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.

A healthier nation is ensured with a more comprehensive PHC system

Efficiency, equity, and responsiveness of the PHC system improved

By end of reporting period, the cluster system reform process has been implemented in all nine districts. The evaluation will be carried out by comparing the findings of the end-line survey against the baseline, as well as analyzing the outcomes of the pilot cluster and HSEP supported non-cluster areas in contrast to the control area.

Outpatient utilization was estimated as the percentage of people in the catchment population who utilized the PHC for outpatient services according to the baseline household survey. The proportion of females in the catchment populations utilized PHC was higher than that of males. The highest utilization rates were observed in the elderly, followed by children under 5 years of age.

The patients' knowledge and satisfaction were calculated using the data from PHC user survey. The details of calculation are available in the Baseline report. At the baseline, overall, 52.8% of the PHC users were satisfied (scored 70% or more in the multi-item satisfaction scale). Satisfaction level was somewhat lower in the 45-64 year age category (50.6%) than those aged below 18 years and above 65 years. Overall, 53.5% of the PHC users were aware (scored 70% or more in a multi-item hospital awareness scale) of the services provided at the PHC. The awareness was higher in females than males.

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

Health information system, disease surveillance capacity, and COVID-19 response strengthened

Policy development, capacity building, and project management supported

Output 1

Out of 135 PMCUs and DH, 35 completed (25.18%)

(Secondary data from the PMU by the end of reporting period), a Gender Consultant has initiated developing the criteria for considering a facility as providing gender responsive health care. M&E team will analyze baseline and annual survey data once the definition has been finalized and agreed upon under the gender responsive and inclusive essential service package for outpatient and clinic services provided by PHC facilities supported in target provinces.

All MOH within cluster areas provide gender responsive nutrition services to infants and children under 5 years of age and school children further MOH provides specific nutrition services to pregnant and postpartum females.

Recruitment of consultancy firm for behavior change and community mobilization for increasing primary health care utilization has been withheld as budget allocation has been transferred to the emergency procurement of medical supplies.

Output 2

Establishment of electronic patient information sharing system for stage one in progress.

(Qualitative study). Two out of 9 clusters (Thambuthegama and Dambulla) have been identified as pilot areas and the initial work is in progress. (Discussion with Director, information, Ministry of Health). Developed software has been piloted.

Only few of the health facilities were sending notifications via email and not by an electronic system under the target of developing a system to send notifiable disease surveillance information via electronically to medical officers

Core capabilities to carry out quarantine services with a score of at least 4 joint external evaluation reports to increase eight ports of entry in Sri Lanka not available after 2017, the latest score was available in the baseline score JEE report 2017 and was 3.0

The target has been completed to establish capacity to screen and diagnose COVID19 diseases by December 2020.

Construction Work conducted for the following hospitals have been completed under the upgrading of primary, secondary and tertiary level hospitals capacity to treat and manage patients including COVID 19 patients:

ICU BH Madirigiriya

ICU BH Thambuttegama

PCR Colombo East Base Hospital

ETU GH Kalutara

ICU TH Kurunegala

PCR TH Karapitiya

COVID-19 ward TH Batticaloa, Hambantota Port

Contract awarded and construction ongoing Galle. SBD has been prepared with price escalation clause for Trincomalee and Colombo. Refurbishment of isolation rooms at NIID in the rebidding process Establishment of Iodine Therapy at GH Rathnapura construction ongoing Establishment of Iodine Therapy at GH Anuradhapura construction ongoing NIID Laboratory Complex - Rebidding process.

Secondary data from Suwa Seriya to be obtained under the upgrading of Suwa Seriya ambulance system in all districts

Output 3

The already available Maternal and Child Health policy, Maternal and Newborn strategy and National strategic Plan for Adolescent and Youth Health are gender responsive under the operational polices and guidelines with gender dimensions to complete delivering a comprehensive package of PHC (incorporating the essential service package, management and functioning of cluster hospitals and geographic information system for based planning and monitoring in health sector.

Discussion with FHB is in progress. Gender dimensions are included in the national MCH policy and the relevant strategies for 11 units of FHB to have integrated gender dimension in all their policies and strategic plans.

M&E firm has developed a database to auto-calculate the indicator of "at least 30% of medical officers and other staff of PMCUs and divisional hospitals in target provinces with increased knowledge in PHC based on the secondary data.

By the end of 2021, a total of 270 health staff from the project districts have undergone online training programmes on gender conducted by the Gender Consultant.

The participants included 141 Medical officers, 101 nursing officers and 14 other staff. Action related to policy development has not been initiated yet under the target of PHC staff from PMUs, divisional hospitals, and medical officers of health areas with increased knowledge in gender sensitivity and gender related policies

heir policies and strategic plans.