Envisioning a path to a more inclusive, affordable Sri Lankan healthcare system

Sri Lanka has witnessed unprecedented growth and development over the recent past as evidenced by rising income levels which stood at US$ 3,759.20 by the end of 2017. While the economic impacts of this remarkable growth trajectory are clearly defined, increasing prosperity tends to be accompanied by changes in lifestyles and increasingly sophisticated demand for better quality products and services. Among the sectors most directly connected to these shifting trends in Sri Lankan society is the healthcare sector.

Elaborating on the ramifications of these changes, Shyam Sathasivam, Chairman of the Sri Lanka Chamber of Pharmaceutical Industries (SLCPI) called for greater partnership between public and private sector stakeholders in order to preserve and enhance the country’s existing facilities while developing specialized capabilities to shift the goal of healthcare outcomes from treatment to prevention. Following are excerpts:

Q: How is Sri Lanka’s healthcare sector changing and what are some of the factors underlying these changes?

A: Like all other basic services, the healthcare sector tends to be directly connected to GDP growth. Particularly when considered over the long-term, the Sri Lankan economy has witnessed tremendous growth over the recent past, as the country continues to move steadily with a GDP growth rate of four per cent, the expectations and aspirations of our citizens is also growing and changing. This trend certainly has important ramifications across all of facets of daily life. Today there are more people living sedentary lifestyles that when combined with increased disposable income and greater leisure options, tends to impact negatively on overall health and wellness, as evidenced by the tremendous rise in Non-Communicable Diseases (NCDs) over the recent past.

Conversely however, we also see that with rising prosperity, there is an increased willingness to invest in healthcare and greater interest in making healthier lifestyle choices. As a middle-income country, I think it’s safe to say that this will be a progressive trend and move forward, expect the tension between these two dynamics. Another important issue to consider is the growing demand for high quality tertiary healthcare services that are affordable and available to all those who want access to such care.

Overall, I would say that Sri Lanka has been quite fortunate to have successfully established a universal healthcare system that – for the most part – works quite well. However, with increased prosperity, the demand for specialized care is also an important factor and it is vital that we accommodate this demand, to ensure that the overall standards of healthcare in Sri Lanka are on par with international standards.

Q: How well equipped is the country’s current healthcare systems and policy towards dealing with these anticipated challenges?

A: Overall, there is a lot about our system and the policies to be positive about and generally our system has provided positive healthcare outcomes for the majority of patients. A powerful advantage of our unified system is the ability of Government to draw upon substantial resources across the island to take action on a national scale. We have seen some highly successful, proactive examples in the recent past like the national Anti-Smoking campaign, and successful campaigns to eradicate Polio and Malaria.

However, we still face substantial challenges in terms of preventing, and combatting disease while ensuring optimal healthcare delivery. Funding will always be insufficient to deal with the scale of challenges faced by the healthcare sector. Therefore it is vital to adopt a systematic approach to healthcare; and I think it’s fair to say that those systems are broadly in place. But there is always more that we can do, particularly in terms of improving access to treatment for all Sri Lankans.

Q: What are some of the most crucial components in ensuring optimal healthcare delivery for all Sri Lankans?

A: One of the most important factors is in ensuring a greater number of qualified and capable healthcare professionals enter the sector. Equally important is that a greater number of allied healthcare professionals are also being trained. In addition to maintaining an optimal doctor-patient ratio – particularly outside the Western Province, I think it is vital to invest at a national level in the establishment and expansion of medical universities in order to build a pool of talent that is internationally recognized, and this is an area which I believe Sri Lanka has immense untapped potential.

From a market-oriented perspective, providers must work to build greater depth in their procurement methodologies to ensure optimum availability of products and services. We need to enhance our systems in order to ensure that medicine and treatment is available across the country. At a consumer level, there is also more that can be done to educate the public about the impact that their lifestyle choices can have on quality of life. By adopting a holistic strategy that addresses all stakeholders, I believe that we can arrive at a truly progressive outcome for all.

Q: Such wide-reaching action would have to start somewhere. What do you believe are some of the low hanging fruit that that the Government and the private sector can look to over the short-term?

A: There are no quick fixes in the healthcare sector and the benefits of any alterations to healthcare policy tend to play over the medium-long term. Nevertheless, one of the best areas to aggressively target would be the development of our diagnostics capabilities. In the healthcare industry, this is often referred to as the ‘Rule of Halves’: of those who are diagnosed with a disease, only half receive treatment from a qualified healthcare professional and again just half of these people achieve their treatment targets. Unfortunately, the Rule of Halves does not end there: only half of this relatively small group actually achieve the desired outcome and live a disease-free life.

Essentially, there tends to be an exponential reduction in the number of people who receive treatment relative to those who require it, and ultimately, this is a problem of awareness. If the general public is more aware of what they can do to prevent illness through early diagnosis, parallel to investments to enhance our diagnostic capabilities, I believe that we as a nation can start enjoying the benefits of these investments fairly quickly. Early diagnosis can often pre-empt the need for treatment – which is significantly more complicated and expensive than diagnosis, therefore these investments will be money well spent.

Q: What are some of the areas which the public and private sectors can work together to deliver positive healthcare outcomes?

A: There are certainly a few areas with low hanging fruit which can be powerfully leveraged through Public-Private-Partnerships (PPP), and one of the most opportune areas in that regard would be in early detection. I believe that the PPP model will be central to driving successful healthcare outcomes, and there are certainly a wide variety of examples of the PPP model in developed and developing economies that have generated remarkable improvements in the availability and delivery of healthcare products and services.

While the Sri Lankan debate on healthcare has tended to focus solely on issues of affordability, we feel that awareness building can serve a much more powerful role in producing better healthcare outcomes – this is an area, which the Government is best equipped to engage with people and communities across the island. The private sector also needs to join in and find means of contributing to these awareness campaigns by following-up in these areas and providing access to affordable healthcare products and services, and in this manner.

Q: Economic policy tends to dictate investments and growth in the healthcare sector, but what is the potential impact of a progressive health policy in economic performance?

A: There is a clear gap in terms of research into pharma-economic dynamics. Hence one of the key recommendations by the SLCPI to the Government has been for the commissioning of robust research into this field to ensure that future policy decisions are evidence-based and clearly reflective of realities on the ground. Such initiatives would naturally result in a much deeper, holistic analysis of the healthcare sector and provide insights into vitally important factors that go beyond simply analyzing the cost of products and infrastructure alone.

There are several other areas to consider: What is the average length for a typical patient at a Government hospital? Is the patient better served by opting for a shorter stay that ensures a full recovery but also allows for a reduced cost to the State?

Minimal invasive surgery is another area that can have a significant impact on cost reduction and recovery time. Such facilities and services require investments that can seem costly and prohibitive when we only consider the Rupee values of such treatments, however when balanced against the duration of stay, and cost of recovery, the patient and the State healthcare system can both benefit immensely. That is why it is absolutely vital to take a nuanced, well considered, evidence-based approach when deciding macro policy. We need to ensure that we preserve what works and reform what does not.

Ultimately, if we are successful in formulating a well-balanced healthcare system, the impacts of these reforms will be far-reaching, and will most certainly be keenly felt when examined from the perspective of economic performance and productivity. Essentially, if we can make lasting improvements to the health of our national workforce, we will almost certainly benefit from greater productivity combined with a gradual reduction in the cost borne by the state; hence we are confident that this is a win-win scenario for the national, and all of its citizens.

Q: What would be an ideal direction for the Sri Lankan healthcare sector to move in over the next decade?

A: Sri Lanka has already the extended its basic and essential healthcare services to all corners of the island under our universal healthcare system. It’s clear that the Government can – and should – play a leading role in primary healthcare services moving forward. However when considering global examples, there is a clear trend towards greater investment by the private sector into tertiary care services and facilities.

This speaks to a fundamental shift that occurs in any nation that transitions into a stable middle-income status. Sri Lankan perceptions around healthcare are changing. In the past our people would perceive medical treatment as something paid for only when needed, today we see a more holistic long-term approach that is tied to quality of life. Today, more Sri Lankans look at their healthcare as a proactive investment in their future. This change in mindset is no trivial matter. Regardless of what resistance there may be to change, ultimately, our systems will have to be reformed in order to meet not only the needs, but also the aspirations of all Sri Lankans.

One possible solution would be the creation of a voucher system through which the Government can ensure those in need are given free treatment at private health care facilities, allowing citizens to get the best possible treatment, while saving the Government the expense of actually constructing and operating a fully-fledged hospital.

Instead, the public sector can look to invest in vital allied services like drug assurance laboratories, or set up joint ventures along those lines in order to aggressively test all products coming in to the country thereby ensuring that our citizens are guaranteed medication of a high quality standard. I think the key point from this is that we need to update our ideas on the role of the public and private sectors in the healthcare sector so that we measure success in terms of simply the amount spent of brick and mortar infrastructure given the vast untapped capacity in the private sector.

Q: Has there been any recent policy progress with regard to the establishment of such quality assurance labs?

A: The NMRA has clarified that a plan for the establishment of quality assurance laboratories is currently being developed however we would like to have some more clarity on the scheme and its scalability. This is a crucial area for ensuring that our citizens are provided with drugs of an appropriate quality standard therefore, stakeholder consultation can only help to ensuring a positive outcome. The best way forward will be for the establishment of PPPs whereby the private sector is tasked with making investments in infrastructure and capacity under stringent oversight from an impartial and empowered public sector regulator. We are concerned that the Government may not wish to make this transition from actually performing a task, to regulating its performance, but ultimately I think there is a growing recognition that currently, the most important step is to set up a robust regulatory framework

Q: You previously alluded to global changes in the approach to healthcare, what are some of the most important trends that you see specific to the pharmaceutical industry?

A: Over the past decade, there has been a drastic improvement in the overall quality of pharmaceutical product in a manner where the molecules have become more precisely targeted. This has been the result of breakthroughs in research and innovation that took place over the past 2-3 decades to the point that we have covered quite a broad spectrum of conditions and there are only a few conditions that we still haven’t been able to develop some form of treatment. In today’s context, we are now seeing more selective innovation and targeting.

The idea of a ‘one-size-fits-all’ medication is giving way to the understanding that any given medication will vary in its efficacy depending on the personal traits and medical history of each patient. Over a large group therefore, one molecule may work for 80% of the population, but for a small but significant group, it wouldn’t have the same efficacy. The advancements that are now being made are mainly to address these types of challenges.

Q: What are some of the key concerns for the SCLPI moving forward?

For our part, the SLCPI will continue to engage with the Ministry of Health, the NMRA and all related regulatory authorities to help set policies that are efficacious for all stakeholders. We have been working with these stakeholders to review existing data and we continue to ask for evidence for the positive benefits of price control to the sustainability of the overall healthcare system. Our goal moving forward is merely to ensure that we take a more systematic approach to policy and that we understand that there is no one silver bullet to fix all of the challenges we face. So we must be organized and systemic in our reforms.