Improving Health at Low Cost: Lessons and Challenges from Sri Lanka
Seminar on Health Developing Asia: Seizing the Opportunities
April 28-30, 1998
It is with a deep sense of humility that I accept the invitation of the Asian Development Bank to address this seminar on the success story of Sri Lanka's achievements in health care delivery to its people.
I feel proud that my country has been selected as an exemplary case in this field. It is indeed a fitting honour for Sri Lanka, in the year of its 50th anniversary of independence. I wish to sincerely express my grateful appreciation, on behalf of my government and my people, for the kind invitation extended to me by President Mitsui Sato of the Asian Development Bank and to the Asian Development Band and the World Health Organisation who have jointly organised this seminar on "Health in Developing Asia : Seizing the Opportunities". My delegation and I are deeply touched by the warm welcome given to us here in Geneva and the excellent arrangements made for our stay.
I shall now attempt to speak to you about "The Lessons Learnt and the Challenges faced by Sri Lanka in improving health at low cost".
Sri Lanka has a long history of the State undertaking responsibility for the provision of health care to the community. Ancient records show that 18 hospitals were established in different parts of the country by King Dutugamunu, in the second century BC. This tradition was kept alive by successive rulers. If I may venture here, to attempt an explanation of this special situation, I would say that it was strongly influenced by the Buddhist tradition of actively caring for the needy, the poor and the sick.
The Lord Buddha stated, in the following words :
"Yo gilanam upattheti so mam upattheti" - if you take care of the sick,you take care of me.
"Arogya Parama Labha" - Health is the prime asset.
The Buddha engaged himself actively in tending the sick, even setting up health care institutions for this purpose.
This tradition was taken over by the ancient Kings of Lanka, who came under the sway of Buddhist philosophy. More recently, the provision of health care as well as education for citizens at the expense of the state, has remained a well-established policy of all governments in the post-independence era.
This has given rise to a situation where, despite low per capita income levels of about US$ 814, Sri Lana can boast of impressive health statistics. We have seen the decline of infant mortality rates to 17 per 1000 live births (1950 - 82 per 1000 live births), maternal mortality to less than 1 per 1000 live births (1950 - 06 per 1000 live births) and we have seen the life expectancy increase from 56 years in 1950 to 73 years today. This is recognised as the best performance among developing countries and Sri Lanka can be genuinely proud of it. This figure compares favourably with richer countries showing much higher per capita incomes such as Thailand (69.5y), Malaysia (71.2y), Phillippines (67 y) and South Korea (71.5y). for a resource constrained, low income country, to have been able to lower infant and maternal mortality rates close to the levels of a developed country, is indeed impressive. As a consequence of these excellent health conditions, Sri Lanka has emerged as one of the first developing countries to complete the demographic and epidemiological transition from high fertility and mortality, to low fertility and increased life expectancy. Although Sri Lanka completed its health transition in just 50 years, it has maintained total national health expenditure at less than US$ 8 per capita per annum. A figure that is much less than in countries comprising 75% of Sub-Saharan Africa's population. This is also well below the US$ 13 cost of the World Bank's "cost effective" package of basic health services.
What then, can be the reasons for Sri Lanka's progress in health care, when compared with its Asian neighbours and other countries of similar economic background?
There are several major driving forces behind the success story of Sri Lanka. First, we believe strongly that these excellent health statistics are result of a conscious policy effort and strong commitment on the part of successive governments to invest in social development, commencing as early as 1931. The public expenditure on health care has remained stable, in the range of 1.5 to 2.0 percent of GDP, during the last 50 years. Secondly, effective health resource mobilisation strategies that used available public and private funds, while maintaining unit costs at low levels, also contributed to these results.
Since the dawn of independence Sri Lanka has launched several significant initiatives in primary and preventive health care. Which have promoted safe motherhood and safe childhood at a minimal cost, while also promoting greater awareness of primary health care. A widespread community network of Maternal and Child Health Services (MCHS), which reaches the remotest areas of the country, has been in operation for the past five decades. This network has revolved around the public health mid-wife and has achieved much success in reaching people in the peripheral areas via peripheral clinics, home-visit systems and by the involvement and active participation of the community in the delivery of health care. The high female literacy rate about 89%, well above countries such as India (36), Pakistan (23), Bangladesh (24), Malaysia (77) and Nepal (12), which we have achieved with the introduction of free education and equal educational opportunities for girls since 1948, has made more women aware of the health needs of their families. The impact of mothers education on the success of immunisation programmes, as well as other preventive health care programmes such as disease control, nutrition improvement and reproductive health, is considerable. This system of MCHS has been expanded and strengthened in the recent past, with more supervision and monitoring.
The Ministry of Health has laid special emphasis on preventive health care during the past few years. Immunisation programmes were expanded to cover the entire island; breast feeding and low-cost weaning practices are actively promoted. These, together with the awareness of good health practices among women are the contributory factors to low infant and child mortality rates. The decentralisation of disease control programmes have succeeded in eradicating deadly diseases like small pox and polio and reducing the incidence of TB and malaria, which were fatal diseases in the first half of the century. Technological advances, coupled with the proper application of control measures, are responsible for this satisfactory state.
We believe that an effective and lasting development of the health sector can only be achieved through the implementation of a comprehensive development plan for all the major sectors of the economy. Free education, the provision of subsidised housing, clean water supply and drainage systems, better access to health care through subsidised public transport and a better roads network, the provision of a social security net for the poor through income transfers and food subsidies have all contributed to Sri Lanka's success story in health care delivery.
The Sri Lankan case amply demonstrates that low income and fiscal constraints are not barriers to improving the health status of a nation. We have proved that low mortality, low fertility and decent health infrastructure can be achieved, by spending considerably less than the recommended per capita cost of US$ 13.
Another factor which has contributed to lowering the costs of health care in Sri Lanka is the wide-spread use of alternate medicine, such as the traditional South Asian system of Ayurveda and other forms of medicine such as Homeopathy and Acupuncture. These systems mainly used natural treatments with medicinal preparations based on herbs and plants, the cost effort through many long years, if we are to maintain the efficacy and equanimity of our health care system. For instance, we have to improve the maternal Child Health Services in the areas which have not performed as expected. Improvements are required in adolescent health services, the nutrition status of the mother and the pre-school child (35% of children under 5 years still suffer from chronic malnutrition). Low cost nutrition and the control and prevention if malaria, which has again raised its head inn Sri Lanka, are areas which need sustained action. The available health care infrastructure was organised to deal with the problems of a population of 14.5 million, but is now compelled to deal with a population of 18.2 million, without any considerable improvements and increase in available facilities and resources. This situation was compounded by the fact that high levels of education and the consequent health literacy and awareness, caused larger numbers of patients accessing the health system, than in many other countries.
Secondly, we are faced with new problems attendant on the higher levels of health standards which we have reached. Sri Lanka is now placed in the third phase of health transition. We now face the health problems encountered by more developed countries.
With life expectancy at 73 years, we have an evolving geriatric population that will need special facilities required by the elderly. We also have to now prepare health structures to manage non-communicable diseases such as diabetes and ischaemic heart disease, the diseases of the so called first and second worlds. We also have to address the preventable diseases typical of richer, modern societies, such as those related to alcohol abuse, tobacco abuse, narcotics and sexually transmitted diseases such as AIDS and also the evident onset of an unusually large incidence of cancer. Mental health is another area which has been grossly neglected in Sri Lanka.
The health care of many thousands of migrant workers such as those workers in industrial zones, and dealing with their occupational hazards need also to be dealt with seriously.
The greatest challenge that the Sri Lankan health system faces today, is perhaps, the whole new sphere of need that has arisen as a consequence of the 14 year long civil war, which has devastated the country. We have also to face the challenges - social, emotional and psychological, thrown up by the political terror which prevailed in the entire country from 1987 to 1991. These situations have engendered about 15000 physically disabled people, about 150,000 refugees, fleeing the areas of conflict and an untold number of young children, wives, mothers and relatives emotionally traumatised by the violence of losing a loved one, in addition to another large number of children and adults suffering the traumas from the experience of living through generally troubled and violent times. This is an area which was not even thought of until last year, when my Government set up special committees to study and recommend action programmes, to manage these vast and most frightening problems that nay modern society has been called upon to deal with. My government fully realises the dangers that this latently explosive situation could pose for a nation struggling to rebuild itself on a new foundation of a strong and prosperous democracy, where all its different peoples could live in peace and harmony, in one united and strong country. The dangers that could be wrought by mainly traumatised and emotionally stunted people, even though they may be a minority, could be terrifying, as demonstrated over and over again by human history. We are only beginning to seize fully, the nature and scale of this problem, in order to evolve new systems to deal with it urgently. We would need much assistance from our friends in international organisations and other countries.
Thirdly, we have also to face the problems and challenges caused by an ageing administrative system, unadapted to modern needs and corrupted, by an all too fast propulsion into a free market economy, without having in place the safeguards required to protect the existing structures and the traditional and cultural ethos of a people. A heavy bureaucratisation of the health care system, undue political interference, a pervasion of the corruption and the rush for self-aggrandisement, prevalent in the state sector, resulted in a distinct, overall deterioration of the quality of the public health service in Sri Lanka.
With the objective of improving the quality of health services, existing clinics, dispensaries and laboratories in the provinces will be improved in an equitable manner.
The facility of a fully equipped hospital, with all requisite resources presently available in the nine provinces of the country, will be extended to all the 24 districts.
A few centres of excellence with sophisticated equipment, intensive care and surgical facilities will also be set up.
These facilities will then be accessible to a patient from the remotest area, within a short space of time, as the district hospitals would be accessible from any point of the said district within 3 hours.
A corporate health care delivery plan is being formulated. This will incorporate all the existing health sectors and define their respective roles within the national health care system.
The state sector, the private sector, and the traditional medical systems will form an integral part of the health care network while the role of each one of these sectors will be clearly defined.
The unequal distribution of health care personnel and resources will be dealt with.
We will also address the need for an improved system of data collection, dissemination and monitoring of performance.
An effective referral system from the remotest periphery to the larger hospitals and centres of excellence will be formulated.
A new institution - the Commission for National Health, will be created for the purpose of formulating national health policy and ensuring that the needs of the provinces will be properly addressed, in addition to the co-ordination of implementation between centre and the provinces. This Commission will be the supreme advisory body on health policy of the Government. It will consist of representatives from the centre and the provinces.
The government has recognised that no improvement in the health care system would be possible unless a vast change of attitudes can be achieved among the doctors and health care personnel within the state sector. The lack of commitment to a patient, the indifference, the lassitude and corruption is much more striking when it concerns the life of a patient, than when it concerns the dealings of any other public servant with his client. The government has designed a scheme of proper appraisal for medical personnel, as well the health care institutions within the state sector. This together with radical changes sought to be effected in the entire educational system from primary school to university where attitudinal changes would take high priority would, it is hoped, give the desired result of a more dedicated and more efficient corpus of medical personnel in Sri Lanka.
Excellencies, Ladies and Gentlemen
It is true that Sri Lanka has achieved many victories in the health sector. But as I have attempted to show you, the problems we have to solve are many and the new challenges we are called upon to face are daunting. I am confident that the special circumstances which helped us achieve the past successes, will now spur us on to meeting the new challenges, with the characteristic courage, commitment and talents of our peoples. As we march into the new millennium, Sri Lanka will strive with added resolve to continue as a model of success, in taking care of the health needs of its people. I am confident that we can continue to count on the understanding and support of the ADB, WHO, the other international organisations, the non-governmental organisations and of course the unstinting support of our friends in governments abroad.
I thank you.