Health for all and all for health
There has not been a single day that passes without an accusation made by the Minister of Health. He blames individuals; he blames officials; he blames trade unions; he blames the industry; he blames anyone and anything connected to health; he laments that he is all alone. Only two persons are spared; himself and the President. The reason is obvious. Media reports and public criticisms concerning the health sector are common and frequent. Accusations, allegations, blames and rivalries have become routine and regular within the health sector. One blames the other and passes the buck. Inter trade union disputes have now turned into intra trade union disputes. The latest is between two factions of the GMOA. Healers seem to be ailing and sick more than the patients.
Since independence the health sector has continuously grown. In addition to colossal public investment, the private sector has stepped in and augmented investment in the health sector. The private sector has added more infrastructure facilities than the public sector in the recent past. Private nursing homes have become private hospitals; single storied buildings have become multi-storey sky scrapers; private channelling and private laboratory services have multiplied. If one becomes nostalgic the famous “Glass House” was an icon in Colombo in the good old days. Glass house has disappeared into thin air and is replaced by a multitude of hospitals. Today one cannot even trace where it was located.
Patients waiting to be treated at a National hospital. File picture
Free universal care
Layers, institutions, specialties, medical personnel and investment in the health sector have increased in many folds. Sri Lanka has achieved a commendable health status measured in terms of traditional health indices. Sri Lanka provides free universal healthcare. Both the Government and private sector have been rapidly building and improving infrastructure, quality of services and human capital base in the healthcare sector. Sri Lanka has a unique healthcare system where one can go directly to the hospital (government or private), to the family GP or directly see a specialist – with no reference.
When we were young we heard of only one Ministry responsible for health. Today, we witness several Ministries responsible for health at the centre flanked by nine Provincial Ministries. One would naturally conclude that the improvements in human resources, institutional framework, infrastructure facilities and services would lead to healthier health indicators; apparently it is not so. Thanks to the generosity of the Treasury, the health sector gets a huge chunk of public investment and has enabled to maintain the old glory of high health indicators among its neighbours. But our rank is on the decline.
Since I am not medical personnel, I am not qualified or competent to perform clinical analysis or dissection on the ailments prevailing in the health sector. But as a layman, I feel my own aches and pains (in addition to that appear in the health sector) caused by my age and health; I have some common sense as well; and I share health sector expenses through payment of indirect taxes (my meagre pension is exempted from direct tax). Thus I believe I am qualified and have a right to talk on the subject. According to my layman’s view, the health sector is suffering from more than a funding issue. It is a combination of factors related to management, coordination and prioritisation.
Dengue, a major threat
The Theme for this year’s World Health Day is “Small Bite, Big Threat” depicting vector-borne diseases. According to a recent statement of the Minister, 60,000 people die in a year due to vector-borne diseases. Dengue is identified as the world’s fastest growing vector-borne disease with a 30-fold increase in disease incidence over the last 50 years. In Sri Lanka dengue has become a major threat to the lives of hundreds of thousands of people. The web page of the Ministry on Dengue under the title of “Dengue is on the rise – let’s get protected” describes at length what a person afflicted by dengue and his/her dear and near ones should do. Unfortunately the web page is silent on prevention. The Ministry web-site carries several pictures of the Minister receiving awards and accolades with a single picture of a mosquito.
‘Bolok Mahattaya’
According to the Ministry web-site, the aim is to minimise the number of deaths caused by dengue but not elimination of the cause for dengue or/and deaths caused by dengue. So far, we have failed to introduce a national programme to eliminate or at least control breeding of dengue mosquito other than requesting the public to take care of their own homes and gardens and mobilisation of armed forces in addition to public health workers. The public is attacked by mosquitoes on the one hand and by health authorities on the other. The Ministry accepts ‘fogging’ as an effective measure to control mosquito breeding but does not apply as it is believed to be harmful to our bio-diversity. When I visited BMICH the other day, I saw fogging going on liberally. Of course the health of ladies and gentlemen working and visiting BMICH is more important than protection of the bio-diversity. Bio-diversity is a concern when it comes to ordinary people like you and me.
The Sri Lankan health system is enriched with a primary health care delivery system which was established about 75 years back during the colonial rule. It appears that the focus of the health sector has shifted from prevention to treatment and from early detection at primary health care to tertiary (hospital) care. The current emphasis is on curative medicine and hospitals at the expense of preventive medicine and primary health care. Sri Lanka enjoys a widely spread preventive health care infrastructure facilities delivered by grass root level PH workers administered by the Medical Officer of Health (MOH). When we were young our mother saw the mid-wife and gave birth to us at home. The midwife was the gynecologist, obstetrician, paediatrician and the nutritionist. Midwife with the assistance of public health inspector (PHI) took care of our environment, hygiene, sanitation and health. They advised us on prevention, cleanliness, hygiene and all other health matters. We hardly saw a doctor. The only doctor known to us was one Dr. Block (my sarong clad father called him bolok dostara mahattaya) whom we saw very rarely.
Primary health care system aims to prevent most health and nutrition problems before they begin. It is necessary to identify which intervention can be most effectively applied in a least-cost method. When working in the Ministry of Plan Implementation, we worked closely with the Ministry of Health and implemented programmes jointly to strengthen the primary health care facilities. In addition to providing buildings and equipment we met the salary bills of the health care workers for a given period. The agreement was that the Ministry of Health would gradually take over the cost of maintenance, repairs, overheads, salary and upkeep of these centres. It did not happen. Recently I paid a visit to one of these centres. It has become a cattle shed.
Each year, thousands of people die from preventable deaths. More than half of all deaths are due to preventable behaviours and exposures. This includes non-communicable diseases such as cancer, diabetes, chronic cardiovascular and lung diseases and unintentional injuries and infectious diseases. Road accidents have become the highest killer. Frequency and impact of accidents are on the increase. The Minister who is fighting tobacco producers is silent on prevention of road accidents. Of course transport is not his business; then tobacco is not his business either. Preventive healthcare is especially important given the countrywide rise in prevalence of chronic diseases and deaths. This system needs to be reviewed and redesigned in the face of changes taken place in demographic, environmental and epidemiological factors and in disease agents, lifestyle choices, food habits etc over the years.
Deteriorating trends
Another area which needs more attention is Community Medicine and Health which shares common ground with Preventive and Social Medicine (PSM) and Public Health. i.e. prevention of disease and promotion of health. If we want to achieve “Health for All”, Community Medicine will be a key factor. Community medicine is applied not only to sick people but also to ‘healthy’ people. Its primary objective is prevention of disease and promotion of health. The decades-old concept of health care approach has experienced a dramatic change. Today health is not merely an absence of disease; it is related to quality of life instead. Medicine is no longer solely for the diagnosis and treatment of diseases. It is also for the prevention of disease and promotion of health.
The health sector was one of the strongest sectors in Sri Lanka. The Sri Lankan health sector was cited as a model by many countries and by international organisations and in many documents. It is losing its glory. Primary Health Care, prevention and community health and medicine are the way forward in regaining its lost glory. It should be the key in achieving the goal of “Health for All”. Otherwise the country will end up with “All for Health”.
(The writer can be reached on
chandra.maliyadde@gmail.com)