Sri Lanka is an outlier for achieving good health status despite being relatively poor in terms of per-capita income and investments in health. A key reason backing this achievement is free universal health coverage — a range of preventive and curative health services at zero-cost to the user.
Although, Sri Lanka’s constitution does not explicitly state health to be a fundamental right, Article 27 2c does indicate to the same. Because of this, the country has made significant improvements in social welfare (source),
· Human Development Index: 0.74
· Life Expectancy at birth: 72.5 years
· Literacy Rate: over 90%
· Declared malaria-free by WHO in 2016 (source)
It is one of the first of the less developed South Asian nations to achieve such staggering statistics.
World Health Organization (WHO) has identified six building blocks of a health system framework to achieve universal coverage and social health protection.
Assessing Sri Lanka’s current health system on these six parameters reveals that despite its stability and success, the country’s health system has a lot of ground to cover.
HEALTH WORKFORCE & ITS CHALLENGES
Sri Lanka has shown significant progress in reducing infant, maternal and child mortality rates over the past two decades:
This has been possible due to:
· Improved infrastructure of neonatal ICUs,
· Increased community awareness about sudden infant death syndrome (SIDS),
· National childhood immunization programs, and
· Increase in accessibility and quality of healthcare services.
None of this would have happened if there were no skilled care. Attendance by a trained healthcare professional at birth is crucial to prevent maternal deaths.
In 2009, the government absorbed all medical graduates into the state health system. Although, challenges persist as geographic misdistribution and insufficient facilities for staff’s training, the biggest issue is brain drain — many of these human resources leave for private hospitals and abroad for better salary and work environment.
Solution: Implementation of overall HR policy, a development plan, and a national-level organization to take the initiative in this area.
HEALTH INFORMATION & ITS CHALLENGES
A lot has been done to disseminate health and care-related information, such as workshops, compulsory education of children for primary medical health, free consultation clinics, etc., something that is left is the use of technology.
Immense pressure would be taken off the shoulders of the healthcare facilities by self-monitoring through health apps, about which there is limited to zero awareness.
Solution: A centralized electronic medical record is the need of the hour. Following the footsteps of Singapore, Sri Lanka must embrace the policy of ‘one patient, one record’, along with extensive use of smart mobile technology.
INFRASTRUCTURE & ITS CHALLENGES
A well-oiled healthcare infrastructure needs:
· Tangible health infrastructure,
· Management information system,
· Medical security and insurance,
· Emergency and trauma care,
· Human resources, and
· Substantial funding.
The way Sri Lanka’s health demographics are changing, there will soon be major health security challenges, especially for the ageing population. While there is a good network of primary, secondary, and tertiary medical care, there is zero infrastructure for the elderly care — both day-to-day and long-term.
Above all, the health centers are not trained and prepared, infrastructure wise, for potential outbreaks of communicable diseases.
Solution: Training to the existing staff, stocking of inventories, and protocol for emergent care.
HEALTH FINANCING & ITS CHALLENGES
Sri Lanka is, as per WHO, now a lower-middle income country. An improved economic status and urbanization has both pros and cons — while it elevates education and living status, it also brings in a greater demand for quality healthcare. This, in turn, is causing the people to opt for privately-funded medical care.
As per the 2005 report by Central Bank of Sri Lanka, more than 62% of outpatient care is provided by private hospitals in the Western Province. This trend would destabilize the public sector.
Since 1960s, Sri Lankan government has maintained its health budget up to 1.7% of GDP. Nonetheless, a dwindling middle-income economy and a steep rise in an ageing and informed population will force this number to increase to 2.0–3.0% if quality of care and consumer satisfaction are not to suffer.
Solution: An organizational reform along with a drastic increment in government spending.
LEADERSHIP & GOVERNANCE & ITS CHALLENGES
There is political unrest in the country from a very long time, owing to which a huge chunk of GDP goes into the defense sector. Resolving the country’s ethnic conflict will help direct a part of defense expenditures to health and education.
Till that resolve, there is a critical question that begs attention — How would an increment in government spending be afforded?
There are two options:
· Increased tax-funding for the health services, or
· Introduction of a universal health insurance system to supplement the tax-funding.
Choosing the first option means a tough time for the governance to raises taxes, while the second option calls for a major social and administrative change, for which Sri Lanka isn’t prepared.
The system, however, will be drifting this way for 5–7 years since these political pressures for change are not that pressing. Nevertheless, as soon as the conflict resolves the situation would turn emergent.
Solution: Efficient allocation and utilization of available resources to achieve more health with the same amount of money (for the time being).
HEALTH SERVICES & THEIR CHALLENGES
The country is experiencing a demographic transition, both in terms of the percentage of kind of illnesses and the population affected by them. Due to the investments made in education and health in the past decades, Sri Lanka is one of the fastest ageing countries of the world. By 2041, every fourth Sri Lankan will be above 60 years!
This will pressurize the country in many ways:
· Number of dependents per 100 working-age people will significantly rise (about 58.3 by 2031),
· Long-term care of the ageing population, and
· Heightened burden of old-age pension provision.
Next comes the fighting the infectious, non-communicable, and chronic illnesses, such as cardiovascular disease, diabetes, cancer, asthma/chronic obstructive disease, and mental illness.
Going by the above statistics, it is time to invest funds and attention in curative treatment of infections, NCDs, and chronic conditions as they are the leading causes of outpatient care.
Solution: Use the productive population in a dynamic way to increase the production of a country with the help of good policies and of course, shell out more money which is again a problem due to limited fiscal space.
THE HOLY GRAIL OF ALL CHALLENGES: The Regional Health Financing Strategy for the Asia Pacific Region by WHO
The strategy is designed to achieve a universal coverage and social protection by deploying three-dimensional resource restructuring.
Dimension 1: Breadth of Coverage (population) — In Sri Lanka, under-served areas are not able to access private care which could be handled by scaling up the primary care system.
Dimension 2: Depth of Coverage (services) — Of the country’s large health service network, most primary care institutions are idle. A re-orientation here will enhance resource utilization. If the Family Practice approach is extended to these institutions, the burden caused by NCDs and elderly care could be eased without additional funds.
Dimension 3: The Height of Coverage (cost) — The higher the individual OOPE, the lower is the population coverage. If essential medicines are made available at primary care facilities, the cost per patient will lower since primary level facilities are cheaper.
Clearly, Sri Lanka’s health system is grappling with new health challenges in form of lifestyle changes, income growth, demographical transition, finances, and new diseases. To prepare it for the future, drastic measures are required on all levels in terms of political reforms, financial policies, infrastructure, and restructuring of available resources.