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Sustainability of Sri Lanka’s free healthcare a significant concern Sunimalee Madurawala

Sustainability of Sri Lanka’s free healthcare a significant concern Sunimalee Madurawala

14 Oct 2023 | By Marianne David

  • Healthcare system exhibits notable strengths and weaknesses
  • Gaps in health financing mechanisms need immediate attention
  • Sri Lanka has a strong foundation for Universal Health Care
  • System must remain vigilant regarding increasing NCDs
  • Economic crisis exerting significant strain on health sector
  • Collaborative efforts needed between Govt. and stakeholders
  • Introduce mechanisms for accountability and monitoring
  • Improve policy coordination efforts, with political commitment


Sri Lanka’s healthcare system exhibits notable strengths and weaknesses, alongside various opportunities and threats, asserted Institute of Policy Studies of Sri Lanka (IPS) Research Economist Sunimalee Madurawala, in an interview with The Sunday Morning.

“The strengths include the provision of free healthcare, effective preventive healthcare programmes like immunisation, a well-established public health system that includes domiciliary healthcare provision, and a skilled healthcare workforce. Sri Lanka’s high literacy rate is also a significant advantage contributing to better healthcare outcomes,” she noted.

Listing critical areas that negatively impact Sri Lanka’s healthcare system and demand immediate attention, she highlighted gaps in health financing mechanisms and efficiency issues, uneven distribution of healthcare resources and facilities, underutilisation and bypassing of primary healthcare facilities, overcrowding of tertiary-level Government hospitals, and regulatory weaknesses.

In terms of achieving the fundamental requirement of Universal Health Coverage (UHC), Madurawala pointed out that achieving UHC was undoubtedly a challenging goal for many countries, Sri Lanka included, especially given the current crises. 

“However, it’s important to understand that UHC is a long-term aspiration. Even though Sri Lanka confronts substantial challenges, it doesn’t mean that achieving it in the distant future is impossible. Sri Lanka has a well-established healthcare delivery system, built on the foundation of providing free healthcare to its citizens. This historical commitment serves as the basis for potential solutions,” she added.

Following are excerpts of the interview:


Could you do a SWOT analysis of Sri Lanka’s healthcare system, as things stand at present?

Sri Lanka’s healthcare system exhibits notable strengths and weaknesses, alongside various opportunities and threats. The strengths include the provision of free healthcare, effective preventive healthcare programmes like immunisation, a well-established public health system that includes domiciliary healthcare provision, and a skilled healthcare workforce. Sri Lanka’s high literacy rate is also a significant advantage contributing to better healthcare outcomes. 

The forthcoming State of the Economy (SOE) report for 2023 identifies critical areas that demand immediate attention, such as gaps in health financing mechanisms and efficiency issues. Moreover, uneven distribution of healthcare resources and facilities, underutilisation and bypassing of primary healthcare facilities, overcrowding of tertiary-level Government hospitals, and regulatory weaknesses negatively impact Sri Lanka’s healthcare system.

Sri Lanka has a strong foundation for Universal Health Care (UHC), given its history of providing free healthcare services to citizens. There is an opportunity to further expand and enhance the quality and accessibility of healthcare services to ensure that all Sri Lankans have access to essential healthcare without financial hardship. 

Additional opportunities for improvement include developing health research and innovation, integrating traditional and alternative medicine more comprehensively into the mainstream healthcare delivery system, promoting medical tourism, and enhancing telemedicine and e-health services.

In terms of threats, the healthcare system must remain vigilant regarding increasing incidences of Non-Communicable Diseases (NCDs), potential communicable disease outbreaks, and the healthcare challenges posed by an ageing population. Furthermore, the current economic crisis exerts significant strain on the health sector.


While the fundamental requirement of Universal Health Coverage (UHC) is yet to be realised despite Sri Lanka being comparatively high on the index, given the exodus of healthcare professionals, deteriorating quality standards, and ongoing shortages of medicines and medical equipment, do you think UHC is possible, even in the distant future?

Achieving UHC is undoubtedly a challenging goal for many countries, Sri Lanka included, especially given the current crises it faces. However, it’s important to understand that UHC is a long-term aspiration. Even though Sri Lanka confronts substantial challenges, it doesn’t mean that achieving it in the distant future is impossible.

Sri Lanka has a well-established healthcare delivery system, built on the foundation of providing free healthcare to its citizens. This historical commitment serves as the basis for potential solutions. 

Collaborative efforts between the Government and relevant stakeholders can pave the way to bring policies and reforms to achieve UHC. This includes addressing critical issues such as retaining healthcare professionals, raising quality standards, and ensuring a consistent supply of medicines and medical equipment. 

Furthermore, we should seek international support and partnerships to gain essential resources, expertise, and funding. Embracing technological advancements holds the potential to enhance healthcare delivery, particularly in underserved areas. Public engagement is also important. 

A long-term vision, guided by strategic planning, sustained commitment, and high-level political support is vital in the journey towards achieving UHC. While progress may take time, this comprehensive approach positions Sri Lanka to overcome current challenges and create a stronger, more resilient healthcare system.


What are the short-, medium-, and long-term steps we need to take to achieve UHC? 

In the short term, our focus should be on addressing immediate needs. Given the current challenges stemming from limited funding, particularly the shortage of medications, it’s crucial to prioritise securing funds to meet the healthcare sector’s requirements. 

To achieve this, seeking external funding emerges as the most viable short-term strategy for Sri Lanka. International development partners, donor countries, and organisations play a pivotal role in this context. 

Moreover, our efforts should be channelled toward reinforcing primary healthcare, enhancing the conditions and motivation of our healthcare workforce, and launching public health campaigns to address risk factors associated with NCDs. 

In the medium and long term, Sri Lanka needs to concentrate on establishing a sustainable healthcare financing system, enhancing efficiency, and strengthening the healthcare system. It’s imperative to establish robust health information systems to guide policy decisions. Implementing quality assurance mechanisms is equally pivotal in this endeavour.


As you’ve pointed out, Sri Lanka’s healthcare system faced gaps in knowledge, capacity, and policy even before the economic crisis, which only worsened a bad situation. How can these issues be effectively addressed?

A recent study conducted by IPS, which focused on planning for UHC, highlighted many challenges within Sri Lanka’s healthcare system. These challenges cut across various domains, including knowledge, capacity, and policy.

According to this study, knowledge gaps are particularly evident, especially in understanding the growing burden of NCDs. Additionally, deficiencies in data collection, information dissemination, and research and development (R&D) represent critical knowledge gaps. 

On the capacity front, several challenges become apparent. Notable deficits are observed in financial resources, planning capabilities, and human resources. The policy domain also reveals significant gaps, including inadequate monitoring and feedback mechanisms, policy inconsistencies, and limited channels for influencing policy decisions. It’s essential to recognise that these gaps are interconnected, necessitating a holistic approach to address them.

To address the knowledge gaps, it is crucial to improve data collection methodologies and establish a centralised knowledge hub that supports well-coordinated and precise awareness campaigns. Furthermore, strengthening the dissemination of knowledge and the ability to influence policy decisions is important, as it contributes to better healthcare planning and informed decision-making.

The introduction of mechanisms for accountability and monitoring can enhance the financial capacity and effectiveness of limited funding resources. Strategic utilisation of donor assistance can also help bolster financial, planning, and technical capacities. Overall, policy coordination efforts need to be improved, with a high level of political commitment to ensure policy consistency. 


You’ve identified two critical areas within the healthcare system as requiring immediate attention and policy action: health financing and efficiency improvement. Could you expand on this and outline what needs to be done? 

Health financing is a critical component of healthcare systems that plays a pivotal role in advancing progress towards UHC. It facilitates the expansion of effective service coverage while safeguarding individuals from financial hardship. Establishing a sustainable and resilient health financing system is essential for countries striving to achieve universal healthcare. 

In Sri Lanka, healthcare financing predominantly relies on two equally-shared sources: (1) Government transfers funded through general taxation and (2) direct payments made by households, often referred to as out-of-pocket expenditure (OOPE). 

In 2019, the Government’s share of total health expenditure stood at 46.3%, while households contributed 45.6%. An upward trend in OOPE is evident over time, accompanied by a decline in the Government’s contribution. 

Studies on health financing suggest that the Sri Lankan healthcare system faces a significant challenge due to insufficient Government spending on health. This inadequacy fails to meet the growing demand for services resulting from epidemiological and demographic transitions. 

‘The State of the Economy 2023’ report offers several health financing options to address these issues, drawing from global experiences. These options include social health insurance, user fees, and public-private partnerships.

Efficiency within the health system aims to assess how resources and expenditures are utilised to achieve valued health system goals. When care is delivered inefficiently, patients may experience suboptimal health outcomes or encounter difficulties within the healthcare system. Inefficiencies at any level of the system can hinder patients from receiving necessary care, potentially resulting in missed opportunities for improvement and even increased risks of adverse health outcomes.

Although the Sri Lankan health system is widely acclaimed for its efficiency, certain areas still require attention due to substantial gaps in efficiency. These include disproportionate spending on hospitals, a lack of systematic priority-setting, fragmentation, data gaps, insufficient monitoring, and human resource challenges. 

Prioritising preventive care, strengthening Sri Lanka’s primary healthcare system, and enhancing health information systems are essential steps towards improving efficiency in the healthcare system.


How sustainable is the free healthcare system, in the face of ongoing challenges?

The sustainability of Sri Lanka’s free healthcare system, especially in the face of limited fiscal resources, is a significant concern. The heavy dependence on Government funding, coupled with the nation’s economic constraints and fiscal challenges, poses a substantial threat to Sri Lanka’s health system’s continued viability. 

Ongoing fiscal limitations may hamper the allocation of sufficient funds to maintain and enhance healthcare services, affecting the long-term sustainability of the free healthcare system. 

As highlighted in the SOE 2023 report, it is crucial for Sri Lanka to explore alternative funding mechanisms, such as social health insurance, and implement strategies to optimise resource allocation and enhance healthcare system efficiency. 

Additionally, seeking external support and forming partnerships becomes imperative to bridge the fiscal gaps and ensure that quality healthcare remains accessible to all citizens.


Given the shortage of specialists, which is worsening amid the ongoing brain drain, what should be done to address this?

Addressing the shortage of specialists in Sri Lanka’s healthcare sector, especially in the context of a brain drain, demands a comprehensive approach. To retain the current specialists, improving their compensation, benefits, and career development opportunities is essential. Regarding recruitment and training, investing in domestic medical education and streamlining training programmes can bolster the local specialist workforce. 

The development and implementation of return incentives tailored for Sri Lankan healthcare professionals abroad can play a significant role in encouraging their return to the country. International partnerships and collaborations with the private sector are critical for facilitating knowledge transfer, specialist exchanges, and enhancing access to specialist services. Offering incentives to specialists willing to work in remote or rural areas can help rectify disparities in healthcare access. 

Promoting research opportunities can make the healthcare profession more appealing to specialists. Long-term workforce planning, based on a comprehensive assessment of future needs and capacity requirements, is crucial. 

Above all, we need a strong commitment from the Government, including adequate budget allocation and political support, which is pivotal in addressing this issue and ensuring the success of these initiatives.


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