Global Public Health
An International Journal for Research, Policy and Practice
ISSN: 1744-1692 (Print) 1744-1706 (Online) Journal homepage: https://www.tandfonline.com/loi/rgph20
Sri Lanka and the possibilities of achieving
universal health coverage in a poor country
Audrey R. Chapman & Samath D. Dharmaratne
To cite this article: Audrey R. Chapman & Samath D. Dharmaratne (2019) Sri Lanka and the
possibilities of achieving universal health coverage in a poor country, Global Public Health, 14:2,
271-283, DOI: 10.1080/17441692.2018.1501080
To link to this article: https://doi.org/10.1080/17441692.2018.1501080
Published online: 20 Jul 2018.
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GLOBAL PUBLIC HEALTH
2019, VOL. 14, NO. 2, 271–283
https://doi.org/10.1080/17441692.2018.1501080
Sri Lanka and the possibilities of achieving universal health
coverage in a poor country
Audrey R. Chapmana and Samath D. Dharmaratneb
a
Department of Community Medicine, University of Connecticut School of Medicine, Farmington, CT, USA;
Department of Community Medicine, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka
b
ABSTRACT
ARTICLE HISTORY
Sri Lanka has been lauded for providing good health coverage at a low
cost despite having a modest per capita income. This article identifies
the unique historical factors that enabled Sri Lanka to achieve near
universal coverage, but it also discusses how this achievement is now
being undermined by inadequate government investment in health
services, the burdens of non-communicable diseases, and the growing
privatisation of health services. In doing so, the article highlights the
challenges of achieving and maintaining universal health coverage in a
relatively low income country with a health system designed to treat
infectious diseases and provide child and maternal health services as the
country undergoes an epidemiological transition from infectious to noncommunicable diseases. Using updated information on developments in
the Sri Lankan health system, this article argues, in contrast with earlier
publications, that Sri Lanka is no longer providing good health at a low
cost. It shows that Sri Lanka’s low investment in health is detrimental
and not an asset to achieving good health. The article also questions the
possibilities of providing coverage for noncommunicable diseases at a
low cost. The article has four main sections. The first details Sri Lanka’s
accomplishments in moving toward universal health coverage. The
second identifies the factors enabling Sri Lanka to do so. The third
describes the equity and access challenges the health system now
confronts. The fourth assesses what the Sri Lankan experience suggests
about the requirements for universal health coverage when providing
health services for treating non-communicable diseases becomes an
important consideration.
Received 13 February 2018
Accepted 29 June 2018
KEYWORDS
Sri Lanka; universal health
coverage; noncommunicable
diseases; affordability; public
health services
Introduction
Achieving universal health coverage has become a global public health priority. Tedros Adhanom
Ghebreyesus, the recently elected Director-General of the World Health Organization (WHO),
described universal health coverage as the top priority at WHO (Ghebreyesus, 2017). Dr. Ghebreyesus’ predecessor Dr. Margaret Chan characterised universal health coverage as ‘the single most
powerful concept that public health has to offer’ and said that UHC represents the ‘ultimate
expression of fairness’ (Chan, 2015). Importantly, universal health coverage is also an international
human rights commitment (Chapman, 2016, chapter 8).
In September 2015, when 193 countries adopted the Sustainable Development Goals (SDGs), the
successor international development agenda to the Millennium Development Goals, they agreed to a
target to achieve universal health coverage by 2030. Goal 3, ‘to ensure healthy lives and promote wellCONTACT Audrey R. Chapman
achapman@uchc.edu
School of Medicine, Farmington, CT, 06030, USA
© 2018 Informa UK Limited, trading as Taylor & Francis Group
Department of Community Medicine, University of Connecticut
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A. R. CHAPMAN AND S. D. DHARMARATNE
being at all ages’, has a target (3.8) applicable to all countries to achieve universal health coverage.
The SDGs conceptualise universal health coverage as requiring financial risk protection, access to
quality essential health-care services and access to safe, effective, quality and affordable essential
medicines and vaccines for all (Transforming our world 2015).
These requirements for universal health coverage are not conceptualised in the SDG text, but as
Darius Puras, the current United Nations Special Rapporteur on the right to health has noted, the
introduction of universal health coverage without targeted measures to confer priority to the poor
and marginalised in the expansion of coverage and in developing priorities as to which services to
provide risks entrenching inequality (Puras, 2016, para. 76). It would also contravene the SDG commitment to leave no one behind. Financial risk protection minimally implies that the poor not be
impoverished by paying for essential health services and that poorer households should not be disproportionately burdened with health expenses as compared to more affluent households. This
requires that essential health services be provided free or at low cost or that poor and disadvantaged
groups receive substantial subsidies (Chapman, 2016, pp. 293–300).
Universal health coverage requires coverage of a minimum package of essential health services for
the primary disease burdens of the local population. It has been suggested that this package should
minimally include treatments for infectious diseases and a subset of non-communicable diseases as
well as traumatic conditions that can be addressed with high effectiveness at low cost (Sachs, 2012,
p. 944). The SDG indicator for the coverage of essential health services is
Coverage of essential health services (defined as the average coverage of essential services based on tracer interventions that include reproductive, maternal, newborn, and child health, infectious diseases, non-communicable diseases, and service capacity and access, among the general and the most disadvantage populations).
However, the role of these tracer indicators is to track universal health service coverage and not to
define service coverage within universal health care (Hogan, Stevens, Hosseinpoor, & Boerma, 2018,
p. e152). Currently there is no accepted methodology to determine the specific content of this package or agreement as to how inclusive it needs to be for universal health coverage to be meaningful.
Moreover, it is more difficult to define which services to treat noncommunicable chronic diseases
should be included in a basic health package available to all people (Perera, 2015).
The achievements of the Sri Lankan health system in approaching universal coverage, and some
would claim achieving it, show the feasibility of the goal for some relatively low-income countries. Sri
Lanka’s per capita income was a modest US$273 in 1980, US$470 in 1990 and US$875 in 2000. Its
per capita income reached US$1,075 in 2004 and then 3,835 in 2016 after a spurt of economic growth
(IndexMundi, 2017 based on World Bank data). However, the unique set of conditions that made the
development of a health system providing close to universal coverage of basic health services possible
likely mean that Sri Lanka’s experience cannot easily be replicated. Moreover, the country’s current
problems with providing widespread access to treatments for noncommunicable diseases suggest
that Sri Lanka’s achievements may not be sustained. The Sri Lankan case therefore raises questions
about what universal health coverage requires in a country undergoing the epidemiological transition from infectious to non-communicable diseases as many countries are currently experiencing
and others are likely to do so in the near future.
Using updated information on developments in the Sri Lankan health system, this article argues,
in contrast with earlier publications, that Sri Lanka is no longer providing good health at a low cost. It
shows that Sri Lanka’s low investment in health is detrimental and not an asset to achieving good
health. Moreover, in a period when the provision of health services for noncommunicable diseases
is important, it suggests it may no longer be possible to provide good health at a low cost. The article
also assesses the relevance of the Sri Lankan experience for other low- and middle-income countries
attempting to progress toward universal health coverage.
This article has four main sections. The first details Sri Lanka’s accomplishments in moving
toward UHC. The second identifies the factors enabling Sri Lanka to do so and the implications
for other countries. The third describes the equity and access challenges the health system confronts
GLOBAL PUBLIC HEALTH
273
despite its ostensibly achieving UHC. The final section assesses what the Sri Lankan experience
suggests about the requirements for UHC when preventing and treating non-communicable diseases
become an important consideration.
Data for this paper were gathered through secondary source analysis of articles and books about
the Sri Lankan health system identified through Google Scholar and RefSeek and in a few cases provided to us by Sri Lankan authors; we also held discussions with a series of health professionals and
health policy analysts in Sri Lanka in 2017, many of whom asked not to be cited by name.
The Sri Lankan health system’s accomplishments
Sri Lanka has achieved near universal health coverage and has done so with remarkably low health
expenditures. The expansion of health care coverage in Sri Lanka, with its pro-poor orientation, dates
from the 1930s. The Sri Lankan health system provides state-funded health care that is free at the
point of delivery to all citizens. The country’s success has resulted in the World Bank citing Sri
Lanka as an example of how a poor country can deliver good health care to its citizens at low
cost (Gottret, Schieber, & Waters, 2008).
Overall national health spending from 1950 to 1990 was 3.0% to 3.6% of GDP, which then was
equivalent to less than US$10 per capita. About half, US$4 to US$6 per capita, was accounted for by
public spending (Rannan-Eliya & Sikurajapathy, 2008, p. 331). As Sri Lanka’s income rose, so did its
health expenditures. Per capita health expenditure in 1999 was US$29 increasing to US$70 in 2008
and then to US$97 in 2014. Slightly less than half of the total was consistently accounted for by public
sector spending with the remainder coming from the private sector (Institute of Health Policy, 2015,
pp. 7–8). In 2014, the most recent year for which data are available, government health expenditure
was 1.62% of GNP and 5.96% of total government expenditure (Department of Health Services cited
in Senanayake, Senanayake, Ranasinghe, & Hewageegana, 2017, p. 44). Private spending is mostly
out-of-pocket spending by households. Health insurance covers only a very small fraction of the
population. Thus Sri Lanka has in the past and is currently spending considerably less than the
5% of GDP health expenditure recommended by many sources including a 2014 Chatham House
report. Government health spending is also well beneath the proposed international standard of
15% of the government budget based on the Abuja Declaration (World Health Organization,
2011). While this modest expenditure may have once been viewed as a positive accomplishment,
the under resourcing of the health system is now very problematic.
Although the public sector in Sri Lanka is widely credited with delivering health care at a low cost
and with high levels of productivity and efficiency (Rannan-Eliya & Sikurajapathy, 2009), no source
seems to be able to explain adequately the basis of this vaunted efficiency. It has been suggested that
strong centralised control of budgets forced health workers to meet increasing demand through
efficiency savings instead of relying on additional resources which would not be forthcoming, but
many other countries have a centralised budget and tight spending controls without it resulting
in significantly greater efficiency. Low administrative overheads likely contributed. The existence
of a strong network of rural hospitals providing primary care facilities may have also been a factor.
A commitment to prioritise access over service quality has had the result of significant overcrowding
and a lower quality of services, but it also has provided health services access to the poor (RannanEliya & Sikurajapathy, 2008, p. 343). Nevertheless, the explanation for the efficiency of the Sri Lankan
health system remains mostly a mystery.
Sri Lanka’s public curative health system is organised into three levels of care depending on the
size and the type of facilities available, namely primary, secondary, and tertiary care institutions. Primary care level institutions include central dispensaries, maternity homes, rural clinics and hospitals,
and divisional hospitals, which offer nonspecialist inpatient and outpatient care, except for the dispensaries, which offer only outpatient care. Secondary care institutions consist of base hospitals, district general hospitals, and provincial hospitals, all of which have general surgical and medical units,
at least one obstetric or gynecology unit, and a pediatric unit. Some of the hospitals also have other
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special units. The teaching hospitals and a few provincial general hospitals that are classified as tertiary care institutions have all the facilities of secondary care institutions as well as other specialty
units, and there are specialised hospitals as for cancer treatment. In 2011 there were a total of
1,067 public hospitals and outpatient facilities and 475 central dispensaries providing various levels
of care (Govindaraj, Navaratne, Cavagnero, & Rao, 2014, pp. 9–10).
Public sector medical care is accessible for most Sri Lankans. With the consolidation of the health
system in the 1960s, physical proximity to basic health services became a reality for most of the
population (Rannan-Eliya & Sikurajapathy, 2009, p. 13). On average Sri Lankans are within
1.4 km of a basic health clinic and 4.8 km from a government-sponsored larger health care facility
(Govindaraj et al., 2014, p. 9). Access is also facilitated by a policy of permitting patients to use any
hospital in the country and the lack of enforcement of a referral system. However, this policy has
meant that patients can bypass primary care facilities in favour of seeking care from the secondary
and tertiary health care facilities. This has resulted in the overcrowding of most of the secondary and
tertiary health care facilities with patients (Senanayake et al., 2017, p. 46).
All government health services, with only a few exceptions, are available free to all citizens, including inpatient, outpatient, and community health services, even antiretrovirals for HIV/AIDS
patients. Public sector health spending is financed from general tax revenues with a small contribution in the form of international development assistance (Rannan-Eliya & Sikurajapathy, 2009,
pp. 9–10). Exceptions to free care include family planning commodities and some medicines. The
government has also developed private paying wards in some government hospitals where facilities
are presumably better or at least more private (Rannan-Eliya & Sikurajapathy, 2009, p. 10). As a consequence of inadequate funding for medicines in the health budget, medicines frequently are not
available in hospital stocks and have to be purchased by patients (Rannan-Eliya & Sikurajapathy,
2008, p. 322). This seems particularly to be the case for many of the treatments needed for noncommunicable diseases.
Sri Lanka’s private health sector consists of a wide gamut of providers from small clinics with a
single or a few general practitioners and small-scale pharmacies to large-scale hospitals and pharmaceutical corporations. The private sector now includes large private hospitals, small outpatient
clinics, laboratories, imaging centres, and pharmacies (de Silva, Ranasinghe, & Abeykoon, 2016,
p. 86). In the absence of widely available health insurance, the private sector is funded primarily
by patient payments for services. The private sector developed after economic liberalisation in
1977 when the government decided that physicians in government service could also consult in private facilities after their working hours. Currently the private sector is still dependent for its staffing
on doctors trained by and working in the public sector. Of the 16,500 medical officers in the public
health sector in 2011, about 4,750 also worked part-time in private hospitals and clinics, ostensibly
during their free time (Govindaraj et al., 2014, p. 17). Private facilities are concentrated in the Western Province and in urban areas (Govindaraj et al., 2014, pp. 10–11). The public sector continues to
dominate the delivery of inpatient care and public health services while the private sector offers outpatient care, the provision of ancillary services, and the supply of pharmaceuticals, medical supplies,
and medical equipment (Govindaraj et al., 2014, p. 26). Patient survey data suggest that the private
sector offers better technology-intensive and costly treatments while for low-cost and routinised procedures the public sector does better (Govindaraj et al., 2014, p. 24).
In contrast with most other low- and lower middle-income countries, Sri Lanka does not suffer
from a shortage of physicians. Primary health care clinics and hospitals, as well as secondary and
tertiary institutions, are staffed by trained physicians. The Colombo Medical School was established
in 1870 and six years later the government instituted a scholarship scheme which underwrote the
cost of training both at the Colombo Medical School and for sending students for post-graduate qualifications in medicine and surgery in the United Kingdom. Uniquely among British colonial medical
services, the Sri Lankan service was staffed and managed predominantly by Sri Lankans from an
early date (Jones & de Silva, 2013, p. 128). The country has had a free educational system since
1945 including public funding for medical degrees. Public medical universities graduate about
GLOBAL PUBLIC HEALTH
275
1,000 physicians each year, the majority of whom are then employed by the Health Ministry and
work in public institutions. Also most of the Sri Lankan doctors who go overseas for postgraduate
specialist training have been returning to practice in Sri Lanka (De Silva et al., 2013) but this may not
continue to be the case in the future. Some analysts have speculated that in the near future there may
even be a surplus of doctors (De Silva, Perera, Gunatunge, & Tantrigoda, 2008).
While an overall physician shortage is not an issue, doctors are not evenly distributed across the
country, and there is a lack of availability of some needed fields of specialisation. Recent medical
school graduates are required to accept postings to rural areas for a period of four years. But afterwards they are free to relocate, and many physicians prefer to practice in the Colombo district. This
has resulted in crowded hospitals and clinics and long waiting lists for surgeries and treatments in
many other parts of the country. Estimates are that the doctor-population ratio in the Colombo district is over 2.5/1,000, which is higher than the ratio in Singapore, while in the Nuwara Eliya district it
was 0.37/1,000 population in 2015 (Academic Circle on HRH, 2017).
Sri Lanka’s health demographics are quite impressive. Life expectancy is 78 years for women and
72 years for men. Maternal mortality, which was 555 per 100,000 live births at independence, has
fallen to 29 per 100,000 live births. In 2013 the total fertility rate was 2.3 children per woman resulting in a low rate of population growth. There is near universal skilled attendance at birth. According
to government data, there is a 99% coverage rate for basic immunizations. Most of the population
has access to safe drinking water and to improved sanitation. Malaria, once a significant cause of
morbidity and mortality, has nearly been eradicated on the island. These accomplishments have
been achieved with a low rate of investment in health. According to government statistics, less
than six percent of the total budget is being invested in health (Medical Statistics Unit, 2017). In
view of the important role that education plays as a social determinant of health, it is also noteworthy
that there is also almost universal primary school enrolment and secondary school participation rates
were also quite high: 91% for females and 86% for males in 2012 ((UNICEF, 2013).
Factors enabling Sri Lanka to progress toward UHC
Key factors contributing to Sri Lanka’s success in expanding health access include the following: the
early development of social services infrastructure including the health and education systems; the
availability of a sufficient tax base to finance health services during the colonial period; the introduction of a competitive democratic electoral process at an early point in time; a shared belief that access
to health services is a citizen right; and an efficient public health sector that is reputed to have facilitated productivity increases that enabled the health system to expand at a low cost. These factors,
which are discussed below, would make the Sri Lankan experience difficult for other countries to
replicate.
In contrast with most other lower income countries, the social service infrastructure in Sri Lanka,
including the foundation for a network of rural clinics and hospitals, was established well before
World War II. The initial expansion of government health services to rural areas took place between
1931 and 1940. Key features of the current system, including an emphasis on primary care and a propoor orientation, were in place by 1959 (Rannan-Eliya & Sikurajapathy, 2009, p. 23). Similarly, Sri
Lanka instituted a policy of free education in 1947; achieved universal primary education by 1964;
and has maintained gender parity in educational access (Liyange & Kamala, 2013). The education of
girls and women has contributed to the commitment to take advantage of the available health
services.
State responsibility for and financing of the health system resulted from several factors. As early as
1832 the Colebrook Cameron Commission sent by the British government to investigate its colonial
government in Ceylon (now Sri Lanka) recommended reforms that resulted in more civil service
positions being opened to the Ceylonese and the establishment of a legislative Council with some
native Ceylonese members (Editors of Encyclopedia Britannica, n.d.). The availability of a tax
base through the imposition of export taxes on tea, rubber, and coconut from the plantation
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A. R. CHAPMAN AND S. D. DHARMARATNE
economy that developed during the British occupation of Sri Lanka provided the authorities with a
ready source of revenue. In the absence of internal or external threats the colonial authorities did not
need to maintain a large military force and instead invested tax revenues to building physical and
social infrastructure, initially to serve the plantation sector and then to other areas of the country
as well. When an unprecedented health crisis, the Ceylon malaria epidemic, took place in 1934–
1935 and resulted in the deaths of a significant fraction of the population and the impoverishment
of many rural households an official government inquiry concluded that direct state intervention was
needed to help affected population survive such events through the provision of hospitals to treat the
sick. The influential 1947 Commission on Social Services explicitly recognised that direct public provision of hospital services was an important form of social insurance (Rannan-Eliya & Sikurajapathy,
2009, pp. 24–25).
Democratic reforms are often cited as a key explanation for Sri Lanka’s health system achievement. The British granted Sri Lankans self-rule under a representative government in 1928. Sri
Lanka has had a democratically elected government since 1931. Until the late 1940s political
party organisation was weak and candidates for elections competed on the basis of their ability to
bring their constituents benefits such as hospitals, schools, and roads. The government responded
to electoral pressure by expanding the rural network of medical facilities throughout Sri Lanka
and most notably in previously underserved districts. By 1945 the health ministry was operating
more than a thousand hospitals and dispensaries for a population which was then only 7 million
people (Rannan-Eliya & Sikurajapathy, 2009, p. 12, 25). Electoral competition with health provision
a popular issue has encouraged a bipartisan consensus on major policy features such as an emphasis
on universal access, lack of user fees, and continuing public sector predominance (Rannan-Eliya &
Sikurajapathy, 2009, p. 6).
That access to health care is treated as a fundamental social right is another factor underpinning
Sri Lanka’s health system achievements. Although there is no constitutional guarantee providing
health care, or any other social right for that matter (Constitution of the Democratic Socialist Republic of Sri Lanka, 2015), there is a close connection between citizenship and a basket of political and
economic and social entitlements that the government is expected to respect and implement (Rannan-Eliya & Sikurajapathy, 2009, p. 13). The link with citizenship has had both positive and negative
implications. It has mean that persons considered to be non-citizens, even those groups with a long
history of residence, are excluded. On the eve of independence most Tamils of Indian origin working
on the tea plantations were deprived of Sri Lankan citizenship even though many of them were descendants of people who had been brought from India more than a century before, and the government left responsibility for their social service provision to the private plantation companies. The
private companies did not provide comparable health services as those in the public sector and
the health status of those workers suffered. In 2003 the Sri Lankan Parliament passed the Grant
of Citizenship to Persons of Indian Origin Act that extended citizenship to all stateless persons of
Indian origin who had lived in Sri Lanka since 1964 (Wijetunga, 2004), and the government funded
health system was then extended into the plantation areas.
Sri Lanka’s healthcare challenges
The success of Sri Lanka’s health system has been linked with its effective public delivery system that
has provided both preventive and curative care at low cost to the country and free to patients at the
point of care. This achievement is now being undermined by the government’s chronic underfunding of the health system, the public health sector’s inadequate response to the epidemiological transition from infectious to non-communicable diseases (NCDs), and the increasing reliance on a
largely unregulated private health sector.
Achieving and maintaining UHC requires a sufficient governmental investment in the health system. As noted, Sri Lanka has a history of low expenditures on healthcare, and at this point in time
chronic government underfunding has exacted a serious toll on the health system. The government’s
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277
limited allocation for healthcare, approximately 1.7–2.0% of GDP, results in government clinics and
hospitals having a shortage of medicines and other resources needed for patient care. It also contributes to limited access to specialist treatment and overcrowding in health facilities (Kumara & Samaratunge, 2016). As recently as 2005 government spending on health was only equivalent to US$23 per
capita and total health spending, including about half by the private sector, was US$50 per capita
(Rannan-Eliya & Sikurajapathy, 2009, p. 7). Total health spending currently amounts to approximately US$97 per person with more than half, 57%, accounted for by private sector expenditures,
much of it in the form of out-of-pocket payments at the point of service delivery (Institute for Health
Policy, 2015, p. 7). This means that the government is only investing about US$47 per capita in
health services, a figure which is quite low even for lower middle-income countries. The share of
public expenditure on inpatient care declined steadily between 1990 and 2009 from 84% to 77%
while public expenditure on ancillary services and medical goods dispensed to outpatients was virtually halved during this period (Govindaraj et al., 2014, p. 26). The decrease in public outlays has
meant that many patients have to turn to the private sector for diagnostic services and medicines.
Because few people have medical insurance most patients pay out-of-pocket for drugs and services
or if they lack the resources have to forgo their use (Govindaraj et al., 2014, p. 26).
Although the government in principle provides universal basic care, it affords limited access to
specialist treatment. The availability of complex surgical procedures and specialist care in the public
sector is primarily limited to Colombo and a few other large hospitals in major cities with long waiting lists. Therefore many people have turned to the private sector for specialist treatment.
Like many other countries, Sri Lanka is experiencing a demographic transition as the population
ages along with an epidemiological transition from communicable to non-communicable diseases
(NCDs). The demographic transition has resulted both from a decline in fertility levels and a longer
life expectancy. Fertility rates began to drop a half century ago and the total fertility rate fell near or
below replacement levels by 1993 (De Silva, 1994). As a result the number of children being born is
falling and the number of elderly increasing. Despite having one of the fastest-ageing populations in
the world, Sri Lanka does not have a sufficient number of geriatric specialists to care for this population of older patients. Nor does it have government provided social services support for them
(Samaraweera & Maduwage, 2016).
Linked with this demographic transition, mortality from infectious diseases is declining while Sri
Lanka faces growing epidemics of diabetes, ischemic heart disease, cancer, asthma, and kidney disease
(Rannan-Eliya & Sikurajapathy, 2009, p. 4). Noncommunicable diseases (NCDs) account for about
70% of deaths (Weerasinghe, Weliange, Basnayake, Bopage, & Karunathilake, n.d., p. 6). Cardiovascular heart disease is now the leading cause of death, and the prevalence of pre-diabetes and diabetes
has been estimated to be one in five adults (Jones & de Silva, 2013, p. 133). The increase in the burden
of NCDs reflects a number of factors: the aging of the population; a rise in obesity; higher rates of
smoking and drinking; and changing lifestyles with the population becoming more sedentary.
A problematic rise in chronic kidney disease, particularly in some rural areas, most likely has
resulted from increased exposure to pesticides used on agricultural products like glyphosate (Van
Der Hoek, Konradsen, Athurkorala, & Wanigadewa, 1998). Several of the pesticides being used in
Sri Lanka are organo-phosphates and herbicides classified by WHO as extremely hazardous, highly
hazardous, or moderately hazardous. Moreover, although farmers are generally aware of the standard safety precautions to prevent exposure during spraying, few of these preventive measures,
like wearing protective clothing and masks, are practiced because it is uncomfortable to do so in
Sri Lanka’s low lands’ hot and humid climate (Van Der Hoek et al., 1998). Although the use of glyphosate was banned in 2015, its use in plantations is still allowed (Civil Society Shadow Report, 2017,
pp. 45–46).
Like many other lower-income countries that face a rapid shift in the noncommunicable disease
burden, the health system in Sri Lanka is poorly prepared to do so. The health system in Sri Lanka
was set up for dealing with relatively short-term infectious diseases and maternal and child care. In
contrast, treatment for non-communicable diseases often has a long-term duration. Also many of the
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A. R. CHAPMAN AND S. D. DHARMARATNE
medications, tests, and treatments for non-communicable diseases are more expensive than the
medications for infectious diseases and they must be taken on a prolonged basis. There is ,a need
for more investment in equipment, drugs, and laboratory facilities to be able to treat NCDs in the
public sector.
Currently the burden of caring for patients with NCDs is being left primarily to the private health
sector (interviews with health policy specialists 2017). This means that the cost of the necessary outpatient care, drugs, investigations, and interventions is being borne by households, even in the rural
areas and among the poor. The increasing burden and expense of NCDs risk exacerbating inequalities in health care access. To provide an example, the annual cost of hemodialysis in Sri Lanka for a
patient with chronic renal failure undergoing two to three dialysis sessions of four hours duration per
week was US$5,869 to $8,804 in 2011, substantially more than Sri Lanka’s per capita income (Ranasinghe, Perera, Makarim, Wijesinghe, & Wanigasuriya, 2011). Additionally, the majority of such
patients are lower income farm workers. Thus families are often unable to pay for the high cost
of renal dialysis treatments (Elledge et al., 2014). The dilemma is that the government’s low investment in health does not provide sufficient resources.
To date the primary government response to NCDs has been to establish model Healthy Lifestyle
Centres in a few districts with a plan to increase the number of districts covered gradually. The primary role of the Healthy Lifestyle Centres is to screen healthy adults for the risk factors of NCDs and
to offer advice on adopting healthy lifestyles to prevent NCDs, but not to treat patients. There have
been problems with this initiative including underutilisation of these services by the target population, particularly men; weaknesses in the services provided; the lack of a registration follow-up system to track clients after their initial screening; and the absence of grass-roots level fieldworkers
dedicated to NCD-related work (Mallawaarachchi, Wickremasinghe, Somatunga, Siriwardena, &
Gunawardena, 2016). A recent survey conducted in six districts by a team of researchers from the
Faculty of Medicine at the University of Colombo (Weerasinghe et al., n.d.) found that most centres
did not meet the expected coverage of the target population. It suggested this failure was likely
because screening and treatment were not integrated, and not all clients received all prescribed
screening activities or education on lifestyle modification. Nor was the necessary equipment or a
doctor trained in the healthy lifestyle protocols usually available. Additionally, there were recurrent
shortages of some essential drugs despite the Ministry of Health circular specifying that 16 essential
NCD drugs should be available in all institutions with a one month buffer stock at any given time. As
a consequence many of the patients going to the Healthy Lifestyle Centres incurred substantial outof-pocket expenditure both for drugs and laboratory tests (Weerasinghe et al., n.d.).
The Government has recently formulated a national multi-sectoral action plan for the prevention
and control of NCDs in Sri Lanka from 2016 to 2020 to raise the priority accorded to the prevention
and control of NCDs. The plan includes major targets and goals relating to a reduction in premature
mortality from NCDs through changes in lifestyle, such as a reduction in the use of alcohol and in the
prevalence of tobacco use, as well as an increase in physical activity. It also seeks to raise the percentage of eligible people receiving drug therapy and counselling and to provide a major improvement
in the availability of affordable basic technologies and essential medicines required to treat NCDs in
both public and private facilities. The plan also includes initiatives to improve the Healthy Life
Centres programme (Ministry of Health, Nutrition and Indigenous Medicine, 2016). While this
plan offers hope for the future it will not be possible to implement such a far reaching initiative without the investment of substantial funds well beyond the current investment in the health sector and
the development of a trained cadre of grass-roots-level field workers dedicated to NCD work. There
is no indication at present that the needed funds or the provision of trained workers will be
forthcoming.
As noted, increasing private involvement in the country’s healthcare sector began in the late 1970s
when government-educated and employed doctors were also permitted to consult privately during
their free time. During the past two decades the private sector has grown, with expansions in hospitals, laboratories, and clinics. Over 100 private hospitals opened between 1990 and 2013. Private
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facilities are disproportionately located in the Western Province in urban or semi-urban areas with
higher income levels (SL Needs improved health financing system, 2015).
While some doctors confine their private practice to after-hours, others apparently curtail their
time at their public duties so that they can leave much earlier in the day. It is half jokingly said in
Sri Lanka not to get sick in the afternoon and seek care from a government facility. Some doctors
also encourage patients who initially see them in public facilities to come to their private clinics
for additional care where they can charge fees and dispense medications not available in the public
sector.
The government does not have a policy framework for the role of private providers in the health
system or regulations for private medical institutions. Other than requiring private medical facilities
to register the government does not impose regulations on them. While the larger private institutions
apparently do comply with the registration/accreditation requirements, a large number of standalone medical testing laboratories, pharmacies, and consulting centre have not been registered
(Govindaraj et al., 2014, p. 7).
Both ‘push’ and ‘pull’ factors incline patients, even those who are poor, to opt for treatment in
private facilities. Long outpatient waiting times, drug shortages, and lack of laboratory and scanning
facilities have been identified as factors pushing households to utilise private care (de Silva et al.,
2016, p. 86). The pull of private care reflects its availability outside normal working hours so that
patients and care-givers do not have to experience a loss of earnings. The desire for more modern
and high quality health care and to be treated by a health care provider of ones choosing constitute
other pull factors (de Silva et al., 2016, p. 86).
Some health care analysts suggest that what Sri Lanka does in effect is to guarantee its poor access
to free health services, particularly basic health care, and then relies on differentials in consumer
quality and convenience to persuade more affluent patients to opt to use and pay for private delivery
(Rannan-Eliya & Sikurajapathy, 2008, p. 320). However, statistics show that this characterisation, if it
ever did, no longer applies. It is not only the more affluent patients who are utilising and relying upon
private health services. On average more than 60% of Sri Lankan households incur out-of-pocket
costs for health care services (de Silva et al., 2016, p. 86). The number of elderly members and
pre-school children in a household and not family income constitute the main predictor of the probability and financial burden of encountering out-of-pocket healthcare expenditures (Kumara &
Samaratunge, 2016). Less than 40% of patients in the lowest income quintile rely entirely on government health services for their care, and only one-third of patients in the next lowest quintile do so (de
Silva et al., 2016, p. 86).
Problematically, government policies have also led to the emergence of what has been termed a
third tier (de Silva et al., 2016, p. 86). The third tier has been defined as payment to a private party for
obtaining goods or services that are supposed to be available free from state sector services. This
includes payments for medicines or laboratory services that should be covered as part of the service
package that is to be provided free at the point of delivery. As noted, many of the doctors trained by
and employed by the public sector also have private practices and may encourage patients to see
them in their private clinics rather than in public hospitals. Also government underfunding has
resulted in shortages of medicines. When needed medicines are not available from public sector
institutions patients have to purchase them. This may impose considerable costs, especially for
poor households, and may also lead to poor compliance. The second type of third tier expenditure
costs are for goods and services needed to complement government funded services. Examples in this
category include purchase of lenses for cataract surgery, pins for bone-fracture repair, and coronary
stents (de Silva et al., 2016, p. 86). While this tier is still small in economic terms it is growing and
counter to the objectives of universal health coverage.
According to a recent assessment, ‘Progress towards universal health coverage requires health systems that maximise health outcomes, and equitably and progressively distribute good quality, financially and geographically accessible services that are delivered efficiently, with low levels of out-ofpocket expenditure’ (Morgan, Ensor, & Waters, 2016, p. 610). Sri Lanka has regressed on achieving
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these goals. It is now questionable whether Sri Lanka continues to provide good health care at a low
cost. On the good health care side of the equation, there are significant income-related differentials in
access to good quality health care. The poor, particularly in rural areas, suffer from limitations in the
availability of curative care, essential drugs, specialty treatment, and health care services for noncommunicable diseases in the public sector. The strategy of by default relying on the private sector for
much of outpatient services, particularly for noncommunicable diseases, places an unsustainable
financial burden on the majority of Sri Lankans who cannot afford the laboratory tests, medications,
surgeries, and nursing care available in private sector facilities. On the second part of the equation, at
this point in time the limited government investment in the health care sector is more of a detriment
than an asset. Moreover it may not be possible for Sri Lanka or other countries for that matter to
adequately provide health services that include for NCDs at a low cost.
Reflections
Sri Lanka’s early progress toward achieving universal health coverage was the product of a series of
factors that would be difficult, if not impossible, for other low- and middle-income countries to replicate. These include an early tradition of representative government committed to providing social
and health services; the establishment of an extensive network of small rural and urban clinics
and hospitals providing free and accessible health care beginning in the 1930s; a sense of universal
entitlement to health care respected by successive governments, and the availability of revenues from
export crops to initially finance health services. Nevertheless the Sri Lankan experience does provide
some important insights applicable to other countries seeking to progress toward universal health
coverage. The Sri Lankan health system provides further evidence for something that has been
known at least from 1978 at the conference that issued the Declaration of Alma-Ata and more
recently reiterated by WHO (2008a), the importance of pro-poor comprehensive primary care as
the foundation for health for all (Declaration of Alma-Ata, 1978). The Sri Lankan success also attests
to the importance of making health services free at the point of service or at least low cost so that no
one is denied access to high-priority services because he or she is too poor to be able to pay for them.
Again, this is something that many studies have shown and was recently advocated for by the WHO
Consultative Group on Equity and Universal Coverage (2014).
Unfortunately, Sri Lanka’s record of providing near universal health care is now being undermined by the government’s insufficient health expenditure, its over-reliance on the private sector,
and its failure, at least up to now, to respond satisfactorily to the emerging epidemics of NCDs.
These three trends are common to many other low- and middle- income countries as well. Whether
the recently formulated multisectoral action plan for the prevention and control of NCDs in Sri
Lanka will be implemented, whether it will be allotted a sufficient investment of funds for its ambitious programme, and whether it will offer a blueprint to turn around the Sri Lankan health system
remain to be seen.
The Sri Lankan experience underscores the importance of devoting more attention to NCDs in
the thinking about the requirements of universal health care and the planning process for moving
toward this goal. Compared with communicable diseases, NCDs have emerged on the global health
agenda more recently and with a lesser sense of urgency. This is problematic because NCDs, mainly
cardiovascular diseases, cancers, chronic respiratory disease, and diabetes, are responsible for an estimated 35 million deaths each year, some 60% of all deaths globally with 80% of deaths from NCDs
taking place in low- and middle-income countries (World Health Organization, 2008b). Also studies
show that low and lower-middle income nations are likely to see dramatic increases in the burden of
premature death and disability from NCDs by 2040. Moreover, as a recent paper points out, the
lower-income countries that face the most rapid shift in the NCD burden tend to be the least prepared. Like Sri Lanka these countries are projected to have the smallest increases in health expenditures in response to the NCD burden and like Sri Lanka they currently lack health system capacity for
dealing with NCDs (Bollyky, Templin, Cohen, & Dieleman, 2017). Additionally, the SDGs
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conceptualise universal health coverage as requiring financial risk protection, and the poor are particularly vulnerable to catastrophic and impoverishing health expenditures as the incidence of NCDs
rises unless they are protected from paying for the cost of needed drugs and services. Therefore the
design of a minimum package of health services for achieving universal health coverage should
include the services and medications needed for the most prevalent NCDs at a subsidised cost.
Like Sri Lanka, many other low- and middle- income countries underfund health services and
financial constraints frequently constitute a barrier to making progress toward universal coverage
or, as in the case of Sri Lanka, maintaining progress. One reason is that in many of these countries
health is considered to be a low priority sector (Chapman, 2016, p. 300). To have sufficient resources
for health investments these countries both need to raise more money domestically through increasing the efficiency of revenue collection and to reprioritize government budgets. Having more
resources to devote to health, and most specifically for NCDs, is an important a requirement for
Sri Lanka as well.
In the absence of sufficient governmental resources for needed health investments, many other
countries besides Sri Lanka have looked to the private sector, but there are often significant problems
in doing so. To make progress towards universal health coverage requires good quality, affordable
health care be widely available in all areas of a country. There is not sufficient space here to discuss
this issue, but it is important to note that private health providers are usually not well situated or
inclined to provide health services to poor communities and neglected areas at a low cost because
it is not profitable to do so. Nor are most governments in low- or middle-income countries well positioned to manage or regulate the private health sector. Reliance on the private sector has frequently
inhibited the extension of health services to the most disadvantaged communities and also made
many services available only through the payment of expensive out-of-pocket fees at the point of
service (Chapman, 2016, pp. 306–307). This indicates that the public health sector will need to
play a major role in providing or at least subsidising the cost for NCDs. The failure to do so will
be detrimental to the health of their populations and to the goal of achieving meaningful universal
health coverage.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This work was supported by Human Rights Institute, University of Connecticut and Healey Chair, University of Connecticut School of Medicine.
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