1. Director Policy Analysis & Development, Ministry of Health, Sri Lanka
Experiences from Sri Lanka – Planning and financing for primary care development
Dr Susie Perera
Director Policy Analysis & Development, Ministry of Health, Sri Lanka
Bangkok, 2009

2. Three tiered health care delivery system

3. Primary care service delivery structure
Preventive, promotive and basic curative services
Government and Private systems
Government system provides care free of charge
Government system has a preventive /community health service based on Health areas ( defined geographical areas and defined populations – provides domiciliary care and clinic care and targeted interventions in identified communities – schools, workplaces, etc..
The Government system has a curative care system which provides institutional care – out patients and hospitalized care
The Government system is said to be “Free of charge at the point of delivery”
Decentralized system – Primary level services come under the Provincial Health Authorities
Central Ministry of Health gives policy and strategic guidance

4. Preventive health services at Primary level
Decentralized system – Primary level services come under the Provincial Health Authorities
Central Ministry of Health gives policy and strategic guidance
Country is divided into 300 Health areas ( known as Medical Officer of Health MOH areas) 50, ,000population
Each MOH area is managed by the Medical Officer of Health and has a team comprising of AMOH, Dental surgeon PHI, PHNS, PHM SDT, Field Assistants
Community volunteers assist the MOH team in field work.

5. Care components delivered through the MOH team
Maternal and child health care including family planning, Ante Natal Care, Home deliveries, Post Natal Care, Growth monitoring for infants and preschool children
Immunization against major infectious diseases-EPI-Tuberculosis, Polio, Diptheria, Pertusis, Tetanus, Measles
Prevention and control of locally endemic diseases-Malaria, Filariasis, Tuberculosis, Rabies, Dengue, JE
Prevention and early detection of malignancies- mainly through health education , Well women clinics
School Health- growth monitoring, early detection and treatment of common ailments /referrals and immunization against Tetanus and Rubella
Growth monitoring, nutrition advice and providing nutrition supplements

6. Care components delivered through the MOH team - continued
Oral health care
Mental Health promotion
An adequate supply of safe water and basic sanitation-testing for quality of water and inspection and relevant advice on basic sanitation
Prevention of blindness –Screening for cataract and referral, health education
Health Education concerning prevailing health problems and the methods of preventing and controlling them
Prevention of home accidents and treatment of minor ailments

7. Access & coverage – MCH Model!
Preventive Health Services Team have defined populations.
The PHMW has to register all eligible families
PHMWs visit homes. Norm- 1PHMW for 3000 population
Antenatal , Child welfare and family planning clinics are conducted at least one clinic for three PHMW areas. Trend now is to have a fortnightly clinic in every PHMW area
Patients have the choice in accessing care that is convenient to them – Government/ private
any institution

8. Control of Communicable diseases at MOH area level
Public Health Inspectors – 1 : 10,000 population
Maintain profile of notifiable diseases in their area, disease registers, spot maps
Investigation of notifiable diseases, contact tracing, out break investigation
Raising Community awareness
Food sanitation – inspection of food handling institutions,
Water sanitation –
Conduction of rabies control program- dog vaccination, sterilization programs
Malaria, Dengue prevention programs
School health programs- basic screening, assisting in medical inspections, referral, promotion of school health clubs

9. Peoples choice
People can chose to utilize services and participate in programs conducted by the MOH health team
All services are provided free of charge

10. Government curative services – 932 institutions at primary level
Different types of hospitals that provide non specialist services
District hospitals, peripheral units, rural hospitals provide hospitalized and ambulatory care ( now re-categorized as Divisional hospitals)
They are small hospitals that range from 20 – 150 beds.
Central Dispensaries and Maternity Homes provide ambulatory care and only in patient care for deliveries – (now renamed as Primary medical Care units and are upgraded to provide basic emergency care and manned by medical Officers )

11. Basic curative care – medical and minor surgical interventions
Services provided at Government curative care institutions at Primary level
Basic curative care – medical and minor surgical interventions
Emergency care is limited and provided only at the divisional type of hospitals
Most institutions provided drugs only for 3 days on discharge

12. Achievements

13. Utilization trend for primary level institutions

14. Trend for utilization of out patient services

15. Shift of care burden to private sector
Gradual shift of out patient care to private sector
Likely reasons

16. Transition Challenges
Aging population whilst the emphasis for Maternal & child health continues
Increasing burden of Non Communicable Diseases whilst Communicable diseases continue
Changing social environment – injuries, accidents
Increasing demand for high end technology , that is further increasing healthcare

17. Priority functions identified by the Consultative group for Public Health Services at PHC level
Communicable diseases – outbreak investigation, Vector borne diseases
Oral hygiene and dental care
Further strengthening Maternal care
Elderly care
Adolescent & school health
New born care, Child health & Immunization
Reproductive health including un met need for FP, STI, HIV/AIDS
Non Communicable diseases- DM, Hyptn, IHD, Cancer, prevention of blindness
Nutrition interventions
Mental Health, psychosocial wellbeing
Water & sanitation
Food safety
Environment, climate change
Care of the sick in the community
Disaster management (Preparedness,……..)
Occupational Health
Health promotion, BCC , community mobilization, intersectoral coordination– cross cutting

18. Priority functions proposed by Consultative group for Curative services to be provided through the existing Primary level curative institutions
Traumatic injury management
Mx of acute medical emergencies
NCD- risk factor assessment, screening, treatment, referral, management of back referrals
Mx of Asthma / COPD
Oral health care
Elderly care
Mental health care
Rehab care
Health of the young yrs
MCH

19. Gaps
NCD care with emphasis on continuity of care- (now being addressed in the policy for chronic NCD)
Elderly care
Care of the disabled in the community

20. Discussion on PHC model -
Consensus on list of functions to be included for primary level care
Relating functions to structure- can the existing structure provide these functions?
If not – what is the rational service model?

21. Family Practice approach – considerations
Continuity of care
Defined population
Linking existing curative institutions to family practice areas
Use of clear care protocols – WHO PEN
Instituting a referral system

22. Sri Lanka’s Health achievements and how these influence change
Achievement of MDGs – on track
Well suited service delivery structure for MCH
High level of Confidence placed in the system by high level decision makers
Sometimes counter productive for change!
Tendency is to include new programs without changing the present service delivery structure
The health staff has to perform multi tasks.

23. Programmatic planning Vs planning for changes at the primary level
Considering required changes of one program area at a time and inclusion of these to the system
Difficulty to capture the multi- functional requirements to be delivered through one structure – workloads, team work, skill mix

24. Structural gaps identified HRH and other resource gaps identified
Functional task analysis and relating required functions to existing structure s
Structural gaps identified
HRH and other resource gaps identified

25. Engagement in other policy dialogues that are relevant to Primary level organization

26. Health expenditure

27. Rational PHC Model
Should be able to address the present and future needs
Evidence based – pilot studies?
Health service organization should be able to accommodate - ***
Culturally acceptable – should emphasize and build on from peoples demands, health seeking behaviors etc
Other levels of care will need to change
Cost feasible

28. If Major changes envisaged-
What is the change management process
Participatory approach and involvement of relevant stakeholders in the development process – MoH,
Public engagment?
Evolutionary dissemination of evidence and awareness on the process

29. Strengthening capacity for evidence based approach
Costing
Steering committee on Healthcare financing
TWG
research in evolution

30. Progress - Emerging models Family / individual centred care Piloting
Protocols for expansion of NCD care at primary level identified
Preliminary costing in progress –
Informing decision makers at stage by stage
MoH, Finance Commission, Treasury

31. What has been the Challenge in the process ?
Getting the need for change onto the agenda – was the most difficult task
Keeping the discussion momentum
Engaging in several cross cutting discussion themes at the same time
Building capacity and strengthening the processes for research related to healthcare financing

32. Thank You