Sri Lanka is well known for having low infant and maternal mortality rates and prolonged life expectancy at birth while being a relatively poor country. There is now a better understanding of how the country achieves these remarkable health indices rapidly and consistently. Dr Saroj Jayasinghe and Dr Sarath Samarage report on how Sri Lanka is tackling the social determinants of health.
The Government’s strategy to deal with the social determinants of health consists of broad-based public interventions. For several decades Sri Lanka has provided universal health coverage free at the point of delivery. From the 1920s the country had a system of health units, where a health team led by a medical officer provided preventive services to a defined population. The primary health care model was incorporated early and worked extremely well, with a wide network of grassroots level workers and health clinics providing quality maternal and childcare. Education was provided free to the user. This led to almost universal literacy without a significant gender gap. Other forms of welfare include food security, livelihoods for poor people, and large-scale rural housing programmes. Within this universal framework, priority was given to regions and social sectors deprived of these entitlements. The provision of basic services to remove the people from states of deprivation became primarily the responsibility of the state. Health and education were kept out of the competitive commercial market.
When comparing Sri Lanka with its neighbours, such as India, there are several key features in its history and culture that may have contributed to the rapid decline in infant and maternal mortality rates. The first is the less rigid caste structure in the country, perhaps a reflection of Buddhist influence. The second is that in contrast to its neighbours, Sri Lanka has a culture that respects females. This has encourageds a high uptake in female education and narrowed the gender gap in literacy rates. Underpinning all this, a strong leftist political movement in from the 1930s to the 1970s was a ‘push factor’ for welfare; and u niversal adult franchise, granted in 1931, became an important ‘pull factor’ for state services and the equitable allocation of resources that included health, education and food subsidies.
Current challenges and responses
A shift in the burden of disease to non-communicable diseases poses a different set of challenges of a more complex character. There are inequalities in access to health care, a lack of resources at household level, inequitable distribution of health care services and wide disparities in life styles due to socio-economic inequalities. In the case of non-communicable diseases, significant health inequalities arise from the escalating costs of medical care and the prohibitive prices of life saving or life-prolonging drugs and procedures. Sri Lanka is also facing a huge humanitarian challenge as a result of civilians displaced by the ongoing conflict in the northern part of the country.
The long-term challenge is to reduce health inequalities caused by the changing disease profile, an aging population, and the effects of the conflict. The Government is attempting the following interventions to tackle the social determinants of health:
- Broad-based equity-oriented strategies for development and reducing socio-economic inequalities and within these strategies, identifying the social determinants of health that could be tackled. Examples include the ‘Gemidiriya’ programme (see below); Naganahira Udaanaya, which revitalises previously conflict-affected areas of the east of the country; and Samurdhi Programme, a targeted poverty alleviation programme that focuses on income transfers, empowerment and capacity development for the self-employment of poor people.
- Enhance capacity for human development, and within it healthy living at the household level. Several NGOs are active in this area, Sarvodaya has taken a lead, especially in rural areas. In the conflict affected areas, health care is being provided through the existing channels, as well as through donors and NGOs such as Sarvodaya and Médecins Sans Frontièires.
- Equitable distribution of health care services. Sri Lanka has developed a wide network of health centres and grassroots level family health workers (formerly known as midwives) who deliver primary health care. This forms the back bone of the health care system. More recently, projects such as the Urban Heart (Health Equity Assessment and Response Tool) are being used to assess some of the determinants of health in urban areas. This is being carried out by the Colombo Municipality and WHO-Kobe.
- Protecting and strengthening the public component of development that deals with improving universal access to health and education and controlling the escalating costs of health care.
The Gemidiriya Community Development and Livelihood Improvement Project is a state-managed project with a comprehensive approach for rural development. Its vision is to develop; “strengthened, empowered, formally organised rural communities active in the path to progress”. The programme covers almost 5,000 villages. It facilitates the building of sustainable village institutions and links with local authorities, and increases the size and diversity of economic opportunities through private sector linkages. Gemidiriya uses a concept where communities participate in village development by forming a company registered under the Company’s Act. They adopt five non-negotiable principles: participation by all without discrimination; priority to poor people, women and youth; transparency; accountability; and cost-sharing.
Decision-making is done by the communities, which elect and manage a village institution. There is a direct transfer of funds to the communities which decide on how to spend the money. In three years 800,000 people have benefitted. Roads are easier to access; drinking water is safer; there are village information centres; training and skills development for youth; and employment opportunities for income generation. Surveys have indicated that more than 50per cent of the population have improved their economic and living standards.
Dr Saroj Jayasinghe, Physician and Professor, Department of Medicine, Faculty of Medicine, University of Colombo
Dr Sarath Samarage, Focal point Social Determinants of Health, Director, Organisation Development, Ministry of Health, Sri Lanka.
Filed under: social determinants of health
