SRI LANKA

Remarkably, the country has achieved all this by spending less than 4% of GDP on health. Two key factors lie behind its success:

• First, it has repeatedly rejected social health insurance as it has found that this cannot ensure health equity amongst the rich and poor. Instead, it has relied on a combination of general tax revenue to fund services for the less well off, and private provision for the wealthier. More specifically, it has built an extensive network of facilities that delivers the full package of services, without user charges, for the poorest and encouraged the better-off to seek private care. The government’s involvement in the private sector is largely restricted to ensuring it employs suitably qualified staff and adheres to professional standards.
• Second, the country has bucked the global trend towards purchaser-provider separation and facility autonomy, and instead opted for a more conventional ‘command-and-control’ approach, run by civil service doctors. Although this approach has failed in many other countries, Sri Lanka has made it work by focusing on three key areas: building a system to train physicians to manage and to lead healthcare delivery at every level; developing effective management and supervision systems; and providing physician managers with the space and autonomy to focus on maximizing service delivery and equity of access. Key unions have also been brought on board to safeguard the system and protect it from political interference.