Sirimal Peiris; Sarvodaya Shramadana Movement & Convenor, People’s Health Movement, Sri Lanka



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Sri Lanka


Sirimal Peiris; Sarvodaya Shramadana Movement & Convenor, People’s Health Movement, Sri Lanka

Sri Lanka, a small South Asian Island nation in the Indian Ocean, is divided into 9 provinces, 25 districts and 326 divisional secretariats for purposes of administration. The provincial administration is vested in the provincial councils, composed of elected representatives of the people, headed by a governor who is nominated by the executive president.

In 2008 the population of Sri Lanka was estimated at 20.2 million. The population density of Sri Lanka is 322 people per square kilometer; however, district level density shows huge regional variation.

Government health expenditure is 1.59% of gross national product (GNP) and 6.9% of the total governmental expenditure. Human resources for health in Sri Lanka consist of (per 100,000 population): medical officers (61.7), dental surgeons (4.2), nurses (148.7), public health midwives (26.4). Additional resources for health include 647 government hospitals, 67,942 hospital beds (ratio of 3.36 per 100,000 population) and 342 medical officer divisions.

In Sri Lanka, the health system includes both public and private sectors. The public sector provides health care for nearly 60% of the population. The Department of Health Services and the provincial health sector provide the entire range of preventive, curative and rehabilitative health care.

In this context, the Department of Health Services has formulated health-related millennium goals which are given below:



Goal No.

Goal Statement

Target

Indicators

1

Eradicating extreme poverty and hunger

Between 1990 and 2015, halve the proportion of people who suffer from hunger

  • Prevalence of under-weight children under 5 years of age.

  • Proportion of the population below minimal level or dietary energy consumption

2

Reduce child mortality

Reduce the under-5 mortality rate by 2/3 between 1990 and 2015.

  • Under 5 mortality rate

  • Infant Mortality rate – special emphasis on neo-natal mortality

  • Proportion of 1 year old children to immunize against measles.

3

Improve maternal health

Reduce the maternal mortality ratio by three quarters, between 1990 and 2015.

  • Maternal mortality ratio

  • Proportion of births attended by skilled health personnel

  • Infant Mortality rate – special emphasis on neo-natal mortality

  • Proportion of 1 year old children immunized against measles.

4

Combat HIV/AIDS, Malaria and other diseases

Combat HIV/AIDS, Malaria and other diseases

  • HIV prevalence among pregnant women, age 15-24 years.

  • The prevalence of condom use

  • Ratio of school attendance of orphans of 10-14 yrs.

5

Ensure environmental sustainability

  • Integrate the principles of sustainable development into the country policies and reverse the loss of environmental resources.

  • Halve by 2015, the proportion of people without sustainable access to safe drinking water and sanitation.

  • Proportion of population with sustainable access to an improved water source in the

  • Urban and rural sectors.

  • Proportion of population with access to improved sanitation.

6

Develop a global partnership for development

Provide access to affordable essential drugs In co-operation with pharmaceutical companies

Proportion of population with access to affordable drugs.

Goal 1: Eradicating extreme poverty and hunger

Target: Between 1990 and 2015, halve the proportion of people who suffer from hunger

Indicator:

  • Prevalence of under-weight children under 5 years of age.

  • Proportion of the population below minimal level or dietary energy consumption


Present distribution of the population by wealth quintiles, 2006-7




Lowest

Second

Middle

Fourth

Highest

Urban

8.3%

9.9%

12.4%

20.1%

49.2%

Rural

19.2%

21.3%

21.0%

21.0%

6.5%

Estates

64.0%

26.4%

2.5%

2.5%

2.5%

The above figures depict the difference between the three sectors.
There is a very close relationship between wealth, food and nutrition. Human survival and activity are dependent on our ability to derive essential nutrients such as protein, carbohydrates, vitamins, fat and mineral salts from food.

Given below are the nutritional levels of children:

In the age group 0-59 months – 19.2% were stunted, 11.7% wasted and 21.6% were under-weight. Severe stunting was seen among 4.6% of the total group. There is a high percentage of stunted children in the Nuwara Eliya (40.9%), Badulla (23.9%) and Ratnapura Districts (26.6%), plantation areas, and a similar pattern was seen in the prevalence of under-weight children. In general, there was a decline in the percentage of stunted, wasted and under-weight children as monthly household income and wealth quartiles increased. Prevalence of anaemia among children was 25.2%. Prevalence of low birth weight among children was 18.1%.

Among non-pregnant women of 15-49 years (by BMI) 18.2% are underweight, 52.6% are at normal weight, 22.5% are overweight and 6.7% are obese.

Among pregnant women, 18.4 % are under-nourished. The prevalence of anaemia is 16.7% among pregnant women, 20.5% among lactating women 22.2% among non-pregnant women. In each economic sector there is a considerable number of households without adequate food supplies: in the urban sector 20.8%, in the rural sector 33.5% and in the plantation sector 55.9%.

Challenges:

Use of chemical pesticides and chemical manure has had a negative impact on agriculture. Chemicals in pesticides often contaminate the vegetable harvest, and there are cases of accidental poisoning resulting from mishandling of these chemicals. The chemicals also destroy farmland friendly creatures, such as earthworms, which enrich the soil. Because of continued reliance on chemical manure, the level of humus in the soil has reduced to negligible levels and, now, without chemical manure, the harvest drops. As well, farmers are unable to invest in fertilizer because of the rising prices. Due to this situation, farmers are now returning to natural farming.

World famous food chains operate in the country, and people are enticed into eating the items offered using various advertizing gimmicks.

Food habits have changed over the years. Some breakfast foods are now used for dinner. Items like sausages have replaced fresh fish and meat. The use of greens and similar healthy foods are ranked low. Fast foods have spread through various outlets, and people are buying meals from outlets rather than preparing their own meals. All these require interventions to develop awareness and mitigate the consequences.



Goal 2: Reduce Child Mortality

Target: Reduce the under-5 mortality rate by 2/3 between 1990 and 2015.

Indicator:

  • Under 5 mortality rate

  • Infant Mortality rate – special emphasis on neo-natal mortality

  • Proportion of 1 year old children to immunize against measles.

The status of children is shown by the under mentioned figures:

Infant mortality rate 11.2 per 1000 neo-natal mortality rate 9.5per1000, perinatal mortality rate 5.6 per 1000. Child (1-4 year old) mortality is 3 deaths per 1,000 live births.

The child mortality rate reflects adverse environmental hazards, e.g., malnutrition, poor hygiene, infections and accidents, in addition to other factors. In addition, there is an inverse relationship between mother’s educational attainment and the probability of a child dying. Mother’s age, birth order, and birth intervals are some of the key factors affecting child mortality.

Goal 3: Improve maternal health

Target: Reduce the maternal mortality ratio by three quarters, between 1990 and 2015.

Indicators:


  • Maternal mortality ratio

  • Proportion of births attended by skilled health personnel

  • Infant Mortality rate – special emphasis on neo-natal mortality

  • Proportion of 1 year old children to immunize against measles.

The bulletin published by the Ministry of Health clearly reflects deterioration of health in the plantation areas and resettlement areas after the war. The national rate of maternal deaths to 100,000 live births is 14.2 whereas in Nuwara Eliya (plantation area) it is 53 and in Killinochchi (resettlement area) it is 55.8. In Batticaloa the rate is 33.7. (No figures are available for Mannar, Vavuniya and Mullaitive.)

Goal 4: Combat HIV/AIDS, Malaria and other diseases

Target: Combat HIV/AIDS, Malaria and other diseases

Indicators:

  • HIV prevalence among pregnant women, age 15-24 years.

  • Prevalence of condom use

  • Ratio of school attendance of orphans of 10-14 yrs.

The first Sri Lankan infected with HIV was reported in the year 1987. The first indigenously transmitted case was reported in 1989. Anti-retroviral treatment was started in Sri Lanka in December 2004.

HIV and AIDS is not a major problem in the health sector in Sri Lanka as it has a low prevalence with estimated 4,300 people living with HIV and cumulative reported cases of 1,597. At high-risk are men who have sex with men, sex workers and intravenous drug users. Vulnerable groups are migrant workers, those who are serving in the armed forces and prisoners. People living with HIV get drugs free of charge from National STD/AIDS Control Programme.



Target: Have halted by 2015 and begun to reverse the incidence of Malaria.

Indicator:

  • Incidence of Malaria per 100,000 population

  • Deaths associated with malaria

  • Proportion of population in malaria risk areas using affective malaria prevention and

  • Treatment measures.

Sri Lanka was once the worst affected countries in Asia for Malaria but is now close to eliminating it. Mortality due to Malaria in Sri Lanka is extremely low between the years 1992 – 1995 and Malaria incidence has shown a gradual reduction. In 2007, only 196 cases were reported.



Target: Have halted by 2015 and begun to reverse the incidence of Tuberculosis (TB)

Indicators:

  • Incidence of TB per 100,000 population.

  • Death rates per 100,000 associated with TB.

  • Proportion of TB cases detected and cured using DOTS.

In Sri Lanka, TB and respiratory diseases control is carried out by a decentralized unit which functions through a network of 25 district chest clinics and one chest hospital in co-ordination with other general institutions. Around 8,500-10,000 new cases of TB are detected annually, and TB still continues to pose a major public health challenge in Sri Lanka. The rate is 43.4 per 100,000 population (2007).

Goal 5: Ensure environmental sustainability

Targets:

  • Integrate the principles of sustainable development into the country policies and reverse the loss of environmental resources.

  • Halve by 2015, the proportion of people without sustainable access to safe drinking water and sanitation.

Indicators:


  • The situation of water supply and sanitation

    Water Supply

    Sanitation

    Source

    %

    Source

    %

    Protected well within the premises

    28.3

    Water seal toilets

    66.5

    Protected well outside the premises

    21.8

    Pour flush toilet

    13.6

    Unprotected wells

    9.8

    Pit

    12.0

    Tube wells

    4.8

    Bucket

    0.4

    Pipe-borne water within the premises

    15.7

    Other

    1.0

    Pipe-borne water outside the premises

    11.2

    Not using a toilet

    4.3

    Delivered by bowser

    2.0

    Not stated

    2.2

    River, tank, stream etc.

    5.2







    Other

    1.5







    Not stated

    1.6







    Total










    Source: Annual Health Bulletin 2007, Ministry of Health, Sri Lanka
    Proportion of population with sustainable access to an improved water source in the urban and rural sectors.

  • Proportion of population with access to improved sanitation.

Field health personnel carry out health education encouraging people to consume water that is safe to drink. Usual advice and encouragement is to use boiled, then cooled, water. Health workers conduct routine tests to ascertain whether chlorine levels conform to the standards issued for treated drinking water.

With regard to toilet facilities, all new houses should have proper sanitary toilets without which the certificate of conformity is not granted by the local authority. Assistance is provided by both governmental and non-governmental organizations for water and sanitary facilities.

Although the disposal of solid waste is a responsibility of local authorities, the disposal of waste from health care institutions demands serious attention from the Ministry of Health.

Challenges:

There are no specifically trained environmental health officers. Public health inspectors could fulfill this role, but have not been properly trained. Even though the number of HIV infections is low, all the factors that could escalate the situation are available.



Goal 6: Develop a global partnership for development.

Target: Provide access to affordable essential drugs in developing countries in co-operation with pharmaceutical companies.
Indicator: Proportion of population with access to affordable drugs.
The government has promised a drug policy, but it seems that it will never be a reality. As there is no legislation to control the drug trade, drugs are sold in the open market under different trade names. Additionally, the government attempted to get doctors to write prescriptions using the generic name of the drug, with the intent of controlling private dispensaries and doctor charges. Both of these approaches have failed.
There is a deterioration of the health services offered by the government, and the people are forced to seek treatment from private sector medical institutions. Elements contributing to the deterioration of health services include: carelessness of some of the medical employees, the sheer neglect displayed by some medical employees and lack of proper supervision of medical employees.
Some of the drugs prescribed by government hospitals have to be purchased from private pharmacies since there is a severe shortage of drugs. A long list of items is given to pregnant mothers to be brought with them when they get admitted to the government hospitals for child birth.
Challenges for Millennium Goals
Before 1977, Sri Lanka’s government had the full support of the people and delivered free health care. Since 1977, Sri Lanka accepted an open economy system, privatizing free government services, and abandoning its responsibility of providing free health services. Permission has been granted to government medical practitioners to engage in private practice. As a consequence, the financial interests of doctors plague government health services. Many of the doctors openly canvass at public facilities to get patients for their private practice. It is reported that these doctors prescribe expensive drugs, by their trade names, and also make patients undergo unnecessary examinations. Further, medical consultants’ charges are not regulated. Only recently, government medical consultants managed to get the approval to treat their patients admitted to private hospitals during their working hours.
Due to these factors, administration of the government health services is rapidly deteriorating and becoming distanced from those who need these services most. As a result, a massive shortage of drugs is being experienced at the government hospitals. Further, government hospitals are overcrowded and in many hospitals two patients share one bed.
Western (allopathic), Ayurvedic, Unani, Siddha and homeopathy systems are practiced in Sri Lanka. Western medicine dominates the main sector, with the government catering to a vast majority of people. The public sector comprises Western and Ayurvedic systems, whilst the private sector consists of practitioners in all types of medicine. Alternative medical system has not received an adequate place in this system. Only the western medical system has a satisfactory communication network. The Department of Health Services is also trying to implement the western ideology. The Department of Health adopts health messages given by the World Health Organization (WHO) and in turn passes them on to the community through medical officers of health, public health Inspectors, public health nurses and midwives. Ayurvedic or other alternative systems do not receive such communications from government indicating that the Department of Health does not recognize indigenous medicine. Consideration or co-operation from government is not offered when indigenous health awareness messages are projected to the community.
The mortality pattern in Sri Lanka is in a transitional stage. It appears to be changing towards a similar pattern as seen in developed countries. The trends in mortality indicate a decrease in deaths from infectious and parasitic diseases. On the other hand, deaths associated with non-communicable diseases have increased. Leading causes of hospital deaths include diseases of the circulatory system, injuries, and poisoning (2008) while other deaths can be attributed to ischaemic heart diseases, pulmonary heart diseases, diseases of the pulmonary circulation, neoplasms, cerebrovascular diseases, diseases of the respiratory system, pneumonia, diseases of the urinary system, and traumatic injuries.
The Sri Lankan community believes that free health care is one of their supreme rights, and previous governments had instituted this. Currently, the government of Sri Lanka is not bound by legislation to implement free health care. As such, privatization of health services seems to be occurring incrementally. A particular threat that may result from this process is government hospitals becoming health care awareness centres rather than actually providing care. In order to avoid this situation, a statement stressing rights of the people to have free health services should be formulated and included in the Constitution under basic human rights of the people.


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