The Institute of Policy Studies of Sri Lanka (IPS) together with the Sri Lanka Medical Association (SLMA) and Centre for Policy Impact in Global Health (CPIGH) of the Duke University, USA, organised a virtual policy dialogue on ‘Planning for Universal Health Coverage (UHC) amidst the 4Ds of Health Transitions’, on August 25, 2021. 

The dialogue was structured around a recent IPS study aimed at understanding how government, donors and key country stakeholders in the health sector perceive these transition challenges and their impact on the progress towards UHC, where they see the biggest gaps emerging and what actions can help to address these challenges and gaps. 

Health sector experts, who spoke at the dialogue, flagged the need for multi-sectoral collaboration to achieve UHC in Sri Lanka.

Commencing the discussion, IPS Director Research Dr. Nisha Arunatilake explained that there are four major, inter-linked transitions in diseases, demography, development assistance for health and domestic health financing – the ‘4Ds’ of global health transition – that complicate Sri Lanka’s efforts to achieve UHC. The associated challenges of these have been worsened by the COVID-19 pandemic. In this context, the IPS and Duke University have conducted research that brings into focus the importance of achieving UHC and the Sustainable Development Goals (SDGs).

Speaking next, SLMA President Dr. Padma Gunaratne reflected on some of the achievements of the national health system, including increased life expectancy and quality of healthcare. She noted that while these achievements are commendable, inequities and inefficiencies in healthcare continue to persist and a meaningful dialogue on planning for UHC is most timely. 

Delivering the keynote address thereafter, Health Ministry Deputy Director General Planning Dr. S. Sridharan pointed out that donor support for the health sector is declining. Meanwhile, there is rising demand for health services, an ageing population and inadequate domestic financing for health. 

He recommended seven steps to address the challenges: (1) strengthening community-response systems, (2) supporting reproductive health – adolescence, maternity and newborn health, (3) supporting platforms for integrated service delivery, (4) strengthening country population and supply chain, (5) investing in human resources (HR) for health and data systems for health, (6) strengthening and aligning national and global strategies and (7) strengthening financial management and oversight. The next speaker, Duke University Policy Associate Ipchita Bharali provided the audience with evidence on health transitions in an international context. She stated that many middle-income countries (MICs) are expected to transition away from concessional multilateral and bilateral development assistance soon. However, they still face several health sector challenges such as high mortality rates, weak health systems and large pockets of poverty in the countries. These challenges are intensified with the onset of the COVID-19 pandemic. 

Session 1: Knowledge, capacity and policy gaps that hinder UHC progress in Sri Lanka in the context of the 4Ds of health transitions and potential opportunities to tackle these gaps.  

Knowledge gaps and opportunities
IPS Research Economist Ashani Abayasekara presented a summary of the study findings identifying the knowledge gaps. One of the findings highlighted was the rising burden of NCDs, as there was an acute focus on curing such illnesses by only considering drugs as the solution and understanding them as disease issues and not health issues. Prominence was also given to the gender disparities regarding NCDs. Lack of detailed and accurate data, poor research and development (R&D) and knowledge dissemination were some of the many gaps that were further identified as areas that needed immediate action.

Health Ministry Deputy Director General Public Health Services II Dr. Susie Perera in her reflections explained that one of the ways of alleviating the gaps is by targeted investments and incentivising stakeholders to conduct proper R&D, data collection and knowledge dissemination. She noted that Sri Lanka has had many opportunities to strengthen its primary health and education systems with donor support, both of which are relevant to reducing the NCD burden.

“A whole of government, multi-sector approach is needed,” she emphasised adding that digital literacy needs to be fostered in the health sector, along with a culture of innovation.

University of Colombo Professor in Economics Prof. Amala De Silva shared similar sentiments and noted that NCDs have an indirect relationship with economic performance. She flagged the need for multidisciplinary studies and proper accountable agency in research activities to achieve UHC in Sri Lanka.

Capacity gaps and opportunities
IPS Research Assistant Thisali de Silva presented the findings of the study on the capacity gaps that hinder UHC in the country. Poor financial and HR capacity was found to be the notable gaps in Sri Lanka. Some of the financial capacity gaps included inefficiencies in financial allocation and financial management issues to name but two. On the other hand, the lopsided distribution of medical professionals and the lack of engagement in the financial side of the health sector have made for concerning capacity gaps in labour. 

First to give thoughts on the study was Health Ministry Human Resource Department Head Dr. Dileep de Silva. On the HR front, he explained that the issue in the lopsided distribution of medical professionals was due to the low applicants especially when looking at nurses, therapists, midwives and PHIs. Furthermore, one of the major reasons for the financial capacity gaps is a result of the underutilisation of capital budgets for the health sector. 

Sir John Kotelawala Defence University Senior Lecturer in Community Medicine Dr. Anuji Gamage identified healthcare migration as a problem driven by economic factors, unsatisfactory work environment and professional career opportunities. She stated that a way of solving the uneven distribution of labour is a mechanism that would assure safety and this is particularly important in a time of a global pandemic. “It is important to use strategies to keep the workforce safe and improve their well-being,” she affirmed. 

Policy gaps and opportunities
The frequent changes made to the number of ministries, reversal of implemented policies and several other implementation hurdles, especially at the provincial level were shown to be some of the major policy gaps identified through the study. Ashani Abayasekara highlighted several opportunities to focus amid all these gaps such as creating a knowledge hub and collaboration and coordination with non-state sectors.
SLMA Past President Dr. Ruvaiz Haniffa in his reflections, called for a grassroots level approach through family doctors and homecare. 

“Too many people are currently missing out on health coverage in the primary preventive care sector. We have not put in policies in the primary curative sector,” he said stressing that the need of the hour is to provide holistic primary curative care. 

Finance Commission Past Chairman Uditha Palihakkara, speaking in his personal capacity, expressed the view that the policy gaps are a result of low national budgets to the health sector as a whole.
Session 2: Multi-sectoral collaboration for Sri Lanka’s health systems – reflections from development partners, private sector, academia and civil society.

Based on the study, World Bank Senior Health Specialist Dr. Deepika Attygalle and National Planning Department Additional Director General Shiranthi Rathnayake asserted that multi-sectoral collaboration is vital for Sri Lanka’s goal of achieving UHC of which, collaboration between the finance and medical sectors is particularly important. 
World Health Organisation Public Health Administrator Dr. Olivia Nieveras spoke about how donors should be more agile in their activities. External Resources Department Additional Director General Sampath Manthreenayake added that there should be a collective system for better results on donor financing.

Way forward
Moderated by Dr. Nisha Arunatilake, a fruitful question and answer session took place with several important questions raised from participants around the world. The proceedings were wrapped up with an iteration on the need for a strong primary curative healthcare system and multi-sectoral collaborations as the 
way forward.