2.9 Patient empowerment

modest (around 17%) but it is envisaged that in the next 5 years it will be able to produce a significant proportion of the medicines needed by the country, especially for the state sector.

Public–private partnerships too have been incorporated and have helped to expand the production capacities and range of medicines subject to regulation by the NMRA.

2.8.4 Health technology assessment There is no specific unit undertaking health technology assessment (HTA) as its primary function. Despite the non-availability of a dedicated unit for HTA, the basic principles are taken into consideration when developing the Essential Drugs List for the country and also in the functions of the Medical Supplies Department for procurement of medicines and vaccines for the country. The MoH and National Authority on Tobacco and Alcohol (NATA) undertook an HTA to make recommendations for increasing the taxes imposed on cigarettes in 2016–2017. There have been a number of proposals to establish an HTA unit under the MoH, but this has not been realized as yet.

2.8.5 Regulation of capital investment There is no formal mechanism for the regulation of capital investments in the state sector. Health development projects are prioritized according to set criteria, though political considerations can also influence these decisions. The resources for capital investments are made available within the annual or longer-term budgetary allocations for the MoH. For private sector investments from sources within the country, there is no formal approval required, while for investments from outside Sri Lanka, the approval of the Board of Investment of Sri Lanka is mandatory.

2.9 Patient empowerment

Patient empowerment has emerged as a relatively new paradigm that can help to improve patient health outcomes while lowering the costs of care. The concept seems particularly promising for the management of chronic diseases, because empowering patients can be instrumental in achieving success in managing these conditions. At a time when much medical information can be accessed via the Internet and easily communicated to health-care providers, patients and other experts, empowering patients would enable them to make use of the information and knowledge to achieve better outcomes.

The desires of our patients regarding doctor–patient communication point towards the need to minimize the predominantly doctor-centred attitudes, as has been demonstrated in a study (Mudiyanse et al., 2015).

In Sri Lanka with its current literacy rate of 95.7% (Department of Census and Statistics, 2015a), a demand for more and more patient-centred attitudes can be expected, such as sharing of information with patients and developing partnerships between doctors and patients. The inclination for this has been expressed in different ways but has been slow to develop due to the longstanding culture of expecting doctors to make the decisions.

2.9.1 Patients’ choice The people’s health-seeking behaviour is explained with reference to their belief systems and explanatory models that include what they believe to be the cause of the illness, what explains the symptoms they suffer and what they believe to be the most appropriate treatment for a particular illness episode (Arseculeratne, 2002). A greater weight of evidence from a user perspective suggests that treatment-seeking behaviour is not governed deterministically by the beliefs in a given medical system, the choice of therapy being determined by more pragmatic factors such as financial cost, distance and time, previous experience of effectiveness, familiarity with the practitioner, social network of patients and the wishes of the family (Liyanage and Ekanayake, 2018). It has been seen that Sri Lankans use both western and traditional systems interchangeably and also in tandem.

A study showed that health facilities of all types were available in close proximity to households. In addition, householders were aware of these facilities. Although the physical proximity to heath facilities was viewed as satisfactory, the utilization pattern raised several concerns. The findings of the study suggested that the phenomenon of bypassing the closest health facility occurs in outpatient services, a phenomenon that was common to all types of health-care facilities. Hence, it was evident that providing healthcare facilities closer to households alone would not improve the utilization of such facilities, unless the issue of bypassing is adequately addressed. The phenomenon of bypassing a closer facility to attend a more distant one could further increase the demand in certain facilities, leading to a rationing and a deterioration in the quality of services (Weerasinghe and Fernando, 2011).

2.9.2 Patients’ rights A charter of patients’ rights is one of the means of improving and strengthening the health system. The current National Health Policy of the MoH for the period 2016–2025 has as its guiding principle, “to direct the health system to be people centred, while ensuring the concept of universal

health coverage (equitable access to quality services, and financial protection for all patients), assuring patients’ rights and social justice” (Ministry of Health, Nutrition and Indigenous Medicine, 2017a).

Further, the Sri Lanka National Action Plan for the protection and promotion of Human Rights (2011–2016) recognized two goals under the topic “health”, these being awareness of rights with regard to health care and respect for patients’ rights (Ministry of Disaster Management and Human Rights, 2012).

The Organization of Professional Associations of Sri Lanka (OPA) grouped themselves as an informal voluntary group to address patients’ rights. They drafted a charter of patient rights following public submissions, which was reviewed and finalized by the representatives of the Law and Society Trust (LST). Peoples Movement for Rights of Patients (PMRP) reviewed and finalized the draft, which was published in the LST Review (Balasubramaniam, 2006).

2.9.3 Complaint procedures The number of medical negligence cases against medical practitioners has been on the rise in the recent past, probably due to increasing awareness and motivation among the general public. A victim seeking redress for a medical injury or a perceived misadventure can make a complaint to the health authorities, forward an affidavit to the SLMC or Human Rights Commission, lodge a complaint at the police station or file a civil case in the District Court (Ruwanpura, 2009).

2.9.4 Public (community) participation Patient and public involvement and engagement (PPIE) is the process of involving patients and the public in health-care service provision and research to ensure public accountability for decision-making and finances (Hanley, Morris and Staley, 2009). PPIE in health-care institutions in the government sector is addressed through hospital committees, while in medical research this is addressed through public involvement in the research ethics committees.

For example, dengue is one of the most critical public health hazards, which has had a severe impact in the recent past in Sri Lanka. The Government of Sri Lanka has been implementing many programmes and policies to control and prevent dengue. Community participation is one of the key strategies that is keenly followed by the government in implementing successful dengue prevention activities (Riswan, 2015).

2.9.5 Patients and cross-border health care The Sri Lanka National Migration Health Policy has been developed by the MoH in recognition and promotion of the right to health for internal, inbound and outbound migrants and their families left behind in Sri Lanka. Identifying the multifaceted nature of migration health, the Ministry adopted a multistakeholder and evidence-based approach involving 13 key government ministries with technical assistance from the IOM in developing the National Migration Health Policy (Ministry of Health, Nutrition and Indigenous Medicine, 2013).

In line with the National Migration Health Policy, IOM conducts migration health assessments and gives technical assistance to the MoH in developing standards for pre-departure health assessments. IOM offers direct access to health assessments for inbound and outbound migrants. These migrantfriendly health assessments are conducted at IOM’s dedicated health assessment facility established in 2014 in Colombo. Adhering to international best practices, the Centre currently provides pre-departure health assessment services to Sri Lankans immigrating to the United Kingdom, Australia, Canada, New Zealand and Malaysia. This includes the early detection and management of pulmonary tuberculosis (TB).

One of the priority areas identified in the National Migration Health Policy for early implementation under the key strategic area of inbound migration is the strengthening of core capacities and quarantine activities at Sri Lankan ports of entry. Cross-border migration is increasingly becoming a challenge for the health authorities. With IOM’s assistance to the MoH, a comprehensive border health system was launched in 2013 to minimize the risk of crossborder transmission of disease (International Organization for Migration -Sri Lanka, 2013).

The Government has also studied the implications of the General Agreement on Trade and Services (GATS) for investments in the health sector and for strengthening services for medical tourism, but this is still a work in progress and Sri Lanka does not yet boast of an active medical tourism sector. There has been ongoing activity under Modes 1 (cross-border trade) and 2 (consumption abroad) and limited utilization of Modes 3 (commercial presence) and 4 (presence of natural persons) for investments in the health sector and inviting personnel to highly specialized service areas, but these are still not significant. There is increasing interest in exploring the range of possibilities without any disadvantage to the national health personnel and available services.