COUNTRY PAPER

Migration of Human Resources for Health within and out of Sri

Lanka – Report and Analysis 2005

Professor Rezvi Sheriff MD FRCP FRCPE FRACP FCCP

Professor and Head Dept. of Clinical Medicine,
Faculty of Medicine,
University of Colombo,
PO Box 271, Colombo, Sri Lanka.
E mail: <rsheriff@emed.lk>

3rd August 2005

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Abstract
The health care system in Sri Lanka is structured to provide a wide range of curative
and preventive health care needs to the people. There are two parallel systems
namely the allopathic and the indigenous systems. The former being the more
utilized in Sri Lanka, this article focuses on this.

The country has done well in health care delivery within the region, as it boasts not
only of a high literacy rate, but also of low infant mortality and maternal mortality
rates and other indicators of health when compared with other countries of similar per
capita income. However, the budget allocated to health care is only 1.7% of the GNP,
and the percentage for human resource development (4% of the allocation of the
health budget) is abysmally low.

This article addresses some human resource problems amongst which migration of
human capital to resourceful settings is detailed as a priority problem. Several factors
have contributed to dissatisfaction and human resources, especially those with
higher skills and qualifications, migrating towards more resourceful settings, both
overseas and within the country. Some examples include inadequate salaries,
inadequate facilities to provide health care services and for continuing professional
development, inadequate personal benefits, eg. poor prospects for children’s
education, unsatisfactory work environment, poor general management of human
resources, prevalence of a trade union culture, poor collaboration with other
organizations such as universities, NGOs in utilizing resources for health
development and health care delivery. The system also suffers from the lack of a
referral system, lack of guidelines and protocols, poor supervision and poor research
ethos with resistance to change. The above factors directly and indirectly, through
complex interactions promote migration of human resources for health.

Beginning to solve the human resource problems in Sri Lanka’s health sector is a
daunting task. This requires immediate action as well as an organized medium and
long-term action plan. Recommended actions include the following:

¾ improving remuneration, both financial, education and professional development

(CPD), personal benefits, incentives coupled with mandatory service in remote
areas and rewards schemes
¾ improving work environment, facilities and human relations and promoting a
corporate culture
¾ improving the management system, developing evidence-based methods and
research for HR and health system development, organizing data collection and
flow with appropriate networking,
¾ developing and implementing a practical referral system
¾ building partnerships and networking with all sectors involved in training HR and
health care delivery, including Universities, NGOs, private sector and other
government bodies such as Social Services, Police, etc.
¾ capacity building of HR, improving basic education and training, CPD and “soft
skills” such as effective communication and people management

It is hoped that developing attractive working environments and incentives schemes

including CPD would help to retain HR within the country, improve the equity of
distribution and promote their professional development, thereby helping to deliver
better health care to the people in both goodness (quality) and fairness (equity of
access).

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COUNTRY PAPER

Migration of Human Resources for Health within and out of Sri

Lanka – Report and Analysis
Professor Rezvi Sheriff MD FRCP FRCPE FRACP FCCP
Professor and Head Dept. of Clinical Medicine, University of Colombo, Sri Lanka.

Health is the state of complete physical, psychological and social well-being and not
merely the absence of disease or disability, as defined by the World Health
Organization. More recently, spiritual well-being has also been included in the
definition. All the organizations, institutions and resources that are devoted to
producing health actions together comprise a health system. Health systems have a
vital and continuing responsibility to people throughout their lifespan, to deliver safe
health care, both in goodness (responding well to what people expect of it) and
fairness (responding equally well to everyone without discrimination).[1]

Resource inputs for health care delivery include physical capital, human resources
(capital) and consumables [1]. The term “human resources” has various definitions. It
was traditionally known as “labor” or “workforce”. However, human beings are not a
predictable “commodity resource”, but are creative and social beings who make
contributions beyond “labor” to society and civilization. The term “human capital” has
evolved, in order to express the complexity of the term [2]. In this paper, we shall
refer to human capital as HR to avoid confusion with Health Care (HC). Human
capital in health, the different kinds of clinical and non-clinical staff, who make each
individual and public intervention happen are the most important of the health
system’s inputs. The performance of health care systems depends ultimately on the
knowledge, skills and motivation of the people responsible for delivering services.

This paper attempts to:

1. describe structure of the health care system, the situation and trends in health
care provision, and priority problems in human resources for health (HRH)
care provision in Sri Lanka

2. propose priority actions that are required in Sri Lanka

3. propose recommendations for development of the work plan (focusing on

information, research, capacity building and in-country mechanisms to
accommodate participatory development of HRH)

(1) The structure of the national health care system of Sri Lanka

Sri Lanka has a long tradition of Indigenous and Ayurveda health care systems
dating back to approximately 2500 years. Archeological evidence confirms the
existence of hospitals and sophisticated surgical practices during this historical
period. Several other systems of medical practice (Unani, Siddha and Allopathic)
were subsequently introduced to the country by different foreign groups. This has
now resulted in a pluralistic health care system with a varying mix of Allopathic,
Indigenous Ayurveda, Unani, Siddha, Homeopathy and Acupuncture. However, the
state allopathic system appears to play a key role in the delivery of health care,
especially in the preventive and in-patient curative sectors. [3]

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The health seeking behaviour of the people varies between urban and rural
communities; acute illnesses and chronic illnesses; some specific conditions.
Ayurvedic medicine still enjoys a fair proportion of clients in treatment of conditions
like bone fractures or joint dislocations, chronic pain resistant to allopathic analgesic
drugs (eg. rheumatoid and osteo-arthritis) dermatological conditions for which topical
applications are available eg. psoriasis, snake bites and some psychiatric disorders.
Following the OXCOL (Universities of Oxford and Colombo) trials in Anuradhapura
district, health-seeking behaviour of patients following snake bites in this mainly rural
population has shifted towards seeking allopathic treatment. However, urbanized
communities preferred allopathic treatment for chronic diseases. A study done in
Gampaha District revealed that approximately 99% of the community preferred
allopathic medicine for the treatment of chronic diseases. Alternative medicines such
as homeopathy and acupuncture are sought for some debilitating diseases that do
not respond to conventional allopathic treatment.

Sri Lanka has done well in health care delivery within the region, as it boasts not only
of a high literacy rate, but also of low infant mortality and maternal mortality rates and
other indicators of health when compared with other countries of similar per capita
income and countries in the South Asian region. In Sri Lanka, health care is provided
by the state and private sectors and Non-Governmental Organizations (NGOs).

The state health care system is structured to deliver health care by two parallel
administration systems viz. the Central and Provincial. The state health services of
the government functions under a Cabinet Minister. With the implementation of the
Provincial Councils Act of 1989, the health services were devolved, resulting in the
Ministry of Health at a national level and eight Provincial Ministries of Health. [5]

The Central Ministry of Health is primarily responsible for the protection and
promotion of people’s health. Its key functions are setting policy guidelines, medical
and paramedical education, management of teaching and specialized medical
institutions, and bulk purchase of medical requisites.

The eight Provincial ministries are responsible for the management and effective
implementation of health care delivery in the respective provinces. These include the
management of curative services including hospitals (provincial, base, district,
peripheral and rural hospitals and maternity homes) and out-patient facilities such as
central dispensaries (CDs) and visiting stations, and the preventive and promotional
health care services through the Medical Officers of Health (MOH) / Divisional
Director of Health Services (DDHS). Curative and preventive (and promotional)
health care are delivered by two parallel systems. [5]

The alternative medicine system is handled by a minister with a more modest but
similar central and peripheral structure.

The basic structure is given in Figures 1a and b below [5]:

NGOs collaborate with the Ministry of Health to carry out some widespread health
care delivery services, such as the Anti-Malaria Campaign, Anti Filariasis Campaign,
Acute Respiratory Diseases Control Programme, Anti Rabies Campaign, Anti
Leprosy Campaign, STD/AIDS Control Programme. Several other programmes
sponsored by NGOs cater to various health care needs of the country, such as
mental health, reducing harm from tobacco and alcohol, women’s health, etc.

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The private sector provides mainly curative services. These include hospital based
in-patient and out-patient services and General or Family Practioners.

Financing of health care

Public taxes are utilized to provide these services to the public free of charge through
the national health care system. The services provided by the state sector are limited
by the available budget allocation. The average percentage of the government
spending on health ranged from 4 – 5% in the last 10 years. During 2002, the
proportion of public expenditure on health was 4.3% of the national expenditure, and
1.6% of the Gross National Product (GNP). The per capita expenditure on health was
Rs. 1339 (equivalent to USD 16) in 2002. [5, 6, 10]

The recurrent expenditure accounted for 84% of the total expenditure. In 2002, Sri
Lanka spent 67.4% of its annual health expenditure on curative services, while
community and preventive services amounted to only 8.6%. 13.6% was for general
administration. The central ministry of health and the Department of Health Services
utilized 65% of the total health expenditure. A meager 4% was allocated for training
and scholarships. The Ministry of Health funds the Nursing, Paramedical schools and
in part, the Postgraduate Institute of Medicine, while medical schools are funded by
the Ministry of Higher Education. [5] (Figure 2: Breakdown of National Expenditure on
Health; Legend: In 2002, the majority (67.4%) of the national health expenditure was
on curative services. Preventive and promotional activities accounted for only 8.6%
of the health budget. A meager 4% was allocated for human resource development
(scholarships and training). Data from Annual Health Bulletin 2002 [5]) and (Table 1:
Public investment: 2005 – 2007 Activity Plan 2005 - Health sector; Legend: Another
example of the low priority given for development of HR is seen in this excerpt from
the Sri Lanka New Development Strategy 2003, which identifies financial allocations
for the year 2003-2004. [7])

The private sector also provides a significant proportion of health care services to the
public. The Annual Health Bulletin 2001 states that in 1997, the state and private
sectors each accounted for approximately 50% of the Total Expenditure on Health
(similar for 2002). 43% of the private sector health expenditure was paid out-of
pocket by the user, and less than 5% by employers or health insurance. Most of the
private sector expenditure was for out-patient primary care and purchase of
medicines from private pharmacies. [5]

Curative services are expensive when compared to the cost-effectiveness of

preventive care. The proportion spent for prevention declined from 11% in 1990 to
6% in 1999 and in 2002, amounted to 8.6%. Preventive health accounted for less
than 1% from private sources. Eg. the Expanded Programme of Immunization
accounts for bulk of the state preventive health expenses. [5]

Another example of the low priority given for development of HR is seen in the
excerpt from the Sri Lanka New Development Strategy 2003 (Table 1), which
identifies financial allocations for the year 2003-2004. [7]

It is evident that HRH development is low priority when one looks at the overall
picture of health financing in Sri Lanka.

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Priority health problems

Some priority areas have been identified by the Perspective Plan for Health
Development in Sri Lanka (1995-2004) [8], which followed the National Health Policy
of 1992 [3]. These include:

• maternal and child health

• nutrition
• care of non-communicable diseases (NCD)
• primary care, prevention and health promotion (eg. tobacco, alcohol abuse)
• mental health issues
• occupation related illnesses
• care of the elderly, disabled – physical and psychological, victims of war and
violence, child abuse

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The Sri Lanka HRH Situation - Country analysis

There are various categories of human resource staffing the Ministry of Health. HR
involved directly in health care delivery in the curative sector include doctors, dental
surgeons, nurses, hospital midwives, assistant medical practitioners (AMPs),
pharmacists and other paramedical staff (Medical laboratory technicians (MLT),
radiographers physiotherapists, occupational therapists, etc.), attendants and
labourers. The preventive and promotional sector includes additional field staff such
as dental therapists, public heath midwives (PHM), Public Health Inspectors (PHI),
Food and Drug Inspectors (FDI), and others shown in Figure 1b. Administrative staff
and non-medical staff such as accountants and clerks are also part of the HR in the
Ministry of Health. All health care professionals - doctors, AMPs, dental surgeons,
nurses, midwives, PHMs, pharmacists and paramedical personnel are required to
register with the Sri Lanka Medical Council (SLMC). The body responsible for issuing
the certificate of competence for those trained by the Ministry of Health is the Ceylon
Medical College Council (CMCC).

Doctors are graduates of mostly state universities, with a few qualifying from other
countries, after having passed an examination under Act 16 of the Medical
Ordinance. Following 1 year of internship provided by the Ministry of Health, they are
registered with the SLMC. To-date, all doctors are absorbed into the Health Ministry
unless they opt to leave to join another institution in the state or private sector. After a
period of service in the Ministry, they may follow postgraduate courses conducted by
the Postgraduate Institute of Medicine (PGIM) with special clinical training to become
specialists.

Dentists receive a graduate training at the University of Peradeniya. They are not
given a period of internship. The last two batches have not been employed by the
Ministry of Health. However, they perform fairly well in the private sector. The
country’s need for dentists is 1:5000 population. At present, the ratio is 1 dentist per
15,000 population. It is much higher in towns, where the dentist : population ratio is
approximately 1:3000, while in rural areas, it is around 1:30,000. Community dental
therapists were trained at a School for Dental Therapy, which has been closed.
Dental surgeons may follow a distance learning course conducted by the PGIM and
College of Dental Surgeons to attain postgraduate qualifications as consultant dental
surgeons.

Nurses are trained at the Nurses Training Institute of the Ministry of Health which
has 13 branches islandwide. They receive a certificate level training, although
selection is based on GCE ‘A’ level performance and university entry criteria. A
graduate training programme for nurses is commencing at University of Sri
Jayawardenapura. Further professional development is a post-basic training at the
Post-basic School of Nursing. Public Health Midwives receive certificate level training
at the National Institute of Health Sciences (NIHS).

Pharmacists are trained mainly by the Ministry of Heath, at NIHS and at the NHSL,
in collaboration with the University of Colombo, where a diploma level course is
conducted. A diploma level External Pharmacists’ Examination is also conducted by
the CMCC in collaboration with the University. The University does not provide tuition
for this examination. Candidates are required to follow a two year apprenticeship with
a “master pharmacist”. A small number of BSc (Pharmacy special) graduates are
produced by the University of Colombo – 10 per year for the past four years. Plans
are underway to commence a B.Pharm course at University of Sri Jayawardenapura.

7
Other paramedical staff such as occupational therapists, PHIs, are trained similarly
by the Ministry of Health, and some categories at Universities. Eg. speech therapists
are given a diploma level training at University of Kelaniya. The majority receive
certificate level training. AMPs are a group of people trained to make a limited
diagnosis and treat simple common disease conditions, as well as to manage drug
stores. The tasks of AMPs above are being taken over by the increasing number of
graduate doctors and pharmacists respectively.

The distribution of health resources, with emphasis on HRH in Sri Lanka, and trends
in HR distribution, numbers of training institutions and outputs during the past 10
years and the trends are shown in the annexure – Table 4 on Basic Information on
Human Resources for Health in Sri Lanka.

Some categories of health care HR are gradually increasing in numbers and also
branching out in specialities, eg. specialist doctors, and paramedical staff such as
speech therapists, occupational therapists. Some others are gradually being phased
out, eg. dental therapists, AMPs. This move appears to be a sensitive issue
responsible for trade union action.

A SWOT analysis of the HRH in Sri Lanka

Below is an analysis of the strengths, weaknesses, opportunities and threats faced
by HRH during health delivery in state and private sectors.

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 SWOT Analysis
Strengths Weaknesses
Strengths of State sector Weaknesses of State sector

Doctors Doctors
• Clinical skills rated on par with • Inadequate skills in management, especially people management within the health care
international standards due to good team and with the public (at present only 1/6 medical schools include inputs on
training programs both graduate management in the medical curriculum), leading to poor cooperation from other
and postgraduate members of the health care team
• All medical schools are state- • Inadequate remuneration – financial and educational, eg. library, IT
owned at present, providing free • Inadequate equipment and support services to carry out professional activities
education to highly competitively • Inadequate infrastructure for social welfare, eg. housing, schools and leisure at stations
selected candidates of service
• Several options for postgraduate • CPD is difficult in peripheral stations due to unavailability of learning resources
qualification by PGIM. Continuing • Waste of human resources due to mismatches in training and recruitment, eg. trained
professional development (CPD) neurosurgeon serving in the periphery as general surgeon, long delays in giving
actively carried out by various internship and post-internship appointments
professional bodies but needs
implementation of the formal
structure. There is some discussion
in professional bodies to link CPD
programs to revalidation of SLMC
registration.

Dental surgeons Dental surgeons

• High level of competence • No longer guaranteed employment by the Ministry of health
• State sponsored free University • Self-employment involves a large capital for purchase of equipment
undergraduate education • Not offered internship
• CPD – postgraduate course • CPD is by distance learning
conducted by PGIM

9
Strengths of State sector Weaknesses of State sector

Nurses
Nurses • Basic nursing course is a Certificate level training program, Traditional training program
• Skilled nurses in government sector – no scientific thinking skills imparted, poor supervision of clinical work during training
(extensive clinical exposure) • Intake for courses conducted by Ministry of Health is not streamlined for annual intake,
• Hard-working and intermittently politically initiated intakes (sometimes very large batches), hence,
• Graduate education available for difficulties in organizing and maintaining consistency of conducting teaching-learning
small number of nurses activities (see Annexure - Table 1)
• Training inputs in management and • Poor CPD, few CPD activities by Sri Lanka Nurses Association, poor participation, no
communication skills, post-basic journals/newsletters published or circulated; no re-validation of registration
nursing program for Nursing Sister • Training conducted in mother tongue (Sinhala/Tamil) limits the nurses’ communication
training gives more comprehensive and functioning in the health care team, as doctors train in English and write notes in
inputs in management and English, and largely converse in English during ward rounds. This creates obvious
administration difficulties in delivery of care, as well as the nurses’ CPD. The number of text books and
other learning resources in the mother tongue is limited.
• Nurses have to work long hours to earn a reasonable wage. Majority being females, the
problems of service to the family, travel by public transport, rising cost of living leaves
very little room for enthusiasm for CPD.
• The trade union culture limits development of professional standards in nursing. Job
descriptions are given by the trade union, rather than by the employer, which limits
CPD. Unfortunately the Nursing Council, though recognized by statute, is still not
operational.

10
Weaknesses of State sector Weaknesses of State sector

Pharmacists Pharmacists
• Few graduate pharmacists from • Grossly inadequate numbers (4.8 per 100,000 population in 2004) lead to work
University of Colombo. overload, and poor quality service, dissatisfaction and difficulty recruiting and retaining
• Pharmacy diploma, internal and HR
external cater to government and • Inadequate physical facilities and working conditions to function efficiently
private sector needs for different • Graduate pharmacists not recruited into key posts where they are needed due to
competencies, eg. those in charge pressure from trade unions and inability to displace the less qualified but fairly
of stores and drug procurement, experienced personnel serving centrally at present, leaving an “intellectual gap” at the
and those in retail outlets. top of the system (waste of available HR)
• Virtually no CPD • Inadequate Internal Pharmacy training programs conducted by Ministry of Health.
• University consultancy sought to a o Difficulty in coordinating due to ad-hoc intake,
limited extent for intellectual o inadequate staff to conduct training and
national decision making process o poor remuneration for teachers
• Poor quality of training for External Pharmacists’ as University does not conduct training.
o Training programme is poorly supervised by a “Master Pharmacist”
o Poor quality of training due to inadequate numbers of trainers resulting in poor
quality of service

Paramedical and Support staff Paramedical and Support staff

• A variety of paramedical staff • The large category of support staff receive little or no training prior to recruitment and
categories are developing and learn “on the job”.
branching out, eg. physiotherapists, • Very little opportunity for career development prospects
speech therapists, X-Ray • A fair percentage of them are “political appointees”, hence they have difficulty in fitting in
technicians and taking orders from their heads of departments. They may contribute to trade
• Their contribution in the face of unionism within their group.
human tragedy is outstanding • Unfavourable attitudes, indiscipline and insubordination interferes with efficiency of
teamwork

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Strengths of Private sector Weaknesses of Private sector

• HR gain skills in providing client • Variable quality and skills

oriented services with courtesy, • Inability to retain skilled HR – due to inadequate recognition, medical professional
sensitivity, privacy and development opportunities and financial remuneration
confidentiality • Clinical and decision making skills of most categories of HR (other than Consultant /
• Risk of litigation drive HR to provide Nurse /Pharmacist-in-charge may be poorer than in public sector, due to constant fear
safer medical care of litigation)
• Recently developed faster than the • Poor coordination/collaboration with public sector and sometimes within private sector
state sector, especially in • Limited availability of data, poor formal medical communication, patient records,
diagnostics and sophisticated reporting for national statistics, eg. communicable diseases, drug problems, etc.
clinical care • Very little research initiatives
• Few preventive and promotional medicine (health screening programmes, well-woman
clinics, cancer screening programmes, health checkups, etc.) are gaining popularity

Opportunities Threats
Opportunities for State sector HR Threats for State sector HR

Doctors Doctors
• Medical skills and knowledge of • “Brain drain” at both levels, both emigrations to other countries as well as from
English – recognized and peripheries to the capital. Concentration in capital is high in both private sector as well
employable internationally as Ministry of Health
• Employment is guaranteed in • Increasing community awareness of patients rights and litigations adversely affect the
Ministry of Health at present. functioning by promoting unnecessarily excessive medical care and waste of resources,
Cabinet has agreed to provide jobs both in public and private sector
for all who pass out till the year • Trade union culture also affects CPD and patient care adversely in the public sector
2009 • Errant officers doing private practice out of hospital during working hours compromises
the quality of care

12
Opportunities for State sector HR Threats for State sector HR

Dental surgeons Dental surgeons

• Private sector / self employment is • No longer guaranteed employment by the Ministry of health
profitable • Self-employment involves a large capital for purchase of equipment

Nurses Nurses
• Nurses trained by Ministry of Health • The trade union culture is the most significant threat. Frequent labor disputes and trade
– employment guaranteed. union action (eg. strikes) cripples patient care as well as development of the health
• Highly skilled nurses - have good sector. The professional development of nurses, too is limited by this. Job descriptions
employment opportunities overseas are given by the trade union, rather than by the employer, which limits CPD.
• Migration to foreign countries is growing. Approximately 40 nurses left Ministry of
Health in 2004. At present, daily 20-25 requests for recommendations received by
Director Nurse Education and Training. However, emigration is limited by the limited
fluency in English.
• However, concentration around the capital is highlighted in the distribution of nurses:
100,000 population.
• Mushrooming private nursing training programs with poor validation or monitoring by a
regulatory body
Pharmacists
• Trained by Ministry of Health are Pharmacists
guaranteed employment. External • Grossly inadequate numbers lead to work overload, and poor quality service. This is a
pharmacists enjoy profitable threat to the health of the patient or client, and also impedes their CPD.
employment (often self- • Mushrooming private tutories with poor validation. Candidates sit for a Pharmacists’
employment) in private sector External Examination, conducted by the Ceylon Medical College Council in the
University of Colombo. However, the pass rates are very low (10% in 2004)
• Political The trade union culture in public sector is a threat here too. Frequent trade
union action (strikes) cripples the service and retards the development of the health
sector.

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Opportunities for State sector HR Threats for State sector HR

Paramedical and Support staff Paramedical and Support staff

• The need in the private sector is • External politics influences trade unions, with frequent disputes over salary, uniforms,
not yet filled. Opportunities in overtime, suddenly crippling services
private sector available for
additional income as well as full
time employment.

Opportunities for Private sector HR Threats for Private sector HR

• Increasing demand for services • Rising cost of care
creates more employment • Fear of litigation lead to over-investigation and overmedication, and also difficulty in
opportunities recruiting and retaining HR
• Surplus of doctors – available as • Undue influence by commercial advertising without independent situation analysis may
HR for private sector affect patient management decisions, leading to wasting resources
• Pleasant working conditions and • Mushrooming of poorly planned and non-validated commercial training courses– lead to
cleaner environment attract HR poorly trained HR
• High demand for training courses

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(2) Some HRH priority problems in Sri Lanka

From the trends in Table 1 and the SWOT analysis above, some of the main
problems that retard the progress of HRH development and health care provision can
be identified are given below. These problems are interrelated to each other.
1. Migration of HRH during training from resource-poor to resourceful settings –
“brain drain” due to migration to greener pastures both abroad and within the
country migration towards the capital and major cities. The former applies more to
doctors and dental surgeons, but is a growing problem among other groups. The
latter applies to all groups of medical and paramedical HR. This is evident in the
distribution of HR in the capital and other parts of the country in the Annexure -
Table 4.

Contributing to the migration of HRH are some factors, which are priority
problems themselves. i.e.

1.1. “Trade union culture” rather than a “corporate culture “in Sri Lanka,
permeating the health sector, crippling the provision of health care at times
and limiting the continuing professional development of the HR. This is
present among all medical staff – doctors, nurses, pharmacists and other
paramedical HR. The Sri Lanka New Development Strategy 2003 of the
Ministry of National Planning highlights “trade unionism” as a factor
hampering development in almost all sectors in Sri Lanka. External political
influences the HR to maintain the trade union culture. Differences in social
status between team members interferes with teamwork in the delivery of
health care, as it interferes with free and frank communication.

1.2. Unsatisfactory system of promotions : system of promotion and transfers

especially amongst medical officers even at top consultant and
administrative positions are very highly weighted towards seniority and very
little weightage is given to academic competence and skills amongst the
Ministry of Health personnel.

1.3. Unsatisfactory work environment and poor management of resources

1.4. Inefficient utilization of resources due to conflicts between Ministry of

Health, Universities, private sector and NGOs and, sometimes, due to
trade union pressure. The Ministry of Health consultants feel that the
University Consultants should restrict themselves to training medical
students, and not involve themselves in service or development of the finer
specalities, and not willing to share human or physical resources for the
public benefit. Eg. sharing of dialysis facilities at the National Hospital of Sri
Lanka.

2. Inadequate competency and numbers of trained personnel – nurses,

pharmacists and paramedical personnel and other support staff – irregular intake
for training programmes, poor coordination and supervision, with inadequate
numbers of teachers, poor incentives to trainers. This breeds inferiority
complexes among some categories of HR, and promotes segregation and trade
union culture.

3. Inadequate numbers of trained personnel - results in some staff being

overloaded with work, poor quality of care and deterioration of professional
interactions.

15
(3) Migration of HRH as a priority problem - discussion

Of the above HRH problems identified, migration of HR appears to be the present

priority problem. Two types of migration are seen, emigration to other countries and
in-country migration towards major cities, especially Colombo. Both are problems in
Sri Lanka.

Migration to other countries is most evident among doctors and dental surgeons
(Table 2: Highest HR losses among specialist doctors emigrating from Sri Lanka
[10]). This was highlighted by a paper on “Brain drain of specialist doctors from Sri
Lanka” [10] that between 1997-2000, 28% of specialists who had qualified MD/MS
had left the country. However, it is a growing problem among the other health care
HR categories, as pointed out by officials in the Ministry of Health.

Migration to resourceful settings within the country too, is a problem among all HR
categories. Annexure - Table 4 gives evidence of this for doctors, nurses, and
pharmacists. The ratio of health care workers : population shows large discrepancies
between the capital and the rest of the country.
Eg. Doctor : population ratio is 131.9:100,000 for Colombo and 35.3:100,000 for the
rest of the country. The situation is similar for dental surgeons and pharmacists.
(Figure 3: Trends in doctor : population ratio in Sri Lanka; Legend: In 2003, the
doctor : population ratio was 131.9:100,000 for Colombo and 35.3:100,000 for the
rest of the country. There is a persistent discrepancy between the number of doctors
: 100,000 population in the capital Colombo and the rest of the country. This gap has
been maintained despite increasing doctor : population ratio.)

The HR in the private sector too, are concentrated in Colombo and major cities, as
utilization of private services are higher among the higher income groups
concentrated in cities.

There are several reasons why HRH migrate. In-depth analysis reveals that priority
problems 1.1 to 1.3 identified above are all directly or indirectly related and contribute
to the increase in migration.

Some probable root causes / factors are identified below:

1. Inadequate financial remuneration

a. Poor financial remuneration, not in keeping with rise in cost of living
and the income generated in other countries (Table 3: Comparison of
monthly take home pays of Sri Lankan doctors, Sri Lankan bank
employees in equivalent grades and of Australian doctors [10])
b. Inequities in salary scales and increases, leading to dissatisfaction
among different categories of HRH

2. Inadequate facilities for clinical work as well as Continuing Professional

Development (Education) leads to de-motivation. – Facilities for CPD are
grossly inadequate in the peripheries. Most hospitals in the peripheries do not
have a library or internet facilities. Equipment and facilities to carry out
procedures are also lacking in peripheries and are concentrated in Colombo.
This attracts highly motivated professionals to the capital and the main cities.
Those who feel they have inadequate facilities tend to migrate abroad for
CPD in their preferred field. HR serving in peripheries often lose the
motivation to keep up-to-date with evidence based practice, with sub-optimal
health outcomes.

16
3. Inadequate facilities for personal wellbeing and social support, eg. housing,
transport, family support and education of children

4. Unsatisfactory work environment

5. Poor Management:
a. The national health system of Sri Lanka lacks a corporate culture. The
management system is rather rigid and restricted to pre-defined limits.
The rigid system of hierarchy impedes rewards on merit rather than on
period of service, results in poor human interactions and creativity that
a human capital is potential of having. Job definitions, too, are very
restricted, and for some categories, are prepared by trade unions and
not the employer. The “workforce” is “forced to work” in conditions
they are not happy with. In an environment where one goes to work
constantly anticipating the end of the day to get out of a hostile
environment, there is no room for creativity and development.
Productivity falls, and the human capital tends to shift elsewhere to a
better environment.
b. Most staff members in administrative positions have not been formerly
trained in management. It was only in 2001 that the Postgraduate
Institute of Medicine began a training programme in Medical
Administration. Of the medical schools, only one provides a basic
introduction to management in the undergraduate curriculum. The
nursing course provides this to some extent, but leaves room for
improvement.
c. Contributing to this may be poor returns for efforts, eg. difficulty in
executing tasks and achieving progress due to poor co-operation of
other team members, poor HR management or sometimes
inadequacy of physical resources. Due to this lack of facilities and
poor management of resources, HR in peripheries tend to transfer
patients who could be managed there to higher level hospitals,
contributing to the overcrowding and work overload in secondary and
tertiary care hospitals.
d. An appropriate system referral is not in place. Although a referral
system exists, it is not implemented. The public generally bypasses
the referral system and directly seek treatment from higher levels of
health care, eg. secondary or tertiary level hospitals or seek
consultants in private sector. This leads to overburdening of tertiary
hospitals and under-utilization of primary care services.
e. Lack of guidelines, algorithms and protocols and uniformity of care.
f. Inadequate clinical audit and research and evidence-based practice
and unavailability of data for planning. – In Sri Lanka, basic data
collection is done for epidemiological purposes. Basic data on HR
such as numbers of various categories of HR is collected and
maintained by hospitals and sent through the Provincial Director of
Health Services to The Medical Statistics Unit of the Ministry of
Health. However, a recent attempt to change the system has reduced
the returns, as seen by the lack of complete data for the years 2004 –
2005. No data on HR needs, work satisfaction or patient satisfaction is
available. It is clearly an area where research is necessary.

6. Poor utilization of available HR, eg. trained neurosurgeon working as general

surgeon, not absorbing graduate pharmacists into key positions, delay in
internship for medical graduates. This contributes to the “brain drain” of

17
 professionals, as they migrate abroad in search of employment when it is
unavailable or delayed in their home country.

7. Social discrimination – eg. Sri Lankan personnel with foreign qualifications

face embarrassment by co-workers with local qualifications. Discrimination on
social status tends to promote segregation of different categories of HR and
interferes with effective communication and leads to general dissatisfaction at
work, reducing productivity. Discrimination on grounds of race or gender is
occasional. There is a need for an equal opportunities policy based on anti-
discrimination laws.

The above factors directly and indirectly, through complex interactions, promote
migration of HRH from resource-poor to resourceful settings. The distribution of
health care HR show gross inequities with unduly large differences in concentration
between Colombo and the rest of the country, which has been maintained through
the past ten years. A higher concentration of HRH is required in Colombo, as the
center of administration, the hub of coordination and conducting of education and
training for all categories of HR, and the final common pathway for referrals.
However, as more facilities are being decentralized and made available to tertiary
hospitals in other Provinces, it is necessary to decentralize relevant categories of HR
to peripheries in proportion to facilities available and services that could be provided
in these centers, and most importantly, the needs of the community.

(4) Priority actions required for Sri Lanka - Developing a work plan

In order to overcome problems due to Migration of HRH from resource-poor to

resourceful settings both immediate, medium term and long-term actions must be
taken. This requires a clear situation analysis, paying attention to all HR needs from
training to morale, continuous investments of time and leadership, and the
involvement of health care workers and community in planning and managing their
own futures.

1. The need to improve remuneration is evident. A larger proportion of the budget

(only 1.7% of GNP in 2004 [6,10]) should be allocated for health by the
government. A larger proportion of the health budget too (4% in 2002 [5]), needs
to be allocated for HR development. Pay policies as well as non-pay incentives
should be strengthened. Salary reforms must be made simultaneously for all HR
categories, so that inequities resulting in salary anomalies that lead to trade union
action are settled and conflicts minimized. Although salaries should be increased
to be on par with other professionals of similar grades, it is understood that
salaries cannot be increased to parallel that of doctors in developed countries.
Therefore, other methods of remuneration need to be used to motivate HRH as
an incentive to serve in areas where their services are required.

Some alternative (non-pay) incentives are discussed below.

• Improving facilities for CPD in peripheries, eg. libraries, CD libraries, IT

facilities eg. 2 computers, with access to internet, promoting institutional
Clinical Societies, regular newsletters from professional bodies, etc. -
Developing “finer specialities” in resource poor settings has been found to
motivate HR in the peripheries towards CPD and improving the quality of
health care. Developing and providing regular on-the-job training, workshops,
and special training initiatives for relevant disciplines, eg. an SHO training

18
 programme, which the PGIM can be requested to conduct in addition to its
regular diploma and degree programmes with the objective of upgrading
skills.

• Additional personal benefits for HR serving in remote areas would serve as

incentives. Eg. improving housing, allowance for transport, benefits with
regard to education for children – providing an open choice of schools, as for
personnel of the Armed Forces, etc. [9] would provide some of the priority
needs of health care HR. Insurance, such as professional indemnity cover,
too would be a useful benefit. It is important to ensure that HR appreciate the
benefits they receive by communicate these to them clearly.

• Improving working environment – Improving physical facilities requires

good management, inventories and regular needs assessments to work out
requirements and ensure that the necessary equipment and drugs are
available when required without waste of resources.

• Improving human relations in the working environment –

A corporate culture has to be developed. Communication between employer
and HR personnel, and among HR as well, should be improved. Job
descriptions should be provided regularly by the employer at the time of
employment, and revisions communicated to the employee.

Better supervision, support and morale-building would improve productivity.

Evidence-based guidelines, management algorithms and protocols should be
displayed in service stations and used appropriately.

There is a need for an equal opportunities policy based on anti-discrimination

laws. Safety guidelines (eg. universal precautions) must be enforced and
security of HR personnel, especially in conflict zones must be ensured.

Regular HR needs assessments must be carried out and steps taken to meet
provide these needs. It is hoped that involving all categories of HR personnel
in the process of achieving the “common goal” of a happy work environment
would promote friendly co-operation rather than rivalry and “trade unionism”.
Improving human relations requires leadership, commitment and a worker-
friendly management system, sensitive to the needs of HR. The occasional
“company outing” or festive activities for the New Year, etc. should also be
encouraged as regular events for the health care team to get to know and
understand each other and participate in leisure activities together away from
work.

• Rewards schemes for productivity and responsiveness – eg. best

hospital / primary care unit in the province award – with a bonus for workers,
best doctor / nurse / health care worker of the year (according to category), to
motivate HR. This would promote corporate culture.

• Scheme of mandatory service coupled with benefits - Service contracts

could be made defining 1-2 years of mandatory service in remote areas, more
likely at the beginning of the service period. This becomes harder to
implement later in the career when education of children becomes a priority.
This should be coupled with the above-mentioned benefits to motivate HR.

19
2. Improving evidence based management - promoting regular collection and
flow of data eg. antibiotic patterns, drug utilization, regular clinical audits and
patient satisfaction, etc. Such records should be maintained at institutional level
routinely. These must be made mandatory, where submission of reports is a
must, and perhaps may be linked to a rewards scheme. Arrangements could also
be made for publication of results in a journal as an incentive to health care
workers. A research culture should be developed. Use of evidence-based
guidelines and protocols would emphasize the need for research.

3. Improving the management of the health system - Developing and using an

information system for HRH would help improve the utilization of available
resources. The information gathering exercise to put this paper together involved
a huge amount of personal contact and time. HRH activity needs a strong
database available at the fingertip of every Director and above in the Ministry of
Health and important associated sectors such as Ministry of Planning,
Universities, etc. Research on HRH should be part of the health systems
research activities to be carried out by the ET&R Unit (which is currently
struggling with education and training, and conducts very little research), and
made available to the Planning Unit of the Ministry of Health. Regular HR needs
assessments must be carried out and steps taken to meet provide these needs. A
networked system should be developed to share information regarding resources
between institutions of the Ministry of Health quickly and efficiently. This is
requires collaboration with other organizations, eg. NGOs, for funding and with
research organizations such as Universities for technical assistance. Developing
and implementing a practical system of referral both between different levels of
services within the Ministry of Health and also between other collaborative
sectors involved in health care provision is also a need for better utilization of
resources.

4. Building healthy partnerships with human resources of all sectors involved in

health development to obtain maximum benefit from institutions such as
Universities, NGOs, private sector, Department of Social Services, Police, etc. as
well as the community (eg. volunteer societies and individuals) in implementing
education and training, curative and health promotional activities.

Eg. Integrated Service development with the Universities [4]

Recommendations which would:
a. Promote positive relationships
b. Correct negative relationships
We should emphasize the concept of inculcating the philosophy of friendly
PARTNERSHIPS of all sectors involved in the development of HRH. This
includes Universities, NGOs and private sector. The vital role of the
Government Medical Officers Association and Faculty of Medicine
Teachers’ Association together is emphasized in this context.

A Memorandum of Understanding (MOU) between the Ministry of Higher

Education University and Ministry of Health as recommended through a
Cabinet decision will provide the necessary foundation for such a partnership.
A concurrent mechanism to iron out early conflict resolution should be
incorporated in the MOU.

This should include formal recognition and exchanging basic job contracts
signed by Deans/Vice Chancellors of Faculties of Medicine and associated
Teaching Hospital Directors and DGHS for individual doctors/others from all
levels in both sectors for Service, Teaching, Research and Sharing of

20
 Resources (human and physical) and Information sharing for National
Development. A spirit of coordinated and integrated work ethos is to be
fostered away from the unhealthy competition as prevails now. This is an
important step in removing obstacles to good HRH development

The trade unions on both sides should be brought together by both Ministers
and this should be worked out. This is achievable as it works well in U.K. It
needs commitment.

5. Brain gain networks [9] - Making use of HR who have migrated abroad – “brain
gain” - eg. partnerships for collaborative research, resource material for CPD, eg.
membership to websites at concessionary rates, as resource persons for CPD
programmes, and workshops, contribution to CPD of HR within the country by
securing overseas training placements, use of medical specialists on short-term
training during return visits, etc. Promoting alumni associations of the training
institutions, eg. medical faculties, PGIM, etc. would provide a base for such brain
gain networks. Networking would thus provide HRH within the country an
additional incentive to develop.

6. Capacity building – Capacity building on management, especially people

management and related “soft skills” is a must for all administrative staff, and
would be useful for all HR. Training of HR needs careful consideration and
planning according to the country’s needs. Training of front-line doctors, medical
specialists and dental surgeons must be accompanied by a concomitant
production of required numbers of appropriately trained ancillary health
professionals, such as nurses, physiotherapists, occupational therapists,
radiographers, medical lab technicians and pharmacists if high quality health care
is to be optimally delivered. Training of nurses, pharmacists and paramedical staff
direly needs to be improved. Curriculum reforms are needed, appraisal systems
need to be prepared for organized supervision of clinical work.

DDG Education, Training & Research (ETR) was created out of the
recommendations in the National Health Policy 1992 in order to address this
shortcoming cited in 6 above. However, dedicated staff to organize and train the
large numbers of categories of workers is essential if we are to ensure regular
annual intakes as a routine matter, and avoid the need for politically motivated
unplanned intakes irregularly. Promotion schemes and incentives for trainers, too,
should be improved in order to retain them. Trainers may be mobilized from the
Universities, but they too, are under-staffed and overworked. Accordingly,
provision should be made for furthering the professional advancement and career
prospects of ancillary health professionals.

In order to sustain and develop the human resources for health in Sri Lanka, our
national development should go hand-in-hand with health sector development.
Finally, our government should take cognizance of the need to motivate and sustain
human resources for health, for the benefits of good health care delivery to reach the
population.

21
Conclusion

Migration of human capital to resourceful settings is a priority problem in human

resources for health in Sri Lanka. Several factors have contributed to dissatisfaction
and human resources, especially those with higher skills and qualifications, migrating
towards more resourceful settings, both overseas and within the country. Some
examples include inadequate salaries, inadequate facilities to provide health care
services and for continuing professional development, inadequate personal benefits,
eg. poor prospects for children’s education, unsatisfactory work environment, poor
general management of human resources, prevalence of a trade union culture, poor
collaboration with other organizations such as universities, NGOs in utilizing
resources for health development and health care delivery. The system also suffers
from the lack of a referral system, lack of guidelines and protocols, poor supervision
and poor research ethos with resistance to change. The above factors directly and
indirectly, through complex interactions promote migration of human resources for
health.

Recommended actions to solve the human resource problems in Sri Lanka include
the following immediate, medium and long-term plans:

¾ improving remuneration, both financial, education and professional development

(CPD), personal benefits, incentives coupled with mandatory service in remote
areas and rewards schemes
¾ improving work environment, facilities and human relations and promoting a
corporate culture
¾ improving the management system, developing evidence-based methods and
research for HR and health system development, organizing data collection and
flow with appropriate networking,
¾ developing and implementing a practical referral system
¾ building partnerships and networking with all sectors involved in training HR and
health care delivery, including Universities, NGOs, private sector and other
government bodies such as Social Services, Police, etc.
¾ capacity building of HR, improving basic education and training, CPD and “soft
skills” such as effective communication and people management

It is hoped that developing attractive working environments and incentives schemes

including CPD would help to retain HR within the country, improve the equity of
distribution and promote their professional development, thereby helping to deliver
better health care to the people in both goodness (quality) and fairness (equity of
access).

Competing Interests

None

22
Acknowledgments

Dr. A. Aroona Abdulla, temporary lecturer, Faculty of Medicine, University of

Colombo did a tremendous job of collating data and helping with the secretarial work.
We collated information from the following sources. We are grateful for their
assistance.

1. The Ministry of Health, Nutrition and Uva Wellassa Development, Sri Lanka
a. Mrs. Padma de Silva, Medical Statistician, and staff of Medical
Statistics Unit
b. Staff of the Medical Information Unit
c. Dr. Stanley de Silva, Director, Education, Training and Research
d. Director Planning and staff of Planning Unit
2. Dr. NJ Nonis, Registrar and staff of Sri Lanka Medical Council
3. Prof. Colvin Goonaratne, Registrar, Ceylon Medical College Council.
4. Prof. Lalitha Mendis, Director, Postgraduate Institute of Medicine
5. Prof. MTM Jiffry, University of Sri Jayawardenapura
6. Prof. Laal Jayakody, Professor of Pharmacology, Faculty of Medicine,
University of Colombo.
7. Prof. Dulitha Fernando, Professor of Community Medicine, Faculty of
Medicine, University of Colombo.
8. Mr. Wijaya Ransi, Secr./ Association of Private Hospitals & Nursing Homes
9. Sri Lanka College of Family Physicians

References

1. WHO: The World Health Report 2000 : Health Systems : Improving

Performance. 2000:77-81.
2. Human Resources for Health. [www.human-resources-health.org]
3. The report of the Presidential Task force on formulation of a National Health
policy for Shri Lanka : The National Health Policy of Shri Lanka. 1992
4. Proceedings of National Workshop on Coordinated Health and Human
Resource Development (COHHRD): September 1997. WHO / University
Grants Commission / Ministry of Health and Faculty of Medical Sciences,
University of Sri Jayawardenapura
5. Department of Health Services, Sri Lanka : Annual Health Bulletins. 1995 –
2002
6. Central Bank of Sri Lanka : Annual Report. 2004, 2002, 2000
7. Department of National Planning, Ministry of National Planning, Sri Lanka :
Sri Lanka New Development Strategy 2003.
[http://www.erd.gov.lk/devforum/NPD/SLNDS.pdf]
8. Management and Development and Planning Unit, Ministry of Health & Social
Services : The Perspective Plan for Heath Development in Sri Lanka
(1995-2004). Colombo; 1995.
9. Mendis L, Jayawardena J, Preena N. : Proceedings of the South Asian
Conference on Postgraduate Medical Education : Brain drain of specialist
doctors from Sri Lanka : 1st - 3rd August 2005.
10. Department of National Statistics : National Accounts of Sri Lanka - first
quarter 2005 :
[http://www.statistics.gov.lk/national_accounts/QuarterlyNA1Q2005), 2004
[http://www.statistics.gov.lk/national_accounts/NA. ACC OF SRI
2004(WEB).pdf ), and 2002 [http://www.statistics.gov.lk/national_accounts/]

23
 11. Department of Census and statistics :
[http://www.statistics.gov.lk/censusofpopulation/Mid-year Population Statistics
by District.pdf]

Annexure – Tables 1-3

Table 1: Public investment: 2005 – 2007 Activity Plan 2005 - Health sector
Central Rs. Provincial Rs.
(Million) (Million)
Rehabilitation of Hospitals 1,003 Sirimavo Bandaranayeke 1,148
Childrens’ Hospital at
Peradeniya
Implementation Plan of Action 120 Development of Jaffna 100
for Children Teaching Hospital
Triposha Programme 585 Bio Medical Engineering Unit 1,500
Equipment
Health Sector HR 25 MLT Unit at Colombo South 40
Development Program Hospital
Health Sector Development 925 Drug Stores at IDH 69
Project
Rehabilitation of Operating 1,110 Development of Kandy, 75
Theatres and ICUs Badulla and Kalmunai (North)
Hospitals
National STD/AIDS Control 635 Nephrology Unit at 75
Program Maligawatte
Global Fund to Fight Against TB 260 New Building and Water 30
Malaria Tanks at NTS Galle
Mother and Nutrition 205
Programme
Computerization of Drug 50
Distribution System
Water Supply and Sewage 30
System for Hospitals
Development of Blood Bank 532
Project
Neuro Trauma Unit at NHSL 800

Table 2: Highest HR losses among specialist doctors emigrating from Sri

Lanka [10]
Speciality Number of specialist doctors emigrating
1993 - 1996 1997 – 2000
Psychiatry 33% 56%
Dental surgery 33% 50%
Anaesthesiology 26% 37%
Ophthalmology 25% -
Medicine - 28%
Microbiology - 29%
Paediatrics - 28%
Surgery - 34%
Obstetrics & Gynaecology - 20%

24
Table 3: Comparison of monthly take home pays of Sri Lankan doctors, Sri
Lankan bank employees in equivalent grades and of Australian doctors [10]

Sri Lankan Sri Lankan Bank Australian Doctors

Doctors (LKR) Employees (LKR) (Australian (LKR equivalent)
Dollars)
Specialists General Manager Specialists Specialists
Rs. 45,000 Rs. 125,000 + AUD 20,000 Rs. 1,500,000
allow
Grade I MO Senior Manager Registrar Registrar
Rs. 35,000 Rs. 45,000 + allow AUD 8,000 Rs. 600,000
Grade II MO Grade I Grade I
AUD 7,000 Rs. 525,000
Preliminary Grade Junior Executive
Rs. 20,000 Rs. 30,000
Interns Interns Interns
Rs. 14,000 AUD 4,000 Rs. 300,000

25
Pictures for COUNTRY PAPER

Migration of Human Resources for Health within and out of Sri Lanka – Report
and Analysis

Figure 1a: Organization chart for health services under Department of Health
Services

Minister

Deputy Minister
Secretary

Director General of Health Services

DDGs PHS I DDGs PHS I DDGs MS I, II DDGs

‰ Lab services
• Epidemiologist • Environ. & • Tertiary care ‰ Biomedical
• Leprosy Occupationa services Engineering
control l Health • Medical services
programme • Maternal & services ‰ Planning
• Malaria Child Health • Nursing ‰ Education,
control • Primary care (MS) Training &
programme services • JMO Research
• STD/AIDS • NCD Colombo ‰ Administration
control • Nutrition • Pvt. sector I,II
programme • Public Developmen ‰ Finance I,II
• Filariasis Health t ‰ Oral Health
control Nursing • Mental ‰ Log & build.
programme • Estate & Health ‰ Investigations
• Youth / elderly Public • NCD
/ disabled Health • Teaching
programme • Health Hospitals
• Public Health Education &
Vet services Publicity
• Quarantine
services

Abbreviations:
DDG : Deputy Director General
PHS : Public Health Services
MS : Medical services
TCS : Tertiary care services
NCD : Non-communicable Diseases
JMO : Judicial Medical Officer
PHN : Public Health Nursing

1
Figure 1b: Organization chart for health services under Provincial Health
Ministries

Provincial Minister of Health

Provincial Secretary (Health Services)

Provincial Director of Health Services

Provincial Level
Regional and Divisional
Level
Deputy Provincial Director of Health Services

Deputy Director of Health

Services (DDHS) /
Medical Officer of Health
(MOH)

Curative
Medical
• Maternal & Child Health Assistant MOH
Services
• Regional Epidemiologist
• Provincial
• Statistical survey officer
hosp.
• Regional dental surgeon • Planning &
• District
• Regional dental therapist Programme
General hosp.
• Divisional RMO officer/ Planning
• Base hosp
• Planning & programme assistant
• District hosp.
officer • SPHI, PHIs
• Rural hosp
• Food & drug inspector • PHNS, SPHM,
PHMs • Peripheral
(FDI)
Units
• PHI (Control • Adolescent
dental clinics, • CD&MH
Programmes (Leprosy,
School dental • CDs
Malaria, etc.)
• Visiting
• Special clinics clinics
• Field staff AMC stations and
(STD/AIDS, Chest)
clinics
• Regional Supervising & AFC
• Branch
PHNO
dispensaries
• Divisional pharmacist
• Mobile
• Supervising PHI
dispensaries
(Divisional)

Abbreviations:
PHS: Public Health Services
PHN: Public Health Nursing
PHNS: Public Health Nursing Sister
SPHM: Supervising Public Health Midwife
PHM: Public Health Midwife
SPHI: Supervising Public Health Inspector
PHI: Public Health Inspector 2
 Figure 2: Breakdown of National Expenditure on
Health
4% 6% curative
14% 67%
community

general admin

training and
9% scholarships
other

Figure 3: Trends in doctor : population ratio in Sri Lanka

140.0
Doctors: 100,000 population

120.0
100.0
80.0
60.0
40.0
20.0
0.0
1995 1996 1997 1998 1999 2000 2001 2002 2003

Capital Rest of Country Overall