HEALTH TRANSITION AND ECONOMIC GROWTH IN SRI LANKA LESSONS OF THE PAST AND EMERGING ISSUES

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1 HEALTH TRANSITION AND ECONOMIC GROWTH IN SRI LANKA LESSONS OF THE PAST AND EMERGING ISSUES Dr. Godfrey Gunatilleke, Sri Lanka

2 How the Presentation is Organized An Overview of the Health Transition in Sri Lanka. The Special Features of the Transition How the Transition is Achieved -The Links between Health, Productivity,Poverty Reduction and Economic Growth The Residual Problems of the Transition. The Emerging Challenges for Economic Growth and Health. The Role and contribution of the NGOs in Managing the Health Transition

3 Overview of the Health Transition in Sri Lanka. A Snap Shot of the Transition Selected Health related Indicators Changing Disease Profile

4 Health Indicators in Sri Lanka Life Expectancy Infant Mortality Maternal Mortality per live birth Crude Birth Rate Total Fertility Rate

5 Health Indicators Figures Life Expectancy Infant Mortality Maternal Mortality per live birth Crude Birth Rate Total Fertility Rate Year

6 Disease and ICD Code Intestinal infectious diseases Tuberculosis Viral hepatitis Malaria Helminthiasis Diabetes mellitus Nutritional deficiencies Anaemias Hypertensive disease Ischaemic heart disease Asthma Diseases of the liver Cases per 100,000 Population Deaths per 100,000 Population

7 1975 Cases per Population 10% 1% 2% 27% 3% 12% 3% 6% 3% 3% 7% 23% 27% 8% 1999 Cases per 100,000 population 12% 3% 3% 1% 6% 26% 0% 11% 2% 1% Intestinal infections diseases (A00-A09) Tuberculosis (A15-A19) Viral hepatitis (B15-B19) Malaria (B50-B54) Helminthiasis (B76,B77,B79,B80) Diabetes mellitus (E10-E14) Nutritional deficiencies (E40-E46,E50-E56) Anaemias (D50-D64) Hypertensive disease ( ) Ischaemic heart disease ( ) Asthma (J45) Diseases of the liver (K70-K76)

8 1975 Deaths per 100,000 Population 1999 Deaths per Population 8% 10% 2% 5% 26% 28% 3% 6% 0% 1% 0% 7% 0% 2% 6% Intestinal infections diseases (A00-A09) Tuberculosis (A15-A19) Viral hepatitis (B15-B19) Malaria (B50-B54) Helminthiasis (B76,B77,B79,B80) Diabetes mellitus (E10-E14) 13% 14% 6% 11% 2% 1% 2% 11% 36% Nutritional deficiencies (E40-E46,E50-E56) Anaemias (D50-D64) Hypertensive disease ( ) Ischaemic heart disease ( ) Asthma (J45) Diseases of the liver (K70-K76)

9 The Special Features of the Transition The Transition takes place within a narrow range of GDP growth and low income - Table and Diagram The total cost of health care is maintained at around 3% of GDP (Problems of estimating private health expenditure) The major share of costs of health care (over 60% initially) is borne by the state through a free health care system accessible to for all.

10 Economic Indicators GDB in current prices Rs. 4,224 25, ,900 1, Per Capita GDP in current prices Rs ,903 36,545 64,885 Per Capita in GDP US$ at current exchange rates

11 GDP & GDP Per Capita at 1970 Constant Prices Year Average Annual Growth Rate GDP GDP Per Capita

12 How did we Achieve the Health transition? The Main Elements of the Strategy that Produced the Health Transition The state and public health initiatives play the major role Priority is given to - The control of major parasitic and infectious diseases Maternal and and child health The health transition becomes an integral part of broad social and economic changes.

13 Other Socio-Economic Indicators Literacy Male Female Total Poverty (rural) Head count Unemployment Child Malnutrition under 5 yrs Low Birth Weight Living Conditions Water Protected sources Sanitation Households with toilets 85 93

14 Free education improves Status of Women Knowledge of health care Reproductive health Food Subsidy Supports households with nutritional supplement. Reduces ill health caused by malnutrition

15 Agricultural growth is closely linked to poverty reduction through - Distribution of state land for small scale rice production and housing of the poor. Settlement of landless poor on newly developed agricultural schemes. State Research and Extension services for increase of productivity in small scale rice farming. Promotion of small scale fisheries.

16 The Ideology of Health and Policy Commitments to Health are strongly supportive of the transition The traditional value system and the indigenous system of health care already provided an ethical and social base for assuming public responsibility for the health of the people. Of all gains, the gain of health is the highest and best a saying of the Buddha Early recognition and priority was given by Sri Lankan policy makers to health as the foundation of human capital and an essential pre-condition of development. An excerpt from the report of the IBRD mission in 1951 on the economic development of Sri Lanka. In the calculation of a country s resources for economic development, health is a primary factor.. Economic improvement will be illusory if the health of the people is not improved Although death rates (in Sri Lanka have fallen ) it remains obvious that there is a great deal of sickness in Ceylon and that the country continues to suffer a grave loss from consequent improvement of productivity.

17 Links between Health and Growth The early phase of development in Sri Lanka is therefore a striking example of the indivisible link between health poverty reduction -productivity and economic growth. Productivity and output had to be increased in a sector of the economy which was most backward and where poverty, disease and illiteracy was highest. The control of disease, protection of health, education and food security became essential for achieving the development goals. The control of malaria and the improvement of the health infrastructure and a healthy agricultural workforce was crucial to the success of the agricultural programme. Growth was highest in the Poorest Segments of the Economy peasant agriculture, fisheries. ( ). Diagram.

18 Sri Lanka Poverty Assessment % of total one month pre-tax income received by each ten percent of ranked spending units, 1953 to 1996/97 Decile / /97 Lowest nd rd th th th th th th Highest

19 Sri Lanka Poverty Assessment % of total one month pre-tax income received by each ten percent of ranked spending units, ( /97) Deciles / /97 Year Highest 9th 8th 7th 6th 5th 4th 3rd 2nd Lowest

20 The Residual Problems Accompanying the Health Transition. The Persistence of Poverty Child and Maternal Malnutrition remains high in the context of reduction of mortality and prolongation of life Relatively High rate of Neo-natal mortality Regional inequality High Survival and Life Expectancy without Corresponding Rise in the Quality of life Chronic Ill health Coexists with Poverty.

21 Other Characteristics of the Health Transition The burden of dependency is progressively shifting from the childhood to old age Age specific morbidity and mortality reflect a similar pattern. The nuclear family progressively replaces the extended family Participation of women in the workforce imposes a double burden of work and household care on women. The Costs of Health Care rises steadily (Table and Diagram)

22 Household Income & Expenditure Survey Survey period Description /96 90/91 85/86 80/81 Expenditure (per month per household) Food and drink Personal care and health Food Ratio (percentage) CCPI (average for the survey period) Mean household income real Median household income real Exchange rate Rs. per US$ Mean household income in US$

23 Description Survey period /96 90/91 85/86 80/81 Expenditure (per month per household Rs) Personal care and health( per Month per household Rs) Personal care and health(% of Expenditure) Real expenditure on personal care and health

24 The Health Care System has been successful in taking the population through the first phase of the transition at a cost which by international standards is unusually low. The system during the health transition was essentially designed for the control of infectious and parasitic diseases and child and maternal health. It is not fully equipped to deal with the health care needs of the emerging disease pattern across income groups as it was able to do in the past The Emerging Disease profile of chronic illnesses requires major adjustments in health care at the national and household level The changing Roles of Patient and physician - the need for more health knowledge and self care Medical institution and home - management of disease at household level Medication and health behaviour - the crucial importance of lifestyles, diet, exercise Control and cure - the vital role of recognition of early symptoms and early diagnosis

25 The Emerging Challenges for Economic growth and Health. If, the estimated 3% of GDP (approximately US$ 30 per capita) on health care remains constant the real expenditure on health will grow at the rate of GDP growth,-in the case of Sri Lanka approximately 4% to 5%. Per capita expenditures will grow by about 2.5% to 3.5%. In 2020 the per capita expenditure will be in the range of US$ 48 to US$ 60 Is this adequate? The current expenditures are not adequate to deal with the residual problems of the transition The pattern of costs in health care is changing dramatically The proportion of costs on child and maternal healthcare has fallen The adolescent and economically productive population will grow at a rate faster than that of the total population The aging population beyond the productive life span will double by The rate of economic growth, investment and household savings has to keep pace with the transition to strengthen the health care system to meet the needs of all these age groups. Meeting the needs of all the age groups is also essential for maintaining the intergenerational bonds that in turn become necessary for sustained growth

26 Economic Growth and the Rising Cost of Health Care Health Expenditure Government Private Current levels of Expenditure Percentage of GDP Output of health care services based on the number of hospital admissions and outdoor patients in the two sectors[1] : 70% 30% Per capita expenditure on health annual in Rs In US dollars [1] Expenditures are adjusted for private expenditure on drugs in respect of treatment received in the government sector.

27 Available resources Total per capita expenditure in US Dollars 30 With GDP growth at 4% per capita health expenditure in 2020 in US$ 48 With GDP growth at 5% per capita health expenditure in US$ in Demand for Heath Care Population increase at 1.5% per capita expenditure should be 40 Unmet current needs of the system 25% 7.5 The increase in the disease burden of the old population 28 Total 75.5 Either GDP must increase by 1% or the health allocation should increase by at least 1% of GDP.

28 In the case of Sri Lanka the existing health care system has high potential for containing costs of the next phase of the health transition. To realize this potential,the best features of the present system, its accessibility, its capacity to service the poor would have to be retained. The state health care system needs to be restructured and strengthened to satisfy the unmet and new needs arising out of the health transition, particularly of the poor households in the health transition The private sector in health services should grow in the context of a strengthened national health care system.

29 The Role of the NGO s The Contribution of the NGOs in the first phase Women s Associations, Sarvodaya, other community based organizations Making the delivery of health care more cost effective Health Education and Public Awareness, Humanitarian Support for Patients of specific Diseases Maternal and Child Health The contribution in the second phase Greater study research and advocacy on the public issues of health care in Sri Lanka- Budgetary allocation for health, the national health care system and privatization;. Monitoring equity in health, regional inequality Focus on the health of the workforce issues of productivity and health ; occupational health. Disease specific activities and support to improve cost efficiency of health care of the aging population specially in regard to non-communicable diseases health education, clinics for diagnostic services; household support.

30 THANK YOU

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