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

Three tiered health care delivery system

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

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) 50,000-100,000population 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.

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

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

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

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

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

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 )

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

Achievements

Utilization trend for primary level institutions

Trend for utilization of out patient services

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

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

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

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 15-25 yrs MCH

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

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?

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

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.

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

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

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

Health expenditure

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

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

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

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

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

Thank You