Sri Lanka: Health System Enhancement Project

Health / Disease control of communicable disease - Health sector development and reform

Sri Lanka has made impressive gains in ensuring access and quality to health services for all. Life expectancy at birth increased to 75 years in 2015 from 70 in 1990. Maternal mortality reduced from 75 to 30 per 100,000 live births and infant mortality from 17.9 to 8.0 per 1,000 live births during the same period. Sri Lanka has achieved these efficiently with low overall health spending at 3.0% of gross domestic product (GDP). Most vaccine preventable diseases are at near elimination stage with immunization coverage at about 99%. Sri Lanka has been polio-free since 1994, and malaria- and filariasis-free since 2016.

While Sri Lanka has benefited greatly from improvements in health outcomes during the Millennium Development Goals period (1990 to 2015), it is facing new health challenges related to population aging, changing disease pattern, economic and social changes, and changing lifestyles. These dynamics have resulted in a dramatic increase in noncommunicable diseases (NCDs), which are causing a surge in demand for health services and an increase in health care costs while reemerging and emerging communicable diseases remain a threat. Disparities in health outcomes, health-seeking behavior, life expectancy, and disease burden remain in lagging geographic areas especially in rural and estate sector populations, e.g., malnutrition in mothers and children is a persistent health issue and more acutely seen in the estate sector. The country is now more exposed to communicable diseases because of increased labor mobility and connectivity. Sustaining control of vaccine preventable diseases, malaria elimination efforts, and containment of global diseases will require continuous investments in the prevention and control of communicable diseases and disease surveillance in Sri Lanka.

Primary health care delivery system. The public PHC system in Sri Lanka has been instrumental in providing universal comprehensive care at no cost to the population at the point of service delivery. One of the most characteristic features of the system is preventive health care services focusing on communicable diseases control and maternal and child care. The system covers 341 geographic areas, each with a population of about 80,000. Each area is managed by a medical officer of health and served by 5 -10 field health centers with midwives, public health inspectors, and preventive health care staff. In parallel, there is an extensive network of curative services in three tiers of care (955 PHC hospitals and dispensaries, and 149 secondary and tertiary health care hospitals). The government health sector provides as much as 90% of inpatient care, nearly 100% of preventive care, and 50% of outpatient care. At present, the health system planning, policy, and stewardship functions are centrally managed while management of primary and most secondary health care services is decentralized to provincial governments.

Constraints. Since 1990, changing health challenges and population aging led to secondary and tertiary health care services being prioritized for investments at the expense of investments for primary curative and preventive care services. Deterioration of PHC facilities led to bypassing of primary curative care services for secondary and tertiary care for most health problems faced by the population. For example, secondary and tertiary health care today manage as much as 93% of childbirths, 75% of NCD patients, and 50% of outpatient services. On the preventive side, the medical officers of health continue to provide antenatal care, nutrition, and immunization services. However, the quality of services decreased because of lower investments (about 4.5% of public health spending), inadequate staffing, and other resource constraints. Expanded outreach and interventions for populations living in vulnerable and lagging areas are also hampered. Preventive health care services are limited to mothers and children and village environments. There is a need to expand the target group to include the total population (children, youth, adult men and women, and elderly) and expand coverage of NCDs.

Government initiatives. The Government of Sri Lanka is reprioritizing PHC in line with its national health policy and strategic master plan. Sector reforms aim to establish a more responsive, patient-centered, and person-focused health care system. The system will enable health seekers to access a comprehensive package of essential health services including financial risk protection. The government's most recent policy on rational health care delivery for universal health coverage provides the guiding framework to reform the existing PHC system.

The government is committed to develop a more comprehensive, accessible, and higher-quality PHC package to strengthen PHC services, reduce bypassing, and reach vulnerable groups. It is also committed to implement e-health to strengthen evidence-based health services. This includes scaling up the introduction of a patient e-health card, connecting health services for referral and better patient care, and improving information on diseases and health-seeking behavior using a geographical information system (GIS). The system will be linked to disease surveillance for national health security. To comply with International Health Regulations standards, the government aims to strengthen the health assessment of migrants and quarantine services at ports of entry (POEs). In support of efforts to strengthen PHC and the digital health information system, policy developments are in preparation for the essential services package, health human resources, family medicine, facility norms, and testing innovative approaches to strengthen PHC. Capacity building will also be implemented in management, e-health, quarantine and health security, procurement, accounting, gender, nutrition, and health care waste management.

Value added by ADB assistance. Asian Development Bank (ADB) assistance brings value by (i) supporting equity-focused health care delivery reform especially in lagging and rural areas such as the plantation and estate sectors; (ii) adopting evidence-based planning based on GIS mapping and vulnerability index to identify and target underserved districts and populations; (iii) enhancing infrastructure design to address climate change and disaster risk resilience; (iv) scaling up e-health card and its integration with the government's web-based health information system to improve continuity of care and disease surveillance; (iv) supporting GIS units in central and district planning departments to improve disease surveillance and monitor health-seeking behavior; (v) institutionalizing distance learning for training PHC staff; and (vi) helping districts develop and implement innovative solutions to integrate and improve PHC services.

Link to national development strategy and ADB sector priority. The project aligns with the government''s priorities identified in the Public Investment Programme, 2017 -2020 and Vision 2025, and with the United Nation's Sustainable Development Goal 3 on universal health coverage. The project is in line with ADB''s country partnership strategy, 2018 -2022 for Sri Lanka and paves the way for a long-term programmatic approach consistent with ADB''s health operations plan.

ADB experience and lessons learned. The project is ADB''s reentry to the health sector in Sri Lanka after a gap of about 20 years. The prior project and other recently completed and ongoing ADB-financed projects in the social sectors have been implemented successfully. These past experiences and the project preparation process indicate strong commitment by the government at the national and regional levels. The leadership provided by the Ministry of Health, Nutrition and Indigenous Medicine (MOHNIM) and the four provincial administrations during the project preparation stage is expected to continue into project implementation.

Development coordination. MOHNIM convened the donor coordination committee to ensure collaboration with and among development partners. The World Health Organization (WHO) has a leading role in policy development and sector coordination. The project will collaborate with WHO in terms of technical assistance to support selected areas related to the essential services package, health system strengthening, human resource development, and health security. The project also intends to work with the United Nations Children's Fund (UNICEF) and the World Food Programme on nutrition, as well as the International Organization for Migration on migrant issues. ADB''s support will be coordinated with the World Bank program support to strengthen PHC, and regular discussions are held to prevent duplication of efforts and to synergize on the results and outcomes.

Primary health care enhanced in Central, North Central, Sabaragamuwa, and Uva provinces

Health information and disease surveillance capacity strengthened

Policy development, capacity building, and project management supported

Output 1

-38 civil works contracts (PMCUs) out of 43 advance contracting packages were awarded and 5 contracts are in the re-bidding process. Matale- 5 contracts to be awarded in Q3, 2020.

-Civil works round 2

D&S consultants have stated designs for 90 facilities in the 9 districts and will be completed in Q4, 2020. The design of 127 filed health centers have also initiated.

-Finalizing the equipment for essential service package (ESP) for target provinces is in progress. Provinces will compete the finalization of requirement with the help of a consultant. Recruitment of gender specialist is in progress.

-The recruitment of consultancy firm to support for community empowerment and capacity building for improving the nutrition status of mothers and children under 5 years in 9 districts is in progress, this will be completed in Q4, 2020. Recruitment of Gender consultant is in progress.

-Recruitments of gender consultant and behavior change and community mobilization for increasing primary health care utilization firm, in progress to initiate behavior communication plan in all target provinces.

Output 2

-Recruitment process of consultancy firm to design and develop HIT system for electronic patient information sharing system and notifiable disease surveillance information systems in progress, EOI evaluation completed.

-capacity to screen and diagnose Covid19 diseases Number of diagnostic tests were drastically increased exceeding the target. As of 30 August 2020, the cumulative number of testing is 132,021; total number of confirmed cases is 3,012; Recovered 2,872; death 12

Output 3

-Recruitment of consultant to support operationalization of ESP within clusters completed and commenced work. Recruitment of consultant for GIS based planning and monitoring will be completed in September 2020.

-Recruitment of gender consultant to work on integrated gender dimensions in all policies and strategic plans, is in progress and will be completed in Sep 2020.

-Training plans for medical officers and other staff on family medicine are approved, objectives are being finalized, training will be started after the COVID-19 situation.

-Training for PHC staff and medical officers on gender sensitivity, gender related policies and interventions in target provinces are being finalized and training will be started after COVID 19 situation, Gender consultant recruitment is in progress and will complete in Sep 2020.

The project is classified as Category B for environment in accordance with ADB's Safeguards Policy Statement (2009).

Adverse environmental consequences of the project will be largely restricted to component 1 under which support will be provided to existing PHC facilities to upgrade 30% (135) of its primary medical care infrastructure facilities and small-scale repairs to field health centers. The nature of construction envisaged will be small-scale, simple and straightforward, mostly restricted to expansion of the outpatient departments for primary medical care facilities and repairs and refurbishment to field health centers.