Sri Lanka has recorded impressive achievements in health, nutrition, and family planning with relatively low levels of public expenditure on health. A commitment to broader social development-including education-is a factor in its success. Current life expectancy is 73 years, compared to a regional average of only 61 years, infant mortality is around 16 per 1,000 births, fertility is near replacement level, and the population growth rate is less than 1 percent a year and falling.
The maternal mortality ratio, at 30 deaths per 100,000 live births, is well below that of countries with similar levels of per capita income. The success of Sri Lanka's health programme, which in its early years targeted infant and maternal mortality and infectious and communicable diseases, is undeniable and is looked to by much of the world for the lessons it can teach. The World Bank has been working with the government of Sri Lanka toward this success, particularly in the reduction of communicable diseases. Having met several important challenges, Sri Lanka must now focus on solving the remaining major public health issues. Malnutrition among children and iron deficiency among pregnant and lactating women are still serious problems, and iodine deficiency may be more of a problem than is generally realized. Part of the population is still at risk of contracting malaria.
Urgent steps must be taken to ensure that HIV prevalence in the population remains low. Because life expectancy has increased and the population is aging, non-communicable and degenerative diseases in adults-such as heart disease, cerebrovascular disease, and diabetes-are becoming more common and must be addressed. The recently established Presidential Task Force on Health Reform will provide guidance on reforms needed to address these challenges. The Bank is committed to working with Sri Lanka on these issues.
There is still poverty in Sri Lanka, and the health system must ensure that basic health services reach the poorest of the poor. At the same time, the current health care system that was so successful in eradicating the majority of health problems affecting developing countries, needs to adapt in order to meet the new and more complex health challenges characteristic of industrial countries.
A Successful Beginning
The World Bank Group began working with the government of Sri Lanka to improve health status over a decade ago through the seven-year, US$17.5 million Health and Family Planning project. The International Development Association (IDA), the World Bank's concessionary lending arm, provided the credit.
The main objective of the project was to improve the delivery of health services. Despite civil conflict that disrupted public institutions during the period, the project achieved this goal. Use of family planning services grew, with about two-thirds of couples using contraceptives by the end of the project, and the increased use of temporary methods indicated that more couples were spacing births. The project helped build partnerships with nongovernmental organizations (NGOs)-specifically, the Family Planning Association of Sri Lanka and the Sri Lanka Association for Voluntary Surgical Contraception-to provide training in family planning counseling.
The project supported the adoption of a World Health Organization
(WHO) strategy for malaria control that succeeded in reducing the numbers of detected cases in four high-prevalence districts. Over the period 1993-95, the number of detected cases declined to between one-fourth and one-third of previous levels. The strategy emphasizes early diagnosis and prompt treatment-using mobile clinics in high-prevalence areas-and sustainable control measures.
The strategy also helped prevent gastrointestinal diseases by focusing on dissemination of knowledge about the diseases and preventive practices among public health inspectors, medical officers, school teachers and school children, and food handlers-groups that had been found to be misinformed or uninformed. The project also had a small civil works component: in three divisional (sub-district) areas the strengthening of primary health care facilities was clearly linked to improved maternal-child health coverage, leading to increases in early registration of pregnant women, in postnatal visits, in the use of modern contraceptive methods, and in deliveries by trained attendants.
The project also supported a health strategy and financing study, the results of which were incorporated into the design of the follow-up project. The Bank also supported Sri Lanka's health sector through the Poverty Alleviation project, which was completed on December 31, 1997. In recognition of the link between health status and poverty, the project contained a US $ 14 million nutrition component, which operated on the premise that high levels of malnutrition among children under age five-and the consequent wide prevalence of stunting and wasting-stemmed from inappropriate feeding and weaning practices rather than food scarcity.
The project involved NGOs as a delivery mechanism for nutrition awareness and communications outreach. The strategy of the nutrition component was to move away from service delivery at maternal-child health clinics and toward a community-based nutrition program. NGO community workers focussed on basic messages on pregnancy, breastfeeding, weaning, and micronutrients. The objective was to reduce moderate and severe malnutrition in children under age three, eliminate severe clinical malnutrition, lower the frequency of wasting in children ages 12 to 23 months by 75 percent, and bring down the incidence of low birth weight by 25 percent.
Preliminary evaluations indicate that the project has reached some of its ambitious performance targets and has succeeded in strengthening the capacity of select NGOs to reach communities.
Source: worldbank.org