PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Case study from Sri Lanka PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Case study from Sri Lanka Principal investigator: Professor Antoinette Perera Faculty of Medical Sciences, University of Sri Jayewardenepura Principal co-investigator: Dr H.S.R. Perera Ministry of Health, Nutrition and Indigenous Medicine, Sri Lanka University of Sri Jayewar, Sri Lanka WHO/HIS/HSR/17.33 © World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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Editing and design by Inís Communication – www.iniscommunication.com PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) Contents Acknowledgements . 1 Abbreviations . .2 Background to PRIMASYS case studies . .3 Abstract: Primary health care system in Sri Lanka. 4 1. Overview of the primary care system . 5 1.1 Introduction . 5 1.2 General information on the country and its people . 5 1.3 Providers and different stakeholders in the health system . 7 1.4 Good health outcomes at low cost . 8 1.5 A system in transition . 9 2. Purpose of the study . 10 3. Methodology . 11 4. Results and discussion . 14 4.1 Health profile, demography and macroeconomic situation . 14 4.2 Policy background . 17 4.3 Governance. 23 4.4 Overview of health sector financing . 30 4.5 Human resources for health . 34 4.6 Planning and implementation . 43 4.7 Review systems . 46 4.8 Regulatory bodies . 47 5. Way forward. 50 5.1 Leadership reforms. 50 5.2 Educational reforms . 50 5.3 Service delivery reforms . 51 5.4 Financial reforms. 51 5.5 Better citizens’ engagement in improving primary care services . 51 Annex 1. Key informant interview guide . 52 Annex 2. Focus group discussion guide: stakeholders. 54 Annex 3. Letter of approval of Ethics Review Committee . 55 Annex 4. Trends in leading causes of hospital deaths . 57 Annex 5. Proposed shared care cluster system . 58 Annex 6. Contributors . 59 References . 62 CASE STUDY FROM SRI LANKA Boxes Box 1. Case study on the People’s Health Movement . 45 Box 2. Civil society contribution to policy development . 45 Box 3. Future plans to strengthen PHC services. 50 Figures Figure 1. Terrain and climate of Sri Lanka. 5 Figure 2. Components of generic health system model. 11 Figure 3. PHC policy measures in Sri Lanka . 17 Figure 4.Visual map of key PHC organization and decision-making bodies and their linkages . 24 Figure 5. Financing system related to health care provision . 31 Figure 6. Types of grants allocated to provinces . 32 Figure 7. Distribution of curative care expenditure by all government hospitals in 2013 by level of care (million Sri Lankan rupees; %) . 33 Figure 8. Staff categories per 100 000 population in allopathic public sector, 1990–2014 . 35 Figure 9. Distribution of medical officers and nurses working in PHC by district (per 100 000 population) . 39 Figure 10. Distribution of public health inspectors and public health midwives working in PHC by district (per 100 000 population). 39 Tables Table 1. Key informants and selection criteria . 12 Table 2. Details of stakeholders participating in study . 13 Table 3. Distribution of focus group discussion participants according to age and sex . 13 Table 4. Demographic profile of Sri Lanka . 14 Table 5. Key health indicators, Sri Lanka . 15 Table 6. Hospitalization trends for selected diseases: top 10, 1985–2014 (number of hospitalizations per 100 000 persons) . 15 Table 7. Macroeconomic profile . 16 Table 8. Distribution of PHC institutions in the government sector . 29 Table 9. Organization and provision of primary care services . 30 Table 10. Staff categories employed in PHC . 34 Table 11. Availability of health workforce. 34 Table 12. Workforce total and ratio in PHC by selected categories, 2014. 36 Table 13. Pathways of recruitment of health staff under the Ministry of Health. 38 Table 14. Availability of medical officers and nurses in different institution categories . 40 PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) iv Acknowledgements We, the team of investigators, wish to acknowledge the technical assistance given by Mrs Amitha Jayawardhana (Senior Staff Officer) and Ms Champika Jayaratne (Technical Officer) of the Department of Family Medicine for technical assistance, and Mr Nishantha Amarasinghe and Ms Thilini Dias for facilitation of meetings. We also wish to thank: • all the stakeholders who contributed their valuable time for key informant interviews and focus group discussions; • the Senior Assistant Bursar, Mrs Nadeeka Ranasinghe, and her staff for handling the finances; • Dean of the Faculty of Medical Sciences, University of Sri Jayewardenepura, Professor Surangi G. Yasawardhana, for her invaluable assistance in dealing with logistics to accomplish the goals within the limited time frame. We thank the World Health Organization, Geneva, for selecting the University of Sri Jayawardenepura to carry out the Sri Lankan case studies. CASE STUDY FROM SRI LANKA 1 Abbreviations BSc Bachelor of Science MDG Millennium Development Goal CSTH Colombo South Teaching Hospital MRCGP Membership of the Royal College of General Practitioners DOTS directly observed treatment, short course MSc Master of Science GCE A/L General Certificate of Education NCD noncommunicable disease Advanced Level NGO nongovernmental organization GDP gross domestic product PHSRC Private Health Services Regulatory GNI gross national income Council GP general practitioner PPP purchasing power parity MBBS Bachelor of Medicine, Bachelor of SLMC Sri Lanka Medical Council Surgery (Latin: Medicinae Baccalaureus, UNICEF United Nations Children’s Fund Baccalaureus Chirurgiae) WHO World Health Organization MCGP Membership of the College of General Practitioners of Sri Lanka MD Doctor of Medicine PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) 2 Background to PRIMASYS case studies Health systems around the globe still fall short of The Alliance has developed full and abridged versions providing accessible, good-quality, comprehensive of the 20 PRIMASYS case studies. The abridged and integrated care. As the global health community version provides an overview of the primary health is setting ambitious goals of universal health care system, tailored to a primary audience of policy- coverage and health equity in line with the 2030 makers and global health stakeholders interested in Agenda for Sustainable Development, there is understanding the key entry points to strengthen increasing interest in access to and utilization of primary health care systems. The comprehensive case primary health care in low- and middle-income study provides an in-depth assessment of the system countries. A wide array of stakeholders, including for an audience of researchers and stakeholders who development agencies, global health funders, policy wish to gain deeper insight into the determinants planners and health system decision-makers, require and performance of primary health care systems a better understanding of primary health care in selected low- and middle-income countries. systems in order to plan and support complex health Furthermore, the case studies will serve as the basis system interventions.