Chronicle Pharmabiz Special
Sri Lanka: Trends in policy development
In 1978 Sri Lanka witnessed a major political change with the establishment of an executive presidency. Legislative powers continued to be vested in parliament but executive authority was exercised by the president and a cabinet of ministers. In 1989 significant decentralization took place with the introduction of provincial councils. This process was further enhanced in 1991 by the establishment of divisional secretariats within each of the provinces. Intersectoral collaboration in health development is demonstrated in national health policy through multisectoral councils and committees at different levels.
Sri Lankan policy, irrespective of the government in power, has always regarded education and health as crucial to socioeconomic development, while the concept of equity and social justice in favour of the underprivileged has also been a feature of state policy. This has resulted in a high literacy rate (88%) and a life expectancy at birth of 69.5 for males and 74.2 for females (1991). There is also substantial investment in poverty alleviation. The overall social status of women is satisfactory and women constitute 42% of the occupational workforce (1985-86).
Within the context of the more recent liberal, market-oriented economic policies, the overall principle has been to promote both equity and efficiency, adopting social safety network measures where necessary. Recently a Presidential Task Force has been constituted to develop a strategic framework for implementation of the national health policy, which retains current policies, consolidates the gains achieved, and prepares to meet new challenges.
Trends in Socio Economic Development
The economy has witnessed a moderately high growth since 1989/1991. The annual growth rate of the GNP was 5.9% and GNP per capita about US $709 in 1995, compared to a growth rate of 4.6% in 1991 and a per capita GNP of US $345 in 1989. This moderately high growth was supported by continuity in reforms towards a market-oriented policy environment, a strong export performance, and an improvement in primary commodity prices. Economic growth in 1995 was spearheaded by the manufacturing sector while other major contributing sectors were trade, agriculture, transport and communication, and financial services. The unemployment rate in 1995 was around 12% as against 13.8% in 1991. Increased foreign employment contributed to easing the labour market pressure. Women have entered the labour force at a faster rate than men but take on lower paid and less prestigious jobs. Until recently, most key infrastructural facilities were operated by the parastatal sector that relied heavily on budgetary support from the central government to cover some of their operating costs. Infrastructural deficiency has been a serious impediment and the government has accepted in principle the need for wider private sector participation. The public sector health services are almost fully financed by the government, with the services available free of direct cost to the consumer.
The last census in 1981 recorded a population of 14.85 million. The mid-year population in 1995 was estimated to be 18.1 million. The annual population growth rate in 1995 was 1.4%. Sri Lanka has passed through the classical phases of demographic transition to reach the third phase of a declining birth rate and a relatively stable low death rate. The base of the population pyramid is contracting and the proportion of the population over 65 years is projected to be 8% and 12% by the years 2000 and 2020 respectively
The thrust of the overall state policy in Sri Lanka has been on social development as reflected by the relatively high resource allocation for education, health and other social measures. The literacy rate in 1990/91 was 90.0% for men and 83.1% for women. Gender inequality in education is gradually narrowing. The proportion of males attaining secondary or higher education in 1986/87 was 43.8% compared to 42.4% for women.
Food supply and nutritional status
The nutritional status of children has not significantly improved over the years. About one-fifth of newborns have a birth weight of less than 2500 grams, largely associated with maternal undernutrition. In 1993 it was reported that 15% of children below five years suffered from wasting (low weight-for-height), 23% from stunting (low height-for-age) and 37% were underweight (low weight-for-age). A high proportion of pregnant and lactating women suffer from iron deficiency anaemia (haemoglobin less than 11 g/dl). The Demographic Health Survey (DHS) of 1993 revealed a marginal increase in the prevalence of acute undernutrition or wasting (15.6%) in children under five years.
This is probably a reflection of the increased cost of living that has affected the purchasing power of families. Wasting was, however, significantly lower in the first year of life and this is due to the strong emphasis being given to improved breast-feeding practices. Seventy percent (70%) of the population live in areas where iodine deficiency exists and some areas (districts) have shown a goitre prevalence among school children 5-18 years as high as 25-30%. In response, the government has initiated a programme for the universal iodization of salt. Vitamin A deficiency exists in pockets and more data are being elicited. The main constraints have been a lack of general awareness about issues pertaining to nutrition, a rising cost of living and therefore reduced purchasing power of families, and the heavy government expenditure incurred on the current armed conflict in the northern and eastern regions of the country.
There is an increasing awareness of lifestyle-related health problems associated with alcohol and tobacco use, substance abuse, diseases of affluence and nutrition, and sedentary lifestyles. About 35% of males are current smokers. Smoking is rare among females. Integrated approaches to alcohol, tobacco and drug prevention programmes have proved viable, with the necessary impetus being given by nongovernmental organizations that play the role of catalyst in motivating organizations and institutions to integrate tobacco and drug prevention programmes into their own activities. Newspapers and the radio have been particularly active in promoting positive lifestyles.
Health & Environment
Sri Lanka has an impressive portfolio of environmental legislation and a set of standards for the quality of air, water, food safety and the workplace. Under the National Environmental Act of 1980, an Environmental Council was established in 1982 with representation from different ministries, including health, that have functions related to the environment.
Under the guidance of the council, a central environmental authority is responsible for implementation of activities that include development of standards and guidelines for pollution control, monitoring major water bodies, control of toxic chemicals, hazardous waste management, chemical and microbiological impact assessment of major development activities, and public information and education utilizing the mass media, schools, NGOs and other community-based organizations. A National Environmental Action Plan was prepared in 1991 and a set of policy measures for environmental health suggested by a Presidential Task Force in 1992.
Human Resources for Health
In 1992 the process for developing a National Health Policy was initiated and this policy was formally presented in 1997. A perspective plan for health development (1995-2004) was formulated in 1994 and supported by annual health plans.
A human resources development council was created to advise the cabinet of ministers on human resource development needs. A study in 1993 revealed that plan-ning for human resource development was episodic and limited in scope, without consideration of the private sector, the demand pattern for services, and technological changes. There have been significant increases in the various categories of medical and paraprofessionals, though the increase has not been uniform across the various categories.
The precise picture for the private sector is not available and information regarding the availability of health personnel by population is available only for those employed in the government (public) sector. On this basis in 1995, the rate per 10,000 population for physicians was 3.27, midwives 3.68, nurses 7.4, dentists 2.3, and others 0.34. Training is provided in the following institutions: one faculty of dental services, 11 schools of nursing, one national institute of health sciences, one medical research institute, and other institutions for health paraprofessionals. A plan for human resources in health is currently under preparation.
Financial resources for health
Financial resources for health care are mainly from the government which provides the health care needs of the vast majority of the population. Service provision in the public sector is mostly free of cost to the consumer. The private sector contribution has been comparatively small in terms of service provision and financing, but has been growing, mainly in urban areas. In 1995 the total government health expenditure as a proportion of the GNP amounted to 1.8%, and the total government health expenditure per capita was SRL Rs 582.00 (US $10.6). The recurrent government health expenditure as a proportion of the total government health expenditure was 80.3%, of which 55% was spent on salaries.
Essential drugs and supplies
All drugs on the essential drug list are available in state hospitals free of cost, but no revision in the list has taken place since 1988. An educational programme ensures that medical and paramedical personnel are informed regarding the use of essential drugs.
Local manufacturers are encouraged to manufacture essential drugs, with priority given to essential drugs at the time of registration. Major constraints include the promotional activities of pharmaceutical companies towards the use of expensive brand names that have higher profit margins, and lack of knowledge among consumers. Currently the essential drugs list is being revised and more emphasis is being given to educating health professionals and the public on the essential drugs concept.
International partnerships for health
Foreign assistance amounted to 4.7% of the government health expenditure in 1996. The major partners are UN agencies, development banks and bilateral agencies. Health economics is being introduced as a management tool for more efficient utilization of resources with more awareness creation on the critical importance of productivity.
The main constraints include differing priorities at times between donors and the government, and the lack of flexibility on the part of donors to meet changing situations that would allow for mid-course corrections during implementation.