Sri Lanka –
Healthcare model to the world
Sri Lanka is known as the ‘Pearl of the Indian ocean’, owing to
its shape, and has also received worldwide fame for the exotic
gems that are found in the island. Even the large blue Star
Sapphire, known as the ‘Star of India’ in the British Crown, is
actually a Sri Lankan gemstone!
But the actual jewels in the crown of Sri Lanka are its people,
and successive governments of the country have invested heavily
towards the health of its people, despite the many challenges
they have faced, that has resulted in excellent health indices
in the country.
The 2009 annual world report of UNICEF released recently gives
special recognition to the Sri Lankan Health Indices.
According to the Report, “Sri Lanka has managed to halve its
maternal mortality rate every six to 11 years by adopting sound
strategies, allocating sufficient resources, providing free
Healthcare, making education for all a priority, and having the
political commitment to improve the health of mothers and
children, which makes it a model for developing countries.”
UNICEF’s representative in Sri Lanka, Phillppe Duamelle said
that, “While the country still faces challenges, the overall
picture of maternal and neonatal health is one of remarkable
progress over past decades.”Between 1960 and 2005, the maternal
mortality ratio fell from 340 to 44 per 100,000 live births.
Since 1990 the under-five mortality rate has dropped from 32 per
1,000 live births to 13 per 1,000 in 2000.
Stakeholders in the Health sector describe the reduction of the
country’s maternal mortality in the 20th century, as one of the
most spectacular achievements due to a multitude of factors
working in unison with each other.
According to them, the interventions that were implemented by
successive governments can be divided into two era’s.
In the pre and immediate post-independent era between 1930 and
1950, the factors that contributed towards the reduction had
• Expansion of Health facilities with infrastructure development
for maternal and child health services and provision of maternal
care by skilled Health workers.
• Provision of free Health services by the State, which made
Healthcare equally accessible to all socio-economic groups.
• Control of malaria infection
• Introduction of antibiotics and other drugs for treatment of
• Introduction of other welfare measures such as free education,
subsidised food rations and subsidised transport,
• Improvements in social status of women
• Improved transport systems due to better networking of roads
• And necessary political commitment.
In the post independent era after 1950, the key factors that
have further contributed to the reduction has been;
• Greater coverage of maternal care services throughout the
country and both domiciliary and institutional services with
emergency obstetric care services being available within
• Improvements in the quality of maternal care services and use
of improved medical technology
• Expansion of blood transfusion services to most of the major
hospitals in the districts
• Functioning of effective referral systems for easy referral to
higher level of care.
• Better supervisory and monitoring system for maternal care
throughout the country,
• Improved communication between higher level referral centers
and other Healthcare facilities within the districts
• The establishment of an active maternal death surveillance
Sri Lanka has a long history of giving importance to Healthcare.
Historical evidence has shown that several hospitals for
indigenous medicine and maternity homes for childbirth had
existed during the reign of the Sinhalese kings as early as 340
– 368 AD. Around the 15th century, a systematised network of
Ayurvedic treatment centres and hospitals throughout the country
was established and Ayurvedic physicians trained to work in
these centres, which resulted in gradual diffusion of Healthcare
within the country. Also, medical historians say that, separate
hospitals existed for women, under the Ayurvedic system of
medicine, where deliveries of pregnant mothers had been
The western system of medicine had been introduced and hospitals
built to provide medical care, when Sri Lanka came under
colonial rule in 1505. Health sector officials say that, the
earliest record of providing organised care and attention for
pregnant mothers, according to the western system in Sri Lanka,
goes back to 1879, when the De Soysa Lying-in Home, now known as
De Soysa Maternity Hospital, was built. But the actual organised
effort to provide maternal and child health services had begun
in 1906, when six trained midwives were appointed to the Colombo
Municipality. The first Health unit of the Health Department was
established in 1927 in Kalutara, that had initiated a broader
service strategy that emphasised preventive and promotive Health
including the Healthcare of the mothers and children.
By 1950, 91 Health units had been established, and this number
had further increased to 104 by 1982, and later, to a total of
258 units to serve the needs of the entire country.
Government policies in the 1930’s established Health services
throughout the country and after universal franchise in 1931,
there had been a political demand for the expansion of Health
The infrastructure that had been developed provide services at
three levels. Primary, intermediate and tertiary levels of care
with the primary level including rural hospitals and maternity
homes with attached central dispensaries that include midwifery
The intermediate level including peripheral units and district
hospitals are manned by medical officers. According to Health
officials, this level of hospitals have a wider range of
maternity units and care, while the tertiary level provides
referral services with specialist attention.
One of the policies in the Health sector that has not been
compromised by any government in power, is the provision of free
Health services to the people. This factor, together with the
introduction of free education system in 1941, led to an
increased literacy rate, which helped increase the level of
Health consciousness, that increased the utilisation of Health
facilities, that has contributed greatly towards the improvement
of the Health Indices.
Health officials further say that, the cornerstone of the
maternal care system is the public health midwife, who serves
all pregnant mothers and children under five years in the
country, within a clearly defined area. She is the first point
of contact for mothers between the Health system and the
household. The basic entry qualifications to become a midwife
requires Advance Level. She receives training for a period of 18
months at a Nurse’s training school, and the training includes a
“hands on” skills training. Health officials explain that the
tremendous expansion in the number of midwives, that started in
the late 1940’s, created a virtual Health revolution within the
country. This has been made possible by the foresight of the
planners and policymakers in providing for adequate training,
that would equip the midwife to meet the demands placed on her.
The use of traditional birth attendants or the promotion of such
a category, such as in other southeast Asian countries, even as
a stop gap measure, had never been considered in Sri Lanka.
Up until 1950, the leading causes of death of pregnant mothers
had been pregnancy induced hypertension (PIH) and infection,
that had collectively contributed to almost 84% of maternal
deaths. Since 1950, the proportion due to PIH had declined,
while the proportion due to bleeding had gained more importance.
According to officials, this change in pattern had been
attributed to better ante natal care that resulted in early
diagnosis of mothers with hypertension, coupled with aseptic
techniques during delivery, that contributed to the reduction of
deaths from PIH and infection.
Health Ministry officials say that, in 2004, the highest
percentage contribution of maternal deaths was due to bleeding,
being 22%, with PIH and heart disease complicating pregnancy
giving equal percentage contribution of 17.24%. Another
significant cause that had contributed to the overall number had
been septic abortion, following unsafe abortion. Previous
studies conducted by professionals had shown that almost 700
abortions take place daily in Sri Lanka. Legislation in Sri
Lanka, allows termination of pregnancy only to save the life of
the mother. As such, it is not possible to conduct abortions
through organised medical services, resulting in those with such
needs, seeking the services of untrained non-medical personnel,
who practice abortion using unsafe methods.
In 1980, formal reviews of maternal deaths had begun with joint
representations of the Health Ministry, Medical Officers of the
area, Heads of Medical Institutions, Obstetricians, the field
Health workers and other relevant personnel. Each death is
discussed in detail and to determine the cause and to analyse
the circumstances that led to the death. This activity too has
contributed a great deal towards the reduction of maternal
deaths, as it identifies existing gaps in the care system.
When deaths of infants in the country are taken into
consideration, the latest available statistics, which is of
2005, is 11.2 per 1000 live births. Of this number, Health
officials explain that, 77% of deaths occur during the first 28
days of life, the majority of which occur during the first week
of life, when the infants are most vulnerable and are affected
by birth trauma and infections.
Sri Lanka’s infant mortality rate is unusually low by the
standards of most developing countries and even by the standards
of countries such as Russia, Ukraine and Argentina that are
considerably wealthier than Sri Lanka.
An international comparison of infant mortality rates, relative
to per capita national income, based on a cross-section of 120
low and medium-human development countries shows that Sri Lanka
has a significantly lower infant mortality rate than would be
expected on the basis of its per capita GDP. The figure suggests
that Sri Lanka has an infant mortality rate that may be a fourth
of what would typically be expected of a country at Sri Lanka’s
level of per capita GDP.
The decline in infant mortality experienced by Sri Lanka, during
the past 50 years, is unprecedented and similar to the decline
in the maternal mortality, say Health officials. Decline in high
initial levels of infant mortality are driven mainly by
reductions in the number of post-neonatal deaths (i.e. deaths
occurring between the age of one month and 12 months.
These deaths are more easily averted by the typical and
relatively inexpensive child survival interventions, such as
child immunisations and oral rehydration therapy. However,
Health Ministry officials explain that, as the overall level of
infant mortality comes down, further reductions in overall
infant mortality can only be obtained via reductions in neonatal
mortality. Averting neonatal deaths, typically requires more
expensive interventions, such as professionally-attended
deliveries, prompt treatment of neonatal infections (such as
pneumonia), and availability of emergency obstetric care at
lower levels of Healthcare facilities. Thus ministry officials
explain that, sustained infant mortality reduction becomes
increasingly more difficult and expensive.
Director — Policy Analysis, Ministry of Health, Dr. Susie Perera,
says that, despite the fact that, we have achieved remarkable
improvements in our Health Indices during the last few decades,
there is yet much room for improvement.
“We have not yet rationalised the system, and most of our
services are concentrated on the secondary and specialist
levels. Regarding maternal mortality, we have a good system,
where we do maternal death auditing and analyse the causes of
deaths, which enables us to improve preventive services, but, we
have to improve the investigation of infant deaths and analyse
the causes”, she explained.
“One thing we have to do is analyse the access of services and
the levels of care. We do have a large network of Health
institutions around the country, but we have to analyse how
people use these institutions and up to which level, and the
quality of care available at these levels. It was seen that,
despite the fact that services are available at places closest
to their access points, some people bypass these places, going
to larger institutions and perhaps causing a delay in the
treatment”, explained Dr. Perera. She further explained that
studies have shown that, the attitudes of the Health personnel,
including the doctors’, have a great impact on the way patients
“Certain access Healthcare centres, despite having adequate
services, the utilising by the people is low, whereas some
places, even with limited resources, have high utilisation
rates. It has been shown that, if there are Healthcare
personnel, mainly doctors, who demonstrate a personal interest
in the patients, the news spreads by word of mouth, and people
start using these places more. Anyway, we are now conducting
scientific studies to analyse the actual causes. By this, we can
analyse whether deaths of infants are due to lack of facilities,
lack of access or even lack or utilisation of the closest access
point, causing a delay leading to deaths”, she explained.
“We also need to strengthen our Primary Healthcare level further
and also change the Training Modules of the Primary Healthcare
workers and also, to reduce the population covered by the
midwife, so that, she would be able to provide more quality
services”, she said.
Pregnancy-Induced Hypertension (PIH)
Pregnancy-Induced Hypertension (PIH) is a form
of high blood pressure in pregnancy. It occurs in about 5% to 8%
of all pregnancies. Another type of high blood pressure is
chronic hypertension, which is high blood pressure that is
present before pregnancy begins.
PIH is also called toxemia or preeclampsia. It occurs most often
in young women pregnant for first time. It is more common in
twin pregnancies, in women with chronic hypertension,
pre-existing diabetes, and in women who had PIH in a previous
Eclampsia is a severe form of PIH. Women with eclampsia have
fits resulting from the condition. In most cases, eclampsia
occurs in about one in 1,600 pregnancies and develops towards
the end of pregnancy
The cause of PIH is unknown. Some conditions may increase the
risk of developing PIH, including;
• pre-existing hypertension (high blood pressure)
• kidney disease
• PIH with a previous pregnancy
• mother’s aged younger than 20 or older than 40
• multiple pregnancy such as twins, triplets
With high blood pressure, there is an increase in the resistance
of blood vessels. This may hinder blood flow in many different
organ systems in the expectant mother, including the liver,
kidneys, brain, uterus, and placenta.
There are other problems that may develop as a result of PIH,
such as premature detachment of the placenta from the womb. PIH
can also lead to fetal problems including poor fetal growth and
If untreated, severe PIH may cause dangerous seizures and even
death in the mother and fetus. Because of these risks, it may be
necessary for the baby to be delivered early, before 37 weeks
Some of the more common symptoms of PIH will be
• increased blood pressure
• protein in the urine
• edema (swelling)
• sudden weight gain
• visual changes such as blurred or double vision
• nausea, vomiting
• right-sided upper abdominal pain or pain around the stomach
• urinating small amounts
• changes in liver or kidney function tests
Specific treatment for PIH will be determined by different
criteria such as
• overall health, and medical history
• extent of the disease
• tolerance for specific medications, procedures, or therapies
• expectations for the course of the disease
The goal of treatment is to prevent the condition from becoming
worse and to prevent it from causing other complications. Health
personnel also try to prolong delivery of the baby, to give a
good chance for the baby to mature.
Treatment for PIH may include;
• antihypertensive medications
Early identification of women at risk for PIH
may help prevent some complications of the disease. Education
about the warning symptoms is also important, because early
recognition may help mothers receive treatment and prevent
worsening of the disease.
Bleeding in late pregnancy can be caused by many
• Cervical problems: An infection, inflammation, or growths on
the cervix (neck of womb) can cause vaginal bleeding. For a few
mothers, light bleeding is a sign of cervical insufficiency,
also known as cervical incompetence, in which the cervix opens
without warning. This can result in preterm labour and delivery.
Cervical insufficiency or incompetence is most common between
18-23 weeks. It requires immediate medical attention.
• Preterm labour: Light bleeding may be a sign of preterm labour.
If a mother has any of the following signs or symptoms, she
should go to hospital straight away.
Contractions every 10 minutes or more often
Change in vaginal discharge (leaking fluid
or bleeding from the vagina)
Pelvic pressure; the feeling that baby is
Low, dull backache
Cramps that feel like your periods
Abdominal cramps with or without diarrhea
• Miscarriage: Miscarriage usually happens in
the first trimester, but it can occur at any time before 20
weeks of pregnancy.
• Placenta previa: Heavy bleeding late in pregnancy, may be a
sign of placenta previa. If there is heavy bleeding, it is best
to go to hospital right away. With placenta previa, the placenta
is attached too low in the uterus (womb). It partly or
completely covers the birth canal. This is a serious condition.
The main sign is painless, bright red vaginal bleeding. The
bleeding may stop on its own, but then come back a few days or
• Placental abruption: A few pregnant mothers have placental
abruption, in which the placenta separates from the wall of the
uterus before birth. This leads to bleeding within the uterus.
The mother often also has pain in her stomach. Placental
abruption usually occurs in the last 12 weeks of pregnancy. If a
mother has heavy bleeding, she should go to hospital right away.
• Uterine rupture: For mothers who have had a previous
c-section, a tear in the scar in the uterus may cause bleeding.
This opening is very dangerous. The mother will feel intense
pain and tenderness in her belly and pain on the scar.
• A sign of normal labour: “Bloody show” is normal at the very
end of pregnancy. If there is thick discharge that is pink or
slightly bloody 1-2 weeks before a mother’s due date, the body
is probably taking the first step to prepare for labor.
It is best to go to hospital straight away, if a mother has:
• Unusually strong cramps
• Severe pain in the belly
• Heavy blood flow
• Continual bleeding for more than 24 hours straight
• Fever or chills
• Contractions, even if they’re not painful (belly tightens
like a fist)
• Discharge containing tissue