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Family Physicians without a Defined Target Population in Sri Lanka
Rasnayaka M Mudiyanse*
Department of Pediatrics Faculty of Medicine, University of Peradeniya, Sri Lanka
*Corresponding author: Mudiyanse RM, Head of the Department of Pediatrics Faculty of Medicine, University of Peradeniya, Sri Lanka, Tel: 0094812222900; E-mail:
rasnayakamudiyanse@gmail.com
Received date: September 8, 2014; Accepted date: October 1, 2014; Published date: October 8, 2014
Copyright: © 2014 Mudiyanse RM. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Sri Lanka is known for its commendable healthcare indices in the region. Now the country is going through a
transition of economic development after the devastation as a result of a 30-year war and the natural disaster of a
tsunami in 2004. At the same time, there is a demographic and epidemiological transition. The proportion of older
population is increasing with a simultaneous increase in non-communicable diseases. The country is achieving its
millennium development goals through improving neonatal mortality, infant mortality maternal mortality, vaccination
coverage and life expectancy, mainly because of the maternal and child health care services delivered to the public
on a well-structured target population. However the target population for delivery of ambulatory care has not been
strictly defined. Freedom of visiting doctors without referrals in a background of not having a target population has
created many problems. Optimum utilization of expert services has been hampered due to overcrowding and mal-
distribution of service demand. Commercialization of healthcare has extended to inappropriate importation of drugs
and opening up of pharmacies. Out-of-pocket spending for out-patient care has escalated over the years at a
significant rate probably contributed to by individual investments in health promotion or NCD prevention. Lack of
responsibility to a target population has undermined the doctor patient relationship that is probably contributing to
some of the prevailing undesirable behavior patterns of healthcare professionals. Organizational reforms including
recognizing target populations and promoting patient centered approaches in establishments and teaching and
training on competencies for family physicians, starting from the undergraduate curriculum, would be a worthy
investment in the future health of the nation.
Keywords: Healthcare; Non-communicable diseases; Family
physicians; Maternal mortality
The Country
Sri Lanka is a 65,610 square kilometer [1] island located south of
India, with 20,483 million [1] multi-ethnic and multi-religious
population. The majority (74.9%) are Sinhalese, 11.2% are Sri Lankan
Tamil, 4.2% are Indian Tamil, 9.2% are Muslim and 0.5% belong to
other ethnic groups [1], Religions Buddhist 70.2% Hindu 12.6% and
Christian 7.4% and Islam 9.7% population, make up the profile [1].
The country is progressing in spite of a 30-year war and the natural
disaster tsunami in 2004. Per capita income has increased up to 3,280
US$ [2] in 2013 from 482 US$ in 1990 [3]. The 2013 United Nations
Development Program Report has categorized the country as a
country with “medium human development” and recommended as a
model for developing societies in not just Asia but everywhere else [4].
Life expectancy has improved to 75.1 years in 2012 [1] from 69.5 years
in 1990 [5], adult literacy ratio in 2012 is 95.6% [1] which is an
increase from 92.8% in 1990 [6]. 95% of the population has access to
clean water [4]. Sri Lanka is experiencing a demographic transition.
Number of people above 60 years is predicted to increase from the
current level of 12.1% to 24.4% by 2040, obesity, diabetes and asthma
are on the rise [7].
Successful Healthcare Delivery
The country is on its way to achieving its millennium goals by year
2015., while improving Neonatal Mortality Rate from 13 per 1000 live
births in 2009 up to 8 per 1000 live births in 2013 [4], Infant mortality
rate has dropped from 18 per 1000 live birth down to 8 per 1000 live
births [5], maternal mortality rate is down to 3 per 10,000 live births in
2014 from 6 per 10,000 in 2009 [6]. Life expectancy 75.1 years [1],
infant mortality 8 per 1000 live births, under-five-mortality 10 per
1000 [5], infant lacking immunization for DTP and measles 1%,
antenatal coverage 99.4%, HIV prevalence <0.1% [5].
This success has been contributed to by the well-established
primary care services delivered to target populations all over the
country through 954 government institutions designated to 276
Medical Officer of Health areas with a workforce of about 50,000
people. High literacy rate and reasonable funding has been other
contributors. There are 3.6 hospital beds per 1000 persons and 2,300
persons per doctor and 826 people per nurse [1,5].
Costs of Health Care
Sri Lanka is currently spending about 70 USD per capita for health
care [2,3]. Health expenditure is 3.5% of GDP [1-3]; out of which
Government of Sri Lanka spends 1.7% [2] of GDP for health care,
which is higher than the average (1.3%) for the region. However, the
national healthcare expenditure as a percentage of GDP is lower than
UK (6.8%), Canada (9.2%), Japan (8.3%), Philippines 3.6%, Thailand
3.7% or Bangladesh 3.9%. Contribution for the national healthcare
expenditure from the private sector and out-of-pocket expenditure
amounts to 1.8% of GDP [2,3]. Out-of-pocket spending (OOPs) for a
Sri Lankan in 1990 was 5.2 billion which rose to 76.1 billion in 2009,
spending Rs 70 billion more on healthcare than what they did 20 years
ago [2].
General Practice Mudiyanse, J Gen Practice 2014, 2:5
http://dx.doi.org/10.4172/2329-9126.1000178
Review Article Open Access
J Gen Practice Effective Health Service Delivery to the Target
Population
ISSN:2329-9126 JGPR, an open access
journal
However almost the entire cost of primary care is covered by public
funds generated by taxes, which amounts to about 1.5% of GDP and
48% of the total health budget in the country. The rest of the health
care cost 1.4% of the GDP (43.1%) [2,3] is generated by out-of-pocket
expenditure and the balance is provided by employers, insurance and
volunteer contributions.
The major share (86%) of the private sector expenditure (46% of
total healthcare expenditure) on health is paid by the out-of-pocket
spending (OOPs), which is defined as expenses for health by the
private household money that is not covered by insurance or any other
means [7]. OOPs amount to 1.4% of the GDP which was 76.1 billion
Sri Lankan rupees in 2009. Employers, insurance and volunteer’s
contribution provide rest of health expenditure [8]. Effect of OOPs on
poverty is inevitable. In a recent study involving 11 Asian countries,
accounting OOPs in the calculation per-capita income has resulted in
an additional 2.7% of the populations falling below the standard
poverty line of 1 $ per day. Almost 30% of the direct and indirect
healthcare costs in Sri Lanka are borne by patients and 10% of patients
declare that it difficult to bear [9]. In such situations only the provision
of social and financial support could prevent the medical poverty trap.
Unfortunately current practice is limited to provision of financial
support and limited numbers of elderly care homes and day care
centers and the necessary provision of services is non-existent [9].
Preference to use private sector healthcare services among better-off
families has made them more vulnerable to catastrophic health
spending than poor families; a phenomenon observed in Thailand
even after the provision of universal health coverage [10].
Cost of management of minor ailments has been inflated due to
free-hand health seeking behavior. People seek specialist’s advice in
main cities even for minor and viral infections, leading to escalation of
costs incurred by the cost of travelling, higher fees for doctors and
more investigations. Such healthcare seeking behaviors become
inevitable due to devastating health care issues like dengue and
chronic kidney disease. Dengue ‘the deadly disease of tropics’ has
disturbed 44 456 people in 2012 and caused 180 deaths, the trend
seems to continue [9]. Prevalence of Chronic Kidney Disease has
increased exponentially over the years; currently the prevalence varies
from 15% to 23% in some districts of the country [11].
Family Physicians, First Contact Doctors and Target
Population
Family practice has been established well over 150 years ago in Sri
Lanka. Most of the time family physicians in Sri Lanka had solo
practices and were not affiliated to the public health care system. The
first National Organization of General Practitioners was the
Independent Medical Practitioners’ Association (IMPA), which was
founded in 1929. The College of General Practitioners of Sri Lanka was
founded in 1974. World Organization of Family Doctors (WONCA)
accepted Sri Lanka to its membership in 1978 [12]. However family
physicians had never recognized defined target populations in Sri
Lanka. Government institutions provided first contact care for people
of the locality even though there was no strictly defined population
and the population served by a medical officer in a recognized area
was too large to develop doctor patient relationships that were
expected from Family Physicians.
Economic reforms in 1977 allowed medical practitioners from the
government service to practice privately outside their official working
hours for a fee charged from the patient [13]. Along with these open
economic policies private sector healthcare expanded extensively. The
public started seeking specialist opinion regarding a variety of health
issues from private consultation centers in main cities frequently.
Non-specialist medical officers also offered after-hours services to the
public for a fee without any demarcation of target populations. The
public had to spend more money out of their pockets. Ever expanding
private sector services offered to the public were not confined to a
target population. There is no referral system and recordkeeping is not
a necessity. Number of private hospitals has gone up from 44 in 1990
to 112 in 2011 [1].These institutions provided out-patient care to
419,000 in 1990 and to 6 million in 2011. Number of patients treated
as inpatients in private hospitals has gone up from 65,000 in 2009 to
401,000 in 2011 [2]. In-hospital services of the private sector have been
utilized mainly by the high-income groups, but the out-patient
services were utilized by people of all income categories. Expansion of
the private sector has opened up 3000 pharmacies and 10,000 new
varieties of drugs were imported in 2011 compared to 2 200 varieties
imported in 2001 [6]. This is probably linked to the prescription
patterns of doctors [8]. This system allows the general public to access
whatever the healthcare facilities in the country without appointments
irrespective of the type of the medical problem. This freedom of access
to healthcare services enjoyed by general public was not without its
own problems.
Impact of Lack of Defined Target Population and
Referral System in the Country
Expansion of the private sector has widened the in inequities and
adversely influences the healthcare seeking behavior of the general
public [14]. Patients visiting specialists are likely to lose the
relationship with medical officers in their locality. When patients start
changing doctors frequently, they will end up in “doctor shopping”,
without proper planning or regular follow up. As there is no proper
record keeping repetition of investigations become inevitable. The lack
of professional guidance has resulted in irrational spending and
escalation of out-of-pocket expenditure with an inevitable impact on
their economic status hampering even some important aspects of their
own health. As people seek for specialist advice more and more, people
gather around popular specialists and popular healthcare centers
resulting in over-crowding and long waiting time in some places while
some of the other private centers as well as public centers were empty.
Scheduled visits were not a routine practice. Patient has the liberty to
visit any doctor on their schedule. Such unscheduled visits to doctors
are bound to cause confusion and disorganization of services [15].
Specialists’ time was consumed by attending to minor ailments and
time available for them was curtailed due to over-crowding. This
situation would have undoubtedly led to deterioration in the quality of
performance. Ultimate result is direct or indirect commercialization of
the entire health service. Multitudes of health care facilities became
available. Competitive nature of private practice was not without
conflicts between colleagues; situation being made worse by the lack of
a target population. Patients under-valuing locally available services
not only spend excess of money by lending and selling their belonging
but also have higher chances of delaying to get even the available
services. Such a system is conducive for errors in diagnosis as the
patients take the initial decision regarding the specialist to consult.
Irrational healthcare seeking behavior and escalation of out-of-
pocket expenditure is likely to end up in catastrophic consequence on
health in a country with an impending explosion of non-
communicable diseases and an ageing population in the country. In
Citation: Mudiyanse RM (2014) Family Physicians without a Defined Target Population in Sri Lanka. J Gen Practice 2: 178. doi:
10.4172/2329-9126.1000178
Page 2 of 4
J Gen Practice Effective Health Service Delivery to the Target
Population
ISSN:2329-9126 JGPR, an open access
journal
the current practice NCD prevention activities seem to be
concentrated in the secondary and tertiary care centers of the
government sector and in the private sector located in main cities
catering for the affluent society [7]. However in a society in the phase
of transitions to affluence, NCD prevention strategies should be
universal and affordable to everybody. The society should be
motivated and guided to invest on health promotion that would be
otherwise surpassed by the escalating out-of-pocket expenditure on
regular ambulatory care.
What could be Done?
Organizational reforms including recognizing target populations
and promoting patient centered approaches in establishments and
teaching and training competencies for family physicians starting from
undergraduate curriculum would be a worthy investment in the future
health of a nation.
Change in the organizational structure is mandatory. Problems of
the healthcare delivery have been recognized mostly as inadequacy of
funding, facilities and regulations [8]. Place for private public
partnership in delivery of health has been highlighted [13]. However
the value of patient centered care, identifying target populations,
promoting doctor patient relationships and the need for teaching and
training competencies for family physicians has not got deserved
attention [16]. Competencies in communication, advocacy,
collaborations, managerial skills and professionalism that trained in
family medicine could be utilized optimally to ameliorate many issues
highlighted earlier. Teaching and training should focus on developing
better attitudes and building relationship. A background of serving for
a target population is essential to achieve this.
Patient centeredness is the key. Doctor centered approaches
promoted in 1950s adopted methods of Western science and data
gathering style of communication was paternalistic and patients’
psychosocial needs were marginalized. Recognition of the value of
patient’s engagements, perceptions and partnership in successful
health care delivery has led to the birth of the concept of patient
centered care that has demonstrated multitudes of benefits all over the
world [16]. Successful primary health care programmes in Sri Lanka
were ‘program centered’ on target populations but not necessarily
patient centered. The public with high literacy ratio exposed to
expanding avenues to access medical knowledge demand more and
more partnerships rather than being passive followers of doctor’s
advice. This situation along with an increasing population of elderly
people with multiple healthcare problems demands more time from
doctors. However working environment distracts the doctor from
patient centeredness [16]. Doctors are occupied with clearing the
crowd and time is diverted to administrative or managerial issues,
entering data into computers and attending meetings [16] People
flocking around the consultation table are prohibitive of personalized
discussion.
The available workforce could be utilized optimally. At present 17
000 doctors are available to deliver ambulatory care to the public in the
public sector [3]. They are ready to extend their working hours by 2-6
hours beyond routine duty hours. This could be utilized optimally.
Family physicians in the private sector and first contact doctors in the
government institutions should be allocated a defined target
population and promote practice of competencies in family medicine.
Such an approach would create more realistic private public
partnerships while preserving doctor patient relationships that are
conducive for well-coordinated healthcare delivery.
Teaching and training has a major role to play. Inculcating patient
centred attitudes, empathy, communication skills and collaborative
skills are immediate essentials for all these doctors as most of them
have been trained previously on a traditional subject based
curriculum. Most of the family medicines competencies are integrated
with attitudes. They are nevertheless trainable. Continuous
professional development programmes targeted to all professionals
that have been initiated by professional bodies need strengthening and
streamlining to achieve the best out of it.
Teaching and training should be initiated from the beginning of the
undergraduate curriculum. As almost all the doctors are accepting the
management of first contact patients, they should be abreast with
family medicine competencies. The undergraduate curriculum should
cater to this need irrespective of student’s preferences on
specialization. The necessity should not be surpassed by introduction
of postgraduate courses in family medicine. So far only 85 out of over
10,000 doctors who are involved in family medicine have undergone
post graduate training [12]. Teaching Family medicine concepts
without real Family Physicians creates an artificial situation. However
some of the medical faculties in the country have created Family
Medicine Units for the purpose of teaching and claim are made that
they are quite successful. Prevailing system diverts the student towards
specialization other than family medicine, marginalizing the need to
learn important competencies for a first contact doctor. There is a
trend to select ultra specialization by students for their carriers because
of convenience or the financially lucrative nature of the job. The
government has an unofficial obligation to provide them with jobs in
main cities even if the peripheries are devoid of the full complement of
basic specialists, partly due to influences on the system either by trade
unions or other influential people such as politicians.
The public has a role to play. Patient centeredness does not confine
to health professionals. Our patients are not patient centered as much
as we could expect from their educational back ground. Most of the
problems are entrenched in the healthcare seeking behavior of the
public for which doctor patient relationship matters more than
anything else. Such relationships could be established by defining
target populations and patient education. Knowledgeable society is the
strength of a healthy nation.
Conclusion
Recognition of target populations and reorganizing the ambulatory
services and establishing universal NCD preventive activities should
further enhance and preserve achievements in health indices in the
country. Establishing proper family medicine system in the country
could mitigate many issues in the delivery of healthcare including
escalating out of pocket expenditure and its consequences. Delivery of
healthcare needs personalized attention and collaborative planning
while paying attention to holistic care and patient empowerment. All
the universities should invest on enhancing their undergraduate
Family Medicine Curricula rather than promoting specialization. The
need for teaching family medicine competencies in undergraduate
curricula cannot be replaced by postgraduate courses in family
medicine.
Citation: Mudiyanse RM (2014) Family Physicians without a Defined Target Population in Sri Lanka. J Gen Practice 2: 178. doi:
10.4172/2329-9126.1000178
Page 3 of 4
J Gen Practice Effective Health Service Delivery to the Target
Population
ISSN:2329-9126 JGPR, an open access
journal
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This article was originally published in a special issue, entitled: "Effective
Health Service Delivery to the Target Population", Edited by Jongwha Chang
Citation: Mudiyanse RM (2014) Family Physicians without a Defined Target Population in Sri Lanka. J Gen Practice 2: 178. doi:
10.4172/2329-9126.1000178
Page 4 of 4
J Gen Practice Effective Health Service Delivery to the Target
Population
ISSN:2329-9126 JGPR, an open access
journal
