The State Of Sri Lanka’s Healthcare

By Dinidu de Alwis, and Chrishanthi Christopher

The Appropriations Bill for the year 2013 was presented to Parliament by the Leader of the House, Minister Nimal Siripala de Silva. In this final analysis, The Sunday Leader takes a look at spending for the healthcare sector in Sri Lanka, and explores spending patterns, policy directions and priorities.
Sri Lanka’s healthcare sector, along with the basic health indicators of the island, has over the past few decades risen above the regional averages. Sri Lankans enjoy a life expectancy of 77.4 – the highest in the region – compared to 73.9 of India and 47.5 in Afghanistan. The infant mortality rate remains 8.5 per 1,000 live births, down from 11.2 in 2005. Maternal mortality is 41.6 per 100,000 live births. Around 84 percent of the population has access to safe drinking water.
The proposed spending for healthcare under the current Appropriations Bill stands at Rs. 125 billion. This is a significant increase compared to last year’s spending of Rs. 74.5 billion. The figures are for central government spending only, and do not include spending through the provincial councils or the private sector.
The number of state-run hospitals have grown to 592 from 502 twenty years ago, but have dropped from a peak of 619 in 2007. The private sector has come in to fill the gap with 3,183 private hospitals being registered by 2011. A total of 17,271 doctors were employed by the state sector by last year, up from 10,975 in 2001. The number of nurses has grown from 14,931 to 29,234 during the same period.
The health infrastructure of the Northern and Eastern province took a hit during the final phases of the island’s civil war, and the slow process of their recovery is not yet complete.
In the Mahinda Chinthana, the presidential manifesto for the presidential election in 2010, the government said that the aim of the Government is to “create a healthier nation that contributes to its economic, social, mental and spiritual development. The future health system is expected to be a patient-focused system that provides services closer to the client. It is a system which ensures easy access to modern health care services and supports a high quality of life.”

Profile Of The Island’s Health Sector

According to the World Health Organisation, the country’s health indicators show a steady improvement over recent decades, particularly in maternal and infant mortality, and life expectancy. “The improvement of these indicators is predominately attributed to the maternal and child healthcare programme implemented nationally as an integral component of the state healthcare system. However, while post neonatal mortality has declined significantly, prenatal and neonatal mortality efforts have been less successful,” the WHO stated in a report on Sri Lanka’s health sector.
“Nutritional status has improved but remained a serious problem among the poorer and vulnerable communities, and even on average is unsatisfactory. This brief analysis is based on information related to the whole country and does not address the disparities that exist among provinces. But when the provincial or district level figures on infant and maternal mortality are compared, there seems to be great disparities, some of which may be due to differential under-reporting or the referral of cases. In particular, information on the conflict affected areas and the estates shows significant variation among and within the provinces,” the report further said. Concerns of these were addressed during the budget speech by the President last week.

Unions And Criticisms

Saman Rathnapriya, a health sector union leader says the allocation for the new budget is not enough.
“The figures although increasing slightly in amounts, when one considers the cost of living and the exchange rate of the dollar, there is minimum or no change in the allocations. “It may be even going down,” he says.
Rathnapriya cited the weakening of the Rupee against the Dollar, and says the growth in real terms of spending is inadequate to meet the island’s health needs.
“The actual amount of work that can be done with the budget allocation is limited. Again although they say they allocate a certain amount for the health sector, all the funds are not spent,” he says, “and there is no cash flow from the Treasury”.
“Although our health sector is functioning in a somewhat satisfactory manner, the expenditure on prevention and care services on non-communicable diseases is mounting. Besides there is a shortage of staff in the health sector,” he says. His trade union, along with various other trade unions backed by different political parties have lobbied for both increased sector-spending and more staff for the sector.
“We need an additional 14,000 doctors and 25,000 nurses to bring the health sector to international standards”.
He also says the hospitals need to be maintained and additional buildings put up. “Salaries need to be revised in keeping with the rising cost of living,” he added.

Forecasted Statistics And Aid

In the same manifesto, the primary policy document of the current government, it forecasts the life expectancy to rise to 86 for males and 80 for females by the year 2020. It also expects the child mortality rate to drop to 6.0 (per 1,000 live births), infant mortality rate to 4.5 (per 1,000 live births), one doctor and 1.5 nurses per 1,000 people, for all births to happen under professional care.
The future strategies, as foreseen by the policy document, include minimising communicable diseases and non-communicable diseases, increasing resources for preventive care, improving efficiency of healthcare delivery services, developing and maintaining Centres of Excellence in Cardiology, Oncology, Neurology and Neuro-trauma, improving medical research, effective mental health services, services for the elderly, and a more regulated private healthcare sector.
Meanwhile the World Bank says that they are currently in negotiations with the Government of Sri Lanka about the funding that would be provided, and that their approach is to support the Government’s program to modernize the health system in SriLanka, by contributing to the Health Sector’s budget. This means that the Bank’s funds can be allocated to any part of the Government program according to need. However, within the Government’s program, the Bank proposes to disburse its funds based on selected results with a special focus on nutrition, non-communicable diseases and system improvement modernization.
The funding and support from the World Health Organisation too will be directed to the same areas. The WHO will contribute approximately US$ 3 million over the next year, and will focus on communicable diseases, non-communicable diseases, maternal health, emergency preparedness and response, and enhanced partnerships and resource mobilisation.

Policies Of The Government

During his Budget Speech on Thursday, President Mahinda Rajapaksa made further commitments and addressed specifics about the health sector.
He said that in order to eliminate provincial disparities in health facilities and to provide a quality health service throughout the country, a modernization program of the hospital network has been undertaken. Under this initiative while expanding the availability of required doctors, nurses, paramedical officers, technical and support staff, there will be ambulances, medical equipment and other facilities also provided.
“The Government has diverted its attention to manufacturing pharmaceutical products locally to meet the rising pharmaceutical demand in the provision of health services. Therefore, funds have been allocated to expand the capacity of the Pharmaceutical Manufacturing Corporation,” he said, keeping in line with some of the commitments made during his election manifesto in 2010.
The health policy of the Government, as reported by the Ministry of Health will be directed at consolidating the earlier gains as well as adopting new policies to raise the health status of the people. The broad aim of the Health Policy is to further increase life expectancy by reducing preventable deaths due to both communicable and non-communicable diseases; improve the quality of life by reducing preventable diseases, health problems and disability; and also emphasizing the positive aspects of health through health promotion.
Health is not a sector in Sri Lanka, which developed on its own. Over decades, the World Health Organisation, UNICEF and the Red Cross have contributed vastly to the betterment of basic health indicators. The lack of a fully-blown population crisis is partly thanks to the work done by the Family Planning Association, another non-governmental entity. As the indicators improve however, it has had a negative effect on funding and donor aid: most agencies and non-government organisations have seen a severe cut in funding with some being completely cut off from aid.
Challenges And Policy Direction
Whilst the health indicators on the island are miles ahead of those in the region, there are still serious concerns to be addressed: the regional disparities in resource allocation, the lack of medical personnel, nutrition, and a growing trend of non-communicable diseases such as heart diseases.
The World Bank, in a recent report, said that the demographic transition in Sri Lanka of an older and aging population is well underway as the country faces escalating health care costs with rising rates of non-communicable diseases (NCDs) such as heart disease, diabetes, cancers, and asthma, as well as their risk factors such as obesity, smoking, high sugar and salt diets, and alcoholism
“The demographic transition stems from a larger proportion of older people in a population as a result of increased longevity and reduced fertility that usually accompany economic growth. People are living longer and having fewer children. Generally the more developed a country is, the farther along in demographic transition it is,” it said.
As a result, older populations often face different types of diseases that can be more chronic and expensive to cure. NCDs have already become the largest contributor to disease burden in Sri Lanka, accounting for 85 percent of ill health, disability and early death. A South Asia regional study found that South Asians suffer their first heart attacks six years earlier than other groups worldwide.
This burden of NCDs will rise in the future, in part, due to further aging of the population with the doubling of the population over the age of 65 from 12.1 percent to 24.4 percent over the next thirty years, according to the Bank.
It adds that these transitions have happened in every country as they move towards middle and high income status. In Sri Lanka though, both transitions are underway and are happening at a very fast pace as the country deals with transitions with a much smaller resource base than most developed nations.
If the government’s dream of higher lifespans and better quality of living is to be achieved, then tackling non-communicable diseases remain the biggest priority, and the area which needs most attention and resources. Looking at some of the policy directions the government and non-state actors have taken of late, the island seems to be on the correct path. Whether the commitments will materialise into longer and healthier lives for Sri Lankans, is a different matter.

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