Sustainability of Free health service concept in SL Prt 3 (Report)

Chapter 01 Introduction

1.1 Background of the study

Better health is the basis of human happiness and well-being. It also makes an important contribution to economic progress, as healthy populations live longer, are more productive, and save more.

Health services include all services dealing with the diagnosis and treatment of disease, or the promotion, maintenance and restoration of health. They include personal and non-personal health services.

Health services are the most visible function of any health system. It related with both users and the general public. Service provision refers to the way inputs such as money, staff, equipment and drugs are combined to allow the delivery of health interventions.

Health care consist of primary secondary and tertiary health care. Primary health care is the most widely concerned component in country healthcare service. Primary healthcare is the essential health care; based on practical, scientifically sound, and socially acceptable method and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and self-determination (World health organization, 1978).

Health expenditure is an important fraction of country economy. There are several health policies and mode of financial allocations to maintain the health care of a country. Government budget allocation, foreign and local NGO funds, Personal and social insurance schemes and personal expend are the common share of total health expenditure.

Sri Lanka is one of few countries which principally accept the free health concept. Therefore it is expected to cover the health expenditure with no “out of pocket” share as a mode of allocation. WHO has identified the share of budget allocations, insurances, NGO funds is 51 % of total health expenditure. Collectively this share is called as public health expenditure.

Public health expenditure consists of recurrent and capital spending from government (central and local) budgets, external borrowings and grants (including donations from international agencies and nongovernmental organizations), and social compulsory) health insurance funds.

Figure 1.1: Share of total health expenditure

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(Source: National Health Accounts, 2002)

This study is basically focused on this discrepancy of health policy and the realistic situation. The gap of public health expenditure and the total health expenditure shows the problem of sustainability of free health. This gap has created several problems on patients who visit the government hospital for their healthcare needs and health development in community.

1.2 Research problem

Health Services of Sri Lanka established with the policy of free health. It is referred with free healthcare services for each citizen of the country. The realistic situation has diverted from the health policy where as citizens spend sum amount of money to fulfill their routine healthcare needs, comprising many of private healthcare institutions such as private hospitals, laboratories, pharmacies and health counseling services etc. Even the patients who are benefitted from state health institutions spend some expenditure to complete their health needs.

It is evident with statistical data of the country provision of sustainable universal healthcare service is a difficult task considering the economic strength of the country.

With this disparity of health service, it has become a difficult task to predict the outcome of health plans based on free health policy. Therefore maintenance of WHO recommended standards of health indicators becomes difficult. And also sustainable planning for basic healthcare needs has become ineffective.

The problems created with this divergent situation have to be identified and well studied to minimize the drawbacks. This study is basically focused to clear out the disparity of the health policy and the present situation to clarify evidently the circulation of additional amount of money in health service other than public health expenditure creating problems of sustainability of free health. This research evaluates the sustainability of present health policy.

1.3 Objectives of the study

- To identify the presence of obstacles to obtain free healthcare facilities from state sector healthcare institutions
- To identify the problems related to the disparity of health policy and healthcare services.
- Secondary data analysis with regard to health financing issues

1.4 Significance of the study

The significance of this study is directly focused on health policy makers, respective authorities of the government, funding agents and community. Ultimately it is expected to change some health behaviors enhancing benefits to the community.

Policy makers should identify the core of the problem to develop health policies with futures of people’s need and expectations integrating all sectors, reducing the social disparities, and increasing stake holder’s participation to ensure the health standard of the community.

Identifying the disparity of free health and current situation is useful in health planning considering strengths, weaknesses, opportunities, and threats. These realistic health activities are more benefitted to the community to achieve their health expectations.

1.5 Methodology

1.5.1 Primary data collection

Respondents from western province were taken as the sample of this study. Western province is one most population density high province and economical variations and cultural variation are high among western province population. Its education status has relatively high standards. And also government and private healthcare systems have been established in competitive level. These variations were taken into consideration in selecting sample population. Over 20 years people were randomly selected with no gender bias.

1.5.2 Sample size

Estimated sample size was 120 but the actual sample size was 105 as some questioners were rejected due to incomplete answering for more than 50% questions out of total question in the questioner.

1.5.3 Data collection instruments

Questioner was the primary data collection instrument of this research. Questions were designed to obtain maximum information from the respondents with regards to the objectives of the research. For example the objective of finding obstacles in government hospitals for free health was covered by respondents who have hospitalization experience in government hospital via question number 10 and 11 Question number 12 was used to find out relationship of obstacles and moving towards private sector (Annexure 1).

Question number 1, 2, 3, 4, and 5 were used to analyze the sample profile of the research. Question number 6 and 9 were designed to collect data on individual share of health expenditure. Question number 7, 8 and 10 were designed to collect data on utility of government and private sector health care services. It was expected to obtain the information of respondents on awareness and attention on current trends of health by using question number 7, 13 and 14. Aptitude on health service was questioned by question number 15 and 16.

1.5.4 The research design

This research was designed on both primary and secondary data. Primary data was analyzed to achieve the objectives of the research. Combined information collected from different questions of the questioner was analyzed to obtain more reliable finding. Secondary data related with research problem were analyzed to ensure the reliability of primary data findings.

1.5.5 The data analysis technique

Graphs, bar charts, pie charts and tables were used as primary data analyzing tools in this research project.

1.5.6 Secondary data

Secondary data collected from Annual reports, country reports and statistical reports available in data bases were used as a part of this research to interpret the underlying health issues of this issue and results of primary data analysis. Statistical data available in WHO and MoH reports were used to ensure the reliability and responsibility of the resource.

1.6 Limitations of the study

Representation of respondents from all provinces is the ideal choice for more reliable and applicable findings. Increasing the sample size increases the accuracy of the finding. Lack of some relevant statistical data such as utility of private health care facilities and annual revenue of private health care services was one limitation of this study.

Though study was carried out considering NCD prevalence as a model of current health trends, malnutrition and mental healthcare are other prominent health issues are to be considered evaluating sustainability of health service.

Chapter 02 Literature review

2.1 Over view

Country's ability to provide quality health services for its citizens is a major component influencing health status of the country. Ministry of health is the important actor, but also the other government departments, donor organizations, civil society groups and communities themselves contribute it. For example: investments in roads can improve access to health services, inflation targets can constrain health spending and civil service reform can create opportunities - or limits - to hiring more health workers. Improving access, coverage and quality of services depends on these key resources being available.

Figure 2.1: Social determinant of Health

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(Source: Dahlgren and Whitehead, 1991)

The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels through the health system of the country.

The social determinants of health are mostly responsible expressing health inequities - the unfair and avoidable differences in health status seen within and between countries. (Harrison and Deen, 2011)

There are several steps to be taken for improving social determinants of health. Adopting improved governance for health and development, Promote participation in policy-making and implementation, further reorient the health sector towards promoting health and reducing health inequities, strengthen global governance and collaboration monitoring the progress and increasing the accountability (The Rio Political Declaration, 2011).

To improve the health determinants there are four WHO established recommendations improving health conditions, tackle the imbalance distribution of power money and resources, measure and understand the problem and assess the impact of action. (Commission on Social Determinants of Health, 2005-2008)

WHO has identified five key elements to achieve the goals of health care.

Reducing exclusion and social disparities in health (universal coverage reforms);

Organizing health services around people's needs and expectations (service delivery reforms);

Integrating health into all sectors (public policy reforms);

Pursuing collaborative models of policy dialogue (leadership reforms); and Increasing stakeholder participation.

The health expenditure of a country should be maintained systematically. There are key modes of allocations to cover the health expenditure of a country.

-Government budget allocation
-Out of pocket
-Health and other relevant insurances
-NGO funds and other donations

Usually most of the countries utilize above all modes of allocations more or less to cover up their health expenditure. The contribution of these modes of allocation gets differ with the economic policy of the country.

2.2 Situation of Sri Lanka

Sri Lanka is a developing country with having population at 19.25 million in 2003. Health status of Sri Lankan population shows transition stage. According to the health indicators Sri Lankan population is an aging population. It is projected that by 2020, 20% of Sri Lanka’s population will be 60 years of age or over, while the proportion in the young age group is decreasing (WHO Country Cooperation Strategy 2006-2011).

Sri Lanka has achieved relatively high standards of health development. In 2002, the Human Development Index was 0.7404 and life expectancy at birth was a creditable

73 years. The Infant Mortality Rate (IMR) has declined steadily since the beginning of the 2000. It was 11.2 per 1,000 live births in 2003. The Total Fertility Rate (TFR) in 2000 reached a new low of 1.9%. (Source: Demographic Health Survey -2000) Sri Lanka has achieved the targets of universal child immunization with immunization coverage of children less than three years reaching above 98.5%. Polio has not been reported and Sri Lanka since 1996. Sri Lanka is still classified as a low HIV/AIDS- prevalence country with slow increase of STI (Millennium development goals country Report 2008/09).

Almost 400,000 Sri Lankans experience a serious mental disorder each year and further 10% of Sri Lankans experience some other form of mental illness each year. Malnutrition is a problem in Sri Lanka (WHO Country Cooperation Strategy 2006- 2011) The Demographic and Health Survey carried out in 2000 shows that the childhood malnutrition rates are high with 29.4% of children underweight, 14% wasted and 13.5% stunted (Millennium development goals country Report 2008/09).

Sri Lanka is experiencing an epidemiological transition while having communicable diseases like malaria, tuberculosis, dengue, Japanese encephalitis, diarrhea and acute respiratory infections, non communicable diseases such as cardiovascular and cerebro-vascular illnesses, diabetes and cancer emerges the high morbidity and mortality pattern. Long-term medication for such preventable chronic illnesses impacts heavily on health financing capacity. (Jayawardane, 2012)

2.3 Organizational Structure

Sri Lanka principally provides free health service to the whole population. The organizational structure of this health care service consists of Ministry of health and provincial health councils. Both of these bodies administrate Teaching hospitals, Base hospitals, district hospitals, Maternity homes. Central dispensaries and health institutions such as National Blood transfusion service, anti malaria campaign and STD control programme.

The tertiary and secondary level hospitals (teaching, general, and base hospitals) occupy over 100% while the primary care hospitals (district and rural hospitals, and peripheral units) often have 30% occupancy rates. The public health laboratory system has not been fully developed. There is an acute shortage of nurses and other allied health personnel.

Table 2.1: Health care institutions in Sri Lanka

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(Source: Management Development and Planning Unit MoH)

Table 2.2: Human resource capacity of health service of Sri Lanka

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(Source: Annual Health Bulletin 2002)

Table 2.3: Expenditure on Medical Supplies, 2008 - 2010

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(Source: Medical Supplies Division, Ministry of Health)

2.4 Health Financing

All regime of the world take part more or less mandatory responsibility on their citizen’s health. Therefore every government get apportion from their GDP to maintain the health status. If a country possesses a free health service, the government of this country should have a confined sustainable preservation of health service and greater part of health expenditure should be covered up by government allocations.

The health status of Sri Lanka is principally based on the government health services as it consists of free health concept. Key responsibility of maintaining the health is laid on the government. Therefore every citizen expects to fulfill their health care needs with regards to the free health services of the country. And also the government is the sole responsible party for both personal health care and preservation of all country health needs.

To achieve the targets of health service the National Health Policy document was published by the Health Ministry in 1996 continues with number of broad health aims. More recently, the Health Ministry published the Strategic Framework for Health Development in Sri Lanka in order to direct the Health Sector Master Plan 2005-2015 aiming

- Delivery of comprehensive health services, which reduce the disease burden and promote health
- Empowering communities to participate actively in health maintenance
- Improving human resources for health delivery and management
- Improving health financing, mobilization, resources allocation and utilization
- Strengthening of stewardship and management within the health system

The health programmes of a country are designed to fulfill the above requirements enhancing community based health standards.

Chapter 03 Data presentation and Analysis

3.1 Sample profile

In data collection the priority was given to collect a random sample for the study. It was collected with no bias on gender, age, Occupation and other socio economic factors.

3.1.1 Gender distribution

The data represents 70% of males and 30% of females.

Table 3.1: Gender distribution of the sample

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

Figure 3.1: Gender distribution of the sample

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(Source: Survey data 2012)

Though the study was not focused on bias of gender distribution, a majority of male represents the sample. It was an extra advantage for the problem is to be analyzed as majority of males represents head of the household.

3.1.2 Age distribution of the sample

In this survey 21% of sample population was less than 35 years and majority (56%) was in between 35 and 55 years. Other 23% was more than 55 years. It was an advantage of representing majority of the study in productive range of age.

Table 3.2: Age distribution of the sample

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

Figure 3.2: Age distribution of the sample

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(Source: Survey data 2012)

3.1.3 Occupational Status of the Sample

It represents the normal distribution of occupational status of the country. Private sector occupied proportion was 40%. Government sector occupation was represented by 34% of sample population

Table 3.3: Occupational Status of the sample

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

Figure 3.3: Occupational Status of the sample

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(Source: Survey data 2012)

3.1.4 Social Status of the Sample

Majority of sample population represents the sub urban living style which is standing for the country status.

Table 3.4: Social Status of the sample

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

Figure 3.4: Social Status of the sample

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(Source: Survey data 2012)

3.1.5 Income Levels of the Sample

Survey was designed with four income levels looking at their monthly income. Monthly income less than Rs. 30,000.00 was considered as the lowest income level and income less than Rs. 50,000.00 was the second level of income. Third level represents the population with less than Rs. 1, 00,000.00 monthly income and income more than Rs. 1, 00,000.00 was considered as the fourth level.

Table 3.5: Income Levels of the sample

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

Figure 3.5: Income levels of the sample

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(Source: Survey data 2012)

3.2 Analysis of primary data

Questioner is the instrument which was used froth primary data collection. Basically two questions were targeted to identify the presence of obstacle in provision of here health to the community. The respondents with previous hospitalizations were questioned to get reliable information on free health in the state hospitals. Answers of question number 10, 11, and 12 were used for information. Only 74 respondents had previous hospitalization experience. Out of this, 47% have admitted in government hospital and 24% have both government and private hospital experiences. Other 29% have private sector experience only.

Table 3.6: Hospitalization in hospitals

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

Figure 3.6: Hospitalization in hospitals

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(Source: Survey data 2012)

The number of respondents with government hospital experience is 53. These people were questioned on question number 11. There was significant information on laboratory facilities and drug availability. Out of 53 admitted patients 72% were asked to bring some drugs from outside. It indicates that the government hospital does not have adequate drugs to treat patients with necessity.

Table 3.7: Drug availability in hospitals

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(Source: Survey data 2012)

And also only 28% of patients were facilitated with all the laboratory investigations inside the hospital. All the tests were outsourced for 15% of admitted patients while 57% patients were requested for some tests to be outsourced. Total amount of outsourced laboratory tests for admitted patients is 72%. Inadequate laboratory facilities are another obstacle to provide free health in government hospitals.

Table 3.8: Laboratory facilities in hospitals

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

Figure 3.7: Availability of facilities in hospitals

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(Source: Survey data 2012)

The patients who admetted in the hospital were in balance aptitude on human resource in the hospital. Fourty seven persent of patients had been satisfied with hospital staff and other 53% was not satisfied with the staff.

Table 3.9: Satisfaction on staff of the hospitals

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

Figure 3.8: Satisfaction on staff of the hospitals

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(Source: Survey data 2012)

The people who are getting health care services from private sector were questioned to analyze the reasons for moving towards private sector. It also helped to further clarify the obstacles in free health. Majority of respondents (41%) agreed with the reason of waiting lists of the government hospitals for getting private sector health facilities. Unavailability of required facilities was the other common reason (24%) of patients to move towards the private health care services. The problem of credibility of government services is another reason for 17% of respondents. Twelve percent of people utilize private health institutions as they are paid by external party.

Table 3.10: Reasons for moving for private sector

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

Figure 3.9 Reasons for moving for private sector

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(Source: Survey data 2012)

It gives reliable information of major obstacle of inadequate facilities in free health to provide universal health care to each citizen.

As the country experiences epidemiological transition from which is being replaced the prevalence of communicable diseases by non communicable diseases is the important problem to be attended. Health policies and health expenditure should be focused on facilitating community preventive healthcare. Therefore information was gathered from respondent with regard to non communicable diseases.

The NCD prevalence was 51% among respondents. Though it’s not tally with the WHO reports it is believed it could be due to unawareness and unknown situation of their persisting non communicable diseases.

Table 3.11: NCD Distribution of the Sample

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

Figure 3.10: NCD Distribution of the Sample

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(Source: Survey data 2012)

Forty one percent of respondents having NCD do not involve in disease management process, regularly. It indicates the negligence of NCD.

Table 3.12: Treatment Habits for NCD

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

Figure 3.11: Treatment Habits for NCD

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(Source: Survey data 2012)

The option of treatment for NCD was government hospitals among 28% of respondent with NCD. Private sector was utilized by 38% of respondents. Both government and private sector were utilized by 34%.

Table 3.13: Usage of Health Services for NCD

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

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Figure 3.12: Usage of Health Services for NCD

(Source: Survey data 2012)

This indicates nearly 50% of population with NCD move towards private healthcare. It indirectly indicates inadequate concern and facilities in government healthcare system.

Table 3.14: Utility of preventive healthcare facilities

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

Figure 3.13: Utility of preventive health care services

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(Source: Survey data 2012)

Data of the survey indicates the unawareness of community on NCD related prevention and treatments. Same way community has a barrier to utilize free health facilities on current health trend. One key responsibility of the government is, to aware the community on the health status of the country as the community is the main fact in country health. Though the health policy is prepared with epidemiological transition from communicable disease to non communicable diseases the infra structure has not developed to achieve the targets of health plans resulting unawareness of community and the lack of opportunities to get the services based on current trend of health.

Aptitude on different health care services was surveyed to obtain the information on awareness of community with regards to the current trends of health. According to the responses of the sample population, collectively prevention has not been identified as an important health care need by the community while they still believe routine curative healthcare and control of epidemic are the most important health needs. Routine curative health care and epidemic control are the most interested health topics among respondents.

Table 3.15: Aptitude on health care services

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

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Figure 3.14: Aptitude on health care services

(Source: Survey data 2012)

Health counseling is another new approach in health as the mental health care of the country has identified as burden in WHO health reports. Mental health policy was developed to develop the mental health status of the country. But the survey indicates very low awareness among community on counseling services. It was only 5 % of the respondents.

The data collection was extended to obtain information on utility of routine curative health care. Though the main component of health care represent the curative health the utility of government health care on curative basis is also not prominent Majority of respondents utilize both sectors for their curative healthcare needs. It represents 77% of sample population. Only 15% utilizes the government health service as their exclusive service provider. Private sector is utilized by 12% totally.

Table 3.16: Utility of Health services in routine curative health

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

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Figure 3.15: Utility of Health services in routine curative health

(Source: Survey data 2012)

This situation indicates a problem of ineffective free health service in Sri Lanka. Because government spends a big amount targeting curative health care standards but it is not utilized by the community in expected level. It shows the disparity of health policy and the health services of the country.

The survey gives a useful evidence of health expenditure of each citizen of the community. Information of primary data is evident that every person spends at least less than 1,000 rupees monthly for their health needs. All other respondents spend more than 1,000 rupees monthly except 17% of respondents. Other 17% of respondents have no idea on their health expenses. Twenty one percent of sample population spends more than 4,000 rupees monthly for their health needs.

Table 3.17: Monthly Expenditure for health

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

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Figure 3.16: Monthly Expenditure for the Health

(Source: Survey data 2012)

Some people spend essentially for their health needs without clear idea of the amount they spend for it. Other important finding is that the respondents who utilized only the government health facilities also spend some amount of money for their health needs. This could not be possible if the health of Sri Lanka is totally free. This miscellaneous health expenditure is one most important factor which has to be elucidated in health expenditure.

Table 3.18: Relationship of utility of health sectors for routine health needs by different income levels of the population

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(Source: Survey data 2012)

Figure 3.17 clearly shows the difference of government and private sector utilization by different economic levels of the community. The utility of both government and private sectors could not be differentiated proportionately in this survey.

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Figure 3.17: Relationship of utility of health sectors for routine health needs by different income levels of the population

(Source: Survey data 2012)

The other finding of this survey indicates the disparity of health concept and real situation of the country. Out of the respondents who utilize the private health care services 78% pay their expenditure from out of pocket. This 78% includes both people with high income levels as well as low income levels specifically less than 30000 rupees monthly income. Private health facilitated population with less than 30000 rupees monthly income was 80% out of respondents.

The mode of payments was also studied in this research. The modes of payments are out of pocket, employer and insurances. Table 3.19 shows the statistics on mode of payment and figure 3.18 illustrates it the graphically.

Table 3.19: Mode of payments for health

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(Source: Survey data 2012)

The data of Table 3.19 is illustrated in figure 3.18 with percentages of each mode of payments.

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Figure 3.18: Mode of payments for health

(Source: Survey data 2012)

Out of private health care consumers, more than 50% are paid “out of pocket”. Percentage of out of pocket in each income level was compared in figure 3.16.

Table 3.20: Percentage of out of pocket expenditure in different income levels Out of pocket

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

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Figure 3.19: Percentage of out of pocket expenditure in different income levels

(Source: Survey data 2012)

A comparison of hospitalization in government hospitals and private hospital among different income levels were carried out in primary data analysis. Data are given in Table 3.21.

Table 3.21: Hospitalization in different income levels

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(Source: Survey data 2012)

Information in Table 3.21 is illustrated in figure 3.20. Hospitalization in both private and government sector was unable to differentiate with more informatively.

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Figure 3.20: Hospitalization in different income levels

(Source: Survey data 2012)

According to the WHO interpretations, it is directly related the delivery of free health to the low income community for the improving health standards of the country. It was proved by the data obtained in this community based research. When increasing the income level the utility of government hospital for hospitalization became reduced and moved towards the private sector. In a situation of deficient budget allocation for free health it is more sustainable if it is possible to deliver the free health aiming the people with low income levels.

Awareness of the community on health is an important for maintaining health standards of the country as it is a community based task. Community should be aware on health issues and trends to overcome the challenging situations of health. And also awareness of the community is mandatory for achieving expected targets of health plans. Therefore this research was focused to gather information on community awareness on health.

Previously analyzed results of the question which was targeted for most important health service and question designed aiming utility of preventive health care facility, gave information on unawareness of current health issues. In both questions more than 50% have not responded with acceptable level of awareness on prevention health care services (Positively responded percentage was about 21% of total respondents) and only 34% of respondents were facilitated with preventive health care services.

The attention on health care service was analyzed using questions number 15 and 16 on present health care service. Out of 105 of respondents Ninety five were suggested that the present health service has to be changed. Table 3.22 summarizes the suggestions of sample population.

Table 3.22: Responses on changing health service

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(Source: Survey data 2012)

The graphical presentation of above data is given below.

Figure 3.21: Responces of changing health service

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(Source: Survey data 2012)

Ninety percent of sample population has suggested that it should be changed but 27% had no idea of the changes to be introduced. Identifying the need of any change in health care services is an indication of that community gets suffered with ineffective health care services. Increasing budget allocation was suggested by 29% of responded population. Introducing insurances and regularization of private health care services are the other suggestions.

3.3 Secondary data analysis

The Government’s policy for health financing is based on universal health services for all its citizens. Public health expenditure should be able to maintain the total health expenditure of the country. Public health expenditure consists of recurrent and capital spending from government (central and local) budgets, external borrowings and grants (including donations from international agencies and nongovernmental organizations), and social (or compulsory) health insurance funds ( Keep M., 2011)

Government of Sri Lanka has a substantial responsibility on health service. The Government maintains health care expenditures at 8% to 10% of total public outlays. Throughout the 1990s, total health expenditure in Sri Lanka was 3.1% to 3.5% of GDP with government and private sectors taking almost equal shares. Most of the public expenditure on health of US $29 per capita is acquired by the Central Government with very little provincial revenue or other public resources (National Health Accounts, 2002).

Table 3.23: Budget allocation for health in 2009

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(Source: Global Health Observatory, 2009)

According to the ranking of countries by the percentage health expenditure of GDP, Sri Lanka is in 115th position and it is a lower position compared with other countries with free health care service. The position of Sri Lanka shows that country spends a low percentage GDP less than many countries like Japan, Bhutan, Thailand and Maldives etc where there do not have free health service (Annexure 2). This situation indicates an underlying divergence of health service in Sri Lanka.

Total health expenditure is the sum of health expenditure. It covers the provision of health services (preventive and curative family planning activities, and nutrition). Total health expenditure gets reduced during last few years.

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Figure 3.22 illustrates the percentage GDP of total budget allocation. It clearly shows the decline of percentage GDP annually since 2005.

Figure 3.22: Total health expenditure (% of GDP)

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(Source: WHO National Health Account, 2010)

Although the government has always supported a policy of providing universal health services for all its citizens, actual government expenditure cannot meet the financial requirements of health needs. Health care financing has become more challenging in the wake of the rising cost of health care, demand for quality health care and changing demographic and epidemiological patterns of the country.

The rapid development of technology will bring deficiencies in health financing into expectation. Rapid growth of health expenditure was expected in future. Figure 3.23 shows the estimated growth of health expenditure from 2001 to 2015. It indicates developing gap of total health expenditure and public health expenditure creating challenging issue on free health.

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Figure 3.23: Estimated Growth of Health Expenditure by Sri Lanka 2001-2015

(Source: National Health Accounts, 2002)

Public health expenditure is always less than 50% of total health expenditure during last15 years.

Figure 3.24: Public health expenditure (% of Total Health expenditure)

(Source: WHO National Health Account, 2010)

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WHO has identified the contribution of each mode of allocations to the total health expenditure of Sri Lanka. The figure 3.25 shows the share of total health expenditure of Sri Lanka.

Figure 3.25: Share of total health expenditure

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(Source: WHO National Health Accounts, 2002)

As a country with free health it is expected to cover the total amount of health expenditure from the government funds, social insurances and NGO/other donations. But the realistic situation is that the total health expenditure is not based on government funds and NGO/other donations (Public health expenditure). Only 51% of total health expenditure is spent by government funds and NGO/other donations.

Around 4.9 % of the expenditure is financed by employer’s health insurance schemes. Around 44% of the total health expenditure is financed through out-of-pocket payments or household expenditure. Only 01 % is financed by social health insurance like organized health management systems (WHO, 2009).

This information proves that there is a major but hidden conflict that has been found in health service of Sri Lanka. The main issue of this situation is the misinterpretation of 51% public health expenditure as the total health expenditure. But the authentic situation is it’s only about half of the total financial requirement for health services. This hidden truth creates an extra conflict as it does not exhibit appropriately. Ultimately this conflict affects the health service in many ways resulting challenges to maintain the WHO health standards with new health trends.

Chapter 4 Conclusions and Recommendations

4.1 Conclusions

From primary data it was evident almost all citizen spends some amount of money for health monthly. Government facilities are inadequate to some extend for provision of health care facilities for all citizens according to their health needs. Some facilities are unavailable or difficult to reach in time at the state sector institutions and community moves towards private sector. It is realized that all economic levels of the society utilizes private sector for their health care needs. But private sector utility has not been evaluated adequately.

Most of people who utilize the private sector pay their bills “out of pockets”. These evidences indirectly show the disparity of free health policy and the nature of persisting health care service. Furthermore primary data gives strong evidence to unorganized health system which is not targeted on new health trends such as prevention of non communicable diseases, mal nutrition and mental health care.

For example the utility of state health sector on NCD treatment was poor in primary data analysis. Though the statistical data has evidently showed that hospital spends considerably high proportion of expenditure to treat patients with complications of NCD still the state health services function with concurrent health issues such as dengue and other communicable diseases.

Community has lack of awareness on new health trends. It affects the health status of the country that is because the community is the main stake holder of country health.

Secondary data analysis could justify the present situation of the country health. Public health expenditure share of total health expenditure is always less than 50%. It means that the alternative modes of expenditure should be organized to fulfill the gap between total health expenditure and public health expenditure. This share of expenditures has been identified as insurances, employers and mainly “out of pocket”.

It creates a massive complication in making policy decision on health service with under strengthen economy whilst community looks for free health service. Health financing policy planning, implementation, management, and analysis requires good knowledge of health financing issues of the contextual constraints and opportunities and adequate tools to support a systematic approach to the issues. In order to improve the health financing system country needs to constantly adapt to the changing situation and readjust their health financing system.

Therefore complete understand on this complicated underlying reality of health should be concerned in provision of sustainable health care service through realistic health planning.

4.2 Recommendations

A social dialogue should be implemented among all stake holders in health system focusing the realistic situation of health financing and new health trends. Traditional health system should be replaced with realistic health policies to utilize resources more effectively.

Vision of health service should ensure support low income population to maximize the impact of better health on poverty and to address the needs of poor people. The structure of heath service should be reorganized increasing opportunities of free health to the poor people to minimize the inequity of health.

It is evident that private sector is an unorganized component of health. It should be regularized by the government. Introducing a tax system for private sector to strengthen the free health fund could be suggested.

Insurance system managed by government should be introduced to health care considering citizen’s unorganized “out of pocket” expenditure and utilizing indirect taxes which is spent by the government.

For a sustainable free health service at least 80% of total health expenditure should be covered by public health expenditure ensuring availability of sufficient percentage allocation of GDP, social insurances and adequate NGO, foreign aids and donations.

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