‘Health for All’ in Neo-liberal Times

Striving for Equity: Healthcare in Sri Lanka from Independence to the Millennium, 1948–2000 is the third of a series of works by Margaret Jones on the history of medicine in Sri Lanka. It follows the Health Policy in Britain’s Model Colony: Ceylon, 1900–48 (2004) and The Hospital System and Health Care: Sri Lanka, 1815–1960 (2009). Drawing on rich archival sources, including an  illuminating ­collection of the World Health Organization (WHO) and government-commissioned studies, as well as expert opinions, Striving for Equity: Healthcare in Sri Lanka from Independence to the Millennium, 1948–2000 charts the evolution of primary healthcare (PHC) in independent Ceylon (and then Sri Lanka), the country’s successes and failures, and its alignment and discord with the international health agenda. Chapter 1 is an overview of health policies/reforms after independence, while the chapters that follow delve into, respectively, tuberculosis control, child malnutrition, immunisation, and the emergent problem of non-communicable diseases, during this period.

From Global to Local

As Jones argues in Chapter 1, the island nation had committed to WHO’s “Health for All” vision in the aftermath of World War II, long before the Alma-Ata Declaration of 1978, as reflected in high levels of state investment, in universal food subsidies, free education, and free healthcare. Although Alma-Ata did result in a rhetorical shift, that is, state espousal of PHC and various pronouncements on its operationalisation, the incumbent government did not set aside additional resources towards reva­mping the PHC. In fact, as Jones astutely observes, the country’s adoption of open economy policies in 1977, which coincided with Alma-Ata, heralded a retreat from universal welfare provision, for instance, the transition from general food subsidies to means-tested nutrition interventions, in line with the emergent neo-liberal global order.

Even as a reversal in welfare orientation thwarted efforts to raise standards of living, the government turned to inter­national agencies to support the development of healthcare. In Chapter 2, Jones outlines the trajectory of tuberculosis control in Ceylon, a programme that initially borrowed heavily from Britain’s experience and then relied on the WHO, UNICEF, and other development agencies for financing and technical guidance. While international coll­aboration was key to tuberculosis control efforts, the chapter throws light on a gnawing contention in global health, that is, misalignment of donor agendas with local prerogatives. The WHO’s community-oriented tuberculosis control progra­mme, which strayed from the “Western” standards of tuberculosis care, adopted in Ceylon, confronted resistance from medical professionals as well as the purported “community,” compelling Jones to critically interrogate policy transfers that neglect local requirements and the community context.

Chapters 2, 3, and 4 provide insights into the forms of international cooperation that existed less than half a century ago. Contrast the tuberculosis control initiatives, Jones describes—investments in health infrastructure, equipment, and human resources—with the projects that are funded today. With their basis in ­“social” entrepreneurship and innovation, today’s global health initiatives promote the use of digital technologies to improve health coverage, for instance, the delivery of mobile health (mhealth) interventions by community volunteers. Supported by private entities, most pro­minently the Bill and Melinda Gates Foundation, these interventions tend to bypass the basic necessities in health infrastructure and human resources, leaving communities in South Asia and sub-­Saharan Africa with virtually no access to healthcare services (Al Dahdah 2021). Crucially, Jones asks, “Why have one medicine for the rich and one for the poor, whether that be within countries or on the global arena?” (p 225), urging us to reflect on the double standards guiding global health interventions in low- and middle-income countries, a que­stion that takes on a new meaning in the light of COVID-19 vaccine inequity.

Technology versus the Social

In Chapters 2, 3, and 4, Jones demonstrates the limits of expanding access to health technologies in the absence of investments in the societal determinants of health. With respect to tuberculosis control, we see Ceylon’s resource-constrai­ned healthcare system struggling to ­deliver universal tuberculosis treatment even as swathes of the population live in conditions of poverty, sans improved housing and nutrition—critical to tuberculosis control. This theme continues in Chapters 3 and 4 as Jones juxtaposes the country’s child (mal)nutrition programmes with the Expanded Programme on Immunisation (EPI), where the latter is presented as a “technological fix” (p 141) that incorporates elements of PHC and selective PHC (SPHC).

Backed by the Rockefeller Foundation, World Bank, and other actors, SPHC favo­ured the delivery of a limited package of cost-effective interventions to achieve quick reductions in mortality and morbi­dity, thought to be more “feasible” than the Alma-Ata vision, which called for a comprehensive and universal access to PHC within the ­national health systems. Embraced by UNICEF in the early 1980s, SPHC underpinned its “Child Survival Revolution,” which incorporated a raft of low-cost technologies (growth monitoring, oral rehydration therapy, breastfeeding and immunisation, later complemented with food supplements, family planning, and female education or GOBI–FFF) and relied on donor-funded vertical program­mes for implementation (Cueto 2004; Rosenfield and Min 2009).

Notwithstanding the stubbornly enduring high rates of malnutrition among young children in Sri Lanka, which Jones rightly attributes to “poverty and social inequality, and the patterns of ­behaviour they induce among rich and poor” (p 134), presenting Sri Lanka’s EPI as having elements of SPHC may obs­cure some distinguishing features that set it apart. The EPI in Sri Lanka is delivered through a well-established preventive health sector, staffed by salaried public sector healthcare workers—medical officers, public health nurses, and midwives, all trained under a free education policy. They operate from an ext­ensive network of state-financed and administered public healthcare facilities that cover the entire island. This system, as Jones points out, is poorly resourced and perennially underfunded, but has achieved more than 90% vaccination rates for 12 infectious diseases (Department of Census and Statistics and Ministry of Healthcare and Nutrition 2017). The very existence of a non-fee levying public healthcare system with referral pathways connecting “patients” to secondary and tertiary healthcare services, makes it very different from the SPHC initiatives, implemented as donor-funded ­vertical disease programmes in other resource-poor settings.

Despite the public healthcare system’s access achievements, half a century later, (public) systems of education, healthcare, food production, and distribution are seeing little investment in Sri Lanka. While PHC services, inclu­ding targeted food supplements, are available for infants and young children, malnutrition abounds, particularly among plantation, rural, and war-­affected communities (Department of Census and Statistics and Ministry of Healthcare and Nutrition 2017).

Free Health and Its Demise

It is rather surprising that Jones only fleetingly mentions the “Free Health” policy adopted in the 1950s in independent Ceylon. The policy itself may not have been crucial when it was adopted because public healthcare facilities did not, for the most part, levy fees. As a policy, however, “free health” has its moorings in decades of left mobilisations (Silva 2014), as well as the anti-colonial movement for free education (Special Committee on Education and Ministry of Healthcare and Nutrition 1943). These policies are ingrained in our consciousness and has been critical to maintaining healthcare and education as non-fee levying public systems, albeit grossly underfunded, since the neo-liberal turn. The free health policy still guarantees, for instance, diagnosis, treatment, and follow-up services for all patients with tuberculosis, on a non-fee levying basis, although insufficient state investment and incentivised private sector expansion have resulted in patchy service coverage for non-communicable diseases, as detailed in Chapter 5.

While the book focuses primarily on the public health sector, missing from the analysis are post-independence developments in the private health sector. The 1950s and the 1960s saw the state attempting to rein in private practice along with its attendant problems amidst protest from the medical establishment, only for all extant restrictions to be ­removed in 1977. A 1972 survey of healthcare services, cited by Jones, indicates that the number of private nursing homes in Sri Lanka was 62, a number that doubled to 125 by 2012 (Amarasinghe et al 2015). A decade later, today, private healthcare flourishes with heightened support for “private sector engagement” bolstered by a global consensus (Kumar 2019). In contrast to the 1970s, when the Alma-Ata Declaration did not even reference the role of the private sector in healthcare delivery (WHO 1978), private providers are key “stakeholders” of universal health coverage ­today (WHO 2020).

Health as Politics

The book reminds us that impediments to achieving health equity are deeply political. The curative sector in Sri Lanka has always been favoured in the health budget, a trend that is not only driven by a consumerist demand for biomedical technologies and the lofty status enjoyed by clinical medicine, but also claims on the state for healthcare. The social and political forces that prevented the restructuring of healthcare along the lines of the three-tiered pyramidal model proposed in the 1970s (p 45), which, among other imperatives, sought to integrate allopathic and indigenous medicine, may be similar to those that impede the adoption of the shared-care cluster system proposed today¹ (Ministry of Health, Nutrition and Indigenous Medicine 2017). Based on historical events, Jones cautions against cookie-cutter approaches, and asks that we heed local politics and circumstances when designing health interventions.

What about the enduring impact of col­onialism and neocolonialism on healthcare systems? In Striving for Equity and prior work, Jones presents Ceylon as a model colony that inherited its public health infrastructure through knowledge transfers from Great Britain (Jones 2004, 2009). Lacking, however, is the “counterfactual,” where would we be, had we not experienced centuries of colonial and racial violence? Jones, while obscuring the violence of the colonial encounter, offers a Colombo-centred narrative of healthcare, through the lens of the coloniser and the elite medical establishment. What kind of story of healthcare might we hear from indentured labourers who were brought to the island by the British to work on coffee and tea plantations, and were subsequ­ently disenfranchised by the newly independent government of Ceylon? And what kind of story might we hear from the rural hinterland of war-torn northern and eastern Sri Lanka? Here, I must pinpoint Jones’s depiction of the civil war as one between the Sinhalese and Tamils, and the assertion that ayurveda is an all-encompassing term for all types of indigenous medicine, ideas that could only have come from Colombo or the West.

In sum, the book provides fascinating insights on healthcare in independent Ceylon (present-day Sri Lanka), and would be of particular interest to scholars studying history of medicine and public health. The equity concerns, Jones grapples with, have greater meaning in the context of the COVID-19 pandemic that has brought underfunded healthcare systems across the world to their knees. Delving into history may indeed help us better understand how to address the global health crisis that we confront today.

Note

1        The shared-care cluster concept guides Sri Lanka’s ongoing health reforms under the World Bank-supported PHC System Strengthening Project. A shared-care cluster refers to a unit made up of an apex public-sector specialist care centre and its surrounding primary care facilities. Within a cluster, empanelled healthcare users will be ref­erred through their designated primary care centres to secondary and tertiary care facilities, which together will offer a comprehensive package of healthcare services (Ministry of Health, Nutrition and Indigenous Medicine 2017). Despite the unsightly references to “public–private partnerships,” if implemented as planned, the reform would require massive state investment and also hamper the system of unregulated private medical practice in operation today.

References

Al Dahdah, Marine (2021): “From Ghana to India, Saving the Global South’s Mothers with a Digital Solution,” Global Policy, Vol 12, No S6, pp 45–54.

Amarasinghe, Sarasi, Sanil De Alwis, Shanaz Saleem, Ravi P Rannan-Eliya and Shanti Dalpatadu (2015): Private Health Sector Review 2012, Colombo, Sri Lanka: Institute for Health Policy, http://www.ihp.lk/publications/docs/PHSR2012.pdf.

Cueto, Marcos (2004): “The Origins of Primary Health Care and Selective Primary Health Care,” American Journal of Public Health, Vol 94, No 11, pp 1864–74.

Department of Census and Statistics and Ministry of Healthcare and Nutrition (2017): Sri Lanka Demographic and Health Survey 2016, http://www.statistics.gov.lk/Health/StaticalInformation/DemographicAndHealthSurvey-2016FullReport.

Jones, Margaret (2004): Health Policy in Britain’s Model Colony: Ceylon (1900–48), New Delhi, India: Orient Longman.

—   (2009): The Hospital System and Health Care: Sri Lanka, 1815–1960, New Delhi: Orient BlackSwan.

—   (2020): Striving for Equity: Healthcare in Sri Lanka from Independence to the Millennium, 1948–2000, Hyderabad: Orient BlackSwan.

Kumar, Ramya (2019): “Public–Private Partnerships for Universal Health Coverage? The Future of ‘Free Health,’” Globalization and Health, Sri Lanka, Vol 15, No 75, https://doi.org/10.1186/s12992-019-0522.

Ministry of Health, Nutrition and Indigenous Medicine (2017): “Reorganising Primary Health Care in Sri Lanka,” Ministry of Health Sri Lanka, http://www.health.gov.lk/moh_final/english/public/elfinder/files/publications/2018/ReorgPrimaryHealthCare.pdf.

Rosenfield, Allan and Caroline J Min (2009): “A History of International Cooperation in Maternal and Child Health,” Maternal and Child Health, pp 3–17, Boston, MA: Springer.

Silva, Kalinga Tudor (2014): Decolonisation, Development and Disease: A Social History of Malaria in Sri Lanka, New Delhi: Orient BlackSwan.

Special Committee on Education (1943): Report of the Special Committee on Education: Ceylon State Council Sessional Paper XXIV, Colombo: Government Press.

WHO (1978): “The Declaration of Alma Ata,” World Health Organization, http://www.who.int/publications/almaata_declaration_en.pdf?ua=1.

—   (2020): Engaging the Private Health Service Delivery Sector through Governance in Mixed Health Systems, World Health Organization, https://apps.who.int/iris/rest/bitstreams/1344380/retrieve.