STRATEGIC FRAMEWORK FOR HEALTH DEVELOPMENT

 IN SRI LANKA 2004 - 2015

April 2003

Ministry of Healthcare and Nutrition - 

Democratic Socialist Republic of Sri Lanka

Contents

The Process (This is better as a preface by the Minister/ Sec/ or DG ?

Strategic Hierarchy for Health Development 

Development Framework 

  Executive Summary 

The Current Situation 

Challenges and their implications 

Aims, Principles and main Thrusts of Strategy 

Strategic Objectives 

The Way Forward 

Strategic Hierarchy for Health Development

VISION: A healthier nation that contributes to its economic, social, mental and spiritual development

MISSION: To achieve the highest attainable health status by responding to people's needs, working in partnership, to ensure access to comprehensive, high quality, equitable, cost-effective and sustainable health services GOAL: A strengthened health system that strives for excellence to improve the health outcomes of the people in Sri Lanka

DEVELOPMENT OBJECTIVES:

1. To ensure delivery of comprehensive health services, which reduce the disease burden and promote health

2. To empower communities towards more active participation in maintaining their health

3. To strengthen stewardship and management functions of the health system

4. To improve human resources for health development and management

5. To improve health financing, mobilization and allocation of resources

The health strategy for Sri Lanka is the synthesized output of two interactive activities, complementary to each other, initiated with the assistance of two development partners, enriched by the outcomes of an extensive consultation process. The document provides the strategic framework within which the health system of Sri Lanka would be developed over the next decade.

The health strategy aims to build on the successes and experiences of the past and to address the challenges of today and tomorrow. These challenges include changing demographic and disease patterns, limited resources, increased demand and expectations by the public, the need for equity and the need to develop a management ethos that ensures good governance and value for money in delivering quality services.

The strategy is carefully designed to support Sri Lanka's overall economic and social goals. It aims to facilitate equity through ease of access to health services and thereby to deliver productivity gains to ensure that resources allocated to health result in a healthier population that is able to contribute to the economic and social well being of the country.

The Government aims to foster a healthier nation that contributes to economic, social, mental and spiritual development. This is to be achieved by responding to the peoples needs, and working in partnership to ensure access to comprehensive, high quality, equitable, cost-effective and sustainable health services. This overarching aim of improving health status and reducing inequalities will be achieved by:

· ensuring delivery of comprehensive health services, which reduce the disease burden and promote health

· empowering communities towards more active participation in maintaining their health

· strengthening the stewardship and management functions of the health system

· improving human resources for health development and management, and

· improving health financing, mobilization, allocation and utilization of resources.

The broad outputs under each developmental objective are outlined below.

To ensure the delivery of comprehensive health services, which reduce the disease burden and promote health it is proposed to achieve the following outputs.

1. Rationalized health network, (that includes allopathic & indigenous as well as public & private services)

2. Priority diseases/conditions reduced through strategic interventions

3. Enhanced quality of service delivery

4. Improved health status of vulnerable populations

5. Increased public confidence and patient/client satisfaction in the health services

6. Accessing new technologies

7. Strengthened public - private partnerships to enhance efficient health service delivery

To empower communities towards more active participation in maintaining their health it is proposed to achieve the following outputs.

1. Improved public awareness of their rights, responsibilities and options for care

2. Improved participation of civil society and Non-Governmental Organizations in promoting behavioral and lifestyle changes

3. Behaviour change communication for healthy living

To strengthen stewardship and management functions of the health system it is proposed to achieve the following outputs

1. Strengthened managerial performance at national and decentralised levels

2. Enhanced efficiency, effectiveness and accountability of the MOH &decentralised units

3. Performance management systems introduced

4. Established a system for regulating the services of public & private providers

5. Strengthened management information system

6. Strengthened coordination and partnerships with other sectors

7. Strengthened capacity in health research and technology assessment

To improving human resources for health development and management it is proposed to achieve the following outputs

1. Strengthened human resources development capacities of National and Provincial Ministries of Health

2. Improved skills and planning of human resource requirements

3. Rationalized distribution and utilization of human resources

4. Improved management, clinical and public health competencies of health staff

To improving health financing, mobilization and allocation of resources it is proposed to achieve the following outputs

1. Improved allocative efficiency of public funds

2. Identified and tested alternative financing mechanisms

3. Identification of financial needs and making optimal use of existing financial resources

4. Strengthened financial management

5. Improved financial equity of health care, and related equity of access to health care services

6. A rational state facilities master plan

7. A mechanism for ensuring adequate drugs, material and equipment is in place Optimized private sector contribution to health development

The process…. 

WE MAY THINK OF MOVING THIS TO A PREFACE/FOREWORD?…

The Strategic Framework for Health Development in Sri Lanka is the combined product of two exercises carried out during 2002 and the first quarter of 2003, with the assistance of two international development partners - Japan International Corporation Agency (JICA) and the World Bank (WB) - on the invitation of the Government of Sri Lanka.

The work assisted by Japan International Corporation Agency (JICA) was initiated in November 2001 with the signing of a memorandum of understanding with a team of JICA representatives. The consultation process commenced with the arrival of the JICA consultant team in April 2002. 

The World Bank assistance to develop an overall health sector strategy commenced in……, with the support of local and international technical assistance. 

Over 75 officials from the Line Ministry, Provincial Ministries, private health sector, other departments participated in this exercise by contributing at the regular technical work group meetings. Periodically provincial stakeholder meetings were conducted providing opportunity to more than 300 additional health and non-health workers from all provinces to contribute to the planning process. The outputs of the two exercises were combined by the Management Development and Planning Unit in order to produce 'The Strategic Framework for Health Development in Sri Lanka' which is the final product of extensive stakeholder consultation enriched by the technical competencies of over 50 international and national consultants. This document, which is yet in its draft form, will be finalized after obtaining the views of professional bodies and other organizations and representatives of the civil society.

1.1 Social, Political and Economic Environment

Sri Lanka's social indicators are impressive for a low-income country with a per capita income of around US$ 800 ( average for the last decade), as indicated by its infant mortality rate of 17 per 1000 live births, expectation of life at birth of 73 years, and adult literacy of 87%, etc. A large measure of these successes could be readily attributed to the social welfare package, which was introduced in the early 1940s. The expansion of health and education services was realized throughout the country during the early post-independence era. However, since 1970s successive governments found it increasingly difficult to maintain these services at an acceptable level of quality due to the adverse economic conditions faced by the country. Furthermore, the structural adjustment programmes in the 1980s reduced social expenditure and increased the income disparities and widened the gaps in access to social services.

In contrast with the progress in the social sector, Sri Lanka's economic development lagged behind in the post-independence period. The post-colonial development policy was characterized by the socialist stance of the government, including import substitution policy in all major economic areas, central planning, nationalization, and state intervention and monopolies in all economic sectors.

Sri Lanka was late in adopting economic development strategies such as market liberalization and export orientation. The economic growth rate recovered in the 1990s to about 5%, aided by the increase of exports, but both budget deficits and external debts have been worsening.

Sri Lanka's experience illustrates the vulnerability of social development programs in the three decades of long stagnant economic performances. However it is postulated that the dawn of peace would strengthen the country's economic situation, which in turn will enable the governments to divert adequate resources to social and economic expenditures with a view to rebuilding a healthier nation.

Only through sustained economic growth can additional resources be allocated to the health sector. Likewise, economic growth will only occur if there is a well-educated healthy workforce with appropriate skills to improve productivity. The main economic challenges are to increase employment by creating new jobs, to overcome the public debt crisis, to invest in resources for reconstruction to improve productivity and increase investment and thus increase income levels. These are to be achieved by promoting the private sector and providing greater freedom for businesses to take decisions to ensure economic efficiency, reforming legislation and removing barriers to productivity, increasing efficiency in government functions and by increasing flexibility in the use of people and increasing their skills.

On the social side, six major pillars constitute the strategic foundation of the Government poverty strategy: They are · Building a supportive macroeconomic environment · Reducing conflict-related poverty · Creating opportunities for the poor to participate in economic growth · Investing in people · Empowering the poor and strengthening governance and · Implementing an effective monitoring and evaluation system

The Government invests in people to build the human resource base for a just and prosperous society. Ensuring the provision of basic needs and opportunities to each citizen to realize their fullest potential, is central to the Government's efforts to address poverty. A larger role for the private sector in the provision of health services is envisioned, enabling the Government to focus its resources on improving access and service quality in poor communities.

As outlined in section 1.1 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/capita. The improvement of these indicators are predominantly attributed to the Maternal and Child Care Programme implemented nationally as an integral component of the state health care system. Similarly, the Infant Mortality Rate of 16.3 per 1,000 live births has been achieved by effective and widely accessible prevention strategies and treatment of minor infections. However, whilst post-neonatal mortality has declined significantly, perinatal and neonatal mortality efforts have been less successful. A neonatal mortality rate of 12.9/1,000 live births suggests limited progress in improving the quality of labour and delivery and in the relatively poor underlying health of mothers, which results in premature deliveries and low birth weights.

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 aging of the population and success in combating the major communicable diseases, the disease burden has started shifting rapidly towards non-communicable diseases including mental health, accidents and injuries. The leading causes of death (by percentage of total mortality for year 2000) are ischaemic heart disease (10.6%), diseases of the intestinal tract (9.3%), cerebrovascular disease (9.0%), pulmonary heart disease and diseases of the pulmonary circulation (8.6%), and neoplasms (7.5%). Over time infectious and parasitic diseases have declined in importance, while cardiovascular diseases and homicide have increased in a proportionate manner. In 1996, violence (accidents, suicides and homicides) accounted for 22% of the deaths, while cardiovascular diseases and diabetes accounted for another 24%, which indicates that the epidemiological transition is rapidly in progress.

Nutritional standards have improved but remain a serious problem among the poorer and vulnerable communities. This brief analysis provides information for the whole country and does not address the disparities that exist between provinces. But when the Provincial or District level figures on infant and maternal mortality rates are compared there seems to be great disparities, some of which may be due to differential underreporting or to the referral of cases. In particular, information on the conflict affected areas and the estates would show the significant variation between and within provinces.

People's health needs are influenced by health services delivery and quality of care, but are more a reflection of the access to resources (sufficient and nutritionally balanced food, safe water, clean air, protective habitat) and the hazards to which they are exposed in society in general and in their occupations, as well as their own life skills and risk behaviour and health seeking behaviour.

The maternal and child mortalities have declined and are at an excellent average level, but as shown in 2.2 Health status variations between provinces and districts, are disturbingly large. The original decline from 1928 onwards seem to have coincided with the development of the economy, the food subsidies and the creation of community outreaches for MCH activities, including the beginning of family planning activities

Beginning in the 1960s, and accelerating in late 80s social strains, new market economies and changes in life style tended to have negatively influenced the health in many age groups. Inability for non exclusive breast feeding, popularisation of fast foods and tobacco and alcohol, early exposure to premarital sexual activity, easy accessibility to agrochemicals and exposure to conflict, trauma and abuse are few factors that can have a negative impact on one's own health. Health promotion will be most successful when societies at large and individual households will understand the key factors that revolve around important health issues and problems.

Today there is an awakening to the fact that lifestyle should be considered, but for too many people in Sri Lanka "health activism" is almost limited to cleanliness, and seeking medical care and special nutrition, rest/exercise dictated by a somewhat diffuse popular understanding of Ayurveda. Therefore the strategic framework appreciate the importance the role of the individuals, households and the communities to play in order to safeguard one's own health status and the interventions the government should carry out enabling the target groups to be responsible for their own health.

In Sri-Lanka, hospital networks, comprising of various types and categories of facilities, from primary level to tertiary, are well developed and spread throughout the country, reaching the majority of the community. Providing health care services in the public sector is the responsibility of the Central Ministry of Health (MoH) and eight Provincial Ministries of Health in the Provincial Councils. The central MoH is responsible for managing national facilities and Teaching Hospitals, procuring drugs and supplies, while the Provincial MoHs are responsible for managing provincial/district health facilities.

Many of the Base Hospitals and Provincial Hospitals have been upgraded recently according to the suggestions by the 1998 Presidential Task Force report. The MoH has initiated steps to adjust the current categorization as a part of the Master Plan for Hospital Development.

The services in the state sector are characterized by a very busy and overcrowded system of national, provincial and base (large town) hospitals and a widely spread network of district hospitals and health care units operating at lower levels of occupancy.

Sri Lanka provided around 0.2 inpatient admissions per capita in 1997. This heavy demand may be due to a number of factors including: lower primary care and outpatient visits estimated as 4 per capita in 1997; 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 causing overcrowding at these facilities . This is aggravated by an absence of clear admission and referral policies.

Primary health care is provided throughout the health service and especially in the network of central dispensaries and maternity homes, rural hospitals, peripheral units and district hospitals. In addition to services in these facilities, public health services, including health promotion and preventive care, are provided by health units and include services in maternal and child health, family planning and the control of communicable diseases. In addition there is a high level of self-care and utilisation of private pharmacies.

The fastest growing segment of private sector health care 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 the 1990 estimate. Of the total ambulatory care market 46% is serviced by the private sector, 27% by government doctors both specialist and non specialists, 12% by private general practitioners and 7% by traditional practitioners. Private hospitals played a minimal role in providing inpatient care till the early 1980s. Reintroduction of private practice for government doctors, liberalization of drug imports and service provision deficiencies in government hospitals resulted in the growth of private hospitals in urban centres.

The alternative health care services, Unani, Ayurvedha and Homeopathy, are well recognized and delivered through the state and private sector health systems.

1.5 Human Resources for Health

In the area of Human Resources for Health (HRH) the numbers in most categories have increased over time. Even though the numbers of nurses and para-medical staff have increased steadily, the system witnesses a considerable shortage of qualified nurses and para-medical staff in almost all medical institutions across geographical boundaries.

However the concept of Development of Human Resources for Health in the Ministry of Health needs to be expanded from 'production and distribution of Human Resources for the public sector services', to a supporting function in order to attain the key objectives in the health sector strategy. The vast majority of technical staff (93%) work in the state sector, although many professionals also are engaged in private practice.

There are severe staff shortages in some occupations particularly specialist doctors, medical teachers, nursing and para-medical tutors, nurses and paramedics. There are also major shortages in some regions, particularly in remote rural areas and in the conflict-affected areas of the country. At the same time there is an over production of doctors, which shows early signs of an excess in supply. The government's commitment to absorbing all medical graduates up to 2010 into the state sector may be difficult to maintain and could lead to doctors moving full time into the private sector or seeking employment abroad. Compounding all of these issues is the questionable relevance and quality of some of the training programmes that are being conducted by the Ministry of Health as well as by the Universities. All in all, there is evidence that the government will have to contend with the dual problems of balance and relevance of the human resources in the ensuing years.

Sri Lanka has achieved extraordinarily good health outcomes given the level of spending on health. Total expenditure on health was Rs 39,177m in 1999 of which 13% was capital investment. This amounts to about 3.53% of GDP or Rs 2,068 per capita (U$29 per capita). There is heavy reliance on taxation and out-of-pocket expenditure (approximately 50%) as financing sources. Government revenue is primarily from central taxation. Private expenditure is predominantly out-of-pocket expenditure with about 10% paid by employers and individuals for private insurance, which is primarily spent on ambulatory care. Health expenditure has been increasing, albeit from a low base. Since 1990, total expenditure has been between 3-3.5% of GDP of which the Government share has fluctuated between 1.4% and 1.7%. The level of external development assistance to this sector is low compared to other developing countries, which is around 4-6% of the total expenditure.

State expenditure has over recent years become increasingly centralized with a large, and increasing, share of state funds being channeled through the Ministry of Health. Though spending on health by Provincial Councils increased by over 20% in real terms, their share of total state health spending declined significantly during the 1990s.

The Sri Lankan Government recently has completed a review to facilitate the charting of a course of action with regard to Macro-economic reforms, including improving health status and strengthening governance and institutional reforms. This seeks to provide guidance for public action designed to achieve high economic growth and preserve the equity the country has been known for until the second decade of the 20th century.

The term "Health Sector Management" is essentially similar to the term "Stewardship", which WHO defines as "being ultimately responsible for the careful management of people's health". Health Sector Management encompasses the tasks of defining the vision and direction of health policy, exerting influence through regulation and advocacy, and collecting and using information for monitoring.

Although Sri Lanka's health sector has been very successful in reducing the major public health problems that still affect other developing countries, at the turn of the 21st century the health system faces several major problems in its organization and management, financing and service delivery mechanism, which require review and effective responses. The prevailing ethos is one of administration, rather than management. Standards and norms are set centrally with little flexibility and authority for managers at peripheral levels to make decisions on finance, staffing and utilization of resources and to deal with emergency and disaster situations. The issues created by the unfinished agenda of decentralization, lack of an efficient management information system, and lack of a result based performance appraisal mechanism pose significant challenges in management.

The devastating results of the twenty-year-old war became more overtly visible with the dawn of peace in 2002. Damaged infrastructure ranging from primary care centres to tertiary hospitals, the scarcity of human resources for health in the war torn areas, breakdown of preventive and promotive services, lack of other supportive facilities such as medical supplies and equipment and the disorganization of other systems such as education, sanitation etc. that have a direct adverse influence on health have created negative health impacts among those living in these districts. The displacement of masses of people further has created a range of physical and psychosocial problems that mandate careful attention. In addition to those districts that belong to the North and the East provinces, four borderline districts that belong to North Central, North Western, and Uva Provinces too were affected to a great extent by the prolonged conflict. The rebuilding of the health system in all of these devastated provinces remains a considerable challenge for the country.

Despite all of the afore-mentioned problems, the achievements made by the health system in Sri Lanka over the past decades are many fold compared to other developing countries. However, over the past years the integrity of the Health System has been subjected to many challenges. Sri Lanka is already facing emerging challenges such as challenges due to demographical, epidemiological, technological and social transitions. The country displays the typical double burden of disease, with a mixed but shifting morbidity and mortality due to communicable diseases and non-communicable diseases and questionable quality of care. These challenges require significant changes in the ways in which health services are funded, resourced, managed, and provided.

2.1 Responding to Changing Disease and Demographic Pattern

The morbidity and mortality trends are changing and demands new service delivery priorities to be established. The population structure is also changing with an increasing proportion of the population being elderly. It is expected that this segment of the population will make increasing demands on the health service, particularly in their last decade of life.

Non-communicable diseases are increasing not only as a proportion of the burden of disease, but also in incidence and prevalence. Among the more important of these are accidents, heart disease, mental illness, diabetes and cancers. Diagnostic and treatment technologies for many such diseases are expensive and outcomes are often poor, but once new technologies are introduced and made freely available, the demanded for such would be enormous. Some of these technologies achieve relatively little in terms of health outcome but incur large costs, while some are effective. The new technologies introduced to the country first by the private sector will quickly affect demand and supply in the state sector and can be a major factor in cost escalation.

The prevention of non-communicable diseases is generally a highly cost-effective use of state funding and can be achieved, to some extent, through accident prevention, injury limitation, healthy diets and lifestyle, reduction in smoking etc.. However, some conditions are chronic and require lifelong treatment or containment. Whilst new problems are emerging, some health problems of the last century still remain at alarming levels. The maternal anaemia rate remain at 35% and childhood malnutrition, which is still thought to be as high as 29% (weight for age) in under fives - a figure which sits uncomfortably alongside Sri Lanka's significant reduction in infant mortality rates. A reduction in malnutrition rates requires targeted education, plus in some cases directs food supplements at community level in the immediate term and poverty reduction measures in the medium term. Many interventions have not delivered and further analysis is required to learn lessons from these experiences.

Malaria remains significant, and potentially serious, although more than half of cases are in the North East and with the restoration of services there are likely to reduce further over the next few years. Dengue and Tuberculosis also pose significant risks. HIV/AIDS is a totally new challenge. Prevalence is still low and there is a window of opportunity to ensure that it remains so. There is a need to strengthen surveillance systems, undertake further research and evaluation, revisit the role of field staff and other sectors and to review inter-sectoral experiences.

Currently Sri Lanka has a multiplicity of categories of health facilities and therefore it is often confusing to patients where to get appropriate care. It is proposed to have only four levels of care with a firm commitment to quality of care at all levels.

Referral and counter referrals need to be clearly formalized and monitored, and supplies and drugs have to be ordered and stocked taking the counter referral possibility into account for the most frequent diseases so that the primary level which will provide the follow up would be conversant with the situation.

As the size of population served varies with population density, the volume of services planned too would vary from institution to institution. But the services offered should be uniformal within a level and will be clearly announced. In principle it is accepted that health facilities with a curative role should increasingly take on secondary and tertiary prevention especially in chronic communicable and non-communicable diseases. Similarly it is accepted that primary preventive units will have to take on more primary prevention tasks in relation to non-communicable diseases.

What is not yet clear is the scope of preventive facilities and the number of workers who will fulfill primary care and curative follow-up activities with screening of diseases and work towards patient and family-centred promotion and prevention. The prevailing paradigm is to use a campaign approach for prevention and restrict patient-centred services for secondary and tertiary care. It is questionable as to how far this paradigm can serve the emergent as well as the prevailing epidemiological challenges.

There are various branches of medicine in Sri Lanka, which contribute to the nations health. They include Unani, Ayuvedha 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 the existing institutions.

At the turn of the 21st century the health system faces several major problems in its organization and management. One major issue is the confusion and attendant conflicts over roles, responsibilities and lines of accountability between central and provincial levels of the MoH, consequent to devolution.

In the past the state health service has been well administered, but the modern environment now requires the services to be well managed. This requires greater delegation, clear accountability, flexibility and freedom for managers to manage, development and implementation of the concepts of good governance, the development of management and financial information systems that encourage and reward the achievement of results and a focus on outputs rather than inputs. At present managerial and financial systems are inadequate and there is shortage of trained staff. In addition the health information system is also beset with many challenges. Lack of an updated policy for information, insufficient coordination among managers of information, uneven information management capacity, substandard quality of the existing data and sub optimal use of information and other technology are important challenges that need to be overcome.

The need to update the health legislation, enhancing effectiveness, efficiency and accountability of the MOH through improved human and financial management, strengthening of managerial performance at provincial and sub-provincial levels with improved capacity and capability to handle decentralized responsibility for managing health care services, strengthening of monitoring and evaluation of health service quality & delivery and enhancing evidence-based decision making by the MOH and other institutions are important challenges for the new centaury.

While Sri Lanka prides itself for a well established public sector for health care provision, the private sector plays a significant role in the health sector. The Government tacitly encourages individuals to pay for their own health care where they are able to do so and for the private health sector to meet these needs. However, Government has an overall responsibility for ensuring that patients are protected and get value for money in both state and private sectors. As such Government needs to consider how to regulate the private health sector without stifling initiative and innovation. Consideration also needs to be given to how best to encourage partnerships between state and private sectors to deliver quality services and contribute to the national health goals. Strengthening of the capacity of the private health sector to provide quality care too is emphasized.

Despite the increasing numbers of specific categories of Human Resources in the health sector the past years have witnessed many problems and challenges. In addition to the shortages of certain cadres of staff, the growing surplus of doctors will have serious cost and quality implications. These doctors may not be properly absorbed into the state health system, although there is an historic commitment to do so. Even if these doctors move into the private sector, a surplus of doctors practicing privately will cause an increase in supply-driven consumption levels. On the other hand, there are serious disparities in the requirements and supply of other categories of health personnel, particularly nurses and paramedical personnel.

One of the recurrent constraints for improving the effectiveness of human resource policy and planning in the health sector is the lack of a comprehensive human resource strategy. There is a significant imbalance existing in the distribution of HRH among districts. Specifically the number and the rate of health personnel in the Northern Province is extremely low while districts such as Colombo, Kandy and Galle have a significantly higher concentration.

The insufficient quality and competency of health staff too has been identified as a challenge for correction. Lack of technical competency and absence of positive humane attitudes have been identified in turn to maximize the responsiveness of the services.

In terms of employment structures and human resource management, Sri Lanka still retains a system whereby certain categories of state sector staff are appointed and controlled by a Public Service Commission or similar state bodies. There are also weaknesses in the recruitment and deployment of other categories of staff. These result in distant, slow and largely unresponsive administration of staff as they strive to work in a changing environment. The challenge is to introduce a modern system of management geared to the defined roles and performance of individuals and institutions. This will require an improvement in the working conditions of staff, a fair and transparent system for promotion, reward, discipline and training, re-certification processes and revised terms and conditions that will generate different incentives for staff who are more responsive to clients needs. Appropriate conflict resolution procedures need to be introduced.

2.6 Living with Limited Financial Resources

The predictions based on the studies done to estimate the financial burden of the health system for the next fifteen years clearly show the extent of the additional funds needed to run the health system. In order to maximize the resource utilization there is significant pressure to make best use of the limited financial resources available. Central Government financial allocations to Provincial Councils are not based on objective and transparent measures of population need - only around 6% of funding is via 'criteria - based' grants (weighted favourably towards the poorer provinces).

Block grants from the Ministry of Provincial Councils constitute the largest component of funding for provinces. Provision of 'matching grants' was aimed at encouraging local revenue rising but it does not seem to have been achieved. In practice, there is no attempt to link national policy to finance through this allocative mechanism. There is neither a contracting mechanism nor is there any evaluation of value for money. Also there is a need to ensure that equitable and fair distribution mechanisms are in place between and within provinces and that these address localized poverty pressures.

With the existing resource allocation mechanisms there is little opportunity for significant improvement in service efficiency, cost effectiveness, quality or ability to focus on the poor without a substantial change. This necessitates the inclusion of more management autonomy, improvements in finance and management systems and financing including allocations based on needs, together with more rational planning and funding of services.

2.7 Improving Responsiveness

There is a growing consumer dissatisfaction with the services rendered by most of the state owned health care facilities and patients are becoming more inclined to express their dissatisfaction. The issues that are particular causes for concern include overcrowding in the larger hospitals, long waiting times, poor surroundings and the unsatisfactory attitudes of some health care workers. Issues of professional negligence are being raised strongly in the national press and recent cases have involved individuals suing the Government for compensation for negligence. There is little or no information on consumer views about the private sector. More information is required on the attitudes and perceptions of the public on the services they receive and appropriate systems will be developed for complaints to be heard and problems resolved.

2.8 The Challenges of the Conflict Affected Areas

The WHO report, Proposal for Recovery of the Health System of Conflict Affected Areas Sri Lanka, September 2002, established an Emergency and Humanitarian Action programme to meet the short term needs of the conflict affected communities leading into mid to long term strategies for health system recovery. A short-term programme has been developed and is being implemented focusing on re-establishing the district health system, establishing a multi - disease surveillance system and providing essential health services based on primary health care.

The approach should be institutionalized and a clear strategy developed to ensure a smooth transition from emergency to development support. The requirement is for the smooth transition of the emergency aid to sustainable health management. Similarly, it is essential that international assistance is maximally utilized to support the rebuilding with a rational plan for services that can be staffed and resourced. The methodology of a sector wide approach would be of considerable benefit in ensuring this.

2.9 Focusing on Vulnerable Groups

The challenge remains to ensure that Government funds in the health sector are targeted towards the poor and most vulnerable in society while that those who can afford to pay are encouraged to do so. Whilst Sri Lanka has been exceptionally successful by international standards in targeting state funds to poorer groups, significant gaps remain - notably for the elderly, the disabled, women, adolescents, those affected by conflict and workers in the estates sector.

2.10 A Sector Wide Approach and Inter-sectoral Collaboration

While the Ministry of Health, Nutrition and Welfare will take the lead in planning for the sector it needs to ensure full participation of all those involved in contributing to a healthy nation. The challenge is to involve all partners, other governmental ministries, the private sector, NGO sector, and development partners as well as civil society. This approach should ensure that contributions from donor agencies are well targeted and contribute to the Government's policy and overall strategy.

The Government of Sri Lanka recognises the need to invest in people to build the human resource base for a just and prosperous society. Ensuring that the basic needs of the entire population are met, and that each citizen is given the opportunities to realize his/her full potential, is central to the Government strategy to address poverty. It is now widely appreciated that better health has an important role in reducing poverty and promoting economic growth.

3.1 Vision 

The government aims to foster a healthier nation that contributes to its economic, social, mental and spiritual well being. It will achieve this by responding to the peoples needs and working in partnership to ensure access to comprehensive, high quality, equitable, cost effective and sustainable health services.

3.2 Underlying Principles

The vision reflects the fact that: 

· People can contribute significantly to their own health and the government should help them release this potential. 

· The role of Government is not just to deliver services but to develop partnerships, between Government departments and external agencies which contribute to improving health. These include: 

* Communities in the design, management and use of services 

* The private sector and Non-Governmental Organizations that play a key role in the delivery and financing of the health care 

*Developmental partners (donor and other international agencies) 

· The Government would ensure that health services are: 

* Accessible and affordable to the state and the public

*State services are free of charge at the point of delivery 

*Comprehensive and serve the whole population 

*Are of an acceptable quality both in the state and private sectors 

*Responsive to emerging and changing health needs 

*Accountable to users and the population at large 

*Evidence based 

*Sustainable

3.3 Strategic Objectives

The vision of improving the health status of the people will be achieved through addressing the following strategic objectives:

· To improve health service delivery and health actions 

· To strengthen health actions of communities, households and individuals

· To improve management of human resources for health 

· To strengthen stewardship and management functions of the health system 

· To improve health finance mobilization, allocation and utilization

The aims and the key objectives under each of the strategic objectives are described more comprehensively in section four.

4.1 Comprehensive Service Delivery

Delivery of comprehensive health services, which forms the keystone of health development, covers many facets out of which the important ones are outlined below.

4.1.1 Organization of a Rationalized Health Network

A detailed National Health Service plan for medium-term, up to 2010, will be prepared relating services to population needs for primary, secondary and tertiary. This will specify the optimum configuration of services for a given level of total annual health expenditure, show the implications for the state sector of assumptions about growth in private sector services, and identify priorities for capital investment. It will take into account, demography and epidemiology, current and future treatment methodologies, including a gradual shift to ambulatory care for diagnostic and surgical procedures and the potential of new technology, e.g. laser and laparoscopic surgery etc., to reduce inpatient stays.

The national health services plan will be used to guide the allocation of recurrent and capital financing to provinces. Mechanisms will be put in place to ensure that this process is transparent and equitable. Donor investments will fit into this plan.

In addition appropriate referral strategy including admission and discharge policies will be introduced to ensure that patients receive treatment at the most appropriate level. This will include home-based-care when and where appropriate. The supportive services too will be developed in a parallel manner.

Sri Lanka will have to continue to deal with existing communicable diseases while developing programmes for prevention and management of injuries, non-communicable diseases and new threats such as HIV/AIDS. Cost effective treatment protocols will be developed for selected diseases such as cardiovascular disease, diabetes, arthritis and renal disease and introduced into all relevant education, training and continual professional development activities. An example of this is the diagnosis, control and maintenance of diabetes through community level interventions with the objectives of minimizing hospitalization and maximizing quality of life. Pilot programmes will be established to introduce easy-to-use ambulatory technologies in the Sri Lankan context.

A quality assurance strategy will be developed to facilitate the delivery of high quality services central to the ethos of the health sector. Although backed by regulation it will have as its basis self-regulation. The Ministry of Health will lead in developing quality assurance in a systematic manner that enhances team spirit and is patient and consumer- focused. This approach will include clinical accountability and the development of peer group review and clinical audit as well as other methods of monitoring patient satisfaction and the quality of service delivery. The need for regulation to include re-certification of doctors, nurses and other health care workers at regular intervals will be discussed with the appropriate professional bodies.

Clear protocols and accreditation processes will be introduced to upgrade and sustain standards in both the state and private sector. To ensure sustainability, professional organizations, medical faculties and service providers will be involved in the developmental process. The role of the Sri Lankan Medical Council in encouraging quality improvements with wide public representation will be reviewed. The quality assurance strategy will ensure regulation and implementation of public health care programmes like food safety, environmental health, occupational health etc.

State health services will give particular attention to the poor and vulnerable groups by:

· Expanding preventive and other state health care programmes, with greater emphasis on health promotion; special efforts will be made to influence the young. Increased efforts will be made to prevent and treat nutritional problems.

· Expanding access to curative health care services through the selective upgrading of facilities in order to make these services more accessible to the rural poor.

Health care services will be expanded to meet the needs of specific groups such as the adolescent, elderly, families of migrant workers, victims of war and conflict and to promote specific areas of health care such as occupational health, mental health and estate health services. Training will be expanded in the area of mental health and geriatric medicine to meet emerging health care requirements.

Survey data are necessary on a regular basis to ascertain patients' and the public's views on the responsiveness of the health system. These surveys will ascertain the consumers' perceptions of the services provided, their level of satisfaction with the services and their views on the sorts of services they would wish to receive. Undertaking these surveys will send a clear message that their views are valued and will facilitate their increased participation in the planning and management of services in future. Findings of these surveys, which will be publicly available, could also be used to inform the policy makers on what changes are needed to develop a responsive and people centred service.

New technologies and innovations will be evaluated and where they clearly demonstrate their value and impact, introduced into the state sector. In particular the use of minimally invasive treatments and interventions including day care surgery will be encouraged as these have clearly demonstrated that they are beneficial to quality of treatment of patients and result in significant productivity gains. Policies will be developed to share investment in this area between the state and private sector where it is cost-effective.

The private sector will be encouraged to develop with a view to providing a better health service especially for those that can afford. The state sector will be encouraged to pilot the purchasing of services from the private health sector for state sector patients. These decisions will be made after careful cost effective studies, thus encouraging private public partnership.

The term "Health Sector Management" is essentially similar to the term "Stewardship", which WHO defines as "being ultimately responsible for the careful management of people's health". Careful review of the management of the health sector at various levels shows some areas need to be strengthened immediately. These areas and issues are outlined below.

4.2.1 Strengthened Managerial Performance at National and Decentralised Levels

The major issues in the health sector management in the country are confusion and conflicts over roles, responsibilities and lines of accountability between central and provincial levels of the MoH caused by devolution. The role/functions of the central MoH is still dominant in the tertiary hospital administration and recruitment and deployment of medical doctors. Provinces still have little control over recurrent expenditure, human resource deployment and disciplines.

Management capacity within the state sector will be strengthened to introduce changes and make the sector more responsive to the emerging and re-emerging challenges. This requires a major shift in the management and organizational structures of all parts of the system. With provinces assuming more responsibilities for operating state services, the role and functions of the Ministry of Health too will be subjected to change. Central Government health sector functions will move towards providing guidance, setting standards, ensuring quality, exercising regulatory functions, and monitoring needs, allocations, performance and value for money mandating significant restructuring of the Ministry of Health and a major change management programme.

4.2.2 Enhanced Efficiency, Effectiveness and Accountability of the MOH and Decentralised Units

The efficient and effective decentralized management in the Line Ministry and the provinces could be achieved by developing capacity of provinces to plan and manage services and by providing technical support, training and funds. Budgets will be linked to targets and technical performance agreed between central and provincial government. Strengthened technical capacity at provincial level will increase the pressure on Provincial Councils to allocate the designated share of budgets to health. Capabilities at field level will be supported to improve front line services and referral and information services too will be developed.

The health sector needs well-trained managers who have the authority and ability to manage the changes proposed and to ensure that their staff and institutions are involved. The immediate priority is to focus on in-service training of those individuals currently acting as managers at national, provincial, district and divisional level. Management development needs will be assessed and a comprehensive management training and development programme established which is open to all professionals. Consideration will be given to setting up an Institute for Health Management and distance learning programmes on health management will be implemented. Universities will be encouraged to develop a post-graduate degree in health management like MBA.

4.2.3 improved Performance Management Systems

All managers and institutions including field health units must be held accountable for the state resources used and the outputs achieved. A system of individual and institutional performance management will be introduced to facilitate their performances. Individual performance management will be based on defining clear roles, responsibilities, agreed performance targets and lines of accountability. It is proposed that the promotion and incentives should be linked to individual performance. Institutional performance management will be based on agreed plans for each institution and annual reports produced to account for the use of resources and results achieved. Guidelines on planning will be drawn up and strategic and operational plans will be developed and distributed for every major institution. The Ministry of Health will hold formal annual review meetings with each province to review achievements, identify challenges and agree on an action programme for the following year.

4.2.4 Established System for Regulating the Services of Public and Private Providers

The role of the MoH and the Provincial Directors in the private health sector in terms of quality assurance, setting up of a regulatory framework, sharing information systems and resources, outsourcing clinical services and manpower training is almost non existing in the country. The MoH and Provincial Directors have been neglecting their role in regulating the private sector to date, and the precise situation of the country is unknown. The MoH has been dependent on the self-regulatory mechanism of the private sectors up to date. However, from the consumer protection point of view, this aspect is one of the most crucial issues in the assurance of quality services. The private sector should be encouraged to raise and maintain standards. Legislation, now in draft, should be finalised, enacted and implemented to regulate private sector standards and the import of expensive technologies. Similar regulation mechanisms should be established for the state and private sectors so that quality is improved in the whole sector.

4.2.5 Strengthened Management Information System

The measurement of the effectiveness and the efficiency of a service basically relies on a well-designed management information system. Without appropriate information it is not possible for health care workers and managers to deliver, or measure, the significant improvements in productivity and quality of the health services or the system. The information policy will be developed and the capacity among managers and users of information will be strengthened. Clinical and management information systems will be reviewed and improved to ensure that managers have appropriate information to make evidence based decisions and deliver value for money. Benefit-incidence analysis will be carried out on a regular basis to ensure equity and access. Institutional data will be linked to community, clinical and epidemiological information.

4.2.6 Strengthened Coordination and Partnerships with Other Sectors

Improving the health status of the people will not occur by simply improving health service delivery. Health is influenced by many other factors and there is a definite need to have good coordination among health related sectors. For example, improvement of school health, reducing road accidents, and preventable disease control programme need to involve all partners including civil societies. It would be important to establish a sub-committee for health at the District and Divisional Development Councils to coordinate between stakeholders. It is hoped that the Ministry will develop clear for a and channels for thematic ongoing coordination, such as Human Resources Development, Nutrition, Non-Communicable Diseases etc..

4.2.7 Strengthened Capacity in Health Research and Technology Assessment

The role of health sector research should be emphasized more in the area of active promotion of evidence-based decision making at all levels. The main areas in urgent need of research are: health delivery system, health promotion, NCD, nutrition, indigenous medicine and health economy. The country has eminent academics and good research potential capacity. However, capacity of health and health related research institutions and researchers will be improved. Building of a national research institute to lead the development of appropriate evidence for decision-making will be emphasized. The mechanism of research sustainability will be achieved by creating suitable career structures, remuneration of researchers and the importance of building up suitable infrastructure for research to meet the increasing demand and competency will be discussed and planned as a national agenda.

The role of the individuals, house holds and the community in health development cannot be underestimated at any point. In order to obtain the maximum corporation it is important that the people are made knowledgeable for their rights and responsibilities, and are provided with inputs that are necessary for positive behavioural changes and also to provide adequate opportunities for maximum involvement in health activities.

4.3.1 Improved Public Awareness of their Rights, Responsibilities and Options for Care

The public, patients and Human and Patient Rights Groups need strengthening in order to make the public and patients aware of their rights and responsibilities. Effort to build and strengthen these groups will be promoted with a view to maximizing the responsiveness of the health system to meet the legitimate expectations of the people of the country. Public will be made to realize of their responsibilities with a view to maximize their involvement to maintain a high degree of responsiveness.

4.3.2 Improved Participation of Civil Society and Non-Governmental Organizations in Promoting Behavioral and Lifestyle Changes

The determinants for behavioral and lifestyle changes are multi-factoral. They are multi faceted and are densely interwoven to the social fabric who has been enriched by ideas, norms, values and believes of people. The effort that need to make to achieve a positive behavioral change in selected population risk groups needs to be equally shared by civil, non-governmental and other governmental organizations as well. In selected areas the programme will work with relevant government departments aiming to achieve healthy public policies and interventions in all sectors. Similarly the community groups and other non-governmental organizations too will be encouraged to participate in these activities.

4.3.3 Promoting Behaviour Change for Healthy Living

The Ministry of Health will lead in planning and sponsoring a major national behavior change communication programme and set off activities aimed at healthy lifestyle change in target population groups. It will be carried out through inter-sectoral and multi-sectoral collaboration with relevant department and agencies. The objective will be to reduce preventable risk factors and the main stakeholder is the population themselves. The Ministry of Health with collaboration with other partners will identify the targets groups and the needed lifestyle changes based on evidence of epidemiology, treatment cost and effectiveness factors. These will include nutrition, exercise, tobacco, alcohol intake, road safety including seatbelt use, and sexual behavior. Commercial sector behavioural change advertising and lobbying companies will be contracted to design, pre-test and implement and manage these programmes.

4.4 Improved management of Human Resources for Health

Significant changes in employment structures are unlikely in the short term. However there will be opportunities for incremental organizational changes and to introduce new incentives for staff. Also there is a desire for more managerial autonomy at all levels in order to raise job satisfaction and service efficiencies. A human resource strategy will be developed to ensure that the right people are available with the right skills in the right locations at the right time.

4.4.1 Strengthened Human Resources Development Functions and Capacities of National and Provincial Ministries of Health

In the present context the basic and post basic training of Human Resources for Health (HRH) is the responsibility of the Central Government. However the responsibility of in-service training remains with both Central and the Provincial Governments. The shortcoming of the supply of certain categories of HRH, and the lack of adequate in-service training and career development opportunities for all categories has been clearly highlighted over the past few decades. The capacity of the Central and the Provincial Governments to coordinate and to corporate in Human Resource Development will be enhanced.

Projections of HRH needs and supply will be made for the next 20 years based on the service needs, demand, actual type of services, workloads and the economical feasibility.

4.4.2 Improved Skills and Planning of Human Resource Requirements

The MoH role and responsibilities in human resource planning and development will be expanded for not only recruitment, training and staff allocation of para-medical health staff but also for policy/planning, development and management, collecting human resource related information, and coordination among human resource - related institutions/units/ministries. Training on managerial skills for managers of health service providers will be provided under Ministry coordination. Comprehensive human resource development plans and policies will encompass not only public health /allopathic sector but also private health sector and non-allopathic sectors as well and will cover all categories of human resource recruitment, training and deployment, and other aspects of human resource development. It would be important to have a unified unit or a mechanism to unify the currently compartmentalized human resource functions existing inside and outside of MoH.

4.4.3 Rationalized Distribution and Utilization of Human Resources

There is a significant imbalance existing in the current distribution of HRH. Specifically the number and the rate of health personnel in the Northern Province is extremely low while Colombo, Kandy and Galle districts have higher concentrations. Other provinces too experience shortages of HRH. The factors that lead to this imbalance will be identified and corrected. The capacity at the central and provincial levels to overcome the imbalance of HRH will be improved. The institutions will be strengthened in order to utilize the available HRH maximally.

4.4.4 Improved Competencies of Health Staff in Management, Clinical, Investigative and Preventive Health Fields

Another important dimension in health human resource development is the issue of quality. The two main aspects of quality are technical competency and human attitudes. Building positive human attitudes and appropriate knowledge and skills in provision of services of defined quality have been emphasized for decades but still need lot of attention. For improvement of technical competency, in-service training and continuing education with career development need to be institutionalized. Once adequate opportunities are made available for re-training, re-registration too could be considered as a mean for improving technical quality. The minimum standards for certain categories trained by the Private Health Sector establishments for internal use too should be ensured as the MoH has a responsibility to look into this aspect of quality assurance from the patient protection point of view.

Building of positive attitudes among health service providers will be given top priority. In house training, supervision and performance appraisal will be established in each institution with a view to building positive attitudes among health care workers.

The need of additional financial resources for the development and the maintenance of the health system should be given high priority. This could be achieved by additional allocation of financial resources as well as by facilitating the optimal use of existing resources. Further the mechanisms to achieve the above while improving the financial equity of health care too will be strengthened.

4.5.1 Improved Allocative Efficiency of Public Funds

An increased share to state health interventions: There are concerns that real expenditure on key state health interventions is declining over the past few years. Though the primary responsibility for the delivery of such services rests with the provinces it will be important to consider what incentives and mechanisms can be put in place to encourage the provinces to strengthen their efforts in this area. The Ministry of Health will take the leadership to set standards and performance indicators along with the provinces and other stakeholders and to assess the cost requirements to achieve these goals. Guidance will be provided on how provincial resources are to be allocated to ensure that they are consistent with national objectives and that equity is enhanced throughout individual provinces. Earmarked grants may be provided to support this process.

A focus on addressing the gaps in provision in the conflict affected areas and the estates sector: Access to health services and health outcomes are clearly much worse in the conflict affected areas and in the estate sector. Reducing such inequalities will require well planned, concerted action. A sustainable investment strategy will be developed based on realistic staff and resource availability.

Removing unwarranted subsidies: The current preferential tax treatment for private health insurance is unwarranted. It involves a net subsidy to the most affluent and should be withdrawn. The revenue foregone through this policy is at least five times greater than the net savings to the government in terms of reduced utilization and expenditures at state hospitals, or the amount of resources released for spending on other patients. This was described in an analysis of PHI in Sri Lanka: Findings and Policy Implications. Institute of Policy Studies, 1997. Government could spend this money better elsewhere. The case for subsidizing the development of private facilities is also questionable and needs to be closely reviewed

Contracting Out where it offers value for money: There is already extensive contracting out of non-clinical services. Government will review the case for contracting out both clinical and non-clinical services where this offers value for money.

Maintaining the share of state subsidies to low income groups: Government will continue to support the low-income groups through:

· Ensuring resources are equitably allocated on a geographical basis between and within provinces. 

· Focusing resources as far as possible on health promotion and disease prevention 

· Focusing services toward vulnerable groups 

· Removing subsidies that primarily benefit the better off - e.g. tax deductibility on private insurance contributions and favorable treatment related to the development of private infrastructure

4.5.2 Identifying and testing alternative financing mechanisms

Tax-based funding has served Sri Lanka well in the past. However, it has not generated sufficient resources to allow services to be modernized in line with the expectations of the population and it has not provided a service that is responsive to changing health needs. Also the limited finances create few incentives for improved performance.

Other approaches that may contribute to the revenue base, and which will warrant review include, either alone or in combination; health insurance (social, community or private), fee for services including co-payments, and earmarked taxation.

Social health insurance offers the potential to address some of these problems. However, the feasibility of developing social health insurance as the primary financing mechanism is constrained by the relatively low level of formal employment and its cost. The high level of informal employment would make it difficult to collect premiums and the additional costs involved would have to be financed - either by Government, by employers or by the people. Preliminary studies are being undertaken to estimate the levels of contribution that can be expected. A programme of work will be developed to assess the feasibility of social health insurance and will draw heavily on international experience. Any decision on the primary financing source will need to consider the extent to which the shortcomings in the current tax based system can be addressed.

User charges are an inequitable and inefficient means of raising revenue for basic health services. State health services will be provided free of charge at the point of delivery. However at facility level, managers would be free to explore alternative ways of raising revenue that does not compromise equity. This could include amenity beds, selling services at full cost to the private sector and raising donations.

A more proactive and rational approach needs to be taken to donations. The current approach is rather ad hoc and there may be much untapped potential. In maximizing such contributions it will be important to ensure that they contribute to national development goals and are rationally distributed. Guidelines will be produced.

Government will also review the case for additional taxation on products that harm health such as alcohol and tobacco and also on vehicle insurance. Whilst this might reduce the demand for such products it may reduce overall tax revenues. The case for earmarking such revenues for health will also be considered.

4.5.3 Identification of Financial Needs and Making Optimal Use of Existing Financial Resources

Detailed work will be undertaken to estimate the costs of running a rationalized health service in Sri Lanka. This will form the basis of a prioritized financing plan that can be implemented as resources allow. This will be periodically reviewed and revised.

In view of the current economic climate and the need to address other priority issues, such as the rehabilitation of the conflict affected areas, the scope for additional resources for health is extremely limited. However, Government is committed under the PRSP to raising state allocations for health to 8-10% of total public expenditure from current levels of around 5 to 6% and this will be confirmed within an agreed Medium Term Expenditure Framework. Such increases will only be forthcoming if the Ministry of Health can clearly demonstrate that the additional funds contribute to improving health.

The Ministry of Health would comply by developing and monitoring a series of performance indicators that will be used to evaluate current structures and interventions and guide future investment.

4.5.4 Strengthened Financial Management

Financial resources will be used more effectively and efficiently. Allocated resources need to arrive at cost-centres in a timely manner. Finance posts need to be filled by those with the necessary skills, and better financial management information is needed. Currently a lot of information is generated but little use is made of it for management and strategic planning purposes. Information will be collected systematically and initiatives such as national health accounts institutionalized. The entire budgeting process will be made more transparent.

4.5.5 Improved Financial Equity of Health Care, and Related Equity of Access to Health Care Services

Financing equity is high in Sri Lanka as the tax system is progressive. In general the poor receive a large share of the tax subsidies and utilize health care services relative to the more affluent. The more affluent increasingly seek care in the private sector, for both inpatient and OPD care. However financial burden on health care including the catastrophic expenditure of certain segments of the population; those from urban slums, displaced, estate workers, rural poor etc. need careful consideration. Efforts would be made to improve the financial equity of health care and the related equity of access to health care services.

4.5.6 Optimizing Private Sector Contribution

Private insurance offers little scope for contributing to national health objectives as it is a private good and is currently only affordable to the more affluent segment of the population. The private health insurance market in Sri Lanka is in its infancy and is beset with major problems. Government has a responsibility for ensuring consumers are protected and therefore needs to consider which forms of regulation are appropriate and to develop a regulatory framework before powerful vested interests have had a chance to fully establish themselves. Other areas for consideration might include the need to: define minimum benefit packages, develop approaches which ensuring transparency and comparability, agree on treatment protocols, ensure guaranteed renewal, reduce companies' ability to deny coverage on the basis of preexisting conditions, establish conflict resolution mechanisms and promote and develop quality assurance procedures. A form of managed care may offer more than traditional health insurance to consumers seeking an alternative to the state sector and providing more of a family medicine/general practice package as well as secondary care.

4.5.7 Developing a Rational State Facilities Master Plan

In conformity to the detailed national health services plan, a facility master plan will be developed based on identified requirements at provincial, district and divisional levels and on the needs for tertiary and teaching hospital facilities. It will be based on demographic, epidemiological data and projections and on the technological advances in medical practices, rather than on historic patterns of provision. The planning systems will be reviewed and made more open, transparent and participatory based on locally assessed requirements. Facilities will be reclassified according to agreed criteria and to reflect the types of service to be provided. The recurrent implications of any capital development programme will be considered as part of the master plan and integrated into the expenditure framework. Donor support needs to fit within the overall master plan.

4.5.8 Ensuring Adequate Drugs, Material and Equipment

The challenges in medical supplies and equipment management are many and interrelated. The essential drug lists for each level of medical institutions need to be reviewed. The purchasing and distribution systems of drugs as well as the storage capacities at provincial, district and divisional levels will be improved minimizing the wastage and pilferage. The quality of medicines in the public sector will be tested routinely to ensure the uninterrupted distribution of potent medicines at the points of service delivery. Similarly the purchasing, distribution, maintenance and repairing systems will be strengthened, for equipment along with the supply of other logistics.

This strategy for a healthier nation is not an end by itself; rather it is the beginning. There will be wide consultations on the draft strategy, and then the agreed strategy will be widely communicated to the general public, health workers, professional bodies, unions of health care workers and other stakeholders for comments. Once finalized this document will be submitted to the Cabinet of Ministers of the Government of Sri Lanka for approval and subsequently submitted for parliamentary approval. (Should this go to the preface?)

The health sector is changing rapidly and the strategy needs to evolve over time to reflect this continually changing environment. Mechanisms will be put in place to ensure that the planning systems and management of the health sector reflects and takes forward the strategy.

In order to identify possible interventions, projects and programmes to realize the objectives described above a series of discussions will be encouraged over the next four months. These working groups will invite more stakeholders from the Ministry of Health and Provincial Ministries, other Ministries, professional groups and other civil society organizations, which will assist the identification of outputs and activities. It is expected to conduct seminars and workshops on specific topics and areas that need further discussion such as health financing, performance evaluation etc..

Based on the outputs described above, the objectives will be developed and the broad activities will be identified as projects and programmes. Once the activities are identified, the inputs, verifiable indicators and means of verifications will be determined along with broad budgets for each activity. Based on the discussions made and the outcome of stakeholder consultations the detailed master plan will be written by a group of writers selected from the Ministry of Health along with international and national consultants.

The most vital component in the strategy is to identify a number of priority interventions in line with the overall strategic objectives. The priority should be considered employing a rational procedure with stakeholder participation as well as a logical phasing of intersectoral linkages.

Implementing the strategy must be an integral part of the management of the health sector and not seen as an additional piece of bureaucracy. Consequently existing structures and regimes should be used to take the process forward rather than creating new institutions and structures.

Of particular importance will be the need to use the financing and planning systems to the best effect. Immediate steps should be taken to strengthen the Ministry of Health's contribution towards the development and negotiation of the budget with the Ministry of Finance. It will be particularly important to develop clear output measures against which investment can be measured. Similarly the planning processes should be improved at an early date to enable transparent plans to be developed and agreed.

Improved inter-sectoral and donor coordination is essential to ensure that a sector wide approach is adapted to the development, financing and implementation of health strategies. The building of a healthier nation is the onerous and inescapable responsibility of each and every citizen of Sri Lanka.