Implementing health-related MDGs:

The Sri Lankan record

From the statement made by Healthcare and Nutrition Ministry Secretary Dr. H.A.P. Kahandaliyanage at the High-level segment ECOSOC Annual Ministerial Review in Geneva on July 8, on “Implementing the Internationally Agreed Goals and commitments in regard of global public health.

The Secretary-General’s report on the theme of this debate, while highlighting successes, outlines the challenges ahead of the international community in respect of health-related Millenium Development Goals (MDGs). As the Report summarizes, health is at the heart of the MDGs and a critical pre-condition for progress on most of them. In today’s globalized world, external circumstances significantly impact on national progress.

Against this background, we are concerned that the multiple crises facing the world could even reverse the progress made by developing countries in achieving the MDGs. As a result of the global financial crisis, resources available to the health sector from within national budgets and from international partners, are likely to shrink. Simultaneously, other global challenges such as the world food crisis, food insecurity and rising food prices are likely to adversely affect public health, and to aggravate under-nutrition and malnutrition. Similarly, the adverse long-term impacts of climate change are likely to affect human health in multiple ways.

The concept and goals of development have evolved over the past decades in a gradual move away from an exclusively or largely material view to a holistic view of human development. Development as it is understood today and as embodied in the (Internationally Agreed Development Goals) IADGs and MDGs, encompasses goals related to human well-being, including freedom and empowerment of people, distribution patterns and environmental sustainability. Despite added challenges, such a broader dimension of development is aligned with Sri Lanka’s pluralistic democratic traditions and its commitment to a people-centred development. Sri Lanka is committed to the realization of the IADGs and MDGs that we have collectively undertaken.

My delegation believes that health promotional policies and spending are justified, not only because they promote human welfare, which is valued for its own sake, but also because they are a part of a society’s investment for further production and growth. Health is an essential input to the process of human capital accumulation, which enables individuals to achieve greater material success in life and States to generate higher national economic growth.

In Sri Lanka, our experience over the past decades has demonstrated that there are clear socio-economic benefits to be derived from improving health conditions of people and that there are strong positive relationships between investments in health and economic growth.

Public healthcare in Sri Lanka

In many other countries improvements in people’s health conditions followed economic growth; Sri Lanka, however, used its revenues to improve people’s health conditions even before attaining such progress.

It is said that globally millions are found unable to seek and obtain needed healthcare because of inability to meet costs. Sri Lanka, however, has developed over the years a very healthcare-friendly system for its people.

Despite our limited resources as a developing country, Sri Lanka have made commendable progress in the health sector. While the Secretary-General’s report identifies maternal and new born health as an area in which much more progress is needed world-wide, in Sri Lanka, the infant mortality rate has declined from 19.8 per 1000 live births in 1990 to 11.2 in 2005, which is one of the lowest for a developing country. Maternal Mortality Rate (MMR) has declined from 4.23 per 10,000 live births in 1991 to 1.97 in 2003 and is on par with developed countries. Under-five mortality rate had declined in 2005 to less than half of what it was in 1990.

Immunization program

The immunization program has been a great success and we have effectively controlled or eliminated all vaccine-preventable diseases. Life expectancy at birth has gradually risen to 71.7 years for males and 76.4 years for females. Sri Lanka has already eliminated the debilitating diseases like filariasis, leprosy, polio and measles as well as iodine deficiency disorders. The health authorities in Sri Lanka are confident of being able to achieve complete malaria elimination by 2015. The prevalence of HIV/Aids in Sri Lanka is low and it is not widespread in the country. All the above health indicators are considered rather exceptional for a developing country with a GNP per capita of US$ 1970.

Progress in the health sector has been positively influenced by the progress we have simultaneously made on other spheres of human and social development. These include high literacy rates among men and women, which have reached 89 per cent for females and 92 per cent for males. We have achieved near universal primary school enrolment covering both male and female children. Empowerment of women through gender equality, female literacy and equality in women’s access to economic resources has had a direct beneficial impact on our success in maternal and new born health. Sri Lanka’s experience substantiates the observation made in the Secretary-General’s Report that “maternal and new born health is also linked with education of both women and men and women’s access to economic resources.”

The expansion and improvement of health infrastructure was mostly responsible for improved health indicators.

Two salient features of the management of Sri Lanka’s public sector healthcare system have been the provision of healthcare free of charge and the provision of services close to patient. The public sector in healthcare has expanded to be able to treat over 4.6 million in-patients and 43 million out-patients. We have around 1 doctor per 1300 population and the current medical intake assures an improvement in this ratio in the future.

Our healthcare system, with its public and private sectors, has gradually developed into one of universal coverage. It has been based on the principle of equity and social justice for the past six decades. Benefits of Government health expenditure reach the poor effectively as health services are widely dispersed to reach out to people in even the distant rural areas as well. Sri Lanka guarantees effective access to free health services, especially hospital care, for the poor, while permitting private facilities to expand, which the more affluent opt to use. Our healthcare system has thus been able to protect the poor and the middle classes against catastrophic financial risks associated with illness.

Achievements in health

The Government takes on the major burden of meeting the people’s in-patient, out-patient and community health needs. Financed by tax revenues, our public sector healthcare institutions ensure that everybody has access to needed health services. Sri Lanka’s achievements in this regard are commendable as these results were achieved by spending only two percent of GNP on health. Sri Lanka incurs an estimated per capita annual health expenditure of US$ 50, out of which the Government bears US$ 23. Sri Lanka’s achievement however, is that its population enjoys health outcomes that are comparable to those of more developed countries spending several times more on health on a per capita basis.

Healthcare in conflict- hit areas

Sri Lanka’s experience relating to maintaining healthcare infrastructure and providing healthcare in times of conflict and crisis is also unique. During the past three decades, the Liberation Tamil Tigers of Eelam (LTTE), a terrorist group proscribed in over 30 democratic countries worldwide, claimed to control parts of the North and the East through the use of force. Even in the so-called LTTE controlled areas, the Government continued to effectively deliver healthcare services to the civilians.

All health infrastructure, including hospitals, medicines, doctors, nurses and healthcare personnel were maintained through funds allocated by the Government since the inception of the conflict.

Healthcare infrastructure and provisions have been maintained in these conflict-affected regions despite the well-known fact that much of the supplies and facilities were being used by the LTTE for their own cadres.

The regular dispatch of medical provisions to the conflict areas by land, air and sea routes was challenging and a risky operation, and its continuation for almost three decades demonstrates on the one hand, the Government’s commitment to looking after the health related needs of all civilians, and on the other hand, the resilience of the healthcare infrastructure and facilities even in conflict situations.

Today, the Government has been successful in defeating terrorism in Sri Lanka.

We are now effectively facing up to the challenge of providing the necessary care and assistance including healthcare to the displaced civilians, who had previously been held hostage by the LTTE and who are now awaiting early voluntary resettlement.

The Health Ministry has mobilized its resources to a maximum for this purpose, with the assistance of the international community, including UN agencies, ICRC and local and international NGOs working in the health sector. Seven hospitals are providing facilities for the IDPs in the North and east.

Additional medical officers and nurses have been dispatched to these areas. The bed capacity has been increased and adequate stocks of essential drugs made available to the hospitals in the North.

Healthcare facilities are also provided in the welfare sites. Preventive healthcare facilities are in place. Routine immunization, drinking water quality surveillance, family planning and dental care are carried out. Primary healthcare centres have also been set up covering 10,000 - 15,000 people per site.

Mental health and psycho-social support have been made available. Most displaced civilians are in poor nutritional health status due to their prolonged stay in areas under LTTE control.

Our healthcare authorities have taken up the task of bringing their health gradually to conditions comparable to those in the rest of the country. UNICEF has been an important partner in this process.

Future challenges

Given the centrality of health to all aspects of human welfare, we need to be mindful of future challenges related to health, both at national and global levels, so that reaching MDG targets is facilitated. The burden of disease in Sri Lanka is gradually shifting from communicable to non-communicable diseases.

The ageing population raises the demand for expensive, but less effective services in elderly care. Under-nutrition due to poverty remains as a part of an unfinished health agenda. Sri Lanka’s Health Master Plan proposes remedial measures to move towards greater equity and minimization of regional disparities in healthcare delivery through improved access to quality services. This is the main guiding principle in determining allocation of capital investment in the health sector.

We need to explore collectively ways and means of ensuring that health systems are protected to the greatest degree possible from the impact of the world financial crisis.

Financing healthcare is the predominant challenge we face right now and we see this as an emerging problem in the coming years.

Healthcare financing needs of developing countries are exacerbated by increasingly sophisticated technology that doctors and patients demand. Leading global financial agencies, such as the World Bank, the IMF and the ADB have a responsibility to find innovative ways and means to bridge gaps that are being created by the global financial crisis.

The contribution from foreign aid in Sri Lanka has been traditionally marginal. This is partly a reflection of the limited global outflow of ODA resources from developed countries, in spite of the 0.7 per cent of GDP commitment.

Collective effort

In conclusion, budgetary support for the social and development sectors, in general, and for the achievement of health related MDGs in particular, is ultimately dependent on the availability of resources generated by a country’s economic progress.

Therefore, the long-term sustainability of the efforts by developing countries to achieve the MDGs is dependent on an enabling global environment for trade expansion and economic development.

External impediments such as barriers to trade, protectionism and inadequate access to concessionary financing need to be addressed as an inherent part of the global partnership that we have collectively undertaken, and embodied in the MDG’s, to improve the lives of millions.