HEALTH SITUATION Sri Lanka is now a lower-middle-income country aided by the rapid economic growth following end of conflict in 2009. Health and education continue to be the two foundational pillars of the society with free health and education prioritized and maintained by successive governments since Independence. Sri Lankan citizens have access to free health care through a vast network of primary, secondary and tertiary health care facilities, and therefore, the country has universal health coverage for a long time. There are many best practices and lessons learnt from the Sri Lankan model of health care that are regional and global public health goods. The country has embraced WHO recommended evidence based guidelines and practices and as member of the WHO Executive Board (EB) from 2017 until 2020, it has the opportunity to share its knowledge and learnings and advocate for health issues of national and regional importance at the global level. Systematic investments in health have resulted in the country’s many health achievements and the country achieved most of the targets of Millennium Development Goals. Major reductions in maternal and neonatal mortality and communicable disease control including elimination of diseases like Malaria, Filariasis and Maternal and Neonatal Tetanus at modest investments are some of the highlights of the country’s health care system that can be labelled as low-cost, high-impact system. The country has also taken major steps in tackling risk factors for NCDs like Tobacco Control and taxation on sugar sweetened beverages. Life expectancy has increased and the country is among the fast ageing societies. Despite these achievements, challenges persist and newer ones are emerging. Noncommunicable disease rates are rising and the proportion of the elderly is increasing. Despite free health care, out -of- pocket spending is increasing. Mental health and road traffic accidents remain as significant health issues. Health systems that have delivered results until now need to be reviewed and reorganized to address the epidemiological and demographic challenges. The supply-driven systems need to be more people-centered with focus on prevention of diseases and health promotion, besides treatment. The island nation is equally, if not more, vulnerable to the adverse impacts of climate change. Disaster mitigation and response need to be further strengthened. To maximize the impact of evidence-based interventions and global best practices, local and contextual evidence supported by data is critical for delivering on the results and sustaining the gains. HEALTH POLICIES AND SYSTEMS The government is committed to achieve universal health coverage and the SDGs. In 2017, the government launched Vision 2025 which underscores priority reforms to make the country more competitive and lift the standards of living of all Sri Lankans. It also recognized the need to address unequal socio-economic development across provinces and the rapidly aging population. As part of this vision, the government passed the Sri Lanka Sustainable Development Act, No. 19 of 2017 to accelerate the achievement of SDGs, and to adopt multi-sectoral and integrated approaches in ensuring the health and well-being of the population. The Sri Lanka National Health Policy, 2016-2025 envisions “a healthier nation that contributes to its economic, social, mental and spiritual development” guided by principles of people-centred care, equity, quality of services and financial protection. The policy of free health care delivered by a network of state health institutions, including traditional providers has significantly contributed to improving the health status of the population. The public sector provides 95% of in-patient care and about 50% of out-patient care. A comprehensive preventive care package is provided through an island-wide network of 344 health units, healthy lifestyle centres and well-women clinics. Moving forward, the government aims to strengthen the public health system through PHC reorganization, improve its health management and monitoring and evaluation systems, and develop a national strategic approach to quality. The health sector will forge strategic partnerships, “think outside the box”, and ensure that no one is left behind in the path to UHC. COOPERATION FOR HEALTH A multitude of partners are active in the health sector in Sri Lanka. The WHO CO actively partners and cooperates with the MOH, other government agencies, UN agencies, development partners, private sector, academia and non-government organizations in implementing its programs and activities. There are 23 UN agencies, including WHO, which work closely with the Government of Sri Lanka, guided by the United Nations Sustainable Development Framework, 2018-2022. Sri Lanka has been designated by WHO as a fast-track country for NCDs to receive “One-WHO”-integrated technical support at the global, regional and national levels. To support reconciliation efforts following the civil war, WHO partners with the UN, MOH and local organizations in implementing the community-based psycho-social support program under the Peacebuilding Priority Plan (PPP). Development partners such as the World Bank, ADB and JICA engage and coordinate with WHO for technical support on health policy and planning in the sector, for example, the Health System Enhancement Project of ADB, the NCD Prevention Project of JICA and the World Bank Health Sector Development Project. As the Vice Chair of the Oversight Committee and as the representative of international partners in the Country Coordinating Mechanism (CCM), WHO continues to provide technical assistance for effective implementation of activities funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. WHO also co-chairs the Development Partners Working Group in Health and Nutrition. WHO received support for implementing activities in response to floods and landslides and dengue control from the South-East Asia Regional Health Emergency Fund, USAID, UN Central Emergency Response Fund and DFAT, Australia. It also facilitates support to other member states in the region on public health– e.g., twinning agreement between the MoH in Sri Lanka and Timor Leste on strengthening immunization services, training of fellows from DPRK in cancer management and cardiac angiography . http:// www.who.int/countries/en/ WHO region South-East Asia World Bank income group Lower-middle-income Child health Infants exclusively breastfed for the first six months of life (%) (2006-2007) 75.8 Diphtheria tetanus toxoid and pertussis (DTP3) immunization coverage among 1-year-olds (%) (2016) 99 Demographic and socioeconomic statistics Life expectancy at birth (years) (2015) 74.9 (Both sexes) 78.3 (Female) 71.6 (Male) Population (in thousands) total (2015) 20715 % Population under 15 (2015) 24.6 % Population over 60 (2015) 13.9 Poverty headcount ratio at $1.25 a day (PPP) (% of population) (2010) 4.1 Literacy rate among adults aged >= 15 years (%) (2007-2012) 91 Gender Inequality Index rank (2014) 72 Human Development Index rank (2014) 73 Health systems Total expenditure on health as a percentage of gross domestic product (2014) 3.50 Private expenditure on health as a percentage of total expenditure on health (2014) 43.94 General government expenditure on health as a percentage of total government expenditure (2014) 11.17 Physicians density (per 1000 population) (2015) 0.881 Nursing and midwifery personnel density (per 1000 population) (2015) 2.794 Mortality and global health estimates Neonatal mortality rate (per 1000 live births) (2016) 5.3 [4.6-6.2] Under-five mortality rate (probability of dying by age 5 per 1000 live births) (2016) 9.4 [8.3-10.5] Maternal mortality ratio (per 100 000 live births) (2015) 30 [ 26 - 38] Births attended by skilled health personnel (%) (2016) 99.5 (DHS) Public health and environment Population using safely managed sanitation services (%) (2012) 80.9% Population using safely managed drinking water services (%) (2015) 93 (Urban) Sources of data: Global Health Observatory May 2017 http://apps.who.int/gho/data/node.cco Sri Lanka WHO COUNTRY COOPERATION STRATEGIC AGENDA (2018–2023) Strategic Priorities Main Focus Areas for WHO Cooperation STRATEGIC PRIORITY 1: Policy support for service delivery This strategic priority aims to maximize WHO’s technical expertise in a wide range of health domains reflected in the SDGs, and its capacity to provide evidence -based guidance to the government on health system issues. WHO is also committed to supporting the national strategy for qual ity improvement, which seeks to secure national commitment to quality and support the drive towards institutionalizing it for overall improved health outcomes and demand for quality services. This Strategic priority will focus on the following areas: Sustainable and equitable health financing Human resources for health to successfully face the health challenges PHC delivery to effectively address changing demographic and epidemiological transition Sustaining and strengthening achievements from the MDGs STRATEGIC PRIORITY 2: Addressing NCDs and determinants The disease burden in Sri Lanka has shifted from a communicable to a predominantly noncommunicable disease pattern, with NCDs as the leading cause of morbidity and mortality. This Strategic priority will focus on the following areas: NCDs, including cancer, chronic kidney diseases of unknown origin and mental health Road traffic injuries STRATEGIC PRIORITY 3: Resilience in the face of health threats Climate change, increasing global travel and trade, rapid and unplanned urbanization, irrational use of antibiotics and many other factors are increasing the vulnerability of people to health threats across the world. The human and health costs following these incidents are huge and the health sector i s expected to play a critical role in the response to minimize damage to human lives and safeguard the health and well - being of survivors. Preparedness is critical, and the core capacities as outlined in the IHR (2005) are needed to effectively prevent, detect and respond to public health threats. Country preparedness for all threats , including anti-microbial resistance (AMR) STRATEGIC PRIORITY 4: Knowledge- based approach to health A knowledge-based approach to health requires generation of knowledge and evidence that is contextual. It is important for sustainable scaling up of interventions and development of supportive policies for UHC. Implementation science/operational research needs to be embedded within programme implementation plans for monitoring progress, making course corrections, and sharing successes and lessons learnt for wider dissemination within and beyond countries. Opportunities provided through innovative solutions and information technology will help the health sector in expanding the us e of and maximizing the digital dividend for the betterment of health and development of populations. Furthermore, it will be important to make linkages between community experience/knowledge/evidence generation on quality of care from frontline workers and central level policy units. This Strategic priority will focus on the following areas: Global health diplomacy Information and evidence for action Community knowledge and empowerment Please note that the 3rd generation CCS 2014-20g finalize © W orld Health Organization 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. This publication does not necessarily represent the decisions or policies of WHO. WHO/CCU/18.02/Sri Lanka Updated May 2018
HEALTH SITUATION Sri Lanka is now a lower-middle-income country aided by the rapid economic growth following end of conflict in 2009. Health and education continue to be the two foundational pillars of the society with free health and education prioritized and maintained by successive governments since Independence. Sri Lankan citizens have access to free health care through a vast network of primary, secondary and tertiary health care facilities, and therefore, the country has universal health coverage for a long time. There are many best practices and lessons learnt from the Sri Lankan model of health care that are regional and global public health goods. The country has embraced WHO recommended evidence based guidelines and practices and as member of the WHO Executive Board (EB) from 2017 until 2020, it has the opportunity to share its knowledge and learnings and advocate for health issues of national and regional importance at the global level. Systematic investments in health have resulted in the country’s many health achievements and the country achieved most of the targets of Millennium Development Goals. Major reductions in maternal and neonatal mortality and communicable disease control including elimination of diseases like Malaria, Filariasis and Maternal and Neonatal Tetanus at modest investments are some of the highlights of the country’s health care system that can be labelled as low-cost, high-impact system. The country has also taken major steps in tackling risk factors for NCDs like Tobacco Control and taxation on sugar sweetened beverages. Life expectancy has increased and the country is among the fast ageing societies. Despite these achievements, challenges persist and newer ones are emerging. Noncommunicable disease rates are rising and the proportion of the elderly is increasing. Despite free health care, out -of- pocket spending is increasing. Mental health and road traffic accidents remain as significant health issues. Health systems that have delivered results until now need to be reviewed and reorganized to address the epidemiological and demographic challenges. The supply-driven systems need to be more people-centered with focus on prevention of diseases and health promotion, besides treatment. The island nation is equally, if not more, vulnerable to the adverse impacts of climate change. Disaster mitigation and response need to be further strengthened. To maximize the impact of evidence-based interventions and global best practices, local and contextual evidence supported by data is critical for delivering on the results and sustaining the gains. HEALTH POLICIES AND SYSTEMS The government is committed to achieve universal health coverage and the SDGs. In 2017, the government launched Vision 2025 which underscores priority reforms to make the country more competitive and lift the standards of living of all Sri Lankans. It also recognized the need to address unequal socio-economic development across provinces and the rapidly aging population. As part of this vision, the government passed the Sri Lanka Sustainable Development Act, No. 19 of 2017 to accelerate the achievement of SDGs, and to adopt multi-sectoral and integrated approaches in ensuring the health and well-being of the population. The Sri Lanka National Health Policy, 2016-2025 envisions “a healthier nation that contributes to its economic, social, mental and spiritual development” guided by principles of people-centred care, equity, quality of services and financial protection. The policy of free health care delivered by a network of state health institutions, including traditional providers has significantly contributed to improving the health status of the population. The public sector provides 95% of in-patient care and about 50% of out-patient care. A comprehensive preventive care package is provided through an island-wide network of 344 health units, healthy lifestyle centres and well-women clinics. Moving forward, the government aims to strengthen the public health system through PHC reorganization, improve its health management and monitoring and evaluation systems, and develop a national strategic approach to quality. The health sector will forge strategic partnerships, “think outside the box”, and ensure that no one is left behind in the path to UHC. COOPERATION FOR HEALTH A multitude of partners are active in the health sector in Sri Lanka. The WHO CO actively partners and cooperates with the MOH, other government agencies, UN agencies, development partners, private sector, academia and non-government organizations in implementing its programs and activities. There are 23 UN agencies, including WHO, which work closely with the Government of Sri Lanka, guided by the United Nations Sustainable Development Framework, 2018-2022. Sri Lanka has been designated by WHO as a fast-track country for NCDs to receive “One-WHO”-integrated technical support at the global, regional and national levels. To support reconciliation efforts following the civil war, WHO partners with the UN, MOH and local organizations in implementing the community-based psycho-social support program under the Peacebuilding Priority Plan (PPP). Development partners such as the World Bank, ADB and JICA engage and coordinate with WHO for technical support on health policy and planning in the sector, for example, the Health System Enhancement Project of ADB, the NCD Prevention Project of JICA and the World Bank Health Sector Development Project. As the Vice Chair of the Oversight Committee and as the representative of international partners in the Country Coordinating Mechanism (CCM), WHO continues to provide technical assistance for effective implementation of activities funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. WHO also co-chairs the Development Partners Working Group in Health and Nutrition. WHO received support for implementing activities in response to floods and landslides and dengue control from the South-East Asia Regional Health Emergency Fund, USAID, UN Central Emergency Response Fund and DFAT, Australia. It also facilitates support to other member states in the region on public health– e.g., twinning agreement between the MoH in Sri Lanka and Timor Leste on strengthening immunization services, training of fellows from DPRK in cancer management and cardiac angiography . http:// www.who.int/countries/en/ WHO region South-East Asia World Bank income group Lower-middle-income Child health Infants exclusively breastfed for the first six months of life (%) (2006-2007) 75.8 Diphtheria tetanus toxoid and pertussis (DTP3) immunization coverage among 1-year-olds (%) (2016) 99 Demographic and socioeconomic statistics Life expectancy at birth (years) (2015) 74.9 (Both sexes) 78.3 (Female) 71.6 (Male) Population (in thousands) total (2015) 20715 % Population under 15 (2015) 24.6 % Population over 60 (2015) 13.9 Poverty headcount ratio at $1.25 a day (PPP) (% of population) (2010) 4.1 Literacy rate among adults aged >= 15 years (%) (2007-2012) 91 Gender Inequality Index rank (2014) 72 Human Development Index rank (2014) 73 Health systems Total expenditure on health as a percentage of gross domestic product (2014) 3.50 Private expenditure on health as a percentage of total expenditure on health (2014) 43.94 General government expenditure on health as a percentage of total government expenditure (2014) 11.17 Physicians density (per 1000 population) (2015) 0.881 Nursing and midwifery personnel density (per 1000 population) (2015) 2.794 Mortality and global health estimates Neonatal mortality rate (per 1000 live births) (2016) 5.3 [4.6-6.2] Under-five mortality rate (probability of dying by age 5 per 1000 live births) (2016) 9.4 [8.3-10.5] Maternal mortality ratio (per 100 000 live births) (2015) 30 [ 26 - 38] Births attended by skilled health personnel (%) (2016) 99.5 (DHS) Public health and environment Population using safely managed sanitation services (%) (2012) 80.9% Population using safely managed drinking water services (%) (2015) 93 (Urban) Sources of data: Global Health Observatory May 2017 http://apps.who.int/gho/data/node.cco Sri Lanka WHO COUNTRY COOPERATION STRATEGIC AGENDA (2018–2023) Strategic Priorities Main Focus Areas for WHO Cooperation STRATEGIC PRIORITY 1: Policy support for service delivery This strategic priority aims to maximize WHO’s technical expertise in a wide range of health domains reflected in the SDGs, and its capacity to provide evidence -based guidance to the government on health system issues. WHO is also committed to supporting the national strategy for qual ity improvement, which seeks to secure national commitment to quality and support the drive towards institutionalizing it for overall improved health outcomes and demand for quality services. This Strategic priority will focus on the following areas: Sustainable and equitable health financing Human resources for health to successfully face the health challenges PHC delivery to effectively address changing demographic and epidemiological transition Sustaining and strengthening achievements from the MDGs STRATEGIC PRIORITY 2: Addressing NCDs and determinants The disease burden in Sri Lanka has shifted from a communicable to a predominantly noncommunicable disease pattern, with NCDs as the leading cause of morbidity and mortality. This Strategic priority will focus on the following areas: NCDs, including cancer, chronic kidney diseases of unknown origin and mental health Road traffic injuries STRATEGIC PRIORITY 3: Resilience in the face of health threats Climate change, increasing global travel and trade, rapid and unplanned urbanization, irrational use of antibiotics and many other factors are increasing the vulnerability of people to health threats across the world. The human and health costs following these incidents are huge and the health sector i s expected to play a critical role in the response to minimize damage to human lives and safeguard the health and well - being of survivors. Preparedness is critical, and the core capacities as outlined in the IHR (2005) are needed to effectively prevent, detect and respond to public health threats. Country preparedness for all threats , including anti-microbial resistance (AMR) STRATEGIC PRIORITY 4: Knowledge- based approach to health A knowledge-based approach to health requires generation of knowledge and evidence that is contextual. It is important for sustainable scaling up of interventions and development of supportive policies for UHC. Implementation science/operational research needs to be embedded within programme implementation plans for monitoring progress, making course corrections, and sharing successes and lessons learnt for wider dissemination within and beyond countries. Opportunities provided through innovative solutions and information technology will help the health sector in expanding the us e of and maximizing the digital dividend for the betterment of health and development of populations. Furthermore, it will be important to make linkages between community experience/knowledge/evidence generation on quality of care from frontline workers and central level policy units. This Strategic priority will focus on the following areas: Global health diplomacy Information and evidence for action Community knowledge and empowerment Please note that the 3rd generation CCS 2014-20g finalize © W orld Health Organization 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. This publication does not necessarily represent the decisions or policies of WHO. WHO/CCU/18.02/Sri Lanka Updated May 2018