1
HEALTH SERVICES DELIVERY
1.5
PROGRAMME FOR VULNERABLE POPULATIONS
1.5.1.
Estate Health (as of March 2008)
A
Focal Point
B
Implementing Agencies
C
Target Areas & Beneficiaries
Estate & Urban Health Unit, Ministry of Healthcare &
Nutrition
Ministry of Healthcare & Nutrition, Provincial Health
Ministries of
Central, Uva, Sabaragamuwa,
Southern, Western and North Western Provinces.
Total plantation population residing in tea, rubber &
coconut estates in Central, Uva, Sabaragamuwa,
Southern, Western and North Western provinces.
Project Summary:
The policy of the Government of Sri Lanka / Ministry of Healthcare & Nutrition is that the
health services in the estate sector should be integrated into the National Health System to be
on par with that of other parts of the country.
The project is to improve the accessibility, availability and quality of curative care, preventive
care and other public health services provision of the National Health Delivery System to the
community residing in the estates to be implemented through Provincial Health Authorities.
The populations benefited will not only the larger estates which are managed by private
companies and SSPC & JEDB but of small holdings.
The major output will include improved accessibility, availability and quality of curative,
preventive and other public health services, improved health services utilization, community
participation and research and its application for effective and sustainable service to the
population residing in the plantation estates.
1. Justification
Plantation sector is the single most important contributor to the balance of payments contributes
directly and indirectly to the G.N.P. There are more than 220,000 families with about 930,000
members residing on the plantation within 6 provinces. The sector employs more than 330,000 people
directly. 95% of them are labour force predominantly female workers. Most of the plantation
communities are descendent of migrant from South India over 150 year ago. They were confined
socially and economically to the plantation industry. The estates reminded as enclave with their system
of health provision determined by the planters health scheme, which fulfilled the requirements of the
ordinance which had been enacted in early part of the twentieth century with the service provision of
78 hospitals and 645 dispensaries in the estate sector, subsidized by the state with free drugs. Then
health indicators for the estate population were better than the national average. Later the estate
services were not considered as part of the national system after the disenfranchisement of the estate
community in 1948. The administrative reports of the health department do not contain any reference
to this sector after 1949 although free drug subsidy continued. There had been a progressive run down
of facilities in seventies. Estate hospitals and dispensaries were not maintained, number of qualified
medical personals was reduced and unqualified personals were deployed by the management to treat
the sick estate workers and their families. Plantation wages were also declined in real terms.
The workers families are housed in single room units provided by the management which are in
unsatisfactory condition without ventilation, space, privacy and access to safe drinking water or
water sanitation facilities. Lack of food security, landlessness, geographical isolation from country
main stream and prolonged labour work in unfavourable environment influence their poor nutritional
status and childcare practices & ill health of the families and community as a whole. Hierarchical
system and social class system still existing in the plantation sector limit the development individually
and socially for the development of healthy life style.
The citizenship and right to vote were granted in this community subsequent to the devolution of
political power to the provincial council in 1987, by which the provision of basic healthcare services
to all citizens including the plantation workers is the responsibility of the Ministry of Health and the
Provincial Health Authorities with community participation. The Health status of the plantation
population is below the general population. The morbidity and mortality, specially the maternal and
infant mortality are reported to be higher than the rest of the country due to socio economical inequity
and disparity in service provisions.
The government health services are far and difficult to reach. Estate workers tend to be dependent on
the managers of the company for healthcare due to the patron, client relationship developed in the
colonial period. Healthcare facilities are not available to the non-workers, their families, handicapped
and elders living in the estates. Emergency care needs are high due to injuries and accidents and lack
of MCH care. Care for emergencies tend to be delayed because of lengthy decision making process,
involving family and management. Manager of the company needs to agree as it is an emergency to
arrange transportation to the nearest government health facilities. Family planning services are
inadequate in quality and coverage due to lack of integration of the services into the National Health
System. The most neglected are the people living in small individual estates. They are not provided
with healthcare by the companies, while the government health facilities are far and difficult to reach.
The cost of transport, loss of days earning, language barrier and attitude of staff are the main factor
influencing their poor healthcare seeking behaviour.
The policy decision was taken by the government in 1990 to integrate the estate health services into
the National Health System and to upgrade the health facilities to the estate population under
provincial health authorities to be and par with that to other citizen in the country.
As initial process of taking over the estate health services into the National Health System, 57 AMOO
were trained and appointed to 54 estate health institutions with creation of new cadres for estate
AMOO, under the Ministry of Health and their functions supervised by the Provincial Health
Authorities. New ambulances and medical equipments supplied, building and facilities reconstructed
through donors as well as state funded programmes. 50 PHM were recruited and trained by Ministry
of Health, employed under the estate management and supervised by the MOOH.
Recently additional MOH, PHI & PHM areas were demarcated to include the estate areas and most
essential cadres of MOOH, PHMM, PHII, PHNS and other preventive sector cadres for estate areas
were created under the Provincial Health Ministry. MCH, family planning, school health and other
public health programmes are implemented by the Provincial Health Authorities.
2. Important Assumptions/ Risks/ Conditions
22 estate health institutions out of ear marked 50 institutions for upgrading have been taken over under
provincial health administration from year 1995 to 2004. Some of these institutions are not able to
function to the expected level because the basic facilities are not upgraded yet. There are issues related
to the procedures in handing over and taking over were not satisfactorily followed and funds were
not provided to the Ministry of Health for the upgrading of the facilities. The funds identified in other
ministries for these purposes did not given the expected result. These constrains should be rectified
and the past experienced to be considered when take over the balance 28 ear marked hospitals to the
optimum benefits of the target population.
There are barriers and obstacles to carry out health programme with community participation and
supervision by the provincial health staff. There are shortages of qualified PHMM and PHII and other
PHC staff to work in the language of the population. The PHMM employed by the company
management are not providing healthcare to the non workers families living within the plantation
areas and at the same time the PHMM and other MOH staff employed by Provincial Health
Authorities have difficulties to reach these people and find places to reside and work .
3. Project Objective
Objective
Indicators
To improve the accessibility,
availability and quality of
curative, preventive and other
public health services of the
NHS
to
the
residential
population in the plantation area
on par with that in other area
 % of staff available to
preventive and curative
service provision to the
national norm.
 % upgraded services
 % of health programmes
coverage
 Health status indicators.
Means of Verification






HIS
Review reports of RDHS
Review reports of MOH
Review reports of heads of
upgrading institutions.
Monitoring supervisions.
Reports from community.
4. Project output / Product
Outputs
Indicators
Means of Verification




No of institutions upgraded
Utilization rates of the institution
Availability of proposed staff
Availability of proposed other
infrastructure facilities for patient
care to the planned level
 Essential facilities for the staff.
 % of population covered.



Review reports of RDHS
Review reports of Head
of the upgrading
institution.
Monitoring supervisions.
Developed preventive and
public care services by
improved accessibility
availability and quality on
equitable basis.
 Availability of proposed staff
 % coverage of planned clinics
and programmes to the targeted
population in identified
locations.



Review reports of RDHS
Review reports of MOH
Monitoring supervisions.
Improved
community
participation in healthcare
development.
 % of planned programmes
implemented with community
and families in decision making
process.
 % of health committees in
estates.
 % of hospital development
committees in estates.

Reports of RDHS, MOH
and heads of
institutions.
Reports from community.
Surveys
Improved accessibility
availability and quality of
curative care services.


Improved health seeking
 Hospital utilization rates,
behaviour and utilization
Prevalence of selected health
of health services using
seeking behaviours.
behaviour
change
communication.
Occupational
safety
standards maintained in
field and factory by the
estate management and
workers.
 No of estates and
factories maintained
occupational standards and field
safety measures
 Rate of injuries treated
 hazards reported
Management Information
Number of divisions linked to
System of the Estate sector the Management Information
established.
system


Hospital Statistics
Behavioural surveillance


Returns and records of
MOOH/ hospitals
Workers awareness
surveillance.
Public complains

Records

5. Related Projects:
Project No.
Project Title
All the Primary Health care projects to the population in the country.
6. Relevant Agencies to be Coordinated:
Provincial Health Ministries of Uva, Sabaragamuwa, Western, Southern and North Western
7. Monitoring & Evaluation:
1. Who?
2. When?
Estate & Urban Health Unit, MDPU, PDHS, RDHS, RE, MO/MCH
Monthly, Quarterly, Annually
8. Activities:
1
Activities
Expected Results
Conduct a situation analysis of Base line information
the health services received by of availability of health care
the plantation population.
facilities,
staff
position,
available services and pattern
of use.
Process Indicators
Develop the TOR.
Develop
the
detailed
protocol.
2
Prepare an action plan for the Efficient,
effective
and District group formed,
integration of estate health into sustainable district action
action plan formulated and
district health system.
plan formulated for the approved.
integration of estate health
services.
3
Carryout
advocacy
and Estate
Health
plan Identify target group
awareness on the Estate Health implemented by provincial Develop the programme
integration into district health health authorities.
system.
4
Provide the necessary facilities Hospitals are functioning with Identify requirements for
for the curative care services by proposed staff, facilities and
up grading selected hospitals.
equipments to the planned
level of upgrading. Residential
facilities to the staff repaired/
rented/ new building.
each institutions.
Develop proposals.
Approval from
provincial authorities.
5
Conduct
monthly
medical
clinics and arrange a system by
which outreached services are
provided by qualified MO to
see the problematic patients.
6
Provide oral health care by
Oral health care
establishing outreached dental services established.
services and upgrading existing
clinics.
Identify the locations.
Develop the proposals.
7
Establish an effective referral Effective referral
system between Primary care system established.
institution and other health care
institutions.
Identify areas.
Develop proposals.
Approval from provincial
authorities and Ministry of
Healthcare & Nutrition.
8
Establish additional MOH units
according to the national
standard in order to strengthen
the Primary Health Care
Services.
Identify areas.
Develop proposals.
Approval from
provincial authorities.
9
Develop centers to provide PHC
packages
delivered Develop proposals
antenatal, natal and post natal equitably to the population in Approval from provincial
care in areas that does not have the estates.
authorities.
well established centers
10
In service training to health staff Improved quality of
serving to the plantation service provided to
population.
plantation population.
11
Organization
of
health
committees
and
hospital
development committees in
estate areas.
Strengthen the Monitoring and
evaluation system for estate
health services development in
central and regional level.
12
Specialist services/ outreached Identify locations.
services
Develop proposals.
provided to the estate
population.
Functioning standard Health
Units
established
with
proposed staff, clinic facilities,
vehicle
and
living
accommodation for the staff.
the Situation analysis to
the identify target group and
develop the programme.
Improved
community Functioning
health
awareness and participation.
committees and hospital
development committees in
estate areas.
Strengthen the process of  Develop data
estate
health
service
information system
development.
at MOH, RDHS
and central level.
 Periodic monitoring
supervision