Funding cuts undermine Sri Lanka’s public hospitals

By Ajitha Gunaratna
22 March 2005

The Sri Lankan government has imposed drastic funding cuts to public hospitals and health services for the payment of overtime or extra duty allowances. The decision has not been publicly announced, but was leaked to the media in late January. Its far-reaching impact on public health care, which is already in crisis, has been largely covered up.

The extent of the cutback is revealed by the overall figures. The Health Ministry has estimated that 3,250 million rupees ($US32.5 million) is needed for overtime payments to health workers this year. The Treasury, however, has granted only 850 million rupees. According to a health ministry official, 100 million rupees is needed just to pay unpaid extra duty allowances for the last three months of 2004.

As a result, the Health Ministry has to slash overtime payments by between 50 to 60 percent. Hospital authorities have already expressed serious concerns about their ability to maintain services. Previously, acute staff shortages had been partially offset by large amounts of overtime.

The National Hospital of Sri Lanka (NHSL) in Colombo has already imposed limits on overtime for drivers, attendants, labourers, sanitary workers and other health auxiliaries.

A senior NHSL official told the World Socialist Web Site: “We have received 1,700 million rupees for all expenses including salaries and overtime. We have been instructed to spend only 140 million on payments for extra duty, but we have to spend 60 million of this to pay the amounts outstanding for the last three months of the previous year.”

Explaining his concerns over the impact on patients, he said: “We cannot avoid a service cut because there is an acute shortage of health workers in each category. We have informed the health ministry. The government has to take responsibility for the curtailment of services.”

NHSL director Hector Weerasinghe wrote to the director general of health services warning that patient care would be jeopardised without adequate overtime payments. Weerasinghe attached letters from some of the hospital units explaining that patient care and surgery would be endangered by the decision.

All areas of the hospital’s operations are being affected. The NHSL’s new cardiac intensive care unit has six beds. Nurses in the unit work a total of almost 1,500 hours of overtime per month. Without these extra hours, the number of surgical cases would be severely limited.

A cardio-thoracic consultant told the WSWS: “If the government stops paying the OT [overtime] nobody will do extra work and cardiac surgery in this unit will be reduced by nearly 30 percent. Patients will be forced to get their surgery done in private hospitals.”

Previously drivers had each been working as much as 240 hours overtime a month. Now, despite the lack of drivers, the figure has been slashed to 120 hours, leading to drastic cuts in transport services.

A hospital driver explained: “Now we do only half of the services we provided earlier. We used to transport patients to special units, including the Rehabilitation Unit in Ragama, the Chest Hospital in Welisara, Psychiatric Hospitals in Angoda and Mulleriyawa and the Cancer Institute in Maharagama in the evenings. But we will not be able to maintain any of these services. We have only two ambulances to transport emergency patients at night whereas before there were four.”

The NHSL has reduced overtime for health workers, including attendants, from 100 hours to 50 hours. Those in charge of wards complain that they simply cannot maintain their services. At a meeting of nurses in late January, speakers pointed out that the quality of care would sharply deteriorate. At the NHSL alone, there is a shortage of 800 nurses.

“I can’t maintain services without deploying nurses and minor employees on extra work. We have more than 350 admissions every day. Now I have only 21 nurses to run five major places—that is, caring for burns, suturing, applying plasters, preliminary care and resuscitation. To reduce the use of nurses on overtime, I need 21 more nurses or the authorities will have to close the accident service gates for admissions,” one sister-in-charge told the WSWS.

Hospital services have already been reduced. Last August, the government slashed allowances to paramedics for being on call. An NHSL radiographer explained that the cardiology unit is unable perform X-rays after 4 p.m. because there has been no overtime since 2002. The lack of access has led to longer waiting times and forced patients to turn to private laboratories and paramedical services.

Staff shortages

The decision to cut overtime payments will exacerbate severe staff shortages in public health services. The Government Nursing Officers’ Union (GNOU) insists there is an islandwide shortage of 20,000 nurses. Currently there are 426 vacancies for pharmacists across the country.

At present there are only 960 medical laboratory technologists to cover nearly 600 health institutions. According to one estimate, a thousand more laboratory technologists are required.

The reduction of overtime will also hit staff, many of whom are in debt and rely on the extra money to make ends meet. Their difficulties are being compounded by rising prices. In February, the cost of living index hit 4,004.8, up from 3,454 a year ago, or 16 percent.

The rundown of public health services by the United Peoples Freedom Alliance (UPFA) and previous governments goes hand in hand with privatisation. Sanitary, security and other public hospital services have already been contracted out to private companies. Late last year, the Sabaragamuwa provincial council health authority called for private tenders for drivers, labourers and hospital attendants.

During the 2004 election campaign, the UPFA promised to boost public health funding and to halt privatisation. Now in power, it is, like the previous United National Front government, cutting public spending in line with the demands of the IMF and World Bank. This is despite the growing demands on public hospitals caused by the tsunami disaster and continuing outbreaks of dengue, viral infections and other diseases.

State expenditure on health in Sri Lanka has fallen drastically since the 1970s. According to the 2003 Central Bank Report, government investment in the health sector has fallen to 50 percent forcing people to bear 43 percent of the health expenditure out of their own pockets. Between 1989 and 1997, government health spending as a fraction of national expenditure fell from 6.5 to 4.7 percent. Over the same period, it declined from 2.3 to 1.6 percent as a proportion of GDP.

The Central Bank report admitted: “In recent years, government has not been able to maintain the same level of investment in the health sector as in the past due to budgetary constraints and due to other priority expenses such as financing the [civil] war.” It went on to call for “alternative financing sources”, including “paying wards in hospitals”, private health insurance schemes and the promotion of private investment. In every case, the financial burden will fall patients.

Over the last year, hospital workers from all sectors have been engaged in strikes and protests over pay and conditions. Strikers have been the subject of a vicious media witch-hunt that has sought to blame them for the crisis in the public health system created by government underfunding and cutbacks. The trade unions, some of which have direct connections to UPFA parties, have blocked any political struggle against the government and time and again caved in.

Clearly nervous about potential unrest in the public hospitals, Health Minister Nimal Siripala de Silva recently called for people to “rise against” workers struggles. “The public face immense difficulties due to ruthless strikes, especially in health sector and it is the responsibility of civil society to defeat these elements,” he provocatively declared.

This crude attempt to scapegoat health workers is a sharp warning of what the government has in store. In line with the demands of the IMF and World Bank, what is left of the free public health system is being undermined and starved of funds. Those who can afford to pay are forced to use private health facilities, while the majority of the population either joins long waiting lists, or receives no health care at all.