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Our Pro-poor health care policy rewarded

The World Health Organization has honoured our country by electing Hon Minister of Health, Nimal Siripala de Silva the Chairman of its Executive Committee. What has made us so prominent in health care? This article examines some unique aspects of our health care policy that has worked – despite skepticism by many foreign organizations.

At the Millennium Summit in September 2000, the largest gathering of world leaders in history adopted the UN Millennium Declaration, committing to a new global partnership to reduce extreme poverty. They set out a series of time-bound targets, with a deadline of 2015. These are known as the Millennium Development Goals (MDGs) and are eight in number, namely, (1) Eradicate extreme poverty and hunger (2) Achieve universal primary education (3) Promote gender equality and empower women (4) Reduce child mortality (5) Improve maternal health (6) Combat HIV/AIDS, Malaria and other diseases (7) Ensure environmental sustainability and (8) Global partnership for development.

The MDG 4, aims to reduce childhood mortality by 2/3rd by the year 2015 from that of 1990. The United Nations have identified 3 indicators to assess its progress i.e. reduction in under 5 mortality rate, reduction of infant mortality rate and administration of the measles immunization to all children at the age of one year.

It is pleasing to note that Sri Lanka has been performing in the forefront in relation to above health indicators. The under 5 child mortality rate in Sri Lanka has seen a steady reduction over the last 4 decades. It currently stands at 14/1000 live births.

The infant mortality rate too also has reduced to 12 /1000 live births. The maternal mortality rates have followed suit and it now stands at 0.6/1000 live births.

Ninety nine percent of children under one year have received immunization against measles.

In a recent report by the UN (2006), the worlds progress in achieving the MDGs were assessed. In this report the target for under five year mortality was considered 20/ 1000 live births for the South Eastern Asian region by 2015. Sri Lanka has already achieved this target.

Thus, at present the child health indicators of Sri Lanka appear to be performing close to that of developed countries. Although this may be pleasing, it should also be noted that these were results of long-term multi-faceted commitment. Thus, it is important for us to analyze and understand what may have led to these improvements.

The Sri Lankan health care system is now considered a health care delivery model for most developing countries across the world. Our public health care system with a good network of health care institutions and a robust referring mechanism to secondary and tertiary care is equitable and free. Thus, it is our duty to nurture and protect it whilst looking for strategies for further improvement. The important aspects in our health care system are mainly its delivery free of charge, with no equation for cost-recovery. Additionally, it should be borne in mind that our private health care system, which is mostly addressing outpatient care, with what ever the criticisms attached to it is complementary to the public ‘Pro-Poor’ health care policy. This means the wealthier patients who are free to opt out of public health care are still continuing to support the public Health Care system. The insurance based system in Sri Lanka supports private health care and to date, this is not allowed to engulf health care as a commodity across the country replacing above.

It should be noted that above health statistics exclude the 5 districts affected by the North-East war i.e. Jaffna, Kilinochchi, Mannar, Multhivu and Vavuniya. It is however noteworthy that the health statistics of those districts were above that of the rest of the country before the war began in 1983.

We are a tropical country with a 20 million population. Its birth rate and death rate are reducing with a reduction in population growth. Currently life expectancy in Sri Lanka is estimated to be 68 for males and 75 for females. As a result, our population pyramid had now begun to invert and Sri Lanka is expected to be the third oldest country in Asia after Japan and Singapore by 2010 in the Asian region. Unfortunately, to date, we are yet to pay sufficient attention to care for our increasingly aged population.

Sri Lanka’s achievements in health statistics is not solely due to effective planning. There are many other factors that may have also influenced these improvements. It is important for us to recognize, nurture and protect these factors.

The current Gross National Income (GNI) of Sri Lanka is 1160 USD/ capita /annum and Sri Lanka spends only 2% of its Gross Domestic Product (GDP) for its public health. Accounting for the estimated wastage, corruption and negligence, the real public health expenditure by the Government can be estimated to be 1% of GDP equaling to 10 USD per capita per annum. The developed countries usually indicate a GNI of at least 20,000 USD per capita per annum and they usually spend at least 10% of their GDP for health. This equals to USD 2000/ capita / annum. Thus, Sri Lankan public health expenditure is 1/200th of that of a developed country. Today more than 50% of our health care costs are borne privately and the national health care system contributes only less than 50%.

Sri Lanka had not always followed the directions offered by the foreign organizations such as World Bank. For example, the International Agencies have consistently offered advice for us to implement a cost-recovery formula for health care delivery. The successive governments of Sri Lanka have constantly resisted this. International health care organizations advice that it is the outpatient care that should be strengthened. But instead, Sri Lanka is pursuing a policy of strengthening in-patient care.

The factors that may have contributed to our health care development include;

1. Cultural, social and historical reasons

a. High level of women’s autonomy

b. Relative gender equality

c. A democratic system based on universal franchise

2. A significant level of consensus on national priorities related to social services

a. Free education since 1947 and high level of female literacy (98%)

b. Improved nutritional status of poor families – via various subsidies for food, water, sanitation systems

3. Important health policy decisions by Government

a. Emphasis on public financing on in-patient care rather that outpatient care

b. Motivated and trained body of health personnel

c. Rejection of cost-recovery as a general financing policy

4. A network of health facilities available across the island close to where they live creating a strong referral system.

i. Western facility within 2.2 miles from home

ii. Indigenous facility within 0.9 miles from home

5. Most women electing to give birth in hospital

a. Strengthened in-patient maternity care

6. A complementary private sector

a. Focusing on mainly outpatient care

b. Provision of higher cost care to those who can pay

7. Pro-Poor "Re-distributative effect"

a. Public facilities are made available to everyone

b. Wealthier patient can self select out of the public system for private outpatient care /in patient care – but they still continue to use and support public in-patient services

This has led to a ‘Pro-Poor’ health care policy. The health care system in Bangladesh, where 67% of its expenditure is targeted for the poor is still considered ‘Pro-Rich’ as user fees are invited.

The complementary service of the private sector that is contributing to the health improvement in Sri Lanka should not be undermined. It is also extremely unfair that patients seeking private heath care are surcharged – almost as a penalty for continuing to pay for public health care and not using it. The private sector that focuses mostly on outpatient care would be no doubt helping patients receive health care without delay avoiding the dreaded complications and the need for aggressive therapy when the situation is worsened with time delays. In the absence of the private sector, one can imagine the number of patients who may have been queuing up for more than 12-18 hours to obtain a medical consultation on the following day. On such an instance, the already crowded public sector Out Patient Departments (OPDs) would merely collapse unable to cope with the workload. Thus, the complementary private sector should be considered as an asset and not a nuisance for the politicians and public.

Instead of planning to ‘tax’ indirectly the patients seeking treatment privately, through surcharging private institutions, the Minister of Health should now focus his attention to reduce the corruption, inefficiency etc prevalent in the Government Hospitals, improve its quality of care and improve accountability. Trying to surcharge medical personnel and institutions that are mostly dependent on public popularity for their survival is leading to an indirect second taxation of the public, who are seeking private health care. This will return most patients back to seek free public health care due to non affordability, ultimately leading to a Pro-Rich scenario. Thus, public well-being will now automatically revert to what it was many decades ago in this country, where only politicians and a few others could access and afford private health care.

The competition among the health care institutions is healthy and this has led to a marked improvement in the quality of care in private institutions and is to some extent self governing. As a consequence, the public demand for such facilities has increased and government hospitals also have no choice but to follow suit to improve. It should be noted that private health care institutions, in particular, the outpatient facilities are contributing to the improved health statistics of this country in a big way. The maintenance of the policy of ‘free health care’ by the successive Governments is a must, especially for in-patient care, and a caring government shouldn’t uphold any attempt to destabilize this equilibrium directly or indirectly. The cost-recovery model should never be introduced to this system, as ‘Health of the Nation’ should, on principle, be considered the ‘Wealth of the Nation’. Thus, it is the duty of all citizens to protect our health care system that is now in an equilibrium serving the poor with a "Pro-Poor" Health policy.

What is now necessary for this system is to ensure that pubic institutions and staffs are more efficient and less corrupt. There is no rewarding scheme for efficiency and innovation in the public health sector, except seniority, which is a notoriously erroneous guide to equate for performance. Efficient staff members and institutions should be recognized and promoted and be prioritized for support and funding. This kind of a self appraising mechanism will enhance the quality of our health care through motivation and exclusion.

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