Sri Lanka has achieved strong health outcomes over and above what is commensurate with its income level. The country has made significant gains in essential health indicators, witnessed a steady increase in life expectancy among its people, and eliminated malaria, filariasis, polio and neonatal tetanus. The Sri Lanka HiT review presents a comprehensive overview of the different aspects of the country’s health system, and the background and context within which the health system is situated. The review also presents information on reforms to address emerging health needs such as the growing challenge of noncommunicable diseases (NCDs) and serving a rapidly ageing population

1. Sri Lanka Health System
Review
Health Systems in Transition

2. 2
Sri Lanka Health System Review
Authors:
Edited by:
Viroj Tangcharoensathien
Walaiporn Patcharanarumol
Haruka Sakamoto
Lalini Rajapaksa Usha Perera
Padmal De Silva Yasoma Weerasekara
Palitha Abeykoon Anuji Gamage
Lakshmi Somatunga Nalinda Wellappuli
Sridharan Sathasivam Nimali Widanapathirana
Susie Perera Rangika Fernando
Eshani Fernando Chatura Wijesundara
Dileep De Silva Ruwanika Seneviratne
Ashok Perera Kusal Weerasinghe

3. 1. Sri Lanka socio-demographic profile and
context
2. Overview of the health system
3. Organization and governance
4. Health financing
5. Physical and human resources
6. Provision of services
7. Principal health reforms
8. Assessment of the health system
9. Conclusion
3
Presentation outline
This map is an approximation of actual country borders
Source: United Nations Cartographic Section, 2008

4. Chapter 1: Introduction

5. 5
Socio-demographic profile
Area An island country spread over
65 625 sq.km
Administrative 9 provinces  25 districts  330
divisional secretary  14 022
grama niladhari divisions
Population • 21.7 Million (2020)
• 81.5% Rural population
• 52% female
• 10.8% above 65 years (2019)
• 2 TFR (2017)
Life expectancy at
birth m/f
75.3 (2016)
Female 78.4 | Male 71.7 (2016)
GDP per capita 4102.5 (current US$)
HDI 76 (2017)
Expenditure on
health % GDP
4.3% (2016)
Age distribution of the Sri Lankan population, 2019
Source: Sri Lanka Health System Review

6. 6
Tax-based heath financing system, Universal health coverage
Pluralistic and mixed Health System
1.1. Ministry of Health provides overall stewardship and monitoring of
government health services throughout the country
2.2. Led by the Ministry of Health: Provincial Ministries of Health have
autonomy to formulate own statutes within the context of broader,
national health policies
3.3. Allopathic (western) medicine & traditional indigenous systems of
medicine
4.4. Health services largely provided by the public sector: 95% inpatient
care & 50% ambulatory care
5.5. Private sector mainly provides ambulatory care, limited inpatient
care and rehabilitative care of varying degrees of sophistication
Sri Lanka – An overview of the health system

7. Chapter 2: Organization and governance

8. 8
Source: Management Development and Planning Unit- Ministry of
Health
Organizational chart of the Ministry of Health, Nutrition and Indigenous Medicine

9. 9
• MoH: Stewardship and monitoring of government
health services
• Director-General of Health Services (DGHS) technical head
• Vertical programmes & technical units and campaign
Central: Ministry of Health
• Implementation of services: preventive and curative
Local: Provincial Ministry of Health (PMoH)
Governance and Administration
Private sector:
• Focus on ambulatory care
• Specialist and outpatient/inpatient care
• Financed through OOP

10. 10
Governance and Administration
Planning and development of the MoH coordinated by the Management
Development and Planning Unit (MDPU)
Network of health institutions: patients have the freedom to chose between
government and private facilities:
Government sector: 90% inpatient visits & ~45% of outpatient visits
Private sector: 50% of outpatient visits (4% inpatient)
Primary level: curative outpatient services
Base hospitals: more specialized services
Essential Service Package: outlines promotive, preventive, curative and
rehabilitative facilities which the government will commit to provide to
citizens.
Health information management

11. Governance and Administration
HIS comprises of inputs from the state health service & other government sources:
Curative/hospital information, preventative health information systems,
administrative and operation information, population census, civil registration,
vital statistics, population-based health and other surveys (demographic and
health survey), STEPwise approach to surveillance (STEPS), and Household
Income and Expenditure Survey (HIES)
Regulation and governance of providers
Medical Service Minute of Sri Lanka: Published 1991, amended 2001 & 2014
Ceylon Medical Council (CMC) established by the Medical Council Ordinance No.
24 of 1924
Nursing Council established under the Sri Lanka Nurses Council Act No. 19 of
1988
Public Service Commission (PSC) was established under the Ceylon (Constitution)
Order in Council dated 15 May 1946
11

12. Governance and Administration
Regulation and governance of pharmaceuticals and medical devices: National
Medicinal Drug Policy (2017). Implemented by National Medicinal Regulatory
Authority (2015).
Patient empowerment; focus on people centred care; proximity of health
facilities to households found to be at satisfactory levels
Sri Lanka National Action Plan for the protection and promotion of Human
Rights (2011–2016). Two goals under health:
oawareness of rights
orespect for patients’ rights
Patient and public involvement and engagement (PPIE) in public health-care
service provision and research: for public accountability, community
participation for implementation of programs
Other:
oOrganization of Professional Associations of Sri Lanka
(OPA) informal group
oPeoples Movement for Rights of Patients (PMRP)
12

13. Chapter 3: Health financing

14. Health financing
14
Funding for health services at the provincial level via the line ministry, health-
specific grants and loans.
Finance Commission disburses funds to the provinces as different types of
grant allocation – role is to: assess needs, apportion grants
Centre: manages procurement of medicines and lab products
Coverage: Universal
 No specific social health insurance.
oAgrahara scheme government for sector employees
oSuraksha: for schoolchildren between the ages of 5-19 years
Voluntary private medical insurance schemes (small, and largely
supplementary/complementary in nature particularly for high-income
groups)
Separate health services for the defence ministry and police departments

15. Health financing
15
Sources of financing:
oGovernment tax revenue
oPrivate spending on health
oExternal financing for health (low)
Current Health Expenditure
oTraditional medicines: separate
government
allocation (less than 1% CHE)
o72% of CHE on curative care
o3% allocated for preventive
services
Source: Ministry of Health, Nutrition and Indigenous Medicine
Source: Ministry of Health, Nutrition and Indigenous Medicine

16. Chapter 4: Physical and human resources

17. Physical resources
Tiered curative care
Total beds (public, curative care) 83,275
Low ALOS – decreasing over time across
tiers from 2004 to 2017
ICU bed availability: 3.8 beds per 100 000
population
17
PMCU: Primary medical care unit
Source: Ministry of Health, Nutrition and Indigenous Medicine
Availability of medical equipment:
 30% facilities equipped with all tracer items at the national level
 Nebulizers in almost all facilities
 More emergency equipment available at tertiary and secondary levels
 High availability of equipment for radiological investigations

18. Physical resources
GSRI: General Service Readiness Index higher in public facilities than private
at tertiary- & secondary-care levels; private sector higher GSRI at the
primary level: public health system responsive to complex & acute care
18
Source: Ministry of Health, Nutrition and Indigenous Medicine
Source: OECD/WHO, 2016

19. Human resources
Nearly 140 000 people employed by the MoH
58% skilled personnel (core HRH: medical officers – specialist and grade
medical officers, nurses, midwives, public health inspectors, dental surgeons,
medical laboratory technologists and pharmacists)
19
Source: based on Annual Health Statistics 2010-2017
Sources: Annual health bulletins 2008-2017; Annual Health
Statistics 2017

20. Human resources
Increase in the number of health workers:
2.2 health workers per 1000 population (2005)  3.7 in 2015
Sri Lanka has almost reached the WHO-identified minimum density threshold of
34.5 skilled health personnel per 10 000
Separate public health cadre – provide clinical care at the field level, and
household visits, plus communicable disease control.
Dual practice is legal
20
Source: Annual health bulletins, 2008-2017 Source: Annual health bulletins, 2008-2017

21. Information technology
23 health information systems – across
directorates and institutions
IT in health systems used for electronic
health records, patient management
(appointments, admissions etc.),
laboratory information systems,
notification of communicable diseases
Way forward
oNeed for better integration
oclear policies guiding health information
management
21

22. Chapter 5: Provision of services

23. Provision of services
The health system provides preventive and curative services
Indigenous medicines are included under the MoH in 2015
No gatekeeping within the health system: curative care accessible across tiers
Public health: structure laid in 1926
oElimination of diseases such as filariasis, leprosy, polio, malaria and neonatal
tetanus, and achieved near-elimination of other VPDs
oPreventive care, including national programmes: 354 medical officers of health.
MOH Unit comprises of: Medical officer, comprises public health nursing sisters
(PHNSs), supervising public health midwives (SPHMs), PHMs, supervising public
health inspectors (SPHIs) and PHIs
oNational programmes supported by technical inputs at the provincial and
national levels
oEpidemiology Unit established in 1959
23

24. Curative care
oInpatient and outpatient care: primary,
secondary and tertiary by the public and private
sectors
oDay-care services across hospitals
oFree at government facilities: 95% inpatient care
& 50% ambulatory care
oDistribution of facilities: nearly one within an
average distance of 4.8km
oInpatient care: bed strength high at 4 per 1000
population
Prevention and control of NCDs under the National Health Policy 1992 & Health
Master Plans 2007-2016 & 2016-2025
NCD Disease unit: Guided by the National Policy on Prevention and Control of
Chronic NCD. Objective to prevent and control NCDs. Reduce premature
mortality by 2% annually over 10 years
24
Source: By authors
Provision of services

25. Provision of services
Private health services
General practitioners and private health institutions providing primary to tertiary
care in the private sector
A separate directorate has been established within the MoH to coordinate private
health-care services
Regulated under the Private Medical Institutions Regulatory Act (PMIRA)
Complementary and alternative medicine, including traditional medicine
Ayurveda, Siddha, Unani and Deshiya Chikitsa (local indigenous medical practices)
Ayurveda Act (1961): regulates TM services. Department of Ayurveda, Ayurveda
Medical Council, Ayurveda College and Hospital Board, and the Ayurveda Research
Committee established under the act
708 Ayurvedic hospitals and dispensaries located island wide
Hospitals provide OPD and inpatient care
Ambulatory care
Most facilities offer ambulatory/primary care services.
No gatekeeping – people can access services at whichever level
Need for changes to address the increase in the elderly population and NCDs
25

26. Provision of services
Care for the elderly
 Initiatives to respond to the social and medical needs of an ageing population.
 The Protection of Elders Act (2000): National Council for Elders, in the Ministry of Social
Empowerment, Welfare and Kandyan Heritage
 home-care services, provision of assistive devices, financial assistance for those in
need, free legal advice services
Palliative care: Essential component of comprehensive care in the
 National Health Policy (2016–2025), 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)
Regulation and monitoring of pharmaceuticals
 Quality under the National Medicines Quality Assurance Laboratory (NMQAL)
 National Medicines Regulatory Authority on availability, safety, quality and efficacy
26

27. Provision of services
National Mental Health Programme: led by the Directorate of Mental Health.
Services provided by a multidisciplinary team
Dental care: Under the Deputy Director-General (Dental Services). Regional
dental surgeons, consultants, dental surgeons and dental therapists of the
department.
Health services for specific populations: Aimed to provide health care for
specific populations such as those working on plantations, internally displaced
populations, refugees etc.
Challenges/way forward
oSystem needs to be more responsive to the demographic and epidemiological
transition
oOutpatient/ambulatory care usually during working hours – challenges for
working population, especially men to access services
oNeed for formal mechanisms to support people who provide long-term care for
family members
27

28. Chapter 6: Principal health reforms

29. Principal health reforms: Major health-
care reforms and policy measures
*Government health professionals are allowed to engage in private practice during off hours
Source: Compiled by the authors

30. Principal health reforms
• Health Services Act of 1952: basis for the first health form and reorganization
of services
• Older reforms: establishment of the health unit system, decentralization of
administration to provinces and Dual Practice Act of 1977 remain relevant
• Some more recent reforms
oNational Authority on Tobacco and Alcohol (NATA)
oNational Policy and Strategic Framework for Prevention and Control of
Chronic Non-communicable Diseases
oNational Migration Health Policy; National Medicines Regulatory Authority
(NMRA)
oNational Policy on Health Information
oPolicy on Health Service delivery for UHC
oNational Policy and Strategic Framework for Prevention and Control of
Chronic Non-Communicable Diseases

31. Principal health reforms
• Focus on PHC in the health service delivery reforms for UHC
• Challenges
o Need to strengthen capacity of personnel to meet goals outlined under
the reforms
o Need for strong political leadership
o Strong influence of tobacco and alcohol industries  need for further
policy advocacy and awareness, and engagement with civil society
organizations

32. Principal health reforms
• National Policy and Strategic Framework for Prevention and Control of Chronic
Non-Communicable Diseases: CVD, DM, chronic respiratory diseases and
chronic renal disease
• National Migration Health Policy: Prevention of eliminated pathogens from re-
entering the country: screening and treatment & Access to health services for
inbound and internal migrants
• National Medicinal Drug Policy & National Medicines Regulatory Authority:
o Country-specific drug policies from the 1950s.
o NMDP (2005): essential medicines, affordability & equitable access,
financing, supply systems & donations, regulations & quality assurance,
quality use of medicines, research, human resources, viable local
pharmaceutical industry, and monitoring and evaluation
• Health Information Policy: convert needed health information systems to
electric systems and encourage innovations in HIS
• Central HRH coordination unit: Based on the recommendations of the HRH
Strategic Plan

33. Primary Health Care Reform: 2009-2018
Source: Compiled by Organisation Development Unit, MoHNIM (2018)

34. Chapter 7: Assessment of the health system

35. Assessment of the health system
“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” Indirect statement in Article 27 2 (c)
• Strong preventive health system with strong health outcomes
• Financial protection and equity in financing:
o Total expenditure on health 3.5-4.5% of GDP
o Government financed health system. Free at point of care
o 8-9% GGHE; increasing OOPE (changes in demand for health)
o OOPE largely for private outpatient care, pharmaceuticals
Source: World Health Organization

36. Assessment of the health system
Equity of access to health care
• Availability of free health services
• Preventive health services universally available to all
• Challenges in equitable access to care: estate sector pooper health outcomes
• Working population demonstrate poorer utilization (especially male) and
access to government health services.
• Difficulty in accessing facilities due to working hour timings, terrain
• 82% of public & 80% of pvt facilities had more than 75% essential medicines
available
Source: Central Bank of Sri Lanka

37. Assessment of the health system
Equity in HRH
• Almost all health workers are Sri Lankan nationals and trained in Sri Lanka
• Equitable distribution of health workers across districts with a few exceptions
Health indicators: population health
• Basic health indicators like MMR nearly at part with developed countries
• Rise in NCDs
• Disaster risk management: vulnerable to natural and human induced
disasters. Climate change and extreme weather conditions
Source: Department of Census and Statistics, 2009 and 2017

38. Assessment of the health system
Outcomes and quality of care
• Childhood vaccination coverage: 96% (polio) to 99.2% (BCG)
• Guidelines for A&E services, and
other standard treatment protocols
• Standards for infrastructure, equipment, drugs and HRH exist
Health system efficiency
• Hospital sector (75-85%) and inpatient services: higher share of budget
• Preventive and public health spending ~25%
• Priority-setting not systematic; resource allocation based on historical trends
Source: Owen Smith. Sri Lanka - achieving pro-poor
universal health coverage without health financing
reforms. Washington DC: World Bank
o Health Economics Cell: for evidence on cost–
effectiveness of interventions
o Sri Lanka spends less in terms of CHE per capita
but achieves better health indicators than
some countries with similar income levels
o High utilization rates: inpatient and outpatient
o Low ALOS in hospitals

39. Assessment of the health system
• National Health Performance
Framework: Monitor performance to
the health system
• A tracker to monitor SDG-related
information
• Annual Health Bulletin and National
Health Statistics to monitor other
performance indicators
• Regular performance reviews at national
and subnational levels
• National Health Accounts for health
financing efficacy
• Right to Information Act: enable access
to public information
Source: OECD/WHO, 2016
Source: Owen Smith. Sri Lanka - achieving pro-poor universal
health coverage without health financing reforms. Universal health
coverage study series. Washington DC: World Bank

40. Chapter 8: Conclusions

41. Conclusion
Achievements
• Relatively high level of health on a modest budget, despite being a LMIC
• Increased life expectancy for both sexes. Increase in healthy live expectancy
• MMR declining | elimination of many communicable diseases
• Small catastrophic health expenditure even if OOPE is increasing
• Drivers of change:
o Policies for easy access to medical care, free at point of delivery
o Focus on free health services
o Improved vital registration systems
• Lessons: 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

42. Conclusion
Challenges
• Epidemiological and demographic transition: NCDs, injuries and mental health
remain high risk factors. Ageing population
• Increase in sedentary occupation and lifestyle
• Need to increase spending on health: state investment on health has
remained low
• HRH distribution: especially rural retention is a challenge
Addressing the challenges
• Retain and reorganize government primary curative health-care services
specially to address NCDs and towards UHC
• Focus on patient-centred continuity of care – especially to home or bed bound
people
o Community engagement and empowerment
• HRH analysis and planning

43. Access full publication at: https://bit.ly/SriLankaHiT
THANK YOU
43
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