WHO Sri Lanka Biennium Report 2018-2019

www.who.int/srilanka WHO Sri Lanka Biennium Report 2018-2019 ISBN: 978-92-9022-739-7 © World Health Organization 2019 Health for All through the Eyes of Children Children’s Art Exhibit at World Health Day 2019 Contents Foreword 1 Acronyms and abbreviations 3 Glimpses of 2018 and 2019 4 Introduction 15 Health of the people, a snapshot in numbers 17 WHO leadership in health – leading by example 19 Our Values. Our DNA. 19 Promoting sustainability 19 Respect in the workplace 19 Staff wellness 21 Activities of the Sri Lanka Chapter of the SEA Region Staff Association 22 Beating NCDs through awareness 22 WHO’s leadership, governance and advocacy for health 22 The Triple Billion Targets 23 The First Billion - Achieving Universal Health Coverage 25 Investing in primary health care for “Health for All” 27 Walking the talk 27 Launching Sri Lanka’s Essential Services Package 28 Visualising progress towards SDG3 29 Improving access to medicines 31 Improving reproductive (and post-reproductive), maternal, newborn, child and adolescent health 32 Providing quality care for mothers and newborns in health facilities 32 Fostering healthy children and adolescents 33 Engaging youth 34 Leaving no one behind – women’s health after their reproductive years 34 Communicable disease achievement in Sri Lanka 36 Accelerating communicable disease control 37 How Sri Lanka safeguarded its people from rubella and CRS 39 Sri Lanka bids farewell to measles despite global resurgence 39 Sri Lanka’s quest to reduce dengue 39 Ending tuberculosis (TB) and AIDS by 2025 41 Accelerating the fight against leprosy 42 Ending rabies – the end is in sight 42 Sustaining Sri Lanka’s malaria-free status 42 Addressing noncommunicable diseases 43 Promoting mental health 43 Data is key 43 Bringing mental health care to the communities who need it most 45 Exchanging ideas and knowledge 47 Psychosocial package for schoolchildren in Sri Lanka 47 Committed to healthy ageing 47 Reaching the elderly through the media 48 Addressing rehabilitation for an ageing population 48 Voices of the people – their needs and hopes for UHC 49 The Second Billion - Addressing Health Emergencies 51 Addressing health emergencies 53 Strengthening Sri Lanka’s health security 53 Building resilience in the face of health threats 54 Caring for people in the face of emergencies 54 Understanding the threat of antimicrobial resistance 55 The Third Billion - Promoting Healthier Populations 57 Addressing NCD risk factors 59 Progress towards eliminating transfat 59 Slowing down on salt: how Sri Lanka is reducing salt intake 59 Combating fat, sugar and salt in processed foods 60 Celebrating the Inaugural World Food Safety Day 61 Efforts to increase physical activity 61 Sri Lanka continues its fight against tobacco 61 Progress towards FCTC 2030 62 A new era: Creating tobacco-free zones 62 Preventing the harmful use of alcohol 63 A unique approach to increasing awareness on suicide 63 Helping journalists to better report on suicide and mental health 64 Promoting road safety through multisectoral action 64 Creating change at the ground level : SLADMS 64 Cancer control activities 66 Empowering women leaders to be agents of change in their communities to prevent NCDs 66 Promoting healthier populations by addressing the environmental determinants of health 67 The Biennium in a word cloud 68 Priorities for 2020–2021 69 References 71 As I sit down to write the foreword of this report and reflect on all that Sri Lanka has accomplished this biennium, I feel immensely proud of what we have achieved together. With the launch of Sri Lanka’s new Country Cooperation Strategy (CCS) 2018–2023 in 2018, and then WHO’s Thirteenth General Programme of Work (GPW13) in 2019, this biennium truly represented a new era for our Country Office. In 2018, the Director-General, Dr Tedros Adhanom Ghebreyesus, and the Regional Director, Dr Poonam Khetrapal Singh, visited Colombo to celebrate World Health Day, the first time such celebrations were held outside Geneva. Both the Director-General and the Regional Director used the occasion to commend and appreciate Sri Lanka’s notable progress towards achieving universal health coverage (UHC), a key goal of WHO’s GPW13 and the Sustainable Development Agenda. Just one month before marking the occasion, Sri Lanka’s Cabinet approved the Policy on Health Service Delivery for UHC, which has provided the impetus and strategic guidance needed to strengthen the primary health care system. WHO is proud to be the leading technical partner in implementing this policy. Just a year later at the 2019 World Health Day celebrations, Sri Lanka launched its Essential Services Package (ESP), which was developed with WHO support. The reorganization of Sri Lanka’s primary health care system provides an opportunity to ensure that “no one is left behind”, not just from a financial perspective but also from a human rights perspective, so that all people receive health care with dignity and without stigma and discrimination. It also provides an opportunity for the country to think about how we can work together better towards a future that is happier, healthier and more fulfilling. This biennium Sri Lanka continued to accelerate action against communicable diseases, with the elimination of measles and mother-to-child transmission of HIV and Syphilis in 2019 and the control of rubella and congenital rubella syndrome control in 2018. But with much to celebrate, there is also a sobering reality. The tragic Easter Sunday attacks in 2019 illustrated the unpredictable nature of disasters and thus reiterated how critical it is to be prepared not only for natural disasters and the effects of climate change but also man-made emergencies. To this end, the country is more determined than ever to improve its disaster preparedness, and this biennium Sri Lanka became the first country in the Region to have a government-endorsed National Action Plan for Health Security (NAPHS) 2019–2023. Moreover, the epidemiological and demographic transition Sri Lanka is undergoing poses new and emerging challenges with the ever-increasing burden of noncommunicable diseases (NCDs), which are the leading cause of death and disability. WHO has been working tirelessly with the Ministry of Healthcare and Indigenous Medical Services (MoH) and other partners to develop new strategies, policies and interventions to address NCDs, such as the National Salt Reduction Strategy (2018–2022) and front-of-pack labelling for pre-packed solid and semi-sold foods. As we continue to accelerate towards the SDGs’ 2030 deadline in the face of UN reforms, it is critical for us to realize that health is more than a biomedical condition; it is a prerequisite for all that we do. I look forward to continuing our fruitful partnership with the MoH and other ministries, along with our sister UN agencies, civil society, local health authorities and other nongovernmental organizations in the coming biennium. I also look forward to continuing to promote health and well-being for all Sri Lankans. Dr Razia Pendse WHO Representative to Sri Lanka 1 Dr. Anil Jasinghe Director General of Health Services, Sri Lanka As we close the biennium 2018-19, there are many successes to celebrate and also, emerging challenges to ponder. WHO has and continues to be a steady and trusting partner to the Ministry of Healthcare and Indigenous Medical Services (MoH) and the partnership has been further consolidated during this biennium. As a member of the Executive Board of the WHO, Sri Lanka has significantly contributed to the development of the 13th General Programme of Work and to global and regional policy dialogues. Universal Health Coverage (UHC) has been the guiding principle for successive governments even before Sri Lanka became independent and continues to be the framework for ensuring health and well-being for all citizens. Participation of WHO Director General and Regional Director of South East Asia in the World Health Day 2018 event in Sri Lanka provided further impetus for the country’s initiatives towards UHC. The Cabinet approved the Policy on Service Delivery for UHC with technical support from WHO. The MoH developed the Essential Services Package (ESP) that was launched during the World Health Day 2019 event, and the integrated service delivery model based on the shared care cluster model is under discussion. The package aims to address the demographic and epidemiological challenges faced by Sri Lanka within the ongoing primary health care reorganization. WHO continues to support other health system areas like human resources, health financing, digitalization of monitoring and information systems, and service delivery. The strong primary healthcare system, especially the robust preventive services, continue to deliver, with recent and ongoing successes in the elimination and control of communicable diseases. This biennium Sri Lanka achieved the elimination of measles and mother-to-child transmission of HIV and Syphilis. Plenty of work remains, however, to maintain and build upon the progress that has been made. Noncommunicable diseases (NCDs) such as heart disease, diabetes, and stroke continue to pose a formidable threat and account for over 80% of all deaths in Sri Lanka. The MoH works closely with WHO to implement the multi-sectoral action plan on NCDs and in combatting tobacco and the harmful use of alcohol. The MoH, Sri Lanka, was commended with the UN Interagency Task Force Award-2018 for leadership and progress towards achieving NCD-related Sustainable Development Goals. Furthermore, MoH and other stakeholders work closely with WHO to strengthen national capacity for disaster mitigation, preparedness, and response. The resilience of the health system was tested once again with the Easter Sunday bombings and I am happy to note that the health systems’ response to mass causalities stood up to the test. There are many reasons to celebrate health in Sri Lanka but there is also much more to be done to ensure “Health for All” and contribute to our country’s efforts to end poverty, boost economic growth, and promote well-being for sustainable and equitable development. I look forward to our continued partnership with WHO as we work together to ensure health and well-being of all Sri Lankans. 2 AMR antimicrobial resistance ART antiretroviral therapy AYFHS Adolescent and Youth Friendly Health Service CCS Country Cooperation Strategy DHS Demographic and Health Survey EPI Expanded Programme on Immunization ESP Essential Services Package FAO Food and Agriculture Organization FCTC WHO Framework Convention on Tobacco Control FHB Family Health Bureau GPW General Programme of Work (of WHO) HIES Household Income and Expenditure Survey HIS Health Information System HRH human resources for health HTA health technology assessment ITAG Immunization Technical Advisory Group IHR International Health Regulations (2005) LF lymphatic filariasis LKR Sri Lankan Rupee MAPP Multi-sectoral Alcohol Prevention Programme MCH maternal and child health MNH maternal and neonatal health MDG Millennium Development Goals MDR multidrug-resistant MHPSS mental health and psychosocial support MoE Ministry of Environment MoH Ministry of Healthcare and Indigenous Medical Services MTCT mother-to-child transmission NATA National Authority on Tobacco and Alcohol NAPHS National Action Plan for Health Security NCDs noncommunicable diseases NMRA National Medicines Regulatory Authority NSACP National STD/AIDS Control Programme OOPE out-of-pocket expenditure POCQI point-of-care quality improvement PHC primary health care PMTCT prevention of mother-to-child transmission SEA Region South-East Asia Region (of WHO) SEARO South-East Asia Regional Office SDG Sustainable Development Goals SSB sugar-sweetened beverages STI sexually transmitted infection SLAGM Sri Lanka Association of Geriatric Medicine TB tuberculosis UHC Universal Health Coverage UNDP United Nations Development Programme UNICEF United Nations Children’s Fund WFP World Food Programme WHO World Health Organization UNIATF UN Inter Agency Task Force on the Prevention and Control of NCDs Acronyms and abbreviations 3 3Glimpses of 2018 and 2019 4 Fostering health and well-being throughout the life course, Early Childhood Development Centre 5 Enhancing mental health skills to provide holistic care, 4 W mapping at WHO Country Office 6 Empowering and investing in the healthcare workforce, Jaffna Teaching Hospital 7 Fighting stigma by creating a compassionate healthcare system, Hendala Leprosy Hospital 8 Preparing for the worst and helping those in need, Colombo 9 Recognizing excellence and leadership in everyone, Ragama Rehabilitation Center, World Health Day 2018 10 10 Standing in solidarity to achieve health for all, Independence Arcade, World Health Day 2019 11 Leaving no one behind by customizing our care, Reach Beyond Autism and Child Development Center 12 Embracing change and showing resilience in adversity, Kalutara Medical Office of Health 13 Engaging communities and partnering to end communicable diseases, Independence Square, The World AIDS Day Walk 2018 14 Sri Lanka’s health system has a long history of strong performance, not only within the South-East Asia (SEA) Region, but compared with other coun- tries of similar income level. Its impressive health outcomes, including the elimination of numerous communicable diseases, low maternal, neonatal and infant mortality and high immunization coverage, along with good financial protection, have seen the country’s health system praised far and wide. The robustness of the country’s health system and the resilience of its population were tested on Easter Sunday, 21 April 2019, when several churches and luxury hotels in Colombo were targeted in a series of coordinated suicide bombings, killing more than 250 people and injuring more than 500. Within minutes of receiving patients, health workers – medical officers, nurses, paramedics, mental health specialists and others – sprang into action and went beyond the call of duty to serve the country and its people in distress. Despite the devastating tragedy, Sri Lanka has numerous key achievements from this biennium to be immensely proud of. The country continued to accelerate progress on combating communicable diseases after being verified as controlling rubella and congenital rubella syndrome in 2018 and in mid-2019, was certified as having eliminated measles. In a major achievement, Sri Lanka also eliminated mother-to-child transmission (MTCT) of HIV and Syphilis in 2019. Recognising that Sri Lanka is facing the dual challenge of noncommunicable diseases (NCDs) and an ageing population, the Government has embarked on an ambitious primary health care (PHC) reorganization, a crucial step towards realising the goal of universal health coverage (UHC), a key goal of WHO’s Thirteenth General Programme of Work (GPW13). In 2018, the Cabinet approved the Policy on Health Service Delivery for UHC, which has provided the impetus for strengthening the country’s primary health care system. As a key technical partner, WHO worked with the MoH to develop an Essential Services Package, which was finalized in April 2019. And with the island’s vulnerability to disasters and the adverse effects of climate change, it has strengthened its emergency preparedness by launching the National Action Plan for Health Security (NAPHS) 2019–2023. As the WHO Country Office continues its work, it will continue to be guided by the Country Cooperation Strategy (CCS) (2018–2023) which is aligned with the SDG Framework, the WHO GPW13, South-East Asia Regional Flagship Priorities, and Sri Lanka’s National Health Policy. As Sri Lanka embarks on its health sector reforms, in many ways they match those of WHO globally: improved access to quality essential services; strengthened country health emergency preparedness; and reduced risk factors through multisectoral approaches. Many health-related challenges re- main and newer ones are emerging, but as ever, WHO endeavors to create impact at the country level and to continue to give all Sri Lankans the best opportunity for a long, healthy life. 15 Introduction Celebrating our achivements, continuously working towards better health and well-being... 16 17 Health of the people, a snapshot in numbers 18 WHO leadership in health - leading by example Our Values. Our DNA. In May 2019, WHO relaunched its Values Charter which highlights how we can reflect our values through our work incorporating the UN Core Values of integrity, professionalism, and respect for diversity. The Charter has five values: trusted to serve public health at all times; professionals committed to excellence in health; persons of integrity; collaborative colleagues and partners; and people caring about people. The Values are inspired by WHO’s mission to promote health, keep the world safe and serve the vulnerable, with measurable impact for people at the country level. The charter is part of a WHO transformation initiative to foster culture change towards a high-performing WHO. Promoting sustainability The SDGs call for a global shift to a more sustainable future. In an effort to achieve the Sustainable Development agenda of 2030 and to promote greater environmental responsibility, the WHO Country Office is fully committed to transform its office environment and “go green”. To do this, WHO is adhering to five key principles: staff involvement in the Green Office initiative; partnership across UN offices and other interested organizations; use of environment-friendly technologies; reduce, re- use and recycle; and protect the environment. To that end, WHO has eight policy objectives to be achieved by mid-2020. Some of these include: to reduce energy use at the office by 10%, to reduce water waste by 90%, and to establish food waste, paper, plastic and e-waste recycling processes. Respect in the workplace Sexual exploitation and abuse have no place in WHO. As part of the #SaySomething Campaign, an Integrity Hotline available to all WHO staff has been set up to receive confidential reports of unethical behaviour in the workplace. The hotline provides a safe and independent mechanism for staff to report any concerns they may have involving WHO. 19 20 Staff wellness A critical part of any healthy workplace is staff wellness – a key element of which is exercise. In 2018, the staff wellness programme began with the launch of the Global Challenge to WHO Staff in May 2019 as part of the “Walk the Talk: The Health for All Challenge”. To support staff wellness and ensure that staff could benefit from the initiative, WHO took numerous steps to facilitate increased physical activity. This included al- locating time within work hours for physical activity, adequately equipping the Office gymnasium, and paying for the use of a badminton court twice a week. In addition, WHO Sri Lanka has supported three weekly fitness sessions run by a renowned fitness group which has also provided education on healthy eating. These have be- come regular activities at the Country Office beyond the “Walk the Talk” Campaign which runs for 100 days each year. Staff enthusiasm for badminton – which has been part of the Office’s physical activity promotion sessions since 2008 – was rewarded when WHO secured fourth place at the Inter-UN Agency Badminton Tournament in 2018. Programme Associate Ms Kumundini Ragel, is one of the Office’s star badminton players (though she doesn’t like to admit it). “It’s a great exercise for your whole body. It’s fun,” she says, donning her badminton outfit on her way to a game. In 2018, 15 staff from WHO had joined the Global Challenge to WHO staff, and this increased to 21 in 2019. The Challenge not only led to staff being healthier, including achieving weight loss, but importantly it provided a platform for staff to engage with one another and work together as a team outside of the office environ- ment. For Mr Ranjan Suriyabandara, Executive Assistant in WHO’s Finance depart- ment, participating in the Global Challenge has not only been a mode of stress relief but also led him to change his lifestyle. “Nowadays I eat less salt, sugar, and oily foods. Before I started the Global Challenge in 2019, I weighed 96 kg, now I weigh 85 kg,” he says proudly. Team assistant Ms Meera Thayaparren loves the team spirit of participating in the Global Challenge. “If we are tired or don’t want to exercise after work, my other team members motivate me, they tell me I have to join,” she says. “It’s really cool because we’re telling our kids and our friends about healthy eating and the benefits of exercising.” And it appears that the healthy habits staff are creating are here to stay. Nowadays, few colleagues are interested in eating pastry items from the nearby bakery and staff there have asked why no one from WHO is dropping by anymore. Go team! 21 Activities of the Sri Lanka Chapter of the SEA Region Staff Association This biennium, staff members embarked on a social service activity of cleaning and painting the gynaecology ward of the Mulleriyawa Base Hospital in Colombo. The Association purchased the paints and equipment while the cleaning and painting was done by staff and their families. To raise money for the activity, the Association con- ducted two sales of household items. The sales were a huge success and contributed more than half of the costs for the activity. Other activities this biennium included a Christmas party, New Year’s Eve celebrations, and a musical night held at the staff office. Beating NCDs through awareness NCDs are the biggest killer in Sri Lanka. Inspired to share the message of the impor- tance of living a healthy lifestyle, WHO is in the process of setting up a model NCD corner. The corner will provide staff and visitors invaluable information on the man- agement and prevention of NCDs. The Office envisions that this initiative will not only contribute to increased awareness among the population on NCDs and WHO’s global initiatives, but that it will strengthen Sri Lanka’s fight against its biggest killer. WHO’s leadership, governance and advocacy for health WHO continues to engage with strategic partners to advocate for UHC. To imple- ment the Country Cooperation Strategy (CCS), Regional Flagship Priorities, GPW13, and the health-related SDGs, the Country Office works closely with the government, development partners, UN agencies, academia, professional associations, and civil society. Contributing to One UN Sustainable Development Framework • As part of the UN Country Team, WHO continues to participate in the four “Driver Groups” to implement the UN Sustainable Development Framework. WHO co-chairs the Outcome Group 3 of the UNSDF on nutrition, social protection, youth & skills and employment and is Chair of the UN Gender Working Group. Steering and coordinating health sector support. • WHO is co-chair of the Technical Working Group on Health and Nutrition of the Development Partner’s Forum, coordinating support among development partners on health and nutrition. • WHO continues to work closely with the World Bank and Asian Development Bank, both of which have provided health sector loans for strengthening primary care – one of the government’s key priorities. Providing strategic and technical leadership in health priorities • As vice-chair of the Oversight Committee and member of the Country Coordinating Mechanism, WHO provides technical assistance to the Global Fund’s activities in Sri Lanka. • WHO continues to work with civil society organizations, the Ministry of Sports, Chambers of Commerce, academic institutions, and the NCD Alliance Lanka to implement the Multisectoral Action Plan for the Prevention and Control of NCDs. Promoting cross-country horizontal collaboration • To promote experiential learning and cross fertilization, WHO Sri Lanka collaborates with other Country Offices to support other Member States in the Region. In 2018, the Country Office collaborated with WHO Timor-Leste for the Twinning Arrangement on immunization; with WHO Maldives on a joint programme for external competency assessment of malaria microscopists; WHO Bangladesh to support the Rohingya crisis response; and WHO Myanmar for its exchange tour on improving access to essential medicines. Strengthening capacity for global health diplomacy • To strengthen the knowledge and skills of government officials on global health diplomacy, WHO along with the MoH, Bandaranaike International Diplomatic Training Institute (BIDTI) under the Ministry of Foreign Affairs, and the Graduate Institute Geneva, developed and conducted a training course on global health diplomacy. This is one of the key priorities of the CCS and an important activity for outward projection of Sri Lanka’s achievements in health at the regional and global level. 22 23 THE TRIPLE BILLION TARGETS 24 25 THE FIRST BILLION: Achieving Universal Health Coverage One Billion More People Benefiting From UHC 26 Investing in primary health care for “Health for All” The quest for the third SDG – good health and well-being – is at the centre of Sri Lanka’s health programmes. The 13 health targets tied to the goal are reiterations of what the country has been committed to since the evolution of its health-care system. A cornerstone of the third SDG and the WHO GPW13 is achieving UHC. WHO is working closely with the MoH and in collaboration with development partners to provide support to strengthen the health system to deliver “Health for All” for Sri Lankans. Providing health care free at the point of delivery, with equitable coverage and of good quality has been the development mandate for health services over the past several decades in Sri Lanka. But while health services to all its citizens are free at the point of service delivery, the country is facing the dual challenge of the rise in NCDs and an ageing population. The transition from communicable diseases to NCDs requires a different type of health service delivery model – it requires a transformation of the health system to make it relevant to the current and future needs of Sri Lankans. This transition requires the establishment of chronic care models close to where people live, which give more attention to continuity of care and personalized prevention strategies. Walking the talk In line with WHO’s GPW13 goals and Sri Lanka’s CCS 2018–2023, the Govern- ment has embarked on an ambitious primary health care reorganization to make the necessary changes and improvements to provide health care services for emerging health challenges. In 2018, the landmark Universal Health Coverage Policy was approved by the Cab- inet. The reform is designed to support the expansion of NCD care, in addition to elderly and disability care and other areas which are not covered by the health-care system, through the reorganization of existing health services. As a key technical partner in taking the PHC reorganization forward, WHO has tak- en the lead in supporting the implementation of the policy. This includes developing a Strategic Health Financing Roadmap to improve the efficiency of public health financial management; reviewing the current Human Resources Strategy; support- ing the development of an architectural framework for digital health infrastructure; developing a National Action Plan for SDG 3; and, assisting in developing an Essential Services Package. Throughout this biennium, WHO has provided support, to strengthen policy and coordination, to human resources for health which included the development of a draft Human Resources for Health Roadmap and a Workload Indicators of Staffing Needs study initiated to determine staffing standards in PHC facilities. Importantly, existing health information systems have been evaluated and the result of the evaluation will form the basis for developing the Health Information System (HIS) architecture to monitor UHC across the country. Moreover, in 2019, Sri Lan- ka became the first country in the WHO SEA Region to populate the Digital Health Atlas, which will not only help to monitor progress towards UHC but provide valuable information on other health indicators. Following World Health Day 2018 celebrations, which were attended by the hon- ourable President, Prime Minister, and Health Minister of Sri Lanka, and WHO’s Director-General and Regional Director, WHO wanted to continue the momentum for UHC by strengthening the primary health care agenda of the Government. To this end, WHO in collaboration with Sri Lanka Medical Association organized a discussion on UHC with Parliamentarians at the Parliament. This was chaired by the Speaker of Parliament. About 60 Parliamentarians participated and contributed to the discussion and signed the UHC pledge. WHO and the MoH, in collaboration with ADB, Global Fund and World Bank, organized a two-day conference (UHC TA.lk ) on 15–16 October 2018. The conference, which was attended by 300 nation- al participants and more than 30 international experts, provided insights and inputs into how Sri Lanka can achieve its UHC and PHC goals. 27 Launching Sri Lanka’s Essential Services Package On World Health Day 2019, Sri Lanka launched its Essential Services Package (SLESP) which defines the list of interventions and services that should be available to all free of cost and at each level of primary health care. The development of the package was coordinated by the MoH with WHO technical support. The SLESP is structured into four main components: • life course services, which includes interventions on reproductive, maternal, neonatal, child and adolescent health, as well as elderly care • communicable disease services, with special focus on the control and prevention of infectious diseases • NCD services, which include interventions on the most common NCDs • grouped services and platforms, which group specific conditions such as dental care, rehabilitation and palliative care together In addition to disease-specific interventions that focus on diagnosis and manage- ment, all services will integrate health promotion along with strong health com- munication and education aimed at strengthening the population’s ability to make important decisions on their own health. The SLESP will be delivered through the shared care cluster system comprising of an apex institution providing specialized investigations and treatments together with the primary health care institutions in geographical proximity. To support the implementation of the Universal Health Coverage Policy, WHO also helped the MoH to carry out a cross programmatic efficacy analysis over the biennium. The analysis found that there were programmatic areas where there could be more overlap and integration, such as HIV and TB, so that resources can be used more efficiently to improve the performance of the health system. 28 29 Facilitated by WHO conunty oce through technical support of UNDP - to analyze, interpret, and use data for better informed decisions and planning - accessible to public unsdglk.socialcops.com 30 Visualising progress towards SDG3 On World Health Day in 2018, several initiatives were launched, which included the SDG tracker. Achieving SDG 3, which aims to “Ensure healthy lives and promote well-being for all at all ages”, will not only give Sri Lankans the best opportunity for a long, healthy life but will also contribute to achieving other SDGs such as gender equality and reducing inequality1. In 2017, WHO developed Sri Lanka’s health SDG profile, an essential first step in creating systems for measuring, implementing, and monitoring the country’s progress towards achieving SDG 3. The MoH has since set up a steering committee for the SDGs and has appointed a national focal point for tracking country progress on SDG 3 through 44 indicators that have been identified and aligned with national health priorities. This biennium WHO jointly with the UN supported the development of an SDG tracker, an innovative online platform to display the SDG indicators and targets and progress towards achieving them for the public. Partnering with the Ministry of Health, the tracker initially monitored the SDG 3 indicators at both the national and subnational level and in 2019 the tracker was expanded to another seven SDGs. The idea behind the tracker is that it will provide a rich database that will enable Sri Lanka to identify trends and who is being left behind. In a further illustration of Sri Lanka’s commitment to achieving SDG 3, with WHO technical support, the country is currently in the process of developing a National Action Plan for the achievement of SDG 3. Improving access to medicines In a bid to ensure access to quality and affordable medicines for UHC, WHO sup- ported the National Medicines Regulatory Authority (NMRA) to review the exist- ing legislations and regulations of medicines in line with the recommendations of WHO’s “Benchmarking of the National Regulatory Authority Global Assessment Tool”. A three-day training workshop on pricing of medicines was conducted for the pric- ing committee of the NMRA. Throughout the biennium, WHO also conducted a survey on the availability and pricing of essential medicines in more than 100 private pharmacies in six districts of Sri Lanka using the mobile phone application Med- Mon. Lastly, WHO provided technical support to improve and strengthen supply chain management of the Medical Supplies Division which involved a logistics man- agement training on vaccines with specific focus on strengthening the cold chain and supporting the development of innovative solutions to ensure an uninterrupted supply of NCD medicines in all government hospitals across the island. 31 Improving reproductive (and post-reproductive), maternal, newborn, child and adolescent health Sri Lanka’s progress in maternal and child health has been one of its key success stories in recent decades. The island nation has demonstrated that success can be achieved when there is political will, sound strategies, and sufficient resources. But while access to health care has improved, there is a need to focus on equity and quality to shift the needle on global and country goals. After all, Sri Lankan children and adolescents are the next generation. WHO is working diligently to support the Government of Sri Lanka in addressing challenges and ultimately improving the lives of mothers and their children. The Millennium Development Goals (MDGs) were critical in spurring collective global action on a range of health issues, and Sri Lanka’s success has served as a model for WHO-SEA Region. This is particularly true in the area of maternal and newborn health. Sri Lanka has an infant mortality rate of 8.2 per 1000 live births; a neonatal mortality rate of 5.6 per 1000 live births; and a maternal mortality rate of 33.8 per 100 000 live births2. While the island nation has already achieved low maternal, infant, and newborn mortality, rates have stagnated in the last decade. More needs to be done to ensure that no one is left behind. The country aspires to achieve single-digit maternal mortality ratio and neonatal mortality rate of less than 2.2 per 1000 live births by 20303. As such, the Maternal and Newborn Care Programme is now focused on identifying and implementing key strategies and interventions including innova- tions in digital health for further improving maternal and newborn health services with the objective of achieving the SDG targets. Providing quality care for mothers and newborns in health facilities In a bid to further reduce maternal deaths, stillbirths and neonatal deaths and move towards the 2030 goal, WHO supported the Family Health Bureau (FHB) to develop maternal and neonatal health (MNH) quality of care standards to improve care around birth. The quality assurance system for institutional-based maternal and newborn care was developed based on WHO MNH quality standards and the regional MNH quality improvement framework. While coverage of MNH 32 evidence-based interventions are almost universal in Sri Lanka, interventions need to reach the entire the target population with high quality, which is integral to im- proving MNH indicators in Sri Lanka. The initiative was scaled up to 20 secondary and tertiary care hospitals and aims to address gaps in MNH and improve specific indicators of MNH across Sri Lanka. In another important development, in early 2018, with WHO technical support, Sri Lanka launched its National Strategic Plan for Maternal and Newborn Health (2017–2025). The Plan has six broad strategic areas with the overarching goal of achieving the targets set out in the SDGs and achieving UHC. The six areas are: strengthening and investing in improving quality of maternal and newborn care; addressing all causes of maternal, perinatal and neonatal mortality and morbidi- ty; strengthening health systems to respond to the needs and priorities of wom- en, newborns and their families, ensuring UHC; addressing inequities in access to quality care; counting every mother, fetus and newborn through measurement, programme tracking and accountability; and harnessing the power of individuals, families and communities in support of MNH. A web-based electronic monitoring system for maternal and child health (MCH) was also developed based on the Digital Health Information System (DHIS2). WHO provided support to the MoH to digitise the system which will provide critical information for timely decision-making. Fostering healthy children and adolescents Sri Lanka, like other countries in the Region and beyond, is experiencing an increasing prevalence of obesity among children and adolescents, in addition to stubborn pockets of under-nutrition in children under-five. To control obesity and overweight early on, a lifecycle approach must be adopted by promoting physical activity and healthy diets. To this end, WHO is working with both the Ministry of Education (MoE) and the MoH to promote healthy diet and physical activity in schools. While a range of policy measures have already been taken in schools, it was time for such policies to be reviewed to identify gaps and improve health outcomes. In early 2018, WHO supported a review of the policies on the promotion of nu- trition and physical activity at schools. The review found that while policies were largely comprehensive and in line with WHO recommendations, there were a few key policy areas that needed strengthening4. This included the lack of adequate and appropriate infrastructure for physical activity and the lack of mechanisms to make healthy food affordable at school canteens in addition to promoting their consumption5. In a further bid to address the triple burden of malnutrition, WHO, along with other UN agencies including UNICEF, the World Food Programme, (WFP) and the Food and Agriculture Organization (FAO), developed a joint proposal to sup- port the Presidential Task Force on Nutrition to implement the Multisectoral Ac- tion Plan on Nutrition. The “Tackling Malnutrition Together” proposal focuses on six districts in five provinces. It has three core focus areas: strengthening advocacy, policy and coordination; greater awareness and understanding of good nutrition and care practices; and improved health service provision and better protocols and nutrition treatment practices. WHO also carried out a rapid assessment on the status of implementation of adolescent and school health programmes in Sri Lanka. The adolescent popu- lation (10–19 years of age) in Sri Lanka represents 16.1% of the 21.7 million population6. In 2005, Sri Lanka introduced its adolescent health programme, the Adolescent Youth Friendly Health Service (AYHFS). AYFHS facilities provide a health service package to school and non-school goers including information, counselling, preventive, diagnostic and treatment services, with referral and link- ages to other services including mental health and nutrition. 33 The assessment found that there was a data gap: a gap in collecting, collating and analysing data with regards to the programme7. The review also found there was a lack of appropriate, dedicated infrastructure facilities and qualified health care professionals to provide hospital-based services. Identifying and addressing area-specific adolescent health problems by effective use of data will not only help improve the programme, but will help to identify gaps and challenges. Lastly, WHO provided technical assistance to the MoH to develop the Adoles- cent Health Strategic Plan (2018–2025), which was launched in 2019. Most of the strategies in this framework are in line with global strategies on Adolescent Health for 2016–2030 and the Global Accelerated Action for the Health of Adolescents Framework (“the Global AA-HA! Framework”). The Adolescent Health Strategic Plan will provide guidance for accelerated implementation of adolescent and youth health programme in the country. Engaging youth In both 2018 and 2019, WHO used the annual National Youth Camp known as “Yowun Puraya” as an opportunity to engage youth on health and well-be- ing. More than 7000 young people were reached with key messages and infor- mation on diverse issues from healthy diets to psychosocial health. Mr Randika Madushan Dissanayake attended the 2019 Yowun Puraya, which was held in Weerawila, in Hambantota district in March. For him, one of the highlights of the camp was attending WHO’s workshop on nutrition. “As young people, when we are hungry, we tend to consume a lot of fast food items because it’s convenient. Previously, when we consumed these food items, we didn’t fully understand their health impact and we didn’t know how to interpret the nutrition information given on the labels,” he says. After he attended the workshop, though, Mr Dissanayake and his peers are now able to make informed choices about the type of food they consume. “We now have good awareness about food labelling and how to interpret in- gredients, especially additives and colourants that are in the food items we consume. We understand the negative health impacts of processed foods. The programme was a good foundation for us in our journey towards good health.” Leaving no one behind – women’s health after their reproductive years Ms Nilakshi Palihakkara is a nursing officer at the health education unit at Kethu- mathi Hospital for Women in Panadura in Kalutara District. She sits proudly at her desk, showing off menopause educational materials for both staff and women who attend the hospital. “Most of the patients who attend the gynaecological clinic at our hospital are between the age of 40 and 60 years. When we talked to them, we realized that they have numerous problems relating to menopause,” Ms Palihakkara says. Recognizing that women’s health after their reproductive years is oftentimes neglected, this biennium WHO supported the Meno- pause Society of Sri Lanka and the Family Health Bureau (FHB) to produce an infor- mation booklet for health workers on issues related to menopause along with a six-part educational video for the public. 34 At Kethumathi Hospital for Women, a video called “Mihiri Mediviya”, otherwise known as “Happy Midlife”, is played at the hospital’s auditorium for the women at- tending the gynaecology clinic. “The women find it very useful,” Ms Palihakkara says. “The video has six sections and is very easy to understand. We are hoping to purchase a television and play this in the clinic as well.” Dr Shiromali Dissanayake, Medical Officer at the hospital and council member of the Menopause Society of Sri Lanka, says such an initiative is helping to break down barriers. “Women are reluctant to speak about sexuality and menopause. There is no place for them to get information,” she says. “We haven’t addressed this aspect of women’s lives. We wanted to give health workers knowledge on menopause but also give women information on the symptoms and signs of menopause so they can understand what they can do.” Dr Dissanayake says that such information is invaluable to also address gender-based violence and unintended pregnancies. “Many unwanted pregnancies happen in this age group because they believe they don’t need any family planning methods because of their cycle changes,” she says. “We must give this information so women know what is going on with their bodies. I think in the future we can do a lot more work on this issue with the support of WHO.” 35 Communicable Disease Achievements in Sri Lanka (disease elimination) 36 Accelerating communicable disease control Systematic investments in health have led to Sri Lanka’s numerous communicable disease achievements, from eliminating malaria to measles. While there has been a disease transi- tion from communicable to NCDs, it is critical that Sri Lanka sustains and accelerates its gains in combating communicable diseases which are still prevalent and which continue to place a burden on the population and the health-care system. Despite being a country in the tropical belt, Sri Lanka has had tremendous success in controlling communicable diseases reflected by rapidly falling morbidity and mortality that was previously associated with a range of communicable diseases. This biennium Sri Lanka has numerous public health achievements to be immensely proud of – achievements that not only highlight the strength of the health system but the high level of community engagement in disease elimination. It is urgent that Sri Lanka contin- ues to sustain the status of eliminated communicable diseases and accelerate interventions to eliminate other targeted diseases. To this end, WHO is focused on reaping the oppor- tunities the primary health care reforms provide to scale up interventions and spur on action to reach global and national-level targets, with the ultimate goal of achieving UHC. 37 38 How Sri Lanka safeguarded its people from rubella and CRS On 2 August 2018, Sri Lanka was verified as having controlled both rubella and CRS by the Regional Verification Commission for Measles Elimination and Rubel- la/Congenital Rubella Syndrome Control. It achieved this goal two year’s ahead of the regional target that was set at the Sixty-sixth session of the Regional Commit- tee for SE Asia in 2013. Sri Lanka’s success in controlling rubella and CRS is the re- sult of strong leadership, sound budgeting, steadfast cooperation, and partnership between the country’s health authorities and development partners, in addition to the committed efforts of countless health workers and officials at the ground level. Sri Lanka was an early adopter of the rubella vaccine, introducing it into the Ex- panded Programme on Immunization (EPI) in 1996, following outbreaks during the previous two years. While the rubella incidence fell substantially, the virus was still potent and 2011 saw a spike in the number of cases reported. But Sri Lanka’s dynamic health system responded immediately. In the same year, two doses of the combined measles-mumps-rubella (MMR) vaccine were introduced as part of routine immunization under the EPI for children aged 1 and 3 years. The country also sharpened reporting and surveillance and worked to ensure high immuni- zation coverage through routine immunization and supplementary immunization activities (SIA). As a result, the number of rubella cases dropped to zero by 2017. Sri Lanka’s success in controlling the disease illustrates the country’s commitment to the health of its people and just how vital partnerships with communities and agencies like WHO is to provide government support, monitoring assistance and knowledge sharing. With its recent success, Sri Lanka believes it is on track to elim- inate rubella by 2021, two years ahead of the regional target of 2023. Sri Lanka bids farewell to measles despite global resurgence In yet another major public health achievement, in mid-2019 Sri Lanka was veri- fied as having eliminated measles. The achievement came at a time when globally measles cases are increasing from France to Madagascar, which is threatening to undermine global progress on fighting this and other vaccine-preventable diseases. Sri Lanka reported its last case of measles caused by an indigenous virus in May 2016. Sporadic cases, reported in the last three years, have all been importations that were quickly detected, investigated and responded to. Like the island nation’s success in controlling rubella and CRS, Sri Lanka’s success in eliminating measles – a Flagship Priority Programme of the Region – is the result of its per- sistent efforts to ensure maximum coverage with two doses of the MMR vaccine, along with strong surveillance, resilient leadership, coordinated partnerships and committed health workers. Dr Deepa Gamage, focal point for the Measles Elimination Programme at the Epidemiology Unit, MoH, specifically points to Sri Lanka’s ability to maintain high immunization coverage at the community level, its sensitive case-based surveil- lance, and efficient outbreak response mechanisms that are in place as key compo- nents of its success. But despite Sri Lanka’s triumph, work must continue, because the risk of impor- tations of measles virus from countries near and far remain. In fact, more than 40 cases of import-related cases of measles were reported in the first five months of 2019. This demonstrates how critical it is to strengthen Sri Lanka’s capacity to detect and respond to measles at the national and sub-national level, which WHO is committed to supporting. “We must strengthen laboratory services and com- munity surveillance. This is our main concern at the moment,” Dr Gamage says. “In addition, in the face of growing global vaccine hesitancy, we must continue advocacy to maintain the demand for vaccination”. Sri Lanka’s quest to reduce dengue A system of continuous professional development of public health staff involved in the prevention and control of dengue was identified as necessary. WHO, the Ministry of Health and the Medical Faculty of Colombo joined hands to develop an online training module. The training content was developed based on a needs analysis performed among different cadres and content was developed accordingly to fulfill these needs. An electronic-based training platform, using Moodle, was developed and handed over to the Ministry of Health to be made available to all public health cadres throughout the country. 39 In addition to the Moodle course, the content of the module was summarized into an android-based application and made available to the many public health cadres as well as the general public to raise awareness of the many aspects of the diseases, its transmission, prevention, and control. The application is freely available to the public through the google app store <dengue app>. Dengue has rapidly spread in all regions of WHO in recent years, largely driven by climate change. In 2017, Sri Lanka faced an unpredicted dengue outbreak. Be- tween 1 January and 31 December 2017, there were 186 101 reported dengue cases and more than 400 deaths, making it the largest dengue outbreak reported in the history of Sri Lanka8. Following the huge outbreak, WHO supported the develop- ment of the Intensified Strategic and Operational Plan to Rapidly Reduce Dengue Morbidity and Mortality in Sri Lanka 2017–2020. As part of the Plan, the MoH has been conducting regular reviews and audits and working to improve the skills and capacities of frontline health staff in vector control and case management. Throughout this biennium, WHO has supported the MoH to further build capaci- ty of health staff on vector surveillance and control using GIS tools, in addition to training on the clinical management of dengue to reduce morbidity and mortality. “With the support of WHO, the National Dengue Control unit and Epidemiology Unit were able to train 25 physicians and 31 pediatricians in 2018. The training was very popular and all members of the training group highly praised the pro- gramme,” Dr Preshila Samaraweera, Consultant Community Physician from the National Dengue Control Unit from the MoH, says. Dr Samaraweera adds that thanks to WHO support, MoH staff are now able to thoroughly analyse dengue data, which is not only making the health-care system more efficient, but also helping to identify trends up to the level of the Medical Officer of Heath. “With dengue, we must identify the exact point of spread. That’s why GIS is very important,” she says. In 2018, there were 51 659 recorded cases and 58 deaths, a significant decrease from the previous year9. However, as of August 2019, there have been more than 42 000 notified dengue cases10. Dr Samaraweera points to the Easter attacks as one of the reasons why there has been a spike in cases, specifically in Galle district, compared with 2018. The tight security situation, she explains, has affected the smooth implementation of dengue control activities to its full potential due to the unavailability of security forces (tri-forces and police) for outbreak control activities. But despite the challenges, Sri Lanka is more committed than ever to fighting this stubborn disease. In a further step towards addressing dengue, in mid-2019, Sri Lanka launched its National Action Plan for the Prevention and Control of Den- gue (2019–2023) which provides a strengthened framework for the prevention, control, and clinical management of dengue through an integrated approach. 40 The Plan aims to move from a reactive response to an emergency situation to proactive risk assessment, early warning system, and preventive measures through advocacy, resource mobilization, strategic partnerships, capacity-building, and monitoring and evaluation. There are two major goals for 2023: to achieve case incidence below 100 per 100 000 and to reduce and maintain the case-fatality rate below 0.1%. Dr Samaraweera knows that there is a lot of work to be done to achieve the 2023 goals but believes that with ongoing commitment and support, it is possible. “This is a big goal. Dengue is a very difficult disease to control. We must keep people motivated to fight this disease from early morning until nighttime.” Ending tuberculosis (TB) and AIDS by 2025 Sri Lanka is a low-prevalence country for both TB and HIV but business as usual will not help the country achieve its ambitious goals for 2025. While the prevalence of TB has remained stagnant over the past decade, the number of multidrug-re- sistant (MDR-TB) cases has been gradually increasing. TB continues to be a public health problem with between 8000–9000 new cases reported every year. Accelerating efforts to End TB by 2030 is a Flagship Priority for the Region. Sri Lanka, however, has committed to end the disease five years ahead of the goal. In 2018, at the Delhi End TB Summit, Sri Lanka declared its commitment to end TB by 2025. Not only has the country committed to ending the ravaging disease by 2025, but it has also announced its commitment to end AIDS. In 2019, Sri Lanka took an important step forward when it was certified as a country that has elimi- nated mother-to-child transmission of HIV and Syphilis. The 2025 Ending AIDS goal, however, will require the country to reach 95-95-95 treatment targets by 2025 instead of 2030. This involves 95% of people living with HIV knowing their sta- tus; 95% of those who know their status on treatment; and 95% of those on treatment having suppressed viral loads. It also requires reducing the number of new infections as well as working towards zero discrimination. Sri Lanka continues to have a low prevalence of HIV in the general population at 0.1%; however, the prevalence is higher among key populations such as men who have sex with men11. With 2025 only a few years away, Sri Lanka, with WHO support, is scaling up its response to TB and HIV/AIDS and is fast-tracking evidence-based interventions. To this end, in 2018, WHO, along with the National STD/AIDS Control Pro- gramme (NSACP) and the National Programme for Tuberculosis Control and Chest Diseases (NPTCCD), organized a national consultative workshop, support- ed by the Global Fund. The outcome of the workshop was a Roadmap for Ending TB and HIV/AIDS, which includes, among others, employing Xpert MTB/RIF and digital X-ray machines across the country to scale up TB case-finding and the use of innovative HIV community-based testing interventions to increase HIV diagnoses. WHO is also supporting the MoH to revise TB guidelines; mobilize donor support for TB screening and diagnosis; contribute to TB-related research; and manage MDR-TB. In respect to HIV/AIDS, the Country Office is also supporting the MoH to update HIV and STI testing guidelines; carry out research on stigma among people who inject drug (PWIDs) and HIV sentinel surveys; and establish an e-learning tool for an electronic patient information system. 41 Accelerating the fight against leprosy There is a common global misconception that leprosy is a disease of the past; how- ever, it is not. In Sri Lanka around 2000 new cases are reported every year, 10% of which are among children12. Sri Lanka has been recognised by WHO as one of 23 “global priority countries” for leprosy. Throughout this biennium, significant progress has been made towards reducing leprosy incidence, with a specific focus on increasing access to treatment and understanding the burden of drug resistance. To this end, WHO supported an evaluation of the country’s peripheral satellite clin- ical programme – clinics that were set up in 2017 with WHO support to bring diagnostic and treatment services closer to communities, especially in rural areas – with the aim of further scaling up clinical services. WHO, in partnership with the Anti-Leprosy Campaign, also trained peripheral health staff to make early diagnosis, timely referrals and manage disability through workshops, sharing experiences from other countries, and through expert advice from the Centre of Excellence in Japan. WHO also worked with the Centre of Excellence in Japan to set up a leprosy senti- nel drug-resistance surveillance system which has led to huge improvements in staff capacity to work on molecular laboratory diagnostics. WHO will continue to work closely with the Anti-Leprosy Campaign and the MoH on enhancing case surveil- lance; improving drug resistance monitoring; building capacity of health staff; and providing multidrug therapy. Lastly, a review of the implementation of the present National Leprosy Strategy (2016–2020) and the activities implemented with support of the Bangkok Declaration Special Fund project were conducted to inform future strategic planning for 2021–2025 on the road to achieving the declared goal of a leprosy-free Sri Lanka. Ending rabies – the end is in sight Rabies is a vaccine-preventable and fatal zoonotic, viral disease which occurs in more than 150 countries and territories across the world13. Deaths in humans are fully preventable through prompt and appropriate medical care. Sri Lanka was the first country in the Region to develop a national strategy for the elimination of dog-mediated rabies, and is a key country in sharing knowledge, expertise and capacity-building in the Region towards achieving the global target of zero rabies deaths by 2030. Following the April 2018 release of a WHO position paper on the rabies vaccine, the Country Office undertook a series of country-wide training sessions to im- prove health-care providers’ knowledge of the new recommendations on human rabies immunization in regard to post-exposure prophylaxis (PEP) and pre-expo- sure prophylaxis (PrEP). As Sri Lanka moves towards its national goal of ending human rabies by 2025, WHO continues to provide technical and other support to revamp rabies elimination initiatives and formulate strategies to achieve set targets. Sustaining Sri Lanka’s malaria-free status Despite huge threats of the re-introduction of malaria into the island nation, Sri Lanka has for the seventh consecutive year successfully maintained its elimination status since the last indigenous cases in 2012. WHO continues to work in collaboration with numerous partners such as the Anti-Malaria Cam- paign and the Global Fund to sustain the country’s malaria-free status, which was achieved in 2016. This biennium WHO supported capacity-building on the clini- cal management of malaria, vector surveillance and taxonomy, and supported the procurement of essential anti-malarial drugs and rapid diagnostics. Importantly, WHO also technically supported the MoH with the development of guidelines on malaria chemoprophylaxis and vector control focused on the prevention of re-introduction. 42 Addressing noncommunicable diseases Sri Lanka’s disease burden has shifted from communicable to noncommunicable causes and NCDs are now the leading cause of death, fuelled by tobacco use, un- healthy diet, harmful alcohol use, and physical inactivity. The reorganization of the country’s PHC system is key to the prevention and treatment of NCDs, which is a major priority of Sri Lanka’s CCS and is essential to achieving SDG 3. Sri Lanka has several critical policies and interventions that aim to counteract this surge in NCDs and this biennium WHO has been busy at work supporting the Govern- ment to address the challenges in NCD prevention and treatment. NCDs are the leading cause of death and disability in Sri Lanka, estimated to account for 83% of all deaths14. Cardiovascular diseases are the leading cause of death, followed by other NCDs and cancers. Sri Lanka is a fast-track country for NCDs and receives “One WHO” technical support from all levels of the organization. Despite the challenges, Sri Lanka has demonstrated notable political commitment and multisectoral cooperation in its fight against NCDs. This was reflected this biennium with the appointment of the President as Commissioner of the High-Level Commission set up by the WHO Director-General to provide guidance on addressing the NCD burden. The MoH was also selected for the UN Inter-Agency Task Force Award 2018 in recognition of the country’s contribution to achieving NCD-related SDGs. Appointments, awards and conferences aside, in 2018 Sri Lanka invited the UN Inter-Agency Task Force on the Prevention and Control of NCDs (UNIATF) to review the country’s progress on its National Multisectoral Action Plan for the Prevention and Control of NCDs (2016–2020), which is the main policy docu- ment guiding the country’s approach to NCD control. It was the second joint mis- sion to Sri Lanka which included representations from six UN agencies. The Mis- sion concluded that while there has been notable progress since 2015, there was a need to further prioritize and scale up evidence-based interventions for NCD promotion, prevention and management15. Following the visit, a highly prioritized action plan (2018–2020) has been devel- oped. It is based on WHO’s “best buys” and country needs for the prevention and control of NCDs endorsed by the World Health Assembly in 201716. The plan includes strengthening restrictions on the marketing of unhealthy food and non-alcoholic beverages to children; strengthening physical education school pro- grammes; and strengthening the Sri Lankan Government and UN collaboration on NCDs through PHC reorganization. It also led to a revision of the National Policy and Strategic Framework for the Prevention and Control of Chronic NCDs in Sri Lanka (2019–2030) which is focused on achieving the SDG targets related to NCDs. Promoting mental health Good mental health is critical to overall well-being. Mental health in Sri Lanka has emerged as a pressing public health problem and with that comes the need for a dynamic and responsive health-care system. WHO is working closely with the Government and other partners to bring mental health services to communities across the country who need it most. Sri Lanka has a suicide rate of 15.4 per 100 000 population, which is higher than the regional average of 11.2 per 100 000. While the country has made major ad- vances in reducing its suicide rate from the peak in the mid-1990s, there are still large numbers of people attempting suicide indicating that there is a level of dis- tress being experienced by the population that needs to be addressed. Very little is known about the underlying factors that lead to suicide in the Sri Lankan context and WHO is committed to helping the country better understand it. The devastating Easter 2019 attacks highlighted the importance of the health sys- tem being adequately equipped to provide mental health and psychosocial support (MHPSS). On the day of the attacks, the MoH deployed a mental health and psychosocial team at all three hospitals that were looking after the injured and their families. A MHPSS desk was established at all hospitals to provide support to all those affected by the tragedy. Staff from WHO visited regularly to provide psychological support. Data is key While Sri Lanka has made significant progress in its health reporting system, na- tional data on the prevalence, pattern and impact of mental health morbidity and disability is not available. In fact, data on mental health are only available for adolescents. 43 44 Despite several surveys and studies having been conducted in Sri Lanka on suicide and self-harm, there is a lack of understanding of the risk factors associated with it. Moreover, while the police department collects data on suicides, the current recording system is patchy and limited due to the limited skills among investigating agencies. Consequently, a lack of reliable data on mental health severely hinders ef- forts towards programme design, systematic interventions and resource allocation. Recognising the importance of understanding the risk factors for suicide and the importance of accurately reporting such events, the country has embarked on developing a suicide registry and suicidal attempt surveillance system with WHO technical support. A pilot registry and surveillance system has been initiated as a pilot in one district, with plans to scale it up. In addition, WHO, along with the Sri Lanka College of Psychiatrists and the Consumer Action Network for Mental Health and other NGOs, supported the MoH to carry out an evaluation of the im- plementation of National Mental Health Policy, which ended in 2015. The review is providing impetus to the development of a National Mental Health Action Plan. Bringing mental health care to the communities who need it most As part of the WHO’s involvement in the peacebuilding process in Sri Lanka, a series of workshops to build conflict resolution skills among community leaders were conducted across the country. The Country Office, with the support of a multidisciplinary team and the Directorate of Mental Health at the MoH, con- ceptualized, designed and implemented the “Manohari” programme to strengthen psychosocial well-being and improve coverage of mental health services through community-based interventions. The programme is an innovative way of imple- menting community-based interventions for people living in conflict-affected ar- eas. Manohari crosses cultural boundaries in Sri Lanka. The word means “harmo- ny” in English, something the programmes seeks to bring to communities where the techniques learned will be practised. Mr N. Karunarathne is a community psychiatric nurse in Monaragala district in Uva Province. A big part of his job is to deliver MHPSS services at the community level. This includes identifying community members with psychosocial needs, and conducting awareness programmes to reduce stigma around mental health and build resilience among the population. Mr Karunarathne participated in the Mano- hari programme and says it changed his perspective on providing MHPSS services. “When I first joined [the project], I felt I knew a lot of things, including what the community needs are but now I understand the value of community empower- ment and facilitating the community to problem-solve,” he says. The Manohari programme takes a participatory, self-reflective approach to MHPSS by taking participants on an experiential journey using storytelling and role plays. The pur- pose of this approach is to support communities to not only understand their psychosocial needs but also prompt positive emotional behaviour change in the face of stressful life situations. For Mr Karunarathe, attending the programme has meant that he is now equipped with the tools and techniques to conduct participatory discussions with his com- munity on sensitive issues, and move away from the typical one-on-one communi- cation. He is one of 64 individuals who have been trained and is now, like the other participants, back in his community putting into practice what he has learnt. The programme is funded by United Nations Peacebuilding Fund, the peacebuilding and response facility. 45 Psychosocial support is an integral part of post-conflict peacebuilding, because it promotes the transformation in relationships necessary to support a sustainable peace. There is a need for individual and community capacity-building to support those struggling to engage meaningfully in life after experiencing conflict. WHO interventions in Sri Lanka have contributed to addressing conflict-related mental health issues in order to reduce inequalities and promote greater state and civic engagement in reconciliation processes. They have also worked to strengthen psychosocial support systems to contribute towards healing and reconciliation at the community level. Support from the Peacebuilding Fund (PBF) has been used for catalytic interventions to develop community resilience in post-conflict settings as well as to address determinants of violence such as alcohol abuse and suicide. Similarly, PBF support has been crucial in supporting increased data in the field of mental health and psychosocial support through stakeholder mapping exercises and a review of the National Mental Health Programme. Psychosocial interventions are part of a more holistic and transformative approach which promotes resilience, social cohesion and lasting peace in Sri Lanka. – Hanaa Singer, United Nations Resident Coordinator in Sri Lanka 46 Exchanging ideas and knowledge In September 2018, WHO took the opportunity to include MHPSS in the Na- tional Youth Social Innovation Challenge, Sri Lanka’s platform for young people to provide innovative solutions to development challenges organised by UNDP. The challenge not only promoted mental well-being but gave young people the opportunity to build online, safe and stigma-free platforms that are accessible to people in need of MHPSS services. The programme will continue to develop ideas with youth groups and ensure that it serves as a place for service providers to come together. Meanwhile, WHO along with numerous other organizations active in the field of MHPSS, launched the Community of Practice (CoP) for MHPSS Knowledge Ex- change in Sri Lanka. It aims to create opportunities for sharing and learning among practitioners, programme managers and policy-makers engaged in MHPSS. It’s an open, informal, platform which is designed to be a supportive space for reflection and dialogue on key issues in the field. As an active member of CoP, WHO has used the platform to share MHPSS projects, outcomes and lessons learnt. As a result, organizations working in the field of psychosocial support in Sri Lanka are aware of WHO’s work and have, as a result, formed links at the district and community levels. Psychosocial package for schoolchildren in Sri Lanka Schoolchildren are the future of Sri Lanka and it is critical that as children age, their psycho-social needs are met. Given the contributory role teachers play in the promotion of children’s and adolescents’ well-being, WHO supported the devel- opment of a handbook for teachers on the psycho-social health promotion of school children. The handbook is designed to provide teachers with the skills they require to improve the psycho-social environment of children. Committed to healthy ageing Sri Lanka has one of the fastest ageing populations in the world. In 2015, 15% of the population was older than 60; this is estimated to go up to 29% percent by 205017. However, geriatric care is not a well-established speciality in Sri Lanka and 47 there are no healthy ageing modules that are taught for general practitioners. In the light of this, during this biennium WHO supported the Sri Lanka Association of Geriatric Medicine (SLAGM) to develop an education module on healthy ageing for General Practitioners to increase their knowledge. The model, called “Wadihity Deviyata Athwelak”, meaning “aide for elderly life”, contains topics such as the prevention and detection of common diseases affecting the elderly. Reaching the elderly through the media Home safety. Medicines that can increase your risk of falling. Sexual health. Alz- heimer’s disease. Ageing gracefully. There is no shortage of issues that affect Sri Lanka’s rapidly ageing population and there is no better way of educating them about such issues than a magazine that is designed just for them. Sunrise is a bimonthly publication that was re-launched this biennium, thanks to WHO support. This non-profit publication is led by one of Sri Lanka’s most prominent journalists, Ms Kumudini Hettiarachchi, with support from her jour- nalist husband, Mr Feizal Samath. Hettiarachchi. The magazine brings to the fore the voices of Sri Lanka’s ageing population and raises relevant policy issues. “Being journalists, we’re very bold in addressing issues. I’m for the people – and the elderly have needs that haven’t been addressed before. Someone needs to do it,” Ms Hettiarachchi says. “We are lobbying the government for the rights of the elderly. Can they access services? This is a group that needs our focus.” The magazine inspires the elderly to get involved with their community. In fact, there’s a 93-year-old woman who frequently sends in inspirational quotes to be included in the magazine. Over the course of the biennium, the magazine’s reader- ship has grown in urban Colombo, reaching more people than ever. Addressing rehabilitation for an ageing population Rehabilitation is an integral part of health services and is essential for achieving UHC. To this end, WHO provided technical support to the MoH to carry out a situational analysis of rehabilitation services in Sri Lanka in late 2018. The assess- ment found that there is a significant unmet need for rehabilitation and that due to an ageing population, needs are increasing. A major concern is the small size of the rehabilitation workforce and the inadequate number of longer-stay rehabilitation beds for people who require long-term care. In response, WHO and the MoH have begun work on the development of a National Rehabilitation Strategic Plan to help address some such concerns. 48 Voices of the people – their needs and hopes for UHC What do people want from Sri Lanka’s health system? With the goal of UHC as a core element of the SDGs, Target 3.8 on UHC emphasizes the importance of all people and communities having access to quality health services without risking financial hardship. So, what do Sri Lankan people think of their health system? What challenges do they face? What are their hopes? Ms Ajanthi Wickramasinghe, 43, from Wahalkada village, Anuradhapura district, North Central province “Our village – Wahalkada, is agricultural. If you need in-ward care, we have to go to Kebethigollewa hospital, which is 24 km away, or to Padaviya hospital. In our hospital, there aren’t enough staff to provide in-ward facilities. The hospital has two wards and beds, but no adequate staff. If this hospital can be upgraded, it will really benefit the residents of our village. There are about 3000 families in our village. One doctor and one nurse cannot cope with the demand. For specialized treatment such as kidney ailments and heart disease attending health clinics outside the village is costly. You have to spend on food and transport and sometimes on childcare if you have to leave your children behind. You also need someone to accompany you to the clinic, which means loss of time and income for that person as well.” Mr Jagath Warnasuirya, 57, tuk tuk driver from Keppetipola, Badulla dis- trict, Uva province “I really appreciate the free health services provided by the state but I feel there should be more facilities. There are not enough services for maternal and child care. The staff are over-worked due to the demand. There are not enough staff for all the patients. A lot of people from low income socio-economic groups use tuk tuks (three-wheeled taxis) as their main mode of transport to go to hospitals and clinics. These are the vehicles that can negotiate small rural access roads. This is not the ideal mode of transport for patients. But this is what can be afforded by the majority of people from low-income groups. There are people who face unexpected circumstances like accidents or emergency situations. Sometimes the doctors or the clinic do not have the equipment or the means to provide care depending on the severity of the accident. In Welimada, there is an accident and emergency clinic which is only open during the day and we don’t have that facility available at night. I think training on first aid should be given to transport providers like taxi-drivers, members of Community Based Organizations and schoolchildren. Then it will be possible to assist patients in an emergency, if necessary.” Mr. H.M. Dayananda from Bibile town, Moneragala district, Uva province “When my children fall ill, we take them to private medical practitioners for treat- ment. Sometimes some medicines are not available in state hospitals, so we go to the private medical services. If the illness doesn’t get better, we go to another doctor. We also go to the state medical sector for health services. But there is a general perception amongst people that private health care is better. People think that channelling a private medical practitioner and getting treatment from them will make you better, faster. This is the general perception. “In rural areas, many people do not attend health clinics. Even when they fall ill, they won’t immediately go to a doctor or to hospital. Instead, they will take some home remedies. Going to rural areas and conducting health clinics and improving awareness of health amongst community members is important. This can be done through state medical officers.” 49 Venupama Yethmini Athapattu, SEARO World Health Day 2019 Art Competition, 1st prize winner 50 51 THE SECOND BILLION Addressing Health Emergencies One Billion More People Protected From Health Emergencies 52 Addressing health emergencies Climate change, increasing global travel and trade, rapid and unplanned urban- ization, irrational use of antibiotics... All these factors are increasing the vulnera- bility of people to health threats across the world. Emergency preparedness and response is an Organization-wide priority for WHO and the Country Office is supporting the Government of Sri Lanka to build capacity to prevent, detect and respond to all public health threats. Emergencies and disasters are becoming more frequent, diverse, and larger in scale globally, and Sri Lanka is not immune. The island nation is extremely vulnerable to climate change and its effects. The country has a vast coastal plain with moun- tainous areas in the southern and central regions. The coastal regions, where a sig- nificant proportion of the population lives, are most vulnerable to climate change. The country is frequently battered by hydro-meterological disasters due to its geo- graphical location. Since 2010, Sri Lanka’s national disaster management system has recorded more than 11 000 incidents leading to disasters of which the leading causes are flood, drought and strong winds. This has resulted in the death of 1727 people with an additional 431 declared missing. Fortunately for Sri Lanka, there were no major graded emergencies this biennium. That, however, does not mean there is time for complacency. In fact, this bienni- um, Sri Lanka became the first country in the SEA Region to have a government endorsed National Action Plan for Health Security (NAPHS) 2019–2023. Strengthening Sri Lanka’s health security In 2018, Sri Lanka made a commitment to further strengthen its core capacities on the International Health Regulations (IHR) 2005 through the development and launch of its National Action Plan for Health Security (NAPHS) 2019–2023. The NAPHS will guide relevant stakeholders to strengthen the core capacities to pre- vent, detect and respond to emergencies, and will ultimately strengthen the health security agenda of the Region. It has been developed to address gaps that have been identified through the IHR Monitoring and Evaluation Framework (MEF) and is being monitored by the National Steering Committee for IHR which com- prises all stakeholders within and outside the health sector. In addition, district management plans incorporating the revised strategic plan for health sector disaster management were developed for eight districts in the south-western and northern provinces – those at highest risk for repeated floods and landslides. The district management plans also work to strengthen Sri Lanka’s emergency preparedness and IHR core capacities. For preparedness and response to all hazards within the framework of the IHR, WHO at all three levels worked with Sri Lanka’s key national stakeholders to strengthen human resource capacity and systems capacity for chemical, biological, radiological and nuclear (CBRN) emergency management. 53 Building resilience in the face of health threats A key part of the WHO Country Office’s work, as set out in WHO’s GPW13 and Sri Lanka’s CCS, is building country capacity to prepare and respond to health emergencies. Health emergencies are not al- ways caused by the environment and the devastating Easter attacks of 2019 illustrated this. In the immediate aftermath of the explo- sions, enormous responsibility was placed on the country’s health sector to care for the survivors as well as the dead. WHO encourages Member States to review emergency response after any significant incident to facilitate improved readiness in the future. As such, with WHO support, the Government decided to conduct a review of the country’s health sector response to the Easter Sunday events with the objective of identifying the strengths and weakness- es of the response system and discuss the way forward to ensure a more efficient, effective and coordinated response for future emer- gencies. Some of the key recommendations of the review include: the need to conduct emergency/disaster response simulations more frequently in health institutions; to display disaster management plans in hospitals; improve facilities and equipment to strengthen ac- cident and emergency departments; and implement improved crowd management methods and improved coordination across response teams. Caring for people in the face of emergencies Recognizing the important role emergency medical teams (EMT) play in the global health workforce, the WHO EMT Initiative assists organizations and Member States to build capacity and strengthen health systems by coordinating the deployment of quality assured medical teams in emergencies. Arriving where needed in the shortest time, and delivering quality care appropriate to the context, EMTs can substantially reduce the loss of lives during public health emergencies. 21st April 2019 Emergency Response EASTER ATTACKS SRI LANKA SIX SIMULTANEOUS EXPLOSIONS AT LUXURY HOTELS AND CHURCHES HOLDING EASTER MASS 256 dead, over 500 injured 8:45 am ACTIVATION OF DISASTER MANAGEMENT National Hospital Sri Lanka / Negombo District General Hospital / Teaching Hospital Batticaloa “3 weeks ago, we rehearsed the contingency plan and as soon as I got the call I put the plan into action” – Dr Wickramasinghe, National Hospital Sri Lanka HEIGHTEN SECURITY AT HOSPITAL “We knew from our experiences with the war, hospitals could be a secondary target. A security perimeter was put up immediately with hospital security, Sri Lanka armed forces and police. I thank them. I was no thinking about my safety but they were.” – Dr Samarakoon, National Hospital Sri Lanka 9:15am PATIENT BAY SETUP “By the time the causalities came in soon after 9 am, the ‘triage’ area with a consultant and his team had been in place assessing them to the primary care unit, OT, ICU or wards. We opened 10 operating theaters and 8 ICUS” – Dr Wickramasinghe , National Hospital STAFF / STATION ON STANDBY Alerting different sections of the hospital and mobilizing resources “we had 6 ambulances at the time so I called all institutions near us for support and we had 24 ambulances ready. I contacted all nearby JMOs as well, I knew with a large influx of bodies there could be a delay in their releases if we were understaffed. You have to save as many lives as you can. That’s my responsibility” – Dr Ranasinghe, Negombo HOSPITAL TRIAGE RECEIVING DEAD BODIES As soon as causalities arrived we tagged them with a number, this would be their bed- head ticket.” “All the bodies were checked for no signs of life and sent to the temporary mortuary. As a backup we got the Defense Ministry and Health Ministry’s Disaster Management Centre to send us two mobile coolers 40 ft x 20 ft to store bodies” – Dr Ranasinghe, Negombo 1:45 pm 7TH EXPLOSION DEHIWALA SOUTHERN COLOMBO 2:15pm 8th Explosion Dematagoda, Colombo TREATING PATIENTS Transferring Patients for specialized care “This was not just one incident. There were several attacks and they didn’t happen all at once. Ambulances continued to deliver people and we continued to work” – Pushpa Zoysa National Hospital Sri Lanka HANDLING RELATIVES & CROWD CONTROL PSYCHOLOGICAL SUPPORT “During our drill 3 weeks ago we realized relatives and family of patients would need special care. We had a special waiting area ready with staff to look after relatives. Colleagues from the National Institute of Mental Health were on ground providing support to families.” – Dr Samarakoon, National Hospital Sri Lanka PROVIDING INFORMATION TO THE PUBLIC & MEDIA & FOREIGN EMBASSIES “We had a high number of foreign nationals being admitted,35 in all. The worst part for people is not knowing. That’s especially true for the relatives who might be far away. We did our best to keep embassies informed. I kept families in the waiting room informed. I knew that feeling of dread, waiting for more information about a loved one. While I was working in Colombo hospital my church in Negombo was attacked, for some time I did not know what had happened to my loved ones. So, I know that feeling of dread.” – Nursing Officer Helani, National Hospital Sri Lanka 22ND APRIL 2019 4 AM DEACTIVATION OF RESPONSE PLAN Triage area empty / Last surgery completed “We had worked through the night and well into the morning, many of us had not taken rest at all. It is truly amazing what the human spirit can achieve when it is tested.”- Pushpa Zoysa, National Hospital Sri Lanka SOCIAL SERVICES & PSYCHOSOCIAL SUPPORT “There were orphaned children, whose entire family were killed. These children were the only persons who could identify their family members. It was horrific. We needed to make sure they had every support they need. We needed to go beyond our assigned duties and we tried our best.” – Dr Nanayakkara, National Hospital “WE PERFORMED 90 SURGERIES IN 1 DAY” THANK YOU TO THE SPECIALISTS, MEDICAL OFFICERS, NURSES, PARAMEDICAL AND SUPPORT STAFF FOR GOING BEYOND THE CALL OF DUTY TO SERVE THE COUNTRY AND ITS PEOPLE IN DISTRESS. WORLD HEALTH ORGANIZATION, SRI LANKA 54 In 2018, Sri Lanka’s Army Medical Assistance Team (SLAMAT) – which is one of only a few full-military EMTs in the world – registered with the WHO EMT Initiative, making it the third country in the Region to register after Thailand and Bhutan. And during this biennium significant progress has been made towards the country becoming classified as an internationally deployable EMT, so much so that it expects classification as early as mid-2020. “We have had the best type of experience in casualty handling because of our long Civil War. I don’t think that many other military services in the SEA Region have the experience that we have,” Colonel Dr Saveen Semage, deputy director of Sri Lanka Army’s Preventive Medicine and Mental Health Services, says. Dr Semage said that thanks to WHO support this biennium, Sri Lanka’s EMT has undergone several invaluable trainings with mentors. These trainings are an important step towards being classified. “One of the results of the trainings we have received is that we have been able to develop our national emergency system. We have had excellent training and now we have smaller teams around the country to respond to local emergencies. When there is an international deployment, we will bring them all together,” Dr Semage said. “Moreover, this Initiative has allowed for very good dialogue among Sri Lan- ka’s three military partners: Army, Air Force and Navy. Earlier we didn’t have good coordination between the three but now we do.” Prone to natural disasters and at risk of climate change, the Region has been in- vesting in strengthening emergency response capacities as a Flagship Priority since 2014. In 2018, the Region passed a resolution to strengthen EMT capacities – a goal which is in sync with WHO’s global goals to ensure one billion more people have better protection from health emergencies. Understanding the threat of antimicrobial resistance Antimicrobial resistance (AMR) is a growing threat to global public health that requires action across all governments and society in every single country. In re- sponse to this looming threat, in 2017, with WHO support, Sri Lanka launched its National Strategic Plan for Combating AMR (2017–2022). Drawing upon the WHO Global Action Plan on Antimicrobial Resistance and based on the One Health Approach, it encompasses all related dimensions of AMR, including hu- man, animal and aquatic health, crop production and food safety. In 2018, WHO supported the development of a sentinel surveillance system to as- sess the extent of AMR in the country through the adoption of WHO-NET soft- ware, capacity-building and providing computers to 26 selected hospitals across the country. In addition, the Country Office also supported the monitoring and evaluation of the sentinel site to ensure that high-quality data is being received at the Centre to understand as accurately as possible the level of AMR in Sri Lanka. Having an electronic data system will not only provide critical insight into the prevalence of AMR in Sri Lanka but will also offer invaluable information to change treatment guidelines and prevent the misuse of antibiotics. The country has also registered in the Global AMR Surveillance System (GLASS) to enable submission of data on bloodstream infections of selected AMR organisms. Building resilience in the face of health threats 55 56 57 THE THIRD BILLION Promoting Healthier Populations One Billion More People Enjoying Better Health And Well-Being 58 Addressing NCD risk factors NCDs are the leading cause of death in Sri Lanka, fuelled by tobacco use, un- healthy diets, harmful alcohol use and physical inactivity. Health promotion of- fers pathways that address these risk factors by focusing on settings where people and communities live, work, play, and make decisions that affect their health and well-being. This biennium Sri Lanka has implemented and strengthened critical policies and interventions that aim to address the risk factors associated with the development of NCDs. Progress towards eliminating transfat Elimination of industrially-produced transfat from the global food supply has been identified as a critical intervention to prevent cardiovascular deaths. In 2018, WHO released “REPLACE”, a step-by-step guide for the elimination of indus- trially-produced trans-fatty acids from the global food supply18. Industrially-pro- duced transfats are contained in hardened vegetable fats such as margarine and ghee (indigenous butter), and are also present in baked and fried foods. Sri Lanka does not have any legislation to date to regulate transfat levels in food. However, the MoH is committed, with WHO support, to formulate a policy and strategy to eliminate industrially-produced transfat in line with REPLACE, a six- step action package. In a first step towards this, the country is in the process of undertaking a landscape analysis of transfat – the first R in REPLACE: REview dietary sources of industrially-produced transfats and the landscape for required policy. Slowing down on salt: how Sri Lanka is reducing salt intake Recognizing the increasing premature mortality due to CVD and the overcon- sumption of salt which increases the risk of hypertension, the Government of Sri Lanka, with WHO support, launched a national initiative to reduce population dietary salt intake. In 2018, Sri Lanka launched its National Salt Reduction Strat- egy (2018–2022), with the goal of reducing sodium intake by 30% by 2025. The strategy aims to reduce salt consumption through five specific strategic directions in alignment with the “SHAKE” technical package of WHO19. The Government has already begun implementation of two strategic directions: measuring and monitoring population salt intake and adopting standards for la- belling and marketing of foods with salt in them. Moving forward, WHO is sup- porting the Government to initiate the implementation of the remaining strategic directions: to educate and empower individuals to eat less sodium; to harness in- dustry by promoting formulation of foods and meals that contain less salt; and to create an environment to promote healthy eating. More specifically, WHO is working to develop a communication package aimed at educating the population to reduce intake of dietary sodium; to provide policy and technical support to the Government of Sri Lanka to engage with the food in- dustry to reduce salt content; and to develop standards to promote healthy eating. 73% 18 - 69 year olds do not consume sufficient fruits and vegetables 59 Combating fat, sugar and salt in processed foods More than a quarter of Sri Lanka’s population is overweight, nearly 6% are obese, and more than 7% of adults are estimated to have raised blood glucose or are cur- rently on diabetes medication20. Diets high in sugars, fat and salt are a significant contributor to NCDs. Following the successful roll out of a “traffic light” labelling system for sug- ar-sweetened beverages (SSBs) in 2016, Sri Lanka in 2019 introduced front-of- pack labelling for all pre-packed solid and semi-sold foods with WHO support and advocacy. The Food (Colour Coding for Sugar, Salt and Fat) Regulations 2019 came into operation on 1 June and target specific levels of sugar, salt and fat. Pack- aged food products from both Sri Lanka and those that are imported containing more than 22g of sugar per 100g will be assigned a red label, 5 to 22g of sugar per 100g an amber label, and less than 5g a green label. Products that contain more than 1.25g of salt per 100g will have a red label, 0.25g to 1.25g an amber level, less than 0.25g a green label. Lastly, for fat, items containing more than 17.5g of fat per 100g will be given a red label, 3g to 17.5g an amber label, and less than 3g a green label. WHO hopes this front-of-pack labelling will drive progress towards meeting the 2025 targets, which include halting the rise in obesity and achieving a 25% rel- ative reduction in premature mortality from CVD, cancer, diabetes and chronic respiratory diseases. The Country Office is supporting an awareness programme to educate the public about the new labelling regulations. Lastly, in August 2019, Sri Lanka launched its first ever Nutrient Profile Model, with the primary purpose of regulating the marketing of foods and non-alcoholic beverages to children. The Model was developed with WHO technical assistance and will spur efforts to shape healthy food habits of children. 60 Celebrating the Inaugural World Food Safety Day On 7 June 2019, Sri Lanka marked the first ever United Nations Food Safety Day with the MoH in partnership with WHO and FAO. Unsafe food is a threat to human health and economies which disproportionately affects vulnerable and marginalized people. In fact, every year there are an estimated 600 million cases of foodborne illnesses annually and 3 million people die from food and waterborne diseases21. In 2018, the SEA Region recorded the second highest burden of foodborne dis- eases among all WHO regions with 150 million illnesses and 170 000 deaths22. This important national event took place in Colombo under the global theme of “Food Safety, everyone’s business”. It was an opportunity to strengthen multisectoral ef- forts to ensure access to safe food for all in Sri Lanka. At present, WHO and FAO support the MoH to develop a food safety policy for Sri Lanka. Efforts to increase physical activity In 2015, the NCD Risk Factor Survey (STEPs survey on NCD risk factors) found that 50% of adults were either inactive or had very low levels of physical activity. In 2018, the Government launched the Physical Activity and Sedentary Behaviour Guidelines, in line with the country’s goal of mobilizing 1 million inactive people by 2020. The Guidelines, developed with WHO technical support, are designed for policy-makers and health professionals and provide information on the types and amounts of physical activity which provide substantial health benefits. WHO is also in the process of supporting the government to develop physical activity guidelines for people with NCDs. Sri Lanka continues its fight against tobacco Every year, more than 8 million people die from tobacco use globally, the majority of whom live in low- and middle-income countries (LMICs)23. In Sri Lanka, one in four adults consume tobacco in either smoked or smokeless form, resulting in 20 000 deaths each year24. In addition to the detrimental impact of tobacco on health, smoking also causes huge losses to the economy. Sri Lanka, however, is a shining example of what can be done together, and what can be achieved, when a multisectoral approach is taken towards combating a ma- jor public health problem. This biennium, Sri Lanka has taken affirmative action on tobacco taxation and plain packaging. The National Authority on Tobacco and Alcohol (NATA) has continuously advocated for increasing tobacco taxes. Over the last two years there has been two significant tax increases which have made the most popular brands of cigarettes the costliest in the Region. With WHO advocacy, the Ministry of Finance (MoF) has also announced that a method of indexation of the tobacco tax will be implemented to keep it in line with inflation. Meanwhile, in 2018, the Cabinet also approved several key tobacco interventions with legislation currently being drafted. This includes the introduction of plain packaging; the prohibition of the sale of tobacco within 100 metres of places where children gather; the prohibition of point-of-sale advertising; widening the definition of smoke-free places to include all public places; strengthening the ban on advertising and promotion; and making infringements of the NATA Act a punishable offence. WHO provided technical support from all three levels of the Organization. Dr Palitha Abeykoon, chairman of NATA, says its relationship with WHO is in- valuable. “WHO is our closest partner in all our work. I think our relationship is quite special. This biennium WHO helped us to develop evidence so such inter- ventions could get passed in the Cabinet,” he says. “It’s unending era of coopera- tion and we are planning a number of big initiatives in the future.” 61 Progress towards FCTC 2030 The WHO Framework Convention on Tobacco Control (WHO FCTC) 2030 is working to strengthen tobacco control in LMICs through promoting and support- ing governments to accelerate the implementation of the Framework. Sri Lanka is one of 15 countries that was selected to receive direct support to implement the FCTC 2030 because of its commitment to advance tobacco control. This biennium the country made significant progress towards enhancing tobacco con- trol, including: drafting national guidelines on preventing tobacco industry inter- ference in public policies, a national tobacco cessation strategy, and strengthening capacity for enforcement of the national tobacco control laws. In June 2019, the WHO Country Office and NATA finalized the Strategy for To- bacco Cessation (2020–2025). The strategy aims to implement Article 14 of the WHO FTCT which states that “each Party shall develop and disseminate appro- priate, comprehensive and integrated guidelines based on scientific evidence and best practices, considering national circumstances and priorities, and shall take ef- fective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence”25. The strategy approaches tobacco use cessation using the two complementary approaches of community and clinical cessation with particu- lar focus on community initiatives given both their effectiveness and affordability. In a further step towards curbing tobacco use, Sri Lanka also launched its national guidelines for the implementation of Article 5.3 of WHO FCTC: to prevent to- bacco industry interference in public policies on World Tobacco Day 2019. The measures recommended aim at protecting against interference not only by the tobacco industry but also by organizations and individuals that work to further the interests of the tobacco industry. The recommended interventions include estab- lishing measures to limit interactions with the tobacco industry; avoiding conflicts of interests for government officials and employees; and not providing preferen- tial treatment to the tobacco industry. Lastly, UNDP finalized and presented their WHO-supported study, the Invest- ment Case for Tobacco Control in Sri Lanka, to the MoH and the Oversight Com- mittee on Health and Human Welfare, Social Empowerment of the Parliament of Sri Lanka. The study found that investing now in six tobacco control measures will avert Lankan Rupee (LKR) 586 billion in health costs and economic losses over the next 15 years and save over 70 000 lives26. Given that tobacco use is a development issue and aligned with numerous SDGs, it recommended increasing awareness about the true cost of tobacco and the benefits of tobacco control in addition to strengthening tobacco control laws and its enforcement. A new era: Creating tobacco-free zones When a village in the Kandy district went tobacco-free, cigarette sellers tried to outsmart public health officials by selling cigarettes from three wheelers and bicy- cles. But it didn’t work, as they were shunned by the community. In 2016, Pangollamada village became a tobacco-free zone where shops do not sell any type of tobacco. “There are 26 shops in this Grama Niladari (GN) divi- sion and all these shops have now completely stopped the sale of cigarettes, bidis, and tobacco leaves,” Mr Linton Senarathne, a public health inspector (PHI) from Dunuwila PHI area in Kandy district, says. “The people who smoked before have completely stopped smoking now. When visitors from other villages visit and try to smoke here, community members advise people that this is a tobacco-free zone.” 62 There are more than 100 tobacco-free zones across Sri Lanka where smoking is not seen in public areas, cigarettes are not sold, and point-of-advertising is banned. The zones have been established by PHIs through the MoH and NATA, with WHO support. Dr Palitha Abeykoon from NATA is immensely proud of communities standing up against the tobacco industry. “The idea of tobacco-free zones is to reduce the supply of tobacco and make accessibility more difficult. We’ve had a lot of resistance from the tobacco industry but in the field, we’ve been able to somehow withstand that pressure. It is a movement that has become infectious with PHIs competing with one another to declare their areas as tobacco-free,” he said. Not only does such an initiative have incredible health benefits but at one pre- school in Pangollamada village, the benefits have trickled down to children. At Beautiful Montessori preschool, each child has their own “money box”, and for those children who used to have parents who smoked, the money they would have spent on cigarettes is added into their boxes. “At the end of the year, the money which has been collected is given to each child. Some parents put the money into children’s bank accounts to pay the preschool fees or to buy gifts such as bicycles for the children,” Ms Zareena, a teacher at the preschool, says. In early 2019, a WHO-FCTC Enforcement Mission to Sri Lanka recognized the tobacco-free area initiative as a good example of communities taking control of tobacco use. The Mission recommended that such initiatives be replicated in other areas of the country. “We hope to light a few fires elsewhere to fuel this move- ment,” Dr Abeykoon says. Preventing the harmful use of alcohol The harmful effects on alcohol consumption on communities around the world are well-known and Sri Lanka is no exception. The harmful use of alcohol not only places significant burden on the health-care system to provide injury and curative care but also on the economy from lost earnings due to morbidity and mortality. In Sri Lanka, 39.6% of men are current drinkers, compared with 2.4 of women27. The 2014 survey found there had been a significant increase in alcohol consump- tion since 2008, when 26% of men and 1.2% of women reported consuming alcohol. Given the high prevalence of men who drink in Sri Lanka, WHO is pri- oritizing an effective, comprehensive, management and rehabilitation programme. This biennium, WHO developed the Multisectoral Alcohol Prevention Pro- gramme (MAPP) based on WHO guidelines, which takes a holistic approach to re- ducing the prevalence of alcohol consumption and managing alcohol dependence. The Programme has so far been implemented in three districts – Nuwera-Eliya, Mannar and Monaragala – while the MoH itself has implemented the Programme in two additional districts. The MAPP uses existing health and social resources in each district to provide primary prevention, detection, referral treatment, and rehabilitation services. As part of the Programme, appropriate health staff are being trained to provide in- and out-patient support, while community leaders and community-based health workers are being empowered to help reduce alcohol availability and accessibility in their communities. Lastly, WHO is working closely with the MoH, the National Authority on Tobacco and Alcohol, and Thailand to develop a taxation formula for alcohol. A unique approach to increasing awareness on suicide In 2018, more than 3000 lives were lost to suicide and thousands more attempted suicide and self-harm. WHO Sri Lanka decided to venture into a unique way of creating awareness about suicide and mental well-being: through the use of per- forming arts. WHO sponsored the stage adaptation of “Every Brilliant Thing”, a Broadway play about the impact suicide can have on the lives of those it touches. The play was performed by Stage Light and Magic theatre group and held at the Lakshman Kadirgamar Institute in March 2018. The play not only received overwhelmingly positive feedback from the partic- ipants but also provided WHO an opportunity to spread awareness about the available support services in Sri Lanka and the importance of mental well-being. More than 200 people attended the play over two nights. It enabled those who attended – members of the United Nations system in Sri Lanka and government and non-government partners – to contribute to on going mental health discourse in the country. 63 Helping journalists to better report on suicide and mental health When WHO decided to venture into performing arts as a means to raise awareness about suicide with the stage adaption of “Every Brilliant Thing”, one bonus was the media attention it received. The media plays a critical role in educating the pub- lic on mental health and suicide. But what is equally important is that journalists report sensitively and respectfully. WHO used the performance to launch suicide reporting guidelines for journalists in lo- cal languages, titled Preventing Suicide: A resource for media professionals. The resource provides necessary information and tools to journalists to enable them to report suicides more sympathetically and responsibly. They are available both online and in hardcopy format. For Ms Kumudini Hettiarachchi, a journalist with the Sunday Times, finding the right words to accurately convey a suicide, without sensationalism, is critical. “The media is trying to find its feet on report- ing on sensitive issues like suicide. The guidelines are helping journalists to use more appropriate words.” Promoting road safety through multisectoral action WHO is at the forefront of developing a knowledge-based approach to health and is working to improve the health of Sri Lankan people through more effective use of information. Road traffic-related incidents cause approximately 3000 deaths every year in Sri Lanka and are the leading cause of death among young people28. Sri Lanka is committed to reducing road traffic-related injuries by improving the quality and accessibility to road safety data. To realize this goal, in September 2018, the Sri Lanka Accident Data Management System (SLADMS), inspired by the GIS analysis system of the Republic of Ko- rea, was launched in collaboration with the police and other partners. To do this, tablets and computers were provided to 50 police stations, headquarters and pilot divisions by the WHO Country Office with the support of the Regional Office. The launch was followed by a series of training work- shops for approximately 300 police officers of the pilot divisions on the use of the platform and tabs for data entry and online transmis- sion. The objective of the SLADMS is to have a sys- tem for easily recording ac- cidents, avoiding data dupli- cation, and reducing delays in emergency care – and ul- timately saving lives. Starting with four pilot areas, the initiative will be expanded to cover a wider geographical area to provide more timely and accurate data to design effective preventive interventions. A Monitoring Taskforce chaired by the Deputy Inspector-General (DIG) of the Traffic Administration and Road Safety Department of Sri Lanka Police has been set up, with WHO and others as members. Since the project’s launch, five task force meetings have been held and a framework of indicators have been developed with inputs from country and regional experts. With WHO Country Office support, the National Road Safety Council also evalu- ated the National Road Safety Action Plan (2011–2020) as a preliminary step in re- vising the Action Plan to be in line with the SDGs and 2030 targets related to road safety. Lastly, coinciding with the release of WHO’s Global Status Report on Road Safety 2018, the Country Office, with partners, conducted a series of workshops for journalists on how to better report road traffic accidents and their aftermath. WHO Reporting Guidelines for Road Traffic Accidents were translated into local languages, which are available online. Creating change at the ground level : SLADMS More than a century after the first vehicles came up on Sri Lanka’s roads, today there are more than 8 million vehicles plying on the island. While extensive roads across the country have been built, the current problem is traffic. 64 The Head of Traffic Police, Deputy Inspector-General Mr Ajith Rohana, says the biggest problem Sri Lanka is facing is inadequate public transport. “Public transport hasn’t been developed and therefore accidents have increased, and we are facing huge traffic congestion, especially in main cities like Colombo and Kandy. We need to find solutions in respect to road traffic accidents and on the other hand we also need to find solutions in terms of traffic conges- tion.” There are an estimated 35 000–40 000 road traffic accidents reported annually. But as Mr Rohana points out, they are just the reported accidents; thousands more go unreported to the police. In 2018, 3152 people were killed and ap- proximately 22 000 were injured in road accidents. “In 2018, a person was killed in a road traffic accident every two hours and 49 minutes and a person was injured every 30 minutes,” Mr. Rohana said. There are 9000 traffic police officers who have been especially trained on road traffic and accident investigations. Numerous steps have been taken in a bid to reduce road traffic accidents – from installing signboards displaying speed limits to legislation increasing fines for drunk–driving, driving without a license and driving without insurance. Mr Rohana says the latest intervention – the SLADMS – is changing and modernizing the way accident data is collected and analysed. Rather than the conventional system of manually analysing data, the SLADMS is all comput- erized, making work more efficient and effective. “We now have a mechanism to get traffic data at the time of investigation. Police officers go to the scene along with digital tablets that have internet facilities and can send the data. We collect the data, analyse it and we can get an idea about accident trends,” he says. “Regularly collecting data allows us to identify trends … and then precautionary actions can be taken. We believe that if we’re able to implement this project in collaboration with WHO across the whole country then we can get day-to-day data and can curtail accidents remarkably.” 65 Cancer Control Activities Throughout the biennium, WHO supported the government to strengthen cancer surveillance through the establishment of a population-based cancer registry at the National Cancer Institute. Moreover, in 2019 the Country Office conducted a multidisciplinary comprehensive review of Sri Lanka’s National Cancer Control Programme jointly with the International Atomic Energy Agency. Oral cancer is a major problem in the Region. In 2019, WHO supported a training on the management of addictive disorders for dental surgeons to prevent oral cancer. The training of trainers (TOT) programme, run by the National Drug De- pendence Treatment Centre and the All India Institute of Medical Sciences, New Delhi, involved more than 30 dental surgeons from across the country. In addition, the National Strategic Framework on Palliative Care was finalized. The Framework strives to improve quality, equity and coverage in the management of chronic NCDs. Lastly, a TOT programme run by the Asia-Pacific Hospice Pallia- tive Care Network with WHO support helped develop the capacities of palliative care teams of selected hospitals in the country. Empowering Women Leaders To Be Agents Of Change In Their Commu- nities To Prevent NCDs Ms Wimala Ranatunga knows all too well the challenges faced by women in her community when it comes to prioritizing health: “Women don’t pay much atten- tion to their own health and well-being. The reason for this is that women mainly focus their attention on the health and well-being of their family. They only pay attention to their own health when they are unwell.” Ms Ranatunga is the president of the Sarvodaya Women’s Movement (SWM), a non-profit organization based in Colombo focused on empowering women by enabling them to realize their rightful place in society. The SWM operates at the village level across Sri Lanka through a network of hundreds of volunteers and runs several awareness-raising programmes on a variety of pressing issues from migrant worker issues to gender-based violence. With support from WHO this biennium, the SWM ran a programme focused on NCDs across five districts, enabling women leaders to become agents of change in their own communities. The focus of the programme was to prevent NCD risk factors through “training the trainers” so that female community leaders could in turn train others in their communities. The trainers were a diverse group of pas- sionate women from teachers to government officials, and a range of topics were covered. Moreover, the women who participated in the programme underwent a health screening so they could identify whether they were at risk of any specific NCDs. “We demonstrated to the participants how to prepare nutritious meals quickly, especially using produce from their gardens, and particularly for the midday meals of schoolchildren, rather than buying fast food items,” Ms Ranatunga says. “The participants were really happy with this programme. They said it was the first time they have participated in such a programme. We would like to conduct it in other areas of the country too. We consider this partnership with WHO to be the begin- ning of a journey.” Along with support from WHO, the organization also received support from the NCD unit of the MoH. 66 Promoting Healthier Populations By Addressing The Environmental Determinants Of Health Health workers are exposed to a multitude of risks in their work environments. Hav- ing healthy staff not only benefits workers but also benefits the health system by pro- tecting patients. It is in this context that the MoH has planned to develop a National Programme for Occupational Health and Safety and Well-being for Healthcare Work- ers with technical assistance from WHO. Initial discussions took place this biennium and the final draft programme is expected before the end of 2019. This biennium, WHO also supported the University of Colombo to develop a train- ing module on the safe handling and prevention of asbestos-related disease (ARD) for high-risk occupations. The training will provide owners and managers of compa- nies involved with a range of high-risk occupations vital education on asbestos that will be passed down to their employees. Safe management of health-care waste (HCW) is also critical to control and reduce infections inside a health-care facility and to ensure that the environment outside is well protected. To ensure proper disposal of health-care waste, WHO supported the MoH in revising the Healthcare Waste Management Guidelines, in collaboration with other relevant ministries and academia. Moreover, in 2018 the UN Global Analysis and Assessment of Sanitation and Drink- ing-Water (GLAAS) was conducted by the Ministry of City Planning Water Supplies and WHO. The report is useful to monitor the delivery of sanitation and drinking water services in the country, with special emphasis on the impact of government policies. WHO also supported capacity-building of engineers, chemists, sociologists, and hy- drogeologists on government water safety plans to ensure the provision of safe water from source to consumer level. WHO also supported an external formal auditing of Sri Lanka’s water safety plans. In collaboration with the MoH, the Ministry of Environment and academia, WHO conducted in 2018 an expert review of the Guidelines on scaling up health-related articles of the Minamata Convention on Mercury. WHO provided technical assis- tance to develop a strategic plan for the implementation of these health-related articles of the Convention. Lastly, action is being taken to address air pollution and mitigate climate change. To this end, advocacy programmes have been – and continue to be – conducted for district-level stakeholders including the MoE, local government and security forces, and are funded by WHO and carried out by the MoH. 67 68 As WHO closes one biennium and begins a new one, 2020–2021 will see continued focus on the triple billion targets of WHO’s GPW13, the Regional Flagship Priorities and the “Sustain, Accelerate and Innovate” agenda within the framework of Sri Lanka’s CCS 2018–2023. WHO will continue to provide technical support to Sri Lanka’s PHC reorganization in addition to strengthening preparedness, mitigation, resilience and rapid response for disasters and emergencies. Addressing the social, cultural, environmental and commercial determinants of health will also be the key strategy moving forward to address the NCD epidemic and promote healthy ageing. The Country Office will also continue to spur efforts to further improve maternal and child health and combat stubborn communicable disease. This work will require harnessing innovation and technology and utilizing digital health to the fullest. It will also require strong leadership in the light of the ongoing UN System reforms to better support the implementation of the SDGs. As Sri Lanka’s UN Resident Coordinator, Ms Hanaa Singer, says: “The UN reform agenda is focused on people and how we as a system collaborate to ‘Leave No One Behind’ and achieve the SDGs. UN reform has provided us with the tools and incentives to bring the best that the UN system has to offer, to support the people of Sri Lanka in achieving national needs and priorities, including universal health coverage for all.” To achieve its triple billion targets defined by the GPW13, WHO’s imperative is to create real impact at the country level to meet the SDG targets. WHO Sri Lanka is committed to this, in line with WHO’s mission to “promote health, keep the world safe and serve the vulnerable”. 69 Priorities for 2020–2021 70 References 1 Sustainable Development Goals. World Health Organization; n.d. (https://www.who.int/sdg/en/, accessed 7 August 2019). 2 Indicators. Family Health Bureau, Ministry of Health, Nutrition & Indigenous Medicine; 2018 (https://fhb.health.gov.lk/index.php/en/statistics, accessed 27 July 2019). 3 Status of Sustainable Development Goals indicators in Sri Lanka: 2017. Department of Census and Statistics, Ministry of National Policies and Economic Affairs (http://www.statistics.gov.lk/sdg/application/publications/book.pdf, accessed 28 July 2019). 4 Review of the policies and supportive documents on promotion of nutrition and physical activity in school settings in Sri Lanka. 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