5.2 Curative care services

The strategic area of health promotion and risk reduction specifies the plans for the following: reduction of tobacco and alcohol use; promotion of a healthy diet high in fruit and vegetables and low in saturated fat and transfat, sugar and salt; promotion of physical activity and healthy behaviour; and reducing household air pollution (Ministry of Health, Nutrition and Indigenous Medicine, 2016c).

Cost-effective strategies adopted include NCD screening programmes at the community level and empowering communities to adopt healthy lifestyles. The NCD screening strategy consists of screening people above 35 years of age at healthy lifestyle centres (HLCs), workplace screening and mobile screening. HLCs will address risk reduction through early identification of both behavioural and intermediate risk factors. Currently, there are some 896 HLCs established throughout the country.

Reorganization of primary health care has commenced. It will provide continuing care for NCDs closer to people’s homes. The Ministry has piloted a Package of Essential NCD Interventions (PEN) and adopted an Essential Services Package for Sri Lanka. Both these packages highlight the need for instituting opportunistic screening at primary health-care settings and these proposed changes would need extra HR with a better skill mix. This warrants a rescaling and retooling of existing staff to meet these demands.

5.1.6 Disease-specific campaigns In addition to the above programmes, specific diseases of public health importance are addressed through specialized vertical campaigns, administered centrally. Tuberculosis (TB), sexually transmitted infections (STIs) and leprosy are some such campaigns. The elimination of malaria and filariasis were led by two such vertical programmes. These programmes undertake preventive, curative and rehabilitative activities in disease-specific areas relevant to their mandate. The preventive and promotive components of these services as well as some curative functions reach the community through the MOH system.

5.2 Curative care services

In the government sector, curative services are provided through an extensive hierarchical network of institutions ranging from primary medical care units (PMCUs), divisional hospitals (DHs), base hospitals (BHs), district general hospitals (DGHs), provincial general hospitals (PGHs), special hospitals and teaching hospitals (THs).13

13 Refer to Chapter 4, Table 4.1.

PMCUs and DHs deliver primary medical care. They are manned by MBBSqualified doctors without specialist qualifications. DHs are categorized according to their bed strength. Type A hospitals have more than 100 beds. Type B DHs have a bed strength of 50–100 beds. Hospitals with a bed strength of less than 50 are categorized as type C hospitals.

BHs and a few Type A DHs constitute the secondary level of care. They provide specialized services in general surgery, general medicine, obstetrics and gynaecology and paediatrics, in addition to outpatient services. A few may provide other subspecialties such as ophthalmology and ENT services. Primary and secondary levels of care come under the purview of the provincial ministries of health.

The DGHs, PGHs, THs, special hospitals and the National Hospital of Sri Lanka constitute the tertiary level of care and provide services in a wide range of specialties. These are managed by the MoH.

All curative services provided in the government health system are free of charge for the patient at the point of delivery. However, due to the large numbers utilizing the system, there are long waiting lists for some of the specialized investigations and clinical procedures.

The institutional network is described in detail in Section 4.1.1. In addition to these state services, there are GPs who work independently and private hospitals that are based mostly in big cities, which provide curative care.

5.2.1 Patient pathways As there is no gatekeeping process within the Sri Lankan health system, citizens can access any of the curative care institutions without any barriers. Once a patient makes contact with an MO at any primary care level, the decision is made to either treat the patient as an outpatient, inpatient or, if deemed necessary, refer to a specialist care unit. Also, patients are able to directly select an institution of their choice independently, irrespective of the level (secondary or tertiary) as the first point of contact. This weakness in the system has given way to overcrowding of secondary- and tertiary-care levels with underutilization of primary care institutions (Ministry of Health, Nutrition and Indigenous Medicine, 2017b). Although there are no official processes to transfer patients treated at private hospitals to state facilities, such instances have been observed (Figure 5.3).

In the private sector, patients can visit a GP who also takes the decision on whether the patient needs specialized care, or whether the patients can themselves directly visit a medical specialist as an outpatient. In Sri Lanka,