Guidance

Country information note: healthcare and medical treatment, Sri Lanka, December 2024 (accessible)

Updated 27 December 2024

Version 2.0, December 2024

Country information

About the country information

This note has been compiled by the Country Policy and Information Team (CPIT), Home Office.

It provides country of origin information (COI) for Home Office decision makers handling cases where a person claims that removing them from the UK would be a breach of Articles 3 and/or 8 of the European Convention on Human Rights (ECHR) because of an ongoing health condition. It contains publicly available or disclosable COI which has been gathered, collated, and analysed in line with the research methodology.

The note aims to be a comprehensive but not exhaustive survey of healthcare in Sri Lanka.

The note’s structure and content follow the terms of reference.

For general guidance on considering claims based on a breach of Article 3 and/or 8 of the ECHR because of an ongoing health condition, see the instruction on Human rights claims on medical grounds.

Section updated: 29 October 2024

1. Healthcare context

1.1 Health indicators, regional comparisons, and long-term progress

1.1.1 CPIT has compiled the table below, using a variety of sources, to illustrate trends in health indicators. Data is compared over a period of approximately one decade and, where possible, Sri Lanka is compared against the regional average (WHO South-East Asia region).

-	Sri Lanka (various 2010 to 2012)	Sri Lanka (various 2019 to 2022)	SE Asia average
Life expectancy at birth (years)[footnote 1]	73.3 (2010)	77.2 (2021)	68.4 (2021)
Under-5 mortality rate (deaths per 1,000 live births)[footnote 2]	10.4 (2012)	6.5 (2022)	-
Probability of dying between ages 30-70 from cardiovascular disease/ cancer/ diabetes/ chronic respiratory disease[footnote 3]	17% (2010)	13% (2019)	-
Suicide mortality rate (per 100,000 population)[footnote 4]	21.9 (2010)	14 (2019)	-
Proportion of health facilities with a core set of relevant essential medicines available and affordable on a sustainable basis (%)[footnote 5]	-	68.3% (2019)	-
Health expenditure as % of GDP[footnote 6]	3.58% (2011)	4.07% (2021)	5.49% (2021)

1.1.2 The World Health Organisation (WHO) stated in their report, Sri Lanka Health System Review, 5 July 2021: ‘Sri Lanka has eliminated/eradicated most of the communicable diseases such as filariasis, leprosy, polio, malaria, and neonatal tetanus, and achieved near-elimination of other VPDs [vaccine-preventable diseases] through successful public health programmes and a dedicated health workforce.’^{[footnote 7]}

1.1.3 The Royal Society of Tropical Medicine and Hygiene (RSTMH), a charity dedicated to improving tropical medicine and global health, noted in an article dated 10 February 2023:

‘… Sri Lanka is a model country which has achieved significant improvement in maternal and child health, and control and prevention of infectious diseases over the last 50 years only with an annual allocation of 1.6 percent of the GDP [Gross Domestic Product] from the government for the health sector.

‘Sri Lanka is ranked among countries with the highest life expectancy in the South Asian region and has achieved significant accomplishments in reducing maternal and child mortality. Sri Lanka has an excellent performance in the national immunization programme by achieving high immunization coverage and disease control in the country such as eradication of poliomyelitis and elimination of neo-natal tetanus, diphtheria, measles, and rubella.’^{[footnote 8]}

1.1.4 On 15 October 2023, The Morning, an online news site reported:

‘Sri Lanka’s healthcare system exhibits notable strengths and weaknesses, alongside various opportunities and threats… The strengths include the provision of free healthcare, effective preventive healthcare programmes like immunization, a well-established public health system that includes domiciliary healthcare provision, and a skilled healthcare workforce. Sri Lanka’s high literacy rate is also a significant advantage contributing to better healthcare outcomes.’^{[footnote 9]}

(See Challenges)

1.1.5 A May 2024 report by WHO tracked the progress of 11 countries within the South-East Asia region towards achieving health-related Sustainable Development Goals (SDGs). The SDGs represent targets that all UN member states are attempting to achieve by 2030.^{[footnote 10]} SDG target 3.4 requires countries to aim to reduce premature mortality from noncommunicable diseases (NCDs) by one third by 2030. NCDs include cardiovascular and chronic respiratory diseases, cancer, and diabetes.^{[footnote 11]} WHO reported that only 2 of the 11 regional countries – Maldives and Sri Lanka – were expected to meet the 2030 target.^{[footnote 12]}

1.1.6 In a 2024 review of Sri Lanka’s public health system, Bandara compared the health system against that of other countries:

‘The public health system of Sri Lanka has been recognized as a relatively successful health system within its income category of lower-middle income countries, regionally and also globally more generally…

‘Sri Lanka’s [UN Sustainable Development Goal] indicators for maternal mortality, neonatal mortality, and under-five mortality all are comparable with countries that have better health systems in the region…’^{[footnote 13]}

1.2 Challenges

1.2.1 On 29 March 2022, the World Bank noted:

‘Non-communicable diseases, including diabetes, cardiovascular diseases, strokes and cancers, account for nearly 90 percent of the disease burden in Sri Lanka. The financial burden of NCD control and care is significant and not equally distributed, affecting rich and poor households differently…

‘The steady rise in NCDs has posed a serious challenge to Sri Lanka’s healthcare system. The management and control of NCDs requires a lifecycle approach with a strong focus on preventive care, and this has warranted a reorganisation of the country’s primary healthcare system. The World Bank-funded Primary Healthcare System Strengthening Project (PSSP) is at the core of the reorganization of primary curative care services planned by the MoH [Ministry of Health]. The objective of the PSSP is to support the government to increase the utilization and quality of primary healthcare services, with an emphasis on the detection and management of NCDs in high-risk groups.’^{[footnote 14]}

1.2.2 The Morning noted on 15 October 2023 that:

‘A recent study conducted by [Institute of Policy Studies of Sri Lanka] IPS… highlighted many challenges within Sri Lanka’s healthcare system. These challenges cut across various domains, including knowledge, capacity, and policy. According to this study, knowledge gaps are particularly evident, especially in understanding the growing burden of NCDs. Additionally, deficiencies in data collection, information dissemination, and Research and Development (R&D) represent critical knowledge gaps.

‘On the capacity front, several challenges become apparent. Notable deficits are observed in financial resources, planning capabilities, and human resources….

‘Studies on health financing suggest that the Sri Lankan healthcare system faces a significant challenge due to insufficient government spending on health. This inadequacy fails to meet the growing demand for services resulting from epidemiological and demographic transitions…

‘Although the Sri Lankan health system is widely acclaimed for its efficiency, certain areas still require attention due to substantial gaps in efficiency. These include disproportionate spending on hospitals, a lack of systematic priority-setting, fragmentation, data gaps, insufficient monitoring, and human resource challenges.’^{[footnote 15]}

1.2.3 On 28 October 2023, The Lancet noted:

‘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 NCD, 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 …’^{[footnote 16]}

(See Financial crisis – impact and recovery and Personnel)

1.2.4 In a 2024 review of Sri Lanka’s public health system, Bandara identified challenges faced by the health sector: ‘Sri Lanka’s health system is facing several contemporary challenges ranging from the need for structural improvement, emerging disease burdens in communicable and NCDs, demographic shifts and issues arising from the current economic crisis.’^{[footnote 17]}

1.3 Financial crisis – impact and recovery

1.3.1 The Swiss State Secretariat for Migration (SEM) published a COI report on 14 April 2023 which focused on mental healthcare in Sri Lanka. The report, which CPIT had translated from German to English via The Big Word translation services and then verified by SEM, commented on the impact of the 2022 financial crisis: ‘The public healthcare system is functioning normally to a large extent, despite the economic crisis that has been going on since 2022. There are no indications of hospitals or departments being closed or medical treatments being discontinued.’^{[footnote 18]}

1.3.2 In March 2024, UNICEF noted:

‘Sri Lanka has a strong health system, with health services provided through a wide network of hospitals and field health clinics for the entire population. The facilities are maintained, and medicines provided by the Government using state resources. However, during the economic crisis, the production and procurement of medicines through the routine government system (i.e., either production at the State Pharmaceutical Corporation or procurement by the Medical Supply Division) were seriously impeded and some hospitals ran out of essential medicines. While there were no reports of clinics or hospitals closing, severe shortages in medicines and other commodities in hospitals were reported, impacting the delivery of critical health services.’^{[footnote 19]}

1.3.3 The UNICEF report also noted: ‘In 2023, Sri Lanka saw some stabilization of its economy with the International Monetary Fund (IMF) debt restructuring agreement signed on 20 March 2023.’^{[footnote 20]}

1.3.4 The UNICEF report added: ‘As the economic crisis stabilized, and the situation in the country improved substantially by early 2023, the Humanitarian Country Team took the decision to scale down humanitarian response operations by March 2023.’^{[footnote 21]}

(See Availability and affordability of medication and Personnel)

Section updated: 29 October 2024

2. Healthcare system

2.1 Governance

2.1.1 The Ministry of Health (MoH) are responsible for healthcare and work ‘in collaboration with the government, non-governmental organisations, private healthcare providers, international agencies and other relevant bodies, to prevent and treat illness and enhance the health status of the Sri Lankan population.’^{[footnote 22]}

2.1.2 The MoH noted in an undated entry on their website:

‘… The public sector provides nearly 95 percent of inpatient care and around 50 percent of outpatient care. The Ministry of Health (MoH) is responsible for stewardship functions such as policy formulation and health legislation, programme monitoring and technical oversight, management of health technologies, human resources, and tertiary and other selected hospitals. The primary and secondary levels of curative care and preventive services function under the nine provincial ministries.’^{[footnote 23]}

2.1.3 The MoH’s annual Performance and Progress Report for 2023 described how responsibility for healthcare is devolved:

‘With the implementation of the Provincial Councils Act in 1989, the health services were devolved creating the Line Ministry of Health at the national level and separate Provincial Ministries of Health in the 9 provinces. Twenty-six (26) Regional Directorates of Health Services (RDHS) implement the Provincial Health plans of respective Provincial directorates. Each RDHS area is sub-divided into several Medical Officer of Health (MOH) areas, and these units are mainly responsible for preventive and promotional healthcare in a defined area. There are 354 MOH areas in the country. The curative arm of the provincial health directorates operates through District General, Base, Divisional hospitals and Primary Health Care units which comes under the purview of provincial health authorities.’^{[footnote 24]}

2.1.4 In a 2024 review of Sri Lanka’s public health system, Bandara described the governance structure:

‘The Ministry of Health is responsible for government health policy formulation, health legislation, and regulating services provided by both the government and private sectors. Additionally, the ministry also directly manages several large, specialized hospitals including the National Hospital of Sri Lanka, teaching hospitals, specialized hospitals, provincial general hospitals, and selected 33 district general hospitals. Overall procurement of medicines and laboratory products is mainly handled by the centre as well…

‘Since Sri Lanka has a provincial governance system, there are provincial ministries of health (PMoH). PMoHs have provincial directors of health as the technical leads and provincial secretaries of health as administrative leads. They answer to both provincial governance leaders (e.g., the governor) but also to the relevant ministry officials, such as [Director General of Health Services] DGHS. The regional and other medical officers and their teams also fall under the purview of provincial directors of health. PMoHs are responsible for the implementation of healthcare services including primary care, secondary care, and preventive services. While health is a devolved subject and provinces are free to formulate their own statutes, they need to abide by national guidelines and policies.’^{[footnote 25]}

2.1.5 WHO in their Sri Lanka Health System Review, 5 July 2021 stated:

‘Vertical programmes, which are mainly promotive and preventive in nature, are co-ordinated by the special campaigns and directorates of the MoH. District-level focal points for such programmes are medical officers responsible for maternal and child health (MOMCH), [non-communicable diseases] NCD and mental health (MOMH), and the regional epidemiologist (RE). These [medical officers] MOs are answerable to the relevant campaigns or Ministry directorate heads as well as the regional directors of health services (RDHSs). The MoHs are also answerable to the relevant RDHS.

‘There are 354 MoH areas in Sri Lanka and each is headed by an MO responsible for a defined population, which on average is around 40,000– 80,000. The MoH is supported by a team of trained field public health staff 32 (public health nursing sister, supervising public health inspector, supervising public health midwife, public health inspector and public health midwife).’^{[footnote 26]}

2.2 Structure

2.2.1 The MoH’s annual Performance and Progress Report for 2023 provided an overview of the different types of healthcare:

‘The health system in Sri Lanka is enriched by a mix of Allopathic, Ayurvedic, Unani and several other systems of medicine that exists together. Of these systems allopathic medicine has become dominant and is catering to the majority of the health needs of the people. As in many other countries Sri Lankan health system consists of both the state and the private sector. The Health Ministry and the Provincial Health Services provide a wide range of promotive, preventive, curative and rehabilitative health care. Sri Lanka has an extensive network of health care institutions.’^{[footnote 27]}

(See Western versus traditional medicine and Public versus private sector healthcare)

2.2.2 The MoH report also provided a graphic which showed the institutional structure of the MoH, divided into 4 main sectors: curative services, disease control programmes, health promotion and protection, and other.^{[footnote 28]}

2.2.3 In a 2024 review of Sri Lanka’s public health system, Bandara described the infrastructure: ‘In the state sector, outpatient department care is provided by all hospitals and primary medical care units. Those in need of further treatment are directed to inpatient care or to the nearest larger hospitals when facilities are not available at the current healthcare facility. Specialized care is available at the base, district general, provincial general, teaching and selects specialized hospitals.’^{[footnote 29]}

(See Facilities, services, capacity)

2.3 Affordability of public healthcare

2.3.1 In June 2022, UNICEF – in an overview, covering 2021, of Sri Lanka’s health sector – noted: ‘Ever since independence, Sri Lanka has adopted a free health policy and provided free public healthcare for all Sri Lankans.’^{[footnote 30]}

2.3.2 The MoH Annual Health Bulletin 2021 stated: ‘Curative care services available at health institutions are public funded and provided for every citizen, irrespective of patient’s usual residence.’^{[footnote 31]}

2.3.3 On 4 October 2022, Amnesty International noted:

‘In Sri Lanka, healthcare (including medicines) is theoretically available free of cost for everyone. The government provides most health services in the country (95 percent of inpatient care and 50 percent of outpatient care as of 2021). The public health system is mainly funded by general government revenues. According to UNICEF, allocations by the central government towards health increased between 2015 and 2021, both in nominal and real [adjusted for inflation] terms.

‘However, governmental expenditures on health as a share of GDP has dropped over the past decade. Governmental health expenditure accounts for about half of Sri Lanka’s total expenditure on health, with private contributions making up the remaining amount, which includes households’ payments for medical goods, health insurance and payments made to private service providers.’^{[footnote 32]}

2.3.4 On 10 February 2023, RSTMH noted: ‘… The most remarkable aspect of Sri Lankan health policy is that anyone can walk into the Out-Patient Department of a government funded hospital and receive the medical care needed without any charges; there is no limitation on the amount of money spent on one person.’^{[footnote 33]}

2.3.5 On 15 October 2023, The Morning, an online news site reported ‘Sri Lanka has a well-established healthcare delivery system, built on the foundation of providing free healthcare to its citizens…’ and that ‘In Sri Lanka, healthcare financing predominantly relies on two equally shared sources: (1) Government transfers funded through general taxation and (2) direct payments made by households, often referred to as out-of-pocket expenditure (OOPE).’^{[footnote 34]}

2.3.6 The Australian Department of Foreign Affairs and Trade (DFAT), Country Information Report of 2 May 2024, stated: ‘The public health system is free for all Sri Lankan citizens and medicines can be accessed free of charge from government-run hospitals in all provinces.’^{[footnote 35]}

(See Public versus private sector healthcare)

2.4 Public versus private sector healthcare

2.4.1 In June 2022, UNICEF published an overview – covering 2021 – of Sri Lanka’s health sector. UNICEF noted: ‘Health services in the public sector are provided at no cost while the private sector provides access to almost all types of healthcare on a fee levying basis.’^{[footnote 36]}

2.4.2 WHO in their Sri Lanka Health System Review, 5 July 2021 stated:

‘The private sector mainly provides ambulatory care [outpatient care e.g., general practitioner services], limited inpatient care and rehabilitative care of varying degrees of sophistication. Private services are financed mainly through out of pocket (OOP) payments by households/ individuals and, on a limited scale, through private health insurance schemes. OOP expenses have been increasing over time and currently stand at 51 percent of current health expenditure (CHE)…

‘The private hospitals provide outpatient and inpatient services and specialist consultations, the latter being mostly by specialists in government service practising in their off-duty hours. In addition, private pharmacies and investigative services have also expanded significantly both within private hospitals and as independent entities.

‘The private sector claims to bring certain advantages to their clients, the main ones being the availability of services at convenient times and absence of waiting lists.

‘In addition, the ability to select the specialist of one’s choice and continuity of care under the same doctor are also considered important reasons for seeking private sector services. Greater confidentiality in private settings as compared to public facilities was also identified to be an important factor in patients choosing private sector services.’^{[footnote 37]}

2.4.3 The WHO report noted: ‘The quality of public sector outpatient primary care in Sri Lanka is generally considered high for a low- middle-income country and was seen to be better than the private sector in many areas. Studies have shown that the quality of the public sector diagnosis and management aspects of care is similar to the private sector. However, the private sector allows patient choice of a provider and better-quality care in non-clinical aspects.’^{[footnote 38]}

2.4.4 The WHO report added: ‘Services obtained in the private sector are mostly paid for by a household’s OOPE [out-of-pocket expenditure] because of the low coverage of voluntary health insurance in the population… almost half of all OOPE is incurred by the two richest deciles 9 and 10 (57% of the total spending on OOPE).’^{[footnote 39]}

2.4.5 The International Labour Organization’s (ILO) Social Protection Department noted in an article from December 2021 that:

‘Despite an extensive range of health care services that are free in practice and widely accessible, funding constraints have led to increasing dissatisfaction with public health services among upper and middle-income Sri Lankans, leading them to seek private services. This has prompted the establishment of a range of employer-financed and private medical benefit schemes…

‘… Overall, employer-financed medical benefit schemes and private medical insurance schemes cover about 10 per cent of the population, mostly comprised of formal sector workers and their dependents. However, they do not provide meaningful coverage of the poor, the chronically ill or the elderly, who would most benefit from improved health care financing.’^{[footnote 40]}

2.4.6 On 4 October 2022, Amnesty international reported: ‘Medicines in the private sector have also become more expensive, because of the de-valuation of the Sri Lankan Rupee and because they are in short supply, making them even more unaffordable… The costs of purchasing their own medication can be too high for many families…’^{[footnote 41]}

2.4.7 RSTMH reported on 10 February 2023:

‘… In contrast to government hospital services, private hospitals are profit oriented businesses where a patient has to pay a fee for every service obtained. Most of the private in-patient care hospitals are also established in highly residential areas. …most of the doctors in private hospitals are working there as part-time doctors after completing their shifts in government hospitals. While the government sector hospitals in the country provide the same expertise medical care as private hospitals, the difference lies in the comfort and convenience that private hospitals offer to the patient. A recent study shows that people tend to choose private sector treatment when their family income is increased.’^{[footnote 42]}

2.4.8 The SEM report of 14 April 2023 noted: ‘Services in private hospitals and clinics can be utilised directly by all persons without restrictions. It is customary to pay for the consultation or medical treatment directly.’^{[footnote 43]}

2.4.9 The Australian DFAT Country Information Report of 2 May 2024, stated: ‘… Private healthcare is available and of high quality, particularly in Colombo; however, it is prohibitively expensive for most Sri Lankans.’^{[footnote 44]}

2.5 Western versus traditional medicine

2.5.1 In June 2022, UNICEF noted: ‘The Sri Lankan health system comprises different systems of medicine; traditional, western, ayurvedic, unani, siddha, homoeopathy, and acupuncture. Of these, western or allopathic medicine is the leading system catering to the needs of the majority…’^{[footnote 45]}

2.5.2 WHO in their Sri Lanka Health System Review, 5 July 2021 stated:

‘The Sri Lankan health system comprises western allopathic [conventional medicine] and other [Traditional Medicine (TM)/Indigenous Medicine] systems, namely Ayurveda, Siddha, Unani, acupuncture and deshiya chikitsa, which derives from ancient Sri Lankan traditional knowledge… Although both allopathic and traditional systems come under the purview of the MoH, the allopathic system caters to the needs of the majority…

‘The indigenous curative and preventive medical services of the public sector (State) are provided to the public through a network of 708 Ayurvedic hospitals and dispensaries located island wide. These facilities come under the administrative purview of the indigenous medical sector of the MoH. In Ayurvedic hospitals and dispensaries, indigenous medical OPD [outpatient] care is carried out daily and, in addition, the hospitals provide inpatient care. The necessary medicines are mainly manufactured locally while a few are imported.’^{[footnote 46]}

Section updated: 21 August 2024

3. Facilities, services, and capacity

3.1.1 For specific information on mental healthcare see the sub-sections under Mental healthcare: Structure, facilities and services, Capacity and Personnel

3.2 Facilities

3.2.1 The MoH website has an interactive map which allows the user to search for different categories of healthcare facilities (e.g., hospitals or Primary Medical Care Units) in specific districts.^{[footnote 47]}

3.2.2 The most recent MoH Annual Health Bulletin, published in March 2024, provided the number of government health care institutions by type in 2021. CPIT has summarised relevant statistics in the table below^{[footnote 48]}.

Government health care institutions	Number
Teaching Hospitals	20
Provincial General Hospitals	1
District General Hospitals	19
Base Hospitals	83
Divisional Hospitals	483
Other Hospitals	35
Primary Medical Care Units (PMCU)	528
PMCU and Maternity Homes	7
Medical Officer of Health	357

3.2.3 Undated information on the MoH website noted:

‘In mid-2022, there were more than 1500 healthcare institutes in total, from which 588 were hospitals and 517 were primary care institutes. Further there were 335 MOH offices. Sri Lanka has 555 government hospitals that provide primary health care. These institutions offer curative, preventive, and rehabilitation services to society as a whole. All citizens and residents are registered for treatment at their local health centre and can be referred to secondary care institutions if necessary. Nursing, pharmacy, laboratory, radiology, and medical records coordinators are part of an integrated medical team that provides the services.’^{[footnote 49]}

3.2.4 The MoH’s Annual Performance Report 2022, published in September 2023, listed the health institutions which fall under the Ministry’s remit. CPIT has reproduced the list in the table below^{[footnote 50]}.

Institution type	Location and/or name
National Hospitals	National Hospital of Sri Lanka, Colombo; National Hospital, Kandy
Teaching Hospitals	Anuradhapura; Batticaloa; Colombo North, Ragama; Colombo South, Kalubowila; Jaffna; Kalutara; Karapitiya; Kuliyapitiya; Kurunegala; Peradeniya; Ratnapura
Specialised Hospitals	Apeksha Hospital, Maharagama; Castle Street Hospital for Women (Teaching), Colombo; De Soysa Hospital for Women (Teaching), Colombo; Lady Ridgeway Hospital (Teaching) for Children, Colombo; Leprosy Hospital, Handala; National Dental Hospital (Teaching), Colombo; National Eye Hospital, Colombo; National Institute of Infectious Diseases – Angoda; National Institute of Mental Health – Angoda; National Institute for Nephrology Dialysis & Transplantation, Maligawatta; National Hospital for Respiratory Diseases, Welisara; National Nephrology Specialized Hospital, Polonnaruwa; Rehabilitation Hospital, Ragama; Teaching Hospital, Mahamodara; Sirimawo Bandaranayake Specialized Children‟s Hospital (Teaching), Peradeniya
Provincial General Hospitals	Badulla
District General Hospitals	Ampara; Chilaw; Embilipitiya; Hambantota; Kegalle; Matale; Matara & Godagama; Monaragala; Nawalapitiya; Negombo; Nuwara Eliya; Polonnaruwa; Trincomalee
Base Hospitals	Akkaraipattu; Gampola; Kalmunai North; Kalmunai South (Ashroff Memorial Hospital); Kantale; Mulleriyawa (Colombo East Base Hospital); Beruwala
Divisional Hospitals	Aluthgama; Dharga Town; Kandana
Board Managed Hospitals	Dr. Nevil Fernando Hospital, Malambe; Sri Jayawardanapura General Hospital, Thalapathpitiya, Nugegoda; Wijeya Kumaranathunga Memorial Hospital, Seeduwa
Public Health Institutions	Anti Filariasis Campaign; Anti Leprosy Campaign; Anti Malaria Campaign; Epidemiology Unit; Family Health Bureau; Health Promotion Bureau; Institute of Oral Health, Maharagama; National Cancer Control Programme; National Chronic Kidney Disease Programme; National Dengue Control Unit; National Programme for Tuberculosis Control and Chest Diseases; National STD/AIDS Control Programme; Renal Disease Prevention and Research Unit (RDPRU)

3.3 Services

3.3.1 On 5 July 2021, the WHO noted:

‘The National Policy on Prevention and Control of Chronic NCDs addresses four major NCDs and strategies for reduction of shared modifiable risk factors: smoking, alcohol, obesity, unhealthy diet, and sedentary lifestyles. These are implemented through the existing health network with the support of both government and NGOs in the country…

‘Cost-effective strategies adopted include NCD screening programmes at the community level and empowering communities to adopt healthy lifestyles. The NCD screening strategy consists of screening people above 35 years of age at healthy lifestyle centres (HLCs), workplace screening and mobile screening. HLCs will address risk reduction through early identification of both behavioural and intermediate risk factors. Currently, there are some 896 HLCs established throughout the country.’^{[footnote 51]}

3.3.2 The most recent MoH Annual Health Bulletin, published in March 2024, gave examples of the services provided by different categories of institutions. CPIT has summarised the information in the table below^{[footnote 52]}.

Primary care: Primary Medical Care Units (PMCU)	Example services: outpatient consultations, dressings, injections, drug dispensing, screening for selected non-communicable diseases (NCDs), dental services, Healthy Life Centres (HLCs), programmes for health education
Primary care: Divisional Hospitals (DH)	Example services: inpatient care, NCD clinics and mental health clinics, HLCs, screening of selected NCDs, programmes for health education
Secondary care: Base hospitals	Example services: specialties including internal medicine, paediatrics, surgery, obstetrics, and gynaecology; support services including laboratory, radiology, pharmacy.
Tertiary care	Provided by Teaching hospitals, Provincial hospitals, and District General hospitals (see example services provided by the National Hospital of Sri Lanka below)

3.3.3 The website of the National Hospital of Sri Lanka, Colombo, listed its services under 4 categories: clinic, outpatient, specialist care and other. CPIT has summarised the information in the table below^{[footnote 53]}:

Clinic services	18 Intensive Care Units, 17 High Dependency Units, 19 operating theatres, Neuro-trauma Centre, Accident and Trauma Unit
Outpatient services	Anti-rabies treatment, injections, dressings, x-ray, ECG, urine and blood testing, surgical clinic, psychiatric clinic, renal and transplant clinic, dermatology clinic, diabetic clinic, psychological counselling, medical nutrition clinic, pharmacy
Specialist care services	Anaesthesia, cardio electro physiology, cardiology, cardiothoracic surgery, chemical pathology, clinical neurophysiology, dermatology, endocrinology, ENT surgery, gastrointestinal medicine, gastro surgery, general medicine, general surgery, genitourinary surgery, nephrology, neurology, haematology, histopathology, microbiology, neurosurgery, plastic surgery, radiology, rheumatology, vascular surgery
Other services	Orthopaedic Workshop, physiotherapy, occupational therapy

3.4 Admissions and beds

3.4.1 The most recent MoH Annual Health Bulletin, published in March 2024, provided the number of admissions, visits, and beds in 2021. CPIT has summarised relevant statistics in the table below^{[footnote 54]}.

Hospital admissions	5,314,193
Clinic admissions	19,635,994
Outpatient department visits	26,094,945
Hospital beds	90,240
Hospital beds per 1,000 population	4

3.5 Personnel

3.5.1 An undated WHO profile for Sri Lanka compared the health workforce density in 2010 and 2021.^{[footnote 55]} CPIT has summarised the data in the table:

	2010	2021
Doctors (per 10,000 population)	7.1	11.9
Nurses and midwives (per 10,000 population)	17.1	24.4
Pharmacists (per 10,000 population)	0.7*	1.1
Dentists (per 10,000 population)	0.5	1.1

*Figure for 2012

3.5.2 On 10 February 2023, the RSTMH noted: ‘Due to the free education system in Sri Lanka, there is no shortage of physicians; however, most of these physicians and health sector personnel prefer [to] stay and work in developed residential areas causing a shortage of skilled personnel in hospitals in rural areas …’^{[footnote 56]}

3.5.3 The MoH’s annual Performance and Progress Report for 2023 recorded the number of new appointments of selected staff between 1 September 2022 and 30 September 2023.^{[footnote 57]}

Category	Number of appointments
Medical consultants	304
Medical officers	2724
Nursing officers	65
Medical laboratory technicians	238
Public health midwives	222
Public health inspectors	12
Radiographers	54
Occupational therapists	45

3.5.4 On 20 June 2024, Al Jazeera reported: ‘According to the Government Medical Officers Association (GMOA), the biggest trade union of government doctors in Sri Lanka, more than 1,700 doctors have left the country over the last two years, primarily for economic reasons. They constitute nearly 10 percent of doctors on the island.’^{[footnote 58]}

(See Financial crisis – impact and recovery)

3.6 Geographical accessibility and variation

3.6.1 On 10 February 2023, RSTMH noted:

‘… most of the Sri Lankans prefer to bypass the regional and provincial hospitals and go to District General and National Hospitals to obtain advanced treatments because regional hospitals are not sufficiently equipped to do so. Specialized care units such as oncology treatments, neurological disorders and cardiovascular diseases are limited to hospitals in the more developed and highly residential areas.

‘People from rural villages have to travel great distances to receive the treatment they need. Most of these patients need high-end laboratory testing, expensive drugs, and services from trained personnel. In the case of a patient without any privileges or means of out-of-pocket spending, that person has to suffer for a long time until their turn arises on the waiting list.’^{[footnote 59]}

3.6.2 Attanayake, D, and others in an article in the peer-reviewed European Journal of Human Genetics, published 23 January 2024 stated: ‘Most of Sri Lanka’s population (81.5 percent) live in rural areas. …Notably, the majority (80.9 percent) of the poor live in rural areas that are underdeveloped in healthcare, public transportation, and education. This has resulted in disparities in access to healthcare between rural and urban populations, mainly due to the lack of retention of healthcare workers in rural areas …’^{[footnote 60]}

3.6.3 The Australian DFAT Country Information Report of 2 May 2024, stated: ‘… Regional disparities exist in the quality of care and facilities, particularly between urban and rural areas. Colombo has the best health services and outcomes in the country. Health services in the north-east have improved in the post-war period; however, they remain of a lower standard to the rest of the country. Private healthcare facilities are also available in the north-east, although financially prohibitive for most.’^{[footnote 61]}

(See Facilities and Services)

Section updated: 29 October 2024

4. Pharmaceutical sector

4.1 Governance

4.1.1 The MoH Annual Health Bulletin 2021, published in March 2024, stated:

‘Medical Supplies Division (MSD) of the Ministry of Health is the central organization responsible to supply all Pharmaceuticals… for all the government sector healthcare institutions of Sri Lanka… In this context, the main functions of MSD are the estimating, indenting, procuring, storing, monitoring, distributing, and accounting of medical supplies. The national requirements of medical items are procured through different suppliers such as State Pharmaceutical Corporation (SPC), State Pharmaceutical Manufacturing Corporation (SPMC) and Local Manufactures.’^{[footnote 62]}

4.1.2 The National Medicine Regulatory Authority (NMRA) published guidelines on the registration of medicines on 25 July 2024 and noted: ‘The National Medicines Regulatory Act (NMRA Act) 2015 is the main legislation that control medicines in Sri Lanka. The Authority established under NMRA Act is tasked with ensuring the quality, safety, and efficacy of medicines… As per the NMRA Act, no person shall manufacture, sell, supply, import, manufacture or advertise any medicine unless the product is a registered as a medicine with the Authority.’^{[footnote 63]}

4.1.3 WHO in their Sri Lanka Health System Review, 5 July 2021 stated:

‘The NMRA plays a leading role in protecting and improving public health by ensuring that medicinal products available in the country meet the applicable standards of safety, quality, and efficacy. The Authority regulates medicines, medical devices, borderline products, clinical trials, and cosmetics. The National Medicines Quality Assurance Laboratory (NMQAL) is charged with ensuring the quality of medicinal products and also functions under the purview of the NMRA.

‘Drug quality assurance is an integral part of the national drug management system. The NMRA and NMQAL are the two principal institutes that work on national drug quality assurance. The NMRA has the mandate of regulating and controlling manufacturing, importation, registration, promotion, sale and distribution of medicinal drugs and devices, and ensuring the quality of drugs that are imported or manufactured in the country.

‘The NMQAL tests samples of medicinal drugs for quality control before they are registered by the NMRA and also has a role in post-marketing surveillance of these medicinal drugs through random assessments.’^{[footnote 64]}

4.2 Supply

4.2.1 WHO in their Sri Lanka Health System Review, 5 July 2021 stated:

‘…Only a small proportion [of pharmaceuticals] (12 percent by value) is locally manufactured, and the rest is imported, with India and Bangladesh being the largest providers of medicines to Sri Lanka… The State Pharmaceuticals Manufacturing Corporation is the state-owned manufacturer and there are a few private sector local manufacturers. The MoH has provided a buy-back guarantee for all locally manufactured medicines, and this has served as an incentive to expand local manufacture…

‘Starting in 2016, the government introduced price regulation through a price formula on selected essential medicines as a means of containing their costs and reducing OOPE. Initially introduced for only 48 high-volume essential medicines, it has now been increased to include 72 categories of medicines, including cancer drugs, insulin, glucometers, and strips. Similarly, price regulation has been introduced for commonly used devices such as intraocular lenses and stents for angioplasty.

‘The [Medical Supplies Division] MSD of MoH provides all drugs and related medical items for all government sector health-care institutions. The MSD imports drugs mainly through the State Pharmaceuticals Corporation. Regional MSDs in each district distribute drugs from the MSDs to health institutions under the purview of provincial councils. The MoH has its own logistic facilities for distribution across the country. Self-distribution is the main mode of distribution of drugs among private importers. The importation and distribution of drugs is regulated by the NMRA guidelines.’^{[footnote 65]}

4.2.2 In an article published in the May 2023 newsletter of the Sri Lanka Medical Association (SLMA), Professor Galappatthy, Chairperson of the Medicinal Drugs Committee, described pharmaceutical supply in the private sector:

‘Pharmaceuticals are provided to patients in the private sector through 3,297 island wide retail pharmacy outlets at 1.6 licensed retail pharmacies per 10,000 population, which includes the [State Pharmaceutical Corporation] SPC owned nationwide chain of Rajya Osu Sala outlets and franchise Osu Salas. The Osu sala outlets ensure quality assured products at affordable prices in the private sector and has been functioning as an unofficial price regulator in the private sector over the years. The affordability of medicines in Sri Lanka reported by nationwide studies, prior to recent price controls can be attributed to the presence of government owned Rajya Osu salas, supplying medicines at affordable competitive prices, that other retail outlets must compete with. Most of the medicines procured through the SPC are essential medicines to be delivered to public facilities via the MSD, but nonessential medicines are also procured for the Rajya Osu Sala outlets to meet the public demand.’^{[footnote 66]}

4.2.3 The SEM report of 14 April 2023 noted:

‘Numerous private pharmacies, including the well-known pharmacies Union Chemists, Asiri Surgical Hospital Pharmacy and Health Guard Pharmacy, have several branches in Colombo. In addition to the branch network, all three also operate an online pharmacy through which patients can order medicines. To do so, they enter their contact details and the pick-up location and upload the prescription. The medication is either sent to their home or made available for collection at a pharmacy.’^{[footnote 67]}

4.2.4 In October 2023, Liyanage and colleagues from the University of Colombo published a study in the peer-reviewed journal BMC Health Services Research. The authors described Sri-Lanka’s 3 types of community pharmacy: ‘“Rajya Osusala” outlets owned and operated by the State Pharmaceuticals Corporation (SPC), SPC franchise pharmacies and privately owned pharmacies… The SPC franchise pharmacies are also privately owned but these are operated in keeping with the standards stipulated by the SPC.’^{[footnote 68]}

4.2.5 The State Pharmaceuticals Corporation (SPC) provided contact details on its website for:

• 54 government owned Rajya Osusala pharmacies^{[footnote 69]}

• 112 franchise Osusala outlets^{[footnote 70]}

4.3 Availability and affordability of medication

4.3.1 The MoH website provides an online database of available medicines. The database, SWASTHA, can be searched by a medicine’s generic name.^{[footnote 71]} The MediVerify database on the website of the National Medicines Regulatory Authority (NMRA) can also be used to search for medicines currently registered in the country^{[footnote 72]}.

4.3.2 The SEM report of 14 April 2023 noted: ‘All registered medicines can be imported. It is possible that certain medicines are not available in the public healthcare system, but can be procured privately. Non-registered medicines can neither be imported nor prescribed and obtained.’^{[footnote 73]}

4.3.3 In 2023, Liyanage and colleagues from the University of Colombo published a study in the peer-reviewed journal BMC Health Services Research. Survey data was collected from 80 community pharmacies regarding the availability and affordability of 100 commonly prescribed medicines. The pharmacies were selected across all 25 administrative districts and included both state-owned and affiliated pharmacies, and privately-owned pharmacies. While the article was published in October 2023, the survey was conducted between July and September 2015 (before the 2022^{[footnote 74]} financial crisis).^{[footnote 75]}

4.3.4 The researchers concluded: ‘The overall availability of [essential medicines] EMs in Sri Lanka for a wide range of indications is high in all categories of community pharmacies. Medicines in Sri Lanka are largely affordable and reasonably priced, although [originator brands] OBs are generally more expensive.’ The authors also found no variation between state-owned and privately-owned pharmacies.^{[footnote 76]}

4.3.5 However, the authors noted several limitations of the study: ‘It does not reflect variations in the availability of medicines throughout the year as it is a single point cross-sectional study. Furthermore, it is limited to community pharmacies and thus, does not reflect the overall availability in all healthcare facilities in the country. Although the daily wage of a lowest paid unskilled government worker was used to assess affordability for most of the population, there may be a significant number of daily wage earners and unemployed individuals with a lower income. Hence, this data may not be a true representation of affordability of medicines for the entire population.’^{[footnote 77]}

4.3.6 WHO data, relating to 2019, indicated that 68.3% of health facilities had ‘a core set of relevant essential medicines available and affordable on a sustainable basis.’^{[footnote 78]}

4.3.7 Amnesty International reported on 4 October 2022: ‘Serious shortages in essential and life-saving drugs and equipment emerged as one of the major concerns in Sri Lanka as the economic crisis began to worsen. Sri Lanka imports close to 80 percent of its medicines and medical equipment. When its foreign exchange reserves began to run low, the government was unable to purchase the required drugs and equipment, leading to severe shortages.’^{[footnote 79]}

4.3.8 The report added:

‘In June 2022, a paediatric surgeon said she had seen shortages in intravenous potassium chloride (used to treat many common illnesses), in intravenous antibiotics, and insulin, as well as shortages in equipment (intravenous lines, canulae, syringes) in paediatric sizes. “We even had a shortage of gauze”, she said. “We didn’t have catheters and endotracheal tubes in smaller sizes, so we were asked to re-use them”.

‘Another doctor working in an Intensive Care Unit (ICU) explained how they had shortages in some drugs prescribed for people with chronic kidney conditions. They previously issued prescriptions for one month but had started to do it for one week at a time. “This increases the costs for the patient, because they need to come to us more often to have [the prescription] filled”, she said.

‘She also said that most hospitals had shortages in blood thinners, anti-venom, and anti-rabies medication. Another doctor working on patients with CKDs chronic kidney diseases said that they had shortages in dialysis fluid. “We used to offer most patients dialysis twice a week, and now we only offer once a week,” she said. “We have moved from optimal management to minimal management”.

‘In other instances, people were asked to purchase medicines or equipment from private pharmacies, because government hospitals did not have stocks. “But not everyone could afford it. Those who couldn’t, just went home and came back worse”, a doctor said…’^{[footnote 80]}

4.3.9 In an article published in the April 2023 newsletter of the SLMA, Professor Galappatthy opined on ways to improve pharmaceutical supply in Sri Lanka. Summarising performance prior to the 2022^{[footnote 81]} financial crisis, Galappatthy noted: ‘Considering the availability and affordability of medicines, several studies conducted over the years report availability of selected essential medicines as high (>80%) or fairly high (50-80%) in both public and private sectors in Sri Lanka… Most medicines were also affordable to the lowest income earners in the community.’^{[footnote 82]}

4.3.10 Galappatthy also noted the impact of the financial crisis:

‘One of the main sectors that was seriously affected by the economic crisis in Sri Lanka, was the pharmaceutical sector. The World Health Organization (WHO) reported that Sri Lanka’s economic crisis rapidly turned into a health crisis amid growing shortages of basic drugs and medical supplies. By January 2023, according to data from Medical Supplies Division (MSD) of the 383 essential medicines, 164 were reported to be out of stock in the MSD, although some stocks were available at the hospitals. Another 90 medicines were available in sufficient stocks only for one month, 38 medicines were sufficient only for 2-3 months and 18 medicines were available only for 3 months. Although the shortages were precipitated by the economic crisis, some aspects of the supply chain were noted to have lapses, which have contributed to these shortages.’^{[footnote 83]}

4.3.11 The MoH’s Annual Performance Report 2022, published in September 2023, provided a breakdown, split by individual hospital, showing the availability of essential drugs for non-communicable disease (NCD) management. CPIT has summarised the data in the table below^{[footnote 84]}, providing the median availability grouped by hospital type, and also the highest and lowest availability within each group.

-	‘Percentage of essential drugs for NCD management available throughout the year’
Type of hospital	Median	High	Low
National hospitals (n=2)	67.18	76.47	57.89
Teaching hospitals (n=11)	76	100	12.5
Specialised hospitals (n=8)	73.12	100	0
District hospitals (n=11)	74	100	18.75
Base hospitals (n=5)	92	93.8	66.6

4.3.12 The SEM report of 14 April 2023 noted: ‘The availability of medicines has stabilised in the state healthcare system [following the economic crisis of 2022]. Patients receive the standard medication they need. Medicines that are temporarily unavailable in the public healthcare system can be obtained from private pharmacies.’^{[footnote 85]}

4.3.13 The SEM report also noted, ‘In the facilities visited by the SEM Country Analysis, common psychotropic drugs and other drugs that treat secondary diseases are available. In Sri Lanka, it is common for the often much cheaper previous generation of drugs to be used (as opposed to the most recent generation of drugs) for reasons of cost.’^{[footnote 86]}

4.3.14 On 16 March 2024 the BBC reported:

‘…the effects of a devastating economic crisis have meant this once celebrated system [free health services] is now dealing with a shortage of drugs and problems with counterfeit medicines…

‘…Sri Lanka imports almost all of its medicine. Pharmaceutical industry experts say there’s still a shortage of many life-saving drugs produced by global pharmaceutical companies, as a result of pricing issues and commercial viability. The prices of imported medicines also soared as the Sri Lankan rupee dropped by nearly 70 percent against the dollar in the 2022-2023 period.

‘”Some unscrupulous people are illegally bringing in medicines from countries like India and Turkey. They charge five or six times the original prices,” a pharmaceutical executive, who didn’t want to be identified, told the BBC.

‘Dr Ramesh Pathirana, the country’s Health Minister, admits that there have been some shortages, but insists the government is committed to increasing funding for the healthcare system. “Some consultants are prescribing newer molecules, expensive drugs, sometimes the government couldn’t bear [the cost],” Mr Pathirana told the BBC. However, he said the budget allocation for health has been increased this year to address the escalating costs of medicines.’^{[footnote 87]}

4.3.15 The DFAT Country Information Report of 2 May 2024, stated:

‘Medical shortages have since eased considerably. In-country sources estimated that, as of June 2023, 90 percent of medications were available in the public system in the Northern Province and expected the situation to return to normal by the end of that year. Where unavailable in the public system, medications were available for purchase at private pharmacies, although inflation and associated cost-of-living pressures impacted affordability for some people (insulin and medication to treat heart disease were reported to be particularly expensive). Medication for diabetes, cholesterol, high blood pressure and influenza were widely available and accessible at the time of publication.’^{[footnote 88]}

(See Financial crisis – impact and recovery)

Section updated: 29 October 2024

5. Mental healthcare

5.1 Governance and policy

5.1.1 In March 2021 the MoH published its National Mental Health Policy 2020-2030. The publication included a graphic showing the structure of ‘advisory and coordinating bodies’^{[footnote 89]}.

5.1.2 The MoH’s annual Performance and Progress Report for 2023 stated: ‘Directorate of Mental Health is the national level focal point of the Ministry of Health responsible for the National Mental Health Program. The unit is responsible for policy development, strategic planning, strengthening of mental health services through improved infrastructure, human resources, and monitoring & evaluation of National Mental Health Program.’^{[footnote 90]}

5.2 Structure, facilities, and services

5.2.1 An undated article on the website of the Directorate of Mental Health noted:

‘There are 7 tertiary care hospitals established in Sri Lanka which are directly governed by the Ministry of Health. All these institutions possess Acute psychiatric in- patient wards to treat psychiatric patients. ‘Currently Acute inpatient units are available in 23 of the 26 districts and also in few regionally managed institutions. Presently there are 61 adult inpatient units, three child inpatient units and one forensic unit in the country.

‘Similarly Medium stay units were available only in five districts in 2004, which has now expanded to 15 districts. The outreach clinics currently exist in almost all health divisions. In addition, Community support centres are being set up at district level to serve as hubs for promotion of mental wellbeing. Mental outreach clinics provide close-to-home services in Sri Lanka to enable better care and follow up on clients, and to reduce the treatment gap.

‘Mental health clinics support continuity of care, assessment, treatment, and home visits. These are conducted by Medical Officer Mental Health or Medical Officer Mental Health Focal Point or Consultant Psychiatrist. Home visits are mainly for the defaulted and also provide assistance to them and their caretakers. Home visits are done by a team consisting of Medical Officer, Nursing officer and Psychiatry Social Worker.’^{[footnote 91]}

5.2.2 The SEM report of 14 April 2023 noted:

‘Access to mental health facilities as well as to psychiatrists is guaranteed throughout the country including in remote, rural areas. Almost all medium and large hospitals in most districts of Sri Lanka have psychiatric departments run by qualified psychiatrists. The hospitals have psychiatric departments for acute and long-term inpatient treatments as well as psychiatric outpatient clinics. On certain days, psychiatric outpatient clinics are also run at small hospitals in rural areas. In many districts, there are centres for the rehabilitation and reintegration of chronically mentally ill persons. In the public healthcare system, waiting times for an appointment with a psychiatrist are usually less than a week and patients have a free choice of doctor. Nationwide and regional psychiatric hotlines are available for psychiatric emergencies.

‘Half of all outpatients’ medical treatments and consultations in the Sri Lankan healthcare system are administered by private healthcare providers. Thanks to modern, app-based booking systems, medical consultations with senior registrars and counsellors can be arranged quickly, sometimes on the same day. Private medical consultations are common in Sri Lanka, and they are not only used by the wealthy…

‘…There are limitations to psychiatric treatment using Cognitive Behavioural Therapy (CBT) and Eye Movement Desensitisation and Reprocessing (EMDR) therapy. Depending on the source, these are only available in a few clinics or are not possible due to time constraints. Psychotherapies with clinical psychologists are available without restriction in the private health care system. In the public healthcare system, psychotherapy is provided by registrars or counsellors.’^{[footnote 92]}

5.2.3 The SEM report of 14 April 2023 further noted:

‘Sri Lanka currently has 61 inpatient psychiatric wards for adults, three inpatient psychiatric wards for children and various specialised psychiatric wards. Outpatient psychiatric care is provided by outpatient clinics in specialised hospitals, as well as in the larger primary care hospitals at provincial and district level. … According to the WHO, there are 126 psychiatric outpatient clinics in public hospitals in Sri Lanka, 320 psychiatric outreach clinics in local health centres, 61 child psychiatric outpatient clinics and numerous specialised psychiatric outpatient clinics, e.g. for addictions…

‘The psychiatric outpatient clinics in the large university hospitals or the main hospitals in the provinces (Provincial General Hospitals) are open daily. As the example of Jaffna University Hospital shows, they also offer daily consultations in the psychiatric departments. In Jaffna, this is the paediatric psychiatry department. At the large hospitals, several psychiatric specialists and a team of therapists are available for consultations every day…

‘There are 22 psychiatric rehabilitation centres in Sri Lanka: medium-stay facilities (six months) and longer-stay facilities (over a year). Medium-stay centres are suitable for people who do not require intensive medical treatment but need treatment and support in developing life skills and social and vocational reintegration into society. An important part of rehabilitation is occupational therapy, which teaches life and work skills. Rehabilitation centres focus on learning everyday skills such as self-care, cooking and cleaning. Most rehabilitation centres are located in hospitals and their management can vary from district to district.’^{[footnote 93]}

5.2.4 The SEM report of 14 April 2023, when referring to the NIMH in Angoda near Colombo, noted:

‘There are a large number of specialised departments, including eight acute psychiatric departments, six departments for patients with intermediate length of stay, a department for long-term psychiatric care, a department for intensive psychiatric care, a department for people with dementia, one for people with learning disabilities, the department for perinatal psychiatry, the forensic psychiatry department for mentally ill offenders, a clinic for victims of sexual violence and a hotline for psychiatric emergencies. The NIMH also runs a psychiatric day clinic where patients are cared for during the day and return home in the evening.

‘The psychiatric outpatient centre of the NIMH is located in the National Hospital in Colombo. It is open daily. According to the doctors in charge, all psychiatric conditions, including post-traumatic stress disorder (PTSD), can be treated at the NIMH.’^{[footnote 94]}

5.2.5 The National Institute for Mental Health (NIMH) published a media bulletin on 11 October 2022 which stated: ‘[NIMH]… is the largest tertiary care hospital in Sri Lanka caring for patients with mental illness… NIMH provides acute care, intermediate care and long-term care as well as specialized services.’^{[footnote 95]}

5.2.6 The bulletin provided information on the services provided by NIMH. CPIT has summarised relevant content in the table below^{[footnote 96]}:

Preliminary care

• 24-hour emergency admissions via Psychiatric Intensive Care Unit (PICU)

• 24-hour outpatient department

• 24-hour 1926 National Mental Health Helpline

Outpatient

• Day treatment facility for minor mental illnesses

• Day Electro Convulsive Therapy facility

• Day rehabilitation facility

• Alcohol relapse prevention therapy

• Gender based violence prevention and care

• Community mental health care

• Adolescent mental health clinics

• Gender dysphoria clinic

Inpatient

• Treatment facilities for acutely ill clients

• Rehabilitation facilities (including occupational therapy and rehabilitation centre)

• Employment-related skills training

• Psychiatric social services

• Medium stay intermediate care homes

• Long term wards

Specialised care

• Forensic psychiatry unit

• Geriatric psychiatry unit

• Adolescent psychiatry unit

• Perinatal psychiatry unit

• Learning disability unit

Other

• Promotion of community mental health via Health Promotion Unit

5.2.7 The Human Rights Commission of Sri Lanka (HRCSL) published a report of their fact-finding mission to the National Institute of Mental Health (NIMH) in December 2023. The report noted:

‘The National Institute of Mental Health (NIMH) …is the largest tertiary care hospital in Sri Lanka caring for clients with mental illness and the only mental health care facility in Sri Lanka facilitating involuntary admissions. The facility provides long-term in-patient care for patients who are suffering from severe mental disorders, while also attending to outpatients with mild mental health conditions. NIMH has a capacity of 1409 beds and annually around 7000 clients are admitted seeking treatment for a wide range of mental diseases. In addition, the hospital has also launched a helpline … which is functioning throughout the day.

‘The patients are housed in different units; the adolescent unit, learning disability unit, perinatal psychiatry unit, acute units, intermediate units, substance misuse unit, forensic psychiatry unit, geriatric unit, neurotic unit, long term rehabilitating male and female units in NIMH and Mulleriyawa, and the paying units (Villas), according to their different mental health conditions. The Commission was concerned about the forensic psychiatry unit’s lack of prison guards and about housing both remand and convicted prisoners (patients in both acute and intermediate stages) in the same space. … In addition, overcrowding and understaffing appeared a common problem faced by a majority of the aforementioned units.

‘… While the conditions of most of the wards were satisfactory, some issues were observed with regards to lighting, temperature, ventilation, bedding, storage, seclusion facility, and pest control.

‘… In addition to pharmacological treatment, electro convulsive therapy, cognitive behavioural therapy, occupational therapy, exposure, and horticulture therapy are being used at NIMH for the treatment of patients. In addition to shortage of medication being an ongoing problem, the hospital also has had several quality failures of the drugs as well. When the medicines are out of stock, alternatives are being used for the treatments. However, it was relayed that most of these alternatives have more side effects than the high-quality medicines that are out of stock. Furthermore, there are also instances where the families of the patients were asked to bring some medication from outside. Due to the high cost, the discharged patients also struggle to afford their medication.’^{[footnote 97]}

5.3 Capacity

5.3.1 The MoH Annual Health Bulletin recorded 800,356 visits to psychiatric clinics in 2021.^{[footnote 98]} The same source recorded 3,084 dedicated psychiatric beds. Most beds were in Colombo (1,525), followed by Gampaha (208), Kandy (199), Anuradhapura (126), with the remaining 1,026 split across the other 22 Divisions.^{[footnote 99]} The figure of 3,084 doesn’t include psychiatric patients who used beds on mixed wards.^{[footnote 100]} The figure is therefore likely to be an underestimate of the number of beds available.

5.3.2 The NIMH media bulletin published on 11 October 2022 stated: ‘… The NIMH has a total of around 1500 beds and annually around 8000 patients are admitted seeking treatment for all types of mental illness… There are about 900 inward patients treated at NIMH on any given day.’^{[footnote 101]}

5.3.3 The MoH’s annual Performance and Progress Report for 2023 provided a graph showing the number of hospital admissions over the 5-year period 2017 to 2021 for a range of mental health conditions^{[footnote 102]}:

5.4 Personnel

5.4.1 The WHO Mental Health Atlas 2020 recorded 1,165 mental health professionals, consisting of 123 psychiatrists, 624 mental health nurses, 61 psychologists, 72 social workers, and 285 other specialised mental health workers (e.g., occupational therapists).^{[footnote 103]}

5.4.2 The MoH Annual Health Bulletin recorded the distribution of specialists across all curative care services in 2021, including 104 psychiatrists.^{[footnote 104]}

5.4.3 The 2022 annual report of NIMH, published in February 2023, provided a breakdown of staff at the institute. As of 31 December 2022, the NIMH had 1,198 full-time staff including: 10 Consultant Psychiatrists, 2 Consultant Physicians, 1 Consultant Haematologist, 79 Grade Medical Officers, 3 Dental Surgeons, 5 Special Grade Nursing Officers, 6 Ward Sisters, 3 Ward Masters, 415 other Grade Nursing Officers, 10 Occupational Therapists, 7 Pharmacists, 6 MLTs, and 9 Psychiatric Social Workers.^{[footnote 105]}

5.4.4 The SEM report of 14 April 2023 noted: ‘Qualified mental health care personnel are available in public and private healthcare facilities throughout the country. This also applies to the largely Tamil-speaking Northern Province. In the Jaffna District, in addition to three consultants, there are six other trained psychiatrists (senior registrars), six mental health medical officers working in psychiatric departments, and a number of mental health nurses, trained counsellors, psychiatric social workers and psychiatric patient rehabilitation specialists.’^{[footnote 106]}

5.5 Suicide and self-harm

5.5.1 The SEM report of 14 April 2023, noted:

‘In Sri Lanka, there is a national helpline for people with mental health problems, which can be reached around the clock in Singalese, Tamil and English on the free phone number 1926. According to its own accounts, the helpline is there for all people in Sri Lanka who are struggling with anxiety, depression, grief and loss, loneliness, self-harm, stress, suicide, trauma and PTSD and are looking for help. Helpline 1926 is run by a team of specially trained nurses who can be contacted by phone or chat via WhatsApp. The helpline specialists primarily listen to the callers, try to calm them down in stressful situations and, if necessary, refer them to psychiatric specialists in all regions of Sri Lanka…

‘The non-governmental organisation Abayam operates a regional helpline in Tamil in the Northern Province on 071 071 2345. It was set up in 2020 in response to the high suicide rate in the region. The helpline is staffed by trained therapists/coaches (counsellors). They can refer callers to social workers and psychiatrists in Jaffna if necessary. The most common concerns of callers are personal crises and suicidal thoughts due to relationship problems and domestic violence. … The psychiatric university hospital in Tellippalai also operates a helpline for people with mental health problems in the Jaffna district.’^{[footnote 107]}

5.5.2 In August 2023, the Sunday Times, a Colombo-based online news site, reported: ‘The National Suicide Prevention Strategy and Action Plan were introduced under the Mental Health Policy to address suicide. There are six strategies highlighted: advocacy, evaluation of existing policies, provision of mental health services, promotion of psycho-social wellbeing, improving environments in institutes of learning, and establishment of an efficient surveillance system… There are 47 centres attached to the MOH that offer mental wellness services. In addition, the Directorate of Mental Health also liaises with teachers, coaches, social workers, and counsellors through a programme called the Gatekeeper Programme for suicide prevention and public awareness.’^{[footnote 108]}

5.5.3 The Sunday Times also provided helpline numbers of 5 organisations which provide assistance to persons experiencing suicidal thoughts:

• 1375 (Lanka Lifeline)

• 1333 (CCC Foundation)

• 1926 (National Mental Health Helpline)

• 0707 308 308 and 0767 520 620 (SL Sumithrayo)

• 0717 639 898 (Shanthi Maargam)^{[footnote 109]}

5.6 Drug and alcohol rehabilitation

5.6.1 An undated article on the website of the Directorate of Mental Health noted: ‘There are seven [alcohol rehabilitation] centres located in Gampaha, Kandy, Jaffna, Batticaloa, Kurunegala, Badulla and Kilinochchi… The rehabilitation activities include play therapy, group therapy, counselling, gardening, religious programs, and family interventions.’^{[footnote 110]}

5.6.2 The MoH provided data on the number of new patients treated in mental health clinics for mental and behavioural disorders resulting from drug use for the period 2018 to June 2020^{[footnote 111]}:

New patients treated	Opioids	Cannabinoids	Sedatives/Hypnotics	Total
2020 (up to June)	2218	541	142	2901
2019	6908	1930	349	9187
2018	6242	1121	127	7490

5.6.3 In July 2023, the MoH published guidance for the management of substance abuse patients.^{[footnote 112]}

(Also see Mental health NGOs and Structure, facilities and services)

5.7 Child and adolescent mental health

5.7.1 The WHO Mental Health Atlas 2020 recorded 578 mental health workers in child and adolescent mental health services and 2 inpatient facilities specifically for children and adolescents.^{[footnote 113]}

5.7.2 An undated article on the website of the Directorate of Mental Health noted:

‘Two main hospitals that specialize in childcare, Lady Ridgeway Hospital in Colombo and the Sirimavo Bandaranayke Specialized Children Hospital in Kandy, address child mental health needs. In addition to the regular outpatient clinics and inpatient services, the Lady Ridgeway Hospital for Children conducts specialized programmes to address the following: Specific Learning Disabilities (SLD), Attention Deficit Hyperactivity Disorder (ADHD), early intervention for Autism Spectrum Disorder (ASD) and family support for children with behavioural disorders. To make childcare available at district level, Directorate of Mental Health has promoted child psychiatry outpatient clinics in all district hospitals. Currently there are four Child and Adolescent Psychiatrists working in 4 districts addressing promotive, preventive, clinical and rehabilitative care for children and adolescents.’^{[footnote 114]}

5.7.3 The Royal College of Psychiatrists in their report, Development of adolescent mental health services in Sri Lanka, January 2023 stated:

‘… Overall, population data from Sri Lankan hospitals providing mental health services has identified that depressive disorders, disorders due to psychoactive substances and schizophrenia are the foremost reasons for seeking treatment, but comprehensive data on youth mental health are not available as the country lacks surveillance data on this population…

‘Sri Lanka’s 2005 Mental Health Policy identified child mental health services as a specialty that needed to be further developed. The policy was implemented within the National Mental Health Action Plan, which had been developed by the Mental Health Directorate and experts in psychiatry. However, there was little specific reference to adolescent mental health services. In the capital Colombo and in the central city of Kandy, in-patient child psychiatry units were established in 2002 and 2014 respectively…’^{[footnote 115]}

5.7.4 The report added:

‘The first adolescent in-patient unit was opened in 2016 at the National Institute of Mental Health, Colombo. Currently, few psychiatric beds in the country are allocated to children (just 12) and only 9 beds are reserved for adolescents. These services are limited to certain districts, and many of the children and youth admitted to them are managed by general adult psychiatrists. Concerns have been raised about the use of debatable practices such as pharmacological treatments designed for adults being used to treat children and adolescents…

‘Owing to the limited number of dedicated beds for children with mental health problems, they may be admitted to other units, a deviation from the 2005 policy, which required children needing admission to be placed in local paediatric wards or children’s mental health wards.

‘Sri Lanka is still in the phase of developing facilities to provide comprehensive child mental healthcare but has yet fully to address the objective of establishing dedicated adolescent and youth mental health services. The country is striving forward with the provision of accessible and community-acceptable psychiatric services for adults, but there are still financial and service structure barriers to be overcome to achieve the objectives …’^{[footnote 116]}

5.7.5 In July 2024, the Sunday Times reported on a speech by Dr Amarasinghe, President of the Sri Lanka College of Psychiatrists, at a psychiatry conference held in Colombo:

‘…Currently, there were only five Child and Adolescent Psychiatrists, all based in the Western Province, with no Child Psychiatrist at the second largest paediatric hospital in the country, the Sirimavo Bandaranaike Children’s Hospital, Peradeniya. Child psychiatry outpatient services in all major General Hospitals were mostly conducted by General Adult Psychiatrists…

‘However… [Dr Amarasinghe] held out hope against fears of a collapse of the system, when he explained that Continuous Medical Education (CME) in child psychiatry was being provided for General Adult Psychiatrists while also improving the mental health knowledge of Medical Officers (MOs) and improving skills and knowledge among other stakeholders such as nurses, social workers, occupational therapists, police officers, emergency department staff, LGBTQ (lesbian, gay, bisexual, transgender and questioning) community and the public. Child-friendly school programmes are also being held by the Health Ministry and the Sri Lanka College of Psychiatrists.’^{[footnote 117]}

5.8 Mental health NGOs

5.8.1 Sumithrayo is a charity based in Colombo which provides free-of-charge support through a phone service or face-to-face meetings ‘for people who are experiencing, feelings of distress or despair, including those that may lead to suicide.’^{[footnote 118]}

5.8.2 The National Council for Mental Health (NCMH) is an NGO which maintains the Borella Resource Centre (Colombo) and the Gorakana Residential Facility (Panadura)^{[footnote 119]}. Services provided by NCMH include:

• counselling

• consultations with a psychiatrist

• day-care programme

• accommodation and care of elderly persons with mental health problems

• short to medium-term residential rehabilitation programme (for psychiatric illness, psychological disorders, and substance abuse)^{[footnote 120] [footnote 121]}

5.8.3 The Alcohol and Drug Information Centre (ADIC) is a Colombo-based charity which provides services to reduce alcohol and drug consumption.^{[footnote 122]} ADIC runs a programme for heroin users, which includes a drop-in centre and support groups. The organisation also provides a Psychological Counselling Programme which provides in-person or telephone counselling to persons with alcohol and other drug use problems.^{[footnote 123]}

5.8.4 During 2023 UNICEF Sri Lanka provided ‘mental health and psychosocial support for 952,551 adolescents.’^{[footnote 124]}

Section updated: 21 August 2024

6. Physical health

6.1 Cancer (General)

6.1.1 The MoH National Cancer Control Programme (NCCP) website provided details of cancer treatment centres.^{[footnote 125]} CPIT complied the following table from the information provided:

Western Apeksha Cancer Institute Maharagama

Base Hospital Avissavella

University Hospital Kotalawala Defense University, Werahera

Colombo North Teaching Hospital Ragama

District General Hospital Gampaha

District General Hospital Kalutara

Southern Teaching Hospital Karapitya

District General Hospital Hambantota

District General Hospital Matara

Eastern Teaching Hospital Batticaloa

District General Hospital Trincomalee

District General Hospital Ampara

Northern Base Hospital Thellipalai

District General Hospital Vavuniya

North Central Teaching Hospital Anuradhapura

District General Hospital Polonnaruwa

Northwestern Provincial General Hospital Kurunegala

District General Hospital Chilaw

Central Teaching Hospital Kandy

District General Hospital Nuwaraeliya

Sabaragamuwa Teaching Hospital Ratnapura

District General Hospital Kegalle

Uva Provincial General Hospital Badulla

District General Hospital Monaragala’^{[footnote 126]}

6.1.2 The MoH Annual Health Bulletin recorded 35,668 new patient registrations at cancer centres in 2021.^{[footnote 127]}

6.1.3 Undated information on the MoH website noted:

‘The National Cancer Institute (NCI) is the leading hospital under the Ministry of Health dedicated to the diagnosis and follow-up treatment of cancer patients. The NCI offers both the diagnostic facilities necessary for the identification of all types of cancer, and specialized care in surgery, chemotherapy, and radiotherapy. A team of expert Consultants manage the hospital services alongside medical doctors, nurses, pharmacists, medical physicists, laboratory technicians and minor workers. Anyone can access the services, free of charge. In addition to delivering quality care services the NCI is the major training centre for medical undergraduates and postgraduates of the Postgraduate Institute of Medicine (PGIM).

‘Names of the Ward/Unit

• Oncology – Chemotherapy

• Oncology – Radiotherapy

• Iodine Ward

• Haemato-oncology

• Paediatric

• Medical

• Surgery

• Gynaecology

• Surgical Intensive Care Unit

• Paediatric Intensive Care Unit

• Medical Intensive Care Unit

• Bone-Marrow Transport Unit

• ETU [Ebola Treatment Unit]

• Chemotherapy Unit

• Medical Nutrition Unit

• Paediatric Chemo Unit

• Dialysis Unit’^{[footnote 128]}

6.1.4 The MoH’s Annual Performance Report 2022, published in September 2023, listed 4 Cancer Early Detection Centres (CEDC), which were located at Narahenpita, Matara, Jaffna and Rathnapura. The same report noted that at the end of 2022, there were 25 breast cancer clinics located in major hospitals.^{[footnote 129]}

6.1.5 The NCCP website provided information on the Cancer Early Detection Centre in Narahenpita which stated it was ‘…open 8.30am to 3.00pm on weekdays, except public holidays, offering the following services free of charge:

• ‘Consultation with a doctor to discuss cancer related issues including, clinical history taking to identify risk of cancer, education on risk factors and guidance on the need to screen and prevent common and preventable cancers.

• ‘Demonstration on correct technique of Self-Breast Examination and Self-Mouth Examination.

• ‘Screening for Breast Cancer… Clinical-Breast Examination, Ultrasound Scanning, Mammography

• ‘Screening for Cervical Cancer… Vaginal Examination…Pap smear

• ‘Screening for Oral Cancer

‘Referrals for specialist opinion and guidance (if and when appropriate) e.g., Breast Clinics / Gynaecology Clinics / General Surgical Clinics / Genetic Counselling Clinics.’^{[footnote 130]}

6.1.6 The same NCCP website listed each province and hospital where specific diagnostic cancer services - colonoscopy and mammography were ‘currently functioning’ or ‘proposed.’^{[footnote 131] [footnote 132]}

6.1.7 Berry, S, and others stated in a study published on 27 May 2022 in the peer-reviewed journal JCO Global Oncology: ‘The Sri Lankan cancer system provides universal free cancer care, accessible regional cancer treatment units, and a national oncology training program …’^{[footnote 133]}

6.1.8 ESMO, the European Society for Medical Oncology representing more than 35,000 oncology professionals in 172 countries, stated in their article, Palliative Care Unit National Cancer Institute (Apeksha Hospital), August 2022:

‘The National Cancer Institute in Maharagama is the main tertiary referral cancer centre in Sri Lanka, where specialized oncological treatments are provided. It is a government-funded institute consisting of adult oncological units with 542 beds, paediatric oncological units with 145 beds, oncosurgical units with 88 beds, an onco gynaecological unit with 41 beds, and haemato- oncological units with 71 beds.

‘In addition, it has a number of units offering chemotherapy, radiotherapy, bone marrow transplantation, radiology, blood transfusion, pain management, palliative care, psychological counselling and spiritual support, social development, nutritional support, as well as a physiotherapy and rehabilitation unit. Holistic compassionate patient centred care is provided by the multidisciplinary team.’^{[footnote 134]}

6.1.9 See Services on the NCCP website.

6.2 Cancer (children)

6.2.1 The Guardian, in their article, A place of healing’: comfort for young cancer patients amid Sri Lanka’s economic crisis, 20 February 2023 stated:

‘Despite a combined economic crisis and drug shortage, Sri Lanka is poised to open its first children’s palliative care centre – and also hopes to vastly improve the country’s poor survival rates for child cancer. The centre will offer end-of-life care as well as a place to stay for families who have to travel long distances to the country’s only paediatric oncology ward in the capital, Colombo. The new centre is called Suwa Arana (place of healing) and is due to open in June…

lack of data collection means the exact survival rate for Sri Lankan children is not known, but doctors at Apeksha Hospital estimate it at 26 percent… The centre is being funded by the [charity] Indira Cancer Trust, …[and] aims to bridge the gap…between children living in Colombo and those in rural areas….’^{[footnote 135]}

6.2.2 The article further added:

‘Suwa Arana is being built close to Apeksha Hospital. With 32 ensuite rooms, it will have enough room to house families… Most rooms will only be used for a few days, although some will house children, with their families, during the last months of their lives.

‘The financial crisis has also caused a widespread drug deficit. “There is a shortage of medicines for cancer throughout Sri Lanka,” says Indira Trust chair Dr Lanka Jayasuriya Dissanayake. “The governmental mechanism for purchasing medicine is disturbed by the lack of dollars – it is running on donations.” The trust has been working nationwide with 22 hospitals to secure outside donations for cancer medication …

‘Even before the crisis, availability of cancer drugs for children was patchy. Between 2019 and 2020, less than half the medication considered essential for treating paediatric cancers was consistently available in Apeksha hospital …’^{[footnote 136]}

6.2.3 The Morning in their article of 2 July 2023 confirmed the opening of Indira Cancer Trust Suwa Arana: ‘Last week (29) saw a landmark event in holistic care in Sri Lanka with the formal opening of the Indira Cancer Trust’s Suwa Arana, Sri Lanka’s first dedicated paediatric palliative care centre. To mark this occasion, The Sunday Morning Brunch spoke with Indira Cancer Trust Chairperson and Trustee Dr. Lanka Jayasuriya-Dissanayake about what it means to have such a palliative care centre for Sri Lankan children.’^{[footnote 137]}

(See also Palliative care)

6.3 Colorectal cancer (CRC)

6.3.1 Berry, S, and others stated in a study published on 27 May 2022 in the peer-reviewed journal JCO Global Oncology:

‘CRC is currently among the top five highest incidence cancers in Sri Lanka (SL) …

‘… Patients with CRC are often referred to NCISL [The National Cancer Institute SL] following surgery for adjuvant therapy or for neoadjuvant/palliative treatment. Although cancer care pathways have expanded in the past few decades, the system continues to face challenges, including inadequate radiation therapy facilities and an exodus of SL-trained oncologists to high-income countries. CRC screening programs in developing countries such as SL are rare, and this has likely led to a higher proportion of advanced-stage CRC at diagnosis.

‘… There is also very limited information on treatment patterns for CRC in SL and their congruence to guidelines…’^{[footnote 138]}

6.3.2 The report further stated:

‘… Despite calls for increased population-based screening for CRC, SL, like many other South Asian countries, does not have a population-based CRC screening program …

‘… overall concordance with treatment guidelines was promising for adjuvant therapy [after primary treatment such as surgery]. Every three out of four eligible patients with colon cancer and more than half of eligible patients with rectal cancer who did not receive neoadjuvant [treatment before surgery] therapy received adjuvant therapy. However, the concordance to guidelines was poor for use of neoadjuvant therapy, where less than half of the patients with an absolute indication for neoadjuvant therapy for rectal cancer received treatment…

‘… Potential explanations for incongruence in adherence to treatment guidelines include a lack of access to radiotherapy, as there were only seven radiotherapy facilities in SL during the study period, long wait times for radiotherapy, and upfront surgery performed in smaller hospitals, which lack quick access to oncology consultation … Equally important, concerning overtreatment rates were found in the study…several patients with Stage I disease who were not indicated for chemotherapy received chemotherapy …’^{[footnote 139]}

(See also Cancer (General) and Palliative care)

6.4 Chronic kidney disease (CKD)

6.4.1 The Ministry of Health in their 2019 Annual Health Bulletin noted: ‘… Hospitalization due to diseases of the urinary system is the fourth leading cause in the year 2019.’^{[footnote 140]}

6.4.2 The Sri Lankan Kidney Foundation (SLKF), a non-profit organisation registered in England and Wales, providing support for persons affected by CKD in Sri Lanka observed in their article, Chronic Kidney Disease and Sri Lanka, 15 February 2022:

‘As of statistics in 2020: There were 164,000 CKD patients diagnosed throughout the whole year and an accumulated study shows that nearly 10 percent of the Sri Lankan population are affected by kidney-related diseases.

‘Statistics as of 2020 further shows the seriousness of this situation as there has been a record number of approximately 10,500 deaths annually due to kidney failure and kidney-related diseases. This is an extremely significant value as it demonstrates that much of the population are unable to address the diagnosis of CKD and kidney-related diseases properly, resulting in so many fatalities in Sri Lanka.’^{[footnote 141]}

6.4.3 On 4 October 2022, Amnesty International reported in relation to the impact of the 2022 economic crisis:

‘… A doctor who provided kidney transplants explained how immunosuppressants for transplant patients were initially given free. But at the time Amnesty International spoke with her, shortages had meant that patients were asked to buy these. “They used to cost under LKR 100 [USD 0.28], now it is LKR 340 [USD 0.95]. They have to take 10 a day. That’s LKR 3,000 [USD 8.35] [£6.57 British Pounds^{[footnote 142]}] to LKR 4,000 [USD 11.14] [£8.77 British Pounds^{[footnote 143]}] a day”, she said …’^{[footnote 144]}

6.4.4 RSTMH reported on 10 February 2023: ‘… Sri Lanka is a country with rapidly increasing CKD cases…. this has caused a problem in distributing resources because of the higher number of patients needing critical care.’^{[footnote 145]}

6.4.5 Damayanthi, H, and others noted in an article in the peer-reviewed journal Public Health Challenges, published 24 January 2024:

‘CKD has now attained epidemic proportions, placing a significant strain on Sri Lanka’s healthcare system… Haemodialysis is the primary form of renal replacement therapy available to end-stage renal disease patients in Sri Lanka. Providing haemodialysis sessions free of cost in the government health sector comes with major costs on the healthcare system…

‘… The high cost for a single dialysis session, lack of resources and workforce to meet demand, occupational barriers of patients, and the economic burdens including OOPE significant barriers in achieving quality treatment sessions and the quality of life of patients. In addition, the absence of a consistent screening program has contributed to the progression of the disease ending up requiring renal replacement therapy …’^{[footnote 146]}

6.4.6 The article continued:

‘… There has been a notable increase in the burden of CKD in the country in the last two decades with the identification of Chronic Kidney condition of Unknown ethology (CKDu) cases among a population residing in the North Central Province, specifically in the Anuradhapura and Polonnaruwa districts. The occurrence of CKD in these regions varies between 5 percent and 15 percent…

‘…. CKD can progress to end-stage renal disease (ESRD), where the patients need to rely on renal replacement therapy (RRT) such as renal transplantation, haemodialysis, or peritoneal dialysis. Haemodialysis serves as the primary modality for RRT among patients with ESRD in Sri Lanka and is predominantly accessible within tertiary care facilities situated in larger urban areas…

‘…. The majority of dialysis units that get state funding are located within hospitals, whereas only a limited number of independent dialysis units exist. The majority of these healthcare facilities are facing significant challenges due to the high volume of patients in need of chronic RRT.

‘… According to the latest records from the MoH, there are only 8 haemodialysis centres currently functioning in Anuradhapura and Polonnaruwa districts, with less than 100 dialysis machines for the treatment of over 1000 patients. As a consequence, many of these units are compelled to prioritize dialysis treatment for individuals who have kidney transplant plans and younger patients with fewer concurrent medical conditions. Unfortunately, this prioritization strategy has led to an increased number of reported fatalities.’^{[footnote 147]}

6.5 Communicable Diseases

6.5.1 WHO in their Sri Lanka Health System Review of 5 July 2021 noted:

‘Sri Lanka has eliminated/eradicated most of the communicable diseases such as filariasis, leprosy, polio, malaria, and neo-natal tetanus, and achieved near-elimination of other VPDs through successful public health programmes and a dedicated health workforce…

‘Although much has been achieved in eliminating or reducing morbidity and mortality from VPDs, communicable diseases such as dengue, leptospirosis, pandemic influenza and tuberculosis still remain important causes of morbidity…’^{[footnote 148]}

6.5.2 The report added:

‘The disease surveillance system consists of:

1. routine notification of communicable diseases;
2. special surveillance on selected communicable diseases; and
3. sentinel site surveillance.

‘Surveillance of notifiable diseases begins with data collection at the hospital level through the bed head ticket (clinical notes), notification card and notification register (ward and institute). These data from all hospitals across the country are then sent to the relevant MOHs for investigation. Each MOH in the country sends a weekly return of communicable diseases containing data from hospitals on notifiable diseases to the Regional Epidemiologist and to the Epidemiology Unit …’^{[footnote 149]}

6.6 Cardiovascular diseases

6.6.1 The Sri Jayewardenepura General Hospital in Thalapathpitiya, Western Province, noted in an undated entry on their website:

‘The Cardiology Unit of the Advanced Cardiac Centre of Sri Jayewardenepura General Hospital is comprised of the cardiology ward, the Coronary Care Unit [CCU], the High Dependency Unit [HDU], the Cardiac Catheterization Lab and the Cardiac Investigation Unit and cardio electro physiology unit each of which provides a unique aspect of cardiac patient care. Cardiology ward, CCU and HDU care for a wide variety of acute and chronic cardiac problems. Most critical cardiac conditions and cardiac emergencies are managed very successfully by well experienced and dedicated team.

‘Cardiac catheterization includes both planned and emergency invasive cardiac procedures such as coronary angiography, percutaneous coronary interventions, right heart catheterization, temporary/permanent pacemaker implantation, ASD [Atrial Septal Defect^{[footnote 150]}] closure etc. A wide range of cardiac investigations including echocardiography, stress testing, ambulatory blood pressure and ECG [electrocardiogram^{[footnote 151]}] monitoring are carried out in the unit.’^{[footnote 152]}

6.6.2 Senaviratna, N, of the Open University of Sri Lanka noted in an article on the burden of cardiovascular disease in Sri Lanka, published in November 2023:

‘… The recent estimates for mortality from CVD for Sri Lanka was 524 deaths per 100,000 which is higher than that observed in many high-income countries. Coronary artery disease (CAD) is the leading cause of death in Sri Lanka while stroke is the third cause of death. CAD accounted for 34 percent of deaths in an autopsy study. For comparison, CAD accounts for only 17 percent of deaths in the US and UK.

‘Many of these deaths are premature (the person dies too early) and could be prevented, delayed or even well-controlled when it is diagnosed at the early stages of the atherosclerosis process, through a number of lifestyle changes and accurate pharmaceutical treatment and management …’^{[footnote 153]}

6.7 Dengue fever

6.7.1 The Epidemiology Unit of the MoH noted in an undated entry on their website:

‘… Many Dengue infections are asymptomatic or produce mild illness, while occasionally it may cause more severe disease or death. Although there is no specific treatment for dengue, early detection and access to proper management may significantly lower the risk of death. Prevention and control of dengue mainly depend on mosquito control. If you are infected, you may not have significant symptoms, but still, you can transmit the disease. Dengue fever should be suspected if, you are suffering with sudden onset of high fever, severe headache, pain behind the eyes, nausea and pain in muscles and joints. Most patients get better in 1–2 weeks while some people develop severe dengue and need care in-hospital care.

‘In severe disease, you may develop a rash and varying degrees of bleeding from various parts of the body including nose, mouth, and skin etc. Dengue Haemorrhagic Fever could be seen only in a small proportion of those infected and is the most severe form with significant bleeding manifestations.’^{[footnote 154]}

6.7.2 The WHO in their report, Dengue Fact Sheet and Situation Report, 22 July 2022 noted:

‘Dengue is a viral infection transmitted to humans through the bite of infected mosquitoes.

‘WHO has been vigilantly monitoring the dengue situation in the country and considering the surge in dengue cases in many high-risk districts, WHO partnered with MoH to support the outbreak response activities through urgent clinical management training, premises inspection, and procurement of insecticides for vector control purposes, which would facilitate dengue control to avoid significant outbreaks with the South-East monsoonal rains. The benefits of the above support are received by 14.6 million persons in 10 high risk districts.

‘WHO Sri Lanka has also been actively engaged in providing technical assistance for assessment of hospital preparedness for dengue, hands-on capacity building exercises for clinical management of dengue and entomological reviews of dengue vector. WHO is also supporting research and evidence generation to better understand the disease and strengthen prevention and control in future.’^{[footnote 155]}

6.7.3 The International Federation of Red Cross (IFRC) stated in their report, Sri Lanka - Dengue Outbreak & Floods, 3 June 2023:

‘Dengue cases have been on the rise since the beginning of the year in the country… A higher number of cases are recorded in the Western, Southwestern, Central, and Eastern provinces, especially in Colombo, Gampaha, Kalutara, Batticaloa, Trincomalee, Galle, Kegalle, and Kandy districts. The National Dengue Control Unit (NDCU) reported … a total of 33,742 dengue cases have been recorded across the island as of 15 May 2023. More than 50 percent of above-mentioned cases were reported from the Western Province. Indeed, Colombo District recorded the highest number of dengue cases… The NDCU also indicated that 22 Dengue-related fatalities have been reported so far this year [2023] …

‘The government authorities have carried out several dengue prevention programmes in various areas of Colombo. The highest number of dengue patients are being treated at the Colombo National Hospital, District General Hospital in Negombo, Infectious Disease Hospital (IDH), Colombo South Teaching Hospital (Kalubowila), Trincomalee General Hospital, Lady Ridgeway Hospital and the National Teaching Hospital in Kandy and they are barely coping with the number of cases admitted…’^{[footnote 156]}

6.7.4 For further information on Dengue Fever and Weekly Dengue Updates for 2023, see Ministry of Health National Dengue Control Unit, Sri Lanka.

6.8 Diabetes

6.8.1 Rasalingam, G, of the University of Edinburgh, stated in an article in the peer-reviewed journal Health Science Reports, published on 28 December 2022:

‘… In Sri Lanka, it is estimated that 1.1 million people live with diabetes and the cost per head is approximately 144.6 USD [£114.29 British Pounds^{[footnote 157]}]. In the current market, a glucose metre costs about 5000 Rs (14 USD [£11.06 British Pounds^{[footnote 158]}]) (An increase of 19 percent), 25 glucose testing strips cost around 2000 Rs (6 USD [£4.74 British Pounds^{[footnote 159]}]) (An increase of 11 percent), and one 10 ml vial of soluble insulin increased from 600 Rs (1.6 USD [£1.26 British Pounds^{[footnote 160]}]) to 1930 Rs (5.9 USD [£4.66 British Pounds^{[footnote 161]}]) (An increase of 53 percent).

‘These prices are very high for the general population… The economic burden already severely impacts individual families. A large proportion of the population will likely not have a choice but to prioritize something else, such as fuel and food, which prices are also steadily increasing.’^{[footnote 162]}

6.8.2 Akhtar, S, and others, noted in an article in the peer-reviewed journal BMJ Open, published in August 2023: ‘Sri Lanka … is experiencing a continuous increase in the prevalence of diabetes and pre-diabetes. Pre-diabetes or diabetes affects 20 percent of Sri Lankan adults (20–79), and one-third of those with diabetes have not yet been diagnosed. Aging populations, expanding waistlines, expanding cities, and declining opportunities for exercise all contribute to a rising tide of diabetes in Sri Lanka…’^{[footnote 163]}

6.8.3 On 14 September 2023, the WHO, noted: ‘… the MoH scaled up NCD services in more than 700 lifestyle centres across the country, where people can measure their fasting blood sugar, lipid profiles, blood pressure, height, weight, and body mass index, or consult on health and lifestyle questions. Through these healthy lifestyle centres, the screening for diabetes and cardiovascular diseases increased by 30 percent nationally.’^{[footnote 164]}

6.9 Dental disease and conditions

6.9.1 In undated information on its website, the Faculty of Dental Sciences of the University of Peradeniya noted:

‘The modern state of the art Dental (Teaching Hospital) Peradeniya has been constructed and equipped for student learning, delivery of patient care and research collaborations…

‘The Dental Hospital occupying the Block B of the building complex contains Academic Departments/Divisions of Oral Medicine, Dental Radiology, Oral & maxillofacial Surgery, Restorative Dentistry, Prosthetic Dentistry, Periodontology, Paedodontics, Orthodontics, Community Dentistry, Oral Pathology and General Pathology. The clinical dentistry disciplines have well equipped clinical floor areas for Student practice and outdoor/indoor patient areas for comprehensive management. All clinical floor areas for student practice are being manned by university dental nursing staff and supporting staff.’^{[footnote 165]}

6.9.2 The Faculty of Dental Sciences of University of Sri Jayewardenepura, stated on their website:

‘… the Faculty of Dental Sciences of the University of Sri Jayewardenepura [is] the second Faculty of Dental Sciences in Sri Lanka…

‘Departments:

• Community Dental Health

• Comprehensive and Geriatric Dentistry

• Oral Medicine and Periodontology

• Oral Pathology

• Oral Surgery

• Prosthodontics

• Restorative Dentistry’^{[footnote 166]}

6.9.3 WHO noted in their Sri Lanka Health System Review of 5 July 2021:

‘The recruitment and training of dental graduates is mainly under the Ministry of Higher Education. Currently, only one state university provides training, producing approximately 75 dental surgeons per year. These graduates must undergo one year of internship to obtain full SLMC [Sri Lanka Medical Council] registration to practise dentistry in Sri Lanka.

‘School dental therapists are trained at the School for Dental Therapists situated in Maharagama in the suburbs of Colombo. It was started in mid-1955 and continues to train around 30 school dental therapists per year. School dental therapists are based in large schools. They provide services to nearby smaller schools as well as preschool children in the community. The services of school dental therapists are available in all districts of Sri Lanka.

‘Community dental services are arranged in several vertical programmes managed by specialists in Community Dentistry, and, at the ground level, community dental services are provided by community dental clinics and adolescent dental clinics. However, there are relatively few community dental clinics and adolescent dental clinics in the country.

‘The overall management of the Dental Health Services of the Country comes under the purview of the Deputy Director-General (Dental Services), who is assisted by regional dental surgeons, consultants, dental surgeons, and dental therapists of the department. They cater to the oral healthcare needs of nearly two million patients a year. The present workforce consists of 1350 dental surgeons of the Department and 55 specialists in the fields of oral and maxillofacial surgery, orthodontics, restorative dentistry, and community dentistry. As an island wide service, appointments, transfers, and any other HR management decisions with regard to dental surgeons are handled by the DDG [Deputy Director General]/DS [Divisional Secretary] of the division and the Director Oral Health.

‘School dental services are handled by the Oral Health Unit of the FHB [Family Health Bureau]. The DDG [ Deputy Director General/DS [Divisional Secretary] of the division co-ordinates with this Unit to upgrade the dental services delivered by dental therapists to the children through the school dental clinics.’^{[footnote 167]}

6.9.4 The MoH published an Oral Health Report 2020/2021 in July 2023 which stated:

‘Oral healthcare services provided by the Ministry of Health Sri Lanka include curative and preventive services. Curative oral healthcare services consist of both general oral healthcare and specialized oral healthcare. General oral healthcare is provided through the clinics located in Primary Medical Care Units (PMCUs), Divisional Hospitals, Base Hospitals, District General Hospitals, Provincial General Hospitals, Teaching Hospitals and National Hospitals.

‘Specialized oral healthcare is provided through specialized oral health units in hospitals such as Oral and Maxillofacial Surgery (OMFS) Units, Restorative Dentistry Units, Orthodontic Units, Oral Pathology Units. Preventive Oral Healthcare services provided through Adolescent Dental Clinics (ADCs), Community Dental Clinics (CDCs), Preventive Oral Healthcare Units and National Programmes.’^{[footnote 168]}

6.9.5 The report added:

‘There were 1,779 dental surgeons including consultants working in the government sector by the end of 2021. As the projected value of the Sri Lankan population was 22.15 million for 2021, the national figure for dentist to population ratio was 12,460.4. When district figures of dentist to population ratios were considered, they varied from the lowest value of 5,975.9 in the Colombo district to the highest value of 21,619.5 in the Gampaha district. Nuwara Eliya and Matara districts also had figures above 20,000, while Kandy, Mannar and Ampara districts, together with the Colombo district had values below 10,000.’^{[footnote 169]}

6.9.6 De Silva, D, and others of the University of Peradeniya, in a report published on 22 September 2023, noted challenges in dental care resulting from the financial crisis:

‘… The availability of dental materials such as light care composite (LCC) bonding, silver amalgam, impression materials and surgical consumables was reduced in the post-economic crisis situation compared to the pre-economic crisis status. Furthermore, dental laboratory charges per item, fees per procedure, salaries to support staff, utility bills including electricity and water, payments to government bodies, travelling costs to the clinic (for the doctor) and other expenses have increased in the post-economic period…

‘… The departure of dental specialists from the country emerged as a significant setback in dental education, with implications for both the present and future. The number of specialists returning to Sri Lanka dwindled considerably, with a significant drop by 2022. The survey indicated that a substantial portion of participants had migration plans, either with certainty or without concrete plans, underscoring the risk of losing highly skilled professionals…’^{[footnote 170]}

(See Financial crisis – impact and recovery)

6.10 Ear, nose, and throat (ENT), audiology and speech therapy

6.10.1 Sri Jayewardenepura General Hospital in an undated entry on their website noted:

‘The Sri Jayewardenepura General Hospital (SJGH) is…government owned… It is located in Sri Jayewardenepura, the capital of Sri Lanka …

‘The ENT unit of Sri Jayewardenepura General Hospital provides both in and out-patient care by a well experienced and highly competent staff. In patient care is provided with a 60 bedded ward and out-patient care is provided through regular ENT clinics. The ENT Clinic is well equipped with modern technology and there are separate Audiological and Speech Pathology units established under the ENT unit. The unit conducts separate hearing assessments and speech therapy clinics.

‘ENT unit carries out a wide range of surgical procedures including major head and neck surgeries and functional endoscopic sinus surgeries. Well-equipped audio laboratory has the capability to carry out investigations such as pure tone audiometry, tympanogram and brainstem evoke response assessments. ENT unit provides endoscopy facilities for fiber-optic laryngoscopy and naso-endoscopic procedures.’^{[footnote 171]}

6.11 Gastroenterological conditions

6.11.1 Hemas Hospitals, stated in an undated entry on their website:

‘Our Centre for Gastroenterology Care is regarded as one of the best & top gastroenterology facilities in Sri Lanka. We are dedicated to the management of diseases of the digestive and hepatobiliary systems in children and adults. Our gastroenterology surgeons offer expert care in both Medical and Surgical Gastroenterology. The facility possesses modern state of art equipment backed by advanced intensive care units.

‘Our experienced gastroenterologists and gastrointestinal surgeons are specialized in diagnosing and treating an array of disorders in the digestive tract. You can turn to us for problems involving the oesophagus, stomach, small intestine, and colon. As one of the most technologically advanced GI centres in the country, we have invested in a high-definition endoscopy and colonoscopy facility, capsule endoscopy facility, PH capsule study facility and a small bowel endoscopy facility. Our state-of-the-art laparoscopy surgical unit allow us to carry out a wide range of advanced gastrointestinal surgeries including removal of cancers in the bowel and stomach, oesophagus related surgeries and gallbladder, pancreas, and liver related surgeries.

‘Conditions Treated

• GERD OR Gastro Oesophageal Reflux Disease

• Hernia

• Acid Peptic Disease

• Pancreatic and Splenic Disease

• Gastrointestinal Cancers

• Gall Bladder Problems

• Appendicitis

• Colorectal Ailments

‘Scope of Services & Treatments we Offer

• Consultations and counselling

• GI related Diagnostics

• UGIE, LGIE, EUS, Capsular studies, PH studies, ERCP

• Radiology Diagnostics: 1.5 Tesla MRI (MRI pelvic Studies & MRCP)

• 128 Slice CT Scanner

• Digital X-Ray

• Gastro-related surgeries

• Esophagectomies, Gastrectomy’s and bariatric related procedures

• Hepatobiliary –liver resections, gall bladder related, pancreas Related.

• Colorectal –colectomies, Hartman’s procedures, reversal procedure

• Rehabilitation services

• Colostomy care servicers’

• Early cancer detection centre

• Palliative care

‘Our endoscopy unit is equipped with the latest in endoscopic technology along with capsule endoscopy facility. Our facilities enable you to undergo a complete upper GI, Lower GI, large and small intestine diagnosis with minimal pain or discomfort. Our High-Definition Endoscopy unit provides clearer images for accurate diagnosis while our revolutionary capsule endoscopy provides a detailed view of images starting from upper GI to colon with zero pain and side effects. Our gastroenterologists and gastrointestinal surgeons possess the experience and understanding to offer you accurate diagnoses.’^{[footnote 172]}

6.12 Geriatric care

6.12.1 The Western Hospital noted on an undated entry on their website:

‘Western Hospital offers geriatric care services in Sri Lanka… Elderly care at WH caters for these needs and is a trusted choice for patients who are immobile, terminally ill, or just of advanced age. We have a gamut of geriatricians, specialized nurses, physiotherapists, dieticians, occupational therapists, and care givers to give your elderly loved one the care they deserve.’^{[footnote 173]}

6.12.2 De Silva, K, and others of the University of Ruhuna, Matara, Sri Lanka stated in their study which aims to explore barriers and facilitators of quality of care in aged care home in Sri Lanka, published on 27 January 2024:

‘… the number of ACHs [aged care homes] and day-care centres in Sri Lanka has increased over the last two decades. About 300 ACHs and 147 day-care centres are within the country. … Aged care homes operate under government funds and provide their services free of charge to their residents. Caregivers provide care for older people living in ACH…

‘Conventionally, almost all the caregivers described the insufficiency of facilities, more importantly, insufficient referring system facilities, as a barrier. Since a considerable proportion of participants live with chronic illnesses, accessible medical care was a key variable in ascertaining the quality of care as perceived by caregivers working in ACHs. However, there was no appointed medical personal to refer residents and had no adequate transportation facilities to transfer residents to hospital or clinics, when needed, impeding the quality of care.’^{[footnote 174]}

6.12.3 The report continued:

‘Both residents and caregivers reported insufficient financial support on infrastructure, supplying medication and employing human resources as barriers to implementing quality care. Additionally, lack of referring system facilities, caregivers’, and residents’ insufficient knowledge of gerontological care and geriatric syndromes, lack of interest in being a caregiver at the ACHs, and lack of in-service programmes for caregivers were identified as barriers for quality care. Meanwhile, donations from philanthropists, supportive leadership, welfare benefits from the government authorities, and positive institutional values were the reported facilitators for quality care in ACHs. The available human and physical resources are insufficient to address the demanding needs of residents in ACHs, apart from the received donations and welfare benefits.’^{[footnote 175]}

6.13 Gynaecological conditions

6.13.1 Iqbal, A and Joseph, N, of the Department of Clinical Oncology, Teaching Hospital, Batticaloa and Department of Clinical Oncology, General Hospital, Hambantota, stated in their article, Cervical cancer in Sri Lanka published online on 25 February 2023:

‘… Cervical cancer is now the fourth commonest cancer among females behind breast, thyroid, and colorectal cancer. Its ASR [age-standardized incidence rate] which currently stands at 8.3 per 100,000 population has remained relatively stable over the past two decades, although incidence of other cancers has seen a steady rise during this period.

‘… Curative cancer treatment is provided by 26 cancer units in tertiary care hospitals established throughout the country. Sri Lanka adopted a clinical oncology model comprising both medical and radiation oncology in the training of oncologists. Postgraduate training in clinical oncology is delivered by the Postgraduate Institute of Medicine of the University of Colombo and spans 5 to 6 years including an overseas fellowship of 1 to 2 years in a centre of excellence.

‘… Sri Lanka’s immunization program has often been hailed as an exemplar for the region, and HPV vaccination was introduced to the national immunization schedule on July 10, 2017. Two doses of recombinant quadrivalent vaccine are now given, 6 months apart, to all girls on completion of 10 years of age (Grade 6). The WHO estimates that successful implementation of the HPV vaccination program would save more than 50,000 lives in the next century in Sri Lanka.’^{[footnote 176]}

6.13.2 The report added:

‘Screening for cervical cancer with cytology is provided to all women aged 35 years or older, by well women clinics conducted by the MOH units distributed across the island…

‘… Most patients are diagnosed in advanced stages…. Diagnostic services are available in secondary and tertiary care hospitals. Specialist gynaecological oncological surgical services are only available in three main tertiary care hospitals in the country. Delays in presentation is a major challenge across many tumours in Sri Lanka and has led to a high proportion of presenting with locally advanced or metastatic disease. Advanced stage at presentation means that surgical treatment is often not feasible for most patients with cervical cancer.

‘…. A recent study revealed that only 10 percent of patients completed their full course of radiotherapy (both external beam radiotherapy and brachytherapy) within 60 days of initiation of treatment. As expected, outcomes were poor in patients who had significant treatment delays. For patients with residual or recurrent disease, salvage surgery is provided by the gynaecological and surgical oncology departments in the main tertiary care centres. Once again, paucity of specialized surgeons as well as lack of operating room and intensive care facilities is a significant obstacle to the delivery of good quality care.

‘For patients with unresectable and metastatic disease, palliative chemotherapy is delivered by the 26 cancer centres in the country…’^{[footnote 177]}

(See also Palliative care and Cancer (General))

6.14 Hepatitis, liver disease and transplants

6.14.1 WHO noted on 28 July 2022:

‘Sri Lanka, however, is reportedly a Hepatitis B low-prevalent country. Sample surveys have shown low prevalence of Hepatitis B even among high-risk groups such as persons living with HIV: 0.3 percent and prison inmates: 0.25 percent and even among blood donors: 0.11percent at the National Blood Transfusion Service.

‘In Sri Lanka, Hepatitis B is a notifiable disease and all physicians treating hepatitis patients are responsible to send information to the national system.

‘Hepatitis B vaccination was introduced to Sri Lanka’s Expanded Programme of Immunization (EPI) schedule in 2003. Since then, all infants in Sri Lanka are receiving three doses of the Hepatitis B vaccines.

‘Data reported to the Epidemiology Unit of the Ministry of Health (Focal point for EPI activities in Sri Lanka), as well as immunization coverage surveys conducted at district level, suggest very high level of immunization coverage (the pentavalent vaccine which includes Hepatitis B had a coverage of 99% in 2019).

‘This is seen as a remarkable achievement for the health sector of a lower-middle income country such as Sri Lanka.

‘With a global initiative underway to eliminate viral hepatitis by 2030 and Sri Lanka reporting a low number of Hepatitis B infections annually and having sound infection prevention and control systems in the hospitals and public health sector, the potential for reaching the elimination target earlier than stipulated is high. In this direction, Sri Lanka has taken major initiatives to keep the prevalence of Hepatitis B at a minimum rate aided by close monitoring of the strong technical body – the Advisory Committee for Communicable Diseases (ACCD) consisting of subject experts.

‘The country has also taken several policy decisions to conduct the ‘high-risk group vaccination approach’ with regard to adult Hepatitis B vaccination. The identified high-risk groups are healthcare workers, sex workers (including men having sex with men (MSM) and transgender), cancer patients, thalassemia patients, chronic kidney disease patients on regular haemodialysis etc. In the case of healthcare workers, they are screened and vaccinated before absorption to the service. All blood donors are also screened for Hepatitis B and C with quality assurance and all the positive donors are linked to treatment services. Sri Lanka follows 100 percent safe injection practices in all healthcare facilities.’^{[footnote 178]}

6.14.2 On 17 January 2024, WHO stated: ‘… Sri Lanka have achieved Hepatitis B control, the World Health Organization announced … after an expert panel verified that… [Sri Lanka] had consistently high coverage of hepatitis B vaccine doses in infants and a low prevalence of the deadly disease…’^{[footnote 179]}

6.14.3 Dassanayake, B, and others, of the University of Peradeniya, Central Regional Referral Hospital Bhutan and London School of Hygiene and Tropical Medicine, London observed in their report, Challenges of liver transplantation programs in low-and middle-income countries: An experience from Sri Lanka, 20 February 2024: ‘Sri Lanka carried out its first [liver transplant] LT in 2010, and the service is provided free of charge in the state health sector… The common challenges include a lack of an adequate number of doctors and post-transplant team members, a low number of organ donors and a long waiting list, all of which can be disadvantageous for transplant programmes.’^{[footnote 180]}

6.15 HIV/AIDS and sexually transmitted diseases (STD)

6.15.1 A National Report submitted to the OCHCR on 30 December 2022 stated: ‘The National STD/AIDS control programme of the MoH operates 30 Antiretroviral Medication centres across the country providing services free of charge…’^{[footnote 181]}

6.15.2 The WFD report An Exploration of Inclusion Gaps: An Assessment of the Health Sector, published in September 2023 conducted qualitative research through 9 focus groups and key person interviews in 4 areas of Sri Lanka and additional consultation with government officials, healthcare providers, development organisations and LGBTQIA community organisations^{[footnote 182]}. In respect of general provision of STD and HIV healthcare the report noted:

‘According to the latest available data, 40 STD/STI clinics are available throughout the island with some districts just having one clinic, and in addition to this, 29 more branch clinics are also available… Whilst HIV/ AIDS is screened for at STD clinics, antiretroviral treatment (ART) (treatment for persons infected with HIV/AIDS) is only available in at the National STD/AIDS Control Programme in Colombo, Teaching Hospital in Kalubovila, Teaching Hospital in Ragama, and the STD clinic in Kandy.’^{[footnote 183]}

6.15.3 WHO, in their article, World AIDS Day 2023, 1 December 2023 noted:

‘Sri Lanka continues to maintain a low-level HIV epidemic… The latest evidence shows that nearly 60 percent of new HIV infections in 2023 in Sri Lanka occur among MSM [men who have sex with men] …

‘The National STD/AIDS Control Programme (NSACP) of the MoH is the government organisation which co-ordinates the national response to HIV and sexually transmitted infections (STDs) in Sri Lanka. It works in collaboration with national and international stakeholders in controlling HIV in Sri Lanka mainly with Global Fund, UNAIDS and WHO. Sri Lanka aims by 2025 to achieve 95%-95%-95% targets for HIV diagnosis, treatment, and viral suppression as per targets set by UNAIDS (the Joint United Nations Programme on HIV/AIDS).

‘… The country has achieved the WHO certification for the Elimination of Mother to Child Transmission (EMTCT) of HIV and syphilis in 2019 and underwent successful revalidation in 2021. Sri Lanka is the fourth country in the region that achieved the validation certificate.

‘WHO continues to support Sri Lanka to implement its National HIV/STI Strategic Plan of Sri Lanka, 2023-2027. WHO assisted the MoH in HIV/STI-related policy decisions, updating of guidelines, data modelling and capacity building of staff on prevention, testing and treatment of HIV/STIs. During the economic crisis, WHO supported the MoH and procured HIV/Syphilis rapid antigen kits for a full cohort of pregnant women in order to maintain the elimination status of mother-to-child transmission of HIV and syphilis…’^{[footnote 184]}

6.15.4 EconomyNext, an economic, financial, and political news service with a primary focus on Sri Lanka stated in an article dated 1 December 2023:

‘As there was still no vaccine or medicine developed to cure an HIV infection, early detection and treatment of the condition was key to live normally, [venereologist] Dr [Thilani] Ratnayake said at an awareness event to mark World AIDS Day on December 1.

‘“We have introduced self-test kits which allow those who are concerned they might be infected to do their own HIV test. Like the Covid test, this is an oral swab test. You will know the results within minutes.”

‘“These self-test kits are now available through our clinics, and we provide a home delivery facility. In addition to this, there’s a web-based app, called Know4sure, which provides HIV information, an assessment tool to determine whether one is at risk, reservation of a clinic appointment, and the facility of ordering a self-test kit.”

‘Once detection is made, the next step is to prevent spreading. Dr Ratnayake said the 41 state-run STD clinics in the country all provide free condoms, at a considerable cost to government… “Treatment methods have been introduced to live a normal life with the disease under control. An HIV preventive treatment called PrEP is now available under medical supervision. You can get this treatment from STD clinics all over the island. This is a very effective method for those at high risk of HIV.” When the virus level is reduced by treatment, the possibility of it being transmitted to another person is also reduced, Dr Ratnayake pointed out. A preventive treatment method is also available. This should be administered within 72 hours.’^{[footnote 185]}

6.15.5 The USSD Country Report on Human Rights Practices for 2023 noted: ‘… hospital officials reportedly publicized the HIV-positive status of their patients and occasionally refused to provide health care to persons with HIV.’^{[footnote 186]}

6.15.6 The MoH, National STD/AIDS Control Programme, Sri Lanka stated in an article, HIV Treatment and Care, last modified on 11 May 2024:

‘‘…all healthcare workers attached to STD clinics are given training in counselling. [HIV] Counselling services are offered at the time of diagnosis, on prevention, ART [Antiretroviral Therapy] adherence, family planning, disclosure, pregnancy, and various social issues. PLHIV, who need psychiatrist services at the central clinic are referred to the visiting psychiatrist clinic every Friday. Other clinics will refer them to the closest psychiatry specialist unit.

‘The National STD/AIDS Control program of the MoH is the sole provider of ART [Antiretroviral Therapy] in Sri Lanka. These drugs are provided free of charge to all people living with HIV. Since there is no cure for HIV at present, people living with HIV have to take these medications throughout their lives. Current anti-HIV medications are very effective in suppressing HIV to undetectable levels (viral load suppression). Once the viral load is undetectable, they no longer transmit the infection to others …

‘…Laboratory tests such as CD4 and HIV viral load testing are available through the NRL and laboratory network.

‘There are NGOs actively involved in services for people living with HIV. e.g., Positive Women’s Network, Positive Hopes Alliance, and Lanka Plus. They are providing halfway shelters for patients attending clinics or requiring a few days’ stays in Colombo for medical and other treatments. These organizations are closely working with us.’^{[footnote 187]}

6.16 Musculoskeletal conditions

6.16.1 The Ministry of Health noted on their website:

‘Currently there are 2 Departments of rheumatology and medical rehabilitation in the National Hospital. They are:

1. The Department of Rheumatology and Rehabilitation (General)…

2. The Department of Rheumatology and Rehabilitation (Special)…

‘There are 3 consultants in Rheumatology and Rehabilitation one serving the General and the other two working at the special department.

‘The illnesses treated at the Department of Rheumatology and Rehabilitation:

‘A. Inflammatory joint diseases

i. Rheumatoid arthritis

ii. Juvenile idiopathic arthritis (after the age of 13 years)

iii. Spondyloarthropathies

1. Ankylosing spondylitis

2. Psoriatic arthritis

3. Reactive arthritis (Reiter’s disease)

4. Enteropathic arthritis

iv. Connective Tissue diseases

1. Systemic Lupus Erythematosus

2. Systemic sclerosis

3. Polymyositis / Dermatomyositis

4. Sjogren’s disease

5. Mixed Connective tissue diseases

v. Crystal induced arthritis

1. Gout

2. Pseudo-gout

vi. Miscellaneous inflammatory arthritis

1. Adult Still’s disease

2. Sarcoidosis

b. Degenerative joint diseases

i. Osteoarthritis

ii. Cervical spondylosis

iii. Lumbar spondylosis

B. ‘Generalised and Regional Pain syndromes

a. Fibromyalgia

b. Neck pain

c. shoulder pain

d. Low-back pain

C. ‘Disease of muscles

a. Polymyositis

b. Dermatomyositis

c. Inclusion-body myositis

D. ‘Disease of Bone

1. Osteoporosis

2. Osteomalacia

3. Other Bone diseases

E. ‘Systemic Inflammatory conditions

a. Vasculitis

i. Polymyalgia Rheumatica

ii. Wegener’s granulomatosis

iii. Polyarteris nodosa

iv. microscopic polyangiitis

v. Churg-Strauss syndrome

vi. Henoch-Schonlein purpura’^{[footnote 188]}

6.16.2 Sri Jayewardenepura General Hospital on their website noted:

‘The Rheumatology and Rehabilitation Unit provides inward care as well as outpatient care through three outpatient clinics per week. Many types of arthritis including osteoarthritis, rheumatoid arthritis, and psoriatic arthritis and connective tissue disorders such as SLE, mixed connective tissue disorders and vasculitis are treated in the rheumatology unit with a well-trained and highly experienced medical team. The unit has special interest and competency in managing osteoporosis and chronic pain syndromes. Rheumatology & rehabilitation unit works in collaboration with other medical clinics to improve the quality of life of patients.’^{[footnote 189]}

6.17 Neurological conditions

a) General

6.17.1 CPIT has compiled the list below, using Google Maps which shows the location of the Neurology Units in Sri Lanka, published on 23 April 2021:

• NHSL [National Hospital of Sri Lanka]

• National Hospital – Kandy

• Colombo South Teaching Hospital – Kalubo

• Teaching Hospital, Karapitiya

• Teaching Hospital, Jaffna

• Teaching Hospital, Kegalle

• District General Hospital, Chilaw

• Provincial General Hospital, Badulla

• Teaching Hospital Anuradhapura

• District General Hospital Negombo

• District General Hospital Matale

• General Hospital Nagoda – Kalutara

• Teaching Hospital Ragama

• Teaching Hospital Kurunegala

• Teaching Hospital Peradeniya

• District General Hospital – Matara

• Teaching Hospital Ratnapura

• Sri Jayewardenepura General Hospital

• Polonnaruwa General Hospital

• District General Hospital Hambantota^{[footnote 190]}

6.17.2 The National Hospital of Sri Lanka has specialist care services in Neurology and Neurosurgery.^{[footnote 191]}

6.17.3 Attanayake, D, and others in an article, Diagnostic outcome of pro bono neurogenetic diagnostic service in Sri Lanka: A wealth creation, published 23 January 2024 stated:

‘… little attention seems to be given to patients with neurogenetic diseases. Neurogenetic testing is almost non-existent in Sri Lankan Government hospitals and is only available in a few private sector centres at exorbitant costs …

‘Sri Lanka is served by 44 neurologists (1 neurologist per 500,000 people), reflecting the gross mismatch between the burden of neurological disorders and the availability of resources … Patients affected by neurogenetic diseases in Sri Lanka must travel between 40 and 50 km to the closest regional hospital to seek speciality care. This results in the high cost of travel to hospitals for disabled or wheelchair-bound patients, which is greater than the monthly income of most families.’^{[footnote 192]}

b) Stroke

6.17.4 Ranawaka U and Venketasubramanian N of the Faculty of Medicine, University of Kelaniya, Sri Lanka and Raffles Hospital, Singapore, in an article published on 28 April 2021 in the journal Cerebrovascular Diseases Extra noted:

‘…An e-mail survey was conducted in 2018 among neurologists attached to all the neurology units in state-sector hospitals in the country, and data was collected from 21 of 22 hospitals with a neurologist (95.5 percent).

‘The survey highlighted the inadequacies of the existing stroke services; only 38 neurologists were present in state-sector hospitals serving a population of 21.2 million, thrombolysis was available in only 14 hospitals and mechanical thrombectomy in only 1 hospital. The capacity to improve stroke care by establishing basic stroke units with limited resources is well documented for Sri Lanka, however, stroke units were available in only 9 hospitals.

‘Patients with stroke in Sri Lanka are managed by neurologists and internal physicians; there are no trained specialist stroke physicians or stroke neurologists in the country, and there is no formal training or accreditation programme in stroke care. Rehabilitation facilities are limited, and community-based rehabilitation services are virtually non-existent. An important limitation of the survey was that it was confined to hospitals with neurologists as key facilities for stroke care such as thrombolysis, mechanical thrombectomy and rehabilitation were available in only such hospitals…

‘… Cheap and effective medications needed for risk factor control and secondary prevention of stroke are readily available in state-sector hospitals. In the survey among neurologists highlighted above, availability of antihypertensive drugs, statins, anti-diabetic drugs, and warfarin was rated as “good” by participants in all the hospitals, and antiplatelet drug availability was rated as “good” in 95 percent of the hospitals….’^{[footnote 193]}

6.17.5 CPIT has compiled the list below, using Google Maps developed by the Association of Sri Lankan Neurologists, which shows the location and province of the Stroke Thrombolysis Centres in Sri Lanka, published on 7 August 2023:

Western National Hospital of Sri Lanka Colombo

Colombo South Teaching Hospital -Kalubowila

Sri Jayewardenepura General Hospital

Colombo North Teaching Hospital

General Hospital Nagoda - Kalutara

Asiri Central Hospital – Central Hospital Limited

Lanka Hospitals

Durdans Hospital

Nawaloka Hospitals PLC

District General Hospital, Gampaha

Base Hospital - Wathupitiwala

Southern Teaching Hospital, Karapitiya

District General Hospital - Matara

Hambantota General Hospital

Central National Hospital - Kandy

District General Hospital Nuwara Eliya

Asiri Hospital Kandy

Teaching Hospital Peradeniya

District General Hospital Matale

Northwestern Teaching Hospital Kurunegala

District General Hospital Chilaw

Sabaragamuwa Teaching Hospital Kegalle

Teaching Hospital Ratnapura

District General Hospital Embilipitiya

North Central Anuradhapura Teaching Hospital

Polommaruwa General Hospital

Eastern District General Hospital Ampara

Teaching Hospital, Batticaloa

District General Hospital Trincomalee

Kalmunai Base Hospital

Northern Teaching Hospital Jaffna

District General Hospital Vavuniya

Uva Provincial General Hospital – Badulla

District General Hospital Monaragala’^{[footnote 194]}

6.17.6 For further information on strokes in Sri Lanka, see Ministry of Health, National Guidelines for Management of Stroke in Sri Lanka, 20 December 2023.

c) Epilepsy

6.17.7 The Ministry of Health, National Hospital of Sri Lanka stated on their website:

‘The Clinical Neurophysiology Unit of Institute of Neurology, NHSL is the only such unit in the country. It provides comprehensive neurophysiology services to patients with various neurological as well as non-neurological disorders. Main interactions are with neurology, neurosurgery, ophthalmology, otolaryngology, orthopaedic & paediatric units as well as with intensive care units. It serves other hospitals in the country including the hospitals of three armed forces and the police…

‘Services:

• Nerve conduction tests (NCS), electromyography (EMG) and other related tests.

• Electroencephalography (EEG) - … The majority of patients who undergo this test are those lined up for epilepsy surgery for which this test is essential…

• Intraoperative Monitoring - This is provided when necessary for epilepsy surgeries and spinal surgeries…’^{[footnote 195]}

6.17.8 The Sunday Observer in an article dated 12 February 2023 noted: ‘Epilepsy is a common neurological condition globally and in Sri Lanka. Unfortunately, despite effective treatment available to them many Sri Lankans delay seeking treatment early due to myths surrounding this condition…’^{[footnote 196]}

6.17.9 Attanayake, D, and others stated in their article, Surgical Outcome of Pharmaco Refractory Epilepsy in the National Epilepsy Centre of Sri Lanka published in April 2024: ‘The National Epilepsy Centre was established at the National Hospital of Sri Lanka in 2017 with the objective of providing tertiary care services in epilepsy including a surgery program…’^{[footnote 197]}

d) Dementia

6.17.10 Arambepola, C, and Jayakody, S, published an article in 2022 in the peer-reviewed journal BMC Geriatrics which stated: ‘… Despite having a well-established health care system in Sri Lanka almost in par with developed countries, it is not geared to handle medical and social issues of rapidly expanding elderly people and notably that of dementia patients. This situation is worsened by the scarcity of knowledge based on research, on the current status of patients with dementia.’^{[footnote 198]}

(See Mental healthcare)

6.18 Paediatrics

6.18.1 UNICEF, in an undated article noted:

‘…Immunization coverage is now universal, under-five mortality rates are in decline, … However, many gaps still exist, and much work remains to be done to achieve an environment in which all children can be guaranteed good health and rapid development in line with the standards set by the United Nations Sustainable Development Goals (SDGs).

‘The quality and access to health and hygiene services remain uneven. Poorer areas sometimes lack the essential infrastructure and basic knowledge needed to maintain acceptable standards.

‘The triple burden of malnutrition, obesity and anaemia are a consistent cause of concern in young children and pregnant mothers…

‘Water, sanitation, and hygiene services (WASH) are unevenly distributed, and the quality of these services can vary considerably, in many instances not living up to the benchmarks set by the SDGs. These shortcomings put young children at risk of infection and disease…

‘A concerted effort to raise awareness and sensitivity surrounding sexual and reproductive health is also a priority.’^{[footnote 199]}

6.18.2 Sri Jayewardenepura General Hospital on their website noted:

‘Sri Jayewardenepura General Hospital Paediatrics Unit provides both in and out-patient care for children. [The] Paediatric Unit provides in-patient care through a ward consisting of 43 beds and [is] well equipped to handle any type of paediatric medical emergency. [A] general paediatric clinic, [a] well baby clinic, vaccination clinic and paediatric asthma clinic are conducted by the unit weekly to provide the maximum service through its dedicated and experienced medical staff.… [The] High dependency unit to gives specialized care for seriously ill patients.’^{[footnote 200]}

6.18.3 Ninewells Hospital in Narahenpita, Colombo in an undated entry on their website described the paediatric services available:

• ‘Advanced Neonatal ICU care… furnished with modern equipment [ensuring] comprehensive care for premature or sick newborns…

• ‘Specialized care units for children featuring ENT, Eye, Dental, and Physiotherapy Units tailored to newborns and children, including hearing screening tests, and dedicated paediatric wards.

• ‘Vaccination and preventive care adhering to WHO standards…

• ‘Emergency-Ready Paediatric Department… operates round-the-clock, equipped with well-trained medical officers and nursing staff, adapt at handing emergencies and offering quality care.

• ‘Specialized paediatric surgeries [boasting] well-equipped operating theatres for a wide array of affordable paediatric surgeries, supervised by expert consultants.’^{[footnote 201]}

6.18.4 The Ministry of Health noted on their website:

‘Lady Ridgeway Hospital for Children… [is] home to more than 25 specialties and more than 40 units, this hospital has more than 1016 in wards beds, and it treats children below 14 years of age from all over the country. It has all supportive services required to provide quality patient care… It is responsible for undergraduate and most of the post graduate medical and surgical paediatric training, which is provided by all the units of the hospital.

‘The Outpatient Department (OPD) and the Accident Service Department of this hospital is open for services 24 hours a day for 365 days. Outpatient clinics conducted by the relevant consultants of inpatient units and visiting consultants of the OPD maintain a continuous link with patients discharged from their units.

‘There is also an emergency treatment unit, diarrhoea treatment unit immunization clinic and nutrition clinic which operate in the OPD to improve the quality of care…

‘Currently the hospital has six general paediatric medical and five general paediatric surgical units. It further has specialised units in Cardiology and Cardiothoracic surgery, Orthopaedic, Orthopaedic Spinal surgery, Rheumatology and Rehabilitation, Dermatology, Ophthalmology, Psychiatry, Neonatology, Intensive Care, Orthodontics, Restorative Dental Surgery, Plastic Surgery, Burns and ENT [Ear, Nose and Throat] Surgery.

‘In addition to these Radiology, Pathology, Haematology, Microbiology and Anaesthesiology departments headed by senior consultants provide quality, assistance to both inpatients and outpatients. Physiotherapy, Occupational Therapy, and speech therapy.’^{[footnote 202]}

6.19 Palliative care

6.19.1 Undated information on the website of the National Cancer Control Programme provided details of ‘Palliative Care Consult Services’:

1) ‘Apeksha Cancer Institute Maharagama

2) ‘Teaching Hospital Ratnapura

3) ‘Lady Ridgeway Hospital for Children

4) ‘Teaching Hospital Karapitya

5) ‘Colombo South Teaching Hospital Kalubowila

‘In addition to these clinics, basic palliative care services are arranged through Oncology clinics in all cancer treatment centres in the country.’^{[footnote 203]}

6.19.2 WHO in their Sri Lanka Health System Review of 5 July 2021 noted:

‘Palliative care has been recognized as an essential component of comprehensive care in [government polices] …

‘The MoH has initiated a steering committee for palliative care and developed a national strategic framework in 2018. The strategy envisages the development of services at all levels of care, including community care. Towards this end, the HR [human resources] necessary, guidelines for practice and means of ensuring the availability of drugs and home-based care are in the process of being institutionalized.

‘The Palliative Care Association of Sri Lanka estimates that around 60 percent of all those who die, i.e., around 68 000 people in the country, need palliative care annually. The number of trained persons and institutions available to provide palliative care in the country are inadequate at present…

‘Currently, consultant palliative care physicians are not available in the country. Towards addressing this deficiency, the Postgraduate Institute of Medicine, Sri Lanka, commenced a postgraduate diploma programme in Palliative Medicine in 2016. Home-based palliative care is planned to be provided by PHC teams based in PMCIs or by the patients’ GP. If further treatment is required, the patient will be directed to secondary-or-tertiary care institutions …’^{[footnote 204]}

6.19.3 The SLMA published practice guidelines to ensure standards in end-of-life care in November 2021^{[footnote 205]}.

6.19.4 ESMO, in their article of August 2022 noted:

‘… With expansion, the capacity, resources, and technology of the hospital [National Cancer Institute] developed and it is now an 850 bedded institute providing total cancer care including pain and palliative care.

‘In August 2015, the palliative care service was established as an outpatient clinic supported by volunteer-based health staff including consultant oncologists, MOs and nursing staff who were working in the National Cancer Institute.

‘In 2017, it developed as a separate palliative care unit with one permanent nursing officer and with the continued support of volunteer staff. With the expansion of the palliative care service, more trained medical and nursing staff joined the unit.

‘Currently the unit is equipped with six MOs who have completed a Postgraduate Diploma in Palliative Medicine and five trained nursing officers. They work under the guidance of five consultant clinical oncologists who are specialist trainers in palliative care.

‘The palliative care unit provides referral based consultative service for both adult and paediatric patients through an outpatient clinic, inward care, and a hotline service. Holistic, compassionate, interdisciplinary care is provided to the patients and their families.

• ‘Pain and other intractable symptom management are done according to the latest guidelines. We work in collaboration with pain management unit in managing complex pain and initiating interventional pain procedures.

• ‘All the nursing procedures are provided.

• ‘The initial assessment of the psychological issues is recognized, and timely referrals are arranged to the counselling and psychiatric unit.

• ‘The social problems are addressed, and social services, financial support and family empowerment are provided via social service officer and NGOs.

• ‘Spiritual support is also encouraged.

• ‘Shared care is arranged in collaboration with the oncology units. Home-based care is provided with the support of public health nursing officers. We provide care at the hospice too.’^{[footnote 206]}

6.19.5 For further information on palliative care in Sri Lanka, see Asia Pacific Hospice Palliative Care Network, General Palliative Care Service Directory, 20 March 2023.

6.20 Reproductive healthcare and obstetrics

6.20.1 A National Report submitted to the OCHCR on 30 December 2022 stated:

‘Well-established basic sexual and reproductive health services including family planning services are being provided by the MoH through a network of more than 1,800 registered clinics, both in the field and in curative institutions. … Sri Lanka maintains one family planning clinic per 10,000 of the population in most areas. Additionally, a strong network of 7,000 Public Health Midwives provides oral family planning drugs and awareness at grass-root level during their domiciliary visits.’^{[footnote 207]}

6.20.2 The Mannar Women’s Development Federation stated in their report, Submission to the United Nations Committee on the Elimination of Discrimination against Women for its consideration of the ninth periodic report of Sri Lanka at its 86th Pre-Sessional Working Group, 30 January 2023:

‘There is a lack of access to family planning and reproductive and sexual health services…for many girls and women… due to women not having access to the limited services available either due to control exerted within families or due to fear of discrimination by State sector service providers.

‘Since most affected women belong to the Muslim minority, there are fears of being further marginalized. These challenges have not been addressed by government or NGOs. …’^{[footnote 208]}

6.20.3 The IFRC noted in a report dated 12 July 2023, in relation to the impact of the financial crisis: ‘The disruption of sexual and reproductive health services had serious and life-threatening consequences for women and girls. Pregnant women, especially those living in remote rural areas, have had difficulty reaching hospitals and clinics, and antenatal and postnatal care have also been affected.’^{[footnote 209]}

(See Financial crisis – impact and recovery)

6.20.4 The CSO Sex Workers and Allies South Asia noted in their submission to the Committee on the Elimination of Discrimination against Women (CEDAW), submitted on 14 February 2023:

‘Sex workers’ health beyond sexual health has not been a priority to health services. They have not been included in the effort at the local level by the MoH to disseminate information on sexual and reproductive health.

‘Many workers have faced discrimination while accessing basic reproductive health services at the hospital. They have been denied services like that of a midwife during pregnancy that is extended to all other women in Sri Lanka.’^{[footnote 210]}

6.20.5 The USSD Country Report on Human Rights Practices for 2023 noted: ‘The government provided access to sexual and reproductive health services for survivors of sexual violence, including emergency contraception and postexposure prophylaxis. Emergency contraception was available at government hospitals and MoH clinics and was provided free of charge. NGOs reported police, however, were often unaware of resources available, limiting referrals.’^{[footnote 211]}

6.21 Tuberculosis (TB)

6.21.1 SLMA stated in their report, SLMA guidelines and information on vaccines, 2023: ‘…there is almost 100 percent [Bacille Calmette- Guerin] BCG coverage in infancy. As a result, complicated types of TB such as tuberculous meningitis, miliary TB, bone and joint TB and renal TB are very rare in children.’^{[footnote 212]}

6.21.2 The Morning, a Sri Lanka news website reported on 17 March 2024:

‘Dr. Shanthilatha … said that reports of patients from high-risk areas – namely the Colombo, Gampaha, and Kalutara Districts – had increased in 2023 …

‘Dr. Shanthilatha said that most of the identified patients were adults, noting that oral treatment on a strict schedule for six months was vital to ensure that they were completely cured.

‘“…Forty-seven deaths were recorded in 2023,” she said, adding that medicines were available for treatment while urging patients to consult chest clinics if they displayed symptoms… “This is the first time we are seeing numbers as high as those recorded in 2010.”’^{[footnote 213]}

6.21.3 WHO stated on 24 March 2024:

‘… tuberculosis is the second leading infectious disease in Sri Lanka after dengue. TB continues to be a public health problem in Sri Lanka, with an estimated incidence of 62 per 100,000 population (2022) as per WHO estimates. TB treatment coverage (notified/estimated incidence) for 2022 was 60 percent meaning that around 40 percent of TB cases either were not diagnosed or reported.

‘The National Program for Tuberculosis Control and Chest Diseases (NPTCCD) is the national lead organisation for prevention and control of TB in Sri Lanka. The services are provided through a network of 26 District Chest Clinics, 2 sub-chest clinics, 108 branch clinics and 189 microscopic centres. Diagnostic culture facilities are available at National TB Reference Laboratory and Intermediate TB Laboratories at Rathnapura, Kandy, Jaffna, and Galle.’^{[footnote 214]}

Research methodology

The country of origin information (COI) in this note has been carefully selected in accordance with the general principles of COI research as set out in the Common EU [European Union] Guidelines for Processing Country of Origin Information (COI), April 2008, and the Austrian Centre for Country of Origin and Asylum Research and Documentation’s (ACCORD), Researching Country of Origin Information 2024. Namely, taking into account the COI’s relevance, reliability, accuracy, balance, currency, transparency and traceability.

Each section has an ‘updated’ date up to which the COI included was published or made publicly available. These dates may vary from section to section. Any event taking place or report published after each section date will not be included in that section.

Sources and the information they provide are carefully considered before inclusion. Factors relevant to the assessment of the reliability of sources and information include:

• the motivation, purpose, knowledge, and experience of the source

• how the information was obtained, including specific methodologies used

• the currency and detail of information

• whether the COI is consistent with and/or corroborated by other sources

Wherever possible, multiple sourcing is used, and the COI compared and contrasted to ensure that it is accurate and balanced and provides a comprehensive and up-to-date picture of the issues relevant to this note at the time of publication.

The inclusion of a source is not an endorsement of it, or any view(s) expressed.

Each piece of information is referenced in a footnote.

Full details of all sources cited and consulted in compiling the note are listed alphabetically in the bibliography.

Terms of Reference

A ‘Terms of Reference’ (ToR) is a broad outline of the issues relevant to the scope of this note and forms the basis for the country information.

For this CPIN, the following topics were identified prior to drafting as relevant and on which research was undertaken:

• Healthcare context

  • Health indicators, regional comparisons, and long-term progress

  • Challenges

  • Financial crisis – impact and recovery

• overview of the structure of the healthcare system including patient access to:

  • Governance

  • Structure

  • Affordability of public healthcare

  • Public versus private sector healthcare

  • Western versus traditional medicine

• infrastructure and staffing

  • Facilities

  • Services

  • Admissions and beds

  • Personnel

  • Geographical accessibility and variation

• pharmaceutical sector

  • Governance

  • Supply

  • Availability of affordability and variation

• Mental healthcare

  • Governance and policy

  • Structure, facilities, and services

  • Capacity

  • Personnel

  • Suicide and self-harm

  • Drug and rehabilitation

  • Child and adolescent mental health

  • Mental NGOs

• specific diseases/conditions in alphabetical order including:

  • Cancer (General)

  • national programme for control and treatment

  • availability of treatment: facilities, personnel, and location

  • accessibility: cost of treatment and other factors affecting access, such as location of particular treatment centres

  • support in obtaining treatment from state, private or civil society sectors

  • Child cancer

  • Colorectal cancer (CRC)

  • Chronic kidney disease (CKD)

  • Communicable diseases

  • Cardiovascular disease

  • Dengue fever

  • Diabetes

  • Dental disease and conditions

  • Ear, nose, and throat (ENT), audiology and speech therapy

  • Gastroenterological conditions

  • Geriatric care

  • Gynaecological conditions

  • Hepatitis, liver disease and transplants

  • HIV/AIDS and sexually transmitted diseases (STD)

  • Musculoskeletal conditions

  • Neurological conditions

  • Paediatrics

  • Palliative care

  • Reproductive healthcare and obstetrics

  • Tuberculosis (TB)

Bibliography

Sources cited

Akhtar, S; Ali, A; Asghar, M; Hussain, I; Sarwar, A, Prevalence of Type 2 Diabetes and Pre-Diabetes in Sri Lanka: a Systematic Review and Meta-Analysis, 28 August 2023. Accessed: 30 April 2024.

Alcohol and Drug Information Centre (ADIC),

• Our services, no date. Accessed: 15 August 2024.

• Who are we?, no date. Accessed: 15 August 2024.

Al Jazeera, Sri Lanka loses 10 percent of its doctors amid exodus after economic crisis, 20 June 2024. Accessed: 15 August 2024.

Amnesty international,

• Submission to the UN Committee on the Elimination of Discrimination against Women; 86th Pre-Sessional Working Group, 27 February - 3 March 2023. Accessed: 30 April 2024.

• We are near total breakdown”’, 4 October 2022. Accessed: 30 April 2024.

Arambepola, C; Jayakody, S,

• Determinants of quality of like among people with dementia: evidence from South Asian population, 12 September 2022. Accessed: 18 July 2024.

• Patient and caregiver perspectives of quality of like in dementia: Evidence from a South Asian population, 18 May 2023. Accessed: 18 July 2024.

Attanayake, D; Dalal, A; Dissanayake, A; Gonawala, L; Gunasekara, H; Hoffman, E; Keshavaraj, A; Mohan, C; Ratnayake, P; Sirisena, D; Steinbusch, H; Wijekoon, N, European Journal of Human Genetics, Diagnostic outcome of pro bono neurogenetic diagnostic service in Sri Lanka: A wealth creation, 23 January 2024. Accessed: 30 April 2024.

Attanayake, D; De Silva, A; Fernando, S; Garusinghe, S; Gunasekara, S; Gooneratne, I; Karunanayaka, S; Kudavidanage, B; Ranasinghe, K; Satharasinghe, S; Senanayake, S; Senanayake, S.J; Suraweera, C; Wanigasinghe, J, ‘Surgical Outcome of Pharmaco Refractory Epilepsy in the National Epilepsy Centre of Sri Lanka’, April 2024. Accessed: 21 July 2024.

Australian Department of Foreign Affairs and Trade (DFAT), Country Information Report, Sri Lanka, 2 May 2024. Accessed: 16 July 2024.

Bandara, S. Public Health System of Sri Lanka, in Routledge Handbook of Contemporary Sri Lanka, 2024. Accessed: 13 August 2024.

BBC News, Sri Lankan parents spending hundreds on children’s leukaemia meds, 16 March 2024. Accessed: 30 April 2024.

Berry, S; Booth, C; Carson, L; Gunasekara, S; Gyawali, B; Jalink, M; Jayarajah, U; Promod, H; Seneviratne, S; Thiwanka Wijeratne, D, Colorectal Cancer Treatment Characteristics and Concordance With Guidelines in Sri Lanka: Results From a Hospital-Based Cancer Registry, 27 May 2022. Accessed: 14 May 2024.

British Heart Foundation, Atrial Septal Defect, no date. Accessed: 30 April 2024.

Damayanthi, H; Dorji, T; Eliseo Lucero-Prisno, D; Jayasekara, J; Siriwardana, E; Weerakoon, D, Chronic kidney disease in Sri Lanka: Health systems challenges of patients on hemodialysis, 24 January 2024. Accessed: 14 May 2024.

Dassanayake, B; Dorji, T; Jayarathna, M; Lamawansa, M; Lucero-Prisno III, D; Pinto, V and Samarasinghe S, Challenges of liver transplantation programs in low-and middle-income countries: An experience from Sri Lanka, 20 February 2024. Accessed: 16 July 2024.

The Democratic Socialist Republic of Sri Lanka, Guidelines for procurement of pharmaceuticals & medical devices of a consumable nature, 2022. Accessed: 16 July 2024.

De Silva, K; Gamage, M; Jagodage, H; Kariyawasam, P and Sundarapperuma, T, Quality of care as perceived by caregivers and residents in aged care homes in Sri Lanka: a qualitative study, 27 January 2024. Accessed: 8 July 2024.

De Silva, D; Jayasinghe, Rasika; Jayasinghe, Ruwan; Jayasinghe, Y and Jayawickrama, S, Challenges Faced in Dental Care Delivery Amid Financial Crisis in Sri Lanka: An Evidence-Based Analysis from the Perspective of Health Professionals, 22 September 2023. Accessed: 16 July 2023.

Dhanapriyanka, M; Jayakody, M; Jayasekara, P and Senavirathne, A, Oral Health Report 2020/2021 Ministry of Health Sri Lanka, August 2023. Accessed: 8 July 2024.

Directorate of Mental Health (DoMH), Our services – introduction, no date. Accessed: 14 August 2024.

EconomyNext, Sri Lanka promotes HIV swab test, app to increase detection, 1 December 2023. Accessed: 30 April 2024.

Epidemiology Unit Sri Lanka, Dengue, could be a silent killer?, no date. Accessed: 22 April 2024.

European Society for Medical Oncology (ESMO), Palliative Care Unit National Cancer Institute (Apeksha Hospital), August 2022. Accessed: 30 April 2024.

Galappatthy, P, SLMA News+, Pharmaceutical supply in Sri Lanka: Can we do it better?, April 2023. Accessed: 14 August 2024

Galappatthy, P, SLMA News+, Pharmaceutical supply in Sri Lanka: Can we do it better?, May 2023. Accessed: 14 August 2024

Google Maps,

• Neurology Units Sri Lanka, 23 April 2021. Accessed: 22 July 2024.

• Sri Lanka Stroke Thrombolysis Centres’, 7 August 2023. Accessed: 22 July 2024.

Government of Sri Lanka,

• Initial report submitted by Sri Lanka under Article 35 of the Convention, due in 2018 [5 December 2019], 13 September 2023. Accessed: 30 April 2024.

• Ninth periodic report submitted by Sri Lanka under Article 18 of the Convention, due in 2021 [22 April 2022], 10 August 2022. Accessed: 30 April 2024.

• Common core document forming part of the reports of States parties’, 1 June 2022. Accessed: 21 July 2024.

The Guardian, A place of healing’: comfort for young cancer patients amid Sri Lanka’s economic crisis, 20 February 2023. Accessed: 14 May 2024.

Hemas Hospital, Gastroenterology, no date. Accessed: 17 July 2024.

Human Rights Commission of Sri Lanka (HRCSL), Interim Report – Fact Finding Mission on Right to Health and Liberty of Patients at National Institute of Mental Health, 11 December 2023. Accessed: 24 June 2024.

International Federation of Red Cross (IFRC),

• Sri Lanka - Dengue Outbreak & Floods, 3 June 2023. Accessed: 22 April 2024.

• Sri Lanka: Complex Emergency - Operation Update, 12 July 2023. Accessed: 22 April 2024.

International Labour Organization (ILO) Social Protection Department, Country Brief Sri Lanka, December 2021 Accessed: 19 June 2024.

Iqbal, A; Nuradh, J, Cervical cancer in Sri Lanka, 25 February 2023. Accessed: 14 May 2024.

The Lancet, Sri Lanka at 75: safeguarding its health achievements, 28 October 2023. Accessed: 14 May 2024.

Liyanage, C.K, and others, BMC Health Services Research, A national survey on registered products, availability, prices, and affordability of 100 essential medicines in community pharmacies across Sri Lanka (Vol 23, Article number 1121), 19 October 2023. Accessed: 15 August 2024

Mannar Women’s Development Federation, Submission to the United Nations Committee on the Elimination of Discrimination against Women for its consideration of the ninth periodic report of Sri Lanka at its 86 Pre-Sessional Working Group, 30 January 2023. Accessed: 14 May 2024.

Ministry of Health (MoH) Sri Lanka,

• About us: Overview of Sri Lankan health sector, no date. Accessed: 6 August 2024

• Annual Health Bulletin 2019, 2019. Accessed: 17 July 2024.

• Annual health bulletin 2021, March 2024. Accessed: 6 August 2024

• Annual Performance Report 2022, 19 September 2023. Accessed: 19 August 2024

• Drug availability - SWASTHA, 24 November 2023. Accessed: 5 August 2024.

• Guideline for the management of patients presenting with opioid, cannabis, methamphetamine or polysubstance withdrawal at primary health care settings, July 2023. Accessed: 15 August 2024

• Health institutions in Sri Lanka, no date. Accessed: 14 August 2024

• Health Institutions In Sri Lanka, no date. Accessed: 19 June 2024.

• HIV Treatment and Care, 11 May 2024. Accessed: 16 July 2024.

• Hospital Based Care, no date. Accessed: 16 July 2024.

The National Hospital Kandy, no date. Accessed: 16 July 2024.

The National Hospital of Sri Lanka, no date. Accessed: 17 July 2024.

Oral health report 2020/2021, July 2023. Accessed: 21 August 2024

Performance and progress report 2021, 13 December 2021. Accessed: 8 August 2024

Public Health Services, no date. Accessed: 16 July 2024.

The Morning,

• Sustainability of Sri Lanka’s free healthcare a significant concern Sunimalee Madurawala’, 15 October 2023. Accessed: 14 May 2024.

• Suwa Arana, 2 July 2023. Accessed: 16 July 2023

• Tuberculosis on the rise in Sri Lanka, 17 March 2024. Accessed: 14 May 2024.

National Cancer Control Programme,

• Cancer Early Detection Centre’, no date. Accessed: 1 July 2024.

• Cancer treatment centres of Sri Lanka’, no date. Accessed: 22 April 2024.

• Colposcopy Centers in Sri Lanka’, no date. Accessed: 1 July 2024.

• Mammography Centers in Sri Lanka By Province’, no date. Accessed: 1 July 2024.

• Palliative Care Consult Services in Sri Lanka’, no date. Accessed: 17 July 2024.

National Council for Mental Health (NCMH),

• Gorakana residential facility, no date. Accessed: 15 August 2024.

• What we do, no date. Accessed: 15 August 2024.

• Who we are, no date. Accessed: 15 August 2024.

National Hospital of Sri Lanka (NHSL), Services, no date. Accessed: 20 August 2024.

National Institute of Mental Health (NIMH), Media bulletin volume 1 2022, 11 October 2022. Accessed: 20 August 2024.

National Medicine Regulatory Authority (NMRA),

• Guidelines on registration of medicines, 25 July 2024. Accessed: 14 August 2024.

• Providing Quality Medicine Regulation in Sri Lanka, no date. Accessed: 29 October 2024

Ninewells Hospital, Paediatrics, no date. Accessed: 16 July 2023.

Ranawaka, U and Venketasubramanian, N, Stroke in Sri Lanka: How Can We Minimise the Burden? 28 April 2021. Accessed: 30 April 2024.

Rasalingam, G, The acute economic recession: WHO diabetes target 2030 becoming unrealistic in Sri Lanka, 28 December 2022. Accessed: 14 May 2024.

Royal College of Psychiatrists, Development of adolescent mental health services in Sri Lanka, January 2023. Accessed: 14 May 2024.

The Royal Society of Tropical Medicine and Hygiene (RSTMH), Burden of a universal healthcare system: The story of a common man from Sri Lanka, 10 February 2023. Accessed: 14 May 2024.

Senaviratna, N, Cardiovascular disease burden in a country: In the context of Sri Lanka, November 2023. Accessed: 22 April 2024.

Sex Workers & Allies South Asia, Submission by Sex Workers and Allies South Asia – Sri Lanka, 2023. Accessed: 14 May 2024.

Sri Jayewardenepura General Hospital,

• Our Services – Cardiology Unit, no date. Accessed: 22 April 2024.

• Our Services – ENT Unit, no date. Accessed: 22 April 2024.

• Our Services – Paediatrics Unit, no date. Accessed: 22 April 2024.

• Our Services – Rheumatology and Rehabilitation Unit, no date. Accessed: 18 July 2024.

The Sri Lankan Kidney Foundation (SLKF), Chronic Kidney Disease and Sri Lanka, 15 February 2022. Accessed: 17 July 2024.

Sri Lanka Medical Association (SLMA),

• Practice guidelines in the end-of-life care, November 2021. Accessed: 2 July 2024.

• SLMA guidelines and information on vaccines, 2023. Accessed: 18 July 2024.

State Pharmaceuticals Corporation (SPC),

• Franchise Osusala Outlets, no date. Accessed: 15 August 2024

• Rajya Osusala Outlets, no date. Accessed: 15 August 2024

State Secretariat for Migration (SEM) (Switzerland), Focus Sri Lanka - Gesundheitswesen: Psychiatrische Versorgung, 14 April 2023. Accessed: 29 October 2024

Sumithrayo, About us, no date. Accessed: 14 August 2024

The Sunday Observer, Timely treatment, key to coping with…, 12 February 2023. Accessed: 22 April 2024.

The Sunday Times,

• Challenges in SL’s mental health arena: brain drain and lack of medicines, 28 July 2024. Accessed: 15 August 2024

• Suicides are unpredictable, not unpreventable, 13 August 2023. Accessed: 15 August 2024

UNICEF,

• Budget Brief: Health Sector, June 2022. Accessed: 14 May 2024.

• Child survival & development, no date. Accessed: 14 May 2024.

• Country profiles: Sri Lanka, no date. Accessed: 13 August 2024.

• Sri Lanka Consolidated Emergency Report 2023, March 2024. Accessed: 13 August 2024.

University of Peradeniya, Dental Hospital (Teaching) Faculty of Dental Sciences, no date. Accessed: 14 May 2024.

University of Sri Jayewardenepura, Faculty of Dental Sciences (departments), no date. Accessed: 14 May 2024.

UN Office of the High Commissioner for Human Rights (OCHCR), National report submitted pursuant to Human Rights Council resolutions 5/1 and 16/21; Sri Lanka, 30 December 2022. Accessed: 30 April 2024.

US Department of State, Country Report on Human Rights for Practices 2023, 23 April 2024. Accessed: 14 May 2024.

Weerasekara, P, Prevalence and associated factors of psychological distress of patients with stroke attending the Neurology Clinics of the National Hospital of Sri Lanka, Colombo, 25 April 2023. Accessed: 17 July 2024.

Western Hospital, Geriatric Care, no date. Accessed: 17 July 2024.

Westminster Foundation for Democracy (WFD),

• An Exploration of Inclusion Gaps:An Assessment of the Health Sector, September 2023. Accessed: 18 July 2024.

• Examining lived experience of LGBT + Sri Lankans on housing, education and employment’, 14 November 2023. Accessed: 18 July 2024.

The World Bank,

• Sri Lanka: Making strides towards a healthier future, 29 March 2022. Accessed: 14 May 2024

• The World Bank Group in Sri Lanka – overview, 2 April 2024. Accessed: 14 August 2024

World Health Organization (WHO),

• Data: Probability of premature mortality from NCDs, 8 January 2024. Accessed: 13 August 2024

• Data: Sri Lanka, no date. Accessed: 13 August 2024

• Data: Suicide mortality rate (per 100 000 population), 8 January 2024. Accessed: 13 August 2024

• Dengue Fact Sheet and Situation Report, 22 July 2022. Accessed: 14 May 2024.

• Global Health Expenditure Database, no date. Accessed: 13 August 2024.

• Improving diabetes and cardiovascular disease prevention though school health and lifestyle programmes. A multisectoral NCD response in Sri Lanka, 14 September 2023. Accessed: 14 May 2024.

• Maldives Sri Lanka achieve Hepatitis B control, 17 January 2024. Accessed: 17 July 2024.

• Mental Health Atlas- Sri Lanka 2020, 15 April 2022. Accessed: 12 August 2024.

• Monitoring the health-related SDGs - country profiles: Sri Lanka, no date. Accessed: 13 August 2024.

• Progress on health-related SDGs in the South-East Asia Region: Where are we now and what is next?, 12 May 2024. Accessed: 15 August 2024

• Sri Lanka data, 2021. Accessed: 19 June 2024.

• Sri Lanka Health System Review, 5 July 2021. Accessed: 14 May 2024.

• World AIDS Day 2023, 1 December 2023. Accessed: 10 April 2024.

• World Hepatitis Day 2022, 28 July 2022. Accessed: 17 July 2024.

• World Tuberculosis Day 24 March 2024 “Yes! We can end TB! 24 March 2024. Accessed: 14 May 2024.

Xe.com, USD to GBP - US Dollars to British Pounds Exchange Rate, 20 May 2024. Accessed: 20 May 2024.

Xe.com, SLR to GBP - Sri Lankan Rupees to British Pounds Rate, 8 July 2024. Accessed: 8 July 2024.

Sources consulted but not cited

Amnesty International, An unstoppable movement: A global call to recognize and protect those who defend the right to abortion, November 2023. Accessed: 10 April 2024.

The Borgen Project, Paving the way to eliminate HIV in Sri Lanka, 10 November 2020. Accessed: 10 April 2024.

Daily Mirror World, Sri Lanka sees uptick in HIV/AIDS cases in 2023, 8 March 2024. Accessed: 10 April 2024.

European Union Agency for Asylum (EUAA), Country of Origin Information, no date. Accessed: 9 May 2024.

Reuters, Sri Lanka’s cancer patients struggle amid economic chaos, 22 December 2022. Accessed: 11 April 2024.

Royal College of Psychiatrists, Development of adolescent mental health services in Sri Lanka, January 2023. Accessed: 10 April 2024.

Sunday Observer, Persons living with HIV/AIDs can lead normal lives with early diagnosis and medication, 4 December 2022. Accessed: 10 April 2024.

Tropical Climate, Tuberculosis in Sri Lanka, 2012-2019. Accessed: 10 April 2024.

VaccinesWork, Transforming tuberculosis treatment in Sri Lanka, 13 December 2022. Accessed: 10 April 2024.

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1. WHO, Data: Sri Lanka, no date ↩

2. UNICEF, Country profiles: Sri Lanka, no date ↩

3. WHO, Data: Probability of premature mortality from NCDs, 8 January 2024 ↩

4. WHO, Data: Suicide mortality rate (per 100 000 population), 8 January 2024 ↩

5. WHO, Monitoring the health-related SDGs - country profiles: Sri Lanka, no date ↩

6. WHO, Global Health Expenditure Database, no date ↩

7. WHO, Sri Lanka Health System Review (section 5.1, 5.1.5), 5 July 2021 ↩

8. RSTMH, Burden of a universal healthcare system …, 10 February 2023 ↩

9. The Morning, Sustainability of Sri Lanka’s free healthcare a significant …, 15 October 2023 ↩

10. WHO, Progress on health-related SDGs in the South-East Asia Region… (page 1), 12 May 2024 ↩

11. WHO, Progress on health-related SDGs in the South-East Asia Region… (figure 1), 12 May 2024 ↩

12. WHO, Progress on health-related SDGs in the South-East Asia Region… (page 6), 12 May 2024 ↩

13. Bandara, S, Public Health System of Sri Lanka (page 349), 2024 ↩

14. World Bank, Sri Lanka: Making strides towards a healthier future, 29 March 2022 ↩

15. The Morning, Sustainability of Sri Lanka’s free healthcare a significant …, 15 October 2023 ↩

16. The Lancet, Sri Lanka at 75: safeguarding its health achievements, 28 October 2023 ↩

17. Bandara, S, Public Health System of Sri Lanka (page 355), 2024 ↩

18. SEM, Focus Sri Lanka (page 7), 14 April 2023 ↩

19. UNICEF, Sri Lanka Consolidated Emergency Report 2023 (page 10), March 2024 ↩

20. UNICEF, Sri Lanka Consolidated Emergency Report 2023 (page 5), March 2024 ↩

21. UNICEF, Sri Lanka Consolidated Emergency Report 2023 (page 29), March 2024 ↩

22. MoH, About us: Overview of Sri Lankan health sector, no date ↩

23. Ministry of Health Sri Lanka, Health Institutions In Sri Lanka, no date ↩

24. MoH, Performance and Progress Report 2023 (page 1), no date ↩

25. Bandara, S, Public Health System of Sri Lanka (page 353), 2024 ↩

26. WHO, Sri Lanka Health System Review (section 2.3), 5 July 2021 ↩

27. MoH, Performance and Progress Report 2023 (page 1), no date ↩

28. MoH, Performance and Progress Report 2023 (page 22), no date ↩

29. Bandara, S, Public Health System of Sri Lanka (page 354), 2024 ↩

30. UNICEF, Budget Brief: Health Sector 2021 (key messages), June 2022 ↩

31. MoH, Annual health bulletin 2021 (page 106), March 2024 ↩

32. AI, “We are near total breakdown” (section 3.1), 4 October 2022 ↩

33. RSTMH, Burden of a universal healthcare system …, 10 February 2023 ↩

34. The Morning, Sustainability of Sri Lanka’s free healthcare a significant …, 15 October 2023 ↩

35. DFAT, Country Information Report, Sri Lanka (paragraph 2.34), 2 May 2024 ↩

36. UNICEF, Budget Brief: Health Sector 2021 (key messages), June 2022 ↩

37. WHO, Sri Lanka Health System Review (section 2.3.1), 5 July 2021 ↩

38. WHO, Sri Lanka Health System Review (section 2.4, 7.3), 5 July 2021 ↩

39. WHO, Sri Lanka Health System Review (section 3.3.1.4), 5 July 2021 ↩

40. ILO, Country Brief Sri Lanka, December 2021 ↩

41. AI, “We are near total breakdown” (section 3.1), 4 October 2022 ↩

42. RSTMH, Burden of a universal healthcare system …, 10 February 2023 ↩

43. SEM, Focus Sri Lanka (page 32), 14 April 2023 ↩

44. DFAT, Country Information Report, Sri Lanka (paragraph 2.34), 2 May 2024 ↩

45. UNICEF, Budget Brief: Health Sector 2021 (section 2.1), June 2022 ↩

46. WHO, Sri Lanka Health System Review (section 2.2, 5.14 ), 5 July 2021 ↩

47. MoH, Health institutions in Sri Lanka, no date ↩

48. MoH, Annual health bulletin 2021 (table 1.5, page 8), March 2024 ↩

49. MoH, Health institutions in Sri Lanka, no date ↩

50. MoH, Annual Performance Report 2022 (pages 8 to 10), 19 September 2023 ↩

51. WHO, Sri Lanka Health System Review (section 5.1, 5.1.5), 5 July 2021 ↩

52. MoH, Annual health bulletin 2021 (page 106), March 2024 ↩

53. NHSL, Services, no date ↩

54. MoH, Annual health bulletin 2021 (page XXXIII), March 2024 ↩

55. WHO, Monitoring the health-related SDGs - country profiles: Sri Lanka, no date ↩

56. RSTMH, [Burden of a universal healthcare system …, 10 February 2023 ↩

57. MoH, Performance and Progress Report 2023 (page 14), no date ↩

58. Al Jazeera Sri Lanka loses 10 percent of its doctors… after economic crisis, 20 June 2024 ↩

59. RSTMH, Burden of a universal healthcare system …, 10 February 2023 ↩

60. Attanayake, D, and others, Diagnostic outcome … (introduction, discussion), 23 January 2024 ↩

61. DFAT, Country Information Report, Sri Lanka (paragraph 2.34), 2 May 2024 ↩

62. MoH, Annual health bulletin 2021 (page 240), March 2024 ↩

63. NMRA, Guidelines on registration of medicines, 25 July 2024 ↩

64. WHO, Sri Lanka Health System Review (section 5.7.2), 5 July 2021 ↩

65. WHO, Sri Lanka Health System Review (section 5.7.1), 5 July 2021 ↩

66. Galappatthy, P, SLMA News+, Pharmaceutical supply… (Vol 16; Iss 2; pg 22), May 2023 ↩

67. SEM, Focus Sri Lanka (page 27), 14 April 2023 ↩

68. Liyanage, C.K, and others, BMC HSR, A national survey… (Vol 23, Article 1121), 19 October 2023 ↩

69. SPC, Rajya Osusala Outlets, no date ↩

70. SPC, Franchise Osusala Outlets, no date ↩

71. MoH, Drug availability - SWASTHA, 24 November 2023 ↩

72. NMRA, Providing Quality Medicine Regulation in Sri Lanka (NMRA Registered Medicines), no date ↩

73. SEM, Focus Sri Lanka (page 63), 14 April 2023 ↩

74. World Bank, The World Bank Group in Sri Lanka – overview, 2 April 2024 ↩

75. Liyanage, C.K, and others, BMC HSR, A national survey… (Vol 23, Article 1121), 19 October 2023 ↩

76. Liyanage, C.K, and others, BMC HSR, A national survey… (Vol 23, Article 1121), 19 October 2023 ↩

77. Liyanage, C.K, and others, BMC HSR, A national survey… (Vol 23, Article 1121), 19 October 2023 ↩

78. WHO, Monitoring the health-related SDGs - country profiles: Sri Lanka, no date ↩

79. AI, “We are near total breakdown” (section 3.1), 4 October 2022 ↩

80. AI, “We are near total breakdown” (section 3.1), 4 October 2022 ↩

81. World Bank, The World Bank Group in Sri Lanka – overview, 2 April 2024 ↩

82. Galappatthy, P, SLMA News+, Pharmaceutical supply… (Vol 16; Iss 2; pg 8), April 2023 ↩

83. Galappatthy, P, SLMA News+, Pharmaceutical supply… (Vol 16; Iss 2; pg 7), April 2023 ↩

84. MoH, Annual Performance Report 2022 (pages 175 to 184), 19 September 2023 ↩

85. SEM, Focus Sri Lanka (page 7), 14 April 2023 ↩

86. SEM, Focus Sri Lanka (page 6), 14 April 2023 ↩

87. BBC News, Sri Lankan parents spending hundreds on children’s leukaemia meds, 16 March 2024 ↩

88. DFAT, Country Information Report, Sri Lanka, (paragraph 2.39), 2 May 2024 ↩

89. MoH, National Mental Health Policy 2020-2030 (page 43), 17 March 2021 ↩

90. MoH, Performance and Progress Report 2023 (page 97), no date ↩

91. DoMH, Our services – introduction, no date ↩

92. SEM, Focus Sri Lanka (page 6), 14 April 2023 ↩

93. SEM, Focus Sri Lanka (pages 9, 11,12,15), 14 April 2023 ↩

94. SEM, Focus Sri Lanka (page 13), 14 April 2023 ↩

95. NIMH, Media bulletin volume 1 2022 (page 4), 11 October 2022 ↩

96. NIMH, Media bulletin volume 1 2022 (page 5), 11 October 2022 ↩

97. HRCSL, Interim Report – Fact Finding Mission on Right to Health and…, 11 December 2023 ↩

98. MoH, Annual health bulletin 2021 (page 110), March 2024 ↩

99. MoH, Annual health bulletin 2021 (page 274), March 2024 ↩

100. MoH, Annual health bulletin 2021 (page 274), March 2024 ↩

101. NIMH, Media bulletin volume 1 2022 (page 4), 11 October 2022 ↩

102. MoH, Performance and Progress Report 2023 (page 98), no date ↩

103. WHO, Mental Health Atlas- Sri Lanka 2020, 15 April 2022 ↩

104. MoH, Annual health bulletin 2021 (page 279), March 2024 ↩

105. NIMH, Annual Report 2022 (page 9), 1 February 2023 ↩

106. SEM, Focus Sri Lanka (pages 6 - 7), 14 April 2023 ↩

107. SEM, Focus Sri Lanka (pages 17-18), 14 April 2023 ↩

108. The Sunday Times, Suicides are unpredictable, not unpreventable, 13 August 2023 ↩

109. The Sunday Times, Suicides are unpredictable, not unpreventable, 13 August 2023 ↩

110. DoMH, Our services – introduction, no date ↩

111. MoH, Performance and progress report 2021 (page 109), 13 December 2021 ↩

112. MoH, Guideline for the management of patients presenting with opioid, cannabis…, July 2023 ↩

113. WHO, Mental Health Atlas- Sri Lanka 2020, 15 April 2022 ↩

114. DoMH, Our services – introduction, no date ↩

115. Royal College of Psychiatrists, Development of adolescent mental … (page 42), January 2023 ↩

116. Royal College of Psychiatrists, Development of adolescent mental … (page 42-43), January 2023 ↩

117. The Sunday Times, Challenges in SL’s mental health arena…, 28 July 2024 ↩

118. Sumithrayo, About us, no date ↩

119. NCMH, Who we are, no date ↩

120. NCMH, What we do, no date ↩

121. NCMH, Gorakana residential facility, no date ↩

122. ADIC, Who are we?, no date ↩

123. ADIC, Our services, no date ↩

124. UNICEF, Sri Lanka Consolidated Emergency Report 2023 (page 10), March 2024 ↩

125. NCCP, Cancer Treatment Centres of Sri Lanka, no date ↩

126. NCCP, Cancer treatment centres of Sri Lanka, no date ↩

127. MoH, Annual health bulletin 2021 (table 7, page 319), March 2024 ↩

128. Ministry of Health, Hospital Based Care, no date ↩

129. MoH, Annual Performance Report 2022 (page 30), 19 September 2023 ↩

130. NCCP, Cancer Early Detection Centre, no date ↩

131. NCCP, Colposcopy Centres in Sri Lanka, no date ↩

132. NCCP, Mammography Centres in Sri Lanka By Province, no date ↩

133. Berry, S, and others, Colorectal Cancer Treatment … (introduction), 27 May 2022 ↩

134. ESMO, Palliative Care Unit National Cancer Institute … (history, profile), August 2022 ↩

135. The Guardian, A place of healing’: comfort for young cancer patients …, 20 February 2023 ↩

136. The Guardian, A place of healing’: comfort for young cancer patients …, 20 February 2023 ↩

137. The Morning, Suwa Arana, 2 July 2023 ↩

138. Berry, S, and others, Colorectal Cancer Treatment … (introduction), 27 May 2022 ↩

139. Berry, S, and others, Colorectal Cancer Treatment … (discussion), 27 May 2022 ↩

140. Ministry of Health, 2019 Annual Health Bulletin (page 18), 2019 ↩

141. SLKF, Chronic Kidney Disease and Sri Lanka, 15 February 2022 ↩

142. Xe.com, $8.35 USD to GBP - Convert US Dollar to British Pounds, 20 May 2024 ↩

143. Xe.com, $11.14 USD to GBP - Convert US Dollar to British Pounds, 20 May 2024 ↩

144. AI, “We are near total breakdown” (section 3.1), 4 October 2022 ↩

145. RSTMH, Burden of a universal healthcare system …, 10 February 2023 ↩

146. Damayanthi, H, and others, Chronic kidney disease in Sri Lanka … (abstract), 24 January 2024 ↩

147. Damayanthi, H, and others, Chronic kidney disease… (introduction, challenges), 24 January 2024 ↩

148. WHO, Sri Lanka Health System Review (page 114, 201), 5 July 2021 ↩

149. WHO, Sri Lanka Health System Review (page 117), 5 July 2021 ↩

150. British Heart Foundation, Atrial Septal Defect, no date ↩

151. British Heart Foundation, Atrial Septal Defect, no date ↩

152. Sri Jayewardenepura General Hospital, Our Services – Cardiology Unit, no date ↩

153. Senaviratna, N, Cardiovascular disease burden in a country … (introduction), November 2023 ↩

154. MoH Epidemiology Unit, Dengue, could be a silent killer?, no date ↩

155. WHO, Dengue Fact Sheet and Situation Report (page 5), 22 July 2022 ↩

156. IFRC, Sri Lanka - Dengue Outbreak & Floods (page 2, 3), 3 June 2023 ↩

157. Xe.com, 144.6 USD to GBP - Convert US Dollar to British Pounds, 16 May 2024 ↩

158. Xe.com, 14 USD to GBP - Convert US Dollar to British Pounds, 16 May 2024 ↩

159. Xe.com, 6 USD to GBP - Convert US Dollar to British Pounds, 16 May 2024 ↩

160. Xe.com, 1.6 USD to GBP - Convert US Dollar to British Pounds, 16 May 2024 ↩

161. Xe.com, 5.9 USD to GBP - Convert US Dollar to British Pounds, 16 May 2024 ↩

162. Rasalingam, G, The acute economic recession: WHO diabetes target …, 28 December 2022 ↩

163. Akhtar, S, and others, Prevalence of type 2 diabetes … (introduction), 28 August 2023 ↩

164. WHO, [Improving diabetes and cardiovascular disease prevention …, 14 September 2023 ↩

165. University of Peradeniya, Dental Hospital (Teaching) Faculty of Dental Sciences, no date ↩

166. University of Sri Jayewardenepura, Faculty of Dental Sciences (departments), no date ↩

167. WHO, Sri Lanka Health System Review (page 106, 110, 136), 5 July 2021 ↩

168. MoH, Oral health report 2020/2021 (page 1), July 2023 ↩

169. MoH, Oral health report 2020/2021 (page 8), July 2023 ↩

170. De Silva, D, and others, Challenges Faced in Dental… (abstract, section 2 and 11), 22 Sept 2023 ↩

171. Sri Jayewardenepura General Hospital, Our Services – ENT Unit, no date ↩

172. Hemas Hospital, Gastroenterology, no date ↩

173. Western Hospital, Geriatric Care, no date ↩

174. De Silva, K, and others, Quality of care as… (introduction, discussion, results), 27 January 2024 ↩

175. De Silva, K, and others, Quality of care as perceived by… (results, conclusion), 27 January 2024 ↩

176. Iqbal, A, and others, Cervical cancer in Sri Lanka (introduction, vaccination), 25 February 2023 ↩

177. Iqbal, A, and others, Cervical cancer in Sri Lanka (vaccination, diagnosis), 25 February 2023 ↩

178. WHO, World Hepatitis Day 2022, 28 July 2022 ↩

179. WHO, Maldives Sri Lanka achieve Hepatitis B control, 17 January 2024 ↩

180. Dassanayake, B, and others, Challenges of liver transplantation programs…, 20 February 2024 ↩

181. OHCHR, National report submitted pursuant … (paragraph 38), 30 December 2022 ↩

182. WFD, An Exploration of Inclusion Gaps (Methodology), September 2023 ↩

183. WFD, Examining lived experiences of LGBT+ (Executive Summary), 14 November 2023 ↩

184. WHO, World AIDS Day 2023, 1 December 2023 ↩

185. EconomyNext, Sri Lanka promotes HIV swab test, app to increase detection, 1 December 2023 ↩

186. USSD, Country Report on Human Rights Practices (section 6), 22 April 2024 ↩

187. MoH, HIV Treatment and Care (services offered), 11 May 2024 ↩

188. Ministry of Health, The National Hospital of Sri Lanka (Rheumatology), no date ↩

189. Sri Jayewardenepura Hospital, Our Services – Rheumatology and Rehabilitation Unit, no date ↩

190. Google Maps, Neurology Units Sri Lanka, 23 April 2021 ↩

191. Ministry of Health, The National Hospital of Sri Lanka (specialist care services), no date ↩

192. Attanayake, D, and others, Diagnostic outcome … (introduction, discussion), 23 January 2024 ↩

193. Ranawaka, U, and others, Stroke in Sri Lanka: How Can We Minimise the Burden?, 28 April 2021 ↩

194. Google Maps, Sri Lanka Stroke Thrombolysis Centres, 7 August 2023 ↩

195. Ministry of Health, National Hospital of Sri Lanka (clinical neurophysiology), no date ↩

196. Sunday Observer, Timely treatment, key to coping with Epilepsy…, 12 February 2023 ↩

197. Attanayake, D, and others, Surgical Outcome of…Refractory Epilepsy (introduction), April 2024 ↩

198. Arambepola, C, and others, Determinants of quality of like … (introduction), 12 September 2022 ↩

199. UNICEF, Child survival and development (the Challenge), no date ↩

200. Sri Jayewardenepura General Hospital, Our Services – Paediatrics Unit, no date ↩

201. Ninewells Hospital, Paediatrics, no date ↩

202. Ministry of Health, Hospital Based Care, no date ↩

203. NCCP, Palliative Care Consult Services in Sri Lanka, no date ↩

204. WHO, Sri Lanka Health System Review (page 131), 5 July 2021 ↩

205. SLMA, Practice guidelines in the end of life care (Preamble), November 2021 ↩

206. ESMO, Palliative Care Unit National … (history, palliative and supportive care), August 2022 ↩

207. OHCHR, National report submitted pursuant … (paragraph 73), 30 December 2022 ↩

208. Mannar Women’s Development Federation, Submission to the UN … (page 6, 10), 30 Jan 2023 ↩

209. IFRC, Sri Lanka: Complex Emergency - Operation Update (page 8), 12 July 2023 ↩

210. Sex Workers & Allies South Asia, Submission by Sex Workers and Allies …, 2023 ↩

211. USSD, Country Report on Human Rights for Practices 2023 (section 6), 23 April 2024 ↩

212. SLMA, SLMA guidelines and information on vaccines (page 7), 2023 ↩

213. The Morning, Tuberculosis on the rise in SL, 17 March 2024 ↩

214. WHO, World Tuberculosis Day 24 March 2024 “Yes! We can end TB!, 24 March 2024 ↩