Inefficiency and corruption are the main two misdemeanours levelled against health as well as rest of the state sector. While there is some amount of truth in this, however, this cannot be taken for granted. Good and bad institutions together with inefficiency and corruption prevail both in the government as well as in the private sector. (In this regard a recent revelation of private sector being more corrupt than the government sector is worth the careful attention of the people concerned. "The Island", 19.12.2007.) At the same time, many notable achievements in health and social indicators right along, and praiseworthy appraisals of some of the government hospitals such as the General Hospital Ampara, Base Hospital Mahiyangana and Castle Street Hospital for Women, in the recent past, both nationally and internationally, speak positively for the state health sector and the strength and capacity it has and the potential for correction through a better management culture. However, although there had not been any comparative studies on efficiency/ effectiveness of the private vis-à-vis public sector, the common notion that ‘public sector is bad; private sector is good’ still continues to loom large. However, now the time has come for us to ask, ‘is this real or something created’ by groups with vested interests, as they provide the very basic premise necessary to infiltrate into the state health sector, and to ‘privatize’ and/or ‘downsize’ it.

Although, by and large, the overt attempts of ‘privatization’ of the health sector have been defeated in the past, the same cannot be said about ‘downsizing’. Especially, at a time when the health sector needed more staff, particularly in the rural areas, to consolidate its gains in health development, came the first major attempt at ‘downsizing’ the health sector during the UNP regimen from 2001 to ‘04, when a circular was issued to halt all recruitments to the state sector. (Also even the State Pharmaceutical Corporation was earmarked to ‘go under hammer’ during that time). At the same time, there were many lucrative packages offered to the workers, encouraging them for ‘voluntary retirement’. Although this was the first real move for downsizing the public health care in this country, this did not last long as the government was defeated in the April 2004 elections.

Today, public - private partnerships in the health sector take place in a big way, yet unnoticed and unchallenged. Since it started happening with "liberalization of economy" in 1977, by and large, the private hospitals in Sri Lanka continue to be privately owned but run by public resources when it comes to skilled human resources (eg. doctors, para-medical staff and even nurses in private hospitals outside the city of Colombo). How this hampers smooth functioning of hospitals is a well known fact, but I would refrain from going to town on that as it would be a deviation from the main topic. (For more on that topic, refer, Privatization of health in Sri Lanka, health and society, "The Island", Thursday 22, April, 2004).

Today, this ‘cohabitation’ has even extended to laboratory services in the government hospitals as well. It is no secret to us, today, many government hospitals ask patients to get tests done from ‘out’, sometimes even identifying the laboratory (or private hospital) by name. Also, the patients require buying many expensive drugs from ‘out’. (I hope, the move by the Ministry of Health to open ‘Osu-Salas’ inside hospital premises, although needs to be applauded, will not be a ploy to facilitate this process).

This division operates not only in the curative sector, but surprisingly, in the preventive sector as well. Today, there exist two immunization schedules in the country, one for the poor (carried out through government clinics) and another for the ‘affordable’ (through private clinics). Thus, today we see more and more parents turning towards the private clinics for the vaccination needs of their children. (Irony is that, the doctors who run the clinics in the government hospitals, also run these clinics in the private sector; what a ‘double standard’ they practice, wittingly or unwittingly, or for reasons best known to them only).

Outsourcing (or contracting) services is generally recommended for reasons such as inefficiency and getting a hold of the workers. Outsourcing gives an opportunity to ‘hire and fire’ the employees, a phrase that has come to the labour jargon in a big way, since the neo-liberal infiltration of the 70s. Outsourcing has started to happen in the health sector too, especially with services such as cleaning and security. Although some argue that this would reduce the overheads by not having to have permanent employees (another measure of downsizing), whether this happens again is a big question, especially with the amount of money spent on these companies for their services (although only a paltry sum goes to the hands of the workers at end of the day).

Considering these facts it is clear that health sector reforms have taken place in the Sri Lankan health sector in a big way, both through political (decentralization) and managerial (marketization, downsizing, public-private partnerships, outsourcing) processes. However, whether this has been subjected to a proper discussion is yet again another question.