Financial Times

Demand for private treatment rises
Public-private sector partnerships urged in health sector
Admitting a child to hospital is a traumatic experience for any parent, but imagine what it would be like if on admittance you find there is no available space in any of the wards. With the most profound apologies, the best that can be done for you is to be kept waiting while phone calls are made to secure a bed at the soonest possible moment.

And no, this isn't another tale of Sri Lanka’s struggling public health sector but of the private one, where your money (or your insurance company's) is meant to get you the best treatment available.

So what's going on, you might ask. Well, it seems that due to better public health awareness, the continuing problems with public hospital waiting lists and the ever-increasing number of breakthroughs in medicine, more and more people are moving over to the private sector.

With the opening up of private health care nearly two decades ago due to the then government’s free market policies, there are now some 8,000-plus beds available nationwide, and according to Dr Harsha de Silva, Director, Private Health Sector, Health Ministry, "that figure is growing at 15-20 percent a year". But, it seems, that still is barely enough, especially considering that Dr Aruna Rabel, Medical Administration Manager, Durdans Hospital, put the growth rate closer to 5 percent.

When asked about possible reasons behind the lack of beds, Dr de Silva said: "These days the number of patients is increasing due to advancements and breakthroughs in medicine. As we can treat more diseases, more people are being treated, meaning that a greater number of beds are taken up for such treatment."

And that seems to be the general consensus from the hospitals contacted. With this better treatment comes another worldwide phenomenon: the ever-increasing number of elderly people, who are living longer. Life expectancy in Sri Lanka has witnessed spectacular growth over the last 60 years, rising from 43 years in 1946 to 73 at present.

Dr de Silva said that, on average, an adult will visit a hospital about four times a year, whereas for an elderly person that number can rise to 14 to 15. The older a person becomes, the higher the chance that they will need a bed for those symptoms associated with old age, such as broken bones, diabetes, cancer and strokes, thus putting more pressure on any particular hospital's bed availability. This has led some hospitals to put more emphasis on preventive care.

There are problems with over-crowding in out-patient departments as well, thus leading to longer waiting times to be seen by specialists; where they themselves are in short supply in some hospitals due to their contractual duties to the public sector, Dr Rabel said. Progress in medical fields is not the only reason for increased numbers filling up the hospitals.

As the country's economic growth continues at around 5-6 percent, more people are realising that they too can move across from the public to the private sector for treatment. On top of this that same economic growth means that there are more companies offering medical insurance to their staff.

A problem that arises here is the way that these new converts (and some persistent regulars) use the private facilities now that they are available.
The temptation is there to feel that a visit to the hospital is necessary even for the most minor of illnesses or injury, where common sense or a visit to a local doctor are the more practical solutions, as well as being cheaper, argued one specialist, who wanted to remain anonymous.

And potential delays don't stop there. When these new patients arrive at the hospital they go straight to see a specialist rather than getting an opinion from an in-house GP first. This leads to an unnecessary number of appointments being made for diagnoses that the general practitioner could have done, which in turn would leave specialists free to treat the more serious and urgent cases.

Durdans’ Dr Rabel said the hospital had introduced a policy to educate patients to better utilise the GPs in their Out Patient Department in a bid to best ensure hospital time isn't wasted on unnecessary visits. He also said that there weren't enough ground-level officers to offer referrals to help ensure that patients were directed to the right people for treatment, and that there seemed to be no government policy to change that.

G. H. A. Wimalasena, Managing Director Asiri Hospital, added that there was no referral system in the country and, seemingly, no policy being put together by the government to address this situation. The lack of a referral system can again lead to backlogs where patients can be left waiting for necessary attention, or leaving others in limbo as they don't know where to go for treatment or end up in the wrong department.

As for full wards, Mr Wimalasena said there were a total of 220 beds spread between the two Asiri hospitals, and in general there was no problem concerning shortages, except in the cases of a dengue fever or other epidemics (such as flu) where beds then do become scarce. Professor Lal G. Chandrasena, General Manager, Nawaloka Hospitals, said that they have 300-325 beds available, where most were taken up on a regular basis but in general there was never a shortage.

When it's obvious that a person needs to be admitted, the leading private hospitals in Colombo - Durdans, Apollo, Nawaloka, Asiri, etc as well as those on the periphery - are quite happy to refer a patient to one another if they find that all their own wards are full. Of course, if the case is critical then that person is not refused admission.

When it comes to in-house doctors there doesn't seem to be a shortage. "In general, the private sector doesn't have a shortage as there are plenty of doctors from the public sector willing to cross over to the private sector to supplement their income," Dr de Silva said.

As far as specialists are concerned, this seems to be more of a problem as the vast majority work for the public sector and are not allowed to cross over during working hours, leaving them only available in the early mornings and evenings, Dr Rabel said.

Prof Chandrasena said Nawaloka employs its own consultants to guarantee coverage, as well as having those working for the public sector available at the end of a phone if the need arrives. So as far as the main private hospitals are concerned there doesn't seem to be a major problem with over-crowding, and many are expanding and have already begun "extensive refurbishments, upgrades, as well as introducing new technical equipment to become more competitive", thus offering more people first-class treatment, according to a report by Bartleet Mallory Stockbrokers. As demand grows, private hospitals are doing their best to fill the gaps, but there is also another way to improve services with the facilities available, according to Dr Rabel.

He points to the need of a public/private partnership where the three areas of care - primary, secondary and tertiary - can be spread between the two sectors enhancing the best of both. Here, Dr Rabel says, the public sector can take on the main aspects of primary and secondary care as the apparatus is already there, and that for only small future investments there can be big results. This would leave the private sector with tertiary care, such as CT Scans, MRIs, bypass surgery and neurosurgery, as the hospitals have already invested in state-of-the-art equipment and qualified technicians, he added.

"Presently, such machinery and operating theatres in the public sector are underused to a large extent due to staff shortages and costs, leading to some hospitals being able only to use theatres in the mornings. This all leads to financial wastage as they sit idle, whereas our sector offers such facilities 24 hours a day," Dr Rabel said.

The administrator continued by saying that before moving to the private sector he worked for the ministry, where he noted there was plenty of time spent planning the way forward, but as far as he was concerned, not enough implementation. "The money was there, but it was underutilised or in some cases, donor money was returned."

Dr Rabel said he would like to see the government put forward a five to 10 year plan that would allow the public and private sectors to work together for the benefit of the public as a whole, as presently the level of planning was very poor.

Prof Chandrasena said that with the listings of private hospitals in recent years, it shows public faith in the direction the institutions are going, with the money raised going to expansion projects, be it in the number of beds or on the services side.

He added that his hospital was expanding its preventative services and lab facilities, with the help of foreign expertise. As for Dr de Silva, he is hoping for positive news to come from Geneva (where the peace talks are being held), and continuous economic growth to encourage foreign investment in the private healthcare sector as the recent political climate has not encouraged such moves. "To build such hospitals takes a huge financial undertaking, and we see that this is a good growth area for foreign investment," he said.

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