Development of healthcare in Sri Lanka from 1948 to 2009

By Usha Perera
Sri Lanka is often lauded for her good health indicators in comparison to other countries of its stature.
Two salient features of the government’s system of management have been responsible for this success namely, free healthcare and convenient locations within a 3-kilometer radius for residents while at the same time allowing the private sector to grow, proving to be a plus to both individuals who prefer alternative treatment and to the government and free education resulting in a high literacy rate. The nation’s immunization programme, has also been hailed as a “great success” with 97 percent of one year old children immunized against measles and allowing “Sri Lanka to eliminate or to effectively control all vaccine preventable diseases.” Furthermore, improvements in sanitation facilities have contributed to an increase in quality of life. Currently almost 100% of births are attended by skilled health personnel in and the infant mortality rate declined from 19.8 per 1000 live births in 1990 to 11.3 in 2005, making Sri Lanka well on its way to achieving the MDG target of 6.6 in 2015. The mortality rate of children under five was less than half of what it was in 1990 and is projected to further decline by two thirds by the year 2015.

But such successes have not come by automatically and is the current fruit of the labour that was sown by dedicated health personnel in the past and most of them knew that the real successes that would come much later would not be witnessed by them during their life span.
The development of the healthcare system during the period between 1948 – 2009 was the topic of the Dr. AVKV De Silva Oration 2011 delivered by Dr. Nihal Abeysinghe, Former Chief Epidemiologist, Ministry of Health, and currently Regional Adviser, Vaccine Preventable Diseases, WHO, South-East Asia Region. Dr. AVKV De Silva was the chief epidemiologist between the years 1980 – 1986.

Extracts from his oration are given below:
In this oration, I would like to review the achievements in health care services in Sri Lanka since 1948 up to 2009 and identify where we are at present and suggest changes we need to improve the services further during the next decade. Being an epidemiologist nurtured by Dr AVKV de Silva earlier in my career I believe its my duty to use his discipline and mine in its best way to assist my fellow colleagues to optimise the services to achieve the goals and aspirations of public of Sri Lanka.
I will try to point out to you that Sri Lankan health care services has reached near optimal level with the current socio-economic background for controlling acute communicable diseases and we have not been able to address adequately to control chronic diseases, issues like injuries and non-communicable diseases. I will show you that the present health care structure with its current policies can manage only acute illnesses but to address chronic illnesses and injuries we need major policy changes. As long as we have the so called mixed economic strategies my prediction is that we will be stagnant and struggling but never achieve what we want. The key words in my oration are therefore communicable diseases, non-communicable diseases, injuries, health financing and good governance.

I will first try to measure the gains achieved by our health care services since independence. I am using Life Expectancy at birth, Infant Mortality Rate, Child Mortality Rate and Adult Mortality Rate as proxy measures. For comparison purposes I will take Thailand from our Region and Malaysia from the Western Pacific Region.
That our Life Expectancy at birth has been far ahead of both countries in 1950 but as of today we are not good as Malaysia but we are not very different from Thailand which is far ahead of us in socio economic status. In both Sri Lanka and Thailand there has not been much gains in Life Expectancy at birth between 1990 and 2000. It has been only a marginal increase of the trend.
The level of achievements in reduction of Infant Mortality Rates could be attributed largely to control of communicable diseases including control of malaria, progress in immunization, control of worm infestation and diarrhoeal diseases for which DR AVKV contributed immensely between 1960-1985.

The next figure shows you that according to World Health Report of 1995 one of the factors that would have contributed to our low Infant Mortality Rate is the high adult literacy rate.
When considering Malaria, the number of confirmed malaria cases has decreased from 210,000 in 2000 to 558 in 2009 and the proportion of cases due to P.falciparum from 28% to 5%. The country is now in the pre-elimination phase of malaria control.
If we look at TB, it is a communicable disease but chronic in nature. You see that we are far better than the other two but in both Sri Lanka and Thailand the incidence has not changed at all between 2000 and 2008.
My observation here is that Sri Lanka has achieved fairly good results in controlling acute communicable diseases, but we have not been able to reduce TB, Non Communicable Diseases and injuries.

However Leprosy is an exception and at the elimination stage now probably due to aggressive behaviour change campaign.
The annual report 2008 of the National Programme for Tuberculosis Control & Chest disease identifies clearly that to sustain the achievements and further control of TB the barriers are:
1. Inequity of health services: irregular distribution of staff
2. Inadequate involvement of health providers other than Government sector in TB control
3. Inadequate public awareness and inadequate community participation
A recently concluded mission report of external Consultancy also hypothesized that:
1. Insufficient case finding and/or case holding in some districts
2. Inadequate contact tracing
3. Long delay and less involvement of the private sector in case finding, as being some important barriers for achieving successful control.

As of today you will agree with me that at least 50% of the public and even more in urban areas seek services from the private sector health care services for their acute health problems. The high income group is seeking both OPD care and in-patient care from the private sector and the low income group still prefers to go for government health care services for inpatient care.
For me this is an issue of access to health care. I believe that our inability to achieve much in the area of Non Communicable Disease is due to limited access to low-income group of the society. Access to health care can be influenced by many factors. It has two sides.
Poor adherence to treatment of chronic diseases is a worldwide problem. Adherence to long-term therapy for chronic illnesses in developed countries averages 50%. In developing countries, the rates are even lower. It is undeniable that many patients experience difficulty in following treatment recommendations due to inability to afford the expenditure for continuous care.

The impact of poor adherence grows as the burden of chronic disease grows worldwide. Non-communicable diseases and mental disorders, human immunodeficiency virus/acquired immunodeficiency syndrome and tuberculosis, together represented 54% of the burden of all diseases worldwide in 2001 and it has been estimated that it will exceed 65% worldwide in 2020.The low income groups are disproportionately affected.
The consequences of poor adherence to long-term therapies are poor health outcomes and increased health care costs. Poor adherence to long-term therapies severely compromises the effectiveness of treatment making this a critical issue in population health both from the perspective of quality of life and of health economics. We have an obvious example from the north central province, the chronic kidney diseases.

Consequences of direct payments
Direct payments have serious repercussions for health. Making people pay at the point of delivery discourages them from using services (particularly health promotion and prevention), and encourages them to postpone health checks. This means they do not receive treatment early, when the prospects for cure are greatest.
It has been estimated that a high proportion of the world’s 1.3 billion low income population have no access to health services simply because they cannot afford to pay at the time they need them They risk being pushed into poverty, or further into poverty, because they are too ill to work. Direct payments also hurt household finances. Many people who do seek treatment, and have to pay for it at the point of delivery, suffer severe financial difficulties as a consequence
Recent studies have shown that these out-of-pocket health payments pushed 100,000 households in both Kenya and Senegal below the poverty line in a single year. About 290,000 experienced the same fate in South Africa. Today, millions of people cannot use health services because they have to pay for them at the time they receive them. And many of those who do use services suffer financial hardship, or are even impoverished, because they have to pay.

Moving away from direct payments at the time services are received to prepayment is an important step in averting the financial hardship associated with paying for health services. We had it in the past though it was not very sophisticated but with the market economy policies we have almost lost it. Now the world is realising that pooling the funds increases access to needed services, and spreads the financial risks of ill health across the population.

Governments should be the “stewards” of their national resources, maintaining and improving them for the benefit of their populations. In health, this means being ultimately responsible for the careful management of their citizens’ wellbeing. Stewardship in health is the very essence of good governance. For every country it means the establishment of the best and fairest health system possible. The health of the people must always be a national priority: Government responsibility towards this is continuous and permanent. Ministries of health must take on a large part of the stewardship of health systems.

Health policy and strategies need to cover the private provision of services and private financing, as well as state funding and activities. Only in this way can health systems as a whole be oriented towards achieving goals that are in the public interest. Stewardship encompasses the tasks of defining the vision and direction of health policy, exerting influence through regulation and advocacy, and collecting and using information. At international level, stewardship means influencing global research and production to meet health goals. It also means providing an evidence base for guide countries’ to improve the performance of their health systems.
For personal health care, the most important in determining health system performance is the difference between prepayment and out-of-pocket spending. Prepayment makes it possible to spread the financial risk among all individuals.
In order to ensure that all individuals have access to healthcare services three interrelated functions of health system financing are crucial:
1. Collection of revenue
2. Pooling of resources
3. Purchasing of interventions
Revenue collection is the process by which the health system receives money. It could be by taxation, salary related mandatory or voluntary health insurance, and risk related voluntary health insurance, out-of-pocket payment and donations.

Pooling of resources is the accumulation and management of the collected revenue to ensure that the risk of health care is borne by all the members of the pool and not by the individual. The purpose is to share the financial risk associated with health intervention for which the need is uncertain. Pooling reduces uncertainty for both beneficiary and the provider.
Purchasing is the process by which pooled funds are paid to providers in order to deliver specified or unspecified set of health interventions.

However, the main challenges are to put in place the necessary technical organisational and institutional arrangements to:
1. Be fair by the beneficiaries
2. Motivate providers to improve their responsiveness
For that we need a sound regulatory mechanism and a system of good governance.
There are four key determinants of health system financing performance
1. the level of pre-payment
2. the degree of spreading risk
3. the extent to which the poor are subsidised and
4. strategic purchasing i.e. continuous search for the best ways to maximise health system performances
A health system where individuals have to pay out of there own pockets at the moment of seeking treatment clearly restricts access to only those who can afford it and is likely to exclude the low income groups of the society.
On the other hand free-of-charge services do not translate automatically into unjustified over utilization of services. Services that are free of direct charge are not necessarily free particularly for the low income groups because of the cost associated with seeking health care, such as cost of medicine, under-the-table payments, transportation or time lost from work.

Whoever is the provider they need to act in accordance with:
a. preventing health problems
b. providing services and solve health problems
c. being responsive to people’s legitimate expectations
d. containing cost
In order to achieve these objectives Sri Lanka has several options.
1. Reorganise general taxation to be fairer to all citizens and have a better revenue collection system i.e. a tax dedicated for health service cost
2. Ministries of Finance and Health to be totally responsible and accountable for pooling and provision
3. Regulate private health sector including private insurance mechanisms i.e. ensure protection either from pooled funds or private insurance mechanism
It means we need to demand for good governance. I sincerely believe that it is the responsibility of the intellectuals at this point of time. If we fail to do that now, very soon we will be losing our gains achieved by the hard work of our predecessors.

If we want to do better and learn from others we can learn from UK, a country which trained more than 90% of our specialists but unfortunately not in the field of managing health financing.
The UK NHS was using the method of capitation, which means a fixed payment per beneficiary to a provider responsible for delivery of a range of services and not at the time of services provided. It offers potentially strong incentives for prevention and cost control to the extent that the provider receiving the capitation will benefit from both.