Management

Sri Lanka
health care system

Sri Lanka’s model of primary health care, available free through a government health system with island-wide availability, form a sound basis for providing universal health coverage. It scores higher than the regional average in healthcare having a high Life expectancy and a lower maternal and infant death rate than its neighbours. It is known for having one of the world’s earliest known healthcare systems and has its own indigenous medicine system.

HEALTH CARE PROVISION IN SRI LANKA: HISTORICAL BACKGROUND

Provision of health care to the population of the country was an important activity for the ancient kings of Sri Lanka. A system of Hospitals, environmental sanitation, and other related services was developed and flourished as documented in ancient chronicles. 

The Portuguese who colonized Sri Lanka in 1505 were the first to introduce western-style medical care to the island.  Later the Dutch established a few hospitals in the maritime provinces, which came under their rule, and the British continued to expand the system of Western medical care and established a military and estate health service aimed at providing health care for those who served in these. In 1859, the Civil Medical Department was established, which primarily provided for the care of the sick, and in 1915 a sanitary branch of the Civil Medical Department was established, which was responsible for environmental sanitation and prevention of communicable diseases.

The establishment of the first ‘health unit’ at Kalutara in 1926 was an important landmark in the development of the health care system of the country. This system emphasized the provision of preventive health services at the community level delivered by a medical officer and a team of field-level health workers.

 The service exhibited many of the features that, even today, are considered important in the provision of primary health care services. During the next few decades, health units were established throughout the island, the functions of which were clearly identified and included the development of staff training programmes for the health units. Although they have undergone modifications since their inception, even today this system of health units constitutes the mainstay of the primary health services of the country.

CONTEMPORARY ORGANIZATION OF HEALTH CARE DELIVERY IN SRI LANKA

The health system in Sri Lanka is enriched by a mix of Allopathic, Ayurvedic, Unani and several other systems of medicine that exists together. Of these systems, allopathic medicine has become dominant and is catering to the majority of the health needs of the people. As in many other countries, the Sri Lankan health system consists of both the state and the private sector. The Health Ministry and the Provincial Health Services provide a wide range of promotive, preventive, curative and rehabilitative health care. Sri Lanka has an extensive network of health care institutions.

The government health care delivery system is free to all citizens at the point of delivery and it has been the commitment of successive governments of Sri Lanka to maintain this policy

The health system has seen incremental changes over the years and was largely set up during the time when communicable diseases were prevalent and episodic management was a key feature. The present health burden of noncommunicable diseases needs to be addressed and further changes to the organization of primary care are in progress.

Special care groups

Several groups have been identified with special needs for health services. They include those who are employed in the plantation sector, various other occupational groups, and populations displaced and disabled through the civil strife.

organizations (NGOs) in the provision of direct health care, although several NGOs do actively participate in health-related activities.

THE HEALTHCARE SYSTEM

The Healthcare system encompasses all agencies, facilities and all providers of healthcare in a defined geographic area. In Sri Lanka, the healthcare system can be subdivided at different levels: 

  • Primary care
  • Secondary care 
  • Tertiary care

Primary care is where every individual usually enters the healthcare system. It mainly deals with early Detection and Prevention of disease in general. It also includes the regular screening and follow-up of common health problems & chronic illnesses that can be managed at home or on an out-patient basis. Providers: MOH, Community health centers/clinics, hospital OPD, GPs, industrial health units, and school health units etc. “Easily Accessible, Acceptable, Affordable and Appropriate’’-WHO Primary Care

Secondary Care Secondary or acute care is concerned with emergency treatment and critical care involving intense and elaborate measures for the diagnosis and treatment of a specified range of illness or pathology. Provider groups for secondary care include both acute- and long-term care hospitals and their staffs. 

Tertiary Care Tertiary care includes highly technical services for the treatment of individuals and families with complex or complicated health needs. Providers of tertiary care are health professionals who are specialists in a particular clinical area and are competent to work in such specialty agencies Ex. psychiatric hospitals and clinics, chronic disease centers, and the highly specialized units of general hospitals, for example, a coronary care unit.

HEALTH POLICIES AND SYSTEMS 

The government is committed to achieve universal health coverage and the SDGs. In 2017, the government launched Vision 2025 which underscores priority reforms to make the country more competitive and lift the standards of living of all Sri Lankans. It also recognized the need to address unequal socio-economic development across provinces and the rapidly aging population. As part of this vision, the government passed the Sri Lanka Sustainable Development Act, No. 19 of 2017 to accelerate the achievement of SDGs, and to adopt multi-sectoral and integrated approaches in ensuring the health and well-being of the population. 

The Sri Lanka National Health Policy, 2016-2025 envisions “a healthier nation that contributes to its economic, social, mental and spiritual development” guided by principles of people-centred care, equity, quality of services and financial protection. 

The policy of free health care delivered by a network of state health institutions, including traditional providers has significantly contributed to improving the health status of the population. The public sector provides 95% of in-patient care and about 50% of out-patient care. A comprehensive preventive care package is provided through an island-wide network of 344 health units, healthy lifestyle centres and well-women clinics. Moving forward, the government aims to strengthen the public health system through PHC reorganization, improve its health management and monitoring and evaluation systems, and develop a national strategic approach to quality. The health sector will forge strategic partnerships, “think outside the box”, and ensure that no one is left behind in the path to UHC.

COOPERATION FOR HEALTH (Role of International Organizations)

 A multitude of partners are active in the health sector in Sri Lanka. The WHO CO actively partners and cooperates with the MOH, other government agencies, UN agencies, development partners, private sector, academia and non-government organizations in implementing its programs and activities. There are 23 UN agencies, including WHO, which work closely with the Government of Sri Lanka, guided by the United Nations Sustainable Development Framework, 2018-2022. 

Sri Lanka has been designated by WHO as a fast-track country for NCDs to receive “One-WHO”-integrated technical support at the global, regional and national levels. To support reconciliation efforts following the civil war, WHO partners with the UN, MOH and local organizations in implementing the community-based psycho-social support program under the Peacebuilding Priority Plan (PPP). Development partners such as the World Bank, ADB and JICA engage and coordinate with WHO for technical support on health policy and planning in the sector, for example, the Health System Enhancement Project of ADB, the NCD Prevention Project of JICA and the World Bank Health Sector Development Project.

 As the Vice Chair of the Oversight Committee and as the representative of international partners in the Country Coordinating Mechanism (CCM), WHO continues to provide technical assistance for effective implementation of activities funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. WHO also co-chairs the Development Partners Working Group in Health and Nutrition. WHO received support for implementing activities in response to floods and landslides and dengue control from the South-East Asia Regional Health Emergency Fund, USAID, UN Central Emergency Response Fund and DFAT, Australia. 

It also facilitates support to other member states in the region on public health– e.g., twinning agreement between the MoH in Sri Lanka and Timor Leste on strengthening immunization services, training of fellows from DPRK in cancer management and cardiac angiography.

HEALTH-CARE FINANCING

Although the healthcare system in Sri Lanka remains a tax-financed, publicly managed one, there is an increasing recognition of the role of the private sector, both in financing and the provision of health services. While shaping the national health system, Sri Lanka was guided by the concept of the welfare state. Almost all the country’s achievements in the health sector can be attributed to the welfare state approach introduced in the 1940s.

 This approach covered areas such as health, education, nutrition and social services. The major task that lies ahead is to develop a strategy for social health protection within the welfare state model. For this purpose, social health protection needs to be placed high on the national agenda and social health protection priorities for the next 4 – 5 years must be identified. Those priorities then need to be linked to the budget.

UNDP- SUSTAINABLE DEVELOPMENT GOALS

What are the Sustainable Development Goals?

The Sustainable Development Goals (SDGs), also known as the Global Goals, were adopted by all United Nations Member States in 2015 as a universal call to action to end poverty, protect the planet and ensure that all people enjoy peace and prosperity by 2030.

Goal 3: Good health and well-being

OUR TARGETS

Goal 3. Ensure healthy lives and promote well-being for all at all ages

3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births

3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births

3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases

3.4 By 2030, reduce by one-third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being

3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol

3.4 By 2020, halve the number of global deaths and injuries from road traffic accidents

3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes

3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all

3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination

3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate

3.b Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all

3.c Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States

3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks

CURRENT STATUS AND TRENDS

Sri Lanka’s health system is well-known for achieving outcomes such as, low maternal and child mortality, and rising life expectancy. However, emerging issues associated with the rapid increase of Non-Communicable Diseases (NCDs) coupled with the swift rate of population ageing and changes in diseases patterns have contributed to transforming the healthcare needs of the country. Sri Lanka achieved the maternal mortality rate global target under the SDGs (Target 3.1) more than two decades ago. In 2015, Sri Lanka’s maternal mortality rate was 33.7 per 100,000 live births, which is well below the SDG target of 70 per live births. Additionally, the under-five mortality rate and the neonatal mortality rates were 10 and 5.8 per 100,000 live births, respectively. These mortality rates are also lower than the relevant SDG target under the SDGs (Target 3.2).

Sri Lanka’s performance with regard to mitigating certain communicable diseases (Target 3.3) such as Malaria and Tuberculosis (TB) is also noteworthy. For example, in 2016 the World Health Organization (WHO) certified Sri Lanka as a Malaria free country; the country’s TB incidence rate in 2015 was 65 per 100,000 population, with a mortality rate of 5.6 per 100,000 population compared to the 37 per 100,000 population in the WHO South East Asian region as a whole.

However, other communicable diseases such as Dengue require close attention. The incidence of Dengue has increased from 142 cases per 100,000 population in 2015 to 260 cases per 100,000 population in 2016.62 Moreover, the Demographic and Health Survey (DHS) 2016 shows that only 33% of women have comprehensive knowledge about HIV AIDS; although Sri Lanka’s HIV prevalence is below 1%, there has been an increase in the reported HIV cases from 95 in 200963 to 285 in 2017.

 In fact, this is the highest number reported in a year since the identification of the first HIV infected Sri Lankan in 1987. The rate of injuries and deaths attributed to road accidents (Target 3.6) is also on the rise. It is estimated that the average number of daily deaths on road has increased from 6.6 in 2014 to 7.5 in 2015.

The death rate due to road accidents was 13.4 per 100,000 population in 2015.66 The entire population is covered by Sri Lanka’s public health system (Target 3.8). However, more than half of the total health expenditure in the country is private expenditure, out of which 83% is out-of-pocket payments by households.

Source:  Voluntary National Review on the Status of Implementing the Sustainable Development goals, Government of the Democratic Socialist Republic of Sri Lanka. June 2018