What ails the Ministry of Health?

Prof. T. W. Wikramanayake

The theme of the Seminar held on the 2nd of June, to inaugurate this “Nutrition Month” was “Let’s unite the Better Nutrition”. Various experts discussed ways and means of improving the nutrition status of the people of this country.

For about two years, a committee, appointed by the Ministry of Health consisting specialists in the different areas of Nutrition, both in the Health Ministry and elsewhere discussed the same ways and means, and produced a document, which I shall refer to as the Policy Document (PD), that has been within Ministry of Health for two years. I inquired from the Minister whether this PD had been placed before the cabinet. He expressed dissatisfaction with the document.

Why nothing has been done about that during the past two years, was a question that came to my mind but was not asked. The Minister seems to think that many of the strategies recommended in the PD had been implemented for 10 to 15 years, with little result. What are the defects in the current programme and how may they be remedied?

A multi-sectoral approach

A very important point made by Dr. Kolosteren of the Institute of Tropical Nutrition, Brussels, in his presentation, was that problems of malnutrition are multi-factorial and attempts to remedy defects must be multi-sectoral. This same point was stressed in a memorandum prepared by the Nutrition Society in 1974 and placed before the then Prime Minister, Mrs. Bandaranaike.

On the advice of two FAO Consultants, Prof. Joy and Mr. Payne (from UK), who endorsed the view of the Nutrition Society, Mrs. B. proceeded to establish a Food and Nutrition Policy Planning Division (FNPPD) within the Planning Ministry, in 1975/76. This Division could not make much headway due to the General Election scheduled for 1977.

It was fortunate that Dr. Wickrama Weerasooriya was made the Secretary to the new Prime Minister (later President). He appreciated the need for action recommended by Joy and Payne (and the Society) and set about it with vigour and determination.

He headed a Committee which included Secretaries and Heads of Departments of Ministries of Health, Agriculture, Education, Fisheries, Food Imports and all Departments that had any impact on nutrition status. This Committee also included a few members of the Nutrition Society. It met at least once every three months and discussed various problems, as they arose.

The FNPPD was given the task of implementing programmes approved by the Committee and also of reporting on progress made. Dr. Weerasooriya worked very conscientiously for about 10 years. Two of the great successes of this Committee were the Immunisation Programme and Family Planning Programme.

The Minister of Health, Dr. Ranjith Atapattu, Dr. Weerasooriya and Dr. Hiranthi Wijemanna of UNICEF travelled to all parts of the country promoting the immunisation of little children and the MOHs and their staff cooperated fully; the results were startling. Within a year or two we had 100% of the newborns immunised!

Family limitation

This programme is continuing, I hope, with the same success. The country was made aware of the need for family limitation with assistance of the UNFPA. Discussions were held in a large number of districts.

There were discussions at which different religious leaders and leaders of political parties participated, and agreement reached. Unfortunately this programme was abated by President Premadasa. However, everyone is now aware of the need for family limitation and methods available.

The high cost of living motivates couples to reduce the number of children to two or three. Joint efforts of all Ministries from 1978 to 1988 produced remarkable results. By 1990 the prevalence of stunting among pre-school children reached a very low level, lower than in all other countries in Asia and close to the value in developed countries.

Unfortunately the FNPPD was dismantled by President Premadasa. However, a unit in the Ministry of Plan Implementation responsible for Poverty Alleviation continued to address the problems of malnutrition. An able head of that unit (knowledgeable in nutrition) co-opted the assistance of the Nutrition Society and continued some of the tasks that had been undertaken by the FNPPD.

A committee discussed reports of various departments responsible for implementing nutrition programmes, and some progress was made, though this was short-lived. A change of government saw new officials and new ministers, clueless or uninterested.

President Kumaratunga paid a little attention to suggestions of this Committee or of the Nutrition Society, relying on the advice of three individuals who had only a superficial knowledge of nutrition. The final blow was given by Prime Minister Wickramasinghe who placed the entire burden of malnutrition on the shoulders of the Minister of Health.

The present Minister has been attempting to make some progress during the past few years. But he has no influence over the policies of the other line ministries. He is now complaining about the high prevalence of underweight children, of low birth weight babies and of anaemia during pregnancy.

The PD that is before him suggests a high powered inter-ministerial committee, and a group of technically knowledgeable persons to implement programmes, approved by this committee. This Document should be ratified by the Cabinet and plans of action drawn up by the end of this year, if we are to see satisfactory results by the year 2015.

Anaemia during pregnancy

There continues to be a high prevalence of anaemia among pregnant women, and anaemia leads to low birth weight and subsequent underweight children, which leads to a high incidence of obesity, and diabetes mellitus at middle age. This anaemia must be controlled. The problem has been discussed at length during the past 10 years, solutions are available; what is wrong is the implementation.

The following problems have been highlighted over and over again.

1. Supplements issued at Maternal and Child Health (MCH) clinics ARE WRAPPED IN A PIECE OF PAPER when issued to the mother. She puts this into her pala-malla. On the way home she buys vegetables and provisions which also she puts into the same basket. When she gets home she finds the tablets wet and soggy and discards them.

We were told by the family health bureau (FHB) that having supplements in “blister packs” to keep them clean would be too expensive and MOHs had been instructed to ask the mothers to bring with them small bottles or cartons for the supplements. Has the FHB checked on whether this is happening? Have the women access to such containers, or are pieces of newspaper still being used?

2. Another defect was that the Treasury does not fund the supply of these supplements. The supply of supplements depends on foreign aid! In 1995 the sum required for all supplements was more than Rs. 12 million.

If the UNICEF grant was Rs. 8 million, then only two-thirds of the supplements will be available to each mother, or some mothers will not receive any! The Government must take the full responsibility for making resources available at Health Clinics.

3. Distribution of supplement depends on the availability of transport. Having government vehicles repaired takes months. When transport is not available, clinics in remote areas will be the most affected. Is this a reason for the high prevalence of malnutrition in the Dry Zone, from Mannar/Puttalam to the NCP, Ampara, Badulla and South to Moneragala and Hambantota?

4. An obstetrician in Galle has reported that two iron tablets a week given with vitamin C tablets are sufficient to control anaemia in pregnancy. This should be looked into.

5. Are facilities available to the MOH in these remote areas adequate? In 1995 the MOHs (both women) at Sooriyaweva and Lunugamvehera each had two small rooms in the hospital for all their work.

At Lunugamvehera one room had to be given to a recently appointed Dental Surgeon, so that weighing of mothers and children, immunisation, distribution of supplements and triposha, health education and advice on family planning had all to be attended to by the MOH, Nurse, Midwives and Public Health Inspector, all in one room. And, the MOH was forced to live in the Nurses home due to lack of quarters. These inadequacies were highlighted in a report to the World Bank, in 1995.

6. The MOHs in these two areas were highly motivated “Russian” graduates. The course in community medicine in Russia is inadequate for our requirements. These graduates will have to work for about a year before they are summoned to a training course, because those in the Western Province and others places close by have to be trained first.

7. The Ministry allocates posts according to a so-called “Merit List” drawn up for new medical officers, depending on their scores at examinations in the clinical subjects on (medicine, surgery, obstetrics and gynaecology paediatrics and psychiatry). Whether the score at community and family medicine is now taken into account I do not know. In any case “foreign graduates” are at the bottom of this list.

I found a Colombo graduate in charge of a Health centre within 10 miles of Colombo who attends clinic only once a month, on pay day. The building, a new one, was in a filthy condition, none of the toilets were working and had squirrels’ cages hanging from the ceiling long after the baby squirrels had left. The labourers were not taking orders from the Nurse.

8. The problems of areas like the Badulla District (where the Uva Basin has been deprived of water and other resources due to the on-going rape of Hakgala Strict Natural Reserve during the past 20 years) cannot be solved without taking into account factors that are even remotely connected with health and nutrition.

9. No amount of supplement distribution will counter the incidence of illness among the urban poor as long as the drains remain filthy and the roads full of garbage.

Village level committees

In addition to the recommendations in the Policy Documents, I urge the formation of committees at village-level, consisting of the Grama Niladhari, the MOH or his representative, the School Principal, Ayurvedic Physician, and Agriculture Extension Officer and one woman (between 20 and 50 years) selected from and by each of a group of 50 households in the Grama Niladhari Division.

It is the woman who is most competent to complain about facilities supplied by the Health Ministry as well as departments connected with roads, sanitation, water supply etc. Their complaints should be considered at provincial level and attended to by that Council or forwarded to the planning secretariat in Colombo for attention.

The public will thus be given an opportunity of participating in the planning process. These committees could also be used in implementing projects supported by the centre.

I urge the Minister of Health to go ahead and implement the recommendations in the Policy Document without further delay. Misgivings he may have about some of the proposals can continue to be discussed and alterations made in the plan of action (if necessary) when we have results of five years of implementation. It takes more than five years for a foetus to reach school age. Results may not be seen in our lifetime. The important thing is to make a start. Please fire the gun for the start.