Experiences from Sri Lanka – Planning and financing for primary care development

1. Experiences from Sri Lanka – Planning and financing for primary care development Dr Susie Perera Director Policy Analysis & Development, Ministry of Health, Sri Lanka Bangkok, 2009

2. Three tiered health care delivery system

3. Primary care service delivery structure • Preventive, promotive and basic curative services • Government and Private systems • Government system provides care free of charge • Government system has a preventive /community health service based on Health areas ( defined geographical areas and defined populations – provides domiciliary care and clinic care and targeted interventions in identified communities – schools, workplaces, etc.. • The Government system has a curative care system which provides institutional care – out patients and hospitalized care • The Government system is said to be “Free of charge at the point of delivery” • Decentralized system – Primary level services come under the Provincial Health Authorities • Central Ministry of Health gives policy and strategic guidance

4. Preventive health services at Primary level • Decentralized system – Primary level services come under the Provincial Health Authorities • Central Ministry of Health gives policy and strategic guidance • Country is divided into 300 Health areas ( known as Medical Officer of Health MOH areas) 50,000-100,000population • Each MOH area is managed by the Medical Officer of Health and has a team comprising of AMOH, Dental surgeon PHI, PHNS, PHM SDT, Field Assistants • Community volunteers assist the MOH team in field work.

5. Care components delivered through the MOH team • Maternal and child health care including family planning, Ante Natal Care, Home deliveries, Post Natal Care, Growth monitoring for infants and preschool children • Immunization against major infectious diseases-EPI-Tuberculosis, Polio, Diptheria, Pertusis, Tetanus, Measles • Prevention and control of locally endemic diseases-Malaria, Filariasis, Tuberculosis, Rabies, Dengue, JE • Prevention and early detection of malignancies- mainly through health education , Well women clinics • School Health- growth monitoring, early detection and treatment of common ailments /referrals and immunization against Tetanus and Rubella • Growth monitoring, nutrition advice and providing nutrition supplements

6. Care components delivered through the MOH team - continued • Oral health care • Mental Health promotion • An adequate supply of safe water and basic sanitation-testing for quality of water and inspection and relevant advice on basic sanitation • Prevention of blindness –Screening for cataract and referral, health education • Health Education concerning prevailing health problems and the methods of preventing and controlling them • Prevention of home accidents and treatment of minor ailments

7. Access & coverage – MCH Model! • Preventive Health Services Team have defined populations. • The PHMW has to register all eligible families • PHMWs visit homes. Norm- 1PHMW for 3000 population • Antenatal , Child welfare and family planning clinics are conducted at least one clinic for three PHMW areas. Trend now is to have a fortnightly clinic in every PHMW area • Patients have the choice in accessing care that is convenient to them – Government/ private • any institution

8. Control of Communicable diseases at MOH area level • Public Health Inspectors – 1 : 10,000 population • Maintain profile of notifiable diseases in their area, disease registers, spot maps • Investigation of notifiable diseases, contact tracing, out break investigation • Raising Community awareness • Food sanitation – inspection of food handling institutions, • Water sanitation – • Conduction of rabies control program- dog vaccination, sterilization programs • Malaria, Dengue prevention programs • School health programs- basic screening, assisting in medical inspections, referral, promotion of school health clubs

9. Peoples choice • People can chose to utilize services and participate in programs conducted by the MOH health team • All services are provided free of charge

10. Government curative services – 932 institutions at primary level • Different types of hospitals that provide non specialist services • District hospitals, peripheral units, rural hospitals provide hospitalized and ambulatory care ( now re-categorized as Divisional hospitals) • They are small hospitals that range from 20 – 150 beds. • Central Dispensaries and Maternity Homes provide ambulatory care and only in patient care for deliveries – (now renamed as Primary medical Care units and are upgraded to provide basic emergency care and manned by medical Officers )

11. Services provided at Government curative care institutions at Primary level • Basic curative care – medical and minor surgical interventions • Emergency care is limited and provided only at the divisional type of hospitals • Most institutions provided drugs only for 3 days on discharge

12. Achievements

13. Utilization trend for primary level institutions

14. Trend for utilization of out patient services

15. Shift of care burden to private sector • Gradual shift of out patient care to private sector • Likely reasons

16. Transition Challenges • Aging population whilst the emphasis for Maternal & child health continues • Increasing burden of Non Communicable Diseases whilst Communicable diseases continue • Changing social environment – injuries, accidents • Increasing demand for high end technology , that is further increasing healthcare

17. Priority functions identified by the Consultative group for Public Health Services at PHC level • Communicable diseases – outbreak investigation, Vector borne diseases • Oral hygiene and dental care • Further strengthening Maternal care • Elderly care • Adolescent & school health • New born care, Child health & Immunization • Reproductive health including un met need for FP, STI, HIV/AIDS • Non Communicable diseases- DM, Hyptn, IHD, Cancer, prevention of blindness • Nutrition interventions • Mental Health, psychosocial wellbeing • Water & sanitation • Food safety • Environment, climate change • Care of the sick in the community • Disaster management (Preparedness,……..) • Occupational Health • Health promotion, BCC , community mobilization, intersectoral coordination– cross cutting

18. Priority functions proposed by Consultative group for Curative services to be provided through the existing Primary level curative institutions • Traumatic injury management • Mx of acute medical emergencies • NCD- risk factor assessment, screening, treatment, referral, management of back referrals • Mx of Asthma / COPD • Oral health care • Elderly care • Mental health care • Rehab care • Health of the young 15-25 yrs • MCH

19. Gaps • NCD care with emphasis on continuity of care- (now being addressed in the policy for chronic NCD) • Elderly care • Care of the disabled in the community

20. Discussion on PHC model- • Consensus on list of functions to be included for primary level care • Relating functions to structure- can the existing structure provide these functions? • If not – what is the rational service model?

21. Family Practice approach – considerations • Continuity of care • Defined population • Linking existing curative institutions to family practice areas • Use of clear care protocols – WHO PEN • Instituting a referral system

22. Sri Lanka’s Health achievements and how these influence change • Achievement of MDGs – on track • Well suited service delivery structure for MCH • High level of Confidence placed in the system by high level decision makers • Sometimes counter productive for change! • Tendency is to include new programs without changing the present service delivery structure • The health staff has to perform multi tasks.

23. Programmatic planning Vs planning for changes at the primary level • Considering required changes of one program area at a time and inclusion of these to the system • Difficulty to capture the multi- functional requirements to be delivered through one structure – workloads, team work, skill mix

24. Functional task analysis and relating required functions to existing structure s • Structural gaps identified • HRH and other resource gaps identified

25. Engagement in other policy dialogues that are relevant to Primary level organization

26. Health expenditure

27. Rational PHC Model • Should be able to address the present and future needs • Evidence based – pilot studies? • Health service organization should be able to accommodate - *** • Culturally acceptable – should emphasize and build on from peoples demands, health seeking behaviors etc • Other levels of care will need to change • Cost feasible

28. If Major changes envisaged- • What is the change management process • Participatory approach and involvement of relevant stakeholders in the development process – MoH, • Public engagment? • Evolutionary dissemination of evidence and awareness on the process

29. Strengthening capacity for evidence based approach • Costing • Steering committee on Healthcare financing • TWG • research in evolution

30. Progress - • Emerging models • Family / individual centred care • Piloting • Protocols for expansion of NCD care at primary level identified • Preliminary costing in progress – • Informing decision makers at stage by stage • MoH, Finance Commission, Treasury

31. What has been the Challenge in the process ? • Getting the need for change onto the agenda – was the most difficult task • Keeping the discussion momentum • Engaging in several cross cutting discussion themes at the same time • Building capacity and strengthening the processes for research related to healthcare financing

32. Thank You