Evolution of the healthcare system
Sri Lanka has a proud health history, in recent times considered the best with regard to certain indices such as maternal mortality rate (MMR) and infant mortality rate (IMR) in the Southeast Asian Region, even comparable to developed countries.
Piecing together the twists and turns health has taken within Sri Lanka, the Sri Lanka Medical Association (SLMA) President Dr. Vinya Ariyaratne traces its beginnings back to over two millennia… the introduction of Buddhism from North India in the 3rd century BC during the reign of King Devanampiyatissa (247-207 BC), marking the beginning of the tradition of medical care in ancient Sri Lanka.
The traditional system of medicine had two components, the truly indigenous system, which existed prior to the advent of King Vijaya known as Deshiya Chikitsa or Hela/Sinhala Vedakama; with the second component being Ayurveda. Currently, the Deshiya Chikitsa system does not seem to exist in its original form due to the influence of other systems.
Allopathic medicine was introduced by the Portuguese, while the Dutch who followed, built hospitals in different parts of the country. The British who took full control of the country from 1815, expanded the allopathic healthcare system, setting up important structures such as ‘Health Units’ in Kalutara in 1926. They brought preventive and curative services under one administration the same year.
Looking at developments 90 years later, Dr. Ariyaratne refers to the new ‘Sri Lanka National Health Policy – 2016-2026’ and the ‘National Strategic Framework for Health Development 2016-2025’. The proposed implementation of significant reforms represents a pivotal moment in the evolution of healthcare provision, he says.
Adopted in December 2017, the Health Policy aims to reorganize primary care, improve healthcare provision through data utilization and strengthen the overall health sector. In this connection, the World Bank in 2018 supported the launch of the Primary Healthcare Systems Strengthening Project (PSSP) which aims to reorganize the primary healthcare system and reinforce integration of preventive and curative care.
According to Dr. Ariyaratne, four years on, significant results towards transformation are seen with innovative tools such as a Grievance Redress Mechanism (GRM) and a citizens’ engagement mechanism through ‘Friends of Health Services Committees’.
The structure of the medical service since Sri Lanka gained independence is captured by Dr. Lucian Jayasuriya and Dr. K.C. Shanti Dalpatadu in a comprehensive chapter in ‘History of Medicine’ 1948-2018 of the SLMA.
To set the backdrop, they venture back to 1801, when British Governor Fredrick North created a Medical Department within the military establishment. The first dispensary for western medicine was set up in Colombo for their troops, followed by military hospitals and dispensaries in other areas, with military doctors attending on civilians too.
A milestone was 1858, when the Civil Medical Department saw the light of day, with its first head Dr. Christopher Elliot being named Principal Civil Medical Officer (PCMO). With the growing importance of public health and the enactment of the Medical and Sanitary Ordinance No. 11 of 1925, the PCMO became the Director of Medical and Sanitary Services (DM&SS).
Universal franchise in 1931 was a great impetus for the expansion of both curative and preventive care. By the time the British left Ceylon in 1948, the Civil Medical Department (and its successor, the Department of Medical and Sanitary Services) had been in existence for 90 years.
The achievements during this period were phenomenal. In 1848, there were only three civil hospitals – a leprosy hospital, a lunatic asylum and a smallpox hospital – and two prison hospitals at Welikade and Hulftsdorp. Thereafter, numerous hospitals and dispensaries had begun dotting the country.
In 1948, the curative and preventive care achievements:
There were 183 including specialized hospitals and 45 rural hospitals. Every province had a General Hospital, with the apex being the General Hospital, Colombo. These tertiary care centres had the four basic specialties of medicine; surgery; obstetrics & gynaecology; and paediatrics. The other specialties available were ophthalmology, otolaryngology, venereology, radiology and pathology while some also had orthopaedics and physical medicine.
Below the General Hospitals were Base Hospitals, District Hospitals, Peripheral Units, Rural Hospitals, Central Dispensaries and Maternity Homes and Central Dispensaries.
The in-patients treated for the year were 502,012.
The 240 central dispensaries, 176 branch dispensaries, and 453 visiting stations, catered to an estimated 7,060,000 outpatients.
Preventive care was provided by Medical Officers of Health (MOH) with each MOH area covering about 100,000 persons. The MOH was responsible for maternal and child care including immunization, communicable disease investigation and control, sanitation and approval of building plans in built up areas. Under the MOHs were Public Health Inspectors (PHIs) and Public Health Midwives (family health workers).
Decentralization of the Health Service
In 1949, the Government of Ceylon appointed Dr. J.H.L Cumpston, former Director General of Health Services of Australia, to advise on reforms and after the Cumpston Report (1950), came the Health Services Act No 12 of 1952 with the Director of Health Services (DHS) as the head. A major recommendation in the report, the decentralization of the health service to 15 Superintendent of Health Services (SHS) divisions, was implemented in 1954. All curative care institutions including the General Hospitals and all MOHs were supervised by the relevant SHS, making the health service efficient and effective.
It was also in the 1950s that special campaigns such as Anti-Tuberculosis (TB); Anti-Venereal Disease (VD); Anti-Leprosy and Anti-Filariasis were established. However, the AntiMalaria Campaign had been launched earlier during colonial rule.
In 1966, the Department of Health Services was amalgamated with the Ministry of Health based on the recommendation of a Committee on Administrative Reforms – Sessional paper ix of 1966.
By 1977, the General Hospital, Colombo was separated from the Colombo Group of Hospitals and upgraded, while in 1980, the project Ministry of Colombo Hospitals supervised the General Hospital, Colombo and other hospitals in Colombo. As this ministry was under the Health Ministry and had little power, it was closed in 1984.
This was followed by a Cabinet level Ministry of Women’s Affairs and Teaching Hospitals which oversaw the 10 teaching hospitals of the medical faculties, while the decentralized division of the Colombo Group of Hospitals was abolished and each hospital was made a decentralized unit. In 1989, however, this ministry was scrapped and absorbed back to the Health Ministry. In 1983, meanwhile, the designation of the DHS was changed to Director General of Health Services (DGHS).
With the implementation of the 13th Amendment to the Constitution in 1989 and the setting up of Provincial Councils (PCs), power was devolved to Provincial Ministries of Health and Provincial Health Departments. The line ministry retained policy formulation, teaching and special hospitals, training and bulk purchases of medical supplies and health legislation. But the PC system with its hierarchy was problematic, while another complication was the power of the relevant PC and its Governor to appoint – even occasionally – any medical officer, even persons who did not have the necessary qualifications as a Provincial Director of Health Services.
The PCs were always poorly funded and found it difficult to manage the hospitals under them and readily handed them over to the line ministry, whenever requested. As such, today the central ministry manages a number of large hospitals in addition to teaching and special hospitals.
Under curative services, in 1996, the General Hospital, Colombo became the National Hospital of Sri Lanka, with more coming in as the National Eye Hospital, the National Cancer Institute and the National Institute of Mental Health.
More specialized campaigns were also launched in the preventive service including the National STD and AIDS Control Programme (NSACP), the Respiratory Diseases Control Programme, the National Dengue Control Unit, the Family Health Bureau, the Health Education Bureau and the Epidemiology Unit.
“There are now 612 hospitals and 475 Primary Medical Care Units, while the number of MOH units stand at 330. The total health sector work force was 123,845 of which 66,993 were in the line ministry and 56,852 in the provincial ministries. They have been treating over 6.1 million in-patients and over 55.1 million outpatients, with the total population served being 20.966 million,” according to the Annual Health Bulletin 2014.