5.7 Pharmaceutical care

continuity of care, that patients are taken to private hospitals. An evaluation of this service is yet to be undertaken, and limited information is available on the quality of the calls received or the services offered.

Prehospital care in Sri Lanka is still evolving. Geographical inaccessibility, unpredictable travel times, inequitable distribution of resources and inaccessibility during extreme weather conditions remain challenges to the road transfer of patients. Therefore, a limited air transfer service for patients was initiated for selected patients with the approval of the DGHS. However, its cost, safety and effectiveness raise concerns in a small island nation like Sri Lanka.

5.6.2 Training of health personnel in emergency care A postgraduate training programme on emergency medicine was initiated in 2012. MOs who enrolled in the course are now entering the service as specialists in emergency medicine. Since the setting up of the 1990 free ambulance service, emergency medical technicians (EMTs) for pre-hospital care have been trained by the Indian agency in charge of setting up the tollfree ambulance system. The MoH conducts some on-the-job training for nurses and other relevant allied health workers. Despite the countrywide expansion of the emergency ambulance service, a formal training programme for EMTs has not yet been developed by the MoH.

Upgrading the training curriculum of technical-level staff and establishing a national simulation centre has been identified as high priority for A&E (Ministry of Health, Nutrition and Indigenous Medicine, 2015b). Currently, the quality of A&E services is monitored using only five A&E indicators. It is planned to periodically review A&E performance at provincial and district levels (Ministry of Health, Nutrition and Indigenous Medicine, 2016b).

5.7 Pharmaceutical care

5.7.1 Pharmaceutical industry It is estimated that around 20% of the national health expenditure is on pharmaceuticals. Only a small proportion (12% by value) is locally manufactured (Daily Mirror, 2018), and the rest is imported, with India and Bangladesh being the largest providers of medicines to Sri Lanka (Trading Economics, 2019). The annual importation value of pharmaceuticals is SLR 65 billion. The State Pharmaceuticals Manufacturing Corporation is the stateowned manufacturer and there are a few private sector local manufacturers. The MoH has provided a buy-back guarantee for all locally manufactured medicines and this has served as an incentive to expand local manufacture.

None of the pharmaceutical manufacturers in Sri Lanka produce any active pharmaceutical ingredients locally. All manufacturers must have a good manufacturing practice (GMP) certificate. Compliance with standards is assessed annually. With the intention of increasing the local production of pharmaceuticals, a drug manufacturing zone was set up as a public–private partnership in 2016. It is expected that once completed, this will provide nearly 60% of the local pharmaceutical requirement.

Starting in 2016, the government introduced price regulation through a price formula on selected essential medicines as a means of containing their costs and reducing OOPE. Initially introduced for only 48 high-volume essential medicines, it has now been increased to include 72 categories of medicines, including cancer drugs, insulin, glucometers and strips. Similarly, price regulation has been introduced for commonly used devices such as intraocular lenses and stents for angioplasty.

The MSD of MoH provides all drugs and related medical items for all government sector health-care institutions. The MSD imports drugs mainly through the State Pharmaceuticals Corporation. Regional MSDs in each district distribute drugs from the MSDs to health institutions under the purview of provincial councils. The MoH has its own logistic facilities for distribution across the country. Self-distribution is the main mode of distribution of drugs among private importers. The importation and distribution of drugs is regulated by the NMRA guidelines (National Medicines Regulatory Authority, 2019).

5.7.2 Regulation and monitoring of pharmaceuticals The NMRA plays a leading role in protecting and improving public health by ensuring that medicinal products available in the country meet the applicable standards of safety, quality and efficacy. The Authority regulates medicines, medical devices, borderline products, clinical trials and cosmetics. The National Medicines Quality Assurance Laboratory (NMQAL) is charged with ensuring the quality of medicinal products and also functions under the purview of the NMRA.

Drug quality assurance is an integral part of the national drug management system. The NMRA and NMQAL are the two principal institutes that work on national drug quality assurance. The NMRA has the mandate of regulating and controlling manufacturing, importation, registration, promotion, sale and distribution of medicinal drugs and devices, and ensuring the quality of drugs that are imported or manufactured in the country (National Medicines Regulatory Authority, 2019).