Sri Lanka's political commitment to growth with equity has been one factor behind the success of its healthcare system. But the health sector is now facing new challenges, including donor pressure to become managers rather than direct providers of healthcare. The old system is beginning to show the strains of too much bureaucracy, and has not been able to respond effectively to the rapid growth of private medical care. Can the Ministry of Health take on a new-look managerial role? And will this transition come through rapid change or gradual evolution?

By international standards, the state's health services in Sri Lanka have done well. Good health services have been provided at low unit costs even compared to the private sector, immunisation rates are high, coverage is fairly extensive and equitable, and there is a strong emphasis on primary and preventive health care. But even after 20 years of adjustment, health reform has yet to make it onto the policy agenda. Central to the challenges it now faces is the need to move from a bureaucratic administration-style of health services to a more flexible and appropriate management role. Researchers from the London School of Hygiene and Tropical Medicine and the University of Colombo have been studying the potential for reform of the Sri Lankan healthcare system.

Among problem areas the study highlights is the bureaucratic culture of the Ministry of Health (MoH), linked to deteriorating staffing and skills levels, particularly at lower levels in the system. The system also suffers inherent weaknesses such as heavily centralised resource allocation systems, which mean that local health service managers cannot be flexible in how they use their resources. Other stumbling-blocks identified in the course of the study include:

• meagre budgets for staff recruitment, training, incentives and the like
• political interference which often bars better planning, for example when resources are shifted from one hospital to another
• lack of private sector regulation, and private provider-MoH relationships. Despite rapid growth of the private sector the MoH has yet to register, let alone regulate, private health providers.

In addition, outdated legislation, lack of staff and information systems, and the fact that most private doctors are also government doctors, have kept private healthcare regulation a low priority. How can Sri Lanka's healthcare system gear itself up to perform better? There are foundations to build on, viz standards of administration are generally competent, although the rules within which administrators operate need changing. New legislation (introduced towards the end of 1997) promises to set up mechanisms for regulating private-public healthcare arrangements, but only at the centre. Finally, scope exists for contracting between MoH and other service providers, but stronger administration and more training in implementing these measures are needed. The researchers conclude that - to ensure progress - capacity needs to built mainly in the areas of:

• staff motivation and development
• developing systems for monitoring and regulating the quality of care
• methodical collection of more complex information about cost, quality and efficiency.

Research observations indicate that political support for reform will be key to its success, and that this reform will need to be gradual rather than radical. Crucially, a 'critical mass' of improved skills, attitudes and behaviours will have to form before more thorough institutional change can be achieved.

Source(s):
Sri Lanka - Reforming the Health Sector: Does Government Have the Capacity? The Role of Government in Adjusting Economies Paper 14, S. Russell and N. Attanyake (1997)

id21 Research Highlight: 1998-Apr-18

Further Information:
S. Russell
Health Policy Unit
London School of Hygiene and Tropical Medicine
Gower Street
London
WC1E 7HT
UK

Tel: +44 (0) 171 927 2277
Fax: +44 (0) 171 656 7679
Contact the contributor: steven@panlanka.net

Health Policy Unit, London School of Hygiene and Tropical Medicine, UK

N. Attanyake
Department of Economics
University of Colombo
Sri Lanka