Better health for Sri Lanka: report on a health manpower study

BETTER HEAL TH FOR SRI LANKA \:~ ... Report on a HEAL TH MANPOWER STUDY by Dr. L. A. Simeonov World Health Organization Regional Office for South-East Asia NEW DELHI November 1975 SEA/PHAi149 , "Price: Equivalent of US$ 1.00" WORLD HEALTH ORGANIZATION B E T T E R H E A L T H F O R S R I by Dr L.A. Simeonov With a Foreword by Dr V.T.H. Gunaratne, Regional Director Principal Collaborators: A. Mejia w.A.B. de Silva H.A. Jesudason N. 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': .·· ........ ....,... ......... ~; Kcluloro Hon,l>ontoto &all• s o_:·, u T _.- H E R "i ' 1 ·· 70 ····-- ------- --·- ··- ·+---- eo ... i i i ------- Scala: I lnOh to SO .,u .. _ ( I : I 1100 1100_) ______ __J CONTENTS Foreword Preface List of abbreviations Introduction CHAPTER 1. 1.1 1.1.1 1.1.2 1.1.3 1.1.4 1.1.5 1.1.6 1.2 1.3 1.4 CHAPTER 2. 2.1 2.1.1 2.1.2 2.1.3 2.1.4 2.1.5 2.2 2.2.1 2.2.2 2.2.3 2.2.4 2.2.5 2.3 CHAPTER 3. 3.1 3.1.1 3.1.2 3.1.3 PLANNING FOR BETTER HEALTH: THE BACKGROUND Sri Lanka The island History, population and social system Education, labour forces, and employment National economy The Five-Year Plan, 1972-1976 Summary Health care services and health planning Recent health manpower planning efforts Summary of the chapter PLANNING FOR CHANGE Strategy of the study Factors conducive to change Decision-makers in health Factors influencing the health decision- making process The place of the NHMS in the decision- making process in Sri Lanka Summary Data, sources, and difficulties in finding them Sub-studies The health information system Certain problems and constraints Differences of interests and the need for compromise Summary Summary of the chapter PRESENT AND FUTURE HEALTH NEEDS AND DEMANDS Problems of population dynamics Historical background The population and its growth Population projection SEA/PHA/149 vii ix xi 1 1 1 1 3 4 5 6 6 10 11 13 13 14 16 18 21 26 26 29 30 33 33 35 36 37 37 37 38 46 SEA/PHA/ 149 Page ii :\ .1.4 3.2 3.2.1 3.2.2 3.2.3 3.2.4 3.2.5 3.2.6 3.3 3.3.1 3.3.2 3.3.3 3.3.4 3.3.5 3.4 3.4.1 3.4.2 3.4.3 3.5 CHAPTER 4. 4.1 4.1.1 4.1.2 4.1.3 4.2 4.3 4.4 CHAPTER 5. 5.1 5.1.1 5.1. 2 5.1.3 5 .1. 4 5.1.5 5.2 5.2.1 5.2.2 5.2.3 5.2.4 5.2.5 Summary Prevalent diseases Diseases in the past Morbidity Disability Mortality Trend of diseases Sunnnary Demand for medical care Outdoor (outpatient) medical care Indoor (inpatient) medical care Private expenditure on medical services Projected demand for medical services Summary Public concern and planned changes The Five-Year Plan The press Summary Summary of the chapter THE HEALTH CARE SYSTEM IN SRI LANKA The western sector The government western sector (1) Services operated by the Ministry of Health (a) Medical care services (b) Public health services (c) Laboratory services (d) Organisation and control (2) Semi-government western services (3) Output of the government western sector The private western sector Summary The ayurveda sector The "other" sector Suilllllary of the chapter HEALTH MANPOWER IN SRI LANKA Medical doctors Current supply Annual new supply Utilization of doctors Loss of doctors Suilllllary Nurses Current supply Annual new supply Utilisation of nurses Loss of nurses Summary 47 48 48 48 51 53 55 58 58 59 63 64 65 68 69 69 72 74 74 77 81 81 81 81 83 84 84 89 90 91 92 93 98 98 101 105 105 110 112 118 120 121 122 122 123 126 127 5.3 5.3.1 5.3.2 5.3.3 5.3.4 5.3.5 5.4 5.4.1 5.4.2 5.4.3 5.4.4 5.4.5 5.5 5.5.1 5.5.2 5.5.3 5.5.4 5.5.5 5.5.6 5.5.7 5.5.8 5.5.9 5.5.10 5.5.11 5.5.12 5.6 5.7 CHAPTER 6. 6.1 6.1.1 6.1.2 6.1.3 6.1.4 6.2 6.2.1 6.2.2 6.2 .3 6.3 6. 3 .1 6. 3. 2 6.3.3 6.3.4 6.4 6.4 .1 6.4.2 6.4.3 6. 4 .4 6.4.5 6.4.6 6.5 Midwives Current supply Annual new supply Utilization of midwives Loss of midwives Summary Ayurveda practitioners Gurr en t supply Annual new supply Utilization Loss Summary Other western qualified personnel Assistant registered medical practitioners Public health inspectors Dental surgeons Medical laboratory technologists (MLT) Radiographers Physiotherapists Dental nurses Pharmacists Dispensers Attendants Other workers Summary Who else sells health in Sri Lanka Summary of the chapter MATCHING HEALTH NEEDS WITH SATISFACTION AND POSSIBILITIES The appropriateness of the health care system Population dynamics aspect Prevention and control of diseases aspect Medical care aspects Summary The adequacy of the health care system Accessibility Inputs Outputs The effectiveness of the health care system Population dynamics aspects Control of diseases aspect Medical care aspect Sunnnary The efficiency of the health care system Capital stock utilization Capital/recurring expenditure ratio Preventive/curative costs ratio Government expenditure on the leading diseases Cost per unit service and its variability Conclusion Summary of the chapter SEA/PHA/149 Page iii Page 127 128 128 129 132 132 132 133 135 137 141 141 142 142 144 145 146 146 147 147 147 148 149 150 151 152 152 155 158 158 160 161 162 162 163 164 165 165 165 166 167 169 169 170 171 172 174 175 176 176 SEA/PHA/ 149 Page iv CHAPTER 7. 7.1 7.1.1 7 .1.2 7 .1.3 7 .1.4 7 .1.5 7 .1.6 7.2 7.2.1 7.2.2 7.2.3 7.2.4 7.2.5 7.3 7.3.1 7.3.2 7.4 CHAPTER 8. THE MAIN PROBLEMS AND POSSIBLE SOLUTIONS Basic problems of the entire health care system Accessibility Services needed Growth of the system Selectivity of utilization Management problems Summary Health priority options Problems of population dynamics Prevalent diseases and their cost Demand for medical care Selection of health programmes Sumnary Health care delivery options Alternatives Summary Summary of the chapter HEALTH MANPOWER IMPLICATION 8.1 Redefinition of the roles of the health 8.1.1 8.1.2 8.1. 3 8.1. 4 8.1.5 8.1. 6 8.2 8.2.1 8.2.2 8.2.3 8.2.4 8.2.5 8.2.6 8.2.7 8.3 8.4 8.4.1 8.4.2 8.4.3 8.5 CHAPTER 9. 9.1 professions Medical doctors Assistant/registered medical practitioners (AMP/RMP) Public health midwives (PHM) Ayurveda practitioners Changes in health manpower structure Sunnnary Supply and maintenance of health manpower Training objectives The curricula The faculty Annual output Time-lag On-job training Summary Integration of the western and the ayurveda systems Basis for policy decision The model The test-run Summary Summary of the chapter INTRODUCING CHANGES Organization of health and manpower planning in Sri Lanka 179 179 179 180 181 185 186 191 191 191 192 193 194 195 196 197 203 203 207 207 209 210 210 210 211 211 211 212 213 213 213 215 215 215 216 217 217 219 220 221 223 223 9.2 9.2.1 9.2.2 9.2.3 9.3 CHAPTER 10. 10.1 10.1.1 10.1.2 10.1.3 10.2 REFERENCES ANNEXES 1. 2. 3. 4. s. 6. Applicability of the findings of the national health manpower study Short-term benefits Medium-term solution The long-term policy Summary of the chapter THE AFrERMATH AND CONCLUSIONS The aftermath Policy level Health sector planning Operational level Conclusions Basic information Methods and approaches for estimating unavailable data Methods of estimating indices and parameters Linear programming model for health manpower requirements List of participants in the national health manpower study Cost of the national health manpower study SEA/PHA/149 Page v 224 224 226 226 227 229 229 229 230 231 231 235 245 277 287 293 307 313 FOREWORD SEA/PHA/149 Page vii The World Health Organization's activities in South-East Asia reflect the endeavours of the governments in this part of 'the world to secure better health for their peoples. The earlier efforts were in the direction of the most pressing health problems, so that, in 1948, top priority was given to malaria, maternal and child health, tuberculosis, venereal diseases, nutri- tion and environmental sanitation; second priority was accorded to public health administration, third to parasitic diseases, fourth to virus diseases, fifth to mental health, and sixth to a miscellaneous collection of other diseases by the First World Health Assembly. Certain other health problems in the Region, e.g., cholera, filariasis, enteric infections, smallpox, and the shortage of trained health personnel, also attracted the attention of the WHO Regional Committee at that time. Since then, many problems have been or are being brought under control. For example, malaria is now not a major killer in this part of the world although its persistence presents other problems; yaws has been eradicated and we are on the threshold of smallpox eradication; life expec- tancy at birth has increased; and the health services have grown in all the countries. However, government expenditures on health are still low and these resources are obviously inadequate to meet the requirement of national priority health problems. In such a situation, governments and WHO have become increasingly aware of the importance of improving the utilization of the available scarce resources, by better management of the health services. As indicated in my programme statement for 1976-1977, much will depend upon the completion of country health programming in the Region by the end of the Fifth General 'Programme of Work of WHO (1973-1977), and it is hoped that governments will also, by that time, have gained sufficient experience in the utilization of modern management techniques and skills in the delivery of different programmes, in monitoring the infoT'!71ation required for repro- gramming wherever necessary, and in evaluating the outcome. Co-operating with goVe'PYllT/ents in the accomplishment of the above task is the main mission of the World Health Organization in South-East Asia, and the publication of this book represents a step in the fulfilment of this mission. This book describes a nation-wide health manpower study carried out by the Government of Sri Lanka in an attempt to improve the management of the health services. Many national institutions and bodies supported the Government's effort, e.g., faculties and schools for the health professions, profess£onal associations, trade unions, the Sri Lanka Medical Council, the Sri Lanka Ayurvedic Medical Council, etc. The World Health Organization provided technical assistance and the United Nations Fund for Population Activit£es and the United Nations Development 'Programme gave financial support. The report on this joint enterprise may be of benefit to other countries, since it shows that the ways leading to the improvement of health SEA/PHA/149 Page viii services may be varied and tha:t it is posaibte to provide adequate heaZth services by the efficient mobiZization and better utiZization of the avaii- abte resources. This book therefore deserves wide pubZicity in WHO and outside the Organization. 31 October 1975 V.T.H, Gunaratne, F.R.C.P.~ D.P.H. Regionai Director PREFACE SEA/PHA/149 Page ix The present growing interest in health manpower planning may be ascribed to the recent expansion of health planning activities and to general concern over the emigration of trained health personnel from the developing countries, as well as to attempts to find suitable solutions to the problem of unemployment in some of these countries. Several studies on national health manpower planning (e.g., in Colombia, Taiwan, Turkey, Peru) and a vast literature on regional and institutional health manpower planning also stimulated both academic and practical interests in this field. In 1970, a WHO scientific group sununarized the experience in the field of health manpower planning research, recognized the need for improvement in health manpower planning practices, and recommended (1) the promotion of studies of health manpower planning in individual countries, (2) establishment of separate study units for health manpower planning, (3) the encouragement of the application of the results of health manpower research to education for the health professions, and (4) the promotion of research activities in the field of health manpower planning methodology (43). The group also stressed the importance of viewing the problem of health manpower in the context of the whole health and socio-economic system of the country. The publication of this book fills a gap between the individual case- studies published elsewhere and the efforts to formalize a theory of health manpower planning. Between these two extremes, this book is intended to show a middle way in the application of abstract health and manpower planning concepts to a real situation, starting with the existing situation in a country and proceeding to the eventual outcome of the health and manpower planning effort. Thus, the approach selected is a great deal more practical than academic. This book is addressed mainly to public health administrators, students, and practitioners of different health occupations, general planners (outside the health field), and decision-makers. To accommodate this wide readership an attempt has been made to avoid the undue use of a technical or planning/management jargon. It was characteristic of all those who participated in the study that they demonstrated high morale, interest, motivation, and efficiency. Their names are listed in Annex 5, but some of them should be mentioned here because they were instrumental in initiating, planning, and conducting the study. Dr C.S. Weeratunge, Secretary of Health, Government of Sri Lanka, and Dr F.A. Wickremasinghe, the Director of Health Services, took a great interest and supported the study at each step. The Study Directorate, consisting of the Study Director, Dr W.A.B. de Silva (Dr H.A. Jesudason, till April 1973), and the Study Co-director, Mr N. Sivagnanapiragasam, as well as the chief researchers, in the various sub-studies put in a great deal of effort. SEA/PHA/149 Page x The unfailing encouragement and interest of the Regional Director, WHO/SEARO, Dr V.T.H. Gunaratne, is especially appreciated. The National Health Manpower Study which provided the factual base for this book, started with the drafting of a protocol in March 1971. The years 1972 and 1973 were devoted to detailed planning for the study and to intensive collection of data, data analysis, and reporting on certain aspects of the health care system and the health manpower process in that system. During this period, substantial support to the study team was provided by Dr A. Bujevic, WHO Representative in Sri Lanka, Dr c. Hart Shaaf, Resident Representative of UNDP and his Deputy Mr M. Priestley, and by the UNFPA project co-ordinator, Dr Majeed Khan. Mr T.K. Sundaresan, Dr John Burton, Dr B. Skrinjar, Dr V. Ovtcharov, Dr S. Litsios, Dr A. Maglacas, Miss T. Rowan, Mr F. Hachette, Mr S. Unakul, Dr G. Cumper, Mr W. Towle, Mr P. Hornby, Mr J. Thilleman, Dr G. Atkinson, Dr Dev Ray and Dr Paul Woolley greatly contributed to the quality of this report by their comments and constructive criticism. However, any errors are the sole responsibility of the author. Mr R.K. Katyal, Mr D.R. Vijh and the "typing pool" in the Regional Office did an excellent job. Finally, the contribution of the principal collaborators, Dr A. Mejia, Dr W.A.B. de Silva, Dr H.A. Jesudason, Dr N. Sivagnanapiragasam and Mrs B. Bubb, and the co-operation of Editorial Services, WHO Headquarters, in the later stages of preparing this book are gratefully acknowledged. AA.IGR A.D. AD AFC AHO AMC AMP A/RMP AVDC ANM B.C. BCG BD BH CD CDN DC DD DH DRS DPT E.H.E. ENT E.Q. & E.R. - FH F.P. LIST OF ABBREVIATIONS Average annual inter-census growth rate Anno Domini Assistant director of health services Antifilariasis campaign Asian Health Organization Antimalaria campaign Assistant medical practitioner Assistant/registered medical practitioner Anti-venereal diseases campaign Auxiliary/nurse midwife Before Christ Vaccine against tuberculosis Branch dispensary Base Hospital Central dispensary "Ceylon Daily News" Disease control Deputy director of health services District hospital Director of health services SEA/PHA/149 Page xi Vaccine against diphtheria, whooping cough and tetanus Environmental health and education Ear-nose-throat (surgery) Epidemiology, quarantine and external resources Family health Family planning SEA/PHA/149 Page xii GDP GMOA GNP HCS HMS HPPD HPPS ILO INH LS MCH MH MLT MO MOH MP MRI MRSP MS NHMS NSES OP OPD p PH PHI PHM Gross domestic product Government Medical Officers' Association Gross national product Health care system Health manpower system Health planning and programming divisions of the Ministry of Health HPPD International Labour Office Insoniazid (anti-tuberculosis drug) Laboratory services Maternity and child health Maternity home Medical laboratory technologist Medical officer Medical officer of health Member of Parliament (National Assembly) Medical research institute Member of the Royal College of Physicians Medical services National health manpower study in Sri Lanka National socio-economic survey, 1969-70 Outpatient Outpatient department Planning Provincial hospital Public health inspector Public health midwife PHN PHS PPBS PU RH RMP Rs SHS TC UK VD vs WHO Public health nurse Public health service Planning-programming-budgeting system Peripheral unit Rural hospital Registered medical practitioner Rupees Superintendent of health services "Times of Ceylon" SEA/PHA/149 Page xiii United Kingdom of Great Britain and North lreLmd Venereal disease Visiting station World Health Organization INTRODUCTION SEA/PHA/ 149 Page xv This report describes the National Health Manpower Study (NHMS) carried out in Sri Lanka in 1971-73. As it was known that much effort and a considerable involvement of staff, funds and material would be needed to complete the study, it was important to judge at the very outset whether such a study should be launched and to try and estimate the chances of its success. The criterion of success must be whether or not the results of the study can be used to generate changes in the existing health care system,* It is therefore necessary to review the health situation prevailing in Sri Lanka before the start of the study and to describe the local factors that may help or hinder the application of the study's findings. The success of the study is important not only with regard to its effect on the health care system as a result of the implementation of its findings, but also from the point of view of establishing health and man- power planning as a continuing process inseparable from the management of the health care system. The following goals of the NHMS were formulated at the time of plan- ning for the study in the context of the national social and economic plans that were to induce and stimulate the health planning process: (1) To assist the government in formulating a health policy includ- ing a policy in the field of family health, and to define the aims and priorities of the activities that are necessary for job definition and task specification in estimating future manpower requirements. (2) To promote the coordination and/or integration of health activi- ties at all levels, whether preventive, diagnostic, therapeutic or rehabili- tative; whether they are based on outpatient or hospital services; whether by voluntary, private, or public agencies, and including also the practi- tioners of indigenous medicine. (3) To assist in strengthening the health statistical system and to contribute to the better utilization of the existing and future demographic and epidemiological information relevant to the health planning process. (4) To promote closer co-operation between the health professional teaching institutions and the national health administration in order to improve the health of the community and to re-orient the education and train- ing of health personnel on the basis of the magnitude of the country's health problems, with due consideration of the role each occupation is to play in the delivery of health services. *For definition of "health system" and "health care system", see Chapter 1, section 1. 2. SEA/PHA/ 149 Page xvi (5) To substantiate the importance of health practice research as a necessary ingredient in education for the health careers and for the administration of health services. To work towards the attainment of the above goals, the following objectives were selected: (1) To determine the pattern of health manpower utilization within the current health care system in order to: (a) identify the points of intervention for the improvement of productivity, and (b) redefine the roles of the basic health occupations. (2) To determine the present needs and demands for health services in order to project future health manpower requirements. (3) To initiate the process of redefining the educational goals for the health professions. This book does not deal exclusively with the findings of the NHMS although they are the starting point. The study's findings are placed in the broad historical, economic, social, and political framework of Sri Lanka with the intention of generating more meaningful conclusions. It may be useful to indicate here the subject matter described in each chapter because some topics may be of particular interest to certain readers. Chapter 1 gives background information on the country, its history, population, sociai system, education, labour forces, employment, and economy. A short description is given of the health services and some recent efforts for health manpower planning are mentioned. Chapter 2 gives an account of the setting in which the decisions for changing the existing health care system should be considered. It represents an attempt to justify the approach applied and to describe certain specific aspects of the NID1S. In Chapter 3 the present and projected health needs and demands of the population are classified in three groups: problems of population dynamics, prevalent diseases, and the demand for medical care. At the same time public concern for these matters, as perceived by the national planners and by public opinion is also described. The existing health care system and its sub-systems: government western (allopathic), government ayurvedic, private western, private ayur- vedic, and private "other" (unqualified, non authorized healers) are depicted in Chapter 4. Each of these is described in terms of capital stock, annual expenditure., and annual output. SEA/PHA/149 Page xvii Chapter 5 gives detailed information on the existing health manpower system. Each category of health manpower is presented in terms of supply, utilization, and attrition. Medical doctors, nurses, midwives and ayurveda practitioners are in the focus of attention. In Chapter 6 an attempt is made at assessing the capacity of the health care system to cope successfully with the health needs and demands of the population. The assessment takes into consideration the appropriate- ness, adequacy, effectiveness, and efficiency of the health care system. The premise in Chapter 6 that the present health care system does not satisfy present demands and is unlikely to satisfy demands in the future is followed in Chapter 7 by an attempt to identify the main problems in the system and their solutions. Because mechanical growth of the health care system will not improve its relevance or selectivity of utilization, the problems of its basic management, or access to it by the population, several options are offered on the reformulation of the national health programme and on the restructuring of the health care system. The economic implica- tions of each alternative are shown. Chapter 8 gives the health manpower implications of each alternative, thus leading to a re-definition of the roles of the health professions and a consideration of the problem of demand for health manpower in the future. The theoretical (based on a model) and practical (based on a test-run in pilot areas) bases for policy decision are discussed. In Chapter 9 the continuation of health and manpower planning as an organized process, and as an indispensable part of a rational health policy is discussed. The aftermath in Chapter 10 describes what happened in the country's health care system as a consequence of the NHMS, and the changed general circumstances which could influence the policies of the decision-maker. The conclusions are confined to three issues: whether the NHMS has achieved its objectives and at what cost, whether the strategy of the study was appro- priate, and what should be done next. SEA/PHA/149 CHAPTER 1 PLANNING FOR BETTER HEALTH: THE BACKGROUND This chapter gives a brief description of the country in its geo- graphic, population, socio-economic, and health-care-services framework. Certain planning efforts that were conducted several years ago in the field of health manpower will also be described. 1.1 SRI LANKA 1.1.1 The Island "Lanka" is derived from Sanskrit and means "resplendence". It is the Sinhalese name of the country. The Aryans, who invaded the island in the fifth century B.C. and founded the Sinhalese race and state, called it Thambapanni, which means copper-coloured, because the earth on the beach where they landed was reddish. The Romans, who used to visit the country sailing from the Red Sea, transformed Thambapanni into Taprobane. The early Arab traders called it Serendib. The Portuguese made Ceilao, Ceylao, and Seyllao out of Serendib. The Dutch preferred Ceilon and Ceylon (17), which name was preserved throughout the period of British rule and after independence till 21 May 1972, when the country was proclaimed the Republic of Sri Lanka, the island of Blessed Resplendence. Sri Lanka is situated very close to India, south-east from the continent, between about 60 and 10° North and divided from the mainland by the shallow Palk Straits. Its surface area is 25,332 sq. miles (18). The climate is tropical with a mean annual temperature in Colombo of 81°F (range 79-82) and mean relative humidity of 77 (day) and 89 (night). However, in the hilly areas up-country, at an altitude of 6,000 to 8,000 feet, the mean annual temperature is around 60°F, but the relative humidity changes very little (18). The north-eastern part of Sri Lanka is the "dry zone" with rather poor vegetation, whereas the "wet-zone" in the south-west has rich tropical vegetation. The hilly central area is where the famous Ceylon tea grows. 1.1.2 History, Population and Social System According to the Mahavamsa, the first Sinhalese chronicles written in the Pali language, the founder of the Sinhalese race (or the Lion race) and Sinhalese state was Vijaya, the leader of the Aryans who invaded the island from India, sometime about SOO B.C. (17). The next important event was the advent of Buddhism in Sri Lanka, brought by Mahinda, a son of the Emperor Ashoka, the Buddhist ruler of the greater part of India, in 247 B.C. (19). Buddhism gave its stamp to the whole cultural and social development of the country until the end of the lSth century, the time of the Portuguese intrusion into the island. The Buddhist period of about 1800 years was dynamic and characterized by frequent wars against the Tamils, who came from South India and finally succeeded in establishing themselves in a considerable number in the north of Sri Lanka. The adminis- trative and cultural centres of the population were located in the "dry zone" SEA/PHA/149 Page 2 where an efficient irrigation system helped to provide food for about 20 million people, according to unconfirmed sources of information. Some irrigation tanks built in the early days of the Sinhalese kingdom still exist in the towns of Anuradhapura, Polonnaruwa, and elsewhere. It is probable that during this period some settlers from Arabia and Malaya came to the island, mainly as traders, and gave origin to the present Muslim connnunity in the island. Robert Knox (20) in his "Historical Relation of Ceylon", which refers to the second half of the 17th century, mentioned the Muslims as an established community. He also wrote about the veddas, jungle tribes considered to originate from the inhabitants of the island before the Aryan invasion. From the 16th century onwards Sri Lanka was invaded by western conquerers. Situated on the route to Indonesia, Indochina, and China, and rich with spices and gems, the island attracted the attention of the Portuguese as early as 1497. Shortly afterwards the Portuguese took over the Sinhalese kingdoms of Kotte and Sitawaka, but not till 1591 did they conquer the Tamil Kingdom in the north. The Portuguese were replaced by the Dutch in 1658. However, neither the Portuguese nor the Dutch succeeded in imposing their rule over the Kandyan Sinhalese kingdom in the central hilly area of the island, which remained free till 1815 when the British obtained control over the whole island. Sri Lanka became politically independent in 1948. During British rule, an English educated middle class secured positions in the administra- tion, including the democratic institutions of the country. The same class continued to hold power after independence was granted, while the Sinhalese- educated and the workers did not have much say in political matters. As Christianity in different forms (Roman Catholics, converted by the Portuguese; Dutch Reformists left behind by the Dutch; and Presbyterians and Anglicans, as a reminiscence of British rule) was the religion of the ruling class, the Buddhist and Hindu religions and their priests occupied a secondary position. Buddhism, however, was the religion of the majority and after its revival in 1956, a political situation was created in Sri Lanka through the efforts of the Sri Lanka Freedom Party. Based on preliminary information from the Department of Census and Statistics, Colombo (27), Tables 1.1 and 1.2 show the percentage distribution of the population of Sri Lanka at the time of the 1971 census, by race and by religion. Table 1.1. POPULATION OF SRI LANKA: PERCENTAGE DISTRIBUTION BY ETHNIC GROUP, 1971 Ethnic group Total Sinhalese Tamil Moor Burghers Malays Others % of population 100.0* 71.9 20.5 6.7 0.3 0.3 0.1 *The individual percentages add up to only 99.8 owing to rounding of the first decimal place. SEA/PHA/149 Page 3 It can be seen in Table 1.1 that the great majority of the population are Sinhalese. However, they are considered to be a heterogeneous group consisting of Low Country Sinhalese and Kandyan Sinhalese. The Tamils are also divided into two groups: Ceylon Tamils and Indian Tamils. A continuous "ethnical transfusion" of Tamils from the mainland is considered to take place even at the present time. The Moors (Muslims) are divided into Ceylon and Indian Moors, and the Burghers are considered to be the descendents of western ethnical groups, mainly the Dutch and British. The Malays are thought to have come as soldiers, mainly along with the Dutch, and settled down in Sri Lanka. Data on the population by religion is presented in Table 1.2 which shows that the Buddhists are in the majority with 67.4%. Table 1.2. POPULATION OF SRI LANKA: PERCENTAGE DISTRIBUTION BY RELIGION, 1971 Religion % of population Total 100.0 Buddhist 67.4 Hindu 17.6 Muslim 7. '2 Christian 7.7 Other 0.1 Whereas the Moors and Malays add up to the percentage of Muslims, considerable proportions of Tamils and Sinhalese seem to belong to the Christian churches among which the Roman Catholics represent about 90%. The Christian, Hindu, and Muslim communities have preserved their typica1 social patterns. The caste system exists only among the Hindus and Buddhists but there are differences regarding the number of castes and the importance attached to them. As in India, there are also scheduled castes (Rodias, Gattaroo). The impression is that, at present, the inter-caste relationship in Sri Lanka is liberal. The total population of the island was 12,771,143 at the time of the 1971 census, with a population density of 462 inhabitants per sq. mile.* 1.1.3 Education, Labour Forces, and Employment "The upper ranks of Kandyans can generally read and write their own language". And "oppressed as the chaliahs or cinnamon peelers were, many *In 1833, the total population amounted to 1,128,808 with about 45 inhabi- tants per square mile. Perhaps about two-thirds of the population were Sinhal.ese (53). SEA/PHA/149 Page 4 of them entertained a desire for information, and endeavour to give their children some degree of education. In 1814, there were 2,000 peelers employed by the Ceylon Local Government, and of this number, the superin- tendent of the cinnamon plantations ascertained that 420 could read and write the Sinhalese language" (22). These quotations were written by Dr H. Marshall in 1846. In an earlier period Robert Knox (23) found that the Sinhalese had no formal schools, but they learned to read and write. However, illiteracy was not considered a shame. A national socio-economic survey in 1970 established that 89.7% of males and 75.4% of females over 10 years of age were literate (24). One of the most acute problems in the country at present is increas- ing unemployment and under-employment. The report (22) of an inter-agency UN Mission organized by the International Labour Office in 1971 estimated the total labour force in the country as 3,798,000, of which the total number of open unemployed was 453,000 or about 12%. This situation of high unemployment led to some political disturbances in the country in 1971. 1.1.4 National Economy According to the Annual Report of the Monetary Board to the Minister of Finance for the year 1972, the gross national product at current J:a, tor cost prices (GNP) was Rs. 12,662 million with a negative factor income from abroad of Rs 137 million, giving a gross domestic product (GDP) of Rs 12,799 million (23).* The structure of the GNP by sector (Table 1.3) shows that Sri Lanka's economy is agrarian. The main crops are tea, rubber, and coconut. Agricul- ture, forestry, hunting, and fishing take up 49.1% of the employed popula- tion (24). Table 1.3. GROSS NATIONAL PRODUCT AT CURRENT FACTOR COST PRICES, 1972 Sector 1. Agriculture, forestry, hunting and fishing 2. Manufacturing, mining and quarrying, electricity and gas 3. Construction 4. Trade, transport and other services 5. Gross domestic product 6. Net factor income from abroad 7. Gross national product Amount (Rs million) 4,119 1,851 711 6,118 12,799 137 12,662 % 33 15 6 48 101 1 100 *The official e:xchange rate is Rs. 6.40 to a US $, whereas the "tourist" rate is 55% higher. SEA/PHA/ 149 Page 5 The gross national expenditure was Rs 13,374 million during the same year (27) and private consumption was Rs 9,777 million. Capital formation in the government sector was Rs 517 million and in the private sector Rs 1,689 million, both together about 14% of the gross national expenditure (28). The distribution of the national income, which in 1972 totalled Rs 9,053 million at constant 1959 factor cost prices (GNI), shows consider- able but not extreme disparities. In 1969-70 the average monthly income per household was Rs 290 (US $45) and the distribution of income was far from equitable. About 44% of households had a monthly income below Rs 200 and they contributed only about 20% to the total national income. Another large proportion (37.2%) had an income between Rs 200 and 400 and their share of the total income was 35.7%. These two large groups with a monthly income of less than Rs 400 per household represented 80.8% of the population and contributed 56.1% to the total income; the remaining 44% of the total income was distributed among roughly 20% of the population. Those with a monthly income of more than Rs 1,000 per household represented 1.8% of the total population and they shared 9.7% of the total national income. The government actual receipts in 1970-71 were Rs 2,818 million of which only Rs 511 million (or about 18%) was revenue from income tax, estate duty, stamps, etc., whereas the rest were receipts from indirect taxation. The revenue planned for 1973 was Rs 5,171 million, but since the classification of sources of revenue was changed in the meantime, the comparison with 1970-71 is very difficult. Health expenditure represented 5.3% of the total government expenditure in the estimate for 1973. 1.1.5 The Five-Year Plan, 1972-1976 The first Five-Year Plan, 1972-1976, was approved in November 1971 by the National Assembly (29). Its objectives and strategy aim at generat- ing fundamental changes in the life of the country. The main features of the plan are: (i) a population policy in order to regulate the excessive population growth; (ii) creating employment opportunities for the unemployed; (iii) increasing the income of low-income groups of the population; (iv) raising living standards by improved housing, nutrition, water supply, education, electricity, and transport, and generally by improving the life of the rural population; (v) more intensive utilization of the existing industrial plants; (vi) expansion of the irrigation system; (vii) increasing the livestock and the production of fish; (viii) improve- ment of the transport facilities; (ix) giving priority to labour-intensive methods of production; (x) development of basic industry, machine tools, light engineering, and the agriculturally based industries; (xi) self- sufficiency in food production and the production of processed foods for local consumption and for export; (xii) development of the merchant fleet; and (xiii) development of tourism. SEA/PHA/149 Page 6 1.1.6 Summary Sri Lanka is an island-country situated south of the Indian sub- continent. Geographically a dry zone, a wet zone, and a central area with mountains up to 8,000 feet high can be distinguished. These areas differ in their vegetation and their potential for agricultural diversification. The climate is tropical with a high relative humidity and the temperature varies mainly with altitude. The country has a rich history dating to 500 B.C. when the Aryans from India invaded the island and founded the Sinhalese race and state. The invasions of the Tamils, the Portuguese, the Dutch, and the British have influenced Sinhalese culture and political life and created a mixture of ethnic groups and religions. However, the predominance of the Sinhalese ethnic group and Buddhism have played an important part in the present political, social, and cultural life of the country. The total population is around 12.5 million (1971) and the population density is 462 per sq. mile. The literacy rate in Sri Lanka is high. One of the major problems is unemployment in an agrarian economy based on three main crops: tea, rubber, and coconut. The GNP per capita is about Rs 1,000 (1972) and the distribution of the national income shows considerable though not extreme disparities. The Five-Year Plan, 1972-1976, declares the willingness of the Government to introduce a population policy, accelerate economic growth, reduce unemployment, make the country self-sufficient in food production, and improve the living standards of those in the low-income groups who live mostly in the rural areas. 1. 2 HEALTH CARE SERVICES AND HEALTH PLANNING "We have al.so accepted the value premise that everything within practical limits should be done to improve health conditions and prevent premature death, independent of the consequences for fertility and morta- lity. This latter value premise is not derived: it stands as a moral imperative" (30). "The missing elements are technical knowledge, capital, specially trained manpower, and a sound plan for using capital, manpower, and technical knowledge". "The modern discussion ••• has been concerned with the parts of the problem rather than the whole". And " •.• we have probably wasted a good deal of time and effort doing things which were right in themse~ves but which made little or no contribution to progress because they were done in an environment which was inconsistent with advance" (31). The above quotations from the writings of G. Myrdal and J.K. Galbraith show how disjointed and uncoordinated recent efforts to assist the less developed countries have been. Thus, in considering the develop- ment of the health services in Sri Lanka it is desirable to keep in mind the above thoughts. In this section a short description of the health services will be given; a more detailed analysis from the point of view of their functioning as a "system" will be found in Chapter 4. SEA/PHA/ 149 Page 7 But first a clear distinction must be made between the health ser- vices as institutions or agents in the community, like hospitals, dispen- saries, general practitioners, etc., and the health services as the work performed in or by these institutions or agents, i.e., as services provided to the public. To avoid ambiguity, the health services as institutions will be called health care services and the health services as the work out- put as simply health services. Another point to be noted is that the provision of health services may be considered to range from a mother's advice to her child to change his shirt when wet with perspiration in order not to catch a cold to the most advanced heart and brain surgery. Often it is difficult to say which service may have a greater impact on matters of health. However, in this study, the more general aspect of health services will not be taken into consideration. From historical sources we learn that ayurveda, the Hindu medical science for the alleviation of physical suffering, developed in the Buddhist period (32) and it is probable that ayurveda skills penetrated into Sri Lanka along with Buddhism in about 300 B.C. In Sri Lanka some health care institutions are reported to have been established in ancient times: "In 161 B.C. King Dutugemunu built 18 hospitals for the care of the sick. In A.D. 421 King Upatissa II erected great nursing shelters. In A.D. 1153 King Parakramabahu the Great built a large hospital, equipped it, and provided each sick person with a special slave (attendant) and female slaves to prepare day and night, according to needs, medicines, foods, solids and liquids. He also founded and equipped many hospitals and even (established) nursing associations" (33). With the decline of Buddhism, these health care services ceased to exist. In the seventeenth century, R. Knox wrote: "Here are no professed Physitians nor Chyrurgeons, but all in general have some skill that way, and are Physitians, and Chyrurgeons to themselves" (34). Dr J. Davy (35) wrote of the Kandyans in 1821: "Their knowledge of medicine, and of its collateral branches, is of a piece with their astrological knowledge; and, as on the one subject, so on the other, they have built up a system of their own, founded merely on fancy, and equally complicated and erroneous. As they have an abhorrence of dead bodies, by the mere touching of which they consider them- selves polluted, they are completely ignorant of anatomy; and are no better acquainted with the true structure of the human body, than they are with that of the universe." He pointed out that medicine was the responsibility of astrologers who acted as health care practitioners. At the beginning of British rule a Civil Medical Establishment was developed under military control and became an independent department in 1858. The western health care services were thus started in the country and their expansion has been very rapid after independence. At present Sri Lanka has a variety of facilities providing health services (Table 1.4). Table 1.4. TYPES OF HEALTH CARE SERVICES IN SRI LANKA, 1972 Sector Type of "Medicine practised Western Ayurveda "Other" Government + + Private + + + Sr:A/PHA/149 Page 8 The number of institutions in the different health care sectors in Sri Lanka in 1972 is given in Table 1.5. Table 1.5. HEALTH CARE SERVICES IN SRI LANKA, 1972*** Sector 1. Government Western 2. Government Ayurveda 3. Private Western 4. Private Ayurveda 5. "Other" All sectors Type of institution Colombo group of hospitals Provincial hospitals Base hospitals District hospitals Cottage hospitals Peripheral units Rural hospitals Maternity homes* Central dispensaries* Branch dispensaries Visiting stations Tuberculosis hospitals Leprosy hospitals Mental hospitals No. of institutions 10 10 12 96 13 94 73 128 424 345 1 017 4 2 3 Other hospitals 12 Officer of Health areas) 98 5 Health units (Medical Specialized campaigns Medical Research Institute Ayurveda hospitals Ayurveda dispensaries Nursing homes Cooperative hospitals Estate hospitals Estate maternity homes Private practitioners Private practitioners "Other" practitioners** Sub-total Sub-total Sub-total Sub-total Sub-total Total 1 2 253 7 211 218 62 14 66 115 530 787 9 823 9 823 10 OOO 10 OOO 23 081 *94 institutions which function both as central dispensaries and as maternity homes have been shown in both categories; thus the total number of facilities has been reduced by 94. **Further details on these "other" practitioners will be found in Chapter 5, Section 5.6. ***The different types of health institutions are defined in Annex 1-1. SEA/PHA/149 Page 9 If all these resources were really the key factors in securing better health to the people, there would not have been much place for concern about the health care services in Sri Lanka. The total of 23,081 health facilities is quite impressive; it shows that there should be about one health care facility per square mile in the country, but the existing concern shows that there are other problems. As far as planning is concerned, a section of The First Five-Year Plan 1972-1976 is devoted to health (33). The declared policy of the Government in the field of health can therefore be suDD11arized as follows: (a) improvement of preventive services; (b) more aggressive health education; (c) improved immunization programmes against poliomyelitis, whooping cough, diphtheria, tetanus, tuberculosis, and smallpox; (d) control of nutritional anaemia in expectant mothers; (e) construction of water supply schemes in 100 rural areas; (f) improvement of services in bigger hospitals by a better supply of drugs, equipment, and trained personnel; (g) expanding and up-grading district hospitals and peripheral units; (h) improvement and expansion of ayurvedic services; (i) improvement and expansion of mental health services; (j) expansion of facilities for cancer therapy; (k) expansion of the network of blood banks; (1) introduction of medical audits; (m) integration of curative and preventive services; (n) expansion of dental services; (o) expansion of laboratory services; (p) adoption of an adequate population policy. These statements of intention hardly find their reflection in the annual budget of the Ministry of Health. The budget is prepared on the principles of the planning-programming-budgeting system (PPBS) and its merits and defects will be discussed in Chapter 4, Section 4.1. SEA/PHA/149 Page 10 Sunnnary The health care services in Sri Lanka have been defined as referring to the agents or institutions that provide health services as the main occupational commitment. Some institutions that were founded in the early days of the Sinhalese kingdom no longer exist. At present, there is an abundance of health care facilities in Sri Lanka. Health planning, as demonstrated in the Five-Year Plan, 1972-1976, includes a list of problems to be solved and now awaits the opportunity to put into.practice the inten- tions expressed in the Five-Year Plan. 1.3 RECENT HEALTH MANPOWER PLANNING EFFORTS In 1964 the Government of Sri Lanka decided to set up a Planning Connnittee on Manpower and Education (37), consisting of the representatives of the following Ministries: (i) (ii) (iii) (iv) (v) (vi) Education and Cultural Affairs Labour, Employment and Housing Industries and Fisheries Health Local Government State. "The task of the Connnittee was essentially to draw up a development programme covering the five-year period 1966 to 1970 in the fields of educa- tion, health, housing, and manpower. This would in the first instance consist of: (a) an examination of the existing progrannnes of the Ministries and Departments under each sector and an indication of the time schedule for completing these programmes; (b) an appraisal of the new schemes and proposals contemplated for the future; and (c) estimating the requirements of manpower of various grades and skills necessary to implement the development programme of all sectors of the economy and to recommend ways and means of meeting these requirements." (37) Data were collected from reports and other information received from the relevant ministries and departments and were supplemented by a survey through a questionnaire sent to govermnent departments, public corporations, and private establishments. The response to the Committee's inquiry was limited in nature and scope. The conclusions of the Committee were based on estimates derived from studies carried out in countries with conditions similar to Ceylon (38). In its report, the Committee considered first the existing and future programmes in the fields of education, health, and housing and then considered the manpower aspects of these programmes. Although there is no evidence that any use was made of the findings and recommendations of the Committee, the SEA/PHA/149 Page 11 report provides data which have been used in some parts of the NHMS, with due regard to any shortcomings and to the different criteria used by the Committee in estimating the demand for health manpower such as: (a) for doctors and dental surgeons, the doctor: population ratio; (b) for nurses, the nurse: bed ratio (in government hospitals); (c) for paramedical personnel, the existing vacancies in Government service. The targets to be achieved by 1970 were set by the Committee as follows: 1 doctor per 3,000 population; 1 dental surgeon per 20,000 population; 2 nurses for 9 hospital beds; there was no shortage of paramedical personnel (39). An interesting aspect of health manpower development in Sri Lanka concerns the international migration of doctors (40). Although the publica- tion cited has an academic character and is not meant to provide a basis for decisions regarding the existing health and manpower system in the country, several speculations about the utilization of health manpower and the reasons for the emigration of doctors from Sri Lanka are very sound, even if there is insufficient factual support. The Five-Year Plan, 1972-1976, contains some general statements un education and manpower, aiming at a more vocational direction of the educa- tion system. Some of these statements are valid for health manpower develop- ment as well (41). 1.4 SUMMARY OF THE CHAPTER Short reviews of the geophysical characteristics of Sri Lanka, its history, population, ethnic groups, social system, education, labour forces and employment, and of the national economy and national planning (especially the Five-Year Plan, 1972-1976) are followed by a brief description of the health care services (to be distinguished from ''health services", which are defined as the work output of the health care services). The health care facilities in Sri Lanka are numerous and include government as well as private sectors and western and indigenous practices. The section on health included in the Five-Year Plan deals mostly with increasing the present services. Certain health manpower planning efforts in the past do not seem to have significantly influenced health manpower development in the country. CHAPTER 2 PLANNING FOR CHANGE SEA/PHA/149 Page 13 In this chapter the strategy of the National Health Manpower Study (NHMS) is discussed first. After an introduction depicting the main concerns of the Government of Sri Lanka which led to a study carried out with the assistance of an interagency mission organized by the International Labour Office (ILO), the factors conducive to change are discussed in the context of the existing health care system in the country. The decision-makers in the field of health are identified, the factors influencing their decisions are discussed, and the place of the NHMS in the decision-making process is located. Finally the tactical approach to the health manpower planning process is reviewed. 2.1 STRATEGY OF THE STUDY In the 1950s, the economy of Sri Lanka seemed to be blossoming, thanks to increased exports and a positive balance of payments, and the country offered its people free education, free health services, free distri- bution of rice, cheap transport, etc. The expenditure on services was given priority over investment, so that when the export boom ended there followed stagnation of the national economy with resulting unemployment as well as borrowing from external sources in attempts to keep the standard of living at the same level. In the late 1960s a crisis was already evident and in February 1970 the Government of Sri Lanka formally proposed a mission under the World Employment Programme of 110 to look into the problem of unemploy- ment in Sri Lanka (4). The terms of reference of the mission were set as follows: "In collaboration with the national authorities, to prepare a long- term strategy for achieving a high level of productive employment in Ceylon, and to suggest how this might best be implemented. As a complement to this strategy, to reconunend measures to reduce the magnitude of the unemployment problem in the short term, and to review crash progranunes for employment creation currently being elaborated by the Government. "To assist the Government of Ceylon to improve their collection of data necessary for this strategy, and to identify areas on which further research is needed. "To indicate what policies and practices the Government of Ceylon might adopt in the field of trade and aid (including technical assistance) for such a strategy, identifying ways in which international, regional and bilateral aid-giving agencies could give support." (5) The mission made an analysis of the stages and trend of development in the country, with a view to proposing appropriate measures for control- ling unemployment, and presented its report in August 1971. The mission also considered certain health issues connected with employment, such as the relationship between health and productivity, health SEA/PHA/149 Page 14 problems of the labour force, and the health sector in employment strategy (6). Thus, the way was paved for a major intervention in the health field. The question then was: how to plan and conduct such an intervention and what were the chances of its success? 2.1.1 Factors Conducive to Change "Change occurs when: (1) need (perception of a "gap" or of a "crisis"), (2) opportunity (existence of different methods and new ideas), (3) resources (to implement new methods), and (4) motivation (of appropriate people to act) all coincide (which they rarely do), and only when these four coincide can change occur". (7) The situation in Sri Lanka with regard to each of these factors before the NHMS was started must now be examined. (1) Need for change There may seem to be no problem connected with the need to introduce changes into any health service, since at present there is an awareness all over the world that no health service is completely satisfactory. There are, however, considerable differences between countries on the shortcomings of their health systems and on the changes that should be introduced. Thus, to say that a national health system needs to be changed, even without any study of its problems, is nearly always certain to be right. The necessity for changing the health system in Sri Lanka was at first not too obvious, especially when compared with other countries in the same geographic area. Sri Lanka was known to have a favourable doctor: popula- tion ratio, a well-developed network of health institutions, a high govern- ment expenditure on health, a free-of-charge health service to the population, a high level of medical education, etc. However, there were hidden deficien- cies in the system~ which were made known by the health authorities and were mainly associated with the development and utilization of health manpower. These are: (a) the inadequate utilization of medical doctors' skills and knowledge in the rural areas; (b) the steady flow of doctors emigrating from Sri Lanka to other countries, developed as well as less developed; (c) the feeling that personnel in the rural public health services were working at a rather low level of efficiency; (d) the considerable maldistribution of doctors with regard to their posting in rural areas and to the services and speciaLities they were employed in; SEA/PHA/149 Page 15 (e) the exclusion of a large number of registered ayurveda doctors (indigenous medical practitioners) from being firmly incorporated in the national health care system, and (f) finally, the evident misutilization of the existing health facilities: for example, the population was bypassing the small rural medical institutions and crowding the bigger hospitals. All these factors were recognized by the government which felt that some changes should be introduced, especially regarding health manpower development and utilization. This shows that there was not only an awareness of the need to change the existing health care system but also an indication of the direction of this change. (2) Opportunity to change There have been some indications that there might be different ways of changing the health care system in Sri Lanka and the government even tried introducing certain practical changes. Thus, the training of assistant medi- cal practitioners (AMP) was discontinued in 1967 and the posts vacated by them in rural institutions were filled by medical officers, in the hope that this would increase the credit of the rural institutions and stop patients bypassing them. Also, the on-the-job training of attendants (an auxiliary category of nursing personnel working in hospitals) was interrupted several years ago and their posts were occupied by staff nurses. The intention of these changes was obviously to improve the quality of hospital care. At the time when this study was being carried out, the Government also decided to abolish the private practice of government hospital specialists in Colombo in order to make them more interested in (and more dependent on) their regular jobs in the hospital wards, which seemed to have been neglected (according to some opinions) in favour of their work in the private clinics, where the doctors' earnings were higher. These are only the prominent examples showing that certain methods and ideas to change the health care system were attempted in Sri Lanka. However, these and similar changes must be evaluated in the historical and socio- economic context of the health care system as a whole, since alternative solu- tions, which might be capable of generating a better delivery of health services in the country, are still needed. (3) Resources As will be shown in a later section of this book, there has been no shortage of resources, i.e., facilities, manpower, and funds. According to the data available at the start of this study, Sri Lanka was much better off regarding health resources than any other country in this part of the WHO South-East Asia Region*, excluding Mongolia and the Democratic People's Republic of Korea. *The WHO South-East Asia Region includes the following countries: Bangladesh, Bhutan, Burma, Democratic Peoples' Republic of Korea, India, Indonesia, Maldives, Mongolia, Nepal, Sri Lanka and Thailand. SEA/PHA/149 Page 16 (4) Motivation In the early 1970s in Sri Lanka, there was a strong probability that changes would come in almost all walks of life. The newly elected government had in its programme a long list of changes to be made in the political, economic, and social sectors. A new constitution proclaimed the country a republic, abolished the Senate or Upper House of Parliament, and established a National Assembly instead. Land reform and a programme to control in- creasing unemployment were two major points in the Government's economic programme. The Government introduced the Five-Year Plan (1972-1976) in which the objectives and strategies of development were stated. This was the first real effort to formulate a structured medium-term development strategy and represented a step forward, in comparison with the Ten-Year Plan (1959-1968) which "was never taken as a specific programme for implementation" (8). Innovations were also introduced in the educational system of the country. The participation of the public at the consumer level in controlling the activities of some Government sectors was encouraged and special Janatha Committees (People's Committees) were established for this purpose. A search for new ideas could also be perceived in the Ministry of Health and certain changes were made, as described in paragraph (2) of this section. In summary, all the factors needed for introducing changes into the health care system seemed to be present at the time the NHMS was started. Success depended on the skill of the health manpower planners to present acceptable solutions and on the perseverance of the decision-makers to implement them. 2.1.2 Decision-Makers in Health Until the end of the nineteenth century, the administration of the country was founded on feudal principles, including the right of chieftains to rajakariya, i.e. the right to request the people to work for them without any emolument. With the establishment of British rule, rajakariya was abolished and gradually over the years a western-type of decision-making on the national level, based on the principles of constitutional democracy, was developed (9).* Today, the country is a republic with a President and a freely-elected legislative body, the National Assembly. The Prime Minister, the leader of the ruling party, is the highest decision-maker in the country and appoints the ministers who constitute the Cabinet. The ministers must be members of the National Assembly (Members of Parliament or, as called colloquially, MPs). The Minister of Health is one of the members of the Cabinet and has a Deputy who is also an MP. A Secretary of Health is the head of the country's health administration, which is divided into the Department of Health, with *For more details on the historical development of socio-political factors in Sri Lanka refer to Chapter 1. SEA/PHA/149 Page 17 the Director of Health Services at the top, and the Department of Ayurveda headed by the Commissioner of Ayurveda.* The situation is less clear regarding the involvement of other ministries in health services management, as for example: (a) The Ministry of Planning, which deals with overall plan- ning, including planning for health, and in the follow-up of plan implementation. (In 1973 a new Ministry for Plan Implementation was established.) (b) The Ministry of Public Administration, Local Government and Home Affairs, which is concerned with the service status of certain categories of health workers employed by the Health Department, as well as with the health care services run by the local authorities. (c) The Ministry of Finance, which has a tight grip on the health expenditure. (d) The Ministry of Housing and Construction which is responsible for the construction of some health institu- tions. (e) The Ministry of Education is responsible for education and training of medical doctors and dentists. (f) The Ministry of Irrigation, Power and Highways has authority over water supply and drainage. (g) The Ministry of Foreign and Internal Trade deals with the importation of drugs, equipment, and supplies for the health care services. (h) The Ministry of Labour is concerned with occupational health. (i) The Ministry of Shipping and Tourism is responsible for port health. (j) The Ministry of Defence and Foreign Affairs is concerned with the Army, Navy and Air Force health services, as well as with the relationship with international agencies in the field of health. (k) The Ministry of Justice is concerned with prison hospitals. (1) The Ministry of Plantation Industry is partly responsible for health care services in estates, which are organized by the Ceylon Planters' Association and subsidized by the Ministry of Health. *For more details refer to Chapter 4, Section 4.2. SEA/PHA/149 Page 18 A problem that involves more than one Ministry and requires a deci- sion is taken for consideration by the Cabinet. The Ceylon (Sri Lanka) Medical Council*, the Ceylon (Sri Lanka) Medical College Council, and the Ceylon (Sri Lanka) Ayurvedic Medical Council, as statutory bodies, have the discretion of licensing certain categories of health workers. Thus, they also participate actively in the decision-making process in matters of health. There are 32 trade unions in Sri Lanka and the great majority of the health workers employed by the government belong to this movement. The private general practitioners also have their association. The Ceylon (Sri Lanka) Medical Association is mainly involved in the technical and profes- sional ethical aspects of the doctors' work. The public, as health service consumers, also take a keen interest in the process of decision-making. Their involvement in different ways has effects on every health institution and on the actions of every health worker. The consmners' opinions are respected but when overestimated may lead to adverse effects on the normal functioning of the health care services. The public in Sri Lanka can influence the work of the health care system in four ways: (i) individually, by giving preference to certain types of institutions and bypassing or neglecting others; (ii) through their MPs. Each MP in Sri Lanka keeps in very close contact with his electorate and, while not intending to interfere directly in the work of the local administra- tion and its services, may confuse the division of legisla- tive and executive functions in the country by his inter- vention in local health matters; (iii) by participating in Janatha Conunittees, referred to in the previous section; and (iv) through the press, which takes a great interest in all developments and problems in the field of health. Although the decision-making process in the field of health in Sri Lanka seems to be rather complex, the principal decision-maker, whose decisions can and do influence the others, is the Ministry of Health. 2.1.3 Factors Influencing the Health Decision-Making Process Decision-makers are themselves conditioned by different aspects of the society in which the intended changes should occur. A short list of *At the time of writing this report, certain bodies were still known officially under their old names (e.g., Ceylon Medical Association). Since most probably all or some of them have replaced "Ceylon" for "Sri Lanka" of which the author is not aware, both names are given in the text. SEA/PHA/149 Page 19 these factors is now given in an order of priority which is close to that attached to them by the decision-makers in health: PoZitiaai considerations seem to play an exceptionally important role in the decision-making process in health matters in Sri Lanka. Almost every decision is assessed from a political viewpoint in terms of the reaction of the electorate to such a decision. This sensitivity to any change in the field of social services is understandable because during the past 20 years in Sri Lanka the population has become accustomed to unprecedented social benefits, including the free distribution of rice to everyone, free education, free health services, etc., all of which absorbs a considerable part of the government expenditure (about 30% in 1973). In 1970, when the NHMS was in the phase of preparation to establish the baseline for health and manpower planning, a further polarization of political forces took place in the country. This polarization really started in 1956 with the defeat of the United National Party, the ruling party since independence, by the then new Sri Lanka Freedom Party. After a setback at the following elections which the United National Party won, the Sri Lanka Freedom Party assumed power again in 1970 in a coalition with some other parties. Although there are deep differences between the two major parties in Sri Lanka, the issues of free rice, education, and health played an important role in both parties' pre-election campaigns. Thus, health lies in a politically very sensitive area. ReZigion deserves special attention since it plays an important role in the life of Sri Lankians and because the clergy or priests seem to exer- cise a significant influence on political decisions. In the near past, the Christian Church was a leading factor, the influence of Buddhism having receded since the thirteenth century (10). During British rule, freedom of worship was granted to all and Buddhism gradually started to reassert itself. This process culminated in the publication, in 1956, of the Report of the Buddhist Commission which claimed a higher status for Buddhism than for Christianity. The report generated comprehensive criticism from the Catholic Union of Ceylon which, instead of weakening, strengthened the position of Buddhism and of the Maha Sangha (the Buddhist clergy), which from that time became one of the most powerful forces in the social life of Sri Lanka. Recently, Buddhism was declared the official religion and Sinhala the official language of Sri Lanka. Connected with the problem of religious differences, there are national differences which have also to be taken into consideration in making decisions at a national level. The main issue here is the compe- tition between the Sinhalese and the Tamils, the other smaller minority groups playing a less significant role. cuiturai deveiopment, as measured by the level of literacy, puts Sri Lanka in an outstanding position among the other countries in South- East Asia. A literacy rate of 87% is impressive and may explain, among other factors, the intensity of public participation in health services management. It may also be connected with the overutilization of the health care services. SEA/PHA/149 Page 20 The other aspects of cultural development in Sri Lanka, in all their intricacies, cannot be analysed here.* Economic aspects of the decision-making process in Sri Lanka can be formulated generally in the question: how much health can be provided for one rupee? The answer to this question is not easy to obtain. The most common manner in which economics is implicated into health programmes is the way in which the available funds, earmarked for health, can be utilized in the most rational way for the provision of health services, with due consi- deration of the other factors described in this section. It is very unlikely that the individual consumer considers the economic aspect of his health care consumption, when in urgent need (11). However, as will be shown later, there is a clear association between the income and health expenditure of a household. Also, in any national economy, at whatever level of planning, economic considerations play an important role in making any decision to introduce changes. Technical considerations refer to an awareness that certain health technologies can produce a beneficial effect on the health of the population in terms of reduction of mortality, prolongation of life, control of diseases, etc. They may seem to occupy a rather low place on the present scale. Some- times, however, the real efficacy of a certain health technology cannot be assessed, nor can it be correlated with the other factors that influence the decision for change; also, there is often a conununication gap between those who formulate the health progranunes and those who make the decisions, since they speak in different terms. The social structure of the population still preserves some charac- teristics of the former strictly caste-conscious conununities (especially in connection with the selection of partners for marriage), but the people are also open to new, western-type social relationships. Society is now also being influenced by the trade union movement which is closely linked with the political life of the country and with its economy. Although often controversial, the trade union movement is to be considered seriously when taking decisions in the field of health. The administrative set-up of the country does not seem to encourage good coordination in the work of different sectors. The country has separate divisions for different kinds of activities: for etections to the National Assembly, for revenue, for administration, for health, etc. Efforts have, however, been made to make appropriate adjustments in order to unify the administrative structure of the country in geographically firmly defined areas. Another characteristic that should be taken into consideration is the existence of "services" in the administrative set-up: administrative service, statistical service, accounting service, health administration service, etc. Each service has its own line of promotion which often carries officers with high competence away from the field of their specific training. *For the interested reader reference is made to Peiris, R, Sinhalese Social Organization, the .Kandyan period, Colombo, The Ceylon University Press (1956). SEA/PHA/149 Page 21 Finally, iegisiation, national and international, should be respected in taking decisions, e.g., the constitutional rights of the people, the control of quarantinable diseases, etc. 2.1.4 The Place of the NHMS in the Decision- Making Process in Sri Lanka The NHMS was not conceived as an isolated attempt to review the health manpower situation in terms of the variety and present numbers of health personnel, and of the demand for them, the supply, and the attri- tion (loss), but was intended to improve the existing health and manpower management by improving the methodology and efficiency of health and man- power planning. It was also expected that the study would reveal certain features in the health care system which could be improved in a short time without major changes in the system, e.g., by controlling some small manage- ment malpractices. It should be stressed at this point that in every health situation there must inevitably be some kind of management of health care services, if management is defined as the administration of these services (12, 13). This management may be good, not too good, or bad, but wherever health care services operate the management process is present as part of their activities. Thus, it is not possible to speak of the "establishment" of a health services management process in Sri Lanka but only of its "improvement" by the introduction of certain management techniques. It may be noted that sometimes management has been described as some higher form of administra- tion, a "technique of establishing goals, detailed plans, and then ensuring those plans are met" (14). This was not the concept underlying the inception of the NHMS in Sri Lanka. Consequently, it should be appreciated that there is already a health and manpower planning process, which is a part of the present health services management in Sri Lanka. The simplest model of the different phases in this process is schematically depicted in Fig. 2.1. Fig. 2.2 is a flow-chart presenting the main events in the health planning process through a sequence of "milestones", without any attempt to estimate the time needed for the individual activities leading from one milestone to the next. Health manpower planning is therefore conceived as a multi-cyclic process which starts with the analysis of data and their arrangement in order to describe a baseline situation. There are three main kinds of data: data related to general development, shown in Fig. 2.2 as milestone 200 under the heading "Five-Year Plan"; data collected in the course of the NHMS, represented by milestone 100 under the heading "Sub-studies", since data were collected through eleven sub-studies; and feed-back resulting from the implementation of earlier changes. This feed-back represents the main source of information at the re-cycling stage of the whole health man- power process. Before proceeding to describe the steps that follow the analysis of data, certain general observations can be made: (1) health manpower planning is conceived as a continuing process; SEA/PHA/149 Page 22 (2) health manpower planning is an integral component of the health planning process; (3) the omission of milestones 500-550-560 in the flow-chart (Fig. 2.2) will show a health planning cycle that excludes the health manpower planning link; and, conversely, by adding further milestones related to the capital stock and/or other variables, like recurring expenditure, external assistance, etc., the whole health planning process can be made more comprehensive; (4) this concept of manpower planning has been based on the assumption that the planners and the decision-makers will enter into a dialogue at certain critical points in the planning process (marked with the letter G for "government" in Fig. 2.2). The purpose of this dialogue is to get the decision-maker involved in the health planning process as early as possible so that small changes and adjustments may be introduced into both the health care system and the NHMS while the study is in progress and to enable the decision- maker to take a decision regarding the most acceptable solution to improve the health and manpower system in the country (15). Fig. 2.1 MODEL OF THE DIFFERENT PHASES IN A PLANNING PROCESS Descriptive ' Predictive ~ Prescriptive phase r phase , phase " 'iJ feed-back ,,. Implementation .... In the analysis of the baseline situation, the data collected should be structured in such a way that the health.needs and demands of the popula- tion (milestone 300), the health care system (milestone 400), and the health manpower system (milestone 500) are all described in quantifiable terms. Regardless of which definition of "planning" is favoured, there is no doubt at all that any planning activity must be related to the future • 100 300 projections of health needs and demands 300 health needs and demands G Fig. 2.2 HEALTH MANPOWER PLANNING CYCLE* I 340 350 G alternative~ priorities 360 selected priorities 1 ~ .400 ~ 450 ~ 460 t~~~~~~~~~~~~~--~ alternative selected health care ~ health care health care :::.-~r~ _j>_lan *G system systems system 1 500 I ~ 550 ~I 560 health alternative manpower health manpower selected health system s_ystem 700 implementation Dialogue with Government manpower system I 600 test-run of selected health ~ ~ ~ =v szstem assessment vt-run ti::I Cf.l Jg f:; (I) ......... ti::I ~~ ......... ..... ~ \0 SEA/PHA/149 Page 24 while based on the past. Consequently, after the description of the base- line situation in the above terms, the next step should be to project this situation into the future. Since "the central methodological problem of manpower planning is to determine the health requirements of the population of a country or region and to calculate from these the manpower needed to provide health care" (16), the most logical approach would seem to be to project the future health needs and demands (milestone 330). For this two major factors should be taken into consideration: (i) the past trend of health needs and demands, however defined, and (ii) the time horizon of the projections. Since any projection will contain a large element of uncertainty, alterna- tive projections should be made, whose variability will depend on the duration of past observations of events and on the time horizon. At this critical point a dialogue with the decision-maker should make it possible to select the projection of events that are most likely to happen. This likelihood depends on a large number of factors (e.g., the prospects for the success of the development efforts, any changes of policy, legislation, etc.) which might be unknown to the planners, but known to the decision- maker. At the same time, a decision should be made as to which of the projected health needs and demands should be taken as the basis for planning. The preparation of alternative lists of priority health needs and demands will be the next milestone, 350. This should be followed by a new dialogue with the decision-maker who must arrange in order of priority the projected health needs and demands of the population. The selected list of priorities (milestone 360) should then be used in designing alternative health care systems, based on the existing system (milestone 400). These alternative health care systems should be presented to the decision-maker who should, with the assistance of the planner, select the most acceptable system. The health manpower planning process may also be reduced to a single projection of the baseline health manpower system, as indicated by milestone 500. However, the situation when (i) no change will be needed in the health care system, and (ii) no changes in the health manpower system will be required as a consequence of (i) must be considered most unlikely. Next, the specific health manpower planning process incorporates the selected health care system from one side and the present health manpower system from the other (milestones 460 and 500), and the acceptance by the government of one of the resulting alternative health manpower systems may be considered the end of the National Health Manpower Study. However, the health manpower planning cycle should continue under the care of the rele- vant health planning unit in the country, which hopefully would be streng- thened to take over the task begun by the NHMS. The test-run of the selected health manpower system, in the context of the selected health care delivery system, represents the very important SEA/PHA/149 Page 25 first step in introducing changes into the system (milestone 600). Occasion- ally, however, the decision-maker may decide to implement the changes wj_thout a preliminary test of their effects in the field. If the decision-maker cannot decide which health care system and which health manpower system are the most acceptable, several alternatives should be tested simultaneously in the field with proper controls. These tests should therefore be conducted as controlled trials and meticulous care will be needed to reduce any bias to a minimum. Thus, the test-run(s) should be planned, conducted, and assessed (milestone 650) rigorously. After the assessment of the test-run(s) the selected system may be implemented, but with proper prograUD11ing of the changes that are to be introduced (milestone 700). It may be noted that the health manpower planning cycle described above permits several points of entry into the health and manpower planning process, since the cycle runs through a closed circuit. For example, a start at milestone 460, based on a hypothetical health system, would lead round the circuit following the health planning process back to milestone 460 and would give an opportunity for corrections to be made during recycling. Much time and effort, however, will be saved if the planning cycle starts at the very beginning, although there may be situations when the cycle would have to start at a later stage. To a large extent, the point of entry depends on the specific concern of the decision-maker at the time of "crisis". After the framework of the National Health Manpower Study had been set, the next problem was who should carry it out. Similar studies in other countries were conducted by educational and research institutions, which were not involved in the national health services management in those countries. In Sri Lanka, the Health Planning and Programming Division in the Ministry of Health was considered the most appropriate focal point for the coordination of all activities in the study and for the collection of all the relevant factors in the country. Besides, such a location promised easy access to the principal decision-maker, the Ministry of Health, which was a much better situation than if the study had been conducted by a medical school under the authority of the Ministry of Education. The Health Planning and Programming Division (HPPD) also offered other advantages. There were three officers in the division who had received training in health planning, one statistician, and ten persons with different but suitable backgrounds for such an undertaking (university science graduates clerks, typists, etc.). Moreover, there was a good working relationship between the HPPD and the Planning Department in the Ministry of Planning and Employment, the Department of Ayurveda, the Department of Census and Statis- tics, the Office of the Registrar General, various schools for the health professions, the University of Sri Lanka, the health professional associations etc. The study was planned to be completed in two years but because of unforeseeable reasons took about 3 years, from early 1971 till the end of 1973. With an adequate health information system, such a planning effort may be completed in 6-12 months. SEA/PHA/149 Page 26 2.1. 5 Summary The National Health Manpower Study in Sri Lanka was initiated in 1971 with the purpose of improving the present process of health services management, especially in its planning aspect. The timing of the study was considered appropriate because there were indications of the need for changes in the health care system; there was also the opportunity to introduce changes; resources were available; and the decision-maker seemed to be motivated to accept change. However, the decision-making process in Sri Lanka is influenced by several considerations. The main decision-maker is the Ministry of Health, supported (or criticized) by the public who are interested in their health services and will not hesitate to express their opinions. The complexity of the decision-making process is mainly due to political considerations and to differences relating to religion, nationality, and cultural development, as well as the economy, technical considerations, the trade unions, the administrative set-up, and existing legislation. The NHMS was planned in the context of a health manpower planning cycle (Fig. 2.2). The study headquarters was located in the Health Planning and Programming Division (HPPD) of the Ministry of Health in order to have easy access to and better rapport with the principal decision-maker, Many of the institutions concerned with the health planning process in the country also contributed to the study, which took up nearly 3 years from early 1971 till the end of 1973. 2.2 DATA, SOURCES AND DIFFICULTIES IN FINDING THEM The data or information basis is considered the core of a planning process. To obtain this basis, appropriate arrangements have to be made involving institutions and other sources of information. A scheme showing the organization of the NHMS is give in Fig. 2.3. The main responsibility for the conduct of the NHMS was laid on the study Director, who was the Deputy Director of Health Services (Planning) and was directly responsible to the Secretary of Health, The Planning Adviser (Finance) to the Secretary of Health was designated Study Co-director. A WHO Public Health Administrator assisted the Study Directorate, The following were the duties of the Study Director: (i) Evolving a detailed study protocol. (ii) Internal planning for the operation and logistics of the study, (iii) Directing the operations leading to implementation. (iv) Recruiting additional staff, as required. (v) Enlisting the interest of all those who might be signi£icantly concerned with the project. (vi) Making periodical progress reports to the sponsoring agencies. Fig. 2.3 NATIONAL HEALTH PLANNING PROCESS MINISTRY OF HEALTH Secretary of Health National Advisory CollDllittee ------------------t---------------------WHO Headquarters and WHO/SEARO for Health Manpower Planning ~---------------[--------------~ ,------------}-------------~ ~----------[----------, r--------------]_-----------, POPULATION CHARACTERISTICS ! ! HEALTH MANPOWER ! ! EDUCATIONAL PROCESS l I HEALTH CARE INSTITUTIONS 1. Demography 1. Census ! ! 1. Medical i i 1. Facilities - analysis - medical - projections - nursing i i 2. Nursing i i 2. Staffing I I I ' - assistant medical 2. Health needs and demands practitioners i i 3. Other l i 3. Cost - mortality - midwives - morbidity - dental i I i i 4. Functional work study I I I ' - socio-economic survey - ayurvedic - technicians ! ! i i 5. Demand for health services 2. Utilization studies - medical - public health - ayurvedic L------------------------------~ 1--------------------------~ ~---------------------~ ~---------------------------I I I I I I : r----------------------------, I I I HEALTH SYSTEM I l I I I I I I I I I I I I l I 1. Components l I L-------------------------------1 2. Economic analysis 1--------------------------------------J l 3. Manpower utilization l I 4. Financing l l 5. Services I l 6. Functioning l L----------------------------~ 'cl C/l & ~ (1) ........ 'cl ~ !;: ........ ...... -!"- '° SEA/PHA/149 Page 28 (vii) Preparing reports on the findings. (viii) Producing manuals with specific instructions for the conduct of the study. A National Advisory Committee for Health Manpower Planning was appointed consisting of the following persons: 1. Secretary of Health (Chairman) 2. Director of Health Services 3. Commissioner of Ayurveda 4. Dean, Faculty of Medicine, University of Sri Lanka, Colombo 5. Dean, Faculty of Medicine, University of Sri Lanka, Peradeniya 6. Director, Academy of Administrative Studies 7. President, Independent Medical Practitioners' Association 8. President, Government Medical Officers' Association 9. Head of the Department of Social and Preventive Medicine, University of Sri Lanka, Colombo 10. Head of the Department of Social and Preventive Medicine, University of Sri Lanka, Peradeniya 11. Professor of Pharmacology, Faculty of Medicine, University of Sri Lanka, Peradeniya 12. Adviser (Sociologist), Ministry of Planning and Employment 13, Deputy Director (Social Overheads), Ministry of Planning and Employment 14. Deputy Director (Medical Services), Ministry of Health 15. Deputy Director (Public Health Services), Ministry of Health 16. Deputy Director (Laboratory Services), Ministry of Health 17. Assistant Director (Planning), Ministry of Health 18. Assistant Director (Maternal and Child Health), Ministry of Health 19. Assistant Director (Health Education and Environmental Sanitation), Ministry of Health 20. Assistant Director (Quarantine, Epidemiology and External Resources), Ministry of Health 21. Chief Nursing Education Officer, Ministry of Health SEA/PHA/149 Page 29 22. Deputy Director (Planning), Ministry of Health (Study Director) The following are the functions of the National Advisory Committee: (1) To represent the interests and viewpoints of the different groups having a bearing on the study; (2) To promote inter-institutional coordination; (3) To enlist community, professional, and public cooperation; (4) To advise the Study Director on the most suitable approach and strategies for the implementation of the study; (5) To assist in surmounting obstacles and solving administrative problems which may arise during the implementation of the study, and (6) To promote a climate favourable to the utilization of findings for policy formulation and decision-making. Additional assistance was provided by the Division of Health Manpower Development, WHO Headquarters, and by WHO South-East Asia Regional Office. Data from four areas were considered the necessary basis for health manpower planning, as shown in Fig. 2.3: (i) Population Characteristics: 1. Demography 2. Health needs and demands (ii) Health manpower: 1. Census of different health personnel 2. Utilization (iii) Educational process for the health professions (iv) ~ealth care institutions. The information collected from the areas was used to describe the existing health care sys~em and health manpower system, and to make projec- tions into the future. 2.2.1 Sub-studies It was decided that the best way to collect data from the above areas was to divide the whole NHMS into eleven sub-studies*, each with its defined *The titLes and specific objectives of the sub-studies are listed in Annex 1-25 SEA/PHA/149 Page 30 objectives. For each sub-study a national expert was appointed chief researcher who, supported by a working group, had to plan, conduct, and report on the sub-study. The terms of reference of the chief researchers and working groups were as follows: Under the guidance of the Study Director, (i) to plan the sub-study; (ii) to decide on the methodology to be used; (iii) to estimate the cost and requirements for its implemen- tation; (iv) to direct the operations; (v) to support the operations and provide logistics; (vi) to review the findings, and (vii) to report and make recommendations to the Study Director. The interrelation of information from different sub-studies is shown in Fig. 2.4. Certain sub-studies were designed to provide data for one single area, e.g. sub-studies A, B, C, D, E and K, whereas data from the other sub-studies were to be utilized for two or more areas of study. The flow-chart (Fig. 2.4) does not provide a time scale to the NHMS. It shows only the relationship between the data collections in the sub- studies; the establishment of the baseline and its projection in terms of health needs and demands, the health care system, and the health manpower system; the formulation of the national health policy in the context of the national policy as stated in the Five-Year Plan; and, finally, the statement of the national health manpower policy. Other information (both quantitative and qualitative) needed for the NHMS, which was not covered by the objectives of any sub-study was obtained from a variety of sources, e.g. by studying circulars, old documents, and the daily newspapers, as well as by formal and informal discussions and inter- views with public health officials, members of the National Assembly, trade union leaders, and others. The enormous task of quoting in detail all the sources of information that contributed to the data base of the NHMS will not be attempted. 2.2.2 The Health Information System A scheme of the agencies and institutions that provide health informa- tion in Sri Lanka is shown in Fig. 2.5. The improvement of this health information system and broadening its base, if necessary, were common objec- tives of all the sub-studies. Sub-studies "A"-Demographic characteristics "B"-Health needs & demands ,-.-------. "C"-Census of doctors '----; Fig. 2.4 INTERRELATION OF SUB-STUDIES Present state & projections Health needs & r---!I demands "D"-Census of nurses, mid- .__ ___ _. wives and dental nurses "E"-Education of doctors "F"-Education of nurses and midwives "G"-Activities of the health personnel "H"-Utilization of doctors 11 J 11 -Staffing, facilities, and cost of health insti- tutions "K"-Demand for medical care services "L"-Ayurvedic practi- tioners ,--i----, I I I ,--------!-~ I I I --------1-J I I I ~ I I I I I I I I I I 1---------J Health care system Health manpower system Health planning Health policy: a) b) c) d) problems priorities systems requirements - techniques - outputs - resources National Policy Health manpower planning Health manpower policy a) Categories of personnel b) Utilization c) Health manpower budget '1:1 en Jg ~ (l) ........ '1:1 ~~ ........ f-' .i,- MIN. OF PLANNING National Policy Employment policy Funds available for health OTHER INSTITUTIONS e.g. Sri Lanka Drug Corporation, etc. DEPT. OF CENSUS AND STATISTICS Demographic characteristics Fig. 2.5 HEALTH MANPOWER INFORMATION SYSTEM I SCHOOLS OF HEALTH PROFESSIONS HEALTH STAT1ST1CS BRANCH Supply of health manpower Needs and demands Operational Utilization of services B I l ~;~;;~;~;~ I 1 [ ~~c~octors, I 1 _ _ _ ...--. _...____~----------, ~ HEALTH PLANNING AND PROGRAMMING DIVISION Planning Evaluation Re-planning _l HEALTH CARE SYSTEM Implementation Feedback j CEYLON MEDICAL COUNCIL Health manpower budget J 1 SRI LANKA AYURVEDIC MEDICAL COUNCIL Health manpower budget I 'o Cl) : ~ (!) --- '"O ~ g: ---f-' ..,. <D SEA/PHA/149 Page 33 At first, the expectation of the study team was that the existing health information system could provide plenty of data and that a special effort would be needed to collect data in only certain matters that were of particular interest to the decision-makers, e.g., the activities of health personnel in rural areas and the utilization of doctors. However, after a review of the data providers in the existing health information system, it became evident that data collection would not be so easy because of the need to check the relevance, reliability, and validity of certain existing data. Consequently, considerable effort was needed to retrieve data and to sort out information regarding the education of health professionals, especially the education of nurses and midwives; the data available at the Health Statistics Branch did not include outdoor (outpatient) morbidity, and there was also no information on the present position of health care services regarding the supply, utilization, and cost of their equipment. Moreover, it was felt that some data should be confirmed, especially data on inpatient morbidity and mortality and on school health; in addition, the data on the current supply of doctors and data on nurses, midwives, and ayurveda practitioners were outdated. The Study Directorate thus became convinced that the whole system for obtaining data relevant to health planning needed organization. For this purpose, the process of data collection for the NHMS involved field collection and analysis of basic information and a close liaison of all the sub-studies with the formal sources of health information in order to streng- then the latter. 2.2.3 Certain Problems and Constraints The participation of such a large number of persons in the NHMS (see Annex 5) gave it basic strength: e.g. (a) the involvement in the planning process of decision-makers at different levels committed them to the plan- ning product; (b) the contribution of so many participants in the planning effort filled in gaps in the knowledge of the professional health planners; and (c) the exposure of such a large ntunber of national health and other personnel to health planning methods presented a unique opportunity for the diffusion of the concepts, techniques, and rationale of efficient health planning. On the other hand, such a broadly based planning effort showed some inherent weaknesses, e.g., problems in decision-making criteria, information preferences, apathy in taking decisions, and conflicts on the role of the health and educational hierarchy (42). Some of these problems and constraintE will now be discussed. 2.2.4 Differences of Interests and the Need for Compromise Certain members of the National Advisory Committee for Health Manpower Planning (or National Committee), the chief researchers of the sub-studies, and some members of the study groups expressed the desire to colle~t data which was of doubtful relevance to the health manpower process. Their need for this data was very often to improve the administration of the sectors for SEA/PHA/149 Page 34 which they were responsible. Appreciating their particular needs and their involvement in the NHMS, the Study Directorate had to digress from the original intention to collect only data relevant to the study. Thus, the collection of data of lower relevance was allowed, but it was not always easy to keep a balance between this kind of extension to the study and the desire to encourage and motivate the participants. For example, in the detailed studies of the activities of health personnel working in rural areas and of the utilization of doctors, certain questions were included in the questionnaires sent to doctors, nurses, and midwives, although it was clear at the outset that the answers were unlikely to contribute signifi- cantly to the objectives of the NHMS. Likewise, the educationists included in the study team were particular about the collection of certain detailed information that might have been useful in a very late stage of programming new curricula. (1) Problems of "oversizing" in the planning of data collection in these studies, there is a great temptation to adopt the methods of clinical and epidemiological research regarding sample size, the duration of observation, the volume of data, e~c. For this reason, the problem of "oversizing" is unavoidable. Very often it is forgotten that the objective of the health manpower planning process is not to produce the best solution for all times, but to offer a set of alter- natives that are considered feasible in the present situation. Thus, there is no place for rigidity in designing and carrying out data collection, against other factors like time, funds, human resources, etc. (2) Time constraint Because the decision-maker requests a solution to his problems within a certain time, the time factor is crucial in determining the acceptability of the recommendations resulting from any health and manpower planning effort. Usually the request of the decision-maker is timed according to the national planning cycle. Any delay in this respect means at least missing a planning cycle. Very often, it may even lead to discrediting the health planning process as inefficient. It is imperative, therefore, for the health planners to be prepared to accept, for instance, a less than perfect design for the study, or to do without the services of the most competent consultants in order to deliver in time the planning product when it is expected by the decision-maker. (3) Point of entry Usually the decision-maker does not intend to change the whole health care system. He is interested in one problem or a set of problems because of their importance from his point of view or because of the pressure put on him to solve them. It may then be the best policy for the health manpower planner to start from that point. Very often the real problem is hidden somewhere else, but the starting point should be the problem area for which the greatest concern is expressed by the decision-maker. (4) Financial constraints SEA/PHA/149 Page 35 Health and manpower planning has still to establish its place in the process of managing the health care system. The investment of 5-10% of funds earmarked for the construction of a building, a road, or a bridge, in the preparation of a blueprint, is not unusual. However, the resources allotted to health and manpower planning are usually negligible in compari- son with the resources spent on health care delivery. For this reason, any health manpower planning effort should be planned and conducted with the greatest economy of funds, material and manpower, as long as the health manpower planning process remains unrecognized as a legitimate and important function of the health care system. (5) Utilization of field investigators It is essential in such studies - it is also one of the objectives - that field investigators should be given the opportunity to acquire the skills needed to conduct this kind of research. However, two matters should be kept in mind: (a) the training of investigators should be organized and conducted with thoroughness since they are not normally trained for these activities, and (b) sometimes, owing to inexperience, what the investigators observe tends to be distorted: either too favourable or too grim. (6) Data processing Data processing should be considered at the planning stage of the study. In a country with huge labour reserves, the utilization of electro- nic data processing equipment should be reserved only for special purposes. (7) Communication It takes time to develop a medium of communication that will be understood by all the participants in the study. It is very important in this regard to try and minimize the use of technical jargon, which might be incomprehensible to field workers and other participants who are not involved in the study at the technical level, and to develop operational definitions for some of the concepts. 2.2.5 Summary The National Health Manpower Study in Sri Lanka was concerned with data from 4 areas: (i) population characteristics, (ii) health manpower, (iii) the educational process, and (iv) health care institutions. All these put together should describe the health system of the country. For practical reasons, data collection was conducted through eleven sub-studies. The existing sources of data, abundant as they were, could not provide adequate information and so the collection of data in the field became unavoidable. The study was located at the Health Planning and Programming Division, Ministry of Health (HPPD), and the Deputy Director of Health Services (Planning) was appointed Study Director. A National Advisory SEA/PHA/149 Page 36 Committee for Health Manpower Planning under the chairmanship of the Secretary of Health and consisting of officials and other persons with an interest in health manpower development was in charge of developing the NHMS. The implementation of the NHMS was incorporated into the health and manpower planning cycle which was developed before the study started. The model of the planning cycle was based on the assumption that health man- power planning represents a step in the health planning process. Thus, it is hoped that the NHMS would have strengthened the health planning capacity of the newly established Health Planning and Programming Division. Another major objective of the NHMS was to encourage improvement in collecting, utilizing and storing health information. Various problems and constraints during the conduct of the NHMS have been fully discussed. 2.3 SDMMARY OF THE CHAPTER The political and socio-economic situation in Sri Lanka at the time of the start of the National Health Manpower Study has been reviewed and the pre-exsiting conditions that suggested successful implementation of the study's findings have been discussed. The National Health Manpower Study meant to make the health planning process in the country more meaningful. The study was planned and conducted by the Health Planning and Programming Division in the Ministry of Health as a part of a health manpower planning cycle. The study involved a great number of decision-makers at different levels and in different areas, as well as planners and investigators, and it enjoyed the support of many institutions connected with health manpower development in the country. At the same time, some problems and constraints had to be solved and overcome in order to complete the study successfully. CHAPTER 3 PRESENT AND FUTURE HEALTH NEEDS AND DEMANDS SEA/PHA/149 Page 37 After an evaluation of past data and of the present health situation in the country with regard to population dynamics, prevalent diseases, and the demand for medical care, projections are presented of these problem. areas in the next twenty years. An attempt is ma.de to identify the problems of highest priority and to describe the concern that these problems have generated in the country, as reflected by the government's acts and by public opinion. 3.1 PROBLEMS OF POPULATION DYNAMICS 3.1.1 Historical Background The first seemingly reliable estimate of the population of Sri Lanka comes from Davy (44). "According to the census made by the collectors of districts in 1814, by order of government, the whole population of our old possessions, the maritime provinces, amounted only to about 476 OOO souls of both sexes and of all ages. The conjectures of the best informed natives, respecting the population of the interior, differ most widely; it being the opinion of some that it may amount to a million, and of others that it does not exceed three hundred thousand." "Now •.. one is disposed of •.• admit that the population of the whole island does not exceed eight hundred thousand souls, which is in proportion of about thirty-eight only to the square mile." The first official population census was taken in 1871 and revealed that there were 2 400 OOO inhabitants in Sri Lanka, which means that in 57 years the population increased by threefold, or by an average annual increase of 2%. The above-mentioned census of 1814 also showed some peculiar features: e.g. a relatively old population with only 37% of the inhabi- tants "below the age of puberty", and an excess in the number of males over females by about 10% (44). R. Knox indicated some practices in the Kandyan Kingdom that may explain the above phenomena. "And for the matter of being with child, which many of them (whores) do not desire, they very exquisitely can prevent the same" (45). "In this country each Man, even the greatest, hath but one Wife; but a Woman often has two Husbands. for it is lawful and common with them for two Brothers to keep house together with one wife, and the Children do acknowledge and call both Fathers" (46). "As soon as the Child is born, the Father or some Friend apply themselves to an Astrologer to enquire, whether the child be born in a prosperous planet and a good hour or in an evil. If it be found in an evil they presently destroy it ••• " (47). Peiris (48) quotes Parker as saying that "a King destroyed all female children" and Hartshorne who records "the tradition that in the time of the Kings, the population of Uva was, upon some Malthusian theory, restricted to the number 12 500 and that it was prevented from rising above this figure by exposing the children upon the mountains in the old Spartan fashion". SEA/PHA/149 Page 38 Thus, in the period before the beginning of the nineteenth century, a set of socially accepted measures and a policy enforced by the kings seemed to exercise a regulatory function in relation to population growth in Sri Lanka. 3.1.2 The Population and Its Growth Beginning from 1871, a census of the population has been conducted at intervals of, on the average, every ten years. Their results are shown in Table 3 .1. According to the most recent census of 1971, there were 12 711 143 inhabitants in Sri Lanka and the population density was 503 per square mile, 15 times more than the estimate by Dr Davy in 1814. The average annual inter-census growth rates (AAIGR) depicted in Table 3.1 show that the rate was less than 2.00% before the year 1946; since then it has been over 2.00% as a result mainly of natural increase because immigration has been negligible. Table 3.1. POPULATION, ANNUAL INTER-CENSUS GROWTH RATE, AND DENSITY, 1871-1971* Population Increase Average Year Population (In over thousands) previous census (%) annual inter-census growth rate density per square mile 1871 95 2400.4 1881 109 2759. 7 13.9 1.4 1891 119 3007 .8 8.6 0.8 1901 141 3566.0 17 .o 1. 7 1911 162 4106.4 14.1 1.4 1921 178 449 7. 9 9.1 0.9 1931 210 5306. 9 16.5 1.7 1941 263 6657.3 22.6 2.3 1953 320 8097. 9 19.5 2.0 1963 423 1 058 2.0 30.7 2.7 1971 503 1 2711.1 20.5 2.3 *Source: Census of Ceylon, Department of Census and Statistics The number of males for between 111 and 114 and showed when it dropped sharply by 7%. and the population over 65, in years age group (Table 3.2). every 100 fem.ales in the population was only small changes till the census in 1971 The population between the ages 0-14 years general, increased in relation to the 15-64 Year 1946 1953 1963 1970** SEA/PHA/149 Page 39 Table 3.2. POPULATION(%) IN THE AGE GROUPS 0-14, 15-64, AND OVER 65 YEARS IN THE PERIOD 1946-1970* 0-14 years 15-64 years Over 65 years % Index % Index % Index 37.4 100 69.2 100 3.4 100 39.71 106 56.8 96 3.5 103 41.5 111 54.3 92 4.2 124 39.3 105 56.3 93 4.4 129 *Source: Department of Census and Statistics **Socio-economic survey, 1970 In the year 1946, 15.4% of the total population were living in urban areas, as defined by the government. In 1950 only 11.4% of the population lived in towns with more than 20 OOO inhabitants and 5.4% in towns with more than 100 OOO inhabitants (49). The last census in 1971 showed that the process of urbanization had accelerated in Sri Lanka, as in some other countries in the region, but still 82% of the population lives in the rural areas. It should be pointed out also that the classification of population into urban and rural is rather arbitrary and that the whole country, because of its size, population density, good transport, and economic characteris- tics, may be considered an example of a rural-urban continuum, without a strict distinction between urban and rural population.*** For the purposes of health manpower planning, it was considered appro- priate to classify the population into two groups on the basis of geographic accessibility to the health services: (i) population residing in the administrative district centres: 9.8% of the total population; (ii) the rest: 90.2% An important group belonging to the rural population is the so-called estate population which makes up about 11% of the total population in the country (24). They represent the population living and working on the tea and rubber estates (plantations). The main ethnic and socio-economic charac- teristics of that population can be summarized as follows: (i) they are mostly Indian Tamils (78.7%); (ii) they are less literate (61.2%) than the average for the island (82.6%); (iii) 94.6% of households in the estate sector earn less than Rs. 400 per month, whereas in the whole country this income group is 80.8% (24); (iv) finally, they have their own health services sponsored partly by the estate owners and partly by the government. ***According to the government's definition, the urban population lives in settlements administered by a municipality or city or urban councils. Thus defined, the urban population represents 18% of the total population of the country. SEA/PHA/149 Page 40 The census information indicated marriages of two types: legal and customary. A marriage is said to be legal if it is registered; the others are classified as customary. The laws relating to the registration of marriages were introduced into the low-country areas in the early part of the nineteenth century and to the Kandyan areas (the hill-country) in the latter half of that century. The laws relating to the registration of Muslim marriages were introduced in 1937. During the fifteenth to the nineteenth century, "sexual relations in general, and marital relations in particular .•. were considered rather as casual and inevitable incidents in a person's life" (51). On the other hand, Dr Davy wrote: "Amongst few people, I believe, are family attachments more strong and sincere: there is little to divert and weaken them; and they are strengthened equally by their mode of life and their religion" (53). It was not so 150 years before Davy made the above observations, since R. Knox observed that the matrimonial relationship was not very firm (54). It is also interesting to observe that at the beginning of the nineteenth century "old bachelors and old maids are rarely to be seen amongst the Singhalese; almost every man marries, and marries young" (55). In recent times, the percentage of married persons (legally and customarily toge~her) has declined from 60.47% at the 1953 Census to 59.25% in 1963, and to ]6.48% in 1970. Another important trend is the postponement of marriages of females; in the period 1956-66, the percentage of brides of the age below 21 years decreased from 47.3% to 27.4%. The crude birth rate has come down from 38.7 per 1 OOO in 1953 to 30.1 in 1971. This phenomenon can be ascribed to two factors: the decrease in the percentage of the married female population, and the postponement of marriage by young females. There is a marked decline in the age-specific birth rate in younger women in the same period, from 64.4 in the age group 15-19 years to 81.7 in the 30-34 years age group. The most productive group now seems to be the age group 35-39 years with index 114.9, whereas for the age groups 40-45 and 45-49 years the indices are 91.9 and 101.5 respectively. There is also a pronounced reduction in the gross fertility rate (GFR)* and gross reproduction rate (GFR)** from 189.5 to 142.2 and from 2.61 to 2.27, respectively, from 1953 to 1968. The net reproduction rate (HRR) * has not changed considerably in the period 1953-68: from 2 115 to 2 023. The decline in the five-year average death rate since 1946 has been remarkable: from 14.21 (per 1 OOO) to 7.62 in 1971, a reduction of 46%. Correspondingly, the life expectation at birth increased from 54.9 years for males and 53.3 years for females in 1948 to 64.8 and 66.9 years, respec- tively, in 1967. The natural increase stayed stable at 2.6 - 2.8 in the period 1953-63. Thereafter a slow steady downward trend is observed, and provisional data show that in recent years, 1970-71, it was 2.1 - 2.2%.** *For definitions, refer to Cox, P.R. Demography, Fourth edition, Cambridge University Press, 1970 **All demographic data were obtained from published and unpublished documents of the Department of Census and Statistics and the Registrar General's Office. Their kind cooperation is gratefully acknowledged. SEA/PHA/149 Page 41 The migration of people does not seem to play a major role in popula- tion dynamics in Sri Lanka, in spite of the movement of Indian Tamils between the island and the sub-continent. The projected distribution of the population of Sri Lanka by age groups and sex in 1971 is shown in Table 3.3. Age group Total 0-4 5-14 15-19 20-59 6o+ Table 3.3. POPULATION OF SRI LANKA BASED ON MEDIUM FERTILITY PROJECTION, 1971 (years) Total (x 1000) Male (x 1000) Female (x 1000) 12 958.8 6 623.2 6 335.6 1 830.7 922.9 907.8 3 220.5 1 629.9 1 590.6 1 358.2 687.4 670.8 5 751.7 2 943.4 2 808.3 797.7 439.6 358.1 (15-45) 5 767.0 2 898.2 2 868.2 Females in the reproductive age group 15-45 years represented 24.2% of the total population in 1971. In the same year they delivered 382 480 babies, which means that about 13.2% of the fertile women delivered during that year. During the 1946-71 period the number of women of reproductive age increased by 23.3%. The relative decrease in fertility may have resulted from the decline in the percentage of married persons as well as from the rise in the mean age at marriage, as already stated. Fertility has been on the decline in Sri Lanka for quite some time, even before and independent of the National Family Planning Programme which, until now, attracted rather a small number of new acceptors of family plan- ning services and could hardly have been responsible for the decline in fertility. The spontaneous decline in fertility cannot be expected to bring about the changes in population dynamics contemplated in the government's Five-Year Plan, so that family planning services for those who demand them and the creation of new demand for these services are essential tasks of the highest priority. The increased health hazards during pregnancy and delivery, on account of which expectant mothers are given special antenatal and natal care, are reflected by the maternal death rates. The overall maternal mortality rates in the period 1961-66 were between 2.2 and 3.0 per thousand, with rather wide fluctuations. Since 1967, there has been a steady decrease in maternal mortality down to 1.2 per 1 OOO in 1971. Antenatal care and the attendance by trained personnel at the time of delivery in an institution or at home are the measures contributing to the decrease in maternal mortality. SEA/PHA/149 Page 42 The percentage of expectant mothers "under care", i.e., registered in the files of the area·public health midwives, has remained in the period 1961-68 at about 60%, except for a fall to 49% in 1965. The number of visits per expectant mother varied annually between 6.4 and 8.5 which may mean that the efforts of midwives were concentrated in limited areas. There are, on average, about 370 OOO live births every year in Sri Lanka. Table 3.4 shows the number of live births according to the place of delivery: institutional (in hospitals and maternity homes) or domici- liary (assisted by a public health midwife [PHM]; or without the assistance of a PHM, but assisted by some other trained or untrained person). The percentage of deliveries attended by untrained persons is quite small, 2.2%, whereas only about 0.2% of deliveries were without any assistance (data for 1969). The discrepancies in Table 3.4 are due to different sources of data and different periods of reference: e.g., the totals of live births refer to calendar years and the other figures refer to financial years, October to the following September. Year 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 Table 3.4. NUMBER AND PERCENTAGE OF LIVE BIRTHS ACCORDING TO THE PLACE OF DELIVERY, 1961-1970 Total Institutional** Domiciliar:y: births* Attended by PHM Not attended No. % No. % No. 363 535 215 505 59.2 56 354 15.5 95 157 370 762 218 760 59.0 53 745 14.5 100 391 365 842 220 304 60.2 52 157 14.3 104 810 361 577 224 295 62.0 54 235 15. 0 110 739 369 437 224 019 60.6 44 043 11.9 102 917 369 153 217 484 58.9 48 392 13.1 116 362 369 531 237 903 64.4 44 688 12.1 113 741 384 178 238 619 62.1 45 544 12.4 122 809 372 774 34 014 9.1 368 211 *According to calendar year (January to December) **According to financial year (October to September) by PHM % 26.2 27,0 28.5 30.6 27.9 31.4 30.7 31.9 The total number of live births increased slightly in the period 1961-70 from 361 535 to 368 211, If the two 5-year periods, 1961-65 and 1966-70 are compared, the increase in the annual average number of live births is from 366 231 to 372 769 or an increase of 1.8% in five years, which gives an average annual increase of 0.36%. The percentage of live births in institutions shows a very modest increase during the ten-year period 1961-70, from 59% to 62%. What is very significant is that this increase is associated with a decrease in the number of domiciliary births attended by PHMs from 15.5% to 12.4% of all live births. SEA/PHA/149 Page 43 The percentage of infant deaths (below 1 year of age) decreased from 25.87% to 20.50% of total deaths during tbe period 1954-68. Also the percentages of deaths in the age group 1-4 years declined from 19.67% to 10.58%. The infant mortality rate in the period 1961-68 was around 50 per thousand. Data on the number of infants under care in clinics (Table 3.5) show that the total number of infants declined by 68% during the period 1961-68 and the number of visits declined by 62% in the same period. The approxi- mate percentage coverage, on the assumption that the number of eligible infants is fairly close to the number of live births in the same year, is rather poor. It shows a sharp decline of 70% during the period 1961-68. The average number of visits paid each year by one infant under care was between 3.5 and 5.6. Year 1961 1962 1963 1964 1965 1966 1967 1968 Table 3.5. INFANTS UNDER CARE AND THE NUMBER OF VISITS MADE BY INFANTS TO CHILD WELFARE CLINICS No. of infants (registered by PHMs) 106 209 89 473 67 092 67 614 62 405 57 833 39 Oll 33 930 Coverage (registered infants as % of total infants) 29.2 24.1 18.3 18.7 16.9 15.7 10. 6 8.8 No. of visits paid by infants 420 703 499 752 319 123 234 218 232 123 223 456 158 601 159 370 Average number of visits per infant 4.0 5.6 4.8 3.5 3.7 3.9 4.1 4.7 It is significant that the sharp decline in the amount of health care delivered to infants was not accompanied by any rise in the infant mortality rate which remained almost constant during the period under review; this fact may cast some doubt on the efficacy and relevance of the health services delivered to infants. Table 3.6 shows the delivery of pre-school health services. A marked decline in pre-school health activities during the period 1961-68 is evi- dent. In 1968 the number of pre-school children under care decreased to 26% and the number of visits to 30% of the figures for 1961. The average annual number of visits by every pre-school child under care increased from 3.7 to 6.9. Based on a rough estimate of the eligible pre-school popula- tion the coverage was less than 2% in 1968. SEA/PHA/149 Page 44 Table 3.6. PRE-SCHOOL CHILDREN UNDER CARE AND THE NUMBER OF VISITS TO CHILD WELFARE CLINICS Year No. of pre-school No. of visits Average number children under care by pre-school of visits per (registered by PHN) children child 1961 97 169 363 701 3.7 1962 88 351 397 941 4.5 1963 46 731 244 381 5.2 1964 46 209 215 578 4.7 1965 45 883 212 573 4.6 1966 32 651 214 991 6.6 1967 20 131 137 249 6.8 1968 15 906 110 122 6.9 The objective need for the maternity and child health services has not increased considerably during the period 1961-68 since the number of pregnancies and newborn infants-increased on the average only by 0.36% per year. At the same time the satisfied need for child health, as expressed by the percentage of infants and pre-school children under care, showed a remark- able decline. There is no information to confirm or to reject the assumptions that the health institutions and agencies directed their activities towards the most needy consumers of the health services or that the services operated according to the convenience of the health personnel. The number of schoolchildren examined according to the evidence avail- able at the Health Statistics Branch, Ministry of Health, for the period 1961-68 shows a considerable increase (Table 3.7). However, it represents only 6.45 - 11.83% of the average number of the school-going population in the country. Since about one third of schoolchildren are eligible for exami- nation annually, the actual coverage was between 19.4% and 35,5%, Year 1961 1962 1963 1964 1965 1966 1967 1968 Table 3.7. NUMBER OF SCHOOLCHILDREN EXAMINED No. of school- children examined 160 613 178 593 193 709 219 099 248 119 353 932 243 529 223 912 School-going population (5-14 years) 2 489 OOO 2 556 OOO 2 777 OOO 2 844 OOO 2 912 OOO 2 984 OOO 3 052 OOO 3 077 400 % of school-going Population examined 6.45 6.99 6.98 7.70 8.52 11.83 8.14 7 .28 SEA/PHA/149 Page 45 The aim of examining schoolchildren is to detect those with "defects" and to correct these defects. The definition of "defect" is rather broad, including symptoms, diseases, and vaccination status, as well as any devia- tions from average physiological norms. In the evaluation of children's health, the subjective judgement of the medical officer who conducts the examinations could be misleading. In order to avoid this, as far as possible, a sample survey was carried out to establish the prevalence of defects using standard methods and criteria. Only 61.3% of urban schoolchildren and 43.0% of rural schoolchildren had the expected average body weight. A considerable percentage had an actual weight well below the average. The percentage of undernourished school- children in rural areas is striking (39.1%). Dental caries is a highly prevalent condition in urban schoolchildren aged 6-9 years. In rural areas also it seems to be a problem of importance but less than in the urban schools. Anaemia, as diagnosed by clinical inspec- tion only, is not common in the urban schools; in the rural schools, however, 7.2% of children had symptoms of anaemia. In a sample of 612 schoolchildrPn 3.4% showed nutritional anaemia with a haemoglobin values less than 8 g per 100 ml. The economically active population in Sri Lanka, between 20 and 60 years of age, represents 44.1% of the total population. On account of the mode of life and the lack of major occupational hazards, there is at present no reason for special concern as far as the health of this age group is concerned. The population in Sri Lanka is young and the proportion of old people is small, as was shown in Table 3.3. At present, therefore, geriatric problems are unlikely to complete successfully with the health problems of the youngest age groups for a greater attention of the health care system. In the present population structure of Sri Lanka the following groups can be identified: (i) (ii) (iii) (iv) (v) (vi) (vii) women of fertile age expectant mothers pregnant women in the stage of delivery newborns infants pre-school children schoolchildren 22% 3%* 3%* 3% 3% 11% 25% Total 64%* Thus 64% of the total population may need the special attention of the health care services. *Groups (ii) and (iii) are included in group (i), however they require much more attention of health care services than the rest of group (i) SEA/PHA/149 Page 46 3.1.3 Population Projection No special population projections were made for this study. The projections presented here were provided by the Ministry of Planning and Employment (56). They are based on the estimated population in 1968 and on three different assumptions of the future trend of fertility with a mortality trend similar to that in western countries (see also Annexes 1-2, 1-3 and 1-4). The high fertility projection assumed that fertility would remain constant over the projection period at the 1968 age-specific rate. The medium fertility projection assumed a slow decline to reach a total fertility rate of 3 060 by 1993-1998. And the low fertility projec- tion assumed the attainment of a total fertility rate of 2 425 by the end of the projected period (1998). There is always much guesswork involved in projecting present events to the future. The "high" projection of the population has been considered too pessimistic, and the "low" projection too optimistic since the recent performance of the family planning progranme does not justify such optimism. Thus, the most probable projection seems to be the "medium" one. A comparison of the projected population for 1971 based on "medium" fertility and the actual population obtained in the 1971 census showed close agreement: 12 800 OOO and 12 711143, respectively. As the Ministry of Planning and Employment based the Five-Year Plan, 1972-1976, on the "medium" fertility projection, it would have been a mistake for the national socio-economic planning and the NHMS to adopt different popu- lation projections. The population projection took into account only those changes that are expected to occur as a result of the natural growth of the population, which is a mechanical process resulting from the interaction of fertility and mortality. These two variables depend on many biological, environmental, and sociological factors which are closely associated with areas of govern- ment interest and policy. As the future policy of the government has been declared in the report of the Five-Year Plan 1972-1976, the full or partial implementation of this plan should lead to: (i) changes in the level of mortality; (ii) changes in the level of fertility; (iii) changes in the distribution of population by age, geographic area, and sector (urban/rural/estate); (iv) changes in literacy; (v) changes in employment opportunities; and (vi) changes in income and its distribution (29). The size and scope of these changes will depend on the level and force of implementation of government policy. SEA/PHA/149 Page 47 Table 3.8 shows that medium fertility projection will bring the population of Sri Lanka to 20 million by 1991, whereas the high and low fertility projections will respectively be more and less than this figure by 2 million. There will also be differences in age structures, as shown in Table 3.9. Table 3.8. POPULATION PROJECTIONS Year High fertility Medi4m fertility Low fertility 1971 12 934 OOO 12 880 800 12 821 500 1976 14 715 400 14 512 100 14 176 300 1981 16 781 OOO 16 282 200 15 430 600 1986 19 200 900 18 160 600 16 698 400 1991 21 901 200 20 067 300 17 950 300 Table 3.9. AGE STRUCTURE OF THE POPULATION Age group High fertility Medium fertility (years) 1973 1993 % increase 1973 1993 % increase All ages 13 585 23 095 70 13 521 20 848 54 0-4 1 955 3 584 83 1 892 2 452 30 5-14 3 320 5 613 69 3 320 4 571 38 15-19 1 429 2 239 57 1 429 2 026 42 20-59 6 027 10 182 69 6 027 10 141 68 60+ 835 1 659 99 855 1 659 94 Finally, two other points should be made: (a) the population size and structure represent the most important single factor in health and manpower planning, especially in a densely populated and still developing country like Sri Lanka, where the law of diminishing returns, among other factors, plays an important role in the economic and consequently politi- cal life; (b) in a country with competing nationalities and religions there exist various groups opposing a rational population policy and any action in this field has strong political repercussions. 3 .1. 4 Summary According to the latest census conducted in 1971, the population of Sri Lanka was 12 711 143 and the population density 503 per square mile. The SF.A/PHA/149 Page 48 great majority live in the villages and small towns, whereas 10% live in the administrative centres of districts and 11% in the estates. Fertility is declining, but is still rather high. The estimated crude birth rate in 1971 was 30.1 per thousand and the crude death rate 7.9 per thousand, resulting in a natural increase of 2.2%. The population structure by age group shows that about 64% of the population may require the special attention of the health care services, regardless of their demand for medical care. The present pattern of fertility will bring the population by 1991 to 22 million; or some 2 million less than this if a gradual and steady reduction of fertility can be achieved as a matter of national policy (medium fertility projection). The uncontrolled growth of the population will place a heavy burden on the health care system, among others. Although such a reduction in fertility seems feasible, there seem to be some constraints in the implementation of a rational population policy. 3,2 PREVALENT DISEASES 3.2.1 Diseases in the Past In the seventeenth century Knox wrote: "They live to a great Age very often to fourscore [eighty], and hale at that age, the Kings Sister was near an hundred. They are healthy and of a sound constitution. The Diseases this Land is most subject to, are Agues [malaria] and Fevours, and sometimes to Bloody-fluxes [dysentery]. The Smallpox also sometimes happeneth among them ••• They are also subject to Aches and pains in their Bodies" (57). Dr Henry Marshall wrote in 1846: "The prevailing diseases in Ceylon, both among emigrants from Europe and the indigenous inhabitants of the island, are endemic fever, bowel complaints and diseases of the liver" (58). 3.2.2 Morbidity Each individual in Sri Lanka experienced on average 2.1 episodes of sickness in 1969/70; this is based on data collected by lay investigators from a stratified random sample of the population in the course of a national socio-economic survey (24). Table 3.10 shows that the female population reported sick slightly more often than the male population. Persons older than sixty experienced 3.8 illnesses annually, and children under 5 years were sick 3.4 times in a year. The hea1thiest segment of the population was the age group 15-19 years with 1.2 illnesses annually. Schoolchildren and adolescents and the productive age group (20-59 years) suffered 1.6 - 1.9 episodes of sickness annually. Data on hospital inpatient morbidity can given an indication of the main morbid conditions in the population. However, hospital statistical data are related to a special category of conditions which must be severe SEA/PHA/149 Page 49 enough to motivate the patients to seek treatment and must also be judged by the doctors to be serious enough to require inpatient treatment. Although hospital statistics may give a biased view of total health needs, they are relevant in planning for hospital care in which context they can be used with more confidence. Table 3.10. NUMBER OF PERSONS REPORTING SICK DURING A 14-DAY PERIOD IN SRI LANKA AND THE PERCENTAGE MORBIDITY RATES IN DIFFERENT AGE GROUPS Age-group {years) 0-4 5-14 15-19 20-59 60+ Total Males Number {x 1 OOO) 118.8 102.9 29.7 190,5 67.4 509.4 % 13.1 6.4 4.4 6.7 15.6 7.9 Females Total Number % Number (x 1 OOO) (x 1 OOO) 115.7 13.1 234.6 93.2 6.2 196.0 33.6 5.2 63.4 219.3 8.3 409.8 34.2 9,9 101.5 496.1 8.1 1 005.5 % 13.1 6.2 4.8 7.4 14.5 8.0 Ten causes of hospital admission (excluding normal deliveries) to five major hospitals in Sri Lanka are given below in order of rank according to the number of hospitals in which they appeared (see also Annex 1-5): 1: lacerations and open wounds (including dog bites); 2-7: complications of pregnancy, child birth, and the puerperium; infections of skin and subcutaneous tissue; diseases of the genito-urinary system; enteritis and other diarrhoeal diseases; pneumonias; other diseases of the skin and subcutaneous tissue; 8-9: chronic bronchitis and unspecified bronchitis; 10: other diseases of the digestive system The data on inpatients discharged from 15 district hospitals, while the sub-study on the utilization of doctors was in progress, do not show much difference with regard to the frequency of the leading diagnoses in comparison with the data from outpatient departments and the data on in- patients in the provincial hospitals (see annex 1-6). Data on outpatient morbidity are shown in Annex 1-7. The rank list of the leading causes of outpatient attendance does not differ much from SEA/PHA/149 Page 50 the rank list of the leading causes of hospital admission, except in regard to: (a) poorer diagnostic work in outpatient departments, which allows for symptoms and ill-defined conditions to appear in the fourth place of the rank list of leading diagnoses; (b) missing categories of complications of pregnancy, child- birth and puerperium, since patients with these ailments are channelled through the ante-natal and post-natal clinics and not through outpatient departments; and (c) diseases of the musculo-skeletal system and connective tissues, which appeared in the sixth place of the rank list of outpatient diseases, were probably not considered serious enough for hospital admission. All three sets of data show the same problems, the only difference being the priority order in which the diseases appear. An analysis of cases (patients with the leading diseases) treated at government hospitals (Annex 1-8) shows the following trend during the period 1951-70 with due reserva- tions regarding the quality of diagnosis and accuracy of reporting in different types of hospitals: (a) Diarrhoeal diseases increase by 42%* (b) Tuberculosis decrease by 48% (c) Anaemia and malnutrition increase by 126% (d) Malignancies increase by 78% (e) Respiratory infections increase by 12% (f) Diseases of infancy and immaturity decrease by 78% (g) Heart diseases increase by 71% (h) Other infectious diseases increase by 47% (i) Accidents and suicides increase by 83% In spite of the above-mentioned limitations of hospital inpatient statistics there are some indications to confirm that the above trend is not far from the truth. For example, there is no doubt that tuberculosis is on the decline in the country; that there are no reasons to expect significant changes in the incidence of respiratory infections; and that the increase of heart diseases and malignancies may be considered a logical consequence of the prolongation of life expectancy and the aging of the population. The following are diseases statutorily notifiable in Sri Lanka: (A) Quarantinable diseases: smallpox, cholera, plague, yellow fever. (B) Other diseases: poliomyelitis, cerebrospinal fever, chicken- pox, diphtheria, dysentery, enteric fever, viral hepatitis, malaria, rabies, simple continued fever, tetanus, tuberculosis, typhus fever, whooping cough. *Expressed as the change (increase or decrease) in the rates of treated cases per 100 OOO population. SEA/PHA/149 Page 51 Though notifications are obligatory, the majority of the cases are notified by the government hospitals, the contribution of the outpatient services and the private sector being negligible. Even in hospitals the completeness of notifications varies, depending on the severity of the diseases. For example, it is estimated that the notification of typhoid may be only 50%, of diphtheria about 60%, and of dysentery only 5% of the treated cases in hospitals. After several years of remission (from 1961 to 1966) of epidemic malaria and after a severe outbreak in 1967 with hundreds of thousands of cases, the disease has settled at a rather high level of incidence which during 1971 and 1972 was more than 1% (Table 3.11). Tuberculosis has shown a remarkable decline during the period 1961-72, the incidence falling from 8.7 to 4.9 per 10 OOO population, a decrease of 44%, or 4% annually. The incidence of venereal diseases was in the range of 7.2 - 8.2 per 10 OOO during the period 1961-69, without showing any time trend. About four times more cases are recorded among males than among females, which may be a reflection of the case-finding policy and not of the dyna- mics of the disease and of the fact that more males tend to seek treatment at anti-venereal disease clinics. As the reported figures refer only to attendance at government clinics, it is likely that the true figures will be higher since a considerable number of cases may have been treated in the private sector. Filariasis is a specific problem in Sri Lanka. The disease is prevalent in the south-west coastal area and the estimated population at risk is about 2 million. Twenty years ago, the annual incidence of micro- filariasis was about 3-5%, which meant that at least 12-20% of the popula- tion at risk was infected at any point in time. Recently, a spectacular decrease in the incidence of the disease has reduced the incidence rate to 0.59% (in 1972); this means that there are about 12 OOO new cases annually in the country. The incidence of leprosy has shown a clear increase during the period 1964-72; from 3 to 7 new cases per 100 OOO population. This increase cannot be ascribed solely to improved case-fihding and registra- tion, since about 25% of new cases registered in 1970-71 were children under 15 years old. The total number of registered cases in 1971-72 was 6 981. 3.2.3 Disability On disability there is no current evidence collected in a systematic way. The existing information comes from the national socio-economic survey (NSES) for 1969-70 (24). There are also no data on permanent disability caused by diseases. The information originating from the NSES defines the disability caused by sickness as "period of absence from normal dµties". Table 3.12 shows the percentage of sick persons who could not attend to their duties in different sectors. The percentage of disabled persons in SEA/PHA/ 149 Page 52 the estate sector is much lower (40%) than that in the urban (55%) and rural (55.5%) population. The percentage of disabled persons, of those reported sick among the whole population, is 54.1%. This observation requires further study; it may be related to the different severity of disease in the population groups concerned, different perceptions of disease and of tolerance to suffering, etc. Table 3.11. NEW POSITIVES CASES (LOCAL AND IMPORTED) OF MALARIA Year 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 Table 3.12. Whole Island Total sick 1 005. 5 Absent from duties 544.1 No. of positive cases 110 31 17 150 308 499 3 466 440 644 537 688 468 199 145 368 132 605 Rate per 1 OOO 0.00137 0.027 0.043 0.29 36.4 43.4 37. 9 11.3 10.1 ABSENCE FROM NORMAL DUTIES AMONG SICK PERSONS (x 1 OOO) Urban Rural Estate No. % No. % No. % 131,9 100.0 779.0 100.0 94.6 100.0 72.4 55.0 433.2 55.5 38.5 40.7 Females (57.9%) show a higher percentage of disability than males (56,5%), At the same time, females have a higher percentage of disability of short duration (less than 14 days): females 34.1% and males 32.6%. It has been estimated that there were 112 354 500 man-days of absence from duty because of sickness in 1969/70 in Sri Lanka: this makes SEA/PHA/149 Page 51 Though notifications are obligatory, the majority of the cases are notified by the government hospitals, the contribution of the outpatient services and the private sector being negligible. Even in hospitals the completeness of notifications varies, depending on the severity of the diseases. For example, it is estimated that the notification of typhoid may be only 50%, of diphtheria about 60%, and of dysentery only 5% of the treated cases in hospitals. After several years of remission (from 1961 to 1966) of epidemic malaria and after a severe outbreak in 1967 with hundreds of thousands of cases, the disease has settled at a rather high level of incidence which during 1971 and 1972 was more than 1% (Table 3.11). Tuberculosis has shown a remarkable decline during the period 1961-72, the incidence falling from 8.7 to 4.9 per 10 OOO population, a decrease of 44%, or 4% annually. The incidence of venereal diseases was in the range of 7.2 - 8.2 per 10 OOO during the period 1961-69, without showing any time trend. About four times more cases are recorded among males than among females, which may be a reflection of the case-finding policy and not of the dyna- mics of the disease and of the fact that more males tend to seek treatment at anti-venereal disease clinics. As the reported figures refer only to attendance at government clinics, it is likely that the true figures will be higher since a considerable number of cases may have been treated in the private sector. Filariasis is a specific problem in Sri Lanka. The disease is prevalent in the south-west coastal area and the estimated population at risk is about 2 million. Twenty years ago, the annual incidence of micro- filariasis was about 3-5%, which meant that at least 12-20% of the popula- tion at risk was infected at any point in time. Recently, a spectacular decrease in the incidence of the disease has reduced the incidence rate to 0.59% (in 1972); this means that there are about 12 OOO new cases annually in the country. The incidence of leprosy has shown a clear increase during the period 1964-72; from 3 to 7 new cases per 100 OOO population. This increase cannot be ascribed solely to improved case-fihding and registra- tion, since about 25% of new cases registered in 1970-71 were children under 15 years old. The total number of registered cases in 1971-72 was 6 981. 3.2.3 Disability On disability there is no current evidence collected in a systematic way. The existing information comes from the national socio-economic survey (NSES) for 1969-70 (24). There are also no data on permanent disability caused by diseases. The information originating from the NSES defines the disability caused by sickness as "period of absence from normal duties". Table 3.12 shows the percentage of sick persons who could not attend to their duties in different sectors. The percentage of disabled persons in SEA/PHA/149 Page 52 the estate sector is much lower (40%) than that in the urban (55%) and rural (55.5%) population. The percentage of disabled persons, of those reported sick among the whole population, is 54.1%. This observation requires further study; it may be related to the different severity of disease in the population groups concerned, different perceptions of disease and of tolerance to suffering, etc. Table 3.11, NEW POSITIVES CASES (LOCAL AND IMPORTED) OF MALARIA Year 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 Table 3.12, Whole Isl.and Total sick 1 005.5 Absent from duties 544.1 No. of positive cases 110 31 17 150 308 499 3 466 440 644 537 688 468 199 145 368 132 605 ABSENCE FROM NORMAL DUTIES AMONG PERSONS (x 1 OOO) Urban Rural No. % No. % 131.9 100.0 779.0 100.0 72.4 55.0 433.2 55.5 Rate per 1 OOO 0.00137 0.027 0.043 0.29 36.4 43.4 37.9 11.3 10.1 SICK Estate No. % 94.6 100.0 38.5 40.7 Females (57.9%) show a higher percentage of disability than males (56,5%). At the same time, females have a higher percentage of disability of short duration (less than 14 days): females 34.1% and males 32.6%. It has been estimated that there were 112 354 500 man-days of absence from duty because of sickness in 1969/70 in Sri Lanka: this makes SEA/PHA/149 Page 53 about 308 300 man-years lost owing to illness, which corresponds to about 2.5% of the total population in the country (Table 3.13). Table 3 .13. TOTAL DURATION OF ABSENCE FROM DUTY DURING A 14-DAY PERIOD OF OBSERVATION Period of absence No. of sick Average duration of Total (days) persons absence in days (man-days) Less than 3 82 400 1.5 123 600 3-6 149 500 5 747 500 7-13 94 OOO 10.5 987 OOO 14 and more 92 600 14 1 296 400 Total 418 500 7.3 3 154 500 Estimate for "unspecified" 150 500 7.3 1 173 750 Grand total 575 OOO 7.3 4 325 250 The above estimates were based on data collected by lay interviewers and referred to events that occurred up to 14 days before the interview. For this reason, the data are unlikely to be extremely correct. However, the information on the disability caused by diseases provides an approxima- tion which, with all its limitations, gives an idea of the size of the problem. 3.2.4 Mortality The crude death rates of the population in Sri Lanka show a steady decline from 1946 onwards (Table 3.14). During the decade 1942-51 the crude death rate fell from 18.8 per thousand (in 1941) to 12.7 per thousand in 1951, a decline of 30%. During the next decade, 1952-61, the decline was from 12.7 (in 1951) to about 8.5 (the crude death rate for 1961 was particularly low, 8.0 and might have occurred by chance, since the rates before and after that year were in the range of 8.5 per thousand, a more probable figure). The reduction of the death rate in the period 1952-61 was 34%. During the last decade, 1962-70, the decline in the crude death rate has been negligible, from 8.5 to 8.0 per thousand. SEA/PHA/149 Page 54 Table 3.14. NUMBER OF DEATHS AND CRUDE DEATH RATES, 1942-1970 Deaths Year Deaths Year Number Crude death Number Crude death rate rate 1942 112 044 18.1 1957 92 759 10.1 1943 131 061 20.8 1958 90 815 9.7 1944 133 985 20.8 1959 87 971 9.1 1945 142 931 21.5 1960 84 918 8.6 1946 135 937 19.8 1961 81 653 8.0 1947 98 544 14.0 1962 88 928 8.5 1948 93 711 13.0 1963 91 673 8.5 1949 91 889 12.4 1964 96 202 8.8 1950 95 142 12.4 1965 90 765 8.2 1951 100 072 12.7 1966 94 419 8.3 1952 95 298 11.8 1967 87 877 7.5 1953 89 003 10.7 1968 94 903 7.9 1954 86 794 10.2 1969 102 356 8.3 1955 94 368 10.8 1970 94 129 8.0 1956 87 561 9.8 The death rate for males was 8.6 per thousand and for females 7.3 per thousand in 1968. Among males the highest mortality rate was in the age groups over 60 years, 54.4 per thousand; next, in children aged 0-4 years, 17.2 per thousand. Schoolchildren and the age group 15-19 years had the lowest death rates, 1.6 and 1.5 respectively. Mortality rates among males of productive age, 20-59 years, was 4.7 per thousand. The leading causes of death in 1965 are shown in Table 3,15 (59). Diseases of infancy and immaturity lead with 107 deaths per 100 OOO population, followed by heart diseases and diarrhoeal diseases. Next, with very similar death rates are respiratory infections, gastroenteritis, and accidents and suicides; then follow anaemias and malnutrition, malig- nancies, and other infectious diseases. Other helminthic diseases and tuberculosis have the same rates, 15 per 100 OOO. Dysentery, hookworm, and typhoid occupy the last three places in the list. The number of deaths of infants represents 20% of all deaths and the number of deaths among pre-school children aged 1-4 years is 10% of all deaths. The common causes of death in infants are diseases of infancy and immaturity, diarrhoeal diseases, and respiratory infections. The most common causes of death among pre-school children are anaemia and malnutri- tion, and diarrhoeal diseases. Schoolchildren die most often from diar- rhoeal diseases, anaemia and malnutrition, and accidents. The commonest SEA/PHA/149 Page 55 causes of death in the age group 15-44 years are accidents and suicides, followed by heart disease. Persons between 45 and 64 years die from heart disease and malignancies most often. The five leading causes of death by age group are shown in Table 3.16. Table 3.15. LEADING CAUSES OF DEATH, 1965 Diseases Mortality per 10 OOO Male Female Both Diseases of infancy and immaturity 116 98 107 Heart diseases 92 58 76 Diarrhoeal diseases 68 71 70 Respiratory infections 45 49 47 Gastroenteritis 47 46 46 Accidents and suicides 61 28 45 Anaemias and malnutrition 32 46 38 Malignancies 27 27 27 Other infectious diseases 23 18 21 Other helminthic diseases 14 17 15 Tuberculosis 18 11 15 Dysentery 5 5 5 Hookworm 2 3 2 Typhoid 1 1 1 3.2.5 Trend of Diseases In any attempt to assess the kind of changes that may be expected in the disease situation during the next twenty years, the following facts are of great importance: (a) The causes of most of the leading diseases in Sri Lanka are deeply rooted in the environment so that without a basic change in the environment a major reduction in these diseases cannot be expected to occur. Thus the Table 3.16. THE FIVE LEADING CAUSES OF DEATH BY AGE GROUP, 1965 AGE GROUP L e a d i n g c a u s e s (years) First Second Third Fourth , Infants diseases of respiratory diarrhoeal other infectious infancy and immaturity infections diseases diseases 1 - 4 diarrhoeal respiratory anaemia and other infectious diseases infections malnutrition diseases 5 - 14 diarr.hoeal accidents and other infectious anaemia and diseases suicides diseases malnutrition 15 - 44 accidents and heart diseases diarrhoeal anaemia and suicides diseases malnutrition 45 heart diseases malignancies diarrhoeal accidents and diseases suicides Total diseases of heart diseases diarrho.:·al respiratory Population infancy and diseases infections immaturity Fifth anaemia and malnutrition accidents respiratory infections malignancies anaemia and malnutrition gastroenteritis "' tn ~ !:: 11) -- "' u, - "'~ -- 1-' .t:- \0 SEA/PHA/149 Page 57 present pattern of leading diseases does not differ significantly from the pattern 25 years ago. For this reason, no major decline in diarrhoeal diseases, infectious diseases, diseases of the digestive system, diseases of the skin and subcutaneous tissues, and of accidents may be expected in the future, if the environment is not improved. Moreover, the development of modern industries and transport may lead to an increase in accidents and occupational hazards. (b) The economic development of the country will lead to the improvement of living standards, if the economic growth is not overtaken by population growth. However, the growth of the GNP (gross national product) per capita cannot show how much the living standard of the population has improved, if data on the distribution of the national income are lacking. Thus, the future trend of anaemias, malnutrition, and diseases of infancy and immatu- rity will depend on the rise in living standards of the population as indicated by the distribution of the national income. (c) The spread of the acute communicable diseases occurs through the environment. Consequently, without major changes in the environment, especially with regard to water supply, sewerage, waste disposal, and vector control, no major improvement in the island-wide control of infectious diseases may occur. However, in respect of poliomyelitis, diphtheria, tetanus, whooping cough, and rabies, 1and in part typhoid, modern health technologies can limit to a great ext;ent the spread of infection. There is a standing risk of transmission of cholera and smallpox from neighbouring countries, although Sri Lanka has been free of smallpox for a long time. It may also be noted that some anaemias may be due to hookworm, a disease main- tained by an unsafe environment. (d) Certain diseases, which are considered of great importance today, may be expected to change in significance in the future: (i) The recent past has shown that malaria is quite an unpredictable disease. Although malaria showed a declin- ing trend in 1971-72, it would be safer not to expect a major success in malaria control during the next 20 years. (ii) During the past 10 years the incidence of all forms of tuberculosis decreased by one half. There is reason to believe, based on the experience in other countries, that during the next 20 years the incidence may decrease again by about 50%, going down to 2.2 cases per 10 OOO popula- tion. (iii) The venereal diseases have not shown any decline recently. Experience from other countries shows that the expansion of a successful family planning programme may lead to an increase in venereal infections. For this reason, no considerable reduction in the problem of venereal diseases may be expected in the next 20 years. SEA/PlIA/149 Page 58 (iv) The incidence of filariasis has shown a spectacular decline in the past 20 years, from 2-3% to 0.60% in the endemic areas. However, during the last 3 years (1969-72) there has been no change in the incidence which shows that the further reduction of the problem will be much slower. (v) The incidence of leprosy is increasing, which does not necessarily mean that the disease is spreading fast because it may be an expression of the more intensive case-finding in recent years. In view of the very chronic course of the disease, major changes are not to be expected in the next 20 years. 3.2.6 Summary Data on the present health situation in Sri Lanka in terms of hospital morbidity and mortality show that the population lives under the influence of a challenging environment, which is expressed in the high incidence of acute and chronic communicable diseases. Malaria occupies a prominent place among them and almost overshadows all other diseases in this group. Special prob- lems are also presented by tuberculosis, leprosy, filariasis, and the venereal diseases, as well as typhoid fever, infectious hepatitis, poliomyelitis, diphtheria, dysentery, and rabies. The diarrhoeal diseases, respiratory infections, and accidents and suicides, which account for a large proportion of hospital admissions and deaths, may also be connected with some effects of the human environment. Anaemia, malnutrition, and some diseases of infancy and immaturity can be related to the socio-economic factors that determine the living standard of the population. These conditions are also among the leading causes of hospitalization and death and occupy the second place in the disease pattern in Sri Lanka. The chronic and degenerative diseases are in the third place. They include heart diseases and malignancies which are also among the ten leading causes of hospital admission and of death. Conditions connected with pregnancy and normal or abnormal delivery are responsible for a large number of admissions to the hospitals in the country. As the above factors are unlikely to change very much during the next twenty years, no major changes in the leading causes of sickness and death may be expected. The only exception is tuberculosis which has shown a very clear downward trend during the preceding eleven years; there is no reason why this trend should not continue, although perhaps at a slower pace. Finally, the increase in the size of the age group above 60 years may bring greater prominence to the problem of malignancies and degenerative diseases. 3.3 DEMAND FOR MEDICAL CARE The demand for medical care services has been defined as the willing- ness of individuals to attend at medical care institutions, when they feel SEA/PHA/149 Page 59 sick and to pay for medical services when required. The government medical services in Sri Lanka, however, provide medical care free of charge to the population (a token charge of Rs. 0.25 for each first outpatient visit was introduced in 1972). The magnitude of this demand for medical services provided by the government sector therefore depends on the perception of illness by the population and on the capacity of the government health institutions. A part of the total demand for medical services is met by private practitioners of western medicine and by the indigenous (ayurvedic) sector (both government and private) of the Sri Lanka health care system. There is also another sector of unqualified persons who play a considerable role in providing medical care; this sector has been designated in this book as the 11other" sector (see Chapter 4, section 4 .3). 3.3.1 Outdoor (Outpatient) Medical Care Every citizen in Sri Lanka has the choice of attending outpatient medical care services in either the government or the private sector; and in each sector he can choose between western medicine and ayurveda. In the private sector there are also 11hom'oeopathic doctors", quacks, and others. Data from the National Socio-economic Survey, 1969/70 showed that the government sector satisfied 54.5% of the demand for medical care services (49.4% western and 5.1% ayurveda) and the private sector attracted 40.2% of the demand (24.9% western and 15.3% ayurveda) (24). However, data from the present study suggests that the shares of the different sectors and sub-sectors in satisfying the demand for medical care services vary and they demonstrate especially the role of the ayurveda sector (Table 3.17). Table 3 .17. DEMAND FOR OUTPATIENT MEDICAL CARE SERVICES Sector Number of visits per year Grand total 73 982 810 Government sector: total western (1971/72) ayurveda (1973) Private sector: total western** ayurveda* other** *Estimates **Assumptions 34 067 394 29 582 599 4 484 795 39 915 416 5 160 OOO 23 805 416 10 950 OOO On the average, an inhabitant of Sri Lanka makes 3 visits to govern- ment western-type medical institutions annually: this includes visits to SEA/PHA/149 Page 60 outpatient departments and to clinics (see Annexes 1-10 and 1-11). The most frequented institutions* are hospitals with 61.2% of all visits to government western medical institutions, followed by central dispensaries, with and without attached maternity homes, which attract 32.5% of out- patients. Branch dispensaries and visiting stations, which work on a weekly or fortnightly basis, meet only 6.3% of the population's demand for outpatient medical care. A repeated one-day census of the outpatient attendance at a sample of health institutions revealed that the patients who patronize the government western-type institutions for medical care come from nearby areas: 61.4 - 96.6% of all patients travel a distance less than 5 miles from their homes. However, a number of patients did not patronize the nearest institution but attended a more distant one. This phenomenon is viewed by the government as one of the major health concerns of the country since it leads to over-utilization of some medical institu- tions and to under-utilization of others. The "bypassing" of the nearest institutions has been analysed (Annex 1-12). The most often bypassed institutions are the central dispen- saries (by 47.2% of patients), followed by the branch dispensaries and visiting stations (44.8%), rural hospitals (23.1%), and peripheral units (11.5%). It is interesting to note that the big hospitals, like provincial and base hospitals, are also bypassed (4.8% and 3.1% respectively). The total percentage of patients who bypass the nearest institution is 19,1% of all patients. The following reasons for bypassing, as stated by the patients, are presented in the order of their frequency in the answers received: (1) 30% had no special reason, but felt that the institution attended provided better treatment than the bypassed one; (2) 14% had previously attended the bypassed institutions without benefit; (3) 12% were in fact referred by the institution which was nearest to their homes; (4) 12% stated that the bypassed institution did not work on all days of the week; (5) 10% stated that no injections or effective drugs were available at the bypassed institution; (6) 9% said it was habitual to attend the institution they went to, while bypassing the nearest one; (7) 6% referred to the convenience of transport; (8) 1% said there was no qualified doctor at the bypassed institution; (9) 6% gave other reasons. *For details on the different types of health institutions, refer to Annex 1-1. SEA/PHA/149 Page 61 It is clear that some of these reasons are not distinctive and that certain other reasons may be concealed behind them. For instance, those who "felt that the institution attended provided better treatment" may have felt like that because of lack of medicaments, or the absence of a doctor, etc. However, some reasons may be singled out as more relevant (i.e., referrals, or the inability to obtain relief at the closest institution when this was needed because the institution did not work every day, or better transport facilities); if these are set aside, the percentage of patients bypassing without good justification will be reduced from 19% to 11% of the whole outpatient attendance, which may not represent a cause for concern. Another aspect of this problem is the change in the workload of all institutions if bypassing is controlled. The workload in provincial hospi- tals, the Colombo group, the base hospitals, district hospitals, peripheral units, and the central dispensaries and maternity homes will decrease by 23, 25, 28, 18, 11 and 2% respectively; whereas the workload in the rural hospitals, central dispensaries, and the branch dispensaries and visiting stations will increase by 12, 34 and 61% respectively. This relationship is shown in Annex 1-12. About 89% of the outpatients spent less than 30 minutes in travel- ling from their homes to the health institution, and 92% spent less than one hour. This shows the relatively easy accessibility to the government medical services. It is mainly the adult population, 20-59 outpatient departments (39% of all attendance); pre-school children, and the aged (20%, 18% and represent only 5% of the attendance, since they mainly at the child welfare clinics. years, who patronized the next come schoolchildren, 8% respectively). Infnnts are probably taken care of The most usual treatment offered to outpatients was a mixture plus tablets (in about 56% of cases). Only 0.4% were not given any treatment and another 0.5% were referred to a better equipped medical institution without giving treatment. The other patients received only a mixture, or dressings, or an injection, or tablets (each item accounting for about 5% of cases). Those admitted to hospitals represented 2.5% of the whole attendance. There were slight differences in the treatment procedures offered by different categories of medical institutions. Outpatient medical care is also provided by the specialized clinics in the western-type government hospitals at an average of 3 million consul- tations annually (see Annex 1-11). The number of all outpatient visits to hospitals, dispensaries, and clinics showed a steady increase in the period 1961-71, an increase that corresponded to the population growth. The consumption of medical care per person, however, remained almost the same throughout the period, around 3 visits per person per year (range 2.8 - 3.2) for all visits and 2.5 per person per year (range 2.3 - 2.6) for first visits. The estimated number of visits paid to the government ayurveda institutions was 4 884 800, or roughtly about 0.3 per person, Of this SEA/PHA/149 Page 62 number, 1 983 200 visits were paid to ayurveda hospitals, and 2 901 600 to ayurveda dispensaries. There is a difference regarding the age distribution of patients patronizing the government ayurveda sector, in comparison with the government western sector. The schoolchildren, pre-school children, and infants seem to favour the western sector, and the old people favour the ayurveda sector. Ayurveda hospitals attract their patients from far away since only about 47% of them travelled less than 5 miles, whereas 95% of the patients to the ayurveda dispensaries came from within the same distance. The private sector of the Sri Lanka health care system is represented by about 530 private practitioners of western medicine; by nursing homes, cooperative and estate hospitals; by an unknown but not very large number of registered (assistant) medical practitioners who practise a western type of medicine; by 9 833 registered ayurveda practitioners who practice the ayurveda, unani, or siddha systems of indigenous medicine; by about 6 OOO non-registered ayurveda practitioners; by about 600 "homeopathic doctors"; by 230 pharmacies; and by an unknown number of quacks. The regional distribution of private practitioners of western medi- cine and of ayurveda by SHS divisions (health regions) is shown in Table 3.18, There are about 20 times more registered ayurveda private practitioners than western private doctors in Sri Lanka. The distribution of both types by SHS divisions is not equitable. It is also not very clear whether one type tends to concentrate in SHS divisions where the opposite is rare. There is evidence, however, that both competition and complementary factors are likely to have influenced the location of private western and ayurveda practition~rs; in some SHS divisions, like Colombo and Jaffna, both western and ayurveda practitioners are concentrated in frequencies above the average for the country, whereas in other SHS divisions, like Kegalle and Kurunegala, ayur- veda practitioners seem to occupy the gaps in the private sectors that are short of private western practitioners. Another factor may be differences in the economic demand for private medical services. Table 3.18. RATIOS OF PRIVATE DOCTORS TO THE POPULATION BY SHS DIVISIONS FOR WESTERN AND AYURVEDA DOCTORS, 1972 S.H.S. division Ratio per 100 OOO western ayurveda Sri Lanka 4.1 80.6 Anuradhapura 1.3 58.5 Badulla 1.9 14.8 Batticaloa 1.9 54.6 Colombo 10.2 100.3 Galle 3.0 98.4 Jaffna 6.2 105.5 Kalutara 3.3 115.3 Kandy 3.0 49.6 Kegalle 1.3 109.3 Ku rune gala 1. 7 94.4 Ma tale 1.9 74.3 Matar a 2.1 86.8 Puttalam 5.1 69.9 Ratnapura 1.8 77 .3 Vavuniya 0.0 32.9 SEA/PHA/149 Page 63 There are no data on the work output of the private sector. Some scattered and indirect observations exist, e.g., data on the annual indivi- dual consumption for personal care and medical services as estimated by the Central Bank of Ceylon in its annual report for 1972 (63), from which it may be assumed that the number of visits to western private practitioners in one year may be around 5 million and to practitioners in the "other" sector around 11 million. The sub-study on the pattern of ayurveda practice gave an estimate of 24 million visits annually to the registered private ayurveda practitioners. Thus, the consumption of medical care in the private sector amounts to about 40 million visits annually. 3.3.2 Indoor (Inpatient) Medical Care The number of inpatients treated in the western type of medical institutions in Sri Lanka showed an increase during the period 1961-70 of about 6.3% (Table 3.19). A comparison of the demand for inpatient treatment expressed as the number per 100 persons in the country during the period 1961-64 with the period 1965-68 also showed an increase from an average of 15.5 to 16.3 or an increase of 5% between the two four-year periods. Year 1961 1962 1963 1964 1965 1966 1967 1968 Table 3.19. NUMBER OF INPATIENTS TREATED IN MEDICAL INSTITUTIONS No. % of population treated 1 609 218 15.8 1 667 414 16.0 1 614 664 15.3 1 642 369 15.1 1 784 791 16.0 1 764 016 15.4 1 945 205 16.6 2 079 984 17.3 1970/71* 2 007 263** 16.8 *Data for the financial year (October to September) **Without maternity homes The increase in the demand for inpatient treatment was not the same in all categories of hospitals and was the highest in the provincial hospi- tals, base hospitals, and peripheral units. This might have been a reflec- tion of the change in bed strength in certain categories of hospitals. There was a decrease in the demand for inpatient treatment in the tuber- culosis hospitals and leprosy hospitals. There was also an increase in the number of patient-days utilized in some categories of medical institutions in the financial year 1970-71 compared with the financial year 1960/61. The increase was not the same for all categories of institutions, the largest increase being recorded in SEA/PHA/149 Page 64 the provincial hospitals (42.2%) and in the base hospitals (33.4%). The Colombo group of hospitals experienced a moderate increase in the number of patient-days (7.7%) and the district hospitals an increase of only 1.2%. The number of patient-days in tuberculosis hospitals decreased by 36.6%, in leprosy hospitals by 13.2%, and in mental hospitals by 15.4%. As a result of the disproportionate increase in the number of in- patients and in the number of patient-days, the average duration of treat- ment in hospitals decreased in all the hospitals under consideration from 8.1 days to 6.2 days (a reduction of 23.5%). This reduction was most pronounced in the mental hospitals (by 50%) and the tuberculosis hospitals (by 25.1%). In the other types of hospitals the decrease in the duration of inpatient treatment varied from 17.5% in the district hospitals to 1.1% in the Colombo group. It is not clear whether the reduction in the duration of hospital treatment is due to higher pressure on hospital admissions and consequently a quicker turn-over of patients, or to changes in the diseases and their severity in these institutions; or to the adoption of more effi- cacious methods of treatment in the hospitals; or to all these factors. The demand for patient treatment in the government ayurveda hospitals as well as in hospitals in the private sector is of limited importance from the health manpower point of view, because of the small number of hospital beds in these health institutions. 3.3.3 Private Expenditure on Medical Services Data on the individual expenditure for private medical services (consultations, hospital treatment, purchase of medicines, etc.) were obtained from two different sources: the socio-economic survey and the Central Bank of Ceylon. Table 3.20 is based on data from the socio-economic survey, 1969/70 (24). It shows that an average household in Sri Lanka spent Rs. 4.28 per month (1.3% of the monthly income of the household) on the purchase of medical services in the private sector in 1969/70. The data relate to all kinds of services, western, ayurvedic, homeopathic, or any other. Table 3 .20. MONTHLY EXPENDITURE ON PRIVATE HEALTH SERVICES FOR HOUSEHOLDS, 1969/70 Income group Households Average Health Percentage of (Rs) in the monthly expendi- monthly income group(%) income ture (Rs) spent on health (Rs) services Under 200 43.5 178.40 2.05 1.1 200-399 37.2 326.14 4.15 1.3 400-599 11.4 501.21 6.50 1.3 600-799 4.3 677 .69 10.52 1.6 800-999 1. 7 877 .so 16.66 1.9 1000+ 1.9 1 371.67 20.02 1.5 all households 100.0 325.64 4.28 1.3 SEA/PHA/149 Page 65 There is a clear relationship between the amount spent on the pur- chase of medical services and the income category of the household. The least privileged households spent only Rs. 2.05 monthly, which represented 1.1% of their monthly income. The most privileged spent ten times more, Rs. 20.02, or 1.5% of their monthly income. The highest percentage spent on "buying health" was recorded in the income group Rs. 800-999 with 1. 9% of the monthly income or about 75% more than the households in the lowest income category. However, the most money came to the "health market" from the income group Rs. 200-399 (37.2%) and from the lowest income group, below Rs. 200 (20.9%) (Table 3.21). The total available money for the purchase of medical services in the financial year 1969/70 was estimated at Rs. 9 039 940 per month, or about Rs. 110 million annually (Table 3.21). However, this may be an underestimate since data from the Central Bank of Ceylon (63) for the financial year 1972 indicate a private consumption of medical care amount- ing to about Rs. 200 million for that year. Income groups (Rs.) Table 3.21. TOTAL MONTHLY EXPENDITURE ON THE HEALTH SERVICES BY HOUSEHOLDS, BY THEIR INCOME GROUP Households in the group No, % Total monthly health expenditure (Rs.) Percentage contributed by income group Under 200 920 170 43.8 1 886 348.50 3 261 630.25 1 561 657.50 20.9 37.2 11.4 200-399 785 935 400-599 240 255 600-799 91 390 800-999 35 150 1000+ 39 235 2 112 135 37.3 11.4 4.3 1. 7 2.3 100.0 950 902.80 585 599.00 785 484.70 9 039 937.80 4.3 1. 7 1.9 100.0 It should be mentioned here that the recently introduced "token fee" of Rs 0.25 for each first outpatient visit may also be considered a form of private or individual payment for health. Small as this fee is, a 30% reduction in the number of outpatient visits to the government western-type institutions was registered. It is difficult to say whether this effect of the "token fee" will last long. 3.3.4 Projected Demand for Medical Services The quantitative per aapita demand for the government western-type inpatient and outpatient hospital services has not shown any significant rise during the past 10 years and it is unlikely that it will change SEA/PHA/149 Page 66 considerably in the future. Thus, the size of the demand for government western-type medical services will depend mainly on the population growth in the future. If it is assumed that the per capita annual demand for inpatient treatment will remain at the level of 0.16 hospital discharge and that for out-patient care will remain at about 3 visits to the government western-type services, the projected demand for government western-type medical services is expected to follow the pattern shown in Table 3.22 for high-fertility and medium-fertility population projections. (The low fertility projection was not taken into consideration since it is the most unlikely one. ) Table 3.22. PROJECTED DEMAND BY INPATIENTS (NUMBER OF PATIENTS DISCHARGED) AND OUTPATIENTS (NUMBER OF VISITS) FOR GOVERNMENT WESTERN-TYPE MEDICAL SERVICES Year 1976 1981 1986 1991 High fertility patients discharged 2 354 500 2 685 OOO 3 072 100 3 504 200 visits 44 146 200 50 343 OOO 57 602 700 65 703 600 Medium fertility patients discharged 2 221 900 2 605 200 2 905 700 3 210 800 visits 43 536 300 48 846 600 54 481 800 60 201 900 If the age-specific demand for medical services, which is above the average for infants and the population above 60 years and below the average for the age groups 5-14 years and 20-59 years, is taken into account, the demand in 1991 may be 3.54% higher (with the high-fertility projection) or 2% lower (for medium-fertility projection) as compared with the data in Table 3.22. A considerable reduction in the number of outpatient visits may be expected if the effect of the Rs 0.25 "token fee" is long-lasting. Thus, the actual demand for the government out-patient medical care services might be considerably reduced in comparison with the projections in Table 3.22. This possibility deserves a follow-up in the near future to establish the trend. The projection of the demand for government western-type medical services is valid as long as the inpatient services remain free-of-charge for the population and the outpatient fee remains at Rs 0.25 per first visit. It is likely that the demand for certain western-type government medical care services will change more significantly, such as: (a) the number of inpatients treated at the provincial, base, and tnental hospitals as well as at the peripheral units may tend to increase rather more than the overall increase in the utilization of inpatient medical care services, whereas the average duration of hospital treatment may decrease further; SEA/PHA/ 149 Page 67 (b) the ntunber of patients treated at the tuberculosis and leprosy hospitals is expected to decline further; (c) the demand for consultations in psychiatry, family plan- ning, neurosurgery, venereal diseases, thoracic surgery, genito-urinary, and orthopaedic specialties is expected to increase considerably. The specific trend of the demand for government ayurvedic hospital inpatient treatment cannot be projected because of the lack of past data. Otherwise it might have been considered in the context of the overall demand for inpatient medical care provided by the government. The demand for medical care services from the private sector (western, ayurvedic, and "other") is a function of the funds available for individual consumption of medical services. The mere growth of the GNP cannot indicate the trend of the future consumption of medical services, since the health expenditure of the population is not a linear function of the household income. The relationship between the increase in the household income and the corresponding increase in the individual consumption of medical care is shown in Table 3.23. For instance, a 2.47 times increase of household income is likely to generate a 1.97 times increase of individual consumption of medical services, etc. Table 3.23. RELATIONSHIP BETWEEN THE INCREASE IN HOUSEHOLD INCOME AND THE INCREASE IN INDIVIDUAL CONSUMPTION OF MEDICAL CARE SERVICES* Increase of household income - by the multi- plicator 2.47 4.26 6.10 7.99 13.39 Increase of individual consumption of medical services - by the multi- plicator 1.97 2.97 4.43 6.13 7.84 *This table has been derived from the data of Table 3.22, based on the average monthly consumption for health services and average monthly income (data from the National Socio-economic Survey) So, not only the growth of the GNP but also the pattern of distribu- tion of income is important. Different patterns of distribution of the national income will generate different funds for individual consumption of medical services delivered by the private sector in Sri Lanka. If two hypo- thetical patterns of the national income distribution are compared and applied to the population projection for 1991 (according to the medium- fertility projection), quite different amounts of money for spending on SEA/PHA/149 Page 68 health will be available in 1991 (assuming that the total amount of funds available for the private consumption of medical care was Rs 200 million in 1972): Income groups % of households (Rs) Pattern I Pattern II Under 200 20 30 200-399 20 30 400-599 51 10 600-799 5 10 800-999 2 10 1000 and more 2 10 All groups 100 100 A rough estimate of the funds that will be available for private expenditure on medical care services in 1991 shows a major difference depend- ing on the distribution pattern of the national income (all other factors being equal): 3.3.5 SuIIDD.ary Pattern I Pattern II Rs 428 million Rs 591 million The expressed demand for medical care services has been defined as the willingness of the population to attend at medical care institutions when they feel sick and to pay for medical services when required. The demand for outpatient medical care in Sri Lanka is met by the government western-type and ayurveda medical care institutions, and by a private sector consisting of western and ayurveda practitioners as well as of different types of non-registered practitioners. The total number of annual outpatient visits per person in the country amounted to 5.7: Government sector: western ayurveda Private sector (estimate): 2.5 visits per capita 0.3 -do- 2.9 -do- There has been no clear tendency for an increase in the demand for outpatient services in government western-type institutions in recent years. The demand for inpatient medical care is met mainly by the government hospitals, whereas the government ayurveda sector and the private hospitals contribute very little. The average annual demand is 16 admissions per 100 persons. The estimated annual expenditure on private medical services is bet- ween Rs 110 and 200 million, probably closer to the latter figure. The consumption is a non-linear function of the income of the household. The projected demand for medical services is likely to depend on the population growth and the income distribution. 3.4 PUBLIC CONCERN AND PLANNED CHANGES SEA/PHA/149 Page 69 The situation regarding population growth, the spread of disease and the demand for medical care, as described in the previous sections, created public concern in Sri Lanka which was reflected in certain government deci- sions and actions as well as in statements in the press. The Five-Year Plan, 1972-1976, is the most important document express- ing the government concern of health matters, as perceived at the time of formulating that document, and it states how the remedies should be found. There are also other documents, like reports on cabinet decisions, circulars from the Health Department, etc., which deal with health matters. Certain health issues that were reported in the daily newspapers also influenced the government in its decisions. It was therefore impossible to collect compre- hensive information on the government's concern and on its action at the time the NHMS was being carried out, but some matters of relevance were obtained. Since a short summary of the government's intentions has already been given (see Chapter 2), a more detailed review of policy statements by the government will now be presented in the light of the already depicted health situation in the country. This review will not be confined to the statements in the Five-Year Plan but will utilize other information as well. The justification for this comparison of the needs and demands of the population and the public concern on health is to observe the way in which health needs and demands become transformed into matters of concern. There is no intention of evaluating the adequacy of the government's health policy, since the emphasis will be on the clear perception of needs and demands and not on the adequacy of the actions taken (or contemplated) for their control. 3.4.1 The Five-Year Plan "The Socio-Economic Survey of 1969-70 indicated that 40 per cent of the households in Ceylon earn less than Rs 200 per month. A further 40 per cent of the households earn between Rs 200 and Rs 400 per month. While the immediate social objective of the Plan is to provide employment, it also aims to bridge the present disparities in incomes and living standards by raising the incomes and living conditions of the low-income households. It also seeks to eliminate the grosser forms of wasteful consumption which have become a conspicuous feature of present-day Sri Lanka by stringent taxation of those in the higher income groups and by the limitation of current expenditures. Those who, either through the inheritance of property or through the ownership of the means of production or other circumstances, are today enjoying standards of living out of all proportion to what the country can afford, will have to alter their consumption habits drastically in the interests of the country's development. "Within these broad social objectives the Plan places heavy stress on a significant advance on the economic front. Indeed the two are inter- related. Redistribution alone cannot improve the living standards of the poorer groups in society. There has to be economic growth. As the follow- ing table (Table 3.24) shows there are wide differentials in the consumption of certain essential items of food in the people's diet. SEA/PHA/149 Page 70 Table 3.24. AVERAGE EXPENDITURE (RS) PER PERSON ON PROTEIN FOOD FOR TWO MONTHS BY HOUSEHOLD INCOME GROUPS* Household monthly income (Rs) 0-50 50-100 101-200 201-400 401-800 801-1000 1001-2000 2001-3000 Over 3000 Meat 0.71 0.73 0.96 1. 71 3.12 4.50 8.18 8.37 12.36 Fish 2.45 2.72 2.82 3,25 3.81 4.28 6.81 7.49 7.14 Eggs 0.24 0.17 0.22 0.42 1.03 2.12 5.46 7.00 6.95 Milk and milk products 0.48 0.73 0.84 1.45 2.55 5.15 8.67 13.21 8.09 *Source: "Survey of Consumer Finance, 1963" - Part II (Central Bank of Ceylon) (64) "The differential indicate not only the low incomes and the inability of some groups to buy an adequate quantity of such food, but also the low level of domestic production of these items. A redistribution of incomes will not lead to an increase in consumption unless more is produced in the country. Thus, if social justice is to have any meaningful impact in raising the standards of living of the poorer sections of the community there must be economic development. In practical terms, this means producing more milk, developing the fishing industry, growing new types of food crops, rehabilitat- ing the coconut industry, producing a wide range of mass consumer goods, and generally raising the level of production. Similarly, the Socio-Economic Survey of 1969-70 indicated that 31 per cent of households in Sri Lanka did not have any sort of latrine while another 40 per cent had only the use of a cesspit. It would seem from these figures that high priority should be given to providing these facilities. But the costs of providing these are very high especially in urban areas where sewerage systems and pipe-borne water are essential. Only a few such projects can be started because of a shortage of capital and foreign exchange. It is only general economic advance which will make it possible to provide these facilities to all house- holds" (65). The first basic consideration governing the choice of the strategy of the plan is the fact that "there is the need to take into account the long-term trends in population growth", the second consideration being the acute "unemployment and the balance of payments" demanding urgent attention (66). Awareness is expressed by the necessity "to raise the living stan- dards of the low-income group by improving housing and sanitation facilities. Also to raise nutrition levels of these groups especially by increasing the production of essential food items such as fish, milk, eggs and fruits and SEA/PHA/149 Page 71 by gearing the production of consumer goods to the needs of the masses" (67). This concern exemplifies the perception by the government of the need for the control of malnutrition as a priority health problem. More specifically, the Five-Year Plan considers the following health concerns to be of priority: (a) "nearly 40 per cent of all morbidity cases in the country and about 30 per cent of the diseases receiving indoor treatment in public medical institutions have their origin in poor environmental sanitation" (68); (b) "over-crowding of large hospitals and under-utilization of smaller medical institutions" (68); (c) "a substantial proportion of the hospital beds are occupied by patients suffering from diseases that can well be treated at outpatients' departments" (69); (d) "incomplete coverage in immunization programmes" (69); (e) "the chief cause of maternal deaths is anaemia due to malnutrition, and the chief cause of infant mortality is pre-maturity which is also mainly due to maternal anaemia" (70); (f) "provision of pipe-borne water supplies and sewerage" (7i); (g) "shortage of drugs, equipment and trained personnel have affected the quality of the curative services" (71); (h) "the ayurvedic services will be developed" (72); (i) "mental health services", "cancer therapy", ''blood banks", "pilfering, indiscriminate prescribing and wastage of drugs" (72); (j) "integrated services", "dental services", "laboratory services" (73); (k) "population policy" (74). Some suggestions to remedy the above problems were described in a working document (75) based on the Five-Year Plan. They include the followLng outlay described in the Development Programme 1972-76: SEA/PHA/149 Page 72 Major items Buildings (a) continuing works (b) new works Water supply (a) continuing works (b) new works Equipment (new) Transport (new) Quarters for staff Current cost (manpower) Total cost 3.4.2 The Press Total 44 317 66 150 110 467 13 337 15 600 28 937 12 390 3 285 7 OOO 102 734 265 313 Department of Health Rs (x 1000) 42 417 51150 93 567 13 337 15 600 28 937 10 270 3 285 7 OOO 96 734 240 293 Department of Ayurveda 1 900 16 OOO 16 900 2 120 6 OOO 25 020 The reaction in all the newspapers in Sri Lanka to the country's health problems was not studied. However~ a sample of titles and quota- tions, which appeared in the leading newspapers published in English, may show the local points of interest regarding health matters in Sri Lanka. The Ceylon Daily News (CDN) of 24 June 1972 gave the Prime Minister's first policy statement in which the following paragraphs are related to health: "Five major water supply schemes in the south-west coastal area for towns north of Colombo ••• and south of Colombo .•• together with twenty urban water supply schemes and 100 rural water supply schemes, with UNICEF assis- tance, will be inaugurated during the next five years. Legislation will be introduced for the establishment of a National Water Supply and Drainage Board to develop, provide, operate, and maintain an efficient and coordinated water supply and sewerage system". The "channelled consultation practice for doctors in government hospitals, which was allowed from 1964 as an inter- mediate step in the total abolition of private practice for medical officers, was abolished within the district of Colombo with effect from February this year. Dental services were extended to several areas of the island with the opening up of 17 branch units. The Family Health Programme which covers family planning and pre-natal health services is being expanded". "A White Paper incorporating the proposed changes in the ayurvedic system of medicine in this country will be published shortly". SEA/PHA/149 Page 73 Regarding the general and health policy of the government, the follow- ing public reactions may be mentioned: "Town and Village", an editorian of CDN of 19 August 1972, made a plea for better treatment of the problems of the rural population. In "Minister's Diagnosis", the Times of Ceylon (TC) in August 1972 expressed appreciation on the acceptance of the Minister of Health of press criticism of the health services. "Still sick" (CDN, 20 October 1972): a critique of the personnel policy of the Department of Health, "A shocking scandal" (CDN, 5 June 1972) describes the irrational management of medical stores in allowing drugs to deteriorate and in keeping idle the equipment needed to be distributed to hospitals. The Mir>ror announces "National Health Policy Soon 11 • In "Medical Bulletin" (CDN, 15 June 1972), the lack of efficiency of the Health Department is pointed out as the reason why "the Prime Minister is personally called upon to clear up the mess or start things moving again". "Jana men and hospital employees play hide and seek" (CDN, 14 June 1972): the members of Janatha (people's) conmittees are to control the late report- ing for work of hospital employees. TC of 20 June 1972 announced the memorandum of the Government Medical Officers Association: "Political inter- ference - cause for brain drain". The memorandum states that "political interference has made it impossible for government medical men to work in peace in hospitals, and hence they preferred leaving the country of their birth seeking new pastures". "Bromides won't do" (CDN, 8 August 1972): implications are made that the lack of foreign exchange is not the major reason for the shortage of drugs. On the occasion of the inauguration in 1972 of the session of the Regional Conunittee of WHO, the Prime Minister stated that "the population explosion had been increasingly engaging the attention of Sri Lanka during the last decade". Other topics of interest in the press included: Population problems: Weekend, 2 July 1972: "Abortionists - killer quacks have field day". ''More proteins for expectant mothers" (TC, July 1972). "Pills vs. planets" (CDN, October 1972) condemns the belief that astrology can "predict accurately the periods when the heavenly bodies make a woman fertile or unfertile". Control of diseases: CDN, 14 June 1972 - ''Malaria scare in Kuru- negala". Medical car>e: The Ceylon Observer>, 31 October 1972: "Shackled in misery ward" describes the accident service ward in the general hospital. TC, 19 June 1962: "Heart patients protest - clinic understaffed, so they march to the Medical Superintendent's office". The Ceylon Observer>, 2 July 1972: "Empty beds and self help" describes the work and atmosphere of the Rehabilitation Hospital. CDN, August 1972: "City clinics to insist on proof of residence" in order to avoid overcrowding with patients from outside Colombo. CDN, 24 August 1972: "Controlled nursing homes" considers the state control of the medical work in private nursing homes. Weekend, 27 August 1972: "Apathy like a cancer grows at the Maharagama Hospital (this is a cancer hospital). SEA/PHA/149 Page 74 Personnel mana,gement: TC, 11 May 1972: "Health: more bundling" reacts to the untimely replacement of doctors after they vacate their posts. CDN: "Harassment of doctors alleged - Medical Department turning a blind eye - GMOA" (Government Medical Officers' Association); CDN, 27 July 1972: "Professionals still lured abroad - can compulsory service stop brain drain? Limit to availability of jabs". CDN, August 1972: "Private practice aboli- tion - don't discriminate, say specialists". TC, 23 October 1972: "Only 96 of 172 General Hospital doctors have quarters". Supply of drugs, etc. : CDN, 1 November 1971: "Quality control vital". Ceylon Observer, 16 January 1972: "Import quota slashed - New allocation with emphasis on austerity". CDN, 20 January 1972: "Startling shortage of drugs in most hospitals - Even aspirin not available". Ceylon Observer, 4 June 1972: "What a waste of drugs! - Auditor General probes Civil Medical Stores". Weekend, 2 July 1972: "What a waste of X-ray films!" CDN, 26 July 1972: "Quota cuts hit essential drugs - Imports get into wrong hands say practitioners: hoarding charge refuted". CDN, 7 August 1972: "Drug shortage: who is to blame?" CDN, 9 August 1972: ''Drugs: the.practi- tioners' view", CDN, 16 August 1972: "Psychiatric drugs in short supply". CDN, September 1972: "No medicine: Prime Minister's staff affected". CDN, 8 September 1972: ''Unnecessary drugs". Weekend, September 197 2: "Bogus drugs flood the local market". Ayurveda: The Ceylon Observer, 20 February 1972: ''More ayurvedic hospitals soon". CDN, 22 February 1972: "Reform of ayurveda". CDN, 12 May 1972: "Sale of medical certificates: [by ayurvedic physicians, Author's note] Ministry powerless". CDN, 30 May 1972: "Research in ayurveda". The Times Weekender, 4 June 1974: one page devoted to the establishment of the Ceylon Ayurvedic Drug Corporation, with a message by the Prime Minister. TC, 5 October 197 4: "Ayurvedic treatment by Rasa medicines" [medicines prepared from metals, Author's note]. 3.4.3 Summary The statements in the Five-Year Plan and some statements by high officials in the country show that there has been a clear perception of the actual health needs and demands, which were described in sections 3.1 to 3.3. There is, however, a gap between those statements and the way in which the basic health problems are to be tackled, as reported in the working documents of the Department of Health. Public reaction, as expressed in the press, was concentrated on several problems, some of which are of the highest priority: population policy, management of health services (particularly personnel management), medical care delivery, mismanagement and shortage of drugs, and the ayurvedic system of medicine. 3.5 SUMMARY OF THE CHAPTER Sri Lanka faces a fast growth of population because the decrease in mortality has nJt been followed by an adequate decrease in fertility. The SEA/PHA/149 Page 75 annual growth rate of the population is 2.2%, which may bring the total population to 22 million by 1991, if a reduction in fertility is not achieved. A moderate reduction in population growth is considered possible, in which case the population may increase to only 20 million by 1991. The present age structure of the population is rather unfavourable from the health point of view, since about 64% of the population require special attention from the health care services. The currently prevalent diseases show that the population continues to live in a challenging environment. The major diseases are respiratory diseases, malaria, tuberculosis, leprosy, filariasis, venereal diseases, enteric infections, and other infectious diseases. Anaemia and malnutrition, as well as diseases connected with childbirth, delivery, and infancy, also 'present major problems. This pattern of morbidity is unlikely to change significantly in the next 20 years, although there may be more geriatric problems owing to an increase in the age group over 60 years, and tuberculo- sis may decline further. The demand for medical care is high; an average of 5.7 visits are paid per person annually to government and private western and ayurveda sources of medical care, as well as to different categories of non-registered practitioners. The demand for inpatient treatment is 16 hospital admissions per 100 persons. The past trend does not indicate that this level of demand is likely to change, which means that the total demand will depend on the population growth. Certain changes in the level of demand may occur as a result of a significant change in the distribution of the national income. Although the government is generally aware of the population's health needs and demands, the planned measures to meet them appear inadequate. Public concern, as expressed in the press, is concentrated on certain issues like the management of the health services, the quality of medical care, the "brain-drain" of doctors, personnel problems (of doctors, mainly), the mis- management and shortage of drugs, and ayurvedic medicine. CHAPTER 4 THE HEALTH CARE SYSTEM IN SRI LANKA SEA/PHA/ 149 Page 77 A definition of the "health care system" is presented for the pur- poses of this study. Its sectors (or sub-systems) are identified in terms of the sources of financing and the type of service delivered (western or allopathic, ayurvedic, and "other"). Each sector is described from three main aspects: capital stock operated by the sector, resources spent, and organization and output (services provided). The word system is often used in different contexts. In this report, it will denote "a set of connected things and parts" (76) which produce a defined effect. Such a broad definition allows for applying the term "system" to anything in the world, from a protozoa to the organization of the United Nations, and from an atom to the Milky Way. The health system of a country represents a part or a sub-system of the socio-economic system of the country. The health system of a community ("community" used in its broadest meaning) involves two main components: (i) the people, or the population with its services, socio- economic base, and its government; and (ii) the health care services, i.e. the health care system. The relationship between the main components of the health system in Sri Lanka, in the context of the socio-economic set-up, is shown in Fig.4.1. The health care system, although presented schematically, is amplified in the chart, whereas the parts of the socio-economic system in the country are simplified. The health needs and demands of the population were described in Chapter 3, but now a basic distinction may be made between the health needs and the demand for health services. The segment of the population that needs health services is conceived to be in a relatively passive position so that this segment is actively sought by the health care system. On the other hand, there are those who express a demand for health services by actively seeking these services from the health care system. Naturally, such a distinction is artificial since a large part of the people with health requirements also express a demand. However, the distinction will be of use in understanding better the roles of the different sectors in the health care system in Sri Lanka. The population provides both a labour force and public and private savings for the national economy and for economic growth. It gets its share of the national income through private consumption and through the services provided by the government, including the services provided by the health care system. Fig. 4.1 RELATIONSHIP BETWEEN DIFFERENT COMPONENTS OF THE HEALTH SYSTEM IN SRI LANKA I national economy ~ national income 1 ;y. saving..:. I government consumption government _w_ ..__ private I ~ consumption I I I ~ labour force J ! I I I I I I I I I I I I I I I I I I I 't population i I I I I I I I I I I govt. other services govt. health services: western ayurveda "' I I I I I "' t= .---- -ir: -------' I I I F : : health needs -------------~--------1----- "' Flow of resources ---- •-1 demand for health services T ------Flow of services and other communications 1 I I I __l_ ... (----------- I , 1-----------] .. health manpower estate health services: western ayurveda + private health services: western ayurveda 11 other 11 ~ r- >d (/l : [;; (1) ...._ >d ~!;;: ...._ I-' +=- '° SEA/PHA/149 Page 79 The health care system has two main sectors, government and private, which have different sources of income. The private sector can be divided into an estate sector, sponsored by the estate owners (Ceylon Planters' Association) with a subsidy from the government, and the private sector proper based on the fees paid by private patients. All three sectors of the health care system in Sri Lanka provide western and ayurveda type of services. The private sector proper also provides a variety of other services which cannot be classified either as western or as ayurveda (see also Chapter 3). The main function of the health care system is to provide health services or to carry out health activities. To perform its main function, the health care system exercises a management function (management process) consisting of planning, organizing, controlling (directing), and evaluating all the activities of the health care system. Both these functions, health services and management of the health care system, will be given principal consideration. However, closely connected with the above functions, the health care system performs other functions, e.g.: (i) industrial function, as an employer of labour, (ii) producer's function, as a supplier of consumable commodities which absorb a considerable portion of the government and private funds for consumption, (iii) social function, by generating changes through family plan- ning, rehabilitation, etc., (iv) educational function, as a factor in changing the patients' attitudes, (v) communication function, by informing people about the services available to combat illnesses, and (vi) political function (indirectly contributing to the distribu- tion of power) by providing credit or discredit to the govern- ment by the level of its efficiency. Thus, the health care services provide the population with health services (health activities) so that the health needs and demands of indivi- duals and the community may be satisfied. The health service as a health care system is also a part (sub-system) of the national socio-economic system. In Sri Lanka, the health services are distinguished on the basis of who pays for their operation and on the kind of health technology applied. Table 4.1 shows the main sectors of the Sri Lanka health care system. SEA/PHA/149 Page 80 Table 4.1. SECTORS OF THE HEALTH CARE SYSTEM IN SRI LANKA Source of funds Government and semi-government Private Type of ''Medicine" practised Western Ayurveda Other + + + + + Since reference will often be made to the different sectors in the health care system, it is important to define them precisely at this stage. Health technologies (types of "medicine") in use are as follows: (1) Western medicine in Sri Lanka is defined as medicine taught in the medical faculties in Sri Lanka and in other medical faculties recognised by the Ceylon (Sri Lanka) Medical Council, and practised by and/or under the guidance and supervision of persons registered as medical practitioners with Ceylon (Sri Lanka) Medical Council. (2) Ayurveda is defined as knowledge of treating diseases as recognized by the Ceylon (Sri Lanka) Ayurvedic Medical Council, and practised by and/or under the guidance and supervision of persons registered as ayurveda practitioners with the Ceylon (Sri Lanka) Ayurvedic Medical Council. It includes the ayurveda, unani, arid siddha systems. (3) "Other" includes: practice of homeopathy; supply of drugs and medicines by pharmacies without a prescription from registered practitioners; any other provision of health care against payment. Customer is defined as the individual or agency which provides funds for health care: (1) The Government, as a customer, includes the Health Ministry as well as all other government sources of funds (deriving from the state budget) for the provision of health care by the central or local authorities. The health care services sponsored by government departments other than the Ministry of Health are here referred to as being provided by the "semi-government" sector. For the purposes of this study the government and the semi-government sectors will often be discussed together under government sector. SE.4/PHA/149 Page 81 (2) Private refers to the provision of funds by individual consumers and by private profit and non-profit organizations and agencies, which cannot be classified as "government" since the funds do not originate from the state budget. In suIIDllary there are five main sectors of the health care system in Sri Lanka: Government western sector Government ayurveda sector Private western sector Private ayurveda sector Private "other" sector 4.1 THE WESTERN SECTOR The practice of western medicine seems to have started in Sri Lanka with the beginning of the British period in 1796. The Civil Medical Department was first developed under military control and in 1858 became an independent department (33). 4.1.1 The Government Western Sector This sector includes, as already mentioned, the health care services operated by the Ministry of Health, by other mini~tries, and by the local authorities (municipality, town and urban councils). (1) Services operated by the Ministry of Health In the administration at the ministerial level, there are a Minister of Health and a Deputy Minister of Health, as well as a Secretary of Health and supporting administrative staff. Attached to the Ministry is the Health Planning and Programming Division, responsible directly to the Secretary of Health and composed of a Deputy Director of Health Services (Planning), an Assistant Director (Planning), one Planning Adviser (Finance), a statistician and a small administrative staff. The operational sidE of the government health services includes different kinds of health personnel working individually or in teams. The individuals and teams carry out their functions in three fairly independent sub-systems: (a) Medical care services; (b) Public health services; and (c) Laboratory services. (a) Medical care services. The medical care services represent the largest part of the government western sector. Their main objective is to meet the demand of the population for medical care, which is provided in different types of institutions (Table 4.2). The first eleven institutions in Table 4.2 are listed according to their size. These institutions provide outpatient treatment and inpatient treat- ment. In 1970 there was a ratio of 3.16 hospital beds per 1 OOO population in the government western sector. The technical level of the work in different types of institutions varies depending on many factors, but, in SEA/PHA/149 Page 82 general, better medical care is provided in the larger institutions. There is, however, an attempt to develop a referral system between the medical institutions in the country. The bed strength in 1964 was 34 454, but by 1970 had increased by 14.21% (in the 6 years) or by 2.24% per year. This corresponds roughly to the annual growth of the population. Table 4.2. CATEGORIES OF MEDICAL INSTITUTIONS IN SRI LANKA OPERATED BY THE MINISTRY OF HEALTH, 1970 Category of health institution Colombo group of hospitals Provincial hospitals Base hospitals District hospitals Peripheral units Cottage hospitals Rural hospitals Maternity homes* Central dispensaries* Branch dispensaries Visiting stations Tuberculosis hospitals Leprosy hospitals Mental hospita1s Other hospitals Total Number of Number of Institutions hospital beds 10 4 811 10 7 085 12 3 642 96 10 719 94 3 388 13 416 73 1 706 128 1 534 424 345 1 017 4 1 670 2 859 3 3 520 12 430 2 149* 39 780 No. of hospital beds per 1 OOO population** 0.38 0.56 0.29 0.85 0.27 0.03 0.14 0.12 0.13 0.07 0.28 0.03 3.16 *CDs and MHs have been shown both as CD and as MHs. **According to the total population in 1970, 12 571 900. SEA/PHA/149 Page 83 (b) Public health seY'l)ices. The main function of the public health services is the promotion of health and the prevention of diseases. These services in Sri Lanka are carried out by 98 health units, which are divided into 700 ranges (or areas) for public health inspectors (PHI) and 2 277 ranges for public health midwives (PHMs). On average, therefore, each health unit has 8 PHis and 23 PHMs. Thus, the basic working unit in public health is the range of the PHMs for family health work and the range of the PHis for environmental sanitation and the control of communicable diseases. In addition, there are 124 school dental clinics with a permanent staff and 2 694 feeding centres. The organization of public health services is carrit.'!d out by the medical officer of health, one for each health unit, with the assistance of supervisory staff (Table 4.3). In addition there are five specialized campaigns concerned with the control of certain diseases: (i) (ii) (iii) (iv) (v) Antimalaria campaign Antifilariasis campaign Antituberculosis campaign Antileprosy campaign Anti-venereal diseases campaign. Table 4.3. SUPERVISORY STAFF OF THE OFFICE OF MEDICAL OFFICER OF HEALTH Personnel Total in the country Per health unit Medical officers of health (MOH) and assistant MOH Public health nurses Supervising public health inspectors Supervising public health midwives Total 124 1.3 196 2.0 44 0.5 65 0.7 429 4.4 All these campaigns are organized independently although some have partly m.erged their activities with the general medical care and public h,:·n l th services. Tbe antimalaria campaign performs two main activities: (a) diagnostic and therapeutic, to individual patients; and (b) spraying of houses with insecticides in the endemic areas. The work is carried out by spraying teams SEA/PHA/149 Page 84 (for spraying the houses with insecticides), mobile and walking teams (for the diagnosis and treatment of malaria in the field), and by malaria assis- tants attached to the general medical institutions. The antifilariasis campaign deals with two aspects of filariasis control: (a) the diagnosis and treatment of cases; and (b) mosquito control, by spraying and oiling stagnant waters. The work is organized and conducted through one centre, one sub-centre, 16 special clinics for treat- ment, and field teams for diagnosis and for vector control work. The antituberculosis campaign is concerned with (a) the diagnosis and treatment of cases of tuberculosis; and (b) BCG vaccination. There is a National Tuberculosis Institute in Colombo, which administers the campaign, as well as 51 chest clinics and branch clinics, 4 special hospitals, and 28 wards for tuberculosis in general hospitals for the treatment of tuberculosis cases. A large number of general medical and public health institutions participate in the work by carrying out BCG vaccinations and treating the diagnosed cases. Some of them also take part in diagnostic work by collect- ing sputum specimens. The antileprosy campaign diagnoses and treats patients at home and in the 2 leprosy hospitals. The anti-venereal diseases campaign deals with the diagnosis, treat- ment, and follow-up of cases of venereal diseases in the Colombo central V.D. clinic, and in 9 full-time clinics and 16 part-time clinics in various parts of the country. (c) Lahora~ory services. At the operational level, there is only one institution: the Medical Research Institute in Colombo, which performs routine laboratory tests for the medical and public health services and carries out basic laboratory research. The other parts of laboratory services are represented in the larger hospitals and in the specialized campaigns. Laboratory facilities are available in the Colombo group of hospitals, provincial hospitals, base hospitals, and district hospitals, as well as for the specialized campaigns. The smaller hospitals and units have no access to laboratory diagnosis, except by referring to one of the above institutions, or through the private sector. (d) Organization and control. The Department of Health is under the Director of Health Services (DHS), some of whose authority is delegated to four Deputy Directors. The organization of health administration at this level in the country is depicted in Fig. 4.2, although the lines of command are actually not as simple as shown in the figure. The schema also includes the Department of Ayurveda. The country is divided into fifteen health divisions, in each of which there is a superintendent of health services (SHS) who is responsible for medical care, public health, and laboratory services. He is supported by a small technical and administrative staff. The responsibilities of the SHS are mostly supervisory, without much involvement in planning. Fig. 4.2 ORGANIZATION OF HEALTH ADMINISTRATION IN SRI LANKA Minister of Health Deputy Miniiter of Health Secretary oi Health l Director of Health Services ------- ----- - -- --- - -- Couunissioner lf Ayurveda Deputy Director (Medical__. Services) Assistant Directors: - medical supplies special services and peripheral units - hospitals - dental services Superintendent of TB campaign Senior medical officers: - auxiliary services - buildings Chief nursing education officer Chief nursing officer (hospitals) Deputy Director (P.H.) ..... Assistant Directors: - Env. health and education - Maternity and child health - Epidemiology, quarantine and external resources - Dental services (prevention) Superintendents: - malaria eradication - fi l.ar ias is eradication - leprosy control - venereal disease control Chief nursing officer (PH) Deputy Director (Lab. Services) Deputy Director.._. (Adm.) Assistant Directors (3) 15 superintendents of health services in 15 health division Deputy :rJirector (Planning) Assistant Director (Planning) Planning Adviser (Finance) '"d CJ'.l : fi1 (1) ..._ '"d 00 ::,:: I.J1 > ..._ I-' .,:,. '° SEA/PHA/149 Page 86 A chief accountant is responsible for the financial management of the Departments of Health and Ayurveda. He is assisted by six accountants. The annual programming process of the government health services was recently converted to the planning-programming budgeting system (PPBS), which is a step towards rational health planning. The adopted PBS system will be referred to again in the discussion on the financing of health services. Here, it is necessary to stress that greater effort will be needed to improve the system, especially with regard to: (i) identifying the programmes and projects in the government health care services on a different basis from that in the present administrative structure of the Ministry of Health; (ii) defining better the physical targets of some projects; and (iii) adjusting the information system of the health care system to the needs of the planning system. As with other systems, the health care system in Sri Lanka has a built-in control system which is in varying stages of development. The controlling aspect of the information system provides feed-back to the decision-maker so that planning, evaluation, re-planning, as well as taking timely corrective actions to rectify some departures from the expected performance may be carried out. The government western sector collects a vast amount of data. The medical care, public health and laboratory services, send monthly or quarterly returns to the Health Statistics Branch, Ministry of Health. All the specia- lized campaigns also have their own centres for data collection and collation. Recently the Family Health Bureau started developing its own information system. The data collected by all these agencies are related to the measure- ment of health problems and to the functioning of the health care services. All data collected from the government western sector are consolidated and published in the annual administration report of the Director of Health Services. The report which appeared in 1973 provides data related to the financial year 1967/68. Since the information collected by routine reporting does not always satisfy the needs of the Ministry of Health, some data are very often collected ad hoe by the Health Department. For example, data on certain characteristics of the health care institutions are collected separately through surveys conducted by mailed questionnaires. The objectives of supervision are to establish whether the work is performed according to the accepted standards (quality) and norms (quantity) and to propose immediate action for the correction of any defects. Manuals with instructions are issued by the Health Department to all categories of government health workers in different areas of the health care system in order to facilitate their supervisory work. These manuals are presently being revised. SEA/PHA/149 Page 87 Supervision requires contact between the supervisor and the super- vised, especially in the working environment of the supervised, so that the supervisor may observe the present and past performance of the supervised and give appropriate advice for improvement. For the smooth functioning of the entire system of health services in Sri Lanka, the system of supervision should operate not only within each health institution but also along the line of services from the Ministry of Health, through the Health Department and the offices of the SHS divisions, to the operational level. Little attempt was made to obtain evidence on the frequency of supervision at the different levels, and on the effects of such supervisors. The purpose of evaluation (assessment) is to establish whether the system as a whole and its sub-systems function according to the expectations set out in the work progrannnes; and if not, to inquire into the reasons for this. An assessment of the work in the government sector of the health care system has been carried out since the recent adoption of the PPB system. The assessment is monthly or quarterly and is expressed in terms of input/output analysis. The reasons behind a given performance of the system or of parts of it were not investigated in a systematic way. The input of resources into the government sector will now be consi- dered as regards capital costs and annual financing. The main resource, health manpower, will be discussed in detail in Chapter 5. There is no readily available evidence on the capital cost, hereafter referred to as capital stock, of the health services in Sri Lanka so that this cost had to be estimated. Annex 1-13 gives the estimate of the capital stock* of the whole health care system in Sri Lanka. For a better comparison between the different sectors of the health care system, the estimated capital stock of the total health care system will be used as the common denominator. The capital stock of the whole health care system in Sri Lanka was estimated at Rs 733 258 300 in 1972 (US$ 115 million at the official rate of exchange of Rs 6.40 to US $1). The government western sector, managed by the Ministry of Health, exploits 80.74% of the capital stock, mainly for operat- ing the medical care services (71.57%), whereas only 2.23% belongs to the public heaith services. The share of the laboratory services is 2.73% and of the administrative services 3.75% of the total health capital. It should be pointed out that the medical care services and the public health services utilize the laboratory services and the administrative services to different extents. The medical services are likely to make more *Capital stock is defined as the value of the sum total of all non-consumable goods belonging to the system (land, buildings, equipment) estimated at the time of purchase and adjusted to present market prices (1972) without depre- ciation. SEA/PHA/149 Page 88 use of the laboratory services, the medical stores, and the administration, and the public health services are likely to use the transport facilities more frequently. On the assumption that the utilization of laboratory services and administrative services may be as shown in Table 4.4, the total capital stock of the government western medical care services may be Rs 588 068 100 or 76.11% of the total health capital stock in the country and the capital stock of the public health services may be Rs 30 857 600 or 4.21%. Table 4.4. DISTRIBUTION OF THE CAPITAL STOCK OF LABORATORY SERVICES AND ADMINISTRATIVE SERVICES BETWEEN THE MEDICAL AND PUBLIC HEALTH SERVICES, 1972 Capital stock Supporting services Medical services PH services Rs (x 1000) % Rs (x 1000) % Total 33 250 70 14 250 Laboratory services 18 OOO 90 2 OOO Medical stores 4 750 95 250 Transport 2 500 20 10 OOO Administration 8 OOO 80 2 OOO The recurrent cost of the health services run by the Ministry Health represents 7.06% of the total estimated recurring expenditure government (for 1973). 30 10 5 80 20 of by the Excluding the annual expenditure on the central administration (Ministry of Health), which represents only 1.04% of the recurring expendi- ture of this sector, the government western sector of the Ministry of Health costs about Rs 267 million annually on the provision of health services from all existing sources in Sri Lanka (see Annex 1-14). This makes the Health Department the main producer of health services in the country. The greatest share, Rs 171 million or 34.37% of the total, is spent on the medical care services. The public health services take up Rs 53 million, or 10.61%. If the expenditure on the laboratory services and the administration are appor- tioned in the same manner as was done for the capital stock, the medical care services will be represented by 38.37% and the public health services by 13.75% of the total health expenditure, which is a fair relationship, the ratio being 2.79:1. The percentage distribution of the expenditure is as follows: Drugs and Salaries dressings Food Other Total Government western sector 66.8 11.6 7.3 14.3 100.0 Medical care services 68.7 10.7 10.6 10.0 100.0 PH services 57.9 20.1 1.3 20.7 100.0 Laboratory services 66.0 7.2 o.o 26.8 100.0 Administrative services 75.2 o.o o.o 24.8 100.0 SEA/PHA/149 Page 89 According to the PPB system, the total recurrent cost (as well capital investment) of the government services is distributed into 24 jects and is meant for the implementation of well defined programmes. outputs are expressed in the number of services to be delivered.* The Health Department operates the following twenty projects: (A) Medical services: 1, Hospital services (general) 2. Hospital services (tuberculosis) as pro- The 3. Assistance to private organizations and local authorities 4. Maintenance of buildings and facilities (B) Public health services: 5. General preventive services and environmental sanitation 6. Family health 7. Health education 8. School health including school dental health 9. Quarantine 10, Eradication of malaria 11. Eradication of filariasis 12. Leprosy control 13. Venereal diseases control (C) Laboratory, research and specialized services 14. Laboratory services 15, Other diagnostic and ancillary services 16. Maintenance of equipment 17. Medical research studies, routine investigations, and production of vaccines (D) General administration and staff services 18. General administration 19. Training and scholarships 20. Transport services (2) Semi-government western services The semi-government western sector does not seem to play an important role in the provision of health care in Sri Lanka. It is represented by 12 hospitais and an unidentified number of dispensaries. Its capital stock has been estimated at approximately Rs 25 million and the annual expenditure at Rs 25 million, which represents 5.03% of the total annual health expenditure in Sri Lanka. The semi-government sector is not organized as a whole; its separate units are dispersed among the government sectors which sponsor those units. *This breakdown into projects was revised in the budget estimate of the Government for 1974 SEA/PHA/149 Page 90 There is no evidence of any formalized planning effort in this sector which is loosely connected with the other sectors of the health care system in Sri Lanka, mainly through the similarity of the services provided and through its financing from the state budget. It has been impossible to identify the real expenditure on this sector or its annual output, or acces- sibility to it by the population which it is expected to serve. (3) Output of the Government western sector Some data on the annual output of the total government sector are provided in Chapter 3. For the sake of completeness of the review, a summary of outputs will be given here: Number of outpatient visits (1970/71) Number of inpatients discharged (1970/71) Number of hospital deliveries (1968) Number of deliveries attended by public health midwives (1969) Number of visits paid to clinics by infants (1968) Number of visits paid by pre-school children (1968) Number of schoolchildren examined (1968) Vaccinations against smallpox (1967/68) Vaccinations against typhoid fever (1967/68) Vaccination with D.P.T. (1967/68) Vaccination against tuberculosis (1971-72) Vaccination against poliomyelitis (1967/68) Laboratory tests for tubercle bacilli (1971/72) Blood examinations for microfilaria (1971/72) Blood examinations for malaria (1971/72) Houses sprayed with insecticides (1971/72) Leprosy cases treated (1971/72) Investigations for venereal diseases (1971/72) Cattle and goats inspected for slaughter (1967/68) *Round figures, as estimated by national experts. 29 582 699 2 007 263 238 619 34 014 159 370 110 122 223 912 270 OOO* 500 OOO* 90 OOO* 750 OOO* 1 284 OOO* 147 OOO* 2 500 OOO* 900 OOO* 4 OOO OOO* 6 900* 305 OOO* 180 OOO* SEA/PHA/ 149 Page 91 Some other activities should be added to this list, e.g., latrine construc- tion, health education, research, etc., but they were not easily expressed in numerical terms. The accessibility to government western-type facilities by the popu- lation can be expressed roughly as the average distance to the facility; the overall accessibility works out to 3 miles (Table 4.5), TABLE 4.5. AVERAGE DISTANCES TO GOVERNMENT WESTERN-TYPE FACILITIES Type of health facilities No. of Cumulative Distance* facilities (No.) (miles) Colombo group and Provincial 20 20 Not applicable hospitals Base hospitals 12 32 15.0 District, TB, leprosy, mental etc. hospitals 117 149 7.4 Peripheral units 94 243 5.9 Offices of medical officers of health 98 341 4.8 Cottage and rural hospitals, CD, MH 544 885 3.0 *For the calculation of distances refer to Annex 3-3. 4.1.2 The Private Western Sector The private sector of the health care services is not organized and directed according to well established methods. Some statutory bodies like Ceylon (Sri Lanka) Medical Council, Ceylon (Sri Lanka) Medical College Council and certain associations and unions may be expected to regulate some of the functions and activities of the large body of private registered practitioners. The part of the private sector providing health services to the estate population, however, is organized through the Planters' Associa- tion under the Planters' Association Estates' Health Scheme, which covers about 50% of the estate population in the country (77). In the private western sector there are 62 nursing homes with 1 178 hospital beds, 14 cooperative hospitals, 66 estate hospitals, and 115 estate maternity homes. There are about 530 private western practitioners' surgeries in the country. All these, except the estate maternity homes, provide medical care to the population. SEA/PHA/149 Page 92 There is no evidence of any formal planning process in the private sector. The Private Practitioners' Association unites about 25% of all the western qualified private practitioners and is concerned mainly with defend- ing the professional and economic interests of its members whenever they are at stake. Information on the private western sector practically does not exist, except for the estate health care services. The data presented here are based on assumptions and estimates (for the methods used, see Annex 2-4). Recently, the Health Department conducted a survey of private nursing homes with the object of assessing their technical capabilities. There is no estab- lished process of regular supervision and evaluation in the private western sector. The estimated capital stock of this sector is Rs 31 million, or 4.27% of the capital stock of the total health care system. It is distributed as follows: Estate health care services Other private Rs 5.8 million Rs 25.2 million Although the capital stock of the private western sector is rather modest, its share of the total funds spent in the purchase of health care annually is substantial, Rs 57 million or 11.46% of the total. The number of outpatient visits in the private western sector could be estimated at about 5 million annually. The number of inpatients treated in the private nursing homes seems to be negligible, since the occupancy rate is below 40%. On the other hand, the occupancy rate in the estate hospitals and maternity homes was about 100%. However, owing to the limited bed strength in this sector, its overall contribution in providing inpatient care is not very significant. If the number of the western type health care facilities belonging to the private sector is added to the number in the government western sector, the average distance from everybody's home to the nearest western type health care facility will be reduced from 3 to 2.2 miles. 4.1.3 Summary The western sector of the health care services in Sri Lanka is represented by (i) government services operated by the Ministry of Health and semi-government services run by other departments and local authorities, all financed from the government budget, and (ii) private services, among which the services operated by the Planters' Association Estates' Health Scheme represent the only organized entity. The western sector operates 88% of the total capital stock of the Rs 733 million (US $115 million) which is at the disposal of the total health care system in Sri Lanka. The annual turnover of this sector is estimated at Rs 341 million or 68.61% of the total annual consumption for the health ser- vices. The government and semi-government western sector take up a much larger share in both the capital stock (Rs 614 million) and recurring cost SEA/PHA/149 Page 93 (Rs 284 million) than the private sector (Rs 31 million and Rs 57 million, respectively). The ratio of the expenditure on medical care to that on the public health services is 2.79:1. The different parts of the sector operated by the Ministry of Health are clearly defined and their method of annual planning is according to the planning-programming-budgeting (PPB) system. The same sector provides a great deal of information which is not always adequately collected, analysed and utilized. The estate health care services also provide some data. The other parts of the western sector are loosely connected with the health information system of the country. The annual output of the western health services, especially of services operated by the Ministry of Health, is quite impressive in both the wide range of services delivered and their number. The facilities providing western-type health care services are situated rather close to the population, the average distance from any home being not more than 2.2 miles. 4.2 THE AYURVEDA SECTOR "The basic difference between the Ayurvedic School and the ,,-2stern medicine lies in the comparatively greater importance Ayurveda attache~ ~o the constitution of the patient as against that attached by the modern medicine to the nature of disease" (78). So the ayurveda school sees the difference between the two systems in Sri Lanka. The indigenous system has a long history in Sri Lanka. "The earlier system of medicine in Ceylon is that which existed in the Island before the advent of Vijaya (500 B.C.). This system has been handed down by the inhabitants ••. from generation to generation and is practised even today (1947) as Desiya Chikitsa or Sinhala Vedakama by not inconsiderable number of ayurvedic physicians" (79). "The word 'Ayurveda' literally means 'Science of Life'" (79). During the reign of Dutugemunu (160 B.C.) it is recorded that "the King maintained at eighteen different places hospitals provided with suitable diet and medi- cines prepared by medical practitioners for the infirm" (80). Buddhadasa (339 A. D.) "patronised the virtuous, discontented the wicked, rendered the indigent happy and comforted the diseased by providing medical relief. He was the author of the work on surgery which is still held in high repute by his countrymen. He built hospitals for the sick and asylums for the maimed ••• " (80). King Parakramabahu (A.D. 1155) erected almonries at the four gates of the capital and hospitals with slave boys and maidens to wait upon the sick, superintending them in person and bringing his medical know- ledge to assist in their direction and management". (80). However, "whatever may have been the past glory of ayurveda, it would by self-deception on our part to think that we sit on a high pedestal. The fact is unfortunately the other way. If the sound principles and methods of SEA/PHA/ 149 Page 94 treating disease with the time-honoured recipes of proved value were not there, the ayurvedic system would have been dead by this time in the struggle for existence". (Dr Gannath Sen) (81). The ayurveda system was recognized by the State in 1929 and started to receive aid from the state (81). After the independence of Sri Lanka, its growth was encouraged by the government and by the population so that in 1962 it was said: "This overwhelming majority of the people of Ceylon has continued to love and approach Ayurveda despite two centuries of unilateral intensive and relentless indoctrination in favour of allopathy through press write-ups, Government press communiques, rural radio broadcasts, cinema newsreels, lantern slides, health lectures, networks of free allopathic hospitals and dispensaries, and total non-availability of free Government Ayurvedic medical facilities except at one institution in Colombo" (82), In 1967 a Report of the Committee of Inquiry into Salaries and other conditions of Service of Ayurvedic Physicians and other Ayurvedic Personnel in Govern- ment and Local Government Services was submitted to the Minister of Health, with the following terms of reference: "To enquire into and report on - (i) A scheme of recruitment and grading for officers undertaking research or teaching in Ayurvedic institutions. (ii) The terms and conditions of service, including salaries and grading of Ayurvedic Physicians in the Government Service and in the Local Government Service having regard to: (a) the pre-entry educational qualifications required at present and previously to obtain a diploma in Indigenous Medicine, the content and level of their training duties and responsibilities of the various posts, and (b) the salaries, allowances and conditions of service, now prevailing among other grades in the Public and Local Government Service. (iii) The formulation of a new scheme of training, recruitment and salaries for an Ayurveda grade of Pharmacists. (iv) The feasibility of transferring Ayurvedic Physicians, Pharma- cists and Nurses between the Public Service and the Local Government Service. (v) The financial and other implications of the recommendations made in regard to the aforesaid matter". Recently, the ayurveda sector has been adopting a more aggressive attitude regarding its involvement in the implementation of the government's health policy. The government ayurveda is represented by 7 ayurveda hospitals with 1 OOO hospital beds and by 211 ayurveda dispensaries established by local SEA/PHA/149 Page 95 bodies with assistance from the government. These institutions work only in the field of medical care and do not participate in public health work. The Department of Ayurveda of the Ministry of Health is directed by the Cormnissioner of Ayurveda supported by a small administrative staff. The Department works in close cooperation with the Ayurveda Medical Council and Ayurveda Medical College in Colombo. The Department of Ayurveda is divided into 4 projects according to the PPB system of the Ministry: 21. Curative services 22. Education and training 23. Research 24. Administration of the Ayurvedic Act The capital stock of the whole ayurveda sector has been estimated at Rs 58 million or 7.92% of the total capital stock of the health care system in Sri Lanka; of this, only Rs 8 million or 1.10% belong to the government and semi-government sector, the rest (Rs 50 million or 6.82%) to the private ayurveda sectors. The estimated annual recurring expenditure of the government and semi- government ayurveda services was about Rs 15 million in 1972, i.e., 2.98% of the total funds spent on purchasing health during the year. The ratio between government expenditure on western and ayurveda services was 18:1, whereas the same ratio in 1946-47, was 73:1; i.e., in about 25 years the government expenditure on ayurveda services has increased, in relation to that on the government western services, about 4 times (84). There are 9.823 private ayurveda practitioners in the country; their estimated capital stock is Rs 50 million and the annual turnover Rs 96 million, or 19.33% of the annual consumption of health services in the country. There were no readily available data on the output of the ayurveda sector, although some estimates had been made by the Department of Ayurveda, some from the data of the socio-economic survey 1969/70, and others from small studies. As the findings were conflicting and could not be correlated with the large number of existing ayurveda practitioners, a survey was conducted by the Ayurveda Medical College in Colombo and the Ayurveda Medical Council, in the scope of NHMS. The estimated annual number of visits by patients to ayurveda practi- tioners was 28 690 211 in 1973, or more than 2 visits per capita per year. Table 4.6 gives data on the number of visits to ayurveda practitioners in different practices and the estimated total annual outputs. The estimated average number of visits per year per ayurveda practitioner is 2.836, the highest number being to practitioners working in hospitals (58 536, or 195 per day) and the lowest to private practitioners (2.423). Some private ayurveda practitioners who specialized in certain services, like treating snake bites, bone-setting, etc., received patients only occasionally. SEA/PHA/149 Page 96 Table 4.6. ESTitIATED ANNUAL WORKLOAD OF AYURVEDA PRACTITIONERS BASED ON THE NUMBER OF VISITS BY PATIENTS Practitioners working in Hospitals Local authorities' dispensaries Private practice All practitioners Average number of visits to one practitioner pm 58 536 11 892 2 423 2 836 Number of visits to all practitioners per year 1 983 147 2 901 648 23 805 416 28 690 211 % 6.91 10.11 82.97 99.99 The pattern of the age distribution of the clientele of the private ayurveda practitioners is associated with the place of practice of the ayurveda practitioners. Those practitioners who work in towns in the ayur- veda hospitals treat many more infants and pre-school children (12.4 and 25.4%) than those in the local authorities' dispensaries or in private practices (5.2, 5.6% and 10.4, 7.3%, respectively). The working population and the aged are better represented in the practice of the private ayurveda practitioners. There is also a marked difference with regard to the sex distribution of patients. Generally, more male patients (56.18%) patronize ayurveda practitioners, but in the ayurveda hospitals and ayurveda dispensaries females represent the large part of the outpatient attendance, 59.8% and 56.9%, respec- tively (see Annex 1-16). An analysis of the annual number of visits to ayurveda practitioners working in all institutions and in their private surgeries, by the age and sex of patients, shows that more than 50% of the visits were by patients in the age group 20-59 years followed by those aged 5-14 years (14.49%), the population over 60 years (10.69%), pre-school children (9.32%), and infants (5.31%). These data do not differ significantly from the data relating to the allopathic government institutions. The ayurveda hospitals attract patients from considerable distances: 23.7 of their patients travel more than 10 miles and 29.5% between 5 and 10 miles. Altogether 53.2% of their patients come from more than 5 miles. Another 20.8% travel between 2 and 5 miles and only 26% of patients live less than 2 miles from the ayurveda hospitals. The patients of the ayurveda dispensaries show a quite different pattern: 82.6% of patients come from a distance less than 2 miles and 12% from between 2 and 5 miles, thus 94.6% of all patients visiting the ayurveda SEA/PHA/149 Page 97 dispensaries live within 5 miles. Hence, whereas the ayurveda hospitals cater for large areas, the ayurveda dispensaries provide their services in their immediate neighbourhood. The private ayurveda practitioners occupy an intermediate place regarding the distance their patients have to travel to reach them, the percentage of the patients who come from within 5 miles being 75.16%. The mode of transport depends ma.inly on the distance between the patients' homes and the health institution. The percentage of patients who come on foot is less than the percentage of those who live less than 2 miles from the ayurvedic practitioners. One can guess that some conveyance is usually used by all patients who come from a distance of more than 2 miles, and also by some of those who live less than 2 miles away. Since Sri Lanka has good bus services, a large proportion of patients travel by bus. Because of the large number of ayurveda practitioners, their services are easily accessible and anyone can usually find an ayurveda doctor less than one mile from his house. The average distance to the different ayurveda facilities is as follows: to an ayurveda hospital 34 miles to an ayurveda hospital or dispensary 6.1 miles to an ayurveda institution or private practitioner 0.9 miles Summary Indigenous medicine in Sri Lanka has a long tradition, since its roots can be traced back before the invasion of the country by the Aryans. The ayurveda system was established at the latest in the second century B.C. After a period of neglect during the greater part of British rule, the develop ment of the ayurveda sector has gathered momentum in the past thirty years and it now plays an important role in providing health services in the country About 29 million visits are paid by the population annually to ayurveda health care facilities. The ayurveda sector is recognized by the government and by the popula- tion. It is administered by the Department of Ayurveda at the Ministry of Health and by the Ayurveda Medical Council. The estimated capital stock of the sector is not very impressive, Rs 58 million, or about 8% of the capital stock of the whole health care system. However, the estimated consumption for ayurveda services amounts to Rs 111 million annually, or more than 22% of the annual consumption for health. The accessibility to the ayurveda services has been estimated to be 0,9 miles average distance from a patient's home to the nearest facility providing ayurveda medical services. The ayurveda services attract more male than female patients, and more grown-ups than children and young people. There is a selectivity in the choice 0£ different categories of ayurveda practitioner (according to the place of their practice) by the different age and sex groups of patients, SEA/PHA/149 Page 98 Since ayurveda practitioners working especially in the ayurveda hospi- tals attract patients from considerable distances, they cannot be considered health workers of strictly local importance but constitute a system for providing services spread over the whole country. 4.3 THE "OTHER" SECTOR Any attempt to estimate the number of the "other" suppliers of medical care in Sri Lanka involves enormous difficulties. Taking into account that there are about 6 OOO known non-registered ayurveda practitioners, 230 pharma- cies and about 600 homoeopathic "doctors", and an unknown number of practi- tioners as well as quacks, one can guess that the number of the "other" practitioners belonging to the private sector should be around 10 OOO. The non-registered ayurveda practitioners comprise two groups: those who have applied for registration and who are awaiting registration; and those who were refused registration since they did not satisfy the Ceylon (Sri Lanka) Ayurvedic Medical Council regarding their ability to practice ayurveda, unani, or siddha. Although non-registered, they usually do practise. The only requirement to establish a pharmacy in Sri Lanka is to obtain a licence from the Health Department. There is considerable freedom in dispensing drugs by pharmacies, even without a practitioner's prescription. The pharmacies obtain their supply of drugs from private firms. Recently, a State Pharmaceutical Corporation was established with the intention of taking over the importation and supply of drugs to both the government institutions and the private pharmacies. Homoeopathic doctors, who call their therapeutic skills "German treat- ment", have been growing in numbers and aggressiveness. Their services are frequently advertised in the daily newspapers and on large street hoardings. The estimated capital stock of this sector is Rs 30 million (4.09% of the total) and the estimated annual turnover Rs 45 million (9.06% of the total). The annual number of visits paid by patients to "other" practitioners was estimated at about 11 million. 4.4 SUMMARY OF THE CHAPTER The health care system of Sri Lank.a has been defined as the industry which provides health services (health activities) to the population. It operates in the context of the whole socio-economic and political system of the country. The health care system is represented by five sectors which differ from each other by the health technologies applied and by the source of funds for operation: the government western sector, the government ayurveda sector, the private western sector, the private ayurveda sector, and the private "other" sector. SEA/PHA/149 Page 99 The Ministry of Health operates the largest part of the health care system with more than 80% of the system's capital stock, Rs 592 million (US $93 million) in 1972; and with 53.84% of the total recurring funds spent on health care, Rs 267 million (US $42 million) in 1973. There are about 40 OOO hospital beds in the country, 3.16 hospital beds per 1 OOO population, The government sector is organized on three levels: peripheral, regional, and national. The regional level is absent in the government ayur- veda sector. The private sector is not distinctly organized, except for the Planters' Association health care services which provide health services to about 50% of the estate population in Sri Lanka. By its output, the government sector provides almost 100% of the public health services, almost the same percentage of the inpatient treat- ment, and about 40% of the outpatient medical services. As far as the private sector is concerned, the ayurveda sector leads with more than 23 million visits annually, which represents 32% of all outpatient services in the country. Considering all the existing state recognized facilities for the provision of health care (excluding the "other" sector), the population of Sri Lanka is fortunate to have access to such services less than 0.8 miles from any home. The per capita consumption for health in Rupees from different sectors of the health care system in Sri Lanka, is summarized in Table 4.7. Table 4.7. ESTIMATE OF THE PER CAPITA CONSUMPTION FOR HEALTH, 1973 Sector/service Total consumption per capita Government total Government western sector Government ayurveda sector Semi-government total Semi-government western sector Semi-government ayurveda sector Private total Pr iv ate western sector Private ayurveda sector Private "other" sector Per capita consumption (Rs.) 36.72 19. 77 19.14 0.63 2.31 1.85 0.46 14.64 4.21 7.10 3.33 CHAPTER 5 HEALTH MANPOWER IN SRI LANKA SEA/PHA/149 Page 101 In this chapter the different elements in the health manpower in Sri Lanka are reviewed and the main aspects of health manpower analysis (i.e., supply, utilization and loss*) are defined. The existing manpower in Sri Lanka is described in the above terms, special attention being paid to the supply, utilization, and loss of doctors, nurses, midwives, ayurveda practi- tioners, and assistant medical practitioners. For the purpose of this study, health manpower refers to "persons who have received, or are receiving, education and training for a specific occupation" (85) in the health care system, as described in Chapter 3. How- ever, a brief account will also be given of other persons who work in or provide informal health care facilities. Because of considerable confusion in the classification of the health professions, the World Health Organization proposed a distribution of 29 categories of personnel broadly in 3 levels: (i) high level, or professional, with a university degree; (ii) middle level, with 6-9 years general education and 1-3 years technical training; and (iii) basic level, or health aides who have only elementary in-service training. (86) This classification includes also practitioners of traditional medicine/ midwifery. In certain less developed countries (87) the health manpower is classified in four levels, in an attempt to obtain a better coverage of the scattered population: (i) graduate doctors, (ii) assistant medical officers, (iii) medical assistants, and (iv) rural medical aides. The health manpower situation in Sri Lanka will be described using the recognized classification in that country. It is well recognized that health manpower is an indispensable part of any health care system, because the functioning of the system depends largely on the number and quality of the health manpower employed. The main functions of the health care system are shown in Fig. 5.1 and the relation- ship between the health manpower planning process and the total health care system, in the context of national planning process, is presented in Fig. 5.2 *In planning terminology the word "attrition" is usually considered more appropriate than "loss". SEA/PHA/ 149 Page 102 Fig. 5 .1. MAIN FUNCTIONS OF HEALTH CARE SYSTEMS Provision of health services: Management of the system: Other functions: health progranunes health activities health tasks technical steps in the performance of tasks management functions (a) planning (b) organizing (c) controlling - evaluation areas of management (a) personnel (b) financial (c) supplies and logistics (d) other political social economic educational other The chart shows two main functions of the health care system: provid- ing health services and management. The managerial function is amplified and two of its aspects are presented: the management function itself comprising of planning, implementation, and controlling; and the areas of management, one of which is the management of personnel. Health manpower planning is intimately connected with the management process of the health care system, linking the health planning with personnel management. Health manpower planning is also directly linked with education and training and indirectly with the total planning process in the country, as carried out at the national level. Thus, it is evident that health manpower planning cannot be divorced from the national planning or from health planning. In this chapter the existing health manpower situation in Sri Lanka will be considered separately for each major category of health personnel in terms of supply, utilization, and loss. The demand for health manpower will be considered in Chapter 8 when discussing the health manpower impli- cations of the possible changes in the health care system. Before proceeding to a review of the different categories of health manpower, some general data and concepts should be laid down for a better understanding of the health manpower process as a whole. Included in all categories of the health care services that provide health services to the population of Sri Lanka, there may be about 70 OOO persons who are employed full-time or part-time. This represents 1.46% of the total labour force in the country which was estimated at 4 782 OOO in 1973 (88). Table 5.1 gives data on estimates of the numbers of workers in different categories employed in the health care system, excluding those in the "other" sector who are difficult to define and identify. Many data concerning different categories of health personnel are incomplete and there is special regret about the low reliability of the information on I' ~ SEA/PHA/149 Page 103 Fig. 5.2 HEALTH MANPOWER PLANNING IN THE CONTEXT OF THE NATIONAL PLANNING PROCESS delivery of HEALTH CARE SYSTEM GOVERNMENT health services , T , ,. management of the -----'l national health care system planning manufacture, agriculture, other sectors management function areas of ~---- management imp 1 emen tat ion: health organizing planning ~ e-directing . - & management of management of personnel materials, etc. 1 - controlling HEALTH MANPOWER education & - PLANNING training . , . - ' ~ I I ' I I I I SEA/PHA/149 Page 104 assistant/registered medical practitioners and public health inspectors. The most reliable data concern medical doctors, nurses, midwives, and dental nurses who were enumerated during the study. Next come the ayurveda practi- tioners who were enumerated by the Department of Ayurveda; and a sample of their responses was analysed. Data on the other categories, which were collected from the Department of Health, reflect the existing positions in the budget for employment rather than the real number of personnel. Table 5.1. HEALTH MANPOWER IN SRI LANKA, 1972 Number of health manpower Government and Private Total semi-government Total western trained: 38 783 4 747 Doctors 2 218* 1 033 Nurses 5 661 797 Midwives 3 394 192 Dental surgeons 180 100** Asst. reg. med. practitioners 1 194 143** Public health inspectors 1 074 129** Medical lab. technologists 455 55** Radiographers 164 - 20** Physiotherapists 129 15** Dental nurses 239 29** Pharmacists 406 49** Dispensers 804 96** Attendents 5 269 632** Other workers 18 867 1 OOO** Total ayurveda trained: 983 9 823 Ayurveda doctors 293 9 823 Other workers 690 TOTAL 41 037 14 113 *Estimated number of semi-government doctors is 173 **Estimates, see Annex 2-4 43 530 3 251 6 458 3 586 280 1 337 1 203 510 184 144 268 455 900 5 901 19 867 10 806 10 116 690 55 150 The utilization of health manpower is the key factor in the analysis of the present situation and in the proposals for change. Thus, health man- power should be developed in order to be utilized, a fact that is sometimes forgotten, e.g., when doctors are being trained for their own benefit. And the manner in which it is utilized determines the way in which it is to be developed. Also, the utilization of health manpower greatly influences the recruitment of potential applicants for training, who may be motivated or repelled by the social and professional status of present health personnel. SEA/PHA/149 Page 105 The utilization of health manpower in Sri Lanka depends on many inter- dependent factors, all of which are linked with the health care system. These factors are: {i) institutions: medical (size and equipment), public health, administration, research, training; (ii) sectors of employment: government or private; (iii) posts occupied: delivery of primary (basic) care, consulta- tive, managerial; (iv) job descriptions: functions, activities, tasks; (v) productivity: output per unit time; (vi) factors outside the health care system: social values and beliefs, organization and union regulations, economic and political influences, etc. As it is not possible to present reliable data on all the above factors for all the categories of health manpower, the utilization of certain catego- ries will be described in terms of one or two of the above variables. The general concept of supply of health manpower in Sri Lanka is presented in Fig. 5.3. The number and quality of applicants to be trained depend on many factors outside the educational system for the health profes- sions, like general education, and socio-economic and other factors; and on factors within the system, e.g., the employment policy {opportunity, promo- tion, benefits, etc.) and the faculty (determining the education policy, selection, educational facilities, the drop-outs during the selection and study, postgraduate training, etc.). The three main categories: the students, who are subjected to the education process and evaluation in order to graduate; the faculty, which selects the students, and teaches and evaluates them; and the graduates, who may or may not be employed depending on the employment policy of the country, are the key factors in the process of health manpower supply. 5.1 MEDICAL DOCTORS. Medical doctors are defined as medical practitioners registered with the Ceylon (Sri Lanka) Medical Council. 5.1.1 Current Supply The current supply or "stock" (89) of doctors in Sri Lanka refers to the total number of doctors available in the country for practising their profession. Data showing the trend in doctors' stock are available only for doctors in the government health care services. The numbers of government doctors between 1950 and 1972 showed a steady increase, especially in the period after 1960 (Table 5.2), SEA/PHA/ 149 Page 106 Fig. 5 , 3. HEAL TH MANPOWER DEVELOPMENT educational social economic psychological educational factors selection for admission APPLICANTS STUDENTS awareness of chances to graduate educational policy FACULTY l GRADUATES DROP-OUTS awareness of career pattern J employment policy l EMPLOYED ~ HEALTH MANPOWER The increase from 1960 to 1972 was 83% (in relation to 1960). About the same time (1959-71), the gross national product of the country showed a growth of 66% (based on 1959), so that the increase in the supply of govern- ment doctors exceeded the economic growth of the country. Year 1950 1955 1960 1965 1972 Table 5,2, NUMBER OF GOVERNMENT DOCTORS Number of Average annual doctors increase 674 952 57 1 173 44 1 546 75 2 046 71 Average annual increase (%) 8.25 4.64 6.36 4.61 SEA/PHA/149 Page 107 In 1972, a census of doctors was conducted in the National Health Manpower Study. A list of all doctors living in Sri Lanka was compiled from various sources and it represents the best available information on the number and geographic distribution of the doctors in the country (see Annex 1-17). In this list there were 3 271 doctors, so that the doctor:population ratio is 25.7 doctors per 100 OOO population (one doctor per 3 910 inhabi- tants). In comparison with some other countries, therefore, Sri Lanka seems to be in a favourable position as far as doctors are concerned (Table 5.3). A census questionnaire to all the doctors elicited responses from 2 561 (78.3%)*. Table 5.3. DOCTOR/POPULATION RATIO IN SRI LANKA AND SOME OTHER COUNTRIES Country Sri Lanka India (94) (estimate) Thailand (95) (estimate) Taiwan (96) Turkey (98) Colombia (97) Peru (99) Ecuador** Guatemala** Jamaica** Malawi** Nigeria** Senegal** Sudan** Year 1972 1972 1973 1962 1963 1966 1964 1962 1962 1962 1965 1962 1962 1962 Number of doctors per 100 OOO population 25.7 22.0 18.7 47.6 70.7 41.0 45.5 35.7 27.8 45.5 0.7 2.0 5.0 34.5 **Bryant, J. Health and the Developing World In its doctor:population ratio, Sri Lanka stands better than India and Thailand and much better than some African countries; but is considerably below the Latin American countries, where the average of all countries is 58 doctors per 100 OOO population (97). These doctor:population ratios are of some value as an index for comparing different health care systems because there are indications of an association between the doctor:population ratio and the crude death rate, infant mortality rate, and mortality of children 1-4 years of age (Annex 1-24) (98). In a study of the regional distribution of doctors within a country, the doctor:population ratio is even more meaningful. In Sri Lanka, some disparities in the regional distribution of doctors are quite evident. The ratio is highest in Colombo SHS division 52.7 and lowest in Kegalle SHS *Including replies received after the dead-line, and after the revision of the list, the coverage rose to 85.7%. SEA/PHA/149 Page 108 divison, 9.7 per 100 000 population (Annex 1-17). If the doctor:population ratio is standardized for the size of the geographic area (SHS division) these disparities become more evident, as shown in Table 5.4. Also, the rank list of SHS divisions changes: Colombo SHS division is again at the top, but the SHS division with the lowest accessibility to doctors is now Vavuniya SHS division. The rationale behind the standardization of the doctor:population ratio is explained in detail in Annex 3-4. Briefly, the object of such a standardization is to show what would have been the doctor:population ratio if the population density were 1 OOO per square mile, and the accessibility to doctors by the population was as actually observed. Table 5.4. STANDARDIZED DOCTOR:POPULATION RATIO IN SRI LANKA SHS division Ratio per Area in sq. miles Standardized 100 OOO in which population ratio per population of 100 OOO live 100 sq. miles* Sri Lanka 25.6 189.2 18.6 Anuradhapura 17.4 491.3 7.8 Badulla 13.2 475.7 6.1 Batticaloa 13.2 396.4 6.6 Colombo 52.7 29.6 95.8 Galle 14.4 87.6 l.). 5 Jaffna 28.7 136.9 24.5 Kalutara 18.9 85.4 20.J Kandy 20.1 84.6 21. 8 Kegalle 9.7 98.5 9.8 Kurunegala 13.6 179.2 10.1 Ma tale 10.4 433.5 5.0 Matar a 10.3 159.5 8.2 Puttalam 20.8 302.6 11.9 Ratnapura 17.1 189.0 12.5 Vavuniya 12.1 1 377 .6 3.3 *The calculation of the standardized doctor:population ratio is shown in Annex 3-2 After standardization, the regional difference become more pronounced, perhaps even more realistic. The range of variation is from 3.3 to 95.8 which means that accessibility to doctors by the population is about 30 times easier in Colombo SHS division than in Vavuniya SHS division. Doctors are located mainly in the district centres. Table 5.5 shows that the overall accessibility to doctors in district centres is 11.7 times better than in areas outside district centres. This difference has a very wide range between SHS divisions, from 2.9 in Puttalam SHS division and 4.~ in Colombo SHS division to 64. 0 in Kegalle SHS division. This means that, on *See Annex 3-1 for calculation of doctors' accessibility index. SEA/PHA/149 Page 109 the average, the population of Kegalle town has 64 times better chance to contact a doctor than the population of Kegalle SHS division outside Kegalle town. Table 5.5. SHS division Anuradhapura Badulla Batticaloa Colombo Galle Jaffna Kalutara Kandy Kegalle Kurunegala Mata le Matar a Puttalam Ratnapura Vavuniya Sri Lanka URBAN RURAL RELATIVE DOCTORS' ACCESSIBILITY INDICES FOR DIFFERENT SHS DIVISIONS Relative doctors accessibility index* 6.2 40.7 41.0 4.2 15.1 6.1 20.5 19.3 64.0 48.7 31.1 29.7 2.9 36.4 13.7 11.7 *See Annex 3-1 for the calculation of the accessibility index. The medical doctors in Sri Lanka are rather young (see Table 5.6), since half of them are younger than 36.7 years. The median age of male doctors is 37.7 and the median age of female doctors is only 31.2. As much as 93.8% of female doctors and 81.2% of male doctors are below 50. The very young female doctors' population indicates a recent increase in the number of graduate female doctors from the medical schools in the country. The distribution of doctors with postgraduate training (specialists according to their specialities) is shown in Annex 1-18. Altogether, 750 or about 30% of the doctors had 841 postgraduate qualifications (some of them had two or more qualifications). The remaining 70% had no postgraduate training. On the average the specialists are 10 years older than the general practitioners. About 59% of the specialists live in Colombo SHS division. The largest groups among specialists are those with a diploma in Public Health, followed by paediatricians, specialists in medicine, in general sur- gery, obstetrics/gynaecology, etc. The corresponding figures from other countries are quite different. For example, only 27% of doctors in Colombia admitted that they were in general practice (99). In Peru the percentage of general practitioners was SEA/PHA/ 149 Page 110 similar, 28% (100). In Turkey 26.2% were general practitioners and 12.3% were undergoing postgraduate training (101). Table 5.6. NUMBER OF MEDICAL DOCTORS BY AGE AND SEX Age-groups Male Female Total (years) No. % No. % No. % 20-24 16 0.79 4 o. 72 20 0.78 25-29 370 18.36 193 34.90 563 21.92 30-34 445 22.08 147 26.58 592 23.05 35-39 240 11.91 77 13.92 317 12.34 40-44 285 14.14 58 10.49 343 13.36 45-49 280 13 .90 40 7.23 320 12.46 50-54 145 7.20 19 3.44 164 6.39 55-59 49 2.43 6 1.08 55 2.14 60-64 60 2.98 4 o. 72 64 2.49 65+ 121 6.00 3 0.54 124 4.83 Not stated 4 0.20 2 0.36 6 0.23 Total 2 015 99.81 553 99.98 2 568 99.99 Average age (years) 40.66 34.88 39.49 5.1.2 Annual New Supply Sri Lank.a has a long tradition in the field of medical education. "The idea of setting up a medical school in Ceylon originated in the head of Governor Sir George Anderson in 1852 (102). However, this remained merely an idea until the 1 June 1870 when the Governor, Sir Hercules Robinson, opened the Colombo Medical School" (103) • In 1962, as a result of the government's impression of an acute short- age of doctors in the country, a new medical school was opened in Peradeniya, near the old capital of Kandy. The census of doctors confirmed that the main suppliers of doctors in Sri Lanka have been the medical faculties in Colombo and Peradeniya: 76.9% of all doctors enumerated during the census were graduates of the Colombo Medical Faculty; 17.2% of the Peradeniya Medical Faculty; 2.1% were gra- duates from India, and 1.9% from the United Kingdom. Those who graduated in India do not differ by age from those who graduated in Sri Lanka, whereas the United Kingdom graduates belong mainly to the older generation of doctors. There is a great demand for medical education in the country. The average annual number of candidates for admission to the medical faculties was 3 583 in the period 1965-70; and only 285 or 8% of them were admitted. SF.A/PHA/149 Page 111 The number of male students represents 67% of all admissions during the last 10 years. However, females are taking the lead and recently their number has considerably increased: in the first and second years of study in the academic year 1971-72, the female students represented 45% of students, whereas in the fifth year of study their number represented only 30% of the total. The curriculum contents and teaching time distribution of two medical schools are shown in Table 5.7. The total number of the teaching hours is 7 112 in Colombo and 6 539 in Peradeniya Medical Faculties and they are distributed among 14 subjects. The premedical subjects absorb 29% of the teaching time in Colombo and 27% in Peradeniya; the paramedical subjects, 24% in Colombo and 19% in Peradeniya; and clinical subjects, 47% in Colombo and 54% in Peradeniya. A. B. c. Table 5.7. CURRICULUM OF MEDICAL FACULTIES IN SRI LANKA AND ALLOCATED TF.ACHING TIMES Subject Colombo Teaching hours % Peradeniya Teaching hours Premedical subjects Anatomy 1 280 18.00 860 Physiology 360 5.06 384 Biochemistry 248 3.49 300 Parasitology 90 1.27 64 Bacteriology 83 1.17 180 Paramedical subjects Forensic medicine 118 1.66 127 Pharmacology 202 2.84 132 Pathology 388 5.46 412 Public health 973 13.68 540 Clinical subjects Medicine 957 13.46 1 306 Su-rgery 1 220 17.15 1 026 Obstetrics & gynaecology 636 8.94 582 Paediatrics 422 5.93 558 Psychiatry 135 1.90 68 Total 7 112 100.00 6 539 % 13.15 5.87 4.59 0.98 2.75 1.94 2.02 6.30 8.26 19.97 15.69 8.90 8.53 1.04 100.00 SEA/PHA/149 Page 112 There is a declared shortage of teaching staff in both medical schools, the teacher:student ratio being 1:5.5. In Peru (104) this ratio is in the range 1:3 - 1:5.2; the optimum ratio is considered by that author to be 1:1.6. There is a considerable variation in Turkey (105) from 1:19 - 1:47. During the period 1962-71, 2 245 doctors graduated from the two medical schools (in Peradeniya only from 1966 onwards) giving an annual average of 267 doctors, 164 from Colombo and 103 from Peradeniya. The average duration of study was 5.3 years. The theoretical minimum duration of study is 5 years. The total recurring cost of one year of study has been estimated at Rs 5 151 per student, or for 5.3 years of study needed for graduation of a doctor, Rs 27 267. This takes into account only the costs incurred in teach- ing and disregards the costs connected with the student's practical work in hospitals,* as well as the capital cost. If the opportunity cost is added, which has been estimated at Rs 844.58 on the average per annum for any member of the labour force in the country, the total recurring cost of training one doctor will be Rs 31 743 (see Annex 2-5 for the calculation of the opportunity cost). Postgraduate training is carried out abroad, mainly in the United Kingdom. The cost of the training of a specialist who spends on average 2 years in postgraduate training can be estimated as follows: salary for 24 months cost of a return air ticket Total 5.1.3 Utilization of Doctors Rs 24 OOO Rs 10 OOO Rs 34 OOO Practically all the doctors in Sri Lanka work full-time, those in part-time occupations representing only 2%. The utilization of doctors depends firstly on the set-up in which they work. Table 5.8 shows the type of employment of those doctors who replied to the census questionnaire, as well as the estimated number of doctors belonging to different categories from among the total number of doctors in the country. · The doctors in government and semi-government services represent about 75% of the total, or 2.101 doctors. The second largest group of doctors is in private practice (in individual and group practices) with 528 doctors or 17.2%. The proportion of doctors working in the government and semi-govern- ment sector decreases with the age of the doctors. About half the doctors over 50-54 years of age have left government services. This proportion might have been much higher if data on the doctors who had left the country were available. The majority of doctors are employed in the field of patient care, 79.1% of the total. The second largest group are health administrators, SEA/PHA/149 Page 113 7.8% of doctors. Then follow: other health tasks (mainly preventive), 5.6%: teaching students, 3.2%; and research 0.9%. Table 5.8. TYPE OF EMPLOYMENT OF DOCTORS Type of employment Data from doctors' census Estimates of No. % all All types 2 568 100.0 1 Government 1 764 68.7 ') Semi-government 149 5.8 Non-practising 71 2.8 Non-government, out of which 572 22.3 Individual practice 347 13.5 Group practice 96 3.7 Industry and estates 10 0.4 Cooperative hospitals 18 0.7 Nursing homes 86 3.3 Others 15 0.6 Not stated 12 0.5 *This figure includes only doctors present in Sri Lanka and practising during the census. The figure of 3 271 include those who are temporarily absent, non-practising, etc. doctors -·--- 056* 101 178 8J 679 413 115 12 21 lul 17 15 Doctors practising in the field of patient care work in different settings and have the cooperation of different kinds of personnel. This influences the utilization of their knowledge and skills. In providing inpatient care, the doctors work with the personnel listed in Table 5.9. Two major assumptions may be made from the Table 5.9: (i) the health care team is more comprehensive in the larger institutions and (ii) there is no institutional working relationship between medical doctors and ayurvedic practitioners. ! . I i i I SEA/PHA/149 Page 114 Table 5.9. HEALTH PERSONNEL PROVIDING INPATIENT CARE Category of personnel ,-f Cl! Category of Cl) u i:: . ..., health institution Cl) 0 ] Cl) ... Q) ... Q) (I) 00 a Q) i:: +J ... i:: 0 Cl) ::, +J 0 . ..., 'M (I) (I) i::: • ..., ,-f +J ,-f Q) Cl! +J Cl! 'M t1I ,-f Cl) > +J • ..., ... +J . ..., t1I Cl.I . ..., Cl) +J Q) u u +J Cl) ~ . ..., u i:: co Q) i:: ... "O Cl) l1l Q) ... ~ Q) ::, 'M ~ ... c.!) ~ Cl) Cl z ,:: ~ Colombo group of hospitals + + + + + - Provincial hospitals + + + + + - Base hospitals + + - + + - uistrict hospitals + + - + + - Peripheral units + - - + + - Rural hospitals - - - - + + Central dispensary & maternity home + - - - + + Maternity home + - - - + + Special hospitals + + - + - - Private nursing homes + + - + + - Estate hospitals - - - - + - Ayurvedic hospitals - - - + - - employed v} ... Q) Cl) i::: +J (jJ 0 i:: i.. ctj • ..., co Cl.I ·o .µ "O ... ~ •i-·'. i::: ::, ~ ~~ I Cl.I 0 ,I.I ..c ::, (Ii +J co >, i.. < e.J <~ + + - + + - + + - + + - + + - + + - + + - + + - + + - + + - + + - + + + When working in the outpatient department (OPD), the doctor in Sri Lanka does not have as many possibilities for cooperation with other health workers, as shown in Table 5.10. SEA/PHA/149 Page 115 Table 5.10. HEALTH PERSONNEL PROVIDING OUTPATIENT CARE Category of personnel employed .-l t'd Category of CJ ·n health institutions* Cl] "Cl Cl] fJl M Q) M 1-1 Q) Cl] s Q) Q) c:: ,I.I c:: Cl] c:: 0 fJl ,I.I 0 ,I.I fJl 0 ~ ·n c:: •n c:: 1-1 t'd ·n .-l ,I.I .-l t'd ,I.I t'd Q) "Cl ,I.I t'd ·n t'd Cl] +J ·~I "Cl 1-1 a, •n M +J •n Q) Cl] ,I.I c:: :::, > ,I.I Q) CJ CJ Cl] ~ CJ Q) 0 1-1 CJ c:: t'd Q) M Cl] t'd ,I.I ,.0 :::, t'd Qi M c.. :::, ~t ,I.I t'd :>, 1-1 c.!) c.. Cl) z < ...:i < c.. Colombo group of hospitals + + + - + + - Provincial hospitals + - + + + + - Base hospitals + - + + + + - District hospitals + - + + + + - Peripheral units + - + + + + - Central dispensary and maternity home + - - + + - - Private nursing home + + + - + + - Ayurveda hospitals - - - - + + + Ayurveda dispensary - - - - - - + *Only those institutions are included in which medical officers work in the OPD. Ayurveda institutions are also given. Tables 5.9 and 5.10 give an idea of the working environment of the government doctors. The same tables will be referred to when discussing the other categories of health manpower. Both individuals and group private practitioners rarely employ skilled health manpower. Some of them also run their own pharmacy for dispensing drugs. SEA/PHA/149 Page 116 There is no place in this book for a detailed job description of all the possible posts that may be occupied by doctors. The list of duties of a medical officer of health (MOH), for example, is rather long and includes 22 different kinds of tasks which are not always well defined. It is also not clear how much time the MOH is expected to spend in each area of activity. The utilization of doctors working in district hospitals was, however, studied. The distribution of working time of district medical officers and house officers shown in Table 5.11 indicates that these doctors in district hospitals spend 58.3%, and 73.6% of their time, respectively, on patient care. A large portion of their time is also spent on general administration, and a very little time on supervision. The time spent with inpatients was on average rather short, 1.6 minute per patient/per day. Table 5.11. PERCENTAGE DISTRIBUTION OF DIFFERENT ACTIVITIES OF MEDICAL OFFICERS IN GOVERNMENT DISTRICT HOSPITALS Activity Administration Staff supervision Drugs, food, diet General administration Judicial work Patient care Other Inpatient Outpatient Antenatal & F.P. clinics Waiting for patients Travel on business Study or journal reading District medical officer % 4.6 1.3 19.2 1.4 37.7 17.0 3.6 5.3 7.5 2.4 26.5 58.3 15.2 100.0 House officer % 2.0 o.o 9.2 1. 2 12. 4 49.0 24.2 0.4 73.6 8.6 3.3 14.0 14.0 A study of the activities of health personnel working in rural areas showed that the actual range of activities of the medical officer of health and the medical officer of a peripheral unit was not very broad. Their work was confined to 65 kinds of simple activities; only 26 and 33, respectively of these activities were of a technical (medical) character whereas the others were administrative (Table 5.12). SEA/PHA/149 Page 117 Table 5.12. MAIN ACTIVITIES OF THE MOH AND MO IN RURAL HEALTH SERVICES Group activities Diagnostic and therapeutic Prophylactic and promotive Administration Maintenance Total No. MOH 7 19 32 7 65 performed by MO 22 11 26 6 65 The MOH spends 58.9% of his time on administrative and 1.8% on main- tenance duties, which w~ans th1t more than 60% of his working time is spent on managerial activities. Only 14.8% of his working time is spent on prophylactic and promotive activities, which are his main concern. The MO spends less but still a third of his working time on administration; and 47.6% on diagnosis and treatment of patients, which are his main responsibi- lity (Table 5.13). Table 5.13. DISTRIBUTION OF WORKING TIME OF MOH AND MO A.~ONG GROUP ACTIVITIES Group activities Diagnostic and therapeutic Prophylactic and promotive Administration Maintenance Travel Non-productive activities % of working MOH 1.2 14.8 58.9 1.8 20.4 3.1 time spent MO 47.6 9.7 34.0 1.0 0.0 7.6 bv The actual health activities carried out by doctors serving as medical officers in rural areas, in the medical and public health services, show considerable departures from what might be inferred from the list of their duties proposed by the Health Department. The most important aspect in the utilization of doctors is their productivity. The productivity can be measured by the number of services (activities) carried out in unit time, or by the time spent in performing one unit service (activity). Also, the time indicated in the calculation of productivity may be the actual average time spent, or the average paid time*, *The time spent is estimated by direct observation and measurement of the time spent on a given type of activity. The paid time is the time for which a salary is received, including idle time, leave, absence for different reasons, etc. SEA/PHA/149 Page 118 including the idle time and the time spent on non-pr9ductive activities, like waiting for patients. Further, there are activities which are not uniform and repetitive, and the assessment of the productivity of doctors carrying out such activities (like health education, supervision, etc.) is extremely difficult. In this book, productivity will be discussed in terms of the average paid time spent iu performing repetitive, fairly uniform activities. Two main categories of activities will be discussed: patient-days and outpatient visits. The time spent on these activities will be expressed in minutes. The paid time of a general practitioner for a patient-day varies between 51 minutes in private nursing homes and 1.26 minutes in the leprosy hospital. Between these two extremes, the largest hospitals (the Colombo group, the provincial hospitals, and the base hospitals), absorb 9.42, 6.97 and 7.1 minutes of the paid time of a general practitioner per patient-day. The district hospitals and peripheral units show 5.35 and 6.61 minutes, respectively. The range for specialists is broader, from 0.2 minutes per patient-day in the ENT ward to 89.6 minutes in the psychiatric ward. The paid time spent by a general practitioner for one OP varies from 0.6 minutes in the peripheral units, to 10.38 in the private nursing homes. In the Colombo group it is 4.98 minutes, in the provincial hospitals 4.8 minutes, in the base hospitals 5.16 minutes and in the district hospitals 0.84 minutes. Among the specialists, the highest paid time for one visit to a specialist clinic is the visit to a dental surgeon in the district hospital, 30.6 minutes, whereas in the bigger hospitals the paid time for visit to a specialist clinic varies between 2.34 and 4.4 minutes. The low- est paid time is spent by an ENT specialist in a district hospital, 0.1 minutes per visit. In conclusion, the productivity of doctors varies widely depending on many factors. The most important seem to be the sector (government or private), the specialization of the doctor, and the size of the institution, although there are variations of productivity which cannot be explained by these factors alone. 5.1.4 Loss of Doctors Table 5.14 shows the percentage of doctors who are expected to be in Sri Lanka and practising medicine at different time interval after the date of their registration with the Ceylon (Sri Lanka) Medical Council, which is when their professional life started. It is striking to note that during the first ten years after registration as many as 41.3% of registered doctors were lost from professional practice for various reasons that were not studied. However~ considering the age at the time of loss from practice, emigration seems to be a major factor. The data displayed in Table 5.14 suggest that there may even be students who start medical studies in order to graduate and emigrate as soon as possible. A reason for this may be the career pattern for doctors in Sri Lanka. Thus, an intern starts with a salary of Rs 600 monthly (US $90) and then follows this line of promotion: Grade II Medical officer, from Rs 950 - 1460 per month, for 10 years; Period of regis- tration 1961-71 1952-61 1942-51 1932-41 Total SEA/PHA/149 Page 119 Grade I Medical officer, From Rs 1 400-1 700 per month; Specialists: from Rs 1 300-1 900 for 11part specialists"; from Rs 1 500-2 200 for "full specialists";* Administrative grade, from Rs 1 400-2 200 per month. Table 5.14. DOCTORS' PROFESSIONAL LIFE EXPECTATION IN SRI LANKA Number of registered doctors 2 215 1 053 490 297 4 055 Number of responding doctors 1 140 583 293 111 2 127 Estimated No. of practising doctors among non- respondents 160 85 35 35 315 Total No. of practising doctors 1 300 668 328 146 2 442 Rate of Practising doctors 58.69 63.44 66.94 49.16 60.22 The Government has tried to neutralize the effect of the relatively low salaries of young doctors by introducing compulsory service in the government sector during the first five years after qualifying but this scheme has not worked as expected. Other attempts to control emigration have been made, such as awarding fellowship or study leave for specializa- tion after the compulsory five years of service, but before the age of 45 years. Another factor may be the effect of postgraduate training in western countries. Two-thirds of doctors who go for training to the United Kingdom are unlikely to return to Sri Lanka (106). In view of this high rate of loss from practice, the actual cost of training of doctors should be corrected as follows: (i) For undergraduate doctors: a) Cost of undergraduate training b) 41. 76% of the above cost for "loss" Rs 31 743 Rs 13 256 Rs 44 999 *"Part specialists" are those who have only a diploma in some field of medicine or surgery, whereas "full specialists" should have a diploma and a Ph.D. or membership (for instance, MRCP). SEA/PHA/149 Page 120 (ii) For postgraduate doctors: a) Cost of undergraduate training b) Cost of postgraduate training c) 39.78% of the above costs for "loss" 5 .1.5 Summary Rs 31 743 Rs 34 OOO Rs 20 ':!97 Rs 92 040* During the last 20 years, the number of doctors in Sri Lank.a has shown a considerable growth, faster than the economic growth of the country, bring- ing the number of doctors to 3 271 in 1971, or 25.7 doctors per 100 OOO popu- lation. The regional distribution of doctors shows great disparities between areas (SHS divisions) and in the urban rural distribution. These disparities are accentuated by the existing regional differences in the population density. years. on the The doctors in Sri Lanka are rather young with a median age of 36.7 The specialists, who represent approximately 30% of all doctors, are average 10 years older than the general practitioners. About 95% of doctors are graduates of the two medical schools, one in Colombo (established in 1870), and the other at Peradeniya (started in 1962). The demand for medical education is high and only 8% of the applicants can be admitted. The curriculum shows that the medical schools in Sri Lanka produce the classical western type of doctors. The teacher:student ratio is 1:5.5. The annual output from the two medical schools is on the average 267 doctors: 164 from Colombo and 103 from Peradeniya (10-year average). The average duration of study is 5.3 years and the cost of study is estimated at Rs 31 743, including the "opportunity cost". Postgraduate training, which is usually in the United Kingdom, adds another Rs 34 OOO to the cost. Seventy-five per cent of doctors work in the government sector, and about 80% of all doctors provide medical care to patients. They work in different set-ups depending on the size of the institution and the composition of teams. In district hospitals the doctors spend, on the average, 58-74% of their time on patient care. The doctors working in the rural health services spend a high proportion of their working time on administration, travel, and non-productive activities. Their productivity, as measured by the average paid time spent in carrying out one OP visit or one patient-day, shows wide variations, depending mostly on the sector in which they are employed, on their field of specialization, and on the size of the institution in which they work. The estimated rate of loss of doctors is very high. During the first ten years after their registration with the Ceylon (Sri Lanka) Medical Council the loss is more than 40%, mainly on account of the emigration of doctors shortly after graduation. *This estimate is valid if the rate of loss of doctors with postgraduate qualifications is the same as the average rate of loss of doctors. 5.2 NURSES SEA/PHA/149 Page 121 The nursing profession seems to have a long history in Sri Lanka which can be tra~ed back to B.C. 161, when the first hospitals were built in the country. This tradition continued till the twelfth century (108). No information could be obtained for the period of the Kandyan Kingdom, as well as for the Portuguese and Dutch period. "During the year 1878, the first attempt to introduce a scientific system of Nursing into the hospitals of the Island was made by the appointment of a Superintendent and a trained Nurse from England, the former to establish a school for the instruction of Probationary Nurses and the latter to assist her and take charge of Nursing arrangements of the general Hospital, Colombo, to which the school is attached" (33). In Sri Lanka, there are several categories of nursing personnel who have had different types of training. They are employed in the government, the semi-government, and the private sector. Although the registration with the Ceylon (Sri Lanka) Medical College Council is a legal requirement to practise nursing, some nurses practise without being registered. The registration of nurses is for lifetime. The Register for nurses consists of several parts: A, B, C, D, E, F and G. According to the Medical Ordinance, 1956 Revision (Government of Ceylon, Legislative Enactments), the register of nurses should be divided into following parts: "(a) Part A shall contain the names of all personnel of the female sex who satisfy the conditions of admission to the register as general nurses. (b) Part B shall contain the names of all persons of the male sex who satisfy the conditions of admission to the register as general nurses. (c) Part C shall contain the names of all persons who satisfy the conditions of admission to the register as public health nurses. (d) Part D shall contain the names of all persons who satisfy the prescribed conditions of admission to the register as assistant nurses. (e) Part E shall contain the names of all persons who comply with the conditions specified in sub-section (3) of section 63 (practical nurses for at least one year who made application for registration before 30 September 1949). (f) Part F shall contain the names of all persons who, having qualified as nurses outside Ceylon, satisfy the Ceylon Medical Council that they possess sufficient knowledge and skill to enable them to carry on efficiently the practice of Nursing." SEA/PHA/149 Page 122 Part G has not been listed in the Medical Ordinance. It provides for registration of emergency nurses who have had six months of institutional training. Nurses belonging to all the above categories will now be considered. 5.2.1 Current Supp!i:_ The census of nurses showed that in 1972 there were 6 457 nurses in Sri Lanka, 5 773 of them in Government service. Compared with 1965, when the government service employed 3 856 nurses, it represents an increase of government nurses by 67%. The regional distribution of nurses is given in Annex 1-19. On the average, there are 50.8 nurses per 100 OOO population (or 1 nurse per 1 969 population. The range is from 89.6 per 100 OOO in the Colombo SHS division to 23.6 in the Matara SHS division. There is a fairly good association between the regional distribution of nurses and the regional distribution of doctors, expressed as nurse/doctor ratio. This ratio is 2.1 for the island, varying from 1.7 in the Batticaloa, Colombo, Kandy, and Puttalam SHS divi- sions to 3.4 in the Kegalle SHS division. Such a close association between the doctor:population ratio and the nurse:population ratio, by SHS division, indicates a significant working interrelation between these two categories of health manpower. In comparison with countries for which data on the nurse:population ratio are available, the nurse:population ratio in Sri Lanka corresponds to the ratio in Thailand, 51 per 100 OOO (115). It is better than in India, 13 (109); Taiwan, 18 (111); Turkey, 6 (112); Colombia, 11 (113); Peru, 28 (114); Ecuador, 6; Guatemala, 12; Malawi, 2; Nigeria, 14; Senegal, 3; and Sudan, 2 per 100 OOO population (115), More detailed data on the distribution of nurses were provided through a census questionnaire which had a response rate of 77% (5 008 nurses). The distribution of nurses by age showed that the majority of them belonged to the age group 30-34 years. There was an association between the age and the field of work: the younger nurses were employed as staff nurses working in the medical, surgical, intensive care, tuberculosis, and paediat- ric units as well as in operating theatres. Those who belonged to the older age groups were working in the administration, teaching, and obstetric/ gynaecological units. The median age of all nurses is 37 years. 5.2.2 Annual New Supply There are eight schools of nursing in the country which provide a 3-year basic training courses in nursing. All schools were administered by the Health Department. The supply of nurses has not been steady during the last 10 years. No students were admitted in 1969 and 1970, but the schools readmitted them again in 1971. SEA/PHA/149 Page 123 There is a great demand for nursing education. On the average, more than 12 500 candidates apply every year for 520 places in the schools. The drop-out rate during the course is about 14% and, on average, 450 nurses graduate every year (except in 1972 and 1973 because students had not been admitted in 1969 and 1970). The orientation of the training is mainly clinical, with rather detailed instructions in some very special and narrow fields of clinical nursing. The faculty of the eight schools is composed of 58 tutors, and part- time lecturers and clinical staff in the hospitals where the students have their clinical training. The average annual cost of training, including the stipend of trainees, is Rs 3 842 per student, or Rs 11 526 for the 3 years of study; this excludes the cost of practical teaching in the hospitals. If the opportunity cost of Rs 844.58 (annually) and another Rs 465 as a portion of the cost of drop-outs are added, the total cost of basic training in nursing will be Rs 14 526 per nurse. During the last 10 years, 1 183 nurses, or 118 nurses per year, underwent training in midwifery for a period of 9 months. This training is conducted in two hospitals permanently and in another two hospitals occa- sionally. Many nurses follow this course for the increased status and pay rather than to practice midwifery. The cost of training a qualified nurse in midwifery is Rs 4 188; with the opportunity cost of Rs 3 682 and the cost of basic training added, the total cost of training a nurse/midwife will be Rs 22 396. There is a Post-Basic School of Nursing in Colombo which organizes and conducts courses for training in some special fields of clinical nursing. Courses of 6-12 months duration are conducted for tutors in midwifery and psychiatric nursing and for ward sisters. Also, short courses of 2 months duration are conducted in paediatric nursing, management, social science, midwifery, and other subjects. 5.2.3 Utilisation of Nurses The occupational distribution of nurses who responded to the census is as follows: Nurses Nurse/midwives Public health nurses 3 874 (77.4%) 1 021 (20.4%) 113 (2.2%) The majority of nurses, 4 905 or 97.9% are employed in the government sector: 238 or 4.8% nurses have post-basic training* (Table 5.15). *Post-basic training is defined as training for a degree or training in a special field, excluding midwifery and public health. SEA/PHA/149 Page 124 Because of its acknowledged importance, the existing situation in the public health services was subjected to a special study. The trained public health nurses* work mainly in the field of public health, 97 out of 113, or 86%. The number of nurses occupying the positions of public health nurses was 161 (Table 5.16). The positions of nurses and nurse/midwives at the time of census are shown in Table 5.17. Their activities covered PHNs a wide range and included performing 99 different tasks, excluding travel: 52 of these were technical and the rest managerial (Table 5.18). Table 5.16. FIELD OF WORK OF NURSES Field of work Total respondents Hospital nurses P~blic health nurses School of nursing Others Not stated Number of nurses 5 008 4 688 161 96 60 3 % 100.0 93.6 3.2 1.9 1.2 Table 5.17. PRESENT POSITIONS OF NURSES AND NURSE/MIDWIVES Present position Number of nurses % Total respondents 4 895 100.0 General medical nurses 2 437 49.8 General surgical nurses 352 7.2 Paediatric nurses 325 6.6 Operating theatre nurses 294 6.0 Psychiatric nurses 231 4.7 Obstetrics nurses 175 3.6 Tuberculosis nurses 170 3.5 All others 911 18.6 Table 5.18. ACTIVITIES PERFORMED BY PH NURSES IN THE RURAL HEALTH SERVICES Categories Diagnostic and therapeutic Prophylactic and promotive Administrative Maintenance Total Number 28 24 35 12 99 *Distinction should be made between the public health nurse by training and the public health nurse by place of work; the latter does not necessarily have to be trained in public health nursing in Sri Lanka. SEA/PHA/149 Page 125 According to the work instructions issued by the Health Department, the public health nurse should carry out the following duties: Family care: home visits to all families especially those with mothers and children and in need of family planning, etc. Child car>e: care of infants, vaccinations, directing to child wel- fare clinic, care of mentally deficient, etc. Supervision of midwives. School health work. General: health education, conducting first aid classes, assistance to MOH in conducting clinics, contact and cooperation with voluntary agencies, immunizations, death investigations related to death of mothers and children, maintenance of equipment, recording and reporting, etc. The distribution of the working time of the PH nurses, as shown in Table 5.19 indicates that technical work occupies 21.1% of the working time. Managerial duties account for 17.3% of the working time; 23.3% is spent on travel, and 16.5% on non-productive activities, e.g., waiting for somebody to come, informal discussions, etc. Table 5.19. TIME SPENT BY PH NURSES ON DIFFERENT ACTIVITIES IN THE RURAL HEALTH SERVICES Activities Diagnostic and therapeutic Prophylactic and promotive Administrative Maintenance Travel Non-productive activities Time spent (%) 4.6 18.5 28.1 9.2 23.3 16.5 The activities of nurses working in other situations were not studied separate1y. The productivity of nurses in different working conditions is expressed by their input per one working day on patient treatment, OPD visit, or in the operating theatre (per one surgical intervention) in paid working time. The range of paid nursing working time input for one average patient- day is from 352.2 minutes in the private nursing homes to 22.1 minutes in the leprosy hospital. In the Colombo group it is 94.74 minutes. Ther~ is no big difference between the provincial and the base hospitals, 51.4 and 54.6 minutes, respectively. In the district hospitals it is 47.9 minutes and in the peripheral units 31.5 minutes. These figures are based on the total nursing inputs, including staff nurses, lower grade matrons, and ward sisters. SEA/PHA/ 149 Page 126 The range of paid nursing time for one patient-day in provincial hospitals is between 595.3 minutes in a psychiatric ward and 24.2 minutes in an ophthalmology ward. However, there are also large differences between provincial hospitals for the same kind of job: for example, the range of nursing time input on a patient-day in ophthalmology wards in provincial hospitals is from 290.9 to 24.2 minutes, depending on the conditions and the demand for services. The paid nursing time for an average OPD visit ranges between 29.64 minutes in the priviate nursing homes, and 1.0 minute in the district hospitals. It is 3.1, 4.0, 2.0 and 2.3 minutes in the Colombo group, the provincial hospitals, the base hospitals, and the peripheral units, respec- tively. The inputs are much higher in specialist clinics, from 113 minutes in the private nursing homes to 6 minutes, in the Colombo group. Surgical interventions absorb an enormous amount of paid nursing working time: 1 701.8 minutes in the tuberculosis hospitals, 835.7 minutes in the district hospitals, 830.8 minutes in the private nursing homes, 474.7 in the Colombo group of hospitals, 414.1 minutes in the provincial hospitals, and 309.5 minutes in the base hospitals. The monthly salaries of nurses in the government sector are between Rs 450 and 900. 5.2.4 Loss of Nurses Direct information on the loss of nurses could not be obtained. An estimate was made using data from the census of nurses and data on the number of nurses in government service in 1965. The calculations are presented in Table 5.20. The rate seems rather low, especially in compari- son with some other countries and in comparison with the rate of loss of doctors in Sri Lanka. The nurses in Sri Lanka often do not stop working after their marriage, which is a common cause of loss in western countries. They are probably also not as exportable as the doctors in Sri Lanka. The data on which this estimate was made are quite reliable, so that this estimate is probably not far from the truth. Table 5.20. CALCULATION OF THE RATE OF LOSS OF NURSES Number of nurses in 1972 Number of nurses in 1965 Total increase in 7 years Estimated supply of nurses in 7 years Estimated number of dropouts in 7 years Average annual dropout Estimated annual rate of loss Nurses in government service 8 733 3 856 All nurses 6 457 4 343* 2 114 3 l.'.:>O 1 036 148 2. 7** *Estimate assuming that the% of government nurses in 1965 was the same as in 1972. **Rate calculated against the mean population of nurses for the years 1965 and 1972. SEA/PHA/149 Page 127 Data obtained from some other countries differ. In Turkey, it was estimated that about eleven years after graduation 60% of registered nurses are no longer actively employed, the percentage of actively employed showing an increase in the following 15 years (116). In Peru, 24% of nurses stop working during the first ten years after graduation, the percentage increas- ing progressively (117). In Taiwan, 30% of nurses after graduation are lost to the profession within the next three years after graduation (118). About 11% of the total nursing force developed in Colombia is estimated to live abroad (119). 5.2.5 Summary There are several profiles of registered nurses in Sri Lanka, who can be grouped into three main categories: nurses, nurse-midwives, and public health nurses. The estimated number of all registered nurses was 6 457 with a median age of 37 years. The nurse:population ratio was 50.8 per 100 OOO, a rather high figure for a country of the level of development of Sri Lanka. There are marked regional disparities, the highest nurse:population ratio being in the Colombo SHS Division, 89.6 per 100 OOO. There is a clear association between the regional distribution of doctors and that of nurses. The supply of nurses has been rather irregular recently. The eight schools of nursing run by the Health Department produce annually about 450 new nurses. The average cost of training, including the opportunity cost, was estimated at Rs 14 526 per nurse. Post-basic education costs roughly another Rs 8 OOO. The great majority of nurses, 97.9%, are employed in the government sector: 93.6% work in hospitals, mainly as staff nurses (87%). Only 161 nurses work in the public health services. PH nurses working in the rural areas spend a large part of their time in administration, travel, maintenance of equipment and non-productive acti- vities. Only 23% of their working time is spent on carrying out technical tasks. The productivity of nurses working in hospitals depends on the kind of activity, on the sector (private or government), and on the ward; and to a lesser degree on the size of the hospital. The estimated annual rate of loss of nurses in the period 1965-72 was 2.7%. 5.3 MIDWIVES Robert Knox wrote in 1681 about the customs in Ceylon: "They have no midwives, but the neighbouring good women come in and do that office" (20). The formal training in midwifery started in 1897, confined only to trained nurses, and until 1926 the nurse/midwife functioned entirely in SEA/PHA/149 Page 128 hospitals. At the same time, the training of auxiliary midwives started. In the following year, the legislation requiring registration of midwives was introduced and this was implemented through the Medical College Council which is still responsible for the registration of nurses and midwives. However, the follow-up of registered midwives poses insurmountable difficul- ties mostly because of the change of names of midwives. Thus, the register of the Ceylon (Sri Lanka) Medical College Council is never up to date. For this reason, a census of midwives was conducted in 1972, together with the census of nurses and dental nurses. 5.3.1 Current Supply According to the list prepared for the census of midwives, there were 3 587 midwives in the country in 1972 (excluding the nurse/midwives consi- dered in section 5.2), out of which 3 399 or 94.8% were in the government and semi-government services and 189 or 5.2% belonged to the private sector, 128 of them working in the estates (see Annex 1-20). Replies to the census questioanaires were received from 3 034 midwives, which makes a response rate of 84.6%. The midwife:population ratio was 28.2 per 100 OOO population for the whole island. The variations between different SHS divisions were not very large, the range being from 35.8 (Kalutara SHS Division) to 8.4 per 100 OOO in the Kandy SHS division which is far below the average. Such a disparity requires a careful inquiry into the staffing of services in the latter SHS division. The midwife:doctor ratio for the whole country was 1:1, i.e., there were roughly as many midwives as doctors in Sri Lanka. This ratio varied between different SHS divisions in a wide range, from +275% to -33% of the average for the country. The regional distribution of midwives is probably a function of the size of the population rather than the develop- ment of health services. The regional distribution of doctors and nurses, however, varies more with the institutions and amenities. The median age of midwives is 32.45 years. 5.3.2 Annual New Supply The training of midwives in Sri Lanka consists of two parts: clinical training conducted during 12 months in 10 hospitals (in 5 hospitals perma- nently and in another 5 occasionally); and field training organized in 9 training areas (6 permanent and 3 temporary). Actually, the great majority of midwives were trained in two hospitals in Colombo, about 62% of all the midwives who replied to the census questionnaires. The training curriculum of midwives includes lectures and practical work in general nursing, ethics, principles of cleaning and desinfection, personal hygiene, general hygiene, nutrition, water supply, bacteria and infection, elementary anatomy and physiology, drugs in common use, care of mothers and baby care, preparation of operation cases, giving intramuscular injections, conduct of labour, post-natal experience in wards, care of the premature baby, and the conduct of mother classes (health education). SEA/PHA/149 Page 129 The staff of all the training centres, in hospitals as well as in the field, consists of 7 public health tutors, 4 supervising public health mid- wives, and a number of part-time lecturers. The average annual output of the training hospitals during the 7 years in which they admitted trainees in the period 1962-71 (in 1966, 1970 and 1971 there were no admissions) was 277 midwives. However, the annual output of the second part (the field training), which had not been interrupted during the same period, 1962-71, was 200 midwives, so that the total output in ten years from both training hospitals and training centres was about equal. There were practically no dropouts during the training. The cost of training a midwife during the whole period of 18 months was estimated at Rs 3 989; adding the opportunity cost for 18 months brings the total cost of training to Rs 5 256. 5.3.3 Utilization of Midwives More than half the midwives who responded to the census (57.9%) worked in the public health services (Table 5.21). This percentage extended to the total number of midwives, gives an estimate of 2 077 public health midwives in the country. The second largest group of midwives work in the hospitals, 39%. A few midwives work in the schools of nursing. Table 5.21. FIELD OF WORK OF MIDWIVES Field of work Number of midwives % Total 3 034 100.0 Public health 1 756 57.9 Hospitals 1 183 39.0 Schools of nursing 42 1.4 Others 53 1. 7 The public health midwives are considered the pillar of the family health services in the country and are concerned with both maternity, child health, and family planning. Each public health midwife has her well-defined area in which she has to reside: she uses one of the rooms of her house as her office, in which she keeps her records and occasionally examines some mother or child. There is a board on each public health midwife's house indicating her occupation. The public health midwives carry out their duties mainly in the homes of the inhabitants of her areas. They also attend the child welfare clinics conducted regularly by doctors for mothers and children from their areas. The range of activities of public health midwives is shown in Table 5.22. Out of 108 kinds of simple activities, 53% are technical by nature (32 related to diagnostic and therapeutic work and 27 to prophylactic and promo- tive work). The other 45% are managerial activities, excluding travel and SEA/PHA/149 Page 130 non-productive activities. It is interesting to observe that public health midwives provide a considerable amount of medical care (diagnostic and therapeutic activities), although their role is mainly with the prophy- lactic and promotive aspects of maternity and child care. It is evident that the public health midwife spends about one quarter of her working time on technical tasks connected with medical care (Table 5.23). Table 5.22. ACTIVITIES OF MIDWIVES IN THE RURAL HEALTH SERVICES Activities Diagnostic and therapeutic Prophylactic and promotive Administrative Maintenance Total PHM 32 27 36 13 108 Performed by Hospital midwife 40 24 33 14 111 Table 5. 23. DISTRIBUTION OF THE WORKING TIME OF MIDWIVES WORKING IN RURAL AREAS Activities Diagnostic and therapeutic Prophylactic and promotive Administrative Maintenance Travel Non-productive activities Percentage of time of PHM Hospital midwife 9.5 17.1 18.3 6.5 30.9 16.7 18.5 9.2 17 .8 21. 2 0.0 33.3 Midwives working in the rural medical institutions (peripheral units, maternity homes, and rural hospitals), have a similar range of activities as the PHMs, the total number of different activities being 111; 58% are technical activities (40 diagnostic and therapeutic and 24 prophylactic and promotive); and 42% are managerial. The distribution of the working time of the public health midwives and those working in hospitals in rural areas is given in Table 5.23. Only 26.6% of the workin~ time of the PH midwives is spent on technical activities: 26.8% on managerial job~: 30.9: on a travel; and 16.7% on non-productive SEA/PHA/149 Page 131 activities, i.e., idle time. The institutional midwives spend 27.7% of their working time on technical jobs; 38% on managerial activities; and 33.3% on non-productive activities. The activities of the midwives working in the larger hospitals were not investigated. The productivity of midwives, estimated by the average annual number of births in the country, will show that a midwife attends to an average of 100 deliveries per year. However, the burden of this work is not equitably distributed. Sixty per cent of the deliveries in the country occur in the institutions in which 39% or about 1 400 midwives work; these midwives must attend an average of 150 deliveries annually, whereas the public health midwives attend an average of 25 deliveries in a year. Other indicators of the productivity of midwives are paid working time inputs on certain repetitive activities. In the maternity homes, midwives spent 2 086.9 minutes (one and a half days) paid working time on one average patient-day. At the other end of the scale are the provincial hospitals, where the input is only 7.8 minutes per one patient-day. The working time input increases as the size of the hospitals get smaller: Base hospitals District hospitals Peripheral units Rural hospitals 14.3 minutes 35.8 minutes 42.1 minutes 51.4 minutes Central dispensary and maternity home 478.4 minutes In the private nursing homes the paid working time of midwives per one patient-day is 37.2 minutes and in the estate hospitals 57.5 minutes. The productivity of midwives in providing inpatient care, in terms of paid time per one patient-day, in the obstetric and gynaecology wards varies between institutions in the same category within the following ranges: Colombo group of hospitals Provincial hospitals Base hospitals District hospitals Peripheral units Rural hospitals Central dispensaries and maternity homes Maternity homes 28.6 - 55.6 minutes 7.1 - 12.8 minutes 47.6 - 65.9 minutes 279 - 282 minutes 76.1 - 167.1 minutes 190.5 - 302.3 minutes 128.1 -1208.5 minutes 682.0 -4348.8 minutes The paid working time per one average specialist visit to a clinic for gynaecology and obstetrics is highest at 113.9 minutes in the maternity homes and lowest at 1.1 minute in the Colombo group, thus showing the same increase with the decrease in the size of the institution which was observed in conne- xion with the time input on inpatient treatment. The paid time input of the public health midwife on an average visit to the child welfare clinics vary between 4.8 and 34.8 minutes, for a home visit 37 .8 - 77.8 minutes, and for an immunization/vaccination 4.4 - 17.4 minutes. SEA/PHA/149 Page 132 For their work in the government sector, midwives are paid Rs 325 to Rs 550 per month. 5.3.4 Loss of Midwives Data on the loss of midwives could not be obtained. However, it may be assumed that the annual rate of loss of midwives might not differ very much from the rate for nurses, 2.7%. 5.3.5 Summary The total number of midwives in Sri Lanka was estimated on the basis of census results at 3 587. The midwife:population ratio is 28.2 per 100 OOO without excessive variations between SHS divisions. The training of midwives lasts for 18 months and consists of two parts: clinical training of 12 months conducted in 10 hospitals, and 6 months of field training in 9 training areas. The average annual number of newly graduate midwives, in the period 1962-71 was 200. The cost of train- ing a midwife, including the opportunity cost, was estimated at Rs 5 526. About 58% of all midwives work in the public health services, each midwife being responsible for a range (area); 39% of midwives work in hospitals and, 1,4% in the schools of nursing. Midwives working in public health services perform 108 different activities, spending about 31% of their time on travel and only 17% on prophylactic and promotive services. Hospital 1uiJwives carry out 111 different activities and only 9 .2% of their time is utilized for prophylactic and promotive activities. Their work efficiency i.3 highest in the base hospitals and lowest in maternity homes. The annual rate of loss of midwives in Sri Lanka was estimated at 2.7%. 5.4 AYURVEDA PRACTITIONERS In the early 1960s, the initiative to establish an "Asian Health Organization" under the aegis of the Colombo Plan led to "A Proposal for setting up an Asian Health Organization based on Ayurveda and other Asian and Eastern Systems of Medicine", which was presented by the Ministry of Health, Government of Ceylon. The proposal also contains a draft Constitu- tion of the Asian Health Organization (AHO) (120). Although the AHO did not get started, it is no wonder that such an idea was born because the practitioners of indigenous medicine in this part of the world are numerous and are well appreciated by the population and by the governments. For example, the estimated number of non-allopathic doctors in India was 146 455 in 1961 (121), since when the existing 76 colleges have been producing more graduates (122). Some hospitals in India employ both western and indigenous practitioners.* There are about 50% more non-allopathic than allopathic practitioners in India and they practise mostly in the rural areas. *Hoolchand Kharaitiram Hospital in New Delhi, for example SEA/PHA/ 149 Page 133 In Thailand, there was almost 1 physician practising the "ancient arts of healing" per 1 OOO inhabitants in 1973, five times more than the number of western-type doctors (123). The indigenous practitioners are therefore a factor not to be neglected in Sri Lanka. The Commission on Indigenous Medicine wrote in 1947: "A system that has stood the test of time in spite of neglect must have something good in it, otherwise over 70 per cent of the population will not resort to it in times of illness. But till 1929, there was neither State recognition nor State aid for indigenous medicine. In 1916, the Government was prepared to consider favourably a practical scheme for the granting of assistance for the training of those seeking to practise the indigenous systems of medicine. In 1919, a building site in Colombo was offered by the Government to the Oriental Medical Science Society for the establishment of an Ayurvedic College and Hospital, but this offer was with- drawn in 1922 as the funds then collected by the Society were not sufficient for building and equipping the proposed institutions. When the Supply Bill of 1925 was considered in the Legislative Council, the Government was asked by some members to vote a sum of money for the training of those seeking to practise the indigenous systems of medicine" (124). The first Board of Indigenous Medicine was constituted in 1928 under the chairmanship of a member of the Legislative Council. The next year, a government grant of Rs 50 OOO was provided for the establishment of the College of Indigenous Medicine with a small hospital and pharmacy in Colombo. In 1941, the College and the Hospital became government institutions (125). 5.4.1 Current Supply The total number of practitioners of indigenous medicine in Sri Lanka was esti-mated at about 16 OOO. Only those practitioners who are registered with the Ceylon (Sri Lanka) Ayurvedic Medical Council will be considered in this section, since they are recognized by the States. The non-registered practitioners have been included in the group of "other" practitioners. Out of 10 116 registered ayurveda practitioners to whom questionnaires were sent during the study, 7 725 replied, which makes a relatively low response of 66.6%. All questionnaires whose registration numbers terminated with the digit 4 were selected for statistical analysis: this gave exactly 600 questionnaires or 5.93% of all registered ayurvedic practitioners. The selected forms for the sample were received from: Private practitioners general practice 314 or 52.3% specialists 266 or 44.3% Hospital and dispensary general practice 18 or 3 % doctors specialists 2 or 0.3% Among the total number of ayurvedic practitioners in the. register, there were 6 177 general practitioners (61.1%) and 3 939 specialists (38.9%). Hence, the specialists in the statistically analysed sample, with 44.6% were over-represented. SEA/PHA/149 Page 134 The indigenous practitioners who are eligible for registration with the Ceylon (Sri Lanka) Ayurvedic Medical Council practise three systems of indigenous medicine: (i) ayurveda, which is based mostly on treatment with decoctions of different herbs; (ii) unani, based on treatment with different oils, and (iii) siddha, or rasa-medicine, based mainly on treatment with metals like mercury, etc. However, all these three systems are labelled by the government and by the public as "ayurveda". The distinction between specialists and non-specialists is also important. Specialists deal with a specific problem or group of problems. They are not expected to treat patients with conditions outside the scope of their speciality, although some of them work as general practitioners. The following specialities are the most common in Sri Lanka: for snake-bites, "for boils and carbuncles, for fractures and dislocations, for children's diseases, for nervous diseases, for eye diseases" (126), for diabetes, and for asthma. Only 7 ayurveda practitioners in the sample (4 general practitioners and 3 specialists) were women. Extended to the total number of ayurveda practitioners, this gives an estimate of about 120 female ayurveda practi- tioners in the whole country. The age distribution of ayurveda practitioners, as represented in the sample, is shown in Table 5.24. The median age of ayurveda practitioners is above 55 years, and 21.6% of them are older than 65. There is no marked difference between the general practitioners and the specialists in relation to their age distribution. Table 5.24. AGE DISTRIBUTION OF A SAMPLE OF AYURVEDA PRACTITIONERS Age-group General Specialists Total (years) practice No. % 25-29 4 1 5 0.8 30-34 13 2 15 2.6 35-39 15 7 22 3.8 40-44 29 26 55 9.5 45-49 47 38 85 14.7 50-54 42 50 92 15.8 55-59 57 42 99 17.1 60-64 40 37 77 13.3 65+ 66 59 125 21.6 Not stated 1 4 5 0.8 Total 314 266 580 100.0 Median age: 55.62 years 55.83 years 55.40 years (both) SEA/PHA/149 Page 135 The distribution of ayurveda practitioners by SHS divisions is shown in Table 5.25. The largest number is in the Colombo SHS division, followed by Kurunegala. However, the ayurveda doctor:population ratio, which is on average 79.3 per 100 OOO for the island, shows the highest concentration in Kalutara SHS division, then in Kegalle, Jaffna, and Colombo. At the other end, the lowest ayurveda doctor:population ratio was found in Badulla SHS division, and after it, Vavuniya SHS division. Table 5.25. DISTRIBUTION OF AYURVEDA PRACTITIONERS BY SHS DIVISION AND THE AYURVEDA PRACTITIONER: SHS division Sri Lanka Anuradhapura Badulla Batticaloa Colombo Galle Jaffna Kalutara Kandy Kegalle Kurunegala Ma tale Matar a Puttalam Ratnapura Vavuniya 5.4.2 Annual New Supply POPULATION RATIOS PER 100 OOO* Ayurveda practitioners (No.) 10 163 340 119 290 2 668 726 743 844 813 713 921 357 807 254 511 57 *Data of August 1973 Ayurveda doctor: population ratio 79.9 58.8 14.7 54.6 99.8 98.8 105.5 115. 3 49.6 109 .3 88.7 74.3 86.8 66.9 77 .2 32.9 In 1946, there were five sources of supply of ayurveda practitioners, as defined by the Commission on Indigenous Medicine: "Practitioners of ayurvedic medicine in Ceylon may be divided into the following groups: (a) those who have obtained diplomas or certificates after receiving theoretical and practical instruction in pre- medical scientific subjects, principles of medical science, and subjects relating to indigenous medicine proper for a period of at least four years in a recognized institution; SEA/PHA/149 Page 136 (b) those who have obtained certificates from certain private schools after undergoing a less extensive course of training; (c) those who have received a training in general medicine after serving a period of apprenticeship under a reputed physician. A large number of practitioners will be found in this group; (d) those who have received a training in a particular branch of medicine by serving a period of apprenticeship under a reputed specialist, In this category will be found the specialists, e.g., nervous diseases, boils, carbuncles, etc. (e) those who do not come within any of the above groups but are practitioners sua sponte who have taken to the practice of indigenous medicine as a means of livelihood. Quacks, medi- cine vendors and holders of bogus certificates will be found in this group." (127) The Commission found such a situation unsatisfactory and recommended that practitioners at the time of registration should be classified as follows: "Class A - Those who have obtained diplomas or certificates after receiving theoretical and practical instruction in pre-medical scientific subjects, principles of modern medical science, and subjects relating to . ayurvedic or unani medicine proper for a period of at least four years in a recognized institution. Class B - Those who have obtained certificates from certain private schools after undergoing a less extensive course of training than those in Class A and those who have received a training in general medicine after serving a reasonable period of apprenticeship under a reputed physician or have been in active practice for over ten years as general practitioners provided they satisfy the Council of Ayurvedic Medicine that they possess sufficient knowledge, experience and skill for the efficient practice of ayurvedic or unani medicine. Class C - Those who have received a training in a particular branch of ayurvedic or unani medicine or surgery by serving a reasonable period of apprenticeship under a reputed specialist, or have been in practice for over ten years as specialists provided that they satisfy the Council of Ayurvedic Medicine that they possess sufficient knowledge, experience and skill for the efficient practice of that branch of ayurvedic or unani medicine or surgery in which they have specialized. These practitioners should be permitted to practise only that branch of ayurvedic or unani medicine or surgery in which they have specialized" (128). The present classification of ayurveda practitioners is very similar. They are classified into three groups: (i) specialists (class C), (ii) heredi- tary (class B), and (iii) graduates (class A). The training programme of the Ayurveda College in Colombo includes the following disciplines (see also Annex 1-21): (a) Science: Chemistry, Physics and Biology (b) Anatomy (c) Sanskrit, Sinhala, Tamil (d) Physiology (e) Midwifery (f) Ayurveda (g) Rasa (Pharmacology) (129) The course lasts five years plus one year internship. SEA/PHA/149 Page 137 Those who want to be registered as hereditary practitioners should show proficiency in any two of the following subjects: (i) (ii) (iii) (iv) (v) (vi) (vii) Preventive health and sanitation (Ayurveda) Panchakarma Chikitsa (Medicine) Nutrition Paediatrics Diagnosis by Pulse Dentistry Mental diseases (130). About half the ayurveda practitioners (51%) belong to the category of hereditary doctors who have learned their skills from their ancestors. The graduates of ayurveda colleges represent 10% of all practitioners. The supply of ayu~veda practitioners during the last 20 years has not been regular, as shown in Annex 1-22. The 5-year annual average of registrations in the early 1950s was 965; this fell to 52 in the period 1961-65, but started to increase again in recent years to reach the present annual average of 602. The 40-year history of the Ayurveda College in Colombo shows its up and downs. The average annual number of graduates has varied between 20 and 9 (considered in five-year intervals from 1933 to 1967). Since 1968, a sharp rise in output has been recorded with an average annual number of graduates of 76. The highest output was observed in 1972 when 103 ayurveda doctors graduated (Table 5.26). The estimated cost of training an ayurveda doctor is Rs 10 565, calculated on the basis of the budget expenditure of the Ayurveda College in Colombo for 1971/72 and the average number of graduates in the period 1968-72. There are two other (private) Ayurveda Colleges, in Jaffna and Gampaha (131). 5.4.3 Utilization The great majority of ayurveda practitioners are self-employed; the number of private practitioners being 9 833 (October 1972); only 244 work in the ayurveda dispensaries of local bodies (town, municipality, and village councils) and 49 are employed by the Ministry of Health in the ayurveda hospitals. SEA/PHA/ 149 Page 138 Table 5.26. NUMBER OF GRADUATES OF AYURVEDA COLLEGE, COLOMBO Year No. 5-year Year No. 5-year average average 1933 40 1953 5 1934 17 1954 22 1935 16 1955 19 1936 23 1956 33 1937 28 25 1957 2 16 1938 16 1958 7 1939 20 1959 9 1940 13 1960 6 1941 7 1961 12 1942 17 15 1962 27 12 1943 13 1963 18 1944 19 1964 27 1945 17 1965 24 1946 28 1966 37 1947 33 22 1967 41 29 1958 21 1968 66 1959 6 19r 75 1960 19 0 65 1961 1971 70 1962 16 9 1972 103 76 The ayurveda practitioners employed in the government hospitals and in the local authority ayurveda dispensaries work full-time in treating patients. The majority of private ayurveda practitioners also carry out otheI occupations, like school teachers, priests, etc., so that their ayurveda practice is a part-time job. This is true especially with regard to the hereditary ayurveda practitioners, since the graduates of the ayurveda colleges mostly work as full-time practitioners. The private ayurveda practitioners usually dispense drugs to their patients. Some of them produce ayurvedic medicines in large quantities for sale to other ayurveda practitioners. The importance of the ayurveda sector as a whole was discussed in the previous chapter (see Section 4.2). Data on the diseases treated by ayurveda practitioners were not collected in the course of this study. The findings of the Commission on Indigenous Medicine (1947) will therefore be quoted in order to provide some idea of the ailments which led people to contact the ayurveda practitioners in the 1940s. These data may not be fully valid today. SEA/PHA/149 Page 139 The pattern of outpatient morbidity registered in the western govern- ment sector in 1972-73 (Chapter 3, Section 3.2) has much in common with that shown in Table 5.27. The leading diseases are gastrointestinal disorders, followed by respiratory diseases, malaria and other fevers, rheumatism and diseases of joints, anaemia, etc. Two striking conclusions may be drawn: (i) that the morbidity pattern in Sri Lanka has not changed very much during the last 30 years; and (ii) that the ailments of the clientele of the ayur- veda doctors do not differ significantly from the ailments of the patients of western practitioners. Table 5.27. MORBIDITY OF OUTPATIENTS, COLOMBO AYURVEDA HOSPITAL* Diseases Number of cases Aug. 1941- Oct. 1942- Oct. 1943- Jan. 1945- Sep. 1942 Sep. 1943 Dec. 1944 Dec. 1945 Malaria and other fevers 9 264 7 612 13 508 16 301 Genito-urinary diseases 2 264 933 4 197 3 454 Diseases of lungs and pleura 13 057 7 270 16 392 19 539 Rheumatism and diseases of joints 9 026 5 117 15 314 13 331 Asthma 4 413 1 301 6 544 6 719 Anaemia 4 843 3 833 7 742 9 915 Abscesses, ulcers and boils 3 416 3 473 5 210 5 312 Paralysis and nervous diseases 1 264 2 435 3 832 3 634 Skin diseases 1 063 2 614 3 837 4 405 Stomach and intestinal disorders 10 699 6 079 19 250 20 709 Eye diseases 984 413 228 273 Fractures and dislocations 772 516 538 434 Tumours and other diseases 1 517 974 3 011 2 818 61 782 42 630 99 603 106 843 *See reference 132 SEA/PHA/149 Page 140 The inpatient morbidity is shown in Table 5.28. Table 5.28. MORBIDITY OF INPATIENTS OF THE AYURVEDA HOSPITAL IN COLOMBO Diseases Number of cases Aug. 1941- Oct. 1942- Oct: 194J.:.. Sep. 1942 Sep, 1943 Dec. 1944 Abscesses and boils 37 19 52 Anaemia 35 23 61 Asthma 34 51 82 Bronchitis and cattarh 64 93 137 Diabetes 41 42 60 Fractures & dislocations 11 24 30 Genito-urinary diseases 38 58 88 Heart diseases 63 57 64 Malaria and other fevers 94 95 143 Paralysis and nervous diseases 179 114 254 Pneumonia and diseases of lungs 22 20 21 Rheumatism and diseases of joints 113 149 226 Skin diseases 61 51 125 Stomach and intestinal disorders 92 114 127 Tumours and other diseases 97 69 63 Total 981 979 1 543 *See reference 132 ·Jan. 1945- Dec. 1945 66 82 96 182 53 20 141 134 198 248 60 293 130 207 39 1 958 SEA/PHA/149 Page 141 The productivity of the ayurveda practitioners working in the govern- ment sector can be assessed in the same terms as the productivity of doctors, nurses, and midwives. The paid working time for one patient-day was 31.9 minutes. The paid time for one OP visit was 7.9 minutes in ayurveda hospi- tals and 12 minutes in ayurveda dispensaries. The average number of visits paid to a private ayurveda practitioner was less than 10 per day so that there is enough room for increasing his productivity. 5.4.4 Loss The estimate on the loss of ayurveda doctors might be only very approximate since this matter was investigated over a very short time. The elections for the Ceylon Ayurveda Council took place in October 1972 and the study of ayurveda practices was conducted in August 1973, ten months later. During this period, 9 out of 133 ayurveda practitioners who were allotted to the sample stopped practising for various reasons. This makes a rate of loss of 8.12% per year. Thus, of the 10 116 ayurveda doctors, about 820 doctors may be expected to stop practising in a year. This assumption seems reasonable, considering the high median age of the ayurveda practitioners. If the supply of ayurveda practitioners does not increase but stays at about 600 annually, the ayurveda profession will undergo heavy losses in the foreseeable future. 5.4.5 Summary There were 10 163 registered ayurveda practitioners in Sri Lanka, 10% of them graduates from the Colombo Ayurvedic Medical College and the others registered with the Ceylon (Sri Lanka) Ayurvedic Medical Council as specia- lists or hereditary practitioners. The number of ayurveda practitioners is more than three times as high as the number of western doctors in the countr1 giving an ayurveda practitioner:population ratio of 79.9% per 100 OOO popula- tion. There is a considerable disparity in their regional distribution. There are very few female ayurveda practitioners in the country. The median age of all practitioners is above 55 years and about 22% of them are older than 65. The ayurvedic practitioners practise one of the three systems of indigenous medicine: ayurveda, unal'i, or siddha. Some of them practise in a narrow field only, like boils and carbuncles, diabetes, snake-bites, asthma~ etc. The training programme of the Ayurveda Medical College in Colombo (there are two other private colleges in the country) includes some subjects from western medicine, like physiology, anatomy, and midwifery. The average annual supply (registration) of ayurveda practitioners during recent 5 years has been about 600. The great majority of the ayurveda practitioners work as part-time private practitioners. They examine on average less than 10 patients per working day. SEA/PHA/149 Page 142 The pattern of outpatient morbidity in the Colombo Ayurveda Hospital, as registered in 1941-45, does not differ significantly from that in the OPD of the government western sector as registered during the recent years. The leading diseases are: gastro-intestinal troubles, respiratory diseases, malaria and other fevers, rheumatism and diseases of joints, and anaemia. The productivity of ayurveda practitioners working in the OPD of the ayurveda hospitals is higher than the productivity of ayurveda practitioners in the ayurveda dispensaries. The estimated rate of loss of ayurveda practitioners is 8.12% annually, which may mean that about 820 ayurveda doctors drop out annually. As the supply is about 600 per year, there is a real possibility of develop- ing a considerable deficit of ayurveda practitioners in the future. 5.5 OTHER WESTERN QUALIFIED PERSONNEL All other western qualified health personnel are here put together not because their importance in providing health care is underestimated, but because the information collected on their role in the health care system of the country was incomplete. It is much regretted that adequate attention was not given to some of them in the course of the study. However, with the data collected it is possible to describe the problem of health manpower utilization and to propose alternative changes in the health care system, although they may not be comprehensive enough for progrannning the introduc- tion of these changes. A coordinated and more comprehensive study of some categories of health manpower should therefore be contemplated after a decision is taken regarding the direction of the expected changes. 5.5.1 Assistant Registered Medical Practitioners The estimated number of assistant (registered) medical practitioners (AMP/RMP) in Sri Lanka in 1972 was 1 337 of whom 1194 (89%) are employed by the government. Data on their regional occupational distribution were not collected, but it is well known that AMP/RMPs are the personnel who provide medical care services mainly in the small rural medical institutions •. As a rule, they are not involved in public health activities. The training of AMPs was discontinued in 1967. Up to that year they were trained for 2 years by the Ceylon Medical College. The demand for this kind of training was rather high, because every year an average of 1 466 candidates competed for 40 places. The drop-out rate during the course was also very high, about 30%. Data on the cost of training this category of health manpower could not be obtained, but the estimated cost of training an AMP/RMP may be about two/fifths of the cost of training a medical doctor, i.e., Rs 12 700 (see Annex 2-7). The AMP/RMPs usually work in the OP departments of hospitals, exclud- ing the Colombo group. In the provincial, base and district hospitals and the peripheral units, the AMP/RMP works under the supervision of the medical SEA/PHA/149 Page 143 officers. In smaller institutions they provide outpatient and inpatient medical care without any innnediate supervision by doctors. The AMP/RMPs usually do not deal with maternity and gynaecology cases. Sometimes, they work as medical records officers or apothecaries in hospitals. A few of them also work in the specialized campaigns. After 20 years of successful work, the assistant medical practitioners can become registered with the Ceylon (Sri Lanka) Medical Council. There- after they can practise medicine privately and are designated registered medical practitioners. As with the other health occupations in Sri Lanka, the productivity of the AMP/RMP varies widely. The paid working time for a patient-day is between 76 minutes in ,the central dispensaries/maternity homes, and 0.24 minutes in the infectious diseases hospitals. In the rural hospitals it is 9 minutes, in the maternity homes 15.2 minutes, and in the estate hospitals 12.8 minutes. The paid working time input into OP visits is between 0.6 minutes in the provincial hospitals and 34.2 minutes in the branch dispen- saries and visiting stations. In the peripheral units and the rural hospi- tals it is 2.8 and 5.3 minutes respectively. The activities of the AMP/'RMP working in the rural health institutions (peripheral units, rural hospitals, cottage hospitals, central dispensaries, central dispensaries/maternity homes, and maternity homes) were studied by direct observations. The findings are presented in Table 5.29. Table 5.29. ACTIVITIES OF AMP/RMPs AND THE TIME SPENT ON THEM IN THE RURAL HEALTH SERVICES Activities Diagnostic and therapeutic Prophylactic and promotive Administration Maintenance Non-productive activities Total No. of activities 32 13 31 13 % of time spent 39.4 1.8 23.9 4.1 30.1 99.3 Table 5.29 shows that the main health activities performed by the AMP/RMPs in rural areas are diagnostic and therapeutic. Very little time is devoted to prophylactic and promotive activities. Administrative acti- vities occupy almost one fourth of the working time: and non-productive activities, one third. The range of their monthly salaries is Rs. 450-900. The estimated rate of loss of AMP/RMPs per year is 2.1% (Annex 2-6). SEA/PHA/149 Page 144 5.5.2 Public Health Inspectors No enumeration of the PHis was conducted, but the estimated number in government services was 1 074, about 89% of an estimated total of 1 203 PHis. Public Health Inspectors are trained in the Kalutara Institute of Public Health. The training course lasts for one year and includes subjects in statistics, communicable diseases control, and environmental sanitation. Every year 40 trainees are admitted and there are practically no drop-outs during the course. The estimated cost of training is Rs 5 256 (see Annex 2-7). The great majority of PHis work in the 770 areas (ranges) in which they reside. Each PHI maintains 24 different registers, 8 books of ordi- nances, 20 copies of regulations, and a reference file containing 8 catego- ries of instructions. He submits a monthly report on 28 pages. Such a list of duties, which makes the PHI the key-worker in the fields of control of communicable diseases and environmental health, combined with heavy administration explains the expenditure of time as observed during the study and presented in Table 5.30. Table 5.30. ACTIVITIES OF PHis AND THE TIME SPENT ON THEM IN THE RURAL HEALTH AREAS Activities No. of activities % of time spent Diagnostic and therapeutic Prophylactic and promotive Administrative Maintenance Travel Non-productive activities Total 12 30 39 11 92 0.6 20.6 28.1 2.0 28,0 20.7 100.0 The paid time input in different repetitive activities of PHis was estimated as follows: Child welfare clinics' visits Immunizations/vaccinations Environmental examination Environmental sanitation 0.6 - 6 minutes 1.2 - 4.2 minutes 14.2 - 56.8 minutes 34.3 - 66.5 minutes The PHis perform similar tasks when working in the specialized campaigns. In government service their emolument is between Rs. 350-900 per month. The annuai rate of loss of PHis may be similar to that of nurses and midwives, around 3%. 5.5.3 Dental Surgeons SEA/PHA/149 Page 145 The estimated number of dental surgeons in the country is 280: 180 in government services and 100 private. The dental surgeons are usually trained in the University of Ceylon (Sri Lanka) in Colombo until 1967, and since 1969 in Peradeniya. The average annual output of dental surgeons has been around 25. The duration of study is 4 years and the cost of one year of study is assumed to be the same as that for doctors, Rs 5 141. Together with the opportunity cost, the cost of the education of a dental surgeon can be estimated at Rs 23 942. The dental surgeons work mainly in hospitals. Very few of them, 9 in 1973, were, employed in the dental public health services. The dental surgeons working in hospitals spend 0.18 and 0.48 minutes of their working time on one patient-day in the provincial hospitals and in the Colombo group, respectively. The paid time input in the examination and treatment of outpatient (visit) depends on the type of institution: Colombo group of hospitals Provincial hospitals Base hospitals District hospitals Peripheral units Private nursing home 2.3 minutes 3.3 minutes 4.4 minutes 30.6 minutes 27.5 minutes 99 minutes The annual rate of loss of dental surgeons is about 3.8%, which was estimated as shown in Table 5.31. Table 5.31. ANNUAL RATE OF LOSS OF DENTAL SURGEONS* Number of dent.s.l surgeons in 1965 200** Number of dental surgeons in 1972 280** Increase in 7 years 80 Output of medical schools in 7 years 144 Loss in 7 years 64 Average annual loss 9.14 Average annual rate of loss 3.8% *Calcu1ated against the mean population of dental surgeons, 1965-72. **Estimate. Their monthly salary in government service is between Rs 750 and 1 850. SEA/PHA/149 Page 146 5.5.4 Medical Laboratory Technologists (MLT) The current supply or stock of MLT was estimated at 510 in 1972, of whom 455 worked in the government services, Exact data on their age, sex, and geographical and occupational distribution are not available. The MLTs are trained at the Medical Research Institute (MRI), Colombo, in a one-year course. The annual output is about 30 MLTs; however, there were no admissions in 1968, 1969 and 1971, so the total output in the period 1962-70 was 206 MLTs. According to the estimate of the MRI, the cost of training of an MLT is Rs 1 800 which seems to be grossly underestimated. A more realistic estimate may be Rs 5 290 (see Annex 2-7). The MLTs employed by the Government work in the medical care services and in the specialized campaigns, but they are under the supervision of the Laboratory Services of the Health Department. The productivity of the MLTs, estimated as paid time spent on one laboratory test, is as follows: Colombo group of hospitals 12 minutes Provincial hospitals 13.8 minutes Base hospitals 12.8 minutes District hospitals 14.6 minutes Infectious diseases hospitals 94.2 minutes Tuberculosis hospitals 13.8 minutes Leprosy hospitals 20.4 minutes Private nursing homes 166.1 minutes Ayurveda hospitals 40 minutes The annual rate of loss was estimated to be 2.9%, In government service, their monthly salary is between Rs 450 and 850. 5.5.5 Radiographers The estimated number of radiographers in 1972 was 184, of whom 164 were employed by the government. The radiographers are trained in the Ceylon (Sri Lanka) School of Radiography at the Colombo General Hospital. The course lasts for 2 years. The number of those who passed out in the period 1962-72 was 92, but in 1964, 1966 and 1967 there were no admissions. The cost of training, as estimated by the school, amounts to Rs 3 000 9 without taking into account the oppor- tunity cost. A better estimate may be Rs 5 290 (see Annex 2-7). . The productivity of the radiographers, expressed as paid working time per one X-ray examination depends on the type.of institution in which they work. The differences are not too large, the paid time being in the range of 15.9 minutes per X-ray examination in the base hospitals to 32.4 minutes in the tuberculosis hospitals. When employed by the Government they earn Rs. 450-850 per month, SEA/PHA/149 Page 147 The rate of loss has been estimated at 3.4%, based on the "stock" of radiographers from 1965 to 1972, and the supply during the same period. 5.5.6 Physiotherapists The number of physiotherapists in Sri Lanka was estimated as 144 in 1972, 129 of them in government service. The School for Physiotherapists in the General Hospital, Colombo, provides a 2-year course with an annual output of 9 physiotherapists. The estimated cost of training in this school is Rs 8 869 per graduate, which with added opportunity cost will make Rs 10 558. The paid working time input of the physiotherapists per unit activity is as follows: In the Colombo group of hospitals In provincial hospitals In base hospitals In private nursing homes 39 58.1 75 8.5 minutes minutes minutes minutes In government services they earn Rs 450-850 monthly. The estimated rate of loss is 6.6% annually. 5.5.7 Dental Nurses According to the census list of dental nurses, there were 239 dental nurses in government service. The estimated number of dental nurses outside government service may be about 29, making a total of 268. All dental nurses are trained at the School for Dental Nursing in Maharagama. The estimated cost of training is Rs 5 256 (see Annex 2-7). The great majority of dental nurses (98%) work in the school dental clinics. The paid working time for one visit to these clinics was between 2.2 and 10.3 minutes. Th~ dental nurses who worked in the private nursing homes were paid for 31.9 minutes per visit. The monthly salary of a dental nurse in government service is Rs 350-750. The rate of loss of dental nurses may not be very different from that of nurses and midwives, i.e., around 3% per year. 5.5.8 Pharmacists The number of pharmacists estimated for 1972 was 455, 90% of them working in the government services. There is a one-year course for pharmacists organized and conducted by the Ceylon (Sri Lanka) Medical College Council. The annual number of SEA/PHA/149 Page 148 applicants for this kind of training averaged 486 in the period 1962-72 (there were no admissions in 1971); 59 (or 12.2%) of them are admitted on the average, and 33 (or 56%) of those admitted pass out. Data on the cost of training could not be obtained. The best estimate, however, considering the duration of training and other factors, seems to be Rs 5 256 (see Annex 2-7). The paid working time input in the dispensing of one prescription by a pharmacist depends on the type of institution, and lies in a wide range between 0.8 minutes in the district hospitals and 650 minutes in the leprosy hospital. In the Colombo group, the provincial, and the base hospitals, the input is 3.4, 3, and 4.4 minutes, respectively. There is a tendency to replace the AMPs with pharmacists in medical care institutions. However, the scope of the activities of the pharmacists is narrower, since they work exclusively in the preparation and dispensing of drugs, whereas the AMPs examine patients and prescribe treatment. In government service they are paid Rs 450-850 per month. The annual rate of loss of pharmacists has been estimated as 1.7%. 5.5.9 Dispensers The estimated number of dispensers for 1972 was 900, of whom 804 were in the government service. They are trained on the job, so no training expenses could be estimated. Dispensers carry out functions similar to the pharmacists in medical care institutions. Their activities were studied and timed as shown in Table 5.32. Table 5.32. ACTIVITIES OF DISPENSERS AND THE PERCENTAGE OF TIME SPENT ON THEM IN RURAL HEALTH SERVICES Activities Diagnostic and therapeutic Prophylactic and promotive Administrative Maintenance Total No. of activities carried out 20 6 26 15 67 % of time spent 35 .1 1.1 15.3 9.8 61.3* *38.7% of the working time was spent on non-productive activities. The scope of activities of the dispensers in the rural health services is not very wide. Their responsibilities are concentrated around administra- tive jobs and simple diagnostic and therapeutic activities. Most of their SEA/PHA/149 Page 149 working time, excluding non-productive activities, is spent on diagnostic and therapeutic activities, followed by administrative functions. The productivity of the dispensers is also related to the type of institution in which they are employed. The paid working time for the dispensing of one prescription is between 1.44 minutes in the Colombo group or base hospitals and 22.6 minutes in the private nursing homes. It is rather high in the rural hospitals (11.9 minutes), the central dispensaries/ maternity homes (13.4 minutes), and the ayurveda hospitals (12 minutes). The monthly salary of dispensers in the government sector is from Rs 250 to 450. There are no data on the rate of loss of the dispensers, but the rate may not be very much different from that of other similar health workers. 5.5.10 Attendants The number of attendants has been estimated at 5 901. About 90% of them work in the government and semi-government services. They are employed in all types of medical institutions and their duties fall within the scope of nursing personnel. Attendants used to be trained on the job for about 6 months, but their training was discontinued several years ago and there is no current supply of attendants. In the sub-study of the activities of the rural health personn.::1, tlle activities of the attendants working in the small rural institutions w.:co2 observed (Table 5.33). Table 5.33. ACTIVITIES OF ATTENDANTS AND THE PERCENTAGE OF TIME SPENT ON THEM IN RURAL HEALTH SERVICES Activities · Diagnostic and therapeutic Prophylactic and promotive Administrative Maintenance Non-productive activities Total No. of activities carried out 46 17 28 13 104 % of time spent 28.7 1.4 5.7 28.2 35.9 99.9 From the distribution of their working time between different catego- ries of simple activities it is evident that the main responsibilities of the attendants are the care of sick persons and the maintenance of equipment and premises. SEA/PHA/149 Page 150 The paid working time input of the attendants in one patient-day varies between 2.4 minutes in the maternity homes, and 21.6 minutes in the mental hospitals. In the OPD, the range is from 13 minutes per one visit in the private nursing homes to 1.2 minutes in the ayurveda hospitals. Attendants are paid by the government Rs 250-450 per month, The estimated annual rate of loss of the attendants is 3.6%. 5.5.11 Other Workers There is a long list of other workers employed in the medical care or public health institutions, in the laboratories or in the administrative services, and working in the institutions or in the field, such as adminis- trative personnel, accountants, labourers, drivers, insecticide sprayers, assistants of all kinds, microscopists, etc. The common characteristics of all of them is that they do not require special formal training in the field of medical and health technologies, although some of them are highly quali- fied in other fields, like administration, accountancy, engineering, etc. Two categories of health personnel have been observed in th~ir work in the rural health institutions, labourers and malaria field assistants (Tables 5.34 and 5.35). Table 5.34. ACTIVITIES OF LABOURERS AND FIELD ASSISTANTS IN THE RURAL HEALTH SERVICES Activities Number of activities by Diagnostic and therapeutic Prophylactic and promotive Administrative Maintenance Total Labourers field assistants 31 11 24 14 80 12 2 21 8 43 Table 5.35. PERCENTAGE OF TIME SPENT ON DIFFERENT ACTIVITIES BY LABOURERS AND FIELD ASSISTANTS IN THE RURAL HEALTH SERVICES Activities Diagnostic and therapeutic Prophylactic and promotive Administrative Maintenance Non-productive activities Total Percentage of time spent by Labourers field assistants 5.3 0.5 7.1 45.4 41.6 99.9 14.4 0.2 35.6 1.1 48.7 100.0 SEA/PHA/149 Page 151 The sanitary labourers' productivity varied between 1 054.6 minutes of paid working time per one patient-day in the maternity homes and 11.43 minutes in the provincial hospitals; and between 12.2 minutes in the estate and ayurveda hospitals and 1.7 minutes per OP visits in the base hospitals. 5.5.12 Summary This section deals with the health manpower employed in the western sector, not considered in the previous sections. The following categories have been described: (a) Assistant/registered medical practitioners (AMP/R1'1P), who provide medical care under or without the supervision of medical officers; (b) Public health inspectors (PHI), whose tasks are related mainly to the control of communicable diseases ,Hid to environmental health; (c) Dental surgeons; (d) Medical laboratory technologists (MLT); (e) Radiographers; (f) Physiotherapists; (g) Dental nurses; (h) Pharmacists; (i) Dispensers; (j) Attendants; (k) Labourers; (1) Field assistants. All of them, except the last four, were especially trained for their respective jobs; the dispensers, attendants, labourers and field workers were trained on the job. The training of assistant medical practitioners and attendants was discontinued several years ago. The approximate cost of the training of each category has been estimated. There is great variation in productivity within each category, as estimated by the paid time for the performance of repetitive activities (like patient-days, OPD visits, clinic visits, etc.). The productivity seems to depend on the sector of employment, on the size of the health institution, and on the special ward where the job was carried out. SEA/PHA/149 Page 152 Thus, the cost of health labour varies widely not only between different types of institutions and conditions, but also between institu- tions and conditions of the same type. This shows that there is room for improving the health care system in Sri Lanka not only by adopting an appropriate health manpower policy, but also by setting certain standards in the performance of duties by the staff in the various institutions. The rates of loss of personnel for each categories have also been estimated. 5.6 WHO ELSE SELLS HEALTH IN SRI LANKA Some medicine can be bought almost anywhere in the country: in groceries and in the so-called "boutiques", the favourite shopping places on the road-site, which sell cigarettes, candies, bananas, soft drinks, condoms, etc. Naturally, the staff in these establishments have no train- ing in dispensing drugs. The personnel working in 230 pharmacies situated in 68 urban areas of the country are also not trained. However, they do dispense drugs, sometimes dangerous ones, and very often without any doctors' prescription. The non-registered ayurveda practitioners represent the largest group of unauthorized "sellers of health". Their number is estimated at 6 OOO. There are many unanswered and unanswerable questions regarding the qualifications,the way of training, and the methods of practice of the homoeopathic "doctors". They are not favoured by either the western or the ayurveda doctors, but they practise freely and their numbers are on the increase, nearly 600, by some guesses. How many and what kind of quacks are there who provide services for a fee in Sri Lanka? Perhaps about 3 OOO; perhaps less; perhaps more. The figure of 3 OOO was estimated on the basis of the available funds for the individual purchase of health and from the annual consumption of drugs. 5.7 SUMMARY OF THE CHAPTER The range of health services in Sri Lanka, as in any other country, may be considered to extend from the advice of parents to children on how to keep healthy and what to do when sick or the commercial advertisements on Radio Sri Lanka, to all kinds of services provided by the health care system, including the technically advanced manipulations in, for example, intensive care units. However, most people would agree that the health care services will be considered as the "industry" that provides health services as its main occupation. From this point of view, health manpower must then exclude the parents and the announcers of Radio Sri Lanka and will refer to the health personnel listed in Table 5.1 in this chapter. The fact that there are 55 150 people employed in the recognized health care services and presumably another 15 OOO performing informal (non- registered) health services, indicates that one in every 200 Sri Lankians is employed, full-time or part-time, in the health industry. SEA/PHA/149 Page 153 There is a marked disparity in the urban/rural and the regional distribution of the leading categories of health manpower. Although there is a justified doubt regarding the validity of using the regional distribu- tion (assessed by the manpower:population ratio) as an index of the health care coverage, this ratio may be useful in comparing areas in which the health manpower utilization is similar. Moreover, there are indications that a significant association exists, in a group of countries with annual per capita income below US$ SOO, between the doctor:population ratio and the infant mortality and the crude mortality rates, as well as between the nurse/midwife:population ratio and the infant mortality rate. (Data borrowed from B. Abel-Smith (98); also see Annex 1-24). Fifteen categories of health manpower have been identified. The great majority of these personnel received formal training, whereas the others were trained on the job. The training of the assistant medical practitioners and attendants has been discontinued. The following are the training facilities for health manpower in Sri Lanka: (i) Two medical schools, one of them training also dental surgeons; (ii) Eight schools of nursing and one post-basic school of nursing; (iii) Ten hospital centres and 9 training areas for midwives; (iv) One government and two private ayurvedic medical colleges; (v) The institute of Hygiene in Kalutara for training of public health inspectors; (vi) The school for medical laboratory technologists at the Medical Research Institute; (vii) School for radiographers; (viii) School for physiotherapists; (ix) School for dental nurses; (x) School for pharmacists, operated by thP. Ceylon Medical College Council. If all the costs incurred in the special training of health personnel are taken into account (excluding the training of accountants, engineers, etc.), the investment into health manpower presently working in Sri Lanka, can be estimated at Rs 342 million (Table 5.36) or Rs 27 per capita of the population (Annex 2-7). SEA/PHA/149 Page 154 Table 5.36. ESTIMATED CAPITAL INVESTED IN HEALTH MANPOWER (WITHOUT DEPRECIATION) Category of health manpower Doctors, including postgraduate training Nurses, including midwifery training Midwives Dental surgeons Assistant medical practitioners Public health inspectors Medical laboratory technologists Radiographers Physiotherapists Dental nurses Pharmacists Ayurveda doctors (graduates only) Total Capital investment in training (Rs million) 140.0 81.3 15.9 6.7 17.0 6.3 2.7 Q.9 0.8 1.0 2.4 66.8 341.9 The estimates given are approximate and require much study for improvement. They are probably on the lower side, since the cost of train- ing highly qualified personnel, such as administrators and accountants, have not been taken into account. Also the costs of training attendants, drivers, and other qualified workers have not been considered. However, these estimates give a broad idea of the costs involved in the development of the present manpower in the health care system of Sri Lanka and indi- cates a field of study for the future. If, as a guess, the average working life of health personnel in Sri Lanka does not exceed fifteen years (which is probable considering the rates of loss in the different categories), then the average annual input in health manpower development, including the opportunity cost, may be about Rs 23 million. There was no data base for calculation of the depr~- ciation of the health manpower stock as investment. The rate of loss of doctors was high during the first ten years after graduation, suggesting the emigration of young graduates from the country. The loss in other categories was not excessive, as estimated from the scarce data available. There is evidence of overlapping responsibilities, especially in the provision of health care in the rural areas. Finally, the productivity of health manpower in Sri Lanka varied very widely in some categories, depending on the sector (government, private), the speciality, and the size of the institution. CHAPTER 6 SEA/PHA/149 Page 155 MATCHING HEALTH NEEDS WITH SATISFACTION AND POSSIBILITIES The basic health concerns in Sri Lanka are those connected with the population dynamics, those arising from the spread of diseases that are closely associated with a challenging environment, and those from the demand for medical care.* To satisfy the needs arising from these concerns, the health care system performs health activities, which in order to solve a given health problem are grouped into health functions. Both activities and functions will now be identified and defined and their relationship to the health concerns assessed in terms of their efficacy, i.e., their appropriateness, adequacy, effectiveness, and efficiency. For the purposes of this study, the following health activities have been identified: 1. Hospital treatment of an acute case 2. Hospital treatment of a chronic case 3. Hospital delivery 4. Surgical intervention 5. Hospital treatment in an ayurveda hospital 6. Out-patient visit 7. Visit to a clinic (preventive) 8. Consultation by a specialist 9. Vaccination/immunization 10. Visit to an ayurveda hospital/dispensary 11. Delivery at home 12. Home visit 13. Environmental examination 14. Environmental sanitation 15. Visit to a private practitioner 16. Visit to an ayurveda private practitioner. [For the sake of simplicity, certain health activities carried cut in the specialized campaigns have been "translated" to fit into the above standard health activities, e.g., in the anti-malaria campaign, - one house-sprayed= one environmental sanitation (No.14 in the above list) - one blood examination in an institution= one out-patient visit (No. 6) - 6 blood collections at home= one home visit (No.12); *It should be clear that only demand can be influenced in the short run by social, economic, or organizational changes. The other two areas of con- cern are subject to a long-range policy. SEA/PHA/149 Page 156 in the antifilariasis campaign, - spraying one sq. mile= 10 environmental sanitations (No.14) - 6 blood collections at home= one home visit (No.12) - number of persons treated= OPD visits (No.6); in the anti-venereal diseases campaign, - one investigation= one OPD visit (No.6). Health activities in the antituberculosis campaign and in the antileprosy campaign are expressed in the same terms as shown above. The hospital treatment of a tuberculosis case or a leprosy case is counted as hospital treatment of a chronic case (No.2).] These health activities can be performed by different types of institution. For instance, the hospital treatment of an acute case may be conducted in one of the Colombo group of hospitals, in a provincial hospital, base hospital, district hospital, peripheral unit, rural hospital, cottage hospital, ayurveda hospital, estate hospital, co-operative hospital, or private nursing home. The categories of health manpower involved in this health activity will differ in different hospitals; also the quality of work, the time-input, and the cost. Health activities can be grouped into health functions in order to solve a given health problem. The following health funations have been identified: 1. Maternity 2. Child health 3. Family planning 4. School health 5. Curative services 6. Tuberculosis control 7. Malaria control 8. Filariasis control 9. Leprosy control 10. Venereal diseases control 11. Control of other communicable diseases 12. Environmental sanitation 13. General health education Each of the above health functions can be carried out by combining different health activities in different proportions. For example, a cholera control programme can be based only (or mainly) on the immunization of the population at risk; or only (or mainly) on the hospital treatment (for rehydration) of those affected; or on environmental sanitation; or on a combination of any or all of these health activities in whatever proportion. Each health institution has its upper limit of output regarding the number of health activities which it can perform, depending on the capital available (buildings and equipment), the resources, and the efficiency of their utilization. SEA/PHA/149 Page 157 Each health programme, if it is to be effective, requires a minimum number of health activities of different kinds to be carried out, The basic questions which should now be answered are: (1) Does the existing health care system of Sri Lanka control the problems in the three areas of health concern for the country? (2) Is the health care system likely to do so in the future without major changes? (3) With what degree of efficacy the health care system works? (The efficacy is defined as the degree of capability of the health care system to cope with the health concerns,) The relationships between the health problem areas and the health functions of the health care system in Sri Lanka are presented in Table 6.1 Table 6.1 RELATIONSHIP BETWEEN HEALTH PROBLEM AREAS AND HEALTH FUNCTIONS Health problem areas (1) Population dynamics (2) Diseases control (3) Demand for medical care Health functions 1, Maternity 2. Child health 3, Family planning 4, School health 5, Curative services 13, General health education 5, Curative services 6. Tuberculosis control 7. Malaria control 8. Filariasis control 9, Leprosy control 10. Venereal diseases control 11. Control of other communicable diseases 12. Environmental sanitation 13, General health education 5. Curative services 13, General health education Table 6.1 shows that the curative services and general health education, which are the only means of satisfying the demand for medical care, appear also in the list of health functions to control the other two problem areas; the health functions to control the problems of popula- tion dynamics and of disease control are otherwise complementary, SEA/PHA/ 149 Page 158 The further analysis of the relationship between health problems and health functions will follow this classification as far as possible. An effort will also be made to apportion adequate parts of the work of curative services to each of the three health problem areas. In this discussion, it will be necessary to refer often to data given in the previous chapters in order to clarify the issues. The existing health care system will be assessed in terms of its appropriateness, adequacy, effectiveness, and efficiency. Such an assess- ment will provide the link between the health concerns and the health manpower process, since this process only materializes within a health care system as a result of legislation or on historical or traditional grounds. As the health care system in Sri Lanka is based on both a long history and extensive legislation, much space has been devoted to their description in the previous chapters. 6.1 THE APPROPRIATENESS OF THE HEALTH CARE SYSTEM To explain what is understood by appropriateness, one must ask the question: is the health care system providing the kind of service that is likely to control the priority health problems of the people? In the case of Sri Lanka the question should read: is the health care system of Sri Lanka providing a health service that is capable of controlling the problems arising from a rapidly increasing population, a continuing spread of diseases, and a rising demand for medical care under the existing circumstances? Thus, appropriateness poses a question of quality, the assessment of which is one of the most difficult tasks in health. There are many vari- ables that should be considered; sometimes they are complementary, and some can be substituted by others or may be inferred from others. The following variables will be considered in this section: (1) acceptability (2) outcome: reduction of the problem (3) approach: preventive vs. curative (4) place of treatment: inpatients vs. outpatients (5) application of recognized standard health technologies (6) technical level of application: what is the technical background of the health staff who apply the health technologies? (7) availability of the equipment needed (8) availability of the supplies needed These criteria of assessment will be applied to the work of the health care services in the three identified areas of concern, 6.1.1 Population Dynamics Aspect "Although various fertility measures have registered a decline since 1963 it is rather difficult to isolate the contribution made by the National Programme to fertility decline since its inauguration in late 1965, In view of the complex effect of several factors on a population's fertility, the importance of each factor cannot be measured precisely. Taking these limi- tations into consideration an attempt has been made to estimate the number SEA/PHA/149 Page 159 of births prevented in 1968 by contraceptive acceptance within the National Progrannne. The new acceptors recruited in 1967 (viz. 36 695) and during the first quarter of 1968 (viz 8027) would have an impact on the decline in the birth rate of 1968. Calculating on the basis of a marital fertility of 220 which was approximately the level in 1968 and assuming estimates for termination rates of loops and also for continuance rates of other contra- ceptives (orals, condoms, etc.) it {s estimated that about 7000 births would have been prevented in 1968 by contraceptive acceptance within the progrannne" (135). Considering the average number of births per year during the same period, the reduction in fertility that might be ascribed to the activities of the health care system may have been 1.95, which represents 69% of the observed average annual reduction in the period 1963-68 (2,9%). The other factors that contributed to the decline of fertility in the same period were most probably the higher average age at marriage, the shift in the mothers' ages at delivery to older age groups, and the decimation of the 1934-38 female cohort, An immediate factor that may also have influenced the fertility in 1968 was the outbreak of malaria in Sri Lanka (136). The annual target for new acceptors of family planning techniques was set at 115 OOO per year. The target attained was 38.2% of this for 1968 and 47.4%, 48.0%, and 43.0% for 1969, 1970, and 1971 respectively. In 1968, there were 43 964 new acceptors, or 6.28 new acceptors per one averted birth. Since 1 in every 7,75 females of fertile age is expected to deliver a child during the year, the assumption of 7000 births having been averted in 1968 by family planning techniques does not seem excessive. Thus, the health care services appear to have contributed to the reduction of fertility in the country, if the above assumptions are correct, Considering the 71 044 new acceptors in 1972, the estimated number of births averted can be about 9000. As far as maternal deaths are concerned, there was a great reduction in the total maternal death rate in the period 1961-71 from 2.6 to 1.2 per thousand. The institutional maternal death rate fell from 3.4 per thousand in 1961 to 1.8 per thousand, in 1968. Since the percentage of births attended by qualified personnel has been about 70% in recent years, it might have influenced the downward trend in maternal mortality. However, there is room for further improvement, since public health nurses in maternity homes can be utilized more efficiently in the field attending deliveries. Although the health coverage of infants and pre-school children decreased during the period 1961-71, the mortality rate in these age groups fell because of other reasons. Evidence on the trend of the health status of the schoolchildren population in the country is not available. The approach in tackling health problems is aggressively preventive. The whole country is divided into small areas which are covered by public health midwives; each PHM in her area is responsible for the acceptors of family planning techniques, for the expectant mothers and for post-natal care and for the infants and pre-school children under her care, The medical officers of health are responsible for the child welfare clinics and for the regular examination of schoolchildren. There is an abundance of hospital beds for maternity cases and 60% of deliveries occur in institutions. About 500 institutions in Sri Lanka SEA/PHA/149 Page 160 offer facilities for hospital delivery to expectant mothers, and there are more than 2000 public health midwives serving in the rural areas. The health care system in Sri Lanka keeps in pace with recent developments in the field of medical and health technologies, as far as family health is concerned. There are often crises in the supply of drugs and in the maintenance of buildings and equipment. The technical level of application of modern technologies, as judged by the qualifications of the personnel involved, is satisfactory. However, a critical review of the effect of some activities, as for example repeated check-ups of healthy people, may be beneficial. There are some problems connected with staff acceptability by the population. According to certain opinions, many public health midwives cannot be considered to be full-fledged health workers who are capable of providing their services independently. They are very often looked upon as a communication link between the population and the doctor who works in some institution. Also, the small maternity homes, operated by mid- wives, do not attract very many expectant mothers for the delivery of their babies there. These institutions are therefore under-utilized. 6.1.2 Prevention and Control of Diseases Aspect The health care services may not be blamed for all the existing disease problems in Sri Lanka, since these problems are rooted deeply in the environment which has not changed considerably in recent years. These services have nevertheless succeeded in protecting the country from the importation of smallpox from the sub-continent, and in reducing the tuber- culosis incidence, as well as the incidence of poliomyelitis. A spectacular decline in malaria was registered till 1967-68 when the disease exploded again and has now settled at an annual incidence of 1%. The leading diseases which are almost the same as 30 years back, depend on a challenging environment, and in this regard the health care services of Sri Lanka do seem to require some adjustments. Barring the respiratory infections, anaemia, and malnutrition, as well as, partly, accidents and suicides, all other leading diseases are determined by the environment: malaria, filariasis, rabies, typhoid, diarrhoeal diseases, dysentery, leprosy, tuberculosis, food poisoning, whooping cough, tetanus, diphtheria, polio, and infectious hepatitis. The health care system, without intensifying its environmental acti- vities, has been investing big efforts in the field of the application of vaccines and immunization and other public health measures, through its well-established preventive services, including mass campaigns against malaria, filariasis, tuberculosis, leprosy, and venereal diseases. However, in spite of the up-to-date technologies applied, the acceptability by the population seems to slacken down. One of the reasons for this phenomenon may be that the preventive activities are carried out completely independently of the medical activities and have not the benefit of the credit which the medical care services enjoy among the population by the very nature of their work. 6.1.3 Medical Care Aspect SEA/PHA/149 Page 161 The fulfilment of the demand for medical services should be assessed by the proportion of those who get relief from the illnesses that led them to attend at the institutions providing medical services. Such data are not available, but some information may give an approximate picture of this aspect of the situation in Sri Lanka (137). (1) Hospital mortality in 1967-68 was: - in the provincial, base, district and cottage hospitals - in the peripheral units - in the rural hospitals L 7% 0.3% 0.2% Such a low hospital mortality may indicate that there was not an adequate selection of patients; or that moribund patients and patients with incur- able diseases were discharged before they died (for example, the hospital mortality in the Cancer hospital was only 3.3%); or both. (2) There was an enormous demand for medical care in the country, esti- mated as 16% of the population demanding inpatient treatment and an average of 6 visits by every citizen to some medical care facility during the year. This may indicate that the provision of medical care, being unsatisfactory, compelled the population to repeatedly express its demand. This assumption may be supported by the fact that the average number of sickness spells per person per year was 2.1 (data from NSES), which means that a sick person made an average of 3 visits to the health care services for each sickness. (3) There was a lack of appreciation by the population of some kinds of institutions, especially the small ones and those without permanent staff. The larger institutions were favoured, for various reasons, mainly by patients seeking "better treatment", whatever they meant by this. There is also a clear indication of the extensive utilization of the indigenous sectors. The over-utilization of hospital inpatient treatment seems inappro- priate, considering the leading diseases in the country which are amenable to outpatient treatment. Moreover, there is evidence from elsewhere that there is no clear association between the ratio of the number of hospital beds to 10 OOO population and such health indices like the crude death rate, infant mortality rate and mortality rate in the age g~oup 1-4 years (98) (see .Annex 1-24). The utilization of certain health technologies, especially modern drugs, is grossly hampered by irregular and insufficient supplies, This matter will be discussed later on in greater detail. It is difficult to list, in order of preference, the population's preference regarding the different medical care services and the acceptability of the services offered. Since this aspect of the appropriateness of the health services was not studied, indirect data were collected from community SEA/PHA/149 Page 162 leaders on the rural population's habits when looking for medical care services. It appeared that the people usually consulted the closest source of medical care, the indigenous doctor, who is usually a well respected person in the rural community. If he could not help in a short time or if he considered that surgery was necessary, he advised the patient to visit a larger hospital. However, there is a belief that even after successful surgical treatment, it is necessary to undergo treatment conducted by the ayurveda doctor, "since the surgery could not provide complete cure". The large number of outpatient visits seems to support the assumption that such attitudes are prevalent in the rural parts of Sri Lanka. 6.1.4 Summary The health care services in Sri Lanka seem to have contributed in reducing fertility and maternal mortality, as well as in eliminating small- pox and reducing poliomyelitis and tuberculosis. Their role in the protec- tion and promotion of the health of infants, pre-school and schoolchildren is difficult to assess. The health care services are unlikely to generate significant changes in the environment, but they have shown a good perform- ance in vaccinations and immunizations. The lack of integration of public health and medical care services may be one of the reasons for the low acceptance of some preventive measures by the population. The easy access of the population to the medical care services seems to provide an opportunity for their over-utilization, especially the over- utilization of hospitals, which is not proportionate to the morbidity pattern in the country. The technical level of performance, in spite of the large number of technically trained staff, is hampered by the lack of supplies and short- comings in the maintenance of equipment. There is, presumably, a special pattern of acceptability of the health care services, which includes those belonging to the different sectors of the health care system, western as well as ayurvedic. 6. 2 THE ADEQUACY OF THE HEALTH CARE SYSTEM While the appropriateness of the health care system is a matter of quality, the adequacy is connected with the quantitative aspects of the system: is the health care system adequately developed, in terms of the existing working units, inputs, and outputs, to deliver the services neces- sary to control the major health concerns to the desired extent? The adequacy of the health care system in Sri Lanka can be assessed in the following terms: (1) the coverage of the population, i.e., the accessibility to the health care services by the population; (2) the inputs in capital stock, recurring cost, and manpower, and (3) the potential output of the health services. 6.2.1 Accessibility SEA/PHA/149 Page 163 The average distance from any home to the office of the nearest public health midwife (considered to be the principal family health worker) does not exceed 1.8 miles, which makes accessibility to the public health midwives by the population very easy. The health care system at its present stage of development, as a whole, is capable of providing all the family health services required to meet the demand of the population for family health, if proper use is made of the abundant resources. Table 6.2 shows the average distance from the home of any citizen to different types of health care service. Every- body in Sri Lanka has some kind of health service within 0.8 miles from his home, excluding the "other" sector private. (If this sector is included, the distance will be reduced to 0.6 miles.) In the average, a government western-type health institution (barring the offices of public health mid- wives and public health inspectors) can be reached within 3 miles from any home in Sri Lanka (allowance being made for the uneven distribution of the population, see Annex 3-3), Table 6. 2 AVERAGE DISTANCES FROM ANY HOME TO HEALTH CARE SERVICES OF DIFFERENT KINDS IN SRI LANKA Type of care service No. Cumulative Distance (miles) Colombo group and provincial hospitals 20 20 Uot applicable Base hospitals 12 32 15.0 District, TB, leprosy, mental and other hospitals 117 149 7,4 Peripheral units 94 243 5.9 Offices of medical officers of health 98 341 4.8 Cottage rural hospitals, CD, MH 544 865 3.0 Private hospitals, nursing homes maternity homes 257 1 142 2.7 Private dispensaries and surgeries 530 1 672 2.2 Ayurveda local authority dispensaries 211 1 883 2.1 Ayurveda hospitals 7 1 890 2.0 Ayurveda private practitioners 9 823 11 713 0,8 SEA/PHA/149 Page 164 Only the health care services with full-time work have been considered, the branch dispensaries and visiting stations being excluded. Including all the services providing formal health care, i.e., registered as legally autho- rized to provide health services on a continuous basis, there is one unit providing medical services of the western or the ayurveda type per 1150 popu- lation. However, this does not give a full picture of the population coverage, since there are still public health services which have not yet been taken into consideration. Adding together all the personnel working in the field of the control of diseases, as shown in the budget estimate for 1973 (financial year), we have the impressive figure of 7809 health workers, or one person working on the prevention of the leading diseases for every 1732 inhabitants: General preventive services and environmental sanitation Control of tuberculosis Eradication of malaria Eradication of filariasis Control of leprosy Control of venereal diseases 6.2.2 Inputs Total Persons 1 485 1 657 3 433 674 387 173 7 809 The total capital stock of the health care system in Sri Lanka has been estimated at Rs 733 million, or Rs 54 per capita (population of 1973). It is difficult to say whether it is too much, or too little, or enough, since comparable figures from other countries could not be found. Moreover, there are no accepted norms recommending an optimum size of capital to be invested in the health industry. A rough idea of the magnitude of the capital stock can be obtained by comparing the ratio of the capital cost with the gross national product (GNP) of the country which is 1:18. As far as recurring expenditure is concerned, the estimate for 1973 was Rs 497 million (including the government and the private consumption for health), which represents 3.7% of the GNP. Here also, it is not easy to assess the adequacy of the inputs. Undoubtedly, Sri Lanka spends on health per capita more than many countries in Asia which are at a similar level of development. But, how much is "adequate"? An international symposium held recently in Oxford, England, expressed deep concern about the fact that "the costs of medical services have recently been growing faster than society can afford" (138) in the developed countries. The main reason seemed to be the "rapid expansion in medical power". The solutions were sought in a better selection of patients for special (expensive) treatment, the promotion of nurse-practitioners, and in putting greater emphasis on health education and preventive medicine. The National Health Services of the United Kingdom need an "infusion" of £800 million a year at least, in order to meet their most pressing needs in investment and run- ning cost (139). SEA/PHA/149 Page 165 6.2.3 Outputs The variety of outputs of the health care system in Sri Lanka were discussed in the previous chapter. Although the activities were grouped for the sake of simplicity, details of the health activities conducted by the rural health services indicate a broad array of services for which the population may opt. More about the delivery potential of the existing facilities will be said when discussing the effectiveness and the efficiency of the Sri Lanka health care system. Here it should be pointed out that the capacities of some categories of health care units have been exceeded, whereas other units have been utilized to a very limited extent. Thus, the question of the adequacy of some parts of the health care system should be reconsidered. 6.3 THE EFFECTIVENESS OF THE HEALTH CARE SYSTEM cators: The effectiveness of a health care system is measured by two indi- (1) output: the volume of health activities actually delivered to the population, and (2) operational coverage: the proportion of those who received services out of those who were expected to receive them. It is clear that the coverage depends mainly on the size of the out- put although a high output does not necessarily mean a high coverage, as may be demonstrated by referring to data already presented in this study. A meaningful assessment of the effectiveness of a health care system can be made only if there are standards and norms for the performance of a stated volume of health activities of a standard quality, in order to achieve an expected coverage of the population at risk. Also, the effectiveness of the health care system is to be considered with the efficiency, which will be the subject for discussion in the next section; services delivered to persons who do not need or demand them are wasteful of resources. A high level of efficiency is not always associated with a high effectiveness; a limited output of health activities, which does not satisfy the expectations regarding the required coverage, may be produced at a very low cost, thus showing a high level of efficiency. Til.us, a clear distinction has been made between the effectiveness and the efficiency of the health care system, as conceived here. The effectiveness of tackling the three principal area of health concern, popu- lation dynamics, control of diseases, and meeting the demand for medical care, will be considered separately. 6.3.1 Population Dynamics Aspects About 12% of all hospital beds in Sri Lanka are allotted to maternity hospitals, maternity wards, maternity homes, and wards for gynaecology/ obstetrics, making a total of about 4700 hospital beds. If the average duration of stay in the hospital or ward were 5 days, the total number of deliveries which could be conducted in the institutions might be 343 OOO SEA/PHA/149 Page 166 annually, which represents 93% of all deliveries that take place in Sri Lanka in one year. Since the actual percentage of institutional deliveries was 60%, the effectiveness calculated as performance in relation to possi- bility (expectation) was 65%. (It may be argued, from the efficiency point of view, whether it is necessary to have such a high coverage of institu- tional deliveries, especially if the low standard of certain health care units is taken into consideration.) In 1972, there were about 71 OOO new acceptors of family planning techniques, representing 47% of the expected 150 OOO new acceptors, or 4.14% of all those eligible for family planning. There are no data on the annual number of visits to the family planning clinics during the same year, but the average annual number of these visits in the period 1965-68 was 22 OOO when the number of new acceptors for the same period was about double, 44 OOO, This shows that a part of the new acceptors were recruited at the maternal and gynaecological clinics, whose annual outputs during the same period were 270 OOO and 70 OOO respectively, This coverage can have only a slight impact on the rate of population growth, In recent years the number of visits paid by expectant mothers to maternity clinics annually was on average, 1,5 million, which should have been sufficient to have a coverage of 4 visits per expectant mother. The actual coverage was around 60%, showing that the distribution of the output was not equitable. (Here also, such a high output of services should be subjected to evaluation regarding its health rational and health care system efficiency; perhaps other areas of activity, like environmental sanitation, may compete for some resources spent on the visits of the expectant mothers?) A different situation may be found regarding the services for infant care; here there is a sharp decline in both output (from 420 OOO to 160 OOO in the period 1961-68) and in the coverage, from 29% to 9% in the same period. Also, the services for pre-school children show a similar drop in the output of services (364 OOO in 1961, 110 OOO in 1968) and in the cover- age, 97 OOO children in 1961 and 16 OOO in 1968. The school health services show an improvement in the output, from 160 OOO to 224 OOO, and in the coverage, from 6.5% to 7.3%, in the same period, 1961-68. What could these figures mean in terms of the improvement of the population's health? 6,3.2 Control of Diseases Aspect The control of diseases, like the problems of population dynamics (family health), is the responsibility of the government western sector. This task has been entrusted to several groups of health care units (health projects, according to the official terminology used in the budget document of the cotmtry). These health projects represent parts of the public health services: (i) General preventive services and environmental sanitation; (ii) Quarantine; (iii) Eradication of malaria; (iv) Eradication of fila- riasis; (v) Leprosy control, and (vi) Venereal diseases control. Nobody can deny that the other parts of the health care system contribute to the problem of disease control, especially the tuberculosis services and all the curative services, governmental and private, western and ayurvedic. In the assessment of the work effectiveness of the health care system in the field of disease control, it will be important to establish (or estimate) the volume of work done by different branches of the health care system, SEA/PHA/149 Page 167 which can be classified under the functions relevant to the control of diseases: tuberculosis control, malaria control, filariasis control, leprosy control, venereal diseases control, control of other communicable diseases, environmental sanitation, general health education (partly), and curative services (partly). It is evident, that the task of separating these out- puts throughout the whole health care system is likely to be extremely diffi- cult. For this reason, the effectiveness of the health care system regarding disease control ~ill be assessed on the basis of the performance of some typical and indicative activities for which reliable data could be collected. Data on the annual output of the Sri Lanka health care services is given elsewhere in this report. It is not inappropriate to reproduce the data relating to disease control and to attempt to estimate the coverage of the population at risk referred to by the data: Vaccinations against smallpox, 270 OOO, or 73% of newborns during the year; a scar survey showed a 51.3% coverage in the 0-14 years population in 1967-68 (140). Vaccinations against typhoid fever 500 OOO, or 15% of the eligi- bles (school-going population). Vaccination with DPT (diphtheria-whooping cough-tetanus), 90 OOO, or 5% of eligibles (3 months to 5 years old). Vaccination against poliomyelitis, 1 284 OOO, covering an estimate of 700 OOO with at least one dose of vaccine, or 80 OOO with all three doses, which makes a coverage of 92% and 11%, respectively (eligibles: children from 3 months to 3 years). Vaccination against tuberculosis, 750 OOO of which 133 OOO were BCG vaccinations of newborns, giving a 36 % coverage of newborn/ infants. Examinations for microfiliaria, 2 500 OOO, or 125% of the popu- lation at risk. Blood examinations for malaria, 900 OOO, or about 6 blood exami- nations per one diagnosed case of malaria. Houses sprayed with insecticides, 4 OOO OOO, which makes an average of two sprayings per house annually. If a conclusion should be drawn from the above data, it may be that the output of the health care system in the field of disease control was quite considerable. However, the coverages, except for diagnostic work in filariasis and malaria, were not very high and are inadequate to control the spread of infectious diseases. 6.3.3 Medical Care Aspect The effectiveness of the medical care services cannot be easily assessed. Firstly, there are no quantitative data on the kind of medical care needed to meet the population's demand. There are indications that SEA/PHA/149 Page 168 the most expensive health care conmodity, treatment in hospital, has been provided at the patients' request rather than on the basis of an objective assessment of their health by the medical practitioners. As a consequence, a large number of the population seem to patronize the outpatient depart- ments of hospitals with the expectation of being admitted to the wards. Table 6.3 shows the reason for admission to district hospitals, which, without providing data on the severity of the diseases, gives an indication of the effectiveness of the utilization of over 10 OOO hospital beds in district hospitals (25% of the total bed strength of the country). 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14, 15. 16. Table 6.3 LEADING CAUSES OF HOSPITAL INPATIENT TREATMENT IN A SAMPLE OF DISTRIGr HOSPITALS, 1972 Diagnosis No. of cases Respiratory diseases 169 Pregnancy and delivery 156 Injuries, accidents, bites 135 Diarrhoeal diseases 86 Ulcers and skin diseases 78 No diagnosis 70 Symptoms and ill-defined conditions 54 Gastro-intestinal diseases 40 Infectious diseases 43 Viral fever 34 Malaria 28 Heart and vascular diseases 26 Diseases of kidneys and urinary tract 23 Helminthic diseases 20 Arthritis 15 Other diagnoses 45 TOTAL 1 022 % 16.5 15. 3 13.2 8.4 7.6 6.8 5.3 3.9 4.2 3.3 2. 7 2.5 2.3 2.0 1. 5 99.9 SEA/PHA/149 Page 169 Secondly, a vast source of supply of medical care services, the private ayurveda sector, is not fully utilized and an average ayurveda prac- titioner carries out only 6 to 11 examinations a day. This may mean that there is a limit to the individual consumption of medical care, posed by the scarcity of funds; or there is an awareness among the population that the ayurveda practitioners have their special place in the health care system and that they can perform only a given kind of medical care service and cannot be considered as multipurpose health workers. All these and other problems on the effectiveness of the health care system deserve further study • 6.3.4 Summary The health care system in Sri Lanka has the potential for a huge out- put of health services. This potential, however, is not completely utilized. There are also indications that the quantity of the output may be connected with a substandard quality of the health activities carried out. There is still room for improvement of the population coverage in the fields of family health and control of diseases. 6. 4 THE EFFICIENCY OF THE HEALTH CARE SYSTEM A health care system that can provide better health for less money, material, and manpower is certainly efficient. Whereas the quantification of the inputs (money, material, and manpower expressed in paid working-time) does not impose important difficulties, "better health" does. To avoid that difficulty as well as to refrain from time-consuming (and very often fruitless) speculation about the measurement of the quality of health, the efficiency can be assessed against other indicators used in economic analysis, i.e., cost analysis and systems analysis. Thus, the efficiency of the health care system in Sri Lanka has been assessed in the following terms: (1) capital stock utilized for the control of problems in the three principal areas of health concern; (2) capital/recurring expenditure ratio; (3) preventive/curative costs ratio; (4) cost of the control of health problems and their consequences; (5) cost of unit services (health activities); (6) disparities in the efficiency and their causes. The PPB system adopted by the Ministry of Health could not provide all the data for this review, and so data had to be collected in a sample of health care services. Since the main topic of this section has to deal with the economic aspect of health and the health industry, it seems necessary to recall the major distinctive characteristics of this kind of activity as formulated by Klarman (141): (1) "A person's need for medical care is asserted as the basis of his right to receive such care, regardless of his ability to pay for it." (2) "Uneven or unpredictable incidence of illness, which is likely to "distort" the regular,flow of consumption of the individual and the family." SEA/PHA/ 149 Page 170 (3) "A person chooses a physician, but does not himself determine how much care he will buy. " (4) "Non-profit motive" in operating health care services. As a consequence, the application of economic analysis to the health industry has quite another meaning than when it is applied to other indus- tries; it must be kept in mind that some flaws in the economic management of health should have to be tolerated because of the specificity of health economics. Also, it is worth while to make clear that the economic impact of illness, in terms of wasted working time because of working incapacity caused by disease, is unlikely to be significant in Sri Lanka because of the low level of employment and the chronic under-employment of a large proportion of the adult population (142). 6,4,1 Capital Stock Utilization The total capital stock of the health industry in Sri Lanka, amount- ing to Rs 733 million, can be distributed roughly in three stocks utilized for carrying out the functions related to the three principal areas of concern: (1) (2) (3) Family health: total 50% of the capital stock of public health services* 12% of the capital stock of government western curative services utilized for hospital deliveries Control of diseases: total 50% of the capital stock of public health services* 40% of capital cost of all curative services Medical care: total Grand total: Rs 97 191 544 22 553 800 74 637 744 267 959 624 22 553 800 245 405 824 368 107 774 733 258 300 % 13.3 3.1- 10.2 36.5 3.1 33.5 50.2 100.00 The above distribution of the capital stock is founded on the follow- ing assumptions: - public health services are utilized in equal proportions for family health and for disease prevention and control; *Including the adequate portion of the capital stock of the laboratory services, medical stores, transport and administration, which might be involved in public health services. SEA/PHA/149 Page 171 - about 12% of beds in the western medical institutions are utilized for maternity and related family health functions; - about 40% of medical care is delivered to persons suffering from the leading preventable diseases (see Table 3.16 and Annexes 1-6). The demand for medical services alone, excluding those medical services connected with family health problems and with the control of the leading diseases, utilizes 50,2% of the wealth of the health care system. If the services presumably delivered on demand arising from population dynamics and spread of diseases are added, 93.9% of the total capital stock of the health care system will be utilized, leaving 3.1% for specific family health functions and another 3.1% for disease control, It should be remembered, that this figure represents the capital stock of the whole system, including government and private, western, ayurvedic, and the "other" sectors. Since the capital stock of the private sector represents only 15.2% of the total, the relationship within the government sector will change insignificantly: the family health and disease control programmes will take up 3.7% each, and the demand for medical care will utilize 92.6% of the government capital stock of the health industry in Sri Lanka. Such a distribution of the capital stock is reflected in other indi- cators of the efficiency of the health services. 6.4.2 Capital/Recurring Expenditure Ratio The capital/recurring expenditure (r.e.) ratio shows what is the most profitable way of investing money. It represents, in this case, the ratio between the capital stock (without depreciation) and the annual expenditure on the health services, as far as the government sector is concerned. The ratios for different parts of the health care system are shown in Table 6.4 The capital/recurring expenditure ratio for the whole health care system in Sri Lanka is 1,70, which means that for Rs 1.70 invested in health the annual expenditure (or gross income, as considered by the private sector), will be one rupee. This shows that the health industry in Sri Lanka does not require a heavy investment, since it is based mainly on the manpower, i.e., it is a labour-intensive industry. Excluding supporting services(like the administrative services which show the highest capital/r.e. ratio since they operate the transport side of the whole health care system), the medical care services have the highest capital/r.e. ratio, 3.08. The ratio is much higher for inpatient services (3.4) than for outpatient services (1.35). The public health services show the lowest capital/r.e. ratio, 0.32, which means that with a very small investment these services can be expanded. If the utilization of the supporting services (i.e., the laboratory services, medi- cal stores, transport, and administration) by the medical care and public health services is taken into consideration, the capital/r.e, ratio will change as follows: for the government medical care services 3.40 for the public health services 0.60 The private sector shows a low capital/r.e. ratio (Table 6.4). SEA/PHA/149 Page 172 Table 6.4 CAPITAL/RECURRING EXPENDITURE RATIOS OF THE HEALTH CARE SYSTEM Sector/services Total health care system Total government sector Total government western sector Medical services Outpatient services Inpatient services Public health services Laboratory services Administrative services Total government ayurveda sector Total semi-government sector Semi-government sector western Semi-government sector ayurveda Total private sector Private western sector Private ayurveda sector Private "other" sector 6.4.3 Preventive/Curative Costs Ratio Capital/recurring expenditure ratio 1.68 2.21 2.28 3.08 1.35 3.40 0.32 1.28 1.38 0.36 0.96 1.00 0.79 0.56 0.55 0.52 0.67 The preventive/curative costs ratio in the health industry is the ratio between the cost of prevention of a condition and the costs incurred in "repairing" the consequences of lack of prevention. Before considering this aspect of the efficiency of the health care system, it is necessary to try and estimate the money inputs in the control of the three major health concerns. The assumption made when discussing the capital stock may not be applied here, i.e., that the proportion of recurring expenditure for controlling health problems will be the same as the proportion of the capital stock involved, since the capital/r.e. ratio in different sectors and services of the health care system varied widely, as was shown in Table 6.4. For this reason, the percentage of the distri- bution of the recurring cost of different problems should be weighted against the capital/recurring expenditure ratios concerned in the following way, in order to compare them at a common denominator: (1) In the field of prevention and in the promotion of family health, the percentage of 3.1% of the total health expenditure should be weighted by SEA/PHA/149 Page 173 the reciprocal value of the capital/r.e. ratio with the corresponding parts of the supporting services, 1/0,60*. The share of prevention and of promo- tion of family health in Sri Lanka will be then 5.17% of the total annual health expenditure in the cotmtry, or approximately Rs 25 655 OOO. (2) Under the same assumptions, the prevention of major diseases will cost annually another Rs 25 655 OOO. (3) The cost of the cure of family health problems can be estimated by the percentage of 10.2 of government expenditure for medical care (western sector), or Rs 17 million per year. (4) The estimated cost for the cure of the main diseases is 40% of the total cost of the curative services in the country, or Rs 168 329 OOO. (5) The medical care delivered to the population for other reasons can be estimated at Rs 262 012 OOO. A sunnnary of the above estimates, which are based both on quantitative data and on a set of realistic but not necessarily correct assumptions and on the preventive/curative costs ratios as defined in this section, is given in Table 6 .5. Table 6.5 ESTIMATES BASED ON PREVENTIVE/CURATIVE COSTS RATIOS Inputs (Rs x 1000) Preventive/curative Health problems costs ratio For prevention For cure Family health 25 655 17 OOO 1.51 Control of diseases 25 655 168 329 0.15 Medical care 259 912 Total 51 310 445 241 0.12 The above table is almost self-explanatory. The expenditure in the area of family health is mainly on prevention, whereas the cost of treatment of the main diseases is about 7 times more than the expenditure on their prevention, The cost of prevention of other ailments, which led to a demand for medical care by the population, could not be estimated, However the expenditure on these services, both government and private, represented the main item in the remaining health costs. The preventive/curative costs ratio of the whole health system was 0,12. In other words, for 12 cents (Rs 0.12) spent on prevention of diseases and on the promotion of health one rupee is spent on treatment.** *By so doing we find the r.e./capital ratio and, multiplying the calculated share of supporting services, come to a figure closer to the reality (since the r.e. of supporting services was apportioned having as a basis apportion- ment of capital stock - see Table 4.4). **It is outside the scope of this book to discuss the issue of cost-benefit, i.e., what could be saved on the "curative" side, if one rupee more was spent on the "preventive" side. SEA/PHA/149 Page 174 6.4.4 Government Expenditure on the Leading Diseases In the previous section, the total costs of prevention, control, and treatment in certain health areas were discussed, including both the govern- ment expenditure and private consumption of health services. Since the government is the principal decision-maker in the field of health, it is natural that there should be government concern on how the government money is spent in providing the services that are to satisfy the population's health demands. Such an attempt has been made in Table 6.6. The estimated costs include prevention and outpatient and inpatient treatment. The cost of services in the field of family health has been included on Table 6.6 since the government is virtually the only supplier of funds for family health activities. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Table 6.6 ANNUAL COSTS TO THE GOVERNMENT OF THE LEADING DISEASES IN SRI LANKA Government Leading diseases expenditure (Rs x 1000) Respiratory infections 28.121.9 Malaria 20 686.2 Anaemia and malnutrition 6 847.4 Accidents and suicide 20 724.5 Filariasis 2 580.2 Diarrhoeal diseases 17 394.3 Leprosy 2 308.2 Tuberculosis 8 891.7 Infectious diseases 12 719.7 Venereal diseases 1 043.3 All leading diseases 121 317.4 Family health 40 555.0 Total government expenditure 258 791.7 for the western sector % 10.9 8.0 2.7 8.0 1.0 6.7 1.0 3.5 4.9 0.4 47.1 15. 7 100.0 Almost half of the government health expenditure is absorbed by ten disease areas. The respiratory infections lead with about 11% of the govern- ment expenditure, more than 80% of the amount spent being preventable, and the government expenditure for the control of some of them is channelled through the public health programmes. However, diarrhoeal diseases and other infectious diseases absorb a considerable amount of the resources for inpatient treatment, whose rationale, together with the rationale for the inpatient treatment of a great proportion of respiratory infections may need some scrutiny. The expenditure on family health services costs the government about Rs 42 million annually, or about 16% of the government health expenditure. The remaining Rs 97 million or about one-third of the total government health expenditure is spent on medical care for various reasons, some of them without a biological need for such services. The greater percentage of this money (62%) is spent on inpatient treatment. SEA/PHA/ 149 Page 173 the reciprocal value of the capital/r.e. ratio with the corresponding parts of the supporting services, 1/0.60*. The share of prevention and of promo- tion of family health in Sri Lanka will be then 5.17% of the total annual health expenditure in the cotmtry, or approximately Rs 25 655 OOO. (2) Under the same assumptions, the prevention of major diseases will cost annually another Rs 25 655 OOO. (3) The cost of the cure of family health problems can be estimated by the percentage of 10.2 of government expenditure for medical care (western sector), or Rs 17 million per year. (4) The estimated cost for the cure of the main diseases is 40% of the total cost of the curative services in the country, or Rs 168 329 OOO. (5) The medical care delivered to the population for other reasons can be estimated at Rs 262 012 OOO. A summary of the above estimates, which are based both on quantitative data and on a set of realistic but not necessarily correct assumptions and on the preventive/curative costs ratios as defined in this section, is given in Table 6 .5. Table 6.5 ESTIMATES BASED ON PREVENTIVE/CURATIVE COSTS RATIOS Inputs (Rs x 1000) Preventive/curative Health problems costs ratio For prevention For cure Family health 25 655 17 OOO 1.51 Control of diseases 25 655 168 329 0.15 Medical care 259 912 Total 51 310 445 241 0.12 The above table is almost self-explanatory. The expenditure in the area of family health is mainly on prevention, whereas the cost of treatment of the main diseases is about 7 times more than the expenditure on their prevention. The cost of prevention of other ailments, which led to a demand for medical care by the population, could not be estimated. However the expenditure on these services, both government and private, represented the main item in the remaining health costs. The preventive/curative costs ratio of the whole health system was 0,12. In other words, for 12 cents (Rs 0.12) spent on prevention of diseases and on the promotion of health one rupee is spent on treatment.** *By so doing we find the r.e./capital ratio and, multiplying the calculated share of supporting services, come to a figure closer to the reality (since the r.e. of supporting services was apportioned having as a basis apportion ment of capital stock - see Table 4.4). **It is outside the scope of this book to discuss the issue of cost-benefit, i.e., what could be saved on the "curative" side, if one rupee more was spent on the "preventive" side. SEA/PHA/149 Page 174 6.4.4 Government Expenditure on the Leading Diseases In the previous section, the total costs of prevention, control, and treatment in certain health areas were discussed, including both the govern- ment expenditure and private consumption of health services. Since the government is the principal decision-maker in the field of health, it is natural that there should be government concern on how the government money is spent in providing the services that are to satisfy the population's health demands. Such an attempt has been made in Table 6.6. The estimated costs include prevention and outpatient and inpatient treatment. The cost of services in the field of family health has been included on Table 6.6 since the government is virtually the only supplier of funds for family health activities. Table 6.6 ANNUAL COSTS TO THE GOVERNMENT OF THE LEADING DISEASES IN SRI LANKA Le~ding diseases 1. Respiratory infections 2. Malaria 3. Anaemia and malnutrition 4. Accidents and suicide 5. Filariasis 6. Diarrhoeal diseases 7. Leprosy 8. Tuberculosis 9. Infectious diseases 10. Venereal diseases All leading diseases Family health Total government expenditure for the western sector Government expenditure (Rs x 1000) 28.121.9 20 686.2 6 847.4 20 724.5 2 580.2 17 394.3 2 308.2 8 891.7 12 719.7 1 043.3 121 317.4 40 555.0 258 791.7 % 10.9 8.0 2.7 8.0 1.0 6,7 1.0 3.5 4.9 0.4 47.1 15.7 100.0 Almost half of the government health expenditure is absorbed by ten disease areas. The respiratory infections lead with about 11% of the govern- ment expenditure, more than 80% of the amount spent being preventable, and the government expenditure for the control of some of them is channelled through the public health programmes. However, diarrhoeal diseases and other infectious diseases absorb a considerable amount of the resources for inpatient treatment, whose rationale, together with the rationale for the inpatient treatment of a great proportion of respiratory infections may need some scrutiny. The expenditure on family health services costs the government about Rs 42 million annually, or about 16% of the government health expenditure. The remaining Rs 97 million or about one-third of the total government health expenditure is spent on medical care for various reasons, some of them without a biological need for such services. The greater percentage of this money (62%) is spent on inpatient treatment. 6.4.5 Cost Per Unit Service and Its Variability SEA/PHA/149 Page 175 The cost per unit health service (health activity) has been estimated in an inductive way by collecting data from health institutions. The philosophy of cost estimate was formulated as follows: (1) What should the government have paid for the health acti- vities delivered, if the health industry had been operated by an agency(ies) which was not controlled directly by the government, as a non-profit organization? (2) What does the individual consumer really pay for the services delivered by private facilities to him? Data on the cost of services in the government sector are rather precise, if not completely representative from a strictly statistical point of view. The data concerning the private sector are estimates and do not claim to be very precise or reliable. The costing took into consideration the following items: (1) the cost of the manpower, estimated on the basis of the paid working time, including annual leaves, sick leaves, idle time, and similar; it has been broken down into the cost of health personnel and the cost of other personnel; (ii) other recurring expenditure, including drugs, food, supplies, contrac- tual services, etc. The capital depreciation could not be taken into consi- deration owing to the lack of data and depreciation tables. There are great disparities regarding the cost of health activities carried out by different categories of health institutions, as shown in Table 6.7. The cost of hospital treatment of an acute case varies from Rs 27.69 (in an average peripheral unit) to Rs 117.44 (in the Colombo group). The cost of a hospital delivery is lowest in the district hospitals(Rs 58.29) and highest in maternity homes (Rs 177.93). A surgical intervention in a provincial hospital costs Rs 50.83 and in a tuberculosis hospital Rs 200.68. This difference is derived mainly from overheads and utilization character- istics. Table 6.7 THE RANGE OF THE COST OF SOME HEALTH ACTIVITIES Health activities Hospital treatment of an acute case Hospital delivery Surgical intervention Hospital treatment in an Ayurveda Hospital OPD visit Consultation of specialist Cost in Rs Minimum Maximum 27.69 117.44 58.29 177.93 50.83 200.68 164.39 0.51 5.86 1.36 6.95 SEA/PHA/149 Page 176 The cost of inpatient treatment in an ayurveda hospital is Rs 164.39. The cost of an OPD visit is lowest in peripheral units and highest in branch dispensaries and visiting stations, Rs 0.51 and 5.86 respectively. Consul- tations by specialists cost, on average, Rs 1.36 in tuberculosis, leprosy, or mental hospitals and Rs 6.95 in district hospitals. Similar differences are not rare in other health care services. Brown (153) demonstrated differences in the prices of certain laboratory services in the USA as much as 3-4 times when delivered by different private laboratories. 6.4.6 Conclusion The efficiency of the health care services is determined by many factors. The most important of them are: (1) the resources employed in providing these services; (2) the extent of utilization of the resources. It may seem quite reasonable that the cost of hospital treatment of an acute case should be about five times higher in the Colombo group than in a peripheral unit, considering the differences in resources, i.e., the number of personnel, the level of their qualifications, the differences in the supply of drugs, etc. Even without an analysis of the technical aspect of the health activities, the difference in the resources utilized implies a higher quality although it is debatable whether the difference in costs should be fivefold. However, the difference in the cost of a hospital deli- very, which ·is three times higher in a maternity home than in Colombo, or the cost of a surgical intervention, which is 4 times more in a tuberculosis hospital than in a provincial hospital, cannot be explained on the basis of a difference of quality but mainly by great differences in the utilization of resources. This seems to be the reason also for the cost differences between an OPD visit performed at a PU and at a branch dispensary, and for the consultations with specialists. A more rational utilization of the available resources promises a great improvement in the health services in Sri Lanka. 6.5 SUMMARY OF THE CHAPTER The health care system of Sri Lanka performs a variety of health activities (services) that have been grouped into 16 categories. Thirteen health functions have been identified, each of them consisting of a mixture of health activities. These health functions are to satisfy the three basic needs and demands of the population arising from population dynamics (family health), the spread of diseases (disease control), and the demand for medical care. In order to answer certain questions relating to the ability of the present health care system to control satisfactorily both present and future health concerns, four basic aspects of the health care system have been discussed. SEA/PHA/149 Page 177 Appropriateness refers to the ability of the health care system to provide services that are likely to control the major health problems in the country, The health care system seems to have contributed to a small reduction in fertility and maternal mortality, the eradication of smallpox, and a lowering of the incidence of poliomyelitis and tuberculosis. There is no evidence that the system may have significantly influenced the health of infants and pre-school and schoolchildren, or the spread of the main environment-borne diseases in the country. The medical care provided might be considerably improved in quality, e.g., by a better supply and distribu- tion of drugs and other items. Adequacy of the health care system indicates the level of accessi- bility to the health care services by the population; the size of inputs in capital stock, recurring cost, and manpower; and the potential output of the services. Assessed in these terms, the health care system is adequate, since a health care service can be found, on the average, less than 0.8 miles from any home; the capital stock and annual expenditure on health are considerable: one in every 200 persons in Sri Lanka works in the health industry; and the potential output of the health services is very high. The effectiveness is measured by the size of the real output and by whether the health services were received by those who are eligible for them (operational coverage). The potential of the health care system in Sri Lanka in providing health services is not fully realized. There are suggestions that the quality of the health services might have been of a better standard. Also, the coverage in family health and in the control of the main diseases might be improved. The efficiency of the health care services depends on the resources employed in providing these services and on the extent of utilization of these resources. Considering the size of the capital stock in use by the health care system, the capital/recurring expenditure ratio, the preventive/ curative costs ratio, the cost of control of the priority health problems, and the unit cost of health activities, it may be concluded that there are large disparities in the functioning of different health care units and that the efficiency of the whole health care system needs improvement. Unless the health care system in Sri Lanka is brought to a reasonable level regarding its appropriateness, adequacy, effectiveness, and efficiency, it is unlikely that it will improve its capacity to solve the present and future priority health problems of the population. Indeed, because of economic constraints and population growth leading to increasing demand for care arising from social and disease factors, the health care system and the health status of the population can deteriorate in the future. CHAPTER 7 THE MAIN PROBtEMS AND POSSIBLE SOLUTIONS SEA/PHA/ 149 Page 179 After having matched the health needs and demands against the solu- tions offered by the existing health care system, and after finding out that there were disparities between the nature and size of the health problems and the manner in which the problems have been tackled by the health care system, the next logical step seems to be to analyze the under- lying causes for this disparity and to indicate possible changes in the functioning of the health care system. This will lead to focussing atten- tion on the development and utilization of appropriate health manpower which is the main resource in this labour-intensive health industry. In this chapter, three topics will be discussed: (i) The basic problems of the existing health care system, i.e., why does the system not work as expected in order to solve the priority health problems? (ii) Which kind of options can be offered to improve the situaiton - whether the out- put of the health care system is to be altered, i.e., is the crux of the problem a wrong health programme? - or (iii) Is the functioning of the health care system to be improved and adjusted better to the existing situ- ation in the coi.mtry? 7 .1 BASIC PROBLEMS OF THE ENTIRE HEALTH CARE SYSTEM The basic problem of the health care services in Sri Lanka can be expressed as answers to the following set of questions: (1) are the health services easily accessible when needed by the population? (2) are the health services as provided relevant, i.e., those which are needed by the population? (3) are the health care services growing in pace with the growth of the population and with the growth of the population's needs and demands? (4) is there any selectivity in the provision of health services, i.e., are the right services provided to the right people? (5) are the resources available to the health care services managed in an efficient way? 7.1.1 Accessibility The accessibility to health services in Sri Lanka is mainly a problem of regional coverage, as far as the government and estate health care ser- vices are concerned. It has been shown that if a Sri Lankian wanted to contact the nearest government institution for a free health service, he need travel no farther than 3 miles from his home. If, however, he was prepared to pay a small fee to a private western or ayurveda practitioner, the distance would be reduced to 0.8 miles. The problem of accessibility to health services virtually does not exist in Sri Lanka. SEA/PHA/ 149 Page 180 7.1.2 Services Needed Another problem is whether the services received are those needed by the patient. There may be many definitions of the "needed" health services. For the purposes of this study, a health care unit should be able to provide at least the basic (or the most elementary) health acti- vities which can make an impact on all three principal areas of health concern (family health, disease control, and the delivery of medical care). From this point of view, many health care units in Sri Lanka do not provide all the needed health services: - the great majority of rural medical care units (like peripheral units, central dispensaries, rural hospitals, branch dispen- saries, and visiting stations) do not carry out health activi- ties meant to control the major diseases and few of them deal with family health problems; - the big hospitals (like provincial, base, and district hospitals) are not responsible for the prevention of communicable diseases, although more than 30% of their bed strength is used for the treatment of these diseases; - the public health services (i.e., public health nurses, public health midwives, and public health inspectors) do not provide medical care; · - the ayurveda doctors do not participate in either family health or in the control of communicable diseases; - the inpatient services of the hospitals consume the greatest part of the government's budget although these services are unlikely to improve the overall health of the population. In short, there is not a single health care unit which delivers "all the needed health care services", as defined in this study. This can be considered one of the major problems of the whole health care system. Moreover, there are indications that instead of co-ordination of activities of the different health care units and sectors of the health care system, there is competition and an overlapping of activities, which is particularly evident with regard to the western and the ayurveda sectors, and between the medical and the public health services in the rural areas. There are also instances when public health personnel have to provide medical care,although they are not equipped with drugs and, sometimes, with adequate knowledge for such activities. For example, the percentages of working time spent on medical care by different categories of public health personnel are as follows: Medical officer of health Public health nurse Public health midwife Public health inspector 1.2% 4.6% 9.5% 0.6% 7.1.3 Growth of the System SEA/PHA/149 Page 181 The growth of the health care services requires considerable efforts for the expansion of the existing health care system. The estimates given in Table 7.1 may be above reality, since they do not take into consideration the "marginal character" of the investment in the already existing health care units. Table 7.1 CAPITAL COST FOR CREATING ONE WORKING PLACE (I.E., A JOB FOR ONE PERSON) IN THE GOVERNMENT SECTOR OF THE HEALTH CARE SYSTEM Sector/ service Total government sector Total government western sector Medical services Public health services Laboratory services Administrative services Total government ayurveda sector Capital cost (Rs) 14 426 14 703 19 216 (20 433)* 1 836 ( 3 412)* 12 346 13 009 4 160 *Including a part of capital investment for laboratory and administrative services. It will be necessary to invest approximately Rs 14 OOO to create a new working place in the government health care services. Since the number of personnel employed in these services is now roughly 55 OOO and the population growth rate is 2.2%, the annual increase of health workers in the government sector should be 1 210 persons, which will require an annual investment of about Rs 17 million. However, there will be a great differ- ence depending on which part of the health care system will be given priority for development: if the medical services are given priority, the investment needed will be Rs 24 million: if the public health services are favoured, Rs 4 million should be invested: and for the ayurveda ser- vices the investment will be about Rs 5 million. A more realistic picture (with the same reservation regarding the "marginality" of investment) can be drawn from the data presented in Table 7.2, which represents the average capital stock per one practitioner who provides health services. This table needs some clarifications. SEA/PHA/149 Page 182 Table 7,2 CAPITAL STOCK PER ONE DOCTOR/PRACTITIONER No. of Sector/services doctors/ practitioners Total health care system 23 416 Total government sector 2 492 Total government western sector 2 443 Medical services 1 987 Public health services 137 Laboratory services 150 Administrative services 169 Total government ayurveda sector 49 Total semi-government sector 422 Semi-government western sector 178 Semi-government ayurveda sector Total private sector Private western sector Private ayurveda sector Private "other" sector 244 20 502 679 9 823 10 OOO *With proportions of laboratory and Administrative services. **Including 195 dental surgeons, excluding AMP/RMP. Capital investment (Rs) 31 314 237 560 241 067 264 126 280 800* 121 223** 225 238* 133 333 162 722 62 739 71 046 140 449 20 415 5 428 46 063 5 090 3 OOO It is assumed that in the present health care system, the key person is the western-type doctor or the independent practitioner of ayurveda or "other" system of medicine. The other health personnel represent members of the team of the doctor or the independent practitioner. Thus, the capital stock necessary for establishing a working place of a doctor/practitioner, is estimated at Rs 31 OOO (roughly). There are great disparities of the capital stock needed to accommodate a doctor/practitioner in different sectors and units of the health care system. The highest investment is connected with the doctors' work in the medical care services, Rs 280 800, and the lowest with the "other" private practitioners, Rs 3 OOO. SEA/PHA/149 Page 183 If one more assumption is made, that all sectors and units of the health care system will grow concurrently and with the same pace, the increase of the capital stock for a 2.2% annual growth of the population will cost: - for SS more doctors/practitioners in the government sector, annually for 9 doctors/practitioners in the semi- government sector - for 451 more doctors/practitioners in the private sector, annually Rs 13 million Rs O. 6 million Rs 2 million It will be observed that the doctors' working places in the public health services are nearly as expensive as those in the medical services, Rs 225 238 and Rs 280 800, respectively. It is not the case with the ayurveda practitioners in the government services, who will require only Rs 62 739 capital investment. The other aspect in the growth of the health care system is the increase of recurring expenditure. Table 7.3 shows the annual expenditure incurred by one doctor/practitioner and his team, calculated without taking into consideration the marginal cost of some services, Le., without assum- ing any change in the efficiency of the health care system.* Table 7.3 THE ANNUAL EXPENDITURE FOR ONE DOCTOR/PRACTITIONER Sector/service Total health care system Total government sector Total government western sector Medical services Public health services Laboratory services Administrative services Total government ayurveda sector Total semi-government sector Semi-government western sector Semi-government ayurveda sector Total private sector Private western sector Nursing homes Co-operative hospitals Estate hospitals Private practitioners Private ayurveda sector Private "other" sector *The cost includes doctor's/practitioner's salary, personnel working with and/or for him, overheads, medicines, maintenance of buildings, etc. **Including dental surgeons, excluding AMP/RMP. Expenditure per one doctor/practitioner (Rs) 21 078** 105 825** 105 932** 85 884** 384 534** 103 993 117 510 100 476 63 552 100 806 25 687 9 530 60 278 65 278 26 447 93 980 60 OOO 9 773 4 500 salaries of all other food in hospitals, SEA/PHA/ 149 Page 184 The average expenditure per one doctor/practitioner and his team is approximately Rs 21 OOO, the range being from Rs 364 354 in the public health services down to Rs 4500 in the private "other" sector. The expenditure per one doctor and his team in the medical care services is only Rs 85 884, which is about 4.5 times less than in the public health services. This difference will increase if the AMP/RMPs are taken into consideration, since they practice as independent practitioners in certain situations. In this case, by adding 1194 AMP/RMP working in the government medical services, the annual expendi- ture per one doctor/practitioner in the medical care services will be reduced to Rs 53 107 or 7.2 times lower than the expenditure per one doctor in the public health services. This fact seems to contradict the classical and long- standing belief that preventive work is cheaper than curative work. However, it does not prove the opposite, i.e., that preventive work is more expensive than curative work in Sri Lanka. It only points to the specificity of the public health organization in Sri Lanka in which one doctor's team is composed of 65 persons on the average, since there are 137 doctors and 8908 other per- sonnel according to the budget estimates for 1973 (143). On the other hand, the team cf one doctor/practitioner working in the medical services is composed of only 8 members, and if only doctors are taken into consideration the team will have 13 members. Since the health industry is a labour-intensive one, the size of the team is expected to be the most decisive factor in determining the amount of expenditure. If the health care system grows in the way described when the growth of the capital stock was discussed, the annual expenditure will have to increase: for 55 more doctors/practitioners in the government sector Rs 6 million for 9 more doctors/practitioners in the semi-government sector Rs 0.6 million for 451 more doctors/practitioners in the private sector Rs 4 million It is not out of place to repeat again that the above estimates of the growth needed in the capital scock and recurring expenditure, in order to keep pace with the growth of the population, were made without assuming any change in the efficiency or any change of emphasis in the development of the different sectors and units of the health care system. It presupposes a simple mechanical growth of the system. Such a growth is likely to require (without considering the effects of inflation): (1) annual growth in the government sector's capital stock: in the range of Rs 13-18 million; annual growth in the semi-government sector's capital stock: about Rs 0.6 million; annual growth in the private sector's capital stock: about Rs 2 million; (2) the annual expenditure for health have to increase: in the government sector, by about Rs 6 million in the semi-government sector, Rs 0.6 million in the private sector Rs 4 million 7.1.4 Selectivity of Utilization SEA/PHA/149 Page 185 There are problems of selectivity in the utilization of the health care services in Sri Lanka, which are due to the admission policy to the hospitals for inpatient treatment and the almost complete lack of an organized referral system. The people in Sri Lanka consider that they have a constitutional right to hospital inpatient treatment, wherever and whenever the wish for such treatment is expressed and that the personnel of hospitals should admit the patient whatever his/her conditions of severity and whatever the situation regarding vacant hospital beds. This is the main reason for (i) the overcrowding in some hospitals, and (ii) the under-utilization of certain medical institutions. As there is no regionalization of the government medical services, anyone can attend any medical institution according to his choice. Thus, although some smaller institutions are situated nearer to their homes, many patients prefer to attend the larger hospitals. Such behaviour is facilitated by the fairly good transport system in the country and is partly justified by the better supply of drugs in the larger institutions. As a result, the bed occupancy rate seems to vary with the size of the hospital (excluding special hospitals). This can be seen in Table 7.4, in which the institutions are listed according to their size. 1. 2. 3. 4. 5. 6. 7. 8. Table 7.4 BED OCCUPANCY AND AVERAGE DURATION OF STAY IN DIFFERENT TYPES OF HOSPITAL Bed occupancy Duration of stay Institution (average) (average) (%) (da s) Colombo group 100 8.33 Provincial hospital 104 7.41 Base hospital 150 6.24 District hospital 114 7.67 Peripheral unit 179 5.20 Rural hospital 92 5.90 Central dispensary and maternity home 27 2.66 Maternity home 17 6.81 There is no clear pattern of a linear association between the size of the institution and its over- or under-utilization. The most over-. crowded is the peripheral unit, which is the smallest (and nearest to the population) institution under the care of a medical officer (western-type doctor). The second over-utilized institution is the base hospital in which the patients have the first opportunity to be seen by a specialist in medicine, surgery, paediatrics, gynaecology/obstetrics, and in some cases in dental surgery, ophthalmology, or ENT. The situation regarding the utilization of different wards is more. confusing, the occupancy rates ranging from 17% in the maternity homes to 199% in the ENT wards of the base hospitals. SEA/PHA/ 149 Page 186 The average duration of stay in hospitals seems to be not well cor- related with the occupancy rate, since it is a function of the kind and severity of the disease treated. However, a comparison of the first three categories of hospitals which admit similar cases, shows that the duration of stay decreases as the over-crowding increases (Table 7.4). There are indications that in some public health services also settled pattern of selectivity is hardly followed, considering some facts already mentioned in this study: (1) the role of the midwife in rural areas seems to be below the level of her training; (2) there is no clear-cut priority selection in providing family health services on the basis of parity, regional area, con- comitant diseases, etc.; (3) the most vulnerable population groups, especially infants and pre-school children, could have a much better health coverage; (4) environmental sanitation should have received greater atten- tion, owing to the morbidity pattern of the country; (5) health education should have been given a better share of the efforts of different public health personnel (Table 7. 5). Table 7.5 TIME DEVOTED BY DIFFERENT PUBLIC HEALTH PERSONNEL TO CERTAIN PREVENTIVE FUNCTIONS Function delivered Family health School health Environmental health Health education Total productive time % MOH 10.6 1.9 1.9 92.8 of time spent by PHN PHM 8.2 23.1 0.9 0.2 0.1 0.1 84.1 84.3 PHI 0.2 2.7 18.6 0.7 85.4 As a result of the lack of regionalization of the medical services, patients have been left to select by themselves the institution they will go to for medical attention. The percentage of patients who were likely to be referred to a better equipped hospital would be about 12% of the 19% who bypassed by nearest medical care institution, and attended another one. Thus, the overall percentage of those referred to by the institution of their first contact can be only 2.3% of all outpatients visits in the country. 7.1.5 Management Problems There are also certain management problems in the government health care system. The budget does not provide for depreciation of the capital SEA/PHA/149 Page 187 stock. The only provision made in the recurring expenditure of the govern- ment health services relates to the repairs of equipment and buildings. It represents about 1% of the total recurring expenditure and less than 0.5% of the capital stock. About half of this provision is meant for the repair of vehicles (145). It will be appreciated that such a sum will not help to maintain the existing capital stock in working condition for a long time and its deterioration can be expected in the near future. The lowest limit of annual depreciation, which should be provided for in the recurrent expenditure, cannot be below 5% of the capital stock (i.e., roughly Rs 30 million). Adding together the necessary resources to keep the existing govern- ment health care system at the present level of efficiency (without any improvements, accepting only the need for the maintenance of the present capital stock and providing for the population growth), the annual expendi- ture of the government should be increased annually by Rs 49 million,which is made up as follows: - maintenance of the existing capital stock - investment for population growth - increase of recurring expenditure for population growth Rs 30 million Rs 13 million Rs 6 million Another management problem is concerned with the significant dis- crepancies existing between ~nstitutions regarding the capital cost per hospital bed, the cost of treatment per discharged patient, the cost of services per patient-day, as well as the supplies and equipment of different institutions which hamper the effectiveness of their work. In Chapter 6, Section 6.2, reference was made to the disparities of costs. Here the problem of inadequate logistics in the supply of drugs and equipment will be given due consideration, Wide variations in the availability of some essential supplies, for example, are shown in Table 7.6. Table 7.6 SUPPLY OF SOME ESSENTIAL ITEMS IN RELATION TO THEIR UTILIZATION Available stock for months Drugs and materials Minimum Maximum Penicillin vials 0.18 19.20 Penicillin tablets 0.05 16.29 Tetracycline vials 0.54 14.37 Tetracycline capsules 10.00 53.54 BCG vaccine vials 0.40 34.75 Antimalaria drugs 3.00 1000.00 Antituberculosis tablets 1.69 25.17 Contraceptive pills 0.00 144.59 Normal saline 0.72 8.55 Insulin lente vials 1.44 5.42 Loops 12.52 250.00 SEA/PHA/149 Page 188 Health institutions are seen to be well supplied with antimalaria drugs, enough for a minimum of 3 months (CD & MH) and a maximum of 1000 months or 80 years (tuberculosis, leprosy, and mental hospitals). The stocks of antituberculosis tablets (INH) are sufficient for from 1,69 months (Colombo group) to 25.17 months (CD & MH). Contraceptive pills are not available in the rural hospitals, the cottage hospitals, the central dispensaries, the infectious diseases hospital, the leprosy hospital, and the mental hospitals, in the Colombe group of hospitals the stock of these pills is enough for 144.59 months (12 years). The stock of normal saline in the institutions that are expected to use it is from 0.72 months in the provincial hospitals to 8.55 months (the infectious diseases hospital). The stock of insulin lente varies from 1.44 months (the PH) to 5.43 months (the tuberculosis hospitals) and soluble insulin from 0.2 months (DR) to 8 months (PH); loops used for family planning are available for from 12.52 months (BR) to 250 months, or more than 20 years (the maternity homes). The availability of some essential equipment is shown in Tables 7.7 and 7.8. The small rural institutions and medical officers of health do not have ambulances, which are concentrated in the large hospitals like the Colombo group, provincial, base, and district hospitals, and for the specia- lized campaigns (not shown in the table). The central dispensaries, which provide about 25% of the outpatient medical care in the country, are equipped with thermometers, sphygmomanometers, and boiling water sterilizers. The same basic equipment is found in the maternity homes, where there are no autoclaves. There are no electrocardiographs and laboratory incubators in the district hospitals which have 25% of the hospital beds in the country. On the other hand, the leprosy hospital is equipped with laboratory incu- bator(s). Tables 7.7 and 7.8 also show the extent of the utilization of the equipment in the wards and in the outpatient departments of institutions. It is assumed that an inpatient is attended to (examined) on the average once a day, thus one patient-day may be compared with one outpatient visit, as far as providing medical services is concerned, The inference from this will be that the equipment available is more abundant in the outpatient departments than in the hospital wards, and the discrepancy is substantial. Also, the availability of the same item of equipment varies widely, in different types of institutions. If the most basic equipment is taken into consideration, thermometers and sphygmomanometers, the ranges are: (1) in wards - thermometers, between 0.02 and 0.35 per 100 patient-days; sphygmomanometers, between 0.002 and 0.18 per 100 patient- days; (2) in OPDs - thermometers, between 0.5 and 149.8 per 100 visits; sphygmomanometers, between 0.1 and 5.5 per 100 visits (or 4. 7, if only the government institutions are con- sidered). Table 7.7 ITEMS AVAILABLE FOR USE PER 100 OPD VISITS CJl CJl I ,.. ~ 0 rn rn .c u: 0 Q) s:: Q) ,I.J p.. Q) ,I.J ,I.J Ill p.. •rl Ill bO Ill Institution Q) s 0 i:: I ,.. :J ,.. a 0 (.) ::l O bO <1,.,1 Q) 0 s:: CJl CJl ,.. 0 ·rl bO e bO ,.. 0 :,,., .µ ·rl ,.. ·rl s., :,,., Q) ,.. ~ (.) '"Cl .µ ,.. 'lJ ..c:: ,I.J (.) Q) ,.. s:: <1,.,1 ..c:: p.. Q) ·rl I ...-l Ill Q) ~ H CJ) s ~ ~ ~ (.) L) 1. Colombo group 2.5 2.9 4.6 3.1 21. 7 2.3 1.4 2. Provincial hospital 3.4 1.2 4.5 6.0 19 .2 2.7 1.1 3. Base hospital 2.4 2.9 4.5 7.8 29.6 3.0 0.7 4. District hospital .8 .4 3.3 11.4 - 5.0 0.4 5. Peripheral unit 1. 8 .1 - - - - 0.7 6. Rural hospital 10.9 2.7 - - - - - 7. Central dispensary and maternity home 2.5 2.7 - - - - - 8. Central dispensary 2.8 1.4 - - - - - 9. Maternity home - - - - - - - 10, Infectious disease hospital - - .1 - - .07 - 11. Tuberculosis hospital 149.8 4.7 3.2 1.5 - 2.5 6.6 12. Leprosy hospital - - .002 - - - - 13. Mental hospital - - - - - - - 14. M.O.H. 36.2 2.6 - - - - 1.2 15. Nursing home 15.2 5.5 23.3 707.4 6.7 16.6 2.5 16. Estate hospital 3.2 J.2 - - - - - 17. Ayurveda hospital 0.5 0.4 4.8 - - 4.90 .02 18. Ayurveda dispensary 3.3 3.3 - - - - - CJl ,.. 0 .µ Ill ,.0 bO :J s:: (.) •rl s:: ,I.J U1 •rl tll Q) . ,.. ...-l .g Q) ,.0 p.. tll ~ 0 .µ 2.8 28.2 0.7 36.3 1.6 18.6 - 40.7 - - - - - - - - - - - - 2.5 276.5 .002 - - - - - 1. 6 266.1 - - - - - - CJl Q) :> Ill ...-l tJ 0 .µ ~ 1.8 0.6 9.3 1.6 5.4 - - - 31.6 - - - ,.. Q) .µ CJl Ill ,.. ;3 Q) N bO •rl s:: ...-l ...-1 ...-1 ...-l ,.. •rl Q) 0 .µ r:Q Cl) 4.0 1. 7 0.2 0.7 0.6 0.4 2.6 1.6 - - 5.5 - - 1.9 4.4 3.3 - - "d Cl) I» P1 (IQ. > 11)- "d ..... ::i:: oo:,,. '°-..... J:-, "° Table 7. 8 ITEMS OF EQUIPMENT AVAILABLE PER 100 INPATIENT DAYS ! (I) ,... (I) I ,... (1) ,... 0 0 ,I.J (I) (1) (1) i:: ,I.J Cll ,... (.) ,I.J Cll Cll :3 (1) Institution co (1) s ,... N i:: s 0 (1) bO ·~ Cll 0 a (I) bO i:: ,...; ,...; s bO ,... ·~ -~ ~ ;:, ,... >, (1) ,... ,...; ,... j (1) ..c: ,I.J '+; ·~ (1) ~ Po (1) ~ 0 +J Ul s pq Cl) 1. Colombo group .001 .07 .01 .005 .02 2. Provincial hospital .08 .04 .01 .001 .01 3. Base hospital .001 .03 .01 .002 .01 4. District hospital .003 .03 .01 .003 .01 5. Peripheral unit .03 .07 .01 .11 6. Rural hospital .11 .03 - .04 7. Central dispensary and maternity home .28 .18 .09 .18 8. Central dispensary -* - - - - 9. Maternity home .35 .15 - .13 10. Infectious disease hospital .001 .12 .01 .01 .02 11. Tuberculosis hospital .25 .002 - .02 12. Leprosy hospital .0001 .01 .01 - .01 13. Mental hospital .03 - .001 .01 14. M.O.H. -* - - - - 15. Nursing home .06 .25 .05 .04 0.11 16. Estate hospital .04 .01 - - 17. Ayurveda hospital .02 .06 .01 - 18. Ayurveda dispensary -* - - - - *Institutions 8, 14, and 18 do not have hospital beds. (I) (1) bO ;:, '+; ~ ,... ,I.J i:: (1) u .001 - (I) (1) p. 0 (.) Cl) 0 ,... (.) :2 .002 .05 '"Cl C/'J Ill ["%1 (IQ > (1) -- '"Cl 1--' ;I: '° > 0 --!--' -I>- '° 7.1.6 Sununary SEA/PHA/149 Page 191 Accessibility to the health care services by the population, which seems to be one of the basic weaknesses of health services in many develop- ing countries, is not a problem in the Sri Lanka health care system. A health care delivery unit can be found, on the average, not further than 0.8 miles from any home in the country and free-of-charge western-type health care services are available within 3 miles of a patient's home. However, the existing health care units do not provide all the "needed II (relevant) health services, since there is no integration of the functions related to the problems of family health, disease control, and provision of medical care; no integration of public health and medical services and no attempt at regionalization of services, as a consequence of a clear health policy. The growth of the existing health care system, in order to keep pace with the growth of the population, will require regular annual investments for increasing the capital stock and for a larger annual recurring expendi- ture on health. Together with the funds needed for the maintenance of the capital stock, the necessary annual increase in the government expenditure in health is estimated at Rs 49 million. This is just in order to maintain the health care system at its present level of services. The selective utilization of different health care units by the most appropriate patients is prevented by the lack of an established hospital admission policy and by an undeveloped referral system. As a result, some institutions are over-utilized, whereas others are underutilized. In the fields of family health, environmental health, and health education, the efforts made by the responsible health workers seem inadequate. Certain management problems require attention, e.g., the maintenance of buildings and equipment, the standardization of capital stock, the rational distribution of supplies and equipment among the health care system working units, and a review and planning of the activities of health workers. 7.2 HEALTH PRIORITY OPTIONS Before contemplating any change in the existing health care system and consequently in the health manpower system, it is necessary to establish whether there is any need for change. This means trying to project all the present health concerns into the future in order to assess how the present health care system will be able to cope with the problems in the future. 7.2.1 Problems of Population Dynamics Jones and Selvaratnam (56) have estimated that a moderate decline in fertility from the current fertility level of the population of Sri Lanka will resu1t in future savings of government money spent on education, health, food subsidies and transport. These savings will add up to billions of rupees during the next 20 years. In this study, an attempt will be made to estimate the extra costs of health care if the population grows according to the high fertility projection instead of according to the medium fertility projection (Annexes 1-3 and 1-4). SEA/PHA/149 Page 192 Considering the present annual expenditure on health (Table 7.4) and that the life expectancy at birth for both sexes is 68 years in Sri Lanka, the average health costs during the lifetime of a person can be estimated at Rs 2497, of which Rs 1501 are to be paid by the state and Rs 996 by the individual. Besides, Rs 62.60 per ccrpita will be needed for capital invest- ment for each new consumer of health care in order to maintain the present standard of the health care system (the cost of depreciation is not taken into account). Another Rs 15.36 per capita should be spent on the training of doctors. (The cost of training the other personnel is included in the cost of the health services. The opportunity cost has not been taken into account.) Since, according to the high fertility projection, there will be 1 883 900 more persons in 1991 than according to the medium fertility projection, this excess of population will require approximately Rs 838 million more in health costs over 20 years, as shown in Table 7.9 Table 7.9 THE COST OF HEALTH SERVICES FOR AN EXTRA 1 883 900 POPULATION IN THE PERIOD 1971-1991 Categories of costs Government capital investment in health Cost of training doctors Cost of government sector health care services (recurring costs) for 10 years Total government costs Private consumption of health care services for 10 years Total (Rs x 1000) 117 932.1 28 168.7 415 965.1 562 065.9 275 823.0 837 868.9 The additional government cost owing to the excess population during the 20-year period for health will be Rs 562 million. As the cost of depre- ciation of the capital stock of the health care system will be approximately Rs 600 million on 20 years, the total cost will be Rs 1162 million. On the other hand, the increase in the government health expenditure, according to the strategy stated in the Five-Year Plan 1972-76, cannot be more than Rs 653 million, if the capital increment grows by an average of 10% per year (as compared with the present annual increment of Rs 25 million) and the government recurring expenditure grows by 5% annually. As a result of the disproportionate growth of the population and the funds for health, a deterioration of the present standard of the health care services can be expected. 7.2.2 Prevalent Diseases and Their Cost It has been shown that the spread of disease in Sri Lanka causes absence from normal duties of a great proportion of the population. This SEA/PHA/149 Page 193 absence is estimated at 308 300 man-years. Considering the national income of the country and assuming that 34% of those absent from normal duties because of illness are likely to belong to the labour forces, one can esti- mate the economic loss as follows (for 1972): - loss of individual consumption - loss of public consumption and capital formation - Total loss of national income or Rs 20.78 per acrpita per year. Rs 68.5 million Rs 192.5 million Rs 281.0 million However, the relevance of such an estimate is more or less purely academic. The level of unemployment and under-employment in Sri Lanka may tolerate such a loss of labour inputs without much jeopardy to the economic development of the country. Consequenlty, the more important aspect of this area of health concern is the expense incurred in the prevention and treatment of these disease conditions. Since major changes in the morbidity pattern of the country are not expected without basic changes in the environ- ment, the costs incurred in the provision of future health care services at the present level will mainly be determined by the growth of the population, as shown in Table 7.9. 7.2.3 Demand for Medical Care The present demand of the population for medical care services is very high. As shown in Table 3.17, the number of outpatient visits to all types of institutions and practitioners was estimated at about 74 million annually or 5.7 visits per aapita per year. The preferences of patients for different sectors of the health care system, as compared with the average monthly income of their households, is shown in Table 7.10. Although there must be reservations regarding the reliability of the data (24), since they seem to have underestimated the role of the ayurveda sector in providing medical services, the data may be acceptable as indi- cating trends rather than values. Table 7.10 DISTRIBUTION OF SOURCES OF MEDICAL CARE, BY INCOME GROUP Monthly income Per cent of visits paid to different sectors of household Ayur. Ayur. Western (Rs) Western Unspe- Total govt. private Govt. private cified Below 200 5.1 17.0 56.4 16.4 7.1 100.0 200-399 4.6 16.1 48.6 27.0 3.7 100.0 400-599 6.7 18.0 41.8 29.0 4.1 100.0 600-799 3.8 15.9 35.9 42.3 2.1 100.0 800-999 6.5 9.6 29.2 51.3 3.4 100.0 1000 and over 4.9 4.9 29.5 58.7 2.0 100.0 All 5.1 16.4 48.7 24.8 5.0 100.0 SEA/PHA/149 Page 194 The low-income groups seem to patronize more often the government western sector and the high-income groups favour the private western sector. Also, the low-income groups patronize the private ayurveda sector, whereas the government ayurveda sector is equally patronized by the poor and by the rich. The future specific demand for medical services from different sectors of the health care system will depend, inter alia, on the distri- bution of the national income. If the targets of the government policy are achieved regarding a more equitable distribution of the national income, it may lead to the decrease of the individual private consumption, for medical services from the private western sector. This, consequently, may lead to a greater pressure on the government sector and probably on the private ayurveda sector which is more competitive as far as fees for ser- vices are concerned. 7.2.4 Selection of Health Programmes A health programme has been defined as a desired amount of health services intended to control the principal sets of health concern, as elicited in this study: family health, disease control, and demand for medical care. A health programme can be expressed in terms of the number of health activities which are likely to achieve the targets set by the decision- maker. The number of different health activities may be expressed in relation to the total population, or to a standard population of a given size, say 100 OOO (which was the basis for the calculation of the manpower/ population ratio). Numerous health progrannnes can be formulated depending on the emphasis given to different problem areas. The anticipated alternatives that are most likely to be accepted by the decision-maker in Sri Lanka are listed below: The present situation, which has the attraction of continuing the established routine and not going through the ordeal of introducing changes: as such, this alternative looks the most acceptable from the health adminis- tration point of view. Emphasis on family health will differ from the present situation by an increase in the number of hospital deliveries, preventive visits to clinics, and home visits. Since the health resources should be kept below a given level, savings may be made on the hospital treatment of acute cases. Such a policy promises a much better return in the long term, but requires certain sacrifices at present. It may hide political inconveniences as a result of the limited provision of medical care which is in high demand in the contry. Emphasis on disease control and medical care will be connected with an increase in surgical interventions, visits to medical institutions, consultations by specialists, vaccinations/immunizations and environmental health projects. This can be achieved by a reduction in the number of preventive visits and home visits. This programme is likely to increase the popularity of the decision-maker because of the seemingly visible and SEA/PHA/ 149 Page 195 spectacular results that may be achieved and because of its impact on public opinion as a "promotion" programme whose results can be easily expressed in quantitative terms. Emphasis on famiZy heaith and disease aontroi will require a greater output of hospital deliveries, preventive visits, vaccinations/immunizations, hoxoo visits, and environmental health projects; and a reduced output of hospital treatment of acute cases, hospital treatment of chronic cases, visits to medical institutions, consultations by specialists, and deliveries at home. This programme is likely to affect the major health problems in both the long-term and medium-term. It includes activities which support each other. However, the programme requires considerable sacrifices at present, which are likely to make it less acceptable for the decision-maker. Emphasis on environmentai heaZth, with an increase in environmental examinations and environmental health projects; and a decrease in the hospital treatment of acute cases, the hospital treatment of chronic cases, and the visits to medical institutions. This progranune might not appeal to the decision-maker, since the political problems likely to be created by the reduction in the medical services are unlikely to be compensated by any spectacular results in the improvement of the environment. Emphasis on hospitai treatment will lead to a higher demand for hospital treatment of acute cases, hospital treatment of chronic cases, surgical interventions, and hospital treatment in ayurvedic hospitals; and decreased numbers of vaccinations/immunizations, home visits, and environ- mental health projects. Such a programme is likely to be politically highly acceptable. However, it cannot contribute substantially to the solution of the two major health concern in the country, family health and disease con- trol, and in the long run will lead to a deterioration of the population's health. The size of the outputs required for each health programme is given in Annex 4. They are based on the present level of effectiveness and effi- ciency of the health care system. 7.2.5 Summary Health programmes have been defined as the desired amount of health services that should be provided by the health care system in order to control the priority health concerns. Six programmes with an emphasis on different problem areas are being proposed to the decision-maker: (1) Present situation - no change (2) Emphasis on family health (3) Emphasis on disease control and medical care (4) Emphasis on disease control and family health (5) Emphasis on environmental health (6) Emphasis on hospital treatment. The reasons for their acceptability to the decision-maker have been discussed. SEA/PHA/ 149 Page 196 7.3 HEALTH CARE DELIVERY OPTIONS The "basic health care services" or the "health infrastructure" should provide the most essential health services intended to meet the basic health needs and demands of the population. The priority health problems in Sri Lanka require an easy access of the population to the following basic health services: (1) family health services, including basic family planning techniques, ante-natal, natal and post-natal care of mothers, care for infants, preschool and schoolchildren; (2) control of leading diseases, diagnosis of the most connnon conditions, first aid, vaccination and immunization, and availability of the most essential drugs and food supple- ments, like iron, vitamins, etc., and (3) referral to better equipped health institutions/agencies of any patient who cannot be dealt with at the basic level. The present concept of the basic health services in Sri Lanka is founded on the following principles which resemble the situation in some western countries: (1) the family health care services are entrusted to the govern- ment sector of the western type and co-ordinated centrally by the Family Health Bureau, except for the work on school health; (2) the control of leading diseases is taken care of by several specialized services (projects) which work without more co- ordination with the other parts of the health care system and between themselves; an exception is the project for the control of tuberculosis which works in close co-operation with the medical care and PH services; in some respects the antimalaria campaign also co-ordinates its activities with the medical care services; (3) the demand for medical care is being met partly by the private sector (western, ayurveda, and "other") and partly by a large number of government and semi-government medical care institu- tions ranging from provincial hospitals to branch dispensaries and visiting stations; hence, the quality of the medical services is likely to vary within large limits. The activities of the above parts of the health care system are unco- ordinated with considerable overlapping. Hence, the population may not know who might be doing what in the health care system, and how well. The kingpin in this organization is the western-type medical doctor since all other per- sonnel are not considered competent enough to make independent decisions regarding the main health problem areas. Such an approach to the development of the basic health services in Sri Lanka will require an enormous increase in the number of western-type doctors working in the rural areas, if the decision-maker also wants to make SEA/PHA/ 149 Page 197 the basic health services easily accessible to the majority of the popula- tion who live in the rural areas, There are indications that a citizen in Sri Lanka is unlikely to walk more than two miles from his home in order to get medical care. This means that if the government desires to use the western-type medical doctor as the basic practitioner providing basic health services to the population in walking distance, then the number of medical institutions with a medical officer in-charge must be doubled for the present population. It is clear that such a solution is not feasible in the present socio-economic context of the country. However, certain alternatives that promise a more rational utilization of the existing resources may be tested and implemented. In this connexion, the government sector has been taken as the focus of attention since it is the largest and the most coherent part of the health care system in the country, and the most likely one to accept and implement changes, in comparison with the rather "amorphous" private sector. The options described in this section have been based on the following basic considerations: (1) to utilize the available resources in a better way; (2) to make the best use of the existing categories of health manpower before advising the development of new ones; (3) to concentrate on solutions that have chances of success, i.e., which look acceptable to the decision-maker, the consumer, and the health professions; (4) the health care system should be capable of delivering the health programme selected by the government (see Section 7.1). 7.3.1 Alternatives The present health care system has shown shortcomings which were discussed in detail in Section 7.1. Its mechanical growth is unlikely to improve the provision of health services and it requires more resources than the country can afford. The health centre concept is another alternative for providing basic health services, The awareness that the health of the population is integral and that the difference between the preventive and the curative services is artificial has led to the concept of the health centre as a health care institution which offers comprehensive basic health services to the population of a defined area. A team headed by a western medical doctor is made responsible for providing family health, control of diseases, and medical care and referral for the whole population of the area. In the rural areas, it is sometimes difficult for the whole population to have the opportunity of contacting a western medical doctor since a large proportion of the popula- tion may live far from the health centre. For this reason, special cate- gories of field health workers are trained who are located closer to the population. They perform some of the activities considered an integral part of the basic health function, as for example, vaccinators against smallpox, malaria workers, midwives, etc. SEA/PHA/149 Page 198 The implementation of such a change in the health care system of Sri Lanka, i.e., establishing an organization of the health care system based on the health centre concept, will require the following steps: (1) abolition of the present health units and distribution of the public health personnel to district hospitals and peripheral units, proportionately to the size of the areas that will be allotted to these institutions, which will start functioning as health centres; (2) up-grading about 100 rural hospitals or central dispensaries/ maternity homes or both so that they may function as health centres, by attaching to them one MOH and a part of his staff and allotting a defined regional area and population; (3) the basic functions of these health centres will be: (a) family health (b) control of leading diseases (c) medical care, and (d) referral to the better equipped medical institutions. This type of health institution may be called the integrated district hospital, or integrated peripheral unit. In such a health centre it should be easier to integrate the functions of the five specialized campaigns against tuberculosis, malaria, _iL1r.iasis, leprosy, and venereal diseases. The staff of these campaigns can be actached to the health centres in order to improve the quality of their work: - the malaria and filaria microscopists will carry on multi- purpose laboratory work; the field workers of public health services, malaria and filariasis campaigns will be involved in multipurpose environmental sanitation work which will include water supply control, sewerage control, vector control, etc.; - the efficiency of work is expected to improve since the range of supervision of the doctor-team leader will be much narrower than at present; each doctor will have under his supervision about 30 field workers, instead of 65 as at present. Such a change will not require special financial efforts from the government: moreover, it-may lead to considerable savings since a number of rural institutions may have to be abolished, as for example, central dis- pensaries, branch dispensaries, visiting stations, and maternity homes. Any- way, some of them are not used very much by the population. The disadvantages of such a change in the health care system may be the following: - the basic health workers, i.e., the western medical doctors, will still be rather far from the population, on an average about 5 miles from the home of the rural citizens; SEA/PHA/149 Page 199 the greater part of the decisions on basic health problems, will still be made by specialized auxiliary personnel; little use will still be made of the vast resource of tradi- tional ayurveda doctors. It is necessary to stress that such a fundamental change in the basic health services will have to generate changes in the superstructure of the whole health care system. An efficient referral system will be one of the main contributing factors to the successful functioning of the health care system based on the concept of the health centre. Also, changes should be made in the field of health services administration establishing clear lines of responsibility. If the decision-maker wishes to make the health services more accessi- ble to the population, it may be done with substantial investments for the development of more health centres and for the training of more personnel. If a western-type doctor is to be available within 2 miles from any home in Sri Lanka, the number of the health centres should be increased to 2000; and if the target is to have a health centre within 3 miles, the number of health centres should be 1000. For the first target of 2000 health centres, the capital investment for the 1700 new health centres will be Rs 150 million. For the other alternative, the 700 new health centres will cost Rs 60 million. The training of the doctors for each alternative, will represent an invest- ment of Rs 54 million and Rs 22 million respectively. The running cost being, on the average, Rs 105 932 per one doctor working in the government sector, the increase in the annual operating cost of such an expansion in the govern- ment health services reaching the above targets will be Rs 180 million and Rs 74 million, respectively, or an increase over the present annual government health expenditure by 70% and 29% respectively. With the above fiscal implications in mind, it is very unlikely that the economy of the country will be able to bear the burden of such an expan- sion of the health care services without other sacrifices. The only possi- bility (without an increase in the health expenditure) will be to transfer funds from the medical care services after closing down some big hospitals. Such a solution will hardly be acceptable to the decision-maker. The concept of AMP/RMP is basically the same as the concept of the health centre. The only difference is in the leader of the team working in the health centre, i.e., the basic health workers. In Sri Lanka, the assistant medical practitioners are recognized by the government and appreciated by the population as competent in providing medical services. They work under the supervision of a medical doctor in some institutions, e.g., in OPDs of the base and district hospitals, and in the peripheral units; and quite independently in the rural hospitals, the cottage hospitals, and the central dispensaries. To entrust them with the responsibilities of basic health care is unlikely to create problems in their aceeptability by the population since they already perform services which overlap with the activities of the medical doctors; 29 out of 45 diagnostic and therapeutic as well as prophylactic and promotive activities in rural health services are performed either by the doctors, or by AMPs/R..11Ps. A basic health centre of this kind may be called an integrated central dispensary. SEA/PHA/149 Page 200 The problems connected with this change may be the following: - special organizational provisions should have to be made to provide referral at health institutions staffed with western medical doctors for all cases and problems which cannot be solved by the AMPs; - hospital treatment will be available at the district, base, provin- cial, Colombo group, and special hospitals; - the ayurveda practitioners will still be partly excluded from the system of basic services. If AMPs are in charge of peripheral units, rural hospitals, cottage hospitals, and central dispensaries with and without maternity homes attached, the accessibility to AMPs by the population will be easier than the accessibi- lity to western doctors. They will be within 3 miles from the homes of their patients. If the standard is to be improved, about 1000 more integrated central dispensaries should be established to bring the total number of rural health institutions up to 1700. This will require the investment of about Rs 60 million. The training of the additional AMPs will cost Rs 12 million. The existing 1300 AMPs should be retrained in family health and preventive techniques for at least 3 months, w~ich is likely to cost Rs 2 million. On the other hand, if the newly trained AMPs are expected to be trained in family health and in the control of diseases, their training should have to be extended to 3 years, which will increase the cost of the training of 100 new AMPs for the newly established centres by Rs 6 million; that is, bringing the total up to Rs 18 million. Thus, the total invest- ment for the expansion of health services and development of health manpower to satisfy the present needs and demands without taking into consideration the popu- lation growth, will be approximately Rs 80 million. In this way, the basic health care services will be brought down to 2 miles, on the average, from any home in Sri Lanka. The total annual recurring expenditure of a central dispensary at present, has been estimated at roughly Rs 18 OOO. In a health centre-type of integrated central dispensary, the recurring expenditure will have to be higher since the public health personnel from MOH offices will be attached to the dispensary. The increase of the expenditure will be in the range of Rs 30 OOO if the number of central dispensaries is unchanged, or Rs 12 OOO if the number of central dispensaries increases by 1000. However, there will be no real increase in the total health expenditures, since the funds allocated to the public health ser- vices will be simply transferred to the integrated central dispensaries, when they start providing basic health services. If the decision-maker decides to expand the network of the integrated central dispensaries, this is likely to incur an additional annual expenditure of Rs 18 million. This will be reimbursed by savings of up to Rs 16 million by closing down the hospital wards in institutions below the level of district hospitals. If the basic health services are delivered by AMPs at the integrated central dispensaries, the next technical level of health services will be the district hospitals. The functions of the specialized campaigns will be en- trusted to the integrated central dispensaries. The public health midwife (PHM) has been shown already to be the provider of certain functions, mainly in medical care, which are outside her direct responsibility. If the public health midwife becomes the basic health worker, she will be very easily accessible since her office is, on the average, within 1.8 miles from any home in Sri Lanka. She is already known to the population as a govern- ment health worker. SEA/PHA/149 Page 201 The midwife delivers 59 technical kinds of services to the rural population, 30 of which are overlapping with the activities of the medical doctor. However, to become a basic health worker she must be trained in the control of diseases and in the delivery of medical services. She may work, as at present, in her field office situated in her home but she will have to be better supplied and supported by the western doctor, who will function as her consultant. A referral link-up should be established between the midwife and the doctor who can be located in the present hospitals and peripheral units which should also carry out some preventive activities. Logically the central dispensaries, the maternity homes, the rural hospitals, and the cottage hospitals, as well as the branch dispen- saries and the visiting stations will become redundant. The retraining of about 2000 midwives for 6 months each may cost about Rs 3.6 million. The training of the midwives in the future should have to be extended to 24 months to make them capable of working as basic health workers. The cost of their training will increase to about Rs 7000 per one midwife. The investment for the work of the midwives as well as the running cost of their services will be minimal, since their work on disease control and medical services delivery will become an integral part of their daily work and will not require special efforts. One of the main problems will undoubtedly be the technical support which the PHMs will have to receive continuously from the integrated district hospitals and the integrated peripheral units, whose number may be reduced, in comparison with the second alternative (see p.197). This support should have to be substantially stronger than the support which will be needed by the AMP-alternative, because of the different technical level of knowledge of the PHMs and because of their working in complete isolation from the other health workers. The functions of the public health services, including specialized campaigns, will be distributed between the PHMs and the integrated district hospitals and the integrated peripheral units. As in the other alternatives, the, ayurveda doctors will be marginally involved in these modified government health programmes. The ayurveda doctor concept. There is a unique opportunity in Sri Lanka to promote the basic health services by utilizing the existing indi- genous system of medicine. As shown already, there are more than 10 OOO registered ayurveda doctors in the country, who offer the following advantages in the establishment of a total health care system based on their services: (1) the ayurveda doctors represent a part of the community in which they live and they are well appreciated in their social environment, moreover, they are influential persons in their milieu; (2) they are so numerous, that the distance of an average citizen of Sri Lanka to the nearest ayurveda practitioner is not more than 0.8 miles; SEA/PHA/149 Page 202 (3) there is a tradition of seeking relief from the ayurveda practitioners by the population when in need. The disadvantages and problems connected with such a solution are the following: (1) there is a complete lack of rapport between the western type of doctors and ayurveda practitioners; (2) the ayurveda doctors have started learning some western medical disciplines, but the western medical educational system has been ignoring the ayurveda; (3) there are indications that the ayurveda practitioners will be reluctant to deliver some family health services, especially family planning services; (4) the ayurveda doctors should have to be trained in some aspects of family health and disease control, like vaccinations, etc.; (5) the great majority of ayurveda doctors work as part-time private practitioners. Ways should be found, e.g., by paying a fee for services or by part-time employment in the health care services, to include the ayurveda doctors in the govern- ment health care system, thus incorporating them in the planned health activities; (6) some ayurveda practitioners have very narrow fields of work, e.g., snake-bite specialists, and there are likely to be great difficulties training them to deliver basic health care. The inclusion of the ayurveda practitioners and their promotion as basic health workers will necessarily have to lead to an integration of traditional and modern medicine. Such a process will call for many bold decisions by the highest health authority, taking into account the various political, educational, cultural, social and other factors. The financial implications of such a course of action will require a special study. Besides, the data collected within the scope of the National Health Manpower Study were not intended to provide information on the technical aspects of the work of ayurveda practitioners. The kind and the duration of the re-training of the ayurveda doctors will have to be assessed in the future. The ayurveda practitioner, as a basic health worker, will have to have free access to the western institutions, for referral, guidance, and advice. In addition, the western health worker should be able to communi- cate freely with the ayurveda doctors. Thus, the borderline between ayurveda and western medicine will become erased in the course of time. The promotion of the ayurveda practitioner as a basic health worker opens completely new perspectives regarding the roles of the different units of the health care system and certain categories of western-type health workers. The small rural institutions will have to be abolished, and the next level of health care delivery, above the ayurveda practitioner, should be the integrated district hospitals and the integrated peripheral units. SEA/PHA/149 Page 203 These institutions should have a stronger family health bias than in the fourth alternative (seep. 200), since the ayurveda doctor's contribution to family health will be, most probably, rather marginal. On the other hand, the responsibilities of the integrated district hospitals and the integrated peripheral units in the control of communicable diseases and environmental health may be taken over by the ayurveda doctors to a great extent. Naturally, all the public health functions, including those carried out in the specialized campaigns, will be delivered by the basic health workers (ayurveda practitioners) and the integrated health insti- tutions. 7.3.2 Summary Five alternative solutions are presented in order to adapt the present health care system to the requirements of the present and future priority health concerns: A. The present health care system, growing along with the population growth. B. The health centre concept, represented by the integrated district hospitals and peripheral units, which will carry out all the basic health functions under the guidance and responsibility of a western-qualified medical doctor. C. The assistant medical practitioner (AMP) concept, based on the development of integrated central dispensaries staffed with health personnel to carry out all the basic health functions under the leadership of an AMP. The western-type doctor will give support from the larger hospitals. D. The midwife concept takes the public health midwife (PHM) as the basic health worker. She will work in her house, performing all three basic functions on a level which corresponds to her training. She will be supported by the western-type doctors and their personnel, working in the integrated district hospitals and peripheral units. E. The ayurveda practitioner concept makes a break through the barrier between the western and the traditional sectors of medicine, in an attempt to integrate them. The advantages and disadvantages of the above alternatives, as well as the problems which are likely to arise during the implementation of the changes are discussed. Some assumptions have been made regarding the possi- bilities of improving the efficacy of the alternative health care delivery systems outlined in this section. 7.4 SUMMARY OF THE CHAPTER Accessibility to the health care services by the population does not present a significant problem in Sri Lanka. However, the kind of service offered throughout the island is not always that needed and demanded by the population. The large government sector of the health care system requires re- sources (£or its maintenance and for keeping the present standard) which seem to be beyond the economic capacity of the country. SEA/PHA/149 Page 204 The absence of selective utilization of the medical care and public health services results in a wastage of resources. Certain management problems, like maintenance, standardization of the capital stock, rational distribution of equipment and supplies, and the supervision of personnel also deserve attention. The health care system is expected to reorganize its activities so that mixed health programme of health services may be provided to the popu- lation. The present health programme does not guarantee the control of all the priority health problems, so five other health programmes have been defined and their acceptability to the decision-maker has been discussed. The implementation of the alternative health programmes requires certain changes on the health care system. The most realistic options seem to be the following ones: A. The present system - no change B. The health centre concept c. The assistant medical practitioner concept D. The public health midwife concept E. The ayurveda doctor concept. The changes in the health care system that will have to be introduced, if any of these alternatives is selected, have been discussed. The estimated cost of changes of the health care system is displayed in Table 7.11. It shows that alternative PHM and Ayurveda doctors, while marginally increasing the capital cost, are likely to incur certain saving of recurrent expenditure in the future. A. B. c. D. E. Table 7.11 ESTIMATED COST OF THE ALTERNATIVE CHANGES OF THE HCS IN SRI LANKA AS COMPARED WITH THE PRESENT COST, EXCLUDING FACTOR POPULATION GROWTH, IN RS. MILLION (GOVERNMENT AND SEMI-GOVERNMENT SECTOR) Cost of the change Increase of running cost of HCS of HCS Alternatives Training Annual Annual Capital recur- mainte- Sub- Net + re- Total Savings stock training ring nance total increase cost cost Present system (a) without change - - - - 30 - - 30 (b) with increased accessibility, 3 miles to the nearest doctor 482 275 757 267 60 327 - 327 Health centre (a) accessibility 3 miles 60 22 82 74 4 78 - 78 (b) accessibility 2 miles 150 54 204 180 9 189 - 189 AMP/RMP 60 20 80 18 1 19 16 3 PHM - 3.5 3.5 7 - 7 11.3 -4.3 Ayurveda doctor - 6.6 6.6 13.2 - 13.2 24 -10.8 Remarks Savings of 4.3 million Savings of 10.8 million "d C/'l : f: ro- "d ~&;'. Ul- ..... ~ '° CHAPTER 8 HEALTH MANPOWER IMPLICATION SEA/PHA/149 Page 207 This chapter describes a health manpower demand-supply model and stresses the important role of the utilization and productivity of health manpower in the balance between demand and supply. The changing roles of health manpower in the alternative health care systems are briefly outlined and the process of their preparation for the new roles is discussed, Special attention is paid to the integration of western (allopathic) and ayurvedic medicine. The quantitative demand for health manpower is estimated by a linear programming model, In the preceding chapters, it has been stated that changes in the health care system must necessarily involve changes in the health manpower process. Thus, a rational management of the health care system requires that the demand and supply of health manpower should be well balanced. Fig.8,1 represents a conceptual health manpower demand-supply model (146). Since all the information needed for working the model has been presented in this book, the health manpower implications of the proposed changes to the health care system will be discussed with reference to this model. Another starting point in this discussion will be the provision of basic health services. According to the concept accepted, there must be a "basic health worker" to carry out certain clearly defined tasks (related to the three principal areas of health concern), and to refer patients to and seek advices and guidance from the higher levels of the health care system, The demand for and supply of this basic health workers will be the pivot around which the demand/supply balance of the other categories of health workers will turn. The outcome of the discussion on the basic health worker should indi- cate: (i) Which kind of health workers will be needed for each alternative health care system? (ii) How many of them? (iii) What kind of knowledge and skills will they need to have to perform their duties efficiently? (iv) How are they going to be trained to acquire skills and acknowledge? (v) What will be the cost of introducing the changes? 8.1 RE-DEFINITION OF THE ROLES OF THE HEALTH PROFESSIONS Re-defining the roles of the health workers in Sri Lanka would have been much easier, if there had been a clear description of their present roles. For some categories, there are lists of duties that the workers are expected to perform, which were compiled by the Health Department; but a mere listing of duties, without a systematic job description, leaves a large room for misinterpretation. On the other hand, it was not within the scope of this study to pro- vide specific job descriptions for all or even the main categories of health manpower. It is hoped that it will suffice if indications are given regarding the desired utilization of the existing health manpower in the future, as compared with their present utilization described in Chapter 5. estimated rates of h.m. losses I present project stock present stock projection of h.m.additions , T description estimation of current of losses suooly in h.m. T education & training revise future addition , Table 8.1. HEALTH MANPOWER DEMAND - SUPPLY MODEL"' describe health care system 1 present utilization 1 present 1 productivity l project project project future future supply demand productivity i l l f 1 project supply demand balance demand for h. services $ 8 T revise demand ' revise productivity economic base sound B $ implement h.m. programme ;,Modified from T. Hall's conceptual model present demand for h.manpower describe present demand for h.services '"d (/) : ~ (t) ......_ '"d N;,::: 0 :> CX> ......_ I-' ~ \0 SEA/PHA/149 Page 209 It should be pointed out that the description of the roles of the different health professions is based on the findings of the NHMS and is not necessarily comprehensive. However, a study of these roles in field tests, under controlled conditions, should indicate the real roles of the health workers concerned. 8.1.1 Medical Doctors Regardless of the changes in the health care system which the govern- ment may undertake, there are some lacunae in the knowledge and attitude of the doctors in Sri Lanka which were evident in a study of their utilization in the district hospitals and of their activities in the rural health care services. A review of the present system of medical education is therefore urgently needed. The doctors spend a considerable part of their time in administrative and managerial activities, without being trained for these jobs during their regular training at medical schools. They have only a short briefing on health administration at the time of their internship and on the job training after they begin their jobs in the district hospitals and rural health care institutions. The doctors need a better orientation into the epidemiological and social situation of the environment in which they live and work. This will hopefully help them to develop different attitudes leading to a better understanding of health problems and of their causes and a better adaptabi- lity to the social environment. The role of medical doctors in each of the proposed alternatives will now be discussed briefly: (1) Doctors in Sri Lanka are overtrained for providing services as "basic health workers" in the present health care system. If the course of "no change" from the existing health care system is accepted by the decision-maker, a revision of the medical training programme and of the duration of study should be made. The NHMS has provided baseline for the formulation of train- ing objectives for doctors, in terms of the tasks which they perform at present. These tasks should be translated into the necessary knowledge,skills, and attitudes which are to be expected from doctors. On that basis the pro- gramme and the curriculum of the medical schools should have to be developed. The preparation of doctors for performing tasks, which require a higher than the basic level of knowledge and skills, should be organized through post- graduate courses. (2) Doctors who will be working as team leaders at the integrated district hospitals and integrated peripheral units ("health centre doctors"), if this alternative is accepted, should have a stronger public health bias. The training programme of medical schools should incorporate a part similar to the training programme of the medical officers of health (MOH) conducted at the Institute of Public Health, Kalutara. (3) The acceptance of the assistant medical practitioner (AMP) concept will free the doctor from having to provide basic health services, but he will have to be able to give technical support to the AMP in both the medical and the public health fields. In this case the doctor should be a half-way specialist in medicine and in public health. SEA/PHA/149 Page 210 (4) The role of the doctor in the public health midwife (PHM) alternative will not differ significantly from his role as team leader of the health centre team. However, in this set-up the doctor will have less clinical and more supervisory responsibilities than in the alternative (2). (5) The role of the western doctor in the "ayurveda practitioner concept" alternative will be similar to his role in alternative (4). However, it seems to be the most difficult one for many reasons. First, the doctor should have to change his attitude towards the role of ayurveda in general. Second, he should have to establish an adequate working relationship with ayurveda practitioners, based on confidence and mutual respect. Third, he should have to help the other health workers with a western type of training to develop a similar attitude. And fourthly, he must acquire the necessary knowledge and skills in traditional medicine to be able to communicate with the ayurveda doctors and to provide the required assistance. 8.1.2 Assistant/Registered Medical Practitioners (AMP/RMP) (1) The training of AMPs was discontinued in 1967. However, there are still a considerable number of them in the country. With the western-type doctors replacing them as officers-in-charge of the small rural institutions (central dispensaries, rural hospitals), they will have to work under the supervision of the doctors, until they are completely abolished. (2) In the "health centre" alternative, the role of AMPs will be similar to their role at present. (3) The "AMP" alternative opens broad perspectives to the AMP. He will have to take responsibilities which require more knowledge and skills than the AMP has at present. He should have to provide family health services, services in the field of control of communicable diseases, including environmental health, and in the field of management of the health care services. All this will require re-training of AMPs and a complete re- examination of the training programme of the AMPs who are to be trained in the future. The alternatives (4) and (5), like alternatives (1) and (2), will not require the AMP to play a special role. 8.1.3 Public Health Midwives (PHM) For the purposes of the implementation of the alternative (4) ("PHM concept"), it will be necessary to promote further the PHM as an independent health worker who delivers health care not only in the field of family health, but also for the control of communicable diseases and medical care. Her office should be accepted by the population as the place of first contact between the people and the health care system. To achieve that, the PHM should be better equipped with knowledge, skills, as well as supplies, to meet the needs and demands of the population. 8.1.4 Ayurveda Practitioners Although the ayurveda practitioners have been recognized as legiti- mate health workers by both the population and the government, their status in the health care system structure needs a better definition. There is an evident willingness of the ayurveda practitioners, especially those who SEA/PHA/149 Page 211 have undergone formal training at an ayurveda medical college, to co-operate actively with the government western sector. Some proposals were made by them to be entrusted with the responsibility of taking charge of those central dispensaries in which there were unfilled vacancies. However, the even simple incorporation of the ayurveda practitioners into the western sector of the government health system is likely to create at least as many problems as it can solve. It will be necessary to consider thoroughly the best and the least painful way in which the two systems, western and ayurveda, can be integrated. All the technical, social, economic, organizational, legal and administrative aspects and problems of communication that may arise should be taken into account. The implementation of this alternative may require exceptionally strong political support at all levels. 8.1.5 Changes in Health Manpower Structure Certain categories of health manpower are unlikely to change their roles, regardless of the decision of the government in relation to the most acceptable health care system. The nurses' activities are likely to be further confined to the larger hospitals. The dental surgeons, the public health inspectors, the medical laboratory technologists, the radiographers, the dental nurses, and the pharmacists will continue to perform their duties by and large as they are doing now. The dispensers are in the process of being abolished from the governmental sector. Consideration should be given once more to the reasons for doing away with attendants as personnel working under the direct supervision of nurses. Further efforts should have to be made to limit the number of the "other" health workers, i.e., those who offer health services without being licensed to do so. This may mean that the non-registered and not-yet-regis- tered ayurveda practitioners, homoeopathic doctors, and the personnel of pharmacies should be given the opportunity to acquire a minimum of knowledge and skills so that the people may benefit from their activities. 8.1.6 Summary Each of the alternative changes to the health care system will require changing the interrelationship between the different categories of health manpower, thus changing their roles in the health care system. Four profiles of the existing health professions are likely to be subjected to major changes the western qualified doctors, the assistant medical practitioners, the public health midwives, and the ayurveda doctors. Certain changes in the role of doctors are advisable regardless of the decision concerning the change in the present health care system to a more acceptable system. The most fundamental changes in the roles of the different categories of health manpower are visualized in connection with implementation of the alternative (5) "ayurveda doctor concept", which should lead to the inte- gration of the two main systems of medicine, the allopathic (western) and the ayurvedic. 8. 2 SUPPLY AND MAINTENANCE OF HFALTH MANPOWER The new roles of the health personnel will raise the question of the supply and the maintenance of health manpower, in order to meet the demand, SEA/PHA/149 Page 212 as displayed in the conceptual model for health manpower demand and supply (Fig.8.1). The schools for the health professions will have to be prepared for a double task: to introduce changes in order to meet adequately the demand for health manpower in their new roles and to re-train the available health personnel, in order to accelerate the process of change in the health care system,,while at the same time assisting the health workers to adapt to the new situation. 8.2.1 Training Objectives The first and immediate step in this process should be to formulate clearly the training objectives for those health professions which are expected to undergo the greatest change in their role, as discussed in the previous section. It will not suffice to describe the functions and responsibilities of each health profession in loose terms, e.g., (1) to provide medical care (2) to perform family planning tasks, etc. A full detailed description of the functions, activities, and tasks should be provided, in terms of, for example, who is going to do what, with whom, how, when and where? In some cases it will be necessary to describe the individual steps, which are especially important in the performance of given tasks. For instance, it will be necessary to describe in full detail the task of smallpox vaccination, starting from the selection of the eligible persons, through their registration, reconstitution of the vaccine, appli- cation of the vaccine, giving instructions to the person vaccinated, and recording and reporting on the performed vaccinations. A useful scheme for the elaboration of the training objectives, may be the deductive way: Health Health Task function c---activity To elaborate on the above example, the course will be as follows: (1) function: communicable diseases control (2) activity: vaccination/immunization (3) task: vaccination against smallpox (4) steps: (a) selection of eligible persons (b) registration (c) reconstitution of freeze-dried vaccine (d) application of vaccine (e) instructions to person (f) recording. Steps Training objectives should be prepared for all the routine tasks which are to be performed by the basic health worker, whoever he or she may be. It is quite clear that the formulation of the training objectives for complicated tasks, e.g., surgery, complicated deliveries, special laboratory tests, etc., will be very difficult and in some cases unnecessary. However, the activities within the competence of the basic health worker will not create problems in their translation into training objectives. 8.2.2 The Curricula SEA/PHA/149 Page 213 The formulation of clear training objectives will help both the trainees and the trainers; the trainees, to have a clear idea of what the health care system will expect them to do, and how; and the trainers, to develop the curricula. in an adequate way. The changes in the present curricula will demand solution to the eternal problem of the proper balance between theory and practice, or between knowledge and skills. Is it helpful to learn 900 hours of anatomy and 400 hours of pathology (or the reverse?) in order to perform the tasks which absorb 95% of the activity of a practising doctor? Is it necessary for the student nurses to have 140 hours of lectures in medicine, and for medical students in Colombo 182 hours and in Peradeniya 60 hours? And so on. When considering the theoretical parts of the curricula one should ask one- self: for the performance of which task or activity, as formulated in the training objectives, should the student be provided with this particular piece of knowledge? Can the future health worker carry out his duties satisfactorily without being taught this part of the subject? 8.2.3 The Faculty The faculty is one of the most powerful and decisive factor in the training for the health professions in Sri Lanka. The faculty is expected to implement the educational policy, select applicants (or set up criteria for their selection), elaborate the curriculum, conduct the training, and evaluate the students. Very often, the faculty will need to be motivated adequately before any change in the training can be contemplated. In Sri Lanka, special efforts have been made recently in the field of teachers' training and there is no shortage of resources to generate appropriate attitudes among the members of the faculties of medical schools towards the acceptance of changes in training or a readiness to introduce the changes. 8.2.4 Annual Output The annual output of the schools for the health professions should correspond to the nature of the changes in the health care system and to the speed with which the government wants to introduce those changes. Also, the annual output will depend on the decision whether the efficacy of the health care system should be improved not only by the acceptance of a given concept of delivery of the basic health services, but also by an expansion of the network of the basic health care units. For example, the required output regarding implementation of the health centre concept with accessi- bility to the population within 3 miles will be quite different from the output for a target of accessibility set within 2 miles from any home in the rural parts of Sri Lanka. Also, the situation will be different again if the government wants to achieve any of these targets in 5 or 10 years. For this reason, the final conclusion regarding the supply of the basic health professions should be the result of a thorough programming effort which takes into consideration all the above factors. It should be pointed out that the pn~sent situatio,-i in the schools for training health manpower will most probably not impose major problems in switching over to a supply of adequate numbers of different health professionals, if the previously dis- cussed conditions regarding the formulation of training objectives, the elaboration of curricula, and the motivation of the faculties are favourable, SEA/PHA/149 Page 214 Table 8.1 gives a rough comparison of the desired output from the different schools for the health professions that will be needed to imple- ment different changes in the health care system, taking into consideration the existing health manpower (which should be properly re-trained), the annual growth of the needs (as a function of the population growth), and the annual rate of loss of that category of health manpower. The alter- native time targets fer the re-alignment of the total health care system have not been taken into account, neither alternative health progrannnes. However, if the decision-maker decides to provide doctors in easy reach of the population, in alternatives (1) or (2), such a decision will require a sharp increase in the output of medical schools and a strong limitation of emigration. It is not an unattainable task for the medical schools, if the country's economy can afford such a solution. Table 8.1 REQUIRED SUPPLY OF "BASIC HEALTH WORKERS" IN THE ALTERNATIVE HEALTH CARE SYSTEM IF THE CHANGE IS TO Bf COMPLETED IN FIVE YEARS Health delivery system Supply of "basic health ------------------------- workers" No Health AMP PHM Ayurveda Doctors: demand in 5 years* present stock loss in 5 years required supply** AMPs: demand in 5 years* present stock loss in 5 years required supply** PHMs: demand in 5 years* present stock loss in 5 years required supply** Ayurveda practitioners: demand in 5 years* present stock loss in 5 years required supply change centre concept concept practitioner conce t 3 635 3 635 3 275 3 275 164 164 554 554 ? ? 1 337 1 337 140 140 3 981 3 981 3 586 3 586 592 592 1 021 1 021 ? ? 10 116 10 116 4 100 4 100 ? ? 3 635 3 275 164 554 1 477 1 337 140 193 3 981 3 586 592 1 021 ? 10 116 4 100 ? 3 635 3 275 164 554 ? 1 337 140 3 981 3 586 592 1 021 ? 10 116 4 100 ? 3 635 3 275 164 554 ? 1 337 140 3 981 3 586 592 1 021 ? 10 116 4 100 ? *Including the private sector, which is expected to grow at the same pace as government sector **The estimated required supply has taken into account the loss of graduates during the 5 years period. The supply of doctors does not need to change along with their changing role in the health care system. SEA/PHA/149 Page 215 The AMPs are to disappear in all alternatives, except for the alter- native (3) • If an expansion of the present 'rural health services is not contemplated, the maintenance of the present stock of AMPs in relation to the population will suffice. The AMPs who work in the larger institutions at present will have to be given more responsible jobs in the smaller institutions, like the integrated central dispensaries. The PHMs do not require any increase in numbers in order to play the role of the basic health workers. They should only be prepared for this role and adequately promoted as a multipurpose health worker. If the ayurveda practitioners are not promoted as basic health workers, it will be difficult to project the demand for them in the future. In the case of their acceptance as basic health workers, a regular supply should be maintained both from the ayurveda colleges and from the pool of the non-registered ayurveda practitioners. It should be pointed out that the figures in Table 8.1 relate to the present health situation in the cotmtry. 8.2.5 Time-Lag It seems not out-of-context to point out that any change in the health care system and in the health manpower development will be connected with a time-lag between the decision for change, the start of its imple- mentation, and the completion of the change. This time-lag is measured not by days and months, but by years. Time is needed to prepare training objec- tives and curricula, to motivate and train the faculties, and to conduct the training. In the case of doctors, it may take 6-10 years at least to start producing a new type of doctors. 8.2.6 On-job training To cut the time-lag between the decision and the implementation of changes, it will be necessary to consider some short-cut solutions, It is disheartening to contemplate a complete re-staffing of a changed health care system by the substitution of the existing manpower by a fresh, newly trained manpower. For this r8ason, the re-training of the available health manpower will have to play the most important role in introducing quick changes. Here also, the problems of training objectives, curricula, faculty, and annual output should be meticulously planned and tested before the start of re-training. And, finally, the maintenance of a given level of productivity by the health personnel will require a process of refresher training included as a part of the regular job of the health workers. 8.2.7 Summary The supply of health manpower for the changed health care system will pose more problems in changing the quality of training, re-training, and on-job training than the problem of numbers of health manpower. The importance of setting clear training objectives in behavioural terms, develop- ing adequate curricula, and motivating and training the faculties of the schools for the medical professions has been stressed. A projection of the SEA/PHA/149 Page 216 health manpower demand and supply in the next five years has been made (Table 8,1). A warning regarding the time-lag between the decision and its implementation has been given, owing to inherent inertia of the health man- power development process. 8.3 INTEGRATION OF THE WESTERN AND THE AYURVEDA SYSTEMS Regardless of which alternative change in the health care system is selected by the decision-maker, the almost complete lack of co-operation and co-ordination between the two main systems of medicine in Sri Lanka represents a special problem whose solution promises the highest pay-off (return). On the other hand, the lack of proper communication between these two systems represents a potential obstacle in the acceptance of the ayurveda practitioner concept which cannot be bridged over before a proper atmosphere of co-operation and co-ordination is created in the health care system. A major step in this direction has already been made with the re- organization of the indigenous system of medicine by establishing the Ceylon Ayurvedic Medical Council. There have also been attempts made by the same council and supported by the Colombo Ayurvedic Medical College and by the Ayurvedic Research Institute to bring the ayurveda art of heal- ing closer to the western (allopathic) system. It will be necessary, however, to proceed further in this direction and to involve the two western-type medical colleges in Sri Lanka, which have kept apart until now. At present, the situation is as follows: (1) the western sector is overburdened with tasks of a very simple nature which do not require the competence of a western doctor; at the same time the AMPs, who have been and still are delivering these tasks, are being abolished as a not competent enough profile of health manpower; (2) it is rather difficult to fill-in the vacancies in rural areas with western doctors, who resent working in the rural environment; (3) the ayurveda practitioners attempt forcefully to get a better share of the delivery of health services in the government sector; (4) the population appreciates both sectors and has its own ideas of the way in which it should make use of both systems. There are no indications that each system has its own clientele. Moreover, it is indicated that both systems have competences which are complementa.Y'y. The integration of the two systems of medicine is not simply a matter of mixing different techniques, although it is always put forward as the most significant issue: the old story of the failure of the one system and the success of the other, in individual cases, There are facts which show that in some conditions neither system can provide a cure, that in another both systems will prove successful since the condition is likely to cure spontaneously, and that treatments of proven efficacy are equally prescribed SEA/PHA/149 Page 217 by the two sectors. On the other hand, there are conditions which clearly require treatment in a modern allopathic set-up, using all the sophisticated equipment available in a big hospital. And there are conditions, especially psychosomatic ones, which need a considerably different doctor-patient relationship than that usually provided by the western sector. Thus, there is a basis on technical grounds to ascribe defined roles to the two systems as far as medical care is concerned. With regard to some standard methods used in family health and in the control of communicable diseases, they can be easily performed after a short period of training by any person who is interested to do them. The technical co-operation between the western-type doctors and other personnel, from one side, and the ayurveda practitioners, on the other, can be based on a working manual prepared by a joint technical body and approved by the medical councils concerned. However, there are o~her aspects of the problem, which should be solved before an attempt at integration of the two systems is made. There are problems of professional prestige, social status, social role, linguis- tic barrier, political issues, etc. Much effort will be required to create an appropriate atmosphere for integration and the experience of other countries should also be thoroughly studied (147, 148, 149, 150). 8.4 BASIS FOR POLICY DECISION 8.4.1 The Model In order to give a more comprehensible basis for a decision regarding changes in the health care system, the government was provided with a set of thirty alternative solutions derived from a linear programming model for health manpower requirements (see Annex 4). The alternatives showed the manpower requirements and the cost of the six health programmes (ref. to Section 7.2), delivered by each of the five health care delivery systems (ref. to Section 7.3). The summary of some alternatives, in terms of cost and capital investment, is presented in Table 8.2. They are related only to the government sector of the health care system. None of the thirty alternatives was shown to the feasible, i.e .. applicable in the framework of the available resources.* Even the existing situation was shown not to be feasible, which looks paradoxical. However, the model was developed to represent a health care system which utilizes its resources within certain reasonable limits of efficiency. When the model was tested for the first time, it was assumed that the hospitals would be utilized at a maximum occupancy of 100%. No feasible solution could be obtained. Then, it was assumed that the turnover of hospitals may be increased by 20%, 10% by a reduction of the average duration of treatment, and another 10% by admitting "floor patients", i.e., patients who do not have a separate bed and sleep on the floor during the night. These two assumptions, which were considered the furthest violation of basic regula- tions while keeping within a reasonably acceptable level of the inpatient treatment, did not improve considerably the feasibility of the solution of the model. It has been shown (with reference to Table 8.2) that there is a deficit of resources for 250 440 hospital admissions annually in the present health care system and under the conditions of the present health *All data used for the estimate of the parameters for the model relate to 1971. SEA/PHA/149 Page 218 prograoune. There are three ways of dealing with the present situation: (i) to continue with the present chaotic admission to hospital wards at the patients' request; (ii) to construct more hospitals which will cost Rs 39 million as investment and Rs 12 million annually for recurring costs; (iii) to develop a rational policy of hospital admissions. Table 8.2 THE TOTAL ANNUAL COST AND CAPITAL STOCK DEFICIT IN MILLIONS OF RUPEES OF HEALTH PROGRAMMES* ---- Code No. Annual expenditure Capital stock deficit (ref. to Table 8. 3) 1 238.9 39.3 2 261.1 108.3 3 265.7 106.1 7 235.8 33.5 8 253.6 50.5 9 248.8 70.1 13 221.3 1.4 14 237.7 33.5 15 225.5 11.0 19 206.8 33.5 20 212.1 45.0 21 217.3 38.4 25 203.8 33.5 26 209.1 45.0 27 209.4 38.4 *The figures in this Table are based on an assumption of higher producitivity than observed, thus they are different from figures in Table 7 .1. For better understanding of the alternatives presented, Table 8.3 has been prepared. It shows the different combinations of health progranuues and health care systems which correspond to particular alternatives. Table 8. 3 CODE NUMBERS AND ALTERNATIVE SOLUTIONS IN TERMS OF HEALTH PROGRAMME AND HEALTH CARE SYSTEM (Refer to Table 8.2) H e a 1 t h p r o g r a m m e s Health care systems Disease Environ-No Family control FH & mental Hospital change health and med. DC health treatment care No change 1 2 3 4 5 6 Health centre 7 8 9 10 11 12 AMP 13 14 15 16 17 18 PHM 19 20 21 22 23 24 Ayurveda doctor 25 26 27 28 29 30 SEA/PHA/149 Page 219 All parameters for the model were calculated from the original data collected from a sample of health care units during the NHMS. Certain adjustments were made to "normalize" the parameters, making allowance for the level of utilization of observed health care units (hospitals, dispen- saries, MOH offices, etc.). It was anticipated that: (1) the integrated district hospitals, peripheral units, and central dispensaries would perform the services of both the medical care institutions concerned and the MOH office, with an efficiency increased by 10%. (2) the PHM would carry out OPD visits (medical care), preventive visits, vaccinations, home deliveries, home visits, environ- mental examinations, and environmental health duties with higher efficiency, because of the proximity to the consumers' homes; (3) the ayurveda practitioners would perform the same services as the PHM (except the home deliveries), and at the same cost. The numbers of the different categories of health activities which constitute different health programmes are shown in Annex 4. The upper limit of the government annual health expenditure in 1971 was Rs 227.4 million. Table 8.2 shows that all alternatives in which the western doctor is the basic health worker exceed this limit. Also, the AMP alternative for the health programme with an emphasis on family health requires about Rs 10 million more than what the government has allocated for health. The other alternatives cost less than the maximum of the government health expenditure. The capital stock deficit has its roots mainly in the high demand for inpatient treatment. It was calculated under the assumption that the hospital bed deficit would be compensated by the expansion of district hospitals and peripheral units, whether integrated or not. The only alter- native with a minimum capital stock deficit is the alternative 13 (see Table 8.2) in which the computer allocated almost all the indoor patients to the integrated central dispensaries and no patient was expected to be treated in the Colombo group of hospitals. It is clear that such a solu- tion, although matherr~tically correct, is practically meaningless, A similar solution is presented as alternative 15. The solutions displayed in Table 8.2 are given as examples of the potential of the application of such a model. The real solution might be a blend of health progranunes and health delivery systems, as defined in this section. The health manpower implications of the above alternatives are shown in Annex 4. 8.4,2 The Test-Run The National Advisory Committee for Health Manpower Planning recom- mended that the alternative health care delivery systems should be tested simultaneously in similar pilot areas; and that the results of the test- runs should be evaluated in terms of (i) the feasibility of organizing the delivery of the services desired, (ii) the acceptability of services by the population and the he3ltb workers; (iii) the output of the health aclivi·- ties and the coverage of the eligible population, and (iv) the cost oi the services~ SEA/PHA/149 Page 220 It was pointed out that all precautions should be taken not to intro- duce bias at any stage of the test-run, in the areas for implementation of different changes, in the selection of personnel, in the intensity of con- trol during the implementation, and in the use of criteria for the assess- ment of the performance, Each pilot area should have between 30 OOO and 60 OOO population and an average development of the health services regarding staffing, equipment, and supplies. The supervision should be conducted without changing the present pattern. Before the test-run, the personnel participating in the test-run should be trained. At the time of the beginning of the test-run, the organization pattern of each pilot area health services should be adjusted to the recommendations given for each alternative health care delivery system: (1) An MOH area should be selected as control, (2) A district hospital and a peripheral unit, each with a population in the surrounding area of about 30 OOO to 60 OOO will be staffed with public health personnel from the area MOH office and specialized campaigns, working already in the area. The MO-in charge will be trained in public health work and he will be responsible for the delivery of all health services in the area. All small rural medical institutions in the area, like central dis- pensaries, rural hospitals, etc., will be closed down. (3) In a fourth area of a similar size, all small rural institutions, including peripheral units, will be put in charge of AMPs, after their undergoing appropriate training. The public health personnel from the MOH concerned will be attached to those institutions and supervised by the AMP- in charge. (4) In a similar area, a district hospital will be staffed with public health personnel, but not with AMPs, The PHMs and the MO-in charge will be appropriately trained before the start of the test-run. All other rural medical institutions in the area will be closed down. (5) Finally, in a similar area, all ayurveda practitioners will be trained appropriately, also the MO-in charge of the district hospital. All rural health institutions will be closed down. During the test-run, the usual records will be regularly maintained, The duration of the test-run should be not less than 6 months, but not more than one year. The Health Planning and Programming Division, Ministry of Health, will be responsible for planning, and organizing the training and evaluation of the test-run. 8.4.3 Summary The feasibility, the manpower, and the financial implications of the altern.ative health care systems and the alternative health programmes were tested by a linear programming model for health manpower requirements (see SEA/PHA/149 Page 221 Annex 4). The solution to the model pointed out the enormous over-utiliza- tion of some health services at present, especially hospital treatment, which seemed hardly to be compatible with an efficient health services delivery. At the request of the decision-maker, a proposal for a test-run of the alternative health care system has been drawn-up. The assessment of the results frofil the pilot areas will indicate to the government the most acceptable alternative. 8.5 SUMMARY OF THE CHAPTER Any change in the health care system, which is meant to control the three main areas of concern and which is aimed at defining who is to deliver the health services, will generate changes in the roles of the health pro- fessions. The most affected in this regard will be doctors, assistant medical practitioners, publi~ health midwives, and ayurveda practitioners. A prograIIDlle of training, re-training, and on-job training should be developed in order to prepare the "basic health workers" for their new roles. The training objectives should be formulated in behavioural terms, the curricula developed, and the teachers trained and motivated, especially for the integration of the western and the indigenous systems of medicine. An increase in the output from the schools for the health professions will probably not present a major problem in Sri Lanka. However, the process of training health manpower for their new jobs is likely to involve a consider- able time-lag. The integration of the western and ayurvedic sectors of medicine seems to be necessary in any situation, There are a few technical and many professional, social, political, and economic issues involved which make the whole problem extremely complicated and difficult to resolve. A mathematical linear programming decision model for health manpower requirements was developed and run on the computer. The solutions showed an extreme over-utilization of hospital treatment and a low cost for the alternatives in which the ayurveda practitioners or PHMs play the role of the basic health workers. The same alternative health care systems should be tested under field conditions with proper control. CHAPTER 9 INTRODUCING CHANGES SEA/PHA/149 Page 223 The acceptance by the government of one of the proposed alternatives, before or after the field test-run, would not be the only reward of all the efforts invested in carrying out the NHMs in Sri Lanka. The main purpose of the study was to help create a mood of receptiveness in the health care system so that the idea of changes in the system would become acceptable whenever a change was felt to be needed. This, in itself, represents a process of change. It also calls for those preconditions which were referred to in the Chapter 2: need, opportunity, resources, and motivation of the decision-maker. It also depends on the prevailing "rationale" for selection, which the decision-maker will respect in selecting an alternative: a rationale composed of and oscillating between political, social, economic, technical, legal, and administrative factors (151). This aspect of health and manpower planning was not investigated separately. However, certain inferences concerning the "changeability" of the health care syc.tem and the health manpower process may be made from the data collected and from certain observations made elsewhere in this book. The problem will be highlighted from two sides: (1) the organization of health and manpower planning on a permanent hasis in the country; and (2) the support by the Health Manpower Study to the objective stated in (1). 9 .1 ORGANIZATION OF HEALTH AND MANPOWER PLANNING IN SRI LANKA The organization of health planning and of health manpower planning as a part of it depends on a given state of mind of the decision-maker, on his attitude, and on the planning expertise available. But not only on that. The planning process needs a defined objective, certain given re- sources, and an appropriate organization which will guarantee the efficient functioning of the planning process. Health and manpower planning at the national level has had the full support of the Ministry of Health and the Department of Planning and Employ- ment in Sri Lanka. Also, the Health Planning and Programming Division has the necessary resources for carrying on its tasks. However, there is an impression that the objectives of the Health Planning and Programming Division need to be defined more clearly. Very often the division is used as a source of data or information on an ad hoe basis, without expecting it to offer any solutions to the problems. On other occasions, complete medium-term health programmes are expected from the division, at short notice, with limited possibilities of studying problems. In brief, the Health Planning and Programming Division has been finding its way. For rational and effective health and manpower planning on a perma- nent basis, it is necessary to state clearly: (1) the objectives of the Health Planning and Programming Division; SEA/PHA/ 149 Page 224 (2) its relationship within the Ministry of Health and outside the Ministry; (3) the methodology of work, including the development of an adequate health information system; (4) the specific relationship with the regional and lowet. levels in the health care system, time, the planning capacity at intermediate institutional levels should be developed. (SHS divisional) At the same (divisional) and It should be pointed out that the establishment of a separate planning and programming unit is very often not appreciated by the health administra- tors, They consider themselves responsible (and capable) of performing all the managerial functions required. For this reason, considerable effort and skill in human relations on the part of the planners will be needed in estab- lishing their activities not in c0mpetition but as supplementary to the activities of the health administrators, whose reaction to the health plan- ner very often can be summarized in the statement: "you find the money, I know how to spend it ! " 9.2 APPLICABILITY OF THE FINDINGS OF THE NATIONAL HEALTH MA.~POWER STUDY The NHMS was meant mainly to promote the health and manpower planning process and to organize it on a permanent basis in Sri Lanka, by providing an example of the benefits from an organized planning effort, with set objectives and clear concepts and methodology. Has it succeeded in this task? It is too early to make conclusions regarding the success or the failure of the study. What can be put on the credit side of the study, is the fact that a large number of health administrators, teachers in the health professions, health workers, and other related persons were exposed to the concept ~nd the methods of health and manpower planning (see Annex 5). Another point for credit is the declared readiness of the government to test the alternatives offered by the study. The potential benefits from the study, which may reinforce the posi- tion of the health planning machinery,may be classified in three categories on the basis of their time dimensions. 9.2.1 Short-Term Benefits The short-time benefits relate to a more rational and efficient way in which the available resources can be utilized at present. The study led to two kinds <:i. conclusions: (1) regarding the improvement of the management of the health care system; (2) regarding the structural changes in the system. SEA/PHA/149 Page 225 The following steps for improving the health care system management are necessary and feasible: (1) improvement of the health information system, for which the focal point would be the Health Planning and Programming Division; information would be supplied by: - the Health Statistics Branch, which would make efforts for regularly checking the reliability of the hospital statistics and the operational data on the health care system; - the Ceylon (Sri Lanka) Medical Council, which should be assisted to develop a systematic follow-up of data on the doctors, the nurses, and the midwives, and to bring these data up-to-date; - the Ayurvedic Medical Council, which should provide regular information on the ayurveda medical practi- tioners; - the medical schools, which should provide information on the applicants, the graduates, the fall-outs, the faculty, and the curriculum changes; - other sources, like the Department of Census and Statistics, the Registrar General's Office, Department of Planning, etc., which will be requested to regularly provide relevant data on structured formats for the purpose of planning and evaluation. (2) Further development of the planning - programming - budgeting system (PPBS) already adopted by the Ministry of Health,which should follow the structural changes of the total health care system. The structural changes of the system are related to: (l) a review of the education policy of the schools for the health professions regarding student admissions, the formulation of training objectives to correspond to the roles of the health professions, a review of the curriculum, and a review of the period of internship; (2) a review of the organizational structure of the government western sector and a consideration of the formulation of programmes on a regional rather than on a technical basis. This will facilitate the future integration of the medical care and the public health services; (3) a review of the efficiency of the different types of health care units (especially the small rural institutions like branch dispensaries, visiting stations, and maternity homes) and closing down those whose efficiency is below a limit (say 50% utilization) provided that it will not create major problems of accessibility by the population. SEA/PHA/149 Page 226 The above measures are likely to improve the health services delivery innnediately or before the end of the present Five-Year Plan, 9.2.2 Medium-Term Solution There are solutions which are expected to improve the health care system in the course of the next five-year period. They must be based on a carefully designed programme and they should be conceived as a step towards the achievement of the long-term objectives of the study. The nature of this programme will be determined by the government's decision on the priority health areas of concern and on the most acceptable health care system, i.e., the medium-term health programme should start with the test-run of the alternative health care systems. The programme of the medium-term solutions should develop along the following list of activities: (1) planning for the test-run; (2) job description of the health workers in their new roles in each alternative health care system; (3) selection of pilot areas for the test-run; (4) training of the personnel working in pilot areas; (5) carrying out the test-run; (6) assessment of the test-run and making a decision regarding the most acceptable health care system; (7) teacher training; (8) re-training of personnel for the implementation of changes throughout the country; (9) gradual implementation of changes by regions (SHS division); (10) changes in the technical and administrative suprastructure to suit the new health care system; (11) changes in the education system for the health professions to suit the new health care system. Certain activities may be performed simultaneously. 9.2.3 The Long-Term Policy This policy should have to be planned and conducted to meet conditions of uncertainty in many respects. However, the data collected during the Health Manpower Study indicated that the uncertainties are linked mostly with SEA/PHA/149 Page 227 the total socio-economic development of the country (including population dynamics) rather than with a changing pattern of morbidity and health technologies. For this reason, it seems reasonable to assume that: (1) the pattern of the health problem is unlikely to change significantly during next twenty years regardless of the development of health technologies, provided a big change in the socio-economic development of the country does not occur; (2) the most important determining factor which should be taken into consideration is the size of the population, i.e., the population growth. Such a simplistic approach to long-term planning bears the risk of introducing distortions, which may be demonstrated by overplanning in some areas of concern, since more problems may be abolished as a result of certain unforeseen developments; and of underplanning in other areas, if the socio-economic development of the country brings the population to the present level of western countries with the health problems that they have. However, in planning for such a long period ahead, some risks would have to be taken, but there should also be an opportunity for timely re- planning. 9.3 SUMMARY OF THE CHAPTER The organization of health and manpower planning in Sri Lanka on a permanent basis is the guarantee that the health care system will become sensitive to changes in the environment in which it operates and will react to them with adequate changes in the system itself. The organization of health and manpower planning depends not only on the development of an adequate organizational structure (Health Planning and Programming Division) capable of applying planning techniques, but also, and very much more, on the demonstration of the benefits which such an organization can contribute to the management of the health care system now, in the near future and in long-tenn. The role of the National Health Manpower Study in Sri Lanka should be considered in the above context. 10.1 The Aftermath* CHAPTER 10 THE AFfERMATH AND CONCLUSIONS SEA/PHA/149 Page 229 Three years is a long period of time under certain circumstances and very short under other circumstances. At the time of reporting to the government on the National Health Manpower Study (NHMS), the mood in the country was not the same as it had been at the time of planning for the study. The urge for a change in the health system slackened, owing to the emergence of more pressing needs in the socio-economic life of Sri Lanka, to personnel changes in decision- making at the national level, to a failure to clearly and aggressivelv communicate the findings and recommendations to the policy makers, etc. The decision-makers could not yet be made to understand that the health care system in Sri Lanka had reached its limits in efficacy and that fundamental changes in the system were necessary to prevent the waste in resources and the deterioration of the health status of the population, which will lead to unnecessary suffering and undesirable social conse- quences. There have already been reports, e.g., in the press, of serious problems in the health care services concerning overcrowding in the larger hospitals, the inadequate distribution of drugs, and the high cost of the services. One of the purposes of this book actually is to convey this message to the right places. Thus, three years has meant quite a lot! On the other hand, it would be too optimistic to expect that a solu- tion with far reaching consequences can be easily accepted. The rigidity of the health care system in Sri Lanka is one of its basic characteristics. And it may be a great mistake to embark on changes without appropriate pre- parations that would ensure success. It is perhaps wishful thinking to believe that a country can start at once to manage its health services in the manner of an efficient business corporation, especially in its twenty- third century of existence. For this reason, three years may be considered a short-time span. What then is there to be done? As the improvement of health services management is a long-lasting process, it is necessary to consider the approaches from different levels and different fronts. 10.1.1 Policy Level There has been little awareness in Sri Lanka that health costs money. The health services were r.onsidered to be like air for breathing, both by the population (consumers) and by a large number of decision-makers; it was a commodity which should be provided on request, free of charge, at any time, *Due ackno-;,_,ledgement is made to Dr Paul Woolley for his contribution of facts and suggestions to this section. SEA/PHA/149 Page 230 at any place, and in any quantity. This still seems to be the official policy, although the government has adopted the Planning-Programming-Budget- ing System. However, the PPBS is still considered more as an accounting technique than as a programming tool. On the basis of the findings and proposals of the NHMS, the Health Planning and Programming Section (HPPS) in the Ministry of Health issued the following documents addressed to the Secretary of Health: (1) Policy implications of the National Health Manpower Study and recom- mendations for implementation, in which an explicit proposal is given on how to implement the recommendations of the NHMS for a policy decision. This may have contributed to the resumption of the training of Ai.'1Ps. (2) Institutional financial analysis and planning, in which the importance of cost analysis for policy is explained. The purpose of this document is to generate cost-awareness at a policy and decision-making level. (3) Planning proposal for nutritional surveillance and intervention. On the example of a special programme the planning function of the Ministry of Health was outlined in terms of: (a) development of a surveillance/information system, (b) development of an intervention strategy, (c) policy of manpower training and in-service training, (d) development of a system of improved management of the health care system with attention to: - referral, - area of coverage, and - definition of the activities of health personnel, (e) co-ordination of external resources of assistance in order to get optimum benefits, (f) projected costs and impacts of the proposed changes. The HPPS discussed extensively the regionalization of the health services, the methods of control on the admission to hospitals on the duration of stay in hospitals, the integration of the services delivering primary health care, and the possibility of increasing the involvement of the ayurvedic services in the implementation of health programmes. 10.1.2 Health Sector Planning It was recognized that health sector planning should be organized through the HPPS, established in 1970. For this purpose the Secretary of Health was advised that: (1) the HPPS needs clearly stated objectives and functions, (2) the relationship of the HPPS to the operational level, i.e., the divisional superintendents of health services (SHS), health institutions, and offices of the medical officers of health, should be defined. SEA/PHA/149 Page 231 (3) a methodology and programme of work for the HPPS should be developed, regarding the development of: - a simple and meaningful health information system, - meaningful measures of work performance for institutions and programmes, - continued review of the efficacy of different types of health institutions and offices, - review of the organizational structure of the government western sector, - review of professional education policy, - co-ordination of external resources of assistance, as a part of the planning process. 10.1.3 Operational Level The planning at divisional (regional) and institutional level should be based on a methodology developed by the HPPS and interlinked with sec- torial planning and policy formulation. This should be one of the future important tasks of the HPPS. 10.2 Conclusions The conclusions will be confined to three important issues: Has the National Health Manpower Study achieved its objectives and purposes and at what cost? Was the strategy of the study appropriate? What to do next? (1) The NHMS produced a fairly comprehensive picture of health manrower utilization. Moreover, it proved that the inappropriate utilization of the existing health manpower was one of the fundamental problems of the health care system in Sri Lanka. Alternative points of intervention have been suggested. Each of them will require redefinition of the roles of different types of health personnel. From the point of view of effectiveness, the most promising alternatives are health centres led by assistant medical practi- tioners (i. e,, "integrated dispensaries") and the integration of allopathic (western) medicine with ayurveda into what might be called "Sri Lanka medicine" in which the responsibility of providing basic health care would be given to ayurveda practitioners. However, the redefinition of the roles of the different health occupations, which can be done by utilizing the comprehensive information from the NHMS, has not been completed because a policy decision regarding changes in the health care systems must first be made. SEA/PHA/149 Page 232 (2) A set of projections of the future health manpower requirements was generated, taking into account the possible decisions for an optimum health programme and optimum health care delivery system (see Annex 4). The step should be to redefine the educational goals, based on the new roles of the different types of health workers. (3) The government was presented with arguments based on evidence to formulate its health policy: to select priorities, to set targets, to choose the most acceptable strategy, i.e., the way of implementation of its health policy, and how to go along that way (tactics). Time will be needed to assimilate the proposals, to take decisions, and to implement them. In this task, the government will need the continuous support of the planners. (4) The NHMS contributed considerably to the strengthening of the national health planning capacity, including the health information system, and to the co-operation between the health administration and the medical schools. The study demonstrated the benefits which may be expected from the application of health practice research. (5) A detailed account on the cost of the study is given as Annex 6. During the one year of preparation and the two years of study, the costs incurred were as follows: Government costs External costs Total cost US$ 80 OOO (or Rs 512 OOO) US$ 283 874 (or Rs 1 816 800) US$ 363 874 (or Rs 2 328 800) Compared with the government annual expenditure on health, the total cost of the study represents 0.45%, out of which the government provided 0.1%. This is equivalent to Rs 0.09 per capita per year, or Rs 0.02 if only the government expenditure for the study is taken into consideration. A regular planning activity, with an adequately organized health information system, is unlikely to incur a higher cost for planning annually than those which were borne by the government, i.e., 0.1% of the budget (or Rs 0.02 per capita). (6) It is rather early to speak of benefits in terms of improvement in the population's health. It is also early to speak about the benefits gained by the health care system. Moreover, it is true that the study has not made a breakthrough with regard to developing new kinds of health workers who will solve all the problems of the country, which any how it was not intended to do. However, the benefits from the study may be summarized as follows: (a) giving support to the organized establishment of health and manpower planning in the country; (b) emphasizing and quantifying the major health concerns; (c) providing a basis for the development of a national health and manpower planning methodology; (d) providing a basis for changes in the health and manpower system with innnediate, medium and long-term consequences; SEA/PHA/149 Page 233 (e) providing options for a better utilization of the available health manpower and for the development and maintenance of health manpower in the future; (f) testing the options by a mathematical model and designing methods for testing the options in the field. (7) A holistic approach to the probLem of health manpower planning is needed if meaningful solutions are to be offered. The study of the whole system has shown that the problem of health care services delivery is a problem of utilization of the available resources and not a problem of shortage of health manpower, as was thought some years ago when it was decided to establish the second medical faculty in Sri Lanka. Also, the study of the whole system pointed out the significance of the ayurveda system in the delivery of medical services. (8) Some important strategic aspects of the study should be underlined: (a) the selection of the Health Planning and Progranuning Division (Section), which belongs to the health administration, as the focal point of the study, immediately gave a more practical and less academic slant to the whole effort; (b) the appointment of the National Advisory Committee for Health Manpower Planning brought together almost all those who were concerned with health and health manpower and gave them an opportunity to get involved in the health planning process from the very beginning. Such a body might develop into a permanent Health Advisory Council to the Ministry of Health; (c) the efforts to strengthen the regular providers of health information were made by involving them in the conduct of the sub-studies related to their areas of concern; (d) the reliance on national investigators, researchers, and experts provided an unique opportunity to them to benefit from their involvement in the national health planning effort. Their experience will be of use in the future. On the debit side of the applied methodology there were: (a) the irregular meetings of the National Advisory Committee because of its large membership. Perhaps a smaller body would have been more effective; (b) the overplanning of some sub-studies was due to the rigiGity in the selection of samples in order to conform to certain statistical principles. In such studies the data might be interpreted with greater liberty. The rigid adherence to statistical principles increased the cost of some sub-studies considerably; (c) the oversizing of some sub-studies was due to the collection of data much above the optimum. Generally, the data collection effort was overestimated. The study and the health and man- power planning could have been easily completed with less data; (d) the computer processed mathematical model did not seem to contribute significantly to the decision of the government. R E F E R E N C E S SEA/PHA/149 Page 235 REFERENCES SEA/PHA/149 Page 237 1. World Health Organization, Twenty years in South-East Asia, New Delhi, WHO Regional Office for South-East Asia, 1967, pp.20-21. 2. Proposed programme and budget estimates for 19?6-19??, New Delhi, WHO Regional Office for South-East Asia, 1974, p.1. 3. Ibid. ref. 2, p.4. 4. International Labour Office, Matching employment opportunities and expectations - a programme of action for Ceylon: the report, 1971, p.X. 5. Ibid. ref. 4, p. XVI. 6. Ibid. ref. 4, The technical papers, pp.215-223. 7. World Health Organization, The use of operational research in health ser'Vices, Copenhagen, WHO Regional Office for Europe, 1970, p.12. 8. Ibid. ref. 4, The technical papers, p.5, para 4. 9. Mendis, G.c., Ceylon today and yesterday: main currents of Ceylon history, Colombo, The Associated Newspapers of Ceylon Ltd., 1963, pp.4-5. 10. Ibid. ref. 9, pp.143-166. 11. Taylor, V.D., In: Bryant, J., Health and the Developing World, Ithaca and London, Cornell University Press, 1969, p.107. 12. The Concise Oxford Dictionary, Fifth edition, Oxford University Press, 1964, pp.17 and 739. 13. Modern management methods and the organization of health services (Public Health Papers No.55) Geneva, World Health Organization, 1974, pp.13-14. 14 •• Application of modern management methods and techniques for the improved delivery of health ser'Vices, New Delhi, WHO Regional Office for South-East Asia, 1973, p,10. 15. Na~ional health planning in developing countries (Technical Report Series No.350) Geneva, World Health Organization, 1967, p.9. 16. The development of studies in health manpower (Technical Report Series No.481) Geneva, World Health Organization, 1971, p.11. 17. Hulugale, H.A.J., Guide to Ceylon, Revised second edition, Colombo. Lake House Investments Ltd., 1973, p.6 ' 18. Department of Census and Statistics, Statistical abstracts of Ceylon - 1969, Colombo, Government Publication Bureau, 1970, p.1. SEA/PHA/149 Page 238 19. Ibid, ref. 18, p. 91. 20. Knox, R., (1681) An historical Relation of Ceylon, reprinted in Sri Lanka, Dehiwela, Tisara Prakasakayo, 1966. 21. Department of Census and Statistics, Census of population, 1971, Preliminary release No.l, Colombo, 1972. 22. Marshall, H., (1846) Ceylon: A general description of the island and its inhahitants, reprinted in Sri Lanka, Dehiwela, Tisara Prakasakayo, 1969, pp, 18-19. 23. Ibid. ref. 20, pp.18-19. 24. Department of Census and Statistics, Preliminary report on the socio- cconomic survey of Ceylon 1969-70, Colombo, 1971, 25. Ibid. ref. 4, The report, pp.22 and 26. 26. Central Bank of Ceylon, Annual report of the Monetary Board to the Minister of Finance for the year 1972, Colombo, 1973, p.23. 27. Ibid. ref. 26, p.26. 28. Ibid. ref. 26, pp.27-29. 29. Ministry of Planning and Employment, The Five-Year Plan, 1972-1976, Colombo, Department of Government Printing, 1971, 30. Myrdal, G., Asian Drcona, An inquiry into the poverty of nations, Penguin Books, 1968, Volume I, p.69, 31. Galbraith, J.K., Economic development in perspective, New York, Faucett Publications, Inc., 1962, pp.12-15. 32. Chakraberty, c., An interpretation of ancient Hindu medicine,Calcutta, 1923. 33. Jainudeen, M.A., Patterns of organization of nursing administration in Ceylon~ Colombo, 1961 (mimeographed unpublished document). 34. Ibid. ref. 20, p.213. 35. Davy, J., (1821) An account of the interior of Ceylcn and of its inhahitan~s with travels in that island, reprinted in Sri Lanka, Dehiwela, Tisara Prakasakayo, 1969, pp.183-184. 36. Ibid. ref. 29, pp.113-121. 37. Ministry of Planning and Economic Affairs, Report of the Planning Committee on Education, Health, Housing, and Manpower, Colombo, Ceylon Government Press, 1967, p.l. 38. Ibid. ref. 37, p .2. 39. Ibid. ref. 37, pp.85-89 and 100. SEA/PHA/149 Page 239 40. Gish, O., Doctor migration and world health, (Occasional aper on Social Administration No.43) London, G. Bell & Sons, 1971, pp.80-86. 41. lb id. r.:f. 29 , pp .109-112. 42. Schaefer, M., Evaluation/decision making in health planning and admin- istration, (HADM Monograph Series No.3) Chapel Hill, The University of North Carolina, 1973, pp.13-16. 43. lb id. ref. 16, pp. 47-51. 44. lb id. ref. 35, pp. 80-81. 45. Ibid. ref. 20, p,173 46. lb id. ref. 20, p, 177. 47. Ibid, ref. 20, p .178. 48. Pier is, R., Sinhalese social organization, The Kandyan period, Colombo, The Ceylon University Press, 1956, p.206. 49. Ibid, ref. 30. 50. Ibid. ref. 9, p.3. 51. Ibid. ref. 48, p,1.57. 52. lb id. ref. 22, p. 20. 53. Ibid. ref. 35, p.216. 54, Ibid. ref. 20, pp.172-175. 55. Ibid. ref. 35, p,213, 56. Jones, G.W. & Selvaratnam, S., Population growth and economic develop- ment in Ceylon, Colombo, Marga Institute, 1972, pp.41-43, 57. Ibid, ref. 20, p.213. 58. Ibid. ref. 22, p.34. 59. Sarnarasekera, R., Report of the Registrar-General of Ceylon on Vital Sta-tisti'.cs for 1965, Part I [Civil (H)], Colombo, 1970. 60. Health planning: problems of concepts and method (Scientific Publi- cation, No.111) Washington, Pan American Health Organization, 1965, p,25. 61. Michael, J.M., Spatefore, G. &Williams, E.R., US Public Health Reports, 83: No.l, Department of Health, Education and Welfare (1968). SEA/PHA/149 Page 240 62. Ruderman, A.P., General economic considerations, In: Reinke, W.A., Health planning, qualitative aspects and quantitative techniques, Baltimore, The Johns Hopkins University, 1972. 63. Ibid. ref. 26, p. 2 7. 64. Ibid. ref. 29, p.2. 65. lb id. c:-ef. 29, p. 3. 66. lb i ,[. ref. 29, p .10. 6 7. lb id. ref. 29, µ.12. 68. ibid. ref. 29, p.113. 69. Ibid. ref. 29, p .114. 70. Ibid, ref. 29, p.116. 71. Ibid. ref. 29, p.117. 72. Ibid. ref. 29, p.119. 73. Ibid. ref. 29, pp. 119-120. 74. Ibid, ref. 29, p.120. 75. Planning and Programming Section, Ministry of Health, Five Year Plan, :,,:"/ ll1 Sector, 1972-1976, (mimeographed working document). 76. 'i/1,; Concise Oxford Dictionary, Fifth edition, Oxford University Press, 1964, pp.13, 14, 77. Planters' Association Estates' Health Scheme, Medical Director's He port for the Year 1969. 78. Ministry of Health, A proposal for setting up an Asian Health Organi- zation (AHO) with constitution and appendices, Colombo, Ceylon Govern- ment Press, 1962, p.S. 79. Report of the Commission on Indigenous Medicine, Sessional Paper XXIV. Colombo, Ceylon Government Press, 1947, p.4. 80. Ibid. ref. 79, p. 5. 81. Ibid. ref. 79, p.6. 82. Ibid. ref. 78, p.2. 83. Report of the Committee of Inquiry into salaries and other conditions of Ayurvedia physicians and other Ayu:rvgdic personnel in government and local government se:rvices, Sessional Paper VII-1967, Colombo, Ceylon Government Press, 1967, p.5. 84. Ibid. ref. 79, p.32. 85. lb id. ref. 16 , p. 9 . SEA/PHA/149 Page 241 86. World Health Organization, Questionnaire No.4, Health ManpOuJer, Division of Health Statistics, Dissemination of Statistical Informa- tion, 1974. 87. Gish, O., Doctor Auxiliaries in Tanzania, Lancet, 2: 1252 (1973). 88. Ibid. ref. 4, The technical papers, p.30~ para 4. 89. Hall, T.L., Health manpOuJer in Peru, a case study ~n planning, Baltimore, The Johns Hopkins Press, 1969, p.87, 90. Planning Commission, Government of India, Fourth Five-Year Plan, 1969-74, Draft, 1969, p.314. 91, Ministry of Public H~alth, Public health in Thailand, 1973, pp.102 & 119. 92, Baker, T. & Perlman, M. Health manpower in a developing economy: Taiwan, a case study in planning, Baltimore, The Johns Hopkins Press, 1967, p. 46. 93. Paredes-Manrique, R. & Agualimpia, c., Study of human resources for health and medical education in Colombia: methods and results, Bogota, Ministry of Public Health of Colombia - Colombian Association of Medical Faculties, 1972, pp.110-111. 94. Taylor, C.E., Dirican R. & Deuschle, K.W., Health manpower planning in Turkey, an international research case study, Baltimore, The Johns Hopkins Press, 1968, pp.11 and 36. 95. Ibid. ref. 89, p,101. 96. Bryant, J. Health and the developing world, Ithaca and London,Cornell University Press, 1969, p.50. 97. Ibid. ref. 93, p.111. 98. Abel-Smith, B., An international study of health expenditure and its relevance for health planning, Geneva, World Health Organization, 1967, (Public Health Papers No.32). 99. Ibid. ref. 93, p .119. 100. Ibid. ref. 89, p, 103. 101. Ibid. ref. 94, pp.37-38. 102. Fonseka, C., The Story of the Colombo Medical Schools, In: The Colombo Medical School Centenary, 1870-1970, Colombo, p.9. 103. Ibid. ref. 102, p.10. SEA/PHA/149 Page 242 104. Ibid. ref. 89, p,115, 105. Ibid, ref. 94, p,111 106. Ibid. ref, 40, p.85. 107. Health Department, Instruction foY' the guidance of public health per>sonnel, Colombo, 1964, pp.27-28, 108. Ibid. ref. 79, p.5. 109. Ibid. ref. 90, p.314. 110. Ibid. ref. 91, p.102. 111. Ibid. ref. 92, p.77. 112. Ibid. ref. 94, p.144. 113. Ibid. ref. 93, p.136. 114. Ibid. ref. 89, p.145. 115. Ibid. ref. 96, p.50. 116. Ibid. ref. 94, pp.146-147. 117. Ibid. ref. 89, p.147. 118. Ibid. ref. 92, p.80. 119. Ibid. ref. 93, p.141. 120. Ibid. ref. 78. 121. Institute of Applied Manpower Research and National Institute of Health Administration and Education, Stock of doctor>s of non-allo- pathic systems of medicine, health and manpoWeY', (IAMR Report No. 3/ 1967) New Delhi, 1967, p.26. 122. Ibid. ref. 78, pp.26-29. 123. Ibid. ref. 91, pp.102-103. 124. Ibid. ref. 79, p,6, 125. Inid. ref. 83, p. 6. 126. Ibid. ref. 79, p.14. 127. Ibid. ref. 79, pp,32-33. 128. Ibid. ref. 79, p,35. 129. Ibid. ref. 83, pp,23-25. 130. Ibid, ref. 83, p.22. SEA/PJ!A/ 14 9 Page 243 111. Ibid, ref. 78, p.29. 132. Ibid. ref. 79, p.22. 133. Ibid. ref. 79, P· 21. 134. Ibid, ref. 107. 135. Department of Census and Statistics, Fertility tY'ends in Cuylmz, 7[153- 1Dti8, a:nd lhe National Family PZannin') I'Y'ogr•0111me (Monograph No, 17), Colombo, 1970, p.14, 116. Ibid. ref. 135, pp.13 and 15. 137. Gunasekara, D.B., Adrninisty,ation PepoPt of the DiY'ectoy, of Health SeY'Vices foY' the yeaY' 1967-68, Colombo, 1973, pp.125 and 127. 138. New Targets for Medicine, BY'itish Medical ,Journal, 5 October 1974, p.5. 139. l3'f'itish Medical ,Journal, 5 October 1974, p.54. 140. Ibid. ref. 137, p. B 439. 141. Klarman, H.E., The distinctive economic characteristics of health services, ,luurnal of Health and flwnan BehaviuuY', 1: 44-49. (1963) 142. Nagpaul, D.R. & Vishwanath, M.K., Economics of health, Pl'o(:,:cdin:1;: of lhe :::Jnd TuheY'cu lucis and Chest DiDcaGes WoY'keY'u' ConfeY'encx, Hyderabad, February 1967, pp.279-300. 143. Government of Sri Lanka, Estimates of the Y'eVenue and expcnd,ituy,e of the Government of the Republic of SY'i Lanka for the financial ycaY', Ll /unua'f'y 1973 to Jlst December 197.i, Colombo, 1973, Volume 2, page 1120. 144. Ibid, ref. 143, p.1112. 145. Ibid. ref. 143, pp.1112-1120. 146. :-lejia, A. et al., Monograph on health manpower' planning: pPinciple.s c1,nd methods (in preparation). 147. Sidel, V.W., The barefoot doctors of the People's Republic of China, The New E:,'ngland <foumal of Medicine, June 1972, pp.1292-1299. 148. Berger, R., Medical training in China, Eastern !Joy,izon f.1ontrily !ievi'.ew, Volume XII, Number 1, Hong Kong, pp.28-44. 149. 150. l ', l . l 52. I C'.., ) J. Chi-Chao Chau, Medical education in mainland China, JouY'nal of Medical 1'7ducation, 47: 32 7-332 (1972). McC:aull, J., A broader view, Z.:-nviPonment, J,J: 32-39 (1972). lbid. ref. 42, pp.29-42. Ibid. ref. 40, pp.81-82. Brown, P.A., The cost of clinical laboratory tesling, ,,'l\(.J/,, ??9: 1350-1351 (1974). ANNEX 1 BAS IC LNFOR!1A'i' ION SEA/PHA/149 Page 245 SEA/PHA/149 Page 247 CATEGORIES OF HEALTH INSTITUTIONS IN SRI LANKA Colombo group of hospitals - This is a group of eight specialist hospitals (besides convalescent homes) situated in the city and suburbs of Colombo; most of them are teaching hospitals. They have a total of 4714 beds, well-equipped pathological laboratories, and other auxiliary services. The General Hospital, Colombo, which belongs to this group, provides for a number of specialties including sub-specialties, like neurosurgery and cardio-thoracic surgery, but excluding paediatrics, obstetrics, ophthalmolcgy, and dental surgery. This hospital also has a well organized accident service and an intensive care unit. The other hospitals in the Colombo group are 2 maternity hospitals, a children's hospital, an eye hospital, a fever hospital. a cancer institute, a dental institute, a convalescent home, and a rehabili- tation centre. Provincial hospitals (P.H.) - These are large hospitals in the main cities in the provinces of the isalnd. An average provincial hospital will have over 600 beds. It will have specialists in medicine, surgery, obste- trics and gynaecology, paediatrics, and E.N.T., eye and dental services, a well equipped pathological laboratory, and other auxiliary services. Base hospital (B.H.) - These are generally based in the large towns and would have a bed strength over 250. They provide only the basic special- ties viz., medicine, surgery, obstetrics and gynaecology. Some of them have eye, E.N.T. and paediatric departments manned by full or part-qualified specialists. They have moderately well equipped pathological laboratories under the care of qualified pathologists and most of them have satisfactory auxiliary services. District hospitals (D.R.) - These are subdivided into large district hospitals with a bed strength over 100 and small district hospitals with a bed strength around 75. A few of the large district hospitals have one or more basic specialities,but in the main, district hospitals are general practitioner hospitals manned by one or more medical officers and assistant medical practitioners. The large district hospitals have pathological labo- ratories under the care of medical laboratory technologist. A few large district hospitals are in the process of being upgraded into base hospitals. The small district hospital is usually manned by a single medical officer, who in certain areas attends to preventive work in the area e.g., maternity and child health and school health work, in addition to his duties at the hospital. For the purposes of this study one large district hospital was included in the sample. Peripheral units (P.U.) - This is the smallest hospital unit in Sri Lanka and is made up of three components, viz., a general practitioner ward (male, female, and children), a maternity home, and a central dispensary. The bed strength of a peripheral unit would be around 25. Most of them are under the care of a medical officer. SEA/PHA/149 Page 248 Rural hospitals (R.H.) - These provide for inpatient and out-patient care, similar to a peripheral unit (but without a separate maternity ward), and have a bed strength around 20. These are mainly under the care of an assistant medical practitioner. Central dispensaries and maternity homes (C.D. & M.H.) - These provide inpatient treatment for maternity cases only (around 12 beds) and general practitioner out-patient treatment as in the central dispensaries (mentioned below) and are under the care of assistant medical practitioners. Maternity homes (M.H.) - These are under the care of midwives and provide inpatient care for maternity patients (around 12 beds). Maternal, family planning,and paediatrics clinics are usually conducted by medical officers in these institutions. Central dispensaries (C.D.) - A central dispensary is the smallest outpatient unit in the island. It is under the care of an assistant medical p~actitioner and provides outpatient treatment for minor ailments, dressing of wounds, and minor injuries. The attendance at an average central dispensary would be in the region of 75 patients a day. Visiting station (V.S,) - An officer from the closest hospital visits this unit; drugs are carried by the officer conducting the clinics, which provide out-patient care only. Private hospitals - These institutions charge a fee and provide general practitioner type of services with some facilities for the basic specialities like medicine, gynaecology and obstetrics, surgery, and paediatrics. Some have moderately well equipped operating theatres and laboratories and other auxiliary services. Estate hospitals - These are similar to the peripheral units in the government sector and have around 20 beds; usually they are under the care of an assistant medical practitioner or qualified estate dispenser. The expenses of these institutions are subsidized by the government. Ayurvedic hospitals - These hospitals, have around 1000 beds and provide inpatient and outpatient treatment for the three systems of Ayurveda, Sidda, and Unani. Ayurvedic dispensaries - Only out-patient treatment is provided at these institutions which are managed by the local authorities with the aid of grants from the Central Government to pay for part of the cost of drugs and the salaries of health personnel. Special hospitals - These are for the chronic illnesses like tuber- culosis, leprosy, mental illnesses, and infectious diseases. SEA/PHA/149 Page 249 Office of the Medical Officer of Health (MOH) - The programmes for preventive work are organized and executed in these units, each under the charge of a Medical Officer of Health (for an approximate population of 100 OOO) who is assisted by a supervising public health inspector, public health nurses, supervising public health midwives, and public health midwives. The programmes for preventive work provide for the control of communicable diseases, sanitation, school health work, epidemiological surveillance, family health, health education, and the enforcement of the food and drugs act in the developed areas. The work of special campaigns for malaria, tuberculosis, leprosy, filariasis, and venereal diseases are executed by separate agencies in liaison with the Medical Officers of Health and their staff. Offices of the Superintendent of Health Services (SHS) - These are responsible for the general administration, finance, and execution of health progrannnes within a defined region (health division), but are subject to general directions on policy from the central health administration. Age group 1973 (years) No. % All ages 13 398.3 100 0 - 4 1 768.4 13.2 5 - 14 3 319.6 24.0 I I 15 - 19 1 429.2 10.7 20 - 59 6 026.5 44.9 60 + 854.6 6.4 Table Al. l POPULATION PROJECTIONS (x 1000) FOR 1973 TO 1993 BASED ON LOW FERTILITY Low fertility 1978 1983 1988 No. % No. % No. 14 713. 2 100 15 968. 8 100 17 217.1 1 696. 9 11. 5 1 679.1 10.5 1 714.1 3 415.3 23.2 3 395.9 21.2 3 318.1 l 622.7 11.0 1 673.6 10.5 1 721.0 6 969.3 47.4 8 030.0 50.3 9 048.2 l 009.0 6.8 1 190.2 7.5 1 417.7 1993 % No. 100 18 474.6 10.0 1 798.5 19.3 3 339.2 10.0 1 656.8 52.7 10 021.4 8.3 1 658.7 % 100 9.8 18.1 8.9 54.3 9.0 '"d Cl) : ~ (1) ...._ '"d ~ s2 0 ...._ ~ -1'- I.D Age group 1973 (years) No. All ages 13 521. 2 0 - 4 1 892,3 5 - 14 3 319.6 15 - 19 1 429.2 20 - 59 6 026.5 60 + 854.6 Table Al.2 POPULATION PROJECTIONS (x 1000) FOR 1973 TO 1993 BASED ON MEDIUM FERTILITY Medium fertility 1978 1983 1988 % No. % No. % No, 100 15 212.2 100 17 037.0 100 18 950.6 14.0 2 074,4 13,2 2 254.8 13. 2 2 389.5 24.6 3 536.8 23.3 3 888.4 22. 9 4 255.7 10.6 1 622.7 10,7 1 673.6 9.8 1 841. 5 44.6 6 969. 3 45.8 8 030.0 47.2 9 046.2 6.3 1 009.0 6.6 1 190.2 7.0 1 417.7 1993 % No. 100 20 847.9 12.6 2 551. 7 22.5 4 570.5 9.7 2 025.6 47.7 10 141. 4 7.5 1 658.7 % 100 11. 7 21.9 9.7 48.6 8.0 "d C/l : f;; ID -"d ~ g; I-' -I-' +"" '° Age group 1973 (years) No. All ages 13 584. 9 0 - 4 1 955.0 5 - 14 3 319.6 15 - 19 1 429.2 20 - 59 6 026.5 60 + 834.6 Table Al. 3 POPULATION PROJECTIONS (x 1000) FOR 1973 TO 1993 BASED ON HIGH FERTILITY! High fertility 1978 1983 1988 % No. % No. % No. 100 15 492.0 100 17 722 .5 100 20 278.4 14.4 2 292.6 14.1 2 66.7. 5 15.1 3 035.5 25.7 3 598.4 23.2 4 164. 2 23.5 4 876,4 10.5 1 622.7 10,5 1 673.6 9,5 1 902.6 44.3 6 949,3 44,8 8 030.0 45.4 9 046.2 6.1 1 009.0 6.4 1 190.2 6.7 1 417.7 1 source: Planning Ministry, Government of Sri Lanka 1993 % No. 100 23 095.2 15.0 3 583.9 25.0 5 612.8 9.4 2 238.6 44.7 10 182.2 7.0 1 658.7 % 100 15.5 24.3 9.7 44.2 7.2 '1::1 Cl) : ~ ro -..... '1::1 N :;i::: V1 > N......._ t-' -1:'- \D Serial No, 1. 2. 3. 4. 5. 6. 7. 8. 9, 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Code (A list of Icn; A 5 A 65(c) A 67(b) A 75 A 83 A 84 A 92 A 93(a) A 93(b) A 96 A 104 A 111 A 113 A 115 A 117 A 119 A 120 A 137 AN 145 AN 146 AN 150 Table Al.4 SEA/PHA/149 Page 253 LEADING DISEASES IN FIVE BIG HOSPITALS No. of Bank of diseases hospitals Name of disease in hospitals in which thE 1 2 3 4 5 diseases appear Enteritis and other diarrhoeal diseases 4 - 2 8 4 4 Other avitaminoses 9 - - - - 1 Other and unspecified anaemise - - 9 - - 1 Inflammatory diseases of eye 10 - - - - 1 Ischaemic heart diseases - 10 - - - 1 Other forms of heart diseases - - - 4 - 1 Other pneumoniae 5 7 - 10 6 4 Chronic Bronchitis and Bronchitis unspecified 6 2 - 6 - 3 Asthma 7 - - - 7 2 Other diseases of respiratory system - - - - 10 1 Other diseases of digestive system - - 3 1 - 2 Other diseases of genito-urinary system - 5 5 2 5 4 Haemorrhage of pregnancy and child birth - 9 - - - 1 Other and unspecifed abortions - 4 8 - 8 3 Other complications of pregnancy, puerperium and childbirth - 1 4 5 2 4 Infection of skin and subcutaneous tissue 1 6 6 3 - 4 Other diseases of skin and sub- cutaneous tissue 8 - 10 9 9 4 Symptoms and other ill defined conditions - - 7 - - 1 Laceration and open wound, including dog bite 3 8 1 7 3 5 Superficial injury, contusion and crushing with intact skin surface 2 - - - - 1 All other unspecified effects of external causes - 3 - - 1 2 *from List A of the International Classification of Diseases,, 1965 SEA/PHA/149 Page 254 Table Al.5 LEADING CAUSES FOR HOSPITAL INPATIENT TREATMENT IN THE DISTRICT HOSPITALS Diagnosis No.of Cases 1. Respiratory diseases 169 2. Pregnancy and delivery 156 3. Injuries, accidents, bites 135 4. Diarrhoeal diseases 87 5. Ulcers and skin diseases 78 6. No diagnosis 70 7. Symptoms and ill-defined conditions 54 8. Gastrointestinal diseases 40 9. Infectious diseases 43 10. Viral fever 34 11. Malaria 28 12. Heart and vascular diseases 26 13. Diseases of the kidneys and urinary tr.act 23 14. Helminthic diseases 20 15. Arthritis 15 16. Other diagnoses 45 Total 1022 % 16.5 15.3 13.2 8.4 7.6 6.8 5.3 3.9 4.2 3.3 2.7 2.5 2. 3 2.0 1. 5 4.4 99.9 Table Al.6 DISEASES IN OUTPATIENTS* Diagnosis ICD code Diseases of the respiratory system 460-519 Infective and parasitic diseases 000-136 Diseases of th~ skin and subcutaneous tissues 680-709 Diseases of the digestive system 520-577 Symptoms & ill-defined conditions 680-796 Diseases of the musculosk~letal system and connective tissues 710-738 Diseases of blood and blood-forming organs 280-289 Ac:cidents, assaults, etc. 800-999 Diseases of the nervous system and sense organs 320-389 Diseases of the genitourinary system 580-629 Endocrine, nutritional,and metabolic diseases 240-279 Complications of pregnancy, childbirth, and the puerperium 630-678 Diseases of th~ circulatory system 390-458 Mental disorders 290-315 Neoplasms 140-239 Congenital abnormalities 740-659 Certain causes of perinatal mortality and morbidity 760-779 Total Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 SEA/PHA/ 149 Page 255 No.of cases % 11525 21. 64 10644 19.98 8771 16.47 4078 7.66 3678 6.91 2791 5.24 2418 4.54 2018 3.79 1844 3.46 1643 3.08 1602 3.01 1167 2.19 806 1.51 1 171 0.32 85 0.16 16 0.03 8 Ll.02 53265 100.00 *Based on the estimated one-day census of outpatients. SEA/PHA/149 Page 256 Table Al.7 NUMBER OF CASES OF LEADING DISEASES TREATED AT GOVERNMENT HOSPITALS AND RATES (PER 100 OOO), 1951 - 1970 Percentage increase(+) Diagnosis 1951 1961 1969 170 or cases rate cases rate cases rate decrease(-) from 1951 to 1970 Diarrhoeal diseases 81 702 1 037 164 032 1 613 180 323 1 470 + 42 Tuberculosis 15 598 198 12 744 125 12 841 105 - 48 Anaemia and mal- nutrition 25 439 323 67 152 660 89 017 729 + 126 Malignancies 4 380 56 5 488 54 12 115 99 + 78 Respiratory infections 189 647 2 408 288 956 2 842 330 124 2 690 + 12 Diseases of infancy and immaturity 13 853 176 22 444 221 4 727 39 - 78 Heart diseases 16 513 210 38 911 392 44 OOO '359 + 71 Other infectious diseases 59 952 761 31 437 309 137 424 l 120 +- 47 Accidents and suicides 87 082 975 99 835 982 219 148 I "/86 + 1n --- ----- - -·--~-·------- ----- - Table Al. 8 NUMBER OF DEATHS FROM LEADING CAUSES OF DISEASF.S, 1965 Disease Diseases of infancy and immaturity Heart diseases Diarrhoeal diseases Respiratory infections Gastroenteritis Accidents and suicides Anaemias and malnutrition Malignancies Infectious diseases Helminthic diseases Tuberculosis Dysentery Hookworm Typhoid Other diseases All causes Estimated no. of deaths 11 845 8 414 7 751 5 201 5 092 4 983 4 202 2 986 2 324 1 661 1 661 554 218 109 33 764 90 765 % of all dec1ths 13.05 9.27 8.54 5,73 5,61 5.49 4.63 3.29 2. 56 1. 83 1. 83 0.61 0.24 0.12 37,20 100.00 Table Al. 9 NUMBER OF VISITS TO OUTPATIENT DEPARTMENTS, DISPENSARIES, AND CLINICS, 1961 - 1971 SEA/PHA/149 Page 257 Year Number of visits No. of visits ner oerson all visits first visit all visits 1961 32 620 461 26 249 901 3.2 1962 31 782 290 26 266 701 3.0 1963 31 224 659 26 167 540 2.9 1964 31 257 553 26 738 007 2.9 1965 31 742 539 27 235 397 2.8 1966 31 703 836 26 556 716 2.8 1967 34 752 130 28 947 593 3.0 1968 36 752 228 31 054 122 3.1 1969 1970 1971/72* 25 753 674 *Provisional Table Al.10 NUMBER OF VISITS TO CLINICS BY TYPE OF CLINIC Type of clinic Number of visits 1961-1964 All types 12 937 979 Medical 883 969 Surgical 492 542 Orthopaedic 213 821 Thoracic surgery 21 635 Neurosurgery 13 942 E.N.T. 568 844 Genitourinary 12 555 Skin 282 874 Nerve 32 423 Paediatric 235 049 Psychiatric 48 746 Epileptic 50 724 Leprosy 9 061** Rabies 488 838 Maternal 1 568 401 Gynaecology 253 208 Family planning 19 276 Tuberculosis 1 719 433 Dental 2 459 462 Cancer 49 486 Venereal diseases 560 988 Child welfare 965 303 Other clinics 1 987 399 *Between 1961-1964 and 1965-1968 **Data refer to 1964 only 1965-1968 13 961 994 894 194 579 673 290 960 34 784 36 391 646 411 23 155 362 97 5 38 439 290 218 240 702 67 513 21 255 276 590 1 064 391 276 998 88 057 2 554 067 2 676 581 51 023 854 404 649 068 1 944 143 first visit 2.6 2.5 2.5 2.5 2.4 2.3 2.5 ~-6 2.2 % increase (+) or decrease (-)* + 8 + 1 + 18 + 36 + 61 + 161 + 14 + 84 + 28 + 19 + 23 + 394 + 33 - 43 - 32 + 9 + 357 + 49 + 9 + 3 + 52 - 23 - 2 Institution Provincial hospitals Colombo group of hospitals Base hospitals District hospitals Peripheral units Rural hospitals Central dispensaries & maternity homes Central dispensary Branch dispensary and visiting station All institutions Table Al. ll ACTUAL AND POTENTIAL ATTENDANCE AT HOSP1TALS OWING TO BY-PASSING OF INSTITlITIONS, 1971/73 No. of No. of Potential patients patients total attending* passing attendance 1 068 500 82 157 1 150 657 813 500 - 813 500 1 083 500 49 480 1 132 980 3 533 OOO 380 910 3 913 910 2 320 OOO 341 985 2 661 985 1 198 OOO 298 530 1 496 530 1 542 OOO 70 984 1 612 984 4 436 OOO 2 407 530 6 843 530 1 119 933 503 003 1 ti22 936 17 114 433 4 134 579 21 149 012 % increase on actual attendance 29 24 27 14 7 17 2 I 41 -4 ') I OU 1 i I *Data refers only to visits to OPDs, not to differen~ kinds of clinics % by- passing 4.8 0.0 3.1 8.0 11.5 23.0 4.3 47. ;>_ 44.o 19.4 l,:j (/) Ill M (lQ 'c-- ro -- --::: N := ....,, > CP ----,.... -I> \Cl Table Al.12 CAPITAL STOCK OF THE HEALTH CARE SYSTEM IN SRI LANKA, 1972 Sector/service Grand total Total government and semi-government sector total government sector total government western sector Medical Services outpatient care inpatient care public health services laboratory services administrative services medical stores transport administration total government ayurveda sector ayurveda outpatient services ayurveda inpatient services total semi-government sector semi-government western sector semi-government ayurveda sector total private sector total private western sector private nursing homes cooperative hospitals estate hospitals private dispensaries total private ayurveda sector total private "other" sector Stock in Rs (x 1000) 733 258.3 621 981.2 591 999.9 588 925.7 524 818.1 35 989.9 488 828.2 16 607.6 20 000.0 27 500.0 5 000.0 12 500.0 10 000.0 3 074.2 517.2 2 557.0 29 981.3 25 000.0 4 981. 3 111 277 .1 31 277.1 13 374.2 3 493.0 5 809.9 8 600.0 50 000.0 30 000.0 % SEA/PHA/149 Page 259 of total stock 100.00 84.82 80.74 80.32 71. 57 4.91 66.67 2.26 2.73 3.75 0.68 1. 70 1.36 0.42 0. 07 0.35 4.09 3.41 0.68 15.18 4.27 1.82 0.48 0. 79 1.17 6.82 4.00 SF.A/PHA/149 Page 260 Table Al.13 ESTIMATED TOTAL ANNUAL COST OF THE HEALTH CARE SYSTEM IN SRI LANKA (FOR 1973) Sector/service Expenditure in Rs (x 1000) % of total Grand total* 436 551. 2 100.00 total government and semi- government sector 298 622.6 60.14 total government sector* 267 355.0 53.84 Total government western sector 258 791. 7 52.12 medical services 170 652.4 34.37 outpatient care 26 693.0 5.38 inpatient care 143 959.4 29.00 public health services 52 681.2 10.61 laboratory services 15 598.9 3.14 administrative services 19 859.2 4.00 total government ayurveda sector 8 563.J** 1. 72 Total semi-government sector 31 267.6 6.29 Western semi-government sector 25 000.0 5.03 Ayurveda semi-government sector 6 267.6 1. 26 western private sector 56 928.6 11.46 ayurveda private sector 96 000.0 19. -~3 "other" private sector 45 000.0 9.05 *Excluding the cost of the Health Ministry itself **Rs 3 640 OOO was given as a grant to local bodies for operating the ayurveda dispensaries. Table Al.14 SEA/PHA/149 Page 261 BREAKDOWN OF THE GOVERNMENT HEALTH SERVICES INTO PROJECTS, ACCORDING TO THE BUDGET ESTIMATE, 1973 Sec tor I services 1. Department of Health Project Medical Services 1. Hospital services (General) Public health services Laboratory research and specialized services 2. Hospital services (Tuberculosis) 3. Assistance to private organizations and local authority 4, Maintenance of buildings and facilities 5. General preventive services and environ- mental sanitation 6. Family health 7. Health education 8. School health including school dental health 9. Quarantine 10. Eradication of malaria 11. Eradication of filariasis 12. Leprosy control 13. Venereal diseases control 14. Laboratory services 15. Other diagnostic and ancillary services Budget estimate for 1973 in Rs (x 1000) 160 159.7 8 891. 7 1 268.6 332.5 11 982.6 11 219.l 353.7 1 977 .o 580.9 20 686.2 2 580.2 2 308.2 1 043.3 3 939.2 7 890.4 Expected output (quantitative) number of patients treated indoor and outdoor number of persons attended (?) undetermined undetermined undetermined number of children under care undetermined undetermined number of persons immunized and number of bags fumigated no. of persons treated and no. of houses sprayed no. of persons treated; no. of blood smears examined no. of persons treated; no. of projects no. of investigations No. of special tests no. of analyses and examination no. of treatments; no. of examinations; no. of pints of blood SEA/PHA/149 Page 262 Sec tor /services Project 16. Maintenance of equipment 17. Medical research studies, routine investigations and production of vaccine General adminis- 18. General administration tration and staff services 19. Training and 2. Department of Ayurveda scholarships 20. Transport services 21. Curative services 22. Education and training 23. Research 24. Administration of Ayurveda Act Budget estimate for 1973 in Rs (x 1000) 1 051. 8 2 627.6 5 461.4 7 755.5 6 346.9 7 280.7 797.6 451. 5 33.5 Expected output (quantitative) undetermined quantities of vaccines and sera produced undetermined no. of trainees and no. of scholarships no. of miles travelled no. of inpatients no. of outpatients no. of students and trainees undetermined undetermined Table Al.15 SEA/PHA/149 Page 263 ESTIMATED ANNUAL NUMBER OF PATIENTS OF AYURVEDA PRACTITIONER BY AGE GROUP AND SEX Number of patients Age group Ayurveda Private T O T A 1 (years) Ayurveda Dis pen- Ayurveda and sex hospitals saries practitioners Number % total 1 983 147 2 901 648 23 805 538 28 690 211 100 0 - 1 37 680 98 656 1 388 706 15 403 910 5.31 2 - 4 52 702 339 493 2 184 099 2 676 240 9.32 5 - 14 232 028 583 231 3 343 133 4 158 492 14.49 15 - 19 200 298 272 755 2 088 453 2 561 506 8.92 20 - 59 1 118 495 937 232 12 338 847 14 394 574 50.17 60 + 243 927 377 214 244 677 3 067 918 10.69 male 797 225 1 250 610 14 072 096 16 119 931 56.18 female 1 185 922 1 651 038 9 733 442 12 570 280 43.82 DOCTOR/POPULATION RATIOS (PER 100 OOO) IN DIFFERENT S.H.S. DIVISIONS IN SRI LANKA, 1972 f Doctors in the Doctors in the S.H.S. division Population government sector semi-government (census and private sectors 1971)* No. per 100 OOO No. per 100 OOO Anuradhapura 581 196 89 15.4 12 2.1 Badulla 807 820 86 10.6 21 2.6 Batticaloa 530 894 59 11.1 11 2.1 Colombo 2 672 620 656 24.5 752 ?.8.1 Galle 737 451 81 11.1 25 3.4 Jaffna 704 350 118 16.8 84 12.0 Kalutara 731 824 92 12.6 46 6.3 Kandy 1 640 413 183 11.6 146 8.9 I Kegalle 652 094 52 7.9 11 l. 7 I ' I Kurunegala 1 028 107 114 11.1 26 2.5 I I Matale 480 200 40 8.3 10 2.1 I Matara 929 259 68 7.3 28 3.0 ) I Puttalam 379 787 47 12.4 32 8.4 . l 661 710 13.9 21 ! Ratnapura 92 3.2 l Vavuniya 173 418 20 11.5 1 0.6 f ; -- ·- : TOTAL 1 797 .. 22b 9.6 ) ::ipe,:.ial Campaig,1s etc. 248 -- - ! ,;Ri~ND TOTAL 112 711 143 2 045 16.l l 2'.!h 9.6 -·--· -·------·----·- --- * Departm.::nt of Census and Statistics, Preliminary Release, June 1972, Colombo No. 101 107 70 1 408 106 202 138 329 63 140 50 96 79 113 21 3 271 Total per 100 OOO 17.4 13.2 13.2 52.7 14.4 28.7 18.9 20.1 9.7 13.6 10.4 10.3 20.8 17.1 12.1 25.7 l"d (/) :~ (l)- l"d ~ [; .i:-- 1-' .i:- '° Table Al.17 DOCTORS WITH POSTGRADUATE DIPLOMAS BY SPECIALITY General medicine P:~.ysical medicine ?aedia::r-ics General surgery Neurosurgery Thoracic surgery Speciality Genito-urinary surgery Plastic surgery Orthopaedics Other branches of surgery Obstetrics and gynaecology E.N.T. Ophthalmology Psychiatry Dermatology with venereology Tuberculosis Infectious diseases Anaesthesia Radiology Dental surgery Public health Forensic medicine Pathology Bacteriology Parasitology Virology Biochemistry Pharmacology Unspecified TOTAL No. jl07 I 5 j i ill8 I 96 3 l 1 4 2 1 .,_ 7 l 87 28 26 25 6 40 1 33 22 4 128 8 35 21 4 3 3 I 6 I 17 I i84l ! SEA/PHA/149 Page 265 Total % l2.7 0.6 14.0 11.4 I}. 4 C.5 0.2 () .1 0.8 0.1 10.3 3.3 3.1 3.0 0.7 4.8 0.1 3.9 2.6 0.5 15.2 1.0 4.2 2.5 0.5 0.4 0.4 0.7 2.0 100.0 SEA/PHA/ 149 Page 266 Table Al.18 NURSE/POPULATION RATIOS (PER 100 OOO) AND NURSE/DOCTOR RATIOS IN DIFFERENT S.H.S. DIVISIONS IN SRI LANKA, 1971 SHS division Number of Nurse/population Nurse/doctor nurses ratio ratio Sri Lanka 6 457 50. 8 2.1 Anuradhapura 160 27.5 1.6 Badulla 195 24.1 1.8 Batticaloa 121 22.8 1. 7 Colombo 2 395 89.6 1. 7 Galle 309 41. 9 2.9 Jaffna 385 54.7 1.9 Kalutara 315 43.0 2.3 Kandy 558 34.0 1. 7 Kegalle 214 32.8 3.4 Kurunegala 418 40.7 3.0 Ma tale 120 25.0 2.4 Matar a 219 23.6 2.3 Puttalam 133 35.0 1. 7 Ratnapura 240 36.3 2.1 Vavuniya 42 24.2 2.0 Specialized Campaigns 449 Ayurveda Hospitals 66 Others 112 Table Al.19 SEA/PHA/149 Page 267 THE RATIOS TO THE POPULATION AND DOCTORS, AND THE DISTRIBUTION OF MIDWIVES IN DIFFERENT S.H.S. DIVISIONS IN SRI LANKA, 1971 Number of Midwife/population Midwife/ SHS division doctor midwives ratio (per 100 OOO) ratio Sri Lanka 3 587 28.2 1.2 Anuradhapura 150 25.8 1.5 Badulla 158 19.6 1.5 Batticaloa 99 18.6 1.4 Colombo 737 27.6 0.5 Galle 231 31.3 2.2 Jaffna 204 27.0 1.0 Kalutara 262 35.8 1.9 Kandy 137 0.4 Ke gal le 223 34.2 3.5 Kurunegala 369 38.2 2.6 Ma tale 133 27.7 2.7 Matar a 221 23. 9 2.3 Puttalam 98 25.8 1.2 Ratnapura 185 28.0 1. 6 Vavuniya 50 28.8 2.4 Estates 128 Ayurveda 3 SEA/PHA/149 Page 268 Table Al. 20 COURSES OF STUDY IN THE AYURVEDA COLLEGE* It was reconunended that the five-year course of studies should be followed by six months apprenticeship in an Ayurvedic Hospital. The subjects of study should be: * First year - Chemistry Physics Biology Sanskrit or Tamil Fundamental principles of Ayurveda or Siddha Second year - Sanskrit or Tamil Anatomy Physiology Nidana Dravya Practical pharmacy. Third year - Anatomy Physiology Nidana Dravya Chikitsa Fourth year - Nidana Dravya Chikitsa Elementary pathology and bacteriology Hygiene and public health Aganda (including jurisprudence and toxicology) 0, P, D • C lini CS Fifth year - Nidana (including modern methods of diagnosis) Chikitsa (including elements of modern medicine) Dravya (including Rasa practical) Prasoothy (including midwifery, gynaecology, and childrens' dis eases) Salya and Salakya (including minor modern surgery) Hospital practice (including clinics at leprosy, infectious diseases and tuberculosis hospitals) Source: Report of the Conunission on Indigenous Medicine (1947), Sessional Paper :XXIV - 1947, Government of Ceylon, Colombo Table Al.21 SEA/PHA/149 Page 269 NUMBER OF REGISTERED AYURVEDA PRACTITIONERS IN SRI LANKA 1951 - 1973 Year of Specialists Hereditary Graduates Total Annual average registration {every five years) 1951 75 296 334 705 i 1952 228 737 16 981 1953 391 800 5 1 196 1954 538 596 22 1 156 1955 305 461 16 785 965 1956 376 269 33 678 1957 59 142 22 223 1958 28 124 7 159 1959 4 88 9 101 1960 - 83 6 89 250 1961 - 128 12 140 1962 - 40 27 67 1963 - - - - 1964 - - - - 1965 - - 54 54 52 1966 276 226 52 554 1967 183 395 41 619 1968 330 156 66 552 1969 462 233 75 770 1970 309 143 65 517 602 197]_ 222 164 70 456 1972 144 38 103 285 1973 44 122 - 166 TOTAL 3 974 5 241 1 038 10 253,1 ·- *There is a difference of 90 ayurveda practitioners, in comparison with Table 5.25 owing to the different points of times of data collection: October 1972 in this Annex and August 1973 in Table 5.25. 8~ ~ ~ C":l :i" t; ~ t,,:j t,,:j O t,,:j Q~ ~~ C":l Ul = = t-3 t-3 ~~ ~~ O t,,:j :o Ul ~ gg > ..... ..... ..... ..... ..... 0 0 0 0 0 ..... ..... ..... ..... ..... 0 0 0 0 0 ..... ..... ..... ..... ..... N N N N N \0 \0 I I °' I °' \0 I I I I .i:,- CX) I I I I °' .,,.. I I I I u, CX) ..... (.,..) I I I I °' N l,O \0 \0 \0 \0 I I I I ..... \0 I I I I CX) ' ..... ..... ..... ..... ..... CX) CX) co o;) CX) ..... ...... ..... ..... ..... '-J -...J '-J -...J -...J °' °' °' °' °' '-.! -...J -...J -...J -...J N N N N N ..... ..... ..... ..... ..... ..... I-' ..... ..... ..... I I I I (.,..) u, u, u, u, u, (.,..) (.,..) (.,..) (.,..) (.,.) 0 0 0 0 0 ..... ..... ..... ..... 0 0 0 0 I 0 0 0 0 0 0 0 0 0 0 0 0 \0 \0 1 \0 °' °' °' I N l,O \0 I 0 I ~ .i:,- 0 -...J 1 I 0 I I 0 N I (.,..) I I I 0 0 ..... 0 I I I I 0 0 0 ..... Colombo group of hospitals N Provincial hospitals (.,..) Base hospitals .,,.. District hospitals u, Peripheral units °' Rural/cottage hospitals Central disp. and -...J maternity homes CX) Branch disp. visiting TB, leprosy, \0 mental hospitals ..... I.D. hospital 0 ..... MOH office ..... ..... Estate hospitals & N maternity home ..... Nursing homes & (.,..) coop hospitals ..... Ayurveda hospitals .i:,- ..... Ayurveda dispensaries u, ..... AMC, AFC and AVDC °' ..... Private practitioners -...J I-' Ayurveda private CX) practitioners ..... Integrated dist. \0 hospitals N Integrated P.U. 0 N Integrated C.D. ..... N ANM office N N Ayurveda DR office (.,..) Ul t-3 § ("") t-3 c::: ~ 0 'rj t-3 ::i::: t,,:j ::i::: t,,:j > t'"' t-3 ::i::: nn ::i::: ~ !z t,,:j 0 t,,:j Cf.l t-3 Ul ..-:: DJ Cf.l o" ~i ..... CD > H(') ..... zo . t-3 z N :::0 Ul N OH 00 c::: t,,:j (') :::0 t,,:j H oz 0 0 H 'rj 'rj t,,:j ~ z t-3 ~ t-3 t,,:j i t-3 H <: t,,:j OLZ -a~'E!d 6171/VHd/WS Health indicator Infant Table Al.23 SEA/PHA/149 Page 271 ASSOCIATION BETWEEN HEALTH SERVICES DEVELOPMENT AND HEALTH STATUS IN SEVERAL COUNTRIES WITH ANNUAL PER CAPITA NATIONAL INCOME BELOW US$ 500 (DATA BORROWED FROM B, ABEL-SMITH: AN INTERNATIONAL STUDY OF HEALTH EXPENDITURE AND ITS RELEVANCE FOR HEALTH PLANNING PUBLIC HEALTH PAPERS 32, WORLD HEAL TH ORGANIZATION, GENEVA, 1967). Association! Indicator of health significant services development r t at 0.05 level No. of hosp. beds mortality rate per 10 OOO - 0.334 1.326 insignificant Mortality rate of age group 0 - 4 years Crude mortality rate No. of doctors per 10 OOO - 0.6074 No. of nurses/mid- wives per 10 OOO - 0,474 No. of hosp. beds per 10 OOO - 0.0067 No. of doctors per 10 OOO - 0.355 No. of nurses/mid- wives per 10 OOO - 0.176 No. of hosp. beds per 10 OOO - 0.335 No. of doctors per 10 OOO - 0.574 No. of nurses/mid- wives per 10 OOO - 0.381 1 r * correlation coefficient; t significant at 0.10 level 3.054 significant 2.015 insignificant* insignificant 0.8502 insignificant 0,476 insignificant 1.326 insignificant 2.62 significant 1. 608 insignificant test of significance SEA/PHA/149 Page 272 Table Al. 24 LIST OF SUB-STUDIES AND THEIR OBJECTIVES A. "Demographic characteristics": (1) to assemble data pertaining to the general demographic characteristics of Sri Lanka from existing information, (2) to analyse the data gathered, (3) to ascertain the alternative weight of selected demographic variables in determining past population changes in Sri Lanka, (4) to make long-term population projections, required for health and manpower planning. B. "Health needs and demands" : (1) to assemble data pertaining to the mortality, morbidity, and disability among the population, (2) to analyse the data assembled, (3) to attempt to establish a p1ofile of the past and current health situation, (4) to provide indicators for projections of future health needs and demands of the population. C. "Census of doctors": (1) to establish the strength* of doctors at present in Sri Lanka, (2) to describe the pattern of employment of doctors, (3) to suggest steps towards maintaining a central record/information system for the processing of demographic and career data of doctors, (4) to suggest steps towards the annual publication of a medical directory. D. "Census of nurses, midwives and dental nurses": (1) to ascertain the total strength of available nursing, midwifery, and dental nursing personnel throughout Sri Lanka, (2) to determine the pattern of their employment, (3) to determine steps for the establishment of a central record/ information system in terms of demographic and other data related to the subjects in the study, which may be utilised for future planning (for training and utilisation of personnel). *"strength" stock present supply. E. "Medical education": (1) to analyse the administrative system of the medical schools, SEA/PHA/149 Page 273 (2) to determine the number and general characteristics of the applicants and students, (3) to quantify available resources (financial, manpower, and facilities), (4) to determine the annual output and admission ratios, (5) to estimate the cost of training per individual student, (6) to estimate the training capacity of the school, (7) to analyse curriculum content, teaching methods, and evaluation systems used. F. "Nursing and midwifery education": (1) to review the administrative system of the nursing and midwifery schools, (2) to determine the number of applicants to nursing, (3) to determine the general characteristics of the students admitted, (4) to determine the annual admission and output of schools, (5) to estimate the training capacity of the schools, (6) to estimate the cost of training per individual student, (7) to quantify available resources (financial, manpower, and facilities), (8) to review curriculum content, teaching methods and evaluation sys terns used, (9) on the basis of the findings of the study, to make recommenda- tions regarding nursing and midwifery education as a component of the total education system for health manpower in Sri Lanka within the context of the National Health Manpower Study. G. "Activities of health personnel working in rural areas": (1) to make available information relating to the amount, type, and range of activities currently carried out by public health field personnel and by personnel working in peripheral medical care institutions, SEA/PHA/149 Page 274 (2) to compare the activities carried out by different personnel in terms of educational preparation and the activities performed, (3) to compare the activities performed by the different cate- gories of personnel with the expectations of the Department of Health as expressed in the manuals and lists of duties, (4) to identify the functional areas to which the activities are related. (5) to detect areas of duplication of activities carried out by different categories. H. "Utilization of doctors": (1) to describe the time spent in the activities and functions carried out by doctors in Sri Lanka, (2) to describe the patients, both outpatients and inpatients, under the doctor's care in the following terms: (a) presenting sym~toms (b) examination performed (c) laboratory tests and X-rays ordered or carried out ( d) diagnosis (e) treatment given (f) referral and disposition of patients (3) to assess the extent to which the doctor is able to utilize and does utilize his training and experience in the diagnosis and treatment of his patients. J. "Staffing pattern, facilities. and cost of health services": (1) to bring up to date and supplement existing information regarding health care institutions in the public and the private sector and to gain a general insight into their present physical conditions, availability of manpower, financial and other resources. (2) to determine the number of posts for personnel and the number of existing personnel, (3) to provide data for the estimation of the cost of services rendered by health instiuttions. K. "Demand for medical care services": (1) to determine outpatient .morbidity, (2) to study the demographic characteristics of the outpatients, (3) to describe the factors influencing the outpatient attendance, like place of residence, distance to institution, facilities provided, transport, etc., (4) to compare methods of treatment offered. L. "Pattern of ayurvedic practice": SEA/PHA/149 Page 275 To establish the present pattern of practice of registered ayurveda practitioners working in hospitals, dispensaries, or elsewhere, in terms of: (1) particulars of ayurvedic practitioners - age, sex, place and type of employment, (2) size and demographic characteristics of outpatients attending for medical care. ANNEX 2 METHODS AND APPROACHES FOR ESTIMATING UNAVAILABLE DATA SEA/PHA/149 Page 277 Annex 2.1 SEA/PHA/149 Page 279 ESTIMATING OF THE CAPITAL STOCK OF THE HEALTH CARE SYSTEM 1. The cost of capital stock of government hospitals and MOH offices was estimated in sub-study "J" (Staffing Pattern, Facilities and Cost of Health Services) by making an inventory of a sample of these institutions. The stock of private nursing homes and estate hospitals was also estimated by sub-study "J 2. The capital stock of AMC, AFC, and AVDC, as well as the capital stock of laboratory services and medical stores (without stocks of supplies) are based on educated guesses. The same method of estimation was used for the estimate of administration, including SHS offices: Antimalaria campaign Rs 20 million Antifilariasis campaign Rs 2 million Antivenereal diseases campaign Rs 1.5 million Laboratory services Rs 20 million Medical stores Rs 5 million Administration, including SHS offices Rs 10 million Transport: 500 vehicles x Rs 25 OOO Rs 12.5 million 3. The capital stock of ayurveda hospitals and dispensaries was estimated by sub-study "J". 4. The capital stock of cooperative hospitals was estimated on the assumptic that the capital stock per hospital bed was the same as the capital stock for a bed in a rural hospital. 5. The capital stock for a dispensary of a private western-type practitione1 was assumed to be Rs 50 OOO. 6. The capital stock of a dispensary of an ayurveda practitioner was assumec to be about Rs 5000; and for practitioner in the "other" sector Rs 3000. SEA/PHA/149 Page 280 Annex 2.2 ESTIMATE OF THE ANNUAL RECURRING COST OF THE HEALTH CARE SYSTEM 1. The expenditure of the Ministry of Health was considered equal to the budget estimate for 1973, minus the expenditure of the Ministry of Health proper. 2. The expenditure of the western semi-government sector was estimated at a lump sum of Rs 25 million, taking into consideration the number of doctors working in these services. 3. The expenditure of the ayurveda semi-government sector (ayurveda dis- pensaries managed by local bodies) was estimated by sub-study "J", based on the cost of services, and on the annual output, estimated by sub-study "L". 4. The expenditure of the nursing homes, the estate hospitals, and the cooperative hospitals was estimated from the data of sub-study "J", under the assumption that the bed occupancy rate was around 50%. 5. The estimate of the total expenditure of the private sector was founded on the data from the Annual Report of the Monetary Board to the Minister of Finance, Central Bank of Ceylon, 1972, showing that the individual consumption for personal care and health expenses in 1972 had been Rs 253 million. Assuming that about 80% of this sum had been spent on health expenses, it makes Rs 200 million. 5.1 It was assumed that 530 western-type private doctors had an average of 28 visits daily on 300 days a year; and that they charged Rs 10 per visit, on average. 5.2 The annual output of the private ayurveda practitioners was estimated by sub-study "L" as 24 million; it was assumed that they charged, on average, Rs 4 per visit. 5.3 The "other" private practitioners were assumed to have had an average of 5 visits per day for 300 days during the year, and to have charged Rs 3 per visit, on average. Annex 2.3 ESTIMATE OF THE TOTAL NUMBER OF WORKERS IN THE HEALTH INDUSTRY SEA/PHA/149 Page 281 The total number of health workers in the government, semi-government, and western and ayurveda private sectors was estimated to be about 55 OOO (see Annex 4-5). It has been assumed that in average one person was assisting every second of estimated "Other" practitioner, thus estimating the number of persons employed in the "other" private sector as 15 OOO. SEA/PHA/149 Page 282 Annex 2.4 ESTIMATE OF THE NUMBER OF HEALTH WORKERS IN ALL SECTORS EXCEPT THE "OTHER" PRIVATE SECTOR 1. The total number of health workers in the government sector was estimated as the number of persons employed by the Ministry of Health (excluding the Ministry proper), according to the budget estimate for 1973. 2. The number and distribution of doctors employed by the government and by semi-government and private sectors was estimated on the basis of data from sub-study "C" (Census of doctors). 3. The number and distribution of nurses, midwives,and dental nurses was estimated on the basis of information from sub-study "D" (Census of nurses, midwives, and dental nurses). 4. The number and distribution of ayurveda practitioners was estimated from the data of sub-study "L" (Pattern of ayurvedic practice in Sri Lanka). S. The number of dental surgeons and their distribution between the govern- ment and semi-government and private sector was estimated hy the Department of Health. 6. The number of all other health workers employed by the Ministry of Health was estimated by the Ministry of Health. The number of some health workers in the semi-government and in the private sector was estimate~ as approximately 12% of the government sector on the assumption that they may follow the employment pattern similar to a pattern half way b€.ctween the distributi0n of nurses and midwives in the government and semi-government sector. Annex 2.5 CALCULATION OF THE OPPORTUNITY COST SF..A/PHA/149 Page 283 The opportunity cost has been defined as the sum of income which has not been materialized because of the occupation of a given person with some- thing else, in this case, with studying. The opportunity cost to be paid by the state because a member of the labour force was studying was calculated in the following manner: 1. the national income for 1973 2. less the private consumption 3. equal to surplus income for capital formation and public consumption 4. divided by the labour force of an estimated 4.6 million, gives Rs Rs Rs Rs 13 691 million 9 773 million 3 918 million 844 per person per year SEA/PHA/149 Page 284 Annex 2.6 ESTIMATION OF THE RATE OF LOSS OF THE ASSISTANT/ REGISTERED MEDICAL PRACTITIONERS Since there has not been any supply of A/RMPs since 1968/1969, the decrease in the number of the employed A/RMP in the period 1968/69 to 1971/72 was assumed to correspond to their loss: number of employed A/RMPs in 1968/ 69: 1265 number of employed A/RMPs in 1971/72: 1194 average annual rate of loss approximately 2% Annex 2. 7 ESTIMATION OF CAPITAL INVESTMENT IN MANPOWER SFA/PHA/149 Page 285 1. The cost of training of each category of health personnel has been multiplied by the number of persons of the same category (stock). The cost of training included also the opportunity cost. 2. The cost of training of doctors was calculated separately for under- graduate and for postgraduate doctors. Also, the cost was calculated separately for nurses with basic and post-basic training. 3. 4. The cost of attrition was also taken into account. The following assumptions have been made: (a) the training of a dental surgeon was equal to 4/5 of the cost of training a doctor, (b) the training of an A/FJ:1P was equal to 2/5 of the cost of training a doctor, (c) the cost of training a public health inspector or one dental nurse, or one pharmacist was equal to the cost of training one midwife, (d) the cost of training a medical laboratory technologist was equal to Rs 3600 plus the opportunity cost of 2 x Rs 844.58, (e) the cost of training a radiographer or a physiotherapist was equal to the cost of training a medical laboratory technologist, (f) Only the cost of graduate ayurveda doctors has been taken into · account. ANNEX 3: METHODS OF ESTIMATING INDICES AND PARAMETERS SEA/PHA/149 Page 287 Annex 3.1 CALCULATION OF THE RELATIVE OOCTORS' ACCESSIBILITY INDEX FOR THE URBAN AND RURAL POPULATION SEA/ PHA/ 14 9 Page 289 This index shows the difference in accessibility to a doctor by populations in the district centres in an SHS division (urban popula- tion) and outside the district centres of the division (rural popula- tion), in terms of the population that is likely to make use of doctors' services. It is obtained by correlating the doctor/population ratio in the district centres and the doctor/population ratio outside the district centres of the same division: Du DR Du x PR : or -- Pu PR Pu x DR where Du the number of doctors working in district centres DR the number of doctors working outside district centres PU the population in the district centres PR the population outside the district centres SEA/PHA/ 149 Page 290 Annex 3. 2 CALCULATION OF THE DOCTOR/POPULATION RATIO STANDARDIZED FOR THE SIZE OF THE AREA This index shows what should be the hypothetical doctor/population ratio per 100 OOO inhabitants, if a given population of an SHS division (health region) lived in an area equal to 100 square miles, in order to have the same accessibility to the doctors by the population. It has been calculated by the following formula: Standardized ratio ~d~o~c~t~o~r~/~p~o~p~u.;:;.;;.l=a=t=i=o~n_;..r=a~t~i~o~~~~~~~ x 10 Area of the SHS division in sq.miles Since the population is neveY equitably distributed by geographical areas, one may argue both ways: 1. that this ratio is not very reliable, since it is based on the assumption of the even distribution of the population throughout the country, and 2. that the concentration of doctors follows the concentration of the population, i.e., more densely populated areas will have a higher doctor/population ratio. Both arguments are correct, for small areas. However, for a whole country and for big regions, this ratio may be a useful indicator if its limitations are known. Annex 3.3 ESTIMATE OF THE AVERAGE DISTANCES FROM HEALTH CARE SERVICES SEA/PHA/149 Page 291 The calculation of the average maximum distance from health care facilities is based on the assumption that the area from which a given source of health care collects its patrons is a circle with the facilities at its centre. The average maximum distance is the radius R of the circle. If the total area of Sri Lanka, 25 332 square miles, is divided by the number of facilities available, we shall have the size of the average area around each facility; from this the radius may be calculated so that: R • I 25 332 ~ _N_o ___ o_f_f_a_c..;;;i_l_i __ t_i_e_s_x_3-. 1-4-- This index presumes an even distribution of the population, which is not the case in Sri Lanka. However, the concentration of health facilities usually follows the concentration of the population, except for deserts, jungles, and similar areas, which are not large in Sri Lanka (the estimated such surface area is not more than 5%). The above index is therefore more likely to under- estimate the accessibility of health facilities than to over-estimate it. ANNEX 4 LINEAR PROGRAMMING MODEL FOR HEALTH MANPOWER REQUIREMENTS A. Perera and L.A. Simeonov SEA/PHA/ll+9 Page 293 SEA/PHA/149 Page 295 The health care system in Sri Lanka can be divided into three sectors, namely government, private, and estate. The objective of the government sector is to meet health demands at the lowest cost, whereas the objective of the other two sectors is to make a profit. It was therefore not feasible to construct an integrated model for the entire health care system in Sri Lanka. However, the government sector, which is the most important of the three sectors and comes under the direction of the Department of Health Servi- ces, is capable of being reorganized; it was therefore considered useful to study this sector. An attempt was made to construct a linear model for this sector. The model was intended to determine the optimum health manpower requirements to meet the given demand of health activities, as stipulated by the several health programmes, at the lowest cost within the limits of the total govern- ment expenditure and the capacity of the institutions. Since the demand in most of the proposed models exceeded the maximum capacity of the institutions, a dummy institution with unlimited capacity and with activity costs higher than those in the existing institutions was introduced. Thus, demand which could not be supplied by the existing institutions overflowed into the dummy institution. To formulate the model the following notation is used: YGOV Expenditure equation YGOV YGOVX expenditure per unit activity of type 1 delivered by the kth institution. th number of activities of type 1 delivered by the k institution. expenditure on all activities delivered by all insti- tutions. number of activities of type 1 delivered by all institutions. ~YGOVkl x AGOVkl YGOV + LYDUMl x ADUMl where YDUM1 and ADUM1 are the activity costs and the number of acti- vities of the dummy institution and YGOVX is the total cost including the dummy institutions. Activity equation + SEA/PHA/149 Page 296 Constraints i) Total cost excluding the dunnny institutions is less than the budgeted estimate. i.e. YGOV ~ 227 .4 million. ii) The number of activities provided by the several institutions should exceed the minimum demand as specified by the health programmes. i.e. AGOV1 ~ Demand as stipulated in the health programmes. iii) Capacity of institutions is limited. However, it was assumed that activities 1 and 3 could be considered supplementary. i.e. AGOVkl ~ AGIV'kl for k + 1 or 3 AGOVkl + AGOVk3 ~ AGOV'kl + AGOV 1 k3 where AGOV'kl represents the maximum capacity of the institutions. Objective function To minimise YGOVX, f the total expenditure of activities including the dummy institution. The model was solved using an IBM S/360 computer g1v1ng the optimum number of activities delivered by each institution. After determining the optimum number of activities delivered by each institution, the optimum health manpower requirements were calculated on the basis of information available from the sub-study "J" on the health manpower inputs per unit activity delivered by each institution. For purposes of this study the health activities (subscript 1) have been grouped as follows: 1. Hospital treatment of an acute case 2. Hospital treatment of a chronic case 3. Hospital delivery 4. Surgical intervention 5. Hospital treatment in ayurveda hospital 6. Outpatient visit 7. Visit to a clinic (preventive) 8. Consultation by specialist 9. Vaccination/immunization 10. Visit to ayurveda hospital/dispensary 11. Delivery at home 12. Home vis it 13. Environmental examination 14. Environmental sanitation 15. Visit to a general practitioner 16. Visit to an ayurveda practitioner SEA/PHA/149 Page 297 The institutions (subscript k) in Sri Lanka in the three sectors were grouped as follows: . G . . . 1 i. overnment institutions 1. Colombo group of hospitals 2. Provincial hospitals 3. Base hospitals 4. District hospitals 5. Peripheral units 6. Rural hospitals 7. Central dispensaries and maternity homes 8. Branch dispensaries and visiting stations 9. TB, leprosy and mental hospital 10. Infectious diseases hospital 11. M.O.H. office 12. Ayurveda hospitals 13. Ayurveda dispensaries 14. Antimalaria campaign, antifilariasis campaign, anti-VD campaign 15. Integrated district hospitals 16. Integrated peripheral unit 17. Integrated central dispensary 18. Office of auxiliary nurse/midwife 19. Office of ayurveda practitioner ii. Private institutions 1. Private nursing homes and cooperative hospitals 2. Private practitioners 3. Ayurveda private practitioners iii. Estate institutions 1. Estate hospitals and maternity homes The health manpower (subscript m) considered in this study is as follows: 1. General practice doctor 2. Paediatrician 3. Surgeon 4. Obstetrician/gynaecologist 5. Dental surgeon 6. Public health specialist 7. Other specialist doctor 8. Nurse 9. Nurse specialist 1 No. 1-14 exist already in Sri Lanka, while No. 15-19 are suggested insti- tutions for more effective use of the health care system. SEA/PHA/149 Page 298 10. Midwife, auxiliary nurse/midwife 11. Registered/assistant medical practitioner 12. Ayurveda practitioner 13. Public health inspector 14, Medical technologist 15. Ancillary personnel The estimates of the capital stock, recurrent cost, and health man- power inputs into different health activities performed in the different categories of health institutions were standardized using data from sub-study "J" (staffing pattern, facilities, and cost of health services). Since the occupancy rate in different health institutions varied within broad limits during the study, the parameters were standardized for an uniform occupancy rate of 100%. Besides, the utilization of institutions in terms of turn- over did not seem to be very rational. For this reason, in order to avoid the utilization of health institutions over 100%, which is an abnormal situa- tion, it was assumed that health institutions should have to increase their turn-over (throughput) by at least 10%. The capital stock of one health activity delivered by one category of health institution was standardized using the formula: observed capital stock x occupancy rate 110 The health manpower input of one category of health personnel into one health activity delivered by one health institution was standardized by: observed health manpower input x occupancy rate 110 and the cost of one health activity delivered by one category of health insti- tutions with the formula: [ (observed cost - drugs - food) x occup.rate + d d foo} 100 rugs an jj I 1.1 The estimate of the parameters regarding health institutions which did not exist and which were offered as alternative solutions to increase the efficiency of the health care system was also made by using the data from sub- study "J". The assumption was that those new health institutions would really be more efficient than some similar health institution that operated in the country. The parameters of the Integrated District Hospital were estimated as follows: medical care services: hospital treatment, hospital deliveries, OPD visits, and specialist consultations: parameters equal to the standardized parameters of district hospitals. SEA/PHA/149 Page 299 public health services: parameters should show an increase of efficiency by 10% in comparison with the standardized parameters for the MOH officer: the capital stock, cost, and health man- power inputs, less for 10%. The parameters for the Integrated Peripheral Unit: medical care services: equal to standardized parameters of peri- pheral units. public health services: standardized parameters of MOH, less by 10%. The parameters of the Integrated Central Dispensary: medical services: equal to standardized parameters of rural hospitals. public health services: standardized parameters of MOH, less by 10%. The parameters of the Office of the Auxiliary Nurse/Midwife: OPD visit: manpower input equal to the standardized input of AMP in a CD recurring cost equal to 90% of the standardized cost of a visit to a CD. capital stock O preventive visit: manpower equal to 90% a midwife working in MOH office: cost at MOH office: capital stock= 0. of the standardized input of 90% of the standardized cost vaccination: cost and manpower input equal to 90% of those stan- dardized in MOH office: capital stock= O. - environmental examination: manpower to standardized manpower input of PHI, less 10%: cost= 80% of the standardized cost of the same in MOH office. - environmental sanitation: in MOH office, less 10%: MOH office. manpower= to standardized input of PHI cost= 80% of the standardized cost of Office of the Ayurveda Practitioner: the same estimates as the estimates for the office of the ANM (except home deliveries which will not be attended to by the ayurveda practitioners). Five alternative health care delivery systems were described: (1) No change= western doctor alternative (2) Health centre (3) Assistant medical practitioner= AMP (4) Public health midwife= PHM (5) Ayurveda doctor SEA/PHA/149 Page 300 Also, six health programmes have been formulated (refer to Tables A4.1 to A4.6). Thus, thirty alternative solutions are presented, although their number may be unlimited., depending on the number of health programmes. The characteristics of the alternatives are given below: Code Numbers of Alternative Solutions in Terms of Health Programme and Health Care System He a 1 t h P r o g r a mm e s Health Care No Family Disease FH and Environ. System change health control disease sanita- and Med. control tion care No change 1 2 3 4 5 Health centre 7 8 9 10 11 AMP 13 14 15 16 17 PHN 19 20 21 22 23 Ayurveda 25 26 27 28 29 doctor Table A4.1 DEMAND FOR HEALTH ACTIVITIES - HEALTH PROGRAMME 1 Present situation (No change) Hospital treatment 6 12 18 24 30 In 'OOO Activities Sector of Health Care System Category of Health Activity Government Private Estate 1. Hospital Treatment of Acute Case 1 715.9 22.7 22.6 2. Hospital Treatment of Chronic Case 18.6 0 0 3. Hospital Delivery* 462.9 LS 7.9 4. Surgical Intervention 161.0 8.1 0 5. Hospital Treatment in Ayurveda Hospital 12.1 0 0 6. Outpatient Visit 30 000.0 1 681.4 761.2 7. Visit to Preventive Clinic 3 382.1 0 21.7 8. Consultation by Specialist 1 572. 9 16.0 0 9. Vaccination/Immunization 3 824.8 0 0 10. Visit to Ayurveda Hospital/ Dispensary 3 427.5 0 0 11. Delivery at Home 20.8 0 0 12. Home Visit 11 750.2 0 0 13. Environmental Examination 296.7 0 0 14. Environmental Sanitation 4 625.8 0 0 15. Visit to Private Practitioner 0 5 000.C 0 16. Visit to Ayurveda Private Practitioner 0 24 000.0 0 *Inclusive gynaecological patients. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Table A4.2 SEA/PHA/149 Page 301 DEMAND FOR HEALTH ACTIVITIES - HEALTH PROGRAMME 2 Emphasis on family health In 'OOO Activities Sector of Health Care System Category of Health Activity Government Private Estate Hospital Treatment of Acute Case 1 489. 7 22. 7 22.6 Hospital Treatment of Chronic Case 18.6 0 0 Hospital Delivery>'< 648.1 2.5 7.9 Surgical Intervention 161.0 8.1 0 Hospital Treatment in Ayurveda Hospital 12.1 0 0 Out-patient Visit 30 OOO. 7 1 681. 4 761.2 Visit to Preventive Clinic 6 292. 7 0 21. 7 Consultation by Specialist 1 572. 9 16.0 0 Vaccination/Iunnunization 3 824.8 0 0 Visit to Ayurveda Hospital/Dispensary ') 427.2 0 0 ., Delivery at Home 4.8 0 0 Home Visit 16 207.1 0 0 Environmental Examination 296. 7 0 0 Environmental Sanitation 4 625.8 0 0 Visit to Private Practitioner 0 5 OOO 0 Visit to Ayurveda Private Practitioner 0 24 OOO 0 *Inclusive gynaecological patients. Table A4.3 DEMAND FOR HEALTH ACTIVITIES - HEALTH PROGRAMME 3 Emphasis on disease control and medical care In 'OOO Activities Sector of Health Care System Category of Health Activity . Government Private Estate 1. Hospital Treatment of Acute Case 1 715.9 22.7 22.6 2. Hospital Treatment of Chronic Case 18.6 0 0 3. Hospital Delivery* 462.9 2.5 7.9 4. Surgical Intervention 224.2 8.1 0 5. Hospital Treatment in Ayurveda Hospital 12.1 0 0 6. Out-patient Visit 41 112.1 1 681.4 761. 2 7. Visit to Preventive Clinic 1 048.8 0 21. 7 8. Consultation by Specialist 2 125.6 16.0 0 9. Vaccination/Immunization 5 354. 7 0 0 10. Visit to Ayurveda Hospital/Dispensary 3 427.5 0 0 11. Delivery at Home 20.8 0 0 12. Home Visit 6 077. 2 0 0 13. Environmental Examination 296.7 0 0 14. Environmental Sanitation 6 938. 7 0 0 15. Visit to Private Practitioner 0 5 000.0 0 16. Visit to Ayurveda Private Practitioner 0 24 000.0 0 *Inclusive gynaecological patients. SEA/PH.A/149 Page 302 Table A4.4 DEMAND FOR HEALTH ACTIVITIES - HEALTH PROGRAMME 4 Emphasis on disease control and family health In 'OOO Activities Sector of Health Care System Category of Health Activity Government Private Estate 1. Hospital Treatment of Acute Case 1 489.7 22. 7 22. 6 2. Hospital Treatment of Chronic Case 9.5 0 0 3. Hospital Delivery* 648.1 2.5 7.9 4. Surgical Intervention 161. 0 8.1 0 5. Hospital Treatment in Ayurveda Hospital 12.1 0 0 6. Out-patient Visit 20 556.1 1 681. 4 761. 2 7. Visit to Preventive Clinic 6 292. 7 0 21. 7 8. Consultation by Specialist 850.2 16.0 0 9. Vaccination/Immunization 5 354.7 0 0 10. Visit to Ayurveda Hospital/Dispensar~ 3 427. 5 0 0 11. Delive~y at Home 4.8 0 0 12. Home Visit 16 207 .1 0 0 13. Environmental Examination 296. 7 0 0 14. Environmental Sanitation 6 938. 7 0 0 15. Visit to Private Practitioner 0 8 000.0 0 16. Visit to Ayurveda Private Practitioner 0 30 720.0 0 *Inclusive gynaecological patients. Table A4.5 DEMAND FOR HEALTH ACTIVITIES - HEALTH PROGRAMME 5 Emphasis on environmental sanitation 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Category of Health Activity Hospital Treatment of Acute Case Hospital Treatment of Chronic Case Hospital Delivery* Surgical Intervention Hospital Treatment in Ayurveda Hospital Out-patient Visit Visit to Preventive Clinic Consultation by Specialist Vaccination/Immunization Visit to Ayurveda Hospital/Dispensary Delivery at Home Home Visit Environmental Examination Environmental Sanitation Visit to Private Practitioner Visit to Ayurveda Private Practitioner *Inclusive gynaecological patients. In 'OOO Activities Sector of Health Care System Government 1 489. 7 9.5 462.9 161.0 12.l 20 556.1 3 382.1 1 572.9 3 824.8 3 427.5 20.8 11 750. 2 741.8 9 251. 6 0 0 Private 22.7 0 2.5 8.1 0 1 681. 4 0 16.0 0 0 0 0 0 0 8 000.0 30 720.0 Estate 22.6 0 7.9 0 0 761.2 21. 7 0 0 0 0 0 0 0 0 0 Table A4.6 SEA/PHA/149 Page 303 DEMAND FOR HEALTH ACTIVITIES - HEALTH PROGRAMME 6 Emphasis on hospital treatment In 'OOO Activities Sector of Health Care System Category of Health Activities Government Private Estate 1. Hospital Treatment of Acute Case 1 986.2 22. 7 22.6 2. Hospital Treatment of Chronic Case 22.1 0 0 3. Hospital Delivery* 462.9 2.5 7.9 4. Surgical Intervention 224.2 8.1 0 5. Hospital Treatment in Ayurveda Hospital 24.2 0 0 6. Out-patient Visit 32 889. 7 1 681. 4 761. 2 7. Visit to Preventive Clinic 3 382.1 0 21. 7 8. Consultation by Specialist 1 572. 9 16.0 0 9. Vaccination/Iunnunization 1 529.9 0 0 10. Visit to Ayurveda Hospital/Dispensary 3 427.5 0 0 11. Delivery at Home 20.8 0 0 12. Home Visit 3 241.9 0 0 13. Environmental Examination 296. 7 0 0 14. Environmental Sanitation 2 312.9 0 0 15. Visit to Private Practitioner 0 5 000.0 0 16. Visit to Ayurveda Private Practitioner 0 24 000.0 0 *Inclusive gynaecological patients. Table A4. 7 COST OF ALTERNATIVE SOLUTIONS Expenditure in Ra million Capital stock Alternative Solution* Without Du11111y With Duunny of Dummy Activities Activities Activities 01 227.4 238.9 39.2 02 227.4 261.0 108.3 03 227.4 265.7 106.1 04 223.8 243.9 33.1 05 211. 3 212.1 2. 7 06 214. 7 232.4 65. 7 07 224.3 235.8 33.5 08 227 .4 253.6 50.5 09 218.8 248.8 70.1 10 206.1 231.6 48.5 11 195.0 207 .1 16.5 12 215.6 236.0 69.9 13 220.4 221. 3 1. 4 14 217.3 237. 7 33.5 15 219.3 225.5 11.0 16 192.0 211. 7 32. 6 17 183. 7 192.3 0.5 18 227.4 237. 9 28.6 19 196. 3 206.8 33.5 20 195.8 212.1 45.0 21 205.3 217.3 38.4 22 178.2 194.5 45.0 23 178. 6 184.8 16.5 24 191. 8 212.2 69.9 25 193.3 203.8 33.5 26 192.8 209.1 45.0 27 197. 4 209.4 38.4 28 173.3 189.6 45.0 29 171. 7 178.3 16.5 30 189.1 209.5 70.0 *See code on p. 383. Table A4.8 REQUIRED HEALTH MANPOWER FOR THE GOVERNMENT HEALTH SERVICES, FOR DIFFERENT ALTERNATIVE SOLUTIONS (REFERENCE PAGE A.89 FOR DEFINITION OF SOLUTIONS) Re<uired Health Manoower Per 100 OOO inhabitants ALTERNATIVE Doctors Ayur. Nurses Midwives AMPs All Doctors Nurses Midwives AMPs SOLUTION Drs. 1 2 3 4 5 6 7 8 9 10 Present stock'~ 2 225 5 661 3 394 1 194 293 37 004 16.9 42.9 25.7 9.0 1 1 945 6 499 6 906 756 302 34 068 15.3 51. 2 54.4 6.0 2 2 165 6 772 9 327 756 302 38 727 17 .0 53.3 73.4 6.0 3 2 395 6 491 4 233 1 442 302 36 693 18.9 51. 1 33.3 11.4 4 1 900 6 099 9 390 307 302 36.535 15.0 48.0 73.9 2.4 5 1 622 5 853 6 906 307 302 31 115 12.8 46.1 54.4 2.4 6 2 223 6 922 15 944 756 62 42 413 17.5 54.5 125.5 6.0 7 2 006 6 431 4 836 431 302 27 932 15.8 50.6 38.1 3.4 8 1 998 6 957 6 318 431 302 31 168 15. 7 54.8 49. 7 3.4 9 2 387 7 263 3 531 439 302 31 823 18.8 57.2 27. 8 3.5 10 1 872 6 258 7 295 237 302 30 841 14. 7 49.3 57. 4 1.9 11 1 635 5 979 5 415 237 302 28 864 12.9 47.1 42.6 1. 9 12 2 373 7 603 2 458 431 333 30 056 18. 7 59.9 19.4 3.4 13 1 563 3 906 4 210 705 302 23 721 12.3 30.8 33.1 5.6 14 1 436 3 574 6 017 799 302 25 392 11. 3 28.1 47 .4 6.3 15 1 713 4 145 2 591 1 079 302 24 915 13. 5 32.6 20.4 8.5 16 919 2 757 6 052 613 302 22 573 7.2 21. 7 47.7 4.8 17 972 2 781 4 193 469 302 21 067 7. 7 21. 9 33.0 3. 7 18 1 889 5 260 1 955 621 333 24 041 14.9 41.4 15.4 4.9 19 1 706 6 253 7 952 129 302 29 703 13.4 49.2 62.6 1.0 20 1 594 6 150 9 719 129 302 31 246 12.6 48.4 76.5 1. 0 21 1 904 6 619 5 655 305 302 29 810 15.0 52.1 44.5 2.4 22 1 433 5 726 9 770 22 302 28 348 11. 3 45.1 76.9 0.2 23 1 437 5 315 7 951 22 302 26 118 11. 3 41. 9 62.6 0.2 24 2 009 6 938 3 800 129 333 28 207 15.8 54.6 29.9 1.0 25 1 565 5 470 2 457 27 7 472 26 450 12.3 43.1 19.3 0.2 26 1 523 5 967 3 609 27 7 772 30 322 12.0 47 .0 28.4 0.2 27 1 848 6 535 2 926 83 4 062 28 732 14.6 51. 5 23.0 0.7 28 1 410 5 783 6 568 - 4 254 27 725 11. 1 45.5 51. 7 - 29 1 411 5 383 5 072 - 4 443 25 392 11. 1 42.4 39.9 - 30 1 937 6 846 1 975 27 2 683 26 626 15.3 53. 9 15.6 0.2 Ayur. Drs. 11 2.2 2.4 2.4 2.4 2.4 2.4 0.5 2.4 2.4 2.4 2.4 2.4 2.6 2.4 2.4 2.4 2.4 2.4 2.6 2.4 2.4 2.4 2.4 2.4 · 2.6 58.8 61. 2 32.0 33.5 35.0 21. 1 All 12 280.3 268.3 304.9 288.9 287. 7 245.0 334.0 219.9 245.5 250.6 242.8 227. 3 236. 7 186.8 199.9 196.2 177. 7 165.9 189.3 233. 9 246.0 238. 7 223.2 205.7 222.1 208.3 238.8 226. 2 218.3 199.9 209. 7 'O Cl) p, :,i (JQ :.."> (1) -... 'O ~ !; -"'-... I-' -"' >!) SEA/PHA/149 Page 305 Table A4.7 shows the cost of each alternative, without (first column) and with the cost of the dunnny activities (second colunm). Also, the required capital stock for delivery of the dunnny activities has been shown in the table (colunm three). The costs relate to the budget estimate for 1971. Table A4.8 presents the health manpower necessary to deliver each alternative health programme by each health care delivery system. In colunm 7-12 the health manpower requirements jor 100 OOO population have been given, for easy projection in the future, taking into consideration the population growth. The cost of the capital stock and health manpower inputs to dummy ~cti- vities were taken from the following institutions: 1. Hospital treatment of acute care: district hospital; 2. Hospital treatment of chronic care: TB hospital; 3. Hospital delivery: district hospital or integrated district hospital or integrated central dispensary, as appropriate; 4. Surgical intervention: district hospital or integrated district hospital; 6. Out-patient visit: as 3 above or visit to PHM or to ayurvedic practitioner, as appropriate; 7. Visit to preventive clinic: peripheral unit, or integrated peripheral unit, or integrated central dispensary; 8. Consultation by specialist: base hospital; 9. Vaccination innnunization: MOH office, or integrated district hospital, or integrated central dispensary, or PHM, or ayurveda practitioner; 12. Home visit: as 9 above; 13. Environmental examination: MOH office or integrated district hospital/peripheral unit/central dispensary; 14. Environmental sanitation: as 13 above. ANNEX 5: LIST OF PARTICIPANTS IN THE NATIONAL HEALTH MANPOWER STUDY SEA/PHA/149 Page 307 Annex 5.1 NATIONAL HEALTH MANPOWER ADVISORY COMMITTEE Dr C.E.S. Weeratunga, Secretary of Health, Chairman SEA/PHA/149 Page 309 Professor K. Rajasuriya, Director of Health Services, till October 1972 Dr F.A. Wickremasinghe, Director of Health Services, from November 1972 Dr S.R. Kottegoda, Professor/Dean, Colombo Medical Faculty Dr B.A. Jayaweera, Professor/Dean, Peradeniya Medical Faculty (till October 1973) Dr A.D.P. Jayatileka, Professor/Dean, Peradeniya Medical Faculty (from October 1973) Dr A.P. Hapudeniya, Director, Academy of Administrative Studies Dr M.P.M. Cooray, President, Independent Medical Practitioners Association Dr J.D. Seneviratne, President, Government Medical Officers Association Dr C. Fonseka, Professor, Head of Department of Social and Preventive Medicine, Colombo Medical Faculty Dr M.A. Fernando, Professor, Head of Department of Social and Preventive Medicine, Peradeniya Medical Faculty Dr S.W. Bibile, Professor, Peradeniya Medical Faculty and Chairman, Ceylon Pharmaceutical Corporation Mr A. Selvaratnam, Adviser Sociologist, Ministry of Planning and Economic Affairs Mr S. Asirwatham, Deputy Director, Social Overheads, Ministry of Planning and Economic Affairs (till August 1973) • Mr J. Anthonipillai, Deputy Director, Social Overheads, Ministry of Planning and Economic Affairs (since August 1973) Dr D.A. Jayasinghe, Deputy Director (MS) till November 1973 Dr S.D.M. Fernando, Deputy Director (MS) from November 1973 Dr H.A. Jesudason, Deputy Director (PHS) Dr L.B.T. Jayasundera, Deputy Director (LS) Dr S.Y.S.B. Heart, Assistant Director (FH) Dr L.N. Rajendra, Assistant Director (E.H. & E.) Dr R.H. Peiris, Assistant Director (E.Q. & E.R.) Mrs P.L.N. de Silva, Chief Nursing Education Officer Dr W.A.B. de Silva, Deputy Director (P), Study Director (Secretary) SEA/PHA/149 Page 310 National Study Director: Annex 5.2 STUDY TEAM Dr H.A. Jesudason, till 3.4.1973 Dr W.A.B. de Silva 9 from 4.4.1973 Study Co-ordinator Mr N. Sivagnanapiragasam Chief Researchers: Dr R.A.S. Rabel Dr N.M.P. Mendis Dr S.S. Munasinghe Miss Hilda de Silva Professor C. Wijesinghe Mrs P.L.N. de Silva Dr R.H. Peiris Dr T.S. de C. Dassanaieke Mr N. Sivagnanapiragasam Dr K. Maheswaran Ayur. Dr D.R. Abeysekera Administrative Study Co-ordinator Mr N. Wijewardana, till 31.12.1972 Statistician Mr E. Chandraraj WHO Project Leader Dr L.A. Simeonov Consultants Dr A. Mejia Professor D.G. Fish Mrs Barbara Bubb Mrs H. Patterson Miss M. Skeet Dr D.J.M. Mckenzie Miss Van Nguyen Dr M. Ishida Miss V. Subhadra Miss R. Varghese Dr (Mrs) M. Francis Sobel Professor G. Zarkovic Mrs S. Sutter Dr A. Perera Statistician Mr S.J. Poti Sub-Study "A" Dr R.A.S. Rabel Dr W.A.B. de Silva Dr N.M.P. Mend is Dr R.H. Peiris Mr Dulles Fernando Sub-Study "B" Dr N.M.P. Mend is Dr R.A.S. Rabel Dr p .D. de le Motte Dr W.A.B. de Silva Mr Dulles Fernando Sub-Study "C" Dr S.S. Munasinghe Dr R.A.S. Rabel Dr M.P .M. Cooray Dr W.A.B. de Silva Sub-Study "D" Miss Hilda de Silva Mrs P.L.N. de Silva Mrs P. El.iyathamby Mrs L. Lecanwasam Mrs K. Gunawardene Mrs K. Sivanadan Mrs T. Marthensz Annex 5.3 SEA/PHA/149 Page 311 MEMBERS OF WORKING GROUPS Sub-Study "E" Professor C. Wijesinghe Professor M.A. Fernando Dr K. Jayasena Professor B.A. Jayaweera Professor S.R. Kottegeda Professor M.A.A. Rodrigo Professor K.N. Seneviratne Sub-Study "F" Mrs P.L.N. de Silva Mrs P. Eliatamby Mrs G. Samarasekere Mrs M. Gomes Mrs N. Valli po ram Mrs J. G. Piyatulleka Mrs L.S. Pieris Mrs K.E. Wikremasinghe Mrs G. Somatunga Mrs Shireen de Silva Mr M.W. Rodrige Mrs C.M. Nanayakkara Mrs J. Jayawardene Mrs M.M. de Alvis Mrs D.D. Sapramadu Mrs T. Wijesinghe Mrs M.A. Weerasuriya Mrs M.A.S. de Silva SEA/PHA/ 149 Page 312 Sub-Study "G" Dr R.H. Peiris Dr R.A.S, Rabel Dr T.S. de C. Dassanaieke Mrs P.L.N. de Silva Mr L.D. Sirisoma Sub-Study "H" Dr T.S. de C. Dasaanaieke Dr W.A.B. de Silva Professor B.A. Jayaweera Professor (Mrs) P. de Soysa Dr K. Heendeniya Dr Anton Fernando Dr J. Seneviratne Sub-Study "J" Mr N. Sivagnanapiragasam Dr T.S. de C. Dassanaieke Mr K. Kumaraswamy Professor A.D.V.D. Indraratne Mr C.J.P. Coilpil:l.ai Dr W.A.B. de Silva Study Directorate Sub-Study "K" Dr K. Maheswaran Dr H.W. Perera Dr S • Ramana than Professor Earle Fonseka Mr K.H. Gaminaratna Sub-Study "L" Ayur. Dr D.R. Abeysekera Mr W. Nawagamuwa Mr W.B. Wewegama Ayur. Dr U. Pilapitiya Ayur. Dr R.M.P. Ranawala Ayur. Dr J. Mendis Ayur. Dr (Mrs) K.L. Silva Professor C.C. de Silva Professor C. Fonseka (Members of all working groups "ex Officio") Dr H.A. Jesudason till 3.4.1973 Dr W.A.B. de Silva from 4.4.1973 Dr S.S. Munasinghe AD (P) Mr N. Sivagnanapiragasam ANNEX 6: COST OF THE NATIONAL HEALTH MANPOWER STUDY SEA/PHA/ 149 Page 313 SEA/PHA/149 Page 315 The estimated cost of the National Health Manpower Study was US$ 363 874 coming from the following sources: 1. The Government of Sri Lanka US$ 80 OOO 2. The World Health Organization US$ 149 474 3. The UN Development Programme US$ 47 OOO 4. The UN Fund for Population Activity US$ 87 400 Total US$ 363 874 It has shown impossible to estimate the cost of each individual sub-study,