Compared to other countries in the Southeast Asia region, Sri Lanka has relatively high health status, with comparatively high-quality provision of basic health services 1. More than 95% of births in 2018 occurred in a government health care setting, and vaccination coverage was about 99% 1. Free education has led to a high literacy rate, which has translated into higher health literacy through public health sector education 2. The vast majority of households have access to electricity (98.5%), safe drinking water (89.7%), and water-sealed toilets (79%) 2. In 2000, Sri Lanka had a comprehensive network of health facilities and a large primary health care workforce 3. However, the health system has faced important challenges, including limited development of human resources in the peripheral health system – outside the largest cities – and inadequate geographical distribution of providers, who preferred to work in the country’s larger urban areas 3. The government had great success prioritizing equity of health care access, but this has led to uneven quality of care. As the population has experienced increases in education and income – as well as a rising burden of non-communicable disease – many have begun to bypass primary care facilities for higher-level care facilities, which has led to underuse of the primary care system and overcrowding of the secondary and tertiary care systems 1.
Facility infrastructure and access
In 2018, Sri Lanka’s public health system provided half of all medical treatments, 95% of hospitalizations, and 99% of the preventive care needs of the population 4. Many medical facilities including the majority of secondary and tertiary facilities are open 24 hours per day 5. In an effort to encourage providers to serve non-urban populations, a “dual-practice” system was developed. This allows government sector providers to engage in private practice when off-duty, so they can maintain their public sector employment alongside part-time private practice. This is an incentive for providers to practice in remote areas while maintaining their primary profession in urban areas, and has helped to improve health care access in harder-to-reach areas 2. This has also helped the government retain many of the highly skilled graduates of the country’s health education system 2.
Importance of assessing both service availability and service readiness
In 2017, Sri Lanka’s Ministry of Health, Nutrition and Indigenous Medicine and Department of Census and Statistics partnered with the Global Fund and WHO to conduct the country’s first Service Availability and Readiness Assessment 5. The results showed that most facilities had a high level of basic amenities: a source of improved water supply was available in almost all (99%) health facilities. Sanitation facilities were available in 91% of public health facilities and all private hospitals. More than two-thirds of facilities (70%) had a consultation room with auditory and visual privacy, and just over half (53%) of facilities had a computer with internet access. However, only 51% of facilities had all tracer items for basic amenities 5, and while there was generally high service availability, service readiness was low for most of the services measured, and particularly with respect to existence of guidelines, staff training in key health service areas, and diagnostic capacity 5.
In Sri Lanka, high levels of facility distribution, equitable access, and service availability has led to comparatively strong health outcomes. However, facility infrastructure assessments have helped to demonstrate gaps in service readiness and determine priorities for the country as it plans for its health system needs going forward. Primary health care facilities are beginning to focus on equipping facilities to prevent, detect, and manage the growing chronic disease burden, continuing Sri Lanka’s commitment to equitable care at a low cost to users and to the government 1. As Sri Lankan’s health needs and expectations change, adapting the health system to improve quality assurance, improve health care waste management streams, and strengthen health facility infrastructure are increasingly recognized as important steps to improve primary health care 1.