Lanka at 75: safeguarding its health achievements

(Lancet) This year, Sri Lanka marks 75 years of independence from the British as well as the 200th anniversary of the arrival of the Malaiyaha Tamil community, brought from South India to work on colonial plantations. Much is owed to this community, whose labour powered the country’s tea industry, generating substantial revenue to Sri Lanka’s economy. Since independence, Sri Lanka has been mired in conflict and turmoil rooted in historical political tensions between ethnoreligious communities entrenched in the legacy of British imperialism and nationalist identity politics.

Sri Lankans are still recovering from the brutal 26-year civil war (1983–2009) between the Sinhalese-dominated (and mostly Buddhist) Sri Lankan Government and the (mostly Hindu) separatist Liberation Tigers of Tamil Eelam. In the past five years alone, Sri Lanka has faced a 2018 constitutional crisis, the Easter Sunday bombings in 2019, COVID-19, and unprecedented mass anti-government protests in 2022 in response to an ongoing crippling economic crisis. Can Sri Lanka hold on to its remarkable gains in health in the face of these crises?

Sri Lanka’s achievements in health have long been a source of national pride. The expansion of universal health-care coverage with a pro-poor focus dates back to the 1930s. Since 1951, Sri Lanka has delivered a much-lauded, tax-funded, and free at the point of access health-care service, although it relies on substantial private sector outpatient care for those who can afford it.

For the past 70–80 years, welfare policies focusing on free education, health care, and women’s autonomy have enabled Sri Lanka to achieve relatively high standards of social and health development (compared with its regional peers), despite being classified as a lower-middle-income country by the World Bank and with a current annual health expenditure of only 1·6% of GDP. Life expectancy is 77 years and continues to rise. Sri Lanka has achieved substantial gains in maternal and child survival and control and prevention of infectious diseases such as malaria, filariasis, polio, and neonatal tetanus.

Not everyone has benefited from Sri Lanka’s health successes equally. Aggregate statistics mask substantial regional disparities in health-care access and broader health outcomes, most markedly in the impoverished plantation workers. A history of denial of citizenship rights, systemic state exclusion, and economic exploitation of the minority Malaiyaha Tamils has been a major driver of the high rates of maternal mortality and child malnutrition in these communities.

During the years of civil war, commendable cooperation between the conflicting parties, centralised leadership of disease programmes with decentralised operations, and stakeholder engagement enabled the provision of health services to populations on both sides of the war, but conflict-affected districts also experienced worse health outcomes, with notable differences in infant and maternal mortality. Disabled ex-combatants and other marginalised groups including LGBTQIA+ people and sex workers (both of which are criminalised in Sri Lanka) continue to have negative experiences and poor health outcomes due to services being inadequately responsive to their circumstances and needs.

Both long-standing and more acute threats to health and health equity in Sri Lanka are now converging. With a rapidly ageing population, the country’s health system has not yet adapted to address the complex and long-term care needs of non-communicable diseases, injuries, and mental illness that represent an increasing disease burden. A gradual weakening and inadequate financing of state health services, growing concerns about the erosion of public health governance (including the integrity of drug procurement processes), and trends towards privatisation present a serious threat to ensuring access to health for most Sri Lankans.

The current economic crisis has resulted in shortages of life-saving medicines, medical supplies, and health services. Furthermore, there is a deeply worrying exodus of health personnel to high-income countries. As talks continue about reaching a debt restructuring plan with creditors following Sri Lanka’s default on its foreign debts last year, the Sri Lankan Government and its bilateral and multi-lateral lenders must all recognise that human capital is key to the country’s recovery and future, and that its citizens’ health is a public good that it cannot afford to compromise.

Indeed, the current crisis could afford an opportunity. As constitutional reforms are being considered, enshrining the right to health and related social and economic rights within the constitution would help ensure access to health services for all citizens, bring action on the key determinants of their health, and re-affirm Sri Lanka’s commitment to one of its key achievements since independence.