National Health Performance (LK0003)

Sri Lanka's health sector is largely seen as successful due to its effective public delivery system, which provides both preventive and curative care at low cost. Public healthcare is free for all citizens and accounts for almost all preventive care and most in-patient treatment. However, the public health sector has inadequate capacity, limited access to specialist treatment and inconsistent service standards. To mitigate some of these challenges, the Health Strategic Master Plan developed by the Government of Sri Lanka has framed a National Health Performance Framework to provide citizens with information regarding health sector effectiveness, efficiency and equity, and empower civil society to play an active role in ensuring that these goals for national health are met at a grassroots level. Citizens would make use of health performance information in different ways to create a healthy dialogue and voice their interest for health development. Performance information will also be useful to create more awareness on the need for supporting change in health behavior/ supportive policies from other sectors. The availability of such information will be a positive trigger to create this dialogue. Issues to be Addressed: Since the disaggregated health budget is not known/available to the public, there is no oversight from civil society of national health performance measures. This policy will address this issue by ensuring public oversight in setting and achieving national health goals. Main Objective: Establish a national health performance framework.

3. National Health Performance

Commitment Text:

National Health Performance

[…] the public health sector has inadequate capacity, limited access to specialist treatment and inconsistent service standards. ^[48]

To mitigate some of these challenges, the Health Strategic Master Plan developed by the Government of Sri Lanka has framed a National Health Performance Framework to provide citizens with information regarding health sector effectiveness, efficiency and equity, and empower civil society to play an active role in ensuring that these goals for national health are met at a grassroots level.

Citizens would make use of health performance information in different ways to create a healthy dialogue and voice their interest in health development. Performance information will also be useful to create more awareness on the need for supporting change in health behavior/ supportive policies from other sectors. The availability of such information will be a positive trigger to create this dialogue.

Milestones:

• 1. Ministry of Health to publish detailed health budget and spending information.
• 2. Raise awareness on the National Health Performance Framework (NHPF) through public consultations.
• 3. Popularise the NHPF through the Ministry of Health website, newspapers, radio, television, public campaigns and the internet.
• 4. Citizens will be actively involved in monitoring the implementation of the framework through a public forum on a quarterly basis.
• 5. Findings and deliberations from the forum to be systematically discussed with government counterparts to ensure follow up actions.

Responsible institution: Ministry of Health, Nutrition and Indigenous Medicine

Supporting institutions: Sarvodaya, Patient’s Rights Movement, People’s Health Movement

Start date: July 2016 End date: July 2018

Editorial Note: The text of the commitment was abridged for formatting reasons. For full text of the commitment, see the Sri Lanka National Action Plan 2016–2018 at http://bit.ly/2wv3jXR.

Commitment Aim:

This commitment aimed to establish a National Health Performance Framework (NHPF) and thus, enhance public access to information on health performance in Sri Lanka. The Ministry of Health anticipated that the public will use this information to proactively participate in—and promote—constructive, evidence-based dialogue on health policy. [49] This, in turn, was expected to improve the quality of decision-making and mitigate the broader challenges faced by the public health sector.

Status

Midterm: Limited

This commitment achieved limited completion by the midterm. In April 2016, the Ministry of Health published consolidated National Health Accounts for 2013 on its website (Milestone 3.1). [50] However, the ministry had not made more recent budget records available.

As the National Health Performance Framework (NHPF) was not finalised by the midterm, no progress was made in raising awareness, through public consultations or otherwise. There was also no public forum to monitor implementation of the framework (Milestone 3.2–3.5). [51]

End of term: Limited

Although the commitment saw positive incremental improvements, implementation remained limited by the end of term.

Milestone 3.1: The Ministry of Health published further budgetary data and spending information through the 2017 Annual Performance Report. [52] This report was available in all three languages. [53]

Milestones 3.2–3.5: The ministry developed the NHPF and published it on its website in April 2018. [54] The framework contains over 80 indicators that may be analysed to assess the state of healthcare in the country. ^[55] According to the ministry, data is available for nearly 50 of these indicators; however, work is needed to extract useful information from the datasets and compile it in an easily accessible format. ^[56] According to civil society, the ministry has not oriented staff or conducted any public-awareness campaigns. [57] Also, as highlighted by civil society and verified by the IRM researcher, the ministry has not yet translated the framework into Sinhala and Tamil.

The ministry conceded that more is needed to be done to institutionalise the NHPF, including the appointment of dedicated personnel to drive and oversee implementation of the framework. ^[58] The monitoring forum, with citizen participation, was also not established by the end of term.

Did It Open Government?

Access to Information: Marginal

Civic Participation: Did Not Change

This commitment marginally improved access to information and open government overall. It did not, however, contribute to a noticeable improvement in civic participation.

At the outset of the action plan, government and civil society efforts to address growing challenges in the healthcare system were stymied by a lack of useful or quality health information. [59] In the absence of a health performance framework, stakeholders were unable to set clear targets, benchmark progress, or adopt evidence-based policies to improve healthcare in Sri Lanka.

The ministry published budgetary data and spending information through the trilingual Annual Performance Report, uploaded on the ministry website. [60] According to civil society, this improved access to fundamental information on health expenditure. [61] Prior to this, the Ministry of Health had published consolidated National Health Accounts from 2013, [62] as well as annual health bulletins [63] which contained limited financial information. Similarly, the ministry also developed and published the National Health Performance Framework (NHPF) [64] which provides a framework to measure the performance of the health system through specific indicators. If effectively implemented, stakeholders agree that the framework would facilitate access to a range of hitherto unavailable information on the effectiveness, efficiency, and equity of health services. [65]

However, civil society noted that some of the data intended to be collected through the NHPF was not available or easily accessible. [66] The NHPF itself was also unavailable in Sinhala and Tamil, and has not been introduced to the public through awareness campaigns. [67] Therefore, the commitment only contributed to a marginal improvement in access to information.

As the ministry has not yet set up the multistakeholder forum to monitor implementation of the NHPF, this commitment did not improve civic participation.

Carried Forward?

Sri Lanka’s second action plan was not released by the time of this report. However, the IRM researcher recommends that this commitment is carried forward into the next action plan. The effective use of the NHPF can significantly improve access to important health service information and may, thus, contribute to constructive discourse toward improved healthcare.

In the 2016–2017 IRM midterm progress report, the IRM researcher recommended a few additional measures to address the lack of information on health and enhance the impact of this commitment. These include: prioritising the introduction of efficient data collection mechanisms; introducing budgetary allocations for collecting data; and publishing key, easily-accessible information gleaned from the NHPF.

[48] “Sri Lanka’s healthcare Challenges,” Economist Intelligence Unit, 24 November 2014, http://country.eiu.com/article.aspx?articleid=1502512534&Country=Sri%20Lanka&topic=Economy&subtopic=Forecast.

[49] Dr. Susie Perera (Ministry of Health, Nutrition, and Indigenous Medicine) and Dr. Amila Chandrasiri (Ministry of Health, Nutrition, and Indigenous Medicine), interview by IRM researcher, 6 October 2017.

[50] Sri Lanka National Health Accounts 2013, Health Economics Cell (Ministry of Health, Nutrition, and Indigenous Medicine, April 2016) http://www.health.gov.lk/moh_final/english/public/elfinder/files/publications/NHA/Sri%20Lanka%20National%20Health%20Accounts%202013.pdf.

[51] Perera and Chandrasiri, interview; and Dr. Vinya Ariyaratne (Sarvodaya), interview by IRM researcher, 26 October 2017.

[52] Annual Performance Report 2017 (Ministry of Health, Nutrition, and Indigenous Medicine, 2018) https://bit.ly/2NtepkR.

[53] List of Publications (Ministry of Health, 2018) https://bit.ly/2y5Bkya.

[54] National Health Performance Framework 2018 (Ministry of Health, 2018) https://bit.ly/2y7zhJN.

[55] Dr. Susie Perera (Ministry of Health, Nutrition and Indigenous Medicine), interview by IRM researcher, 28 September 2018.

[56] Id.

[57] Dr. Vinya Ariyaratne (Sarvodaya), interview by IRM researcher, 27 September 2018.

[58] Perera, interview.

[59] “Upgraded Record Keeping Helps Save Lives in Sri Lanka” (The World Bank, 17 April 2014) http://www.worldbank.org/en/news/feature/2014/04/17/upgraded-record-keeping-helps-save-lives.

[60] Annual Performance Report 2017 (Ministry of Health, Nutrition, and Indigenous Medicine, 2018) https://bit.ly/2NtepkR.

[61] Ariyaratne, interview.

[62] Sri Lanka National Health Accounts 2013, Health Economics Cell (Ministry of Health, Nutrition, and Indigenous Medicine, April 2016) http://www.health.gov.lk/moh_final/english/public/elfinder/files/publications/NHA/Sri%20Lanka%20National%20Health%20Accounts%202013.pdf.

[63] Annual Health Bulletin (Ministry of Health, Nutrition, and Indigenous Medicine, 2016) https://bit.ly/2tGOjn9.

[64] National Health Performance Framework 2018 (Ministry of Health, 2018).

[65] Dr. Susie Perera (Ministry of Health, Nutrition, and Indigenous Medicine), Dr. Amila Chandrasiri (Ministry of Health, Nutrition, and Indigenous Medicine) and Dr. Vinya Ariyaratne (Sarvodaya), interviews by IRM researcher, 27 September 2018.

[66] Ariyaratne, interview.

[67] Id.