The Sri Lankan healthcare system is weighed down by a 'double burden' - the lingering threat from infectious diseases rooted in poverty, coupled with a rising threat from lifestyle diseases that are ironically normally associated with affluence.

By Nalaka Gunawardene

May 1999

Colombo: Sri Lanka's healthcare system is often held up as a model for developing countries. But a recent trend has begun to worry health planners and managers in this South Asian island nation - the emergence of non-communicable diseases.

These ailments include heart diseases, stroke, cancers and diabetes and are commonly associated with a lifestyle akin to that led by people in far wealthier countries than Sri Lanka. It usually follows a rise in incomes. The trouble is, they emerge at a time the country is still coping with a host of infectious diseases rooted in poverty.

It is a paradox health planners call a 'double burden' - and it is expected to come into sharper focus in the early part of the next century. The country's problem is that while infectious disease is no longer the leading cause of death, it is far from eradicated. And its place as a killer is being rapidly taken by lifestyle disease.

That Sri Lanka has made remarkable progress in healthcare delivery is beyond doubt. The figures speak for themselves: the infant mortality rate of 16.5 per 1,000 live births is better than that of many wealthier countries and few mothers die at childbirth.

Many communicable diseases have been brought under control. In a country of 18.3 million, the total number of hospital deaths from such diseases - mainly typhoid, tetanus, viral hepatitis, malaria, pneumonia and meningitis - was 1,348 in 1996.

The achievements have been attributed to several factors: rising income levels, improvements in medical technology and facilities, effective public health programmes and increased health-awareness and education.

But they are apparently insufficient to ensure good health for all: communicable diseases continue to cause sickness, keeping many away from school or work.

Few reliable statistics are available on sickness rates, and most experts consider this a major problem.

'The war against communicable diseases is by no means won,' says Dr Vinya Ariyaratne, a community health expert who works with Sarvodaya, the country's largest non-governmental organisation. 'It's just that the problem has assumed a different character in recent years.'

Against this backdrop, the emergence of non-communicable diseases is forcing the healthcare system to fight on two different fronts.

Already, these diseases are among the top 10 causes of hospital deaths. Heart disease is number one: with 3,109 deaths in 1996, it alone was responsible for more hospital deaths than all communicable diseases combined. Strokes, other forms of heart ailments and cancer are among the top six killers.

Diabetes, while not directly causing many deaths, is a debilitating condition that now affects an estimated 5% of people living in cities and towns.

Other conditions of lifestyle are increasingly impinging on the well-being of individuals and communities. These include dependence on drugs and alcohol, sexually transmitted diseases and suicide. Road accidents take an increasing toll on life and limb. Mental disorders have also shown a marked increase, with more cases being reported and more people seeking treatment than ever before.

'With all these factors to cope with, it is quite clear that we are not going to achieve health for all by the year 2000,' says Prof. Ravindra Fernando, a medical researcher and President of the Ceylon College of Physicians.

He points out that most non-communicable diseases, and resulting deaths, are preventable - but they need adequate attention, education and resources. Fernando points out that only 17% of the health budget in 1996 was spent on community health services, which play a major role in preventing the outbreak of diseases.

But resources are hard to find. A decades-old civil war places a severe burden on the healthcare system - much money has to go into the conflict and the health service is called upon to attend to the wounded. War injuries have disabled hundreds for life, draining scarce funds for their rehabilitation. In addition, there are over one million internally displaced people.

'Taking the war factor into account, I would say we are actually confronted with a triple burden,' says Dr Ariyaratne, whose organisation works closely with the government in providing relief to people in the conflict-ridden areas.

Economists and development planners are well aware of the challenges. In its recent annual report on the state of the economy, the Central Bank of Sri Lanka has drawn attention to the emergence of non-communicable diseases, urging more resources for preventive health.

The challenges are considerable, not least because the health gains themselves need building upon. For instance, a Sri Lankan male can expect to live for 70 years and a woman for 75 years. Both will add five more years to their life expectancy by 2025.

'Of course, later death is a benefit, but increased longevity without quality of life is an empty prize,' says Prof. Fernando, pointing out that as people live longer, the risk of non-communicable disease can grow.

Clearly, a major challenge before Sri Lanka is how to add life to the years - not just years to life. - Third World Network Features/PANOS

About the writer: Nalaka Gunawardene writes for PANOS from Colombo. The above article first appeared as a Panos Feature (7 April 1999).