1.4 Health status

and cities, respectively, while the pradeshiya sabhas administer demarcated clusters of villages (Parliament of the Democratic Socialist Republic of Sri Lanka, 1987). The country has been able to maintain its democratic traditions despite periods of political unrest, the insurrections of 1971, 1987–1989 and a three decade-long civil conflict, which was successfully settled in 2009.

Sri Lanka’s judiciary consists of a supreme court – the highest and final superior court, a court of appeal, high courts and a number of subordinate magistrate courts. Roman Dutch law is called the “common law” of the country. Criminal law is based predominantly on British law. The civil procedure code, which governs civil matters, is influenced by the Indian, British and American rules of procedure. The constitutional and administrative law has been derived from the Anglo-American systems while the Roman Dutch law is the basis for private legal matters. Kandyan Law, Muslim Law and Thesawalami are laws applicable to certain aspects of life and to defined sections of the population (Ranasinghe et al., 2007).

Since Independence, Sri Lanka has experienced three armed conflicts. There were two insurrections in the south, which mainly involved the Sinhalese youth. These were led by the Janatha Vimukthi Peramuna (JVP), currently a leftist political party in the mainstream politics of the country, the first being in 1971 while the second was a more protracted conflict from 1987 to 1990. These conflicts did not trigger major mass movements of the population, though many individuals and families were temporarily displaced from their homes.

The most severe conflict the country has faced was the 30-year armed conflict waged by the Liberation Tigers of Tamil Eelam (LTTE), aiming to create an autonomous Tamil state encompassing the Northern and Eastern provinces of the country. This was decisively ended when the Sri Lankan army overcame the LTTE in 2009 (Siriwardhana and Wickramage, 2014).

1.4 Health status

Sri Lanka has been able to achieve a relatively high level of health while still being a low-middle-income country. The country has been able to eliminate malaria, filariasis, leprosy, polio and neonatal tetanus and achieve near elimination of most other vaccine-preventable diseases (VPDs) targeted by the EPI. Hospital data show declining trends in admissions for gastrointestinal infections and parasitic diseases. However, emerging new infections such as dengue, epidemic influenza and leptospirosis, and reemergence of old infections such as tuberculosis pose challenges to health (World Health Organization, 2018a).

Figure 1.4 shows that NCDs form the bulk of the disease burden and contribute the highest number of deaths per 100 000 population, the next highest being injuries, suggesting that the country is in the late stages of the epidemiological transition. A steady decline in deaths and disabilityadjusted life years (DALYs) due to all three categories is noted, indicating improvements in health and the social determinants of health.

Figure 1.4 Deaths and DALYs per 100 000 population for major groups, 2004–2016

Deaths/100 000 population 1200

1000

800

600

400

200

0

2004 2008 2016

Group 1 Group 2 Group 3 DALYs/100 000 population 50 000

40 000

30 000

20 000

10 000

0

2004 2008 2016

Group 1 Group 2 Group 3

Group 1–Communicable, maternal, neonatal and nutritional diseases; Group 2–NCDs; Group 3–Injuries, violence, self-harm and accidents Source: Institute for Health Metrics and Evaluation, 2020b

1.4.1 Mortality Table 1.6 shows that LE at birth has been increasing steadily for both sexes, with women enjoying 6.7 years more of life than men. Healthy life expectancy (HLE) at birth has also shown an increase over the years but at a much slower rate than LE. The difference between the two measures has increased over time, suggesting increasing survival with ill-health. The increase in LE and HLE for men over the period 2000–2016 is 4.4 years and 3.6 years, respectively, which is more as compared to 3.7 and 3.1 years, respectively, for women. The increase in HLE at 60 years of age during the 16-year period 2000–2016 is the same for both sexes (1.7 years). These figures suggest that improvements in mortality have been mainly in those below 60 years of age.

Table 1.6 Life expectancy and healthy life expectancy for Sri Lanka by sex, 2000–2016

Both sexes 2000 2005 2010 2015 2016

Life expectancy (LE) 71.0 73.9 74.4 75.1 75.3 Healthy LE (HLE) 63.4 65.7 66.1 66.6 66.8 Healthy LE at 60 years 14.3 15.5 15.5 15.9 16.1 Difference between LE and HLE

7.6 8.2 8.3 8.5 8.5

Male

LE HLE HLE at 60 years Difference between LE and HLE

Female

67.5 70.4 70.9 71.7 71.9

60.8 63.1 63.5 64.2 64.4

13.4 14.2 14.3 15.0 15.1

6.7 7.3 7.4 7.5 7.5

LE HLE HLE at 60 years Difference between LE and HLE

74.9 77.7 77.9 78.4 78.6

66.2 68.5 68.6 69.0 69.3

15.2 16.8 16.6 16.8 16.9

8.7 9.2 9.3 9.4 9.3

Sources: LE: World Bank, 2020; HLE: World Health organization, 2019a

A gradual decline in crude death rates is noted in both sexes. The crude death rate in males (195.7 per 1000 adult males) is 2.7 times that of females (72.9 per 1000 adult females) and is a cause for concern. The country has an effective MCH care system dating back to 1926, which has produced significant gains in terms of IMR (8), NMR (5.8), U5MR (9.4) and MMR (26.8). However, the rate of decline of these indicators has slowed down in the past decade (Table 1.7). It is important to note that both infant and child mortality rates are marginally more in girl children compared to boys.

The bulk of childhood mortality is due to neonatal deaths (71%) and, of the neonatal deaths, the majority (71%) are early neonatal deaths2 (Ministry of Health and Indigenous Medical Services, 2019)3. The most significant causes

2 The death of a live newborn during the first 28 days of life. An early neonatal death is considered by WHO to be death within the first 7 days of life. 3 The Ministry of Health of Sri Lanka has undergone numerous name changes over the past 20 years. In the text of this document, we use “Ministry of Health”, which is the current iteration.

However, when referencing ministry publications, we use the name that was used by the Ministry at the time of publication

of newborn deaths in Sri Lanka are congenital anomalies, prematurity, birth asphyxia and neonatal sepsis (Ministry of Health and Indigenous Medical Services, 2019). Accidents and congenital abnormalities account for about 58% of deaths among 1–5 year olds (Ministry of Health and Indigenous Medical Services, 2019).

The decline in MMR in the country has received many accolades. However, over the past decade, it has been fluctuating between 40.2 and 31.1 per 100 000 live births. It is noted that 65% of deaths in 2017 were due to indirect causes. The most common causes of deaths were dengue haemorrhagic fever (21), heart disease complicating pregnancy (20), respiratory disease (17) and obstetric haemorrhage (11), accounting for 54% of deaths in 2017 (Ministry of Health and Indigenous Medical Services, 2019b).

Table 1.7 Trends in mortality rate, 1970–2018

Indicators 1970 1980 1990 2000 2010 2015 2016 2017 2018

Mortality rate (male) per 1000 adult males 248.3 224.1 258.9 244.8 202.1 198.0 195.7 .. ..

Mortality rate (female) per 1000 adult females MMR (modelled estimates) Neonatal mortality rate (NNMR) IMR

IMR – male 171.4 138.2 120.8 99.9 78.8 74.1 72.9 .. ..

.. .. .. 56.0 38.0 36.0 36.0 36.0 ..

32.1 20.4 12.7 9.6 5.9 5.5 5.3 .. ..

54.4 39.6 18.1 14.2 10.0 8.2 7.8 7.5 6.4

.. .. 16.3 12.8 9.0 7.4 .. 6.8 6.9

IMR – female .. .. 19.9 15.5 10.8 8.9 .. 8.2 5.8

Under 5 mortality rate (U5MR) 71.7 50.1 21.3 16.5 11.6 9.5 9.1 8.8 7.4

U5MR – male .. .. 19.4 15.1 10.6 8.7 .. 8.0 8.1 U5MR – female .. .. 23.1 17.9 12.6 10.4 .. 9.6 6.8

Note: No data were available for perinatal mortality rate and post neonatal mortality rate. Source: World Bank, 2020

It is estimated that NCDs account for 81% of all deaths. The three leading causes of death in the country are ischaemic heart disease (IHD), CVDs and diabetes. All three show increases since 2007, the highest increase being in diabetes (43.4%). Death due to asthma is ranked fourth, with Alzheimer disease and lower respiratory tract infections following. Death due to Alzheimer disease has increased by 50.9% while asthma shows a very small

increase of 1.5% and lower respiratory tract infections an increase of 17.2%. The highest decrease in deaths is seen for self-harm (10.2%) (Institute for Health Metrics and Evaluation, 2020b).

IHD and neoplasms have been the leading causes of deaths in government hospitals, both in 2010 (23.9%) and 2016 (26.1%) (Ministry of Health, Nutrition and Indigenous Medicine, 2018a). The increased caseload of dengue and leptospirosis had increased the rank of zoonotic and other bacterial diseases (Table 1.8).

Table 1.8 Leading causes of deaths in government hospitals in Sri Lanka, 2010 and 2016

Rank Condition 2010 (%) Condition

2016 (%)

1 Ischaemic heart disease 12.8 Ischaemic heart disease 14.1 2 Neoplasms 11.1 Neoplasms 12.0 3 Pulmonary heart disease and diseases of the pulmonary circulation 8.7 Zoonotic and other bacterial diseases 11.6 4 Cerebrovascular diseases 8.7 Pulmonary heart disease and diseases of the pulmonary circulation 8.7

5 Disease of the respiratory system excluding upper respiratory tract infection (URTI) 6 Zoonotic and other bacterial diseases 7.0 Disease of the respiratory system excluding URTI 8.3

6.6 Cerebrovascular diseases 8.2

7 Diseases of the gastrointestinal tract 8 Diseases of the urinary system 9 Pneumonia

10 Symptoms, signs & abnormal clinical and laboratory findings 6.2 Pneumonia 6.4

5.7 Diseases of the urinary system 6.2

5.2 Diseases of the gastrointestinal tract 5.0 Traumatic injuries 5.5

3.9

Source: Ministry of Health, Nutrition and Indigenous Medicine, 2018a

1.4.2 Burden of disease The disease burden in terms of death and disability due to NCDs is estimated to be substantial and has been increasing over the years. From 2007 to 2017, CVD has remained the leading cause of DALYs while diabetes and

kidney disease have gained in importance. This is likely to be due to the increasing problem of chronic kidney disease of unknown aetiology (CKDu) seen in agricultural communities in parts of the dry zone of the country (Ruwanpathirana et al., 2019). In 2017, chronic respiratory diseases showed increased importance, while self-harm and interpersonal violence had a lower ranking in 2017 as compared to 2007 (Table 1.9).

Table 1.9 Top 10 leading causes of DALYs for Sri Lanka, 2007–2017

Sl. No. 2007

1 CVDs 2 Self-harm and interpersonal violence 3 Diabetes and kidney diseases

2012 (%)

CVDs (2.4%)

2017 (%)

CVDs (4.8%)

Diabetes and kidney diseases (18.9%)

Diabetes and kidney diseases (28.6%) Neoplasms (10.2%) Neoplasms (18.4%)

4 Neoplasms

5 Musculoskeletal disorders Musculoskeletal disorders (10.8%)

Musculoskeletal disorders (21.4%) Mental disorders (4.3%) Mental disorders (9.3%)

6 Mental disorders Chronic respiratory diseases (2.7%) Chronic respiratory diseases (7.6%)

7 Chronic respiratory diseases Self-harm and interpersonal violence (–41.9%) Neurological disorders (17.9%)

8 Neurological disorders Neurological disorders (8.3%) Self-harm and interpersonal violence (–44.5%)

9 Other NCDs Other NCDs (2.7%) Other NCDs (–5.8%)

10 Unintentional injuries Unintentional injuries (–11.8%) Sense organ diseases (24.3%)

Note: Percentage change given in parenthesis CVD: cardiovascular disease; DALYs: disability-adjusted life years; NCD: noncommunicable disease Source: Institute for Health Metrics and Evaluation, 2020b

Table 1.10 shows that the largest contributor to the burden of disease in men is ischaemic heart disease, followed by DM, self-harm and stroke, in that order. In women, the biggest contributor to burden of disease is DM followed by IHD and stroke. It is noted that in IHD and stroke, the years of life lost (YLL) form a very high proportion of the DALYs, ranging from 73% to 97%. In men, self-harm and road injuries also show a similar picture, the percentage contribution of YLL to DALYs from these two conditions being 99.6% and 84.5%, respectively.

An important feature that contributes to the burden of disease is the fact that both DM and CVD in Sri Lanka are characterized by early onset and severe course of the disease, leading to disabling complications and premature death (Ministry of Health, Nutrition and Indigenous Medicine and World Health Organization, 2019). These conditions have the potential to produce a sizeable impact on the economic productivity of the country. The need for primary prevention using multidisciplinary approaches is recognized.

Table 1.10 Top five causes of DALYs lost and YLL as a proportion of DALYs by sex, 2017

Sl. No. Causes

Male YLL YLD DALYs Proportion of YLL/ DALYs

(x 1000) (x 1000) (x 1000)

1 Ischaemic heart disease 296.8 10.0 306.8 96.7

2 Diabetes mellitus 118.3 82.6 200.9 58.9 3 Self-harm 147.5 0.6 148.1 99.6 4 Stroke 112.8 21.5 134.4 83.9 5 Road injuries 83.4 15.3 98.7 84.5

Female

1 Diabetes mellitus 101.7 89.7 191.4 53.1 2 Ischaemic heart disease 151.6 7.6 159.2 95.2 3 Stroke 79.4 29.5 108.9 72.9 4 Low back pain 0 88.5 88.5 0 5 Headache disorders 0 84.8 84.8 0

YLL: years of life lost; YLD: years lived with disability; DALY: disability-adjusted life year Source: Institute for Health Metrics and Evaluation, 2020b

Figure 1.5 shows the top 10 leading causes of YLL and the changes over the 10-year period from 2007 to 2017. The highest increases are noted in diabetes, chronic kidney disease and IHD.