Long Term Investment in Primary Health Care Pays Off in Sri Lanka
Since the late 1920s, the Sri Lankan health system has been centered on the foundation of formal primary health care (PHC). Given the country’s prioritization of equitable access for a population where ~70% of patients live in rural areas, Sri Lanka has seen remarkable health gains over the last several decades, including rising life expectancy due to reduced mortality among mothers, infants, and children. Sri Lanka has worked hard to integrate public health and primary care with health stations across the country in an effort to try to ensure all patients have a health facility - even just a one-person station offering basic clinical care and public health interventions - within 20 kilometers, and coverage of basic medical facilities are typically situated closer (~1.4km – 4km).
As the focal point coordinator for COVID-19 response in the regional healthcare institute in Sri Lanka, I have witnessed the critical role of strong primary health care systems in responding to emergencies. In Sri Lanka, nearly 50% of primary care consultation, 95% of hospitalizations, and 99% of the preventive care needs of the country are provided by the public health system, integrated with these local health facilities designed to improve geographic access to services. By bringing together the public health system with these primary care service delivery centers working together with local communities, in the time of COVID-19 Sri Lanka has been able to promote a “Three E” approach of engagement, empowerment and enforcement. This has allowed communities to catch the virus faster by initiating testing first through this primary care network, then in secondary and tertiary levels.
Sri Lanka’s health system was designed during a time when communicable diseases were widespread. The past few decades have required adaptations to the organization of the country’s PHC system as the population has begun to see a shift in health needs due to the rising burden of non-communicable disease and the growing aging population, both of which require longer–term and more expensive services.
Compounding the challenges of the aging population and the rise of NCDs, Sri Lanka is now faced with the COVID-19 pandemic, which poses an additional threat to the country’s significant health improvements. As in many other countries, Sri Lanka instituted a lockdown to reduce the spread of the infection. Unlike most of these countries, however, Sri Lanka allowed patients seeking essential medical services to continue to do so. While this approach has promoted the continuity of essential and routine services, it has created some challenges with patient and provider safety due to limited access to PPE. Wherever possible, the Sri Lankan health system has sought to make essential and routine services accessible in a safe way, utilizing telephone consultations, remote refills for prescriptions, and home visits for monitoring NCDs, among other measures.
In addition to the maintenance of essential health services, contact tracing has been critical to control the spread of the virus, which was handled by a field called medical officers of health (MOH). Once a patient is confirmed positive for COVID 19, a notification is forwarded to the relevant MOH areas, where officers trace the contacts including primary and secondary. Once identified, the traced contacts are requested to quarantine for 14-21 days, and are subsequently tested for COVID-19 before reintegrating into their community. Contact tracing is a key action Sri Lanka undertook to control the spread of COVID-19 - these testing and tracing efforts depended on the primary health care system to help carry out.
Now, given that a limited number of local cases are being identified, the government has initiated the testing of all incoming passengers from abroad at airports and ports. This heavy load of responsibility to do sampling of numerous samples in a limited time creates tremendous pressure on staff. I personally participated in early June and became exhausted after nonstop sampling of passengers as part of a team of 5 medical doctors.
Sri Lanka’s ability to quickly and effectively coordinate stakeholders from across the health system in response to the COVID-19 pandemic would not have possible without the strong foundation of primary health care to build upon. Though this crisis has taken its toll, the burden has been significantly mitigated by our early, organized efforts to build a health system centered on the principles of equity, access, and prevention, all of which are core tenets of primary health care.
I am delighted to share more details regarding experiences responding to COVID-19 in Sri Lanka in the video interview linked here.