Sri Lanka: Health System Enhancement Project

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

Sri Lanka''s health indicators are generally well-performing, and the sector is known for achieving good health at relatively low cost. Government spending on health as share of the gross domestic product is comparably low in the region, yet the sector has achieved outcomes on a par with developed countries, including a life expectancy of 75 years and nearly 100% institutional delivery and immunization coverage. Sri Lanka has also done well to control infectious diseases, being the first in the region to eliminate diseases such as smallpox, polio, diphtheria, pertussis, and tetanus, and more recently filariasis and malaria through focused campaigns. This indicates hitherto effectiveness of the country''s health system, with contributing factors including dedicated delivery of preventive health services at the community-level and an extensive public hospital system throughout the island.

Despite its achievements, Sri Lanka''s health system today is facing challenges to sustain its performance due to rapidly changing demographic and epidemiological transitions. The cost of health care has been increasing due to the sharp rise in noncommunicable diseases linked to lifestyles and a rapidly aging population. The national health system also needs to further strengthen expanding services to vulnerable populations with lagging health indicators. In addition, there is increased threat of emerging and resurging infectious diseases linked to environmental factors and increased cross-border migration. The status quo of the health system is inadequately prepared to deal with these evolving challenges without significant reorientation and further improvements.

Primary health care. Primary health care (PHC), including both primary care and preventive health services, in Sri Lanka needs significant strengthening to tackle the rising costs of health care, as well as to improve basic health services to lagging populations. The current health system underinvests in primary care, and limited government funds largely cater to higher level hospital services. The underinvestment at the primary care level has led to inadequate facilities and generally poor utilization of primary care level institutions and increased burden on higher-level health care facilities. As hospital care is costly, overuse of hospital services also creates an inefficiency in the use of government health expenditures. The cost pressures arising from increased noncommunicable diseases and population aging, however, have catalyzed the beginning of government reforms to rationalize health care utilization with increased focus and orientation towards PHC. Still, the actual reform model is still evolving, and there is a need for external assistance to further inform and help operationalize PHC reform initiatives.

Lagging populations. Preventive health services, which are organized separately from curative medical services in Sri Lanka, also need enhancement to bridge in-country disparities in health status and expand basic health access to lagging communities. While Sri Lanka''s dedicated preventive health services has significantly contributed to the country''s past performance in health indicators, actual government spending in this area has been decreasing from 10% of current health expenditure in 1990 to about 5% in 2013. This is impacting the further reach of basic health services to vulnerable populations, such as in the estates, which have lagged behind in health and nutrition status. Although the Government made the decision to integrate estate health services into the national health system since the 1990's, the implementation progress has been slow, largely owing to limited resources and capacity of the health system to further extend, and lack of effective coordination with estate management. Moreover, strengthened PHC is needed in rural, remote areas affected by prevalence of chronic kidney disease of unknown etiology (CKDu), especially to improve the communities' access to early detection and management of the disease. Inadequate facilities, lack of mobility and transport, shortages of staff, and staff accommodation are some of the notable barriers to providing adequate preventive health services to these lagging communities.

Disease prevention. While Sri Lanka made significant achievements regarding control and elimination of communicable diseases, there is a need to further improve the health system's capacity to detect and respond to emerging and resurging infectious disease threats. The communicable disease surveillance system, while effective and comprehensive, is still largely paper-based and needs to leverage modern technology to further improve efficiency and timeliness and accuracy of data capture, reporting, feedback, and analysis. There are also increasing threats of disease spread from more in-flow of migrants and cross-border activities, with corresponding need to step up monitoring and surveillance at points-of-entry and health screening procedures of in-bound migrants. There is also need to sustain hard-won gains such as with malaria elimination, while stepping up prevention and control of pressing issues like dengue, which requires cross-agency collaboration, better environmental management, effective vector control, and more community outreach.

Primary health care strengthened, especially in lagging areas

Health and disease surveillance capacity improved

Policy development supported