Random thoughts on healthcare
Address by Healthcare and Nutrition
Minister and World Health Assembly President Nimal Siripala de Silva at
the annual Convention of the International Medical Sciences Academy (IMSA)
on October 24 and 25 in Chandigarh, India.
From the medical science angle, the most basic change in healthcare
in the past decades has been our view of human biology, and the way we
see the individual.
Previously we used to visualize the individual purely from a biological
and molecular level as a “Case”, but now we see him also from a cultural
angle, as part of a family and society, and this has altered the way we
look at health and sickness. Therefore we now know that simple disease
models are not enough, and we have to understand how personal and
collective behaviours contribute and give rise to disease, and therefore
regard the whole family and the community as the “patient”.
In Sri Lanka, three main systems of medicine prevail; main stream
being allopathic medicine but this has not deprived the people of
gaining access to other systems of medicine namely Ayurveda, Homeopathy
and traditional systems of medicine.
My personal opinion is that it would be wrong to compartmentalize
ourselves to a single discipline of medicine. All of these disciplines
could work holistically in an integrated manner towards one all
important ultimate goal - the health and well-being of mankind.
It is logical to have all these forces work in a harmonious manner,
may even be under one roof, in reaching the above mentioned health goal
in a cost effective manner. I believe the primary healthcare movement
that resulted in the Alma Ata Declaration 30 years ago helped to make
this fundamental shift. This has led to the second important change,
which is the recognition of the limits to curative bio-medicine.
We have come to recognize the limits to very expensive “after the
fact” remedial technical interventions. There is no doubt that high
level sophisticated technology when applied judiciously can work wonders
to help save patients’ lives. But their injudicious application is
driving the healthcare costs far beyond the capacities of our developing
countries. I find this dilemma each working day as the Health Minister
in my country.
My observation is quite often the results in terms of quality of life
and life years gained remain in doubt. In most countries communicable
diseases as the cause of
Sri Lanka spends enormous funds on non-communicable disease
prevention. File photo
death has been replaced by non communicable diseases (NCD) such as
the chronic and old age diseases and cancers for many of which medicine
has few complete cures. In my country, non-communicable diseases now
predominate as the leading cause of mortality. As you are aware,
managing NCD’s would be a costly excercise which a developing country
could not possibly afford.
Primary and secondary prevention of NCDs need to be given priority in
our health system. For us this is the way ahead and it has changed the
way we Sri Lankans are now trying to organize our health services.
Health promotion and behavioural aspects are now receiving much greater
attention in my country.
Social determinants of health is another important area that any
government should consider to improve the health status of their
countrymen. Here we are looking at the “causes of causes” and research
and evidence should play a big role in making a change.
The macroeconomic commission a few years ago recommended a minimum of
35 US dollars per capita as an essential investment, but I would suggest
that we all try to invest much more than this. Sri Lanka currently
spends around 80 US dollars per capita and we find that even this is not
sufficient. But we have been fortunate that my President, Mahinda
Rajapaksa, in his vision for development Mahinda Chintanaya, has put a
high premium on health and education.
This meant that in spite of fighting a ruthless terrorist
organization, the LTTE, which took away a lot of our valuable resources
that we could have used for development, we did not curtail our
expenditure on health. Fortunately we got rid of the LTTE now - although
we still have to remain alert to any new threats - and we are optimistic
that we would be able to invest even more in the social sector,
particularly in health and education. One of the serious concerns are
the issues related to the migration of health personnel, particularly
the doctors, and now it has also spread to the nurses.
Sri Lanka is a country that has been suffering from Brain Drain for
sometime now. We have seen some of our brightest and the best trained
young doctors leave seeking greener pastures to the developed countries.
Firstly consider the investment. Successive Governments have considered
health and education as investments to produce a healthy and literate
workforce. Therefore primary, secondary, tertiary education and even
postgraduate education have been provided absolutely free to all the
people. The doctors have optimally benefited from these social sector
We find it extremely difficult to replace the specialist doctors who
migrate as the training of a specialist takes a long time and is
We are really making a huge subsidy or a resource transfer to these
developed countries. Being a free and democratic country, we need to
allow freedom of movement and the freedom to live and work where
individuals prefer to do, but should there not be some international
covenant or understanding on this matter, so that our countries do not
suffer too drastically from this phenomenon?
I have been advocating very strongly for such a Covenant or Charter
both in the World Health Organization as well as in the Commonwealth
Health Ministers Meetings for almost a decade. It is heartening that the
WHO has now developed a Code of Practice for the receiving and the
source countries to adhere to.
Even though this is only a moral obligation at the moment, I hope it
will be taken seriously and adhered to by all the countries.
This Code is not likely to solve all our problems but it will help
mitigate some of the adverse effects and allow for some forms of
compensation to the developing countries which are losing their valuable
intellectual and scientific capital.
We as policy makers can do more to create a conducive environment for
our doctors to live and work in our countries. But I feel that
Associations such as yours also have a major role to play in this
matter. How could you instill a sense of national mindedness in the
young medical graduates of our countries? In addition to fine-tuning
their knowledge and skills, how can we provide them with a value based
education, an education that will stimulate them to stay in their own
countries and humanize them to respect the rights of the poor and the
less privileged people in our communities to obtain optimum health care?
I also like to highlight the need for us in South and South East Asia
to strengthen our collaboration in medicine and medical education. With
the shifting of the economic axis to Asia, I see this as a necessary
development, so that we can share our expertise and resources more
productively and in mutually beneficial ways.
For example, why should we not mutually accredit and recognize our
education and training programs? Why do we not embark on more Continuing
Professional Development Programs among our countries? Why should we not
encourage greater movement of our health personnel among the countries
within our region?
Why do not we embark on more research collaboration activities on
health problems of common interest to us? Why should we not foster
greater professionalism among our health professionals? I see these as
urgent and it is time for us to begin.
I need to mention here the great respect we in Sri Lanka have for
your former President, Prof Abdul Kalam. We consider him to be one of
the best scientists of South Asia, the whole world, in the last century
and have been inspired by his powerful intellect, his simplicity and
above all his patriotism to give back to the country much more than he
possibly could have received. Your organization is in a very pivotal
position to provide leadership in many of these activities.
I wish to submit to you that all of the great philosophies, most of
the fundamental scientific principles and inventions originated from
Asia and have spread to the West. Buddhism, Hinduism, Christianity and
Islam all originated in our neighbourhood and it would be a great pity
if we do not explore their potential value for medical education and
practice much further.
We in Sri Lanka also have many of these examples in engineering and
scientific achievements which have been feats at which Western
scientists marvel even today. In this way, they long predate similar
Western scientific development. We should try to foster our own models
for developing the medical sciences and its practice and generate our
own scientific temper.
These in turn could be models for both the East and the West to
consider in the future. One essential feature of all such models of
health development will have to be a concern for humanity and to ensure
that they ultimately lead to the improvement of the lives of our common
In an intricately globalized world, I would like to offer this as an
exciting regional level challenge for your esteemed organization to
address in the next few years.