By Sumudu Chamara
During the past few weeks, especially after the Sinhala and Tamil New Year, many parties have raised concerns about expanding the services to efficiently deal with the rising number of Covid-19 cases from what some are describing as the Covid-19 third wave. Sri Lankans are especially fearful of an India-like health crisis arising in the island and are therefore keen on ensuring that the health sector is sufficiently resourced to deal with whatever is to come. The Morning spoke to several individuals who play crucial roles in the health care and Covid-19 prevention machinery to determine if Sri Lanka is under-resourced or sufficiently prepared to handle the ‘third wave’.
Amidst allegations, debates and new developments, Sri Lanka’s Covid-19 management efforts continue; however, owing to the rapid increase in Covid-19 cases and deaths, with each passing day, the health authorities face new challenges as far as the available resources are concerned.
During the past few weeks, especially after the Sinhala and Tamil New Year, many parties have raised concerns about expanding the services to efficiently deal with this fresh onslaught of the pandemic. In addition to the increasing number of Covid-19 cases, issues pertaining to the exact number of daily Covid-19 cases and deaths were also a reason people started talking more about improving the health services, especially the laboratory services.
Delays
The Public Health Inspectors’ Union of Sri Lanka (PHIUSL) told The Morning early this week that due to the delays in the process of conducting polymerase chain reaction (PCR) tests and getting in touch with those who test positive for Covid-19, there are a number of issues in Sri Lanka’s Covid-19 management efforts.
Explaining the adverse impacts of such delays, PHIUSL Secretary Mahendra Balasooriya noted: “Any person can get a PCR test done as per medical advice. The report is usually a confidential one, and the person who is getting the test done is the one who receives the report first. If they test positive for Covid-19, the relevant laboratory lets them know that their Covid-19 status would be conveyed to the health authorities. Then, the relevant information is referred to the other health authorities such as the regional epidemiology units and the PHIs, which takes several days. In the meantime, the infected person stays at home. Usually, the priority is to hospitalise the infected person for 10 days, and sometimes, by the time the health authorities contact the infected person for the purpose of giving treatment, it has already been around 10 days. In a context where it is likely to take several more days until the facilities for the hospitalisation of the infected person become available, there is no point then in hospitalising them at that juncture.”
Laboratory services
In addition to such coordination related delays, Sri Lanka’s laboratories and laboratory technicians are also facing a number of difficulties due to the unavailability of adequate facilities, according to the Sri Lanka Association of Government Medical Laboratory Technologists (SLAGMLT) President Ravi Kumudesh.
He added that most of the existing issues are a result of the failures of those responsible for resolving the issues faced by the sector. Also, he claimed that certain administrative and coordination issues also lead to delays in issuing PCR test results.
He added: “First and foremost, it takes a lot of time for a PCR test result to reach the field because the Epidemiology Unit has not devised a proper plan for that purpose. Usually, a laboratory can conduct a PCR test within around 16 hours. For example, if the samples for the test come after 12 noon, the test can be conducted only in the evening. However, several officials of institutions such as the Medical Research Institute (MRI) including directors and virologists do not allow the laboratory technologists to conduct those tests at night, and therefore, we are left with no choice but to conduct the tests the following day. Due to this situation, it inevitably leads to a delay of around 24 hours in addition to the delays in the field. Sometimes, even the samples taken from the field take about a day to reach the laboratories, and we have to return the samples that have not been sent in accordance with the accepted guidelines – some have not been packed properly while some do not have the necessary accompanying details mentioned. There is no proper mechanism to reconsider those samples. The owners of those samples wait for the results of their tests but as per our standards, we have not received a proper sample to conduct the tests.”
Even though The Morning attempted to contact the MRI administration to inquire about Kumudesh’s claims, they were not reachable.
Confirming Balasooriya’s claims about the delays in communicating PCR test related information in the current Covid-19 management process, Kumudesh added: “Also, we conduct the test and send the results to virologists, and they then forward it to the Epidemiology Unit. It is then sent to the Regional Epidemiologists, the Medical Officers of Health (MOH), and the PHIs, respectively. It is only then that it reaches the relevant parties and this process takes around five days, and that is not something the laboratory can control. What laboratories can control are the three steps known as pre-laboratory, laboratory and post-laboratory, and what we can do is to minimise the time spent for laboratory related processes. We have not delayed that process and it certainly takes place about 16 hours, in the context of the facilities and conditions available currently.”
Emphasising the importance of newer and more facilities for the process of conducting PCR tests in laboratories, Kumudesh said: “If we are given the necessary technological support, we would be able to give the reports within one to one and a half hours as opposed to the long time we spend currently under the traditional systems. Once, the Bandaranaike International Airport (BIA) received such technology (a machine) as a donation which could help conduct tests within one to two hours; however, the Health Ministry’s laboratory service has not granted permission to install that machine since last December. Due to the prevailing situation, laboratory technologists at the MRI conducted tests in the evening hours after their work hours. But, when they asked for overtime pay which they are entitled to, it has been patently ignored by certain officials, and that disheartens those working more than they are supposed to.”
He added that despite the said hardships, laboratory technologists continue to work without taking trade union action for the well being of the public.
“The MRI possesses three laboratories and all these three institutions conduct a total of 1,500 tests a day, because of the conduct of the said officials. At the BIA, we conduct an astound 4,000 tests a day, whereas the MRI, despite having three laboratories, only conducts about 1,500, mainly due to administrative issues. This process is being handled as per the needs of some high ranking officials, instead of the needs of the country, and the Health Ministry seems to be very lethargic in this connection. The biggest issue affecting this process at present is the lack of capacity. This calls for more attention to the MRI’s capacity to conduct tests within eight hours as opposed to 24 hours. When it receives more samples than it can handle within eight hours, issues arise. For example, if we assume that the MRI received 3,000 samples, according to how the MRI conducts tests currently, only 1,500 tests can be conducted a day.”
Also, Kumudesh claimed that the centralised laboratory system is heading towards a mafia-type operation and emphasised that the number of daily tests cannot be conducted within the limits that are in effect. He therefore requested that a decentralised system be established with new technology. “It does not take much monetary resources or time, and if steps are taken to do so, we can increase the number of daily PCR tests up to three times within around two weeks,” he said.
He warned that under the existing centralised system, it is not possible to conduct the required number of tests within the coming two weeks, and that Sri Lanka has already exceeded the limit.
“In order to amplify the capacity of the laboratories, we need to be innovative and take proper decisions without working according to invidious agendas. Secondly, even if we increased the capacity of laboratories, there are field related delays as well. We should be given facilities to send test results through a laboratory based system. Sri Lanka has 72 Base Hospitals and around 490 Divisional Hospitals, and if technicians and point of care PCR machines are made available, we can conduct 100 tests at each place within no time. If we start it at 100 places, there would be no issues regarding sending reports. PHIs, midwives, MOHs and Regional Epidemiologists will be easily available at the spot and we can conduct 100 tests from the respective area and finish it. It would prevent major delays,” Kumudesh added.
He also alleged that even though the laboratory technologists have put forward a proposal four weeks ago, with clear technical guidance, on how to deal with the increasing number of cases with the limited laboratory facilities, so far, no proper discussion has been initiated in this connection.
The number of confirmed Covid-19 cases, reported every day, is also impacted due to the above mentioned issues, according to Kumudesh. He added that Covid-19 cases are increasing at a rate of two times the previous number, and that even now, Sri Lanka gets to hear only a small number of cases because PCR tests are not conducted adequately. He opined that the actual number of cases is at least five times bigger than what is reported currently.
Speaking of the necessary facilities, Kumudesh said: “Sri Lanka has no issue about the number of PCR machines; it is the new technology that we want. There are PCR machines that can differentiate variants of the virus and also point of care PCR machines, and these are what we want. Spending millions for PCR machines without taking into account the nature of the system that can cater to the demand will not be beneficial to the public. Around eight extraction machines have also stopped working, and that also slows down the process significantly.”
Authorities’ response
However, when contacted, Health Ministry’s Laboratory Services Director, Dr. Vijith Gunasekera, said that the Health Ministry has paid attention to the status quo concerning the Covid-19 pandemic in the country, and that the authorities are in the process of taking a number of measures to increase laboratory services and facilities.
Steps are being taken to set up new laboratories, increase the capacity of existing laboratories (used to conduct PCR tests) and improve certain technical aspects pertaining to the tests, according to Dr. Gunasekera.
He added: “Since some tests are conducted by the private health care sector, we encourage them to increase the capacities of their laboratories as well.”
When queried as to whether the authorities are planning on purchasing more PCR machines due to the increasing number of Covid-19 cases, Dr. Gunasekera noted that plans are in progress to purchase more PCR machines under a World Bank (WB) supported project as well as several other projects. According to him, more PCR machines would be purchased utilising Health Ministry funds as well.
In response to the allegations levelled by Kumudesh that laboratory technicians are not compensated properly and do not receive adequate facilities, Dr. Gunasekera added: “They are also entitled to the facilities given to healthcare workers, and there is no significant difference as far as the facilities are concerned. Also, there has not been any significant difference in their rosters. When it comes to overtime pay, the Health Ministry has taken steps to see to it that they receive the due payments without any hindrance if they work properly. Also, the directors of hospitals have been given the authority to take the necessary steps in this connection.”
Multiple attempts to contact the Minister of Health Pavithra Wanniarachchi and the Director General of Health Services Dr. Asela Gunawardena proved futile.
However, when the State Minister of Primary Health Care, Epidemics and Covid-19 Disease Control, Dr. Sudarshini Fernandopulle had been questioned at a recent media briefing if there is a shortage in the health sector, be it in terms of the staff, doctors, intensive care unit (ICU) beds, vaccines or any other resources, she said that there is no shortage at present.
“At the moment we have sufficient doctors, nurses and other healthcare workers. But if the patient numbers grow significantly, there could be an issue. For example, if we have a lot more patients, we will need more ICU beds and this requires trained healthcare workers. The whole of Sri Lanka has only an ICU bed capacity of 600 - 700. A bulk of this is utilised for non Covid-19 patients and patients undergoing post surgery care. There are 140 ICU beds for Covid-19 patients. So if the numbers of patients grow exponentially, we can increase the number of ICU beds but we can’t increase the number of healthcare workers for those beds. For example, it takes five and a half years to train a doctor, and around 10 years to train a specialist doctor, while for nurses and laboratory technicians it takes three years. So health workers can’t be imported or purchased in the short term. All countries are facing this issue. Therefore, the prevention of the spread of this virus is the best solution.”
It is true that Sri Lanka has very limited resources and that improving these resources is not an easy task. Also, at a time when the country’s economy is hanging by a thread, managing the available monetary resources is also a challenge.
However, by putting the available resources to good use, great results can be achieved, and the relevant stakeholders’ involvement in the decision making process can in fact help the authorities to see the best ways to achieve it.
