4.2 Human resources

management; clinic management; Laboratory Information System (LIS); pharmacy stock management; notification of communicable diseases; outpatient department (OPD) management; performance and monitoring of report generation; ward management; user management; Permission and Picture Archiving and Communicating System (PACS) modules. A performance management dashboard is also included in the HHIMS.

By 2017, 35.71% of secondary- and tertiary-care institutions were using EHR for record-keeping at OPDs and clinics. Of these, in 40% of hospitals, 100% of OPD prescriptions were electronic. Electronic prescription can facilitate a review of the prescription and consumption of different types of antibiotics in response to antimicrobial resistance (AMR) through improved stewardship.

4.2 Human resources

The health workforce can be defined as “all people engaged in actions whose primary intent is to enhance health” (World Health Organization, 2006). HR in health care comprises different kinds of clinical and non-clinical staff responsible for public and individual health interventions. Undoubtedly, the most important of the health system inputs, the performance and benefits the system can deliver, depend largely on the knowledge, competencies, attitudes and motivation of those individuals responsible for delivering health services.

The MoH employs slightly over 140 000 staff (both in the line ministry and provincial health ministries). Of all staff, 58% are skilled personnel and, of them, the core is composed of medical officers (specialist and grade medical officers), nurses, midwives, public health inspectors, dental surgeons, medical laboratory technologists and pharmacists (Ministry of Health, Nutrition and Indigenous Medicine, 2017b). Distribution of selected main staff categories and the health facility levels at which they work are shown in Table 4.13.

Table 4.13 Distribution of selected main staff categories and the health facility levels at which they work (2015)

Category Number Curative and preventive care Preventive care TH, PGH, DGH, BH DH PMCU MOH

Medical officers 18 243 √ √ √ √

Dental surgeons Nurses

1 340 √ √ 42 420 √ √

Public health nursing sisters 290

Public health inspectors 1 604 Public health midwives 6 041 Hospital midwives Pharmacists 2 765 √ 1 504 √

Dispensers Medical laboratory technicians 1 177 1 554 √

Microscopists (PHLT) 245 Radiographers 588 √ Physiotherapists 519 √ Occupational therapists 90 √ School dental therapists 349 Dental technicians 50 √ Ophthalmic technician 178 √ Food & drug inspectors 55 ECG recordists 298 √

EEG recordists 66 √

PH field officers 403

Others

2 236

Skilled personnel 82 015

Attendants 9 070 √

Support

Total

49 120 √ √ √

140 205

at RDHS level

BH: Base Hospital; DGH: District General Hospital; DH: Divisional Hospital; MOH: Medical Officer of Health; PGH: Provincial General Hospital; PHLT: public health laboratory technician; PMCU: Primary Medical Care Unit; RDHS: Regional Director of Health Services; TH: Teaching Hospital Sources: Ministry of Health, Nutrition and Indigenous Medicine, 2017b and 2019a

The proportion of non-skilled staff members is relatively higher compared to skilled staff. Although non-skilled staff members do not have formal training, they engage in high-volume multiple tasks, which are necessary in the Sri Lankan context, considering the relatively slow rate of mechanization

and automation of processes. Further, specific assistant staff categories are limited in the Sri Lankan setting; thus, work such as handling electrical equipment, plumbing, lighting adjustments in the theatre, distribution of food in the hospital, some cleaning processes, etc. are handled by the nonskilled staff. Thus, some degree of multitasking is evident, which has some favourable as well as unfavourable consequences on the current system.

The private sector contribution to the provision of health care in Sri Lanka has been growing immensely during the past two decades. Specialists, MOs, nurses and selected PSM and paramedical categories in the state sector have been granted permission to engage in off-hours private work; most of the private sector specialists and MOs are from the state sector. However, the exact number of health-care personnel employed in the private sector currently is not known. The national health workforce accounts would fill in the gaps in statistics in the private sector.

According to a private health sector review (2015), there are 424 full-time and 4845 part-time MOs (Amarasinghe et al., 2015a). The number of nurses working in private hospitals was approximately 4500; most work full-time while some of the nursing tasks were done by nursing assistants. It is estimated that around 50–60% of government sector MOs and more than 90% of government sector medical specialists (consultants) work part time in the private sector. However, private health-care delivery has greatly improved in the past two decades and anecdotal evidence suggests that HR estimates should be much higher than that given by Amarasinghe et al. (2015a).

4.2.1 Health workforce trends The number of health workers in the MoH has been steadily increasing from 2005 to 2015. Given that the population did not grow as fast as the number of health workers, the increase in health workers has led to an improvement in the number of health workers per population. In 2005, there were 2.2 health workers (including doctors, nurses and other cadres) per 1000 population and, by 2015, there were 3.7 doctors, nurses and midwives per 1000 population (World Health Organization, 2018b). This represents a 70% increase in the ratio of health workers to population over the past decade in Sri Lanka. Furthermore, Sri Lanka has almost reached the WHO-identified minimum density threshold of 34.5 skilled health personnel per 10 000 population (World Health Organization, 2014a) in the context of universal health coverage, with a level of 33 skilled health personnel (physicians, nurses and midwives) per 10 000 population. However, this upward trend in the number of staff has not been uniform across all categories (World Health Organization, 2018b). This increment has been significantly higher in MOs, dental surgeons and nurses relative to other staff categories.

Doctors, dental surgeons and nurses

By 2017, there were 19 800 medical doctors (including specialists), 1473 dental surgeons, 45 480 nurses (including trainees) (Ministry of Health, Nutrition and Indigenous Medicine, 2019b). Improvement in the numbers and density of doctors, nurses and dental surgeons is shown in Table 4.14 and Figure 4.2, respectively. During the 2005–2017 period, out of the three staff categories, the number of nurses increased by 128%. The number of MOs and dental surgeons increased by 94% and 54%, respectively. The increase in the number of nurses has been unsteady, with large surges in the number of nurses in 2006, 2007, 2010, 2014 and 2015. Among MOs, such inconsistency is less evident but was seen in 2008 and 2009.

Table 4.14 Distribution of the numbers and density of the health workforce – medical officers, dental surgeons and nurses, 2005–2017

Number Health workforce density, per 1000 population

Year Medical officers

Dental surgeons Nurses Medical officers

Dental surgeons Nurses

2005 10 198 954 19 934 0.52 0.05 1.01 2006 10 279 1 181 24 988 0.52 0.05 1.26 2007 11 023 1 314 31 466 0.55 0.06 1.57 2008 12 479 858 30 063 0.62 0.04 1.49 2009 13 737 1 046 31 297 0.68 0.05 1.53 2010 14 668 1 139 35 367 0.71 0.06 1.71 2011 15 273 1 147 35 870 0.73 0.05 1.72 2012 15 910 1 223 36 486 0.79 0.06 1.79 2013 16 690 1 279 35 629 0.82 0.06 1.73 2014 17 615 1 360 38 451 0.85 0.07 1.85 2015 18 243 1 340 42 420 0.87 0.06 2.02 2016 18 968 1 433 42 556 0.89 0.07 2.01 2017 19 800 1 473 45 480* 0.92 0.07 2.12

*Including around 7500 trainees Sources: Annual Health Bulletin, 2008–2017; Annual Health Statistics, 2017

The ratio of doctors per 1000 population in Sri Lanka increased from 0.52 in 2005 to 0.92 in 2017. However, this is lower than the OECD average of 3.4 doctors per 1000 population in 2015 (World Health Organization, 2018b). The ratio of nurses has doubled during the past decade to reach a density of 2.12 nurses per 1000 population by 2017. This is still significantly lower than the average across OECD countries, where there were around 9 nurses per 1000 population in 2015 (World Health Organization, 2018b).