S
ri Lanka (the British colony of Ceylon until independence in 1948), has despite economic, political and social problems and thirty years of a bitter civil war ending in 2009, consistently maintained overall exemplary health indicators for a developing country. In the first decade(s) of the twenty-first century it has health indicators (life expectancy of 82 for women, 78 for men and an infant mortality rate (IMR) rate of 5 per 1000 live births) akin to much richer countries. Whilst acknowledging the contribution of socio-economic and political factors to this achievement, the effectiveness of its health care system, must take pre-eminence.The foundations of this health care system, which has made it a model for developing countries, were laid down in 1858 in the colonial period. From the beginning western trained Sri Lankans were providers of state medical care in hospitals and dispensaries. The Colombo medical school, founded in1870, was crucial in the extension of the medical services as it was from these Colombo trained professionals that pressure for the extension of the health services to the general population came. The two decades of self-government before independence following the Donoughmore Constitution in 1931 with the instigation of
universal suffrage contributed to a further rapid expansion of health services as politicians sought support from the electorate.
Furthermore, the devastating 1934–35 Malaria epidemic (with an estimated 80–100,000 deaths) was instrumental in extending the health infrastructure to hitherto neglected rural regions. It also exposed the widespread poverty of the Sinhala peasants (who constituted the majority of the population). It entrenched welfarism (free health care, food subsidies and free education) in nationalist elitist politics and shaped public policy and state interventionism in the first three decades after independence. Free education was also particularly salient for health; by the end of the colonial period Sri Lanka was notable for its levels of female literacy—44 per cent by the mid-1940s. Since women are deemed the principal health providers in families and communities, this was a significant contributing factor to this health record.
The experience of the traditional medical systems—
principally Ayurveda, alongside Siddha and Unani—was also singular in the colonial period. In the 1920s and 1930s the colonial government established and subsidized a Board of Indigenous Medicine, a training college and a hospital.
Although funded minimally compared with expenditure on the Western medical services, traditional medicine was from the onset of independence an integral part of the official medical landscape. Additionally, the indigenous medicine of Sri Lanka places great value on good health and eschews a fatalistic attitude to illness. Thus, cultural norms fostered a health seeking behaviour that encouraged accessing medical aid in whatever form and medical pluralism was firmly established.
Lastly, Sri Lanka had an extensive preventive health care system from the 1920s. In 1926 as a collaborative venture between the Rockefeller Foundation and the colonial government a Health Unit was established at Kalutara.
The programme of work of this first health unit included maternity and child welfare services, health education, sanitary work, communicable diseases work and school medical inspections. In 1937 malaria control work was also incorporated into health unit programmes concurrently with the multiplication of these units. The purpose of the health unit was preventive not curative and as they expanded across the island they formed the basis of the primary health care infrastructure that continues to this day.
The legacy of the colonial period was an extensive infrastructure of both curative and preventive services.
In 1949 S. W. D Bandaranaike, then Minister of Health, declared his government’s acceptance of the WHO’s concept of health as a fundamental human right. All governments since have recognized and maintained this commitment. By the 1970s there were nearly 2000
hospitals, five specialized campaigns for tuberculosis, malaria, filariasis, leprosy; and 98 health units. However, whilst mortality declined the incidence of morbidity did not. Aside from the underlying causes of ill-health (poor housing, insanitary conditions, lack of pure water supply, poverty), there were inherent problems within the health care system itself. Firstly, not all had equal access to these services. The ad- hoc establishment of medical institutions meant a vastly uneven spread. The rural poor, who made up about 70 per cent of population, were ill served by this infrastructure. They lived in villages, away from roads and transport links, in areas where doctors were reluctant to serve and where services were thin on the ground. The Tamil labourers on the tea estates too suffered from the same disparities. Their health indicators noticeably deteriorated in the decades following independence in relation to the general population. Between 1972 and 1975 IMR in this rural estate sector was over 100 per 1000 live births—twice the reported national rate.
Moreover, there was little coordinated planning in the use of the health services. There was no structure of referral and people by-passed the local institutions for the hospital that had the specialists, the best facilities, medical technology and the drugs. Therefore the large urban hospitals of Colombo, especially were always oversubscribed and the smaller provincial and district institutions under-utilised further cementing the inequalities. An offshoot of this was that it was hard to persuade doctors to work in rural areas where career and monetary rewards were limited.
The Ayurveda sector was government funded and flourishing. The ratio of government funding between the Western and Ayurveda sector increased from 73:1 in 1946–47 to 18:1 in 1972—but this still only made up about 3 per cent of total health expenditure. Their services were easily accessible—in 1972 the average distance to an Ayurveda practitioner or institution was 0.8 miles. They constituted a system for providing services spread over the whole country but they did not participate in either family health or in the control of communicable diseases.
It was recognized from the 1940s onwards that what was needed was a ‘health policy’ rather than a ‘disease policy’
as summed up by the director of the medical services Dr W.
G. Wickremesinghe as early as 1945. Despite this ongoing acceptance of the benefits of preventive medicine the balance of government expenditure was overwhelmingly in favour of curative medicine as is the case in most other countries. One estimate of this balance in 1975 suggested that for every rupee spent on the curative sector only 12 cents was spent on prevention of disease and the promotion of health. This situation prompted the director of the Colombo Hospital to ask in 1970: “Was it more important to improve sanitation, nutrition, and health education and provide basic facilities for health and patient care for the masses of this country; or was it more important to go in for sophisticated and expensive programs like heart transplant units?” (Daily News, 3 Sept 1970). However, the hospitals were the visible symbol of Sri Lanka’s free health service and the symbol of modernity; switching resources
to preventive public health was a highly politically contentious issue.
There were deep roots to the development of primary health care services in Sri Lanka and it represented at international level an example of what could be done without the levels of expenditure common in developed countries. Sri Lanka´s experience was an essential part of the debate on primary health care which took centre stage at international level in the 1970s. Furthermore, given the extent of its hospital based curative system it was also a perfect illustration of the limits of that model for low-income countries in the context of a burgeoning population and economic crisis. However, in the succeeding decades the challenge for Sri Lanka has remained that of finding the most effective route to reducing morbidity. This is now an ever more pressing priority with the demographic transition to an ageing population and the resulting double disease burden.
Dr Margaret Jones University of York United Kingdom