Sri Lanka Health System Review: ISBN-13 978 92 9022 853 0

Health Systems in Transition
Vol. 10 No. 1 2021
Sri Lanka
Health System Review
Health Systems in Transition Vol. 10 No. 1 2021
Sri Lanka
Health System Review
Written by:
Lalini Rajapaksa
Padmal De Silva
Palitha Abeykoon
Lakshmi Somatunga
Sridharan Sathasivam
Susie Perera
Eshani Fernando
Dileep De Silva
Ashok Perera
Usha Perera
Yasoma Weerasekara
Anuji Gamage
Nalinda Wellappuli
Nimali Widanapathirana
Rangika Fernando
Chatura Wijesundara
Ruwanika Seneviratne
Kusal Weerasinghe
Edited by:
Viroj Tangcharoensathien
Walaiporn Patcharanarumol
Haruka Sakamoto
World Health Organization Regional Office for South-East Asia
Sri Lanka health system review
Health Systems in Transition. Vol-10, Number-1
ISBN 978-92-9022-853-0
© World Health Organization 2021

(on behalf of the Asia Pacific Observatory on Health Systems and Policies)
Some rights reserved. This work is available under the Creative Commons Attribution Non-
Commercial Share Alike 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 adopt 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. If you adopt the work, then you must license your work under the
same or equivalent Creative Commons licence. If you create a translation of this work, you should
add the following disclaimer along with the suggested citation: “This translation was not created
by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this
translation. The original English edition shall be the binding and authentic edition.”
Any mediation relating to disputes arising under the licence shall be conducted in accordance with
the mediation rules of the World Intellectual Property Organization (http://www.wipo.int.amc/en/
mediation.rules).
Suggested citation: Rajapaksa L, De Silva P, Abeykoon A, Somatunga L, Sathasivam S, Perera S et al.
Sri Lanka health system review. New Delhi: World Health Organization Regional Office for South-East
Asia; 2021.
Cataloguing-in-publication (CIP) data. CIP data are available at http://apps.who.int/iris/.
Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders/. To
submit requests for commercial use and queries on rights and licensing, see http://www.who.int/
about/licensing/en/.
Third-party materials. If you wish to reuse material from this work that is attributed to a third party,
such as tables, figures or images, it is your responsibility to determine whether permission is needed
for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from
infringement of any third party-owned component in the work rests solely with the user.
General disclaimers. The designations employed and the presentation of the material in this
publication do not imply the expression of any opinion whatsoever on the part of the World Health
Organization concerning the legal status of any country, territory, city or area or of its authorities,
or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent
approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they
are endorsed or recommended by the World Health Organization in preference to others of a similar
nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are
distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information
contained in this publication. However, the published material is being distributed without warranty of
any kind, either expressed or implied. The responsibility for the interpretation and use of the material
lies with the reader. In no event shall the World Health Organization be liable for damages arising
from its use.
The views expressed in this publication are those of the authors and may not necessarily represent
the decisions or policies of the World Health Organization.
Printed in India
Contents
Preface�� xi
Acknowledgements�� xiii
Acronyms and abbreviations��xiv
Executive summary�� xix
1. Introduction�� 1
Chapter summary��1
1.1 Geography and sociodemography��2
1.2 Economic context�� 11
1.3 Political context�� 12
1.4 Health status�� 13
1.5 Human-induced and natural disasters �� 24
2. Organization and governance�� 26
Chapter summary�� 26
2.1 Historical background�� 27
2.2 Overview of the health system �� 28
2.3 Organization�� 29
2.4 Decentralization and centralization�� 32
2.5. Policy formulation and health planning�� 34
2.6 Intersectorality�� 35
2.7 Health information management�� 37
2.8 Regulation�� 40
2.9 Patient empowerment�� 44
3. Health financing�� 48
3.1 Health expenditure �� 49
3.2 Sources of revenue and financial flows �� 57
3.3 Overview of the public financing schemes�� 61
3.4 OOP payments�� 69
3.5 Voluntary private health insurance�� 73
3.6 Other financing�� 75
3.7 Payment mechanisms�� 76
4. Physical and human resources�� 78
4.1 Physical resources �� 80
4.2 Human resources�� 93
iii
5. Provision of services�� 113
5.1. Public health �� 114
5.2 Curative care services�� 121
5.3 Ambulatory care�� 123
5.4 Inpatient care�� 124
5.6 Emergency care�� 126
5.7 Pharmaceutical care�� 127
5.8 Rehabilitation �� 129
5.9 Long-term and informal care�� 131
5.10 Palliative care�� 131
5.11 Mental health care�� 133
5.12 Dental care �� 136
5.13 Health services for specific populations�� 137
5.14 Complementary and alternative medicine, including traditional
medicine�� 138
6. Principal health reforms�� 139
6.1 Analysis of the significant health reforms that affected health
developments in Sri Lanka �� 140
6.2 Analysis of recent major reforms �� 141
6.3 Future developments �� 150
7. Assessment of the health system�� 157
7.1 Objectives of the health system�� 158
7.2 Financial protection and equity in financing �� 160
7.3 User experience and equity of access to health care�� 171
7.4 Health outcomes, health service outcomes and quality of care�� 179
7.5 Health system efficiency�� 190
7.6 Transparency and accountability�� 196
8. Conclusions�� 199
9. Appendices�� 206
9.1 References�� 206
9.2 HiT methodology and production process�� 224
9.3 About the authors�� 226
Asia Pacific Observatory on Health Systems and Policies (APO)
publications to date�� 227
iv
List of figures
Figure 1.1 Map of Sri Lanka................................................................................. 3
Figure 1.2 Age distribution of the Sri Lankan population, 1981 and 2019...... 7
Figure 1.3 Age dependency ratio for Sri Lanka by age group, 1970–2019...... 7
Figure 1.4 Deaths and DALYs per 100 000 population for major groups,
2004–2016......................................................................................... 14
Figure 1.5 Top 10 leading causes of YLL for Sri Lanka in 2017 and
percentage change during 2007–2017........................................... 20
Figure 1.6 Top 11 leading causes of YLD for Sri Lanka in 2017 and
percentage change during 2007–2017........................................... 21
Figure 1.7 The top 10 risk factors driving most deaths and disability
combined for 2017 and percentage change during
2007–2017......................................................................................... 22
Figure 2.1 Organizational chart of the Ministry of Health, Nutrition
and Indigenous Medicine (2017)..................................................... 30
Figure 2.2 Organizational structure of the Provincial Ministry of Health .... 34
Figure 3.1 National health expenditure by financial sources, 2016 .............. 49
Figure 3.2 Trends in health expenditure as a share (%) of GDP
in selected countries, 2000–2017................................................... 53
Figure 3.3 Domestic general government health expenditure
and OOPE as a percentage of CHE, 2000–2016............................. 54
Figure 3.4 Distribution of government CHE by categories
of health-care providers.................................................................. 56
Figure 3.5 Share of CHE by health-care functions over time,
1990–2016......................................................................................... 56
Figure 3.6 Financing system related to health-care provision...................... 59
Figure 3.7 CHE per capita by province, 2000–2015......................................... 60
Figure 3.8 OOP spending on health by expenditure deciles, 2016................. 62
Figure 3.9 OOPE as a percentage of CHE, 2000–2016.................................... 69
Figure 3.10 Breakdown of the OOP spending on health, 2016 ........................ 70
Figure 3.11 Trends in different components of OOPE (average monthly
amount in SLR per person), 2010–2016......................................... 71
Figure 3.12 Incidence of catastrophic health expenditure, 2016..................... 71
Figure 4.1 Number of beds and beds per 1000 population
for Sri Lanka, 1965–2017 ................................................................ 81
Figure 4.2 Trends in health workforce density (medical officers,
dental surgeons and nurses), 2005–2017...................................... 97
v
Figure 4.3 Trends in health workforce density (PSM & paramedical
categories), 2008–2017.................................................................. 100
Figure 4.4 Number recruited for training in MLT, Radiography and
Physiotherapy, 2010–2016 ............................................................ 100
Figure 4.5 Trends in health workforce density – public health cadre,
2008–2017....................................................................................... 102
Figure 4.6 Density of medical officers and bed strength by district............ 103
Figure 5.1 Organization of the National Family Health Programme at
different levels of the health system ........................................... 116
Figure 5.2 Epidemiological surveillance mechanism
for infectious diseases .................................................................. 118
Figure 5.3 Patient pathways for curative care .............................................. 123
Figure 5.4 Proposed model for delivery of palliative care – community
level to institutional care............................................................... 132
Figure 5.5 Organizational arrangement of dental care services in
Sri Lanka......................................................................................... 136
Figure 6.1 Chronological events: towards primary health care reform
in Sri Lanka, 2009–2018................................................................. 152
Figure 6.2 Proposed “shared care cluster” ................................................... 154
Figure 7.1 Current health expenditure in Sri Lanka by source
of financing, 2000–2016................................................................. 161
Figure 7.2 Current and capital health expenditure as a share
of GDP (%), 2000–2016................................................................... 161
Figure 7.3 Government expenditure on health and education
as a share of the GDP (%), 2011–2016 ......................................... 162
Figure 7.4 General government health expenditure as a share
of general government expenditure (%), 2000–2016.................. 162
Figure 7.5 Comparison of GGHE-D as a share of GGE (%) among
selected Asian countries, 2012–2015........................................... 163
Figure 7.6 Share of OOPE as percentage of CHE, 2000–2016...................... 163
Figure 7.7 Share of OOPE (%), selected countries, 2000–2016 ................... 164
Figure 7.8 Health services obtained through OOP payments, 2016............ 165
Figure 7.9 OOP payments by households by expenditure quintiles,
2016 ................................................................................................ 165
Figure 7.10 Structure of OOP health payments by expenditure quintile,
2016................................................................................................. 166
Figure 7.11 Incidence of catastrophic health expenditure, 2016................... 167
Figure 7.12 Percentage families having catastrophic health
expenditure by expenditure quintile, 2016................................... 167
vi
Figure 7.13 Universal health coverage financing frontier ............................. 168
Figure 7.14 Comparison of total and per capita CHE by provinces
and districts, 2013.......................................................................... 169
Figure 7.15 Estimated per capita spending of the government
by provinces and districts, 2013 ................................................... 170
Figure 7.16 Equity analysis of demand for family planning services
and satisfaction with the use of modern methods...................... 177
Figure 7.17 District distribution of selected health worker categories
per 100 000 population, 2016 ....................................................... 179
Figure 7.18 Percentage of hospital deaths out of hospital admissions
for selected diseases 2010-2016.................................................. 183
Figure 7.19 Comparison of the UHC index of selected countries ................. 185
Figure 7.20 Antenatal care coverage and demand for family planning
satisfied according to wealth, 2006/2007 and 2016 ................... 186
Figure 7.21 Equity analysis of under-5 mortality in Sri Lanka,
2006 and 2016 ................................................................................ 187
Figure 7.22 Under-5 mortality rates across provinces of Sri Lanka,
2016................................................................................................. 187
Figure 7.23 Equity analysis of stunting among children under 5 years........ 188
Figure 7.24 Percentage of government spending according to the type
of health-care institution, 2013 .................................................... 191
Figure 7.25 Annual doctor consultations per capita of selected
countries, latest available year..................................................... 192
Figure 7.26 Annual hospital discharges per 1000 population
of selected countries, latest available year................................. 193
Figure 7.27 Estimated annual consultations per doctor in the primary
health care setting in selected countries,
latest available year....................................................................... 194
Figure 7.28 Utilization patterns of state and private sector facilities
for inpatient and outpatient care, by expenditure quintile,
2016................................................................................................. 195
Figure 7.29 Average duration of hospital stay among selected
countries, latest available year..................................................... 195
vii
List of tables
Table 1.1 Population of Sri Lanka by province ............................................... 4
Table 1.2 Trends in demographic indicators, 1970–2019............................... 5
Table 1.3 Trends in ageing and dependency in Sri Lanka, 1970–2019.......... 6
Table 1.4 Comparison of Sri Lanka with selected countries in the
WHO South-East Asia and Western Pacific regions, 2017 .......... 10
Table 1.5 Macroeconomic indicators, 1970–2018......................................... 11
Table 1.6 Life expectancy and healthy life expectancy for Sri Lanka
by sex, 2000–2016............................................................................ 15
Table 1.7 Trends in mortality rate, 1970–2018.............................................. 16
Table 1.8 Leading causes of deaths in government hospitals
in Sri Lanka, 2010 and 2016........................................................... 17
Table 1.9 Top 10 leading causes of DALYs for Sri Lanka, 2007–2017.......... 18
Table 1.10 Top five causes of DALYs lost and YLL as a proportion
of DALYs by sex, 2017...................................................................... 19
Table 1.11 Summary of combined risk based on STEPS 2015 ..................... 23
Table 1.12 Prevalence of stunting and wasting, 2006 and 2016.................... 24
Table 3.1 Trends in health-care expenditure in Sri Lanka – 2000
to 2017.............................................................................................. 50
Table 3.2 Key socioeconomic and health expenditure, and selected
health outcome indicators of selected countries......................... 51
Table 3.3 Distribution of CHE by selected health-care functions:
2014 to 2016 (SLR million at current prices)................................ 55
Table 3.4 Source of revenue as a percentage of CHE (2016) ...................... 57
Table 3.5 Government contributions to health............................................. 64
Table 3.6 Tax breakdown in Sri Lanka, 2010 and 2018 ................................ 65
Table 3.7 Share of public CHE by financing source (%)............................... 66
Table 3.8 Private expenditure on health (2000–2016).................................. 72
Table 4.1 Distribution of state hospitals by category of institution
and bed strength ............................................................................ 80
Table 4.2 General Service Readiness Index and domain readiness
scores (out of 100) among health facilities, by facility type
and group (n=331), Sri Lanka 2017................................................ 82
Table 4.3 Readiness score (overall and by domain) for surgical
management services in health facilities that are expected
to provide service, by facility type and group (n=157),
Sri Lanka, 2017................................................................................ 83
viii
Table 4.4 Average duration of stay (days) in selected types
of hospitals per quarter from 2004 to 2017.................................. 83
Table 4.5 Distribution of ICU facilities by province....................................... 86
Table 4.6 Percentage distribution of basic equipment................................. 87
Table 4.7 Percentage availability of emergency equipment tracer
items by type of facility .................................................................. 87
Table 4.8 Percentage availability of tracer items for basic
amenities among health facilities, by facility type
and group (n= 755), Sri Lanka, 2017.............................................. 88
Table 4.9 Percentage availability of tracer items for diagnostic
capacity among health facilities, by facility type and group
(n=755), Sri Lanka, 2017................................................................. 88
Table 4.10 The percentage of health facilities with the capacity
to manage acute myocardial infarction, stroke and provide
haemodialysis and renal transplantation..................................... 89
Table 4.11 Availability of imaging and therapeutic equipment
in selected Asia Pacific countries ................................................. 90
Table 4.12 Health information systems in Sri Lanka*.................................... 91
Table 4.13 Distribution of selected main staff categories and
the health facility levels at which they work (2015)..................... 94
Table 4.14 Distribution of the numbers and density of the health
workforce – medical officers, dental surgeons and nurses,
2005–2017........................................................................................ 96
Table 4.15 Main functions and work settings of selected PSM and
paramedical categories.................................................................. 98
Table 4.16 Distribution of numbers of health-care personnel in
selected PSM and paramedical categories, 2006–2017 ............. 99
Table 4.17 Distribution of the number of health-care personnel in
public health categories, 2005–2017........................................... 101
Table 4.18 Training of Professions Supplementary to Medicine and
paramedical categories................................................................ 108
Table 5.1 Summary of the different services by level of care and
management authority ................................................................ 125
Table 6.1 Major health-care reforms and policy measures ..................... 140
Table 7.1 Availability of essential medicines and commodities
by type of hospital, 2017............................................................... 176
Table 7.2 Distribution of staff categories by district per 100 000
population in 2016......................................................................... 178
ix
Table 7.3 Percentage of children protected through childhood
vaccination programmes, 2016 ................................................... 182
Table 7.4 Availability of selected guidelines in health facilities................ 184
Table 7.5 Readiness for standard precautions for infection
prevention and control among health facilities.......................... 184
Table 7.6 Comparison between Sri Lanka and other
lower-middle-income countries on UHC indicators.................. 186
x
Preface
The Health Systems in Transition (HiT) profiles are country-based reports

that provide a detailed description of a health system, and of reform and
policy initiatives in progress or under development in a specific country. Each
profile is produced by country experts in collaboration with international
editors. To facilitate comparisons between countries, the profiles are based
on a template, which is revised periodically. The template provides detailed
guidelines and specific questions, definitions and examples needed to
compile a profile.
A HiT profile seeks to provide relevant information to support policymakers

and analysis in the development of health systems. This can be used:
• to learn in detail about different approaches to the organization,

financing and delivery of health services, and the role of the main
actors in health systems;
• to describe the institutional framework, process, content and
implementation of health-care reform programmes;
• to highlight challenges and areas that require more in-depth analysis;
• to provide a tool for the dissemination of information on health
systems and the exchange of experiences between policymakers and
analysts in different countries implementing reform strategies; and
• to assist other researchers in more in-depth comparative health policy
analysis.
Compiling the profiles poses a number of methodological issues. In many

countries, there is relatively little information available on the health
system and the impact of reforms. Due to the lack of a uniform data source,
quantitative data on health services is based on a number of different
sources, including the World Health Organization (WHO), national statistical
offices, the Organisation for Economic Co-operation and Development (OECD)
health data, the International Monetary Fund (IMF), the World Bank, and any
other sources considered useful by the authors. Data collection methods
and definitions sometimes vary, but typically are consistent within each
separate series.
xi
The HiT profiles can be used to inform policymakers about the experiences
in other countries that may be relevant to their own national situation.
They can also be used to inform comparative analyses of health systems.
This series is an ongoing initiative, and the material will be updated at
regular intervals.
Comments and suggestions for further development and improvement

of the HiT series are most welcome and can be sent to the
apobservatory@who.int. HiT profiles and HiT summaries for
countries in Asia Pacific are available on the Observatory’s website at
https://www.healthobservatory.asia and https://www.apo.who.int/.
xii
Acknowledgements
The authors of the Health System in Transition (HiT) profile on Sri Lanka
gratefully acknowledge the valuable contributions of many persons during
its preparation. Prof Amala De Silva (Professor in Economics, University of
Colombo), Dr Prabhath Werawatte (Director, Teaching Hospital, Kuliyapitiya)
and Dr Olivia Nieveras (Public Health Administrator, WHO Office, Colombo)
provided expert technical inputs. A special word of thanks to many colleagues
in the Ministry of Health for helping with the required information. Dr Nima
Asgari-Jirhandeh, Dr Anns Issac and Ms Ritu Aggarwal, acting as the
Secretariat for the Asia Pacific Observatory on Health Systems and Policies
(APO), provided the overall support for development of the HiT.
The authors are grateful to Drs Viroj Tangcharoensathien, Walaiporn

Patcharanarumol and Haruka Sakamoto for their editorial inputs. They
give special thanks to the three independent reviewers, Dr Eduardo Benzo,
Dr Owen Smith and Dr Rohan Jayasuriya, for their valuable commentaries
on the profile.
xiii
Acronyms and abbreviations
A&E accident and emergency

ADIC Alcohol and Drug Information Centre
AI agglomeration index
AMR antimicrobial resistance
AR administrative regulations
ART antiretroviral therapy
BH Base Hospital
BMI body mass index
BOI Board of Investment
BP blood pressure
CDD Cosmetic Devices and Drugs
CHE current health expenditure
CKDu chronic kidney disease of unknown aetiology
CMC Ceylon Medical Council
CMCC Sri Lanka Medical College Council
CRVS Civil Registration and Vital Statistics (System)
CVD cardiovascular disease
DALY disability-adjusted life year
DCS Department of Census and Statistics
DDC District Development Committee
DDG Deputy Director General
DGH District General Hospital
DGHS Director General of Health Services
DH Divisional Hospital
DHS Demographic and Health Survey
DM diabetes mellitus
DNMS District Nutrition Monitoring System
DP development partner
DRPD Disaster Preparedness and Response Division
DS Divisional Secretary
e-IMMR Electronic Indoor Morbidity and Mortality Reporting
xiv
ECG electrocardiography
EHR electronic health record
EMT emergency medical technician
EPI Expanded Programme on Immunization
ERPM Examination for Registration to Practice Medicine
ETU Emergency Treatment Unit
FCTC WHO Framework Convention on Tobacco Control
FHB Family Health Bureau
FOSS free and open-source software solution
FR financial regulations
GATS General Agreement on Trade and Services
GBD global burden of disease
GBV gender-based violence
GDP gross domestic product
GGE general government expenditure
GGHE general government health expenditure
GGHE-D domestic general government health expenditure
GN grama niladhari
GP general practitioner
GSRI General Service Readiness Index
GYTS Global Youth Tobacco Survey
HAQI Healthcare Access and Quality Index
HDC Health Development Committee
HDI Human Development Index
HFS Health Facility Survey
HHIMS Hospital Health Information Management System
HIES Household Income and Expenditure Survey
HIMS Healthcare Information and Management System
HIS Health Information System
HiT Health Systems in Transition
HLC healthy lifestyle centre
HLE healthy life expectancy
HMN Health Matrix Network
HMP Health Master Plan
HPB Health Promotion Bureau
HR human resources
HRMIS Human Resources Management Information System
HTA health technology assessment
xv
ICD-10 International Classification of Diseases, tenth revision
ICT information and communication technology
ICU intensive care unit
IMMR Indoor Morbidity and Mortality Register
IMR infant mortality rate
IOM International Organization for Migration
IPC infection prevention and control
IT information technology
JICA Japanese International Cooperation Agency
JVP Janatha Vimukthi Peramuna
LBW low birth weight
LE life expectancy
LIS Laboratory Information System
LTTE Liberation Tigers of Tamil Eelam
MAPS mHealth Assessment and Planning for Scale
MCH maternal and child health
MDPU Management Development and Planning Unit
MLT Medical Laboratory Technologist
MMR maternal mortality ratio
MNCH maternal, neonatal and child health
MO medical officer
MOH medical officer of health
MoHNIM Ministry of Health, Nutrition and Indigenous Medicine
MoMCH Medical Officer of Maternal and Child Health
MSD Medical Supplies Division
NATA National Authority on Tobacco and Alcohol
NBTS National Blood Transfusion Service
NCD noncommunicable disease
NGO nongovernmental organization
NHDC National Health Development Committee
NMDP National Medicinal Drug Policy
NMHAC National Mental Health Advisory Council
NMQAL National Medicines Quality Assurance Laboratory
NMR neonatal mortality rate
NMRA National Medicines Regulatory Authority
OECD Organisation for Economic Co-operation
and Development
OOP out of pocket
xvi
OOPE out-of-pocket expenditure
OPD outpatient department
OT occupational therapist
PACS Permission and Picture Archiving and
Communicating System
PDHS Provincial Director of Health Services
PEN Package of Essential NCD Interventions
PET positron emission tomography (scan)
PGH Provincial General Hospital
PHC primary health care
PHI Public Health Inspector
PHM Public Health Midwife
PHNS Public Health Nursing Sister
PHSRC Private Health Services Regulatory Council
PMC Primary Medical Centre
PMCI primary medical care institution
PMCU primary medical care unit
PMIRA Private Medical Institutions Regulatory Act
PMoH Provincial Ministry of Health
PPIE Patient and Public Involvement and Engagement
PPP purchasing power parity
PSC Public Service Commission
PSM professions supplementary to medicine
RDHS Regional Director of Health Services
RE Regional Epidemiologist
RHMIS Reproductive Health Management Information System
SARA Service Availability and Readiness Assessment
SARI severe acute respiratory illness
SDGs Sustainable Development Goals
SDT School Dental Therapist
SLMC Sri Lanka Medical Council
SLR Sri Lankan rupee
SPC State Pharmaceutical Corporation
SPHI Supervising Public Health Inspector
SPHM Supervising Public Health Midwife
SPMC State Pharmaceuticals Manufacturing Corporation
STEPS STEPwise approach to surveillance
STI sexually transmitted infection
xvii
TB tuberculosis
TH teaching hospital
TM Traditional Medicine
U5MR under-5 mortality rate
UHC universal health coverage
UNFPA United Nations Population Fund
UNHCR United Nations High Commissioner for Refugees
UNICEF United Nations Children’s Fund
URTI upper respiratory tract infection
VHI voluntary health insurance
VPD vaccine-preventable disease
WHO World Health Organization
WWC Well Woman clinic
YED Youth, Elderly and Persons with Disabilities
YLD years lived with disability
YLL years of life lost
xviii
Executive summary
Sri Lanka is a country with a population of 21.7 million which is ageing

rapidly and is in the late stages of both demographic and epidemiological
transitions. It has achieved strong health outcomes over and above what is
commensurate with its income level. Equity and efficiency of these outcomes
are largely credited to the strong state health care system.
Significant gains have been made in neonatal, infant, under-5 and maternal
mortality. Life expectancy at birth has increased steadily for both sexes,
and women currently live 6.7 years longer than men. The country has been
able to eliminate malaria, filariasis, polio and neonatal tetanus and is set
to eliminate other vaccine-preventable diseases such as measles and
congenital rubella syndrome and other infectious diseases such as lymphatic
filariasis and leprosy. These gains may be attributed to the socio-political
milieu of the country from early on and the widespread health services which
have been free at the point of delivery, which acted as drivers of demand.
Although much has been achieved in eliminating or reducing morbidity

and mortality, communicable diseases such as dengue, leptospirosis,
pandemic influenza and tuberculosis still remain important causes of
morbidity. Noncommunicable diseases (NCDs), injuries and mental illness
form the bulk of the current disease burden, while ischaemic heart disease,
cardiovascular diseases and diabetes constitute the leading causes of
disability-adjusted life years (DALYs) lost. It is estimated that nearly 75% of
deaths in the country are due to NCDs. The prevalence of risk factors for
NCDs is significantly high.
The health system constitutes of both curative and preventive services.

Preventive healthcare is provided through 354 geographically defined areas
covering the whole island. Each area is served by a medical officer of health
(MOH) and a team of community-based professionals who provide a well-
defined package of preventive services. A key strength of the MOH system is
the strong supportive supervision backed by monitoring mechanisms that
have evolved and been fine-tuned over the years. Curative care encompasses
different levels, ranging from outpatient-only facilities and primary care
institutions to tertiary-care institutions and specialized hospitals organized
into a hierarchical network. They provide a comprehensive range of health
care services but not an explicit package of benefits. All state provided
sservices are free of charge at the point of delivery and covers about 95% of
inward care and 50% of total ambulatory care in the country. There is also a
xix
free community ambulance service, which provides increased health-care
access in an emergency. The state also provides the required medicines and
investigations free of charge to the patient.
Although there is no explicit targeting of the poor within the Sri Lankan
health system, utilisation patterns suggest that there is implicit targeting of
the poor due to the better off segments of the population opting out of the
public sector where waiting times are longer, choice of provider is limited and
service hours not very convenient. Studies suggest that the quality of care
across public and private sectors is comparable.
The State health services function under a Cabinet Minister. The Ministry
of Health, Nutrition and Indigenous Medicine (MoHNIM) is responsible for
stewardship functions such as policy formulation and health legislation,
program monitoring and technical oversight, management of health
technologies, human resources and tertiary and other selected hospitals.
Following the 13th amendment to the constitution, health became a partially
devolved subject and the primary and secondary levels of curative care and
preventive services came under the nine Provincial Ministries.
Government revenue and out of pocket spending are the two main sources
of health financing. Government spending as a share of gross domestic
product has remained around 1.7% during the period 2013 to 2016. The
household contribution to current health expenditure (CHE) is significant and
is largely from out-of-pocket expenditure (OOPE) but households reporting
catastrophic health expenditure is low mainly because most of the OOPE
is incurred by the rich and the fact that the government remains the key
provider of inpatient care. The need for increased fiscal space for health is
recognized. However, within the present budgetary constraints better health
outcomes are being targeted through reorganization and retooling.
Although the organisation of the state sector curative care facilities is

conducive to the implementation of a referral system, there are no clear
referral policies and clearly demarcated catchment areas for institutions.
Individuals are free to access services at any state sector institution without
a proper referral. This has enhanced equity within the system to a certain
degree but poses problems in the continuity of care needed particularly in
dealing with NCDs. The phenomenon of bypassing has been shown to be
based on people’s perceptions of better facilities, availability of medicines,
and better quality of care and provider competency. The MoHNIM response
to this problem until recently has been to enhance resource allocation to
secondary- and tertiary-care institutions, However the focus has recently
shifted to reorganising primary care services so as to make available quality
xx
services close to patient homes ensuring continuity of care and referral when
needed. The implementation of reforms acceptable to providers and the
recipients while maintaining equity poses a major challenge.
In response to these challenges, a policy on health-care delivery for universal

health coverage (UHC) (MoHNIM, 2018b) has been launched and many
supportive policies towards promoting health have been formulated in recent
years. The establishment of the National Authority on Tobacco and Alcohol
(NATA), National Policy and Strategic Framework for Prevention and Control
of Chronic Non-communicable Diseases, National Migration Health Policy,
establishment of the National Medicines Regulatory Authority (NMRA),
National Policy on Health Information, and Policy on Health Service delivery
for UHC are some of these. However, implementation gaps have been
identified and these highlight the need for strengthening these new agencies
to fulfil their mandates.
Even though there have been many developments in recent times,

information management remains a weak point in the health system.
Some of the issues that have been identified as needing rectification are
compartmentalisation of information governance, inadequate coordination
and limited data sharing between existing systems and weaknesses in the
quality of data collected.
The health system of the country has not transformed to address the
demands of the demographic, epidemiological transitions and the changing
expectations of a society undergoing social evolution. Addressing the risk
factors of NCDs will need rational needs analysis and innovative approaches
to ensure adequate numbers of appropriately skilled staff. Health workforce
cadres as well as the optimal skill mix to match evolving health care needs
of the reform process are areas that need attention. Human Resources (HR)
planning, management and periodic audits will have to be institutionalized,
as well as continuing processes to anticipate and respond to emerging health
needs. Ensuring retention of HR in primary health care settings and equitable
distribution across the country also pose challenges.
The MoHNIM has identified reorganisation of services with special emphasis

on primary health care services while retaining the current strengths of the
system as a means of addressing the challenges and enhancing UHC. These
changes will necessitate increased government spending on the health
sector and addressing the social determinants of health, ensuring equity in
social, environmental, and economic policies. It will also need a concentrated
and transformative effort to engage individuals and communities to adopt
healthy behaviours and lifestyles and take responsibility for their own health.
xxi
1. Introduction
Chapter summary
Sri Lanka is an island in close proximity to the southernmost tip of India.
It is home to 21.4 million people. It has a multiethnic society comprising
Sinhalese (75%), Sri Lankan Tamils (15%) and Sri Lankan Moors (9%). The
country’s population is rapidly ageing and the percentage of those over 65
years of age increased from 3.7% in 1970 to 10.8% in 2019, with an increasing
feminization.
The country, had achieved upper-middle-income status although it was

downgraded to lower-middle-income in July 2020. The earlier predominantly
export-oriented agricultural economy has been transformed to a free-
market economy. It recorded an average annual growth rate of around 6.4%
during the period 2003–2012, but this had slowed down to 3.1% in 2017. The
country remained a parliamentary democracy since Independence in 1948
till 1972, when it declared itself an independent republic. A new constitution
adopted in 1978 provided for an elected executive president and a unicameral
parliament. A major amendment in 1987 decentralized power to nine elected
provincial councils.
Sri Lanka had achieved a relatively high standard of health while it was still
a low-middle-income country. An effective maternal and child health (MCH)-
care system dating back to 1926 produced significant gains in terms of infant
mortality rate (IMR), neonatal mortality rate (NMR), under-5 mortality rate
(U5MR) and maternal mortality ratio (MMR), but the rate of decline has
slowed during the past decade. The country has eradicated polio, neonatal
tetanus, malaria, filariasis and leprosy, and has achieved near elimination of
other diseases covered by the Expanded Programme on Immunization (EPI).
It is in the late stage of the epidemiological transition. However, an epidemic
of noncommunicable diseases (NCDs) and emerging new infections such
as dengue and re-emergence of old infections such as tuberculosis pose
challenges to health.
Risk factors that underlie the disease burden are high fasting plasma
glucose, dietary risk, high blood pressure and tobacco consumption, in that
order. It is estimated that 90% of Sri Lankan adults (18–69 years) have at
1
least one NCD risk factor, 73.5% have 1–2 risk factors, and 18.3% have 3–5
risk factors, the prevalence being similar in males and females.
The changing epidemiology has prompted a reorganization of the health

services, focusing on equitable, patient-centred quality care at the primary
and secondary levels.
1.1 Geography and sociodemography

Sri Lanka is an island situated at the southern tip of India and separated from
it by a strip of sea about 20 km in width at its narrowest point (Madduma
Bandara, 2007). Historically, it has been referred to by many names. The
British, the last colonial rulers, called it Ceylon. The country was officially
renamed Sri Lanka in 1972, Lanka being the country’s ancient name and the
prefix meaning resplendent. The island’s strategic position in relation to the
ancient sea routes of the Indian Ocean and its close proximity to India has
led to waves of immigration, invasion and colonization throughout its history.
This diversity of influences has shaped the social, cultural, political and
demographic picture of the country.
The total land area of the country is 65 625 sq.km and includes the main
island and several small islands in close proximity to the main land mass.
The mainland extends 433 km from north to south and 226 km from east
to west at its widest point (Madduma Bandara, 2007). Administratively, the
country is divided into nine provinces (Figure 1.1), which are subdivided
into 25 districts. The districts are divided into 330 divisional secretary (DS)
divisions and these are subdivided into grama niladhari (GN) divisions. There
are 14 022 GN divisions constituting the smallest administrative units of the
country (Ministry of Public Administration and Home Affairs, 2018).
2
Figure 1.1 Map of Sri Lanka
Source: United Nations Cartographic Section, 2008
The climate of the island is dominated by tropical monsoon systems. The

mean annual temperature in Sri Lanka is largely homogeneous, regional
differences being largely due to altitude rather than to latitude. In the
lowlands up to an altitude of 100–150 m, the mean annual temperature
3
varies between 26.5 ºC and 28.5 ºC, while in the highlands, e.g. Nuwara Eliya,
which is 1800 m above sea level, it is around 15.9°C (Chandrapala, 2007).
Analysis of long-term data on rainfall and temperature indicate a decrease
in the annual average rainfall together with a higher variability in the annual
rainfall anomaly and a trend of increasing air temperature, which have been
attributed to climate change (Basnayake, 2007).
The population of Sri Lanka by province is given in Table 1.1. Trends in

demographic indicators for selected years are given in Table 1.2. Trends in
ageing and dependency in Sri Lanka are given in Table 1.3.
Table 1.1 Population of Sri Lanka by province

% of
Population in % of total Population population
Province
1000’s population density 60 years and
over
Western Province 6129.0 28.3 1705.8 13.4
Central Province 2750.0 12.7 493.3 12.8
Southern Province 2637.0 12.2 472.3 14.0
Northern Province 1131.0 5.2 136.4 11.8
Eastern Province 1710.0 7.9 182.7 7.8
North Western Province 2536.0 11.7 337.9 12.2
North Central Province 1366.0 6.3 140.2 9.4
Uva Province 1364.0 6.3 163.6 10.8
Sabaragamuwa 2047.0 9.4 416.0 13.8
Sri Lanka 21 670.0 100.0 345.6 12.4
Source: Department of Census and Statistics, 2020
1.1.1 Population and ageing

The country is home to 21.7 million people of whom 52% are females.
The average population density is 347.1 persons per sq.km. However, the
population is unevenly distributed among the nine provinces (Table 1.1).
Nearly a third of the country’s population lives in the Western Province, the
country’s administrative and economic hub (Department of Census and
Statistics, 2015a). The population density of this province is nearly five times
the country’s average at 1705.8 persons per sq.km. The crude birth rate,
total fertility rate and average annual population growth rate have declined
steadily over time, while life expectancy (LE) at birth has increased. It is noted
that women have a nearly 7-year advantage over men in LE.
4
Table 1.2 Trends in demographic indicators, 1970–2019
Indicators 1970 1980 1990 2000 2010 2016 2017 2018 2019
Total population (in 12.5 14.7 17.3 18.8 20.2 21.2 21.4 21.7 21.8
millions)
Population density 199.1 239.8 276.3 299.5 322.1 338.1 342 345.5 347.1
(people per sq.km)
Population, female 48.5 49.0 49.5 50.1 51.3 51.9 51.9 51.9 51.6
(% of total)
Birth rate, crude 30.6 27.0 20.6 18.5 17.5 15.3 15.0 .. ..
(per 1000 people)
Fertility rate, total 4.3 3.4 2.5 2.2 2.2 2.0 2.0 .. ..
(births per woman)
Death rate, crude 7.8 6.3 6.5 7.0 6.5 6.9 6.9 .. ..
(per 1000 people)
Population growth 2.1 1.9 1.4 0.7 0.7 1.1 1.1 1.0 ..
(average annual
growth rate)
Life expectancy at 64.1 68.2 69.5 71.0 74.4 75.3 75.5 .. ..
birth
Rural population (% 80.5 81.2 81.4 81.6 81.7 81.6 81.5 81.5 81.5
of total population)
School enrolment – 45.9 53.6 72.0 .. 96.9 97.7 97.9 .. ..
secondary (%)
Source: World Bank, 2020
The majority of the people (81.5%) live in rural areas (Department of Census
and Statistics, 2015a). The proportion of the urban population has in fact
decreased by 1% from the 1970 value. However, it must be noted that the
definition of “urban” is based on an administrative demarcation, i.e. the
population living within municipal and town council areas. This may have
resulted in an underestimation of the degree of urbanization and the urban
population. A study carried out by the Institute of Policy Studies has provided
an alternate estimate of urban population at 43.8%. In this classification,
each GN division is classified as urban based on a minimum population of 750
persons, a population density greater than 500 persons per sq.km, firewood
dependence in less than 5% of households and well-water dependence in
less than 5% of households. This value is closer to the 47% estimated by the
agglomeration index (AI) (Weerarathne, 2016).
Sri Lanka is a multi-ethnic society, predominantly Sinhalese (74.9%), the

majority of whom are Buddhists. Sri Lankan Tamils make up around 15.3%
of the population and Sri Lankan Moors a further 9.3%. The proportion of
each of the other ethnicities (Burgher, Malay, Sri Lanka Chetti, Bharatha
and others) is 0.2% or less. Hindus form 12.6% of the population, 9.7% are
5
Catholics and 6.2% belong to other Christian denominations (Department of
Census and Statistics, 2015a).
Both Sinhalese and Sri Lankan Tamil cultures place a high value on
education. National statistics indicate that secondary school enrolment
(calculated as the percentage of children 10 years old who are in school) is
high (97.7%, 2016). Adult literacy was high at 91.3% for males and 82.0% for
females in 1981, which increased to 92.9% for males and 90.9% for females
in 2017 (World Bank, 2020). In 2018, Sri Lanka was placed seventy-sixth
globally on the Human Development Index (HDI) (0.770). It is noted that
between 1990 and 2018, Sri Lanka’s HDI value increased from 0.625 to 0.770,
an increase of 23.2% (United Nations Development Programme, 2016).
The population of Sri Lanka is ageing progressively. The population of

those 65 years and over has increased from 3.7% in 1970 to 10.8% in 2019,
while those 80 years and over has increased from 0.5% to 1.6% during the
same period (World Bank, 2020). An important feature of this process is its
feminization, as seen in Figure 1.2, and indicated by the higher LE at birth for
females (78.6 years) compared to males (71.9 years). Population projections
(standard) suggest that the share of the population 60 years and over will
reach 16.3% by 2022 and 23% by 2024. By the year 2052, one in every four
persons will be 60 years or over. This amounts to an addition of 4 million old-
age persons during the period 2012–2052 (De Silva and De Silva, 2015).
Table 1.3 Trends in ageing and dependency in Sri Lanka, 1970–2019

Indicators 1970 1980 1990 2000 2010 2016 2017 2018 2019
Population aged 0–14 years (% 40.3 35.9 32.1 26.8 25.4 24.6 24.4 24.2 24
of total)
Population aged 65 years and 3.7 4.4 5.5 6.2 7.4 9.8 10.1 10.5 10.8
above (% of total)
Population aged 80 years 0.49 0.51 0.81 1.03 1.41 1.58 1.6 1.62 1.64
and above of both sexes (% of
total)
Child (0–14 years) dependency 71.9 60 51.4 40 37.8 37.4 37.3 37 36.7
ratio
Elder (65+ years) dependency 6.6 7.3 8.8 9.3 11.1 14.9 15.5 16 16.6
ratio
Age dependency ratio* 78.5 67.4 60.2 49.2 48.8 52.4 52.7 53.1 53.4
(population 0-14 and 65+ years
/ population 15-64 years)
* The age dependency ratio is an age – population ratio of those typically not in the labour
force (the dependent part, ages 0–14 and 65+ years) and those typically in the labour force
(the productive part ages,15–64 years). The total dependency ratio can be broken down into the child
dependency ratio (0–14 years) and the aged dependency ratio (65 years and above).
6
Figure 1.2 Age distribution of the Sri Lankan population, 1981 and 2019
100+ Male 0.0% 0.0% Female 100+ Male 0.0% 0.0% Female
95-99 0.0% 0.0% 95-99 0.0% 0.0%
90-94 0.0% 0.0% 90-94 0.1% 0.1%
85-89 0.1% 0.1% 85-89 0.2% 0.3%
80-84 0.2% 0.2% 80-84 0.3% 0.6%
75-79 0.4% 0.4% 75-79 0.7% 1.1%
70-74 0.7% 0.6% 70-74 1.4% 1.9%
65-69 1.0% 0.9% 65-69 1.9% 2.3%
60-64 1.3% 1.1% 60-64 2.3% 2.7%
55-59 1.6% 1.5% 55-59 2.7% 3.0%
50-54 1.9% 1.8% 50-54 3.0% 3.2%
45-49 2.1% 2.0% 45-49 3.1% 3.2%
40-44 2.4% 2.3% 40-44 3.4% 3.7%
35-39 2.9% 2.8% 35-39 3.3% 3.7%
30-34 3.6% 3.5% 30-34 3.0% 3.5%
25-29 4.2% 4.1% 25-29 3.2% 3.5%
20-24 5.0% 4.9% 20-24 3.5% 3.5%
15-19 5.4% 5.3% 15-19 3.9% 3.9%
10-14 5.8% 5.6% 10-14 4.1% 4.0%
5-9 5.9% 5.7% 5-9 4.0% 4.0%
0-4 6.5% 6.3% 0-4 4.0% 3.9%
10% 8% 6% 4% 2% 0% 2% 4% 6% 8% 10% 10% 8% 6% 4% 2% 0% 2% 4% 6% 8% 10%
Source: UN DESA, 2019
The dependency ratio for older persons has increased from 6.6 to 16.6
during the period 1970 to 2019, although there has been a decline in the
total dependency ratio from 78.5 to 53.4. A feature of the decline in total
dependency has been a lowering of the child dependency ratio (71.9 to 36.0)
(Figure 1.3) due to the declining birth rate (Table 1.1). The ratio of 0–14 years
to those 65 years and over declined from 10.9 to 1 in 1970 to 2.2 to 1 in 2019
(Table 1.3).
Figure 1.3 Age dependency ratio for Sri Lanka by age group, 1970–2019
90
80
70
60
50
Ratio
40
30
20
10
0
197 0 198 0 199 0 200 0 201 0 201 6 201 7 201 8 201 9
Year
Child dependency ratio Elderly dependency ratio
Total dependency ratio
7
The parental support ratio is 8, measured as the number of persons aged
80 years and over per 100 persons aged 50–64 years based on the 2012
Census. This is due to the fact that there are a large number of persons in the
50–64 years age cohort born during the baby boom during 1948–1962. In the
current demographic scenario of families having fewer children and the older
cohorts expected to live longer, this is very likely to change (United Nations
Population Fund, 2017).
Like the population itself, ageing is also not distributed evenly across the
nine provinces in the country. In the Northern Province (5.2% of the total
population, 11.8% of the population is 60 years and over), North Central
(6.3% of the total population, 9.4% of the population is 60 years and over),
Uva (6.3% of the total population, 10.8% of the population is 60 years and
over), Sabaragamuwa (9.4% of the total population, 13.8% of the population
is 60 years and over) and Southern Province (12.2% of the total population,
14.0% of the population is 60 years and over), the proportion of those 60
years of age and over are more than its population proportion, suggesting
provincial variations in the pace of the demographic transition (United Nations
Population Fund, 2017).
It is noted that more than half of older people have some physical and/or
mental impairment. Nearly 22% of the older people have visual difficulties,
11.3% have hearing difficulties, 19.4% have walking problems while nearly 8%
have cognitive dysfunction. Among those aged 80 years and over, 19% were
unable to care for themselves and 10% had communication difficulties. About
60% of persons 80 years and over had experienced at least one disability and
30% had experienced three or more (United Nations Population Fund, 2017).
It was also noted that 45% of those 60 years and over have at least one
NCD; those mostly associated with ageing being cardiovascular disease
(CVD), cancer, diabetes mellitus (DM), arthritis, depression, dementia and
Alzheimer disease (United Nations Population Fund, 2017). Prevention and
early detection of these diseases and adequate service provision for managing
them, as well as disability and long-term care and ensuring economic security
for older people remain priorities, especially in the provinces and districts
with a large number of such persons.
At present, the country does not have a comprehensive social protection

mechanism for the older population and, as such, it is important to examine
the status of economic activity as an indicator of economic well-being of this
group. The 2012 Census showed that 75% of those over 60 years of age were
economically inactive; 43% of the men and 11% of the women were employed.
Among those employed, 38% of the women were in elementary occupations
while 31% of the men were skilled workers in agriculture, forestry and
8
fisheries. It was also recorded that one in every three women over 60 years of
age was widowed, which increased to 50% among those 80 years and older.
Extended families play a vital role in the care of older persons. The majority,
especially women, are also economically dependent. Although increasing
longevity should be looked upon as an achievement to be proud of, the
older population is a resource that is not fully utilized. Thus, the creation of
opportunities for older persons to engage in productive and healthy ageing is
a priority (United Nations Population Fund, 2017).
1.1.2 Comparison with selected countries

Comparing Sri Lanka with selected countries in the World Health Organization
(WHO) South-East Asia and Western Pacific regions (Table 1.4), it is seen that
while Sri Lanka is the smallest country in terms of size and total population,
its population density is second only to that of the Philippines.
Of the countries selected, Thailand is the only country that has a higher
percentage of those 65 years and over (11.4%) compared to Sri Lanka (10.1%),
but the population below 14 years of age in Thailand (17.3%) is the lowest
of all the countries used in the comparison, resulting in the lowest age
dependency ratio.
Life expectancy at birth in Sri Lanka (75.3 years) is on a par with Malaysia and
Thailand but is one year less than that of Viet Nam (76.3 years). Adult literacy
(91.2%) is the lowest of all the countries used in the comparison; however, the
HDI is second to only that of Malaysia.
Among the comparison countries, Sri Lanka is ranked third in respect of

the gross domestic product (GDP) per capita, but it is less than half that of
Malaysia and around 62% of that of Thailand.
Healthcare Access and Quality Index (HAQI), calculated using 37 of the 50

Sustainable Development Goals (SDGs), is a proxy measure of the overall
effectiveness of the health-care system. Sri Lanka’s score of 73 out of hundred
is the highest score among the comparison countries (2017a). When the
SDG index is considered, Malaysia is ranked higher than Sri Lanka, while all
other comparison countries are ranked below Sri Lanka. It is noted that in
respect of the SDG score, the country has shown progress from 38 in 1990
to the current score of 62 (GBD 2016 SDG Collaborators, 2017). Among the
comparison countries, Sri Lanka is ranked fourth in service coverage, despite
having universal coverage for indicators such as bed availability, immunization
and pregnancy care. The low value of this indicator for Sri Lanka is mainly due
to the reported poor coverage for indicators such as care-seeking behaviour
9
for pneumonia (52%),1 antiretroviral therapy (ART) for HIV (27%) and cervical
cancer screening (25%).
Table 1.4 Comparison of Sri Lanka with selected countries in the WHO
South-East Asia and Western Pacific regions, 2017
Sri
Indicators Indonesia Malaysia Thailand Philippines Viet Nam
Lanka
Population, total (millions) 21.44 264.65 31.11 69.21 105.17 94.60
Land area in sq.km 62 710 1 811 570 328 550 510 890 298 170 310 070
Population density/sq.km 342.0 145.7 96.3 135.1 351.9 308.1
Population ages 0–14 years 24.0 27.4 24.3 17.3 31.7 23.1
(% of total)
Population ages 65 years 10.1 5.3 6.3 11.4 4.8 7.1
and above (% of total)
Age dependency ratio (% of 51.7 48.5 44.1 40.2 57.5 43.3
working-age population)
Age dependency ratio, 15.3 7.9 9.1 15.9 7.6 10.2
old (% of working-age
population)
Age dependency ratio, 36.4 40.6 35.0 24.3 50.0 33.0
young (% of working-age
population)
Life expectancy at birth 75.3 69.2 75.3 75.3 69.1 76.3
(2016)
Total adult literacy rate % 91.2 92.8 93.1 93.5 95.4 93.4
(2008–2012) *
HDI ** 0.77 0.69 0.79 0.74 0.68 0.68
GDP per capita (current 4065.2 3846.9 9944.9 6593.8 2989.0 2343.1
US$)
SDG – UHC indicator (3.8.1) 62 49 70 75 58 73
Service coverage indicator
SDG index (GBD) 2016 62 40 66 58 48 46
(Global Burden of Disease
(2016) Collaborators, 2017)
UHC – GBD 2015 (Global 72 39 65 72 38 59
Burden of Disease (2015)
Collaborators, 2017)
HAQI – GBD 2015 (Global 73 49 67 71 52 66
Burden of Disease (2015)
Collaborators, 2017)
GBD: global burden of disease; GDP: gross domestic product; HDI: human development index; SDG:
Sustainable Development Goal; UHC: universal health coverage
Sources: World Bank, 2020; *UNICEF, 2018; ** United Nations Development Programme, 2019
1 The data for the indicator on care-seeking behaviour for pneumonia is from the Demographic
and Health Survey (DHS) 2016. The information sought in the survey is on “Treatment for acute
respiratory infections in children under 5 years of age”. The percentage represents children
who had been taken to a health facility for advice or treatment. In the absence of information
on health-seeking behaviour specific to pneumonia, this percentage has been used in the
compilation of the index and 52% may be an underestimate.
10
1.2 Economic context
The economy that evolved under British rule was oriented towards plantation
agriculture. As such, at Independence, Sri Lanka inherited an agriculture-
based export economy, deriving more than a third of its income from the
export of tea, rubber and coconut. Favourable export incomes supported
the pursuit of a welfare economy focused on equity, which paid dividends
in the form of significant improvements in the area of human development.
The high consumption, low investment in economic development, declining
commodity prices and failure to diversify led to a decline in the economy.
Plantations, the petroleum industry, the port and omnibus companies were
nationalized by a socialist regime. The change of government in 1977 brought
a change in policies that introduced a free-market economy, which promoted
privatization, deregulation and promotion of private enterprise (Indraratna,
1998) (Table 1.5).
Table 1.5 Macroeconomic indicators, 1970–2018

Indicators 1970 1980 1990 2000 2010 2016 2017 2018
GDP (local current US$) in billions 2.3 4.0 8.0 16.6 56.7 82.4 88.0 88.9
GDP, PPP (current US$) in billions .. .. 40.5 82.5 168.8 261.7 276.2 291.5
GDP per capita (current US$) in 183.9 267.7 463.5 869.5 2808.4 3886.3 4104.6 4102.5
thousands
GDP average annual growth rate 3.8 5.8 6.4 6.0 8.0 4.5 3.4 3.2
for the past 10 years (%)
Public expenditure (% of GDP)/ 103.1 122.6 107.9 110.6 107.3 107.3 107.2 107.3
gross national expenditure (% of
GDP)
Current account balance (% of .. -16.3 -3.7 -6.4 -1.9 -2.1 -2.6 -3.2
GDP)
Tax burden (% of GDP)–tax revenue .. .. 19.0 14.5 11.3 12.2 12.4 ..
(% of GDP)
Public debt (% of GDP)–Central .. .. 96.6 96.9 71.6 .. .. ..
Government debt
Value added in industry (% of GDP) 24.2 29.9 26.3 27.3 26.6 27.3 27.3 27.0
Value added in agriculture (% of 28.8 27.8 26.7 19.9 8.5 7.5 7.8 7.9
GDP)
Value added in services (% of GDP) 47.1 42.3 47.0 52.8 54.6 56.9 55.7 56.8
Labour force (total) in millions .. .. 7.4 7.8 8.2 8.5 8.5 8.6
Unemployment, total (% of labour .. .. 15.9 7.7 4.9 4.4 4.2 4.4
force)
Poverty rate (poverty headcount .. .. .. .. .. 4.1 .. ..
ratio %)
Income or wealth inequality .. .. 8.7 .. .. 7.0 .. ..
(income share held by lowest 20%)
Real interest rate .. .. .. .. -10.2 6.2 .. ..
Official exchange rate (US$) 6.0 16.5 40.1 77.0 113.1 146.5 152.4 162.5
GDP: gross domestic product; PPP: purchasing power parity
11
In 2018, Sri Lanka transited to an upper-middle-income country according
to the World Bank definition, with a per capita GDP of US$ 4102.5 (however,
in July 2020, World Bank downgraded Sri Lanka to lower-middle-income
status). This led to a change in the beneficiary status for foreign aid and a
limiting of the developmental assistance to the country. The economy grew
markedly in the post-conflict period (8.0% in 2010) but has shown a declining
trend at 4.5% in 2016 and 3.2% in 2018.
The poverty headcount ratio was reported as 4.1 in 2016 (World Bank, 2020)
and the income share held by the lowest 20% at 7.0, a decline from 8.7 in
1990 (World Bank, 2020). The main sectors of the economy are tourism,
and tea, apparel and textile export while overseas employment contributes
substantially towards foreign exchange earnings (Ministry of Finance, 2019).
1.3 Political context

The documented history of the country begins with the arrival of the first
Indo – Aryan immigrants from the north-western region of India, in the
fifth century BC. The island was ruled by kings from then on, until the last
kingdom, the kingdom of Kandy, was ceded to the British in 1815 (De Silva,
2005). The more recent political history of the country has been greatly
influenced by its history as a British colony.
In 1948, the country received autonomy within the British Commonwealth

as the Dominion of Ceylon and continued to be governed as a parliamentary
democracy. A new constitution adopted in 1978 provided for an elected
executive president and a unicameral parliament. The President is the head
of State, head of government and the commander in chief. The President
heads the cabinet and appoints ministers from among the members of
parliament. The Parliament of Sri Lanka is a 225-member legislature with
196 members elected from 22 multi-seat electoral districts and 29 elected
from the national list allocated to the parties and independent groups in
proportion to their share of the national vote (Parliament of the Democratic
Socialist Republic of Sri Lanka, 1978).
With the Thirteenth amendment to the Constitution in 1987, the

administration was decentralized, and nine provincial councils were created.
Provincial councils are directly elected for a 5-year term. The leader of the
council’s majority party serves as the chief minister and is assisted by a board
of provincial ministers. A provincial governor and a provincial secretary, who
is the head of the provincial administration, are appointed by the President.
Below the provincial level are several elected bodies. Municipal councils
and urban councils are responsible for the administration of municipalities
12
and cities, respectively, while the pradeshiya sabhas administer demarcated
clusters of villages (Parliament of the Democratic Socialist Republic of Sri
Lanka, 1987). The country has been able to maintain its democratic traditions
despite periods of political unrest, the insurrections of 1971, 1987–1989 and a
three decade-long civil conflict, which was successfully settled in 2009.
Sri Lanka’s judiciary consists of a supreme court – the highest and final
superior court, a court of appeal, high courts and a number of subordinate
magistrate courts. Roman Dutch law is called the “common law” of
the country. Criminal law is based predominantly on British law. The
civil procedure code, which governs civil matters, is influenced by the
Indian, British and American rules of procedure. The constitutional and
administrative law has been derived from the Anglo-American systems while
the Roman Dutch law is the basis for private legal matters. Kandyan Law,
Muslim Law and Thesawalami are laws applicable to certain aspects of life
and to defined sections of the population (Ranasinghe et al., 2007).
Since Independence, Sri Lanka has experienced three armed conflicts. There
were two insurrections in the south, which mainly involved the Sinhalese
youth. These were led by the Janatha Vimukthi Peramuna (JVP), currently
a leftist political party in the mainstream politics of the country, the first
being in 1971 while the second was a more protracted conflict from 1987
to 1990. These conflicts did not trigger major mass movements of the
population, though many individuals and families were temporarily displaced
from their homes.
The most severe conflict the country has faced was the 30-year armed
conflict waged by the Liberation Tigers of Tamil Eelam (LTTE), aiming to
create an autonomous Tamil state encompassing the Northern and Eastern
provinces of the country. This was decisively ended when the Sri Lankan army
overcame the LTTE in 2009 (Siriwardhana and Wickramage, 2014).
1.4 Health status

Sri Lanka has been able to achieve a relatively high level of health while
still being a low-middle-income country. The country has been able to
eliminate malaria, filariasis, leprosy, polio and neonatal tetanus and
achieve near elimination of most other vaccine-preventable diseases (VPDs)
targeted by the EPI. Hospital data show declining trends in admissions for
gastrointestinal infections and parasitic diseases. However, emerging new
infections such as dengue, epidemic influenza and leptospirosis, and re-
emergence of old infections such as tuberculosis pose challenges to health
(World Health Organization, 2018a).
13
Figure 1.4 shows that NCDs form the bulk of the disease burden and
contribute the highest number of deaths per 100 000 population, the next
highest being injuries, suggesting that the country is in the late stages of
the epidemiological transition. A steady decline in deaths and disability-
adjusted life years (DALYs) due to all three categories is noted, indicating
improvements in health and the social determinants of health.
Figure 1.4 Deaths and DALYs per 100 000 population for major groups,
2004–2016
1200 50 000
Deaths/100 000 population
DALYs/100 000 population

1000 40 000
800
30 000
600
20 000
400
200 10 000
0 0
2004 2008 2016 2004 2008 2016
Group 1 Group 2 Group 3 Group 1 Group 2 Group 3
Group 1–Communicable, maternal, neonatal and nutritional diseases; Group 2–NCDs; Group 3–
Injuries, violence, self-harm and accidents
Source: Institute for Health Metrics and Evaluation, 2020b
1.4.1 Mortality
Table 1.6 shows that LE at birth has been increasing steadily for both sexes,
with women enjoying 6.7 years more of life than men. Healthy life expectancy
(HLE) at birth has also shown an increase over the years but at a much
slower rate than LE. The difference between the two measures has increased
over time, suggesting increasing survival with ill-health. The increase in
LE and HLE for men over the period 2000–2016 is 4.4 years and 3.6 years,
respectively, which is more as compared to 3.7 and 3.1 years, respectively,
for women. The increase in HLE at 60 years of age during the 16-year period
2000–2016 is the same for both sexes (1.7 years). These figures suggest that
improvements in mortality have been mainly in those below 60 years of age.
14
Table 1.6 Life expectancy and healthy life expectancy for Sri Lanka by sex,
2000–2016
Both sexes 2000 2005 2010 2015 2016
Life expectancy (LE) 71.0 73.9 74.4 75.1 75.3
Healthy LE (HLE) 63.4 65.7 66.1 66.6 66.8
Healthy LE at 60 years 14.3 15.5 15.5 15.9 16.1
Difference between LE 7.6 8.2 8.3 8.5 8.5
and HLE
Male
LE 67.5 70.4 70.9 71.7 71.9
HLE 60.8 63.1 63.5 64.2 64.4
HLE at 60 years 13.4 14.2 14.3 15.0 15.1

and HLE
Female
LE 74.9 77.7 77.9 78.4 78.6
HLE 66.2 68.5 68.6 69.0 69.3
HLE at 60 years 15.2 16.8 16.6 16.8 16.9
and HLE
Sources: LE: World Bank, 2020; HLE: World Health organization, 2019a
A gradual decline in crude death rates is noted in both sexes. The crude
death rate in males (195.7 per 1000 adult males) is 2.7 times that of females
(72.9 per 1000 adult females) and is a cause for concern. The country has
an effective MCH care system dating back to 1926, which has produced
significant gains in terms of IMR (8), NMR (5.8), U5MR (9.4) and MMR (26.8).
However, the rate of decline of these indicators has slowed down in the past
decade (Table 1.7). It is important to note that both infant and child mortality
rates are marginally more in girl children compared to boys.
The bulk of childhood mortality is due to neonatal deaths (71%) and, of the
neonatal deaths, the majority (71%) are early neonatal deaths2 (Ministry of
Health and Indigenous Medical Services, 2019)3. The most significant causes
2 The death of a live newborn during the first 28 days of life. An early neonatal death is considered
by WHO to be death within the first 7 days of life.
3 The Ministry of Health of Sri Lanka has undergone numerous name changes over the past 20
years. In the text of this document, we use “Ministry of Health”, which is the current iteration.
However, when referencing ministry publications, we use the name that was used by the Ministry
at the time of publication
15
of newborn deaths in Sri Lanka are congenital anomalies, prematurity, birth
asphyxia and neonatal sepsis (Ministry of Health and Indigenous Medical
Services, 2019). Accidents and congenital abnormalities account for about
58% of deaths among 1–5 year olds (Ministry of Health and Indigenous
Medical Services, 2019).
The decline in MMR in the country has received many accolades. However,
over the past decade, it has been fluctuating between 40.2 and 31.1 per
100 000 live births. It is noted that 65% of deaths in 2017 were due to indirect
causes. The most common causes of deaths were dengue haemorrhagic
fever (21), heart disease complicating pregnancy (20), respiratory disease
(17) and obstetric haemorrhage (11), accounting for 54% of deaths in 2017
(Ministry of Health and Indigenous Medical Services, 2019b).
Table 1.7 Trends in mortality rate, 1970–2018

Indicators 1970 1980 1990 2000 2010 2015 2016 2017 2018
Mortality rate (male) 248.3 224.1 258.9 244.8 202.1 198.0 195.7 .. ..
per 1000 adult males
Mortality rate 171.4 138.2 120.8 99.9 78.8 74.1 72.9 .. ..

(female) per 1000
adult females
MMR (modelled .. .. .. 56.0 38.0 36.0 36.0 36.0 ..
estimates)
Neonatal mortality 32.1 20.4 12.7 9.6 5.9 5.5 5.3 .. ..
rate (NNMR)
IMR 54.4 39.6 18.1 14.2 10.0 8.2 7.8 7.5 6.4
IMR – male .. .. 16.3 12.8 9.0 7.4 .. 6.8 6.9
IMR – female .. .. 19.9 15.5 10.8 8.9 .. 8.2 5.8
Under 5 mortality rate 71.7 50.1 21.3 16.5 11.6 9.5 9.1 8.8 7.4
(U5MR)
U5MR – male .. .. 19.4 15.1 10.6 8.7 .. 8.0 8.1
U5MR – female .. .. 23.1 17.9 12.6 10.4 .. 9.6 6.8
Note: No data were available for perinatal mortality rate and post neonatal mortality rate.
It is estimated that NCDs account for 81% of all deaths. The three leading
causes of death in the country are ischaemic heart disease (IHD), CVDs and
diabetes. All three show increases since 2007, the highest increase being
in diabetes (43.4%). Death due to asthma is ranked fourth, with Alzheimer
disease and lower respiratory tract infections following. Death due to
Alzheimer disease has increased by 50.9% while asthma shows a very small
16
increase of 1.5% and lower respiratory tract infections an increase of 17.2%.
The highest decrease in deaths is seen for self-harm (10.2%) (Institute for
Health Metrics and Evaluation, 2020b).
IHD and neoplasms have been the leading causes of deaths in government
hospitals, both in 2010 (23.9%) and 2016 (26.1%) (Ministry of Health, Nutrition
and Indigenous Medicine, 2018a). The increased caseload of dengue and
leptospirosis had increased the rank of zoonotic and other bacterial diseases
(Table 1.8).
Table 1.8 Leading causes of deaths in government hospitals in Sri Lanka,

2010 and 2016
2010 2016
Rank Condition Condition
(%) (%)
1 Ischaemic heart disease 12.8 Ischaemic heart disease 14.1
2 Neoplasms 11.1 Neoplasms 12.0
3 Pulmonary heart disease 8.7 Zoonotic and other bacterial 11.6
and diseases of the diseases
pulmonary circulation
4 Cerebrovascular diseases 8.7 Pulmonary heart disease and 8.7
diseases of the pulmonary
circulation
5 Disease of the respiratory 7.0 Disease of the respiratory 8.3
system excluding upper system excluding URTI
respiratory tract infection
(URTI)
6 Zoonotic and other 6.6 Cerebrovascular diseases 8.2
bacterial diseases
7 Diseases of the 6.2 Pneumonia 6.4
gastrointestinal tract
8 Diseases of the urinary 5.7 Diseases of the urinary system 6.2
system
9 Pneumonia 5.2 Diseases of the 5.5
gastrointestinal tract
10 Symptoms, signs & 5.0 Traumatic injuries 3.9
abnormal clinical and
laboratory findings
Source: Ministry of Health, Nutrition and Indigenous Medicine, 2018a
1.4.2 Burden of disease

The disease burden in terms of death and disability due to NCDs is estimated
to be substantial and has been increasing over the years. From 2007 to
2017, CVD has remained the leading cause of DALYs while diabetes and
17
kidney disease have gained in importance. This is likely to be due to the
increasing problem of chronic kidney disease of unknown aetiology (CKDu)
seen in agricultural communities in parts of the dry zone of the country
(Ruwanpathirana et al., 2019). In 2017, chronic respiratory diseases showed
increased importance, while self-harm and interpersonal violence had a
lower ranking in 2017 as compared to 2007 (Table 1.9).
Table 1.9 Top 10 leading causes of DALYs for Sri Lanka, 2007–2017
Sl. No. 2007 2012 (%) 2017 (%)
1 CVDs CVDs (2.4%) CVDs (4.8%)
2 Self-harm and Diabetes and kidney Diabetes and kidney
interpersonal violence diseases (18.9%) diseases (28.6%)
3 Diabetes and kidney Neoplasms (10.2%) Neoplasms (18.4%)
diseases
4 Neoplasms Musculoskeletal Musculoskeletal
disorders (10.8%) disorders (21.4%)
5 Musculoskeletal Mental disorders (4.3%) Mental disorders (9.3%)
disorders
6 Mental disorders Chronic respiratory Chronic respiratory
diseases (2.7%) diseases (7.6%)
7 Chronic respiratory Self-harm and Neurological disorders
diseases interpersonal violence (17.9%)
(–41.9%)
8 Neurological disorders Neurological disorders Self-harm and
(8.3%) interpersonal violence
(–44.5%)
9 Other NCDs Other NCDs (2.7%) Other NCDs (–5.8%)
10 Unintentional injuries Unintentional injuries Sense organ diseases

(–11.8%) (24.3%)
Note: Percentage change given in parenthesis

CVD: cardiovascular disease; DALYs: disability-adjusted life years; NCD: noncommunicable disease
Table 1.10 shows that the largest contributor to the burden of disease in men
is ischaemic heart disease, followed by DM, self-harm and stroke, in that
order. In women, the biggest contributor to burden of disease is DM followed
by IHD and stroke. It is noted that in IHD and stroke, the years of life lost
(YLL) form a very high proportion of the DALYs, ranging from 73% to 97%. In
men, self-harm and road injuries also show a similar picture, the percentage
contribution of YLL to DALYs from these two conditions being 99.6% and
84.5%, respectively.
18
An important feature that contributes to the burden of disease is the fact that
both DM and CVD in Sri Lanka are characterized by early onset and severe
course of the disease, leading to disabling complications and premature
death (Ministry of Health, Nutrition and Indigenous Medicine and World
Health Organization, 2019). These conditions have the potential to produce
a sizeable impact on the economic productivity of the country. The need for
primary prevention using multidisciplinary approaches is recognized.
Table 1.10 Top five causes of DALYs lost and YLL as a proportion of DALYs
by sex, 2017
YLL YLD DALYs Proportion

Sl. No. Causes of YLL/
DALYs
(x 1000) (x 1000) (x 1000)
Male
1 Ischaemic heart 296.8 10.0 306.8 96.7
disease
2 Diabetes mellitus 118.3 82.6 200.9 58.9
3 Self-harm 147.5 0.6 148.1 99.6
4 Stroke 112.8 21.5 134.4 83.9
5 Road injuries 83.4 15.3 98.7 84.5
Female
1 Diabetes mellitus 101.7 89.7 191.4 53.1
2 Ischaemic heart 151.6 7.6 159.2 95.2
disease
3 Stroke 79.4 29.5 108.9 72.9
4 Low back pain 0 88.5 88.5 0
5 Headache 0 84.8 84.8 0
disorders
YLL: years of life lost; YLD: years lived with disability; DALY: disability-adjusted life year
Figure 1.5 shows the top 10 leading causes of YLL and the changes over
the 10-year period from 2007 to 2017. The highest increases are noted in
diabetes, chronic kidney disease and IHD.
19
Figure 1.5 Top 10 leading causes of YLL for Sri Lanka in 2017 and
percentage change during 2007–2017
Ischemic heart disease 1 4.1%
Diabetes 2 34.3%
-9.5% 3 Stroke
-16.6% 4 Self harm
-8.8% 5 Cirrhosis
-31.8% 6 Neonatal disorders
-4.6% 7 Lower respiratory infections
-9.6% 8 Asthma
-13.0% 9 Road injuries
Chronic kidney diseases 10 8.1%
-4 0.0% -3 0.0% -2 0.0% -1 0.0% 0.0 % 10. 0% 20. 0% 30. 0% 40. 0%
Communicable, maternal, Injuries Non-communicable

neonatal and nutritional diseases
diseases
Source: Institute for Health Metrics and Evaluation, 2020a
Morbidity
Data on admissions to government hospitals show that admissions due
to IHD have steadily increased over the past decade, the rate being 547
admissions per 100 000 population in 2017. Hospital admissions for DM have
shown a parallel trend, but at a lower level compared to IHD (Ministry of
Health, Nutrition and Indigenous Medicine and World Health Organization,
2019). Declining trends are observed in admissions for gastrointestinal
infections and parasitic diseases, while emerging new infections such as
dengue, epidemic influenza and leptospirosis and re-emergence of old
infections such as tuberculosis pose challenges to health (World Health
Organization, 2018a). However, it must be noted that hospital admissions
may not reflect a true prevalence of the condition; they identify health service
utilization and the burden to the health-care system.
YLD indicate conditions that people live with and for which services need
to be provided (Figure 1.6). DM, age-related hearing loss, blindness and
impaired vision, chronic obstructive pulmonary disease and low back pain
make a significant contribution to YLD.
20
Figure 1.6 Top 11 leading causes of YLD for Sri Lanka in 2017 and
percentage change during 2007–2017
Lower back pain 1 19.0%
Diabetes 2 36.6%
Headache disorders 3 9.3%
Age related hearing loss 4 24.4%
Depressive disorders 5 10.0%
Blindness and vision impariments 6 23.9%

Other musculoskeletal problems 7 20.9%
Chronic obstructive pulmonary disease 8 21.9%
Anxiety disorders 9 11.7%
Neck pain 10 19.8%
-21.0% 11 Dietary iron deficiency
-30.0% -20.0% -10.0% 0.0% 10.0% 20.0% 30.0% 40.0%
1.4.3 Risk factors

Figure 1.7 shows the top 10 risk factors driving death and disability in 2017
in order of importance and the percentage change from 2007. It is seen that
high fasting plasma glucose level has overtaken dietary risk as the leading
risk factor during this period, and alcohol use and high body mass index
(BMI) have shown an increase of 39.7% and 35.5%, respectively. Malnutrition
shows the highest decrease (26.9%).
21
Figure 1.7 The top 10 risk factors driving most deaths and disability
combined for 2017 and percentage change during 2007–2017
High fasting plasma glucose 1 21.4%
Dietary risks 2 3.4%
High blood pressure 3 7.2%
-2.9% 4 Tobacco
High body mass index 5 35.5%
-1.0% 6 High low-density lipoprotein
Alcohol use 7 39.7%
-21.3% 8 Air pollution
-26.9% 9 Malnutrition
Impaired kidney function 10 8.4%
-40.0% -30.0% -20.0% -10.0% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0%
Metabolic Behaviour Environment /
risks risks Occupational risks
The WHO NCD STEPwise approach to surveillance (STEPS) for Sri Lanka
(WHO STEPS, 2015) estimated that 90% of Sri Lankan adults (18–69 years)
have at least one NCD risk factor, 73.5% have 1–2 risk factors and 18.3% have
3–5 risk factors, the prevalence being similar in males and females.
The STEPS survey 2015 also estimated that nearly 46% of men and 5.3% of
women were current users of a tobacco product and that most were daily
users. The current prevalence of smoking tobacco was 29.4% in men, more
than two thirds being daily smokers. A little over a third (34.8%) of men were
current alcohol users and nearly half of them (17%) reported heavy episodic
drinking during the 30 days preceding the survey (World Health Organization,
2015) (Table 1.11).
The cost of alcohol and tobacco-related illness is high. It is estimated that

tobacco is responsible for about 20 000 deaths annually, constituting 16% of
all deaths (Ministry of Health, 2009b). Direct and indirect costs of alcohol and
tobacco in Sri Lanka for the year 2015 was estimated to be SLR. 209.03 billion
(alcohol SLR 119.66 Billion, tobacco SLR 89.37 Billion) accounting for 1.95%
of the GDP for that year (National Authority on Tobacco and Alcohol, 2017).
22
Table 1.11 Summary of combined risk based on STEPS 2015
Summary of combined risk All Male Female
Percentage with no known* risk 8.2 7.6 8.8
factors
Percentage with three or more of 12.5 12.1 13.0
the above risk factors, aged 18–44
years
years
years
*Based on current daily smokers, overweight (BMI >25 kg/m3), less than five servings of fruits and
vegetables, raised BP (SBP >140 and/or DBP >90 mmHg or currently on medication for raised BP)
and insufficient physical activity
Source: World Health Organization, 2015
Both routine data and surveys (WHO STEPS 2015; DHS survey of 2016)
highlight the increasing problem of overweight and obesity in the country.
Routine data from the Reproductive Health Management Information System
(RHMIS) (Ministry of Health, nutrition and Indigenous Medicine, 2018b) report
that 21.3% of women who registered for antenatal care before 12 weeks of
pregnancy had a BMI of over 25. The NCD risk factor survey of 2015 identified
that nearly one fourth of males (24.6%) and one third of females (34.3%) in
the age group of 18–69 years were either overweight (BMI 25.0–29.9) or obese
(BMI 30 or more) (World Health Organization, 2015). The Demographic and
Health Survey (DHS) 2015 reports that among non-pregnant women aged
15–49 years who have not given birth in the 2 months prior to the survey, 32%
were overweight while 13% were obese.
It is well recognized that low birth-weight (LBW) babies are at increased

risk for NCDs in later life (Barker, 2007). The prevalence of LBW has been
fluctuating between 13.3% and 11.4% in the years 2007–2015 (Ministry of
Health, nutrition and Indigenous Medicine, 2018b). The DHS 2016 reported
a higher rate of 16.7% among live births in the 5 years preceding the survey,
based on the Child Health and Development Record.
LBW is also the most important modifiable risk factor for malnutrition during
the first 2 years of life. Maternal BMI being a major determinant of LBW, it
is important to note that undernutrition is also seen among women in the
reproductive age group. The RHMIS reports that in the period 2009–2015, a
fifth to a quarter of women who registered for antenatal care before 12 weeks
had a BMI less than 18.5.
23
Linear growth retardation in the first 2 years of life and subsequent obesity
are known risk factors for NCDs, especially CVD (Black et al., 2013). Table
1.12 shows that the rates of childhood undernutrition remain unacceptably
high. There are interdistrict and intersectoral disparities. There has been
little change between 2006 and 2016, except in the prevalence of stunting in
the estate sector,4 probably a result of many nutrition-specific and nutrition-
related programmes carried out especially in this sector.
Table 1.12 Prevalence of stunting and wasting, 2006 and 2016

Prevalence of stunting % Prevalence of wasting %
Source Sri Sri
Urban Rural Estate Urban Rural Estate
Lanka Lanka
DHS (2006) 17.3 13.8 16.2 40.2 14.7 14.7 14.8 13.5
(2.8) (3.3) (14.2) (3.2) (2.7) (3.8)
DHS (2016) 17.3 14.7 17.0 31.7 15.1 12.9 15.6 13.4
(3.6) (4.0) (8.8) (1.6) (3.2) (3.7)
DHS: Demographic and Health Survey

Sources: Department of Census and Statistics, 2009; Department of Census and Statistics, 2017
1.5 Human-induced and natural disasters

Sri Lanka experiences many natural hazards such as drought, floods,
landslides, cyclones and coastal erosion. Some of these events have
impacted life and infrastructure to an extent that can be called a disaster. The
vulnerability of the country to natural disasters is noted to have increased
in recent times and is attributed to increasing population pressure, land
degradation and climate change.
The tsunami of 26 December 2004 was the most devastating natural disaster
in the recorded history of the country, resulting in nearly 31 000 deaths
and causing extensive damage to property (Galappathi and Karunanayake,
2007). The tsunami reached the east coast of the island within 2 hours
of the earthquake, wrapped round the island affecting the south-east,
southern, south-western and parts of the western coastline (Galappathi and
Karunanayake, 2007).
Since Independence, Sri Lanka has experienced three armed conflicts, which
impacted the whole country. Two insurgencies originated in the south of the
4 Urban sector: all areas administered by municipal and urban councils constitute the urban sector.
Estate sector: estate sector consists of all plantations that are 20 acres or more in extent and
with 10 or more resident labourers. Rural sector: all areas other than urban and estate sectors
comprise the rural sector. Source: Department of Census and Statistics, 2011a
24
country led by the JVP, a leftist party currently in mainstream politics. Many
lost their lives and a considerable number were injured and displaced from
their homes. However, these did not result in a major population migration
(Siriwardhana and Wickramage, 2014).
The third was the more severe and protracted conflict with the LTTE. It is
estimated that this resulted in the death of 61 878 people of all ethnicities
during the period 1989–2009, and many more injured (Uppsala Conflict
Data Program, 2020). This also resulted in the largest internal and external
displacement experienced in Sri Lankan history. Studies have provided
evidence of increased mortality, morbidity and disease burden, and increased
prevalence of maternal and neonatal mortality, LBW, stillbirths and a
decline in the use of antenatal care during the period of conflict and its
immediate aftermath. Malnutrition, infectious diseases such as hepatitis A
and leishmaniasis were prevalent among displaced persons. The conflict also
had an enormous impact on the mental health of the population, particularly
among those in the northern and eastern provinces. It is also important to
recognize that health services in the conflict-affected areas continued to be
funded, supplied and staffed at government expense throughout the conflict
years, honouring the right to free care for all its citizens, including the rebels
(Rannan-Eliya and Sikurajapathy, 2009). The resilience of the country’s health
system enabled this continued service coverage and function within the
conflict-affected areas in the face of many resource limitations and threats
to individual safety. In the years since the cessation of the conflict, there has
been a comprehensive restructuring of the health services in the affected
areas with special attention to the needs of the population (Siriwardhana and
Wickramage, 2014).
25
2. Organization and governance
Chapter summary
The Sri Lankan health system comprises western allopathic and other
traditional systems, with the former serving the majority of the population.
Government health services commenced with the initiation of a civil medical

department in 1858. In 1926, the preventive services were reorganized with
the creation of the health unit system. Curative services are provided by a
network of tertiary- and secondary-care institutions, divisional hospitals
(outpatient and inward care) and primary medical care units offering
outpatient care. The medical officer of health (MOH) and his team provide
preventive services through health units that cover the whole island. All state
sector services, both curative and preventive, are free of charge at the point
of delivery. In addition, separate service facilities are available for the armed
forces, police and prisons.
The public sector provides nearly 95% of inpatient care and around 50% of
outpatient care. Although the private sector is becoming a growing presence,
their services are available to only a fraction of the population due to the high
costs involved. Furthermore, patient-related statistics from the private sector
are limited since the national Health Information System (HIS) includes only
the state sector. The state health services function under a cabinet minister.
Following the Thirteenth amendment to the Constitution, health became a
partially devolved subject. The Ministry of Health (MoH) is responsible for
stewardship functions such as policy formulation and health legislation,
programme monitoring and technical oversight, management of health
technologies, human resources, and tertiary and other selected hospitals.
The primary and secondary levels of curative care and preventive services
function under the nine provincial ministries.
The first comprehensive national health policy based on primary health

care (PHC) was prepared in 1992 and later revised with a focus on universal
health coverage (UHC) (2014–2016). The current policy (2016–2025)
addresses emerging health issues, quality and safety, and the expectations
of the people.
26
The legal framework for health services of the country is the Sri Lanka
Health Services Act 12 of 1952, with revisions in 1956 and 1962. The Medical
Service Minute of Sri Lanka No. 662/11 gazetted in 1991 and amended in
2001 and 2014 is applicable to medical personnel employed in the health
services of the country (Parliament of the Democratic Socialist Republic of
Sri Lanka, 2015a).
2.1 Historical background

From the time of the ancient kings, the State has assumed responsibility
for the protection and promotion of the health of the people. There is
archaeological and literary evidence that the State provided hospitals,
“houses of delivery”, convalescent homes, institutions for the crippled and
hospitals for the blind (Uragoda, 1987). The indigenous system of medicine is
called deshiya chikithsa. Legend suggests that Ravana, the prehistoric king of
Lanka, was a physician. The authorship of several books on medicine, namely
Arkaprakasaya, Kumarathanthraya and Udishasasthraya, is attributed to him
(Uragoda, 1987).
The indigenous system of medicine of the country is a confluence of the

Ayurvedic system of medicine from north India, the Siddha system from
southern India, the Arabic Unani system and the traditional deshiya chikitsa.5
The western allopathic system of medicine that predominates current service
provision was introduced in the country by the Portuguese and the Dutch,
but they provided services mainly for their military units and colonial staff.
The foundations of the present health-care system were laid down during
the British colonial period with the creation of a civil medical department in
1858 and a sanitary branch in 1913 (Medcalf A et al., 2015). The civil medical
department and its sanitary branch functioned independently (although
the sanitary branch was organizationally placed within the civil medical
department) until they were brought under one office, that of the Director
of Medical and Sanitary services. To date, the government health service
displays this dichotomy as two functional arms, preventive and curative,
albeit with different nomenclature and few cross-links, under a single
Director General of Health Services (DGHS) and served by two hierarchical
structures.
5 Sri Lanka has its own indigenous scheme of traditional medicine, which is called “Hela
wedakama of Deshiya Chikitsa”. It is a traditional system of medicine mainly in the form of
manuscripts. Hela wedakama considers the body as a whole ailment and sees health and disease
in holistic terms. It emphasizes on the harmony of mind, body and spirit to cure diseases. This
system has been practiced for many centuries.
27
The Colombo Medical School was founded in 1870 to train doctors to
serve in the government health services. The locals trained in allopathic
medicine were able to exert pressure on the government for the extension
of health services to the general population. The granting of universal
franchise in 1931 and election of people’s representatives to the state council
led to a demand for health care, education and increased road access.
Furthermore, the devastating malaria epidemic of 1934–1935 (with an
estimated 80 000–100 000 deaths) was instrumental in extending the health
infrastructure to hitherto neglected rural regions. Two principles that have
influenced the health system of the country to date, i.e. the emphasis on
well-dispersed services and the need to provide protection from financial
impoverishment following illness, emerged from this calamity (Ranan Eliya
and Sikurajapathy, 2009).
An important development in the preventive services of the country was the

establishment of the first health unit in Kalutara in 1926. A health unit is
headed by an MOH and a team of professionals who serve the population
of an identified geographical area. This system of provision of care spread
gradually to cover the whole island.
The World Health Organization (WHO)’s concept of health as a fundamental

human right was accepted by the very first government of independent
Sri Lanka in 1949 and all subsequent governments have maintained
this commitment.
2.2 Overview of the health system

The Sri Lankan health system comprises western allopathic and other
systems, namely Ayurveda, Siddha, Unani, acupuncture and deshiya chikitsa,
which derives from ancient Sri Lankan traditional knowledge. Almost all
preventive care and most of the curative care needs of the country are
provided by the government health system free of charge at the point
of delivery.
In both systems, i.e. allopathic and indigenous, health care is provided by

the government and the private sector, with very limited services being
provided by non-profit organizations. Although both allopathic and traditional
systems come under the purview of the MoH, the allopathic system caters
to the needs of the majority (Ministry of Health, Nutrition and Indeginous
Medical Services, 2019). In 2017, the government allopathic system provided
care for 6 910 249 inpatients and 55 339 335 outpatients (Ministry of Health,
Nutrition and Indeginous Medical Services, 2019), while the government
indigenous system served only 36 088 inpatients (0.5% of the allopathic case
28
load) and 4 339 302 outpatients (7.8%) of the allopathic case load) (Health
Statistics Unit, MoH). Furthermore, information on the types of morbidities
and characteristics of patients seen in the traditional systems is not
routinely available (Ministry of Health, Nutrition and Indigenous Medicine,
2016a). Hence, the information presented in this publication is mainly on the
allopathic system.
Allopathic medical care is provided through both the public and private
sectors. The public sector provides 95% of inpatient care and 50% of
outpatient care services (Ministry of Health, Nutrition and Indeginous
Medicine, 2016a). In addition to the MoH, the Ministry of Defence and the
Police Department provide curative health-care services to their personnel
and their families through their own hospitals. The prison hospitals provide
curative care to prisoners. The Department of Motor Traffic provides a service
limited to medical examinations for those who apply for new or renewal
of vehicle licenses. A few local government authorities, such as selected
municipal councils, are responsible for providing preventive and curative care
services to their taxpayers.
The Sri Lankan health system is recognized internationally as a high-

impact, low-cost model (Perera et al., 2019). This achievement was built
on the foundations of a health-care system that has been free at the point
of delivery since 1951; adopting key primary health-care principles since
1926 (significantly in advance of the Declaration of Alma-Ata in 1978);
and establishment of a wide network of close-to-client primary health-
care services. Sri Lanka therefore seems well positioned to achieve UHC,
although current demographic, epidemiological, social and economic
transitions are challenges that need to be overcome to ensure universal and
equitable provision of health financing and care (De Silva, Ranasinghe and
Abeykoon, 2016).
2.3 Organization
The MoH provides overall stewardship and monitoring of government health
services throughout the country. The Ministry is headed by a minister and a
secretary, and the latter is usually a senior administrator from the Sri Lanka
Administrative Service or sometimes a senior doctor who is a specialist
administrator. Figure 2.1 depicts the organizational structure of the Ministry.
29
Figure 2.1 Organizational chart of the Ministry of Health, Nutrition and Indigenous Medicine (2017)
30
MINISTER
Healthcare and Nutrition
Deputy Minister Deputy Minister

Healthcare and Nutrition Healthcare and Nutrition
Secretary
Healthcare and Nutrition
Addl. Secretary Director General of Addl. Secretary Addl. Secretary

(Uva Wella. Deve.) Health Services (Medi. Services) (Admin)
Chairman Chairman Chairman Chairman

Chief Accountant SJGH DG/HSR
Wij K H SPC SPMC
SAS SAS SAS SAS Chief Inte.

Uva Wella. (Info & Pub) Pla & Mo. Admin Auditor
DDG DDG DDG DDG DDG (Build. DDG

DDG (MS I) DDG (MS II) DDG (LS) DDG (Plan.) DDG (ET&R) DDG(F) I DDG(F) II DDG(A) I DDG(A)II
(PHS I) (PHS II) Den. Hea. (BMES) & Logistics) Investiga.
Director Director (F) Director Assistant

Director Director Director Director Director Director Director Director (F) Director (A) Director (A) Director
ALC Expenditure Buildings Secretaries
E & OH TCS MS (LS) Planning Training (BMES) (Budge. Con.) (3) (1) NHDF
(Expenditure 1) (Engineering) Investi.
Director Director Director Director (F) Director Asst. Sec. Project

Epidemi- Director (A) Director Director Director (F) Director (A) Director (A)
MCH Nursing Organization Expen. 11 Buildings Planning & Directors
ologist MS MT&S MRI (Stock Verific.) (6) (2)
(MS) Development (Expendit. 11) (Administ.) Monitoring
Director Director Director

Director Director Director Director Director (F) Director Director
Est. & Ur. Primary Health
AM NCD CCP NIHS Expen.111 Exam. (4)
Health Care Services Information
Director Director
Director Director Director Director/Fin. Director (F)
AFC Nursing Director
Nutrition Prt.Se.Dev. NBTS (Planning) (Ca & Cord.)
(Education) Trans
Port
Director Director Director Director
Director Director (F)
NSACP Nursing Mental Hea. International
NDQAL (Book Keep.) Assist.
(Pub. Health) Services Health
Secre.
(Admin)
Director
Director Director Director Director Director (F)
Policy Analy.
PHVS HE&P RMO MSD (Supplies)
& Develop.
Legal
Officer
Director Director Medical
Y. E. D. D Nutriti. Cor. Statistician
Division
Director
Quarantine
Director
NPTCCD
Coordinator
Dengue C.U.
Updated June 2006
Source: Management Development and Planning Unit- Ministry of Health

The Director-General of Health Services (DGHS) is the technical head of
the Ministry and is supported by a number of deputy directors-general
(DDGs). These positions are usually held by senior specialist administrators
or specialist community physicians with wide first-hand experience of the
services from the ground level up. In addition, key national programmes
have separate units headed by directors. Both curative and public health
services are supported by such directorates, each of which serves as the
national focal point responsible for reviewing the policies, system strategies,
training curricula, programme implementation and other organizational
and managerial inputs to meet emerging issues and challenges. They make
recommendations to the DDGs and DGHS and thereby to the Health Secretary
and the Minister. In addition to these, there are several agencies such as the
National Authority on Tobacco and Alcohol, National Medicinal Regulatory
Authority and Human Resources for Health Coordination Division, which are
placed under the overall administrative purview of the Secretary Health.
Provincial health services are the responsibility of a Provincial Ministry

of Health (PMoH) under the leadership of a Provincial Minister of Health.
Provincial councils are vested with powers to formulate their own statutes
pertaining to the subjects devolved to them. Thus, health is a devolved
subject and PMoHs are able to function within the boundaries of overall
national health policies. At the provincial ministry level, the minister and the
secretary may have multiple portfolios, which may result in health having to
compete with other services for priority and resources. Details of the funding
of provincial services are described in section 3.2 of Chapter 3.
Vertical programmes, which are mainly promotive and preventive in

nature, are coordinated by the special campaigns and directorates of the
MoH. District-level focal points for such programmes are medical officers
responsible for maternal and child health (MOMCH), noncommunicable
diseases (MONCD) and mental health (MOMH), and the regional
epidemiologist (RE). These MOs are answerable to the relevant campaigns or
Ministry directorate heads as well as the regional directors of health services
(RDHSs). The MOHs are also answerable to the relevant RDHS.
Technical units and campaigns under the MoH such as the Family Health
Bureau, Epidemiology Unit, NCD Unit and Anti-Malaria Campaign (AMC)
provide technical guidance to the RDHSs in programme implementation in
the respective districts.
There are 354 MOH areas in Sri Lanka and each is headed by an MO
responsible for a defined population, which on average is around 40 000–
80 000. The MOH is supported by a team of trained field public health staff
31
(public health nursing sister, supervising public health inspector, supervising
public health midwife, public health inspector and public health midwife).
2.3.1 The private sector

The private sector mainly provides ambulatory care, limited inpatient care
and rehabilitative care of varying degrees of sophistication. Private services
are financed mainly through out of pocket (OOP) payments by households/
individuals and, on a limited scale, through private health insurance
schemes. OOP expenses have been increasing over time and currently stand
at 51% of current health expenditure (CHE) (Table 3.1, Chapter 3). A private
health sector review carried out in 2015 reported that there were 424 full-
time and 4845 part-time MOs (Amarasinghe et al., 2015b). The part-time
practitioners are government MOs engaged in private practice in their off-
duty hours who provide the bulk of private primary outpatient care. Most of
these private clinics are operated on a solo practitioner basis and most also
dispense medicines. Full-time private practitioners are a gradually dwindling
group, because only a very limited number venture into taking up private
practice as a full-time vocation.
The private hospitals provide outpatient and inpatient services and specialist
consultations, the latter being mostly by specialists in government service
practising in their off-duty hours. In addition, private pharmacies and
investigative services have also expanded significantly both within private
hospitals and as independent entities.
The private sector claims to bring certain advantages to their clients, the
main ones being the availability of services at convenient times and absence
of waiting lists. In addition, the ability to select the specialist of one’s choice
and continuity of care under the same doctor are also considered important
reasons for seeking private sector services. Greater confidentiality in
private settings as compared to public facilities was also identified to be an
important factor in patients choosing private sector services (Govindaraj
et al., 2014).
2.4 Decentralization and centralization

The MoH is responsible for managing the health services of the country
and is the lead agency providing stewardship to health service development
and delivery. Its main function is formulating government health policy,
health legislation and regulating services provided by both the government
and private sectors. It is also responsible for directly managing several
large specialized hospitals (National Hospital of Sri Lanka, teaching
hospitals, specialized hospitals, provincial general hospitals and selected
32
district general hospitals), while the nine provincial health ministries are
responsible for effective implementation of services in their respective
provinces, especially in the areas of primary care, secondary care and
preventive services.
Central and provincial links in health care are maintained and strengthened
through the National Health Development Committee and regular meetings
of the directors of institutions under the Ministry of Health. Provincial
health administrators meet regularly with the Ministry authorities and
discuss problems and, to some extent, monitor activities at provincial and
district levels.
Although decentralization has given the provinces the power to formulate

their own statutes, decentralized decision-making is not common and is
affected by the control imposed by the central level over functioning at the
provincial level and the high degree of financial dependence of the provinces
on the Central Government. Certain processes are affected by the additional
administrative layers and administrative costs. Thus, it is generally surmised
that most provincial councils have not been as efficient and effective in
service delivery as the line ministry.
The administrative head of the PMoH is the Secretary Health. The Provincial
Director of Health Services (PDHS) is the technical lead of the provincial
health department. He is also accountable to the Secretary and DGHS on
technical matters. Each health district of a province has an RDHS who
is answerable to the PDHS as well as to the MoH administrative officials
(Figure 2.2).
33
Figure 2.2 Organizational structure of the Provincial Ministry of Health
HE-The President of Sri Lanka
Provincial Governor Provincial Chief Minister
Provincial Chief Secretary Provincial Health Minister
Provincial Health Secretary
PDHS D-PD
ROHS D-RD
Technical team
Provincial Health Medical Officer of Health Units National Campaigns
Regional Epidemiologist,
Medical Officers
− Base Hospital-A MCH/EPI/E&OH/CD/NCD
of (Maternal and Tuberculosis/
prevention/school health/
Child Health, Non- − Base Hospital-B Filaria/Malaria
adolescent health/food safety/
communicable Diseases, − Divisional Rabies/Leprosy
community dental care
Planning, Malaria, Filaria, Hospitals
Mental Health, Quality, − Primary Medical
Training), Regional Dental Care Units Medical Officer of Health AMOH
Surgeon, Regional Dental
Therapist, Supervising
PHI, PHI-Leprosy, PHI- PHNS SPHI Dental Surgeon HEO
Vector Borne Disease,
PHI-Rabies, Regional
SPHM PHI Dental Therapists
Supervising Public Health
Nursing Sister, Health
Education Officer
PHM
PDHS: Provincial Director of Health Services; RDHS: Regional Director of Health Services; D–PD:
Deputy Provincial Director; D–RD: Deputy Regional Director; AMOH: Additional Medical Officer of
Health; PHNS: Public Health Nursing Sister; SPHM: Supervising Public Health Midwife; PHM: Public
Health Midwife; SPHI: Supervising Public Health Inspector; PHI: Public Health Inspector; HEO: Health
Educational Officer; E&OH: Environmental and Occupational Health
Source: By authors
2.5. Policy formulation and health planning

2.5.1 Policy formulation
Policy formulation in health is a function of the line ministry. The initial
impetus for most policy initiatives comes from health-care professionals,
while the actual policy formulation occurs after extensive consultation with
experts and other stakeholders, including development partners. The draft
policy is then submitted for the approval of the Cabinet of Ministers, followed
by presentation as an Act to the Parliament for adoption. Policy formulation is
normally followed by a strategic action plan for implementation, monitoring
and evaluation. Recent policies such as the National Health Policy 2016–2025
and policy on health-care delivery for Universal Health Coverage–2018 were
all formulated in this manner.
34
2.5.2 Health planning
Planning and development of the MoH is coordinated by the Management
Development and Planning Unit (MDPU) within the Ministry. Development of
long-term, medium-term and annual plans for the government health-care
delivery system is a core function of this unit. The medium-term and annual
health plans for districts, and thereby provinces, are based on the broad
strategic directions of the National Health Policy 2016–2025. The district
annual plans are formulated based on the district health priorities and the
provincial annual plans are formulated by consolidating the district plans.
These, and the plans of line ministry directorates, institutes and special
programmes are compiled to derive the annual plan of the Ministry of Health.
2.5.3 Role of development partners in policy and planning

Development partners (DPs) refers to the lead technical agencies, donor
agencies and international cooperation agencies based in a specific country.
The influence of DPs on the policy and planning process is based on financial
resources, technical expertise, and indirect financial and political incentives.
Considering the policy formulation process in Sri Lanka to be principally
nationally driven, the DPs, especially the lead technical agencies such as
WHO, United Nations Children’s Fund (UNICEF), United Nations Population
Fund (UNFPA) and, to a lesser extent, the International Organization for
Migration (IOM), bring in best evidence, comparative information and
standards on health from across the globe. For example, in the early stages
of devolution of power in Sri Lanka when planning expertise at the provincial
level was relatively weak, the DPs played a critical role in helping the
government improve the planning capabilities of the provinces and districts.
Further, these agencies may influence the policy and planning process
through international conventions such as the Framework Convention on
Tobacco Control (FCTC) and Sustainable Development Goals (SDGs). There
are also instances where the policy and planning process, especially that of
financial direction and fund allocation, is influenced by donor agencies. For
example, the current PHC reorganization and the introduction of an essential
services package have been facilitated by the World Bank and WHO.
2.6 Intersectorality
All major policy decisions on health are made collectively by the Cabinet
of Ministers and cooperation is often sought between ministries and
sectors on an ad hoc basis to deliver services. There is a parliamentary
Sectoral Oversight Committee on Health to ensure “health in all policies”.
A key strategy for intersectoral action and coordination at all levels is the
establishment of the National Health Development Network, consisting of
35
the Health Development Committee (HDC) at the sectoral level, the National
Health Development Committee (NHDC) and the ministerial National Health
Council, viewed as the apex body.
The NHDC is established to ensure intersectoral coordination for health

development activities. It is chaired by the Secretary Health, has relevant
secretaries as members and is composed of technical focal points in
ministries. The NHDC functions as a good platform to facilitate the
coordination of health development efforts between the Ministry of Health,
the provincial ministries and other health-related sectors and agencies.
National-level intersectoral committees have been set up under the

DGHS to address major issues in communicable and noncommunicable
disease control, prevention of injuries, school health, nutrition and other
programmes. These committees, comprising relevant government and
nongovernment agencies and development partners, meet on a regular basis
to ensure intersectoral collaboration and policy harmonization.
Being the implementors of all national-level policy directives, many

intersectoral communications take place at the provincial level. The Planning
Division of the Province, headed by the Deputy Chief Secretary – Planning,
convenes several meetings a year for planning and monitoring of activities
within a holistic developmental approach. The Provincial Director and team
represent the health sector.
The District Development Committee (DDC), operating at the district level

under the political leadership of and coordinated by the District Secretary
(government agent), is a forum for discussion involving many sectors. The
health sector is represented by the Regional Director of Health Services.
The DDC operates at the divisional level under the political leadership of the
division and is coordinated by the Divisional Secretary. The health sector is
represented by the MOH of the area. The DDC carries out divisional-level
multisectoral coordination.
The 17 SDGs highlight the interconnectedness and the importance of health

in all goals and that achieving SDG 3 (ensure healthy lives and promote
wellbeing for all at all ages) is the key to achieving many other SDGs, as it is
essential to have a healthy population for economic productivity and national
development.
36
2.7 Health information management
2.7.1 Information systems
The current national HIS consists mainly of the information inputs obtained
from the state health service, supplemented by other government sources.
The present sub-systems of HIS include curative/hospital information
systems, preventive health information systems, administrative and
operational information systems, population census, civil registration and
vital statistics system, and periodic population-based health and other
surveys, e.g. Demographic and Health Survey (DHS), STEPwise approach to
surveillance (STEPS) and Household Income and Expenditure Survey (HIES).6
Taken together, these sources provide information on population growth,
births, marriages, morbidity and mortality, health-care access, health-care
coverage, utilization, human resources for health and their distribution,
health financing and other health-related data.
2.7.1.1 Population-based health information systems

Sri Lanka has a history of census-taking dating back to 1871 and there have
been decennial censuses except during times of war and armed conflict
within the country. The most recent was in 2011–2012. These provide
accurate geographically referenced health and health-related data and other
social determinants of health.
In addition, the Department of Census and Statistics (DCS) carries out health
and health-related surveys such as the DHS, the first of which was held in
1987. This is repeated every four to six years, the last being in 2016. The HIES
conducted every three years provides health-related costing information. All
these surveys are sampled to provide disaggregated district-level data. In
2014, a National Survey on Self-reported Health in Sri Lanka was conducted
by the DCS, which provided information related to chronic illnesses.
Health data related to services provided by the MOH and team are available
through the Reproductive Health Information Management System
(RHIMS). The majority of the MOH areas are congruent with administrative
boundaries at the divisional level. This information is linked to the services
offered by the MOH and is fairly robust, with vaccination, antenatal care
(ANC) and institutional deliveries being near-universal in Sri Lanka. The
planned primary curative care reform7 and information system will provide
community-based, geographically referenced morbidity and mortality data.
6 Health information systems are detailed in Chapter 4.

7 Detailed in Chapter 6.
37
2.7.1.2 Civil registration
Sri Lanka has had a long history of registration of vital events based on
Ordinance No.18 of 1867, which came into operation in June 1868. This was
optional at the outset but was made compulsory in 1897. The system covers
births, marriages, deaths and stillbirths. Stillbirths are registered only in
“proclaimed areas” where a medically qualified person is the registrar of
deaths. An assessment of the production, quality and use of vital statistics
in Sri Lanka (Gamage et al., 2009) has shown that the coverage of births and
deaths is high.
The death registration system of the country provides population-based

mortality information. The events are reported by place of occurrence as well
as by place of usual residence of the deceased individual. The completeness
of the reporting of events has been shown to be high; however, reporting of
the cause of death needs considerable improvement. Nearly 50% of deaths
take place in hospitals and the notification of death (death declaration) giving
the immediate, underlying and related morbidity is reported by MOs. The
death declaration is submitted to the registrar of deaths for the issue of a
death certificate. Shortcomings are seen in the death declaration as well
as in the death registration and coding of causes of death at the level of the
registrar general’s office, both regional and central (Gamage et al., 2009).
Many initiatives have been undertaken and are continuing to improve the
quality of cause of death information, including training regarding medical
certification of cause of death based on the International Classification
of Diseases, tenth revision (ICD-10) for the relevant officers and the use
of verbal autopsy to verify the cause of death. These have resulted in
improvements in the certification of the cause of death (Hart et al., 2020).
2.7.1.3 Institution-based health information

Morbidity and mortality data from patients seeking treatment as inpatients in
government allopathic medical-care institutions are available from a paper-
based quarterly return sent to the medical statistics unit of the Ministry of
Health. The degree of accuracy and coverage of the data is variable. Although
the diagnosis should be based on the ICD-10 classification of disease, the
quality of the information is variable. In spite of efforts taken to improve the
quality of diagnosis given in the patient records, there is still a large group
of patients for whom the medical statistician reports symptoms, signs and
abnormal clinical and laboratory findings not elsewhere classified.
Information from most of the outpatient services of government institutions

is limited to attendance numbers only. Information from the private sector,
including private hospitals, general practitioners, hospitals under the armed
38
forces and police, prison hospitals and indigenous treatment centres, are not
included. As an initial step to overcome these inadequacies in the current
system, a web-based electronic Indoor Morbidity and Mortality Reporting
(e-IMMR) system has been introduced, limited at present to selected large
hospitals in the government sector.
For MCH activities, the country has a well-established information system

extending from the grass-roots level to the central level, which has evolved
over nearly a century. The current RHIMS was initiated in 1986 by the Family
Health Bureau under the MoH for monitoring, evaluating and planning of
MCH services in Sri Lanka. Some of the core indicators that are used by the
MoH are based on this information system. To improve the quality of this
system, the MoH is currently developing a web-based electronic reproductive
health information management system (eRHIMS) to complement and
gradually replace the existing paper-based system.
Sri Lanka is reputed as a country having a very strong immunization

programme. The Epidemiology Unit of the MoH is responsible for EPI
surveillance. The information is collected through the web-based
immunization information system. With near-universal coverage of EPI,
the information system is robust and covers the entire country. In addition
to this, the Epidemiology Unit is responsible for the surveillance of
communicable diseases and gets its information through the notification
system of communicable diseases, which currently tracks data on some 28
conditions (Epidemiology Unit, 2008). This information is collected through
the network of MOH offices covering the country. A tested and proven system
is in place to monitor these disease conditions at the level of MOHs, districts,
provinces and at the national level.8 In addition to these notifiable conditions,
the Epidemiology Unit gets regular information through the severe acute
respiratory illness (SARI) surveillance for influenza-like conditions through
some 34 sentinel sites across the country. Some conditions that have not
been included in the list of notifiable diseases are collected through the
respective public health campaigns maintaining specific information systems
through registries and databases.
There are several other information systems maintained by national focal

agencies for administrative and operational purposes. The MoH maintains
the Human Resources Management Information System (HRMIS), Health
Facility Survey (HFS), Medical Supplies Information System and a Blood
Transfusion Management System for operational support purposes.
Both the HRMIS and the HFS do not have the latest and most updated
8 Detailed in Chapter 5.
39
figures as updating of information is yet to be made mandatory and fully
institutionalized. The HRMIS is yet to be linked with the information systems
of the professional councils and the university system in Sri Lanka or the
other training facilities within the MoH. The Medical Supplies Information
System is fully functional, down to the level of specialized hospitals.
Information is compiled through several registries, such as the Sri Lanka

Cancer Registry (Ministry of Health, 2020), Sri Lanka Stroke Clinical Registry
(launched in 2015 with web-based data collection at the hospital level) and
the National Road Traffic Trauma Registry, which compile and maintain
disease-specific data. These are maintained by the respective programmes
and are regularly updated.
2.7.2 Information management system for emergencies

A disaster surveillance system has been established for the surveillance
of health-related emergencies and disasters by the Disaster Preparedness
and Response Division of the MoH. The sources of surveillance data include
local and international radio channels, newspapers and weather forecasts.
The Ministry has further strengthened the Disaster Health Information
Communication Management system through the development of a disaster
health information dashboard, website and through providing satellite
communication facilities to the unit.
2.8 Regulation
The legal framework for health services in independent Sri Lanka was the
Health Services Act 12 of 1952, which was based on the recommendations
of the Cumpston Report (1950). The Act provides the Constitution and
outlines the responsibilities of the department of health and provides for
the establishment of regional hospital boards and hospital committees “to
secure more efficient administration”. The Act was later revised as Act Nos
10 of 1956, 13 of 1962 and 13 of 1987.
The Thirteenth Amendment to the Constitution of the Socialist Democratic

State of Sri Lanka devolved power to the nine provincial councils, with
“health” being a partially devolved subject. A Finance Commission, which
is an independent body, was established under Article 154 R (4) of the
Thirteenth Amendment to the Constitution. The main responsibility of the
Commission is to make recommendations to the President and formulate
principles, policies and guidelines on the apportioning of funds between the
nine provinces with the objective of achieving balanced regional development
in the country.
40
2.8.1 Regulation of private medical institutions
The Private Medical Institutions Regulatory Act (PMIRA) requires all
persons establishing or maintaining a private medical institution to
obtain a Certificate of Registration from the MoH. The Private Health
Services Regulatory Council (PHSRC), which includes representation
from professional bodies such as the Sri Lanka Medical Council (SLMC),
Independent Medical Practitioners Association and Dental Association and
is headed by the DGHS, performs and discharges its powers, duties and
functions under the PMIRA. The PHSRC manages the development and
monitoring of standards to be maintained by the registered private medical
institutions and acts as a structure to evaluate the standards maintained
by such private medical institutions. It further aims to ensure that the
minimum qualifications for recruitment and minimum standards for training
of personnel are adopted by all private medical institutions and ensures the
quality of patient care services provided by such private medical institutions
(Ministry of Health, Nutrition and Indigenous Medicine, 2018c).
It is mandatory for every private hospital to register with the PHSRC

and to meet minimum regulations prior to setting up operations. As per
the regulations, registered staff, equipment, laboratory, X-ray and other
diagnostics, operating theatres and other facilities have to be registered
prior to start up. Subsequently, an application addressed to the Provincial
Director of Health Services is required in order to obtain approval to start the
operation. Thereafter, the PHSRC will monitor the hospital after operations
commence to ensure that the stipulated conditions are met.
2.8.2 Regulation and governance of third-party payers

The contribution made by third party payers in Sri Lanka is very limited
because the main contribution for the Sri Lankan health sector comes from
general taxation and OOP payments from households and individuals. The
health insurance scheme for public servants (Agrahara) and the scheme
for schoolchildren (Suraksha) remain the major contributors of third-party
payments for health. In addition, voluntary insurance schemes exist that are
contributed to by individuals and employers.
The National Insurance Trust Fund was established in 2006 as a statutory

body to offer Agrahara Insurance for the public sector through the National
Insurance Trust Fund Act No. 28 of 2006 and subsequently, by the National
Insurance Trust Fund (Amendment) Act No. 28 of 2007. The Agrahara
insurance scheme provides coverage in the form of reimbursements up to
a capped amount mostly for inpatient admissions in government or private
sector hospitals. Outpatient coverage was provided only for purchasing
41
spectacles and hearing aids. The governance document for the insurance
scheme for children (Suraksha) is the General Circular No. 24/2019 issued by
the Ministry of Education under which all schoolchildren in the state sector
are insured up to a certain amount to receive any required health care.
2.8.3 Regulation and governance of providers

The Medical Service Minute of Sri Lanka, which was published under the
Special Gazette notification of Socialist Republic of Sri Lanka Number 662/11
in 1991 and subsequently amended in 2001 and 2014, applies to medical
personnel in the health services of the country.
2.8.3.1 Registration of human resources

The SLMC is a statutory body established for the purpose of protecting
health-care seekers by ensuring the maintenance of academic and
professional standards, discipline and ethical practice by health professionals
who are registered with it. The SLMC was established by the Medical
(Amendment) Act No. 40 of 1998 when the title was substituted for the Ceylon
Medical Council. The Ceylon Medical Council (CMC) had been established by
the Medical Council Ordinance No. 24 of 1924. The general duty of the Council
is to protect the public and uphold the reputation of the profession. The
Council does this by maintaining and publishing registers of qualified persons
in different categories, by prescribing and overseeing the standard of medical
education, providing advice on professional conduct and medical ethics and
taking action against those who are registered with the Council if they are
deemed to be unfit to practise and exercise the privileges of registration. The
Medical (Amendment) Act No. 30 of 1987 makes provision for the Council to
ascertain whether the courses of study, qualifications and staff, adequacy
of equipment and facilities at such universities and institutions conform to
prescribed standards. If they fail to conform to the prescribed standards, the
Council may recommend the withdrawal of recognition of such institutions.
There is a Nursing Council established under the Sri Lanka Nurses Council

Act No. 19 of 1988, which has similar functions as the Medical Council
with regard to the nursing profession. There is no separate council for
pharmacists, physiotherapists or other allied health professionals. They are
awarded certificates of proficiency by the Ceylon Medical College Council and
are eligible for registration in a separate register in the SLMC.
The Public Service Commission (PSC) was established under the Ceylon
(Constitution) Order in Council dated 15 May 1946 with the main objective
of promoting an efficient, disciplined and contented public service to serve
the public with fairness and to carry out the task of appointing officers
42
for public service. Accordingly, the executive powers in respect of the
appointments, promotions, transfers, disciplinary control and dismissal of
senior-level staff of the MoH are vested in the PSC. This has been amended
several times and the last amendment was made following the Eighteenth
amendment to the Constitution in 2010. According to the Amendment, the
PSC consists of nine members appointed by the President. The President
appoints one of these members as its Chairman. They hold office for a term
of 3 years and are eligible to be reappointed for another term.
2.8.3.2 Regulation and governance of pharmaceuticals and medical

devices
Until the year 2015, the legal basis for medicinal drugs in Sri Lanka was
provided through the Cosmetic Devices and Drugs (CDD) Act (Act No. 27 of
1980). However, from the 1990s onwards, there were major lobby groups
advocating the implementation of a fair pricing mechanism for essential
medicines. As a result, the government approved the National Medicinal Drug
Policy (NMDP) in 2007. After years of negotiations, the implementing body,
which is the National Medicinal Regulatory Authority (NMRA), was finally
established by an Act of Parliament in 2015 (Parliament of the Democratic
Socialist Republic of Sri Lanka, 2015b).
The new Act introduced changes in governance for the regulation of

medicines and medical devices in Sri Lanka. Through the previous CDD
Act, the Drug Regulatory Authority functioned under the DGHS, MoH but
under the new NMRA Act, the new NMRA functions as an independent
authority. This Act stipulates the appointment of 13 members to the NMRA
by the Minister of Health for a term of 3 years. The NMRA has undertaken a
number of key activities to improve the availability and quality of medicines
and devices. The major remaining challenges seen in implementation of the
policy include the recruitment of required human resources for the NMRA
and improvements to the National Drug and Quality Assurance Laboratory.
The State Pharmaceutical Corporation (SPC) is the procurement agency

for drugs and medical supplies for the Ministry. It follows the national
procurement guidelines and other stringent procedures for evaluation and
selection as laid down by the Ministry. It was established in 1971 under the
State Industrial Corporations Act No. 49 of 1957. The State Pharmaceuticals
Manufacturing Corporation (SPMC), which was a grant-in-aid from the
Japanese Government through the Japanese International Cooperation
Agency (JICA), was incorporated in June 1987 under the State Industrial
Corporation Act No. 49 of 1957 with the commitment to manufacture quality,
effective and safe medicinal drugs at affordable prices for the public of
Sri Lanka. The share of the local pharma market held by the SPMC is still
43
modest (around 17%) but it is envisaged that in the next 5 years it will be able
to produce a significant proportion of the medicines needed by the country,
especially for the state sector.
Public–private partnerships too have been incorporated and have helped

to expand the production capacities and range of medicines subject to
regulation by the NMRA.
2.8.4 Health technology assessment

There is no specific unit undertaking health technology assessment (HTA)
as its primary function. Despite the non-availability of a dedicated unit for
HTA, the basic principles are taken into consideration when developing the
Essential Drugs List for the country and also in the functions of the Medical
Supplies Department for procurement of medicines and vaccines for the
country. The MoH and National Authority on Tobacco and Alcohol (NATA)
undertook an HTA to make recommendations for increasing the taxes
imposed on cigarettes in 2016–2017. There have been a number of proposals
to establish an HTA unit under the MoH, but this has not been realized as yet.
2.8.5 Regulation of capital investment

There is no formal mechanism for the regulation of capital investments in
the state sector. Health development projects are prioritized according to set
criteria, though political considerations can also influence these decisions.
The resources for capital investments are made available within the annual
or longer-term budgetary allocations for the MoH. For private sector
investments from sources within the country, there is no formal approval
required, while for investments from outside Sri Lanka, the approval of the
Board of Investment of Sri Lanka is mandatory.
2.9 Patient empowerment

Patient empowerment has emerged as a relatively new paradigm that can
help to improve patient health outcomes while lowering the costs of care.
The concept seems particularly promising for the management of chronic
diseases, because empowering patients can be instrumental in achieving
success in managing these conditions. At a time when much medical
information can be accessed via the Internet and easily communicated to
health-care providers, patients and other experts, empowering patients
would enable them to make use of the information and knowledge to achieve
better outcomes.
44
The desires of our patients regarding doctor–patient communication point
towards the need to minimize the predominantly doctor-centred attitudes, as
has been demonstrated in a study (Mudiyanse et al., 2015).
In Sri Lanka with its current literacy rate of 95.7% (Department of Census
and Statistics, 2015a), a demand for more and more patient-centred attitudes
can be expected, such as sharing of information with patients and developing
partnerships between doctors and patients. The inclination for this has been
expressed in different ways but has been slow to develop due to the long-
standing culture of expecting doctors to make the decisions.
2.9.1 Patients’ choice

The people’s health-seeking behaviour is explained with reference to their
belief systems and explanatory models that include what they believe to be
the cause of the illness, what explains the symptoms they suffer and what
they believe to be the most appropriate treatment for a particular illness
episode (Arseculeratne, 2002). A greater weight of evidence from a user
perspective suggests that treatment-seeking behaviour is not governed
deterministically by the beliefs in a given medical system, the choice of
therapy being determined by more pragmatic factors such as financial cost,
distance and time, previous experience of effectiveness, familiarity with the
practitioner, social network of patients and the wishes of the family (Liyanage
and Ekanayake, 2018). It has been seen that Sri Lankans use both western
and traditional systems interchangeably and also in tandem.
A study showed that health facilities of all types were available in close
proximity to households. In addition, householders were aware of these
facilities. Although the physical proximity to heath facilities was viewed as
satisfactory, the utilization pattern raised several concerns. The findings of
the study suggested that the phenomenon of bypassing the closest health
facility occurs in outpatient services, a phenomenon that was common to all
types of health-care facilities. Hence, it was evident that providing health-
care facilities closer to households alone would not improve the utilization
of such facilities, unless the issue of bypassing is adequately addressed. The
phenomenon of bypassing a closer facility to attend a more distant one could
further increase the demand in certain facilities, leading to a rationing and a
deterioration in the quality of services (Weerasinghe and Fernando, 2011).
2.9.2 Patients’ rights

A charter of patients’ rights is one of the means of improving and
strengthening the health system. The current National Health Policy of the
MoH for the period 2016–2025 has as its guiding principle, “to direct the
health system to be people centred, while ensuring the concept of universal
45
health coverage (equitable access to quality services, and financial protection
for all patients), assuring patients’ rights and social justice” (Ministry of
Health, Nutrition and Indigenous Medicine, 2017a).
Further, the Sri Lanka National Action Plan for the protection and promotion
of Human Rights (2011–2016) recognized two goals under the topic “health”,
these being awareness of rights with regard to health care and respect for
patients’ rights (Ministry of Disaster Management and Human Rights, 2012).
The Organization of Professional Associations of Sri Lanka (OPA) grouped

themselves as an informal voluntary group to address patients’ rights.
They drafted a charter of patient rights following public submissions,
which was reviewed and finalized by the representatives of the Law and
Society Trust (LST). Peoples Movement for Rights of Patients (PMRP)
reviewed and finalized the draft, which was published in the LST Review
(Balasubramaniam, 2006).
2.9.3 Complaint procedures

The number of medical negligence cases against medical practitioners has
been on the rise in the recent past, probably due to increasing awareness and
motivation among the general public. A victim seeking redress for a medical
injury or a perceived misadventure can make a complaint to the health
authorities, forward an affidavit to the SLMC or Human Rights Commission,
lodge a complaint at the police station or file a civil case in the District Court
(Ruwanpura, 2009).
2.9.4 Public (community) participation

Patient and public involvement and engagement (PPIE) is the process
of involving patients and the public in health-care service provision and
research to ensure public accountability for decision-making and finances
(Hanley, Morris and Staley, 2009). PPIE in health-care institutions in the
government sector is addressed through hospital committees, while in
medical research this is addressed through public involvement in the
research ethics committees.
For example, dengue is one of the most critical public health hazards, which
has had a severe impact in the recent past in Sri Lanka. The Government of
Sri Lanka has been implementing many programmes and policies to control
and prevent dengue. Community participation is one of the key strategies that
is keenly followed by the government in implementing successful dengue
prevention activities (Riswan, 2015).
46
2.9.5 Patients and cross-border health care
The Sri Lanka National Migration Health Policy has been developed by the
MoH in recognition and promotion of the right to health for internal, inbound
and outbound migrants and their families left behind in Sri Lanka. Identifying
the multifaceted nature of migration health, the Ministry adopted a multi-
stakeholder and evidence-based approach involving 13 key government
ministries with technical assistance from the IOM in developing the National
Migration Health Policy (Ministry of Health, Nutrition and Indigenous
Medicine, 2013).
In line with the National Migration Health Policy, IOM conducts migration
health assessments and gives technical assistance to the MoH in developing
standards for pre-departure health assessments. IOM offers direct access
to health assessments for inbound and outbound migrants. These migrant-
friendly health assessments are conducted at IOM’s dedicated health
assessment facility established in 2014 in Colombo. Adhering to international
best practices, the Centre currently provides pre-departure health
assessment services to Sri Lankans immigrating to the United Kingdom,
Australia, Canada, New Zealand and Malaysia. This includes the early
detection and management of pulmonary tuberculosis (TB).
One of the priority areas identified in the National Migration Health Policy for
early implementation under the key strategic area of inbound migration is the
strengthening of core capacities and quarantine activities at Sri Lankan ports
of entry. Cross-border migration is increasingly becoming a challenge for
the health authorities. With IOM’s assistance to the MoH, a comprehensive
border health system was launched in 2013 to minimize the risk of cross-
border transmission of disease (International Organization for Migration -Sri
Lanka, 2013).
The Government has also studied the implications of the General Agreement
on Trade and Services (GATS) for investments in the health sector and
for strengthening services for medical tourism, but this is still a work in
progress and Sri Lanka does not yet boast of an active medical tourism
sector. There has been ongoing activity under Modes 1 (cross-border trade)
and 2 (consumption abroad) and limited utilization of Modes 3 (commercial
presence) and 4 (presence of natural persons) for investments in the health
sector and inviting personnel to highly specialized service areas, but these
are still not significant. There is increasing interest in exploring the range of
possibilities without any disadvantage to the national health personnel and
available services.
47
3. Health financing
Chapter summary
Government tax revenue and private spending are the two main sources
of health financing in Sri Lanka, as there is no significant social health
insurance. As the major source of taxation is indirect, it is not considered
progressive. External financing for health has been historically low,
accounting for around 1% of CHE. Government allocations for health services
has increased in monetary terms over the years, although it has remained
low as a percentage of GDP at around 1.7% during the period 2013 to 2016. In
2016, the domestic general government health expenditure as a percentage
of general government expenditure was 9%. Although the government
investment is higher than the private share for capital formation, in totality
this has remained low over the period 2000–2016 at 0.4% of GDP. While there
is clearly a need to increase public spending on health, there is currently a
lack of fiscal space to do so.
The household contribution to CHE is significant and is largely from out-

of-pocket expenditure (OOPE). More than 10% of household expenditure
spent on health is deemed catastrophic; the percentage of households thus
affected is 6.4%.
Demand driven and voluntary utilization of the private sector is observed

among the higher-income groups. Supply-side constraints in the state sector
may also be pushing persons, including poorer households, to utilize the
private sector. However, as the government is the key provider of inpatient
care, there has been no significant increase in private inpatient care
utilization.
The government has from time to time initiated insurance schemes such as
Agrahara for government employees and Suraksha for children, but these
schemes are limited and have flaws, resulting in an increase in the state
burden. There is lack of demand for private health insurance coverage as
reflected by the small private health insurance market in the country.
48
The need for an increase in fiscal space for health by the government
is identified. Efficiency improvements and better health outcomes are
being targeted through reorganization and retooling within the budgetary
constraints at present. It is envisaged that gradual enhancing of health-care
financing and evaluation of alternative health-care financing strategies would
support reforms to sustain Sri Lanka’s commendable health status and
outcomes and to achieve UHC.
3.1 Health expenditure

In Sri Lanka, health-care expenditure is shared almost equally between
the government and households. The trends in health expenditure are
demonstrated in Table 3.1. The national economy in terms of overall GDP
grew rapidly over the period 2000–2012 and thereafter the rate of increase
has slowed down (2013–2016). CHE as a percentage of GDP has remained
at around 3.8%. With the growth in the national GDP, CHE per capita
has increased over time. CHE comprises both government and private
contributions. In 2016, approximately 43% of CHE was from government
sources, a considerable decrease from 54% in 2000. As government and
private households are the two main sources of financing for health care,
domestic private expenditure on health has increased from 45% of CHE in
2000 to 56% of CHE in 2016. External contributions to CHE have remained
minimal throughout at 1% of CHE (Figure 3.1).
Figure 3.1 National health expenditure by financial sources, 2016
0.4 0.01
6
Household OOPE
14 Central government
State/regional/local
government
50 Voluntary health insurance
payment schemes
Compulsory contributory
health insurance schemes
30
Rest of the world schemes
Note: “Rest of the world” denotes external contributions, i.e. foreign governments and development
agencies.
Source: Ministry of Health, Nutrition and Indigenous Medicine, 2018d
49
Voluntary health-care payment schemes contribute 6% of CHE, voluntary
health insurance contributes 2%, primary/substitutary health insurance
schemes 2%, employer-based insurance (other than enterprises schemes)
1%, and other primary coverage schemes contribute 1%. This differs from
the compulsory contributory health insurance scheme known as Agrahara
available to government employees and their dependants (0.4% of CHE)
(Ministry of Health, Nutrition and Indigenous Medicine, 2018d).
Table 3.1 Trends in health-care expenditure in Sri Lanka – 2000 to 2017

Expenditure 2000 2005 2010 2015 2016 2017
CHE (million SLR)* 524 885 1535 2434 2447 -
CHE per capita at 44 57 109 151 153 159
nominal value (US$)
CHE per capita at PPP 221 265 323 466 490 504
GDP (million SLR)* 15 940 24 518 56 516 81 780 81 259 -
CHE as a share 4.25 4.01 3.87 3.89 3.89 3.81
(percentage) of GDP
Nominal growth rate in 17 14 12 15 9 -
CHE (percentage)*
Nominal growth rate in 14 17 33 6 8 -
GDP (percentage)*
Domestic general 53.63 52.64 40.44 43.96 43.12 42.95
government health
expenditure as a
percentage of CHE
Domestic private 45.46 46.52 58.40 54.67 56.01 55.71
expenditure on health
as a percentage of CHE
External health 0.91 0.84 1.16 1.37 0.87 1.34
expenditure as a
percentage of CHE
government health
expenditure as
a percentage of
general government
expenditure
government health
expenditure as a
percentage of GDP
OOPE payments as 40.04 40.50 53.30 48.93 50.12 49.76
percentage of CHE
CHE: current health expenditure; SLR: Sri Lanka Rupee; GDP: gross domestic product
Sources: World Health Organization, 2020; * Amarasinghe, Dalpatadu and Rannan-Eliya, 2018.
50
3.1.1 Comparison of health expenditure and health outcomes in
selected countries of South-East Asia and Western Pacific
regions
Table 3.2 compares Sri Lanka with selected countries in the South-East Asia
and Western Pacific Regions. The GDP per capita in the selected countries
ranges from US$ 3831 in Bangladesh to US$ 27 683 in Malaysia and the
CHE per capita (in Int$ purchasing power parity [PPP]) varies from US$
88.3 in Bangladesh to US$ 1035.78 in Malaysia. Sri Lanka has one of the
lowest CHEs as a percentage of GDP with the exception of Bangladesh. Sri
Lanka (465.89 $ PPP) has a considerably low CHE compared to Malaysia
(1035.78 $ PPP) and Thailand (597.31 $ PPP).
Thailand has the highest percentage of government contribution to health

among the countries considered in the comparison. Despite the higher
spending on health per capita in Thailand, Sri Lanka shows better health
outcomes with respect to life expectancy and child mortality rates. It is noted
that the MMR is higher in Sri Lanka as compared to Thailand.
Sri Lanka’s percentage of government contribution to health is comparable

with that of Malaysia, which has a per capita GDP more than twice that of
Sri Lanka and is ranked higher in terms of Human Development Index (HDI).
Despite the much higher health spending per capita of Malaysia, Sri Lanka
shows better maternal health outcomes and similar life expectancy and child
mortality rates.
Table 3.2 Key socioeconomic and health expenditure, and selected health
outcome indicators of selected countries
Bangladesh
Philippines
Sri Lanka
Viet Nam
Malaysia
Thailand
Country
GDP per capita in PPP Int$ 12 624 3831 27 683 17 110 7804 6296
(2016)1
CHE as a percentage of GDP 3.89 2.46 3.89 3.67 4.32 5.65
(2015)
CHE per capita $ PPP (2015) 465.89 88.30 1035.78 597.31 317.27 335.34
government health
expenditure as a percentage
of CHE (2015)
Population in millions (2019)2 21.32 163.05 31.95 69.63 108.12 96.46
51
Table 3.2 Key socioeconomic and health expenditure and selected health
outcome indicators of selected countries (contd)
Bangladesh
Philippines
Sri Lanka
Viet Nam
Malaysia
Thailand
Country
Life expectancy at birth 72.1/78.5 71.1/74.4 73.2/77.6 71.8/79.3 66.2/72.6 71.7/80.9

(male/female) (2016)
MMR (per 100 000 live births) 30 176 40 20 114 54
(2015)
IMR (probability of dying 7.5 26.9 6.7 8.2 22.2 16.7
between birth and age 1 per
1000 live births) (2017)
U5MR (probability of dying 8.8 32.4 7.9 9.5 28.1 20.9
by age 5 per 1000 live births)
(2017)
HDI3 (2017) (rank) 0.77 0.61 0.80 0.76 0.70 0.69
(76) (136) (57) (86) (111) (116)
CHE: current health expenditure; GDP: gross domestic product; MMR: maternal mortality ratio; IMR:
infant mortality rate; U5MR: under-5 mortality rate; HDI: Human Development Index
Sources: World Health Organization, 2019a; 1 World Health Organization, 2020; 2 UN DESA, 2019;
3 United Nations Development Programme, 2019
Sri Lanka has seen a decrease in CHE as a percentage of GDP from 4.25% in
2000 to 3.89% in 2017. Globally, an increase is seen from 5.4% to 6.3% over
the same period. During this period, Sri Lanka prioritized national security,
which may explain the inability to increase CHE. Sri Lanka’s budget deficit
for the period 2000–2015 averaged around 6% of GDP. Revenue generation
and expenditure structures have affected the maintenance of sufficient fiscal
space. The need to increase the percentage GDP on health is understood,
but an additional barrier has been the present expenditure structure of the
budget with its limited manoeuvrability.
Over the years, Sri Lanka has done remarkably well in achieving good health
outcomes despite the low CHE as a percentage of GDP and is considered
a model for good health at a low cost (Smith, 2018). Most health indicators
have continued to improve over the years; communicable diseases show
a low prevalence and the MCH indicators are on a par with some of the
developed countries. The likely explanation for these health gains despite
low health spending may be the continuing investments in social and human
development policies of successive governments such as free education and
poverty alleviation programmes. These have resulted in improved health-care
52
behaviour, while improvements in infrastructure development has resulted in
improved health-care access (Smith, 2018) .
The health system has, however, to face new challenges due to the
demographic, epidemiological and social transitions that the country is
undergoing. More financial resources as well as more appropriate models of
health-care provision will be needed to address these challenges effectively
and to achieve UHC. Figure 3.2 shows the trends in health expenditure as a
share of GDP over time across selected countries.
Figure 3.2 Trends in health expenditure as a share (%) of GDP in selected
countries, 2000–2017
7
6
CHE as % of GDP
5
4
3
2
1
0
200 0 200 5 201 0 201 5 201 7
Bangladesh Malaysia Philippines

Sri Lanka Thailand Viet Nam
Source: World Health Organization, 2019a
Figure 3.3 shows the domestic general government health expenditure and
OOPE as a share of CHE in selected countries over the period 2000–2016.
Of all the countries considered, Thailand has the highest government
contribution to health. The government health expenditure of Thailand as a
percentage of total CHE ranged from 58% in 2000 to 76% in 2015. Thailand
and Malaysia are upper middle-income countries. Sri Lanka, Thailand and
Malaysia have better health outcomes than the other three countries.
53
Figure 3.3 Domestic general government health expenditure and OOPE
as a percentage of CHE, 2000–2016
100
90
80
70
60
50
40
30
20
10
0
2000
2005
2010
2015
2016
2000
2005
2010
2015
2016
2000
2005
2010
2015
2016
2000
2005
2010
2015
2016
2000
2005
2010
2015
2016
2000
2005
2010
2015
2016
Sri Lanka Bangladesh Malaysia Philippines Thailand Viet Nam
GGHE-D as % of CHE OOPE as % of CHE
3.1.2 Government health expenditure by service type

Table 3.3 provides information on health expenditures for curative care
(outpatient and inpatient), rehabilitative care, preventive care, ancillary
services, medical goods and governance. The table uses information
available in the routine government financial information system. The
curative function consumes 72% of CHE. The bulk of medicinal drugs
and commodities purchased through central procurement are included
in this expenditure category. Preventive services are allocated a low
share of only 3%.
54
Table 3.3 Distribution of CHE by selected health-care functions: 2014 to
2016 (SLR million at current prices)
Health-care function 2014 2015 2016
Amount Amount Amount
(SLR % (SLR % (SLR %
million) million) million)
Curative care 269 767 72% 306 054 72% 339 069 73%
Inpatient care 174 277 47% 196 794 46% 218 231 47%
General inpatient curative 6196 2% 7165 2% 7612 2%
care
Specialized inpatient 168 081 45% 189 629 45% 210 619 45%
curative care
Outpatient curative care 95 490 26% 109 261 26% 120 838 26%
General outpatient 84 520 23% 96 692 23% 106 828 23%
curative care
Specialized outpatient 10 969 3% 12 569 3% 14 010 3%
curative care
Rehabilitative care 219 0.1% 279 0.1% 299 0.1%
Ancillary services (non- 22 000 6% 25 263 6% 27 673 6%
specified by function)
Laboratory services 16 402 4% 18 817 4% 20 935 5%
Imaging services 4775 1% 5471 1% 6099 1%
Medical goods (non- 50 776 14% 58 180 14% 64 852 14%
specified by function)
Preventive care 11 724 3% 13 529 3% 13 812 3%
MCH-FP programme 9678 2.6% 11 009 3% 11 354 2%
Governance, health 4406 1% 4801 1% 5074 1%
system and financing
administration
MCH-FP: maternal and child health–family planning

Figure 3.4 describes the distribution of government CHE for curative care
by service provider, of which tertiary-care institutions consume the largest
proportion (48%).
55
Figure 3.4 Distribution of government CHE by categories of health-care
providers
8%
Primary care institutions

48%
Secondary care institutions
44%
Tertiary care institutions
(including specialized hospitals)
Figure 3.5 shows trends in CHE by function. It should be noted that the
share allocated to rehabilitative care is extremely low and that for preventive
services is consistently low and declining. Despite the low spending, public
health programmes have contributed to good health outcomes, but these
programmes must now adapt to address emerging challenges adequately.
Also noted is a significant decline in expenditure for outpatient services from
the year 1990 and a stagnant trend in most recent years, which can indicate a
gap in required outpatient care.
Figure 3.5 Share of CHE by health-care functions over time, 1990–2016
60
50 Outpatient care
40 Inpatient care
Preventive care
30
% of CHE
Governance, and health

20 system and financing
administration
10 Ancillary services
0 Rehabilitative and
1990 1995 2000 2005 2010 2015 2016 longterm care
Year
Source: Amarasinghe, Dalpatadu and Rannan-Eliya, 2018
56
3.2 Sources of revenue and financial flows
The government sector is predominantly financed through general revenue
taxation, while the private sector is financed through OOP spending, private
insurance, direct employer payments, employer insurance and contributions
from non-profit organizations.
External health financing is small in Sri Lanka in general, though there were
large inflows after the tsunami in December 2004. Donor financing is largely
channelled through the government sector, though in specific instances it is
paid out to nongovernmental organizations (NGOs) working in specific areas
related to health. Foreign governments and international NGOs contributed
a much smaller proportion of revenue in terms of transfers compared to
national government contributions.
Table 3.4 gives the various sources of revenue as a percentage of CHE.
Table 3.4 Source of revenue as a percentage of CHE (2016)

Source of revenue US$ (million) % of CHE
OOPE 1598.5 50.1
Government domestic revenue 1361.5 42.7
Employer contribution to the CHE (in the form of health 116.3 3.6
insurance premium and other methods)
Private health insurance 65.2 2.0
Rest of the world financing schemes 27.7 0.9
Social health insurance 13.8 0.4
Nongovernmental organizations 6.3 0.2
Total CHE 3189.3 100.0
Figure 3.6 is a schematic representation of the flow of funds in the health

system, illustrating that there are two sets of arrangements in the Sri Lankan
context – administration and financial linkages. There are three main funding
sources: government, individual citizens and donors. General taxes to the
government are disbursed to state health institutions (providers) through a
chain of financing agents. The treasury collects tax revenue and disburses
the funds to hospitals that are directly managed under the Ministry of Health,
i.e. teaching, general and specialized hospitals that provide specialized care
as well as PHC services,9 and vertical preventive/disease control units.
9 In Sri Lanka, institutions are classified as tertiary-, secondary- and primary-level institutions and,
in all of these, outpatient services are provided, which fulfils primary care needs.
57
Hospitals managed by the Ministry of Defence, i.e. Army, Navy, Air Force
and police hospitals and Ministry of Justice, i.e. prison hospitals are funded
through their respective ministries. Institutions managed by the provincial
governments (base hospitals, divisional hospitals, primary care units and
MOH units) and local governments (municipal council and pradeshiya sabha
health clinics) and other health-related activities by the local government
are funded through the Finance Commission. In addition, the MoH directly
channels a considerable amount of funds to provincial-level institutions.
Local governments are able to generate and use funds for the provision of
health services for institutions under their purview in addition to the funds
received through the Finance Commission. There is wide variation in the
amount generated through local tax and its contribution is very small, except
in the Western Province.
Households in Sri Lanka share a considerable burden of health-care

financing as OOP spending. A small proportion of individual citizens
and employers purchase private health insurance and only a very small
proportion of health-care services are funded by external donors,
managed by a financial arrangement recognized as external contribution
from foreign governments and development agencies (Rest of the World
Financing Scheme).
58
Figure 3.6 Financing system related to health-care provision
Funders Financing agents Providers
NGOs Charity-based
health services
Other ministries Health facilities

providing under other
health care ministries
Indigenous health
services
Donors
Specialized
hospitals
Ministry Specialized
of Health, campaigns
Central ministries Nutrition and
Indigenous
Medicine
Tertiary care
Government Treasury services
Provincial
directorates of Secondary care
health services
Finance Provincial
Commission ministries of
health
Local government Primary care
health services services
Individual citizens
Insurers
Employers Private health

services
Rest of the world Home-based care,

self-care
Source: Perera and Perera, 2017: p.31
3.2.1 Provincial financing mechanisms

The Finance Commission of Sri Lanka was established by the Thirteenth
Amendment to the Constitution of the Democratic Socialist Republic of Sri
Lanka in 1987. Its job was to disburse treasury funds under the decentralized
59
system to achieve balanced regional development throughout the country,
recognizing different specific provincial needs.
The Central Government also channels substantial funds to the provinces

through the line ministry for both capital and recurring expenditures.
Provinces are also benefited through health-specific grants and loans
negotiated by the Centre. Procurement of medicines and laboratory products
is mainly handled by the Centre.
Each province consists of a health ministry and a department of health

services, which is responsible for improving the health of the people in their
area. The Finance Commission disburses funds to the province in the form
of different types of grant allocation. The functions of the Commission are
to assess provincial needs, apportion the annually granted funds among
provinces, divide the total amount allocated to each province between
recurring and capital needs, distribute capital funds between province-
specific development grants (PSDG) and criteria-based grants, and allocate
PSDG across identified development sectors, where health is one such
sector. Figure 3.7 shows the CHE per capita.
Figure 3.7 CHE per capita by province, 2000–2015
8000
7000
6000
5000
SLR (Million)
4000
3000
2000
1000
0
Western
Central
Southern
Northern
Eastern
North-Western
North-Central
Uva
Sabaragamuwa
2000 2005 2010 2015
Source: Amarasinghe, Dalpatadu and Ranann-Eliya, 2018
Expenditures are allocated provincially taking into consideration the demand

and supply of health-care services. As shown, the Central and Northern
Provinces had the highest per capita expenditure, while the Sabaragamuwa
Province incurred the lowest. The reasons for the different CHE per capita
60
could be due to the disease profile, number of health-care institutions in the
province and the population.
3.3 Overview of the public financing schemes

3.3.1 Coverage
3.3.1.1 Breadth: who is covered?
Sri Lanka holds a unique position in South Asia as one of the first to
provide universal health, free education, strong gender equality and a
better opportunity for social mobility for its citizens since Independence
in 1948 (Samarage, 2006). Sri Lanka has an extensive network of health-
care institutions and patients have the freedom to choose between the
state and private sectors. The HIES (2016) reveals that 90% of inpatient
visits and approximately 45% of all outpatient visits are to the government
sector facilities. While the upper wealth quintiles are seen to opt out and
access private health care often, what is notable in the Sri Lankan context
is that many persons access both sectors, and that even the lower wealth
quintiles access the private sector for outpatient care and the richer quintiles
the public sector for inpatient care (Department of Census and Statistics,
2018a). The government health system provides a safety net, but despite the
intention to cover all citizens, disparities may arise due to the accessibility
and availability of services, medications and investigations. Although health
services are universal and therefore entitlement is for all, subnational
variation is observed in accessing health services.10 Further, disparities in
health-seeking behaviour may exclude certain populations. Attempts to cover
all people are seen by the gradual expansion of health-care programmes
dedicated to specific target groups, e.g. estate, urban sector, the elderly,
youth, adolescents and, more recently, the focus on migrant populations.
Females show better health-seeking behaviour than males and have a

larger number of interactions with the health services, some of which can be
attributed to a well-organized maternal care service. This difference between
males and females is reflected in the percentage of males over 18 years
who had never measured their blood sugar level (58.4%) as compared to the
percentage of females (43.1%) (World Health Organization, 2015). Similarly,
only 65.7% of males previously diagnosed were currently taking medication
prescribed for diabetes, as compared to 73.1% of women.
Sri Lanka is still in the process of reorienting health services to cater for the
emerging needs of its population due to demographic, epidemiological and
social transitions (refer Chapter 6). Strengthening primary care is considered
a timely intervention to expand coverage.
10 Refer to Chapter 7.
61
Estate populations have received considerable attention. In the past, health
services were provided by the estate management; however, a policy decision
was taken in 1996 to deliver government services to this group. Currently, all
preventive health services of the estate sector are provided by the provincial
health authority and curative health services are progressively being
absorbed into the state sector. Within the estate sector, problems of physical
access to health services due to the difficult terrain, distance and limited
transport facilities may affect timely availability of specialized services. Also,
women and young people in the plantation sector face significant barriers in
timely access to sexual and reproductive health services (Periyasamy, 2018).
Non-Sri Lankans are able to access health services at private health

institutions through payment for services, or through state institutions at a
nominal fee. Resident visa holders have outpatient and emergency health
services covered by the government sector through a health protection plan,
which includes a mandatory health assessment introduced recently.
3.3.1.2 Utilization of health services by income category

Analysis of the OOPE on health by expenditure deciles reveals that nearly
57% of the total spending on OOPE had been borne by the wealthiest quintile
(deciles 9 and 10). This indicates a drop from 63%, the corresponding value
given in HIES 2012–2013. Figure 3.8 demonstrates the OOPE spending by
expenditure deciles for 2016.
Figure 3.8 OOP spending on health by expenditure deciles, 2016
45 42.8
40
35
30
25
20
14.7
15
10.2
8.4
10 6.4
4.4 5.1
2.8 3.6
5 1.7
0
Exp D1 Exp D2 Exp D3 Exp D4 Exp D5 Exp D6 Exp D7 Exp D8 Exp D9 Exp D10
Source: De Silva SHP, De Silva A, Chandrarathna NA, Nieveras O, Kumara R, Amarasinghe S, 2018.
Chapter 4
62
A study comparing household income and expenditure data of 2006–2007
with that of 2009–2010 shows that the proportion of expenditure on health
had increased in all income quintiles, but was more for the middle-income
group (Kumara and Samaratunge, 2016). Possibly, the effects would be more
for the lower- to middle-income groups, considering their disposable income
for other needs.
3.3.1.3 Scope – what is covered?

Health care in Sri Lanka is provided through the public and private sectors.
The MoH is responsible for comprehensive health-care provision throughout
the country (Fernando, 2000).
Curative services at primary medical care units consist of only outpatient

services, while specialized services are provided from base hospitals
upwards. It is important to note that apart from selected programme-
specific packages such as for MCH, and a list of medicines available for
each level of hospital, there was no explicit service package defined for the
whole population.
The government recently announced the explicit “Essential Service

Package” (Ministry of Health, Nutrition and Indigenous Medicine, 2019a)
defining the promotive, preventive, curative and rehabilitative facilities
which the government will commit to provide to citizens. The purpose is to
improve quality, efficiency and continuum of care in view of the changing
demography and disease burden. This is a significant shift from what was
practised when services were provided based on available resources. The full
implementation of the Essential Service Package requires many changes.
In addition to the resources, this would mean a change in service providers’
attitudes and accountability.
A major health sector reform to strengthen primary curative health care

is under way, which would ensure that people avail the services that they
require closer to home. This will also address issues in continuity of care,
which is especially important for the control of NCDs and in the context of
an ageing population. The reform would also improve access to diagnostic
facilities and essential drugs in the state sector. The Essential Service
Package is part of this reform. The reform in general takes on from the
successes of the current PHC approach, which mainly targets MCH services.
This model has been adapted to plan the primary curative care reforms so as
to comprehensively address the current and emerging challenges.
63
3.3.1.4 Depth – how much of benefit cost is covered?
State health services are provided free at the point of delivery and account for
about 90% of inpatient care and 45% of outpatient visits. The private sector
plays an important role in the provision of ambulatory care, and accounts
for over 50% of outpatient visits and a very small portion of inpatient care
(4% of total). Services obtained in the private sector are mostly paid for by a
household’s OOPE because of the low coverage of voluntary health insurance
in the population. OOP spending accounted for 50% of CHE (Ministry of
Health, 2019), but almost half of all OOPE is incurred by the two richest
deciles 9 and 10 (57% of the total spending on OOPE). Analysis of HIES (2015–
2016) data showed that the upper quintiles are more likely to access health
services in the private sector, especially in urban areas (Smith, 2018).
The major portion of OOPE is incurred on general medical practitioners

(SLR 40 billion/year; 40.6%), followed by medical and laboratory services
(SLR 31 billion/year; 31.5%), private hospitals and nursing homes (SLR 20
billion/year; 20.3%) (Department of Census and Statistics, 2018a). As seen,
laboratory tests and drugs account for approximately one third of the total
OOP spending, of which a sizeable proportion is among those accessing
services in the state sector.
3.3.2 Collection
The contribution from the general government budget constitutes the main
financing mechanism for health as depicted in Table 3.5. There are no
specific collections for health.
Table 3.5 Government contributions to health

Item 2005 2010 2015 2017
Total government budget (million 584 784 1 831 654 3 475 411 3 860 318
SLR)
Total MoH health budget (million 49 079 83 511 189 857 232 536
SLR)
% Contribution to MoH from total 8.39 4.56 5.72 6.02
government budget*
* This represents the contribution to the MoH from the total government budget. The allocation for
tri-forces’ medical services and that of the Ministry of Higher Education are not included here.
MoH: Ministry of Health; SLR: Sri Lanka Rupee
Source: Management, Development & Planning Unit, Ministry of Health, Nutrition & Indigenous
Medicine
Tax composition in Sri Lanka is a mix of direct tax (consisting of personal

income tax, corporate income tax and tax on interest) and indirect tax
(consisting of value added tax [VAT], excise tax, import duties and other
64
indirect taxes), as shown in Table 3.6. Income tax can be charged on
residents’ and non-residents’ profits and income. Residents are charged on
their global income while non-residents are charged on income arising in or
derived from Sri Lanka. There is no earmarked tax for health.
The Sri Lankan tax system is considered less progressive (Amirthalingama,

2013) (as only 18–19% of tax revenue is from indirect taxes in a country
where the Gini coefficient was 0.41 in 2016 (Department of Census and
Statistics, 2018b).
The tax system does not generate the potential revenue in Sri Lanka.
Although Sri Lanka’s per capita GDP at current market prices has increased
from US$ 473 in 1990 to US$ 4065 in 2017 (Central Bank of Sri Lanka, 2018),
the fiscal space measured by tax as a percentage of GDP had declined from
19.02% of GDP (1990) to 12.6% of GDP (2017) during this period.
Although the system is decentralized, the provincial health system too

depends on centrally allocated funds through allocation by relevant
ministries. Provincial and local taxation contributes only minimally to the
Central Government revenues, amounting to only 4% (0.6% of GDP).
Table 3.6 Tax breakdown in Sri Lanka, 2010 and 2018

2010 2018
Percentage Percentage
SLR SLR
Item of total tax of total tax
(million) (million)
revenue revenue
1. Taxes on net income and 135 623 19 310 449 18
profits
1.1. Personal 30 993 52 242
1.2. Corporate 75 208 212 112
1.3. Tax on interest 29 422 35 991
1.4. Capital gains tax - 104
2. Taxes on domestic goods 355 366 49 959 365 56
and services
2.1. VAT 219 990 461 740
2.2. Excise tax 129 864 484 287
2.2.1. Cigarettes 40 675 92 243
2.2.2. Liquor 36 654 113 944
3. Taxes on foreign trade 130 749 18 288 341 17
4. Others 103 008 14 154 162 9
Total tax revenue 724 747 100 17 12 318 100
Source: Central Bank of Sri Lanka, 2019
65
Table 3.7 shows the share of government health spending by financing
source.
Table 3.7 Share of public CHE by financing source (%)

1990 1995 2000 2005 2010 2015 2016
Ministry of Health 39 49 56 56 58 60 61
Provincial departments of 47 39 33 35 35 32 32
health
Local governments 11 6 4 3 2 2 2
Other government 3 5 4 3 3 5 4
ministries, departments &
agencies
Employees Trust Fund 0 0 0 0 0 0 0
President’s fund 1 1 3 2 1 1 1
Source: Amarasinghe, Dalapatadu and Rannan-Eliya, 2018
The share of CHE from the MoH has increased from 39% in 1990 to
61% in 2016, while the share from the provincial departments of health
has decreased from 47% to 32% in the same period and that from local
governments had reduced significantly from 11% to 2%.
3.3.2.1 Social health insurance pooled by a separate entity or entities

Sri Lanka does not have a social health insurance scheme. A semblance of
such a scheme, the Agrahara insurance scheme, exists only for government
sector employees (14% of employees are in the government and semi-
government sectors) and their immediate family members. Limited
insurance schemes are also available for some large-scale private sector
companies. However, the informal sector of the country accounts for 60% of
employees in the country (Labour Force Survey Annual Report, 2017).
The Agrahara, a public insurance scheme, provide three components:
i. medical insurance scheme

ii. personal accident and natural death insurance scheme
iii. loan guarantee scheme.
Contributions are collected from the monthly payroll, which goes into the
National Insurance Trust Fund. All government employees are beneficiaries
of this sickness benefit scheme. It pays compensation and reimburses
selected medical bills. Recently, two types of benefit packages were
introduced, depending on the premium an employee wished to pay. This
insurance is limited because it only covers inpatient care and spectacles,
66
hearing aids and some mobility aids, but not outpatient care or drugs. The
benefit scheme promotes utilization of the government sector in preference
to the private sector. There is no benefit to the government health-care
facilities through the system as payments are made to the patient and
government facilities do not charge for services.
Another health insurance available in the country is Suraksha. This is a

free health insurance policy covering schoolchildren between the ages of 5
and 19 years. The health insurance policy eases the financial burden when
students are faced with illnesses, accidents and disabilities in and out of
school. It helps students to continue with their education, overcoming any
health-related obstacles they may encounter, irrespective of financial status.
Suraksha provides inpatient (state and private sector) cover and outpatient
benefits for a few but uncommon conditions – cancer, end-stage renal failure,
multiple sclerosis, major organ transplant, paralysis, blindness and third-
degree burns.
A separate pool of funds exists as the President’s Fund, which was

established in 1978 by an Act of Parliament. This was created as a
discretionary fund to draw on in order to assist those in dire need or
deserving of help in the areas of health, education and other basic needs.
The President’s Fund comes from public sources, including proceeds of
lotteries, e.g. the Niroga lottery, which is health specific and collected by
the National Lotteries Board. Financial assistance for medical treatment
approved from the President’s Fund includes surgeries (heart, brain, kidney
transplant, bone marrow transplant, liver transplant and eye surgery), cancer
treatment, prostheses, orthopaedic implants and spinal disease. It specifies
a list of hospitals (government, semi-government, private sector and foreign
hospitals) where treatment/procedures could be obtained.
3.3.3 Pooling of funds

3.3.3.1 Allocation from collection agencies to pooling agencies
The most significant pooling of funds for health occurs through general
taxation. The general taxes are the largest pool where relevant government
department collections are available of import and export duties, excise
tax, personal and corporate income tax, other non-tax revenue and pooled
general revenue of the government. The revenue is disbursed for health
through the health allocation in the annual budget following legislative
approval. In addition, the treasury receives a very small amount of external
funds (1%) from donors and as loans specifically for health budgetary support
(Ministry of Health, Nutrition and Indigenous Medicine, 2018d).
67
3.3.3.2 Budget planning process
Historically, there has been a system of incremental, input-based budgeting
for health over the years. Budgets are formulated for curative services,
preventive services and administration. The funds are channelled through
several financial arrangements within the national government.
Several socioeconomic indicators are taken into account in apportioning

funds among the provinces under the province-specific development grants
and criteria-based grants. The health-specific indicators include neonatal
mortality rates and birth weights recorded in each province.
The MoH proposes major developments that are planned to be undertaken by

them to the Department of National Planning under the Ministry of Finance.
Large budget allocations require approval by the Cabinet of Ministers. In
addition to this, special budget allocations are decided on during the course
of the budget debate in the legislative process.
The Ministry of Indigenous Medicine was combined with the Ministry of

Health in 2015 and thereafter the budget allocations for these two systems
have been integrated into one common one.
Provincial ministries of health usually function together with one or two other
sectors, housed under one ministry. The allocations received may therefore
be subject to competing interests of other ministries.
3.3.3.3 Allocating resources to purchasers – revenue generation and

pooling of funds
Sri Lanka’s health-care system relies almost solely on a tax-based health-
care financing mechanism. Thus, social health insurance is not observed in
the country.
3.3.4 Purchasing and purchaser–provider relations

No purchaser–provider arrangements are seen in the government health
delivery system, as the government is both the financier and as well as the
health-care provider. There are no strategic purchasing arrangements for
entire institutions or for patient or community health service delivery. In
the state sector, line budgets are used to manage services where direct
responsibility for staffing, personnel management, procurements and
capital improvements all lie with the provider and no purchaser–provider
separation is seen.
68
3.3.4.1 Purchasing of ancillary services
Simple contractual agreements are present for selected outsourced
functions from the private sector, such as security services, laundry services,
preparation of meals and cleaning services. These contracts are given at the
local hospital level and mainly apply to the larger hospitals. More recently,
laboratory services for selected tests that are not available in state health
facilities are outsourced to the private sector at no cost to the patients.
Hospitals also can make limited local purchase of drugs that are not routinely
available for the special needs of patients.
The government system is free for all types of patients, including those
who are covered by private insurance. Service fees are not collected. Some
gaps are seen in the availability of investigations, supplies and personnel at
different levels of the system. Currently, there is no gatekeeping function,
and patients are free to seek care at the health institution of their choice;
in particular, bypassing PHC services for secondary and tertiary care
hospitals. The expansion of specialized care services throughout the country,
improved geographical access and changing expectations of the people have
contributed to increased demand and also to creating a situation where
people are more likely to bypass primary care institutions.
3.4 OOP payments

The global health expenditure database indicates that OOP payments
constitute 50% of the current total health expenditure. It increased from
40% in 2000 to 50% in 2016. The trend of OOPE from 2000 to 2016 is shown
in Figure 3.9.
Figure 3.9 OOPE as a percentage of CHE, 2000–2016
60 53 53
51 51 52 50
49 49 49
50 45
40 41 40 41 41 41
38
40
OOPE as a % of CHE
30
20
10
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Year
69
3.4.1 Composition of OOP payments
Several distinct categories of OOPE can be identified. They include payments
for private outpatient care (general and specialized care), private inpatient
care, medicines (self-prescribed or prescribed by a physician) and other
health-related devices, e.g. spectacles, prostheses, laboratory investigations,
dental care and indigenous treatment. According to HIES 2016, fees paid to
private medical practitioners accounted for one third of the OOP payments for
health, while purchase of medical and pharmaceutical items accounted for
26%. Payments to private hospitals and nursing homes constituted 18% and
payment for medical laboratory tests accounted for 9%. One of the reasons
for accessing private outpatient care has been the restricted hours of service
in the government system. Attempts have been made recently to extend
service hours, but challenges have been experienced in staffing (Ministry of
The breakdown of the OOPE on health is presented in Figure 3.10. The OOPEs
on pharmaceuticals, while reflecting an inadequacy of funding for medicines,
can also reflect on the non-adherence to clinical protocols for prescribing.
Figure 3.10 Breakdown of the OOP spending on health, 2016
X Ray
Scan (US,CT etc.) 0.3% Other health
2% expenses
3%
Hearing aids
0% Fees to private
medical practices
Spectacles 33%
1%
Fees to Ayurvedic
Purchase of
practitioners
medical/pharmacy
2%
products
27% Consultation fees to
specialists
Payments to private 6%
hospitals/ nursing
Payments. to medical
homes
laboratories
17%
9%
Source: Department of Census and Statistics, 2018a
The trends for components of out of pocket expenditure is given in Figure

3.11. The main component of the OOPE is fees to private medical practices.
There is a steady increase in the amount spend for purchase of medical/
pharmacy products.
70
Figure 3.11 Trends in different components of OOPE (average monthly
amount in SLR per person), 2010–2016
180 Fees to private

medical practices
160
Payments to private
140
hospitals/nursing
120 homes
Purchase of
SLR (Million)
100
medical/pharmacy
80 products
60 Payments to medical
laboratories
40
Consultation fees to
20
specialists
0
Other
2010 2013 2016
Sources: Department of Census and Statistics, 2011b, 2015b and 2018a
3.4.2 Catastrophic health expenditure

An analysis of the HIES 2015–2016 reveals that 5.33% of households in Sri
Lanka spent more than 10% of their total household budget on health and
0.91% of households spent more than 25% (Figure 3.12). Further analysis
showed that at a poverty line of US$ 1.90, the percentage of the population
under the poverty line is 0.07%, while 14 000 people are pushed below the
poverty line annually. When a poverty line of US$ 3.10 is considered, the
percentage of the population under the poverty line is 0.83%, with 170 000
people pushed below the poverty line (Wang, Torres and Travis, 2018).
Figure 3.12 Incidence of catastrophic health expenditure, 2016
7 6.4
6
% of households
4
3.2
3
2
1.1
1
0
10% threshold 15% threshold 25% threshold
71
Table 3.8 depicts important indicators pertaining to private expenditure
on health in Sri lanka from 2000 to 2016. There is an increasing trend in
private sector utilization in Sri Lanka. The bulk of private sector financing
consists of household OOPE, which amounts to 85% of private expenditure
(Amarasinghe, Dalpatadu and Rannan-Eliya, 2018) . Expenditure by
companies for providing health care and medical benefits to their employees
has been the next largest source of private financing (5–8%).
Due to the high OOPE, several considerations have been taken into account
to introduce insurance systems, the most recent one being the child health
insurance (Suraksha) mentioned earlier. Currently, the health financing
strategy is under review.
Table 3.8 Private expenditure on health (2000–2016)

Indicators 2000 2005 2010 2015 2016
CHE as percentage of GDP 4.25 4.01 3.87 3.89 3.89
Voluntary health insurance as 1.45 2.16 1.32 1.95 2.04
percentage of CHE
OOP as percentage of CHE 40.04 40.50 53.30 48.93 50.12
OOPE per capita in US$ 17.50 23.23 57.89 74.07 76.73
OOPE per capita in PPP Int$ 88.39 107.15 172.22 227.97 245.82
Transfers from government domestic 2.28 2.11 1.56 1.71 1.68
revenue (allocated for health
purposes) as percentage of GDP
CHE by financing schemes as 4.25 4.01 3.87 3.89 3.89
percentage of GDP
Government schemes and 2.32 2.14 1.61 1.76 1.71
compulsory contributory health-care
financing schemes as percentage of
GDP
Household OOP payment as 1.70 1.62 2.06 1.90 1.95
percentage of GDP
3.4.3 Cost-sharing (user charges)

There are no user fees charged for services in the state sector, even for
patients who are covered by private health insurance and government
employees covered by Agrahara. For non-citizens, an official communique
stipulates that user fees should be charged. This has not been updated, and
in the absence of billing systems at hospitals, this is poorly practised.
72
3.4.4 Direct payments
In the public sector, no official charges are incurred for inpatient/outpatient
services. However, there are user charges only for paying wards. As a large
segment of the population is not covered through prepayment insurance
schemes, most private sector encounters would result in direct payments.
3.4.5 Informal payments

Lewis (2006) reported that informal payments do occur to obtain admission
to a hospital, obtain a bed and to receive subsidized medications. In a study
conducted in Colombo involving 200 households, 61.2% of respondents said
that they had used personal relationships with hospital staff to circumvent
formal procedures such as reducing waiting time for consultation and
procedures, while 52.0% pointed out that they had given money or gifts to
hospital staff (Transparency International Sri Lanka and Friedrich Ebert
Stiftung, 2009). There has not been any recent study on informal payments
that patients may incur to obtain services, despite their being free.
3.5 Voluntary private health insurance

3.5.1 Private medical insurance schemes
The Presidential Task Force on National Health Policy (1993) identified
voluntary health insurance (VHI) as one mechanism to increase health sector
financing. A report in 1997 (Rannan-Eliya, 1997) observed that:
• VHI expansion would support expansion of private health services,

thus reducing the demand on government sector facilities where
higher-income groups could opt for private health care.
• VHI was seen as a mechanism with the potential to bring in additional
financial resources for the private health sector, as the public sector
has limitations on charging a fee from VHI.
• VHI was also expected to support increased cost recovery by
MoH facilities, in particular with respect to “pay-beds” at Sri
Jayewardenapura General Hospital.
3.5.2 Market role and size

Although the economy has grown and the upper middle-income group has
expanded, the corresponding increase in VHI is relatively small. In 1990, the
VHI penetration was less than 1% of total health expenditure (THE) (Rannan-
Eliya, 1997) and in 2013 it was 2.1% of CHE (Ministry of Health and Indigenous
Medicine, 2016). Withanachchi (2009) reports that in 2004, it was estimated
that VHI premiums account for 4.9% of THE. As a share of private health
73
insurance, VHI accounts for 9.7%, and around 10.4% of the total population
have subscribed to long-term VHI (Withanachchi, 2009). VHI generally
covers health risks that manifest less frequently and require expensive
treatment in tertiary-care institutions. All insurance schemes offer coverage
of inpatient treatment. Outpatient care is mostly covered too. The market
has not been efficient enough to attract people adequately for VHI, which is
reflected by its poor growth. Over time, with expanding per capita income,
people’s expectations too have changed and there has been an expression of
demand for private facilities within government hospitals to provide inpatient
care. This has largely been from the upper- and middle-income groups.
Government policies have in fact encouraged growth of the private health
sector as a means of shifting more affluent people to access these services,
whereby the government could focus more on providing care to lower-income
groups. VHI schemes are largely based on the ability to pay. The increase in
VHI is relatively small and mainly by the corporate sector for its employees.
In fact, the growth of the private sector has not attracted a corresponding
growth in VHI. Despite some growth in the health insurance market in
recent years and many policies and competition between local companies,
the overall contribution of private health insurance to health-care resource
mobilization is still minimal in Sri Lanka.
3.5.3 Market structure

One government organization (National Insurance Trust Fund [NITF]),
one not-for-profit firm and 13 for-profit firms provide health insurance
in Sri Lanka (Withanachchi, 2009). Since Sri Lankan health care is
universal and accessible to all, private insurance coverage is small and
often supplementary or complementary in nature, benefiting the higher-
income groups.
Private VHI is largely by enrolment of employed groups and, to a very low

extent, by individual enrolment (Govindaraj, Navaratne, Cavagnero, &
Seshadri, 2014). Pooling of OOPEs and formulating an insurance model of
financing is not relevant as the dominant government health-care delivery
is not organized in a way that can accept insurance payments and inpatient
private beds are still limited.
3.5.4 Market conduct

Pricing and promotion strategies of private health insurance providers are
diverse and decided by the industry. To some extent, the scope of services
provided by the government health services would have an influence, as seen
after the recent price reductions for essential drugs and devices by the MoH.
74
The government emphasis on health and well-being can also influence the
promotion strategies of the insurance industry.
3.5.5 Public regulation of VHI

The insurance industry is bound by the Regulations of Insurance Industry
Act No. 43 of 2000. The Insurance Act has vested the Insurance Board of Sri
Lanka (IBSL) with the authority to regulate the for-profit and not-for-profit
insurance firms (Withanachchi, 2009).
Regulation of private health care comes under the purview of the MoH but
the regulation of VHI schemes, which has the potential to improve access to
the private health sector by higher-income groups, has not been addressed.
Considering the increase in purchasing power of the higher-income group
and even the middle-income group, the regulation of the industry and pricing
policies can contribute to reducing OOPE and improving health financing.
The Insurance Industry Act requires insurers to collect and provide basic
statistics on the operation of their schemes and make this information
publicly available.
3.6 Other financing

3.6.1 Parallel health systems
The defence ministry and police departments have established their own
health services, including tertiary-care hospitals. However, their employees
can access government services as well. The Defence Ministry Scheme
(Armed Forces and Police Hospitals) accounted for 0.4% of CHE in 2016 (SLR
284 million at current prices).
Estate health services originated as a parallel health system, which is now

being absorbed gradually into the national health services.
Traditional medicine systems, including for both ambulatory and inpatient

services have been in existence for longer than the allopathic services. They
receive a separate government allocation. Government health expenditure
for this system accounts for less than 1% of CHE (2017). The utilization of
traditional medicine is limited when compared to services provided by the
allopathic system. There are specific illnesses, usually of a chronic nature,
for which traditional medicine is sought after most often by the population.
75
3.6.2 External sources of funds
The contribution of external sources is approximately 1% of CHE.
This constitutes grants and loans from developmental partners and
bilateral agreements.
3.6.3 Other sources of financing

Sri Lanka does not receive any other regular financial support of any
significance from other sources.
3.7 Payment mechanisms

3.7.1 Paying for health services
Line item budgets are allocated for different services, i.e. hospitals, public
health programmes, training institutes and administration. Further, these
budgets are categorized under recurring and capital, purchase of medicines
and supplies, laboratory services and administration and are listed
separately in the annual budget.
Budget allocation is based on the allocation of earlier years and incremental

calculations, where each year, unless there is a very specific need or item,
the previous year’s budget is increased by a percentage without taking into
account the actual figures of consumption or the outputs delivered.
The private sector operates on different terms and the payments are
generally based on actual outputs to be delivered and on the overall
business strategy.
3.7.2 Paying health workers

Payment mechanisms for health workers differ between the government
and private sectors. The government employees get a fixed salary as per
their scheme of recruitment, salary code, educational background, grade
and duration of service. The government system also pays staff for working
extra duty hours based on the rates applicable to the service category and
grade of service.
There are no payments given based on capitation or fee for service as

provider incentives and all payments strictly adhere to the well-established
government financial regulations.
76
Private sector employees receive payments based on whether they are
working full time, part time or on a fee-for-service basis. The emoluments
could vary depending on the demand and supply of the specific category
of staff. Further, compensation in the private sector is subject to variation,
mostly on the basis of performance.
A significant number of MOs work both in the government and private

sectors, the latter being after duty hours. This is known as dual practice or
moonlighting. In the private sector, they would work on a fee-for-service
basis, i.e. the number of patients seen or procedures performed.
77
4. Physical and human resources
Chapter summary
The state curative facilities in the allopathic system are organized into a
tiered structure, each providing a defined level of care. They range from the
National Hospital of Sri Lanka and teaching hospitals with super specialties;
provincial, district, general and base hospitals with selected specialties;
to divisional hospitals (outpatient care and inward care) manned by non-
specialist doctors and primary medical care units offering only outpatient
care. Some 628 hospitals provide inpatient care facilities and have a
combined total bed strength of 83 275 with an average of 3.9 beds per 1000
population. The public health services are mostly provided by the state sector
through a network of some 354 MOH units, which run 3825 branch clinics
spread across the country.
Sri Lanka completed a Service Availability and Readiness Assessment (SARA)

survey in 2017 among a sample of 755 facilities, including curative and
preventive service delivery points, the relevant findings from which have been
summarized in this chapter.
Investment proposals are identified through the respective national and

provincial budgets. Institutions that come under the line ministry are seen
to get a major share of funding for physical resources. In the private sector,
investment for ambulatory care clinics (general practitioner [GP] practices)
is borne by the practitioners themselves. Investment for the establishment of
private hospitals is done mostly through Board of Investment (BOI)-approved
projects by entrepreneurs.
The past decade has witnessed the development and deployment of many
institution-based electronic HISs in Sri Lanka. There are successful and
scaled-up models (i.e. electronic Indoor Morbidity and Mortality Reporting
[e-IMMR], Health Information Management System [HIMS], Hospital Health
Information Management System [HHIMS], Reproductive Health Management
Information System [RHIMS] and District Nutrition Management System
[DNMS]), which have been implemented with varying levels of maturity, while
the rest are limited to pilot implementation and have failed to scale up to the
national level. Major concerns identified are lack of clear policies guiding
78
health information management, compartmentalization of the information
governance mechanism, inadequate coordination among existing information
systems, limited data-sharing, moderate use of information for decision-
making and insufficient automation leading to a relatively modest quality of
health information. The National Policy on Health Information (2016) seeks to
rectify this situation.
The Ministry of Health (MoH)11 employs approximately 140 205 persons

(both in the line ministry and provincial health ministries) belonging to 327
different categories. The health workforce has gradually increased during the
period 2005–2015. However, this increase has not been uniform across staff
categories and an appropriate skill mix is yet to be identified. Further, along
with the evolving reforms in health care, service delivery cadres need to be
revised. Private sector health-care delivery is expanding but estimates of the
workforce are not available.
Recruitment and training of MOs has been regular through the university
system. However, in other staff categories, such as nursing, professions
supplementary to medicine (PSM) and paramedical categories, it needs
be streamlined. Initiation and expansion of graduate programmes in
state universities for nursing and some PSM staff categories have been
a significant achievement in the development of human resources (HR)
for health. Doctors have evident career development opportunities, but
more attention needs to be paid to career development pathways for other
staff categories.
Data on the professional mobility of health workers is limited. Monitoring

mechanisms need to be strengthened on dual practice, professional mobility
and private sector health workforce.
At present, key HR management functions of the MoH, HR planning,

recruitment services, training and development, services administration such
as administration of salary structures, service minutes, transfers, discipline,
performance appraisals, etc. are performed by various divisions of the MoH.
The Human Resource Coordination Division was established in 2017 to
improve coordination among these units.
11 The Ministry of Health (MoH) of Sri Lanka has undergone numerous name changes over the past
20 years. In the text of this document, we use “Ministry of Health (MoH)”, which is the current
iteration. However, when referencing ministry publications, we use the name that was used by the
Ministry at the time of publication.
79
4.1 Physical resources
This chapter describes the physical and human resources in the allopathic
system of medicine in Sri Lanka.12
4.1.1 Capital stock and investments

The state curative facilities are organized into a tiered structure, each
providing a defined level of care. They range from teaching hospitals linked to
universities that have super specialties, provincial, district, general and base
hospitals with selected specialties, to divisional hospitals (outpatient care
and inward care) manned by non-specialist doctors, and primary medical
care units offering only outpatient care. There are also a few specialized
hospitals that serve as centres of excellence in the system. In 2017, the total
number of hospital beds in the state sector curative facilities stood at 83 275
(Ministry of Health, Nutrition and Indigenous Medicine, 2018a; Ministry
of Health, Nutrition and Indigenous Medicine, 2019b). The numbers and
bed strength according to different types of state hospitals as of 2016 are
presented in Table 4.1.
Table 4.1 Distribution of state hospitals by category of institution and bed

strength
Number of
Category of institution Bed strength
hospitals
Tertiary care Teaching hospital 16 20 310
Provincial general hospital 3 5 076
District general hospital 19 12 080
Subtotal 38 37 466
Secondary Base hospital – Type A 24 8 891
care Base hospital – Type B 50 8 960
Subtotal 74 17 851
Primary care Divisional hospital – Type A 50 5 345
Divisional hospital – Type B 134 9 076
Divisional hospital – Type C 296 7 901
PMCU with maternity beds 11 145
Subtotal 491 22 467
Other hospitals 25 5 491
Total 628 83 275
PMCU: primary medical care unit

Source: Ministry of Health, Nutrition and Indigenous Medicine, 2019b
12 Although contemporary Sri Lanka has a pluralistic health system, the allopathic system caters to
the majority of the population. As stated in Chapter 2, this publication is mainly on the allopathic
system.
80
In addition to these state sector health-care facilities, the private sector has
around 200 hospitals, which have a combined bed capacity of 5120 (Ministry
of Finance, 2019). Private sector ambulatory care services are provided
through 424 full-time general practices and 4845 part-time general practices
(Amarasinghe et al., 2015a). Preventive services are mostly provided by the
state sector through a network of 354 MOH units and 3825 of their branch
clinics spread across the country.
The number of beds and the number of beds per 1000 population from
1965 to 2017 are presented in Figure 4.1. It indicates a 129% increase in the
number of beds per 1000 population from 1965 to 2017. With the private
sector combined, the overall bed strength has increased to 3.85 beds/1000
population. A comparison with selected countries in the Region shows that
in 2012, Sri Lanka (3.8/1000 population) had the highest bed availability, with
the least being reported by Indonesia (0.9/1000 population). Philippines,
Malaysia, Thailand and Viet Nam recorded 1.0 (in 2011), 1.9, 2.1 (in 2010) and
2.5, respectively (World Bank, 2020).
Figure 4.1 Number of beds and beds per 1000 population for Sri Lanka,
1965–2017
90 000 4.5
80 000 4.0
70 000 3.5
60 000 3.0
50 000 2.5
40 000 2.0
30 000 1.5
20 000 1.0
10 000 0.5
0 0.0
1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2017
Number of beds Beds / 1000 population
Source: Compiled by the authors from the Annual Health Bulletins of MoH 1980–2017
A SARA carried out in Sri Lanka in 2017 used a nationally representative

sample of 755 facilities drawn from a population of 2543 health facilities in
Sri Lanka. The sampling considered the type of facility and the geographical
variation within the country, and was appropriately weighted. Table 4.2
81
indicates the General Service Readiness Index (GSRI) and domain readiness
scores (out of 100) among health facilities by facility type and group (n=331).
The SARA describes a GSRI, which is a composite measure designed to
combine information from the five general service readiness domains: basic
amenities, basic equipment, standard precautions, laboratory diagnostics
and essential medicines. It is evident that the GSRI is higher in the private
sector than in the public sector and that the public sector gets a reduced
value due to the poor performance of primary care facilities. It is important to
note that at the tertiary- and secondary-care levels, the public facility GSRI is
higher than that for the private sector. This indicates that the public system is
more responsive to complex and acute care (Ministry of Health, Nutrition and
Indigenous Medicine, 2018b).
Table 4.2 General Service Readiness Index and domain readiness scores
(out of 100) among health facilities, by facility type and group
(n=331), Sri Lanka 2017
Readiness index
General Service
Basic amenities
for infection
precautions
prevention
equipment
Diagnostic
medicines
Essential
Standard
capacity
Basic
Facility type
Overall average 91 90 84 45 83 79
Public sector 91 89 83 41 83 77
Public tertiary 97 96 96 76 96 92
Public secondary 96 96 91 76 94 91
Public primary 90 87 80 33 80 74
Private hospitals 92 94 88 62 81 83
Source: Ministry of Health, Nutrition and Indigenous Medicine, 2018f
The SARA survey assessed readiness in several domains: staff and

guidelines, equipment, medicines and commodities, and overall readiness.
Table 4.3 shows that domain-specific as well as overall readiness on
these aspects were better in the public sector as compared to the private
sector. The government sector tertiary health-care services recorded the
highest values.
82
Table 4.3 Readiness score (overall and by domain) for surgical
management services in health facilities that are expected to
provide service, by facility type and group (n=157), Sri Lanka,
2017
Medicines
Staff and
Equipment and Overall
guidelines
Facility type readiness commodities readiness
readiness
score readiness score
score
score
Overall average 32 86 75 76
Public sector 42 94 86 85
Public tertiary 59 99 93 92
Public secondary 33 92 83 82
Public primary - - - -
Private hospitals 25 80 67 69
The average length of stay for acute care

Overall, there has been considerable improvement in the infrastructure
facilities of hospitals, both in the line ministry as well as in the provincial
health department. Sri Lanka has a low average duration of stay in hospitals
relative to countries of the Organisation for Economic Co-operation and
Development (OECD) and other countries in the Region (Smith, 2018). In
terms of type of services, the longest duration of stay is observed in the
leprosy hospital followed by mental hospitals. A decreasing trend can be
observed in the average duration of stay in all hospitals over time. This may
suggest improved technical efficiency over the years. A summary of the
average hospital stay over time by type of facility is presented in Table 4.4.
Table 4.4 Average duration of stay (days) in selected types of hospitals

per quarter from 2004 to 2017
Year
Type of hospital
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
National 4.8 4.4 4.4 4.3 4.3 4.2 4 4.3 3.9 3.9 3.7 3.7 3.7 3.5
hospitals
Teaching - - 3.6 3.6 3.5 3.4 3.3 3.2 3.1 3.2 3.3 3.2 3.1 2.9
hospitals
Provincial 3.9 4.2 3.1 3.3 3.2 3.1 2.6 - - - - - - -
hospitals
Base hospitals 3.0 3.0 2.4 2.3 2.2 2.1 2.1 - - - - - - -
District hospitals 2.3 2.2 1.9 2.0 2.1 2.1 1.8 - - - - - - -
Peripheral units 2.2 2.0 1.9 2.0 1.9 1.9 1.6 - - - - - - -
83
Table 4.4 Average duration of stay (days) in selected types of hospitals per
quarter from 2004 to 2017 (contd)
Year
Type of hospital
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Rural hospitals 2.1 1.9 1.8 1.9 1.9 2.2 1.6 - - - - - - -
Provincial - - - - - - - 3.5 2.9 2.9 3.2 3.1 3 2.9
general hospital
District general - - - - - - - 2.5 2.4 2.3 2.4 2.3 2.2 2.3
hospital
Base hospital - - - - - - - 2.3 2.0 2.1 2.1 2.1 2.0 2.1
type A
Base hospital - - - - - - - 2.2 2.1 2.3 2.1 2.1 2.1 2.1
type B
Divisional - - - - - - - 1.8 1.7 1.8 1.9 1.7 1.7 1.7
hospital type A
Divisional - - - - - - - 1.9 1.7 1.7 1.6 1.6 1.5 1.6
hospital type B
Divisional - - - - - - - 1.8 1.6 1.8 1.7 1.6 1.6 1.5
hospital type C
Children’s 3.0 3.1 2.9 3.3 3.2 3.0 2.8 3 2.8 2.9 2.8 2.9 2.8 2.7
hospital
Eye hospital 8.0 7.3 3.8 3.3 3.8 4.4 3.6 4.3 4.0 4.2 4.5 3.5 3.3 3.7
Cancer hospital 8.9 10.0 8.3 8.2 7.0 7.0 7.0 6.7 5.9 5.8 5.1 4.7 4.3 4.3
Mental hospitals 54.6 62.8 30.2 60.0 65.9 60.2 27.7 33.6 28.7 36.5 38.7 51.2 51.4 49.5
Chest hospitals 25.0 8.7 14.4 NA 12.5 10.5 14.7 14.3 12.3 15.7 14.7 15.9 15.5 14.9
Maternity 4.5 5.5 5.7 3.6 3.3 3.4 3.6 3.1 3.5 2.7 3.7 3.8 3.8 3.5
hospitals
Maternity homes 2.4 2.2 3.1 2.6 1.4 1.6 1.6 1.8 1.4 1.1 - - - -
Leprosy - - 73.3 77.0 87.9 75.0 88.1 74.5 84.4 77.6 87.7 81.9 81.9 75.5
hospitals*
Rehabilitation - - 24.5 30.0 26.1 26.9 26.5 33 24.0 29.3 30 30 18.9 17.1
hospitals
* It must be noted that the leprosy hospital is an institution from the past, when leprosy patients were
isolated in institutions. It holds patients who have been there over a long period of time and would be
closed when all the current patients are discharged.
The average hospital stay for Sri Lanka in secondary- and tertiary-care
hospitals is approximately 3.2 days (for acute care), while this is much lower
(around 2 days) for smaller institutions. The average for OECD countries
was 6.9, indicating that Sri Lanka experiences a high turnover of patients
for acute care, probably a reflection of the differences in morbidity among
admitted patients.
84
Investment and funding
Investments for physical resources are identified in the annual budget
estimates at central and provincial ministerial levels. The Treasury will
evaluate these proposals and decide on funding through domestic or external
resources. Some investment for physical resources is received as grants
and the majority is negotiated as soft loans. Institutions that come under
the line ministry are seen to get a major share of the funding for physical
resources. It is probably a reflection on the type of institutions that are under
the line ministry.
In the private sector, investment for ambulatory care clinics (GP practices)
are borne by the practitioners themselves. Investment for the establishment
of private hospitals is done mostly as BOI-approved projects. Both local and
foreign funds may be used for these investments.
Four companies, Nawaloka, Asiri Hospital Holdings, Lanka Hospitals and

Durdans, deliver the bulk of private health-care services. Most of the
private health sector is locally owned and operated, although around 3% of
medium-size health facilities have a foreign partner. The low level of foreign
investment could stem from the hostile takeover of Apollo, an Indian hospital
company, in 2006 by a local business magnate. However, in 2012, a UK-based
global private equity firm, Actis, invested US$ 32 million for approximately
30% of Asiri Hospital Holdings.
It appears that the high fixed costs of operating health-care facilities have
served as a barrier to new entrants. Nevertheless, the big four have all
engaged in expanding their capacity over the past few years, either within
Colombo or to other cities outside the capital. The number of private
hospital beds increased by 70% between 2006 and 2013 (The Economist
Intelligence Unit, 2014).
Nongovernmental organizations (NGOs) have a very small role in the health-

care system, focusing mainly on supplementing family planning services
provided by the government sector.
4.1.2 Infrastructure
4.1.2.1 Accident and Emergency (A&E) units and intensive care units
A&E services
In 2002, a need was identified to develop A&E services in the country. A
five-year project was launched to improve A&E services covering level 1 to
level 4 centres. A total of LKR 8 billion was invested in 12 new, purposely
designed A&E units and in upgrading the existing 22 A&E units. With the
current reorganization, it is envisioned that every hospital should have an
85
emergency treatment or A&E unit. A&E policy and implementation guidelines
have already been issued to streamline A&E services. The A&E expansion
project is expected to add 800 dedicated emergency beds to the system. At
present, A&E data are not reported to the national level and there is a data
gap regarding A&E service provision.
Intensive care services

According to a rapid survey conducted by WHO in 2020, it was identified
that there were some 831 functional intensive care unit (ICU) beds in 141
ICUs across the country, with an average ICU bed availability of 3.8 beds per
100 000 population. The fact that each district will have at least one District
General Hospital and two or more base hospitals guarantees that ICU beds
are equitably distributed in the provinces. It is planned to increase ICU beds
by 10% every year for the next five years. The distribution of ICUs by province
is presented in Table 4.5 below.
Table 4.5 Distribution of ICU facilities by province
ICU beds/100 000
Province Number of ICUs ICU beds
population
Western Province 51 344 5.6

Central Province 21 103 3.7
Southern Province 17 127 4.8
Northern Province 7 30 2.7
Eastern Province 14 78 4.6
North Central Province 8 39 2.9
North Western Province 7 37 1.5
Uva Province 8 42 3.1
Sabaragamuwa Province 8 31 1.5
Total national 141 831 3.8
Source: World Health Organization, 2020b
4.1.3 Medical equipment

The SARA survey of 2017 assessed the availability of the following basic
equipment: adult weighing scale, child weighing scale, thermometer,
stethoscope, blood pressure (BP) apparatus and light source. Facilities were
also assessed on the availability of the following tracer equipment needed for
emergency or specialized care: intravenous infusion kits, ophthalmoscope,
peak flow meter, spirometer, nebulizer, spacers for inhalers, infusion pump,
pulse oximeter, cardiac monitor, defibrillator, oxygen supply with flow meter,
speculum, spatula and colposcope. The summary of their availability as per
SARA 2017 is presented in Tables 4.6 and 4.7.
86
According to the SARA (2017), the availability of adult weighing scales
and BP apparatus was high among all levels of care. The private sector
indicated greater availability than the public sector for all the tracer items.
The availability of child weighing scales was low, particularly in primary
health care facilities (30%). At the national level, 30% of facilities were
equipped with all tracer items, with tertiary- and secondary-level facilities
having high scores.
Table 4.6 Percentage distribution of basic equipment
basic equipment
Adult weighing
Child weighing
Thermometer
Facilities with
BP apparatus
Light source
tracer items
Stethoscope
Facility type
scale
scale
Sri Lanka 96 38 71 75 94 79 30
Public sector 96 36 69 73 94 78 28
Public tertiary 98 80 98 98 100 100 78
Public secondary 100 86 100 96 98 99 80
Public primary 98 30 83 72 97 82 22
Private hospitals 100 66 100 100 100 100 66
According to the SARA (2017), nebulizers were seen to be available in almost

all facilities. The private sector indicated greater availability than the public
sector for all the tracer items. Of the public facilities, more emergency
equipment was available at tertiary- and secondary-levels of care.
Table 4.7 Percentage availability of emergency equipment tracer items by

type of facility
Defibrillator
infusion kits
Intravenous
Ophthalmo-
supply with
flow meter
Nebulizer
oximeter
Facility type
Infusion
monitor
Cardiac
Oxygen
scope
Pulse
pump
Sri Lanka 67 63 91 38 51 40 36 43
Public sector 65 60 90 33 46 36 32 40
Public tertiary 98 98 100 98 98 95 95 98
Public secondary 100 99 100 91 95 99 97 98
Public primary 68 56 89 19 41 29 24 44
Private hospitals 90 88 100 56 86 69 71 88
87
The SARA also assessed the availability of communication facilities,
computers with Internet access, availability of emergency transportation,
an emergency source of power, an improved source of water supply and
sanitation facilities. It was observed that the private sector facility profile was
better than that of the public sector and, among the public sector, tertiary-
care facilities were functioning optimally with near 100% values (Table 4.8).
Table 4.8 Percentage availability of tracer items for basic amenities

among health facilities, by facility type and group (n= 755), Sri
Lanka, 2017
tion equipment
Computer with
Power source
water source
Communica-
Emergency
Sanitation
transport
Improved
Facility type
facilities
Internet
Sri Lanka 91 53 86 92 99 92
Public sector 90 51 93 91 99 91
Public tertiary 100 100 98 98 100 100
Public secondary 99 100 99 97 100 100
Public primary 91 41 - 89 99 94
Facility for radiological investigations was high, for example, 79% of

secondary-care hospitals and 95% of tertiary-care hospitals had X-ray
machines, and 90% of secondary-care hospitals and 95% of tertiary-care
hospitals had ultrasound equipment. X-ray and ultrasound equipment was
available at most private hospitals too (65% and 75%, respectively). The
availability of CT scanners was limited to several government tertiary-care
hospitals and major private hospitals (Table 4.9).
Table 4.9 Percentage availability of tracer items for diagnostic capacity

among health facilities, by facility type and group (n=755), Sri
Lanka, 2017
Ultrasound
Facility type X-ray machine CT scanner ECG machine
machine
Sri Lanka 68 76 34 58
Public sector 71 77 59 55
Public tertiary 95 95 59 98
Public secondary 79 90 - 98
Public primary - - - 51
Private hospitals 65 75 27 80
88
The percentage of health facilities with the capacity to manage acute
myocardial infarction, stroke and provide haemodialysis and renal
transplantation was assessed. The findings indicate that most of the state
sector tertiary-care services have these services and that these facilities
are lacking in some secondary-care facilities. The public sector had more
services in this category than the private sector, where it was available in only
a limited number of major private facilities (Table 4.10).
Table 4.10 The percentage of health facilities with the capacity to manage
acute myocardial infarction, stroke and provide haemodialysis
and renal transplantation
cardiac functions
Management of
transplantation
cardiovascular
Haemodialysis
angioplasty or
Thrombolysis
Monitoring of
Coronary
stenting
disease
Renal
Facility type
Sri Lanka 59 46 51 35 21 16
Public sector 64 47 93 38 26 60
Public tertiary 100 100 97 38 59 19
Public secondary 99 86 92 - 11 -
Public primary 56 38 - - - -
Mammography services, imaging services such as CT and MRI, angiography

and positron emission tomography (PET) scans are available only at tertiary
care facilities and several specialized hospitals. Specialized hospitals refer
to those for diseases of the eye and ear, nose, throat (ENT), cancer, children,
maternity, chest, among others, specialized for a group of people or specific
diseases or services. The availability of these equipment depends more
on the availability of specialized HR to provide these services. Data on the
availability and distribution of these technologies or data on population
numbers served are not routinely available.
While access to medical technologies that may result in better diagnosis and
treatment has improved over time, this has also contributed to increases in
health spending. The availability of CT, MRI, mammography and radiation
therapy units were considered for cross-comparison with other countries
in the Asia Pacific Region. It had been reported that in 2013, per 1 million
persons, there were 1.7 CT scanners, 0.4 MRI machines, 0.6 radiation therapy
units, and 2.8 mammography machines per 1 million females 50–69 years
(OECD/WHO, 2016). The availability of these in comparison with Asia Pacific
regional and OECD countries are presented in Table 4.11.
89
Table 4.11 Availability of imaging and therapeutic equipment in selected
Asia Pacific countries
Mammography/ Radiation
CT/million MRI/million
Country million females therapy/million
population ** population **
50–69 years * population **
Sri Lanka 1.7 0.4 2.8 0.6
Thailand 6.0 - 27.9 1.0
Myanmar 0.1 0.1 0.7 0.1
Malaysia 6.4 2.9 86.7 1.4
Singapore 8.9 7.8 127.7 3.5
Philippines 1.1 0.3 13.1 0.2
OECD 25.0 14.8 176.7 7.2
* for the year 2014 except for Sri Lanka, which was for 2013; ** 2013
Source: OECD/WHO, 2016
Sri Lanka fares better than Myanmar and worse than Thailand in the Region
and lower than countries in the Western Pacific Region (Malaysia and
Singapore) and the OECD countries. This may reflect the impact of limited
investment on health as indicated by an investment of less than 2% of the
GDP during the past decade.
4.1.4 Information technology

The past decade has witnessed the development and deployment of many
institution-based electronic health information systems in Sri Lanka. There
are successful and scaled up models (i.e. electronic Indoor Morbidity and
Mortality Reporting [e-IMMR], Healthcare Information and Management
System [HIMS], Hospital Health Information Management System
[HHIMS], electronic Reproductive Health Management Information System
[e-RHIMS] and District Nutrition Monitoring System [DNMS]), which have
been implemented with varying levels of maturity at the moment.
There are about 23 different types of health information systems currently

used by different directorates, programmes, institutions and focal points of
the MoH (Table 4.12). Since an evaluation has not been done of the different
systems by reviewing their intended use, scope, capabilities, outputs,
platforms on which they have been developed and their interoperability,
limited effort has been expended in linking the information generated
within each of these systems. Efforts to integrate these systems at
different levels have been identified as an urgent need, yet the execution
shows slow progress due to varied reasons. This has led to lost gains and
gross duplication of information, and extra effort to input information into
these systems
90
Table 4.12 Health information systems in Sri Lanka*
Health information systems in Sri Lanka
Curative care
Electronic Indoor Morbidity and Mortality Reporting (e-IMMR)
Hospital Health Information Management System (HHIMS)
Hospital Information Management System (HIMS)
Accidents and Emergency Information System, OPD Information System
Preventive care
Electronic Reproductive Health Management Information System (e-RHMIS)
District Nutrition Monitoring System (DNMS)
Web-based Immunization Information System (WEBIIS)
Electronic Mental Health Management Information System
Disease-specific
HIMS – Anti-Malaria Campaign
National HIV/AIDS Programme (EIMS)
Quarantine Health Record Management and Surveillance System (QHRMS)
Anti-Leprosy Campaign (LeIS)
Administrative and other

Health Facility Survey System (HFSM)
Medical Supplies Management Information System
Human Resource Management Information System (HRMIS)
National Blood Transfusion Service (NBTSIS)
Electronic Monthly Statistics Reporting System (eMSRS)
Civil Registration and Vital Statistics System (CRVS)
*List collected through personal communications, official channels and from already published
material; an open invitation was sent to all MoH stakeholders to provide information about their HIS
systems.
Major concerns identified by the national policy on health information can

be listed as lack of clear policies guiding health information management,
compartmentalization of the information governance mechanism,
inadequate coordination among existing information systems, limited data-
sharing, moderate use of information for decision-making, and insufficient
automation leading to a relatively modest quality of health information. It
has also been noted that new information systems/solutions were developed
with the use of a significant amount of resources by the government and the
private sectors. Efforts to integrate the systems at different levels have been
identified as an urgent need.
91
A detailed electronic health information system mapping was conducted in
2018 by the MoH with technical support from WHO. The assessment was
based on the mHealth Assessment and Planning for Scale (MAPS) toolkit
as the primary evaluation tool, which has a proven validity internationally.
Twenty-three data points of four types of systems from curative care, four
types of systems from preventive care, four disease-specific systems and
six types of administrative (other) systems were included in the evaluation.
The number of health-care workers using the systems varied from 50 to over
2000 workers. Most of the systems were national-level implementations with
most using universal classifications/coding systems and data standards such
as the ICD-10 and Health Level Seven (HL7) international standards.
The MAPS evaluation identified the following:
• An architectural plan needs to be developed to address the business

requirements of the MoH.
• Systems that are not available need to be developed and those that are
already implemented need to be fine-tuned to suit the requirements of
the business architecture.
• Data architecture should deal with the data elements that need to
be shared between systems. The data architecture of the current
systems could serve as the baseline for a better, interoperable data
architecture.
• Technology architecture should deal with hardware and network
requirements.
• Target application architecture should decide the applications that
fulfil the needs of the identified business architecture.
Hence, the MAPS evaluation and the information derived from it should
provide a comprehensive starting point.
Use of information technology (IT) in health systems

For the continued progress of health care, electronic health records
(EHRs) are the next step that can strengthen the relationship between
patients and doctors. The data, timeliness and availability of records would
enable providers to make better decisions and provide better services to
stakeholders of the Sri Lankan health sector, including decision-makers.
The information and communication technology (ICT) agency of Sri Lanka
developed the HHIMS (Hospital Health Information Management System) at
the request of medical practitioners and administrators of the government
health sector as far back as 2010. It is a free and open-source software
solution (FOSS). The system includes an electronic medical record with
separate sections for: patient admission, giving appointments and queue
92
management; clinic management; Laboratory Information System (LIS);
pharmacy stock management; notification of communicable diseases;
outpatient department (OPD) management; performance and monitoring
of report generation; ward management; user management; Permission
and Picture Archiving and Communicating System (PACS) modules. A
performance management dashboard is also included in the HHIMS.
By 2017, 35.71% of secondary- and tertiary-care institutions were using EHR

for record-keeping at OPDs and clinics. Of these, in 40% of hospitals, 100%
of OPD prescriptions were electronic. Electronic prescription can facilitate a
review of the prescription and consumption of different types of antibiotics in
response to antimicrobial resistance (AMR) through improved stewardship.
4.2 Human resources

The health workforce can be defined as “all people engaged in actions whose
primary intent is to enhance health” (World Health Organization, 2006). HR
in health care comprises different kinds of clinical and non-clinical staff
responsible for public and individual health interventions. Undoubtedly, the
most important of the health system inputs, the performance and benefits
the system can deliver, depend largely on the knowledge, competencies,
attitudes and motivation of those individuals responsible for delivering
health services.
The MoH employs slightly over 140 000 staff (both in the line ministry and
provincial health ministries). Of all staff, 58% are skilled personnel and, of
them, the core is composed of medical officers (specialist and grade medical
officers), nurses, midwives, public health inspectors, dental surgeons,
medical laboratory technologists and pharmacists (Ministry of Health,
Nutrition and Indigenous Medicine, 2017b). Distribution of selected main
staff categories and the health facility levels at which they work are shown
in Table 4.13.
93
Table 4.13 Distribution of selected main staff categories and the health
facility levels at which they work (2015)
Curative and preventive care Preventive care
Category Number TH, PGH,
DH PMCU MOH
DGH, BH
Medical officers 18 243 √ √ √ √
Dental surgeons 1 340 √ √
Nurses 42 420 √ √
Public health nursing 290 √
sisters
Public health inspectors 1 604 √
Public health midwives 6 041 √
Hospital midwives 2 765 √
Pharmacists 1 504 √
Dispensers 1 177 √
Medical laboratory 1 554 √
technicians
Microscopists (PHLT) 245 √
Radiographers 588 √
Physiotherapists 519 √
Occupational therapists 90 √
School dental therapists 349 √
Dental technicians 50 √
Ophthalmic technician 178 √
Food & drug inspectors 55 at RDHS level
ECG recordists 298 √
EEG recordists 66 √
PH field officers 403 √
Others 2 236
Skilled personnel 82 015
Attendants 9 070 √
Support 49 120 √ √ √ √
Total 140 205
BH: Base Hospital; DGH: District General Hospital; DH: Divisional Hospital; MOH: Medical Officer of
Health; PGH: Provincial General Hospital; PHLT: public health laboratory technician; PMCU: Primary
Medical Care Unit; RDHS: Regional Director of Health Services; TH: Teaching Hospital
Sources: Ministry of Health, Nutrition and Indigenous Medicine, 2017b and 2019a
The proportion of non-skilled staff members is relatively higher compared

to skilled staff. Although non-skilled staff members do not have formal
training, they engage in high-volume multiple tasks, which are necessary in
the Sri Lankan context, considering the relatively slow rate of mechanization
94
and automation of processes. Further, specific assistant staff categories
are limited in the Sri Lankan setting; thus, work such as handling electrical
equipment, plumbing, lighting adjustments in the theatre, distribution of
food in the hospital, some cleaning processes, etc. are handled by the non-
skilled staff. Thus, some degree of multitasking is evident, which has some
favourable as well as unfavourable consequences on the current system.
The private sector contribution to the provision of health care in Sri Lanka
has been growing immensely during the past two decades. Specialists, MOs,
nurses and selected PSM and paramedical categories in the state sector
have been granted permission to engage in off-hours private work; most of
the private sector specialists and MOs are from the state sector. However,
the exact number of health-care personnel employed in the private sector
currently is not known. The national health workforce accounts would fill in
the gaps in statistics in the private sector.
According to a private health sector review (2015), there are 424 full-time
and 4845 part-time MOs (Amarasinghe et al., 2015a). The number of nurses
working in private hospitals was approximately 4500; most work full-time
while some of the nursing tasks were done by nursing assistants. It is
estimated that around 50–60% of government sector MOs and more than 90%
of government sector medical specialists (consultants) work part time in the
private sector. However, private health-care delivery has greatly improved
in the past two decades and anecdotal evidence suggests that HR estimates
should be much higher than that given by Amarasinghe et al. (2015a).
4.2.1 Health workforce trends

The number of health workers in the MoH has been steadily increasing from
2005 to 2015. Given that the population did not grow as fast as the number
of health workers, the increase in health workers has led to an improvement
in the number of health workers per population. In 2005, there were 2.2
health workers (including doctors, nurses and other cadres) per 1000
population and, by 2015, there were 3.7 doctors, nurses and midwives per
1000 population (World Health Organization, 2018b). This represents a 70%
increase in the ratio of health workers to population over the past decade in
Sri Lanka. Furthermore, Sri Lanka has almost reached the WHO-identified
minimum density threshold of 34.5 skilled health personnel per 10 000
population (World Health Organization, 2014a) in the context of universal
health coverage, with a level of 33 skilled health personnel (physicians,
nurses and midwives) per 10 000 population. However, this upward trend in
the number of staff has not been uniform across all categories (World Health
Organization, 2018b). This increment has been significantly higher in MOs,
dental surgeons and nurses relative to other staff categories.
95
Doctors, dental surgeons and nurses
By 2017, there were 19 800 medical doctors (including specialists), 1473
dental surgeons, 45 480 nurses (including trainees) (Ministry of Health,
Nutrition and Indigenous Medicine, 2019b). Improvement in the numbers and
density of doctors, nurses and dental surgeons is shown in Table 4.14 and
Figure 4.2, respectively. During the 2005–2017 period, out of the three staff
categories, the number of nurses increased by 128%. The number of MOs
and dental surgeons increased by 94% and 54%, respectively. The increase in
the number of nurses has been unsteady, with large surges in the number of
nurses in 2006, 2007, 2010, 2014 and 2015. Among MOs, such inconsistency is
less evident but was seen in 2008 and 2009.
Table 4.14 Distribution of the numbers and density of the health workforce
– medical officers, dental surgeons and nurses, 2005–2017
Health workforce density, per 1000
Number
population
Medical Dental Medical Dental
Year Nurses Nurses
officers surgeons officers surgeons
2005 10 198 954 19 934 0.52 0.05 1.01
2006 10 279 1 181 24 988 0.52 0.05 1.26
2007 11 023 1 314 31 466 0.55 0.06 1.57
2008 12 479 858 30 063 0.62 0.04 1.49
2009 13 737 1 046 31 297 0.68 0.05 1.53
2010 14 668 1 139 35 367 0.71 0.06 1.71
2011 15 273 1 147 35 870 0.73 0.05 1.72
2012 15 910 1 223 36 486 0.79 0.06 1.79
2013 16 690 1 279 35 629 0.82 0.06 1.73
2014 17 615 1 360 38 451 0.85 0.07 1.85
2015 18 243 1 340 42 420 0.87 0.06 2.02
2016 18 968 1 433 42 556 0.89 0.07 2.01
2017 19 800 1 473 45 480* 0.92 0.07 2.12
*Including around 7500 trainees

Sources: Annual Health Bulletin, 2008–2017; Annual Health Statistics, 2017
The ratio of doctors per 1000 population in Sri Lanka increased from 0.52
in 2005 to 0.92 in 2017. However, this is lower than the OECD average of 3.4
doctors per 1000 population in 2015 (World Health Organization, 2018b). The
ratio of nurses has doubled during the past decade to reach a density of 2.12
nurses per 1000 population by 2017. This is still significantly lower than the
average across OECD countries, where there were around 9 nurses per 1000
population in 2015 (World Health Organization, 2018b).
96
The ratio of nurses to MOs in 2005 was 1.95 nurses per MO and this had
increased to 2.3 by 2017. However, this is still below the OECD average in
2015, where there was 3 nurses per MO (World Health Organization, 2018b).
Figure 4.2 Trends in health workforce density (medical officers, dental
surgeons and nurses), 2005–2017
2.50
2.00
Density/1000 population
1.50
1.00
0.50
0.00
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Medical Officers (including specialists) Dental Surgeons Nurses
Sources: Annual health bulletins, 2008–2017; Annual health statistics, 2017
Professions supplementary to medicine (PSM) and paramedical categories

Several health-care categories are identified under the PSM and paramedical
categories. The main functions and work settings of selected categories are
shown in Table 4.15.
97
Table 4.15 Main functions and work settings of selected PSM and
paramedical categories
Category Main functions Work setting
Pharmacist Issuing medicines, pharmaceutical Hospitals, regional medical
devices and other health-care supplies divisions
products prescribed by medical Central institutions (e.g.
professionals Medical Supplies Division
Providing health-care information [MSD]), private hospitals
for Good Pharmacy Practice
Maintaining institutional medical
supplies
Medical Laboratory Conducting medical laboratory tests Medical laboratories at
Technologist (MLT) and procedures government hospitals
and specialized health
institutions, central
research institutions
Physiotherapist Providing physiotherapy services to Physiotherapy units in
patients hospital settings
Occupational Involved in rehabilitation activities Occupational therapy units
Therapist (OT) with patients who have physical and/ in hospitals and community
or psychological health problems settings
School Dental Looking after the oral health needs School dental clinics
Therapist (SDT) of schoolchildren from 3 to13 years
Radiographer Performing radiological Radiography units of
investigations hospitals
Radiotherapists/ Delivering radiation treatment, Hospital/institutional
Radiation therapist primarily for people diagnosed with radiotherapy departments
cancer
Health Entomology Carrying out entomological Field-level officers –
Officer investigations and assisting in Medical Officer of Health
vector control activities areas and local government
institutions
Ophthalmic Involved in detecting eye and visual Optometry units of hospitals
Technologist abnormalities
Prosthetist and Designing and applying prosthesis Prosthetics and orthotics
Orthotist and orthosis units of major hospitals
Electrocardiogra- Performing investigations such as In hospital settings
pher electrocardiography (ECG), exercise
ECG test, Holter monitoring, etc.
Electroencephalog- Performing neurophysiological In hospital settings
rapher investigations
Source: Compiled by Human Resources for Health Coordination Unit - Ministry of Health, Sri Lanka
(2020)
98
The distribution of health-care personnel in these categories is shown in
Table 4.16. During 2006–2016, the number of pharmacists increased the most
(103%) followed by MLTs (82%). Physiotherapists, occupational therapists,
ophthalmic technicians and dental technicians increased by 62%. However,
the increment is grossly irregular across all staff categories. In some
categories, the number has been static or nearly static in consecutive years.
Table 4.16 Distribution of numbers of health-care personnel in selected

PSM and paramedical categories, 2006–2017
Dental technicians
Physiotherapists
Entomological
School dental
Occupational
Pharmacists
Ophthalmic
technicians
therapists
therapists
assistants
MLTs
2006 786 716 193 43 403 18 34 77

2007 886 858 233 57 402 27 43 105
2008 959 973 243 56 335 21 47 111
2009 1086 1155 278 73 341 39 63 142
2010 1240 1402 345 87 345 40 88 138
2011 1336 1480 369 84 386 46 95 145
2012 1365 1478 381 85 392 42 91 140
2013 1348 1483 385 103 434 54 98 132
2014 1469 1461 452 112 365 52 125 180
2015 1504 1554 519 90 349 50 140 178
2016 1546 1566 500 111 364 47 141 198
2017 1626 1724 618 137 368 42 155 240
Sources: Ministry of Health, 2015; Ministry of Health, Nutrition and Indigenous Medicine, 2019b
As per Figures 4.3 and 4.4, there is a gradual positive trend in the number
and density of pharmacists, MLTs and physiotherapists. In some health-
care professions, the numbers had declined towards the latter part of
the reporting period. As shown in Figure 4.3, recruitment for training of
MLT, radiographers and physiotherapists has been irregular. Most of the
other PSM and paramedical categories have not been recruited during the
2013/2014 period.
99
Figure 4.3 Trends in health workforce density (PSM & paramedical
categories), 2008–2017
0.0 9
Health workforce density per 1000 population
0.0 8
School Dental
0.0 7 Therapists
0.0 6 Occupational
Therapists
0.0 5
Physiotherapists
0.0 4
0.0 3 Medical
Laboratory
0.0 2 Technologists
0.0 1 Pharmacists
0.0 0
200 8 200 9 201 0 201 1 201 2 201 3 201 4 201 5 201 6 201 7
Sources: Annual health bulletins, 2008–2017
According to the Global pharmacy workforce report (International

Pharmaceutical Federation, 2012), out of the 82 countries that had been
included, the mean density of pharmacists was 6.02 per 10 000 population.
The South-East Asia Region has a reported density above 3 per 10 000
population. The Sri Lankan figure is well below the average.
Irregularity in recruitment for training has resulted in fewer PSM and

paramedical staff joining services annually. This is well expressed in Figure
4.4. In all three categories, no recruitment has taken place for training during
2011–2013 and a larger number of trainees have been recruited afterwards.
Figure 4.4 Number recruited for training in MLT, Radiography and
Physiotherapy, 2010–2016
MLT Radiographers Physiotherapists
400 80 150
300 60
100
200 40
50
100 20
0 0 0
2010
2011
2012
2013
2014
2015
2016
2010
2011
2012
2013
2014
2015
2016
2010
2011
2012
2013
2014
2015
2016
No. trained No. trained No. trained

Capacity Capacity Capacity
Source: Compiled by the Human Resources for Health Coordination Unit, Ministry of Health Sri Lanka
based on Annual Health Statistics 2010–2017
100
Public health cadres
Categories considered under public health cadres are public health midwives
and public health inspectors, public health nursing sisters and public
health midwives working in the field. At field level, they provide clinic care
(at maternal, child welfare, family planning and well-woman clinics) and
domiciliary care (provided during household visits to children and pregnant
mothers) and communicable disease control. The target population for a
public health midwife is 3000 in rural settings, including the estate setting,
and 5000 in urban settings.
Public health inspectors are responsible for environmental management

in relation to health, investigation and control of communicable diseases,
maintenance of occupational health, school health, food safety, health
education and health promotion, and enforcement of public health law. The
target population for a public health inspector is 10 000. The distribution of
numbers and density over 2005–2017 is shown in Table 4.17.
Table 4.17 Distribution of the number of health-care personnel in public

health categories, 2005–2017
Public health Public health Hospital
Year PH inspectors
nursing sisters midwives midwives
2005 313 4896 2371 1512
2006 299 5080 2555 1354
2007 290 6167 2828 1548
2008 270 5331 3016 1475
2009 264 5389 2768 1398
2010 380 5477 2971 1436
2011 349 5491 2884 1501
2012 332 5821 2605 1510
2013 322 5950 2848 1544
2014 277 5954 2888 1526
2015 290 6041 2765 1604
2016 277 6247 2365 1692
2017 328 5746 2485 1720
The number of public health nursing sisters has remained almost static,
other than the surges in 2010 and 2017. The number of public health
midwives and public health inspectors has increased by only 17.4% and
13.8%, respectively, during the 2005–2017 period. This increment too has
101
been irregular over the period and can clearly be explained by the variation
in recruitment of trainees. The number of hospital midwives also increased
by 4.8%, but this too has been irregular throughout. Compared to other staff
categories, the increase in public health staff has been low. This is mainly
due to reluctance among the younger population to enter the public health
sector and an irregular recruitment process. Thus, the target population for
service provision usually exceeds the expected number and sometimes a field
public health midwife has to look after vacant service areas. This jeopardizes
the quality of services. In addition, the numbers leaving the service through
retirement have not been adequately addressed by new recruitments, as
seen in 2017 (Figure 4.5).
Figure 4.5 Trends in health workforce density – public health cadre,
2008–2017
0.350
Density per 1000 population
0.300
0.250
0.200
0.150
0.100
0.050
0.000
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Public Health Inspectors Hospital midwives Public health midwives
Distribution of health staff across districts

According to the annual statistics for 2015 (Ministry of Health, Nutrition
and Indigenous Medicine, 2017b), health staff are concentrated in relatively
urban, developed districts and around areas with teaching hospitals. The
density of MOs is highest in Colombo district, where seven tertiary care
hospitals out of the 16 in the country are located. The second highest is in the
Kandy district, where three tertiary care hospitals are located. The density
of MOs demonstrates a close positive relationship with bed strength (Figure
4.6). In addition, these districts have many teaching units, giving rise to a
number of teaching and training staff. The District of Ampara demonstrates
an increase due to having two health regions within the district. Equity
of human resources for health is further described under section 7.3.2
and Table 7.1.
102
Figure 4.6 Density of medical officers and bed strength by district
9.00
8.00
7.00
Per 1000 population
6.00
5.00
4.00
3.00
2.00
1.00
0.00
Mullaitivu
Colombo
Galle
Mannar
Ratnapura
Matale
Moneragala
Matara
Vavuniya
Kegalle
Nuwara Eliya
Kandy
Gampaha
Kalutara
Puttalam
Hambantota
Killinochchi
Trincomalee
Kurunegala
Badulla
Ampara
Jaffna
Anuradhapura
Polonnaruwa
Batticaloa
Medical Officers / 1000 population Beds / 1000 population
The government has implemented several measures to improve the

maldistribution of staff. Some of these measures are targeted admission
policies, a policy to recruit students based on district quotas with special
attention to rural areas, establishing state medical faculties, recruiting
nurses and PSM/paramedical staff categories to cover almost all provinces,
and instituting compulsory appointment of intern and post-intern MOs to
relatively underserved areas. Further attempts are under way to define
certain medical institutions as difficult medical institutions based on some
selected criteria and appoint staff to them.
In the private sector, of the 125 private hospitals recorded in 2011, 51

(41%) were in the Western Province, which is home to nearly a third of the
country’s population and where Colombo, the country’s administrative and
commercial capital, is located. Furthermore, the Western Province accounted
for approximately 54% of the total private hospital beds in 1990 and this has
increased to 65% in 2011 (Amarasinghe et al., 2015a).
Skill mix
Sri Lanka is yet to identify the most appropriate skill mix of staff categories
for hospital settings, which would be necessary to face the evolving health
sector challenges. Along with efforts that are under way to restructure and
103
strengthen PHCs, HR needs and the right skill mix at varying hospital levels
will be defined. Workload studies (workload indicators of staffing needs) are
being conducted; these will help to identify the HR needs and skill mix in
primary care institutions.
Among public health cadres, population standards are already set and
implemented, the population per public health midwife (PHM) being 3000
in rural settings and 5000 in urban settings, and the population per public
health inspector (PHI) being 10 000. Currently, fulfilling these cadres
with adequately qualified personnel has been challenging due to lack
of preference for these staff categories among the younger generation.
This is highly evident among PHMs. On several occasions (in 1996, 2000,
2002 and 2009), recruitment criteria were changed for PHMs, lowering
the educational qualifications to improve service delivery in rural and
underprivileged districts, and war-affected areas of the Northern and
Eastern Provinces where there are difficulties in providing adequate care. As
financial incentives, several allowances are given to PHMs and PHIs. PHMs
are provided with an office allowance (LKR 250 per month), field allowance
(LKR 3000 per month) and a clinic allowance (LKR 400 per additional clinic
session with a maximum of 5000 per month), with some cadres getting extra
duty payments up to a maximum of 50 hours. PHIs are given a risk allowance
(LKR 3000 month), office allowance (LKR 1000 per month), uniform allowance
(LKR 15 000 per year), combined travelling allowance (maximum LKR 5000
month upon fulfilling the criteria for the allowance). However, some of these
allowances have not increased on a par with the current cost of living and
need to be revised.
In the curative sector, the medical specialties to be established at each level

have been identified. Along with the specialty’s establishment, expansion of
relevant supportive services and infrastructure development have been taken
into consideration to optimize HR allocation and utilization.
4.2.2 Professional mobility of health workers

An HR projection on specialists (De Silva, 2017) has indicated that during
2016–2025, a total of 765 specialists will be lost to the MoH due to joining
local universities, defence establishments, the private sector or the global
market. However, apart from those joining the global market, others will be
serving the Sri Lankan population.
Migration of medical professionals is a long-recognized problem in Sri Lanka,

but it has not been studied in depth. In 2000, the number of Sri Lankan-born
doctors working in OECD countries was estimated to be 4668 and, by 2010, it
was estimated to have reached 5784. This could be considered as an increase
104
of 24%. When the annual stock of foreign-trained Sri Lankan doctors in five
English-speaking OECD countries is considered, the UK and Australia are
the largest recipients of Sri Lankan doctors (World Health Organization,
2018b). However, recent evidence suggests that the pass rate of the clinical
component of the Australian Medical Council examination has declined.
The Sri Lanka Bureau of Foreign Employment encourages the migration

of skilled HR, which includes doctors, nurses and paramedics as a policy.
However, coordination is not well established in regulating this process
between the Ministry of Foreign Employment and MoH and there is no proper
understanding/monitoring of health worker flow.
The number of Sri Lankan-born nurses working in OECD countries was

estimated to be 2032 in 2000 and, by 2010, it had more than doubled and
was estimated to be 5372. However, the Nursing and Midwifery Council in
the UK showed that there were only 83 nurses of Sri Lankan nationality and
training in the UK in 2017 and it is assumed that others may be working as
unregistered nurses/ informal carers (World Health Organization, 2018b).
Migration of nurses is generally considered to be low and one reason for
the low levels of migration of nurses it that a large majority of nurses in Sri
Lanka do not hold university degrees; therefore, their nursing training may
not be recognized outside Sri Lanka.
A study in 2009 showed that of the postgraduate trainees who migrate

for overseas training, 11% have not returned or left the country without
completion of the bond period. The main reasons for migration were to
seek a better quality of life, avoid compulsory placements in rural parts of
Sri Lanka and for career development and social security (De Silva et al.,
2013). Among medical undergraduates and new graduates, 24% has shown
an intention to migrate and the underlying reasons for this is presumed to
be a better quality of life, need for a higher income and availability of better
medical services (De Silva et al., 2014).
4.2.3 Training of health workers
Doctors
There are currently 10 government faculties of medicine (with two newly
established) under the state university system and another medical school
is planned. There are no private medical schools in Sri Lanka. The medical
faculties are under the Ministry of Higher Education and the MoH does
not decide the intake to these faculties. The current output is around
1100–1200 and it is estimated that another 150–200 physicians trained by
these three new state medical faculties will enter the health workforce 6–7
years from 2019.
105
Currently, all medical graduates from state universities are employed by
the government system and recruitment for service is under the MoH.
Graduates from state universities are given provisional registration from the
Sri Lanka Medical Council (SLMC) to proceed with their internship. Following
successful completion of internship, which consists of two tenures of 6
months each of surgery (General Surgery or Obstetrics and Gynaecology)
and medicine (General Medicine or Paediatrics), a full SLMC registration is
granted, allowing them to practise medicine in Sri Lanka.
There has been a substantial increase in the number of Sri Lankan students
studying medicine abroad. Once they return, foreign medical graduates are
required to pass a licensing examination (Examination for Registration to
Practice Medicine, ERPM) conducted by the SLMC before they are granted
permission to do internship. Following completion of internship, full SLMC
registration is granted, allowing them to practise medicine in Sri Lanka.
Candidates completing the ERPM have doubled, from just over 100 in 2010
and 2011, to an average of more than 200 per year in the four-year period
2014–2017. Therefore, foreign medical graduates now comprise about 15% of
new entrants to the medical workforce.
Dental surgeons
The recruitment and training of dental graduates is mainly under the Ministry
of Higher Education. Currently, only one state university provides training,
producing approximately 75 dental surgeons per year. These graduates must
undergo one year of internship to obtain full SLMC registration to practise
dentistry in Sri Lanka.
Nurses
Nurses are involved in the care of patients from a wide variety of health-care
institutional settings such as hospitals (medical, surgical, maternal and child
care, critical care, psychiatry, infection control, health promotion, quality
management, etc.) and preventive care institutions (public health nursing).
Two separate training programmes are available for nurses under the MoH
and Ministry of Higher Education. Training under the MoH is conducted in
16 nurses training schools, which are located throughout Sri Lanka. Around
2500–3000 are recruited annually to the nurses training schools. Following
completion of this 3-year training, a Diploma in General Nursing is awarded
and the nurses are recruited to public sector service. A graduate programme
for nurses (Bachelor of Science in Nursing) is also available under the
Ministry of Higher Education. Currently, training is available in five state
universities. These graduates are given the opportunity to enrol in state
106
service following application, once these applications are gazetted and after
completing a six-month training in a hospital. Annually, 120–150 nursing
graduates are produced by the university system and the government aims to
upgrade the diploma awarded by the training colleges to university degrees.
Following completion of the diploma/graduate programme, a certificate

of proficiency is obtained from the Ceylon Medical Council (CMC) affiliated
to the University of Colombo. The certificate of proficiency is needed to
acquire registration to the Nursing Council, which is a pre-requisite for
practising nursing in Sri Lanka. However, in the private sector, leading private
hospitals have their own nurses training schools attached to their hospitals.
Information on the numbers and quality of the training is yet to be evaluated
and streamlined.
Undergraduates who complete a state university nursing degree are also

recruited to the MoH. They are given six months’ orientation and coordination
training prior to employment. They have to follow the same registration
process as nurses who complete the Diploma in Nursing.
PSM and paramedical categories

Duties, responsibilities and work settings of PSM and paramedical categories
are shown in Table 4.18. A summary on the training of PSM and paramedical
staff and the qualifications awarded are shown in Table 4.18. All training
for the PSM and paramedical categories is provided in training schools
under the MoH. Following completion of training, a certificate of proficiency
is awarded. With this certificate, registration with the Ceylon Medical
College Council (CMCC) must be obtained to practise as a professional
in these categories. Degree programmes for several PSM categories
were initiated in 2005 under the Ministry of Higher Education. The annual
cumulative recruitment of trainees to training schools for the PSM and
paramedical categories is approximately 1500–1750 and, in addition, nearly
400 are enrolled in the university system. The MoH is currently running at
the maximum training capacity for the PSM and paramedical categories.
Capacity for training cannot be increased in the short run as it is necessary
to improve infrastructure facilities and recruitment of trainers to improve
training capacity.
Following completion of the diploma/degree programme, a certificate of

proficiency is obtained from the CMCC, which is affiliated to the University
of Colombo. The certificate of proficiency is needed to acquire registration
in the SLMC, which is a necessity to practise in Sri Lanka. Graduate trainees
must undergo a mandatory six months of internship if they wish to enter
government service.
107
Table 4.18 Training of Professions Supplementary to Medicine and paramedical categories
108
Training school Graduate programme in state universities
Name of the training
course Training Annual Training Approximate
Qualification awarded Qualification awarded
Service period intake period annual intake
Professions Medical Laboratory 2 years Higher Diploma in Medical 150 4 years Bachelor of Science in Medical 160
Supplementary Technologist Laboratory Technology Laboratory Sciences
to Medicine Pharmacist 2 years Higher Diploma in Pharmacy 300 4 years Bachelor of Pharmacy 120
Physiotherapist 2 years Higher Diploma in 20 4 years Bachelor of Science in 50
Physiotherapy Physiotherapy
Occupational 2 years Higher Diploma in 60 NA
Therapist Occupational Therapy
Radiographer 2 years Higher Diploma in Diagnostic 40 4 years Bachelor of Science in 40
Radiography/Higher Diploma Radiography/Radiotherapy
in Radiotherapy
Speech Therapist/ 4 years Bachelor of Science (Speech 40–50
Audiology and Hearing Sciences)
Paramedical School Dental 2 years Higher Diploma in Dental 30 NA
Therapist Therapy
Health Entomology 2 years Higher Diploma in Health 30 NA
Officer Entomology
Ophthalmic 2 years Higher Diploma in 30 NA
Technologist Ophthalmic Technology
Prosthetist and 3 years Higher Diploma in 15 NA
Orthotist Prosthetics and Orthotics
Public Health 1 ½ years Diploma for Public Health 395 NA
Inspector Inspectors
Electrocardiographer 1 year Diploma in Cardiography 100 NA
Electroencephalog- 1 year Diploma in 25 NA
rapher Electroencephalography
Source: Compiled by the Human Resources for Health Coordination Unit - Ministry of Health, Sri Lanka (2020)
4.2.4 Career paths of doctors
Following completion of one year of internship, doctors are appointed to
permanent posts. Often, the first appointments are to relatively underserved
areas. Annual transfer schemes enable doctors to change their posts at
4-year intervals and enable some choice towards a career path. Doctors
have the opportunity to expand their careers as grade MOs or specialists.
Doctors start their career as a preliminary grade MO. They can upgrade
to Grade II MO upon completion of an efficiency bar examination, which
assesses managerial knowledge and language proficiency. Thereafter, a
Grade II MO can get upgraded to Grade I after 6 years if they complete an
additional diploma or a master’s degree provided by the Post Graduate
Institute of Medicine. Otherwise, they can reach Grade I upon completion of
12 years in service.
Specialist training for MOs is provided at the Post Graduate Institute of

Medicine, and this specialist training is funded by the MoH for public sector-
employed doctors. Currently, 36 specialty training courses are conducted.
Opportunities available and the numbers admitted for postgraduate training
of doctors is determined by the current and projected numbers of vacancies
in the health system. However, the requirements of the private health-care
market are not worked into the system in a coordinated manner.
Postgraduate training is facilitated by the government by providing study

leave with salary; the overseas component of the specialist training is also
funded by the MoH. Thus, there is a great interest among medical graduates
to pursue specialist training courses. Following specialist training, they are
entitled to salary increments and practice in the private sector, with a higher
payment rate than grade MOs. Currently, some specialists are engaged in
full-time private practice.
However, when a request for specialist training is accepted, the candidate

is required to submit to a bond agreeing to return after training and work
in Sri Lanka for four years. If they fail to complete the bond period, they are
liable to reimburse the stipend and the salary that they received during their
foreign training period, which is relatively modest compared to the potential
remuneration in an overseas country.
4.2.5 Other health workers’ career paths
Dental surgeons
Dental surgeons have the opportunity to expand their career as a grade
dental surgeon or a specialist. Dental surgeons start their career as a Grade
109
II dental surgeon. After they reach the Grade II level, a grade dental surgeon
can upgrade to a Grade I dental surgeon after 9 years if they complete an
additional diploma or a master’s degree provided at the Post Graduate
Institute of Medicine. Otherwise, they can reach Grade I upon completion of
15 years in service.
Postgraduate training for dental surgeons is also provided by the Post

Graduate Institute of Medicine, and this specialist training too is funded
by the MoH for public sector-employed doctors. Currently, there are five
specialties; Oral and Maxillofacial Surgery, Community Dentistry, Restorative
Dentistry, Orthodontics and Oral Pathology. Clinical specialist dental
surgeons (consultants) are employed in higher hospital settings (secondary-
and tertiary-care hospitals).
From 2008 to 2015, the number of specialist dental surgeons has increased
more than fourfold. Similar to doctors, dental surgeons’ postgraduate
training is facilitated by the government by providing study leave with salary
and funding for the overseas component of the specialist training through the
MoH. Following specialist training, they are also entitled to salary increments
and practice in the private sector, at a higher payment rate.
School dental therapists are trained at the School for Dental Therapists
situated in Maharagama in the suburbs of Colombo. It was started in mid-
1955 and continues to train around 30 school dental therapists per year.
School dental therapists are based in large schools. They provide services to
nearby smaller schools as well as preschool children in the community. The
services of school dental therapists are available in all districts of Sri Lanka.
Community dental services are arranged in several vertical programmes

managed by specialists in Community Dentistry and, at the ground level,
community dental services are provided by community dental clinics and
adolescent dental clinics. However, there are relatively few community dental
clinics and adolescent dental clinics in the country.
Nurses
Nursing officers start their careers as Class III nursing officers. They have
the opportunity to upgrade to Class II upon completion of 10 years of service,
and from Class II to Class I upon completion of 10 years from reaching
Class II. Nursing officers at the Class II level can sit for post-basic training
(in Hospital Services, Public Health or Nursing Education) and can reach
the Class I level in a shorter time. Nursing officers in Class I are known as
110
Special Grade Nursing Officers; they can reach super grade on completion of
10 years in Class I (special grade).
Nursing officers can expand their career in the field of nursing education
by becoming a tutor at a nurses training school. Nursing officers can follow
training for 1.5 years in a post-basic training school and become a nursing
tutor. Following completion of 5 years in the nursing tutor position, they can
upgrade to special nursing tutor, and subsequently to nursing principal.
Postgraduate schemes (MSc) for nurses are available in two state

universities. Following completion of 5 years of service, nursing officers can
apply for a postgraduate degree. Study leave with salary is given to follow
these courses.
PSM and paramedical categories

Opportunities for following the graduate schemes mentioned in Table 4.18 via
lateral entry are facilitated by provision of paid study leave.
PSM and paramedical categories start their careers in Class III. They then
have the opportunity to upgrade to Class II after 10 years’ service from
completion of training/appointment. They can go from Class II to Class I upon
completion of 10 years in Class II. From the Class I level, they can reach a
super grade upon completion of 10 years and special grade after 5 years
in super grade.
PSM and paramedical categories can expand their career in the field of
education by becoming a tutor in PSM and paramedical training schools.
They can apply for tutor posts when they reach Class II or Class I level.
Following completion of 5 years in the tutor position, they can upgrade to a
senior tutor’s post and subsequently, to a principal’s post after 3 years as a
senior tutor.
Postgraduate training is provided at six state universities for selected PSM

categories – Radiography, Pharmacy, Physiotherapy, Medical Laboratory
Technology. Three years of duty leave is provided to follow the course.
Continuing professional development in the health sector

A national continuing professional development (CPD) certificate has been
introduced by the SLMA for doctors and specialists. However, this certificate
is not mandatory for renewal of registration. A CPD certificate is awarded
by the National Centre for CPD in Medicine (NCCPDIM), which comprises
representatives from all recognized medical professional bodies in Sri
Lanka. The certificate is valid for three years once issued (Sri Lanka Medical
111
Association, 2010). The CPD system for nursing and other health categories
has been piloted in two hospitals. Much attention is needed to formulate and
implement CPD systems for all health staff categories.
4.2.6 Dual practice

In Sri Lanka, dual practice is legal and several health staff categories in
the public sector are allowed to engage in private practice after working
hours since 1977. Dual practice among health professionals is used as
a supplementary source of income where base salaries are considered
inadequate and serve as a mechanism for improving recruitment and
retention in rural areas.
Doctors and dental surgeons have been enjoying this privilege since the
Dual Practice Act of 1977. The Act legally permits public sector doctors to
work in the private sector after working hours. While routine statistics are
not available, sample studies indicate that 40–60% of doctors,70% of dental
surgeons and 90% of specialists employed in the public sector are engaged
in private practice after hospital working hours (De Silva, 2017). This includes
public sector doctors in academia and the Ministry of Defence.
However, the monitoring mechanism for engagement in dual practice

as per staff categories is not well implemented. Also, the impact of dual
practice on rural retention, quality of care in public sector institutions
during official working hours and migration of staff categories has yet to be
fully understood.
112
5. Provision of services
Chapter summary
Sri Lanka has an extensive health-care system encompassing both
curative and preventive services, which have historically been separated
into two parallel arms operating within the same organizational structure.
Preventive health-care services are provided by 354 MOHs and a team of
professionals covering all parts of the country. They provide a package of
preventive services, including MCH services, to a defined population. Curative
care comprises different levels, ranging from outpatient-only facilities
and primary care institutions to tertiary-care institutions and specialized
hospitals. These are organized into a hierarchical pyramidal network, the
higher-level institutions acting as referral institutions for the lower-level
facilities. The state-owned health system is free of charge for the care
seeker and covers about 95% of inward care and 50% of total ambulatory
care services in the country. Indigenous medicine services, though not the
mainstream health system, have been included under the purview of the
Ministry of Health since 2015. However, this document discusses mainly the
allopathic system, since public demand is mainly for this sector.
Private health services comprise general practitioners and private health

institutions providing primary to tertiary care and is governed by the PMIRA.
A separate directorate has been established within the MoH to coordinate
private health-care services.
The state health services in the country are well distributed as there is
a health institution or facility within a distance of 4.8 km on an average
(Ministry of Health, Nutrition and Indigenous Medicine, 2017b). There is
also a free community ambulance service, which has increased health-care
access in an emergency. The state also provides the required medicines
and investigations free of charge to the patient. Together, all these have
enabled Sri Lanka to achieve near UHC based on the principles of primary
health care.
However, the system has not evolved and transformed appropriately to meet
the changing demands of the demographic and epidemiological transitions.
113
Hence, the health services of Sri Lanka will continue to be challenged by
the rapidly ageing population and the changing disease burden. Within the
present structure for delivery of care, some selected functions are organized
as vertical programmes. Although this system has been able to deliver the
desired results in the past, a more integrated approach to service delivery
is needed to address emerging challenges. Given the financial limitations,
a major challenge would be to reorient the system so that human and other
resources function in a synchronized manner with optimal productivity.
5.1. Public health

In Sri Lanka, the origins of the current structure for delivery of public health
services began in 1926 with the setting up of the first health unit in Kalutara.
However, written laws relating to public health predate this initiative by a few
decades. The initial legislation was mostly concerned with prevention and
control of major communicable diseases, e.g. the Quarantine Ordinance No. 3
of 1897. Strict implementation of these laws was responsible for a reduction
in the incidence of diseases such as smallpox, plague and cholera.
Sri Lanka has eliminated/eradicated most of the communicable diseases

such as filariasis, leprosy, polio, malaria and neonatal tetanus, and
achieved near-elimination of other VPDs through successful public health
programmes and a dedicated health workforce. The National Health Policy
(1992) and Health Master Plans of 2007–2016 and 2016–2025 recognized the
prevention and control of NCDs such as CVDs, diabetes, chronic respiratory
diseases, mental health and malignancies as priority areas of work.
The provision of preventive health services is the responsibility of the 354

MOHs. Four of these units are managed by the municipal councils and the
others are managed by the provincial health authorities. An MOH unit is
served by a team of professionals led by an MO, and comprises public health
nursing sisters (PHNSs), supervising public health midwives (SPHMs), PHMs,
supervising public health inspectors (SPHIs) and PHIs. It provides services
to the people living in a defined geographical area, usually comprising a
population of 50 000–100 000.
National programmes such as those of the Family Health Bureau (FHB),

Epidemiology Unit and the Health Promotion Bureau, as well as national
disease-specific vertical programmes reach the community through MOHs
and their staff. They are supported by technical inputs from relevant officials
at provincial and national levels. At the community level, the PHM plays a
key role in all components of the national family health programme and
immunization services. She is supported in this work by the SPHM and
114
PHNS through regular supervision. Communicable disease prevention,
environmental and occupational health and food sanitation come under
the purview of the PHI. School health services are provided by the MOH
supported by the PHI and PHM of the area.
All preventive health-care services are monitored and supervised by the

district-level supervisory staff: Medical Officer of Maternal and Child Health
(MoMCH) and the Regional Epidemiologist (RE). These officers are in turn
supervised at the provincial level by provincial consultant community
physicians and the national focal agencies: the FHB and Epidemiology Unit.
5.1.1 National Family Health Programme

The FHB is the focal point for MCH in Sri Lanka. The organization is
responsible for planning, coordination, monitoring and evaluation of MCH
and family planning services in the National Family Health Programme.
The main components of the National Family Health Programme are:
preconception care, maternal care, intrapartum and newborn care, infant
and child health including child development, nutrition and care of children
with special needs, schoolchildren and adolescent health, family planning,
women’s health including perimenopausal care and gender concerns. The
organization of the components of the National Family Health Programme
within the different administrative levels of the health system are presented
in Figure 5.1.
With the introduction of the concept of reproductive health in 1996, well

women clinics (WWCs) were incorporated into the Family Health Services.
These function mainly in MOH clinics and provide screening services for
women over 35 years of age against common NCDs such as diabetes,
hypertension and breast and cervical cancers.
Training and supervision of health personnel and quality assurance of the

MCH programme is an important function of the FHB. Towards this end, data
on the provision of services and the impact of the programme at the field
level are collected through the Reproductive Health Management Information
System (RHMIS) based on quarterly and annual returns originating from
PHMs. In addition, morbidity and mortality data are also collected through
the Maternal Morbidity and Mortality Surveillance System. The information
collected is used for monitoring and evaluation of programmes, while
timely operational research provides supportive evidence for programme
management (Ministry of Health, Nutrition and Indigenous Medicine, 2017b).
115
Figure 5.1 Organization of the National Family Health Programme at
different levels of the health system
Administrative Technical Care Referral Back Referral

Guidance Guidance Provision Pathway Pathway
Key
Level of Preventive Care Creative Care

Health system
Ministry Secretary Health Tertiary Care

of Health DGHS FHB
Hospital
DDG-PHS
Provincial Provincial Provincial Provincial

Directorate Director CCP General Hospital
MOMCH RE
District General
Regional Hospital
Regional
Directorate Director
Base Hospital
A/B
RSPHNO SPHID
Medical Officer
of Health
SPHI
Divisional
PHNS Hospital A/B/C
Divisional
(MOH) PHI Primary Medical
Unit SPHM care Units
(CD & MH/CD/MH)
PHM
Home Field Clinic
CCP: Consultant Community Physician; FHB: Family Health Bureau; RE: Regional Epidemiologist;
MOH: Medical Officer of Health; MOMCH: Medical Officer of Maternal and Child Health; PHM: Public
Health Midwife; SPHM: Supervising Public Health Midwife; PHI: Public Health Inspector; SPHI:
Supervising Public Health Inspector; SPHID: Supervising Public Health Inspector – District; RSPHNO:
Regional Supervising Public Health Nursing Officer; PHNS: Public Health Nursing Sister
Source: Ministry of Health, 2014: p.3
5.1.2 Epidemiology Unit

The Epidemiology Unit of Sri Lanka was set up in 1959 with the support
of WHO, with a WHO consultant and a local MO with public health
qualifications. Since then, the Epidemiology Unit has developed into a centre
of excellence for VPDs and is recognized around the world. The mission of the
Epidemiology Unit is “Promoting health and the quality of life by prevention
and control of disease, injury and disability”.
116
Notifiable diseases were first gazetted, and notification of communicable
diseases became a legal requirement in Sri Lanka as early as 1897.
Legislation drafted in relation to major communicable diseases included
measures such as restricting the movement of people during epidemics,
immunization and compulsory notification. The list of notifiable conditions
is approved on the recommendations of the Advisory Committee on
Communicable Diseases (Epidemiology Unit, 2008). Currently, a total of 25
diseases are on the list of notifiable diseases and this is revised based on
emerging priorities from time to time.
Every registered medical practitioner professing to treat diseases, who

attends on any person having symptoms of any disease in the notifiable
disease list, is required to notify this to the proper authorities. Any person
who contravenes this regulation shall be guilty of an offence and is liable to
be prosecuted in a magistrate court.
The disease surveillance system consists of:
1. routine notification of communicable diseases;

2. special surveillance on selected communicable diseases; and
3. sentinel site surveillance.
Surveillance of notifiable diseases begins with data collection at the hospital

level through the bed head ticket (clinical notes), notification card and
notification register (ward and institute). These data from all hospitals across
the country are then sent to the relevant MOHs for investigation. Each MOH
in the country sends a weekly return of communicable diseases containing
data from hospitals on notifiable diseases to the Regional Epidemiologist and
to the Epidemiology Unit. Data on inpatients available in the Indoor Morbidity
and Mortality Register (IMMR) are sent to the Medical Statistics Unit. The
data collected through the IMMR also reach the Epidemiology Unit through
the Statistics Unit, while data from different campaigns are sent directly to
the Epidemiology Unit where central-level surveillance is undertaken.
The Epidemiology Unit produces a weekly epidemiology record, which

summarizes the trends and the situation in respect of the week under
consideration. This is sent to all curative and preventive institutions within
the MoH. A summarized flow diagram of the information system is presented
in Figure 5.2.
117
Figure 5.2 Epidemiological surveillance mechanism for infectious
diseases
Hospital MOH Office
Notification Notification Range

register register PHI
Weekly Return of Communicable

Diseases
Infectious
Diseases
Register
Special Epidemiological
Notifications Unit
Cholera BY TELEPHONE/TELEGRAM
Polio
In-patients Register
Neonatal tetanus
Measles/Other EPI Diseases
Japanese Encephalitis
Dengue Haemorrhagic Fever FOR SURVEILLANCE
Indoor Morbidity Rabies INVESTIGATION
and Mortality
Airport/Seaport Health Office

Fever Hospital, Angoda
Medical Statistician Medical Research Institute & other Regional Laboratories
Disease-specific programs
Source: Das Gupta et al., 2013
5.1.3 Environmental and occupational health services

The Environmental and Occupational Health Unit of the MoH is responsible
for coordination with the relevant ministries and other agencies in relation
to environmental health, strengthening infrastructure facilities at the central
and regional levels, training public health staff on environmental health
issues, establishing occupational health units at the district and provincial
levels, and conducting awareness and training programmes for targeted
high-risk groups, including the industrial sector.
118
Technical guidance is provided to other ministries, relevant agencies and
the general public on environmental health in the areas of waste disposal,
biosafety, water supply and sanitation, climate change, environment and
health toxicology and air and water pollution, among others. Interministerial
and interagency collaborative activities are carried out in order to strengthen
the environmental health measures in the country.
Public health staff are trained on environmental health issues and strategic
solutions. Major activities related to environmental health are developing
policies and guidelines on environmental health, waste management
(including health-care waste management) and research. Additionally, many
activities related to occupational health are also conducted to increase
awareness of occupational health and safety and to promote occupational
health among marginalized and socially deprived workers.
5.1.4 Health Promotion Bureau

The health education services in the country date back to the mid-twentieth
century with a small unit in the public health section of the Department
of Health Services. The main focus then was the prevention of common
communicable diseases prevalent at the time such as malaria, worm
infestations, diarrhoeal diseases and typhoid fever through public meetings
and distribution of public health material such as posters, leaflets and
brochures. Major reorganization of the services commenced in 1972 with the
appointment of a full-time MO in the administrative grade in charge of the
unit. Within the next few years, with the support of WHO, the organization
developed rapidly into a full-fledged bureau with a large complement of
technical staff. The rising burden of NCDs and the threat of epidemics of
communicable diseases identified the need to plan, implement, monitor
and evaluate efficient health promotion strategies, thereby leading to the
upgrading of the health education services to the status of the current Health
Promotion Bureau (HPB). Twelve specialized units have been established
to effectively implement the strategies identified in the National Health
Promotion Policy.
The HPB is the centre of excellence in Sri Lanka for health education, health
promotion and publication of health information. The activities of the Bureau
are coordinated and implemented through seven units, which are under
the supervision of consultant community physicians and a consultant in
community dentistry. The individual units include: Training, Evaluation and
Research Unit; Nutrition and Family Health Communication Unit; Health
Promotion Unit; Behaviour Change Communication Unit; Oral Health Unit;
Planning Unit and the Publicity Unit.
119
Public awareness aiming for healthy behavioural changes in the community
is a unique service that has been provided for years by the HPB and
appreciated by all sectors. In addition, the HPB plays a vital role in public
awareness of health promotion and healthy behavioural changes by actively
participating in mass-scale health exhibitions, national campaign days
and community events. Developing households and public places such as
hospitals, schools, villages, workplaces as health promotion settings is
another successful programme being conducted by the HPB.
5.1.5 Noncommunicable Diseases Unit

As described in Chapter 1, NCDs are of increasing importance. The
implications of demographic transition and increased prevalence of NCDs
are numerous. The provision of care for the chronically ill will require
additional HR, infrastructure, medical facilities and financial resources
(Jayasinghe, 2013).
To face this emerging disease burden, the MoH has a separate unit for NCDs
under a Deputy Director-General. The mandate of the unit is to prevent and
control the rapidly growing NCDs in partnership with relevant stakeholders,
guided by the National Policy on Prevention and Control of Chronic NCD.
The objective of the NCD prevention programme is to reduce premature
mortality (less than 70 years) due to chronic NCDs by 2% annually over the
next 10 years through expansion of evidence-based curative services, and
individual and community-wide health promotion measures for the reduction
of modifiable risk factors. This would lead to healthy lives free of morbidity,
disability and premature mortality, and lessen the human, social and
economic impact on the people.
The National Policy on Prevention and Control of Chronic NCDs addresses

four major NCDs and strategies for reduction of shared modifiable risk
factors: smoking, alcohol, obesity, unhealthy diet and sedentary lifestyles.
These are implemented through the existing health network with the
support of both government and NGOs in the country. Further, there is
a National Multisectoral Action Plan for the Prevention and Control of
Noncommunicable Diseases 2016–2020, which has been developed in order
to achieve the 10 voluntary targets adopted by Sri Lanka based on the nine
global targets and the specific regional targets identified for the South-East
Asia Region.
This Plan is composed of four strategic areas: advocacy, partnership and

leadership; health promotion and risk reduction; strengthening health
systems for early detection and management of NCDs and their risk factors
and surveillance; and monitoring, evaluation and research.
120
The strategic area of health promotion and risk reduction specifies the
plans for the following: reduction of tobacco and alcohol use; promotion of a
healthy diet high in fruit and vegetables and low in saturated fat and trans-
fat, sugar and salt; promotion of physical activity and healthy behaviour; and
reducing household air pollution (Ministry of Health, Nutrition and Indigenous
Medicine, 2016c).
Cost-effective strategies adopted include NCD screening programmes at the

community level and empowering communities to adopt healthy lifestyles.
The NCD screening strategy consists of screening people above 35 years
of age at healthy lifestyle centres (HLCs), workplace screening and mobile
screening. HLCs will address risk reduction through early identification of
both behavioural and intermediate risk factors. Currently, there are some 896
HLCs established throughout the country.
Reorganization of primary health care has commenced. It will provide

continuing care for NCDs closer to people’s homes. The Ministry has piloted
a Package of Essential NCD Interventions (PEN) and adopted an Essential
Services Package for Sri Lanka. Both these packages highlight the need for
instituting opportunistic screening at primary health-care settings and these
proposed changes would need extra HR with a better skill mix. This warrants
a rescaling and retooling of existing staff to meet these demands.
5.1.6 Disease-specific campaigns

In addition to the above programmes, specific diseases of public health
importance are addressed through specialized vertical campaigns,
administered centrally. Tuberculosis (TB), sexually transmitted infections
(STIs) and leprosy are some such campaigns. The elimination of malaria and
filariasis were led by two such vertical programmes. These programmes
undertake preventive, curative and rehabilitative activities in disease-specific
areas relevant to their mandate. The preventive and promotive components
of these services as well as some curative functions reach the community
through the MOH system.
5.2 Curative care services

In the government sector, curative services are provided through an extensive
hierarchical network of institutions ranging from primary medical care units
(PMCUs), divisional hospitals (DHs), base hospitals (BHs), district general
hospitals (DGHs), provincial general hospitals (PGHs), special hospitals and
teaching hospitals (THs).13
13 Refer to Chapter 4, Table 4.1.
121
PMCUs and DHs deliver primary medical care. They are manned by MBBS-
qualified doctors without specialist qualifications. DHs are categorized
according to their bed strength. Type A hospitals have more than 100 beds.
Type B DHs have a bed strength of 50–100 beds. Hospitals with a bed
strength of less than 50 are categorized as type C hospitals.
BHs and a few Type A DHs constitute the secondary level of care. They
provide specialized services in general surgery, general medicine, obstetrics
and gynaecology and paediatrics, in addition to outpatient services. A few
may provide other subspecialties such as ophthalmology and ENT services.
Primary and secondary levels of care come under the purview of the
provincial ministries of health.
The DGHs, PGHs, THs, special hospitals and the National Hospital of Sri
Lanka constitute the tertiary level of care and provide services in a wide
range of specialties. These are managed by the MoH.
All curative services provided in the government health system are free
of charge for the patient at the point of delivery. However, due to the large
numbers utilizing the system, there are long waiting lists for some of the
specialized investigations and clinical procedures.
The institutional network is described in detail in Section 4.1.1. In addition

to these state services, there are GPs who work independently and private
hospitals that are based mostly in big cities, which provide curative care.
5.2.1 Patient pathways

As there is no gatekeeping process within the Sri Lankan health system,
citizens can access any of the curative care institutions without any barriers.
Once a patient makes contact with an MO at any primary care level, the
decision is made to either treat the patient as an outpatient, inpatient or, if
deemed necessary, refer to a specialist care unit. Also, patients are able to
directly select an institution of their choice independently, irrespective of the
level (secondary or tertiary) as the first point of contact. This weakness in the
system has given way to overcrowding of secondary- and tertiary-care levels
with underutilization of primary care institutions (Ministry of Health, Nutrition
and Indigenous Medicine, 2017b). Although there are no official processes to
transfer patients treated at private hospitals to state facilities, such instances
have been observed (Figure 5.3).
In the private sector, patients can visit a GP who also takes the decision on
whether the patient needs specialized care, or whether the patients can
themselves directly visit a medical specialist as an outpatient. In Sri Lanka,
122
dual practice is permitted for state medical professionals. It is documented
that between 40% and 60% of MOs and 90% of specialists engage in dual
practice. The MOs provide services mostly as part-time GPs, and some may
work part time in private hospitals. Medical specialists are seen to offer
their services to the public mostly at “channel centres” and private hospitals
(Rannan-Eliya et al., 2015b).
Figure 5.3 Patient pathways for curative care
Specialist
Community
Pharmacy
Private PMCU DH BH DGH PGH/TH NHSL

Hospital
Patient
GP
PMCU: Primary Medical Care Unit, DH: Divisional Hospital, BH: Base Hospital, DGH: District General
Hospital, PGH: Provincial General Hospital, TH: Teaching Hospital, NHSL: National Hospital of Sri Lanka
Source: By authors
5.3 Ambulatory care

5.3.1 Primary/ambulatory care
All curative care hospitals in the country are geared to look after the primary
health-care needs of the community. Most of the facilities provide ambulatory
care from 08.00 to 16.00 during weekdays, 08.00 to 12.00 on Saturday and
08.00 to 10.00 on Sundays. It is noted that secondary- and tertiary-care
hospitals offer ambulatory services during extended hours. People can
directly access secondary and tertiary hospitals, bypassing the primary level
altogether, leading to underutilization of the PHC curative sector. PHC does
not act as a gatekeeper in the current system. This may be due to the limited
capacity of the primary care system to provide comprehensive PHC facilities,
lack of after-hour services and essential medicines, and limited access to
investigations (Ministry of Health, Nutrition and Indigenous Medicine, 2017b,
Perera and Weerasinghe, 2015).
123
The increase in the elderly population and NCDs have added to the burden
on the existing health-care system, which has been slow to respond to
these changes. The proposed reorganization of the PHC would ensure that it
would act as a gatekeeper towards accessing secondary- and tertiary-care
services. Accordingly, specialized services would be made available through a
referral pathway from the PHC system. These changes in the referral system
would be facilitated through the use of IT solutions. However, it should be
recognized that the success of PHC reforms would depend on a sea change in
population and provider perceptions and behaviour.
5.3.2 Specialized ambulatory care (day care/day hospitals/day clinics/

surgical centres)
The MoH promotes the provision of day-care services in all hospitals with a
view to providing comprehensive patient care without unnecessary delays and
as a means of reducing admissions, hospital-acquired infections and the cost
of patient management.
Currently, selected hospitals provide day-care services such as day

surgeries, radiological and other investigations, family planning procedures,
rehabilitation, haemodialysis services, physiotherapy, occupational therapy
and speech therapy. Although day-care services are functioning within
the system, their performance data are not captured separately in the
HIS. In addition to these services, the state has introduced the concept of
preliminary care units in many of its secondary- and tertiary-care hospitals,
so that all patients needing acute care are first treated at these PCUs and
then reviewed by the respective consultants. Only those who need inward
care are admitted for further management. This too has significantly
reduced the number of admissions and has been identified as an initiative
that reduces the inward workload and congestion and improves the quality
of inward care.
5.4 Inpatient care

Among countries in the Asian region, Sri Lanka is a country with a high
hospital bed penetration (4 per 1000 population) (World Bank, 2020). Inpatient
care is provided by both public and private hospitals with state sector
institutions providing the bulk of the services. The health facility survey
of 2016 identified 628 public hospitals (Table 5.1), accounting for 73% of
hospitals and 93% of the bed strength in the country (Department of Census
and Statistics, 2016). Levels of care have been categorized, facilities for each
level of care have been identified and institutions are being developed in a
phased manner.
124
The same survey identified 141 private institutions located mostly in Colombo
and other large cities.14 Inpatient care by the private sector contributes
around 5% to the total patient care (Ministry of Health, Nutrition and
Indigenous Medicine, 2017b). Subspecialization is noted within private
hospitals in Colombo in areas with a high demand, such as neurosurgery,
cardiac surgery, maternal and newborn care and cancer treatment. Inpatient
care in the private sector is provided mainly by a few key players who hold
nearly 50% of the private sector bed capacity.
Table 5.1 Summary of the different services by level of care and

management authority
Curative, rehabilitative & palliative care Preventive care
Tertiary care Teaching hospitals 16 Directorates under Public
Provincial general 3 Health Services I
hospitals Directorates under Public
District general 19 Health Services II
National
hospitals Directorates under Environment
Subtotal 38 & Occupational Health
Secondary Base hospital – Type A 24 Directorates under
care Base hospital – Type B 50 noncommunicable diseases
Subtotal 74 (NCDs)
Primary care Division hospitals – 50 354 Medical Officer of Health
Type A (MOH) units covering entire
Divisional hospitals – 134 country
Type B On average 40 000–80 000
Divisional hospitals – 296 population/MOH area
Type C
Provincial
Primary medical care 11

unit (PMCU) with
maternity beds
Subtotal 491
Other Including rehabilitation 25
hospitals hospitals, Cancer
Institute Maharagama
and others
Total 628
Source: Department of Census and Statistics, 2016
14 This is based on the Health Facility Survey (2016) and is an update of the 2011 figure of 125 stated
in Chapter 4.
125
5.6 Emergency care
Although care for emergencies and accidents have been available in
government health institutions since the inception of health care, the current
model of specific services for emergency and trauma care in Sri Lanka was
established with the introduction of the first ever Emergency Treatment
Unit (ETU) at the Base Hospital, Nuwara Eliya in 1988. This was followed by
the rapid establishment of similar units in many other hospitals (Ministry of
Health, Nutrition and Indigenous Medicine, 2015b). The establishment of the
Accident Service of the National Hospital in Sri Lanka in 1991 was a major
milestone in emergency and trauma care. The A&E policy of the country
was developed in 2016, the main aim being the organization of coordinated,
stratified and cost-effective A&E care services within the country.
In Sri Lanka, provision of both pre-hospital and emergency care are under
the purview of the MoH. The ageing population and an increase in the
numbers of people requiring emergency care for NCDs, especially traffic
accidents, have resulted in an increased need for emergency care services.
Currently, an A&E treatment unit is available in all government facilities,

including and above the level of BHs. These offer A&E services of varying
sophistication. Some DHs also have small emergency care units. PMCUs,
which currently provide only outpatient care, will have functional emergency
care units as identified in the Essential Services Package under the
new reforms.
5.6.1 Services for patient transport and pre-hospital care

Pre-hospital care was available as a fragmented service, provided in
response to demand through the fire brigade ambulance service within the
Colombo municipal area, ambulance service in Jaffna, St John’s Ambulance
Brigade and small-scale privately owned ambulance services. Furthermore,
the public sector has 689 ambulances in running condition used for
transporting patients between institutions, which can be mobilized in case of
emergencies.
A pre-hospital toll-free ambulance transport service (Suwasariya) was

initiated in 2016 as a donation to the Sri Lankan people from the Indian
Government. This service was first instituted as a pilot system and since then
has been scaled up to cover the entire country. It is implemented under the
Ministry of Economic Development and Public Distribution and is managed by
the MoH. A toll-free hotline 1990 has been made available for this service. It
transports patients from their homes or accident victims from any location to
government hospitals. It is only in very rare situations, such as the need for
126
continuity of care, that patients are taken to private hospitals. An evaluation
of this service is yet to be undertaken, and limited information is available on
the quality of the calls received or the services offered.
Prehospital care in Sri Lanka is still evolving. Geographical inaccessibility,

unpredictable travel times, inequitable distribution of resources and
inaccessibility during extreme weather conditions remain challenges to the
road transfer of patients. Therefore, a limited air transfer service for patients
was initiated for selected patients with the approval of the DGHS. However,
its cost, safety and effectiveness raise concerns in a small island nation
like Sri Lanka.
5.6.2 Training of health personnel in emergency care

A postgraduate training programme on emergency medicine was initiated
in 2012. MOs who enrolled in the course are now entering the service as
specialists in emergency medicine. Since the setting up of the 1990 free
ambulance service, emergency medical technicians (EMTs) for pre-hospital
care have been trained by the Indian agency in charge of setting up the toll-
free ambulance system. The MoH conducts some on-the-job training for
nurses and other relevant allied health workers. Despite the countrywide
expansion of the emergency ambulance service, a formal training
programme for EMTs has not yet been developed by the MoH.
Upgrading the training curriculum of technical-level staff and establishing

a national simulation centre has been identified as high priority for A&E
(Ministry of Health, Nutrition and Indigenous Medicine, 2015b). Currently,
the quality of A&E services is monitored using only five A&E indicators. It is
planned to periodically review A&E performance at provincial and district
levels (Ministry of Health, Nutrition and Indigenous Medicine, 2016b).
5.7 Pharmaceutical care

5.7.1 Pharmaceutical industry
It is estimated that around 20% of the national health expenditure is
on pharmaceuticals. Only a small proportion (12% by value) is locally
manufactured (Daily Mirror, 2018), and the rest is imported, with India and
Bangladesh being the largest providers of medicines to Sri Lanka (Trading
Economics, 2019). The annual importation value of pharmaceuticals is SLR
65 billion. The State Pharmaceuticals Manufacturing Corporation is the state-
owned manufacturer and there are a few private sector local manufacturers.
The MoH has provided a buy-back guarantee for all locally manufactured
medicines and this has served as an incentive to expand local manufacture.
127
None of the pharmaceutical manufacturers in Sri Lanka produce any active
pharmaceutical ingredients locally. All manufacturers must have a good
manufacturing practice (GMP) certificate. Compliance with standards is
assessed annually. With the intention of increasing the local production of
pharmaceuticals, a drug manufacturing zone was set up as a public–private
partnership in 2016. It is expected that once completed, this will provide
nearly 60% of the local pharmaceutical requirement.
Starting in 2016, the government introduced price regulation through a

price formula on selected essential medicines as a means of containing
their costs and reducing OOPE. Initially introduced for only 48 high-volume
essential medicines, it has now been increased to include 72 categories of
medicines, including cancer drugs, insulin, glucometers and strips. Similarly,
price regulation has been introduced for commonly used devices such as
intraocular lenses and stents for angioplasty.
The MSD of MoH provides all drugs and related medical items for all
government sector health-care institutions. The MSD imports drugs
mainly through the State Pharmaceuticals Corporation. Regional MSDs
in each district distribute drugs from the MSDs to health institutions
under the purview of provincial councils. The MoH has its own logistic
facilities for distribution across the country. Self-distribution is the main
mode of distribution of drugs among private importers. The importation
and distribution of drugs is regulated by the NMRA guidelines (National
Medicines Regulatory Authority, 2019).
5.7.2 Regulation and monitoring of pharmaceuticals

The NMRA plays a leading role in protecting and improving public health by
ensuring that medicinal products available in the country meet the applicable
standards of safety, quality and efficacy. The Authority regulates medicines,
medical devices, borderline products, clinical trials and cosmetics. The
National Medicines Quality Assurance Laboratory (NMQAL) is charged with
ensuring the quality of medicinal products and also functions under the
purview of the NMRA.
Drug quality assurance is an integral part of the national drug management

system. The NMRA and NMQAL are the two principal institutes that work on
national drug quality assurance. The NMRA has the mandate of regulating
and controlling manufacturing, importation, registration, promotion, sale
and distribution of medicinal drugs and devices, and ensuring the quality of
drugs that are imported or manufactured in the country (National Medicines
Regulatory Authority, 2019).
128
The NMQAL tests samples of medicinal drugs for quality control before
they are registered by the NMRA and also has a role in post-marketing
surveillance of these medicinal drugs through random assessments.
5.7.3 Blood and blood products

The National Blood Transfusion Service (NBTS) is a fully state-owned special
campaign for maintaining blood transfusion services across the country.
The NBTS has a service history spanning more than 55 years. There are 99
functioning blood banks within the state hospitals at the level of BHs and
above, and two stand-alone blood centres (the National Blood Centre and the
Southern Regional Blood Centre) affiliated to 19 cluster centres, based on
the geographical distribution. Each cluster centre is headed by a consultant
transfusion physician who provides clinical and technical guidance. The
service provides quality-assured blood and blood components and relevant
laboratory testing for the entire state sector hospitals and for most of
the private sector hospitals. Sri Lanka collects 100% of the blood from
voluntary donors. All donated blood is tested for HIV, hepatitis B and C, and
syphilis (National Blood Transfusion Services, 2016). The human leukocyte
antigen (HLA) laboratory of the NBTS is the only place in Sri Lanka where
cross-matching for organ transplantation is carried out. Other functions
of the NBTS include manufacturing laboratory reagents and reagent red
cells, promoting appropriate clinical use of blood and blood components
through hospital transfusion committees, conducting training programmes
for postgraduate trainees on transfusion medicine and haematology, and
promoting transfusion medical research.
5.8 Rehabilitation
Although the true extent of disability in Sri Lanka is unknown, WHO estimates
that 15% of the population has some form of disability. Currently, both
inpatient and outpatient rehabilitation care are available in secondary- and
tertiary-care institutions in the government sector and in the larger private
hospitals. In addition, special rehabilitation hospitals at Ragama, Digana
and Laliambe provide dedicated rehabilitative care to around 4500 patients
every year (Ministry of Health, Nutrition and Indigenous Medicine, 2016b).
These services are under consultant rheumatologists and their supportive
technical teams comprise general physiotherapists, speech therapists and
occupational therapists. Lack of knowledge among the general population
about what can be achieved through rehabilitation has led to a degree
of acceptance of disability. This, together with insufficient services, both
institutional and community based, problems of accessibility and cost remain
as barriers to rehabilitation.
129
The two key ministries working in the area of disability are the Ministry of
Social Services and the MoH. The Ministry of Social Services is the nodal
agency for programmes for persons with disabilities. A separate secretariat
has been set up in the Ministry of Social Services with a directorate providing
support for assistive devices, livelihood and monetary support. A significant
achievement was the launch of the World Disability Report, which highlights
the different barriers that people with disabilities face – attitudinal, physical
and financial. This was followed by the formulation of a National Action
Plan on Disability (World Health Organization, 2014b). A National Steering
Committee for the Care of People with Disabilities is chaired by the Secretary
Health. The Secretary of this Committee is the consultant community
physician attached to the Directorate of Youth, Elderly and Persons with
Disabilities (YED).
At the level of the MoH, the Director YED is responsible for providing
technical guidance, including policy and guidelines for rehabilitation.
The Directorate also supports rehabilitation facilities that function under
the MoH. These include rehabilitation hospitals and other hospitals with
rehabilitation departments and facilities. At the provincial level, the PDHS is
responsible for providing disability and rehabilitation services in the facilities
managed by the province.
Four types of health institutions provide rehabilitation services in Sri Lanka.

They are: (i) rehabilitation hospitals under consultants in rheumatology
and medical rehabilitation; (ii) all tertiary-level GHs and some DGHs and
BHs, many of whom have consultant rheumatologists; (iii) some DGHs and
BHs that provide limited rehabilitation services and physiotherapy; and (iv)
hospitals with no rehabilitation services, with patients being referred to
higher levels or for community-based rehabilitation.
Together with the MoH, the Ministry of Social Services implements

community-based rehabilitation programmes. These aim to promote
rehabilitation of persons with disabilities in order to enable them to enjoy
their rights, carry out their responsibilities and create opportunities through
social development programmes to integrate them into society. The Ministry
attempts to promote early identification and intervention and educate the
community to encourage home-based care rather than institution-based
care, and thereby improve the quality of life of persons with disabilities by
promoting and protecting their rights.
130
5.9 Long-term and informal care
Increasing longevity and the changing epidemiological profile of the country
have resulted in the need for increasing access to quality long-term care.
Currently, such facilities are scarce within the state sector. There are a
few NGOs (HelpAge Sri Lanka and Sarvodaya) and some private sector
institutions that provide nursing care for a fee, and a few fee-levying homes
for elders and communities where assisted living is provided.
In the past two decades, many initiatives have been taken to respond to the
social and medical needs of the ageing population. The Protection of Elders
Act (2000) has led to the formation of the National Council for Elders, which
is located within the Ministry of Social Empowerment, Welfare and Kandyan
Heritage. Other initiatives include home-care services, provision of assistive
devices for elderly individuals with disabilities, financial assistance for
those in need, free legal advice services and support for income-generating
activities. However, the services available are insufficient to meet the need
(Samaraweera and Maduwage, 2016).
The curative care needs of those in long-term care are met by the curative
care system of the state as well as that of the private sector. Preventive care
programmes such as healthy living for elders are conducted by the MOH and
staff. Provision of dedicated units for long-term care in primary medical care
institutions (PMCIs), which are closer to people’s homes, and extension of
nursing and other services such as physiotherapy services to the community
are options being considered in the current reorganization of primary
curative care services.
There are no formal mechanisms to support family carers who provide long-
term care for a family member, i.e. providing allowances for low-income
family carers of senior citizens living with them. The National Council for
Elders has provided some training for carers, but these services are patchy
and inadequate.
5.10 Palliative care

Palliative care has been recognized as an essential component of
comprehensive care in the National Health Policy (2016–2025) and in several
other policy documents such as the National Policy and Strategic Framework
for Prevention and Control of Chronic Non-communicable diseases (2010),
National Policy and Strategic Framework for Prevention and Control of
Cancers (2015), National Elderly Health Policy and the Essential Services
Package for Sri Lanka (2019). The MoH has initiated a steering committee
for palliative care and developed a national strategic framework in 2018. The
131
strategy envisages the development of services at all levels of care, including
community care. Towards this end, the HR necessary, guidelines for practice
and means of ensuring the availability of drugs and home-based care are in
the process of being institutionalized.
The Palliative Care Association of Sri Lanka estimates that around 60% of all
those who die, i.e. around 68 000 people in the country, need palliative care
annually. The number of trained persons and institutions available to provide
palliative care in the country are inadequate at present. A draft National
Strategic Framework for Palliative Care 2018–2022 (draft 05.11.2018) has
been developed.
Currently, consultant palliative care physicians are not available in the

country. Towards addressing this deficiency, the Postgraduate Institute of
Medicine, Sri Lanka, commenced a postgraduate diploma programme in
Palliative Medicine in 2016. Home-based palliative care is planned to be
provided by PHC teams based in PMCIs or by the patients’ GP. If further
treatment is required, the patient will be directed to secondary- or tertiary-
care institutions. Figure 5.4 shows the proposed model for palliative care.
Figure 5.4 Proposed model for delivery of palliative care – community
level to institutional care
Patients with life ‘Palliative Care Primary Medical Home Based Care
limiting illnesses Consult Service’ Care Institution PHNO
at the Tertiary attached to Tertiary (DH, PU, RH, CD) Trained Family Care
(TH/PGH) & (TH/PGH) & Palliative care trained Giver Trained
ccondary (DGH, BH) Secondary (DGH,BH) Medical Officer & Volunteer Care Giver
Care Hospitals Care Hospitals Public Health Nursing
(Cancer, End stage renal (Consultant, Medical Officer
disease, Heart Failure, Officers trained in (PHO)/
etc.) Palliative Care, Nursing
Officers trained in General
Palliative Care, Community
Practitioner
Social Services Officers Support
Physiotherapist Counsellor Group (NGO,
Pharmacist, etc.) CBO...)
Local MOH
Office
Patients with unmet MOH, PHNS,
palliative care needs PHI, PHM
in the community
CBO: Community based organization; PHNO: Public Health Nursing Officer

Note: A PHNO is a Nursing Sister further trained for 1 year and attached to MOH Units.
Source: National Cancer Control Program, 2018
132
5.11 Mental health care
The Directorate of Mental Health is the national-level focal point responsible
for the National Mental Health Programme within the MoH, Sri Lanka. The
Directorate is responsible for policy development and strategic planning,
coordination, supporting implementation and monitoring and evaluation
of mental health services in the country. A Mental Health Act has been
under deliberation since 2005. After years of multiple drafts and competing
interests, a diverse task force consisting of representatives from the MoH,
WHO, Sri Lanka College of Psychiatrists, NGOs and other stakeholders have
compiled a draft act, and this is being reviewed currently prior to finalization.
The Act will replace the present Mental Diseases Ordinance of 1956.
The National Mental Health Advisory Council (NMHAC) was established

in 2007 to advise the Director Mental Health. The Secretary of Health was
appointed as the Chair with the DGHS as the convener, and consisted of
a diverse, interdisciplinary team with both technical and administrative
expertise. Within a couple of years, it was reconfigured as the National
Committee on Mental Health, chaired by the DGHS and convened by the
Director Mental Health.
The mental health sector provides its services through a multidisciplinary

team consisting of consultant psychiatrists, MOs of mental health,
psychologists, counsellors, occupational therapists, speech therapists,
physiotherapists, psychiatric social workers and community workers. Over
the past 15 years, there have been major gains in HR development for mental
health across all cadres to support the growing demands on services.
At the district level, an MO Mental Health is the focal point. The MO assists
the Regional Director of Health Services and coordinates all mental health
services within the district, having a close linkage with the national level,
district health team and all other relevant departments and community
groups. Within a district, services are provided through a network of medical
institutions and health units.
A major shift has occurred in the level of organization of services, from

institutionalized mental health-care delivery to care in smaller facilities
and outpatient care closer to people’s homes. In 2007, the main mental
hospital located at Angoda was restructured into the National Institute of
Mental Health.
There are seven tertiary-care hospitals in Sri Lanka with facilities for acute
psychiatric inpatient care. In addition, acute inpatient units are currently
available in 23 of the 26 districts and in few regionally managed institutions.
133
Presently, there are 61 adult inpatient units, three child inpatient units and
one forensic unit in the country.
Medium-stay units were available in only five districts in 2004, which has now
expanded to 15 districts. Outreach clinics currently exist in almost all MOH
areas. In addition, community support centres are being set up at district
level to serve as hubs for the promotion of mental well-being.
Outpatient care is provided through specialist, divisional and outreach clinics.

Mental outreach clinics provide close-to-home services that enable better
care and follow up of clients, and reduce the treatment gap. These clinics
support continuity of care, assessment, treatment and home visits. They
are conducted by the MO Mental Health or MO Mental Health Focal Point
or Consultant Psychiatrist. Home visits are mainly for tracing defaulters
and providing assistance to their carers. Home visits are done by a team
consisting of an MO, nursing officer and psychiatry social worker.
The main hospitals that specialize in child care, Lady Ridgeway Hospital in
Colombo and the Sirimavo Bandaranayke Specialized Children’s Hospital
in Kandy, address child mental health needs. In addition to the regular
outpatient clinics and inpatient services, the Lady Ridgeway Hospital for
Children and the Colombo North Teaching Hospital conduct specialized
programmes to address specific learning disabilities (SLDs), attention
deficit hyperactivity disorder (ADHD), early intervention for autism spectrum
disorder (ASD) and family support for children with behavioural disorders.
To make child care services available at the district level, the Directorate of
Mental Health has promoted child psychiatry outpatient clinics in all DHs.
Currently, there are four child and adolescent psychiatrists working in four
districts, addressing promotive, preventive, clinical and rehabilitative care for
children and adolescents.
The number of mental health rehabilitation centres in Sri Lanka has grown
from one in 2000 to 22 in 2017. These include medium-stay (6 months) and
long-stay (1 year-plus) rehabilitation centres. Medium-stay units provide
services to individuals who do not require intensive medical interventions
but need further treatment and support to develop life competencies to live
productively in society. An important part of rehabilitation is occupational
therapy that builds life and vocational skills. The rehabilitation centres focus
on the client’s learning of daily life skills such as self-care, cooking and
cleaning. Most of these centres are hospital based and their management
may differ from one district to another. In addition to these government
rehabilitation centres, NGOs such as Nest and Sahanaya have their
own facilities.
134
The mental health programme also addresses the issue of gender-based
violence (GBV). GBV desks and mithuru piyasa centres have been set up and
are being managed in tertiary-care institutions in selected districts. They
collaborate with other relevant services such as the police, social services,
child protection, probation, legal/justice, education and NGOs.
Deaddiction rehabilitation units (alcohol rehabilitation centres) are another

initiative to combat the increasing use of alcohol. There are seven centres,
located in Gampaha, Kandy, Jaffna, Batticaloa, Kurunegala, Badulla and
Killinochchi. The client-centred model of rehabilitation provided in these
centres requires voluntary admission; however, they may be encouraged and
motivated to enrol by community workers and mental health professionals.
Rehabilitation activities include play therapy, group therapy, counselling,
gardening, religious programmes and family interventions.
Responding to mental health needs during emergency situations is another

area that has evolved satisfactorily over the past few years. Mental health
teams, other community officers and volunteer groups provide psychosocial
support for victims of natural disasters and in emergency situations. The
Directorate of Mental Health has trained teams of master trainers and
established them in all vulnerable districts. During disasters, the Directorate
of Mental Health mobilizes these teams to train the staff of affected areas
and take action to provide psychosocial support to the community.
“Consumer and care groups” is a nationally widespread concept. There are

about 70 groups representing most districts. Ten of them are registered as
non-profit entities. The Consumer Action Network Mental Health Sri Lanka
(CANMH Lanka), which operates from the National Institute of Mental Health,
is one such successful organization. The Network was established for the
collaboration of people affected by mental health issues and their carers to
advocate for a secure mental health system.
District review meetings act as a platform for the Mental Health Directorate
to monitor and guide service provision. These meetings review district mental
health services (gaps and challenges), outreach clinics, school programmes
and other initiatives carried out in the district. Further, mental health-related
guidelines that are developed at the national level are customized and
implemented at the local district level through this platform.
135
5.12 Dental care
Organizational arrangements for dental care services in Sri Lanka are given
in Figure 5.5.
The overall management of the Dental Health Services of the Country comes
under the purview of the Deputy Director-General (Dental Services), who
is assisted by regional dental surgeons, consultants, dental surgeons and
dental therapists of the department. They cater to the oral healthcare needs
of nearly two million patients a year. The present workforce consists of 1350
dental surgeons of the Department and 55 specialists in the fields of oral
and maxillofacial surgery, orthodontics, restorative dentistry and community
dentistry. As an islandwide service, appointments, transfers and any other
HR management decisions with regard to dental surgeons are handled by the
DDG/DS of the division and the Director Oral Health
Figure 5.5 Organizational arrangement of dental care services in
Sri Lanka
Director General of
Health Services
PDHS DDG/DS DDG/PHS 2
RHDS Director/
Dental Services Director FHB
Regional
FHB Oral Health Unit
Dental Surgeon
Line Ministry Hospitals

Provincial Gov. • Dental OPD School Dental
Hospitals • OMF Units Clinics (Therapists)
• Dental OPD • Restorative Units
• OMF Units • Dental Comm. Units
• Restorative IOH Maharagama
Units ADC/CDC/ DI Colombo
MOH (DS) Dental Hospital Peradeniya
ADC/CDC/MOH (DS)
ADC: adolescent dental clinics; CDC: community dental clinics; DDG: Deputy Director-General; DI:
dental institute; DS: Dental Surgeon; FHB: Family Health Bureau; IOH: Institute of Oral Health; MOH:
Medical Officer of Health; OMF: oral and maxillofacial ; OPD: outpatient department; PDHS: Provincial
Director of Health Services; RDHS: Regional Director of Health Services
Source: Ministry of Health, 2012b
136
School dental services are handled by the Oral Health Unit of the FHB. The
DDG/DS of the division coordinates with this Unit to upgrade the dental
services delivered by dental therapists to the children through the school
dental clinics.
5.13 Health services for specific populations

The Sri Lankan health system has a special focus on delivering health
care to specific populations. Plantation sector employees, internally
displaced people, refugees, the prison community and slum dwellers are
not adequately captured by the mainstream health system. The policy on
health services in the plantation sector addresses the health issues of this
population, which comprises the largest group under this category.
During the colonial era, it was the responsibility of the estate management
to provide for the health needs of this community. With the Land Reform law
brought about in 1970, the Sri Lankan government took more responsibility
for the plantation sector. Since then, many of the plantation sector hospitals
have been taken over by the provincial ministries of health and the necessary
mechanisms put in place to integrate these into the mainstream health
system by providing the necessary HR and the other resources. Subsequent
governments have continued upgrading the infrastructure facilities of estate
hospitals and also improved the sanitary facilities in the estates (National
Cancer Control Program, 2018).
Indigenous communities in Sri Lanka live in semi-evergreen dry monsoon

forests. Due to immigration and colonization, the distinctive characteristics of
their culture have changed. But like all Sri Lankans, these Indigenous people
have full access to the free state health services of Sri Lanka (Institute of
Policy Studies, 2017).
Prison medical services are under the purview of a DDG Medical Services
of the Ministry of Health, and the prison hospitals are administered by a
medical director. The International Committee of the Red Cross helped to
develop prison hospitals with the consensus of this Directorate. The National
Programme for Tuberculosis Control and Chest Diseases runs its screening
programmes in prisons because inmates are considered a high-risk group
for TB. Similarly, the National STD/AIDS Control Programme has been
carrying out screening programmes on HIV and other STIs on inmates since
2005. Apart from screening, life skills-based education and health promotion
programmes are carried out in prisons (Ministry of Health, Nutrition and
Indigenous Medicine, 2017b).
137
There are about 42 000 internally or internationally displaced persons within
the boundaries of Sri Lanka (Internal Displacement Monitoring Center, 2019).
Malaria, TB and dengue awareness programmes are being conducted for
them with the collaboration of the United Nations High Commissioner for
Refugees (UNHCR) and IOM. The health sector of Sri Lanka closely liaises
with UNHCR to provide psychosocial support and counselling services to
those who are in need (United Nations High Commissioner for Refugees,
2018). The MoH collaborates with UNHCR and other stakeholders to conduct
awareness-raising sessions for international refugee protection.
5.14 Complementary and alternative medicine, including

traditional medicine
In Sri Lanka, the Traditional Medicine (TM)/Indigenous Medicine system
comprises Ayurveda, Siddha, Unani and Deshiya Chikitsa (local indigenous
medical practices). The Ayurveda Act, enacted in 1961, regulates the TM
system in the country, including TM education. The Department of Ayurveda,
Ayurveda Medical Council, Ayurveda College and Hospital Board, and the
Ayurveda Research Committee were established under the Ayurveda Act
no. 31 of 1961 (Parliament of the Democratic Socialist Republic of Sri
Lanka, 1961). The Department of Ayurveda, under the guidance of the MoH,
administers and regulates the TM system with the assistance of provincial
councils and local government bodies. The Ayurveda Medical Council is the
main regulatory body for Ayurvedic practitioners, Ayurveda pharmacists
and Ayurveda nurses. In addition, the Council is responsible for formulating
rules to regulate ethical conduct and the practice of Ayurveda, and any
matter relevant to service provision and education. The Ayurveda College
and Hospital Board regulates the content of courses on Ayurvedic medicine,
appoints examiners and conducts examinations for awarding diplomas,
exhibitions (Jatha dakshina), bursaries, medals and other prizes for students
(Parliament of the Democratic Socialist Republic of Sri Lanka, 1961). It
regulates and controls admissions, discipline and the moral development of
students. The Ayurveda Research Committee is responsible for carrying out
research in all branches of Ayurveda to promote its development and provide
advice to the Department of Ayurveda and Ayurvedic educational institutions.
The indigenous curative and preventive medical services of the public

sector (State) are provided to the public through a network of 708 Ayurvedic
hospitals and dispensaries located islandwide. These facilities come under
the administrative purview of the indigenous medical sector of the MoH. In
Ayurvedic hospitals and dispensaries, indigenous medical OPD care is carried
out daily and, in addition, the hospitals provide inpatient care. The necessary
medicines are mainly manufactured locally while a few are imported.
138
6. Principal health reforms
Chapter summary
This chapter discusses some of the major health-care reforms and policies
that have taken place from 2006 to date: the establishment of the National
Authority on Tobacco and Alcohol (NATA), National Policy and Strategic
Framework for Prevention and Control of Chronic Non-communicable
Diseases, National Migration Health Policy, establishment of the National
Medicines Regulatory Authority (NMRA), National Policy on Health
Information, and Policy on Health Service delivery for UHC. These policies
and reforms address the needs of the country brought about by demographic,
epidemiological and social transition. Some of the problems in service
provision are highlighted in Chapters 5 and 7.
Despite strong policy commitment to health reform such as NATA, the

National Human Resource Coordinating Division and NMRA, implementation
gaps point to the need for strengthening the technical aspects of human
resources in these new agencies to fulfil their mandates.
The Health Services Act of 1952 was the basis for the first health reform and
reorganization of services in an independent Sri Lanka. Some of the reforms
and policies such as the establishment of the health unit system 93 years
ago, which predates Independence, and the Dual Practice Act of 1977, remain
relevant and have a considerable influence on how services are provided even
today. Decentralization of administration to the provinces in 1987 and health
becoming a partially devolved subject have had many implications on service
provision, quality and equity.
The ongoing health service delivery reform for UHC emphasizes PHC and
attempts to shift focus from the current predominance of specialized care
to that of more coordinated care across all levels. This is based on the
evidence of the merits of patient-centred PHC combined with a proper
referral system in achieving equitable access to care. It is envisaged that
this would lead to better health systems efficiency and quality of services for
chronic NCD conditions. This needs continued strong political leadership, as
the key missing reform policy is an increase in fiscal space for health. The
government should increase its spending on health, which currently stands
at 8% of the GGHE (average 2009–2016). This is to help reduce the current
high level of OOPE, which was 50.1% of CHE in 2016 (see Chapters 3 and 7).
139
6.1 Analysis of the significant health reforms that affected
health developments in Sri Lanka
The reforms date back to 1926 when the MOH system was established.
The principal reforms in Sri Lanka are described in Table 6.1 and can
be categorized with reference to the six health systems building blocks.
Although almost all these policies change the impact of multiple building
blocks of the system, each is seen to have an impact on one component more
than the rest. These reforms include the following:
a. governance: legislation of the Health Service Act 1952; regulation

of the private sector in 2006; addressing health risks such as the
tobacco and alcohol policy in 2006; and establishing the framework
for prevention and control of NCDs in 2009;
b. medicines and medical products: establishment of the NMRA in 2015;
c. health workforce: dual practice policy in 1977; establishment of HR
coordinating division in 2016;
d. health delivery systems: decentralization of health services to the
provincial health departments in 1987; establishment of a DGH in
each district in 2000; and policy towards health service delivery for
UHC in 2018; and
e. HIS strengthening in 2016.
Table 6.1 Major health-care reforms and policy measures

Year Reform
1926 Establishment of health unit (Medical Officer of Health) system
1952 Health Services Act (No. 12 of 1952)
1977 Dual practice*
1987 Decentralization of health services and establishment of provincial health departments
1991 Management reform to amalgamate preventive and curative care services in keeping
with local administrative boundaries
2000 Development of one hospital to the level of a district general hospital for each district
2005 National Medicinal Drug Policy
2006 Private Health Sector Regulation Act
2006 National Authority on Tobacco and Alcohol
2009 National Policy and Strategic Framework for Prevention and Control of Chronic Non-
Communicable Diseases
2013 National Migration Health Policy
2016 Establishment of National Human Resource Coordinating Division
2017 National Policy on Health Information
2018 Policy on Health Service Delivery for UHC
* Government health professionals are allowed to engage in private practice during off hours.
Source: Compiled by the authors
140
6.2 Analysis of recent major reforms
This section highlights key health-care reforms from 2006 to date, which are
considered to have a significant impact on the health of the population and on
the health system.
6.2.1 National Authority on Tobacco and Alcohol (NATA)

The requirement for a national-level coordinated response to address the
harms from tobacco and alcohol in Sri Lanka was building up since the
late 1990s. A vibrant nongovernment sector, professional bodies and some
sections of the government apparatus saw the need for such a response and
strongly advocated for it for over a decade. Initial steps consisted of banning
advertising of tobacco in the media, inclusive of the national press and
billboards through the amendments to the Consumer Protection Act in 1999.
The restriction at that time was enforced partly through legislation and partly
through voluntary actions by the tobacco industry. The Global Youth Tobacco
Survey (GYTS) of 2003 revealed that 8.7% of schoolchildren were current
users of tobacco products and 79.1% and 78.5% had seen pro-smoking
messages on billboards and newspapers, respectively. The almost-parallel
process of negotiation and finalization of the WHO FCTC in 2003 added
impetus to this process, although there were many obstacles placed by the
alcohol and tobacco industries. The findings of the GYTS reinforced the need
for a national authority for the effective implementation of the FCTC and this
resulted in the National Authority on Tobacco and Alcohol Act, No. 27 of 2006.
The role of the NATA was defined as “Identifying the policy on protecting
public health for the elimination of tobacco- and alcohol-related harm
through the assessment and monitoring of the production, marketing and
consumption of tobacco products and alcohol products; to make provision
for discouraging persons, especially children, from smoking or consuming
alcohol, by curtailing their access to tobacco products and alcohol products”
(Parliament of the Democratic Socialist Republic of Sri Lanka, 2006).
The implementation of a strict anti-tobacco and alcohol policy by NATA, in

collaboration with strong non-state stakeholders such as the Alcohol and
Drug Information Centre (ADIC) saw the use of tobacco products among
youth decreasing from 8.7% in the GYTS of 2003 to 3.7% in the GYTS of
2015. Vigorous health promotion activities directed at target groups starting
from the preschool age upwards, the persistent vigilance against direct
and indirect advertising, and advocating for an increase in taxes on tobacco
and alcohol products have paid dividends. Statistics from the Sri Lanka
Customs show that cigarette production fell from 4800 million in 2006 to 2600
million, which is a substantial drop of 45% (World Bank, 2017). According
141
to islandwide statistics by the Alcohol and Drug Information Centre (ADIC)
in 2014, 31.2% of the population continue to use tobacco products, which
has shown a steady but slow drop in the recent past. In recognition of the
outstanding achievements in tobacco control, NATA Sri Lanka was conferred
with the “World No Tobacco Day Award” by WHO Regional Office for South-
East Asia in 2017. NATA mainly conducts advocacy, and the actual regulatory
functions are carried out through health ministry officials, the police and
departments of excise and customs. Pertinent cultural elements and
vociferous civic participation continue to play a major role in bringing down
tobacco and alcohol use among the public and, in particular, among children
and the youth.
The tobacco and alcohol industries have continued to actively interfere

with the government’s policy to foster implementation of best buy
interventions such as increasing tax and controlling the availability of alcohol
(Tuangratananon et al., 2019, Tangcharoensathien et al., 2019). Between 2010
and 2017, alcohol consumption has increased by 34% in the South-East Asia
Region from 3.5 to 4.7 litres per capita per year (Sornpaisarn et al., 2020). The
prevalence of current drinkers in the South-East Asia Region is forecasted
to increase from 39% in 2018 to 45% by 2030, while the prevalence of heavy
episodic drinkers will increase from 11% in 2018 to 14% by 2030. It is also
observed that in Sri Lanka’s per capita total alcohol consumption rose from
4.0 litres in 2010 to 4.3 litres in 2016 (World Health Organization, 2018c).
This calls for further policy advocacy, improved awareness on harm from
tobacco and alcohol, and improved government regulatory capacity to combat
both direct and indirect advertising and marketing, with a particular focus
on young people and women. Persistent strategic alliances and engagement
with civil society organizations and active citizens are recommended.
6.2.2 National Policy and Strategic Framework for Prevention and

Control of Chronic Non-Communicable Diseases
Over the past few decades, NCD mortality in the country has shown a sharp
increase. CVD has been the leading cause of death over the past 40 years,
while mortality from DM and cancer has doubled. WHO estimates for 2016
suggest that over 80% of the mortality in the country is due to major NCDs
(Ministry of Health, Nutrition and Indigenous Medicine and World Health
Organization, 2019). Based on a 20% increase in hospital admissions due
to cerebrovascular diseases and related causes observed from 1999 to
2005, a projection had been made for the next 10 years, which predicted
an exponential increase in these diseases (Premaratne, Amarasinghe and
Wickremasinghe, 2005). In 2008, Katulanda et al. reported that pre-diabetes
142
or diabetes affected one in five adults in Sri Lanka and one third of them were
undiagnosed. Significant mortality due to asthma has been observed over the
past two decades, with prevalence rates varying from 20% to 25% based on
the geographical region. Chronic renal disease of unknown etiology (CKDu)
was emerging as a public health problem in the North Central and North
Western provinces of the country (Ruwanpathirana et al., 2019).
The policy on management and control of chronic NCDs was adopted in

2009 to accord priority and ensure resource efficiency in responding to
the emerging epidemic of chronic NCDs in the country (Ministry of Health,
Nutrition and Indigenous Medicine, 2009). The policy was a result of
multi-stakeholder consultation and gained high-level political support for
implementation. It was also reflective of the global discourse on chronic
NCDs and drew upon a series of international policy documents, including
the guidance on NCDs developed by WHO, the World Health Assembly
Resolution on the Global Strategy on Diet and Physical Activity, Health
and Preventing Chronic Diseases, and the WHO Strategic Framework for
NCD Control and Prevention 2008–2013 (Ministry of Health, Nutrition and
Indigenous Medicine, 2009).
The scope of the policy was to address four major NCDs and their risk
factors: cardiovascular diseases, DM, chronic respiratory diseases and
chronic renal diseases. The policy identified the need for a comprehensive
approach, with equal emphasis on health promotion, prevention, early
detection, proper case management, and reorganizing health-care delivery to
ensure effective implementation. Important changes to health-care delivery
were the identification of an essential list of medicines for management
of NCDs at primary-level health institutions, which was guided by the pilot
experience of the WHO Package of Essential NCD Interventions (PEN)
project. Guidelines for the management of chronic NCDs at the primary care
level were developed and rolled out to strengthen the capacity of frontline
health workers. The key emphasis of the policy was on expanding services
to detect the undetected. This took the form of establishing Healthy Lifestyle
Centres (HLCs) islandwide. By 2018, 900 such centres had been established.
The NCD prevention project by Japanese International Cooperation Agency
(JICA) provided key inputs to organizing HLC services. The intervention,
although implemented on a wide scale, did not achieve the expected results
due to not being optimally utilized by people. Male participation for screening
was seen to be very low (Mallawaarachchi et al., 2016). HLC was the key
strategy implemented as a service delivery intervention towards reducing
preventable mortality.
143
Considering the high prevalence of risk factors for NCDs, prevention of the
main risk factors is the main policy focus through the application of best buy
interventions as proposed by WHO (Ministry of Healthcare and Nutrition,
2008). Increasing the size of pictorial warnings on cigarette packages,
increasing taxation on alcohol and tobacco, a traffic light system on sugar-
sweetened beverages, introducing a tax on sugar-sweetened beverages,
increasing public awareness on reducing sugar and salt consumption and the
importance of physical activity, are some of these.
Many interventions adopted in the policy fell short of the service delivery
organization changes mentioned as a key strategy. The reforms for PHC
services were conceptualized initially to address the growing problem of
NCDs and evolved as a policy to provide UHC (see Section 6.3.1).
6.2.3 National Migration Health Policy

Migration has played a pivotal role in the socioeconomic development of
Sri Lanka. Although known as a labour-exporting country with foreign
employment being the principal foreign exchange earner, a mixed profile
is seen at present, where the country has also become a labour-receiving
country (Weerarathne, 2018).
In 2015, 54% of the foreign exchange received was from remittances coming
from migrant workers employed in the Middle East. The Sri Lanka Bureau
of Foreign Employment in their corporate plan 2017–2021 state that 1.5
million Sri Lankans were estimated to be living outside the country on foreign
employment. The Government of Sri Lanka felt that special attention needed
to be focused on the health needs of families left behind to ensure that the
benefits are reaped without enduring negative consequences (Siriwardhana
and Stewart, 2013).
In 2008, the MoH took actions as recommended by the World Health

Assembly resolution on promoting the health of migrants, and set up a
secretariat with the support of International Organization for Migration
(IOM). This aimed to conduct a rapid assessment to identify the migration
health profile, policy gaps and where service coverage should be improved. A
National Steering Committee on migration health was established under the
chairmanship of the Secretary Health, with participation of high-level officials
from other relevant government ministries. A technical task force functioned
under the chairmanship of the DGHS. The technical task force was supported
by IOM in conducting further research based on the rapid assessment carried
out. The findings of the commissioned studies contributed to policy drafting.
144
The National Migration Health Policy was published in 2013 (Ministry of
Health, Nutrition and Indigenous Medicine, 2013).
The National Migration Health Policy highlights the need to protect health
and access to health services by outbound migrants and families left behind,
inbound migrants and internal migrants through multisectoral approaches.
Having eliminated communicable diseases such as malaria and lymphatic

filariasis as public health concerns, Sri Lanka had to take the necessary
steps to prevent the reintroduction of these pathogens through incoming
migrants, as the entomological profile continues to be vulnerable to an
outbreak. This is conducted through health screening of all resident visa
applicants and treatment of positive cases of malaria and filariasis.
The MoH entered into a memorandum of understanding with IOM to establish

a health assessment facility for residence visa applicants in 2018, applying
a model of build, operate and transfer. Residence visa applicants are to be
screened for malaria, filariasis, HIV and TB at this certified facility and will be
referred to national programmes for confirmation and follow-up treatment.
The Policy provides the opportunity to link several other disease control
efforts. A national Pre-Departure Health Assessment (PDHA) for outbound
migrants from Sri Lanka was finalized in 2017 following an international
consultation, which was themed “PDHA as a global public health good”. The
event brought in participants from several countries, both labour-receiving
and -sending. Experts were able to discuss and address the challenges
in screening protocols, which were often misinterpreted as diagnostic,
particularly in the case of TB. Protocols followed at these inbound and pre-
departure health assessments offer linkages to the National TB Control
Programme for follow-up care of those who screen positive.
Sri Lanka has actively advocated for migration health within the country,
regionally and globally, and has succeeded in sensitizing and getting
migration health on the agenda of many regional and global meetings. The
Policy will have many opportunities in forging greater understanding on
important public health issues such as the control of TB and elimination of
malaria from the South-East Asia Region.
6.2.4 National Medicinal Drug Policy

Sri Lanka has made efforts to develop country-specific drug policies from
the late 1950s onwards These led to the development of the first-ever
Ceylon Hospital Formulary. The landmark report, “The Management of
Pharmaceuticals in Ceylon” in 1971, by Professor Senaka Bibile and Dr
145
S.A. Wickremasinghe, who had been officially tasked by the then Prime
Minister of Ceylon to recommend ways to rationalize the medicines
policies of the country, made a signal contribution towards the formulation
of a comprehensive policy. In 1980, Sri Lanka approved the Cosmetics
Devices and Drugs Act (CDD) (1980 Act No. 27), which formed the legal
basis for the regulation of medicinal drugs until 2015. The Cosmetics
Devices and Drugs (CDD) division functioned under a Director with powers
delegated by the DGHS.
From the 1990s onwards, major lobby groups were working towards the
development of a comprehensive national medicines policy based on the
“Bibile principles” and its implementation in Sri Lanka. As a result, the
government formulated and approved the National Medicinal Drug Policy
(NMDP) in 2005 (World Health Organization, 2016). This Policy, which involved
a wide range of stakeholders, covered 10 main elements: selection of
essential medicines, affordability and equitable access, financing options,
supply systems and donations, regulations and quality assurance, quality
use of medicines, research, human resources, viable local pharmaceutical
industry, and monitoring and evaluation.
The government reactivated the policy process in 2015 and the Parliament
of Sri Lanka passed National Medicinal Regulatory Authority Act in and
established the National Medicines Regulatory Authority (NMRA) the
same year. The new NMRA Act also replaced the existing CDD Act, which
regulated medicinal drugs in Sri Lanka from 1980 to 2015 (Jayakody and
Galappatthy, 2015).
The establishment of NMRA as the regulatory body introduced changes to

the governance of regulation of medicines in Sri Lanka. Through the previous
CDD Act, the drug regulatory authority functioned under the DGHS; under
the new NMRA Act, the NMRA functions as an independent authority, with
an independent board to regulate medicines, medical devices and borderline
products. The Minister of Health is the appointing authority who also appoints
the advisory committee, which includes civil society representation. In
comparison to the previous CDD Act, the new Act does not include cosmetic
products, but includes a new area designated as “borderline products”. This
comprises substances that may fall in between foods and drugs, which were
not identified in the previous act. Under the powers of the new act (NMRA),
the government can issue a maximum retail price for essential medicines.
This Act also enables the NMRA to consider cost and need in addition to
quality, safety and efficacy in registration. The implementation of the NMRA
Act also guaranteed affordability and equal access.
146
The remaining components of the National Medicinal Drug Policy are at
various levels of implementation. This requires the support and collaboration
of multiple stakeholders, including public, private, health and non-health
partners. The other major challenges seen in implementation of the total
activities under the Policy are the recruitment of required qualified HR
and further expansion of the capacity of the National Drug and Medicines
Quality Assurance Laboratory to assess medicines at pre-registration and
for post-market surveillance of medicines in the market. Post-marketing
quality assessment and pharmacovigilance are also crucial aspects that
need continued political commitment and support (Jayakody and Galappatthy,
2015). The NMRA is likely to make significant improvements in the availability
of quality-assured medicines at affordable prices in the country.
6.2.5 Health Information Policy

The HIS has developed over decades and supports developments in the
government health system. Several contributing subsystems are identified,
i.e. hospital information systems, preventive health information systems,
population census, Civil Registration and Vital Statistics (CVRS) system and
routine population-based health surveys. A survey conducted by the MoH
in 2009 using the WHO Health Matrix Network (HMN) tool (unpublished)
highlighted that resources and data management were present but not
adequate when compared to the HMN suggested standards. The survey
also identified compartmentalization of the information governance
mechanism, limited data-sharing, moderate use of information for
decision-making, insufficient automation leading to a relatively modest
quality of health information, and the need for explicit policies on health
information management.
Based on the results of the HMN survey in 2009, policy directions were
identified through a series of focus group discussions with relevant high-
level stakeholders from the health and other relevant sectors. A draft policy
was submitted to officials of the MoH, registrar generals of departments,
Department of Census and Statistics and other development partners for
comments, which led to approval by the Cabinet of Ministers in 2017. This
Policy is aligned with the national e-government policy (Information and
Communication Technology Agency of Sri Lanka (ICTA), 2009 ).
The Health Information Policy aimed to systematically convert appropriate

areas of HIS to an electronic information system and encourage
innovations in the field of HIS (Ministry of Health, Nutrition and Indigenous
Medicine, 2016d).
147
The broad policy objectives of the Health Information Policy are:
• to ensure that 50% of all health institutions generate, disseminate and

use timely and quality health information to support organizational
management and development;
• to make available comprehensive systems for personalized and
community-based health information management for shared and
continuous care recipients who receive care at 50% of all BHs, DGHs,
PGHs and THs;
• to ensure optimal data-/information-sharing and access to health
information in relation to all sharable data in HIS, while ensuring
ethical considerations and confidentiality of care recipients;
• to encourage suitable innovations related to health information
management and e-health in all information processes, while
ensuring interoperability of information systems;
• to ensure the security and integrity of all health data/information; and
• to ensure the sustainability of all HIS.
The Policy has allowed the identification of cadres in relation to health

information management in currently established health programmes and
the need for terms of reference for medical informaticians and other related
health-care cadres involved in HIS. The contribution of this dedicated cadre
will require further evaluation.
Several pre-existing manual health data collection and reporting processes

have been computerized. The details of these are explained in Chapter 5.
The full implementation of the National Health Information Policy is expected

to result in an integrated national HIS. The patient information component
of the planned system will provide a unique patient identification number
(PIN) and a personal health record (PHR), which will ensure patient-centred
integrated care delivery and follow up to support UHC as well as population-
based morbidity data. The e-health record will be initiated with the envisaged
reforms on PHC.
Implementation of the Policy is further complemented by the National Act

on Right to Information (Parliament of the Democratic Socialist Republic of
Sri Lanka, 2016). Public access to information and its effect on transparency
and public engagement in health development as well as improving health
literacy through providing timely information are key gains expected through
policy harmonization, which health authorities must put into practice.
148
6.2.6 Establishment of a central HRH coordination unit
Historically, the MoH did not have a specific Human Resources for Health
(HRH) department or unit, and HRH functions were scattered across several
units and departments. The publication Better health for Sri Lanka: report
on a health manpower study by Simenov et al. in 1975 had identified the
need for coordinating key HRH functions such as planning, production
and deployment. But little meaningful action seemed to have resulted
from this. The increasingly complex nature of health services delivery and
associated HRH functions reflect the urgent need for a more coordinated
approach towards HRH in Sri Lanka. Therefore, a number of processes
towards improving HRH coordination have been initiated within the MoH.
Significant policy formulation milestones that can be identified in this regard
are the Staffing Study for Cadre Determination of all Medical, Nursing and
Paramedical Personnel in 1981, Presidential Task Force for the formulation
of the National Health Policy Report of 1992, which gives a comprehensive
analysis of HRH and recommendations, the National Health Policy Report
of 1996, emphasizing the need to support and strengthen HR development,
National Strategic Plan for Nursing and Midwifery Development 2001–2010,
Perspective Plan for Health Development in Sri Lanka (1995–2004) and
the Health Manpower Development Plan (1997–2006). These strategic
documents on HRH were developed during a phase when sustained interest
through a focal unit within the Ministry for HRH did not exist. Many of these
did not influence the system in any tangible way due to these organizational
deficiencies.
The HRH strategic plan developed in 1998 through external technical

assistance of WHO for the period 1999–2009 listed an initial set of policy
proposals to support the objectives of the plan. This plan too has not been
implemented because of low stakeholder involvement and poor advocacy
on the process. The latest of this series of policy documents is the HRH
strategic framework 2009–2018, which was commissioned in response to the
recommendations of the Health Master Plan (HMP) for Sri Lanka 2007–2016.
Although comprehensive in scope, adoption of the strategic framework has
also been far from satisfactory. The functions of training, recruitment and
deployment of HRH are carried out by different units in the MoH and that may
have impeded a consolidated effort to develop HRH in Sri Lanka.
A recent development recommended in the HRH Strategic Plan materialized

through strong political influence, and the HRH Coordinating Unit was
established within the MoH in 2017 to coordinate the multiple HRH functions.
Its focus has largely been on workforce projections and sharing information
on training plans. Enhanced capacities are required on HRH policy analysis
149
to improve the scope and functions of this unit, which could also lead to
transforming health professional education through coordination with other
ministries such as Education/Higher Education and units in the MoH.
Slow but steady progress of this Unit has increased its acceptance and its
coordination functions, which extend to liaising with administrative bodies
that influence HRH outside the Ministry. However, this Unit has to strengthen
its own capacity in the main HRH functions and infrastructure facilities to
conduct its operations and liaise with existing units in the Ministry mandated
to perform these functions.
6.3 Future developments

6.3.1 Health service delivery for UHC, emphasizing primary care
reforms
Primary health care, which was introduced through the establishment of
the health unit system (MOHs) to address health needs in 1926, has been
the backbone of the Sri Lankan health system. Subsequent governments
have supported and enhanced this model of addressing the preventive
health issues of a defined population. The population served by an MOH
area and its subunits is defined so that it coincides with local government
boundaries. The strengths of the MOH system have been its well-trained field
public health staff, supportive supervision and a system of accountability for
health outcomes in a defined population, supported by a good management
information system.
In 1987, a major political and administrative reform was the Thirteenth

Amendment of the Constitution of Sri Lanka, which created provincial
councils with a degree of decentralization of governance to the provinces.
With this process, health became a partially devolved subject. Important
service components that became the responsibility of the provinces were
the primary-level health services comprising the MOH system for preventive
care, the network of DHs and PMCUs for curative care, and the BHs that form
the secondary level. Larger secondary-level hospitals are being managed
with difficulty by the provincial health authorities due to limitations in
resources. Eight BHs out of 83 have been handed over to the MoH. Although
difficult, many provincial authorities maintain their management position
to secure even the limited financial allocations they receive. The Treasury
is tasked with allocating the limited health budget between the Centre and
provincial authorities. More large and specialized institutions coming under
the direct management of the Centre has seemed to justify the Centre
receiving a significantly higher financial allocation than the provinces.
150
A management reform to amalgamate the preventive and curative sectors
was introduced in 1991 as a step to further the decentralization process,
conforming to the local administration unit, i.e. the DS divisions. The reform
assigned the MOH as the administrative head of primary-level curative
hospitals situated within the same DS/MOH area. This reform was short
lived as it was perceived as having a negative impact on preventive services
provided by the MOH and is seen as a premature reform without adequate
pilot implementation or assessment.
In 2000, a policy aimed at strengthening one hospital to the level of a DGH

was implemented to improve the infrastructure facilities and specialist
services in each district. Over the past decade, there has been significant
expansion of specialized services, with major capital funding diverted to
larger hospitals. This has benefited MCH services, where free hospitalization
and better access to specialized care and emergency services have led to a
reduction in mortality. In the absence of a clear set of guidelines for rational
development, this policy led to some ad-hoc developments of secondary and
tertiary hospitals. The expansion of secondary- and tertiary-care institutions
resulted in the bypassing of primary care institutions, compromising
continuity and the quality of care. The policy on health service delivery for
UHC is a significant change that will give more emphasis to primary care and
address some of the gaps in service delivery.
The policy has taken considerable time to develop and has been catalyzed
with political commitment and development partner interest. Refer to Figure
6.1 for the timeline.
151
Figure 6.1 Chronological events: towards primary health care reform in Sri Lanka, 2009–2018
152
2017
Presentation on
2008/2009 2011 draft policy at NHDC
16 essential drugs Discussions with professional
Initiation of work for management of 2015 colleges on the reform
2013
Finalization of the policy chronic NCDs at Survey carried out by
primary care level Pilot interventions Draft policy uploaded on
on Chronic NCDs policy unit to identify ministry website for comments
in 3 locations in requirements to improve
Stakeholder consultation and Issue of Priority Polonnaruwa, residential facilities) Draft policy developed and advocacy
finalization of 10 advocacy NCD Drug circular Nuwaraeliva and with recommended road map
posters on the need for the Hambantota
Budget allocation to ADB project negotiations
new model Development of tools for
address NCDs
through primary supervision of primary Mapping of clusters
Discussion on 3 curative care institutions
conceptual models care approach Mapping of Specialists' locations
National Scientific and Budget debate & Hon.

Policy forum Guidelines for Concept of “shared care Cabinet
strengthening Health Minister announce memorandum
Decision for piloting taken cluster system” put “family doctor for all” &
healthcare at forward - discussion
primary care cluster system for future
Engelgau et. al. – Prevention papers prepared Approval of the
developed for pilots Draft policy presented policy (10 April)
and Control of selected NCDs:
Policy Options and Action to senior officials
Personal health Development of a common
WHO PEN Project record developed competency framework for Development of indicators Rapid out-patient
doctors with the involvement for monitoring of morbidity survey
Samadhigama - An initiative for 2012 and introduced of all medical faculties performance
a change in primary healthcare Primary care identified as Drafts Essential
infrastructure Personal health a priority in the Health Services Package
NCD prevention project record revised Master Plan (2016–2025) developed
supported by JICA 2014 2016 2018
2010
Source: Compiled by Organization Development Unit, MoHNIM (2018)

The need to reorganize the system from a model for predominantly acute
illness management to a model for chronic illness care in response to the
changing disease epidemiology has formed the basis for reorganization of
primary curative care.
A key concern addressed by the policy has been to respond to the increasing
burden of NCDs, including mental health, cancer and injuries as well as
the health-care needs of an ageing population, while also addressing the
health needs of young persons. The policy, through integration at the primary
care level, will offer opportunities for unresolved health challenges such as
controlling TB and malnutrition.
The changes envisaged based on this policy are as follows. All health
institutions below the level of BHs, which are the DHs and PMCUs (together
named as PMCI) (Perera and Perera, 2017; Perera et al., 2019), will be
linked with their closest specialist hospital (BH and above) to constitute a
cluster. At present, PMCIs have varying capacities for patient management.
The catchment population living in the GN divisions in the proximity of each
PMCI will be empanelled to it and the institution would be responsible for
the delivery of a comprehensive range of PHC services to the identified
population. The GN areas have varying populations that can range from 200
to 2000 or more. For each PMCI, the closest secondary- or tertiary level-
hospital will be identified as a referral institution. As described above, the
group/cluster of PMCIs sharing a common referral institution will form a
“shared care cluster”. A model of this is presented in Figure 6.2. Care would
be shared between primary and specialized services, providing continuity;
and the varying resources within the cluster would also be shared, including
medicines, diagnostics and health-care workers such as physiotherapists.
It would also include the rationalization of HR with a skill mix necessary for
optimum service delivery at each level. These would be complemented by
ancillary services and essential supplies. The reform focuses on curative
care but emphasizes on integration of preventive and promotive functions.
These are currently carried out by the MOH/community health services
through functional linkages with guidelines, protocols, job descriptions of
key health personnel available at the primary care level (both curative and
community health services).
153
Figure 6.2 Proposed “shared care cluster”
PMCU: Primary Medical Care Unit

Source: Ministry of Health, 2019a
The reform will introduce a package of essential services delivered in their

own locations focused on the management of NCDs; link curative, preventive
and promotive services; and ensure patient-centred continuity of care. This
would also provide vertical programmes within the Ministry, such as those for
NCDs, TB, elderly care, child health, opportunities for greater integration at
the primary care level and added efficiency gains. The reforms envisage the
incorporation of new technology into the health-care system in a judicious
and equitable manner.
A unique ID and an individualized patient record system would form an

integral part of the envisaged service provision to citizens. Each person will
be provided a secure smart health card, which will contain personal health
information accessible at both public and private health-care delivery points.
This would further strengthen the synergies between the private and public
sectors and facilitate continuity of care. The patient information system
would be synchronized with institutional as well as disease notification and
surveillance systems.
The reform process faced many challenge, namely, overcoming the strong
emphasis by policy-makers and demand to build larger specialized care
hospitals (BHs, DGHs, THs and hospitals for specialties and subspecialties),
and the fact that responsibility for primary care lies with the provincial
councils, which often experience resource constraints. This has led to a
lack of public confidence in primary curative care institutions, resulting in
bypassing of these institutions. Although the right of individuals to access
154
services in any government curative care facility at whatever level has
ensured equity, it has contributed to the phenomenon of bypass, inefficient
use of PHC resources and potential low quality of tertiary hospitals due
to overcrowding. In a resource-scarce provincial setting, the demand for
care in secondary- and tertiary-level institutions has led to expansion of
infrastructure and resources to these institutions at the expense of primary-
level institutions, contributing to underutilization of the latter.
However, given the long years of experience the MoH has with the evolution of
community-based preventive health services, there is opportunity to build the
envisaged primary curative care by taking into consideration the strengths of
the system and, more importantly, the lessons learnt over the years.
Implementation of the UHC policy needed many other health development

interventions to fall into place. Noteworthy were the finalization of the Policy
on Chronic NCDs (2010), the issue of Priority NCD Drug Circular No. 02-
135/2011 on adoption of 16 essential drugs for the management of chronic
NCDs at the primary care level (2011), development of guidelines for the
management of NCDs in primary health care (2012), pilot interventions
to introduce different tools such as the personal health record, lifestyle
modification training and tools, and supervision tools. Each of these has
been developed with extensive participation of experts in the respective
fields of clinical medicine, public health and administration, economics and
communication.
Vital to the reform are the clinical and non-clinical competencies (such as
communication towards change in lifestyles in the population) among PHC
health cadres to provide person-centred continuity of care. While several
other HR gaps need to be addressed, the changes required in the curriculum
of undergraduate medical and other allied professional education were
considered of paramount importance. Discussions involving all the medical
faculties led to the development of a common competency framework for
doctors to deliver better primary care, and the MoH informing the Ministry of
Higher Education of these requirements. This work has to necessarily expand
to include other health professional cadres.
Key instruments to implement the UHC policy are the action plan with
adequate funding support and effective monitoring and evaluation systems,
Essential Services Package, Cluster Management Framework and the
National Health Performance Framework 2018, which will serve as an
overarching policy monitoring framework. The policy aims at further
improving efficiency and effectiveness, and providing financial protection
within the current health-care delivery system. The underlying limitation
in doing this is the requirement for critical decisions to be taken to allocate
155
resources prioritizing the strengthening of primary care. As specialized
care also forms the continuum of care, overall policy implementation would
require more government allocation for health. As efficiencies are to be
gained through phased-out reorganization and retooling, the allocation
required will not be too large to manage but requires careful planning and
strategic decisions.
The policy process attracted and has also been catalysed by the interest of
key development partners. Significant technical contributions have been
made by WHO and through the financial support of the Asian Development
Bank (ADB) and the World Bank (WB).
The Cabinet of Ministers approved this policy in April 2018, laying the
foundation on which UHC will be implemented in Sri Lanka. This is in keeping
with our commitments towards achieving the Sustainable Development
Goals (SDGs).
156
7. Assessment of the health system
Chapter summary
The health system of Sri Lanka has a proven track record of satisfactory
performance and has gained international recognition as a successful model
of “good health at low-cost”. It has achieved commendable health outcomes
above what is commensurate with its income level. The objective of Sri
Lanka’s health services from inception has been to ensure and maintain
health care of a high quality, free at the point of delivery to all its citizens.
Sometimes, maintaining equity has had priority over quality. However, this
has not been through a reduction in clinical standards of care but through
accepting a lower quality of amenities. A key feature of the services is that
they are provided close to people’s homes through a widespread network
of government health institutions, and a person is free to seek care at any
hospital in the country without a formal referral. This has ensured increased
accessibility for all persons to any service offered in the government sector.
However, there is increased inequity when the poor cannot afford to seek
health care at higher-level institutions due to travel and incidental expenses.
Free choice of health institution may also result in overcrowded tertiary care
hospitals, leading to constraints in the quality of care.
Health financing indicators demonstrate that the health system is both pro-
poor and efficient compared to other low- or middle-income countries in the
region (refer Table 3.2). Although OOP expenditure as a proportion of CHE
has risen steadily during the past two decades, financial hardships due to
illness are minimal, mainly because catastrophic illness is taken care of at
public facilities.
The country has a preventive system, which adopted a primary care approach
from as far back as 1926. This, together with the prioritization of social
interventions, such as female education and nutrition interventions, have
delivered health indices, such as life expectancy at birth, neonatal, infant,
under-five mortality and maternal mortality rates, better than those in
countries with much higher incomes. Tracer UHC indicators on prevention
show a high score while those for treatment coverage do not reach the same
level, identifying the need for reform in the curative sector.
157
The major challenges facing the system at present are inadequate
government spending on health to match the demand for services resulting
from the epidemiological and demographic transitions, increasing allocative
efficiency and maintaining equity and quality of services, particularly at the
primary care level. There is a system mismatch since the prevailing system
had been built mainly for managing episodic acute conditions. The level of
GGHE, 8–9% of GGE, is inadequate, as reflected by the high level of OOPE,
which has been more than 50% of CHE since 2008. The government health
allocation since the beginning of the “good health at low cost” era in the
1980s cannot meet the current health challenges.
Further, implementation of health system reforms to provide quality people-

centric, first-contact curative care services, manage the rising burden of
NCDs and the problems of an ageing population, while maintaining equitable
access and improving the quality of services poses a challenge. Outbreaks of
diseases such as dengue and H1N1 infections, and both acute and chronic
undernutrition among children under 5 years of age continue to burden the
system. In response to these challenges, a policy on health-care delivery for
UHC (Ministry of Health, Nutrition and Indigenous Medicine, 2018e) has been
launched and many supportive policies towards promoting health have been
formulated in recent years.
This chapter aims to provide an assessment of the health-care system in Sri

Lanka, especially regarding financial protection, equity in financing, access
to health care, user experience, health and service outcomes, quality of care,
and health system efficiency, transparency and accountability.
7.1 Objectives of the health system

The Constitution of the Democratic Socialist Republic of Sri Lanka does
not explicitly state that health is a fundamental right. However, an indirect
statement in Article 27 2 (c) reads as follows:
“The realization by all citizens of an adequate standard of living for

themselves and their families, including adequate food, clothing and housing,
the continuous improvement of living conditions and the full enjoyment of
leisure and social and cultural opportunities” (Parliament of the Democratic
Socialist Republic of Sri Lanka, 1978).
The present health-care system in Sri Lanka is a result of the Health Services
Act of 1952 (Parliament of the Democratic Socialist Republic of Sri Lanka,
1952), many policy interventions since then and the Provincial Councils Act
of 1987 (Parliament of the Democratic Socialist Republic of Sri Lanka, 1987).
The founding principles of the health service of independent Sri Lanka has
158
been to ensure health care of high quality, free at the point of delivery to all
its citizens, thus ensuring services to all rather than focusing on a demand-
based approach.
The country has a commendable preventive health-care system with health

indices comparable to those of developed nations, but the same is not
true for curative care services, which are resource intensive. Tracer UHC
indicators on prevention have achieved high levels when compared to other
lower-middle-income countries but indicators on treatment coverage are
lagging behind. The system is increasingly under pressure to bring about
the changes necessary to address the challenges of the demographic and
epidemiological transitions but has been slow to respond. This has led to the
formulation of many policies in health and related areas in recent times.
The enactment of the National Authority on Tobacco and Alcohol (NATA)

Act No. 26 of 2006, after the FCTC ratification in November 2003, saw the
establishment of NATA, which resulted in measures such as 80% pictorial
warning on cigarette packs, ban on advertising and smoking in public places,
and the increase in taxation of tobacco leaf and stick. The total tax on tobacco
was 62.1% of the retail price of most sold brands of cigarettes in 2016. The
government had not increased retail prices between 2008 and 2016 to make
tobacco less affordable until the increase in taxes in 2017 (World Health
Organization, 2019b).
2017 saw the revision of the 1992 health-care policy. The new policy will be in
operation until 2025 (Ministry of Health, Nutrition and Indigenous Medicine,
2017a). The new strategic plan consists of four separate volumes of HMPs
for each of the following areas: preventive health services, curative care,
rehabilitative care and health administration, and human resources for
health. The objectives of the health system, as stipulated in the new policy
document, are as follows: strengthen service delivery to achieve preventive
health goals, provide appropriate and accessible high-quality curative care
for all Sri Lankan citizens, promote equitable access to quality rehabilitation
care, strengthen evidence-based service delivery to support the journey
along the continuum of care, develop new strategies to reduce OOP spending
and financial risk, ensure a comprehensive health system through better
restructuring, including HR management, and develop strategic partnerships
with all providers of health care.
In addition to the National Health Policy, 2017 saw the introduction of

policies such as on migrant health, health information, and prevention and
control of micronutrient deficiencies.15 Another key strategy introduced
15 National Strategy for Prevention and Control of Micronutrient Deficiencies in Sri Lanka 2017–2022
159
recently was taxation on the sugar content of sugar-sweetened beverages
and implementation of a traffic light system indicating the sugar content
in beverages as mechanisms to empower consumers and increase public
awareness of the sugar content with an aim to halt and reverse the NCD
burden. This has now been extended to the salt and trans-fat content of food.
Recently, a policy on health-care delivery for UHC was introduced (Ministry

of Health, Nutrition and Indigenous Medicine, 2018e). This envisages the
provision of quality first-contact care through strengthening primary-level
curative services with a special focus on NCDs. A patient- and family-centric
approach would be used, and continuity of care ensured. An Essential
Services Package for Sri Lanka has been developed, which describes the
services to be delivered in all primary medical care settings. A multisectoral
action plan for the prevention and control of NCDs, formulated in 2016,
underpins some of these reforms.
Since Independence, all successive governments have supported and have

been committed to the provision of free health care to the population as a key
social policy. In the past, various directorates under the MoH had developed
subsector policies and strategic plans, for which approval had been granted
by the Cabinet of Ministers of the Government of Sri Lanka. These policies
have been directed towards the maintenance of free health care to the
population and to further raise the health status of the people (Ministry of
The Cabinet is the forum in which inter-ministerial coordination takes

place and the system ensured that all important policy decisions were
taken collectively. There is a parliamentary “Sectoral Oversight Committee
on Health” and this committee is key to ensuring health in all policies.
Cooperation between ministries has been sought between and among
sectors, on an ad-hoc basis, to deliver the services and implement
programmes at a decentralized level.
7.2 Financial protection and equity in financing

7.2.1 Financial protection
UHC encompasses three domains: population (who is provided), services
(which services at what quality) and cost (how much of the cost is covered).
There is also a requirement that all people receive health services of
appropriate quality without being exposed to financial hardships.
As of 2017 (latest available data), the government contributes to 42.95%

of total CHE, while private expenditure accounts for 55.71% (World Health
160
Organization, 2020). Of private expenditure on health, approximately 95% is
by households (Amarasinghe et al., 2015b). It is noted that the proportions of
public and private expenditure on health as a proportion of CHE has become
inverted from 2007 when the proportion of domestic private expenditure
surpassed the proportion of government health expenditure (Figure 7.1).
Figure 7.1 Current health expenditure in Sri Lanka by source of
financing, 2000–2016
80.00
Percentage CHE
60.00
40.00
20.00
0.00
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
GGHE-D as % CHE PVT-D as % CHE
The total expenditure on health as a percentage of the GDP fluctuated

between 3.5% and 4.5% during the past 15 years, which is lower than the
global average. An increase is being noted in more recent years. CHE as
a share of the GDP has significantly decreased, especially from 2004 to
2012, currently being around 4.3% of the GDP (Figure 7.2). This was mostly
driven by public spending on health growing at a slower rate than the
overall economy.
Figure 7.2 Current and capital health expenditure as a share of GDP (%),
2000–2016
5.0
4.5
4.0
Percentage of GDP
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
CHE as % GDP Health Capital Expenditure (HK) % GDP
161
Government expenditure on health and education from 2011 to 2016 as a
percentage of GDP is depicted in Figure 7.3. Spending has been higher for
education than for health throughout the years. During the same period,
the state income has not increased as a percentage of GDP and the debt
servicing has increased as a percentage of GDP, signifying the lack of fiscal
space for greater government investment in health care.
Figure 7.3 Government expenditure on health and education as a share
of the GDP (%), 2011–2016
2.5
2
% of GDP
1.5
0.5
0
2011 2012 2013 2014 2015 2016
Education / GDP Health / GDP
Source: Central Bank of Sri Lanka, 2018
Figure 7.4 shows government spending on health from 2000 to 2016, where a
decline in GGHE as a percentage of GGE from 2004 to 2009 is seen. This has
remained around 8% from 2009 to 2016.
Figure 7.4 General government health expenditure as a share of general
government expenditure (%), 2000–2016
12.0
% General government expenditure
10.0
8.0
6.0
4.0
2.0
0.0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Comparing Sri Lanka with other countries (Figure 7.5), it is observed that
Thailand has the highest government spending on health while Bangladesh
162
has the lowest. In Malaysia and Philippines, the percentage GGHE is seen to
be increasing from 2012 onwards while a decline is seen in Viet Nam over the
same period.16
Figure 7.5 Comparison of GGHE-D as a share of GGE (%) among selected
Asian countries, 2012–2015
16
14
12
10
% of GGE
8
6
4
2
0
Sri Lanka Bangladesh Malaysia Philippines Thailand Viet Nam
GGHE-Domestic as a % of GGE
Country
2012 2013 2014 2015
Figure 7.6 shows OOPE as a percentage of CHE from 2000 to 2016. From 2007
onwards, the OOPE as a percentage of CHE has been more than 45% and the
trend is seen to be rising.
Figure 7.6 Share of OOPE as percentage of CHE, 2000–2016
60. 0 53.3 53.3 51.2 51.9

50.6 48.9 48.9 50.1
48.7
50. 0 44.9
40.0 41.1 40.5 41.0 40.5 41.0
37.6
40. 0
% of CHE
30. 0
20. 0
10. 0
0.0
200 0
200 1
200 2
200 3
200 4
200 5
200 6
200 7
200 8
200 9
201 0
201 1
201 2
201 3
201 4
201 5
201 6
Year
16 Figure 3.3 demonstrates the same trend over a longer period.
163
The share of the OOP as a percentage of CHE for the same comparison
countries is presented in Figure 7.7. OOPE for Thailand is seen to be the
lowest (12.1%) while that of Bangladesh is seen to be the highest (71.9%).
Over the past 16 years, two countries have reduced their OOPE. Thailand
shows a steady decline and has been able to decrease the OOPE by nearly
65% from the value in 2000. Sri Lanka, on the other hand, demonstrates
the highest percentage increase over the same period, an increase of 25%
from the year 2000 value of 40%. The increase in state spending on health
has reduced the OOPE in Thailand, while an increase in social/government
spending on health has not had the desired reduction in OOPE in Viet Nam
and Philippines.
Figure 7.7 Share of OOPE (%), selected countries, 2000–2016
80.0
70.0
60.0
Percentage of CHE
50.0
40.0
30.0
20.0
10.0
0.0
Bangladesh Malaysia Philippines Sri Lanka Thailand Viet Nam
2000 2004 2008 2012 2016
In Sri Lanka, OOP payments are high and are mainly utilized for: private
outpatient care (general and specialized care), payment for pharmaceuticals
(self-prescribed or physician prescribed), payment for private hospitals and
payment for laboratory investigations (Figure 7.8); the top three areas of
spending were for private doctors, 33%; pharmaceuticals, 27% and private
hospitals, 16% (Department of Census and Statistics, 2018b). The payments
made for a GP consultation often include the cost of medication provided
by the GP from the internal pharmacy maintained by the practice. This
means that the payments listed as for the GP given in the HIES may be an
overestimation while the pharmaceutical cost is an underestimation.
164
Figure 7.8 Health services obtained through OOP payments, 2016
Other
4%
X-ray & scans (CT, Private doctors
US etc) 33%
3%
Ayurvedic
practitioners
Pharmaceuticals 2%
27%
Specialist
consultations
6%
Private hospitals
16% Laboratory services
9%
Sources: Department of Census and Statistics, 2018a
Figure 7.9 shows OOP payments for health made by households according to
expenditure quintiles for the year 2016. The OOPE on health as a proportion
of total household expenditure and non-food expenditure increases by
quintiles. The first quintile spends about 2.2% of their household expenditure
on health while the richest quintile spends almost 3.7%. OOPE is highest in
the wealthiest quintile (SLR 4717.30) and nearly 13 times that of the poorest
quintile (SLR 366.41). The wealthiest quintile paid approximately two thirds of
the entire OOPE of the country. Almost similar findings have been reported
from the Household Income and Expenditure Survey (HIES) 2012/2013 and by
others (Govindaraj et al., 2014).
Figure 7.9 OOP payments by households by expenditure quintiles, 2016
6 5000
5 4000
4
3000
% of OOPE
3
SLR
2000
2
1 1000
0 0
Q1 Q2 Q3 Q4 Q5
Expenditure quintiles
HE as % of non-food expenditure HE as % of total expenditure
Total health expenditure (LKR)
Chapter 4
165
When considering the structure of OOP payments by income quintile, the
richest spend around 24% of OOP payments on private practitioners, 28%
on private hospital care and 23% on drugs (Figure 7.10). The poorest spend
around 51% on private practitioners, around 3% on private hospitals and
32% on drugs. Despite the state health sector offering health care free at the
point of service delivery, some of even the poorest quintile utilizes the private
sector for health due to reasons of convenience, i.e. more convenient hours,
shorter waiting times, choice over selection of doctor and perceived shortage
of medication and investigations in the state sector.
Figure 7.10 Structure of OOP health payments by expenditure quintile,
2016
100.0
90.0
80.0
70.0
% of OOPE
60.0
50.0
40.0
30.0
20.0
10.0
0.0
Q1 Q2 Q3 Q4 Q5
Expenditure quintiles
Private practitioners Specialist consultations Lab tests
Private hospitals Medicines Others
Chapter 4
OOP spending that pushes households below the poverty line is termed
impoverishment and that is minimal in Sri Lanka. Though OOPE is increasing,
financial protection coverage in Sri Lanka is at a satisfactory level. Financial
protection coverage denotes the proportion of the population with a
large household expenditure on health as a share of the total household
expenditure or income. According to the HIES 2015/2016, 6.4% of households
in Sri Lanka spent more than 10% of their total household budget on health
and 1.1% of households spent more than 25% of their total household budget
on health (Figure 7.11). The catastrophic health expenditure at both 10% and
25% are lowest in Q3 and highest in Q5, as observed in Figure 7.12.
166
Figure 7.11 Incidence of catastrophic health expenditure, 2016
7 6.4
6
% of households
4
3.2
3
2
1.1
1
0
10% threshold 15% threshold 25% threshold
Figure 7.12 Percentage families having catastrophic health expenditure by

expenditure quintile, 2016
7.00 2.50
6.80
% of households @ 10%
% of households @ 25%
6.60 2.00
6.40
1.50
6.20
6.00
1.00
5.80
5.60 0.50
5.40
5.20 0.00
Q1 Q2 Q3 Q4 Q5
@ 10% @ 25%
As the country is currently facing demographic and epidemiological

transitions, adequate and sustainable health financing is an immediate need
for the following reasons: rising demand and need for more costly treatment
methods and citizens’ expectation of higher service quality; increased
medical technology advancement – diagnostics, treatment and medicines,
greater need for health and social services by an ageing population, and
catering to emerging and re-emerging disease conditions and NCDs, which
place a higher economic strain on individuals due to their chronic nature and
tendency for leaving residual disabilities (Institute of Policy Studies, 2016).
167
7.2.2 Equity in financing
In the Sri Lankan context, a health system comprising publicly financed
government service provision, free at the point of care, with inadequate public
funding to meet the increased demand for health, has resulted in a high level
of OOPE in the private sector; thus achieving UHC and, in particular, ensuring
financial risk protection is, at best, is a difficult challenge.
The Sri Lankan health-care system is recognized as one that has achieved
good health at low cost. Figure 7.13 shows that, despite having moderate
pooled funds for health, the UHC index is comparatively high, at almost 70%,
reflecting a high level of health systems endowment.
Figure 7.13 Universal health coverage financing frontier
100
80 South Korea
China
Sri Lanka Canada United
Universal health coverage index
States
60 Vietnam
Bangladesh South Africa
Marshall Islands
40 Kiribati
Chad
South Sudan
Afghanistan
a Republic
Central Africn
Somalia
15 100 500 1,000 2,000 4,000 8,000
Pooled health spending per person
Central Europe, Eastern Europe, and Central Asia Notes: Pooled health spending per person for 2015 is measured in 2017 purchasing
GBD high-income
Latin America and Caribbean Each dot represents a country color-coded by Global Burden of Disease super-region.
North Africa and Middle East GBD = Global Burden of Disease
South Asia Source: Financing Global Health Database 2017
Southeast Asia, East Asia, and Oceania
Sub-Saharan Africa
Source: Institute for Health Metrics and Evaluation, 2018: p.89
The main source for state sector health expenditure is through contributions
of the Central Government through budget allocations to the MoH. In
addition, provincial departments of health, local governments, other
government entities, the President’s Fund, and the Employees Trust Fund
(ETF) also make contributions annually.
168
Approximately 75% of the government health budget is through the Ministry
of Finance, where resource allocation is mainly based on infrastructure and
staffing, a method that has been followed for decades (Ministry of Finance,
2016). When considering the distribution across different geographical
regions, CHE shows an equitable distribution across most districts, the
Western Province being the most notable exception with an outstandingly
high level (Figure 7.14). The Western Province houses nearly a quarter of the
population and has a majority of the national referral hospitals as well as
training facilities that may have contributed to this outcome.
Figure 7.14 Comparison of total and per capita CHE by provinces and
districts, 2013
120 000 25 000
100 000
20 000
CHE in millions SLR
80 000
CHE per capita SLR

15 000
60 000
10 000
40 000
5 000
20 000
0 0
CHE in million LKR (district) CHE in million LKR (province)

CHE per capita LKR
Source: Health Economics Cell, 2016: p.20
Funds allocated to the provincial departments of health by the Central

Government is based on a formula developed using principal components
analysis (PCA) thereby ensuring equity. The socioeconomic indicators used
for the PCA analysis are: population, provincial GDP, poverty head count ratio,
median per capita income of the province, persons per MO and the number of
169
candidates qualified for universities in the science stream from the province
(Financial Commission of Sri Lanka, 2017). However, there is significant
dependence of allocations on the previous years, approved civil servant
cadres and thus the requirement is not based on the principle of meeting
needs alone. Thus, the mechanism for allocating funds among provinces
could be better matched with population need (Smith, 2018).
In certain instances, it is observed that provinces that need a higher

allocation may not necessarily receive it, i.e. a disproportionate share of
government health spending is allocated to certain provinces; for example,
Eastern and Northern have the lowest per capita allocations in the country
(Figure 7.15). However, it should also be noted that per capita financial
allocation should not be the only criterion to decide on equity as other
factors such as geographical extent or the size of the province as well as the
availability of a road network leading to problems in accessibility also play a
role when deciding on equity in finance allocation.
Figure 7.15 Estimated per capita spending of the government by provinces
and districts, 2013
40 000
12 000
35 000
10 000
Government CHE in millions SLR
30 000
Per capita CHE SLR

25 000 8 000
20 000 6 000
15 000
4 000
10 000
2 000
5 000
0 0
Government CHE in million LKR (district) Government CHE in million LKR (province)
Per capita CHE LKR
Source: Health Economics Cell, 2016: p.38
170
In addition to provincial disparities, inequity also exists in several key
domains with regard to allocation of limited financial resources. Disparities
in allocation between curative and preventive health care and in allocation to
different levels of curative institutions are the main issues in this context. In
Sri Lanka, approximately 91% of the CHE was utilized for curative health care
while only 4.5% was utilized by the preventive services in 2013. NCDs utilized
35%, while 22% of the CHE was on infectious and parasitic diseases. Nearly
10% of the expenditure was for reproductive health services and 7.7% for
injuries (Health Economics Cell, 2016).
The most critical gaps identified in the present health-care financing system
in Sri Lanka are due to inadequacies of resource mobilization, allocative
inefficiencies and weaknesses in financial management. Possible solutions
are (i) generate more fiscal space for health through reforming taxation
systems, ensuring tax and government revenue as % GDP, and strong
political and financial commitment to increase the fiscal space for health
(GGHE, as %GGE), (ii) improve allocative efficiency through investment
in cost-effective interventions, primary prevention of NCDs such as best
buy interventions, effective coverage of key interventions, and (iii) improve
effective financial management.
The ultimate goal may be to improve equity by enhancing access across

all wealth quintiles. To improve access and utilization by upper wealth
quintiles, there has to be marked improvement in the “hotel” facilities
within government institutions. However, this is a feature that has been
compromised in trying to achieve universal access while keeping costs low.
7.3 User experience and equity of access to health care

7.3.1 User experience
Sri Lankans can obtain services at any hospital in the country as there is
no clear referral policy from primary- or secondary- to the tertiary-care
level. The majority of hospitals do not have an appointment system as
there is no systematic registration process of patient information with easy
retrieval. Patients with acute health care needs are seen by doctors at the
outpatient department and they may prescribe medicine/investigations or
admit if required (or demanded), regardless of bed status. Any patient with a
condition that requires specialist attention is referred to a consultant clinic
in the outpatient department and is required to get an appointment from the
relevant consultant clinic. Tertiary hospitals have the services of dedicated
specialists for the outpatient department, but the majority of the hospital’s
clinics are conducted by the specialist and his/her staff attached to a ward.
171
Sri Lanka records some of the highest patient consultations (5.2 visits per
person per year) and number of hospital admissions (24 admissions per
100 persons per year). The bed occupancy rates are found to be very high in
tertiary care hospitals, up to 3.9 days. Many PHC facilities are staffed by a
medical doctor with a minimum qualification of MBBS. In the state sector,
there is a waiting list for high-end investigations as well as planned surgical
procedures. Still, the country lacks equitable access to some specialized care
services such as cardiothoracic surgery, dialysis, renal transplantation and
cancer care (Ministry of Health, Nutrition and Indigenous Medicine, 2018e).
Persons who need these services will require registration on a waiting list
and some tend to seek care from the private sector within the country as well
as overseas. This may result in catastrophic health-care spending for some
of these households.
Since there is no easily retrievable patient records system in many of the

outpatient departments, follow up of these patients is difficult. In most
clinics, patients carry their own clinic record books in which doctors enter
the status and drug prescriptions. In the case of admissions to hospital,
a diagnosis card containing a detailed discharge summary, including the
management plan for follow up, is provided to the patient. The ward notes
are kept in the hospital records room but on subsequent admissions, the
diagnosis card from the previous admission is needed for retrieval. The onus
is on the patient to remember to bring his or her diagnosis card and clinic
record book whenever they attend hospital. The absence of an electronic
patient health record that can be easily retrieved poses problems in the
follow up of patients as well as in providing continuity of care for those who
need it, in particular, for the management of chronic NCDs. The limited HIS
currently in place at most of these facilities lacks the capability to provide
details of the numbers who are on medication and are being followed up. This
information is critical for assessing the effective coverage of interventions.
Private hospitals offer specialist consultation as well as inward care services.

The possibility of direct consultation of specialists of their choice, obtaining
services at a time convenient to the clients and at a relatively affordable
price, and the possibility of being referred to the state services by the
specialist seeing the patient seem to create a demand for services from
private facilities.
Sri Lanka is still in the process of institutionalizing a routine mechanism

to measure user experience surveys in the country. A national-level survey
is yet to be carried out by the MoH. However, a few limited surveys provide
information on satisfaction with services provided by the government
health services.
172
Russel and Gilson (2006) studying an urban population in Sri Lanka found
that, irrespective of income group, people relied on the government sector for
technical competence, especially in receiving inpatient care. But government
sector service providers were found to lack soft skills and interpersonal
skills so that high-income populations and even a considerable proportion of
middle-income persons resorted to seeking private sector care for moderate
or less severe illnesses. Children with high-risk symptoms were taken to
government sector institutions whereas the children with low-risk symptoms
were taken to the private sector.
The quality of public sector outpatient primary care in Sri Lanka is generally
considered high for a low- middle-income country, and was seen to be better
than the private sector in many areas (Rannan-Eliya et al., 2015a). Studies
have shown that the quality of the public sector diagnosis and management
aspects of care is similar to the private sector. However, the private sector
allows patient choice of a provider and better quality care in non-clinical
aspects (Rannan-Eliya et al., 2015b).
The patients’ personal information is usually not accessible to the public

except through a legal order in case of medicolegal questions. This
information, written on paper-based bed head tickets (BHTs) and outpatient
department consultation forms, is stored with health institutions once the
patient is discharged from the institution. The records are kept secure in
the medical records room and are not made accessible even to health-care
providers unless prior written permission is taken from the head of the
institution. Patients have their own individual clinic records in the form of
clinic books/notes with them.
Patients are usually informed of their conditions when taking treatment

for chronic diseases. They are aware of the conditions that they are being
treated for. Patients’ involvement in deciding on the type of prescription or
drugs is minimal in the public sector. Usually the prescription is solely at the
discretion of the treating physician. In situations requiring major procedures/
surgery, patients are informed of the need for the procedure prior to
obtaining written informed consent. However, the opportunities that patients
get to discuss alternative treatment options are limited.
One aspect of quality of care is time spent on a consultation. Rannan-Eliya

et al. found that the average consultation time for outpatient visits was 3.1
minutes in state sector health-care institutions and 7.8 minutes in private
health-care institutions. As the doctors working in both sectors are largely
the same, the same study found a similar quality of clinical care provided in
both the public and private sectors (2015b).
173
7.3.2 Equity of access to health care
The distribution of health workers and facilities across the population
The preventive health-care service has a defined package of MCH services
that are delivered by the MOH and a team of health-care professionals to a
geographically defined population. This package is universally provided and is
available to all, irrespective of the geographical location in the country. Very
high coverage indicators are evident with minimal geographical inequalities
(Department of Census and Statistics, 2018a).
In addition to the MCH packages of service, the MOH provides screening for
NCDs. The Well Woman Clinics conducted by the MOH provide screening
services to women above 35 years for the common NCDs – diabetes,
hypertension, breast and cervical cancer. In addition, the HLCs attached to
primary curative care institutions offer screening services to both men and
women for common NCDs. These services are equitably distributed and are
open from 8.00 am to 4.00 pm on specified days of the week. However, it has
been noted that attendance for screening by working age men is low (male:
female 2.9:7.1), highlighting the need for making services available at times
convenient to the working population, especially those in the informal sector.
The same cannot be stated in relation to the curative care service of the
country. Each district would have at least one tertiary-care facility and one
or more secondary-care facility and a number of primary curative care
facilities some with beds and others providing only OPD services. Despite
having the desired level of care at each district level, many services are
seen to be having an inequitable distribution. Several districts are seen
to lack the full range of specialized services, and the optimal staff size to
deliver these services on a 24x7 basis such as for Obstetrics, Neonatology
and Anaesthesiology (Ministry of Health, Nutrition and Indigenous
Medicine, 2018e).
Further, it is noted that despite the availability of free health-care services,

many people are not using these services appropriately. The estate sector is
seen to have significantly poorer health outcomes than the urban and rural
sectors in Sri Lanka. Almost all health indicators are seen to be lagging
behind in the estate sector, including MCH indicators, nutritional indicators
and psychosocial indicators (Department of Census and Statistics, 2018a).
Another group with poor utilization and access to state-managed health
services seems to be the working population. Male participation/utilization
is seen to be poor, especially in the working age groups. The STEPS survey
in 2015 reports that nearly a third of the adult population had never been
screened for hypertension and diabetes. This is attributed to the fact
174
that services are not usually available at times convenient to the working
population. The majority of outpatient facilities offer services to the public
from 08.00 to 16.00 hours on weekdays, 08.00–12.00 hours on Saturdays and
08.00–10.00 hours on Sundays.
Difficulty in accessing health-care facilities (difficult terrain in the estate

sector), restriction due to overlapping working hours of the health sector with
that of the normal working population (normal working hours from 08.00 to
16.00 for all categories) are important barriers to access, especially for some
groups. Not having a regular supervision and monitoring mechanism for the
curative care system similar to that of the preventive arm of the services, is a
deficiency that needs to be rectified.
Availability of pharmaceuticals
Sri Lanka considered 42 essential medicines as a proxy for assessing the
availability of essential medicines and commodities for the SARA survey in
2017. This survey demonstrated that all public health-care institutions and
95.3% of private health-care institutions had more than 50% of the essential
medicines specified. In addition, 82% of public health-care institutions and
80% of private health-care institutions had more than 75% of the essential
medicines available. However, only 21% and 53% of public and private health-
care institutions, respectively, had stock levels of more than 90% of essential
medicines, highlighting that there is room for further improvement in
ensuring equitable access to medicines. In particular, 6.7% of public primary
care (DHs Type A/B/C) had more than 90% of these essential medicines. The
findings of the survey are summarized in Table 7.1 below.
175
Table 7.1 Availability of essential medicines and commodities by type of
hospital, 2017
Facilities Facilities Facilities Facilities
with 50% with 75% with 90% with all
of tracer of tracer of tracer tracer
Facility type items items items items
(except for (except for (except for (except for
PMCU) PMCU) PMCU) PMCU)
(%) (%) (%) (%)
Sri Lanka 99.05 81.77 27.82 6.35
Public sector 100.00 82.16 21.44 4.60
Public tertiary 100.00 100.00 92.68 46.34
care hospitals
National hospital 100.00 100.00 100.00 0.00
Teaching 100.00 100.00 83.33 27.78
hospitals
Provincial general 100.00 100.00 100.00 33.33
hospitals
District general 100.00 100.00 100.00 68.42
hospitals
Public secondary 100.00 100.00 77.70 11.26
care hospitals
Base hospitals (A 100.00 100.00 77.70 11.26
& B)
Public primary 100.00 77.87 6.65 0.00
care hospitals
Divisional 100.00 77.87 6.65 0.00
hospitals Type
A/B/C
Private 95.29 80.26 53.07 13.29
hospitals
Major private 100.00 100.00 79.68 34.19
hospitals
Minor private 94.06 75.11 46.14 7.84
hospitals
It is generally assumed that as health care is free in the state sector, there
is equitable access across the population; irrespective of gender, age,
education, wealth, etc. The DHSs in 2007 and 2016 assessed the demand for
family planning services and satisfaction with the use of modern methods.
Comparison of the two surveys demonstrates that there is greater equity
between the sectors but lesser equity when the districts are compared
(Figure 7.16). This indicates that equity has improved by place of residence
(urban, rural and estate setting) but disparities have widened across districts.
176
Figure 7.16 Equity analysis of demand for family planning services and
satisfaction with the use of modern methods
Sri Lanka, DHS 2007, 2016

District Residence
2016
2007
20 30 40 50 60 70 20 30 40 50 60 70
Estate Rural Urban District
Sources: Department of Census and Statistics, 2009 and 2017
The MoH has identified the reorganization of PHC as the means of achieving
UHC and specifically as a means of addressing the growing burden of NCDs.
Improved supply chain management, laboratory services, improved skill mix,
personalized health records and follow-up care with proper referral pathways
are envisioned in this reorganization (Ministry of Health, Nutrition and
Indigenous Medicine, 2018e). It is anticipated that once the proposed shared
care cluster system is introduced, the accessibility of health-care services
will be further increased.17
Equity of the HRH situation in Sri Lanka

Almost all the health-care professionals in Sri Lanka are nationals. Other
than MOs, almost all other cadres are trained in Sri Lanka, reflecting self-
sufficiency in health professional training. Like many other countries,
medical graduates are recruited to the system from all local medical
faculties and from recognized medial universities in other countries. The
MoH operates a system through which these health cadres are recruited,
trained, deployed and also provided with an opportunity to transfer within the
system every 4–5 years based on seniority.
The distribution of staff by district for the five main categories of care is
presented in Table 7.2. The rate for the five main categories as well as an
index (district index as compared with the national average) is presented in
the table. There is equitable distribution in many of the districts, except the
17 Further explained in Chapter 6.3
177
districts that have superspecialized referral and training facilities, such as
Colombo, Kandy and Galle districts, and those that are served by the estate
sector (Nuwara Eliya) and where access is remote (Puttalam).
Table 7.2 Distribution of staff categories by district per 100 000

population in 2016
technologists
Public health
Five selected
Pharmacists
laboratory
HRH index
midwives
District
Nursing
Medical
Medical
officers
officers
cadres
Nuwara-Eliya 40.1 55.1 43 2.8 2.5 143.5 0.50
Puttalam 59.8 75.8 23.6 5.1 4.5 168.8 0.59
Gampaha 86.1 99.6 19.3 4.9 4.6 214.5 0.75
Killinochchi 88.5 73.8 46.7 4.1 3.3 216.4 0.76
Rathnapura 58.9 115.4 32.4 5.6 4.4 216.7 0.76
Mullaitivu 72.6 94.7 45.3 3.2 4.2 220.0 0.77
Kalutara 65.5 109.8 37.2 4.3 6.3 223.1 0.78
Monaragala 66.2 105.8 40.3 5.6 5.4 223.3 0.78
Trincomalee 74.3 103.7 38.1 7.2 5.4 228.7 0.80
Kegalle 59.8 127.5 30.8 6.1 5.2 229.4 0.80
Kurunegala 63.4 130.7 27.1 5.4 5 231.6 0.81
Matale 75 114.6 32.1 5.9 4.5 232.1 0.81
Batticaloa 78.5 113.5 34.4 6 5.6 238.0 0.83
Jaffna 97.8 105.8 29.1 8 5.6 246.3 0.86
Anuradhapura 62.4 147.1 25.6 5.9 5.7 246.7 0.86
Matara 69.8 135.6 32.1 6.3 5.3 249.1 0.87
Hambantota 66.6 148.2 32.7 6.1 5.2 258.8 0.90
Badulla 71.8 138.8 34.5 7.3 6.7 259.1 0.91
Mannar 98.1 106.6 55.7 5.7 5.7 271.8 0.95
Polonnaruwa 92.9 140.5 28.9 9.9 6.1 278.3 0.97
Vavunia 125.8 101.1 48.4 1.6 8.2 285.1 1.00
Sri Lanka 89.5 152.5 29.5 7.3 7.4 286.2 1.00
Galle 81.5 188.6 28.1 7.3 6.7 312.2 1.09
Ampara 104.8 165.4 41.8 9.3 9.6 330.9 1.16
Kandy 126.4 234.2 30.7 9.6 9.1 410.0 1.43
Colombo 188.5 330.7 18 16.4 20.8 574.4 2.01
Source: Ministry of Health, Nutrition and Indigenous Medicine, 2018g
178
The district distribution of selected health workers is presented in Figure
7.17. It is evident that the number of pharmacists and MLTs per 100 000
population is minimal and does not show any significant difference between
districts. The number of PHMs mostly remains the same without much
fluctuation while the highest district differentials are shown by the numbers
of MOs and nursing officers, both categories being higher in districts where
superspecialized, specialized and teaching facilities are located, such as
in the districts of Colombo, Kandy, Galle and where two health districts are
represented within the same administrative district of Ampara.
Figure 7.17 District distribution of selected health worker categories per
100 000 population, 2016
350
300
Per 100 000 population
250
200
150
100
50
0
Rathnapura
Gampaha
Kalutara
Mullativu
Hambantota
Colombo
Killinochchi
Trincomalee
Puttlam
Kurunegala
Vavunia
Galle
Badulla
Mannar
Nuwara-Eliya
Matale
Matara
Monaragala
Ampara
Anuradhapura
Polonnaruwa
Jaffna
Kegalle
Sri Lanka
Kandy
Batticaloa
Medical officers Nursing officers

Public health midwives Pharmacists
Medical laboratory technologists
Source: Ministry of Health, Nutrition and Indigenous Medicine, 2018g
7.4 Health outcomes, health service outcomes and quality

of care
When considering the return on investment for the health sector, Sri
Lanka has achieved good health outcomes in many fields, including MCH,
attendance at birth by skilled health-care personnel and control of VPDs
at a comparably low cost. The population coverage of many vaccines of the
national Expanded Programme on Immunization is between 96.2% and 99.2%
The country managed to achieve most of the Millennium Development Goals

and has already achieved some of the targets identified in SDGs such as the
maternal, under-five and neonatal mortality rates that are due to be achieved
179
by 2030.18 Polio, neonatal tetanus, malaria and lymphatic filariasis have been
eliminated and the country is on target to achieve elimination of rabies and
mother-to-child transmission of HIV and syphilis.
During 2017, Sri Lanka experienced outbreaks of several communicable

diseases, including dengue (868 cases per 100 000 population), influenza,
which caused 89 influenza-related deaths, and leptospirosis (48 related
deaths). There is also a considerably high prevalence of NCDs in the country,
a high prevalence of hypertension, diabetes and high blood cholesterol
reported in the Colombo district (Central Bank of Sri Lanka, 2018). The
high levels observed in the Colombo district may be real or may be due to
having more opportunities to be diagnosed or both. Chronic kidney disease
of unknown aetiology (CKDu) needs continuing attention from health-care
providers, academics and policy-makers due to its adverse socioeconomic
impact, especially on low-income households. According to the DHS 2016,
the prevalence of CKD was 0.6% in the country (Central Bank of Sri Lanka,
2018). Given the multifactorial nature of CKDu, which may be related to one
or more environmental agents, changes in agricultural practices, provision of
safe drinking water and occupational safety precautions are recommended
(Rajapakse et al., 2016).
With the rapid ageing of the population and the success in combating major
communicable diseases, the disease burden has started shifting rapidly
towards NCDs, including mental health conditions, accidents and injuries.
Furthermore, while the nutritional status has improved, undernutrition
remains a problem throughout the life cycle, with increasing obesity and
overweight and micronutrient problems. These are some of the areas that
need to be improved in order to achieve UHC and attain Goal 3 of the SDGs.
7.4.1 Population health

The maternal mortality ratio in Sri Lanka is closer to that of developed
countries and this success story has been attributed to many strategies
carried out over the years, including implementation of strong preventive
health-care services. The MOH and team of public health staff provide
comprehensive pre-pregnancy, antenatal, postnatal and childcare packages
at clinics close to the residence of the patient and through domiciliary visits.
Improved clinical care is provided through the availability of comprehensive
emergency obstetric care 24x7 and specialized neonatal and paediatric care
services across the country. Free education leading to high literacy rates
among women has contributed to the near-universal utilization of these
18 Refer to Table 1.7.
180
services by women for themselves and their children. Despite the success in
maternal, neonatal and child health (MNCH), the past few years have seen
NCDs emerge as the leading causes of hospital deaths in Sri Lanka; i.e.
ischaemic heart disease, neoplasms, cerebrovascular disease, pulmonary
heart disease and diseases of the pulmonary circulation (Ministry of Health,
Nutrition and Indigenous Medicine, 2018g).
The WHO NCD risk factor (STEPS) survey conducted in 2015 reported
that 45.7% of men and 5.3% of women were current users of some form
of tobacco products. The survey further showed that 34.8% of men were
current alcohol users (drank in the past 30 days), while 40.2% were lifetime
abstainers. When considering women, 96.5% were lifetime abstainers. Nearly
29% of adults were estimated to be overweight or obese, 24.6% in men and
34.3% among women. Only 27% of men and 28% of women were consuming
adequate amounts of five or more servings of fruits and/or vegetables per
day. The survey also showed that 22.5% of men and 38.4% of women did not
meet the WHO recommendations of engaging in physical activity for at least
150 minutes per week.
Limited studies are available on cancer survival. A retro-prospective

study, conducted using all breast cancer patients who had sought
immunohistochemistry services of the Department of Pathology, Faculty of
Medicine, University of Ruhuna from May 2006 to December 2012, concluded
that the overall 5-year breast cancer-specific survival rate was 78.8%,
whereas the 5-year survival in the UK is 86.6% and in Malaysia, 43.5% (Peiris
et al., 2017; Ibrahim et al., 2012).
A study conducted to assess the survival of cervical cancer patients

diagnosed in 2008 in the Western Province of Sri Lanka revealed that one-,
three- and five-year survival rates were 86%, 70% and 62.5%, respectively
(Vithana et al., 2018). There are no follow-up studies or previous studies to
compare whether survival rates of these cancers have improved over the
years. The 5-year survival of cervical cancer patients in Malaysia was 71.1%
and in the UK it was 64.4% (Muhamad et al., 2015). The percentage of cervical
cancer diagnosed at the third and fourth stages in Sri Lanka is 48.6% and
4.5%, respectively. Imaging facilities for breast cancer screening are limited
and not equitably distributed. Although facilities for Pap smears for cervical
cancer are available in all MOH clinics, it is noted that the uptake is variable
and still low, though improving.
At present, population-based health data are limited to surveys. It is expected

that the envisaged information system linked to the primary curative care
reforms would provide population-based morbidity and mortality data.
181
Experiences on disease registries from various countries are useful for
monitoring treatment outcomes, such as survival and quality of life (Parkin
and Sanghvi, 1991).
7.4.2 Health service outcomes and quality of care

Health service outcomes are assessed using a set of indicators. OECD
indicators compare the performance of health systems across countries
using indicators on mortality such as life expectancy at different ages,
causes of mortality, maternal and infant mortality, potential years of life
lost; morbidity indicators such as perceived health status by different
stratifications, low birth weight, communicable diseases, cancer; health-
related lifestyles such as tobacco and alcohol consumption, body weight;
total health and social employment, including health human resources;
physical and technical resources; immunization; screening, etc. (OECD,
2020). Comparison of indicators in the identified countries is difficult due to
lack of data from a comparable source. Immunization coverage for childhood
illnesses can be considered as a dimension of the quality of preventive care.
As shown in Table 7.3, the coverage of childhood vaccination programmes

is very high, ranging from 96.0% (polio 3) to 99.2% (BCG) in Sri Lanka
Table 7.3 Percentage of children protected through childhood vaccination

programmes, 2016
Type of Vaccine Coverage as a %
BCG 99.2
DPT 3 97.0
Polio 3 96.0
MCV 1 97.1
Tetanus toxoid 96.2
Another indicator to assess the quality of care is in-hospital mortality. Figure

7.18 gives the proportion of hospital deaths out of admissions to hospitals
from 2010 to 2016. It is apparent from Figure 7.18 that the mortality rates
are low for diabetes and asthma but there is no improvement in the mortality
rates over time. However, mortality rates due to ischaemic heart disease
(IHD) has slightly declined from 2014 (Ministry of Health, Nutrition and
Indigenous Medicine, 2018g).
182
Figure 7.18 Percentage of hospital deaths out of hospital admissions for
selected diseases 2010-2016
7
Percentage of deaths from admissions
0
2010 2011 2012 2013 2014 2015 2016
IHD Asthma Diabetes mellitus
IHD: ischaemic heart disease

The country has developed a manual as well as guidelines for accident and
emergency care services. Standard treatment protocols are in place for
surgical, medical, paediatric, obstetric, gynaecological, ENT and psychiatric
emergencies with algorithms. Standards for infrastructure, human
resources, equipment, drugs have been identified for government health
institutions, though quality indicators have yet to be introduced.
The SARA survey conducted in 2017 assessed the readiness score for
standard precautions for infection prevention and control (IPC) among health
facilities; the readiness score obtained was 76 out of 100. It is seen that the
private sector has performed well compared to the public sector regarding
readiness for IPC. According to the SARA survey 2017, the availability of
183
guidelines and clinical protocols in both public and private hospitals was not
optimal, and deficiencies are more apparent in the private sector (Table 7.4).
Table 7.4 Availability of selected guidelines in health facilities

Availability in the facility
Guidelines and clinical protocols
Public Private Sri Lanka
Management of stroke and myocardial infarction 16% 3% 14%
Management of diabetes 53% 7% 26%
Best practices, protocols for surgical management 31% 13% 21%
Appropriate use of blood and safe transfusion 67% 41% 53%
practices
National guidelines on maternal care 12% 6% 11%
National guidelines on newborn care 18% 3% 14%
Emergency obstetric care 37% 4% 18%
National immunization guidelines 95% -- 95%
HIV testing 80% -- 80%
Post-exposure prophylaxis against HIV 83% -- 83%
Antiretroviral therapy (ART) 73% -- 73%
Management of cardiovascular risk by primary care 54% -- 54%
providers
According to the same survey, the readiness for standard precautions for
IPC among health facilities is summarized in Table 7.5. The readiness
observed in private facilities is seen to be better than in public facilities.
Table 7.5 Readiness for standard precautions for infection prevention and
control among health facilities
Dimension Public Private Sri Lanka
Guidelines for standard precautions 32% 37% 32%
Soap and water or alcohol-based hand rub 88% 98% 89%
Availability of latex gloves 92% 100% 92%
Appropriate storage of infectious waste 45% 87% 48%
Appropriate storage of sharps waste 89% 93% 90%
Availability of disinfectant 82% 90% 83%
Availability of disposable or auto-disable syringes 88% 100% 89%
Safe final disposal of sharps waste 85% 93% 85%
Safe final disposal of medical waste other than sharps 79% 90% 80%
184
One aspect of quality care is the time spent by a patient at the health
institution. One study found that the average consultation time for outpatient
visits was 3.1 minutes in state sector health-care institutions and 7.8 minutes
in private sector ones (Rannan-Eliya et al., 2015b). As the doctors working in
both sectors are largely the same, the same study found a similar quality of
clinical services provided in both the public and private sectors.
7.4.3 Equity of outcomes

UHC can be considered as a proxy indicator for equity of services and
outcomes. The UHC index is a composite index of sixteen indicators.
Figure 7.19 Comparison of the UHC index of selected countries
90 85
80 73
68 70
70
58
60
50
UHC Index
50
40
30
20
10
0
Sri Lanka Bangladesh Malaysia Thailand Phillipines Viet Nam
Country
When comparing the UHC index with other countries, Sri Lanka is seen as a
country with an average performance. However, when UHC tracer indicators
of Sri Lanka are compared with other lower-middle-income countries, as
shown in Table 7.6, it is apparent that, apart from treatment coverage of
conditions such as hypertension, diabetes and antiretroviral therapy for HIV,
Sri Lanka is performing well.
185
Table 7.6 Comparison between Sri Lanka and other lower-middle-income
countries on UHC indicators
Tracer UHC indicators 2017
Average of lower-middle-
Sri Lanka (%)
income countries (%)
Prevention and health promotion
Family planning 68 46
Antenatal care 99 86
Skilled birth attendance 99 74
DPT3 immunization 99 86
Tobacco non-use 85 78
Access to improved water 94 83
Access to improved sanitation 92 59
Treatment coverage
Antiretroviral therapy 19 29
Tuberculosis 86 82
Hypertension 21 27
Diabetes 10 11
Source: World Development Indicators, 2018
Selected UHC tracer indicators have been further evaluated on their

equitable coverage by assessing them against selected equity stratifiers.
The antenatal care coverage and demand for family planning services met
with modern methods are compared by wealth quintiles (poorest and richest)
for 2006/2007 and 2016. Inequalities between the poorest quintile and the
highest wealth quintiles on antenatal care coverage is seen to be almost
non-existent while gaps between rich and poor in the demand for family
planning services being met have decreased over the years. It is noted that
the poorest quintiles have a higher satisfaction rate than the richest quintiles
(Figure 7.20).
Figure 7.20 Antenatal care coverage and demand for family planning
satisfied according to wealth, 2006/2007 and 2016
Antenatal care coverage, 2006 & 2016 Demand for family planning met with
modern methods, 2006 & 2016
100
% coverage
99.5 100
% satisfied
99
50
98.5
98 0
2005 2010 2015 2020 2005 2010 2015 2020
Q1 Q5 Q1 Q5
Q: quintile
186
Under-5 mortality is considered a good indicator for assessing the equity of
health outcomes. The national average decreased from 21 in 2006 to 11 per
1000 live births in 2016. As shown in Figure 7.21, the urban–rural–estate
and rich–poor gaps have reduced over this period, reflecting gains in more
equitable outcomes.
Figure 7.21 Equity analysis of under-5 mortality in Sri Lanka, 2006 and
2016
35 35
Under 5 mortality rate
Under 5 mortality rate

30 30
25 25
20 20
15 15
10 10
5 5
0 0
Q1 Q5 Urban Rural Estate
Wealth quintile Sector of residence
2006 2016 2006 2016
Similarly, the geographical disparity in child mortality across provinces

varies between 5.7 in the Sabaragamuwa province and 13.3 in the Northern
province, showing more than a twofold gap (Figure 7.22).
Figure 7.22 Under-5 mortality rates across provinces of Sri Lanka, 2016
Northern 13.3
Cenral 12.4
Western 11.9
North Western 10.4
North Central 8.8
Southern 6.9
Uva 6.8
Eastern 6.5
Sabaragamuwa 5.7
0.0 5.0 10.0 15.0
187
When chronic malnutrition in children under 5 years of age is considered,
measured as “proportion of children under 5 years who are stunted”, no
improvement could be observed in the national average during the 13-year
period (17.3% in 2003 and 2016). However, disparities regarding place of
residence, mothers’ educational status and wealth quintiles have reduced.
But geographical disparity among districts decreased in 2016 (Figure 7.23).
Figure 7.23 Equity analysis of stunting among children under 5 years
Stunting by mothers' education Stunting by wealth quintile Stunting by residence
50 30 60
20 40
10 20
0 0 0
2005 2010 2015 2020 2005 2010 2015 2020 2005 2010 2015 2020
No education Passed O/L
Degree Q1 (Poorest) Q5 (Richest) Urban Rural Estate
Percentage stunting by district

45
Colombo
Gampaha
Kalutara
40
Kandy
Matale
35 Nuwara Eliya
Galle
Matara
30 Hambantota
Jaffna
Mannar
25 Vavuniya
Mullaitivu
Killinochchi
20
Batticaloa
Ampara
15 Trincomalee
Kurunegala
Puttalam
10 Anuradhapura
Polonnaruwa
Badulla
5 Moneragala
Ratnapura
Kegalle
0
2006 2008 2010 2012 2014 2016 2018
188
7.4.4 Disaster risk management for health
Sri Lanka is prone to disasters, both natural and human induced, and health
sector preparedness and responses are critical. Climate change and extreme
weather conditions are becoming increasingly important. The human cost
in relation to morbidity, mortality and population displacement needs to be
managed effectively and appropriately by the health sector with the support
of other relevant stakeholders.
The Health Sector Disaster Management (DM) Framework was developed

in 2015 in alignment with the Disaster Management Act no. 13 of 2005
and the National Disaster Management Framework. This Act was initiated
based on the tsunami of 2004 and the lessons learnt from the tsunami
catastrophe. A dedicated focal unit, the Disaster Preparedness and Response
Division (DPRD), was established to coordinate all health sector disaster
management activities in collaboration with other relevant sectors. Technical
guidance to the DPRD is provided through the National Advisory Committee
for Health Sector Disaster Management, led by the Secretary of the MoH.
The DPRD is under the supervision of the Secretary (Medical Services) of

the MoH and is headed by a national coordinator. The DPRD coordinates
closely with the Ministry of Disaster Management, which is the lead agency
for all disaster management activities in the country. This ensures that
health sector activities are in line with the national policies, strategies and
frameworks. The DPRD rolls out disaster risk management activities through
a network of focal points at the provincial and regional directorate levels, as
well as through the main hospitals in the country.
The Strategic Plan for Health Sector Disaster Preparedness, developed

based on international guidelines and frameworks, guides the activities of
the health sector in relation to disaster preparedness and response. The
initial Strategic Plan for Health Sector Disaster Preparedness was developed
in 2011 based on the Hyogo Framework for Action. In 2015, the Sendai
Framework for Disaster Risk Reduction, which follows a more “proactive”
rather than “reactive” path, was adopted globally and, accordingly, the
Strategic Plan for Health Sector Disaster Preparedness of the country
was revised.
A key feature of the revised Strategic Plan is the Safe Hospitals and Health
Facilities Initiative advocated by WHO, which promotes the structural, non-
structural and functional integrity of health facilities through disasters.
Improving human resources, promoting multi-stakeholder coordination,
improving information support, knowledge management and research,
enhancing community participation, and integrating results-based
189
monitoring and evaluation with health sector disaster management are some
of the strategies specified.
7.5 Health system efficiency

7.5.1 Allocative efficiency
Allocative efficiency is said to occur when limited resources are used to
purchase an appropriate mix of health services.
In 1985, the Rockefeller Foundation indicated that Sri Lanka is one of the
countries that achieves good health at low cost (Halstead et al., 1985).
The country is globally recognized for its health outcomes comparable to
developed countries despite the relatively low levels of spending. Government
spending on health has remained at around 8% for the past 10 years and CHE
on health at around 3% of the GDP (World Health Organization, 2017). Despite
the fact that the Sri Lankan health system is considered to be a highly
efficient system, there is a need for (i) mobilizing additional resources for
the health sector to match the increased demand for health services by the
population and reduce OOP payment in the private sector; and (ii) improving
health systems efficiency (Ranan Eliya and Sikurajapathy, 2009).
Disproportionately high hospital spending and low spending on primary

care
Sri Lanka has consistently followed the historical precedence of allocating
the largest share of its budget to the hospital sector (between 75% and 85%
of the total budget) and, within that, to inpatient care services. Preventive
and public health spending has averaged 25% or less of the budget and
has been less than 12% during the past decade. The emphasis on hospital
care has been a feature of the system since the 1950s (Ranan Eliya and
Sikurajapathy, 2009).
Figure 7.24 shows the percentage of government spending according to the

type of health-care institution in 2013. The highest amount of government
spending is on secondary and tertiary hospitals while primary care hospitals
and preventive care received only 13% and 10% of government spending,
respectively.
190
Figure 7.24 Percentage of government spending according to the type of
health-care institution, 2013
45
38.4
40
35
30 25.9
% out of CHE
25
20
13.2 12.5
15 10.0
10
5
0
Tertiary care Secondary care Primary care Preventive care Others
Source: Health Economics Cell, 2016
According to Rannan-Eliya et al., this strategy made sense for two reasons:
first, the key goal of health policy in the country, and benefiting the poor the
most, has been protection against catastrophic risk; and second, government
hospitals are an efficient way of delivering primary care owing to economies
of scale (Institute of Policy Studies, 2016).
With the epidemiological and demographic transition, the system must

adapt to the increasing burden of NCDs, mental health problems, ageing
and injuries, among others. The new policy on health-care delivery for UHC
will be implemented mainly to strengthen the PHC system of the country.
An essential services package to be delivered through a shared cluster of
PHC facilities includes a referral system, which is expected to result in some
efficiency gains and better quality of care.
Priority-setting not systematically undertaken and resource allocation

based on historical trend
The MoH has established the Health Economics Cell to generate evidence on
the cost–effectiveness of interventions.
The health budget is mainly managed by the central ministry and allocated
based on the historical pattern related to infrastructure and staffing.
According to a study, “there is a lack of an objective and transparent measure
of population needs for the allocation of provincial funds and there is no clear
link between the level of financing, performance and outcome” (Institute of
Policy Studies, 2016).
191
7.5.2 Technical efficiency
Sri Lanka spends less in absolute (such as CHE per capita) and relative terms
(such as GGHE as % GGE and CHE as % GDP) compared to countries with a
similar level of development but achieves better health indicators than some
countries with similar income levels. According to Smith (2018), there are
several likely reasons for the relative efficiency of the system, starting with
low input prices. Half of government spending is for the payrolls of the health
workforce, which receives modest compensation. This is supplemented by
their private practice, low pharmaceutical prices due to a strong procurement
agency and reliance on line item budgets and salaries for provider
payment. Relatively low compensation may result in poor morale and poor
responsiveness in the public services. Also, it may minimize performance
such as through off-hour private practices (dual practice, which is legal).
However, due to the increase in NCDs, which require a considerably large
amount of resources, the allocation for health will have to be substantially
increased to maintain a well-performing health-care system.
High outpatient and inpatient utilization rates

Based on consumer surveys, the average number of annual outpatient visits
per capita is 5 and hospital discharges per 1000 population is 274, higher
than in neighbouring countries (Smith, 2018).
Figure 7.25 Annual doctor consultations per capita of selected countries,
latest available year
8.0
Annual doctor consultations per capita
6.8
7.0
6.0
5.0 5.1
5.0
4.0 3.5
3.0 2.3
2.1
1.7
2.0
1.0
0.0
Singapore Thailand Viet Nam Malaysia China Sri Lanka OECD
192
Figure 7.26 Annual hospital discharges per 1000 population of selected
countries, latest available year
300 274
Hospital discharges per 1000 population
250
200
154
150 130 137
120
110
88
100
50
0
Singapore Malaysia Viet Nam China Thailand OECD Sri Lanka
The high outpatient visit rate may suggest unnecessary care or low-quality
care requiring repeated visits. It may also be a result of the free health-
care policy, where people seek health-care often, including when they want
social/emotional support and reassurance. The high inpatient rate may be
affected by the definition of “admission”–in Sri Lanka, an individual is taken
as an admission even if they spend only a few daytime hours at the hospital
(Smith, 2018).
Based on visits to government hospitals and clinics, the average annual

consultations per doctor is 5930, this is equivalent to 22 visits per day, given
22 working days per month; which suggests a high level of output per doctor.
However, this patient flow may be too high to give adequate and high-quality
care to outpatients. In a study conducted by Rannan-Eliya et al. (2015b), the
average consultation time in a government hospital in the Western Province
was 3.1 minutes, compared to the National Health Service (NHS) in the
United Kingdom (UK), which is over nine minutes (Smith, 2018). In the same
study, it was noted that the average consultation time in the private sector
was 7.8 minutes. Nevertheless, the same study found the clinical aspects of
care to be of high quality in the government sector. Figure 7.27 provides the
number of annual consultations per doctor in selected countries. Sri Lanka is
the second highest.
193
Figure 7.27 Estimated annual consultations per doctor in the primary
health care setting in selected countries, latest available year
7000 6563
5930
6000
Annual consultations per doctor
5000
4233
4000
3014
3000 2541
1879 2068
2000
1000
0
Viet Nam OECD China Malaysia Singapore Sri Lanka Thailand
Treatment and hospitalization at a higher-level hospital than medically

necessary due to non-functioning referral system (Ministry of Health,
Nutrition and Indigenous Medicine, 2017c)
Overall, there has been a considerable improvement in the infrastructure

and facilities of hospitals, both in the line Ministry as well as in the PHD.
However, the referral system is not functioning optimally and is not routinely
enforced. Hence, patients bypass small medical institutions, resulting in
underutilization of lower-level health-care institutions and overcrowding
at higher-level health-care institutions (Ministry of Health, Nutrition and
Indigenous Medicine, 2018g). Overcrowding results in a potentially poor
quality of consultations, limited consultation time and inadequate non-
pharmacological interventions for NCDs, such as advice on changes
in lifestyle.
In the private sector, a gradual increase in the utilization of outpatient care

could be observed among high-income customers; whereas the opposite
could be seen in the public sector where there were fewer members of high-
income groups. Around 90% of inpatient care is delivered by public hospitals.
The utilization of state and private sector facilities by expenditure quintiles
are presented in Figure 7.28. This clearly demonstrates that people of all
income groups utilize the state facilities for inpatient care while the richest
quintiles increasingly utilize the private sector, the tax-funded public health
services have limited policy levers to enforce referral and prevent patients
from bypassing primary hospitals and going to tertiary-care ones.
194
Figure 7.28 Utilization patterns of state and private sector facilities for
inpatient and outpatient care, by expenditure quintile, 2016
Utilization of public facilities Utilization of private facilities

25 25
Percentage who used
Percentage who used

20 20
services
services
15 15
10 10
5 5
0 0
1 2 3 4 5 1 2 3 4 5
Expenditure quintiles Expenditure quintiles
Outpatient (past month) Inpatient (past year) Outpatient (past month) Inpatient (past year)
Source: Smith, 2018: p.22
Low average length of stay in hospitals

Sri Lanka has a low average duration of stay in hospital relative to other
countries in the region and OECD countries (Smith, 2018). This may reflect
the low level of severity in the case mix of admissions, as discussed in section
7.5.2, e.g. for reassurance and other reasons beyond clinical indications.
Figure 7.29 Average duration of hospital stay among selected countries,
latest available year
12.0
10.0
Average duration of hospital stay
10.0
7.7
8.0 6.7
6.0 5.0
4.2 4.2 4.4
4.0 3.0
2.0
0.0
Sri Lanka Malaysia Thailand Indonesia Singapore Viet Nam OECD China
As expected, the longest duration of stay is observed in specialized hospitals

for conditions that require long-term observation (the leprosy hospital
followed by psychiatric hospitals). A decreasing trend could be observed
in the average duration of stay in all hospitals over time. This may suggest
195
an improvement in technical efficiency over the years, although in some
instances, overcrowding may also stimulate a high rate of turnover.
Table 4.4 of Chapter 4 indicates the average duration of stay among different
types of hospitals from 2004 to 2016. A decreasing trend has been observed
in the average duration of stay in all hospitals over time. Except for a few
unanswered questions such as indications for a high admission rate, an
overall assessment of the system suggests that it is efficient in its use of
resources. The points mentioned should be analysed to see the gaps and
areas where efficiency can be improved. A good HIS will facilitate patient
information reporting, prevent duplication of investigations/services, allow
for disaggregation of data, analysis and monitoring of services. Currently,
data cannot be tracked due to a lack of proper recording and information
system at PHC facilities. Special efforts/measures in the reform process
would be necessary to attract patients who use health care in an ad-hoc
manner to these facilities.
7.6 Transparency and accountability

In Sri Lanka, a top–down approach is mainly seen in health policy
formulation. The persons involved in managing the relevant public health
agencies, along with professional colleges and UN agencies for technical
inputs, support the policy development process, mainly upon request.
However, once the policy is drafted, it goes through a process of public
hearing as well as relevant stakeholder consultations.
All draft policies must be advertised to the public on the MoH website prior
to subsequent approval, implementation and adaptation. However, public
consultations do not occur routinely. The public is made aware of the policies
through publication on the website of the MoH as well as through gazette
notification, in the case of an Act.
The public sector financial allocation, service provision and service utilization
in health care are documented regularly in the Annual Health Bulletin and the
National Health Accounts published by the MoH. These documents, published
on the website of the MoH and other relevant websites of government
departments, are freely accessible to the public. In addition to this, the health
coverage indicators, health condition and risk factor survey reports are also
made available to the public. As these are technical reports, the public may
lack the technical knowhow to understand these. Advocacy briefs and short
reports in simple language are seen to be lacking for the public. Although
annual reports include hospital statistics, there is no reporting of hospital
196
performance to the public in the form of a report. Hospital statistics are
made available to the public through a notice board maintained by hospital
and ward staff.
The AR (administrative regulations) and FR (financial regulations), as they are

known, govern most of the administrative procedures within the state sector,
including that of the MoH. According to the AR and FR, there is a system
for lodging a complaint and an auditing system embedded within the health
system. An independent panel appointed by the MoH will investigate any
complaints submitted in writing to the health authorities. There are AR and
FR related to the issues of procurement, false claims, leakage, wastage and
financing mechanisms, which are adhered to accordingly.
The paper-based HIS maintained at the health-care facilities in Sri Lanka

are considered as legal documents and thus maintained at these institutions
under strict protection. The medical records are not made available to the
public and are kept for a period of five years at the hospital medical records
archives. These are produced only under the orders of the judiciary. Currently,
there are plans to introduce an electronic medical record (EMR) with the
current PHC reorganization. However, handling of EMRs pose considerable
legal challenges in relation to privacy and confidentiality, quality of records
and tort-based liability. While the Sri Lankan legislation recognizes electronic
records as legally valid in most instances, it does not provide sufficient legal
backing when it comes to sensitive personal health data (Ratnayake, 2013).
To monitor the performance of the health system in both the public and
private sectors, the MoH has developed the National Health Performance
Framework. In addition, the state has also endorsed the SDG framework
where the MoH has agreed to monitor and keep track of some 46 health-
related indicators. The baselines for these indicators have been assessed
and the sources identified for extracting the values serially. The need to get
the people empowered and to transform the health system from the current
hospital-centred care model into a “people-centred” system has been
recognized in the envisaged PHC reorganization.
A tracker has been developed with the technical support of WHO for
monitoring SDG-related information, while the Annual Health Bulletin and
National Health Statistics will monitor the other performance indicators.
Performance is reviewed both at national and subnational levels regularly.
The MoH initiated the production of the National Health Accounts as an in-
house publication since 2016 with the publication of the SL – NHA 2013.
The National Health Accounts describe from where the health system was
financed and how the financing was done. It is possible to assess the efficacy
197
of the system when coupled with the effectiveness and coverage indicators of
diseases. Several national-level surveys are conducted by the Department of
Census and Statistics such as the DHS and the HIES, which too feed into the
performance monitoring framework.
The state passed a Right to Information Act (Parliament of the Democratic

Socialist Republic of Sri Lanka, 2016), which ensures that people get access
to any public information. This Act was passed to increase the accountability
of the government to the public as well as to increase the people’s
engagement in the governance process. This Act has come into effect since
2017. The impact of this on the health system has yet to be assessed.
The pharmaceutical industry, diagnostics, private health-care industry as

well as the food and beverages, tobacco and alcohol industries are directly
related to the health care of the people. Many instances of conflicts of
interest have been identified in relation to the influence of these industries
on the MoH or its personnel, which have been documented. The case of
marketing of breast milk substitutes within the hospital setting was one such
instance where the MoH totally prohibited such marketing practices and
endorsed the “baby-friendly hospital initiative”. This is an example where
the state intervened to prevent any conflict of interest from arising. A similar
case can also be made with pharmaceutical industry marketing within the
hospital premises.
The MoH’s efforts to curb the use of tobacco and alcohol through introduction
of taxes, pictorial warnings, sale of single sticks and standard plain
packaging in line with the WHO FCTC have come across stiff resistance from
these industries.
198
8. Conclusions
Achievements
Sri Lanka has been able to achieve a relatively high level of health on
a modest budget, despite being a low-income/lower-middle-income
country. The state health-care system is acknowledged as being efficient
and equitable.
Life expectancy at birth has increased steadily for both sexes, and women
currently live 6.7 years longer than men. Healthy life expectancy also has
improved over time, but at a much lower rate than life expectancy, thus
widening the difference between the two measures over time.
Significant improvements have been made in the crude death rate and infant
and child mortality rates. The MMR continues to decline, albeit at a slower
pace during the past five years. The country has been able to eliminate
malaria, filariasis, polio and neonatal tetanus (World Health Organization,
2018a) and is set to eliminate other VPDs such as measles and congenital
rubella syndrome and other infectious diseases such as lymphatic filariasis
and leprosy.
The main drivers of these health gains have been policies that ensured
widespread and easy access to medical care, free at the point of delivery. The
demand for services was fuelled by the early granting of universal franchise
and the introduction of democratic politics and resultant voter pressure. This
induced successive governments to continuously expand free state health
services into hitherto unserved and underserved areas. Vital registration
systems drew the attention of politicians and health planners to common
causes of mortality and their differentials. Thus, not only did democracy
serve to establish a widespread government health infrastructure, but
also acted to ensure its survival even under difficult fiscal conditions. The
high value placed on female education, together with societal norms that
enabled empowerment of women and community-based methods of service
delivery such as the MOH system, resulted in increasing access to services,
especially MCH services. The expansion of coverage enabled the service to
incorporate selected advances in global medical technology, resulting in
rapid and substantial reductions in mortality. Importantly, the expansion also
199
led to reductions in urban–rural health inequalities. Income and food subsidy
programmes, which provided a safety net for those in need, were other
supportive social factors contributing to the health gains.
The government allopathic health-care delivery system consists of two

distinct strands, namely, curative services and preventive and promotive
services, a dichotomy that has been present from the inception of allopathic
health development. Curative services are provided by an extensive network
of institutions ranging from teaching hospitals, provincial, district general
and base hospitals with varying levels of specialties, to divisional hospitals
(outpatient care and inward care) and PMCUs offering only outpatient care.
This extensive network has resulted in a high level of physical access. The
preventive health-care system provides a comprehensive package of care
mainly focused on MCH services, sanitation, food and water hygiene, and
prevention and control of communicable diseases through a network of 354
health units, each unit serving a geographically demarcated area and its
catchment population. Each such area is served by a team of health-care
professionals led by doctors, and includes nursing sisters, PHMs and PHIs.
A key strength of this system has been the strong supportive supervision and
monitoring mechanisms that extend through the system.
Patterns of utilization of services indicate that many persons access

both the government and private sectors, and that even the lower wealth
quintiles access the private sector for outpatient services. As the health
delivery system is universal and there is no explicit targeting of the poor,
the utilization patterns suggest an implicit targeting because the higher
wealth quintiles opt out of the public system, which is unable to meet their
service expectations such as choice of provider, absence of or shorter waiting
times and better “hotel facilities” that are available in the private sector.
However, studies have shown that the quality of diagnosis and management
of outpatient care is similar in both sectors (Rannan-Eliya et al., 2015).
Comparison of the quality of inpatient care between the two sectors showed
that the overall quality scores were better in the public sector and that they
performed better in those indicators that are not constrained by resource
limitations. Quality was comparable in clinical assessment and investigation,
but the public sector performed better in treatment and management (70%
vs 62%) and drug prescribing (68% vs 60%) but was modestly worse in terms
of outcomes (92% vs 97%) (Rannan-Eliya et al., 2015).
The Sri Lankan experience suggests that a tax-based and public system
of provision of health care, the model of “publicly financed public services,
literally free at the point of service delivery” can be an appropriate model
for providing UHC, especially in a country where a large percentage of the
200
population lives in rural areas and where the majority are employed in the
informal sector.
Challenges
Although much has been achieved in eliminating or reducing morbidity and
mortality from VPDs, communicable diseases such as dengue, leptospirosis,
pandemic influenza threats and TB still remain important causes of
morbidity. Currently, NCDs, injuries and mental illness form the bulk of the
disease burden, while ischaemic heart disease, CVD and diabetes constitute
the leading causes of DALYs lost. It is estimated that nearly 75% of deaths in
the country are due to NCDs.
The prevalence of NCD risk factors is high. It is estimated that 90% of Sri
Lankan adults (18–69 years) have at least one of the NCD risk factors, and
that 73.5% have one to two risk factors (World Health Organization, 2015).
The risk factors contributing to most DALYs in Sri Lanka are high fasting
plasma glucose, dietary risks, high blood pressure, high body mass index
and tobacco use. Alcohol and drug abuse have shown an increase despite
implementation of a package of interventions (Institute for Health Metrics
and Evaluation, 2020).
There is an increase in sedentary occupations and lifestyles, access to

high-fat and high-density foods, and high salt and sugar consumption.
Continuing high levels of low birth weight and childhood malnutrition,
especially in the first two years of life, are factors adding to NCD risks in later
life. Indoor air pollution from the use of firewood for cooking still remains a
problem; only 28% of the population are primarily using clean fuels (World
Health Organization, 2019c), as against the South-East Asia Regional
average of 45%.
The epidemiological transition is compounded by a demographic transition

resulting in a rapidly ageing population. The population over 65 years
increased from 3.7% in 1970 to 10.1% in 2017. An important feature is that
56% of the elderly are women, and this proportion increases to 61% among
those 80 years and over. A large percentage (45%) of those 60 years and over
have an NCD, the common illnesses being cardiovascular diseases, cancer,
diabetes, arthritis, depression, dementia and Alzheimer disease (United
Nations Population Fund, 2017).
Although the public sector curative care facilities are organized in a

hierarchical manner that is conducive to a referral system, such a system is
not implemented effectively. Clear referral policies and clearly demarcated
catchment areas for institutions are lacking, and all institutions provide
201
primary care facilities in their outpatient sections. This results in individual
care seekers often bypassing primary-level institutions and seeking first-
contact care at higher-level institutions, even across district and provincial
boundaries. This situation, where PHC cannot serve as a gatekeeper, is not
ideal for the continuity of care needed to meet the emerging burden of NCDs.
However, it has imparted a degree of equity within the system. Studies have
shown that the phenomenon of bypassing is based on people’s perceptions
of better facilities, availability of medicines and quality of care and provider
competency. It has been shown that patients with better social support
and stable incomes tend to bypass the closest health facilities (Perera and
Weerasinghe, 2015).
Until recently, the MoH’s response to this bypassing has been to enhance
resource allocation to secondary- and tertiary-care institutions to meet the
increased demand at these levels. However, recognizing the complexity of
providing lifelong monitoring and treatment needed for the management of
NCDs, the MoH has shifted its focus to improving and reorganizing primary
care services. This will make available quality services closer to patients’
homes, i.e. “close-to-client services”, providing continuity of care and referral
when needed. The planned reform is expected to address inequities as well
as reduce the current high levels of OOPE.
Increases in the cost of health-care provision

The state investment on health has remained low compared with the global
average, around 1.7% of GDP or lower throughout the past decade. OOPE has
shown a steady increase and now accounts for more than half of the CHE.
Despite this, catastrophic health-care spending has remained at a low level
(6.4% at a 10% threshold and 1.1% at a 25% threshold), with only a small
percentage going into impoverishment compared to economically similar
and regional countries. This is mainly because the majority of OOP spending
is made by the wealthiest quintile and public sector health-care utilization
of indoor services, which account for a majority of the high-cost items.
The stagnant investment in the health sector, the increasing OOPE and the
demographic and epidemiological transitions suggest that the meagre health
budget of 1.7% of GDP being currently provided by the state is not adequate
to meet the increased healthcare needs of the population. The need to
increase spending by the state on health, as well as strategic allocation of the
available limited financial resources to achieve maximum health outcomes
are critical if the past gains are to be sustained in the face of growing
challenges in the future.
202
Human resources for health
Despite being able to achieve the minimum numbers of the health
workforce in relation to requirements in the main categories of service
providers (doctors, dentists, nurses, midwives, pharmacists and laboratory
technicians), their distribution, retention in PHC settings and the skill mix
still pose considerable challenges, especially in view of the planned primary
care reforms. The policy of allowing state-employed medical personnel to
engage in private practice outside official work hours and off government
premises has had a significant impact on rural retention of doctors.
During the period 1970–1977 when this concession was abolished, the
distribution of government MOs to rural areas was seen to suffer (Rannan-
Eliya and Sikurajapathy, 2009). Evaluation of the impact of this policy on
service provision and effective and comprehensive interventions to support
rural retention of the health workforce is urgently required (World Health
Organization, 2010). The country will not only need more numbers of medical
personnel, but also require them to possess clinical and public health
competencies, be more equitably distributed and provide an extended range
of services to the people.
Information system
Health-care services can only be as good as the HIS. Preventive health care
has a time-tested information system that spans a range from the national
aggregated values to the most granular data at the household level. This is
currently being converted into a digital information system with real-time
tracking. The state curative care sector has many fragmented information
systems where data interoperability across different platforms is a major
challenge. The country is in the process of integrating and harmonizing these
into a uniform HIS linked through unique citizen identifiers, where each
person will be accounted for accurately and patient records can be retrieved
whenever needed from any place within the health system.
Gaps in service provision

It is seen that the health system has not evolved in a manner appropriate to
meet the changing demands of the demographic, epidemiological and social
transitions. Although overall utilization of services is high, access is poor
among working-age men. This is mainly due to the fact that service hours at
outpatient departments other than accident and emergency services coincide
with the general working hours of the population. User-unfriendly service
hours is a root cause of private sector utilization and OOP payment.
203
The rate of decline in the MCH indicators has slowed down, necessitating a
re-examination of the current strategies. The present curative care system
is ill-equipped to deal with the long-term chronic ailments of an ageing
population. Taking into consideration the rapidity of the ageing process
observed, the active promotion of healthy ageing at younger ages is an
important intervention.
HLCs attached to primary care units were an innovation to promote

primordial and primary prevention of NCDs. At present, the main function of
these centres appears to be screening of healthy adults in the age group of
40–65 years for NCDs. Attendance is noted to have a clear female bias. Part
of the problem has been identified as the inconvenient hours, particularly for
working men, inadequacy of appropriately skilled staff to man these centres,
inadequate access to laboratory facilities and the current paper-based
system of record-keeping (De Silva and Weerasinghe, 2018).
Primary preventive strategies for the prevention of road traffic accidents,

pre-hospital care and ambulance transport of accident victims are areas
that need more attention. Continuity of care in chronic diseases needs
to be strengthened further. Improving the overall quality of services to
meet the changing expectations of the people is another challenge facing
the services. Given the current financial constraints, these appear to be
daunting challenges.
Addressing the challenges

The MoH has identified the reorganization of the government primary
curative health-care services, while protecting the current strengths, as
a means of addressing NCDs as well as achieving UHC. Each primary
curative care institution will be allocated a defined population and a package
of essential services for the management of NCDs and other common
morbidities in the community.
This would ensure patient-centred continuity of care at a centre close to

home. It is envisaged that care services would be extended to the patient’s
home, in particular, to home- and bed-bound individuals as needed. An
important part of this process would be population engagement and
empowerment of individuals to take responsibility for their own health, and
help in oversight of the health-care system. Such a service is expected to
reduce the iniquitous and ever-increasing OOP expenses for medical care.
There is a need for a rational analysis of future service needs and HR

requirements in terms of numbers, quality and mix to meet these service
projections for both the state and private sectors. In HR production, the
204
expansion of numbers, reviewing and updating the curricula to improve
the quality of education and establishment of standards, accreditation
mechanisms for training programmes, continuing professional development
and appropriate revalidation processes, as recommended by WHO, would
be essential (World Health Organization, 2013). HR planning, management
and periodic audits will have to be institutionalized, as well as continuing
processes that can anticipate and respond to emerging health needs.
The current paper-based HIS would be replaced by an electronic system,

including a personal health record with a unique identification number.
Technological advances and innovations would be used judiciously for
this process.
Addressing the stagnant MCH indicators may need special targeted

interventions. Mothers at risk of a low birthweight baby, infants and young
children at risk of growth failure, and small groups such as migrant
populations who currently do not appear to benefit from the services
provided, need to be identified and innovative approaches considered to meet
these challenges, including safety nets.
These improvements to the health-care system will require increased

government spending on the health sector, as the domestic GGHE has been
around 9% of GGE. Also needed are transformative educational approaches
for capacity-building of health personnel, supported by a more effective
stewardship role by the MoH. Improving the health of the population
requires addressing the social determinants of morbidity and mortality in a
comprehensive manner rather than with a narrow focus on delivery of health
services alone. This entails ensuring equity in social and economic policies,
addressing environmental issues and concentrated efforts to change the
personal behaviour of people.
205
9. Appendices
9.1 References
Amarasinghe SN, Alwis S, Saleem S, Rannan-Eliya R, Dalpatadu S (2015a).
Private health sector review 2012. Technical reports series no.2. Colombo:
Institute for Health Policy (https://www.ihp.lk/publications/docs/PHSR2012.
pdf, accessed 25 April 2021).
Amarasinghe SN, Dalpatadu K, Rannan-Eliya R (2018). Sri Lanka health

accounts: national health expenditure 1990–2016. Health expenditure series
no.5. Colombo: Institute for Health Policy (https://www.ihp.lk/publications/
docs/HES1805.pdf, accessed 24 April 2021).
Amarasinghe SN, Thowfeek FR, Anuranga C, Dalpatadu KCS, Rannan-Eliya RP

(2015b). Sri Lanka health accounts: national health expenditure 1990–2014.
Health expenditure series no.4. Colombo: Institute for Health Policy (http://
ihp.lk/publications/docs/HES1504.pdf, accessed 24 April 2021).
Amirthalingama K (2013). Importance and issues of taxation in Sri Lanka.

Colombo Business Journal. 4(1):13–22. doi: http://doi.org/10.4038/cbj.v4i1.30.
Arseculeratne SN (2002). Interactions between traditional medicine and

‘western’ medicine in Sri Lanka. Social Scientist. 30(5/6):4–17. doi: https://doi.
org/10.2307/3517999.
Balasubramaniam K (2006). Towards improving and strengthening of the

national health system: the need for a charter of patients’ rights. Law and
Society Trust (LST) Review.16:6–13.
Barker DJ (2007). The origins of the developmental origins theory. J Intern

Med. 261(5):412–7. doi: 10.1111/j.1365-2796.2007.01809.x.
Basnayake BRSB (2007). Physical and biological environment: climate change.

In: The National Atlas of Sri Lanka (2nd ed). Colombo: Survey Department
of Sri Lanka.
Black RE, Victora CG, Walker S, Bhutta ZA, Christian P, De Onis M et al.
(2013). Maternal and child undernutrition and overweight in low-income and
middle-income countries. Lancet. 382(9890):427–51. doi: 10.1016/S0140-
6736(13)60937-X.
206
Central Bank of Sri Lanka (2018). Annual report 2017. Colombo (https://www.
cbsl.gov.lk/en/publications/economic-and-financial-reports/annual-reports/
annual-report-2017, accessed 25 April 2021).
Central Bank of Sri Lanka (2019). Annual report 2018. Colombo (https://www.
cbsl.gov.lk/en/publications/economic-and-financial-reports/annual-reports/
annual-report-2018, accessed 24 April 2021).
Chandrapala I (2007). Physical and biological environment: temperature.

In: The National Atlas of Sri Lanka (2nd ed). Colombo: Survey Department
of Sri Lanka.
Daily Mirror (2018). Sri Lanka hopes to meet 60% of pharma demand locally
by 2020. 11 January (http://www.dailymirror.lk/article/Sri-Lanka-hopes-to-
meet-of-pharma-demand-locally-by--143733.html, accessed 24 March 2021).
Das Gupta M, Dalpatadu KCS, Shanmugarajah CK, Herath HMSSD (2013).

Multisectoral preventive health services in Sri Lanka : lessons for developing
countries in providing public goods in health. Policy research working paper
no. 6558. Washington, DC: World Bank.
De Silva A, Liyanage I, De Silva S, Jayawardana M, Liyanage C, Karunathilake

I (2013). Migration of Sri Lankan medical specialists. Human Resour Health.
11:21. doi: 10.1186/1478-4491-11-21.
De Silva A, Ranasinghe T, Abeykoon P (2016). Universal health coverage and

the health sustainable development goal: achievements and challenges
for Sri Lanka. WHO South-East Asia J Public Health. 5(2):82–88. doi:
10.4103/2224-3151.206257.
De Silva KM (2005). A history of Sri Lanka. India: Penguin Books.
De Silva MD (2017). How many medical specialists do Ministry of Health, Sri

Lanka need by 2025: use of system dynamics modelling for policy decisions.
Ceylon Med J. 62(3):141–8. doi: 10.4038/cmj.v62i3.8517.
De Silva NL, Samarasekara K, Rodrigo C, Samarakoon L, Fernando S,

Rajapakse S (2014). Why do doctors emigrate from Sri Lanka? A survey of
medical undergraduates and new graduates. BMC Res Notes. 7:918. doi:
https://doi.org/10.1186/1756-0500-7-918.
De Silva S, Weerasinghe M (2018). An assessment of the major non

communicable disease (NCD) programme in secondary and primary health
care institutions in Sri Lanka. Colombo: Health System Research Unit,
University of Colombo.
207
De Silva SHP, De Silva A, Chandrarathna NA, Nieveras O, Kumara R,
Amarasinghe S (2018). Health Financing Situation Position Papers for Sri
Lanka: Chapter 4 - Out of Pocket Expenditure Analysis, Report submitted by
Ministry of Health to WHO (Unpublished).
De Silva WI, De Silva R (2015). Sri Lanka 25 million people and implications:
population and housing projections 2012-2062. Colombo: United Nations
Population Fund.
Department of Census and Statistics (2009). Demographic and health

survey - Sri Lanka 2006/7. Colombo (http://www.statistics.gov.lk/Health/
StaticalInformation/FinalReport, accessed 18 January 2021).
Department of Census and Statistics (2011a) Concepts and definitions for the
census of population and housing. Colombo: Ministry of Policy Planning and
Economic Affairs (http://www.statistics.gov.lk/pophousat/cph2011/index.php
?fileName=ConceptsandDefinitions&gp=StudyMaterials&tpl=2, accessed 12
January 2020).
Department of Census and Statistics (2011b). Household income and

expenditure survey 2009/2010. Colombo: Ministry of Finance and Planning
(http://www.statistics.gov.lk/IncomeAndExpenditure/StaticalInformation/
HouseholdIncomeandExpenditureSurvey2009-2010FinalReport, accessed
14 April 2020).
Department of Census and Statistics (2015a). Census of population and

housing - 2012. Colombo: Ministry of Policy Planning and Economic Affairs.
Department of Census and Statistics (2015b). Household income and

expenditure survey 2012/2013. Colombo: (http://www.statistics.gov.lk/
IncomeAndExpenditure/StaticalInformation/HouseholdIncomeandExpenditur
eSurvey2012-2013FinalReport, accessed 14 April 2020).
Department of Census and Statistics (2016). Health facility survey

2016. Colombo.
Department of Census and Statistics (2017). Demographic and health

survey - Sri Lanka 2016. Colombo (http://www.statistics.gov.lk/Health/
StaticalInformation/DemographicAndHealthSurvey-2016FullReport, accessed
18 January 2021).
Department of Census and Statistics (2018a). Household income and

expenditure survey 2016. Colombo: Ministry of National Policies and Economic
Affairs (http://repo.statistics.gov.lk/bitstream/handle/1/784/HIES2016_
FinalReport.pdf?sequence=1&isAllowed=y, accessed 18 January 2021).
208
Department of Census and Statistics (2018b). Annual survey of industries
2016. Colombo.
Department of Census and Statistics (2020). Vital statistics: estimates on mid-

year population 2015–2020. Colombo (http://www.statistics.gov.lk/Population/
StaticalInformation/VitalStatistics, accessed 25 February 2020).
Epidemiology Unit (2008). List of notifiable diseases. Colombo: Ministry of

Health (http://www.epid.gov.lk/web/index.php?option=com_content&view=art
icle&id=145&Itemid=446&lang=en, accessed 7 April 2019].
Fernando D (2000). Health care systems in transition III. Sri Lanka, Part I. An
overveiw of Sri Lanka’s healthcare system. Journal of Public Health Medicine.
22(1):14-20. doi: 10.1093/pubmed/22.1.14.
Financial Commission of Sri Lanka (2017). Financial Commission

recommendations to the President. Colombo.
Galappathi R, Karunanayake MM (2007). Physical and biological environment:

tsunami hazard, In: The National Atlas of Sri Lanka (2nd ed.) Colombo: Survey
Department of Sri Lanka.
Gamage S, Rampatige R, Samarakoon J, Ranadheera S, Mikkelson L, Aung E

(2009). Assessing the production, quality and use of vital statistics: a case study
of Sri Lanka,. Queensland: Australia School of Population Health, University
of Queensland.
GBD 2015 Healthcare Access and Quality Collaborators (2017). Healthcare

access and quality index based on mortality from causes amenable to personal
health care in 195 countries and territories, 1990-2015: a novel analysis from
the Global Burden of Disease Study 2015. Lancet. 390(10991):231-266. doi:
10.1016/S0140-6736(17)30818-8.
GBD 2016 SDG Collaborators (2017). Measuring progress and projecting

attainment on the basis of past trends of the health-related sustainable
development goals in 188 countries: an analysis from the Global Burden of
Disease Study 2016. Lancet. 390(10100):1423-59. doi: https://doi.org/10.1016/
S0140-6736(17)32336-X.
Govindaraj R, Navaratne K, Cavagnero E, Sheshadri SR (2014). Health care

in Sri Lanka: what can the private health sector offer? Health, nutrition and
population discussion paper. Washington, DC: World Bank.
Halstead SB, Walsh JA, Warren KS (eds.) (1985). Good health at low cost.
Bellagio: Rockefeller foundation.
209
Hanley B, Morris C, Staley K (2009). An evaluation of the process and impact
of patient and public involvement in the advisory groups of the UK Clinical
Research Collaboration. London: UK Clinical Research collaboration.
Hart JD, Sorchik R, Bo KS, Chowdhury HR, Gamage S, Joshi R (2020). Improving
medical certification of cause of death: effective strategies and approaches
based on experiences from the Data for Health Initiative. BMC Med. 18(1):74.
doi: 10.1186/s12916-020-01519-8.
Health Economics Cell (2016). Sri Lanka national health accounts 2013.
Colombo: Ministry of Health Nutrition and Indigenous Medicine (http://www.
health.gov.lk/moh_final/english/public/elfinder/files/publications/NHA/
Sri%20Lanka%20National%20Health%20Accounts%202013.pdf, accessed
21 March 2020).
Ibrahim NI, Dahlui M, Aina E, Al-Sadat N (2012). Who are the breast cancer
survivors in Malaysia? Asian Pac J Cancer Prev. 13(5):2213-8. doi: 10.7314/
apjcp.2012.13.5.2213.
Indraratna ADVDS (ed.) (1998). Fifty years of Sri Lanka’s independence: a socio
economic review. Colombo: Sri Lanka Institute of Social and Economic Studies.
Information and Communication Technology Agency of Sri Lanka (2009). Policy

and procedures for ICT usage in government (e-Government Policy). Colombo
(http://www.data.gov.lk/download/file/fid/359, accessed 16 February 2021).
Institute for Health Metrics and Evaluation (2018). Financing global health
2017: funding universal health coverage and the unfinished HIV/AIDS agenda.
Seattle (http://www.healthdata.org/sites/default/files/files/policy_report/
FGH/2018/IHME_FGH_2017_fullreport_online.pdf, accessed 23 April 2020).
Institute for Health Metrics and Evaluation (2020a). Country profile – Sri Lanka.
Seattle (http://www.healthdata.org/sri-lanka, accessed 1 August 2020).
Institute for Health Metrics and Evaluation (2020b). Global Health Data
Exchange. Seattle (http://ghdx.healthdata.org/gbd-results-tool, accessed 12
October 2020).
Institute of Policy Studies (2016). Sri Lanka: State of the Economy 2016. Colombo.
Institute of Policy Studies (2017). Responding to the challenge of an ageing

population. Colombo.
Internal Displacement Monitoring Center (2019). IDMC - Country profile of Sri

Lanka. Geneva (http://www.internal-displacement.org/countries/sri-lanka,
accessed 7 May 2019).
210
International Organization for Migration -Sri Lanka (2013). Migration Health.
Colombo (https://srilanka.iom.int/migration-health, accessed 3 May 2019).
International Pharmaceutical Federation (2012). Global pharmacy workforce

report. The Hague: International Pharmaceutical Foundation (https://www.fip.
org/file/1414, accessed 16 April 2021).
Jayakody R, Galappatthy P (2015). Some key points in the new National Medicines
Regulatory Authority (NMRA) Act. The Sri Lanka Prescriber. 23(2):10-12.
Jayasinghe S (2013). Illness and social protection: an agenda for action in Sri
Lanka. Sri Lanka Journal of Social Sciences. 33(1-2):25-29. doi: http://doi.
org/10.4038/sljss.v33i1-2.5455.
Katulanda P, Constantine GR, Mahesh JG, Sheriff R, Seneviratne RD, Wijeratne

S et al. (2008). Prevalence and projections of diabetes and pre-diabetes in
adults in Sri Lanka--Sri Lanka Diabetes, Cardiovascular Study (SLDCS). Diabet
Med. 25(9):1062-9. doi: 10.1111/j.1464-5491.2008.02523.x.
Kumara AS, Samaratunge R (2016). Patterns and determinants of out-of-

pocket health care expenditure in Sri Lanka: evidence from household surveys.
Health Policy Plan. 31(8):970-83. doi:10.1093/heapol/czw021.
Lewis M (2006). Governance and corruption in public health care systems.

Working paper number 78. Center for Global Development (https://www.cgdev.
org/sites/default/files/5967_file_WP_78.pdf, accessed 25 April 2021).
Liyanage C, Ekanayake P (2018). Competency and challengesof traditional

medical systems in postcolonial Sri Lanka. Social Sciences and Humanities
Review. Faculty of Humanities and Social Sciences, University of Ruhuna.
Madduma Bandara CM (2007). Physical and biological environment: releif

and drainage. In: The National Atlas of Sri Lanka (2nd ed.). Colombo:
Survey Department.
Mallawaarachchi DV, Wickremasinghe SC, Somatunga LC, Siriwardena VT,

Gunawardena NS (2016). Healthy Lifestyle Centres: a service for screening
noncommunicable diseases through primary health-care institutions
in Sri Lanka. WHO South-East Asia J Public Health. 5(2):89-95. Doi:
10.4103/2224-3151.206258.
Medcalf A, Bhattacharya S, Momen H, Savedra , Jones M (2015). Health for

all: the journey of universal health coverage. India: Orient Blackswan (https://
core.ac.uk/download/pdf/42614977.pdf, accessed 24 April 2021).
211
Ministry of Disaster Management and Human Rights (2012). Sri Lanka:
national action plan for the protection and promotion of human rights 2011–
2016. Colombo.
Ministry of Finance (2016). Annual report 2015. Colombo (http://oldportal.

treasury.gov.lk/documents/10181/12870/2015/07e97126-41af-4d72-98ef-
a0a813e83731, accessed 24 April 2021).
Ministry of Finance (2019). Annual report 2017. Colombo (http://oldportal.

treasury.gov.lk/documents/10181/12870/2017.pdf/2bce4f3d-ebde-4409-b2b5-
c8a0801b3edc, accessed 24 April 2021).
Ministry of Health (2009a). Annual health bulletin 2005. Colombo: Medical

Statistics Unit.
Ministry of Health (2009b). Brief profile on tobacco control in Sri Lanka. Colombo.
Ministry of Health (2010). Annual health bulletin 2006. Colombo: Medical

Statistics Unit.
Ministry of Health (2011). Annual health bulletin 2007. Colombo: Medical

Statistics Unit.
Ministry of Health (2012a). Annual health bulletin 2008. Colombo: Medical

Statistics Unit.
Ministry of Health (2012b). Dental services – organogram. Colombo (http://

www.dental.health.gov.lk/about-us/organization-structure, accessed
21 April 2020).
Ministry of Health (2014). Annual report on family health 2013.

Colombo: Family Health Bureau (https://drive.google.com/file/
d/1MwexX8NmDWWrpxcUCLHdMKPOr6AG-wNs/view, accessed 20
February 2020).
Ministry of Health (2016a). Annual health statistics 2009/2010. Colombo: Medical

Statistics Unit (http://www.health.gov.lk/moh_final/english/public/elfinder/
files/publications/AHB/AHS2009-2010.pdf, accessed 14 February 2020).
Ministry of Health (2016b). Annual health statistics 2011. Colombo: Medical

files/StaffNotices/2017/2011AHS_19-12-16.pdf, accessed 12 February 2020).
Ministry of Health (2016c). Annual health bulletin 2012 Colombo: Medical

files/publications/AHB/Annual%20Health%20Bulletin%20-%202012.pdf,
accessed 12 February 2020).
212
Ministry of Health (2020). Cancer control program: cancer registries. Colombo
(https://www.nccp.health.gov.lk/en/populationBasedColombo, accessed 10
August 2020).
Ministry of Health and Indigenous Medical Services (2019). Annual health

bulletin 2017. Colombo: Medical Statistics Unit (http://www.health.gov.lk/
moh_final/english/public/elfinder/files/publications/AHB/2020/AHB_2017.
pdf, accessed 17 February 2020).
Ministry of Health and Indigenous Medicine (2016). Annual health bulletin

2013. Colombo: Medical Statistics Unit (http://www.health.gov.lk/moh_final/
english/public/elfinder/files/publications/AHB/AHB2013.pdf, accessed 13
February 2020).
Ministry of Health, Nutrition and Indigenous Medicine (2009). The national

policy and strategic framework for preventon and control of non-communicable
diseases. Colombo.
Ministry of Health, Nutrition and Indigenous Medicine (2013). National

migration health policy. Colombo.
Ministry of Health, Nutrition and Indigenous Medicine (2015a). General circular:

01/10/2015: Extension of services of the out patient departments of the
hospitals. Colombo: Director General of Health Services (http://www.health.
gov.lk/CMS/cmsmoh1/viewcircular.php?cno=01-10/2015&med=english,
Ministry of Health, Nutrition and Indigenous Medicine (2015b). Accident and

Emergency Care Policy of Sri Lanka 2016. Colombo (http://www.health.gov.
lk/moh_final/english/public/elfinder/files/publications/publishpolicy/15_
Accident%20n%20Emergency.pdf, accessed 21 February 2020).
Ministry of Health, Nutrition and Indigenous Medicine (2016a). Annual health

moh_final/english/public/elfinder/files/publications/AHB/AHB2014.pdf,
Ministry of Health, Nutrition and Indigenous Medicine (2016b). Guidelines for

accident and emergency care services in government hospitals in Sri Lanka.
Colombo (http://www.health.gov.lk/moh_final/english/public/elfinder/files/
publications/2017/A-E%20Guidelines2016.pdf, accessed 24 February 2020).
Ministry of Health, Nutrition and Indigenous Medicine (2016c). National

multisectoral action plan for the prevention and control of noncommunicable
diseases 2016-2020. Colombo (https://www.iccp-portal.org/system/files/
plans/national_ncd_action_plan_sri_lanka.pdf, accessed 25 February 2020).
213
Ministry of Health, Nutrition and Indigenous Medicine (2016d). The National
Policy on Health Information. Colombo.
Ministry of Health, Nutrition and Indigenous Medicine (2017a). Sri Lanka

National Health Policy 2016–2025. Colombo.
Ministry of Health, Nutrition and Indigenous Medicine (2017b). Annual health

moh_final/english/public/elfinder/files/publications/AHB/2017/AHB%20
2015.pdf, accessed 13 February 2020).
Ministry of Health, Nutrition and Indigenous Medicine (2017c). Reorganising

primary health care in Sri Lanka: preserving our progress, preparing our future.
Colombo (http://www.health.gov.lk/moh_final/english/public/elfinder/files/
publications/2018/ReorgPrimaryHealthCare.pdf, accessed 25 February 2020).
Ministry of Health, Nutrition and Indigenous Medicine (2018a) Annual health

statistics 2016. Colombo. Medical Statistics Unit (http://www.health.gov.lk/
moh_final/english/public/elfinder/files/publications/AHB/2017/AHS%202016.
pdf, accessed 17 February 2020).
Ministry of Health, Nutrition and Indigenous Medicine (2018b). Reproductive

Health Management Information System. Colombo: Family Health Bureau.
Ministry of Health, Nutrition and Indigenous Medicine (2018c). Private

health services regulatory council. Colombo (http://www.phsrc.lk,
accessed 3 May 2019).
Ministry of Health, Nutrition and Indigenous Medicine (2018d). Sri Lanka

National Health Accounts 2014, 2015 & 2016. Colombo (http://www.health.gov.
lk/moh_final/english/public/elfinder/files/publications/2019/National%20
Health%20Accounts%202014-15-16%20-D8-%20Justified.pdf, accessed
24 March 2021).
Ministry of Health, Nutrition and Indigenous Medicine (2018e). Policy on

healthcare delivery for universal health coverage. Colombo (http://www.
health.gov.lk/moh_final/english/public/elfinder/files/publications/2018/
Policyonhealthcaredelivery.pdf, accessed 26 February 2020).
Ministry of Health, Nutrition and Indigenous Medicine (2018f). Service

Availability and Readiness Assessment Sri Lanka–2017. Colombo: Department
of Census and Statistics (http://www.health.gov.lk/moh_final/english/public/
elfinder/files/publications/2019/SARASriLanka2017REPORT.pdf, accessed 20
January 2020).
214
Ministry of Health, Nutrition and Indigenous Medicine (2018g). Annual health
moh_final/english/public/elfinder/files/publications/AHB/2017/AHB_2016.
pdf, accessed 12 March 2020).
Ministry of Health, Nutrition and Indigenous Medicine (2019a). Sri Lanka

Essential Health Services Package. Colombo: Management, Development and
Planning Unit (http://www.health.gov.lk/moh_final/english/public/elfinder/
files/publications/2019/SLESP-2019.pdf, accessed 26 February 2021).
Ministry of Health, Nutrition and Indigenous Medicine (2019b). Annual health

statistics 2017. Colombo: Medical Statistics Unit (http://www.health.gov.lk/
moh_final/english/public/elfinder/files/publications/AHB/2017/AHS2017.pdf,
Ministry of Health, Nutrition and Indigenous Medicine, World Health Organization

(2019). Status, determinants and interventions on cardiovascular disease and
diabetes in Sri Lanka: a desk review of research 2000-2018. Colombo (https://
apps.who.int/iris/handle/10665/329430, accessed 16 February 2021).
Ministry of Healthcare and Nutrition (2008). National non communicable

disease risk factor survey 2008. Colombo: Directorate of Non Communicable
Disease (https://www.who.int/ncds/surveillance/steps/2006_STEPS_Survey_
SriLanka.pdf, accessed 17 February 2020).
Ministry of Public Administration and Home Affairs (2018). Grama Niladhari

Divisions in Sri Lanka. Colombo (http://www.moha.gov.lk/web/index.
php?option=com_content&view=article&id=43&Itemid=175&lang=en,
accessed 30 November 2018).
Mudiyanse R, Weerasinghe G, Piyasinghe M, Jayasundara J (2015). Patient’s

expectations during doctor patient communication and doctors perception about
patient’s expectations in a tertiary care unit in Sri Lanka. Archives of Medicine
(https://www.archivesofmedicine.com/medicine/patients-expectations-
during-doctor-patient-communication-and-doctors-perception-about-
patients-expectations-in-a-tertiary-care-unit-in-sri-lanka.php?aid=7716,
accessed 25 April 2021).
Muhamad NA, Muhamad A, Adon M, Mohamed A, Mohamed F, Tamim N et

al. (2015). Survival rates of cervical cancer patients in Malaysia. Asian Pac J
Cancer Prev. 16(7):3067-72. doi: 10.7314/apjcp.2015.16.7.3067.
215
National Authority on Tobacco and Alcohol (2017). Economic and social cost of
tobacco and alcohol in Sri Lanka 2015. Colombo: World Health Organization
(https://untobaccocontrol.org/impldb/wp-content/uploads/sri_lanka_2018_
annex-1_economic_and_social_costs_of_tobacco_and_alcohol_2015.pdf,
accessed 24 March 2021).
National Blood Transfusion Services (2016). National blood transfusion service.

(http://www.nbts.health.gov.lk/, accessed 26 May 2021).
National Cancer Control Program (2018). National strategic framework

for palliative care development in Sri Lanka 2018 -2022. Colombo (http://
www.nccp.health.gov.lk/images/PDF_PUBLICATIONS/National_Strategic_
Framework_for_Palliative_Care_Development_in_Sri_Lanka/English/1_
National_Strategic_Framework_for_Palliative_Care_Development_
English_05_11_2018.pdf, accessed 7 April 2019).
National Medicines Regulatory Authority (2019). National medicines regulatory

authority: overview. Colombo (http://nmra.gov.lk/index.php?option=com_cont
ent&view=article&id=50&Itemid=92&lang=en, accessed 7 April 2019).
Organization for Economic Cooperation and Development (2020). OECD Health

Statistics 2020. Paris (http://www.oecd.org/els/health-systems/health-data.
htm, accessed 12 December 2020).
Organization for Economic Cooperation and Development (OECD), World Health

Organization (WHO) (2016). Health at a glance: Asia/Pacific 2016: measuring
progress towards universal health coverage. Paris.
Parkin DM, Sanghvi LD (1991). Cancer registration in developing countries.

IARC Sci Publ. (95):185-98.
Parliament of the Democratic Socialist Republic of Sri Lanka (1952). Health

Service Act no. 12 of 1952. Colombo.
Parliament of the Democratic Socialist Republic of Sri Lanka (1961). Ayurveda

Act no. 31 of 1961. Colombo.
Parliament of the Democratic Socialist Republic of Sri Lanka (1978). The

constitution of the Democratic Socialist Republic of Sri Lanka–1978. Colombo.
Parliament of the Democratic Socialist Republic of Sri Lanka (1987). 13th

Amendment to the constitution of the Democratic Socialist Republic of Sri
Lanka. Colombo.
216
Parliament of the Democratic Socialist Republic of Sri Lanka (2006). The
National Authority of Tobacco and Alcohol Act no. 27 of 2006. Colombo (http://
www.nddcb.gov.lk/Docs/acts/NATA%20Act%20English.pdf, accessed 17
February 2021).
Parliament of the Democratic Socialist Republic of Sri Lanka (2015b). National

Medicines Regulatory Authority Act no. 5. Colombo (https://nmra.gov.lk/
images/PDF/Legislation/5e_nmdra_07.pdf, accessed 12 March 2020).
Parliament of the Democratic Socialist Republic of Sri Lanka (2015a). The

Gazette of the Democratic Socialist Republic of Sri Lanka: Medical Service
Minute of Sri Lankan Health Service. no. 1883/17. Colombo.
Parliament of the Democratic Socialist Republic of Sri Lanka (2016). Right to

Information Act no. 12 of 2016. Colombo (http://extwprlegs1.fao.org/docs/pdf/
srl174310.pdf, accessed 17 February 2021).
Peiris HH, Mudduwa L, Thalagala N, Jayatilaka K (2017). Do Breast cancer risk

factors affect the survival of breast cancer patients in southern Sri Lanka?
Asia Pac J Cancer Prev. 18(1):69-79. doi: 10.22034/APJCP.2017.18.1.69.
Perera A, Perera HSR (2017). Primary Health Care System (PRIMASYS): case
study from Sri Lanka,. Geneva: World Health Organziation (https://www.who.
int/alliance-hpsr/projects/alliancehpsr_srilankaprimasys.pdf?ua=1, accessed
12 March 2021).
Perera S, Nieveras O, De Silva P, Wijesundara C, Pendse R (2019).

Accelerating reforms of primary health care towards universal health
coverage in Sri Lanka. WHO South-East Asia J Public Health. 8(1):21–25. doi:
10.4103/2224-3151.255345.
Perera S, Weerasinghe M (2015). Bypassing primary care in Sri Lanka: a

comparative study on reasons and satisfaction. Vietnam Journal of Public
Health. 3:69–76 (http://www.vjph.vn/index.php/publichealth/article/view/39,
Periyasamy N (2018). Update on the health status of plantation community

in Sri Lanka. Journal of the College of Community Physicians of Sri Lanka.
23(4):135–43. doi: http://doi.org/10.4038/jccpsl.v23i4.8135.
Premaratne R, Amarasinghe A, Wickremasinghe R (2005). Hospitalisation

trends due to selected non-communicable diseases in Sri Lanka, 2005–2010.
Ceylon Medical Journal. 50(2):51–4. doi: http://doi.org/10.4038/cmj.v50i2.1568
Rajapakse S, Shivanthan MC, Selvarajah M (2016). Chronic kidney disease

of unknown etiology in Sri Lanka. Int J Occup Environ Health. 22(3):259-264.
doi: 10.1080/10773525.2016.1203097.
217
Ranasinghe A, Thamilmaran VT, Arandara AKDDD (2007). National Atlas of Sri
Lanka (2nd ed.).Colombo: Survey Department.
Rannan-Eliya RP (1997). Analysis of private health insurance in Sri-Lanka:

findings and policy implications. Health Policy Programme occasional paper
03. Colombo: Institute of Policy Studies (https://www.ips.lk/analysis-of-
private-health-insurance-in-sri-lanka-findings-and-policy-implications2/,
Rannan-Eliya RP, Sikurajapathy L (2009). Sri Lanka: “Good Practice” in

expanding health care coverage. Research studies series. Colombo: Institute
of Health Policy (https://www.ihp.lk/publications/docs/RSS0903.pdf, accessed
20 March 2021).
Rannan-Eliya RP, Wijemanne N, Liyanage IK, Dalpatadu S, De Alwis S,

Amarasinghe et al. (2015a). Quality of inpatient care in public and private
hospitals in Sri Lanka. Health Policy Plan. 30(suppl 1):i46–58. doi: 10.1093/
heapol/czu062.
Rannan-Eliya RP, Wijemanne N, Liyanage IK, Jayanthan J, Dalpatadu S,

Amarasinghe S et al. (2015b). The quality of outpatient primary care in public
and private sectors in Sri Lanka – how well do patient perceptions match
reality and what are the implications? Health Policy Plan. 30 (suppl 1):i59–74.
doi: 10.1093/heapol/czu115.
Ratnayake HM (2013). Negotiating privacy, confidentiality and security issues

pertaining to electronic medical records in Sri Lanka: a comparative legal
analysis. Sri Lanka Journal of Bio-Medical Informatics. 4(2):32-39. doi: http://
doi.org/10.4038/sljbmi.v4i2.5859.
Riswan M (2015). Community participation in dengue prevention activities

in the Kalmunai Regional Health Services area, Sri Lanka. Journal of
Education and Social Sciences. 1:187-98 (https://www.jesoc.com/wp-content/
uploads/2015/07/J_SS_17_KLiCELS-2015-Journal-of-Education-Social-
Sciences.pdf, accessed 23 March 2021).
Russel S, Gilson L (2006). Are health services protecting the livelihoods the
urban poor in Sri Lanka? Findings from two low-income areas of Colombo. Soc
Sci Med. 63(7):1732-44. doi: 10.1016/j.socscimed.2006.04.017.
Ruwanpathirana T, Senanayake S, Gunawardana N, Munasinghe A, Ginige S,

Gamage D et al. (2019). Prevalence and risk factors for impaired kidney function
in the district of Anuradhapura, Sri Lanka: a cross-sectional population-
representative survey in those at risk of chronic kidney disease of unknown
aetiology. BMC Public Health. 19(1):763. doi: 10.1186/s12889-019-7117-2.
218
Ruwanpura R (2009). Litigation against medical practitioners: facts and myths.
Galle Medical Journal. 14(1):56-58. doi: http://doi.org/10.4038/gmj.v14i1.1176.
Samarage DSM (2006). Migration and human resources for health: from
awareness to action. Geneva: ILO/IOM/WHO (https://www.iom.int/jahia/webdav/
site/myjahiasite/shared/shared/mainsite/microsites/IDM/workshops/
mhrh23240306/presentation_samarage.pdf, accessed 20 March 2020).
Samaraweera D, Maduwage S (2016). Meeting the current and future health-

care needs of Sri Lanka’s ageing population. WHO South East Asia J Public
Health. 5(2):96-101. doi: 10.4103/2224-3151.206259.
Simeonov LA (1975). Better health for Sri Lanka: report on a health manpower
study. New Delhi: World Health Organization Regional Office for South-East Asia.
Siriwardhana C and Stewart R (2013). Forced migration and mental health:

prolonged internal displacement, return migration and resilience. Int Health.
5(1):19-23. doi: 10.1093/inthealth/ihs014.
Siriwardhana C, Wickramage K (2014). Conflict, forced displacement and

health in Sri Lanka: a review of the research landscape. Confl Health. 8(1):22.
doi: 10.1186/1752-1505-8-22.
Smith OK (2018). Sri Lanka - achieving pro-poor universal health coverage

without health financing reforms. Universal health coverage study series.
Washington DC: World Bank (http://documents1.worldbank.org/curated/
en/138941516179080537/pdf/Sri-Lanka-Achieving-pro-poor-universal-
health-coverage-without-health-financing-reforms.pdf, accessed
20 March 2021).
Sornpaisarn B, Shield K, Manthey J, Limmade Y, Low WY, Van Thang V et al.

(2020). Alcohol consumption and attributable harm in middle-income South-
East Asian countries: epidemiology and policy options. Int J Drug Policy.
83:102856. doi: 10.1016/j.drugpo.2020.102856.
Sri Lanka Medical Association (2010). National CPD information and guidance
book. Colombo.
Tangcharoensathien V, Chandrasiri O, Kunpeuk W, Markchang K, Pangkariya

N (2019). Addressing NCDs: challenges from industry market promotion
and interferences. Int J Health Policy Manag. 8(5):256 –60. doi:10.15171/
ijhpm.2019.02.
219
The Economist Intelligence Unit (2014). Sri Lanka healthcare challenges.
24 November (http://country.eiu.com/article.aspx?articleid=1502512534&
Country=Sri%20Lanka&topic=Economy&subtopic=Forecast, accessed 13
December 2020).
Trading Economics (2019). Sri Lanka imports of pharmaceutical products.

(https://tradingeconomics.com/sri-lanka/imports/pharmaceutical-products,
Transparency International Sri Lanka, Friedrich Ebert Stiftung (2009). Integrity

in government hospitals in the Colombo district. (https://www.tisrilanka.
org/pub/pp/pdf/Abstract%20colombo%20hospital%20study.pdf, accessed
23 March 2021).
Tuangratananon T, Wangmo S, Widanapathirana N, Pongutta S, Viriyathorn

S, Patcharanarumol W et al. (2019). Implementation of national action plans
on noncommunicable diseases, Bhutan, Cambodia, Indonesia, Philippines,
Sri Lanka, Thailand and Viet Nam. Bull World Health Organ. 97(2):129 –71.
doi:10.2471/BLT.18.220483.
UNICEF (2018). Country profile – Sri Lanka. (https://www.unicef.org/

infobycountry/, accessed 12 October 2019).
United Nations Cartographic Section (2008). General maps - Sri Lanka. No.
4172, Revision 3 (https://www.un.org/Depts/Cartographic/map/profile/
srilanka.pdf, accessed 20 January 2020).
United Nations Department of Economic and Social Affairs (UN DESA) (2019).
World population prospects - 2019. New York (https://population.un.org/wpp/,
accessed 25 September 2019).
United Nations Development Programme (2016). Human Development

Report–2016: human development for everyone. New York (http://hdr.undp.
org/sites/default/files/2016_human_development_report.pdf, accessed
20 March 2021).
United Nations Development Programme (2019). Human development index.

New York (http://hdr.undp.org/en/content/human-development-index-hdi,
accessed 25 September 2019).
United Nations High Commissioner for Refugees (2018). Sri Lanka fact sheet.
Sri Lanka (https://www.unhcr.org/protection/operations/561681326/sri-
lanka-fact-sheet.html, accessed 16 December 2018).
220
United Nations Population Fund (2017). Ageing popualtion of Sri Lanka:
emerging issues, needs and policy implications, thematic report based on
Census of Population and Housing 2012. Colombo (https://srilanka.unfpa.org/
sites/default/files/pub-pdf/UNFPA%20Ageing%20Monograph%20Report_0.
pdf, accessed 20 March 2021).
Uppsala Conflict Data Program (2020). Country - Sri Lanka. Uppsala:

Department of Peace and Conflict Research (https://www.ucdp.uu.se/
country/780, accessed 25 June 2020).
Uragoda C (1987). A history of medicine in Sri Lanka. Colombo: Sri Lankan

Medical Association.
Vithana PVSC, Bandarage VP, Dheerasinghe DSAF, Perera S, Samarakoon PN,

Amaradasa UVHS et al. (2018). Survival of the patients diagnosed with cervical
cancer and associated prognostic factors in the western province of Sri Lanka.
Journal of Global Oncology. 4(suppl 2):105s-105s.
Wang H, Torres LV, Travis P (2018). Financial protection analysis in eight

countries in the WHO South-East Asia region. Bull World Health Organ.
96(9):610-20E. doi: 10.2471/BLT.18.209858.
Weerarathne B (2016). Re-defining urban areas in Sri Lanka. Working paper

series no. 23. Colombo: Institute of Policy Studies of Sri Lanka (https://www.
ips.lk/wp-content/uploads/2017/01/RE-DEFINING-URBAN-AREAS-INSRI-
LANKA_ips_E_Book.pdf, accessed 20 March 2021).
Weerarathne B (2018). Sending Sri Lankans and receiving Chinese workers:

emerging trend of labour migration in Sri Lanka. Colombo: Institute of Policy
Studies of Sri Lanka (https://www.ips.lk/talkingeconomics/2018/12/18/
sending-sri-lankans-and-receiving-chinese-workers-emerging-trend-of-
labour-migration-in-sri-lanka/, accessed 10 August 2020).
Weerasinghe M, Fernando D (2011). Access to care in a plural health system:

concerns for policy reforms. Journal of the College of Community Physicians
of Sri Lanka. 141):39-45. doi: http://doi.org/10.4038/jccpsl.v14i1.2947.
Withanachchi N (2009). Bottlenecks to the growth of health insurance. Colombo.
World Bank (2017). Sri Lanka: overview of tobacco use, tobacco control
legislation, and taxation. Washington, DC (https://openknowledge.worldbank.
org/bitstream/handle/10986/32069/Sri-Lanka-Overview-of-Tobacco-Use-
Tobacco-Control-Legislation-and-Taxation.pdf?sequence=1&isAllowed=y,
accessed 19 Februray 2021).
221
World Bank (2020). World development indicators. Washington, DC (https://
data.worldbank.org/country/sri-lanka, accessed 25 July 2020).
World Health Organization (2006). The world health report 2006. Working
together for health. Geneva (https://www.who.int/whr/2006/whr06_
en.pdf?ua=1, accessed 20 March 2021).
World Health Organization (2010). Increasing access to health workers

in remote and rural areas through improved retention: global policy
recommendations. Geneva (https://apps.who.int/iris/bitstream/
handle/10665/44369/9789241564014_eng.pdf?sequence=1&ua=1, accessed
20 March 2021).
World Health Organization (2013). Transforming and scaling up health

professionals’ education and training. Geneva (https://apps.who.int/iris/
bitstream/handle/10665/93635/9789241506502_eng.pdf?sequence=1,
World Health Organization (2014a). A universal truth: no health without a

workforce. Geneva (https://www.who.int/workforcealliance/knowledge/
resources/GHWA_AUniversalTruthReport.pdf, accessed 20 March 2021).
World Health Organization (2014b). Paradox of healthcare in Sri Lanka: a

snapshot of the decade from a partnership of sixty years. Colombo: World
Health Organization Country Office for Sri Lanka (https://apps.who.int/
iris/bitstream/handle/10665/255195/ParadoxofhealthcareinSri%20Lanka.
pdf?sequence=1&isAllowed=y, accessed 18 March 2020).
World Health Organization (2015). STEPS: Non communicable disease risk

factor survey - Sri Lanka. Colombo: World Health Organization and Ministry
of Health - Sri Lanka (https://www.who.int/ncds/surveillance/steps/STEPS-
report-2015-Sri-Lanka.pdf, accessed 18 February 2020).
World Health Organization (2016). India - Global Youth Tobacco Survey - 2015.
New Delhi: World Health Organization Regional Office for South-East Asia,
and Ministry of Health and Family Welfare - Government of India (https://nada.
searo.who.int/index.php/catalog/40, accessed 19 February 2021).
World Health Organization (2017). Health financing profile 2017: Sri Lanka. World
Health Organization Regional Office for South-East Asia (https://apps.who.int/
iris/bitstream/handle/10665/259644/HFP-SRL.pdf?sequence=1&isAllowed=y,
accessed 16 April 2021).
222
World Health Organization (2018a). Sri Lanka–WHO country cooperation
strategy–2018–2023. Colombo: World Health Organization Country
Office for Sri Lanka (https://apps.who.int/iris/bitstream/hand
le/10665/272611/9789290226345-eng.pdf?sequence=1&isAllowed=y,
World Health Organization (2018b) Health labour market analysis: Sri Lanka.
Colombo: World Health Organization Country Office for Sri Lanka (https://
apps.who.int/iris/bitstream/handle/10665/324911/9789290226925-eng.
pdf?sequence=1&isAllowed=y, accessed 16 February 2021).
World Health Organization (2018c). Global status report on alcohol and health
2018. Geneva (https://apps.who.int/iris/rest/bitstreams/1151838/retrieve,
World Health Organization (2019a). Global health observatory data. Geneva

(https://apps.who.int/gho/data/node.main, accessed 18 February 2019).
World Health Organization (2019b). WHO report on the global tobacco epidemic,
2019: country profile of Sri Lanka. Geneva (https://www.who.int/tobacco/
surveillance/policy/country_profile/lka.pdf, accessed 17 January 2021).
World Health Organization (2019c). World health statistics 2019: monitoring

health for the SDGs: sustainable development goals. Geneva (https://
apps.who.int/iris/bitstream/handle/10665/324835/9789241565707-eng.
pdf?sequence=9&isAllowed=y, accessed 26 March 2021).
World Health Organization (2020). Global health expenditure database. Geneva

(https://apps.who.int/nha/database/ViewData/Indicators/en, accessed 20
October 2020).
223
9.2 HiT methodology and production process
HiTs are produced by country experts in collaboration with an external
editor and the Secretariat of the Asia Pacific Observatory based in the WHO
Regional Office for South-East Asia in New Delhi, India.
HiTs are based on a template developed by the European Observatory on

Health Systems and Policies that, revised periodically, provides detailed
guidelines and specific questions, definitions, suggestions for data sources
and examples needed to compile reviews. While the template offers a
comprehensive set of questions, it is intended to be used in a flexible way to
allow authors and editors to adapt it to their particular national context. The
template has been adapted for use in the Asia Pacific region and is available
online at: http://www.who.int/iris/handle/10665/208276
Authors draw on multiple data sources for the compilation of HiTs, ranging
from national statistics, national and regional policy documents to published
literature. Data are drawn from information collected by national statistical
bureaux and health ministries. Furthermore, international data sources may
be incorporated, such as the World Development Indicators of the World
Bank. In addition to the information and data provided by the country experts,
WHO supplies quantitative data in the form of a set of standard comparative
figures for each country, drawing on the Global Health Observatory (GHO)
data and Global Health Expenditure Database. HiT authors are encouraged to
discuss the data in the text in detail, including the standard figures prepared
by the Observatory staff, especially if there are concerns about discrepancies
between the data available from different sources.
The quality of HiTs is of real importance since they inform policy-making and
meta-analysis. HiTs are subject to wide consultation throughout the writing
and editing process, which involves multiple iterations. They are then subject
to the following.
• A rigorous review process consisting of three stages. Initially, the

text of the HiT is checked, reviewed and approved by the Asia Pacific
Observatory Secretariat. It is then sent for review to at least three
independent experts, and their comments and amendments are
incorporated into the text, and modifications are made accordingly.
The text is then submitted to the relevant ministry of health, or
appropriate authority, and policymakers within those bodies to check
for factual errors.
• There are further efforts to ensure quality while the report is finalized
that focus on copy-editing and proofreading.
• HiTs are widely disseminated (hard copies, electronic publication,
224
translations and launches). The editor supports the authors
throughout the production process and, in close consultation with the
authors, ensures that all stages of the process are taken forward as
effectively as possible.
225
9.3 About the authors Dileep De Silva – Head, Human
Resource Management and
Editors: Coordination Unit, Ministry of Health,
Sri Lanka
Viroj Tangcharoensathien – Senior
Advisor, International Health Ashok Perera (Late)–Deputy Director,
Policy Program, Ministry of Public Healthcare, Quality and Safety,
Health, Thailand Ministry of Health, Sri Lanka
Walaiporn Patcharanarumol – Usha Perera (Late)–Consultant

Director, Global health division, Office Community Physician, Disaster
of Permanent Secretary, Ministry of Preparedness and Response
Public Health, Thailand Division, Ministry of Health, Sri Lanka
Haruka Sakamoto – Researcher, Yasoma Weerasekara – Consultant

Department of global health policy, Community Physician, Human
University of Tokyo Resource Management and
Coordination Unit, Ministry of
Overall authors: Health, Sri Lanka
Lalini Rajapaksa – Former Anuji Gamage – Senior lecturer in
Professor in Community Medicine, Community Medicine, General Sir
University of Colombo John Kotelawala Defence University,
Padmal de Silva – National Colombo, Sri Lanka
Professional Officer, Health Systems Nalinda Wellappuli – Senior registrar
Policy and Evaluation, WHO Country in Community Medicine, Ministry of
Office for Sri Lanka Health, Sri Lanka
Palitha Abeykoon – Former Director, Nimali Widanapathirana – Senior
Health Systems Development, registrar in Community Medicine,
WHO Regional Office for South East Ministry of Health, Sri Lanka
Asia, New Delhi
Rangika Fernando – Registrar in
Chapter authors: Community Medicine, Ministry of
Health, Sri Lanka
Lakshmi Somatunga – Additional
Secretary, Public Health Services, Chatura Wijesundara – Registrar in
Ministry of Health, Sri Lanka Community Medicine, Ministry of
Health, Sri Lanka
Sridharan Sathasivam – Deputy
Director General, Planning, Ministry Ruwanika Seneviratne – Registrar
of Health, Sri Lanka in Community Medicine, Ministry of
Health, Sri Lanka
Susie Perera – Deputy Director
General, Public Health Services II, Kusal Weerasinghe – Registrar in
Ministry of Health, Sri Lanka Community Medicine, Ministry of
Health, Sri Lanka
Eshani Fernando – Director Planning,
Ministry of Health, Sri Lanka
226
Asia Pacific Observatory on Health Systems and Policies (APO) publications to date
Health Systems in Transition (HiT) • Use of community health • What are the challenges facing
review (18 countries) workers to manage and prevent Myanmar in progressing towards
• The Fiji Islands (2011) noncommunicable diseases (2019) universal health coverage?
• The Philippines (2011 & 2018) • Strategies to strengthen referral • How can health equity be
• Mongolia (2013) from primary care to secondary improved in Myanmar?
• Malaysia (2013) care in low- and middle-income • How can the township health system
• New Zealand (2014) countries (2019) be strengthened in Myanmar?
• Lao People’s Democratic • ASEAN mutual recognition • How can financial risk protection be
Republic (2014) arrangements for doctors, dentists expanded in Myanmar?
• The Republic of the Union of and nurses (2019) • The Kingdom of Cambodia (2016)
Myanmar (2014) • Strengthening primary health care • Increasing equity in health service
• Solomon Islands (2015) for the prevention and management access and financing: health
• The Kingdom of Cambodia (2015) of cardiometabolic disease strategy, policy achievements and
• Bangladesh (2015) in LMICs (2019) new challenges
• Republic of Korea (2015) • Overseas medical referral: the health • The Kingdom of Thailand (2016)
• The Kingdom of Thailand (2015) system challenges for Pacific Island • Health system review: achievements
• The Kingdom of Tonga (2015) Countries (2020) and challenges
• People’s Republic of China (2015) HiT policy notes (four countries) • Bangladesh (2017)
• The Republic of Indonesia (2017) • The Republic of the Union of • Improving the quality of care in the
• The Kingdom of Bhutan (2017) Myanmar (2015) public health system in Bangladesh:
• Japan (2018) #1. What are the challenges facing building on new evidence and current
• Independent State of Papua New Myanmar in progressing towards policy levers)
Guinea (2019) Universal Health Coverage? Comparative country studies (six
Policy brief (13 series) #2. How can health equity be series)
• Direct household payments for health improved in Myanmar? • Public hospital governance in Asia
services in Asia and the Pacific (2012) #3. How can the township health system and the Pacific (2015)
• Dual practice by health workers in be strengthened in Myanmar? • Case-based payment systems
South and East Asia (2013) #4. How can financial risk protection be for hospital funding in Asia: an
• Purchasing arrangements expanded in Myanmar? investigation of current status and
with the private sector to • The Kingdom of Cambodia (2016) future directions (2015)
provide primary health care in • Increasing equity in health service • Strategic purchasing in China,
underserved areas (2014) access and financing: health Indonesia and the Philippines (2016)
• Strengthening vital statistics strategy, policy achievements and • Health system responses
systems (2014) new challenges to population ageing and
• Quality of care (2015) • The Kingdom of Thailand (2016) noncommunicable diseases
• The challenge of extending universal • Health system review: achievements in Asia (2016)
coverage to non-poor informal and challenges • Resilient and people-centred health
workers in low- and middle-income • Bangladesh (2017) systems: progress, challenges and
countries in Asia (2015) • Improving the quality of care in the future directions in Asia (2018)
• Factors conducive to the development public health system in Bangladesh: • Moving towards culturally competent,
of health technology assessment building on new evidence and current migrant-inclusive health systems: a
in Asia (2015) policy levers comparative study of Malaysia and
• Attraction and retention of rural HiT policy notes (four countries) Thailand (2021)
primary health-care workers in the • The Republic of the Union of
Asia-Pacific region (2018) Myanmar (2015)
The APO publications are available at https://www.healthobservatory.asia and https://apo.who.int/
227
The Asia Pacific Observatory on Health
Systems and Policies (the APO) is a
collaborative partnership of interested
governments, international agencies,
foundations, and researchers that promotes
evidence-informed health systems policy
regionally and in all countries in the Asia
Pacific region. The APO collaboratively
identifies priority health system issues across
the Asia Pacific region; develops and
synthesizes relevant research to support and
inform countries' evidence-based policy
development; and builds country and regional
health systems research and
evidence-informed policy capacity.
ISBN-13 978 92 9022 853 0
PHIL
IC
O F TH E
IP
BL
PI
U
REP
NES
* *
TH
DEP
AL
FL LI
R
OR PU
E AT PO
HE
S A L U B R I TA S
A
TM
ENT OF

Sri Lanka Health System Review: ISBN-13 978 92 9022 853 0

Uploaded by

Copyright:

Available Formats

Sri Lanka Health System Review: ISBN-13 978 92 9022 853 0

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Sri Lanka Health System Review: ISBN-13 978 92 9022 853 0

Uploaded by

Copyright:

Available Formats

Health Systems in Transition

Vol. 10 No. 1 2021

© World Health Organization 2021

The Health Systems in Transition (HiT) profiles are country-based reports

A HiT profile seeks to provide relevant information to support policymakers

• to learn in detail about different approaches to the organization,

Compiling the profiles poses a number of methodological issues. In many

Comments and suggestions for further development and improvement

The authors are grateful to Drs Viroj Tangcharoensathien, Walaiporn

A&E accident and emergency

Sri Lanka is a country with a population of 21.7 million which is ageing

Although much has been achieved in eliminating or reducing morbidity

The health system constitutes of both curative and preventive services.

Although the organisation of the state sector curative care facilities is

In response to these challenges, a policy on health-care delivery for universal

Even though there have been many developments in recent times,

The MoHNIM has identified reorganisation of services with special emphasis

The country, had achieved upper-middle-income status although it was

The changing epidemiology has prompted a reorganization of the health

1.1 Geography and sociodemography

Source: United Nations Cartographic Section, 2008

The climate of the island is dominated by tropical monsoon systems. The

The population of Sri Lanka by province is given in Table 1.1. Trends in

Table 1.1 Population of Sri Lanka by province

Source: Department of Census and Statistics, 2020

1.1.1 Population and ageing

Source: World Bank, 2020

Sri Lanka is a multi-ethnic society, predominantly Sinhalese (74.9%), the

The population of Sri Lanka is ageing progressively. The population of

Table 1.3 Trends in ageing and dependency in Sri Lanka, 1970–2019

Source: UN DESA, 2019

Child dependency ratio Elderly dependency ratio

Total dependency ratio

Source: World Bank, 2020

At present, the country does not have a comprehensive social protection

1.1.2 Comparison with selected countries

Among the comparison countries, Sri Lanka is ranked third in respect of

Healthcare Access and Quality Index (HAQI), calculated using 37 of the 50

Table 1.5 Macroeconomic indicators, 1970–2018

1.3 Political context

In 1948, the country received autonomy within the British Commonwealth

With the Thirteenth amendment to the Constitution in 1987, the

1.4 Health status

DALYs/100 000 population

Group 1 Group 2 Group 3 Group 1 Group 2 Group 3

Difference between LE 6.7 7.3 7.4 7.5 7.5

Table 1.7 Trends in mortality rate, 1970–2018

Mortality rate 171.4 138.2 120.8 99.9 78.8 74.1 72.9 .. ..

Table 1.8 Leading causes of deaths in government hospitals in Sri Lanka,

Source: Ministry of Health, Nutrition and Indigenous Medicine, 2018a

1.4.2 Burden of disease

10 Unintentional injuries Unintentional injuries Sense organ diseases

Note: Percentage change given in parenthesis

YLL YLD DALYs Proportion

Ischemic heart disease 1 4.1%

-16.6% 4 Self harm

-31.8% 6 Neonatal disorders

-4.6% 7 Lower respiratory infections

-13.0% 9 Road injuries