SriLanka

4. HEALTH RESOURCES

4.1 Human resources for health

There had been several initiatives to develop human resources for health. In the 1960s, a task force, set up by the Ministry of Health, designed a national health plan. In 1975, a health manpower study was undertaken. In the late 1970s and early 1980s, two studies, one on cadre determination of medical, nursing and paramedical personnel and other on nursing, were under taken. In 1992, a national health policy was initiated. In 1993, a study was undertaken by the human resource development council on human development in the health sector.

A perspective plan for health development in Sri Lanka (1995-2004) was formulated in 1994. The ministry of health has been implementing annual health development plans, reviewing policy and planning initiatives, training key health workers, issuing Human Resources for Health (HRH) policy guidelines, and conducting consultative meetings, among others, to develop HRH in Sri Lanka.

A study on HRH in the health sector in Sri Lanka (1993) finds that health manpower planning in Sri Lanka has been episodic and to a large extent limited in scope; health manpower development in the private sector has not been given due consideration; and the demand pattern for services and the technological changes have not been taken into account. It has recommended that the training of health manpower be vested in the education system.

Sri Lanka’s commitment to attaining the goal of health for all by the year 2000 necessitated the orientation of primary healthcare workers towards community health, restructuring training programmes and curricula to produce personnel of various grades of required skill and competencies, and training and recruiting health volunteers.

Further significant improvement in the health manpower situation for primary healthcare was an outcome of Sri Lankan strategic policy on primary healthcare approach. As a result, the Public Health Midwives (PHM) increased from one per 5000 population to one per 3000 population. There were increases in the number of Public Health Inspectors and the Medical Officers of Health/Divisional Health Officers, which made the geographic area of operation smaller than before.

There have been significant increases in the number of various categories of manpower in the public sector. The government is absorbing all the medical graduates passing out from the medical faculties. There are 6 doctors per 10,000 populations in 2006 and 14 nurses per 10,000 populations in 2006.

A wide disparity in the regional distribution of health personnel is evident. The Colombo district has a high concentration of most categories of health personnel except public health staff. In 2001, 35 percent of the specialists were concentrated in the Colombo district. The Districts of Kilinochchi, Mullativu and Mannar did not have a single specialist, and the absence of specialists in four basic clinical specialities is also noteworthy. During 2001, the Department of Health Services recruited 167 foreign qualified medical graduates.

Manpower Output in the Health Service in 2001

The precise picture on the private sector is not available. However the availability must have definitely increased, as the number of private healthcare providers has rapidly increased.

Related Links

Human Resources

Human Resources – WHO/SEARO

4.2 Financial resources for health

The government health sector takes care of healthcare needs of the vast majority of the population. The private sector in health had been small in terms of service provisions and financing. It is only recently that the private sector has been growing mostly in urban areas. The private sector contribution has been mainly in urban areas. In 1998, the total health expenditure as a portion of GDP amounted to 3.4 percent, and the government health expenditure constituted 51.3 percent of total health expenditure. The health expenditure for 2001 was Rs 22,899 million, which is an increase of 20 per cent over the previous year. This increase is higher compared with the increase in 2000 (6 percent) over 1999. During 2001, the proportion of public health expenditure on health service was 1.6 per cent of the GDP and 4.9 per cent of the national expenditure. The per capita health expenditure was increased to Rs 1,222 in 2001. In 2003, the total health expenditure as a proportion of the GDP amounted to 3.5 percent.

Recurrent Health expenditure accounted for 81 percent of the total expenditure. A major proportion of the health expenditure is utilized by the patient care services. In 2001, patient care services utilized 66 percent of the health expenditure, while community health services utilized only 8 percent. Of the balance, 22 percent were spent for general administration and staff services and 3 percent were spent on training and scholarships.

During 2001, the Department of Health Services of the Ministry of Health released the first estimates from the Sri Lanka National Health Accounts System (SLNHA). This system was developed to establish a permanent expenditure monitoring system for the country and also to meet international standards for reporting of health expenditure data. It is a framework based on the “System of Health Accounts” published by the Organization of Economic Development and Cooperation (OECD) in 2000.

Total expenditure on health (TEH) is defined to include all expenditures on personnel health services, community (Public Health and Preventive) health services and gross capital formation in healthcare providers. TEH as estimated to be Rs 28.3 billions in 1997, with per capita spending equivalent to Rs 1,530. This was equivalent to US $ 26 per capita, or 3.2 percent of GDP.

Public expenditures on health grew from Rs 5.6 billion in 1990 to Rs 14 billion in 1997. Private expenditures grew from estimated Rs 5.6 billion to 14.3 billion. Throughout the decade, government and private sources accounted for approximately 50 percent each of total financing, or about 1.7 percent of GDP.

Central government ministries and departments accounted for a growing share of total public sector expenditure during 1990-1999. The provincial councils share declined to 31 percent. The bulk of central government expenditures are from the Ministry of Health. Household (among out-of-pocket spending) accounts for the largest share of private spending (43 percent of national total), which accounts for less than 5 percent of total national spending. Personnel health services accounted for the largest share of total health spending (78 percent). In-patient expenditures accounted for 23-25 percent. Preventive and public health expenditures declined as a share of the national total from 11 percent in 1990 to 6 percent in 1999. The bulk of preventive health expenditures and most in-patient expenditures are funded by the government sector. Most private expenditures are for out-patient primary care services, and purchases of medicines from pharmacies and shops.

Each year Ministry of Health receives foreign aid in the form of money, materials, drugs, medical equipment and technical inputs. During 2001, foreign aid component of the health expenditure was Rs 501 million. This accounted for 3.6 percent of the health expenditure. This proportion has decreased over the years. The foreign aid component during 1998 and 1999 was 10 and 5 percent, respectively of the total health expenditure.

Related Links

Finance

4.3 Physical infrastructure for health

Adequate emphasis is given in the past in building physical infrastructure, including facilities and equipment, as a means of developing national healthcare system. This has lead to a countrywide, comprehensive network of health centres, hospitals and other medical institutions.

Health Facilities and hospital beds 2002

Source: Annual Health Bulletin 2001

There is no explicit, clearly laid down formal policy on development of physical infrastructure. Hospitals and dispensaries had been considered to ensure planned development and maintenance of physical infrastructure.

There is a comprehensive network of health centres, hospitals and other medical institutions located countrywide, with about 576 medical institutions with in-patient facilities and 411 Central Dispensaries in 2002 compared to 569 and 406, respectively in 2001. The national rate of beds for in-patient care was 3.1 per 1000 persons (2002). 

Related Links

PHC

Infrastructure

Provincal Health services

4.4 Essential drugs and other supplies

National Medicinal Drug Policy (NMDP)

Sri Lanka had a written/unwritten Drug Policy since 1960s. It was “written” as elements of a policy, beginning from selection of drugs for the government drug supply and the Ceylon Hospitals Formulary in early 1960s, the Bibile Wickremasinghe report in 1971, the Cosmetics Devices and Drugs Act (1980). However there was no comprehensive document.

There were attempts to develop a NMDP in 1991 & 1996; while the documents were accepted by the Ministry of Health, they did not reach the final step of cabinet approval. Hence no comprehensive document exists at present. The present effort of building upon previous efforts brings together the elements of a National Medicinal Drug Policy in one document and has been developed based on WHO documents through discussion with all stakeholders. It is hoped that this effort will see a formal National Medicinal Drug Policy being adopted by the cabinet for the country.

The objectives of the Sri Lankan National Medicinal Drug Policy are:

1.      To ensure the availability, affordability of efficacious, safe and good quality medicines relevant to the healthcare needs of the people in a sustainable and equitable manner.

2.      To promote the rational use of these medicines by healthcare professionals and consumers.

3.      To promote local manufacture of Essential Medicines.

The Sri Lankan National Medicinal Drug Policy will:

1.      be within the overall health policy of the country

2.      be based on the Essential Medicines Concept

3.      be focused on the health sector but include the relevant areas such as education, finance, pharmaceutical industry and trade

4.      safeguard the rights of the patients/consumers

An NMDP should cover all systems of medicine including allopathic, homeopathy, ayurveda, sidda, unani and any other systems recognized in the country. The primary concern of this policy is allopathic medicines; however policies for the others systems of medicines will be developed in consultation with stakeholders of those systems.

The Sri Lankan NMDP will have the following elements:

1.      Selection of essential medicines

2.      Affordability and Equitable Access

3.      Financing options

4.      Supply systems and Donations

5.      Regulation and quality assurance

6.      Quality Use of Medicines

7.      Research

8.      Human resources

9.      Viable Local Pharmaceutical Industry

10.   Monitoring and evaluation

Essential Medicine list

All drugs in the essential drug list are available in government hospitals for free of charge but uniform availability throughout the year is not ensured. Medical and paramedical professionals are educated in the use of essential drugs during their academic training. Workshops and seminars are held in order to make them aware of the essential drug concept. Local drug manufacturers are always encouraged to manufacture drugs in the essential drug list. Priority is given for essential drug list at the time of drug registration.

Rational Use of Medicine

The Ministry of Health has developed standard treatment guidelines for the treatment of major conditions in 1980s. But unfortunately, almost all the young doctors do not know about them, and hence not practised properly. Copies are not made available to them and not consulted. Therefore, most of the time, instructions are not followed.

National medicine formulary manual was printed in 1994. Public education campaigns for rational use of medicine are incorporated into the course curricula for medical students and for pharmacy students. In 2003, national legislation has been modified to implement the Trips Agreement. However, the draft bill was challenged in the courts. The courts ruled that there were sections in the draft bill which are unconstitutional. The state was requested to re-draft the bill.

All drugs on the essential drug list are available in state hospitals free of cost, but no revision in the list has taken place since 1988. An educational programme ensures that medical and paramedical personnel are informed regarding the use of essential drugs. Local manufacturers are encouraged to manufacture essential drugs, with priority given to essential drugs at the time of registration. Major constraints include the promotional activities of pharmaceutical companies towards the use of expensive brand names that have higher profit margins, and lack of knowledge among consumers. Currently, the essential drugs list is being revised and more emphasis is being given to educating health professionals and the public on the essential drugs concept.

Related Links

EDM WHO/SEARO

WHO HQ 

4.5 International partnership for health

Sri Lanka has all along been active in promoting international cooperation and partnership for health development at country level and in the region specially with members of various international organizations like WHO, UNICEF, UNFPA, JICA, JBIC, IMF, WB, ADB, etc. Sri Lanka has committed to the goals of socio-economic and health development by means of international solidarity and mutual cooperation. Financial support from external sources to health service development in Sri Lanka has been an important positive factor. During 2001, foreign aid component of the health expenditure was Rs 501 million. This accounted for 3.6 percent of the health expenditure. This proportion has decreased over the years. The foreign aid component during 1998 and 1999 was 10 percent and 5 percent respectively of the total health expenditure.

Health economics is being introduced as a management tool for more efficient utilization of resources, with more awareness creation on the critical importance of productivity. The main constraints include differing priorities at times between donors and the government, and the lack of flexibility on the part of donors to meet changing situations that would allow for mid-¬course corrections during implementation.