On 24 February 2016, the Munk School of Global Affairs hosted a talk on the structure of government-funded healthcare in Sri Lanka, entitled ‘Public Healthcare in Sri Lanka: An Endangered Model of ‘Universal Health Coverage?’ The event’s speaker was Ramya Kumar, a Lupina Senior Doctoral Fellow and Doctoral Candidate at the Dalla Lana School of Public Health. Also speaking at the talk was Chizoba Imoka, a doctoral student at the Ontario Institute for Studies in Education and a Junior Fellow at Massey College. Chizoba is the founder and CEO of Unveiling Africa, a non-profit foundation that engages young Africans in political advocacy, community mobilization, and community service.
Kumar began the talk by introducing the Sustainable Development Goals (SDGs), a set of global initiatives put forth by the United Nations in September 2015 – as guidelines to structure and assist international development until the year 2030. There are a total of seventeen SDGs that focus on different approaches in eliminating poverty and encouraging international well-being. The third SDG emphasizes the importance of leading a healthy life, and was one of the key ideas of the lecture. The third goal sets a number of target areas for improvement in the field of healthcare, particularly for developing countries. In accordance with the Doha Declaration on the TRIPS (Trade-Related Aspects of Intellectual Property Rights) Agreement and Public Health, which maintains the right of developing countries to provide access to life-saving medicines, the third SDG aims to improve the affordability of healthcare facilities and achieve Universal Health Coverage (UHC). It also aims specifically to reduce the global maternal mortality ratio to less than 70 per 100,000 births by 2030. However, Kumar also pointed out a number of issues within the third Goal, including the fact that non-communicable diseases are not given sufficient priority. Given that non-communicable diseases such as strokes, heart attacks and cancer kill over 37 million people each year, this proves to be a noteworthy omission.
Kumar then highlighted the analysis of financial concerns and their impact on the quality of the health-related provisions. These were addressed by the sixty-fourth World Health Assembly in a report published in 2010. She further pointed out that recent UHC assessments focus on health insurance as a solution to the global healthcare problem. The discussion then took an economic turn as the speakers brought in economic considerations of health insurance. They pointed out that health insurance is based on an understanding that separating the provider and the purchaser will improve the efficiency of health systems, and is centered on the idea that market competition keeps costs low. However, the system can bring certain drawbacks and does not always function with as much equality as it does efficiency. This is particularly evident in economically disadvantaged nations, where there is an ever-widening gap between those who can afford healthcare and those who cannot. Such discrepancy is also seen in more developed countries, where some are covered through an inclusive work insurance program whereas others are not.
This exclusivity of healthcare has been long-since regarded as a phenomenon experienced in countries with a private healthcare system. As Kumar mentioned, UHC advocates for a public healthcare system as opposed to a private one. Ideally, the government would be the primary purchaser and provider of all civilian healthcare. This would be the ideal model of healthcare for less developed countries who have an inequitable distribution of facilities. Publicly-owned healthcare facilities are preferred due to their equitable dispensation of services and cost-effective procedures, meaning that more citizens have access to these services regardless of their socio-economic backgrounds. Countries with government-led healthcare systems include the United Kingdom, Canada, Singapore, and Hong Kong.
Sri Lanka is also officially included in the roster of countries that provide UHC. Kuwar outlined the developmental history of the Sri Lankan public healthcare system for listeners, beginning with the colonial period. In 1706, Hendala Hospital, the first hospital to treat leprosy was opened by the Dutch in the country’s western province. In 1819, Pettah Hospital opened in the capital, Colombo. In the 20th century, the British began setting up various government systems, including universal enfranchisement in 1931, followed by food subsidies in 1942, and free education in 1945. Free healthcare was introduced in 1951, but twenty years later a ‘stamp charge’ was imposed on outpatient services at public facilities. In the 1970s and 90s, the government began working towards expanding the private healthcare sector by making concessions and creating incentives such as state sponsorship. This led a number of private healthcare facilities to increase from 66 to 125 between 1990 and 2011.
The talk went on to highlight the progress of expanding the private healthcare sector. According to Kumar, there has been some success with managing the level of communicable diseases. Although, there is still much to be desired in terms of managing non-communicable diseases. Most private hospitals are found in the country’s capital and largest city Colombo; they enjoy minimal regulation by the government. Kumar revealed that most private institutions also rely on public sector employees – allowing them to navigate patients to public hospitals if and when necessary. She then highlighted the strengths and weaknesses of public sector treatments. The public sector is known for its strengths in the fields of pediatric, obstetric and emergency care. However, it has significant problems in treating non-communicable diseases, which require higher levels of specialized knowledge and equipment. There are little to no family-run practices in the public system. As well, outpatient programs frequently see long line-ups and with the rise of non-communicable diseases, Sri Lankans’ out-of-pocket spending on healthcare is growing rapidly.
Yet privatizing healthcare is not the way forward, as the speakers pointed out, especially in the case of Sri Lanka. Private healthcare makes for an inequitable distribution of facilities. More than half of the private hospitals in the country are clustered around the western provinces, where higher incomes and greater profitability attract ample investment. If the provision of healthcare is left to the private sector and the free market, it is likely that hospitals and facilities will develop around the most profitable locations –instead of where they are needed the most. With expensive treatment costs and limited locations, private hospitals are becoming an income-draining choice for many of Sri Lanka’s 20 million citizens. A more viable option brought up at the discussion was the idea of public financing of private healthcare. Initially drawn upon in a series of proposals in 2001, this approach would finance the development of healthcare by mobilizing resources through insurance and partnerships. There is also a significant role to be played by voters in indicating their preferences to the government and demanding change in healthcare policies as they see fit.
The talk concluded by reflecting on the intricacies and complexities of building an effective healthcare system. The speakers talked about how it is a deeply political process at heart, involving decades of committed local dedication and public investment rather than a series of technocratic interventions at a global level.
Emaan Thaver is a third year student studying International Relations and Economics at Trinity College in the University of Toronto. Her academic areas of interest include the historical periods of post-war Europe and the logistics of peace as well as contemporary global economic development.