PRIMARY HEALTH CARE 

. . safe water and sewage disposal.. 

. . mother and child care . . 

information on health problems . . 

.. proper nutrition and good food .. 

.. adequate housing . . 

. . immunization . . 

. . treatment for injuries. 

/ 

MEDICAL CARE 
AND 
PUBLIC HEALTH 

It has often been said that the 
mortality rate and the life expec­
tancy in a country would be some 
of the most revealing indicators of 
its socio-economic development. An 
increase in life expectancy would 
reflect a host of contributory factors 
such ns adequate housing and sani­
tation, adequate nutrition, an in­
crease in real incomes and an equit­
able access to resources such as 
food and health care facilities. Tn 
some exceptional cases, however, 
an increase in life expectancy hr..y 
beon made possible by advance s in 
medical science and le*s by general 
improvements in living conditions. 

In BA Lanka in 1945 for instance 
the infant mortality rcte W£,s 140 
per 1,000 live births while the crude 
cloath rate was 21.5 per 1,000. By 
1977 these had.fallonto 42 per 1,000 
and 7.4 respectively. This decline 
was reflected in a rise in life expe-
tancy from 42 years in 1964 to 65 
yoars in 1972. 

Compared with other Asian coun­
tries Sri Lanka's achievements in 
this regard are quite mpressive as 
the table below shows: 

Death Rate and Life Expectancy in 
Some Asian Countries 

Death Life 
Rate Expec­
per tancy at 

Country 1,000 Birth 
Bangladesh 18 53 
India IS SI 
Nepal 22 43 
Pakistan 16 54 
Indonesia 18 48 
Rep. of Korea . . 9 64 
Malaysia 10 60 
Philippines 11 59 
Singapore 5 70 
Thailand 11 62 
Sri Lanka 8 65 

Moreover, in Bri Linka, diseases 
which affected the population ad­
versely such as small-ptx, typhoid 
and cholera had almost been era­
dicated. 

Si-i Lanka has also a wj l distri-
butod variety of health care insti­
tutions. A western mecical facility 

3 



is available within 3 miles of an 
average house while an ayurvedic or 
indigenous facility is accessible with­
in 0.8 miles. Among the western 
medical facilities, they consist of a 
curative set up of 2 University 
specialist hospitals, 10 provincial 
hospitals, 18 base hospitals, 110 
district hospitals, 108 peripheral 
Units, 87 rural and 27 maternity 
homes. It has a preventive public 
health system of 102 medical offi­
cers of health units and 1200 cli­
nical outlets. 

Existing side by side with western 
medicine is the practice of an indi­
genous system of medicine. It has 
had a long tradition in the country 
and its origins can be traced over 
a long period of time. Though it 
was neglected during the nineteenth 
century during the British colonial 
period it now plays an important 
role in the health care services in 
the country. 

The main difference between the 
indigenous system of medicine and 
western medicine is that indigenous 
medicine attaches greater impor­
tance to the constitution of the 
patient as against western medicine 
which attaches greater importance 

' to the nature of the disease. 

There are three main systems of 
indigenous medicine. Ayurveda 
is based mainly on the treatment of 
illness through decoctions of differ­
ent herbs, Unarti is based on treat­
ment by different oils while Siddha 
is based mainly on treatment with 
metals such as mercury. AH these 
three systems are of Den described 
Under the term ayurveda. 

The total number of registered 
ayurvedic practioners has been esti­
mated to be nearly 11,000, being 
more than three times as high as 
the number of western doctors in 
the country. The ayurveda doctor 
population ratio in 1973 was 79.5 
per 100,000 for the island with the 
highest ratio being in the Kalutara 
S.H.S. division. (See Box on pages 
4and5) 

Treatment cf patients by ayur­
veda ' is undertaken by government 
as well as private practitioners. There 
are estimatedto be 12 government 
hospitals with a 1,000 hospital beds 
and 238 ayurvedic dispensaries. On 

4 ECONOMIC REVIEW, JANUARY 1980 



AYURVEDA a I *; "•' " / 
The Traditional System of Medicine 

in Sri Lanka is popularly known as 
Ayurveda which is the term used in 
India for the Traditional System of 
Medicine in that country. The word 
Ayurveda in legal terms in Sri Lanka 
includes the Ayurveda, Siddha and Unani 
systems of medicine. It also includes the 
indigenous system of medicine known 
as "Deshiya Chikitsa". Ayurveda which 
means science of life is expected to pro­
mote physical, mental and spiritual 
health of the individual and the com­
munity, to prevent disease, to treat and 
cure it when it occurs. Ayurveda not 
only deals with human beings, it also 
deals with animals or veterinary science 
(Sathva Ayurveda) and plants (Vruksha 
Ayurveda). It is based on sound scientific 
data and principles which are clearly 
described in ancient"literature. 

Writing about Ayurveda Dr. B. Thiru-
malara, FRCS, Edinburg, DLO London; 
Surgeon, King George Hospital has 
stated that "there is still a great deal to 
learn from the ancient systems of medi­
cine. They have got an extensive pharma­
copoeia. They have developed dietetics 
almost to a fine art. We may have yet to 
learn from the observations of the 
ancient physicians, their decisions and 
the principles they have laid down and 
the methods they adopted for treat­
ment". 

It is remarkable that the earliest refer­
ences to, medicine are associated with 
Ravana, a King of Sri Lanka dating back 
to prehistoric times, who was himself 
a great physician. A researcher may 
dismiss this reference as more legend 
but it is not impossible that there is at 
least a nucleus of truth bekiud the legend. 

History records that Ayurveda was u 
very developed system of medicine in 
Sri Lanka. King Pandukabhaya in the 
4th century B.C. founded a hospital to 
the north of the walled city of Anura-
dhapura; he was also renowned for 
public health measures he had intro­
duced in the ancient capital city of 
Anuradhapura. At Mihintala, near the 
ancient capital of Sri Lanka, one can see 
the ruins of a hospital, said to have been 
constructed in the 3rd century B.C. The 
medicine boats turned out of stone and 
used for medicinal oil baths are still in a 
fine state of preservation. 

A number of cave inscriptions of the 
3rd century B.C. mention several physi­
cians by name. The Piccandiyava Cave 
Inscription in the Puttalam District speaks 
of a Brahmin named GOBHUTI as the 
physician and teacher of the great king 
Devanampiya Tissa. The Rajangane 
Cave inscription speaks of a Vejja 
(physician) named Mitta. The Gonagala 
Cave inscription in Hambantota District 
refers to a physician named Tissa. 

King Dutthagamani who was in 
power in the 2nd century B.C. had been 
a great benefactor of the sick and had 
bestowed on them their food and medi­
caments as ordered by the physicians. 

History also records names of several 
kings who were great physicians them­
selves, the chief among them being King 
Buddhadasa who reigned in the 4th 
century A.D. He was a great medical 
practitioner and a Skilled surgeon. The 
chronicle speaks of several feats of sur­
gery he has successfully performed not 
only on human beings but even on 
animals. He had set up medical halls for 
the sick and placed physicians in them. 
He had also appointed a physician to be 
in charge of every .five villages and by 
way of remuneration given them the 
produce of ten fields. Physicians also 
had been appointed for elephants, horses 
and soldiers. Hospitals had been put up 
for the treatment of the crippled and the 
blind. Above all he had made a summary 
of the essential content of all the medical 
text books. 

The Culavamsa refers King Parakrama-
bahu I as a King well versed in Ayubbeda 
(Sinhala equivalent for Sanskrit Ayur­
veda) who could test the physicians in 
their healing activities and point out to 
them the proper use of the instrument. 
Not only did he build hospitals, he also 
visited them regularly. Apart from the 
physicians, he appointed male and 
female attendants to these hospitals. 
This king is referred to as an expert 
physician, who coujd distinguish be­
tween the curable and incurable by the 
methods described by the rules of'the 
order. 

The evidence in recorded history 
throws light on the practice of tradi­
tional medicine in Sri Lanka from its 
small beginnings which individual physi­
cians gradually expanded over the years 
into an organised system, under royal 
patronage till it constituted a network 
of institutions and establishments to 
render patient care services to the people. 

There is also evidence that Ayurveda 
had been included in the curriculum of 
practically all the principal seats of 
learning in the past. The extent to which 
the education in medicine had been popu­
lar is seen from the number of treatises 
on medicine produced in ancient times. 

The tributes paid to the practice of 
indigenous medicine in Sri Lanka by the 
Western writer Robert Knox from what 
he had witnessed here is an indication 
that the practice of traditional medicine 
moved on uninterrupted even after the 
advent of the Portuguese and the Dutch. 
It appears that it had received a set-back 
after the coming of the British, perhaps 
because of their enthusiasm to achieve 
quick results by implanting their own 
systems in this country. 

However, owing to the vicissitudes of 
history and periods of foreign domi­
nation, these valuable traditional systems 
of medicine, have perished and been neg­
lected to a large extent. Yet some of 
these traditions have been passed down 
from generation to generation, from 
father to son and are still popularly 
practised in Sri Lanka. Besides the. 
Ayurveda introduced from India, there 

4 ECONOMIC REVIEW, JANUARY 1980 



is, in Sri Lanka a more ancient system 
called "Deshiya Chikitsa" which is 
indigenous to Sri Lanka. There are still 
well known traditional physicians who 
are reputed in the treatment in special 
branches such as Eye diseases, Fractures 
and Dislocations, Snake bites, Burns 
and Ulcers, Hydrophobia etc. "Deshiya 
Chikitsa" has not been recorded and 
published but has been handed down by 
tradition. Action has now been taken 
for the compilation of these valuable 
prescriptions. 

Most of the traditional physicians do 
not have the benefit of a written educa­
tion in this system of medicine, but have 
learnt it after long periods of apprentice­
ship at the feet of Master Physicians. 

The Ayurveda system of medicine uses 
plant, mineral and animal materials for 
the preparation of drugs. In ancient 
times the supply of herbs required for the 
Ayurveda Institutions had been met by 
assigning to each hospital, gardens and 
lands where they were grown as indi­
cated in several inscriptions. Medicinal 
forests found in several parts of Sri 
Lanka are ample testimony to organised 
cultivation of medicinal plants in the past. 

The traditional physicians used to pre­
pare their own drugs in their home 
pharmacies in the past, but with the 
commercial production of drugs, they 
too now tend to buy their drugs from 
commercial manufacturers. The Ayur­
veda Act No. 31 of 1961, has made 
provision for registration of commercial 
manufacturers of drugs and the pharma­
cies of these manufacturers are licenced 
annually by the Commissioner of Ayur­
veda. 

The revival of Ayurveda became an 
issue in the agitation for Independence 
from the British rulers. 

Organised teaching of Ayurveda was 
started in 1929 with the establishment 
of the Svadesiya Vaidya Vidyalaya 
(College of Indigenous Medicine). This 
College became a government institution 
in 1941. In 1929 another seat of ayur­
vedic studies, the Gampaha Siddha 
Ayurveda College was started with a 
sense of dedication by the late Ayurveda 
Chakrawarlhy Pandit G. P. Wickrama-
arachchi out of his own funds. His repu­
tation as an eminent physician was such 
that "Gampaha treatment" almost came 
to be identified as something apart from 
the Ayurveda system. 

The practice of traditional medicine 
in Sri Lanka today can be broadly 
grouped under two types, viz. "Ayur­
vedic Medicine" and- "Indigenous Medi­
cine" (Deshiya Chikitsa). 

Ayurvedic medicine is practised in the 
form of all its components, Ayurveda, 
Siddha and Unani. In Ayurveda the 
therapeutic agents for curing disease 
are mostly herbal preparations, while in 
the Siddha system they are predomi­
nantly mineral preparations. The Unani 
system differs from the other two in its 
fundamental concepts. These three 
systems are identical with what appears 

under the same names in India. It is 
historically evident that Ayurveda and 
Siddha systems came here from India 
along with several waves of culture that 
passed over Sri Lanka from India. The 
Unani system has left its imprint here 
through the Arabs who came for pur­
poses of trade. What is designated as 
"Indigenous Medicine', (Deshiya Chi­
kitsa) originated in Sri Lanka, probably 
during prehistoric times and developed 
on its own lines. It is practised mainly as 
a traditional process, knowledge being 
handed down from father to son, often 
being jealously guarded as a special 
preserve of the family. For the same 
reason there is a high degree of speciali­
sation in certain fields such as Ophthal­
mology, Hydrophobia, Fractures etc. 

The special fields of specialisation in 
Indigenous Medicine which we may 
conveniently refer to as "Paramparika" 
treatment, may be enumerated as follows: 

1. As Vedakama (Opthalmology) 
2. Gedi Vana Vedakama (treatment 

of boils and carbuncles) 
3. Sarpavisa (Snake poison) 
4. Pissubalu Vedakama 

(Hydrophobia) 
5. Vidum Pilissum (a system similar 

to Acupuncture) 
6. Kadum Bindum (treatment of 

fractures) 
7. Pilissum (treatment for burns) 
In this treatment magico-ritual per­

formances like Bali (offering of oblations), 
lime-cutting, Santi (appeasement) are also 
used, particularly for treatment of mental 
afflictions. 

The Ayurveda system of medicine had 
received official and legal recognition 
nearly fifty years ago. The Ayurveda 
Act No. 31 of 1961 replaced the previous 
legislation and made provision for regis­
tration of Ayurveda physicians, nurses 
and pharmacists. It also provided for 
establishment of an Ayurveda Medical 
Council, an Education of Hospital 
Board, an Ayurvedic Research Com­
mittee and a separate department to 
handle matters pertaining to the subject 
of Ayurveda. 

The Government College of Ayurveda 
which has now been made the .Institute 
of Ayurveda of the University of Ceylon 
is the main training Institute imparting 
knowledge of Traditional Medicine. 
Admission to the Institute is at the 
level of General Certificate of Education 
(Advanced Level) and a student has to 
follow the course for five years. On 
completion of the five years, he has to 
undergo an internship of one year in an 
Ayurvedic Hospital, before he could be 
registered with-the Ayurvedic Medical 
Council. 

The Siddha Ayurvedic College, Gam­
paha, a College of Traditional Medicine 
also trains students to become Ayur­
vedic Physicians and has received official 
recognition of the Ayurvedic Medical 
Council. The period of training in this 
College too is five years. There are few 

other Colleges which train students to 
become Ayurvedic Physicians and the 
period of such training varies from three 
to five years. These Colleges have not 
been recognized yet by the Ayurvedic 
Medical Council. Master Physicians 
well-versed in "Deshiya Chikitsa" also 
train their children or faithful pupils for 
long periods. Since the "Deshiya Chi­
kitsa" has not been recorded properly, 
the students have to spend long periods 
of apprenticeship before they could 
become well trained physicians, 
Ayurveda Education and the Hospital 
Board hold examinations for these stu­
dents and grant diplomas to the success­
ful candidates. Those who pass the 
diplomas could get themselves registered 
with the Ayurveda Medical Council as 
Practitioners. Others continue their 
apprenticeships while practising as physi­
cians in their limited field of training and 
experience. There are approximately 
16,000 Ayurvedic Physicians in Sri Lanka 
of whom about 2,300 have been insti­
tutionally trained, and of the balance 
about 7,500 have been registered as 
Physicians by the Ayurvedic Medical 
Council while others are not registered. 

A Research Institute for Ayurvedic 
Research was established at Nawinna 
in 1962. This Institute is responsible for 
Clinical, Literary and Drugs Research 
in Ayurveda. The Department of Ayur­
veda runs, Ayurveda hospitals at 
Colombo, Kurunegala, Ratnapura, 
Anuradhapura, Beliatta and Jaffna. 
These hospitals have a total bed strength 
of 941 while the research hospital at 
Nawinna has 48 beds. They also pro­
vide out-patient services to several 
thousand persons daily. In addition to 
this, out-patient services are provided 
at places where new hospitals are being 
built, namely Kandy (Pallekelle) and 
Diyatalawa. As a Pilot Project, an 
Ayurveda Out-patient Department is 
being run at the Government Hospital 
at Lunawa, where the daily attendance is 
very high and most encouraging. The 
Department of Ayurveda grants financial 
assistance to Local Authorities to main­
tain free Ayurvedic Dispensaries in their 
areas and there are 238 such dispensaries 
receiving financial assistance at present. 

The Sri Lanka Ayurvedic Drugs Cor­
poration meets the major portion of the 
requirements of prepared drugs of the 
hospital managed by the Department of 
Ayurveda and the dispensaries run by 
Local Authorities. 

Approximately 95 percent of the raw 
drugs required for the manufacture of 
Ayurveda drugs is found locally and 
only about 5 percent is imported. 

Since it is the policy of the Government 
to give greater impetus to the develop­
ment of Ayurveda including Siddha and 
Unani systems of medicine to ensure a 
better system of health care to the 
people, a comprehensive plan for its 
expansion is now under active con­
sideration. 

ECONOMIC REVIEW, JANUARY 1980 5 



the average an ayurvedic medical 
facility is found within 0.8 miles of 
a house. 

Sri Lanka also stands better than 
many countries in the region as well 
as among most African countries in 
respect of its ratio of doctors of 
western medicine to population. 
The table below gives these ratios. 

Country Year No. of 
Doctors 
100,000 
popula­

tion 

This gives a ratio (excluding plan­
tations) of approximately 100 for 
100,000 population. 

The maldistribution of doctors is 
indicated in the table below. It 
shows the distribution in each Supe­
rintendent of Health Services divi-' 
sion. 

Sri Lanka . . 1972 25 .7 
India (estimate) 1972 22 .0 
Thailand (estimate) 1973 . 18.7 
Taiwan 1962 47 .6 
Sudan 1962 34 .5 
Senegal 1962 5.0 
Nigeria 1962 2 .0 
Malawi 1965 0 .7 

However, in spite of this impres­
sive performance in Sri Lanka, a 
deeper examination of the health 
care system reveals many hidden 
deficiencies. For instance though 
the national infant mortality rate in 
1971 was 44.8 per 1,000 live births 
and maternal mortality' was 1.4, 
these average figures hide many 
tragedies in remote communities. 
For example in the estate sector in 
1971 the infant mortality rate was 
85 per 1,000 live births and maternal 
mortality was 2.5. Similarly, mor­
bidity figures indicate increases in 
specific illnesses such as malaria, 
venereal disease> filaria and tuber­
culosis in certain specific areas. 

. The distribution of western doc­
tors in the health care institutions 
show a heavy bias in favour of large 
towns while nearly 80% of people 
live in the rural areas. Hjre the 
hospitals are poorly staffed and 
badly equipped. Naturally the 
institutions in the periphery are 
by-passed and patients flock to the 
better equipped provincial hospi­
tals. Tnis has resulted in an over-
Utilisation of the better equipped 
hospitals in the big towns, thereby 
lowering the standards of health 
care in these institutions. The brunt 
of the responsibility of catering to 
the health needs of the rural popu­
lation is borne by the ayurvedic 
physician. It is estimated that out 
of the. 10,000 practitioners over 
90% practise in the rural areas. 

SHS Division 

Ratio 
per 100,000 
population 

(1972) 

Anuradhapura . . 17.4 
Badulla 13.2 
Batticaloa 13.2 
Colombo 52 .7 
Galle 14.4 
Jaffna 28 .7 . 
Kalutara 18.9 
Kandy 2 0 . 1 
Kegalle 9.7 
Kurunegala 13:6 
Matale 10.4 
Matara 10.3 
Puttlam 20.8 
Ratnapura 17.1 
Vavuniya 12.1 

As it indicates Colombo SHS 
division has the highest concen­
tration of doctors with 52.7 per 
100,000 with Jaffna S.H.S. division 
coming second with a doctor popu­
lation, of 28.7. Kegalle has the 
lowest ratio with 9.7. The mal­
distribution is even more evident 
when a comparison of some of these 
figures is made with the. actual 
population figures. For instance 
Colombo S.HS. division with 21% 
of the total population of the island 
has 45% of the practising doctors. 
Moreover, 59% of the specialist 
doctors live and work in the S.H.S-
division of Colombo. While urban 
areas have 25,254 hospital beds 
rural areas with1 nearly 80% of the 
population have only 7,044 beds. 

Staffing 
Staff depletion is regarded as the 

single biggest problem presently ex­
perienced in Sri Lanka's delivery of 
health services. This situation, 
which is felt very much more acutely 
in the rural areas, is a result of a 
shortfall against the cadre require­
ments further vitiated by malcistri-
bution of the available numbers of 
most categories of staff. An official 
proposal from the Department of 
Health has suggested various mea­
sures to meet this problem. The 
official view is as follows: 

"This proposal presupposes a reversal 
of both these trends if successful imple­
mentation is to be achieved. The first will 
hopefully be reversed in the next few years, 
the intake for basic training courses being 
increased considerably in the case of several 
of the relevant staff categories. The need 
will therefore be to reverse the second 
trend, namely maldistribution. 

The following are suggested as possible 
interventions in order to achieve this end. 
(a) Priority needs to be given to appoint­

ment of staff to positions, both existing 
and new, in the development areas. 
Action needs to be taken in the short-
term to fill the existing and proposed 
vacancies and in the long-term, to for­
mulate a scheme whereby all new re­
cruits are required to serve an initial 
period of a few years in the "difficult" 
areas. 

(b) Staff opting to serve in these areas need 
to be given special privileges in the 
choice of a station when transferred 
out of the area after a specified number 
of years, as an incentive for opting. 

(c) Comfortable housing quarters with the 
basic facilities of electricity and water 
service are a sine qua non. 

(d) Staff undertaking field activities need 
to be provided with transport facilities 
to be determined by the area charac­
teristics and services to be performed 
and 

(e) Preference should be given to staff who 
have worked or are working in these 
areas in selections for training courses, 
scholarships, fellowships and pro­
motions". 

Brain Drain 
One of the reasons for the in­

equitable distribution of doctors in 
the island and the malfunctioning 
of the health care system is the 
depletion of trained medical staff, 
particularly of fully qualified dec-
tors, due to migration from rural 
areas to towns or emigration abroad. 
This problem of internal and exter­
nal migration reflects a deeper prob­
lem which is linked to the training 
system of doctors. . 

The Ceylon Medical School was 
the first professional school to be 
set up in the island during British 
colonial rule in 1870. In 1887 tho 
Licentiate which was granted by 
the School was reccgnised by the 
Privy Council in England and the 
school was authorised to confer 
diplomas in surgery and medicine 
and holders of tho School's licence 
were registered in the Colonial 
Medical list. In 1942 the Medical 
School acquired university status 
and granted its own medical degrees 
which continued to be recognised by 

ECONOMIC REVIEW, JANUARY 1980 



the British Medical Council until a 
few years ago. This recognition 
meant that the local degree main­
tained a standard that was accept­
able in the United Kingdom. 

In reality undergraduate training 
programmes in medicine based on 
the British model have been in 
existence in the island for nearly a 
century. These training programmes 
are heavily biassed in favour of 
curative medicine with training in ' 
relatively sophisticated hospitals. In 
B.'i L*nka doctors are trained in two 
teaching hospitals in Colombo and 
Kvndy where until recently "the 
curriculum in medicine was not very 
dissimilar to that which was avail­
able in the United Kingdom for 
British medical undergraduates. This 
training in well-equipped urban hos­
pitals isolated the medical student 
from the environment and condi­
tions in which the majority of 
people live. Consequently a medical 
doctor who is posted to a poor 
rural area found that he was unable 
or ill-equipped to work. His exper­
tise was seldom required to treat 
simple preventive diseases which 
ware predominant among rural 
people. Moreover the poorly 
equipped rural hospitals could not 
provide the technology for such 
doctors to practise their profession. 
Tney often lacked the simple drugs, 
or equipment that the trained doc­
tor required for his curative practice. 
This was often described as a lack 
of 'job satisfaction' by such doctors. 
As a result doctors soon moved 
from the rural areas to the towns 
where conditions were more con­
ducive to the practice of their 
profession. 

Until the Institute of Postgraduate 
Medicine commenced to function 
this year and provide training cour­
ses in subjects relevant to the 
country, postgraduate training in 
medicine was undertaken abroad 
mainly in the United Kingdom. 
(See box on Pages 8and9) 

The preliminary examinations of 
the Rjyal College of Surgeons and 
Pnysicians have been held in the 
island since 1948- However, in 
ordor to obtain full* membership 
these British profassional bodies re­
quired that the graduates be resident 
in the United Kingdom and trained 

Diseases . 1971 1974 1976 
Bacillary dysentry and amoebiosis 147 166 331 
Enteritis and other diarrhoeal diseases . . 4 7 1 2 6524 6 8 1 6 
Infectious hepatitis 75 8 0 8 2 

Total 4 9 3 4 6770 7329 

in hospitals approved by the Gene­
ral Medical Council in the United 
Kingdom. The consequences of 
training Sri Lankan' graduates in 
the United Kingdom was that they 
acquired skills and training relevant 
to a developed country which aliena­
ted them from their own environ­
ment where they had to work and 
in which conditions are so different. 
Training in affluent coitntries meant 
thp,t the students wore trained' in 
skills and specialities relevant to a 
highly affluent society with a pattern 
of disease related to that society, 
such as degenerative diseases, vascu­
lar diseases and cancer, while those 
associated witih a developing country 
arc largely prevontible diseases. 
Moreover, in an affluent country 
the skills taught to students had an 
increasing omphasis and expendi­
ture on technical advances in medi­
cine. 

The acquisition of degrees abroad 
had other consequences as well. It 
provided the doctor with an inter­
nationally recognised qualification. 
One of the reasons that lead to 
doctcis' emigrating abroad was this 
international recognition of local 
medical degrees as well as his 
membership to a professional body 
in- the United Kingdom. During 
the period 1970-1979 it has been 
estimated that 1101 doctors have 
left the government service, the 
greater number have gone abroad, 
averaging a loss of 145 doctors per 
year. Today it is estimated that 
there is a shortago of nearly 800 
doctors in the government sector. 

Another contradiction that exists 
is that inspitu of the availability of 
a variety of health care institutions, 
inspitc of the achievements in health 
attained as depicted by the naticnal 
statistics, ill-health eharactt litis the 
majority of the people. It seems 
that the sophisticated technok gy of 
modern medicine has failtd to en­
sure simple health for the majority 
of the people. This is reflected in 
the charactei of diseases prevalent 
in the. island as shown in the table 
below. 

In 1951 the fcliree loading discuses 
treated in government hospitals were 
respiratory diseases with 46.58 % of 
the total, diarrhoeal diseases with 
20.07 and other infectious disiasts 
with 14.73 % of the total. Tn 1971 
the disease pattern remained similar 
in respect of the first and second 
leading diseases, that is respiratory 
diseases with 64.78% and diarrhoeal 
diseases with 25.99% of the total, 
while,, anaemia and malnutrition 
came third in order of importance 
with 10.64% of the total. Between 
1969-70 the order of the three lead­
ing diseases was respiratory diseases 
with 40.74%. diarrhoeal diseases 
with 22.25% and other infectious 
diseases with 16.95% of the total. 

A recent study has indicated that 
deaths from water-borne disease 
alone have steadily increased in the 
past few years. The types of in­
fections and the number of deaths 
are given in the table above. 

These leading diseases which 
afflict the majoiity of the people are 
diseases of the environment. They 

Number of cases of leading diseases treated at Govt. Hospitals and 
Percentages of total leading diseases in 1951-1970 

Cases % Cases % Cases % 
Diagnosis 1951 1961 1969 : 1970 

Diarrhoeal diseases 81,802 20.07 164,032 25.99 180,232 22 .25 
Tuberculosis 15,598 3.83 12,744 2 .02 12,841 1.58 
Anaemia and malnutrition 25,439 6 .25 67 ,152 10.64 89 ,017 10.98 
Malignancies 4,380 1.08 5,488 . 3 7 12,115 1.49 
Respiratory infections 189,647 46 .58 288,956 45.73 330,124 40 .74 
Diseases of infancy and im­

. 5 8 maturity 13,853 3.40 22,444 3 .56 4,747 . 5 8 
Heart diseases 16 ,515 4 .06 38,911 6 . 1 6 44,000 5.43 
Other infectious diseases . . 59,952 14.73 31,437 4 .98 137,424 16.95 

Total 407,084 100 631,164 100 810,571 100 

ECONOMIC REVIEW, JANUARY 1980 7 



POST-GRADUATE INSTITUTE 
OF MEDICINE 
Post-graduate Medical Education in Sri 

Lanka has since the late 19th century 
been centered around British Medicine. 
Post Graduate students from this coun­
try had to proceed to Britain to spe­
cialize in every discipline of 'Medicine 
including even Tropical Medicine. The 
ambition of every doctor was to obtain 
a Fellowship or Membership of one of 
the Royal Colleges in the U.K. or a 
doctorate from a British University. 
These added diplomas were highly priced 
as they were recognized throughout the 
English. speaking world, the doctors 
being able to obtain appointments in their 
chosen specialities in any country thus 
draining our talent. to other countries. 
It was also a hallmark for appointments 
in the Health. Department and it helped 
to enhance the earning capacity of the 
Doctor in the private sector. 

For the past decade or two the Univer­
sity of Colombo has awarded Doctorates 
and Masterships in Medical disciplines 
but these were few and far between. 
They were not even recognized by the 
Health Department.as full qualification 
in that particular discipline. The train­
ing of the undergraduate in Sri Lanka 
Universities has long been recognized 
and accepted by the developed countries. 
They had from past experience realised 
.that the Sri Lankan doctor was a better 
choice for employment than his counter­
part from other Asian countries and 
consequently employment was easily 
obtained in Britain or the United States. 
The doctor himself sought such appoint­
ments because of the ennanced salaries 
paid to them in the state services or their 
ability to earn much more in the private 
sector. The facilities available to him in 
those countries gave him a great deal of 
work satisfaction. However much they 
may have yearned to come back to their 
own country these considerations out­
weighed any sense of patriotism. It 
appeared from talks with these ex­
patriate doctors that monetary con­
siderations were not the only factor that 
lured them to foreign land. They felt 
that on the salaries paid to them by the 
Health Department they were unable to 
adequately meet the cost of living. • The 
conditions under which they had to 
practise their profession in the hospitals, 
did not give them the job satisfaction 
which most of them desired. 

An unsympathetic administration, poli­
tical meddling in transfers, appointments 
and awards, lack of adequate transport, 
of housing facilities, the difficulty and 
cost of educating their- children, were 
added factors which encouraged the 
exodus. A good percentage of doctors 
who were sent on Government Scholar­
ships, or on pay leave never returned, 
thus upsetting any long-term plan that 
the Health Department had. While in 
the affluent countries to which he was 
sent for training, the doctor realised 
that he had vast untapped earning capa­
cities. On his returning home he would 
have to exist on his salary as he was 

debarred from engaging in private prac­
tice outside his working hours. All these 
factors contributed to the so-called 
'brain drain*. 

The Health Ministry found itself un­
able to give the necessary health care to 
the people of this' country due to the 
drain on this trained manpower. Where­
as a great deal of money was spent by 
the government in producing a doctor 
at no cost to nim, this investment was 
wasted when the doctor decided to leave 
the country. An adequate balance could 
not be maintained between the produc­
tion of doctors and the exit of doctors 
to other countries, retirements and 
deaths. Moreover the availability of 
parts of foreign examinations of the 
Royal Colleges of Surgeons, Physicians 
and Obstetricians and Gynaecologists 
in the country helped the doctor to get 
over some of the hurdles in his quest 
of postgraduate qualifications. 

From time to time the governments 
had to resort to draconian measures to 
restrain the loss of its medical talent to 
otner countries. One of these was the 
introduction of the Compulsory Services 
Act and the other the non-issue of pass­
ports to doctors by the previous Govern­
ment. These though they may have had 
an impact at first were gradually re­
sented by the doctors and again political 
interference favoured some who were 
able to get over these barriers with con­
summate ease leaving a set of frustrated 
doctors who had no such political pull. 
The Government now realised that co­
ercion was not the answer to the brain 
drain. 

The introduction of the scheme of 
channelled consultation practice for all 
doctors was introduced and this had a 
great impact on the exodus as the doctor 
could now utilise his full earning capa­
city if he chose to do so, outside his 
hospital practice. Plans to improve 
housing for doctors, the release of 
foreign exchange to enable him to buy 
a car and to attend seminars and con­
gresses of international standard were 
other factors introduced' by the present 
Government. 

The Government has also during this 
time given thought to the question of 
post-graduate training for doctors in the 
country. The reasons for this were 
many. The training a doctor obtained 
abroad in his postgraduate studies, was 
not relevant to the diseases prevailing 
in this country. It was more geared to 
pattern of diseases in the country in 
which he chose to do his postgraduate 
work. The conditions under which he 
was being trained and the facilities 
available to him to practice his art were 
not those he would have on his return. 
The doctor would have to be away from 
the country for at least 3-4 years to 
obtain his qualifications and experience 
thus causing a hiatus in the manpower 
available to the department. It was also 
realised that a great many doctors were 
not being trained in a speciality but were 
studying solely with the idea of obtain­

ing a post-graduate diploma. He was 
sustaining himself by Obtaining employ­
ment in nospitals abroad in disciplines 
quite alien to what he hoped to specialise. 
in. To combat these two deterrents in 
its efforts to offer health care to the 
people, namely the loss of manpower by 
emigration both permanent and tempo­
rary, and the lack of relevancy in the 
training of its doctors abroad, the 
Government decided to establish post­
graduate education locally, in iv74 an 
Institute of Post-graduate Medicine was 
established affiliated to tne University 
of Ceylon and based in Coiomoo. Tnis 
consisted of a Director, a CuuncU of 
Management, the establishment of • 
Boards of Study and an Academic 
Syndicate. The teacher 01' post-graduate 
medicine were available bom in tne 
medical faculties in Colomoo and Pera-
deniya and in the Teaching Hospitals. 
The facilities for training^ uch as equip­
ment and library faculties wmch were in­
sufficient for undergraduate teaching 
was sadly lacking, thus frustrating tne 
Boards of Study in its endeavours to 
set up curricula, training programmes 
etc. The .Health Ministry was unable to 
supply all the facilities required due to 
foreign, exchange problems, hence the 
decisions of the Boards of Study could 
not be implemented. The only discipline 
which began a training programme was 
that in Community Medicine, com­
mencing in 1V77 and finishing its final 
examination in January 1980. The post­
graduate student himself was not inte­
rested in obtaining any local degrees at 
this time as foreign primary and Part I 
examinations of the Royal Colleges in 
the U.K. were still being held in Sri 
Lanka. On obtaining this preliminary 
qualification the Health Ministry were 
sending these doctors on no-pay leave 
to the U.K. for their Part IL quali­
fications. 

The very fact that facilities for post­
graduate training were not available; 
foreign examinations were being held 
and that the postgraduate degrees given 
by the University were not recognized 
by the Health Ministry on a full quali­
fication, hindered all the efforts of the 
fledging Institute. 

The present Minister of Health seeing 
all the difficulties his Ministry faced in 
providing health care to the people took 
a ' bold step in this direction. He 
decided that as Government policy 
foreign examinations in medicine were 
to be prohibited after 31st December 
1979. He also decided with the 
concurrence of the Minister of 
Higher Education to reconstitute the 
existing Institute of Post-graduate Medi­
cine. On May 1979 by a Government 
Gazette No. LD/B 21/78 the Post­
graduate Institute of Medicine was pro­
mulgated, with a view to postgraduate 
training and holding of post-graduate 
examinations. The Post-graduate Insti­
tute of Medicine was affiliated to the 
University of Colombo and consisted of a 
Director, and a Board of Management 
who were empowered to form a Board 

8 ECONOMIC REVIEW, JANUARY 1980 



of Studies in the various disciplines of 
Medicine. 

The Board of Management consisted 
of ex-officio members, including the 
Secretary of Higher Education, Health, 
Finance and Planning. The Deans of the 
Faculties of Medicine in Colombo and 
Peradeniya, two representatives of each 
Faculty elected by the Faculty members, 
the Director of Health Services, and the 
Deputy Directors of Medicine and 
Laboratory Services. In addition there 
were nine members nominated by the 
University Grants . Commission, seven 
of whom were to be from the Medical 
Profession. The Board of Management 
empowered the Director to form Boards 
of Studies in the clinical discipline in the 
first instance, in Medicine, Surgery, 
Obstetrics and Gynaecology, Paediatrics, 
Anaesthesiology, Pathology, Psychiatry, 
Community Medicine, Radiology, Oph­
thalmology and General Practice/Family 
Medicine. 

The Boards were to comprise of repre­
sentatives from the Faculties of Medicine, 
of Colombo and Peradeniya and from 
the College or Associations of the 
various disciplines. Its functions were 
to formulate the policy of selection of 
candidates for specialised training, a 
training programme and an examination 
leading to a doctorate or mastership in 
the respective disciplines and were to be 
awarded by the University of Colombo. 

The finances of the Institute were to be 
shared both by the Ministry of Higher 
Education through the University Grants 
Commission and by the Ministry of 
Health. The WHO through its regional 
Director for South East Asia also pledged 
their help in implementing the pro­
gramme. 

One of the stipulations laid down by 
4he Board of Management was that 
standards of training and examining 
should not be lowered at any cost. The 
degrees awarded were to be on par with 
those diplomas which were already 
recognised in Sri Lanka. The degrees 
granted by the Institute would be re­
cognised as full qualifications in that 
particular discipline for payment of 
allowances and for recognition as con­
sultants after board certification and 
after a deadline be given preference over 
foreign diplomas for appointments to 
consultant posts in the Health Depart­
ment or Universities. It was also stipu­
lated that every successful candidate in 
all disciplines should be sent abroad to a 
recognised institute for a period of one 
year to gain further experience. This 
last stipulation was the responsibility 
of the Institute which would obtain the 
necessary appointments abroad. The 
postgraduate student going abroad 
would be given full pay leave and some 
form of scholarships or other award. It 
was only after successfully completing 
the one year abroad that the post­
graduate doctor would be Board Cer­
tified as a consultant. 

This did not mean that all doctors 
were compelled to go through this pro­
gramme. The Ministry would still allow 
those already holding the Primary or 
Part I examinations of the Royal College 
of the U.K. to proceed to the U.K. on 
no-pay leave on a phased programme to 
complete their Part II examinations. 
However after a deadline to be given by 
the Ministry the local post-graduate 
degree would be giving preference over 
foreign degrees in the matter of state 
appointments. Any doctor not willing 
to do his post-graduate diploma in Sri 
Lanka was also free to go for foreign 
examinations if he so desired after 
serving his compulsory service period. 

Within three months of its formation 
the Post-graduate Institute of Medicine 
has constituted all Boards of Study 
except that in Ophthalmology. Exami­
nations for the Part I in most disciplines 
were to be held in the first part of 1980 
to choose candidates for the various 
training programmes. Part I exami­
nations would also be held in the latter 
part of 1980 or early 1981 for those 
already holding the Part I of foreign 
examinations and who would have com­
pleted the necessary training programmes 
drawn up by the various boards. 

There has been a great deal of enthu­
siasm and encouragement from the 
Board of Management, the Ministry 
of Health, the University Grants Com­
mission and the World Health Organi­
sation. 

The Ministry of Health has offered a 
block of land on Norris Canal Road, 
close to the General Hospital, Colombo 
to the Institute to construct a building 
of its own. The University Grants Com­
mission increased its financial contri­
bution to Rs. 600,000 and the Health 
Ministry doubled its previous contri­
bution. The WHO has undertaken the 
task of obtaining examiners trom abroad 
and teachers and other advisors on a 
short-term consultancy basis. 

Although there is much agitation from 
the Government Medical Officers' Asso­
ciation for holding foreign examinations 
in the future, and its instructions to 
members to refrain from taking local 
post-graduate training or examinations, 
pending further negotiation with the 
Ministry of Health, the response from 
many younger doctors for post-graduate 
training and qualifications has been en­
couraging and the first examinations 
due to commence in January 1980. 

Undergraduate Medicine has been in 
existence for over a century in Sri Lanka, 
Yet post-graduate medicine has not made 
any headway at all. This country has 
depended too long oh British Medicine 
for its post-graduate training even though 
a great personality in the Medical field 
Lord Rosenheim exhorted us to break 
away and do our post-graduate medical 
training suitable to our country as we 
have both the talent and potential to 
do so. 

ECONOMIC REVIEW, JANUARY 1980 

are caused by the spread of con 
tamination, lack of adequate sani­
tation, lack of a safe supply of 
drinking water and by malnutrition 
which weakens the body leaving 
people vulnerable to further disease. 

It is evident that without a basic 
change in the environment a major 
reduction in these diseases cannot be 
expected to occur. It is also signi­
ficant that the present morbidity 
pattern does not differ significantly 
from the pattern of 25 years ago. 
Furthermore, the pattern of disease 
shows' that major problems in the 
people 8 health are basically pro 
vent able. 

Malnutrition is not a medical 
problem, but a health problem. AH 
the article from World Health states, 
on page 10 it is not caused by an in­
sufficient knowledge of what human 
beings should eat nor is it caused 
by the country's incapacity to pro­
duce the food required by its popu­
lation. It is in reality a problem of 
inequitable distribution of food 
within countries and between coun­
tries. Even in those countries which 
do not produce sufficient food to 
feed their populations adequately 
the chief problem is not a physical 
inability to do so, but that the 
socio-economic structure which res­
tricts the capacity of sections of the 
population to produce or buy the 
food they require to oat. In this 
sense "malnutrition is one of the 
consequences of social injustice and 
is a factor which contributes to its 
maintenance". 

The predominance of preventive 
diseases points to another imbalance 
in the health care sorvicos. This 
imbalance is between the preventive 
and curative services which is re­
flected in the percentage of the 
health budget spent on theso servi­
ces. For instance in 1976 out of a total 
health budget of Rs. 416,589,000, 
66% of it 'was spent on patient 
care services while only 24% was 
spent on preventive services. In 
1977 the proportionate figures spent 
on curative and preventive health 
were 66 % and 27 % respectively. In 
1978 the expenditure on preventive 
services showed a marginal increase 
with 28 % of the health budget while 
curative sorvicos accounted for 65% 
of the expenditure. 

9 



There are many reasons for this 
continuing bias in favour of curative 
services while the predominant dis­
eases prevalent in the country are 
preventive ones. For one thing the 
tradition of medicine has been in 
curing illness. The building of hos­
pitals, moreover, are far more tangi­
ble and visible than the invisible 
benefits from commencing a cam­
paign of immunization of children 
or the benefits from the installation 
of latrines in a village, which would 
in the long-term have major impact 
on increasing health and decreasing 
infant mortality. It is thus evident 
that the disproportionate share spent 
on curative health is essentially a 
political decision based on prefer­
ence rather than on real conditions. 

This problem however, cannot be 
solved by merely redistributing medi­
cal manpower and resources from 
the richer urban areas to the poorer 
rural areas, even if this wero possi­
ble- Tiiis is because an expensive 
curative-biased medical system in 
this context is inappropriate to the 
health needs of the mass of the 
population. The diseases prevalent 
in the country as the evidence 
shows is caused by poor environ­
mental conditions. These diseases 
are highly susceptible to preventive 
health measures. 

The appropriate cure for these 
diseasos and ill-health is not expen­
sive hospitals with highly-trained 
medical doctors and sophisticated 
equipment. It is the provision of 
sanioary living conditions, clean 
water for drinking, elementary 
hygiene, education and the avail­
ability of the right kinds of food. 

As a preliminary measure then 
it is clear that the percentage of the 
health budget must increasingly be 
spent on community health services. 
While it is true that the rate of 
morbidity in the country is high and 
curative services are essential, it is 
however, clear that if an improve­
ment of the health status of the 
people is to be achieved, more em­
phasis will have to be placed on 
preventive services. Some of the 
most positive steps taken in this 
direction are the plans for preven­
tive health care between 1979-1983. 
Among them are plans for in­
creased immunisation to reduce in­
fections, improving nutrition edu­
cation and south west coastal water 

C R U E L P A R A D O X 

Although our planet has more than 
enough potential resources to feed the 
entire human population adequately, 
now and for some decades to come, yet 
a high proportion of its people remain 
chronically undernourished. This cruel 
paradox arises from three main causes. 

In the first place, even in the indus­
trialized world the crop yields per hec­
tare fall far short of the yields that are 
technically feasible. In the poorer coun­
tries, there is chronic under-use of land 
and a traditionally ingrained concen­
tration on low-food-value crops. 

Secondly, the world's grain markets 
remain highly unstable—subject to crop 
failure and famine, or to sudden man-
made shortages and gluts. 

The message of correct eating habits 
could come through a programme of 
health education, which can help avoid 
cases of malnutrition and debility such 
as this. But, even with a knowledge of 
the best food habits, if it is not available 
to the population the problem will not be 
solved. 

Thirdly, there are serious failures in 
distribution at the regional, national and 
local levels, so that the right quantities 
of food supplies never filter down to those 
whose need is greatest. The greed of 
middlemen and retailers ensures that a 
healthy diet remains far beyond the 
reach of the poorest of the poor. 

All three of these causes are techni­
cally amenable to improvement; all three 
are likely to remain largely intractable 
for the foreseeable future. Yet plenty 
can still be done on the food front to 

improve the lot of the under-served. 
What most of the deficiency diseases 
that plague humanity have in common 
is that they are preventable. Only quite 
minor additions to the diet, available 
now and at low cost, would suffice to 
avoid such pitiful conditions as nutri­
tional anaemia, endemic goitre or the 
blinding disease, xerophthalmia. Im­
provements to an unsatisfactory en­
vironment or the provision of clean 
drinking water can have very positive 
results. In some parts of India, for 
instance, gastroenteritis is the root cause 
of malnutrition in young children. Else­
where, cultural taboos and superstitions 
may be helping to create malnutrition. 

Then, nutritional studies invariably 
throw up strange discrepancies in feeding 
habits, not only between villages in the 
same area but even within families. How 
can such inequalities be overcome? 

The most valid answer is: by health 
education. The message of good eating 
habits—starting with the inestimable 
value of breastfeeding babies and then 
weaning them wisely on to the right 
foods—must be conveyed to people by 
every means at our disposal. Radio, tele­
vision, newspapers and posters are 
powerful media for conveying such 
messages, including the value of grow­
ing a oroad range o£ vegetables in the 
backgarden. In line wnn WHO's con­
cept of primary health care, the word 
about good food is also being spread by 
community health workers and other 
health professionals in many countries. 

Schoolchildren in particular readily 
accept a reasoned explanation of why it 
may be necessary to break away from 
too narrow lood habits. This is impor­
tant when it comes to convincing com­
munity leaders that better foods need not 
depend on exotic and expensive "im­
ports" from outside, and mat some of 
the best sources of energy, proteins and 
vitamins are locally-grown cereals, pulses, 
vegetables and fruits. 

Malnutrition is both a consequence of 
social injustice and a leading factor con­
tributing to its maintenance. It bears 
hardest on small children, exacting an 
appalling toll in death and disability 
among the young. Together with other 
adverse environmental factors, it inter­
feres with the adequate growth and nor­
mal disease-resistance of the survivors, 
and reduces their capacity to learn 
during childhood and to earn during 
adulthood. 

As the Director-General of WHO, 
Dr Halfdan Mahler, wrote in an earlier 
issue of this magazine, "the inevitable 
result is a downward spiral in which poor 
malnourished parents produce mal­
nourished children who in turn will be­
come poor and malnourished parents". 

Courtesy: World Health, Aug/Sept 1979 

10 ECONOMIC REVIEW, JANUARY 1980 



supply projects and rural water 
supply schemes. 

The establishment of an adequate 
preventive service implies in the 
first place a better utilisation of 
the existing preventive services and 
perhaps where it is inadequate, the 
training of a number of preventive 
cadres. For instance it has been 
reported that Medical Officers of 
Health who head the preventive 
service spend as much as 60% of 
their working time on adminis­
tration and only 35% on preventive 
health care for which they are 
trained. Moreover the cadres that 
today form the backbone of the 
preventive health service such as 
Public Haalth Midwives, Inspectors 
and Nurses would need to be ex­
panded and beter equipped if their 
services are to be adequately utilised. 

The Public Health Midwife is at 
the heart of the preventive system 
in the periphery. However, the 
availability of tho FHM is in­
adequate. In 1976 for instance the 
ratio of PHMs to population was 
about 1 :6,000. Naturally the 
time spent on preventive work is 
low especially when one considers 
that the PHM has to travel wide 
distances-in addition to reach her 
patients. 

As mentioned at the outset the 
country's health care system consists 
of (a) a curative set-up of various 
grades of hospitals and maternity 
homes', (b) a preventive public 
health system made of 102 Medical 
Officers of Health (MOH) units and 
1,200 clinic outlets. The smaller 
institutions are spread out mainly 
in the periphery and are charac­
terised by a host of deficiencies, par­
ticularly, lack of staff; lack of equip­
ment and malfunctioning of equip­
ment; inadequate drugs and ser­
vices and inadequate staff quarters 
and improper maintenanc of build­
ings. The result is that there is often 
a bypassing of these institutions and 
an underutilization of the 110 Dis­
trict Hospitals and smaller Rural 
Hospitals in order to avail of the, 
better facilities in the 10 large Pro­
vincial Hospitals of the island, 
which are generally overutilized. 

.The existing health care services 
have developed through a regional 

network system of health insti­
tutions'. In the early phase cf this 
development, (particularly 1930-g0) 
the control of communicable dis­
eases and preventive measures were 
generally emphasised, but later re­
gional treatment centres like the 
Provincial, Bas e and District Hospi­
tals became established and a major 
portion of the health budgets came 

to be diverted to develop and main­
tain these hospital services. TLus 
today nearly 66 percent of tho bud­
get is allocated to patient care ser­
vices while the public health budge* 
amounts to enly about 28 percent. 
It is further accepted that iu.t tnly 
do the greater proportion of all 
forms of resources go into the deve­
lopment and maintenance of mcdi-

MEDICAL SPECIALIST SERVICE 
Immediately after the removal of the 

legal barrier for medical specialists in 
the Government Service to run private 
hospitals or to serve in such institutions 
specialist medical care in the country had 
taken a new look. After careful investi­
gations we tried to study the current 
position of this sphere of services. In 
order to observe how these services were 
carried out and to collect necessary data, 
we visited the General Hospital, Colombo 
and five other selected private hospitals 
situated in Colombo in the latter part of 
November 1979. 

Although there were medical specialists 
not in government service practising in 

the private hospitals our attention had 
been drawn only to medical specialists 
attached to the General Hospital, 
Colombo, in compiling these data; and 
where the number of patients were recor­
ded only outdoor patients at the private 
hospitals were taken into account not 
taking into consideration their inmates. It 
was observed from the available facts, 
that SO to 75 patients who need specialist 
medical care had to go back unattended 
at the General Hospital in any one day. 
Although consulting hours were exhi­
bited in the private hospitals, as shown in 
this table had been reported that consul­
tations could be arranged even at other 
hours. 

Following are some of the facts compiled on such visits 

General 
Hospital Private Hospitals 
Colombo 

1. No. of medical 
specialists who 
attend to consul­
tations in a day* 

2. No. of patients 
who consult 
medical specialists 
in a day 

3. Consulting hours 

4. Specialist fee for 
consultation 

* Estimated 

75 

1120 

35 25 16 15 

400 150 70 50 20 
12.00 to 12.00 to 12.00 to 06.30 to 12.00 to 
?.00p.m. 1.00 p.m. 1.00 p.m. 7.00 a.m. 1.30 p.m. 

05.00 to 05.00 to 05.00 to 12.00 to 05.00 to 
7.00 p.m. 8.00 p.m. 8.00 p.m. 1.00 p.m. 6.30 p.m. 

07.00 to 
9.00 p.m. 

30/- 30/- 30/- 30/- 30/-

Rs. 25/- for the specialist and Rs. 5/- for the institution. 

In addition to the details enumerated 3. 
above the following features were noticed 
in this investigation. 
1. Although daily attendences of Medi­

cal specialists at the General Hospital 
were declining it was not so at the 
private hospitals. 

2. Some patients who had consulted 4 . 
Medical specialists at the General 
Hospital on earlier occasions were 
attending private hospitals where 
the particular specialist serves 
for interviews and for specialist 
treatment. 

It was observed that some patients at 
the General Hospital had letters 
issued by specialists, whom they 
wanted to consult, and we were told 
that these letters were obtained by 
making prior payment to the spe­
cialist for such consultations. 

Generally about 2\ minutes were 
taken per patient at the General 
Hospital for a consultation, but at 
the private hospitals more than 
5 minutes were devoted per pat­
ent. 

ECONOMIC REVIEW, JANUARY 1980 11 



cal services, but also that much of 
these inputs are for the urbanised 
areas of the country where only 
about 20 percent of the people live, 
while almost 80 percent of the popu­
lation who live in the rural areas 
jjet a comparatively small share of 
the Country's medical care expen­
diture and services. 

These rural people have totravel 
long distances, sometimes at great 
personal expenBe and inconvenience 
in order to obtain treatment for 
some simple conditions such as 
fever, headache, or diarrhoea at a 
medical care institution. The Minis­
ter of Health inaugurating a work-, 
shop on Primary Health Care 
Workers' in August 1979, drew 
attention to the enormity of the 
problem and the inability of the 
primary health worker in the village 
to be of much help in these cir­
cumstances. He said, "all the time 
the Public Health Midwife, the 
Public Health Nurse and the Public 
Health Inspector ha v e to stand by 
and watch, because they do not have 
the training and the -authority to 
give any help to these people". He 
emphasised that this had l e d to a 
"gross inequality in the health status 
of the people, which is politically, 
Bocially and economically unaccept­
able Indeed if the present 
system persists the attainment of 
better health will remain as elusive 
as ever for the rural poor". He 
added that his Ministry was in the 
process of planning a Primary Health 
Car e System appropriate to the 
needs of Bri Lanka. 

In order to achieve these objectives 
the Ministry had decided to review 
the job description of those health 
workers who are at present closest 
to the people at the village l e v e l -
namely, the Public Health Inspector, 
the Public Health Nurse and Public 
Health Midwife. The aim is to 
infuse various types and degrees of 
skill and knowledge into these 
workers to enable them to carry out 
their numerous tasks and respon­
sibilities mere efficiently as members 
, of a carefully selected team. This 
concept of teamwork implies a co­
ordinated delivery, of health care in 
the form of preventive, promotive, 
curative and rehabilitative .Services, 
including nutrition programmes, en­
vironmental control, fertility pro­

grammes and communicable disease 
control. The main significance of 
such a programme is that it would 
help to integrate the preventive and 
curative services at the village level 
by imparting a certain degree of 
curative knowledge and skills among 
those primary health care workers 
whose training is now Confined tp 
the preventive' side only. For 
instance, the midwife if taught the 
diagnosis and treatment of simple 
medical and surgical Conditions can 
play a far more useful role to the 
great relief of the people she serves 
in the villages as well as that of the 
qualified medical practitioners who 
candevotetheirtimeto more impor­
tant tasks. A major role assigned 
to the National Institute of Health 
Sciences at Kalutara, .which com­
menced functioning as a separate 
decentralised unit in the Health 
Ministry from July 1979, will be the 
planning out of such an integrated 
health care system and providing 
the necessary training facilities for 
its implementation. (Bee Box on 
Page 13). 

Environment 
As we have seen the bulk of the 

country's health problems are deeply 
rooted in the environment. For 
instance, it is estimated that only 
between 15 percent and 25 percent 
of the people have access to safe 

.. Water; or less than 10 percent have 
access to piped Water. The majority 
of the people use shallot unprotec­
ted wells and in settlement areas 
tanks and water channels are the 
source of drinking water. It has also 
been found that the proper disposal 
of human and other waste through 
sewerage systems and latrines is 
also limited, less that one-third of 
the population having satisfactory 
latrine facilities. Again, theie is in­
adequate emphasis by local autho­
rities on water supply and excreta 
disposal programmes. At present 
it is estimated that 5Q percent in the 
rural areas and 60 percent in the 
urban areas have access to these 
facilities. It is not surprising there­
fore that about 40% of the People 
Beeking treatment at Government 
.Medical Institutions are suffering 
from bowel diseases. (Bowel dis­
eases constitute mainly Typhoid, 
Amoebic and Bacillary. Dysentry, 
Infectious Hepatitis, Gastroenteritis 

Colitis and Worm Infestations). Ihe 
cause of this alaiming incidence of 
bowel disease is due to the unsatis­
factory environmental sanitation and 
personal hygiene. 

In the control of communicable 
diseases too sufficient attenl ion has 
not been paid to environmental fac­
tors. It has thus beenjaccepted that 
for example, malaria, diarrhoeal 
diseaBes, V.D., T.B., or Filaria, 
eradication programmes should in­
clude not only the control of vectors 
or the treatment of the diseases but 
also factors linked to the places 
people live in, the occupations they 
carry out and the pattern of their 
movements. A typical example is 
the Malaria control programme 
where gemming, chena cultivation, 
and settlement areas in the dry zone 
have been identified as high risk 
ar eas. Or again, whooping c cugh, 
polio and tetarus still account for 
10 % of the deaths of children under 
five years- An expanded irtrcuni-
sation programme no'ff planned in­
tends to provide protection to 50 % 
of the population at risk. 

Nutrition 

Nutrition or more particularly 
nutritional deficiency is another 
major health problem. One aspect 
has been the lack of Consensus as to 
the proper nutrition strategy among 
nutritionists. More important, how­
ever, is the fact that this problem is 
closely related to employment^ avail­
ability of food, droughts and har­
vests. It has also been established 
that though significantly related to 
agricultural and economic factprs, 
socio-cultural factors like breast » 
feeding, wearing practices and food'" 
taboos criticallydeterminethe nutri­
tional status of large sections of the 
people. 

There are still other general cbn^ 
straints in the Health Car e System.- • 
Increasing demands have thus gene- ' 
rated a response fremthe health care 
system to provide: increased and 
more appropriate manpower re­
sources; increased output and ser­
vices by staff; larger and quicker 
turnover of.patients bcth indcor 
and outdoor and increased outlets 
and service points. 

12 ECONOMIC REVIEW, JANUARY 1980 



The most evident constraints in 
the present system observed are 
overutilization of specialised ser­
vices (e.g. teaching and provincial 
hospitals) especially in out-patient 
care; underutilization of district 
hospitals and some provincial hos : 

pitals; by-passing of institutions 
and Shortages and less of trained 
manpower—e.g. "Brain Drain" of 
most categories—Doctors, Nurses, 
A.M.P. Radiographers, Lab-tech­
nicians etc. 

The acute shortage of manpower 
has required intensive manpower 

development programmes, for in­
stance, the opening up of new 
schools of medicine and increasing 
the intake of medical students, more 
nursing and midwifery schools and 
training programmes; increasing in­
take of students by about fiO %; and 
also restarting ccmses for middle 
level personnel like Assistant Medi­
cal Practitioners. Infact, man­
power resources are required in all 
categories, especially these that are 
needed to work in rural areas, with 
more conducive conditions to fun­
ction in a field setting. 

Providing better facility 6 fc r c x:M -
ing instituticr.8 in laboratory Fci via K 
d rugsand supplies, (we pages 25-33) 
diagnostic equipment, and repairs 
to buildings is another crucial 
requirement. 

While attempts are currently be­
ing made by the government to in­
crease the availability of preventive 
health staff, with the limited re­
sources at its disposal and tho rising 
costs of health care, it is unlikely 
that tho state could provide large 
numbers of. trained personnel in tho 
preventive field. Moreover as tho 

THE NATIONAL INSTITUTE OF HEALTH SCIENCES 

The Government of Sri Lanka, as a 
member state of WHO made a positive 
commitment towards the objective of 
Health for All by 2030 at the Confer­
ence on Primary Health Care held in 
Alma-Ata in 1978. 

Although the country is small in 
extent when compared to other nations 
in the South Asian Region, Sri Lanka 
too is confronted witn the common 
problem in this region, viz. that of 
providing basic comprehensive health 
care to 80 percent of the population 
living in rural areas while over 70 per­
cent of medical doctors practice in the 
urban and semi-urban areas of the 
country. 

In order to meet this challenge the 
Sri Lanka Government througn its 
Ministry of Health has embarked on 
a muiti-faceted programme of action to 
develop primary Health Care in the 
country. The challerge is to be met 
in a threo-pronged manner. 

(1) By increasing the numbers of the 
existing Health workers in -he 
periphery- namely the Public 
Health Inspector, the Public 
Health Nurse and the Public 
Health Midwife. The training 
curricula of these workers have 
been revised in such a way as to 
strengthen their capabilities in 
the provision of Primary Health 
Care. 

(2) By increasing the output o f 

Assistant Medical Practitioners 
who will supplemsnt the medi-
cal graduates. The training of 
Assistant Medical Practitioners 
is to be community-oriented, 
so that they will be motivated 
to serve in the rural areas. 

(3) By increasing the number of 
Health Volunteers, who form the 
interphase between the commu­
nity and the midwife. 

As an initial step in the implemen­
tation of this strategy the Health 
Ministry has established the National 
Institute of Health Sciences at Kalutara. 

The National Institute of Health 
Sciences is a training complex which is 
made up of: 

(i) The former Institute of Hygiene, 
Kalutara. 

(ii) The area of CMOH, Kalutara-
wmch is 52 sq. miles in extent 
and now serves as the Field 
Practice Area of the NIHS. 

(iii) The Base Hospital, Kalutara. 
(iv) The Rural Hospitals at Aluth-

gaou and- Alatngamveediya. 
(v) The Central Dispensary at the 

Police Training College. 

The Institute of Hygiene at Kalutara, 
started functioning as tne first Health 
Unit in Sri Lanka in 1926. In 196o tne 
Health Unit was renamed "Institute of 
Hygiene" and moved to the present 
spacious building at Nagoda. Tne 
Institute which was headed by a Chief 
Medical Officer of Health was up­
graded, and in 1974 a permanent 
Director was appointed as its Adminis­
trative head. In June 1979, the Insti­
tute of Hygiene together with the above 
mentioned units was established as the 
National Institute of Health Sciences, 
functioning as a separate decentralized 
unit of the Department of Health 
Services. 

The Government of Sri Lanka has 
been assured of the support of UNICEF, 
WHO and US AID in he further deve­
lopment of the NIHS in the five year 
period 1979-1983. 

The National Institute of Health 
Sciences will conduct multi-disciplinary, 
community-oriented, field-based train­
ing programmes for the Primary Health 
Care Workers. 

The NIHS will thus play a key role 
in developing training programmes that 
will lay stress on teamwork with the 
objective of enabling Health Care wor­
kers to learn how to work efficiently as 
a team. This is in keeping with the 
world trend towards team work in 

planning for the development of rural 
health care. 

The National Institute of Health 
Sciences is at present solely responsible 
for the training of Public Health 
Inspectors and Public Health Nurses. 
It is also one of the training centres for 
Public Health Midwives and will be 
responsible for co-ordinating and moni­
toring the Midwife training programmes 
in other centres as well. Thus the 
Institute is in a unique position to 
initiate multi-disciplinary training. 

The activities of the NTHS will be 
expanded to include the training of 
Assistant Medical Practitioners in 1980. 
By doing so the AMP's will also be 
oriented towards teamwork and Com-
munty Health. 

The NIHS will also conduct training 
in Community Health Management 
for middle level managers such as 
MOH's, DMO's and other super­
visory grades. The training curriculum 
for this course is now ready and it is 
hoped to commence the first course in 
August 1980. The NIHS will spearhead 
the efforts of the Ministry of Health to 
increase the numbers of Primary Health 
Care Workers and already new training 
curricula for these workers have been 
developed and submitted to the D.H.S. 

The Health Ministry has already re­
cruited 2,604 persons to be trained as 
Public Health Midwives and with the 
additional intake of A.M.P. students 
to the NIHS, the P.H.S. service will be 
strengthened considerably in the next 
few years. 

The N.I.H.S. will also undertake re­
search primarily into alternate methods 
of Health Care Delivery. Towards this 
end the NIHS has taken steps to imple­
ment a new Primary Health Care Deli­
very Model in its Field Practice Area. 
This will be done concurrently with a 
WHO-funded project for strengthening 
the Primary Health Care Management 
Training. This operational research 
project will also be implemented in 
1980. 

ECONOMIC REVIEW, JANUARY 1980 13 



data indicate the measures needed 
to reduce the ill health caused, by 
poor environmental factors are not 
of a highly technical nature. It is 
increasingly being realised in deve­
loping countries that there must be 
a change of emphasis and outlook 
on medicine and the commonly 
encountered diseases must be stress­
ed . This is seen in the work under­
taken now in Bangladesh, India and 
Tanzania. This implies that the 
health services would need different 
cadres for the treatment of pre­
ventive diseases. 

The Volunteer Health Workers 

In Bri Lanka the need for such 
health cadres is even more import­
ant when one considers that pre­
ventive illness predominates the dis­
ease pattern among the majority 
of the population in the country. 
Preventive medicine in addition de­
mands far less resources than cura­
tive medicine. The concept of the 
volunteer health worker arose out 
of the realisation that health was 
not merely the province of a doctor, 
but that the community should also 
participate with the assistance of 
paramedical cadres in solving the 
health problems and maintaining 
health amongst the community. 

The volunteer health programme 
commenced in 1975 with the train­
ing of volunteer health workers par­
ticularly in the rural areas by the 
Health Education Bureau of the 
Ministry of Health. The pro­
gramme draws on the fact that there 
already exists particularly in the 
villages a sense of sharing and co­
operation among the peoples. 

The volunteer worker is a mem­
ber of the community and takes the 
responsibility for health care of the 
segment of the community amongst 
whom he works. He offers his ser­
vices without any monetary gain. 
Volunteers are selected by the village 
leaders and the preventive staff of 
the department of health which 
serves the areas such as the Public 
Health Midwife, Nurse and Inspec­
tor. Volunteers are usually edu­
cated people and range between the 
ages of 18-40 years- Their education 
and membership of village societies 
confers a certain status on them 

within their family as well as among 
their immediate neighbours among 
whom they will work. 

The volunteer assists the preven­
tive health staff at the periphery 
level in the delivery and utilisation 
of primary health care. He is 
trained by the preventive staff. The 
training includes learning from visits 
to clinics, to homes and through 
lectures based on case studies. 
Through this training he learns to 
detect simple illnesses such as 
scabies, to train people in per­
sonal hygiene, the use of latrines 
and to drink boiled water, identifies 
home accidents and how to offer 
possible solutions to their pre­
vention. In the sphere of nutrition 
the volunteer identifies possible 
sources to supplement food, re­
cognises the misuse of foods and 
helps to supplement the diet with 
the cultivation of heme gardens. 
In cases of immunisation the volun­
teer detects infants needing immu­
nisation. He also identifies com­
municable diseases such as malaria 
and infectious diseases such • as 
measles and simple diarrhoeas. 
Once these are identified he is 
taught to administer drugs for 
fevers, anti malaria tablets to pre­
vent malaria and provide rehydra-
tion fluids in the case of diarrhoea. 

These actions are essentially de­
signed to supplement and com­
plement the woik of the primary 
health care woikers at the peri­
pheral level. In short, the volunteer 
becomes an active link between 
preventive health wcikers and those 
who seek primary health care. To­
day there are 500 villages in which 
volunteers woik. 

The effectiveness of the work of 
the volunteer health wcikers is seen 
for instance in the malaria campaign 
in 1976 in the Public Health Inspec­
tor area of Rajangane in the Anura-
dhapura district. Due to the assis­
tance of the volunteer in the cam­
paign of spraying and the distri­
bution cf preventive drugs, there 
was a remarkable decrease in the 
incidence of malaria. In a highly 
malaria endemic area after the pro­
gramme commenced, only 4% of 
the population is reported to have 
developed malaria. 

Another,example comes from the 
village of Maddegama in the K&ndy 

district. - This programme which 
commenced in 1976 gave priority 
to personal hygiene and environ­
mental factors in health. It included 
the construction of latrines, the 
popularisation of boiled water for 
drinking. As a result the diarrhceal 
diseases were drastically reduced and 
over a period of one year no cases 
of dysentry or typhoid were re­
ported in the village. In the same 
village, immunisation of children 
increased from 12 to 88 %, the inci­
dence of infectious diseases declined 
from 28 % .in 1976 to 6 % in 1979. 

Though the training of volunteer 
health workers for primary health 
will go a long way towards im­
proving the health of the mass of 
the population, it is necessary that 
this segment be well integrated into 
the general health services, and 
motivated to retain their interest. 

For instance the volunteer wor­
kers must be a recognised link be­
tween the community and the pre­
ventive health personnel at the level 
of the periphery. Through the pre­
ventive staff a referral system must 
exist which will link the peripheral 
hospital in a hierarchy to the base 
and provincial hospitals. For such 
a system to operate smoothly it is 
necessary that there must be ade­
quate transport to shift patients 
needing specialist attention from the 
periphery to hospitals with the 
necessary staff and equipment. This 
could eliminate the pressure that cur­
rently exists on the urban hospitals 
that are better equipped. 

Soao-Ecocomic Conditions 

However, the health care service 
alone cannot solve every problem 
that arises out of ill health. It must 
be borne in mind that one of the 
major causes of ill health is the 
poor environment in which people 
live. This includes not merely the 
physical envircriment, hut the socio­
economic conditions within which 
people live. At the most elementary 
level, it is necessary that the majo­
rity of the population must have the 
purchasing power to pay at least for 
their food or have the means to 
produce it. Otherwise malnutrition 
and diseases would prevail. 

14 ECONOMIC REVIEW, JANUARY 1980