PUBLIC HEALTH INTERVENTIONS THEN AND NOW-HOW THEY WILL SHAPE THE FUTURE HEALTH SYSTEM IN SRI LANKA

DOI: http://dx.doi.org/10.4038/sljma.v13i0.5338 Sri Lanka Journal of Medical Administration Vol.13 2011 pp.6-13

As human beings, our health is a matter of daily concern.
course. However, with time scientific knowledge evolved, Regardless of age, socioeconomic or ethnic background, containment measures became more sophisticated and we consider health to be our most basic and essential asset. some infectious disease outbreaks were gradually brought Health, one of the highest aspirations of man, does not exist under control with improved sanitation and the discovery in isolation. It is related to and influenced by a complex of of vaccines. However, microbial organisms are well environmental, social and economic factors ultimately equipped to invade new territories, adapt to new ecological related to each other. niches or hosts, change their virulence or modes of transmission and develop resistance to drugs I intend to describe some important public health interventions that have had significant impact on global History/ Landmarks health and how these have affected our country.
As highlighted by Milan La, quote "The struggle against Significant milestones in the history of health development human oppression is the struggle between memory and in Sri Lanka would be relevant to this topic and will discuss forgetfulness" Unquote -Discussed below are some how Sri Lanka may adopt selected internationally significant landmarks in Public Health interventions recommended public health interventions to strengthen globally. health service delivery for the future.
Plague and Quarantine The WHO's constitution which was first articulated in The practice of separating people with disease from the 1946, defines health as a state of complete physical, mental healthy populations is an ancient one, with both biblical and social wellbeing and not merely the absence of disease and koranic references to the isolation of lepers. The term or infirmity. The enjoyment of the highest attainable th quarantine dates from the late 14 century and the isolation standard of health is one of the fundamental rights of every of people arriving from plague infected areas to the port of human being without distinction of race, religion, political Ragusa for a period of 40 days. Such public health belief, economic or social condition.
measures became international subsequently. The right to health has few key dimensions.
Cholera and Sanitation Firstly "The right to health is an inclusive right" This The physician John Snow's famous work on cholera includes a wide range of factors that can help us lead a notably during the 1854 epidemic in London was based on healthy life. Secondly, the right to health contains freedom.
years of careful recording of outbreaks and heated debate This freedom includes the right to be free from non as to the causes. His work eventually led to improvements consensual medical treatment, such as medical in sanitation in the United Kingdom that reduced the threat experiments and research or forced sterilization. Thirdly, of cholera. the right to health containing entitlements. Fourthly, health services goods and facilities must be available, accessible, Smallpox and immunization acceptable and of good quality.
Smallpox is one of the oldest known human diseases. The right to health is not the same as the right to be healthy.
There is evidence of its existence over 3000 years ago in A common misconception is that the state has to guarantee Egypt. During the 18th century, smallpox killed every us good health. However, good health is influenced by seventh child born in Russia and every 10th child born in several factors that are outside the direct control of states, France and Sweden. Edward Jenner's experiment in 1796 such as an individual's biological makeup and socio brought hope that the disease could be controlled. Jenners economic conditions. Throughout, history, humanity has procedure was soon widely accepted, resulting in sharp been challenged by outbreaks of infectious diseases and falls in smallpox death rates. Through the success of the other health emergencies that have caused death on 10-year global eradication campaign that began in 1967, unprecedented levels and threatened public health security the global eradication of smallpox was certified in 1979. with no better solution than wait until the epidemic ran its diseases. This has resulted in dramatic decline in the tuberculosis, venereal disease and maternal and child incidence of new syphilis infection since 1950. health. The health assembly added two more namely Emergence of Dengue Haemorrhagic Fever nutrition and Environmental Sanitation. These priorities Dengue fever has been reported in South East Asia and came to be known as the "Big Six" and member countries th Western Pacific regions since 19 century. But in 1953 a adopted the strategies.

Major International Public Health Interventions in
new haemorrhagic form of the disease appeared first time Malaria st in Philippines and the 1 epidemic was reported in 1958 in The control of malaria was considered as one of the priority Bangkok with a CFR of 10%. In 1976 WHO identified DHF as one of the priority problems in the region and taken programs of WHO because of the very high morbidity and further action on controlling the disease. These actions mortality. In 1950-1951 control measures were strengthen include establishment of collaborating centres for research with DDT spraying. The first signs of resistance to DDT in on Immuno-pathology of DHF, Dengue Vaccine anopheles was noticed in 1951 in Greece and in 1965 Development and establishment of Aëdes Research Unit in World Health Assembly suggested a change in WHO Thailand. Support was also given for studies on A. aegypti policy on Malaria from control to eradication. The DDT in Indonesia and for the development of rapid diagnostic based malaria eradication campaigns proved to be a techniques in the WHO Collaborating Centre in Virology dramatic success in their early stages. The campaigns at the National Institute of Virology, Pune, India.. reached their pinnacle of success in the mid 60s after which Epidemiological studies on dengue fever, dengue the situation began to deteriorate. haemorrhagic fever (DHF) and dengue shock syndrome changing fast. Diseases such as malaria and tuberculosis, (DSS) were also supported in Indonesia, Myanmar, Sri once thought to have been controlled, threaten the lives of Lanka and Thailand. millions of people in the Region. Plague and kala-azar, which were on the verge of eradication, have resurfaced.

Expanded Programme on Immunization
New diseases, such as a new strain of cholera, and HIV WHO has taken strong initiative in eradication of Small infection, are spreading rapidly in some countries of the Pox from the planet in 1958. Last case of Small Pox in the Region. The 33 World Health Assembly, on the 18 day of May Many of the great natural disasters in history have occurred 1980 declared that the world is free from Small Pox which th in the South-East Asia Region. In addition, there are manwas a most devastating disease in the 20 centaury.
made emergencies such as explosions, chemical pollution, In identifying the fact that diphtheria, pertussis, tetanus, armed conflicts, and ethnic and other civil strife. WHO's measles and Poliomyelitis, in particular was rapidly involvement in emergencies and disaster relief dates from reaching epidemic proportions, the WORD Health its inception in the early years. Later, WHO's policy shifted Assembly in 1974 called on WHO to intensify its activities to the promotion of preparedness at the country, regional pertaining to the development of immunization and global levels. WHO has assisted Member countries in programmes. This resolution formed the basis for the strengthening national capacities for disaster preparedness establishment of the WHO Expanded Programme on and response. Immunization in 1977.

Essential drugs Diarrhoeal Diseases
In collaboration with WHO, countries have established The Control of Diarrhoeal Disease (CDD) programme was national' essential drugs lists and mechanisms for updating launched by the WHO in 1979 and ITS main aim is to them. The trend is towards ensuring adequate supply of reduce the mortality and morbidity from diarrhoeal essential drugs for primary health care. Most countries diseases and their associated effects particularly have also strengthened their distribution system to ensure malnutrition in infants and young children.
availability of essential drugs at health posts and at the first Oral Replacement Therapy was introduced by the WHO as referral level. Some countries have established and a solution to dehydration caused by diarrhea. The strengthened facilities for the production of essential drugs and introduced the concept of Good Manufacturing effectiveness of ORT in reducing mortality was unmatched Practices (GMP). in its simplicity and accessibility to even the poorest families Vision 2020 "The Right to Sight" Iodine Deficiency Disorders WHO statistics show that there are 45 million people who are blind worldwide and 124 million and 134 million There was a high prevalence of iodine deficiency disorders suffering from low vision and retroactive errors in the countries of the Region. These include goitrous respectively. 90% of those people are living in developing enlargement of the thyroid glands. still births. abortions.
countries. 75% of the blindness in the world is either congenital anomalies and endemic cretinism. The World preventive or treatable, yet millions of men and women Health Assembly, in 1990, decided that WHO should aim and children all over the world remain blind. In 1999 WHO at eliminating iodine deficiency disorders in all countries has instituted a joint programme with APB as a global by the year 2000.Universal Salt Iodization was introduced initiative for the elimination of avoidable blindness by year as one of the key measures in controlling IDDS.
2020. It has been captioned "Vision 2020" the "The Right Emerging infectious diseases to Sight": and intends to raise awareness and mobilize resources. For the past 50 years, WHO and its Member States have initiated battle against infectious diseases. As a result of WHO initiative in Preventing Diseases Through this, smallpox, has been eradicated and diseases like Healthy Environment neonatal tetanus and leprosy were eliminated. However, How much disease can be prevented through healthier with the world becoming a "global village" as a result of environments is a question lies at the heart of our global extensive travel and trade, and because of the increase in efforts address the root causes of ill health through antibiotic resistance, the hopes of the 1980s regarding the improved preventive health strategies using the full range eradication or elimination of most infectious disease' are of policies interventions and technologies in our arsenal of Deshiya Chikithsa often based on herbs and medicinal oils, knowledge. Acting together on the basis of coordinated for many centuries in Sri Lanka. health environment and development policies member Historical Background countries can make a real difference in human well being In the early British period the military controlled the health and quality of life.
institutions. The creation of the Civil Medical Department Primary Health Care and Health for all by 2000 in 1858 can be considered as the beginning of the Health The concept of primary health care can be traced back to service in Sri Lanka. Initially, preventive medicine was 1937 international conference held in Indonesia. The confined to measures aimed at preventing the spread of recommendation made at the conference fore shadowed major communicable diseases, smallpox, plague and those made at the international conference on primary cholera. It was only in 1912 that preventive health was health care at Alma-Ata nearly 40 years later.
given due recognition when a Sanitary Branch of the Civil Medical Department was established. The achievements of The concept of primary health care was at first essentially the Civil Medical Department which existed for 90 years an expansion of the ideas contained in the concept of basic health services. But in the Alma-Ata conference it went were considerable. At its creation in 1858, there were only beyond that provision and provided a political dimension 8 hospitals in the country. Shortly before the British left, to primary health care. The principals of primary health the tally was 183 hospitals (including 45 rural hospitals, care philosophy are equity, community involvement, 240 central dispensaries, 176 branch dispensaries and 453 appropriate technology and multi sectoral approach. visiting stations).

Revitalizing Primary Health Care
The concept of establishing campaigns was initiated by the th Rockefeller Foundation which was the first international Year 2008 marks both the 60th birthday of WHO and 30 organisation to assist Sri Lanka's health services. It began anniversary of the declaration of Alma-Ata on primary its operations in 1915 with the object of controlling health care in 1978. While our global health context has hookworm disease. changed remarkably over six decades the values that lie at the core of the WHO consultation and those that informed Health institutional development the Alma-Ata on primary declaration have been tested and Health Manpower in quality, quantity and appropriate remain true. Yet, despite enormous progress in health distribution is critically important for the efficiency and globally, our collective failures to deliver in line with these effectiveness of the health service. Services. Sanitary Officers were appointed to control of pertinent that we look back to the systems of health that infectious diseases and epidemics, bazaar sanitation, and prevailed prior to the onset of foreign domination. The sanitation of urban, rural estate areas. Whilst the general ayurveda system of medicine introduced from India was public health activities became the responsibility of predominantly practiced among the inhabitants of this island. Before introduction of Ayurvedic system with Medical Officers of Health (MOH), Specialised Buddhism in 300 BC historical evidence confirmed a Campaigns for the control of diseases were established presence of a sophisticated system of health care known as from time to time.

Vaccine-preventable Diseases
All these outcomes strongly suggest that Sri Lanka is an exception and outlier in provision of health care with Sri Lanka has a history of immunisation against vaccinelow per capita health expenditure among all developing preventable diseases that dates back to the 19th century. countries in the world. However it appears that to face The success story of immunisation in Sri Lanka started in the present challenges the health system needs to 1886 and continues to this day.
undergo incremental changes as well as system reforms. It is interesting that all activities leading to the present high As such I intend to elaborate the re orientation of the level of immunisation commenced after the declaration of health services to include process reengineering and independence. A streamlined, organised programme was reforms in order to face those challenges successfully. set into motion only in 1978 with the introduction of the Way Forward Expanded Programme on lmmunisation (EPI). This programme has received assistance from the World On the whole globally, people are healthier, wealthier and Health Organisation (WHO) and United Nations live longer today than few decades ago. If children were Children's Fund (UNICEF), as well as other non-dying at 1978 rates, there would have been 16.2million governmental organisations. The results of the deaths globally in 2006. In fact there were only 9.5 million immunisation programme are seen in the decline in such deaths. This shows progress is possible. It can also be vaccinepreventable diseases.
accelerated. There have never been more resources available for health than now. The global health economy Health Financing is growing faster than Gross Domestic Product (GDP), With a population of 20 million and GDP per capita of just having increased its share from its 8% -8.6% of the worlds over US$ 2,000, Sri Lanka is a lower-middle-income GDP between 2000-2005. In absolute terms, adjusted for country. The country is predominantly rural, with only 20 inflation, this represent a 35% growth in the worlds percent of the population living in urban areas. Total health expenditure on health over 5 years period. However there spending-at US$ 43 per capita-is about 4.3 percent of are other trends that must not be ignored. First the GDP, below average for its income level. Government substantial progress in health over recent decades has been spending on health is about 8.4 percent of the overall deeply unequal. Secondly aging and effects of its ill budget. Sri Lanka's population health indicators are better managed urbanization and globalization accelerates than those of comparable income countries. In 2004, life worldwide transmission of communicable diseases and the expectancy was 75 years, and the infant mortality rate was increase of the burden of NCD. Thirdly health sector 12 per 1,000 live births. In 2005, the number of physicians remains massively under-resourced in many countries. and hospital beds per 1,000 was 0.55 and 2.9, respectively, Forth unregulated commercialization is accompanied by higher than in comparable income countries.
blurring of the boundaries between public and private sectors, while the negotiation of entitlement and rights is On the whole, Sri Lanka has achieved enviable results in its increasingly politicized. In many regards, the responses of health sector. Sri Lanka was and remains a high performer the health sector to changing world have been inadequate. in health status terms, with better health indicators than other low-income and low-middle income countries.
Health challenges in Sri Lanka Mortality rates are low and continue to decline at above Despite long list of successes in the health sector, Sri Lanka average rates in comparison with other comparable is forced with an extended health agenda demanding countries. Fertility is already below replacement levels and increasingly more resources. Evidence suggests that the life expectancy projected to reach US levels by 2020.
immediate challenge to be addressed for Sri Lanka is to st Leprosy and filariasis are eliminated as the 1 country in sustain the efforts and successes. Since Sri Lanka is on a South East Asia and the national immunization programme higher base now, any incremental benefit from now on against 10 communicable diseases has been quoted as the ward require higher incremental cost. The main challenges best in the region and one of the finest in the world. Cardio Health spending is justified for two reasons as an According to MDGs, Sri Lanka has to bring child mortality rate down to 7 per 1000 live births. Sri Lanka should aim at investment and as promotion of welfare. Health is an the global best of 3 per 1000 live births. The possible route essential input to produce human capital ultimately to achieve this is the reduction of perinatal mortality, low resulting in improved economic productivity.
birth weight and child malnutrition. More resources, Diseases impede economic growth and development in including high tech equipment, human resources and three ways. First, avoidable diseases reduce number of advanced technology needs to be allocated for this. years of healthy life expectancy. Second, societies with Taking Sri Lanka towards global best high infant and child mortality rates have higher rates of fertility. Large number of children restricts the ability of Despite the phenomenal successes, it is appropriate to the household to spend on the health of each child. Third, place Sri Lanka in a global context in order to know where the high prevalence of diseases also undermines industries the country stands in terms of health achievements. This returns to investment as they are required to spend more will help her to plan the future priorities, so we can move resources to keep their workers fit.
ahead rather than sinking itself in complacency. Sri Lanka has some distance to traverse before she catches up with Similarly it seams that 'wealth is health' because wealthy the world's best. For instance, life expectancy at birth, nations are found to be healthy too. Analysis of GDP per though high still fall below the best achieved in the world capita and life expectancy at birth in 70 countries reveals by 12%. Similarly 80% improvement is possible in that life expectance increases with GDP percapita and reducing IMR, under five mortality, MMR, TB and malaria stabilizes at about 10,000 USD.
deaths. In Sri Lanka reasonably good economic conditions after Health care system as an engine of health development independence permitted the expansion of health care facilities. About 7% of GDP was spent of health, education, As identified MDGs (poverty in particular), lifestyle disorders, ageing, and health system defects as the major housing and food. Health alone received 2.5% of GDP. The priorities requiring immediate attention during the next combined spending on health, education, housing and food decade. Among the four, the first three are welfare issues increased to 10.5 % of GDP from 1961 to 1965. The with implications for health whereas the last one is the expansion and the improvement of the health care health care system issue. More specifically, it explains how infrastructure was largely responsible for the decline in the health care system can act as an engine for the progress morbidity and improved health status. Although higher of health. Efficient macro-organization ensures adequate growth of economy resulted in higher investment in health funding for health care which, in turn, results in efficient till 1960s and benefits accrued were quite apparent, the public sector provision of health care. On the other hand, links appears to have been a short term affair and efficient public provision avoids wastage and enhances the disappeared afterwards. In other words further growth of resource availability which is a prerequisite for the the economy did not favour a higher government spending efficient organisation of health care. All these three on health in Sri Lanka.
positively influence health outcomes, especially for the JICA EBM (evidence based management) study has disadvantaged populations. clearly shown that with the increasing elderly population Strategies identified by national policies and out of proportion emergence of NCD in Sri Lanka the budgetary allocation on health has to be increased by about Sri Lanka falls short of the global best by 12.2 per cent in three fold by 2015. Hence it is essential for the government life expectancy, 35.3 per cent in morbidity, and 8 1 .3 per to spend more on health so as to enhance health and cent in IMR. Poverty is also unacceptably high in Sri Lanka. Regression results indicate that every percentage with conditions ( severe injuries. for instance) defined as increase in per capita GDP results in a significant increase requiring inpatient care should be seen in the inpatient in life expectancy. Nevertheless, given the fact that life facilities. Patients once discharged from the inpatient expectancy in Sri Lanka has already reached a very high facilities will be referred back to the nearest (to the patient) level, it would require a very high increase in per capita outpatient institution. Facilities required for such follow GDP to raise the life expectancy by one year.
up such as drugs should he made available in the outpatient centres. Three policy documents were released during the previous decade. National health Policy 1996, Presidential Task The split of institutions requires commencing new Force 1997 and Health Master Plan 2003 are the three outpatient institutions in urban areas, reclassification of major policy initiatives of the government thus far.
already existing health care institutions, and reallocation of Enhancement of health care resources, comprehensive man power. equipments and other facilities. Private sector health care that includes private sector, decentralization, and the traditional system of medicine should be an recognition of service provision performance appraisal integral part of all these classifications. Each level of system, and quality of care are the key strategies identified government health care institutions must be provided with by these policy documents.
autonomy and incentives adequate enough to deal with local emergencies and needs. Macro organizational structure of health care system affects the efficiency and quality of health services. In One of the major drawbacks of the government health structuring macro-organization for health care, the care system, which the private sector tries to cash in, is that fundamental question is how to divide the complex the government institutions are open only during specified functions of different organizations and make them times of the day. People are forced to use the private sector accountable in achieving societal goals. At present, if they fail to make it to the government centre within the services are concentrated at higher level while the lower specified time. In order to overcome this drawback, level institutions operate without even the basic minimum government can operate late clinics in government facilities. The present organisation does not help to address institutions to cater to the demand arising after the office the problems of the poor and elderly. An issue that has to be hours. The late clinics, to be charged a fee equivalent to 50 addressed through macro organizational structure is how per cent of the private consultation fee, can be staffed by to efficiently and equitably organise primary, secondary. either government or a private doctor(s) on a fee sharing and tertiary care services.
basis. In Sri Lanka, given the disparity in health care loaded in Human resource development and distribution favour of urban areas, it is important to move the health care system (government and private) close to the At present, the size and the quality of the health manpower disadvantaged (estate. rural and old age) populations. One are inadequate in many areas, especially in rural and estate of the strategies available to the government to serve the areas. At the same time, there is excess manpower in some poor and the elderly health is to split the outpatient and urban government institutions. Regarding the size, some inpatient care services in the country. All the outpatients sort of balance between the doctors, nurses and paramedics (whether they hail from urban, rural, or estate) should needs to be worked out and implemented. receive a uniform quality of care. For this purpose, it An increase in the number of physicians over and above the necessary that all the minimum diagnostic and curative combined needs of the government and non-government facilities should be made available at the outpatient sectors might result in supplier induced demand on centres. The most common illnesses can be diagnosed and physician services. Economic theory predicts that an treated at the outpatient level, complicated diseases may require specialists and/or inpatient services, while the most increase in supply of physicians should reduce the price of complicated and serious illnesses may require tertiary care.
services. But in the health sector, an increase raises the Geriatric care, care for non-communicable diseases, and prices. An increase in medical school admissions would treatment follow up should he part of outpatient services.
increase the number of physicians, but also expand the number of specialties and specialists. In turn, it transforms Conditions that would be treated as outpatient and the medical labour market and modality of medical inpatient should be defined clearly and announced to the treatments and Increases the price and quantity of services people through a citizen charter so that people can easily delivered, thus resulting in Increases in overall health care choose the specific institutions for appropriate care. Only' costs. those patients with referral from outpatient centres or those Recommendations government commitment to maintain its cherished principle of high quality public sector and free healthcare I. Increase government spending on health at least service provision will not be compromised at any cost. 2.5-3.0 percent of GDP. Private spending would Therefore introduction of innovative schemes of continue to be about 1.5-2.0 GDP so that the total financing, reorganization and reorientation of health expenditure would be 4.5-5.0 of GDP services, higher investment in health, increase allocative II. Reduction of out of pocket expenditure below efficiency towards preventive health care, enhancing 30% of total health expenditure public sector efficiency will definitely ensure the complete light generated by government vision to guide us along the III. Marking efforts to link national policies and the bumping local and global health development road. national and provincial budgets so that national policies are reflected in resource allocation.

IV.
Restructuring of macro-organizational framework to improve efficiency and equity by splitting outpatient and in patient services. Reclassification of existing healthcare institutions and reallocation of resources will enhance equal facilities at out patient services through out the country.
V. Late clinics should be established in government institutions to cater to the demand arising after the office hours. This will reduce out of pocket expenditure for poor people.
VI. Reorientation of preventive and promotive care to cater for many adolescents, elderly population and lifestyle disorders. Budgetary allocation to preventive health should be increased at least to 20% of total health budget.
VII. Rationalization of manpower (both size and skills) required in each level institution.

VIII.
Periodical performance appraisal of healthcare institutions against their specified objectives and focused on improving quality and good governance.
IX. Establishment of a national health commission to deal with all the health policy matters and healthcare investments both public and private sector.
X. Sri Lankan health system should not only confine to revitalization of primary healthcare and attaining Millennium Development Goals but should be focused on moving towards global best.
In conclusion Sri Lanka is known as a country with a modest economic growth but phenomenal health achievements. The successes at the health sector in Sri Lanka are often commended globally and have been well documented. But it is also the reality that Sri Lanka is now facing new and more formidable challenges. However, the