The Asia-Pacific regional MDG report 2011/12 jointly compiled by the UNESCAP, ADB and UNDP was launched in New Delhi on 18 February at a high level sub-regional forum with the participation of government policymakers in the South Asian countries, representatives of multilateral and regional development agencies, civil society leaders and academia in the region.
The current report, sixth in the series of interim reviews published hitherto, analyses the level and degree of achievement of 22 MDG targets by the region and by individual countries. The report also attempts to assess the targets which could not be achieved and the reason for setbacks with a view to develop a road map for future course of action to meet the impending challenges.
The high level forum was organised by the newly established UNESCAP sub regional office for the South and South West Asia (SSWA), New Delhi.
The UN Millennium declaration of 1990 aimed at achieving seven millennium development goals by fulfilling 22 targets through 34 indicators by the year 2015 (please see box 1).
The Asia and Pacific region recorded the proportion of people living on less than $ 1.25 per day from 50% in 1990 to 22% in 2012 or from 1.57 billion to 871 million people, thus surpassing the poverty goal.
On gender, the region has successfully reduced disparities in primary secondary and tertiary education. On health, the region was successful in reducing the prevalence of HIV and has stopped the spread of tuberculosis. On environment, it has increased the proportion of land area covered by forest while also reducing the consumption of ozone depleting substances.
On the other hand, the region is lagging behind in 10 of 22 indicators. It is yet to ensure that all children complete primary school. The region has also been unable to extend basic sanitation. The region also did not demonstrate to prevent people going hungry, stop children dying before their fifth birthday, prevent mothers dying from causes related to child birth and has an increasing proportion of the world’s deprived people.
In other words, despite the impressive economic growth, rising income and employment, the MDG indicators and targets relating to health and sanitary realm display dismal records throughout the region, except in a few countries.
Many people in the region have prospered economically while large numbers still live in miserable conditions, posing a threat to national economic and social stability. Wide disparities in achieving the goals between the countries and within the countries are prominently visible.
For example, the poverty level in Malaysia records zero while Nepal has poverty level of 55%. The infant mortality average in the region is 36 per 1,000 live births while the rate in Afghanistan is 103. Within countries there are striking health gaps between urban and rural areas and men and women.
In respect of Sri Lanka, the report evaluates that we have already achieved 13 targets even before reaching year 2015. The targets Sri Lanka has already achieved are halving poverty, all three targets on education, all three targets in respect of gender equality in education, targets on skilled birth attendance and antenatal care, reducing TB prevalence and reducing ODP substance and providing safe drinking water and basic sanitation.
No doubt that these salutatory developments, sometimes even comparable with developed countries, are achieved mainly due to the heavy investment by the public sector over a long period of time on health, education and social safety net.
The democratic institutions, particularly the introduction of early universal franchise, gender empowerment and high literacy rate despite imperfect operational lacunas, helped Sri Lanka to achieve these targets.
One should not also be overwhelmed by these achievements as the benchmarks set on MDGs were generally at minimum levels. At the same time one must also be happy that Sri Lanka is well above and over the achievements of many countries in the Asia and Pacific in respect of those targets. Targets on HIV prevalence and TB incidents, according to the report are on track to achieve by 2015.
Low nutrition needs urgent attention
However, three targets – under-five mortality, infant mortality and maternal mortality – show slow achievements and Sri Lanka is expected to meet the targets only after 2015. As per the report findings, Sri Lanka is regressing in achievements of targets such as underweight children, forest cover and CO2 emission.
Even in respect of the target relating to partly off tracked and completely off tracked with no progress are comparably at high levels as our target began with a relatively high degree of achievements in the region.
In other words, we have to start for example achieving infant mortality targets from the already low level of 11.3 infant deaths per 1,000 live births. Sri Lanka will have to make additional efforts to achieve MDG target of 5.9 deaths per 1,000 live births by 2015.
However, regional disparities on these targets prevailing in different regions in Sri Lanka should be a concern for policymakers. Underweight children particularly living in the rural and estate segments should receive more attention from the health policy planners. The low nutritional status prevalent among the children in Sri Lanka is a serious issue that needs the urgent attention of the policy makers.
In fact malnutrition is somewhat puzzling issue in Sri Lanka particularly in the context of relatively high income level and its extraordinary achievements in female literacy. In complete contrast to this scenario, increasing trend of overweight children particularly school children and adolescents need more counselling on food habit, lifestyle and regular exercise.
Invest more in health
Economic growth, increased income and employment certainly contribute in general towards achieving the health-related MDG targets. However, it has been revealed that economic growth alone does not necessarily reduce the proportion of underweight children and incidents of maternal and child mortality.
To achieve those targets, the Government should invest more per capita on health, both public and private combined. In this regard, Sri Lanka should reinvigorate the once highly-acclaimed family counselling and extensive services in the rural and the estate sectors with skilled extension service personnel who can reach families directly. The re-emerging Northern and Eastern Provinces should be regarded as high priority areas for family health extension services.
Application of better standards in governance of health administration is an important area where policymakers can utilise limited and scare resources available in the health sector for a better use and high impact delivery of the services.
Corruption relating to procurement and distribution of drugs, medicines and health equipment should always be subject to close scrutiny and the follow-up of a well-established procurement system by the health administrators. The waste of resources both material and human due to inefficient management system and administrative practices should be identified and addressed immediately for the better utilisation of resources and to target needy people.
The quality of the health services largely depends on the availability of sufficiently qualified health staff at all levels. Improved infrastructure facilities such as a reliable supply of electricity, internal road network and enabling service recipients to reach the service centres at low cost and on time.
The women who are empowered in literature and education are in a stronger position to care for their children, so the continuation of the gender empowerment programs particularly in the backward regions in the island would facilitate the achieving of the health targets in relating to the MDG.
In respect of maternal mortality, according to the report, Sri Lanka seems to be regressing despite the fact that it has made a 100% achievement in respect of skilled birth attendance. With high rate of skilled birth attendance, it can be reasonably argue that the maternal mortality rate in fact should decline rapidly.
However, this has not happened in Sri Lanka and therefore warrants further investigations by health planners to ascertain the main course for lack of progress on the maternal mortality rate. Some researchers suggest that this trend is due to the lower success of pre-natal and neo-natal mortality. It is however should be emphasised that our maternal mortality rate is lowest in the region as almost 98% are institutional deliveries in the country.
Though Sri Lanka has a relatively low rate of migration from rural to urban areas compared with the many countries in the South Asian region, there are high incidents of overseas migration from rural areas of Sri Lanka, particularly rural women to West Asian countries.
Though overseas migration has evoked some clear benefits, it may also have negative impacts on underweight children and under-five mortality. This is another area one has to research further. It has also been observed that the health environment and the quality of the life are better in general in rural areas than among the urban poor in Sri Lanka.
Health services and private sector involvement
According to Government health planners, Sri Lanka spends Rs. 100 billion annually on the health sector, representing the third largest expenditure of the National Budget. There are over 60,000 beds available islandwide and one doctor serves approximately 1,500 patients. Every citizen can access a Government medical facility within a range of three km. Approximately 49% of total healthcare expenditure is financed by the Government Budget though the allocations are marginally declining in relation to GDP growth.
Private sector involvement in delivering what is traditionally preserved as ‘public goods’ has been expanded to the health services rapidly in the island recently. Private sector involvement was initiated with the relaxation of rules pertaining to involvement of public sector medical personnel in private practices, which was subsequently spread throughout the island and become a parallel health service provider.
The corporate sector now manages large-scale, fully-fledged yet Colombo/urban centred medical institutions and hospitals in major urban centres. Clinical laboratory services maintained by the private sector even serve rural areas in the island through established networks.
The imports, distribution and retail trade of pharmaceutical products are largely now in the hand of the private sector. Providing medical insurance by the private insurance companies is rapidly gaining currency in the market. At present it is estimated that private insurance covered 3% of the medical expenditure in the island. Ambulance services, mobile emergency services and home nursing are also becoming increasingly popular among private sector investors.
The involvement of the private sector in the health services certainly eases the pressure and stress on the public health system and the Government Budget. Private sector services also offer options/choices for a certain segment of the consumers in society. The new investment in the sector also provides employment generation and avenues for new research in the medical field.
The private health system provides an opportunity for specialists to earn more remuneration, encouraging them to retain their service in the country. If the private sector can rise to the level of international standards of health services, the opportunity for the development of medical tourism is promising.
It is estimated at present that the value of the private health services is at Rs. 20 billion per year. More space is available for further investment in the sector given the fast ageing population and prevalence of non-communicable diseases.
However, it is widely believed that corporate sector medical services have an arbitrary pricing policy which is not being monitored by any independent body to oversee whether the cost is indeed a necessity in terms of the medical requirements and commensurate with the services provided.
There are certain complains with regard to waiting time of patients to see medical practitioners at private facilities. The waiting time even at public facilities is no better. This phenomenon is mainly due to the heavy demand on the both private and public sector medical service providers.
The private health service providers mainly concentrate on curative medicine rather than preventive medicinal practices. The services of the private facilities are mainly available only for the affluent section of society, marginalising the less affluent but needy people. The lack of contracts between private hospitals and visiting medical consultants are another area of concern. There is a gray area on the relations and the responsibilities regarding the conduct of visiting consultants and their treatment protocols with the private service providers.
Public goods and corporate sector involvement
The Sri Lanka corporate sector has been involved in the delivery of public goods such as telecommunication, financial services, public transport, construction, education and health services for a considerable period of time. Many believe that the participation of the private sector in the telecommunication, financial services and construction sector demonstrates clear benefit to the society.
Private sector involvement in the public transport sector seems to be a failure. The productive involvement of the private sector in the health services depends on how best a monitoring and accreditation mechanism can be placed in the system to ensure the transparent pricing policy and delivery of high quality services to the recipients.
There is a tendency in increasing out-of-pocket spending on health services. Some researchers estimate that out-of-pocket expenditure on health services in Sri Lanka as high as 86%. However, Government sources estimates the out-of-pocket expenditure on health services as 49%. WHO set a benchmark on out-of-pocket expenditure at 50%.
If higher out-of-pocket expenditure trend continues at a high rate, there is a danger of accessing health facilities by the marginalised and vulnerable segments of the society. Policymakers should be alive to this tendency.
Corporate sector involvement in the private medical business is likely to increase in the future due to the demographic changes and the emerging lifestyle of society. It is therefore necessary to place a proper monitoring and accreditation system to improve the delivery of quality health services by the private sector.
Safe drinking water
In addition to the health sector, the New Delhi high level sub regional forum had a special session on improving basic sanitation, access to safe drinking water and policy options based on the experience of participating countries.
In respect of Sri Lanka’s experience, the representative of SARVODAYA narrated its experience in providing community-based sanitary and drinking water supply network. One of the other highlights was private-public sector participation in a project for supplying of safe drinking water by the Real Estate Division of The Finance Company (TFC) in Sri Lanka in association with the Water Board in a small hamlet in the Kandy District.
The TFC with its financial resources has invested Rs. 158 million to supply drinking water to the Haragama Village in the Kandy District from the Mahaveli River which would benefit almost 3,500 rural families who have hitherto deprive of safe drinking water. The National Water Supply and Drainage Board, Kandy provides technical assistants to the project. The project is expected to be completed in April this year and the attention of the relevant authorities on a priority basis is called for early completion of the project.
(This paper has been compiled by the Research and Policy Advocacy Unit of the FCCISL. Comments are welcome via email to [email protected]. Further research papers of this nature could be access by visiting the FCCISL Trade Watch Blog – www.blog.fccisl.lk. The columnist who attended the high level forum in New Delhi presented a paper on the involvement of the Sri Lankan corporate sector in the health services.)