Sunday Times 2
Health in Lanka: After MDG, prescription for SDG
View(s):Consultant Venereologist Dr. Iyanthi Abeyewickreme was inducted recently as the new President of the Sri Lanka Medical Association (SLMA) for 2016 at a ceremony held at the Hatton National Bank auditorium in Colombo.Here are excerpts of her speech based on the theme, ‘From MDGs to SDGs — Moving from Millennium Development Goals to Sustainable Development Goals’.
Iyanthi Abeyewickreme
The millennium development goals or MDGs were adopted in 2000 following the Millennium Summit of the United Nations.
The MDGs encapsulated eight globally agreed goals — poverty alleviation, education, gender equality and empowerment of women, child and maternal health, reducing HIV/AIDS, malaria and other communicable diseases, environmental sustainability and building a global partnership for development.
Let us now consider Sri Lanka’s progress of the health related MDGs. You will be pleased to know that Sri Lanka has been remarkably successful in moving towards achieving the target of reducing the under-five mortality rate by two-thirds.
The decrease in the under-five mortality rate from 1991 reflects improved health care services in terms of availability, access and quality. However, it is important to note that regardless of progress made, regional variations remain significant. For example, in 2009,the Vavuniya district had an under-five mortality rate of 85.3, much higher than the country average. A few other districts such as Mullativu, Kandy, Batticaloa and Colombo also had higher values.
Dr. Iyanthi Abeyewickreme (also below), the new president of the Sri Lanka Medical Association, delivering her induction speech
The infant mortality rate at the national level decreased from 17.7 deaths per 1,000 live births in 1991 to 9.4 in 2009, putting Sri Lanka on track to meet the 2015 target. It is also important to note that nearly three quarters of infant deaths in Sri Lanka occurred during the neonatal period similar to the global situation. Prematurity and congenital abnormalities were the main causes of infant deaths in 2013.
The expanded programme on immunisation introduced in 1978 in Sri Lanka, has achieved impressive results in reducing preventable diseases. According to the national immunisation schedule, the first dose of measles, mumps and rubella or MMR vaccine is given at 9 months of age followed by a second dose at completion of 3 years of age. Sri Lanka has almost achieved universal measles immunisation.
Where does Sri Lanka stand with regard to MDG 5?
Sri Lanka has come a long way in improving maternal health. In 1948, around 1,700 pregnant women per 100,000 live births died due to a cause related to pregnancy. By 2014, this number has been reduced to 32 per 100,000 live births. This is a significant decrease and bears testimony to the improved care provided to pregnant women in this country over the years.
Maternal deaths can occur due to causes directly related to pregnancy and delivery or due to indirect causes. In 2014, the leading causes of maternal deaths were indirect causes such as respiratory disease, heart disease complicating pregnancy, hypertensive disorders and other medical disorders whereas haemorrhage was the leading cause of maternal deaths globally.
While it is heartening to note that currently Sri Lanka is on par with developed countries with low levels of maternal deaths, it must also be acknowledged that the decline in maternal mortality has been stagnant during the past few years.
The proportion of births attended by skilled birth attendants was 98.8 percent in 2014 and, virtually all births in Sri Lanka involve institutional deliveries, with doctors attending on more than 70 percent of deliveries.
What has been the progress for MDG 6 in Sri Lanka?
In 2000, the number of new HIV infections reported by the National STD/AIDS Control Programme (NSACP) was 54. The reported numbers indicate the numbers have doubled since 2010.
However, this increase is coupled with a stable number of newly reported deaths each year, and a consistently low HIV prevalence of less than 1% across all populations tested. In fact, HIV testing has increased by 67% since 2010. Since the number of AIDS cases has proportionally risen over the same period, increased testing has not necessarily detected people living with HIV at an earlier stage.
By end 2015, there were 1,708 persons detected to be living with HIV. This represents around 53% of the estimated number of people living with HIV in Sri Lanka at present. Therefore, the need to improve access to testing services to close the gap cannot be over emphasised.
Sri Lanka was able to provide ART for HIV infected persons in late 2004 with assistance from the World Bank. Since then, these drugs were procured with assistance from the Global Fund. The Ministry of Health has undertaken to purchase anti-retroviral drugs from this year onwards, which is a progressive step as donor funds are dwindling. By the end of the third quarter of last year, 746 HIV infected persons were on anti-retroviral treatment, which, however, falls short of the MDG 6 target.
Sri Lanka has experienced several major epidemics of malaria. The most devastating of these was the epidemic of 1934-1935 during which about 1.5 million people contracted the disease — and 80,000 deaths were reported. However, in recent years, control of malaria in Sri Lanka has led to remarkable results. For the first time in recorded history, no indigenous cases of malaria have been reported for three consecutive years! Therefore, we are now eligible for World Health Organisation certification as a malaria-free country. Even if the current burden of malaria is extremely low or non-existent, we need to be cognizantof the fact that the potential for outbreaks and a resurgence of malaria exists.
Let us now look at tuberculosis control in Sri Lanka and if the MDG target has been achieved. Though tuberculosis is a treatable and a curable disease, it still remains a public health problem in Sri Lanka. Treatment success has reached the global target of 85 percent. There were 8,767 new cases of tuberculosis reported in 2013, giving an incidence rate of 44.1 per 100,000 population. The mortality rate associated withTB also declined from 7.5 deaths per 100,000 people in 1990 to 1.1 in 2012.
The Government has adopted the global target of a treatment rate of 85% and a case detection rate of 70% as minimum goals.
Let me now summarise the achievements of Sri Lanka with regard to MDGs 4, 5 and 6. Sri Lanka has successfully reduced both infant mortality and child mortality rates and if these trends have continued, MDG targets for both would have been met by 2015.
As the maternal mortality ratio has declined from 92 deaths per 100,000 live births in 1990 to 32 in 2014, the target of reducing the ratio by threequarters will likely be met by 2015. Sri Lanka has maintained a low HIV prevalence since the first case was reported in 1987 and it is unlikely that Sri Lanka will experience a generalised epidemic.
We have been free of local or indigenous malarial infection for three consecutive years. The next challenge is to eradicate malaria from this country. Although the indicators are encouraging, there is still much to be done to control tuberculosis in Sri Lanka.
Moving on from Millennium Development Goals to Sustainable Development Goals, the MDGs were expectedto be achieved by 2015. Hence a further process was needed to agree and develop, development goals from 2016 to 2030.
What are these global or sustainable development goals?
The new goals are not a mere simple continuation of the MDGs but goes well beyond them. The 2030 Sustainable Development Agenda is described as one of unprecedented scope and ambition, and applicable to all countries. The SDG agenda is a plan of action for people, planet and prosperity.
The SGDs consist of 17 goals and 169 targets unlike the MDGs which consisted of eight goals and 21 targets. Some criticised the goals as being too broad and ambitious. However, at the United Nations Development Summit held in September last year, 193 nations adopted the SGDs.
At this summit, President Maitripala Sirisena said the Government fully supports the post-2015 sustainable development agenda in pursuance of the 17 SDGs. I would now like to draw your attention to Goal three of the SDGs which is, to “Ensure healthy lives and promote well-being for all, at all ages”.
Unlike with the MDGs this health goal is broad and has 13 targets. Health has a central place as a major contributor to and beneficiary of sustainable development policies. There are many linkages between the health goal and other goals and targets, reflecting the integrated approach that is underpinning the SDGs.
The targets identified under the health goal vary from reducing maternal mortality to strengthening the capacity of all countries for early warning risk reduction and management of national and global health risks.
Non-communicable diseases on the increase
You may be aware that while Sri Lanka has been successful in combating communicable diseases, non-communicable diseases or NCDs are on the increase.
In October 2015, a mission carried out by the UN Task Force on NCD concluded that the epidemic of NCDs has now become a serious economic as well as public health issue in Sri Lanka and is fuelled by tobacco use, unhealthy diet, harmful use of alcohol and physical inactivity. According to the World Health Organisation, in 2014, non-communicable diseases accounted for 75% of deaths in Sri Lanka with diabetes accounting for 7% of deaths. This is a significant increase from 2008, where diabetes accounted for only 4% of deaths.
The Annual Health Bulletin published by the Ministry of Health lists ischaemic heart disease as the leading cause of hospital deaths in 2012. Ischaemic heart disease has ranked as the leading cause of death since 1995. There are many causes of ischaemic heart disease and diabetes is one of them.
There has been a dramatic increase in the prevalence of diabetes in Sri Lanka over the past decade. The Non-Communicable Diseases Unit of the Ministry of Health estimated that in 2014 around 20% of all Sri Lankan were affected. This estimate has been validated by data from the Diabetic Association of Sri Lanka, which indicate that there are nearly 4 million diabetics in Sri Lanka at present.
I would like to draw your attention to the recently formulated strategic framework of the SLMA covering a period from 2015 to 2020. In this framework, diabetes has been selected as the specific disease focus.
The SLMA diabetic initiative will prioritide Sri Lanka’s response to diabetes. This fits in well with SGDs health goal where, by 2030, countries are expected to reduce by one-third premature mortality from non-communicable diseases.It is appropriate that the World Health Organisation is focusing on diabetes at this year’s World Health Day which falls on April 7 because the diabetes epidemic is rapidly increasing in many countries.
According to the national council for road safety, 2,538 deaths occurred due to 2,360 road accidents during the first 11 months of last year. Of these, 760 died due to motorcycles accidents, and 726 were pedestrian casualties. The number of vehicles on the road has grown exponentially. As such, we need to take remedial action urgently. One of the SDG targets refers to halving the deaths due to road traffic accidents by 2020. It is hoped that the authorities in Sri Lanka will seriously consider adopting this target as one of its main priorities.
The National STD/AIDS Control Programme of the Ministry of Health plans to screen all pregnant women for HIV from this year. Screening alone is not sufficient. Those found positive have to be counselled and offered anti-retroviral drugs for their own health which would also prevent their babies from being infected. This is the strategy that is being followed globally to completely eliminate HIV in future generations. I am confident that Sri Lanka can be one of first countries in the South East Asia Region to eliminate mother to child transmission of HIV within the next two years and end the epidemic of AIDS before the year 2030.
Another area of concern that is of relevance to healthcare providers and the general public is antibiotic resistance. Although antibiotic resistance is not a specific target under the new health goal, it has been alluded to in the SDG declaration recognising that it is a growing threat that needs urgent attention. Antibiotic resistance occurs when bacteria change in response to the use of antibiotics. It is the bacteria not humans that become resistant. Infections such as pneumonia, tuberculosis, sepsis and gonorrhea are becoming more difficult, and sometimes impossible, to treat as antibiotics become less effective.
In Sri Lanka antibiotics can be bought over the counter without a prescription. Although we do have standard treatment guidelines, over prescription as well as over-use is prevalent. These practices add to the development and spread of antibiotic resistance.
We urgently need to change the way antibiotics are prescribed and used. It is also worrying that very few new antibiotics are in the pipeline. Even if new drugs are developed, without behaviour change, antibiotic resistance will remain a major threat. If the status quo continues, a post-antibiotic era, in which common infections and minor injuries can once again kill may not be too far away.