INTRODUCTION Naveen Shandilya

2011 HF015PHHP

HEALTH SYSTEM OF SRI LANKA

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

yrs. (male); 77 yrs. (female).StatisticsTotal population 20,238,000 Gross national income per capita (PPP international $)- 4,460 Life expectancy at birth m/f (years) - - 73/77Probability 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

4

Sri Lanka is demarcated

into

Administrative hierarchy

of 9 provinces,

25 districts,

325 Divisional Secretariat

(DS) divisions

14,009

Grama Niladhari (GN)

divisions.

Lankan GeographySri Lanka is Located in South Asia, Sri Lanka is an island in Indian Ocean positioned about 18 miles off the southeast coast of India. http// www.123independenceday.com

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. http//www.123independenceday.com

Almost 40% of Sri Lanka constitutes lush tropical forests. This island has an abundance of natural resources. Climate of Sri Lanka includes tropical monsoons

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.

http//www.123independenceday.com

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 tea, rubber and coconut being important exports.

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 healthas 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 2000-2003and 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 IMR

1935 246

1950 80

1970 50

1991 2003

17.2

11.2

(Statistical Pocket Book – 2004, Department of Census and Statistic, Colombo, Sri Lanka)(Statistical Pocket Book – 2004, Department of Census and Statistic, Colombo, Sri Lanka)

YEAR LIFE EXPECTANCY AT BIRTH( YEARS)

1946 43

1981 70

1991 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 1505-1656 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 ofSri 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 Homeopathy.

Sectors

+Others

++Indigenous

++Western

PrivateGovernment

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 Lankahealth system

Objectives of healthcare sector are (1) To improve health

(2) To prevent povertyGovernment pays for most inpatient careDual systemPublic sector hospitals and preventive services -Free of charge, no user feesPrivate sector doctors and hospitals -Not free - patients pay feesGovernment doctors can work in private practice

after work hours and charge fees for the same

Dual system

Source: Annual Health Bulletin 2001

Making Healthcare Accessible to the PoorZero user feesPatients may have to buy drugs, but poor are

often protectedHigh density of facilities in rural areasHealth facility within 2 miles of most villages

Rural facilities are staffed by qualified doctors supported by nurses

Accessible tertiary careLarge budgetary allocation to secondary hospitalcare - poor patients entitled to “expensive” care

Private Practice byGovernment DoctorsFirst introduced in 1860sProblem: How to pay for government doctorswhen government cannot afford BenefitsDoctors can supplement low wages, but don’t

leave public sectorPoor people can still see the doctors in public

clinics for free, and rich people can pay to see them outside

ProblemsDoctors can break rules - needs strict

enforcement

Concept of Preventive Health CareSri 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 Ayurveda2)National Institute of Traditional Medicine3)Bandaranaike Memorial Ayurveda Research Institute4)Ayurveda Medical Council5)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 12.7% and Unani 2.7 %.

(Source- Ministry of Indigenous Medicine, Sri Lanka)

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 technologyTo 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 SystemPreventive Health Information SystemDisease Surveillance SystemPopulation CensusSurveys Other special surveys (NCD Risk

Factor Survey)

Ms. Navdeep

Financing of health care in Sri Lanka

Health ExpendituresTotal 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 trendsBy 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 FinancingPublic financing: general tax revenueinternational 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 top quintiles

Spending by nongovernmental organizations (NGOs) is around 1%.

TaxationPredominantly from a mix of indirect taxes: value-added taxes and excise taxesSmaller contributions from import taxesDirect 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 liberalisationA 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 spendingMost 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 spendingHospital 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 Lanka’s 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%.

Dr.Narendra

HEALTH MASTER PLAN AND OTHER POLICY STRATEGIES

FIVE STRATEGIES1. 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 GROUPS1.Continuing problems.

2.Emerging problems.

3.Evolving problems.

POLICY FRAMEWORKPillar 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 Mechanismi. 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

Dr.P.K.Amarnath Babu2011 HF 016

SWOT ANALYSIS

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

WEAKNESS

Progressively underfunding of health systemsNo human resources policy in health sector-

shortage of medical and largely paramedical staffOvercrowding in public hospitals, long waiting

time, not so clean hospital surroundingsWeak surveillance Health data reports from Private health care

sectorInconsistency in drug supply and availability in

public hospitalsPharmaceutical 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

OPPORTUNITIES

Middle Income country- Economic growthIntegrated – intersectoral approachBetter human resource policyHMIS- good data management systemPharmaceutical sector- promoting

generic drug production within countryContinued training for medical and

paramedical staffExternal funding

Opportunities –contdIntegerated appraoch

THREATS

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 diseasesNon Communicable diseases Mental illnessSuicides

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

QUESTIONS????

Thank You