Sunday Times 2
Unequal access to healthcare in Sri Lanka?
In the last two decades, there has been a steady erosion of the provision of free health care by a quickly spreading private health system. Middle class families are paying out-of-pocket or becoming dependent on health insurance schemes, while poorer families are being forced to access private health care in life and death matters.
Chronic non communicable diseases (NCDs) like diabetes, hypertension, heart disease, asthma, cancer, and, now, chronic kidney disease, are on the rise and give cause for concern. The success story of free health is overshadowed by the inability of the public sector to provide adequate care for NCDs.
Current approach to NCDs
The Ministry of Health’s approach to NCDs focuses on promoting “health lifestyles” and improving access to screening and treatment. A range of health educational initiatives are underway to foster public awareness on the dangers of excessive salt, sugar or fat intake, and nation-wide campaigns seek to curb the use of alcohol and tobacco, also “risk factors” for NCDs.
The Ministry has strengthened screening and treatment for cardiovascular disease through “Healthy Life Style Centres” at the community-level. The government has also invested billions of rupees in technologies for the detection and treatment of NCDs. These efforts have materialized in new cardiac catheterization labs, cancer centers and dialysis units in government facilities.
Growing out-of-pocket payments
Even so, a large proportion of the population accesses care for NCDs from the private sector. More and more patients, including those attending government clinics, pay out-of-pocket for the monitoring and treatment of these conditions.
Public sector patients are now directed to the private sector to purchase expensive medical devices unavailable in government hospitals. For instance, angioplasty and stenting, accessible through cardiac centers in government facilities, involves substantial payments as medical accessories (amounting to about Rs. 2.5 lakhs per stent) are
purchased directly by patients from pharmaceutical representatives stationed within hospital premises.
The President’s Fund does cover a part of this cost (Rs. 1.5 lakhs per stent), and provides significant relief to those struggling to make ends meet. But that cannot be the answer as access to the Fund involves a procedure that is not immediate; many cannot afford the balance; and a patient may apply only once to the Fund in her/his lifetime.
The example of chronic kidney disease
Consider the story of a carpenter in the plantation sector, diagnosed with the disease late last year. He needed frequent dialysis and traveled to Kandy two to three times a week, often renting private vehicles during difficult hours when public transport was not available. His wife gave up her job to travel back and forth with him because a chaperone is required during dialysis.
When the patient was advised to undergo kidney transplant, his wife decided to donate her kidney. But they found that the waiting list was excessively long; pre-operative assessment in the public sector could take months to over a year. Although they could ill afford it, they opted to do these tests in private laboratories to expedite the process. They also collected Rs. 2 lakhs for post-operative treatments.
This patient eventually faced complications and died awaiting transplant. Although the hospital provided dialysis, free of charge, the family was burdened with the costs of testing, transportation and accommodation. They spent a substantial amount of money, collected through loans and donations, in the course of a year. The patient’s wife, now unemployed, is left with four children to look after.
Notably, the family did not receive contributions from the President’s Fund as it does not cover day-to-day expenses incurred during the course of illness. In the end, the long waiting list, other delays, and social circumstances adversely influenced the outcome.
Compare this public sector experience with that of a patient who can afford a kidney transplant in the private sector. Apart from those with “connections” (who may jump the waiting list and access the transplant in a timely fashion in a government hospital), the vast majority of better-off patients spend large amounts of money to obtain this care in the private sector. But the President’s Fund does cover a portion of expenses for a transplant in the private sector.
Political vision
Chronic kidney disease, now a contentious political issue, exemplifies some ways in which politicians have tackled or hope to tackle the crisis of NCDs. President Sirisena launched the National Kidney Fund earlier this year to provide relief for these patients, and increased allocations from the President’s Fund for kidney transplant (in the private sector).
Several political parties addressed the NCD crisis directly or tangentially in their respective election manifestos. Both the UNP and the UPFA pledged to install new dialysis units in hospitals, and the UPFA promised a handout of Rs. 7,500 to families with a critically ill kidney patient.
Notably, both the UNP and UPFA supported the introduction of health insurance. The UPFA’s manifesto included an insurance scheme for senior citizens covering up to Rs. 500,000 per surgical procedure; it also proposed to “assist” expansion of private hospitals.
The JVP committed itself to the provision of free medicine and treatment, and recommended a temporary collaboration with the private sector to expedite access to urgent cardiac procedures and kidney transplant.
Myth of private healthcare
Some of these proposals do/seek to strengthen “free health”, for example, the JVP’s pledge to provide free medicines and treatment. Installing dialysis units in rural areas would improve access, and handouts to critically ill kidney patients would be a source of relief. Yet, improving access for expensive medical procedures in the private sector through funds from the President’s Fund, or health insurance, or private hospitals expansion contradicts the principle of “free health”.
Borrowing from health economics discourses propagated by the World Bank, and some professional bodies and think tanks in Sri Lanka, these strategies support the expansion of private healthcare. But private healthcare companies are accountable to their shareholders, not the public. The profit motive of private healthcare is amply evident in the concentration of major private hospitals where per capita income is higher (in Colombo, its suburbs, and larger towns).
If private healthcare is to relieve the burden of NCDs in rural areas, the government would need to step in to finance its provision. The government would either directly finance private sector provision through structures like the President’s Fund (a “public-private partnership”?), or through an insurance scheme that covers private healthcare for the low-income bracket.
The conditions on disbursements from the President’s Fund, and the limits placed on claims by local insurance companies already signal problems to come. Relying on the private sector to address the deficit of government health services may not be sustainable in the long-run owing to the rising costs of private healthcare, as evidenced in other resource-poor settings.
Other motivations?
Achieving “universal access” in resource-poor countries through public provision is presumed unfeasible in the first instance. Even the World health Organization has abandoned the idea and instead adopted the mantra of “universal health coverage” – to be achieved through “innovative” financing mechanisms like “public-private partnerships” and “risk protection”, which harness contributions from the private sector. While these strategies are recommended by health economics gurus who advocate the separation of the financing and providing functions of health systems to improve “efficiency”, the model of healthcare in Sri Lanka is not even considered in these deliberations.
But NCDs provide avenues for profitmaking for the private healthcare industry. Imagine the profits to be made if the government financed these procedures. Private healthcare companies, and, in particular, the burgeoning insurance industry, would keenly support the introduction of health insurance. A government desperately in search of capital inflow would also like to open the health sector for foreign investment.
Winners and losers
Before we uncritically accept the proposals of politicians, policymakers, and lobby groups to address the NCD crisis, we must ask ourselves some questions. Are there ways to strengthen the existing system to provide better access to NCD care? Do we really need unproven financing mechanisms that will direct public monies to the private sector? In reflecting on these questions, it may be helpful to think about who stands to lose the most from a free health service that shrinks opportunities for private healthcare. While the healthcare industry lines the pockets of its shareholders, healthcare providers make fat salaries working in both the public and private sector.
The costs of healthcare for NCDs are excessive, and basic health services may need to be prioritized over advanced medical technologies. But we do have the health infrastructure and human resources to work toward strengthening the existing system.
The public health system in Sri Lanka was built on principles of justice; let’s protect it.
(The writer thanks those whose contributions shaped the ideas expressed in this article. She may be reached at
ramyasrilanka@gmail.com)