Random thoughts on healthcare

Address by Healthcare and Nutrition Minister and World Health Assembly President Nimal Siripala de Silva at the annual Convention of the International Medical Sciences Academy (IMSA) on October 24 and 25 in Chandigarh, India.

From the medical science angle, the most basic change in healthcare in the past decades has been our view of human biology, and the way we see the individual. Previously we used to visualize the individual purely from a biological and molecular level as a “Case”, but now we see him also from a cultural angle, as part of a family and society, and this has altered the way we look at health and sickness. Therefore we now know that simple disease models are not enough, and we have to understand how personal and collective behaviours contribute and give rise to disease, and therefore regard the whole family and the community as the “patient”.

In Sri Lanka, three main systems of medicine prevail; main stream being allopathic medicine but this has not deprived the people of gaining access to other systems of medicine namely Ayurveda, Homeopathy and traditional systems of medicine.

My personal opinion is that it would be wrong to compartmentalize ourselves to a single discipline of medicine. All of these disciplines could work holistically in an integrated manner towards one all important ultimate goal - the health and well-being of mankind.

It is logical to have all these forces work in a harmonious manner, may even be under one roof, in reaching the above mentioned health goal in a cost effective manner. I believe the primary healthcare movement that resulted in the Alma Ata Declaration 30 years ago helped to make this fundamental shift. This has led to the second important change, which is the recognition of the limits to curative bio-medicine.

We have come to recognize the limits to very expensive “after the fact” remedial technical interventions. There is no doubt that high level sophisticated technology when applied judiciously can work wonders to help save patients’ lives. But their injudicious application is driving the healthcare costs far beyond the capacities of our developing countries. I find this dilemma each working day as the Health Minister in my country.

My observation is quite often the results in terms of quality of life and life years gained remain in doubt. In most countries communicable diseases as the cause of

death has been replaced by non communicable diseases (NCD) such as the chronic and old age diseases and cancers for many of which medicine has few complete cures. In my country, non-communicable diseases now predominate as the leading cause of mortality. As you are aware, managing NCD’s would be a costly excercise which a developing country could not possibly afford.

Primary and secondary prevention of NCDs need to be given priority in our health system. For us this is the way ahead and it has changed the way we Sri Lankans are now trying to organize our health services. Health promotion and behavioural aspects are now receiving much greater attention in my country.

Social determinants of health is another important area that any government should consider to improve the health status of their countrymen. Here we are looking at the “causes of causes” and research and evidence should play a big role in making a change.

The macroeconomic commission a few years ago recommended a minimum of 35 US dollars per capita as an essential investment, but I would suggest that we all try to invest much more than this. Sri Lanka currently spends around 80 US dollars per capita and we find that even this is not sufficient. But we have been fortunate that my President, Mahinda Rajapaksa, in his vision for development Mahinda Chintanaya, has put a high premium on health and education.

This meant that in spite of fighting a ruthless terrorist organization, the LTTE, which took away a lot of our valuable resources that we could have used for development, we did not curtail our expenditure on health. Fortunately we got rid of the LTTE now - although we still have to remain alert to any new threats - and we are optimistic that we would be able to invest even more in the social sector, particularly in health and education. One of the serious concerns are the issues related to the migration of health personnel, particularly the doctors, and now it has also spread to the nurses.

Sri Lanka is a country that has been suffering from Brain Drain for sometime now. We have seen some of our brightest and the best trained young doctors leave seeking greener pastures to the developed countries. Firstly consider the investment. Successive Governments have considered health and education as investments to produce a healthy and literate workforce. Therefore primary, secondary, tertiary education and even postgraduate education have been provided absolutely free to all the people. The doctors have optimally benefited from these social sector policies.

We find it extremely difficult to replace the specialist doctors who migrate as the training of a specialist takes a long time and is extremely costly.

We are really making a huge subsidy or a resource transfer to these developed countries. Being a free and democratic country, we need to allow freedom of movement and the freedom to live and work where individuals prefer to do, but should there not be some international covenant or understanding on this matter, so that our countries do not suffer too drastically from this phenomenon?

I have been advocating very strongly for such a Covenant or Charter both in the World Health Organization as well as in the Commonwealth Health Ministers Meetings for almost a decade. It is heartening that the WHO has now developed a Code of Practice for the receiving and the source countries to adhere to.

Even though this is only a moral obligation at the moment, I hope it will be taken seriously and adhered to by all the countries.

This Code is not likely to solve all our problems but it will help mitigate some of the adverse effects and allow for some forms of compensation to the developing countries which are losing their valuable intellectual and scientific capital.

We as policy makers can do more to create a conducive environment for our doctors to live and work in our countries. But I feel that Associations such as yours also have a major role to play in this matter. How could you instill a sense of national mindedness in the young medical graduates of our countries? In addition to fine-tuning their knowledge and skills, how can we provide them with a value based education, an education that will stimulate them to stay in their own countries and humanize them to respect the rights of the poor and the less privileged people in our communities to obtain optimum health care?

I also like to highlight the need for us in South and South East Asia to strengthen our collaboration in medicine and medical education. With the shifting of the economic axis to Asia, I see this as a necessary development, so that we can share our expertise and resources more productively and in mutually beneficial ways.

For example, why should we not mutually accredit and recognize our education and training programs? Why do we not embark on more Continuing Professional Development Programs among our countries? Why should we not encourage greater movement of our health personnel among the countries within our region?

Why do not we embark on more research collaboration activities on health problems of common interest to us? Why should we not foster greater professionalism among our health professionals? I see these as urgent and it is time for us to begin.

I need to mention here the great respect we in Sri Lanka have for your former President, Prof Abdul Kalam. We consider him to be one of the best scientists of South Asia, the whole world, in the last century and have been inspired by his powerful intellect, his simplicity and above all his patriotism to give back to the country much more than he possibly could have received. Your organization is in a very pivotal position to provide leadership in many of these activities.

I wish to submit to you that all of the great philosophies, most of the fundamental scientific principles and inventions originated from Asia and have spread to the West. Buddhism, Hinduism, Christianity and Islam all originated in our neighbourhood and it would be a great pity if we do not explore their potential value for medical education and practice much further.

We in Sri Lanka also have many of these examples in engineering and scientific achievements which have been feats at which Western scientists marvel even today. In this way, they long predate similar Western scientific development. We should try to foster our own models for developing the medical sciences and its practice and generate our own scientific temper.

These in turn could be models for both the East and the West to consider in the future. One essential feature of all such models of health development will have to be a concern for humanity and to ensure that they ultimately lead to the improvement of the lives of our common people.

In an intricately globalized world, I would like to offer this as an exciting regional level challenge for your esteemed organization to address in the next few years.