Sri Lanka’s model of primary health care, available free through a government health system with island wide availability, forms a sound basis for providing universal health coverage. However, this system is increasingly under pressure notably from the high burden of non-communicable diseases (NCDs), increasing elderly care needs and the growing out of pocket expenditure for chronic diseases. Whilst the government’s commitment to maintaining universal health services of good quality for all continues, the need for change has been recognized. The government is exploring now how a rational model of care can best be instituted given limited resources.
Primary health care in Sri Lanka developed, as two parallel services:
Community health services, focusing mainly on maternal and child health and on communicable diseases and adopting prevention and health promotion strategies, based on the health unit system. The health units have defined catchment areas that coincide with local government administrative units and currently number 341 areas. Also known as MOH areas, they are managed by a medical doctor, supported by public health field staff.
Curative services consisting of 496 Divisional hospitals providing both hospitalization and ambulatory services and 474 Primary Medical Care units providing only ambulatory care which function with non-specialist medical doctors and other staff.
The present decentralized pyramidal system was established in 1989. Three levels of health care are offered. At the first, management of the primary health care services was devolved to provincial councils. At the secondary level 68 basic hospitals and 18 district general hospitals provide diagnosis and treatment facilities. At the tertiary level the central authority manages the National Hospital, the teaching hospital and 10 larger specialist hospitals together with the procurement of drugs, recruitment and deployment of staff and training.
This system has many positive aspects, not least that the continuing government commitment ensures a good standard of free healthcare from government services. With the abolition of user fees in 1977 healthcare is financed by general taxation and delivered by graduate and post-graduate trained (at government expense) health personnel. Other factors having a positive effect on the policy environment for universal healthcare include the free education system. Universal education has had a positive impact on female empowerment and has promoted the health seeking behaviour of mothers, who are the chief health providers of the family. In addition the permission given to government health personnel to work in the private sector after duty hours has improved retention of personnel in rural areas by compensating for low salaries. It has also improved access to health services at all hours even though this out of duty hours service is not free.
However, the problems with this system are evident with ever-increasing challenges within the health environment. Decentralisation has contributed to an unequal distribution of health resources which is exacerbated by the emphasis on expanding specialised services. This has reduced funding for primary care, the subsequent effect of this on the quality of primary level services, alongside the lack of a referral/gatekeeping system to filter access to specialized services, has accentuated the by-passing of primary level care; inefficiency is thus built into the system. Furthermore, chronic diseases result in a more difficult to define health package; the present system does not yet cater for this and the individual is left to negotiate his/her own way through this problem entailing much out of pocket expenditure.
In the period 2008–2013 the policy unit at the Ministry of Health undertook an analysis with pilot studies and discussions with Sri Lankan experts on a suitable model for reform. The consensus was that the existing model should be expanded to adopt chronic care needs rather than setting up a parallel structure for NCDs at the primary level. An important aspect of this will be a transition from the present episodic type of patient management to a continuing personalised and family centred care which is much more appropriate for NCDs. In addition, the principles of family medicine need to be integrated into health training so that attitudes and practices of primary level personnel are adapted to this approach. Improvements also need to be effected in the availability of essential drugs and basic laboratory tests for NCDs in order to limit the necessity to by-pass primary level units. Lastly, there should be an emphasis on community education to reduce risk and improve health seeking behaviour.
To facilitate and foster these improvements a new organisational structure is proposed termed the Shared Care Cluster System. Services will be grouped around a hospital providing specialist care at the apex with surrounding primary care curative institutions at divisional and primary level. The objective is to provide universal access to continuing care that makes the best use of the existing system and the optimum use of resources. The cluster system is designed to bring about a system of accountability for care as it will have a defined catchment area and defined areas of responsibility. While it is hoped that it will rationalise and make government allocation more efficient and effective there remains still the unfinished agenda of health financing the accompanying dilemma attached to the challenge of NCDs to Sri Lanka’s primary health care model.
