Sri Lanka Healthcare better than US?

by Michael Patrick O'Leary

I wrote this for Open Salon back in January 2010. I see that my friend Jonathan Wolfman is posting on Open Salon on a relatd subject.

I can’t join in on OS but come over here and comment Jonathan.

Sri Lanka Healthcare better than US?

Will Obama, or anyone else, succeed in providing as effective a health service to poor and middle- income US citizens as Sri Lanka provides for its citizens?

When I told English friends that I was moving to Sri Lanka one said: “How can you risk leaving behind the National Health Service?” As it turned out, I found the Sri Lankan health service to be excellent whenever, which fortunately was not often, I had to use it. When I had a head injury, I was promptly and effectively dealt with free of charge at Bandarawela general hospital. In similar circumstances in England I have had to wait for hours in Accident and Emergency in the company of violent drunks (patients not doctors) and screaming children, eventually to be dealt with by a condescending junior doctor who had probably not slept for days.

My wife had a brain scan at a top London hospital some years ago when she was suffering severe headaches. Nine years on, she has still not received the scan results. Her civil efforts to get the results caused her to be reprimanded by her London General Practioner (GP) for harassing her staff. Sri Lanka is far superior to England in the matter of diagnostic tests. Here it is easy to get the tests done at a reasonable cost and get the results quickly.

The Sri Lankan authorities responded far more effectively to the 2004 tsunami than did US authorities to Hurricane Katrina. Sri Lanka’s past investments in a broad-based public health system and community awareness of basic sanitary and hygienic practices ensured that there were no disease outbreaks. Essential medical aid, emergency food, and other relief supplies were mobilized within a day. It was possible to feed, clothe, and shelter survivors; provide the injured with medical attention; and ensure that the thousands of bodies were quickly cremated or buried.

Susantha Goonathilake wrote in his book, Recolonization, about the influence of foreign NGOs on Sri Lanka: ‘While NGOs stood wringing their hands or trying to mobilize funds only from international sources, Buddhist temples around the country were the quickest to respond. Those affected by the tsunami rushed into temples where they were received with warmth. These temples along the coast became havens of shelter, not only for Buddhists, but also for Hindus, Muslims and Christians. There are innumerable stories of the incredible generosity of these temples. Monks gave up their robes to bandage victims, looked after their children and babies, fed them from whatever little provisions they had, and comforted them. Illustrative of the genuineness of this response was the remote Eastern province temple of Arantalawa. Here LTTE (Liberation tigers of Tamil Eelam) death squads had once hacked to death young Buddhist monks. Now Arantalawa opened itself to nearly 1,000 refugees, most of whom were from the Tamil community and may well have included the very assassins who had hacked the young Buddhist monks’.

Despite international criticism the health services more recently coped well with the closing stages of the war against the LTTE (Liberation Tigers of Tamil Eelam)and the aftermath of the 300,000 internally displaced persons (IDPs). The extremely dire outbreaks of disease in the IDP camps predicted by foreign NGOs just did not materialize.

Prime Minister Wickramanayaka has claimed that public financing for healthcare began in Sri Lanka more than 2,000 years ago when Buddhist kings established public hospitals and maintained them with royal revenues. Ancient records show that 18 hospitals were established by King Dutugemunu in the second century B.C. This tradition was strongly influenced by Buddhist culture which accords high priority to actively caring for the needy, the poor and the sick, he said.

According to the World Health Organisation, a modern health service can be said to have started in Sri Lanka in 1858 with the creation of the Civil Medical Department under a Principal Civil Medical Officer (PCMO). The department initially concentrated on the establishment of new hospitals in large towns. Primary care facilities at village level were initiated in 1877. Initially, preventive medicine was confined to measures aimed at preventing the spread of major communicable diseases.

Today, management of all healthcare institutions, other than private hospitals, teaching hospitals and field services, is the responsibility of the provincial councils but funding is provided by central government from general taxation. There have been significant increases of manpower in the public sector. The government health service is absorbing all the medical graduates graduating from the medical faculties. In 2006 there were six doctors per 10,000 of population and 14 nurses per 10,000.

A wide disparity in the regional distribution in Sri Lanka of health personnel is evident. The Colombo district has a high concentration of most categories of health personnel except public health staff. In 2001, 35 percent of the specialists were concentrated in the Colombo district. The Districts of Kilinochchi, Mullaitivu and Mannar (these areas were controlled by the LTTE) did not have a single specialist.

Reintroduction of private practice for government doctors, liberalization of drug imports and service provision deficiencies in some government hospitals have resulted in the growth of private hospitals in urban centers. There is a thriving private sector in health in urban areas and particularly in Colombo, which boats a number of modern, well-equipped and well-staffed hospitals such as Apollo, Asiri, Nawaloka and Ninewells Gynecological Hospital.

However excellent Colombo’s private hospitals may be, research by Oxfam shows that scaling up government-provided health services is the only proven route to improving life chances in poor countries. Parts of the US are very third-world. Despite serious problems in many countries, publicly financed and delivered services successfully reduced child deaths by between 40 and 70 per cent in a decade in Botswana, Mauritius, Sri Lanka, South Korea, Malaysia, Barbados, Costa Rica, Cuba, and the Indian state of Kerala.

Recently, I suffered severe pain as a result of an ear infection and a perforated eardrum. I went to my GP, who has a clinic in a small private hospital. He normally charges me about 300 rupees ($2.62) but on this occasion did not charge anything as he referred me to a specialist at a private clinic. He does not charge poorer patients anything. The private clinic charged 460 rupees ($4.02). The clinic was overcrowded, noisy and none  too clean. There was a very long wait but the consultant when seen was sympathetic, approachable and competent. He quickly and correctly diagnosed my condition but suggested that, as he did not have the appropriate technology at his private clinic, I should see him the next morning at the general hospital where I would be seen free of charge.

Most specialist who provide services free at the general hospitals dash around all day from private clinic to private clinic. The patients at these clinics are by no means rich but the charges are not high. A new GP clinic has set up in a private home near our temple. The doctor there also works at the general hospital. In Colombo there is an excellent service where one can pay an annual membership fee to have an ambulance with doctor and paramedic call at one’s home when the need arises. They also call at one’s home to take blood tests and deliver the results. The doctors operating this service also work at the government general hospital.

Badulla general hospital has recently opened a magnificent, huge, new building which is extremely clean with spacious wards, modern lifts and equipment. Unfortunately it was opened to the public before they put up any signs so there are a lot of dazed and confused people wandering about at the mercy of vague security guards. We ended up on the maternity ward looking for our eighty-year-old male friend who was being treated for a broken arm.

The MDGs (Millennium Development Goals) have set the agenda for social development in developing countries for the 21st century. In the health sector, it encompasses reducing maternal mortality, under-five mortality and malnutrition; halting and reversing the HIV/AIDS epidemic; reducing the incidence of malaria and tuberculosis; provision of access to affordable essential drugs; to halve by 2015 the proportion of people without sustainable access to safe drinking water and sanitation. (Sri Lanka’s MDG scorecard can be examined at http://www.mdg.lk/)

An article in the January 2010 issue of Le Monde diplomatique by Allan Popelard and Paul Vannier describes the hell that is Detroit. In the course of the article, the authors discuss the inadequacy of health provision in that city. General Practitioners have not been persuaded to stay in the inner city to tend the poor but have migrated to the suburbs where they can make more money. Although the city has some of the best hospitals in the country, only the rich can afford to use them. Popelard and Vannier say “The health indicators for the local population are equal to those of a developing country: infant mortality is 18 per 1,000 [live births], three times higher than the rest of the US and the same as Sri Lanka.”  It is interesting to note that in 2003-05, the infant mortality rate (IMR) in the US as a whole for African Americans was 13.6; the rate for White Americans was 5.7 per 1000 births. IMR is generally seen as an indicator of a nation’s level of health development and is a component of the physical quality of life index. IMR is generally considered to correlate very strongly with, and is among the best predictors, of state failures.

Popelard and Vannier’s statement jarred with me. Sri Lanka has many problems but to one who has lived in the country for over eight years it does not feel anything like a “failed state”. The World Health Organisation (WHO) has said that Sri Lanka’s health indicators are improving all the time.

True, the CIA Fact Book puts Sri Lanka’s IMR at 19 but perhaps the juxtaposition of “CIA” and “Fact” constitutes an oxymoron.

According to WHO’s website, Sri Lanka’s IMR was 11.2 in 2003, significantly better than Detroit today and somewhat better than the US IMR for black citizens. I checked with WHO on 25 January 2010 and they told me that the provisional IMR figure for Sri Lanka for 2006, based on data from the Registrar General (RG) Department, is 10 per 1,000 live births. IMR for 2005 was 11.2. (The source for that is a statistical abstract published in 2008 by the Department of Census and Statistics using RG data.) WHO regards this as a great success and attributes it to “effective and widely accessible prevention and primary healthcare strategies including treatment of minor infections”.

WHO believes that  Sri Lanka’s “Maternal Mortality Ratio of 2.3/10,000 live births in 2000 is an exceptional achievement for a developing country with an income level of about US $ 800 per capita. The improvement of these indicators is attributed to the maternal and child healthcare programme implemented nationally as an integral component of the state healthcare system.” Not just good luck then, but planning, hard work and dedication by selfless professionals who might make more money in other countries.

Life expectancy in Sri Lanka has risen steadily. In 1946 (when the Brits were still running the show) it was 43.9 for males and 41.6 for females. Life expectancy in 2001 for males was 70.7 years; for females, it was 75.4 years. (Life expectancy for black US males was 70 in 2003; the average life-span of an African-American in New Orleans is 69.3 years, nearly as low as life expectancy in North Korea, according to www.measureofamerica.org September 17, 2009).  Sorry if I seem to be picking on Louisiana here. The state does unfortunately seem to come in at number 50 among US states on many quality of life indicators. I had a serious eye condition when I was in Louisiana and received excellent care at a clinic in Baker. However, going to a clinic on Frenchman’s in New Orleans proved to be a traumatic experience that I do not intend to repeat.

WHO says: “Sri Lanka has achieved extraordinarily good health outcomes compared to the level of spending on health.  … During 2001, the provision of public expenditure on health services was 1.6 percent of the GNP and 4.9 percent of national expenditure. The per capita health expenditure was Rs 1,222 ($13.71) in 2001. Recurrent expenditure amounted for 81 percent of the total expenditure.”

In 2001, patient care services utilized 66 percent of health expenditure, while community health services utilized only 8 percent. While the UK has been, since the early 90s, putting more emphasis on primary care in the community to divert patients away from acute hospital care, Sri Lanka’s state services are characterized by a very busy and overcrowded system of national, provincial, general and (Army) base hospitals and a widely-spread network of district hospitals and healthcare units. Sri Lanka reported 0.2 per capita in-patient admissions in 1997. This heavy demand may be due to a number of factors including patients being admitted to hospital when, with better primary care, they could have been treated as out-patients.

My perhaps superficial impression is that Sri Lankans from all social classes are hypochondriacs. Better-off people are always talking about their bowels and their blood-pressure and everyone knows their sugar-level and lipid count. Poor people seem to get validation by going to hospital for minor ailments like the common cold (which they call “fever”) and judge a doctor’s competence by the number of pills they get. I was recently at the birthday celebration of a 96-year-old friend (a good advertisement for the health service – she has survived many serious ailments) where a catholic priest was telling me that his new doctor was much better than his previous one because he had given him eight different pills for his chesty cough rather than the mere seven he had got before.

This is not to say that there are not harsh critics in Sri Lanka of the way the government runs the health service. The Sri Lankan health service is not perfect. There have been public concerns about the quality of drugs imported from India and China and there have been some deaths of children during immunization programs. There are complaints about broken equipment not being replaced and in any system there will be inefficiencies and sloth and torpor. Always in Sri Lanka there are dark hints about corruption. However, the WHO indicators give encouragement that future problems will be addressed. Black citizens of Detroit or New Orleans might be impressed by the health service offered in Sri Lanka.

Dr. Godfrey Gunatilleke, Chairman Emeritus Marga Institute, a private think tank, warned recently that 20% of the world’s population belongs to the elderly category. Sri Lanka’s birth rate is not meeting replacement requirements and the nation’s population is ageing. A strategy for treatment of non-communicable diseases among the elderly needs to be different to the way maternal and infant communicable diseases are addressed.  Gunatilleke said that primary healthcare for ageing revolves around “treatment for morbidity.”  Mental health is one of the non-communicable diseases that have been on the increase. He said that market economics which treat health as a commodity would have to be reconsidered. “When poverty declines, life expansion increases,” he said.

This echoes the findings of an Oxfam study published in a 2009 report entitled Blind Optimism: Challenging the myths about private health care in poor countries. Anna Marriott, author of the report, says  “Thanks to increased state spending on health in Sri Lanka, for instance, women can now expect to live almost as long as those in Germany, despite an income ten times smaller,” Marriott said. “The World Bank and other donors need to put their blind optimism about the market behind them. To achieve universal and equitable access to health care, the public sector must be made to work as the majority provider.”

Although health services are available free of charge to anyone regardless of ethnicity or religion, the Tamils living in the north and east have not been getting the welfare services that they were entitled to. This was not because they were discriminated against by the central government. Even during the fierce fighting at the end of the war the government was trying to get medicines to civilians but was thwarted by the separatist rebels. Possibly the biggest challenge is to re-integrate into the national health service those areas previously controlled by the LTTE. In spite of the millions of dollars flowing to that organization from the Tamil diaspora, LTTE stewardship did nothing for the infrastructure of the de facto statelet and did nothing but undermine the welfare of its people.