7.4 Health outcomes, health service outcomes and quality of care

The district distribution of selected health workers is presented in Figure 7.17. It is evident that the number of pharmacists and MLTs per 100 000 population is minimal and does not show any significant difference between districts. The number of PHMs mostly remains the same without much fluctuation while the highest district differentials are shown by the numbers of MOs and nursing officers, both categories being higher in districts where superspecialized, specialized and teaching facilities are located, such as in the districts of Colombo, Kandy, Galle and where two health districts are represented within the same administrative district of Ampara.

Figure 7.17 District distribution of selected health worker categories per 100 000 population, 2016

Per 100 000 population 350 300 250 200 150 100 50 0

Colombo Kandy Ampara Galle Sri Lanka Vavunia Polonnaruwa Mannar Badulla Hambantota

Medical officers Matara Anuradhapura Jaffna

Public health midwives Batticaloa Matale

Medical laboratory technologists Kurunegala Kegalle Trincomalee Monaragala Kalutara Mullativu Rathnapura Killinochchi Gampaha Puttlam

Nursing officers Pharmacists Nuwara-Eliya

Source: Ministry of Health, Nutrition and Indigenous Medicine, 2018g

7.4 Health outcomes, health service outcomes and quality of care

When considering the return on investment for the health sector, Sri Lanka has achieved good health outcomes in many fields, including MCH, attendance at birth by skilled health-care personnel and control of VPDs at a comparably low cost. The population coverage of many vaccines of the national Expanded Programme on Immunization is between 96.2% and 99.2% (Department of Census and Statistics, 2018a).

The country managed to achieve most of the Millennium Development Goals and has already achieved some of the targets identified in SDGs such as the maternal, under-five and neonatal mortality rates that are due to be achieved

by 2030.18 Polio, neonatal tetanus, malaria and lymphatic filariasis have been eliminated and the country is on target to achieve elimination of rabies and mother-to-child transmission of HIV and syphilis.

During 2017, Sri Lanka experienced outbreaks of several communicable diseases, including dengue (868 cases per 100 000 population), influenza, which caused 89 influenza-related deaths, and leptospirosis (48 related deaths). There is also a considerably high prevalence of NCDs in the country, a high prevalence of hypertension, diabetes and high blood cholesterol reported in the Colombo district (Central Bank of Sri Lanka, 2018). The high levels observed in the Colombo district may be real or may be due to having more opportunities to be diagnosed or both. Chronic kidney disease of unknown aetiology (CKDu) needs continuing attention from health-care providers, academics and policy-makers due to its adverse socioeconomic impact, especially on low-income households. According to the DHS 2016, the prevalence of CKD was 0.6% in the country (Central Bank of Sri Lanka, 2018). Given the multifactorial nature of CKDu, which may be related to one or more environmental agents, changes in agricultural practices, provision of safe drinking water and occupational safety precautions are recommended (Rajapakse et al., 2016).

With the rapid ageing of the population and the success in combating major communicable diseases, the disease burden has started shifting rapidly towards NCDs, including mental health conditions, accidents and injuries. Furthermore, while the nutritional status has improved, undernutrition remains a problem throughout the life cycle, with increasing obesity and overweight and micronutrient problems. These are some of the areas that need to be improved in order to achieve UHC and attain Goal 3 of the SDGs.

7.4.1 Population health The maternal mortality ratio in Sri Lanka is closer to that of developed countries and this success story has been attributed to many strategies carried out over the years, including implementation of strong preventive health-care services. The MOH and team of public health staff provide comprehensive pre-pregnancy, antenatal, postnatal and childcare packages at clinics close to the residence of the patient and through domiciliary visits. Improved clinical care is provided through the availability of comprehensive emergency obstetric care 24x7 and specialized neonatal and paediatric care services across the country. Free education leading to high literacy rates among women has contributed to the near-universal utilization of these

18 Refer to Table 1.7.

services by women for themselves and their children. Despite the success in maternal, neonatal and child health (MNCH), the past few years have seen NCDs emerge as the leading causes of hospital deaths in Sri Lanka; i.e. ischaemic heart disease, neoplasms, cerebrovascular disease, pulmonary heart disease and diseases of the pulmonary circulation (Ministry of Health, Nutrition and Indigenous Medicine, 2018g).

The WHO NCD risk factor (STEPS) survey conducted in 2015 reported that 45.7% of men and 5.3% of women were current users of some form of tobacco products. The survey further showed that 34.8% of men were current alcohol users (drank in the past 30 days), while 40.2% were lifetime abstainers. When considering women, 96.5% were lifetime abstainers. Nearly 29% of adults were estimated to be overweight or obese, 24.6% in men and 34.3% among women. Only 27% of men and 28% of women were consuming adequate amounts of five or more servings of fruits and/or vegetables per day. The survey also showed that 22.5% of men and 38.4% of women did not meet the WHO recommendations of engaging in physical activity for at least 150 minutes per week.

Limited studies are available on cancer survival. A retro-prospective study, conducted using all breast cancer patients who had sought immunohistochemistry services of the Department of Pathology, Faculty of Medicine, University of Ruhuna from May 2006 to December 2012, concluded that the overall 5-year breast cancer-specific survival rate was 78.8%, whereas the 5-year survival in the UK is 86.6% and in Malaysia, 43.5% (Peiris et al., 2017; Ibrahim et al., 2012).

A study conducted to assess the survival of cervical cancer patients diagnosed in 2008 in the Western Province of Sri Lanka revealed that one-, three- and five-year survival rates were 86%, 70% and 62.5%, respectively (Vithana et al., 2018). There are no follow-up studies or previous studies to compare whether survival rates of these cancers have improved over the years. The 5-year survival of cervical cancer patients in Malaysia was 71.1% and in the UK it was 64.4% (Muhamad et al., 2015). The percentage of cervical cancer diagnosed at the third and fourth stages in Sri Lanka is 48.6% and 4.5%, respectively. Imaging facilities for breast cancer screening are limited and not equitably distributed. Although facilities for Pap smears for cervical cancer are available in all MOH clinics, it is noted that the uptake is variable and still low, though improving.

At present, population-based health data are limited to surveys. It is expected that the envisaged information system linked to the primary curative care reforms would provide population-based morbidity and mortality data.