Healthcare absorbs a major part of public and private expenditure in almost all countries around the world. In some developed countries, it hovers around 15% of the GDP. The increasing cost of healthcare provision is partly a reflection of growing commercial interests in healthcare and partly the result of the increasing cost of labour, medical technology and pharmaceuticals. The expansion of the health sector has undoubtedly led to improved quality and choice of healthcare services, though increasing costs have also imposed greater economic burdens on end users of such services. Even though various risk sharing arrangements such as national and private health insurance schemes have cushioned patients and their families against prohibitive health costs to a great extent, the cost of health insurance itself has become a significant burden on low-income groups in some countries.
As is well known, the provision of basic healthcare to citizens by the state free of charge has ensured almost universal access to at least basic health facilities in all parts of Sri Lanka. Yet inadequate public investments in the health sector in a context of increasing cost of labour, equipment and drugs have resulted in poor quality health care, overcrowding of large hospitals and inadequate services in rural areas. The situation changed often for the worse when private healthcare providers emerged following the introduction of liberal economic reforms in 1977. The rise of the private health sector enabled the well-to-do patients to rely entirely on private healthcare services, relegating the poor to often poor quality public health services.
The result is a widening gap between private and public institutions in terms of the availability and quality of health facilities. This has encouraged even non-affluent patients to rely on private providers, at least for out-patient treatment and routine medical tests. This is clearly evident from official statistics on in-patient and out-patient treatment in the country. In the absence of affordable private or public health insurance, out of pocket expenses incurred by patients have become a severe burden on households. Yet, many people do not see an alternative as publicly provided health services are often inadequate and unsatisfactory.
It is unrealistic to expect any significant increase in public expenditure in real terms in the near future for economic and political reasons. The present public finances in the country do not permit large additional allocations for the social sectors like health and education unless there is a major reallocation of public resources across different sectors of public investment. Given the current development thinking and political priorities, it is unrealistic to expect any major shift in a way the public resources are allocated across different sectors. In other words, socially important sectors such as health, education and social protection are unlikely get priority treatment. Given this situation, it is necessary to figure out what sort of reforms are feasible in order to improve the performance of the health sector. An attempt is made below to identify and list several areas that can be strengthened with minimal additional resources. These can be outlined under the following topics:
Optimal use of existing resources within the health sector
Mix of health care institutions
Relationship between public and private institutions
Role of health insurance and nInter-sectoral action to deal with health issues
As mentioned earlier, private providers of healthcare play a significant part in the health sector today. Though they make use of many medical specialists attached to public institutions, private healthcare institutions are run entirely as private enterprises. Patients usually have to pay fees upfront and often do not get such expenses reimbursed as they are not covered by health insurance. This situation restricts private residential care to a small minority of affluent patients or those who are covered by limited private health insurance available in the country. This is a major constraint to the expansion of private healthcare institutions. What is also noteworthy is the absence of private but non-profit healthcare institutions in the country.
It is necessary to go beyond the present duality between private and public healthcare institutions and diversify the institutional mix in the health sector. The establishment of healthcare institutions as non-profit, social enterprises and the introduction of affordable health insurance schemes could potentially facilitate the expansion and diversification of healthcare facilities leading to optimal mobilisation and utilisation of resources in the sector for the benefit of patents belonging to all social strata. The present polarisation between public and private healthcare institutions is neither rational nor socially just.
" Yet inadequate public investments in the health sector in a context of increasing cost of labour, equipment and drugs have resulted in poor quality health care, overcrowding of large hospitals and inadequate services in rural areas "
As is well known, Sri Lanka does not have a systematic referral system. It is not mandatory for a GP to refer a patient to a specialist, particularly in the private sector. So, most patients go direct to specialists, thereby creating long waiting lines at private consultation rooms. Moreover, patients are not well distributed among GPs as the spatial distribution of GPs is not regulated. Many patients do not go to the same GP on a regular basis and, as a result, the management of case loads is not done in a systematic fashion. As is well known, the services provided by GPs are critically important for the health system in terms of treatment, monitoring and follow-up of cases. GPs provide a critical link between the community and the healthcare institution. If the patients first go to a GP, the number of patients turning up at specialist consultation rooms will be drastically reduced, allowing specialists to allocate more time for patients. Yet, such a system can work only if realistic fee structures are worked out and patients are covered by health insurance that reimburses most of their out-of-pocket expenses.
An overall reduction of the disease burden in a country is critical for the effective functioning of a modern healthcare system. In other words, disease prevention through inter-sectoral action needs to be elevated to a higher level goal of the health sector. The measures needed to be taken go beyond the health sector and involve inter-disciplinary collaboration in research, policy formulation and programme development and inter-sectoral collaboration in public health, occupational health, environmental management, housing, sanitation, transportation, accident prevention, alcohol prevention, etc. Sri Lanka’s recurring Dengue epidemic is a clear case in point. So are widespread alcohol abuses, increasing traffic accidents, suicides and increasing non communicable diseases and inter-personal violence.
Public expenditure on health in this country remains less than 2% of the GDP, though private expenditure has also been increasing. Given such a low level of expenditure, the achievements in terms of positive health indicators are noteworthy. Yet, the day-to-day experience of ordinary citizens with respect to availability, accessibility, affordability and quality of healthcare is much to be desired. While allocation of more resources coupled with institutional improvements can go a long way in improving healthcare services, there are many other measures that can also make a significant difference. This essay has touched on some of these measures which need further analysis. Continuing to boast about our achievements in health while being complacent about persisting issues is not the way to go about improving the quality of healthcare and health outcomes for all Sri Lankans, not just the rich and the powerful.