Sri Lanka is a densely populated island nation, with about 20 million people whose per capita income is US$1,500, well above the South Asian average. The country’s health outcomes are among the best in South Asia and comparable to many industrialized countries. The country’s public preventive and curative health services are available free of charge to its citizens. Notwithstanding these achievements, Sri Lanka still has an unfinished health agenda with a need to address malnutrition, non-communicable diseases, some remaining and newly emerging communicable diseases, and issues related to fast-aging population. Current major challenges are two-fold: strengthening the stewardship functions at the central level so that services can be better delivered through the decentralized health service delivery system; and addressing the healthcare needs of vulnerable populations, particularly the conflict-affected in the Northern and Eastern provinces.
The IDA-financed Health Sector Development Project was launched in 2004 to contribute to improvements in efficiency, utilization, equity of access, and quality of public sector health services in Sri Lanka. It supports provincial and district health authorities to improve service delivery and outreach, as well as helping meet the special health care needs of the conflict-affected Northern and Eastern provinces. Financial assistance was provided to the Central Ministry of Healthcare and Nutrition to improve efficiency and quality of hospital services. Additional support was also given to policy development in maternal and child health, nutrition, immunization, non-communicable diseases, and mental health programs.
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The approach taken by the project consists of two main principles. First, in line with Government’s policy of devolving primary and secondary health care to the provincial and district levels, the bulk of the project resources are allocated to those decentralized levels; in fact, the recent restructuring and additional financing has moved more funds from the center to the provinces where the IDA funds are more needed and make a greater impact. Second, largely programmatic in its design, the project is guided by and contributes to the health plans of each district thus the approach is to build systems and capacity, which are sustainable, rather than financing isolated interventions.
The project improved health care quality by increasing the proportion (from 13.3 percent to 35.3 percent) of primary and secondary-level health facilities that provide emergency health services. It also increased the proportion (from 2.2 percent to 27.1 percent) of hospitals meeting service quality standards in Sri Lanka. The proportion of pregnant women screened for anemia increased five-fold, from 14.3 percent to 73 percent.
Highlights:
- Women’s preventive healthcare improved. The screening of women over 35 years for non-communicable diseases — such as diabetes, hypertension, breast cancer and cervical cancer — doubled from 1,011 to 2,367 per 100,000.
- Screening capacity expanded. The number of non-communicable disease-screening facilities expanded. The number of districts with at least 10 well-women screening centers increased from 12 to 16.
- Post-partum care improved. The proportion of women receiving post-partum care increased from 67 percent to 75 percent.
- Policies and training strengthened. Policies were developed for nutrition, non-communicable diseases, maternal and child health, and mental health. A Pilot National Nutrition Surveillance System was established in 30 nutritionally vulnerable areas in Sri Lanka. The Public Health Midwife Nutrition training curriculum was updated after a lapse of 40 years.
- Prepared for the worst. The establishment of isolation facilities in 20 hospitals to be better prepared for future pandemic threats.
- Established a series of firsts. A countrywide, 25,000-household National Demographic Health Survey was conducted, with district-wise data being available. A Human Influenza Surveillance System is being established in Sri Lanka. Ninety-three clinical guidelines were developed for quality improvement of in-patient services. As a result of the introduction of a decentralized, digitalized death registration system, the eight-year delay in producing national death registration data in 2003 was reduced to two years.
The Health Sector Development Project launched in 2004, is expected to close on December 31, 2010. The total project cost initially was US$72.6 million, with US$60 million from IDA. The project has undergone two amendments during implementation: the first reallocated US$19 million to tsunami rehabilitation in early 2005 and the other reallocated US$3.5 million to support avian influenza initiatives in late 2007. To replenish the shortfall in funds created by these reallocations and to cater to the new needs emerging from the end of the 2009 military conflict in the North and East, it received additional financing of US$24 million with a six-month extension. The new funding would continue to support decentralized health service delivery at the provincial and district levels. Of the additional amount, US$12 million are allocated to the conflict-affected Northern and Eastern provinces.
The Ministry of Healthcare and Nutrition, the Finance Commission, and the nine provincial councils of Sri Lanka implement the Health Sector Development Project as part of the overall health sector program. The World Health Organization, the Japan International Cooperation Agency, UNICEF, UNFPA, UNAIDS, GAVI, and the World Bank Group are collaboratively providing technical support for capacity building and implementation.
Challenges remain in what the original project focus areas sought to address. The team is currently working on an analytic and advisory activities (AAA) study on curative care services and non-communicable diseases, as well as a detailed project preparation to better address nutrition in rural Sri Lanka. Based on these findings and in close collaboration with the Ministry of Healthcare and Nutrition, the World Bank Group is expected to initiate project preparation for a new Health Sector Development Project in 2010.
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