2.4 Decentralization and centralization

(public health nursing sister, supervising public health inspector, supervising public health midwife, public health inspector and public health midwife).

2.3.1 The private sector The private sector mainly provides ambulatory care, limited inpatient care and rehabilitative care of varying degrees of sophistication. Private services are financed mainly through out of pocket (OOP) payments by households/ individuals and, on a limited scale, through private health insurance schemes. OOP expenses have been increasing over time and currently stand at 51% of current health expenditure (CHE) (Table 3.1, Chapter 3). A private health sector review carried out in 2015 reported that there were 424 fulltime and 4845 part-time MOs (Amarasinghe et al., 2015b). The part-time practitioners are government MOs engaged in private practice in their offduty hours who provide the bulk of private primary outpatient care. Most of these private clinics are operated on a solo practitioner basis and most also dispense medicines. Full-time private practitioners are a gradually dwindling group, because only a very limited number venture into taking up private practice as a full-time vocation.

The private hospitals provide outpatient and inpatient services and specialist consultations, the latter being mostly by specialists in government service practising in their off-duty hours. In addition, private pharmacies and investigative services have also expanded significantly both within private hospitals and as independent entities.

The private sector claims to bring certain advantages to their clients, the main ones being the availability of services at convenient times and absence of waiting lists. In addition, the ability to select the specialist of one’s choice and continuity of care under the same doctor are also considered important reasons for seeking private sector services. Greater confidentiality in private settings as compared to public facilities was also identified to be an important factor in patients choosing private sector services (Govindaraj et al., 2014).

2.4 Decentralization and centralization

The MoH is responsible for managing the health services of the country and is the lead agency providing stewardship to health service development and delivery. Its main function is formulating government health policy, health legislation and regulating services provided by both the government and private sectors. It is also responsible for directly managing several large specialized hospitals (National Hospital of Sri Lanka, teaching hospitals, specialized hospitals, provincial general hospitals and selected

district general hospitals), while the nine provincial health ministries are responsible for effective implementation of services in their respective provinces, especially in the areas of primary care, secondary care and preventive services.

Central and provincial links in health care are maintained and strengthened through the National Health Development Committee and regular meetings of the directors of institutions under the Ministry of Health. Provincial health administrators meet regularly with the Ministry authorities and discuss problems and, to some extent, monitor activities at provincial and district levels.

Although decentralization has given the provinces the power to formulate their own statutes, decentralized decision-making is not common and is affected by the control imposed by the central level over functioning at the provincial level and the high degree of financial dependence of the provinces on the Central Government. Certain processes are affected by the additional administrative layers and administrative costs. Thus, it is generally surmised that most provincial councils have not been as efficient and effective in service delivery as the line ministry.

The administrative head of the PMoH is the Secretary Health. The Provincial Director of Health Services (PDHS) is the technical lead of the provincial health department. He is also accountable to the Secretary and DGHS on technical matters. Each health district of a province has an RDHS who is answerable to the PDHS as well as to the MoH administrative officials (Figure 2.2).