7.1 Objectives of the health system

The major challenges facing the system at present are inadequate government spending on health to match the demand for services resulting from the epidemiological and demographic transitions, increasing allocative efficiency and maintaining equity and quality of services, particularly at the primary care level. There is a system mismatch since the prevailing system had been built mainly for managing episodic acute conditions. The level of GGHE, 8–9% of GGE, is inadequate, as reflected by the high level of OOPE, which has been more than 50% of CHE since 2008. The government health allocation since the beginning of the “good health at low cost” era in the 1980s cannot meet the current health challenges.

Further, implementation of health system reforms to provide quality peoplecentric, first-contact curative care services, manage the rising burden of NCDs and the problems of an ageing population, while maintaining equitable access and improving the quality of services poses a challenge. Outbreaks of diseases such as dengue and H1N1 infections, and both acute and chronic undernutrition among children under 5 years of age continue to burden the system. In response to these challenges, a policy on health-care delivery for UHC (Ministry of Health, Nutrition and Indigenous Medicine, 2018e) has been launched and many supportive policies towards promoting health have been formulated in recent years.

This chapter aims to provide an assessment of the health-care system in Sri Lanka, especially regarding financial protection, equity in financing, access to health care, user experience, health and service outcomes, quality of care, and health system efficiency, transparency and accountability.

7.1 Objectives of the health system

The Constitution of the Democratic Socialist Republic of Sri Lanka does not explicitly state that health is a fundamental right. However, an indirect statement in Article 27 2 (c) reads as follows:

“The realization by all citizens of an adequate standard of living for themselves and their families, including adequate food, clothing and housing, the continuous improvement of living conditions and the full enjoyment of leisure and social and cultural opportunities” (Parliament of the Democratic Socialist Republic of Sri Lanka, 1978).

The present health-care system in Sri Lanka is a result of the Health Services Act of 1952 (Parliament of the Democratic Socialist Republic of Sri Lanka, 1952), many policy interventions since then and the Provincial Councils Act of 1987 (Parliament of the Democratic Socialist Republic of Sri Lanka, 1987). The founding principles of the health service of independent Sri Lanka has

been to ensure health care of high quality, free at the point of delivery to all its citizens, thus ensuring services to all rather than focusing on a demandbased approach.

The country has a commendable preventive health-care system with health indices comparable to those of developed nations, but the same is not true for curative care services, which are resource intensive. Tracer UHC indicators on prevention have achieved high levels when compared to other lower-middle-income countries but indicators on treatment coverage are lagging behind. The system is increasingly under pressure to bring about the changes necessary to address the challenges of the demographic and epidemiological transitions but has been slow to respond. This has led to the formulation of many policies in health and related areas in recent times.

The enactment of the National Authority on Tobacco and Alcohol (NATA) Act No. 26 of 2006, after the FCTC ratification in November 2003, saw the establishment of NATA, which resulted in measures such as 80% pictorial warning on cigarette packs, ban on advertising and smoking in public places, and the increase in taxation of tobacco leaf and stick. The total tax on tobacco was 62.1% of the retail price of most sold brands of cigarettes in 2016. The government had not increased retail prices between 2008 and 2016 to make tobacco less affordable until the increase in taxes in 2017 (World Health Organization, 2019b).

2017 saw the revision of the 1992 health-care policy. The new policy will be in operation until 2025 (Ministry of Health, Nutrition and Indigenous Medicine, 2017a). The new strategic plan consists of four separate volumes of HMPs for each of the following areas: preventive health services, curative care, rehabilitative care and health administration, and human resources for health. The objectives of the health system, as stipulated in the new policy document, are as follows: strengthen service delivery to achieve preventive health goals, provide appropriate and accessible high-quality curative care for all Sri Lankan citizens, promote equitable access to quality rehabilitation care, strengthen evidence-based service delivery to support the journey along the continuum of care, develop new strategies to reduce OOP spending and financial risk, ensure a comprehensive health system through better restructuring, including HR management, and develop strategic partnerships with all providers of health care.

In addition to the National Health Policy, 2017 saw the introduction of policies such as on migrant health, health information, and prevention and control of micronutrient deficiencies.15 Another key strategy introduced