chemicals in 2021, the World Food Programme noted in a 2022 report on food security in the country.

While donations of medicine are helping address current needs, longer-term reforms are needed to ensure adequate long-term medical supplies, according to a November editorial in the BMJ. “The government must support initiatives to increase local production of pharmaceuticals, improve national information systems to include real-time tracking of drug shortages, and establish mechanisms to stabilize power and fuel supply to essential healthcare facilities, including hospitals,” the editorial said. “Additionally, the government must make comprehensive, sustainable plans to request and use international development assistance for health, targeted towards restoring the supply of essential medicines, supporting healthcare workers, and improving delivery of services.”