Country Case Study Sri Lanka

Transcription

1 Country Case Study Sri Lanka "The presentation should be in the next room" Improving equitable access to health care through increasing patient and public involvement in prioritisation decisions - Brocher Foundation, Geneva 9th 13th November 2015 Dr K Weerasuriya Former Professor of Pharmacology, University of Colombo and ex- WHO

2 The Health Care system (1) Island in the Indian Ocean, population 20 million, Low Middle Income HCS - From the 1930s Universal Health Care - driven by Universal Franchise as part of social welfare (education, nutrition) Free at point of care preventive and curative Financed by taxes centrally collected Good health indices Universalised the basic/minimum, continuing to add to that Initial connection to British system still major influence System has no accountability and patients in turn abuse the system Strong central control medicines purchased centrally and distributed, centre controls provincial health authorities Provides clinical guidelines (implementation not monitored, therefore ignored) Parallel private health care (limited) cherry picking Medicines not available in hospital go buy it in the private pharmacy Survived civil conflict of 2 decades 2

3 Public and Patient involvement in prioritisation Minimal or none at all Social Contract Patient will get whatever is available in the clinic/hospital Sri Lanka had the most number of transplants???!!! Medicines whatever is available and no patient choice Single provider (government) and therefore overwhelms public/patient Is voting the government out at the elections the ultimate public participation? Governance, accountability, transparency non-existent Does this mean skewed priorities, corruption, vested interest? Maybe at the margins but difficult to move the centre (or is it the bureaucracy, the immovable force?) 3

4 Current Successes and Challenges Maintenance of a preventive stream (as opposed to curative) Formal budget line for preventive postgraduate education, career tracks, medical administrator stream Clinical - Private sector work allowed outside official hours (retains them in government sector) Potential abuses & especially with Consultants, private sector major part of income Centralised procurement of medicines medicines availability reasonable Escape valve outpatient, unsatisfactory go to private sector Inpatient private sector, too expensive back to public hospital Single provider (government) and therefore overwhelms public/patient Succeeded in health indices but where in patient satisfaction? No court challenges for lack of services No powerful patient groups 4

5 Prioritisation Case Study Human Papilloma Virus (HPV) vaccine (for girls) should it be included in National Immunisation Program (NIP) government funded Initiated by Epidemiology Unit in Ministry Existing childhood vaccines + hepatitis B, H influenzae HPV will be most expensive vaccine if adopted into NIP HPV vaccine available in the private sector What was the work up for the considering the HPV vaccine? Established the frequency Cancer Registries Community surveys demonstrated the existence of HPV infections Extensive discussion (in the Health Care System) on where vaccination would be incorporated in the vaccination schedule, acceptability by health workers involved in vaccination Parents reaction considered (daughters, why at 12 years?) To be incorporated into NIP schedule in

6 Issues Highlighted HPV vaccine decision based on external evidence, internal judgment Cost considered GAVI prices but will become expensive graduating out of low middle income Where will the funds come from? Unclear. Who will be the losers? Maybe not health (Treasury will provide funds) (would be affordable - advantages of bulk procurement) Final vaccine (bivalent, quadrivalent) to be decided Why was HPV prioritised? Why not another vaccine? Unclear Was there pressure from vaccine manufacturers? (Unlikely) Who were the clinicians for the vaccine (oncologists, pediatricians). No clear comparison with alternatives in cervical cancer control OR opportunity costs possible Necessity for a communication strategy focused on the public acknowledged No involvement of the public 6

7 Country Specific Issues A long-established HCS with momentum of it's own? The inexorable expansion of health care facilities (Hospitals expanded, more staff, better facilities BUT part of Health Ministry plans, not patient demand) Government commitment to free health services sacrosanct Political suicide to withdraw any part of it Limit services because of cost? Never explicitly but other means (shortages, rationing) Is the HCS good at guessing what will be needed next? Public dissatisfaction how is it expressed? Newspapers, questions in parliament Current issue high cost of medicines (what exactly?) High cost innovator brands doctors prescribe, out of pocket payment for patient Cheaper generics available but no promotion Cancer drugs government has a special budget 7

8 Questions on this unusual HCS The HCS has survived contributing to better indices The level of services has been slowly downhill BUT sufficient to keep the HCS going What are the possible improvements if there had been greater public / patient participation? Better facilities, greater accountability, more funding Is this a function of general citizen participation in defining government services rather then health alone? (Better roads, law and order, education) Remember this presentation is from the next room The country gets the politicians it deserves Does it also get the healthcare system it deserves? How do we assess this HCS that seems to run mainly on Auto Pilot 8