This success story is based on findings from the Monitoring and Evaluation activities conducted under the Health System Enhancement Project (HSEP) by the Sri Lanka Business Development Centre (SLBDC) on behalf of the Ministry of Health and the Asian Development Bank.
In 2018, Sri Lanka set out on a visionary journey to achieve Universal Health Coverage. The strategy? Strengthen the Primary Health Care (PHC) system through an innovative "Shared Care Cluster System." Partnering with the Asian Development Bank, the Ministry of Health launched pilot clusters across 9 districts to turn local clinics into high-quality, accessible health hubs.
The project's independent Monitoring and Evaluation (M&E) programme, implemented by the SLBDC, rigorously tracked progress from the baseline assessment in 2021 through periodic evaluations, culminating in a comprehensive endline evaluation in early 2026.
The data paints a clear, honest picture of a system in transition. It shows remarkable triumphs, steady steps forward, and clear roadmaps for future improvement. Here is the balanced story of the HSEP journey.
Success Stories
The primary goal of the HSEP reform was to build public trust in local clinics so patients wouldn't have to bypass them for larger hospitals. In this arena, the project achieved outstanding success.
- A Surge in Local Clinic Trust: In the pilot areas, the number of people choosing their local outpatient clinic for curative care nearly doubled, leaping from 29.1% in 2021 to 52.7% by 2026.
- Prioritizing Our Elders: The growth was most profound among senior citizens (aged 65+), where local clinic utilization surged from 27.0% to 55.9%. Local clinics successfully became the primary home for treating chronic conditions like hypertension and diabetes.
- Modern, Inclusive Spaces: Infrastructure received a massive, dignified upgrade. Out of 135 targeted facilities, 111 were fully renovated with gender-responsive and accessible designs. Today, 80.6% feature ramp access at entrances, and 70.1% provide full wheelchair access across all internal service areas, including restrooms.
- Stronger Referral Networks: Clinics are no longer operating in isolation. Today, 80.6% of cluster-linked facilities have established functional referral systems to secondary care hospitals—significantly outperforming non-cluster clinics.
Moderate Gains
Systemic change takes time, and the M&E data highlights areas where steady, foundational progress is being made, though there is still room to grow.
- User Satisfaction & Responsiveness: Patients are noticing the upgrades. High ratings for clinic responsiveness jumped dramatically from around 30% in 2021 to over 74% by 2026. General satisfaction with care also climbed steadily to 68.3%. While these are positive shifts, we aim to push these numbers even higher.
- Staff Training: Significant effort went into capacity building, with staff trained across crucial areas. Up to 20.1% of PHC staff received specialized training in primary healthcare and family medicine, while others were trained in infection control (13.4%) and gender sensitivity (11.6%).
- Gender-Inclusive Care Packages: By the end of the evaluation, 86.6% of the pilot cluster facilities were successfully classified as providing a "gender-responsive and inclusive essential care package," laying a solid foundation for equitable care.
Areas for Improvement
A true success story is also a transparent one. The M&E endline data highlighted vital areas where physical improvements have outpaced behavioral or digital shifts, marking our clear priorities for the next phase of development.
- Rebuilding Community Awareness & Attitudes: Interestingly, while physical clinic usage grew, high community awareness scores regarding assigned clinics experienced a slight decline (dropping from 53.3% to 44.5%), alongside a dip in overall positive attitude scores. This highlights a clear lesson: structural upgrades must be matched by continuous, active community engagement and health literacy campaigns.
- The Digital Frontier: The groundwork for a connected health network via Unique Patient Identification Numbers (HID) has begun, but full implementation is a major hill to climb. Currently, only 9% of pilot facilities are actively sharing patient records electronically across their cluster. However, the blueprint is alive and thriving in the Dambulla (Matale) and Thambuttegama (Anuradhapura) clusters, which serve as models for future scaling.
- Expanding Specialized Services: While dietary counseling services grew beautifully for adults (reaching 89.6%), the data showed that specific nutrition and dietary services designed for the elderly are still lagging behind and require immediate targeted intervention. Furthermore, making family planning services fully gender-inclusive (currently at 34.3%) remains a priority.
The Verdict
The HSEP pilot cluster reform has proven to be a highly effective catalyst for shifting patient preferences toward local primary care, creating a much stronger network of clinics. By celebrating our major infrastructure and utilization wins, recognizing our steady gains in patient satisfaction, and actively addressing our gaps in digital health and community awareness, Sri Lanka is building a transparent, scalable blueprint for an equitable national health system.