A glimpse on Public Health Care in Sri Lanka

Introduction

Being a majority of the Sri Lankan population (81.9%) rural (Upul Senerath, Sanath Senananayke et al. Ceylon Medical Journal, 64, 3, 9, 2019) Sri Lanka has acquired quite a unique position in the region of South Asia, providing universal healthcare and educational system- a restriction even in many of the developed countries in the region. Since independence, the country’s successive governments have implemented initiatives that derive the essence in the free public healthcare and education sectors — two fields that projects the best outcomes for a nation. As a result, Sri Lanka has collated high Human Development Index (HDI=0.74) with a life expectancy closing 75 years, a literacy rate of above 90%, thus can be concluded as a success story for a third-world country. (CIA World Factbook, 2018) , and of the celebrated feats in Sri Lankan public healthcare system is eradication of polio. (Polio Eradication-Endgame strategies, Polio Type 2 withdrawal, 2015).

Sri Lanka’s healthcare system is composed of fields in,

Allopathic, Ayurvedic, Unani and other medicinal systems that are merged- out of which Allopathic as a field of medicine has been dominant in recent history and caters to the majority population of the country. Like in many other countries, Sri Lankan healthcare system has its fair share in both the public and private sectors. Coming forth from its falls, private sector has assembled themselves to perform in the healthcare field, while the Health Ministry and Provincial Health Services provide an array of promotive, preventive, curative and rehabilitative health care. (M. Samarage, 2006).

The firm network of Medical Officers in health units, provide a comprehensive collection of a total healthcare package covering aspects of reproductive, maternal, child-care, disease diagnosis and surveillance, prevention, control and promotive and preventive terms of services. Ground-level public health services’ workers in the country are responsible for entire country’s household level health services and they are obliged to provide with strategic interventions 1 based on guidelines (Openheartmindcoaching.com, 2019). Supervision of officers at different levels of administration starting from ground-level upwards till the national level positions provide supportive feedback to field officers. To maintain the standards, the culture in existence in the current healthcare system provides the integrated delivery system Sri Lanka has been achieving throughout recent history with the limited amount of resources available, and at a low cost (M. Samarage, 2006).

Curative Public Healthcare Services

Two focus types of PHC Services are recognizable dedicated to the provision of curative services.

1. Primary Medical Care Units (PMCU) — Earlier referred to as, Central Dispensaries, are comparatively basic facilities, dedicated to outpatient care. Main services provided compose of, OPD (Out-Patient Department) consultations, dressings and injections, and drug dispensing. Majority of PMCUs do not have dental services, but a few have dental services. Human resource allocation at each PMCU is generally Medical Officers (usually not more than two) or Assistant Medical Officers (AMO) and drug dispensers- recent addition was the Nursing Officer.
2. Divisional Hospitals (DH) — A DH can be termed simply as a PMCU with inpatient capacity. The number of Medical Officers is higher, in comparison, as they provide a full-on service in the facility- a DH usually have few nursing staff as well. Key facilities include the availability of laboratories and the availability of a technician to perform laboratory tests.
3. Outpatient Departments of secondary and tertiary care institutions (facilities that are available in addition to specialized hospitals) (Ministry of Health, 2017).

Referral Facilities

Referral facilities are composed of vast variations — from first level referral to incorporating special units. Generally, Referral facilities are of three types.

1. Secondary Care hospitals — Base Hospitals is the main category of two different levels A&B. The secondary level institutions are divided into four subcategories namely: Internal medicine, Pediatrics2, Obstetrics3 and Gynecology4 and surgery. Human resources available are medical consultants working with the assistance of medical officers. BH falls as the primary level of referral for PHC institutions. Majority of the BHs are funded by the provincial and district health authorities.
2. Tertiary Care Hospitals — Facilities from teaching hospitals, Provincial General Hospitals to District General Hospitals come under institutions that provide tertiary care. All tertiary care hospitals are funded centrally by MOHNIM. (Ministry of Health, Nutrition & Indigenous Medicine). Examples for a few exclusively specialized hospitals are: Maharagama Cancer (Apeksha) Hospital, Lady Ridgeway or Sirimavo Bandaranaike paediatric hospitals, De Soysa Hospital for women, Castle Street Hospital for women, Eye hospital, mental hospital- providing much needed service to the healthcare service of the country. In addition to the key services provided by the tertiary care centers, primary health services such walk-in OPD services are offered as well.
3. Special Clinics — Some public health institutions serve a unique set of services that cover programs for selected diseases such as Tuberculosis, HIV AIDS etc. Special clinics are often staffed by MOs. These institutions perform final diagnosis of the related conditions, as their prime service. (Sri Lanka Essential Health Services Package, 2019).

In brief, there is a countrywide complete system of health centers, emergency clinics and other medicinal facilitators, with around 57,000 medical clinic beds and a huge workforce occupied with therapeutic and general health activities. In the public domain, HR (Human Resource) figures revealed for 2017 were: 11,132 doctors, 23,155 nurses, and 4,793 health attendants and midwives (Ministry of Health, 2017).

Nonetheless — the peripheral health system experienced constrained development of human resource and lacking geological distribution. Besides, health training focuses on the generation of medicinal specialists. Medical experts are reluctant to work in the remote zones and prefer practice in urban centers for practice. A health information framework is set up comprising of the management data (assets accessible and services provided) and epidemiological data, including routine observation data for communicable diseases. A framework to routinely screen trends in non-communicable diseases and their risk elements has still to be set up. The information reported are not up to the expected quality, especially those from hospital medical reports, which are fragmentary majority of the time (Who.int, 2019).

A mammoth-leap was witnessed in medical services provided in the public sector of the country with the implementation of e-Indoor Morbidity and Mortality Report (eIMMR) that managed reports of over 15 million records as at 2017. The digital transformation introduced to the sector brought light to many other projects the government was looking forward to capitalizing the free healthcare services on. Thus, the country’s healthcare was aligning itself to a more digital-savvy outlook and experience. (Digital Health in Sri Lanka ‘Sustainable Implementation of Digital Health Solutions through Local Capacity Building’, 2017).

History of Public Health Services in Sri Lanka

Health services being a prime need, sketches draw back to the earliest of the civilizations and Sri Lanka was more of the same order — it was an important activity hailing from ancient times. Existence of well-structured environmental sanitation, hospitals and other assisting services are stated with evidence in ancient chronicles.

According to sources, Sri Lanka was first exposed to western-style medicinal practice when Portuguese arrived in Sri Lanka in 1505, and was subjected to constant change over the centuries followed. From the 1850’s the British focused more on upliftment of the services; establishing Civil Medical Department in 1859, that provided care and medication for the sick and another in 1915, a sanitary branch for the Civil Medical Department. This establishment was held responsible for environmental sanitation and prevention of communicable diseases. Recent history dates to the establishment of the first ‘health unit’ to the 1926 in Kalutara. This marked a milestone in the development of country’s healthcare system. The system initiated, dated back to early 1900’s, still stands as a part of the existing framework emphasizing the provision of preventive health-care services grass-root level medical officers and teams of related workers should offer to the community. Over the next decades health services in the country witnessed constant development addressed in a way it gave the demand a reasonable response.

Statistics always were not in-favor. All through the 1990s, health expenses rounded around 3.4% of the GDP (Gross Domestic Production). Monetary assets for healthcare are given essentially by the government and foreign aid added up to 4% of the health expenses in 1998, to cover up the costs in maintenance to overcome the cost surplus with, then prevailing civil war of the country (Who.int, 2019).

Regional Health Services Statistics and Sri Lanka’s stand

South Asia, a region of much importance to global trade and strategic importance has its less-focused aspect, health services. Five countries namely: India, Bangladesh, Pakistan, Sri Lanka and Nepal are home to approximately to one-fifth of the entire world’s population. But in much contrast, however, these are the countries that home more than two-third of the world population that survive with less than $1 per day. South Asia’s biggest issues in health services speak volumes under the categories of malnutrition, infant mortality and occurrence of TB (Tuberculosis) and STDs (Sexually Transmitted Diseases) such as HIV/AIDS (Human Immuno-deficiency Virus/ Acquired Immuno-deficiency Syndrome) are statistically second only to of sub-Saharan populations in Africa. The most affected geographies in the region face from issues of poor access to healthcare services, poor sanitation, poor maternal healthcare — and often one of the biggest communicable diseases in the region — malaria. Despite the vulnerabilities these countries struggle through, in terms of healthcare, the efforts taken do not reflect on a direct determination to reduce the risk factors- these countries spend way less (less than 3.2%) than the global average of around 8% of their Gross Domestic Production (GDP) to uplift the persisting conditions.

Value Addition to the service across the region has been uneven in the recent history. The most vulnerable communities are the rural areas, since they face from similar hardships but with dire consequences in areas of life expectancy, immunization rates maternal health etc.- in brief, all health services. Statistics show similar differences across regions of India between literate and illiterate communities of the nation. Sri Lanka is a standout compared to the rest of the countries in the region. Life expectancy in Sri Lanka averages at 75% — that is higher than other countries by a margin of approximately 8 years, despite the civil war the country went through for 30 years. (Hate and Gannon, 2010).

Healthcare quality improvement compared with the region

Sri Lanka has shown signs of continuous development over the past decade, driving through waves of macro-economic hurdles.

1. Following the end of the decades-long civil war in 2009, the country’s economy has shown steady growth averaging 5.6% from 2010–2018 (World Bank, 2019).
2. According to the Global Burden of Disease Study (GBDS) Sri Lanka has maintained its rank in terms of healthcare, in South Asian region. Previously, ranked 73, Sri Lanka has developed in the healthcare aspect to rank at 73. In 1990 GBDS index score was 55.3- in 2015 the score was at 66.3 and currently at a score of 73. In the mean-time countries in the same region such as India ranks at 154 with a score of 43, and Bangladesh with a score of 52 (Daily FT, 2017).

All statistics extracted from — References

Polio Eradication-Endgame strategies Polio Type 2 withdrawal National tOPV-bOPV switch plan. (2015). 1st ed. [ebook] Colombo: Epidemiology Unit, Ministry of Health. Available at: http://www.epid.gov.lk/web/images/pdf/Polio/switch_plan_sri%20lanka_updated_nov%2020 15.pdf

M. Samarage, D. (2006). Health Care System: SRI LANKA. [ebook] Geneva: Ministry of Healthcare & Nutrition, Sri Lanka., pp.1–2. Available at: https://www.iom.int/jahia/webdav/site/myjahiasite/shared/shared/mainsite/microsites/IDM/workshops/mhrh23240306/abstract_samarage.pdf

Openheartmindcoaching.com. (2019). What Is Strategic Intervention? | Tess Vergara, Soul Powered Executive Coach. [online] Available at: https://openheartmindcoaching.com/home/strategic-intervention/

Sri Lanka Essential Health Services Package. (2019). 1st ed. [ebook] Colombo: Ministry of Health, Nutrition and Indigenous Medicine Sri Lanka. Available at: http://www.health.gov.lk/moh_final/english/public/elfinder/files/publications/2019/SLESP2019.pdf

Polio Eradication-Endgame strategies Polio Type 2 withdrawal National tOPV-bOPV switch plan. (2015). 1st ed. [ebook] Colombo: Epidemiology Unit, Ministry of Health. Available at: http://www.epid.gov.lk/web/images/pdf/Polio/switch_plan_sri%20lanka_updated_nov%2020 15.pdf

Developing conceptual clarity and a WHO roadmap for action (2018). Available at: http://apps.who.int/bookorders.

WHO | South-East Asia (no date). Available at: https://www.who.int/macrohealth/action/southeastasia/en/

Who.int. (2019). WHO | Sri Lanka. [online] Available at: https://www.who.int/hac/donorinfo/lka/en/index1.html

World Bank. (2019). Overview. [online] Available at: https://www.worldbank.org/en/country/srilanka/overview

World Health Organization. (2019). Sri Lanka. [online] Available at: https://www.who.int/countries/lka/en/

Euro.who.int. (2019). Public health services. [online] Available at: http://www.euro.who.int/en/health-topics/Health-systems/public-health-services/public-health-services

Digital Health in Sri Lanka ‘Sustainable Implementation of Digital Health Solutions through Local Capacity Building’. (2017). 1st ed. [ebook] Colombo: Health Informatics Society of Sri Lanka, p.16. Available at: http://www.hissl.lk/Digital_Health_SL_1998-2017.pdf

Hate, V. and Gannon, S. (2010). Public Helath in Sri Lanka. 1st ed. [ebook] Washington DC: Center for Strategic & International Studies, pp.1–3. Available at: https://csis-prod.s3.amazonaws.com/s3fs-public/legacy_files/files/publication/100715_Hate_PublicHealthSouthAsia_Web.pdf

Sri Lanka: Achieving Pro-Poor Universal Health Coverage without Health Financing Reforms”. Universal Health Coverage Study Series №38, World Bank Group, Washington, DC

World Bank. (2019). Overview. [online] Available at: https://www.worldbank.org/en/country/srilanka/overview

Daily FT (2017). Sri Lanka jumps rank on healthcare index. [online] Available at: http://www.ft.lk/article/616595/Sri-Lanka-jumps-rank-on-healthcare-index

The Independent (2018). Bangladesh ahead of Pakistan, India in healthcare access. [online] Available at: http://www.theindependentbd.com/home/printnews/151669