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5. DEVELOPMENT OF
THE HEALTH SYSTEM
5.1 Health policies
and strategies
The broad aim of the health policy of Sri Lanka is
to increase life expectancy and improve quality of life. This is to be
achieved by controlling preventable diseases and by health promotion
activities. The concern of the Sri Lankan government is to address health
problems like inequities in health service provision, care of elderly and
disabled, non-communicable diseases, accidents and suicides, substance abuse
and malnutrition.
The president appointed a presidential task force in 1997
to formulate a health policy and to suggest strategies to address health problems
and issues. The policy addresses the need of expanding services to people
with special needs (the elderly, disabled, victims of war and conflict,
occupational health problems, mental health services). It also focuses on
resource mobilization and management, including alternative financing
mechanism, resource sharing between private and public sectors, and
rationalized human resource development. The thrust areas will be addressed
through western, Ayurvedic and all other systems of
medicine. The government will take every effort to maximize the financial
allocations on health development. This will enable the government to provide
an efficient health service throughout the country, accessible to the needy
people.
Millennium
Development Goals
The progress made towards achievement of health related MDGs is given in Annex-2
Related Links Health Policy Strategic
Frame Work Health System – WHO Srilanka Health Policy – WHO/HQ
5.2 Inter-sectoral
cooperation
The National Health Policy of Sri Lanka clearly identifies
inter-sectoral action for health as an important element in the health
development process. A national health council presided over by the prime
minister has been established. It is supported by a national advisory
committee, and task force of experts deal with specific health concerns. A
secretariat has also been established to coordinate NGO activities.
Inter-sectoral action has influenced the health status of
the people positively in most instances. Making the health related sectors
and their contribution for health transparent has paved the way for
developing new strategies and timely decision-making for improving health
sector, resulting in health development. There is no direct evidence to say
that inter-sectoral action has negative influence on the health status of the
people. But there are experiences of motivation for health staff, where NGOs
pay them for new projects whereas government is unable to do so.
A constraint to inter-sectoral coordination has been the
weak horizontal linkages between health related ministries and the Ministry
of Health, as well as the lack of appreciation of importance. New Strategies
that have proved successful were in the integration of healthcare into rural
development projects and programmes.
The creation of the Civil Medical Department under a
Principal Civil Medical Officer (PCMO) in 1858 can be considered as the
beginning of the health service in Sri Lanka. The department
initially concentrated on establishment of new hospitals in large towns. Then
the primary care facilities at the village level were initiated in 1877.
Initially preventive medicine was confined to measures aimed at preventing
spread of major communicable diseases. The concept of establishing specialised campaigns for the control of major diseases
was initiated by the Rockefeller foundation, which was the first international
organization to assist Sri
Lanka’s health services.
Following the declaration of Alma-Ata
in 1978, Sri Lanka
signed the charter for Health Development in 1980 for achieving the goal of
Health For All by the year 2000, adopting a strategy for primary healthcare.
A health development network for Sri Lanka was established in
1980, which comprises the National Health Council chaired by Prime Minister;
the National Health Development Committees chaired by the Secretary, Health;
and the District Health Development Committees chaired by the district
minister.
With the introduction of provincial council system in
1989, the entire Provincial, District and Divisional level administration was
restructured. With the devolution of powers and functions to the provincial
councils, several functions have been transferred to the Provincial
Ministries of Health. Management of all healthcare institutions, other than
teaching hospitals and field services, is the responsibility of the
provincial councils.
Further decentralization of powers was introduced in 1992
by appointing Divisional Directors of Health Services (DDHS) to provide
comprehensive healthcare to a population ranging from 60,000 to 80,000. The
Provincial Director of Health Services (PDHS) supervises the DDHS administratively.
Full financial control is delegated to the DDHS from the Provincial Health
Directorate to implement the health activities.
In 2001 there were 25 Deputy Provincial Directors of
Health Services (DPDHS), to assist the eight Provincial Directors of Health
Services. DPDHS areas are similar to administrative districts, except for Killinochchi DPDHS area, which is amalgamated with Mullativu and Ampara districts
subdivided to form two DPDHS areas: Ampara and Kalmunai.
In 1999, the Ministry of Health was restructured, which
resulted in the separation of the Department of Health Services from the
Ministry of Health. The Director General of Health Services heads the
Department and has immediate support from Deputy Directors General (DDG) of
Health, each in charge of a special programme area. They have, under their
jurisdiction, a number of Directors responsible for different programmes and
organizations.
Related Links WHO
Organization Structure Department of Health Services Logistic Division Admin Management and Planning Division
Structure of
Private Health system
Private Health System consists of Allopathic (Western), Ayurvedic, Siddha-Ayurvedic, Unani-Ayurvedic, Homeopathy and Acupuncture streams. But
over 80 percent of the population seek western medicine stream when they are
sick. The Western Private Health
Sector consists of large hospitals with all the finer specialities
including open heart surgeries, medium size hospitals with basic specialities (General Surgery, General Medicine, Paediatrics, Obstetrics and Gynaecology
with operation theatre facilities) and small hospitals with MBBS qualified
doctors who are catering for Obstetrics, General Surgery, General Medicine, Paediatric services, etc. In addition to these hospitals,
there are large numbers of “Channelling Centres” that serve as ambulatory care clinics conducted
by government doctors at off-duty hours. There are over 750 registered
General Practitioners (with MBBS or more qualifications), conducting day and
night clinic service. There are large numbers of laboratories and pharmacies
in the private sector to cater for the needs of laboratory investigations and
drug dispensing.
Private-Public
sector linkage
The private sector will be encouraged to develop with a
view to providing a good quality health service, especially for those who can
afford. New regulations are underway to promote and regulate the private
health sector in the country in order to provide good quality treatment for
sick people.
Careful cost effectiveness studies will be carried out
comparing acquisition and use of technology with purchasing of services from
the private health sector for state sector patients, thus encouraging
private-public partnership. The state sector will be encouraged to pilot such
partnerships.
Referral system and
its efficiency
Although there is a referral system in the government
health sector, its practice is not proper. Bypassing of facilities is a very
common phenomenon and all the secondary and tertiary care centres
are overcrowded while primary care institutions are under-utilized. Several
studies have been carried out to establish a good referral system, but
without success. The main obstacle is that there is no clearly demarcated
geographical area or a draining population for hospitals in the country.
Also, the very relaxed admission policy of the government hospitals
contributes to a greater extent for poor referral system in the country.
The constraints have been the shortage of experienced
medical staff to take on the positions of Divisional Directors of Health
Services (DDHSs) and the paucity of financial
resources for improving physical infrastructure and for providing supplies
and equipment.
Related Links Medical
Services Lab services Health
System – WHO/SEARO
5.4 Managerial
process
The managerial process for health development has been in
place at different levels of the administration. The Ministry of Health is
responsible for developing health policy, management of tertiary hospitals,
special programmes and teaching hospitals; bulk purchase of pharmaceuticals
and equipment; personnel administration of doctors and dental surgeons;
enforcement of regulations concerning health; providing guidelines on
administrative and professional matters; mobilization of resources; and inter-sectoral
and international coordination in health matters.
At provincial level, mechanisms for policy planning,
coordination and development are in place.
The main constraints are inadequate inter-sectoral
coordination in planning and programme management.
Related Links Ministry
of Health Departmental of Health Services
5.5 Health
information system
The national Health Information System (HIS) consists of
following subsystems:
 Maternal and Child Health Information System
Epidemiological Surveillance System
Hospital Information System
Special Disease Surveillance system
Public Health Information System
Human Resource Information System
Administrative Information System including
healthcare financing systems
Vital registration system for births, death
and marriages
Although there are several components in the national
health information system data recording, collection, and compilation at
institutional level and transmission are done using manual paper based
systems. Data analysis is done using computers, only at national level
institutions.
The Health Information Centre (HIC) of the Management
Development and Planning Unit of the Ministry of Health has
developed four different software programmes for Hospital Management, Human
Resource Management, Drugs and Logistics Supply Management, and to manage an
Office of the Medical Officer of Health. Also, the HIC has established a
dedicated e-mail service and web service for the ministry and is planning to
establish a Wide Area Network (WAN) for the government health sector
connecting all provincial, district, and divisional offices and large
hospitals to the Ministry of Health using “Internet Protocol – Virtual
Private Network” (IPVPN) technology. The planned IPVPN will be the
information super highway of the Ministry of Health during coming years.
The appointment of a Director for Health Information has
administratively strengthened the process of HIS development. A steering
committee has also been set up to network institutions and programmes for
data collection, analysis, use and feedback.
Related Links Process and Performance Report
5.6 Community
action
National Health Policy recognizes community participation
as an important component of the health development process. Health
volunteers have been used to assist health department personnel in the work
situations, especially in the rural set up. Another positive contribution
made through community action is the improvement or strengthening of
activities for early childhood development. Apart from the contribution made
by community involvement for improving health service provision,
infrastructure facilities for health service delivery have been provided by
community action in some areas. In addition, maintenance of medical care
institutions also has been done through community participation in certain
areas.
In cases of natural or man-made disasters, community
action has contributed to healthcare delivery. Initiations of emergency blood
donation campaigns, supply of drugs and basic amenities, food, water,
clothes, etc., have contributed to government efforts and also have saved lives
of people. But the tendency of people to give priority to material comfort
and hence the need for more and more money for personal living has created a
vacuum in some areas where health volunteers used to contribute a lot.
The Government has taken some measures to obtain community
participation effectively. They are:
Establishment of Village level health
committees, Divisional level committees and District level committees.
Establishment of Hospital Committees to
support, monitor and evaluate the healthcare facilities available in the
local hospital. This activity has paved the way to strengthen infrastructure
facilities in the local hospitals in some places.
Use of mass media to highlight positive and
important contributions made by the community for betterment of their health
status. This type of publicity tends to stimulate others for provision of
food supplement.
Promotion of parent/teacher participation in
school health activities.
Appointment of Samurdhi
animators who are the members of the same locality to identify problems and
to find ways and means of resolving them.
5.7 Emergency
preparedness
The government of Sri Lanka has a set of guidelines
issued to the different departments and agencies at different levels. A
multi-sectoral emergency preparedness committee is in place and guidelines
have been issued. A multi-disciplinary health emergency management committee
is also in place and guidelines for emergency preparedness in the health
sector have been issued. Emergency preparedness training and education
programmes are ongoing activities.
A national multi-disciplinary health emergency management
committee is in place chaired by the Deputy Director General (Medical
Services). There are committees at other levels of the administration. Every
teaching, provincial and base hospital has a disaster management committee. A
circular setting out the guidelines for emergency preparedness in the health
sector is available to all institutes. All medical institutions in conflict
areas are well prepared in terms of drugs, manpower and other service
provisions to manage health emergencies.
Related Links Tsunami Annual Health Bulletin EHA-
WHO/SEARO EHA-
WHO/HQ
5.8 Health research
and technology
The promotion and development of research is a
prerequisite to overall national development of any country. The importance
of health research as a strategy for improving health services has long been
recognized in Sri Lanka.
Many individuals, institutions and organizations have been engaged in health
research over the years. With the increasing realisation
of the positive contribution that research can make towards health
development, research activities have been expanded considerably during the
last few years.
Medical Research Institute (MRI), which is situated in Colombo, is responsible
for carrying out biomedical research. The institute deals with clinical
biochemistry, microbiology, virology, parasitology,
entomology, rabies diagnosis, vaccine production and laboratory technology.
The faculties of medicine in the universities also carry
out biochemical, clinical and epidemiological research. Clinicians in major
hospitals also carry out clinical research. Various units under Ministry of
Health and other related ministries carry out limited research in their
respective areas (e.g., Family Health Bureau, Epidemiology Unit, and Specialised Campaigns).
The trainees attached to Post Graduate Institute of
Medicine conduct research as requirement for their postgraduate degrees.
There are many institutes other than health sector that conduct research on
health related issues (e.g., Ministry of Environment, Institute of
Fundamental Studies, Central Environment Authority, Family Planning
Association, National Water Supply and Drainage Board, etc.).
The Health System Research (HSR) programme of the Ministry
of Health was established at the National Institute of Health Sciences
(NIHS). The objectives of the HSR programme were to implement, coordinate,
monitor and evaluate a programme of research on priority health problems;
provide technical and financial assistance; disseminate research findings;
and ensure that such findings are implemented.
The National Resources, Energy and Science Authority
(NARESA) promote health research by awarding grants and disseminating
research information. A separate unit (Education, Training and Research Unit)
to promote health research is established at the Ministry of Health under a
Deputy Director General of Health Services. Priority areas of research are
updated regularly and informed to the prospective researchers and research
institutes.
The main constraints have been inadequate funding, minimal
health research utilizing a multidisciplinary and inter-sectoral team
approach, inadequate dissemination of information, and under-utilization of
research findings.
Related Links Training and Research NIHS Research – WHO/SEARO Research-
WHO/HQ 
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