By Shashika Bandara and Inosha Alwis
Sri Lanka is facing a severe political and economic crisis, and the health system is at risk of collapse. The crisis has been caused by years of economic mismanagement, an abrupt ban on agrochemicals in April 2021 causing a steep drop in agricultural output, and the covid-19 induced decline of the tourism industry.In early April 2022, Sri Lanka declared itself insolvent and unable to service its overseas debt.
Interconnected challenges, including a severe shortage of essential medicines, a worsening socioeconomic landscape, and human rights violations, remain substantial threats to health in Sri Lanka. Understanding and addressing Sri Lanka’s health crisis is an urgent priority, both for its population and for other low- and middle-income countries facing similar challenges.
During the first quarter of 2022, lengthy power cuts and medicines shortages undermined the provision of effective healthcare across the country. Efforts to resolve these problems have fallen far short of requirements, and over 150 essential drugs remained out of stock as of November. Additionally, essential surgical consumables and laboratory items are in short supply, affecting medical, surgical, and diagnostic capacities in all hospitals.
Sri Lanka’s health system, traditionally free at the point of care, has been recognised as both low cost and high impact. But increasing out-of-pocket expenditure and health related inflation of nearly 40% are threatening this legacy.8 Uncertain power and fuel supplies continue to compound these challenges, interrupting not only service delivery but also disease surveillance and medical supply chains.
A steep rise in poverty and unemployment in Sri Lanka has harmed population health and reduced access to care. Social determinants of health such as education, food, and income continue to be adversely affected, and people on the lowest incomes such as plantation sector workers have been hardest hit. Public health measures to prevent the spread of infectious diseases such as covid-19 have had to contend with overcrowding on public transport because of fuel shortages.
Nearly six million Sri Lankans—three in every 10 households—are food insecure and face an 80% inflation rate for food. Poor diets and missed meals increase the risk of non-communicable diseases through conditions such as hypertension and dyslipidemia. The government has recognized food shortages as a key priority in its strategic plans.
Unicef estimates that over two million children in Sri Lanka require humanitarian assistance. Depression and deaths by suicide are direct consequences of the crisis, and the mental health of children and young adults is deteriorating. Prevailing human rights conditions that deny freedom of assembly and association also have a big effect on public health. Specifically, citizen protests that highlight shortages of food, medicine, and other essentials continue to face violent crackdowns by the state despite warnings from human rights organizations.
Healthcare workers are personally affected by the economic and health crises facing all Sri Lankans. But they also face serious challenges at work were severe shortages of power, medicines, and vital equipment put them under immense pressure. Consequently, burnout is common and the emigration of healthcare workers has increased. The government facilitates this migration with the short-term expectation of earning foreign currency, which is likely to further weaken the health system.
Policy imperatives
Sri Lanka’s leaders need to improve their policy on health system strengthening in both the short term and the long term. One of the most immediate concerns is a shortage of essential medicines: the current donation-based stopgap solutions are not sustainable.5 The government must support initiatives to increase local production of pharmaceuticals, improve national information systems to include real-time tracking of drug shortages, and establish mechanisms to stabilize power and fuel supply to essential healthcare facilities, including hospitals. It must also urgently rethink its current budgetary policy, including the budget for 2023, which continues to prioritize defense spending ($1.1bn; £900m; €1bn) over other sectors such as health ($880m).
Additionally, the government must make comprehensive, sustainable plans to request and use international development assistance for health, targeted toward restoring the supply of essential medicines, supporting healthcare workers, and improving the delivery of services
In the longer term, Sri Lanka’s current crisis is an opportunity for the government to prioritize strengthening the health system in critical areas such as primary care, to move mental health up the national agenda, and to improve social support for poor and marginalized women and children.
(Originally published on BMJ 2022;379:e073475)