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.

4.1.2 Priority Diseases/Conditions Reduced through Strategic Interventions

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.

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.