What ails Sri Lanka   's health sector?

By Ranee Mohamed, Dilrukshi Handunnetti, Risidra Mendis, Arthur Wamanan and Nirmala Kannangara

The health sector in Sri Lanka has been ailing for a long time. This remark, the health authorities would simply dislike, but a few visits to Sri Lanka's national, base and teaching hospitals will prove what ails our health sector.

There is no denying that we lack doctors, nurses, beds and equipment. If the rest of the country can manage, then the northeast suffers from lack of medical staff, despite the trying conditions that prevail.

The World Health Organisation (WHO) in December commended Sri Lanka as a shining example of 'good health' and invited poverty stricken and under-developed Nepal to emulate us. It is good to be lauded for the good health indicators but it is altogether another story when corruption, controversy and bad administration cripples a system. That all is not right in the sector is manifest in the multiple strikes we have witnessed in the recent past.

To our credit, this island has always enjoyed good health indicators. To complete the picture, we require a healthcare system that enhances good health of a populace. Our hospitals are in dire want, some more so than others, while medical and nursing staff for the northeast is a perpetual need.

Let us also not forget the scams. The complaints we receive about the pharmaceutical industry, medical equipment, the monopolies, commissions and how politicised as well as how corrupt the administration is, are too many to be listed.

Health is a prime requirement of any society. As much as healthcare, after care is needed. In one Western Province government hospital, in 2003 alone, some six children died, post heart surgery. We create that kind of statistics where operations are recorded as successful but patients die soon afterwards.

The issues are too numerous. The Sunday Leader attempts here to highlight some glaring instances, concerns and severely neglected areas with the hope that the administrators would consider them worthy of their attention.

It is also sad that neither Healthcare and Nutrition Minister Nimal Siripala de Silva nor the Ministry Secretary thought it fit to answer some of our queries. Hence the absence of the official government version.

The key hospitals in and around Colombo are ailing due to a shortage of manpower. But the Cancer Hospital is living up to the affliction. Inside sources say that not only are patients put on the floor after surgery, but also the main operating theatre itself is in a cancerous mess, with the old wiring system catching fire during surgery.

Cancer surgery is carried out from 8 a.m. to 6 p.m. everyday including Saturdays at the National Cancer Institute, Maharagama, also called the Cancer Hospital.

The main operating theatre is an old kitchen which has been converted to an operating theatre and has been in existence since the early 1960s. It is learnt that surgeons and the staff of the operating theatre are put to great risk and inconvenience to the non-availability of a proper operating theatre. There are hundreds of patients at the Cancer Hospital and the numbers keep increasing.

A room filled with fungus is threatening to drive to imaginary status, the sterile conditions which the staff are very particular about.

Besides the overcrowding in the medical wards and a crumbling old operating theatre the staff and patients of the Cancer Hospital have to battle another affliction- the threat of dengue due to the swarms of mosquitoes rising out of the foundation of a private hospital in its vicinity.

Meanwhile, the shortage of manpower continues to plague almost every hospital in the government sector. Chief among them is the shortage of nurses while a shortage of MLTs and pharmacists are also causing a crisis.

Investigations conducted also highlighted grave complications due to overcrowding.

Overcrowding

A spokesperson for the Colombo South Teaching Hospital said the overcrowding at the Kalubowila Hospital is caused because patients chose to bypass regions as Matugama, Agalawatte, Horana and even Wattala and seek treatment at the Kalubowila Hospital.

Meanwhile the Director of the Hospital, Dr. W.G. Gunewardene when contacted by The Sunday Leader said that the Colombo South Teaching Hospital has no problem as regards facilities and infrastructure.

"The hospital has continued to grow and improve since 1989," said Dr. Gunewardene.

Available and unavailable

Meanwhile a spokesperson for the Sri Jayewardenepura General  Hospital (SJGH) when contacted by The Sunday Leader said that they have no problems as regards drugs and surgical consumables such as gauze, suture materials and catheters, and went on to say that their investigation laboratories are also satisfactory.

He went on to point out however that the CT Scanner at the hospital ceased to function about two months ago and that the hospital authorities have been trying to make some arrangement to get it back to working order.

"When there is such a breakdown during that time of the year, then it becomes a problem to get it repaired," pointed out the spokesperson.

He also went on observe that a shortage of nurses is also causing some problems in the hospital. "We hope to remedy this situation as soon as we have advertised for nurses," he said.

Meanwhile investigations revealed that the patients admitted to theNational Hospital are undergoing hard times due to a shortage of beds. Patients who visited the OPD also complained of difficultand stuffy conditions therein.

Director of the National Hospital, Dr. Hector Weerasinghe when contacted by The Sunday Leader said that the hospital has embarked on several large-scale projects that will be completed by the end of the year and among them is the expansion of the OPD.

Grandiose

"We have drawn up a plan for the development of the OPD at the same pace at which the other parts of the hospital have developed. We are in the process of looking for a foreign donor," said Dr. Weerasinghe.

The plan for the development of the OPD requires Rs.1000 million (Rs.1 billion). The expansion plan is to commence this year and the end of the expansion project will see the OPD in a landscaped area. The approximately two acres of land at the OPD will house the new section with a large area to be landscaped. A multi storeyed car park with parking space for over 300 cars is also in the plan, according to the Director.

The best for free

National Hospital Director, Dr. Hector Weerasinghe also went on to invite the investigations desk to the hospital for any treatment. "Few people know about the National Hospital and the free treatment that we give. There are no charges whatsoever. The neuro-trauma unit completed at a cost of US $ 15 million will be completed in April and will have state-of-the-art equipment. It will have CT scanners, MRI Scanners and intensive care units and wards for patients with head and spinal injuries. Our treatment is free of charge," stressed Dr. Weerasinghe.

The Director also went on to point out that a third medical wards complex in the form of a 10 storey high-rise building will be completed by the end of thisyear. "But the 400 beds in this complex will not be an added feature to the hospital because it will come in place of similar numbers to be demolished in the old buildings," he said.

He said that the National Hospital does not have a shortage of doctors and consultants but they do have problems due to the shortage of nurses, paramedics, MLTs and pharmacists.

When asked about the shortage of hospital beds and overcrowding, the Director said that the overcrowding and shortage of beds is caused by people who believe that they must come to the National Hospital for treatment of each and every ailment.

"Patients come to the National Hospital from far away places. This is why we ought to commence a referral system where patients will seek treatment at the National Hospital only if they need to. Today, patients pass the hospitals in their regions and travel several hundred kilometres to seek treatment at the National Hospital," pointed out the director.

Our investigations led us to the discovery that the CT scanner at the National Hospital which is over 10 years old is not in working order. According to a highly placed source in the hospital, such equipment cannot be used for more than 5-10 years and when it breaks down, the repairs tend to cost more than the original cost of the machine.

Stress and distress

Anew Act introduced for the regulation of private medical institutions laying down the rules of how to run theirprivate medical practice is causing stress and distress to the private medical practitioners. The Act which has been passed in parliament and gazetted is now law.

The Act extends its tentacles to general practitioners, large private hospitals, shady laboratories and clinics. In short, anyone doing any form of medical service is treating medical institutions like grocery stores, charge the doctors.

"It is all right for the government to ask private medical practitioners to have basic facilities for their patients in their practices, but to ask them to put their charges up on a board, just like the prices of rice, dhal and dry fish and to make them pay Rs.10,000 for the government for no services rendered whatsoever is not only demeaning but immoral too," said an angry group of private medical doctors.

They claim that the Act, which is aimed at controlling the private sector has a good side to it, but in this instance it certainly appears to take an extra pound of flesh off the private medical practitioners.

Humiliation

Private doctors say that the Act is imprudent because it allows the provincial director of the area free access to walk into any clinic at any time and inspect any document. "Supervising is certainly good, but this certainly smacks of a future trend towards having to give a small 'gift' to visiting bodies," said the doctors.

"Medicine is a noble profession and no other profession is being treated the way we are now being treated. Engineers, lawyers and accountants are not subject to this type of humiliation," said private medical doctors who went on to say that the Act itself is an ailing one.

"We wish to point out to the government authorities so keen to regulate that there are some doctors who see patients in shacks. There may be no spittoons and no toilet facilities there. Insisting on the basic facilities is laudable, but extending that to controlling something good is despicable," said the private medical doctors when contacted by The Sunday leader.

The Private Medical Institutions (Registration) Act. No. 21 of 2006 says that "It shall be lawful for any authorised officer, without prior notice, at any time by day or night, to enter any private medical institution, any premises appertaining thereto, and do all such acts as may be reasonably necessary for the purpose of carrying out any inspection, examination, investigation or survey for the purposes of this act."

Private practitioners charge that the regulations for this purpose are in the process of being formulated by the council headed by the Minister of Health and has only 13 private sector representatives as against 15 representatives, among them the personal appointees of the minister, charge the doctors.

Doctors also charge that the council has not approved the laws that are being formulated by the minister.

Dictated to

"The basic requirements in a medial institution are also being dictated by the council," allege the private medical practitioners who go on to point out that they will now have to pay Rs.10,000 yearly with the threat of it being increased in the future.

"Why do we have to pay Rs.10, 000 to the government? What benefits do we get from this payment?" ask the doctors who say that health authorities can break in at any time to inspect premises similar to the cordon and search operations conducted in the city or even a police raid. "Needless to say this can be a humiliating exercise," they chorused in disgust.

An aspect that has improved in the health sector are the cardiovascular units, a prime need given the country's increasing number of heart patients.

Numbers differ

Most government hospitals when contacted by The Sunday Leader said hospitals in the country have sufficient cardiologists to run their operations smoothly. The number of cardiologists at each hospital differs in number but sufficient according to the hospital administrators, to treat the large number of patients who enter government institutions.

Speaking to The Sunday Leader Director, National Hospital, Dr. Hector Weerasinghe said they have four cardio surgeons at the Cardiovascular Unit in the hospital.

"We had three cardio surgeons till the end of 2007. But from January 1 we have recruited a fourth cardio surgeon. Four surgeons are sufficient for the unit to function smoothly," Dr. Weerasinghe said.

He added that all their pharmaceutical stocks  are supplied by the Medical Supplies Division (MSD). "We place our orders for stocks of pharmaceuticals one year in advance with the MSD. However if the MSD runs short in some supplies of pharmaceuticals we purchase the required drugs from Osu Sala," Dr. Weerasinghe explained.

According to Dr. Weerasinghe the hospital staff's priority is to increase the number of surgeries performed at the Cardiovascular Unit every year. "Depending on the available resources we hope to perform more operations this year," he said.

Enough cardiologists

Director, Sri Jayewardenepura Hospital, Dr. D. L. Lanerolle said his hospital has two cardiologists working in the Cardiovascular Unit.

"Two cardiologists are more than enough for us to be of good service to our patients. All our nurses are registered with the Sri Lanka Medical Council. We have an experienced team at the hospital and offer very reasonable charges in comparison to private hospitals when it comes to surgeries," Dr. Lanerolle explained.

According to Dr. Lanerolle the Sri Jayewardenepura Hospital gets its supplies of pharmaceuticals also from the MSD. "Ninety percent of our pharmaceuticals are supplied by the MSD. However if the MSD is out of stock for drugs that we require, the hospital calls for quotations and purchases them from the cheapest supplier. We have to purchase the required drugs from the cheapest supplier as we cannot expect our patients to spend large sums of money on medication," Dr. Lanerolle said.

Director, Colombo South Teaching Hospital, Kalubowila. Dr. W. G. Gunewardene said his hospital has one cardiologist at the Cardiovascular Unit. "We can manage with one cardiologist for the moment. If a situation arises where the number of patients suddenly increases we refer these patients to the National Hospital. We get our pharmaceutical supplies from the MSD. But if the MSD is out of stock  we purchase from Osu Sala," Dr.  Gunewardene said.

Jaffna Hospital

However, he said that it would help improve the hospital if the services of another cardio surgeon could be obtained for his hospital, one of the busiest hospitals in the country.

    Director, Teaching Hospital, Jaffna, Dr. A. E. Gnanajothy said his hospital has one cardiologist. We have a temporary cardiologist but this doctor is attached to the Batticaloa Hospital. The hospital can manage with one cardiologist for the moment. The facilities at the cardiovascular unit are reasonably sufficient for the moment. However if the required facilities are not available for some patients we refer them to the National Hospital in Colombo," Dr. Gnanajothy said.

     He added that the hospital does not have a ward and only acute patients are treated at the Cardiovascular Unit. "We hope to open a ward within the course of this year so patients could be treated and warded at the hospital," Dr. Gnanajothy said.

     The Jaffna Hospital gets its supplies of drugs for the Cardiovascular Unit from the MSD. "If the MSD is out of stock we go to Osu Sala or a pharmacy in Colombo for our drug supplies," Dr. Gnanajothy said.      

The loss of a CT scanner has caused much heartache to patients visiting Sri Jayewardenepura Hospital for treatment, moan affected patients.

Now they have to visit the Cancer Institute, Maharagama or private hospitals in order to get scans done before submitting medical reports to the SJGH for further medical assistance.

Tragic

But the SJGH's CT scanner is a story by itself.  And a tragic one at that, which makes the patients pay the penalty for administrative sins. This is due to the non-availability of a CT scanning machine at the hospital since mid last year.

Originally, informed sources said, it was to be repaired at the cost of Rs. 2 million. Subsequently, there were ministerial instructions to buy a brand new unit at the cost of Rs. 25 million, a proposal that got shelved. Eventually, the hospital is sans the vital services of a CT scanner making patients go to other hospitals for their scans.

SJH patients are now forced to go to the Cancer Institute with where the SJH has an understanding, and to some other private hospitals too.

Patients have been pushed to this state for nearly six months and still the machine has not been repaired or replaced.

However, Director, Sri Jayewardenepura Hospital, Dr. D.L. Lanerolle told The Sunday Leader that the delay in getting the new machine was due to the tender procedures which are still in progress.

According to Dr. Lanerolle, the hospital would get the new CT scanning machine once the tender procedure is completed.

Tenders

"The delay is because of the tender procedure. It is still in progress. We are expecting the new machine once this is over," Dr. Lanerolle explained. 

As the patients continue to face such problems, concerns were also raised with regard to the cost of buying a new machine.

The cost to repair the machine was said to be very much cheaper than buying a brand new CT scanner. However, the hospital had opted to buy a new scanner than to repair the existing one spending 12 times more than the cost of repair. The new unit is said to cost Rs. 25 million.

Dr. Lanerolle stated that it was decided to buy a new machine in order to provide a better service to the patients who regularly visit the hospital for treatment. He stated that a new CT scanner would be more effective and technically advanced than the machine used by the hospital.

The CT scanner to be brought down to the hospital consists of around 16 slides as opposed to the earlier machine, which had only one slide. The previous CT scanner has been used for the last seven years before it broke down last year.

However, according to the Director, it was decided to buy a new machine as the old machine would have given more problems in the long run if it were repaired.

 "The difference in the cost is a technical matter. However, we opted to buy a new machine as it has advanced technology and more slides than the previous machine we were using. We have to offer a better service to our patients. The other thing is that even if the machine was repaired, it might start to give problems in the long run as it has been used for many years," Dr. Lanerolle added.

Dispute

The hospital is also in the process of building a new nephrology ward. This also saw a number of twists and turns before it was decided that the new building would house nephrology wards.

The building was initially planned to have nephrology wards but halfway through it was decided to convert it into a paying ward as per ministerial instructions, The Sunday Leader reliably learns.

Dr. Lanerolle said that the structural engineers did not give the green light on this as the building was not designed for paying wards.

"There is no issue on that. Work is going on to build a nephrology ward as planned earlier. There were several requests to convert this into a paying ward. However, it is not possible. We have now taken measures to convert one of our existing wards as a paying ward. We have to look into it because many patients prefer paying wards. They want the solitude that a paying ward can bring," he added. 

He however added that the plans had to be revised a few times due to the changes halfway through the process but added that all those issues were now sorted.

Generic against the brand

Health care sector stakeholders have come out opposing certain ideology clauses to be included in the proposed National Medicinal Drug Policy claiming that it would make the patient the loser and pharmacists, the winners.

According to the said clauses it is now proposed that doctors are instructed to prescribe drugs according to their generic name and not the brand name. While this is expected to do away with any monopolies and discrepancies, there are those who believe that pharmacists could nevertheless issue drugs according to the generic name but charge higher prices, as the brand name is not specified in prescriptions.

"Brand names are a matter of choice. That should be allowed," some medical experts explained.

However, they say that they do not oppose the medical policy per se and certainly do not oppose a regulatory authority being created.

Appeasing

While frowning on Health Minister Nimal Siripala de Silva over his intention to bring back the rejected clauses into the draft policy to please political allies that would prove disastrous to the poor patients, the medical sources told The Sunday Leader that the stakeholders were taken aback when the draft policy was released a fortnight ago.

"In order to introduce the NMDRA (National Medical Drug Regulatory Authority) instead of the Cosmetic Devices and Drugs Act (CDDA) of 1980 to regulate the importation of medicine to the country, the National Standing Committee (NSC) was introduced to prepare the draft act and members of the Chamber of Pharmaceutical Industry, Pharmaceutical Society of Sri Lanka, State Pharmaceutical Corporation, Pharmaceutical Manufacturers Association and Medical Scientific Association that come under the Sri Lanka Medical Council (SLMC), Government Medical Officers Association (GMOA), Professors of Pharmacology and the Patients Rights Movement -  an arm of Health Action International which is a controversial NGO, were appointed to the NSC," the sources alleged.

According to the sources although the stakeholders had discussed widely as to what should be introduced for the betterment and what should be included in the draft, none of the recommendations had been included in the final draft to the utter dismay of the learned committee members of the NSC.

WHO recommendations ignored

"Leave the local committee members' suggestions aside, but the government has even failed to implement the WHO expert, Dr. Susan Walters' suggestions which she forwarded after consulting all the Sri Lankan stakeholders," the sources alleged.

According to the sources Dr. Walters' 100-page report that was submitted in mid 2007 gave 'good' guidelines to be followed and had clearly stated what is best included as well as excluded.

"When we noted that the World Health Organisation (WHO) recommendations were totally ignored, specific clauses that were rejected, nor discussed nor agreed on were included which were the ideology of the controversial Marxists. Thus, most of the NSC members were taken aback," claimed the sources.

"We never know whether a new draft would be introduced or parliamentary approval obtained for the draft that was rejected by the NSC members. Although the Minister is trying to convince everyone that the generic prescription would be useful than the prescription with the brand names, the consequences the patients will have to undergo will soon be evident," warned the medical experts.

Meanwhile according to the sources, a WHO report that was published two years ago clearly says that Sri Lanka has the lowest prices for drugs compared with all other developing countries in the world. "According to the report the highest prices for drugs are in the Philippines and the Sri Lankan prices are the lowest. Even with the fluctuation of the US dollar against the rupee, Sri Lanka still sells imported drugs at a competitive rate. This has been so for years," added these sources.

The sources further stated that competition among drug importers has helped keep the prices low  even when compared with drugs manufactured in India.

Deputy Minister ousts trainees

One of the latest controversies that had led to protests is the acquisition of a training centre premises which has now been converted to the office of Deputy Minister, Healthcare and Nutrition, Vadivel Suresh.

Following this decision, training courses at the Health Education Bureau (HEB) has come to a virtual standstill with lodging facilities being suspended while the conversion is underway.

All training courses at the HEB at De Saram Road, Maradana have come to a virtual standstill as the government has handed over the building in 2005 to the Deputy Minister to house his office.

"This three storey building was opened in 2001 by the present Minister, Nimal Siripala de Silva to overcome the difficulty faced by the outstation nursing staff, MLTs and medical service students who are provided with lodging during their training in Colombo. This was the building that provided the trainees with the necessary hostel facilities when undergoing training courses," an official explained.

First acquired for two months

Following the assumption of power by President Mahinda Rajapakse, the said building was first acquired for two months. Some 20 months later, the building has not been returned causing extreme problems for trainees while some of the courses are not conducted simply due to the problem of providing lodging to trainees.

"This is where training courses are largely conducted for nursing, MLT, paramedical and other medical services students," explained a highly placed health sector source, objecting to the occupation of this vital building by the deputy minister.

These sources added that nobody objected to the minister being provided with an office which was a requirement but explained that they strongly objected to the choice of building.

Meanwhile, authoritative sources added that not only was the three storied building being used as the  Deputy Health Minister's office but it also doubled up as his Colombo political office.