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Sri Lanka – Healthcare model to the world

By Usha Perera
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 included;

• 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 complications,
• 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 reasonable distance
• 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 system.

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 conducted.

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 services.

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 services,

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 utilise services.

“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.

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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 pregnancy.

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
• diabetes
• 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 stillbirth.
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 gestation.
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
Treatment
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;
• bedrest
• hospitalization
• antihypertensive medications

Prevention

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.

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Bleeding in late pregnancy

Bleeding in late pregnancy can be caused by many things..
• 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 pushing down

  • 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 weeks later.

• 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

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