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This is a preliminary report assessing the current status
of Sri Lanka’s health care system, its problems, future
challenges, and issues to consider in the development of
potential reform options. It provides an overview of the
status of health system in the areas of organization, financing,
performance in terms of meeting health status objectives,
equity and efficiency, and the interface with the private
sector. The health system is assessed in terms of both public
and private components, but the description of the public
sector is necessarily more detailed, since information on
the private sector is weak, and since the public sector
remains the dominant actor in the health system. The data
and evidence presented is largely secondary owing to time
and budgetary constraints, but some new data from a private
hospital survey, carried out specially for this report,
are used.
Preceding all this is a short description
of the economic and fiscal context to provide critical background
to assess the availability of increased general revenue
funding for the health sector in the medium term future.
This section indicates that the options for increasing general
revenue funding will be extremely limited in the next few
years, whether or not the internal conflict ceases. This
constraint is not related to the priority which GOSL places
on health, which has historically been high, but the limitations
caused by decades of cost-cutting in other areas, and the
necessary needs of internal security. Room for further cost-cutting
in the budget does not exist, and if additional resources
become available after peace is restored, the priority for
public spending must be economic infrastructure.
The sections on organization and financing
demonstrate that Sri Lanka’s publicly dominated health
care provision and financing has been highly effective in
providing effective and equitable health care services to
the whole population at low cost to both the economy as
a whole as well as the public treasury. National health
expenditures have been low, and have not inflated with time
or with economic development and market liberalization post-1977.
Contrary to reports previously by other commentators and
by Sri Lankan observers, the empirical evidence demonstrates
that the Sri Lankan public hospital system manages available
resources highly efficiently, and achieves productivity
and efficiency levels not only unrivalled in Sri Lanka’s
private sector, but also in any other comparable country.
Nevertheless, the evidence points to an inability in the
system to change or manage organizational reforms. The principle
reason for this appears to be lack of resources at the margin
to fund additional management capacity or to increase human
and financial resources in the delivery of services. While
Sri Lanka’s public system is a centrally managed command
and control system, it lacks the resources to shift to a
more effective or responsive management structure. This
constraint requires significant new financial resources
to resolve, and must be dealt with before attempting major
organizational changes.
In the course of each section, issues related
to devolution are highlighted. In general, the evidence
indicates significant problems in both the original conceptualization
of devolved government as well as its actual implementation
since 1987. A decade of experience with devolution has not
resolved many of the real implementation and design issues.
Political commitment to decentralization has also been lacking,
and has manifested itself in all areas contributing to continued
confusion and ambiguity.
Table of Contents:
- Introduction
- Executive Summary
- General Context
- Health Status
- Organization of Health Care Delivery
- Reorganization of the Central and Provincial Health
Services
- Financing of Health System
- Private Sector Issues
- Regulation
- Assessment of the Health Sector’s Performance
- Next Steps
- Bibliography
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