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8. OUTLOOK FOR THE
FUTURE
8.1 Overall
assessment and strategic issues
Health status of
the population
The country’s health indicators show a steady improvement
over recent decades, particularly in maternal and infant mortality, and life
expectancy. The Maternal Mortality Ratio of 2.3/10,000 live births in 2000 is
an exceptional achievement for a developing country with an income level of
about US $ 800 per capita. The improvement of these
indicators are predominately attributed to the maternal and child
healthcare programme implemented nationally as an integral component of the
state healthcare system. Similarly, the Infant Mortality Rate of 11 per 1000
live births has been achieved by effective and widely accessible prevention
and primary healthcare strategies including treatment of minor infections.
However, while post neonatal mortality has declined significantly, prenatal
and neonatal mortality efforts have been less successful.
Life expectancy has risen steadily to around 75 for
females and 71 for males (1997), and the fertility rate has declined to
around 2.0 - below population replacement level. With the rapid ageing of the
population and success in combating the major communicable diseases, the
disease burden has started shifting rapidly towards non-communicable diseases
including mental diseases, accidents and injuries. The leading causes of
death (by percentage of total mortality for year 2000) are ischaemic heart disease (10.6 percent), diseases of the
intestinal tract (9.3 percent), cardiovascular diseases (9.0 percent),
pulmonary heart disease and diseases of the pulmonary circulation (8.6
percent), and neoplasms (7.5 percent). Infectious
and parasitic diseases have declined in importance, while cardiovascular
diseases and homicides have increased in a proportionate manner. In 1996,
violence (accidents, suicides and homicides) accounted for 22 percent of the
deaths, while cardiovascular diseases and diabetes accounted for another 24
percent, which indicates that the epidemiological transition is rapidly in
progress.
Nutritional status has improved but remained a serious
problem among the poorer and vulnerable communities, and even on average is
unsatisfactory. This brief analysis is based on information related to the
whole country and does not address the disparities that exist among
provinces. But when the provincial or district level figures on infant and
maternal mortality are compared, there seems to be great disparities, some of
which may be due to differential under-reporting or the referral of cases. In
particular, information on the conflict affected areas and the estates shows
significant variation among and within the provinces.
Health Policy
The broad aim of the health policy of Sri Lanka is
to increase the life expectancy and improve the quality of life. This is to
be achieved by controlling preventable diseases and by health promotion
activities. However, the concern of the Sri Lankan government is to address
health problems like inequities in health services provision, care of elderly
and disabled, non-communicable diseases, accidents and suicides, substance
abuse and malnutrition. A presidential task force was appointed in 1997 to
formulate a health policy and to suggest strategies to address health
problems and issues.
Recommendations made by task force:
 Improve one hospital in each district in a
planned manner, to reduce inequities in the distribution of services and to
provide high quality facilities to people living in remote areas
Expand the services to areas of special needs
Develop health promotional programmes with
special emphasis on revitalizing the school health programme
Reforms of the organizational structure, to
improve efficiency and effectiveness, especially in the context of devolution
Resource mobilization and management,
including alternative financing mechanisms, resource sharing between private
and public sectors, and rationalized human resource development
The government will take every effort to maximize the
financial allocations on health development to ensure provision of an
efficient and cost effective health services throughout the country,
accessible to the needy people.
Health Resources
Sri
Lanka has achieved extraordinary good
health outcomes compared to the level of spending on health. The total
expenditure on health was Rs 222 899 million in 2001. During 2001, the
provision of public expenditure on health services was 1.6 percent of the GNP
and 4.9 percent of national expenditure. The per capita health expenditure
was Rs 1 222 in 2001. Recurrent expenditure amounted 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 for general administration and staff services and 3 percent were
spent on training and scholarships.
The Ministry of Health and the Department of Health
Services (Central) utilized 74 percent of the total health expenditure. It
utilized 74 percent of the expenditure on patient care services, and 39
percent of the expenditure on general administration and staff services.
Development of
Health System
The services in the state sector are characterized by a
very busy and overcrowded system of National, Provincial, General and Base
hospitals and a widely spread network of district hospitals and healthcare
units operating at lower levels of utilisation and
occupancy.
Sri
Lanka reported 0.2 per capita in-patient
admissions in 1997. This heavy demand may be due to a number of factors
including insufficient diagnostic capabilities in lower primary care and
out-patient departments and patients being admitted when, with better primary
care, they could have been treated on an ambulatory basis. Also, it is
observed that patients bypass the lower level services keeping occupancy
rates low at peripheral hospitals, in favour of
larger city and provincial hospitals, thereby overcrowding at these
facilities. This is aggravated by an absence of clear admission and referral
policies.
The fast growing segment of private sector healthcare is
out-patient or ambulatory care. Over 36 million out-patient visits were
estimated to have taken place in 1997, an increase of 2 million over 1990
estimate. Reintroduction of private practice for government doctors, liberalisation of drug imports and service provision deficiencies
in government hospitals have resulted in the growth of private hospitals in
urban centres.
As the size of the population served varies with
population density, the volume of services planned too would vary from
institution to institution. But the services offered should be uniform with
each level of services and should be clearly known to everyone.
A primary care and curative follow-up activities with
screening of diseases and work towards patient and family-centred
promotion and prevention needs to be in place. But the scope of such
preventive facilities and the number of workers required to fulfil these tasks is not clear.
There are various branches of medicine in Sri Lanka,
which contribute to the national health. They include Ayurveda,
Siddha, Unani, and
Homeopathy and other systems of medicine. All of them collectively constitute
an integral part of the health sector and must be included in the planning
process. The development of these systems needs to be ensured by a clearer
conceptual basis for coordination of health services, coupled with adequate
resource allocation and the strengthening of existing institutions.
8.2 Future vision
Development of
National Health Objectives and Targets
The MDGs have set the agenda for
social development in the 21st century. In the health sector, it encompasses
reducing maternal mortality, under-five mortality and malnutrition, halting
and reversing HIV/AIDS epidemic and incidence of Malaria and Tuberculosis,
and provision of access to affordable essential drugs. In addition, it
targets to halve by 2015 the proportion of people without sustainable access
to safe drinking water and sanitation.
The future health scenario in Sri Lanka desired by the year
2020 encompasses the following ten dimensions.
Disease elimination/eradication
(Polio/Neonatal Tetanus/Measles/Leprosy, etc)
Mortality reduction (Mainly communicable
diseases)
Disease containment (Mainly non-communicable
diseases, HIV/AIDS and hepatitis)
Mitigation of specific concerns (Substance
abuse, alcoholism, suicide, poisoning and accidents)
Improvements in health status indicators (Life
expectancy, Infant Mortality Rate, Neonatal Mortality Rate, under-5 mortality
rate, crude death rate, maternal mortality ratio, contraceptive prevalence
rate and socio-economic productivity)
Improvement in nutritional status
Issues relating to health and environment
Health planning and management
Socio-economic aspects related to health
Improvement in health system management
8.3 Proposed
strategies
The proposed strategies for future national health
development, which will constitute a renewed commitment to health for all,
are as follows:
To consolidate the achievements in
infrastructure development, service provision and disease prevention
To meet the challenges to health posed by new,
emerging and re-emerging diseases and non-communicable/degenerative diseases,
substance abuse and environmental degradation.
To sustain the process of health development, emphasising the quality of care, and equity and
efficiency issues, particularly in the context of a free market economy
To sustain and strengthen programme planning
and management
8.4 Basic Health
Indicators including the U.N. Millennium Development Goals MDGs See
Annex-1 
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