Sri Lanka has been described as the archetypal "Third World Welfare State". It boasts a legacy of direct provision by the State of public services such as healthcare and water supplies, matched by strong public perceptions of government as the proper provider of such services. Despite a lengthy period of economic liberalisation, a recent research study found institutional reforms in the health and water sectors have been limited by various factors, not least by public opinion.

The study, by researchers from Sri Lanka's Centre for Inter-Sectoral Community Health Studies, the London School of Hygiene and Tropical Medicine and the University of Wales, formed part of a wider programme of multi-country research on the Role of Government in Adjusting Economies. It showed that as private health care provision has grown, government financing of public health services has declined. The resulting two-tier system has meant a two-track healthcare delivery order, says the study report. Reform in the water sector has also been uneven, relying mainly on institutional restructuring and gradual commercialisation of the various National Water Supply and Drainage Boards. Even so, most people value officially-run services highly and concertedly oppose any further privatisation.

Conducted via a series of Focus Group discussions among urban residents, the study set out to explore people's use of service providers and factors influencing this use. It also aimed to gauge public satisfaction with health and water service providers, compare use of (and satisfaction with) government vis-à-vis alternative providers, and to sample opinions about proposed reforms in the urban sectors.

Sri Lanka's strong historical commitment to free and comprehensive health and water services means transition to a more liberalised regime has been vexed. According to the report, Sri Lankans are highly politicised. Trade unions have been focal points of opposition to reforming the role of government. But more subtle forces are also at work.

• The introduction of 'Western' medicine over the past 20 years has changed the nature of service demand and delivery in Sri Lanka, putting provision by indigenous, or 'Ayurvedic' medical practitioners in the shade.
• As middle income groups increasingly turn to more costly Western-oriented clinics and medicines, State commitment to public health services has declined.
• As to water, services were formerly reckoned to be good, so privatisation moves have been heavily criticised. Poor management and organisational difficulties have limited the effectiveness of devolution away from centralised water services.

Despite numerous complaints, Focus Group participants saw government service delivery arrangements as having two main advantages over private providers:

• Services are accessible and free (or affordable) for all sections of society
• In official healthcare, hospital staff are well qualified and can be trusted.

Among official steps the study recommends as ways to adjust to such changes are:

• encouragement of a pluralistic health care system based on common facilities
• more inputs to enable the private sector to supply services to a decent standard.

Source(s):
The Opinions of Health and Water Service Users in Sri Lanka. Paper 25 in The Role of Government in Adjusting Economies series, University of Birmingham. By Tudor Silva, Steven Russell, and Carole Rakodi (1997)

Funded by: ESCOR (DFID), UK (1997)

id21 Research Highlight: 1998-June-19

Further Information:
Richard Batley
School of Public Policy
International Development Department
University of Birmingham
Edgbaston
Birmingham
B15 2TT
UK

Tel: +44 (0) 121 414 4985
Fax: +44 (0) 121 414 7164
Contact the contributor: IntDev@bham.ac.uk

The International Development Department of the School of Public Policy, University of Birmingham, UK