Sri Lanka has embarked on an ambitious and timely plan to promote primary health care as the first point of contact for all.
The US $ 60 million project which is financed by the Asian Development Bank (ADB) took off the ground in 2018, covering four provinces as a pilot project. The ADB is providing $ 37.5 million as a concessionary loan, and $ 12.5 million as a grant, while the equivalent of $ 10 million will be met by the Sri Lanka government. Actual work began in January 2019 and the project is set to be completed by November 2023. This is the first ADB financed health programme in Sri Lanka in twenty years.
Sri Lanka’s focus on promoting primary health care follows the WHO’s 1978 Alma-Ata Declaration which identified primary health care as the corner stone of ensuring Health for All.
The Declaration made at an International Conference on Primary Health, with representatives of 150 governments in attendance, states ‘ ‘Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.’
The Sri Lanka project, titled the Health Systems Enhancement Project (HSEP) envisages the upgrading or where necessary, construction of buildings which would be fully equipped to handle health issues of the people, more or less on their doorstep. The project is being implemented in the Central, North Central, Uva and Sabaragamuwa Provinces and a 127 field health units, have been chosen on the basis of one per Medical Officer of Health area. While it has been determined that the largest concentration of extreme poverty is found in the North Central, Uva and Sabaragamuwa provinces, within the Central Province too there are a considerable number living below the poverty line. A total of 7 million people that is 33% of the entire population from the chosen provinces are set to benefit under HSEP.
By subscribing to such a programme, Sri Lanka is actively moving towards health sector reforms, a trend seen world-wide.
At the moment, the first phase of the plan has been completed at the Endana Divisional Hospital, in the Sabaragamuwa Province and a community engagement committee involving health care professionals ,community leaders and civilians appointed to introduce the new model to locals.
HSEP delivery is envisaged as an all-encompassing concept; that is, while the smaller local health units falling within the purview of a Medical Officer of Health will be upgraded to provide the best primary health care to residents, a campaign to effect attitudinal change amongst the people and health professionals is also planned.
For the longest time, Sri Lankan’s have learned to by-pass the closest Health Centers preferring to travel many miles to obtain medical help from the national, general or teaching hospitals. It is their belief that even the smallest of ailments, will be better addressed at these larger or better known and equipped hospitals. But the end result is that Out Patient clinics are bursting at the seams and patients end up waiting long hours to see a doctor who has to rush through the cases. It also means that a doctor’s ability to adequately addressing the health issues of a complicated ailment is limited owing to the sheer volume of patients with minor ailments seeking treatment. Instead, if patients are encouraged to access their local units for minor and common ailments, medical staff in the national hospitals will be free to concentrate on patients whose illnesses need more specialist care.
Under HSEP, the concentration will be partly preventative and partly curative in the case of, especially non-communicable illnesses that could be handled at local level. While the Base Hospitals will be upgraded with latest lab testing facilities and those services will be accessible to smaller health centers and hospitals which will be clustered together and connected to the Base Hospital, patient records will also be digitally available to all the doctors working within that area. Where necessary, doctors will be able to book on-line referrals with specialist doctors attached to the Base Hospitals. Better outreach facilities would also ensure that medical professionals would have the ability to work on the preventive aspects, where residents will receive guidance on life-style changes that could help thwart the development of an illnesses such as diabetes or hypertension for instance. The programme envisages a closer relationship between residents and health care professionals ensuring all those in the target group are registered with the assistance of a Public Health Inspector or a Midwife at the closest hospital; a case in point is the current COVID-19 crisis. A closer relationship between residents and health care professionals would have ensured that the latter would be aware of the medical and travel history of a given resident, and would have, a) enabled the health care professional to advise and monitor the vulnerable residents, b) ensure anyone who has been out of the country/province and had possible exposure to the virus be monitored and encouraged to be tested etc.
Another focus area of the project is to ensure better nutrition for the people, especially mothers and children. Again, the close contact established between locals and health care professionals will come into play in determining the nutritional care required. In the preventative care component the services of civil society members will also be included to help raise awareness amongst the public.
Therefore output of HSEP will be fourfold: Developing primary medical care services, improving preventative measures at primary care level, better communication in raising awareness on using locally available health facilities and improved and district specific continuing care practices, with even online skill development training for health care providers.
Under this scheme, doctors will be exposed to skills in maintaining close relationships with families and individuals in the locality, effective use of doctor-patient relationship to maximise the use of all forms of therapy, utilising and deploying community and health care resources for the benefit of the patient and early identification and health related changes in patients under their care and make screening and testing as necessary, available at local level. A natural fallout of that would be reduced pressure for specialist care and crowding at National hospitals.
Indeed, amongst the populace to benefit most from these reforms will be those who live in the most isolated and deprived communities.
With the full and effective implementation of HSEP, primary care will become the cornerstone to the public having full access to quality and essential health services on an equitable and efficient basis.