Sri Lanka: out of a study of contrasts emerges a model healthcare system

For the American student (and I imagine quite a few other people), things in Switzerland are undeniably more expensive than they are in most of the rest of the world. Geneva is ranked 4th internationally for highest cost of living, while Zurich is ranked first. Perhaps expectedly, the Swiss have high disposable incomes and purchasing power compared to many other residents of Europe. But still, every time I order a vanilla latté (which will probably become an increasingly rare occurrence)….

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…I pay $7 USD. Really, Switzerland? Really??? (though, admittedly, the Swiss are never lacking for presentation)

But in reflecting on the value of what I pay for in a country that is notorious for its high prices, I wanted to write about something that I’ve heard mention of everywhere from Tanzania to the mountains of Mexico to the WHO’s HQ here in Geneva: just how much Sri Lanka has been able to achieve with its healthcare system on a remarkably small budget. Having spent my entire life studying in the U.S., the country where I was born is naturally my point of reference for most healthcare-related queries. But ever since the WHO’s publication of the World Health Report in 2000, the fact that the U.S. was ranked first in per capita health expenditures while coming in 37th overall for quality of its healthcare system (based on 5 factors – health, health equality, responsiveness, responsiveness equality, and fair financial contribution) has probably been more of a glaring indication of what not to do than anything else.

And so, I began to look for countries that are doing it right–or at the very least, could provide me with an opportunity to learn something. I’ve been traveling to Sri Lanka to visit family and friends ever since I was born, but little did I know that this is where I would find my answers.

When I arrived at the WHO in late May, I saw this at the entrance to the Resource Center advertising the summer’s Global Health Histories Seminars. Lo and behold, there it was: “Sri Lanka: an example of model healthcare.”

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Now, there is no denying that Sri Lanka is a nation that has its problems–from post-civil war strife to income inequality, but at least in the realm of healthcare, the small island nation has been remarkable in its ability to achieve high levels of social and health development in comparison to other nations of similar GDP. Sri Lanka has a high Human Development Index  (summary measurement used to assess long-term progress in human development and rank countries based on life expectancy, education and income), which was reported to be 0.715 in 2012. Comparatively, India’s is 0.554. Additionally, Sri Lanka has a literacy rate of over 90% and the highest life expectancy at birth of any country in the region. Let’s put that into context in terms of cost (all prices in USD):

In 2008, the UK had a per capita GDP of $45,700 and a life expectancy of 78 (males) and 82 (females). In comparison, Sri Lanka had a per capita GDP of just $2,014 and a life expectancy of 71.7 (males) and 76.4 (females). In terms of health expenditures, these results were achieved with $71 per capita in Sri Lanka compared to $3, 760 per capita in the UK in 2008 (Source: ‘The Sri Lankan Path to Health for All: From the Colonial Period to Alma-Ata; Dr. Margaret Jones, WHO, May 2014). The differences are startling.

Sri Lanka’s impressive progress in healthcare delivery is especially evident in efforts to reduce its maternal mortality ratio (MMR) despite highly limited resources. Some scholars credit this to the government’s provision of universal healthcare and free education–a practice that dates back to the colonial period and was not replicated elsewhere in the British Empire–as well as the implementation of a community health worker model which employs Public Health Midwives (PHMs) throughout the country. More generally, the Sri Lankan healthcare system has long made use of traditional medical practitioners (TMPs) as important members of the health workers’ team throughout the country. In response to the Alma-Ata Declaration and the slogan “Health for All by 2000” which was made at the 1978 International Conference on Primary Health Care (PHC), the Sri Lankan government restructured its health services, using a bottom-up approach and making a political commitment to honor policy guidelines for health development. In its newly vertical system, district Medical officers of Health (MOHs) were assigned to monitor and provide promotive and preventive health services (ex. Immunization, DOTS program for TB treatment, screening for NCDs, etc.).

Notable, too, is the mix of health systems that exist within the country’s broader healthcare scheme. While living and working in Mexico, I was studying the interaction of allopathic (or Western) medicine, local/cultural remedies, and other systems of medicine that exist outside of the Western frame of reference. I saw firsthand the tension that can exist between these varying types of treatment and the providers who deliver them, as well as the way in which patients navigate a slate of diverse options. But in Sri Lanka, a mix of Allopathic, Ayurvedic, and Unani care is represented in the healthcare system, providing a degree of cohesiveness that is rare between methods that have such great potential to clash. And while there are both public and private providers, the government system remains the most highly utilized source of healthcare in the country.

In writing this post, I know that Sri Lanka’s system is not perfect—far from it. Disparities in delivery still exist, and there are still significant imbalances in health care personnel availability between the conflict-afflicted North and East in comparison to cities such as Colombo, Kandy and Galle which have well-staffed tertiary healthcare centers. The country also has a rapidly aging population which will inevitably lead to new healthcare challenges, as will the increasing incidence of noncommunciable diseases (NCDs), chronic diseases, mental health disorders, and cancer, among others.

And yet, Sri Lanka’s healthcare system remains a tour de force for public health specialists and development experts worldwide. As an aspiring healthcare practitioner, I care a great deal about the medicine that I will one day be using. But in my experiences in observing healthcare delivery around the world, it seems to me that perhaps I should care even more about the system that I will be working in. This, after all, is what will dictate both my and my patients’ choices. What can doctors do to change their healthcare systems for the better? In Sri Lanka, overseas training is mandatory for all specialists–a requirement that has no doubt helped the country’s healthcare system to advance. Implicit in such a requirement is the humility to recognize that there are always opportunities to learn from those around us. Perhaps the United States, too, can take heed and require its doctors to receive part of their training in a foreign country.
And finally, I write, too, because in my experience, those who criticize Sri Lanka’s healthcare system the most are often Sri Lankans themselves (and believe me, I am a strong advocate for the value of self-criticism as a motivation for progress). However, I don’t think we give this country enough credit where it is due. There are many other nations who are striving to achieve the level of healthcare that Sri Lanka has, and if for that reason alone, out of this study of contrasts emerges a real reason to be proud.
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