HEALTH SYSTEM OF SRI LANKA

INTRODUCTION
Naveen Shandilya 2011 HF015 PHHP

Health profile
Health: Infant mortality rate--18.57/1,000. Life expectancy--73

yrs. (male); 77 yrs. (female). Statistics Total population 20,238,000 Gross national income per capita (PPP international $)- 4,460 Life expectancy at birth m/f (years) - 73/77 Probability of dying under five (per 1 000 live births) - 16 Probability of dying between 15 and 60 years m/f (per 1 000 population) -275/82 Total expenditure on health per capita (Intl $, 2009) - 193 Total expenditure on health as % of GDP (2009) -4
The Global Health Observatory (2009)

Geographical position

Sri Lanka is demarcated into Administrative hierarchy of 9 provinces,

25 districts,
325 Divisional Secretariat (DS)

divisions
14,009 Grama Niladhari (GN) divisions.

Lankan Geography
Sri Lanka is Located in South Asia, Sri Lanka is an island in Indian Ocean positioned about 18 miles off the southeast coast of India.
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The average yearly temperature of Sri Lanka ranges from 28 degree centigrade to 30 degree centigrade with January being the coolest month of the year and May the warmest month.
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Almost 40% of Sri Lanka constitutes lush tropical forests. This island has an abundance of natural resources.

Cont..
The average yearly temperature of Sri Lanka ranges from 28 degree centigrade to 30 degree centigrade with January being the coolest month of the year and May the warmest month.
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Sri Lanka is a developing country in South Asia with a population of approximately 20 million and an annual growth rate of 0.5%.
S. S. Sheikh (2011). Pakistan, International Medical Journal Of Students Research

Sri Lanka is primarily an agricultural country. The chief crop is rice, mainly for domestic consumption, with

Political system
Historical perspective: European Colonialists in the 16th century. Disestablishment of the monarchy in 1815.

Buddhism was introduced in 3rd century

Independence was finally granted in 1948. Status of a Republic in 1972

Cont..
The country has enjoys a democratic multi-party System. President of Sri Lanka is both the head of state as well head of the govt. Sri Lankan policy, irrespective of the government in power, has always regarded education and health as crucial to socioeconomic development, The concept of equity and social justice in favour of the underprivileged has also been a feature of state policy.

Economic growth

Economic policies

1948 to 1977:Government intervention was often seen as the solution to economic problems. Government participation and tightly regulated system especially during 1970 to 1977, State dominate international trade and payments , the plantation, financial, and industrial manufacturing sectors. It also played a major role in the domestic wholesale and retail trade.

After 1977 :The public investment program, was implemented . In early 1988 development of the nation's infrastructure, Govt. reduces its role in regulation, commerce, and production. Generous amounts of foreign aid to finance development program. Relaxing import controls

Demographic
Nationality: Noun and adjective--Sri Lankan(s). Population: 21.3 million. Annual population growth rate: 0.9%. Ethnic groups (2002): Sinhalese (74%), Tamils (18%), Muslims (7%), others (1%). Religions: Buddhism, Hinduism, Islam, and Christianity. Languages: Sinhala and Tamil (official), English. Education: Years compulsory--to age 14. Primary school attendance--96.5%. Literacy--91%. Males- 93% Females- 87% (Bureau of South and Central Asian Affairs 2011)

Birth, Death and Growth rates

Demographic Trends

Literacy Rate and Life Expectancy

Demographic transition
Sri Lanka has passed through the classical phases of demographic transition to reach the third phase of a declining birth rate as it has stabilized at 19 per 1000 population during 2000-2003 and showed a relatively stable low death rate at 6 per thousand population during the same period. Sri Lankans over the age of 65 has increased markedly over the last 25 years and is expected to increase from 6.3% to 12.3% in the next 25 years
(Statistical Pocket Book 2004, Department of Census and Statistic, Colombo, Sri Lanka).

The median age of the population is also projected to increase from 23 years in 1998 to 40 years in 2025
[Demographic and Health Survey (DHS)2000]

YEAR 1935 1950 1970 1991 2003

IMR 246 80 50 17.2 11.2

(Statistical Pocket Book 2004, Department of Census and Statistic, Colombo, Sri Lanka)
YEAR LIFE EXPECTANCY AT BIRTH( YEARS)

1946
1981 1991

43
70 72

2001

73.2

(Department of Health Services, Ministry of Health, Annual Health Bulletin 2002).

Buddhism was introduced in Sri Lanka in the third century B.C. Introduced Ayurveda in Sri Lanka. Buddhism has considered care of the sick as a meritorious act of the highest order which laid foundation of their social welfare policy for healthcare
The Portugese who occupied Sri lanka between 15051656 introduced the western system of medicine in the country for the first time. Western hospitals were set up in urban regions for Portugese officials.

The Dutch occupation of Sri lanka (1656-1796) further spread western medicine in Sri lanka

During the British period (1796-1948) western medicine took root in lanka. because the prosperity of the colony depended on the cultivation of coffe, tea, and rubber by labour intensive methods, so several British governments had been concerned about the health of the labour force. So the Western medicine became available for the common public who used traditional ayurvedic and herbal medicines until then several British Governments had been concerned about the health of the labour force. In the early 19th century, military surgeons who came to Sri Lanka with the British army taught medicine to arbitrarily selected persons on an individual basis.

Healthcare Delivery System of Sri Lanka

-Dr.Kiran Kamble

Typology of Healthcare System of Sri Lanka

Welfare State System

The Sri Lankan health care system is considered a health care delivery model for most developing countries across the world. Healthcare for the people of Sri Lanka is provided through both public and private sectors. Western system of healthcare, traditional systems of medicine, especially Ayurvedic system and other types of healthcare including

Sectors
Government Private

Western
Indigenous Others

+
+

+
+ +

Organization of Public Healthcare System

The Ministry of Health (Central Govt.) is primarily responsible for provision of comprehensive health services. The main organizational structure through which Ministry of Health plans and delivers health services is Department of Health Services, headed by Director General of Health Services. The key functions of Department of Health Services include setting policy guidelines, training of health personnel, management of teaching and specialized medical institutions and purchase of medical requisites.

Organization of Public Healthcare System (Contd.)

At central level, responsibility for technical

aspects related to healthcare services is vested with Deputy Director Generals for Public Health Services (DDG.PHS), Medical Services (DDG.MS), Laboratory Services (DDG.LS), Education, Training and Research (DDG.ETR), DDG Finance, DDG Management & Planning

Key features of Sri Lanka health system

Objectives of healthcare sector are

(1) To improve health (2) To prevent poverty Government pays for most inpatient care Dual system Public sector hospitals and preventive services -Free of charge, no user fees Private sector doctors and hospitals -Not free - patients pay fees Government doctors can work in private practice after work hours

Dual system
Source: Annual Health Bulletin 2001

Making Healthcare Accessible to the Poor

Zero user fees Patients may have to buy drugs, but poor are

often protected High density of facilities in rural areas Health facility within 2 miles of most villages
Rural facilities are staffed by qualified doctors

supported by nurses Accessible tertiary care Large budgetary allocation to secondary hospital care - poor patients entitled to expensive care

Private Practice by Government Doctors

First introduced in 1860s Problem: How to pay for government doctors

when government cannot afford Benefits Doctors can supplement low wages, but dont leave public sector Poor people can still see the doctors in public clinics for free, and rich people can pay to see them outside Problems Doctors can break rules - needs strict enforcement

Concept of Preventive Health Care

Sri Lanka for long have followed the model of

Selective Primary Health Care as against Comprehensive Primary Health Care proposed at Alma Ata conference. Preventive health care operates through Health Units. The first health unit was started since 1926 and it is the first health unit among Asian countries. This is time tested and proven model.

INDIGENOUS MEDICINE IN SRI LANKA

Four systems of traditional medicine have been

adopted in Sri Lanka: Ayurveda, Siddha, Unani and Deshiya Chikitsa Institutes under the Ministry of Indigenous Medicine 1) Department of Ayurveda 2) National Institute of Traditional Medicine 3) Bandaranaike Memorial Ayurveda Research Institute 4) Ayurveda Medical Council 5) Sri Lanka Ayurvedic Drugs Corporation Number of Ayurveda physicians registered under the Sri Lanka Ayurveda Medical council is around 19754 as at 31st Dec.2010 As per the statistics available, Out of the indigenous physicians, Ayurveda counts 84.6%, Siddha system

Source: Annual Health Bulletin 2001 ,http://www.searo.who.int/LinkFiles/Sri_lanka

Pharmaceutical Supply and Regulation

Public sector initiated policies for the control and

management of medicines in government hospitals as early as in the 1950s, several decades before WHO adopted the concept of the rational use of drugs. Pharmaceutical supply and regulation policies include a national formulary of drugs approved for use in government hospitals, a policy of purchasing public sector drugs only through international tender and bulk purchasing, the use of only generic medicines in the public sector, and the adoption of a national essential drugs list. The private sector may import any drug that is registered with national authorities.

Medical technology
To control medical technology, there is no policy

other than a basic registration requirement. Despite the lack of a formal policy, adoption and purchase of expensive high technologies are tightly controlled in the health ministry using managerial procedures.

Health Information System in Sri Lanka

Components of National HMIS:

Hospital Information System Preventive Health Information System Disease Surveillance System

Population Census
Surveys Other special surveys (NCD Risk Factor
Survey)

Financing of health care in Sri Lanka

Ms. Navdeep

Health Expenditures
Total expenditure on health during 2005 => Rs.

100 billion (US$1 billion)

=> 4.2 percent of GDP (of which 1.9 % was by govt., majorly on curative care) ie, 46% govt financing and 54% private financing Health services account for 8 percent of government budgetary spending.

Expenditure trends
By the mid-1950s, national health spending was

between 3.2 and 3.5 percent of GDP, of which the public share was about 60 percent From the early 1960s, spending fell, as the government faced stringent fiscal constraints, and has remained in the range of 1.3 to 1.8 percent of GDP until 2005, while private spending has gradually increased its share of total financing to more than half. Govt spends more of GDP on education, food subsidy and social welfare programs

Govt recurrent health spending

Public and Private Financing

Public financing:

general tax revenue

international development assistance (less than 5

percent). There is no social insurance. Government health spending is mostly by the central government (62 percent of public) and provincial governments (36 percent) Private financing: out-of-pocket spending by households smaller contributions from employers and individually purchased insurance, paying private hospitals, serving

Taxation
Predominantly from a mix of indirect taxes: value-added taxes and excise taxes Smaller contributions from import taxes Direct income taxes on individuals contribute to a

small fraction of revenues. The burden of paying for the half of total health expenditures that come from general revenues falls mostly on the richer households because of direct progressive taxes

Impact of economic liberalisation

A key element in the post-1977 economic

liberalization was the removal of export taxes, followed by further tax reductions. This led to a collapse in government revenues, and caused a structural fiscal deficit The fiscal deficit has resulted in and the inability of the government to increase social expenditures or to invest in needed physical infrastructure. As a consequence, government policy is now focused on raising taxes, recognizing that there is no room for more substantial spending reductions.

Private spending
Most private spending (around 80%) is for

outpatient care and for purchasing medicines, but the share of hospital spending in private outlays has increased Between 50 and 70 per cent of the private sector case load is dealt with by government doctors acting in their private capacity.

 There also exist a few fee-levying homes for the

elderly and disabled. User fee and private insurance have been tried but not found as effective as general taxation or out of pocket expenditure. Still some private insurance exists in the form of life insurance with disability coverage and elderly insurance packages

Public spending
Hospital spending accounted for about 70 percent of

government recurrent spending in the 1950s, and the share has changed little since then With respect to allocation by service type, Sri Lanka has consistently followed a strategy of allocating the largest share of its budget to hospitals (between 75 and 85 percent), and within that to inpatient care. Preventive and public health spending has averaged 25 percent or less of the budget and less than 12 percent during the past decade.

Pro- poor spending by government

Govt. spending has been pro- poor. In 2003/04 the

poorest quintile received 20 percent of government health spending; the richest quintile, 15 percent. Outpatient spending is more pro poor. Reasons for the pro-poor targeting of government health subsidies are: a dense network of health facilities that makes government health services physically accessible to the poor lack of user charges the voluntary opting-out of the rich into the private sector

 Sri Lankas health system performs very well in

protecting the poor against catastrophic financial risks associated with illness Only 0.3 percent of Sri Lankan households are pushed below the PPP$1.08 international poverty line as a result of health expenditure. In India its 3.7%.

HEALTH MASTER PLAN AND OTHER POLICY STRATEGIES

Dr.Narendra

FIVE STRATEGIES
1. To ensure the delivery of comprehensive health services,

which reduce the disease, burden and promote health; 2. To empower communities (including households) towards more active participation in maintaining their health; 3. To improve the management of human resources for health; 4. To improve health financing, resource allocation and utilisation; and 5. To strengthen stewardship and management functions of the health system

INTERREALTIONSHIP BETWEEN THE FIVE STRATEGIC OBJECTIVES

FIVE ELEMENTS OF ORGANIC HEALTH SYSTEM

THREE PROBLEM GROUPS

1.Continuing problems. 2.Emerging problems. 3.Evolving problems.

POLICY FRAMEWORK
Pillar 1: Responding to Epidemiology (Service and

System) Principle 1: Prioritisation & Characterisation of Disease Principle 2: Exploration and Development of New Strategy Principle 3: Linking and Integrating Services and Systems Pillar 2: Responding to Patients' Expectations (Culture and Care) Principle 1: Improvement of "Quality and Safety" Principle 2: Securing of "Patients Rights" Principle 3: Enhancement of "Client Satisfaction" Pillar 3: Responding to Efficacy of the System (Mission and Management) Principle 1: Be Accountable Principle 2: Be Flexible Principle 3: Be Efficient

POLICIES AND MEASURES FOR IMPLEMENTATION

Formation of an Implementation Mechanism

Platform Building for Political Commitment & Endorsement ii. Institutionalisation of the Health Master Plan iii. Social Consensus Building and Ownership iv. Formulation of Action Plans for Priority Projects v. Capacity Building for Program Management vi. Financial Resource Mobilisation vii. Monitoring of Programme Implementation viii. Organisational Arrangement for Programs Review and Monitoring
i.

SWOT ANALYSIS
Dr.P.K.Amarnath Babu 2011 HF 016

STRENGTHS
Good health at Low cost Equitable distribution and access to public health and health care Uniformly accessible education system Assurance of adequate nutrition across all segments of population Pro people health policies Equity in provisioning of health care Health care is a prime political agenda Good coordination between public and private health

care institutions Widely distributed public hospitals- no one has to travel further than 1.4 km to reach a fixed health facility Health care seeking behavior of the population- 99% of deliveries take place in hospitals Increased community participation

Strengths Contd
Only 0.3 percent of Sri Lankan households are pushed

below the PPP$1.08 international poverty line as a result of health expenditure Never relied upon disease focused resource allocation Quality of healthcare-National Guidelines for Improvement of quality and safety of health care institutions- recent Other social sectors- Education, Improved sanitation and good water source and supply MDG goals- SL on steady progress

WEAKNE SS
Progressively underfunding of health systems No human resources policy in health sector- shortage

of medical and largely paramedical staff Overcrowding in public hospitals, long waiting time, not so clean hospital surroundings Weak surveillance Health data reports from Private health care sector Inconsistency in drug supply and availability in public hospitals Pharmaceutical sector -90% import dependant

Weakness contd.
Non Availability of advanced medical treatment

modalities and lack of high end investigatory equipments in public hospitals Social sectors- Poverty and child malnutrition

OPPORTUNITI ES
Middle Income country- Economic growth Integrated intersectoral approach Better human resource policy HMIS- good data management system

Pharmaceutical sector- promoting generic

drug production within country Continued training for medical and paramedical staff External funding

Opportunities contd Integerated appraoch

THREAT S
Health transition Financial implications Commission on Macroeconomics and Health has stated that

Srilanka GDP per capita < US$ 1,200(in 1999) => US$34 per capita per year for health expenditure to provide basic adequate health services in 2007(at US$2002) Srilanka when she moves into Lower Middle income countries=> $40 per capita in 2015 (at US$2002) Health transition in terms of epidemiology of diseases Non Communicable diseases Mental illness Suicides Continuing problems- MCH related, Vector borne diseases Emerging problems HIV/AIDS, Accidents, Violence Evolving problems- Life style related, urbanisation

Threats Contd
Emerging Infectious diseases- Leptospirosis, Dengue,

Chikungunya, Typhus, Avian Influenza, SARS

Source: Emerging infectious diseases, Sirimali Fernando et al, J.Natn.Sci.Foundation Sri Lanka 2008 36 Special issue: 127-133

Relationship between Longevity and Economic growth

Population Pyramid for Sri Lanka

Male > 15 years of age- 58 % Smokers Abortion- 1,50,000 to 1,75,000 anually

Thank You
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