Sunday Times 2

Following are excerpts of the speech of Dr. Ruvaiz Haniffa after being inducted as the President of the Sri Lanka Medical Association (SLMA) on January 20.

In today’s medical practice the focus on the holistic/comprehensive care of the individual (as opposed to the patient) has become subservient to attempting to treat/manage illness in patients. The concept of preserving good health by incorporating and practising preventive and curative aspects of medicine to achieve physical, mental and social well-being in individuals, families and communities by medical professionals adhering to the highest possible standards of professional ethical conduct seems to be a utopian ideal.

There are numerous reasons for not being able to achieve this desired state, but the problem is that over time, Sri Lanka seems to be moving away from this ideal rapidly. We as doctors are forgetting why patients come to us. We are imposing our ‘superior’ knowledge and skills on patients more often than not in an unsolicited manner. We have developed and come to accept as normal a system of doctor-centred care, in which a medical condition/disease has become the fundamental issue needing the doctor’s attention. We have lost the art of focusing on the holistic health needs of patients. A minuscule amount of these health needs will definitely require addressing medical conditions/diseases. This is why we need to shift our focus back to patients.

Analysing the past and present of the Sri Lankan health system, I will attempt to answer: Why we need to shift the focus from disease to patients? Why we need to begin now? Thereafter, I will lay out a few proposals for change and how I see the SLMA’s role in such changes.

Sri Lanka over the past 100 years has transformed in terms of demography and epidemiology. Sri Lanka has the highest ageing population in the world and 1.7 million persons will be added to the elderly cohort during the next 15 years. The relative contribution from mortality due to Non-Communicable Diseases (NCDs) which is currently very high (80.7%), is projected to remain high by 2030 (81.8%). Furthermore 35% of Disease Adjusted Life Years (DALYs) in Sri Lanka in 2015 was from three risk factors – poor diet, uncontrolled blood pressure and uncontrolled blood sugar and more than 50% of the risk factors contributing towards DALYs in 2015 were found to be amenable to behaviour interventions/changes. What this data shows is that risk factors which contribute to the highest morbidity and mortailiy in Sri Lanka are not disease-specific but are patient-specific, requring patient-specific general measures rather than disease-specific interventions.

Sri Lanka is said to have a health care facility within 3.6 km of a household which delivers free health care. The question we in the health system should be asking is: What should these free healthcare facilties and staff be doing to improve the individual/family and community health status in a rapdidly changing society with increased expectations of quality care in terms of personalised care?

A brief overview of the western healthcare system is: Teaching Hospitals – 16; Specilaised Hospitals – 11; Provincial General Hospitals – 3; District General Hospitals – 20; Base Hospitals Type A – 24; Base Hospitals Type B – 47; Divisional Hospitals – 475; Primary Medical Care Units (PMCUs) – 500; Healthy Lifestyle Centres (HLCs) – 830; Medical Officer of Health (MOH) Units – 354; private hospitals – 225; Specialists – 1,703; Medical Officers – 20,458; Dental Surgeons – 1,416; Nursing Officers – 32,499; and Technicians – 4,101.

Particular attention should be drawn to the 830 HLC, 500 PMCUs and 354 MoH Units spread throughout Sri Lanka. These are the points of delivery of Primary Ambulatory Curative and Primary Preventive Care. The HLCs and PMCUs are severely under-utilised due to the poor quality of care they currently offer leading to the ‘by-passing phenomenon’. The state-hospital based Out-Patient Departments (OPDs) accounted for 54,652,070 patient encounter episodes in 2015. The overwhelming majority of these visits were primary ambulatory curative care visits, which do not require secondary/tertiary hospital based ambulatory care. In these settings the focus of attention should be the patients rather than the diseases in terms of screening for NCDs and treating minor health issues and referring patients to higher levels of care for ‘disease–specific’ health interventions and follow-up if needed.

Out-of-pocket expenditure on health
A comparison of Sri Lanka’s health status internationally shows that most of the health indicators are on par with developed countries. But, what is alarming is that Sri Lanka is having a high out-of-pocket expenditure on health (42.1%). This is of concern and given the demographic, epidemiological and health consumption/utilisation patterns, has the potential to push vulnerable sections of society into catastrophic health spending. This ironically is taking place in a state-sponsored health care system that is supposed to be free at the point of delivery!

According to the Household Income and Expenditure Survey (HIES) of 2012/13, the average out-of-pocket expenditure on health ranges from Rs. 213.88 to Rs. 7,323.68 with a mean of Rs. 1,488.28 a month for the total sample. For households, which incurred any health expenditure during the study period, the out-of-pocket expenditure on health ranged from Rs. 609.16 to Rs. 9,419.44 with a mean of Rs. 2,557.03 a month. Taking the out-of-pocket expenditure per household as Rs. 1,488.28 a month the total out-of-pocket expenditure on health for Sri Lanka in 2012/3 was Rs. 96 billion (excluding other indirect costs such as transport and payment to ‘bystanders’).

The analysis of the HIES in terms of specific disease and population groups shows that if a household has a member suffering from a chronic disease and who is elderly that household will have catastrophic health spending which is going to push them into poverty as a direct result of out-of-pocket health spending. With the increasing elderly population and persons with NCDs, the average out-of-pocket expenditure on health will show an exponential increase in the coming decades, further aggravating the problem of impoverishing healthcare.

In this context, has Sri Lanka got health system mechanisms in place to provide services to match the current and future healthcare consumption needs of our population?
In the seven decades since independence what we have done is:

• Essentially concentrated and achieved ‘development’ of Tertiary and Secondary Health Care Services – in quantity and to some extent in quality mainly in the state sector
• Achieved Primary Preventive Care Service delivery in terms of both quantity and quality, exclusively in the state sector. This constitutes the foundation of our excellent basic health statistics.

More importantly, in the seven decades since independence what we have not done is concentrate on the development of Primary Ambulatory Curative Care Services both in terms of quantity and quality in both the state and private sectors.
A quick review shows that:

• We have come to be good at treating disease – eliminating polio, malaria and control of Communicable Diseases to a point that these no longer are a major cause of mortality across the age groups
• We seem to be measuring the health status of our population based on the presence or absences of disease and infirmity – Infant Mortality Rate, Maternal Mortality Rate, rates of hospital admission, number of ‘cases’ of a specific disease.
• The number of disease-based health indicators we get are based on the number of patients who decide to seek ‘treatment’ from a healthcare facility geared to ‘treat’ illness (as opposed to facilities predominantly focused on preserving health while also treating ‘illness’)
• We seem to have little emphasis on ‘wellbeing’ of the population as a health indicator and even less emphasis on ‘taking care of the whole person’ in our healthcare system.

A conceptual framework for what needs to be done:

• Need to shift from the concept of identifying, understanding and managing health from a perspective of ‘absence of diseases’ to one which identifies, understands and manages health from a perspective of ‘wellbeing’
• Need to shift from measuring disease as health to measuring wellbeing as health
• Need to address these health issues within and without the health system in a patient-centred manner

The application, implementation and practice of Universal Health Care (UHC) in a sustainable manner within the Sri Lankan health system will allow today’s vision of shifting focus from diseases to patients, to become tomorrow’s reality.
The role of a national Medical Association in this process:
Set up mechanisms to

• Address provision of UHC through patient-centred healthcare through the dvelopment of an essential service package for primary healthcare – same healthcare at PMCU settings for all
• Development of technical guidelines for patient referral pathways for holistic healthcare – Rational heathcare delivery guaranteeing UHC
• n Development of staffing needs based on workload as opposed to staffing needs based on cadre requirements – Guaranteeing quality care
• Create awareness and introduce healthcare innovations to
• n Make the shift from evidence generation to innovations and development in healthcare setting up a Healthcare Innovations and Practices Hub (SLMA-HIPH) at the SLMA

Develop partnerships to increase access to healthcare

• Between systems – Primary/Secondary/Tertiary and between Western and Traditional systems
• Between public and private sectors

Advocate at all levels for

• Patient-centred, integrated healthcare delivery system
• Team-based care addressing the whole spectrum of patient needs

Through these developments, the SLMA with other local and international partners would envisage that the next decade or more in the health sector development of Sri Lanka will be dedicated to the development of Primary Ambulatory Curative Care.

We from the SLMA urge all stakeholders to join us in calling on the government to declare the next decade as the Decade of Primary Curative Care.

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