PHA-Exchange> Health services in Sri lanka

[Claudio]

FAST DETERIORATING HEALTH SERVICE I IN SRI LANKA.

 

 

The Sri Lankan Health indicators  were in the forefront, in South East Asia, sometime ago. This was mainly due to the free health services, free education, food subsidy, for low income earners and a host of other welfare measures provided by the governments in power since independence. However, at the present time, the situation has changed and it would not be wrong to state that the health sector is in crisis state.

 

The open market economic policies adopted by the government of Sri Lanka in 1978 paved the way for the gradual privatisation of the health sector. Food subsidies and other welfare schemes were withdrawn. Legislation was enacted to encourage private sector investment by way of credit from state banks, on favourable terms, and tax holidays etc. As a result several private hospitals, nursing homes and dispensaries were set up in many parts of the country. The media was used to project a good image of these institutions - very often misleading the unsuspecting general public. There is no stated policy or state supervision of these institutions. Monitoring of their services and standards in non existent or any check on the charges levied. Together with the introduction of the open economic policies the government medical officers were granted permission to engage in private practice which may be referred to as the single most contributory factor for the rapid deterioration of the state health services. Official residences of state medical officers turned overnight into private dispensaries. This was more true in the rural areas than in the towns. A consultant who would examine a maximum of 10 - 15 patients in his hospital clinic would see and treat as many as 100 - 150 patients at the private consultation centre. Many consultants openly canvassed patients for private practice. They also worked hand in glove with multi national drug firms and other diagnostic services and often prescribed expensive branded drugs and laboratory tests of no relevance to the condition of the patient.

 

The twenty year old civil war in the country has also contributed in a big way to the decline in the health services. The prolonged conflict has resulted in a serious dislocation of the health infrastructure in the north and east of the country. The war has resulted in damage, destruction and closure of almost all hospitals in the Jaffna district and many others in Mullaittivu, Kilinochchi, Amparai and Batticaloa districts. Due to lack of preventive measures malaria has increased by nearly five fold. The infant mortality rate in Jaffna has increased from 22 to 38.4 percent. Due to shortage of food acute and under nutrition has increased by over 400 percent. These facts, among others,  were disclosed by Prof. N.Sivarajah, Head of the department of community Medicine, Faculty of Medicine, Jaffna University while reading a paper on "War & Health" at the Jaffna Science Association. In addition to these the war has imposed severe pressure on the economy of the 

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country and the government has been forced to cut down on allocations for health, education and other social welfare measures. As a result many government hospitals very frequently report shortage of essential drugs and patients are asked to purchase these from outside. This has led to more corruption and malpractices.

 

The prevailing pluralistic health culture in Sri Lanka and its non recognition by the health authorities is yet another important factor that has caused problems in the health sector. Even though the Health Department had the sole monopoly in deciding and fashioning the health care services they have not been able to change the pluralistic health seeking behaviour of the people. This is not an easy task as it is deeply rooted in their conscience. Pluralistic health care practices are based on traditional medical knowledge, ayurveda, belief in astrology and also the knowledge and influence of western medicine. This can be illustrated by a simple example. A person suffering from fever would, in the first instance, boil some corriander seeds with a few herbs and drink its water. He would also apply some medicinal oil and eaudecolongue on the head and also take two tablets of paracetamol. If its some other ailment like chicken pox, generally referred to as "gods diseases" he would resort to religious practices like offerings to god, doing bodhi poojas and even checking his horoscope. If its snake bite or a broken bone he would go to the traditional healer at first. Even if he had taken western treatment he would very often consult a native or ayurvedic phyician and apply the oils given by him. Unfortunately this aspect of health behaviour has been totally ignored by our policy makers.

 

The Sri Lankan Health Department does not seem to have an action plan, programme or formula to solve the health problems of its people. It is generally believed that all actions and plans are formulated according to the wishes of the WHO, the western medical practitioners and the aspirations of the multi nationals. There is no evidence to show that the health department is concerned about the prevailing health culture in the country or the need to integrate it into the overall national health policy. This is further established by the fact that there is no social scientist in the department for this purpose. The health department which operates on the direction/advice of the WHO  has even changed the health messages given to the general public, from time to time, as directed by the WHO. Health messages formulated by the WHO is passed on to the people through the Medical Officer of Health, the Public Health Nurse, the Public Health Inspector, Family Health worker and even the Health Educators. But the fact remains that the health practices and treatment based on traditional knowledge could not be eliminated mainly due to the deep rooted health culture.

 

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Health care - both preventive and curative - based on western medical system  has become a big burden on the countries economy. Tried and tested native medicines which have been used by the local people for generations are being totally ignored and hence being forgotten. While on the other hand western medicines are actively promoted  and advertised in collaboration with the multi nationals.

 

The concept of Primary Health Care introduced by the WHO could be referred to as the first and the last attempt to break the monopoly of the western medical system on the health sector. In Sri Lanka several seminars, workshops and consultations were held to create awareness among all those concerned. Even though the Primary Health Care concept emphasised the need for a pluralistic approach and to empower low level para medics, like the Family Health Worker and the Public Health Inspector to treat simple ailments and to read the blood pressure and to use the stethescope, the plan had to be shelved due to opposition by western medical practitioners - who felt threatened. This effort was even possible mainly due to the progressive thinking and direction of then director of WHO Halfdan Mahler and the presence of the soviet bloc at that time.

 

The Health Department is under the total control of the western medical system right from the Director General of Health services down to the Provincial Director and the District Medical Officer. In this context there is little hope that progressive measures would be introduced into the system so that it would be people and patient friendly, cost effective and accepted by all sectors of the population.

 

The latest and the most recent threat to the already ailing health services has come from within its employees. Trade union action has become a common feature in the recent times. The Doctors, middle grade officers and the low level workers are resorting to strike action very frequently holding the poor patients to ransom and making serious threat to their lives.. The Health Department is yet to take any meaningful and acceptable action to solve  their long standing grievances. Even in finding solutions the western medical practitioners are given preferential treatment and their problems solved to their satisfaction while the other sectors are discriminated. If this situation prevails the state health sector would close down very soon and the Private Medical Shops would prosper without any hindrance. 

 

Political interference and the tug a war between the central government and the provincial councils has also brought the health services to near destruction. Provincial councils governed by the opposition party are not given sufficient 

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resources to run their affairs by the central government and  as a result health services in those councils are severely affected. A good example is the Anuradhapura General Hospital which is engaged in a long standing tug a war with the central government for essential resources.   

 

Due to the impact of the present political and economical issues, Sri Lanka is emerging new health problems.  Some of the problems which were controlled in the past have surfaced again as all steps proposed to be taken under the PHC Programme have been abandoned.  Even the Health Department could not fulfill at grass-root level the human resources  required such as Estate  Medical Assistants, Assistant Medical Officers, Dental Therapists and Health Education Specialists due to various threats from unethical professionals.  At the moment, people's health activists are facing great unavoidable challenges to empower the people.  Only people's power can overcome these barriers to health.

 

 

 

Sirimal Peiris

People's Health Forum 

Nagarodaya Centre

155, Danister de Silva Road

Colombo 8

Sri Lanka
 

 

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