Background:

Sri Lanka was and remains a high performer in health status terms, with better health indicators than other low income and low middle income countries. . Mortality rates are low and continue to decline at above average rates in the comparison with other comparable countries. With life expectancy projected to reach current US levels by 2020, the country faces a rapid aging process with an increasing portion of the population suffering from chronic diseases. The number of elderly is expected to increase rapidly after 2010.

The total midyear population (2005) is 19.6 million. The island has a land area – Sq Km 62,705. The per capita GNP was Rs 119,413 (USD 1,188) with a GDP growth rate of 6% (2005)

Sri Lankans enjoy a long life expectancy and in 2006 for male life expectancy was 71.7 yrs, and for female 76.4yrs. In the recent years the male to female difference has been widening.

Health system

The Key provider of health care is through the Government health care system. Western and Ayurvedhic systems are practiced. The Western system of medicine is more popular at present; however significant interest in the Ayurvedhic systems is seen.

The Government health care is totally free of charge to the patient. However out of pocket spending is incurred for transport and sometimes for drugs and investigations that may not be available at the time of seeking care.

The Government health system has a wide coverage that provides accessible care throughout the country. The Health system is hospital based, and preventive and preventive health care being provided through the community health care system.

International comparisons:

Sri Lanka’s per capita income in 2008 is USD 1600 (source – Central Bank, Sri Lanka ) The per capita expenditure on health is USD 31 ( 2003) When compared with other countries that have achieved similar life expectancy and % population above 60yrs Sri Lanka has been able to do this with lesser expenditure on health care.

Table 2. International comparison of health outcomes and expenditures

Source World Health Organization 2006 Countries are ranked in order of increasing GDP per capita

Sri Lanka’s Health sector performance as reflected through selected health indicators (maternal and infant mortality, life expectancy)are far ahead of the averages for countries at comparable levels of income. These health indices however correctly reflect non communicable diseases which have posed a significant health burden affecting all demographic strata and are seen to affect out of pocket health care expenditure. NCDs contribute to 65% of all cause mortality. This is a high rate where the WHO – SEARO region rate is 50% and WHO – EURO regions rate is 85%. (page 68, Sri Lanka: Addressing the needs of an aging population – The WB , Human development division South Asian region, 2008) The cost of addressing non communicable diseases is high in a situation where there is already significant prevalence (Diabetes mellitus 14.2% men and 13.5% women (Wijewardene et al. 2005).

Early diagnosis and long term treatment to prevent adverse outcomes is vital. The management of adverse clinical outcomes of these NCDs becomes costly and hence more emphasis needs to be placed on earlier diagnosis and treatment (secondary prevention). Recent analysis of Sri Lanka’s mortality data (Institute of Policy studies, Sri Lanka) shows that the age adjusted mortality rates are 20-30% higher in Sri Lanka than in the developed countries.

Present Health cadre

The Government health system has 296 categories of staff. As of end December 2008, 46378 approved cadres in the Line Ministry institutions and 52433 in the Provincial Health Institutions, which indicates a total of 106,298 in the Government health workforce? With the 13th amendment to the Governments Constitution the Health system which was a de concentrated system where there was more Central control from the Ministry of Health became a decentralized system from year 1989 onwards. However training of HR and their recruitment and deployment is largely a central function. Minor staff categories are recruited by the Provincial Health Authorities.

Key issues in HRH development-

Several issues are identified ranging from HRH planning, HRH management, training, lack of personnel policies, lack of job description, lack of HR performance management systems. The need for updating of existing staffing norms has been identified.

The Health Master plan, which is the Health Policy document for Sri Lanka outlines the Strategic Framework for Health Development.

A Framework identifies the pivotal role of HRH in the ultimate efforts to improve health service delivery where

1. HRH need to improve- quantity , quality, efficiency, motivation,

2. HR stewardship and management needs to improve

3. Financing for HRH

needs to be improved.

Thus the key determining factor in improving health care delivery is in having adequate, well trained, quality workforce equitably distributed throughout the country.

These key HRH issues have lead to several development initiatives by the Ministry of Healthcare & Nutrition.

HRH expenditure:

The Government spends a large proportion of the health budget on Drugs, Staff salaries and overtime and other allowances.

Health Ministry expenditure (in Rs millions) on selected major items, 2005, 2007

The Deputy Director General (Planning) from the Ministry of Health participated as a Temporary Advisor at the Expert Group Meeting for Finalizing Regional Guidelines for Health Workforce (HWF) Strategic Planning and HWF Database, 28-29 August 2008 in Katmandu, Nepal.

Three Medical officers from the Ministry of Health participated at the AAAH training workshop on Regional Guidelines for Country Strategic Planning of HRH held in 2008. They contributed to the development of the HRH Strategies.

Reviewing HRH needs in revitalizing primary level health care

In keeping with the Health master plan the MoH has initiated policy dialogues with several National Program Directorates and Provincial Health Authorities who are the implementers, to identify how primary health care level can be better suited to address the changing demographic and epidemiological pattern Sri Lanka. These are mainly to address chronic non communicable diseases, mental health, care of the Elderly and emergency care. Ongoing discussions suggest that there will be some changes to existing primary level structures & job functions of Public health staff. Thus a training needs assessment is to follow that will identify gaps in existing training curricula or suggest other capacity building inputs for all primary level staff ( curative and preventive programs)

Following actions are envisaged in the future

1. Restructuring at MoH to have a separate HRD coordinating unit.

2. Policy decisions on HRH at Primary care level

3. Review of HRH training needs

(eg. Develop knowledge and clinical skills for the management of chronic NCDs at primary care level, Management / leadership program for health managers, clinical leaders etc)

4. Revitalize the NIHS as a regional training institute for Public health & management training.

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Sri Lanka the Land like No other