It is important to take note of these achievements as well as residual and new challenges. This is crucial because Sri Lanka is at a transition stage. Its demographic, epidemiological and public health demands are evolving. That aside, after 30 years of conflict, it is beginning to rebuild its economy and looking towards a sustained peace dividend. Inevitably, this will lead to changes that would have implications for its health sector as well.
Sri Lanka is unusual among developing countries in that it has a robust public health network, with more than 1,000 institutions across the country. Most Sri Lankans live within three km of a public health facility. While there is a system of primary and referral facilities, in practice patients are free to go to the institution of their choice and the one that is most accessible. This is remarkable even when compared to developed and Western countries that have widespread public health systems.
Tellingly, it is rooted in Sri Lankan tradition. The chronicles of King Dutugemunu, dating back to the second century BC, document the creation of a nationwide network of 18 hospitals. This is among history’s earliest records of planned public-health infrastructure augmentation and capacity building.
Much of Sri Lanka’s gains in the health sector have been the result of focused and intelligent government spending. Public outlay on health amounts to 1.7 per cent of GDP (2008 figures). This is significantly higher than the 1.3 per cent of GDP average for South Asia and also places Sri Lanka as among the better performing of the 11 countries of the World Health Organisation (WHO) South-East Asian Region.
While this is a solid base to build on, it needs to be recognised that the future trajectory of public health issues in Sri Lanka might deviate from the known path. This would be triggered by social and economic evolution, new compulsions and the changes in people’s needs. Much of what Sri Lanka goes through in the coming years, in health and medical as well as economic and social transitions and its responses to these, would offer lessons for its neighbours and other nations that are similarly placed.
For a start, there is the accelerated rise of the private sector as a health-care provider. While public/government spending on health is a strong 1.7 per cent of GDP (as we saw earlier), it is matched and even bettered by private sector spending (1.8 per cent of GDP). Gradually a pattern is emerging. The public sector appears to dominate inpatient provision (over 90 per cent). The outpatient burden is seeing an expanding role for the private sector, concentrated in urban areas.
This has implications for health financing, especially in a society that has pioneered a “health for all” approach paid for by tax revenues and managed by the state. Long waiting times in public health facilities – not unknown in other parts of the world either – the quicker availability of new technologies developed elsewhere, the propensity of people to seek direct specialist care, even without primary referrals, is increasing out-of-pocket expenses.
This process is being pushed ahead by rising incomes, following recent years of economic growth. As a consequence, equity, one of the cornerstones of the public health policies of the Sri Lankan government, is starting to come under pressure. How this is addressed by Sri Lankan health authorities would be enormously educative for other countries.
Like many other emerging and newly-independent nations in the second-half of the 20th century, Sri Lanka worked hard to address communicable diseases and vaccine preventable diseases. Today, though, non-communicable diseases (NCDs) are the leading killers. Urbanisation, lifestyle transformations and related factors are causing a surge in cases of cardiovascular diseases, diabetes, various cancers and carcinomas.
Even so, communicable diseases have not ceased to be a threat. While the number of mortalities may be small, Dengue, Leptospirosis and Tuberculosis remain a problem or have encountered a recrudescence. In the recent past, Sri Lanka has also felt the impact of disease epidemics such as the H1N1 Influenza outbreak. A greying population points to anticipated gaps in areas such as rehabilitation, medicine and geriatrics.
Sri Lanka has done well in respect of the Millennium Development Goals and reduced its infant and maternal mortality rates sharply. Nevertheless maternal and child under-nutrition are noticeable. One in six children born in the country is of low birth weight, a predicament that could have long-term physical and cognitive consequences.
This set of emergent challenges will require inter-sectoral collaboration (to neutralise for example the phenomenon of under-nutrition), meeting human resources lacunae (among others for care-givers and specialists who can work with the significant elderly population), and pursuing an information and communication programme that would stress the cheaper option of NCDs prevention rather than the more expensive one of NCDs treatment.
To be fair, the Sri Lankan government is alive to these realities, and is putting in place mechanisms to meet them. The efficacy and success of these mechanisms would be closely watched. When it set up an exemplary basic health-care system, Sri Lanka constructed a template for other developing countries. Now, as it copes with the health implications of its many parallel transitions, it has a chance to repeat history.
The author is a noted international public health specialist and former Deputy Regional Director, WHO South-East Asia Region