Public Health Systems in Sri

Lanka
Dr T M E Dabrera
(MSc, MD in Community Medicine)
Consultant Community Physician
Puttlam District
 Public Health

“The art and science of preventing disease, prolonging life and

promoting health through the organized efforts of society”
(Acheson, 1988; WHO)

Public health focuses on the entire spectrum of health and wellbeing,

not only the eradication of particular diseases

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 “Everyone has the right to a standard of living adequate for the health
and well-being of himself and his family…”
Article 25 of the Universal Declaration of Human Rights

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Public Health Core Functions
1. Assessment:
Surveillance of disease/injury
- Monitoring trends
-Analyzing causes
-Identifying needs

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2.Policy Development
Broad community involvement
Promote scientific basis of decision-making
Strategic approach
Development of comprehensive public health policies

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3. Assurance
Seeing to the implementation of legislative mandates as well as
fulfilling statutory responsibilities
Encourage, require and provide necessary services
Guarantee high priority personal and community-wide health
services, including subsidization for those unable to afford them

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The Ten Essential Services
1. Monitor health status
2. Diagnose and investigate health problems
3. Inform and educate
4. Mobilize communities to address health problems
5. Develop policies and plans
6. Enforce laws and regulations
7. Link people to needed health services
8. Assure a competent health services workforce
9. Evaluate health services
10.Conduct research for new innovations
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Principles of Public Health
• Humans are inherently social and interdependent.
• The effectiveness of institutions depends heavily on the public’s trust
• Collaboration is a key element to public health
• People and their physical environment are interdependent
• Each person in a community should have an opportunity to contribute
to public discourse
• Identifying and promoting the fundamental requirements for health
in a community are of primary concern to public health

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Base for action
• Knowledge is important and powerful
• Science is the basis for much of our public health knowledge
• People are responsible to act on the basis of what they know
• Action is not based on information alone

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History of Preventive Health Services
• First dispensary for western medicine –Colombo (for troops) in 1800
• Military hospitals and dispensaries
• Civil Medical Department -1858 (Principal Civil Medical Officer and
Inspector General of Hospitals as head)
• Provincial Surgeons were appointed for administration of provinces
• By 1886, CMD has established 26 civil hospitals, 8 district hospitals, 6
immigration hospitals, 14 district outdoor dispensaries, Leper asylum and
Lunatic asylum
• Only type of public health work undertaken was –control of large scale
epidemics
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• Public Health and Suppression of Nuisances Ordinance No 15 of 1862
1st legal enactment following the establishment of CMD
• Boards of Health headed by Government Agents were appointed to the
provinces under this ordinance
(These Boards were empowered to frame regulations under the provisions of this ordinance)
• Regulations to
inspect premises
abate nuisances
ensure sanitation
institute legal proceeding for contraventions of the law
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• Enactment of the Municipal Councils ordinance No 17 of 1865
Public health responsibilities of the Boards of Health were transferred to those councils
(Colombo, Kandy, Galle)

• Other large towns were brought under the control of Local Boards of Health
• In 1892, small towns were brought under the control of Sanitary Boards after the enactment of
Small Towns Sanitary Ordinance of 1892
• Sanitary Board
headed by the Assistant Government Agent
senior officer of the Public Works Department
senior officer of the Medical Department
2-4 members nominated by the Governor

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• Establishment of municipal, urban, town and village councils
Environmental health functions eventually became the
responsibility of these councils
• Enforcement of the Ordinance and implementation of environmental
health activities was carried out by local authorities under the
guidance of medical officers of health and sanitary inspectors of the
Department

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• Ordinance No 09 1863 - extend and make compulsory the practice of vaccination
• This was later repealed by the enactment of the Vaccination Ordinance No 20 of 1886
• Provincial Surgeons were appointed Superintendents of Vaccination for their provinces
• They were required to carry out a programme on vaccination in their provinces in
consultation with the Government Agents by dividing each district into convenient
divisions and ensure that all adults and children over 3 months of age were vaccinated
• Vaccination of unvaccinated and re-vaccination of vaccinated was performed in case
of an outbreak of small pox
• Trained vaccinators were employed as active agents for carrying out vaccinations in
the island

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• The Quarantine and Prevention of Diseases Ordinance was enacted in
1897 with special regulations segregate cases of the major
communicable diseases
smallpox
cholera
plague

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Establishment of the Sanitary Branch
• Sanitary Branch of the Civil Medical Department was established in
1913, under a Senior Sanitary officer
• Sanitary Officers, later to be designated Medical Officers of Health
were appointed and stationed mainly in the large towns
• Sanitary Inspectors (training of 6 months) were appointed to assist
them

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Ancylostomiasis Campaign and Rockefeller
Foundation
• A campaign for control of hookworm disease was inaugurated with
the assistance of the International Health Division of Rockefeller
Foundation
• Provision of sanitary facilities (sp for estate and rural areas)
• Mass campaigns for treatment of infected persons

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Malaria control
• First organized efforts to control malaria started at Kurunegala (1911)
• Additional Anti-Malaria campaign centres were opened in Mahara,
Anuradhapura and Trincomalee (1922/1923)

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Amalgamation of Curative and Preventive
Services
• Recognition of the of the growing importance of public health
Curative and preventive services were brought under the control
of a Director of Medical and Sanitary Services In 1925
• The Principal Civil Medical Officer and Inspector General of Hospitals
were appointed to the post
• The Assistant Principal Civil Medical Officer was appointed as the
Deputy Director of Medical and Sanitary Services
• Two assistant directors –one for medical services, one for sanitary
services

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Inauguration of the Health Unit System
• In 1926 –first Health Unit in Kalutara established
• To undertake all public health work on an intensive scale in a well-
demarcated area
• MOH was appointed in charge
• Assisted by PHI who were responsible for environmental health and
the control of communicable diseases
• PHNS and PHM –responsible for maternal and child health activities
• Each Health Unit was expected to serve a population of 40-80
thousand people

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Activities of Health Units
• Carry out general and health surveys into various problems in the
area
• Collection and study vital statistics in the area
• Health education
• Investigation and control of infectious diseases
• Maternal and child health
• School health work
• Rural and urban sanitation

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• Provide a most efficient system for the delivery of preventive health
care
• It has remained the basis for the implementation of public health
activities over the years with little modification
• This was instrumental in changing the whole outlook of public health
in the island -Chellappah

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Establishment of the Sanitary Engineering
Division (Public Health Engineering Division)
• 1927- Sanitary Engineering Division of the department established
with the support of Rockefeller Foundation

Later –absorbed to Buildings Department

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All-Island Malaria Control and Health
Scheme
• 1934 – 1.5 million cases/80000 deaths (7 months)
• Adoption of All-Island Malaria Control and Health Scheme in 1936
• Designated Field Medical officers (55)- appointed to carry out
preventive health work in the rural areas and to execute a programme
of malaria control
• Strengthened the public health services and paved the way for an
extended general health programme based on the Health Unit system

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• Under this programme a five point rural sanitation scheme was
introduced
1. A well ventilated house
2. Boiled, cooled water for drinking
3. A sanitary latrine
4. A manure pit
5. A kitchen garden

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• Designation changed to Department of Health Services
Health Services Act No 12 –in 1954

• In 1954 - decentralization
15 SHS divisions to deliver curative and preventive health care

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• Devolution of power to the provinces -1987
• Did not seriously affect the health care delivery system at divisional
level.
• Most public health functions were already devolved

Public Health services are delivered through programmes of several

units and campaigns

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Control of Communicable Diseases
• Epidemiology Unit
• Anti Malaria Campaign
• Anti –Filariasis Campaign
• Anti-Leprosy campaign
• National STD/AIDS Control Programme
• Public Health Veterinary Services
• National Programme for Tuberculosis Control and Chest Diseases
• National Dengue Control Unit

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Epidemiology Unit –1959

• Disease surveillance
• Control of Vaccine preventable diseases
• Outbreak management
• Supervision
• Monitoring and evaluation
• Research

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Anti Malaria Campaign

Objectives
• To prevent re-introduction and re-establishment of malaria in Sri
Lanka
• To maintain zero mortality due to malaria in Sri Lanka

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Activities
• Diagnosis and treatment
• Parasitological surveillance
• Entomological surveillance
• Vector control

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Anti –Filariasis Campaign
Main areas of filariasis control activities include:
01. Control of Parasite
02. Control of Vector
03. Management of lymphoedema cases

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Staff of the AFC and RFCU conducts
01. Parasitological surveys (through night blood filming among humans)
and treatment of mf positive persons
02. Entomological surveys and vector control activities
03. Disability management programmes for lymphoedema patients

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Anti-Leprosy campaign

• Anti Leprosy Campaign (ALC) is the focal point in the Ministry of Health, Nutrition
and Indigenous Medicine that is responsible for prevention and control of leprosy in
Sri Lanka.

Main functions of the ALC include,

• Program planning, implementation of planned programs,
• Monitoring and evaluation of all activities related to leprosy
• Collection of leprosy related data
• Dissemination of information among all stakeholders
• Build and sustain partnerships with partners and coordinate and solicits support for
the Leprosy Program Action Plans.
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National STD/AIDS Control Programme
(1952)
Main activities of the National STD/AIDS Control Programme
• Coordinating the national response to HIV epidemic
• Carrying out HIV prevention interventions
• Helping to create an enabling environment for STI and HIV prevention
• Provision of clinical services for sexually transmitted Infections and sexual
health promotion
• Provision of treatment and care for people infected and affected by HIV
• Provision of laboratory services for STI and HIV diagnosis and management
• Condom promotion for STI and HIV prevention

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• Provision of counseling services for STIs and HIV
• Prevention of mother to child transmission of HIV and syphilis
• Training and capacity building of health and non-health staff
• Carrying out HIV and STI surveillance
• Carrying out research in STI and HIV
• Carrying out Monitoring and evaluation of STI and HIV services
• Dissemination of Strategic information on STI and HIV

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Public Health Veterinary Services

1.To ensure protection for those exposed to suspected rabies infection.

2.To ensure protection for those who are at a higher risk of contacting
rabies.
3.To establish herd immunity in animal reservoirs with special emphasis
on dogs.
4.To control the population of animal reservoirs with special emphasis
on dogs through appropriate methods.
5.To remove all rabies suspected dogs humanely.
6.To reduce the transmission of Japanese Encephalitis in pig population.

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National Programme for Tuberculosis Control and Chest Diseases

• To ensure that every patient with tuberculosis or a respiratory disease

has access to effective diagnosis, treatment, cure and rehabilitation.
• To interrupt the transmission of tuberculosis.
• To prevent the emergence of drug resistance.
• To reduce the social and economic toll caused by tuberculosis and
other respiratory diseases.

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National Dengue Control Unit

• Intensify epidemiological surveillance to detect and notify dengue cases real-time.

• Intensify entomological surveillance to forecast vector density and to take
appropriate control measures.
• Apply appropriate integrated vector management (IVM) strategies to interrupt
dengue transmission.
• Improve early diagnosis and case management.
• Detect epidemics early and to respond to potential epidemics effectively.
• Strengthen monitoring and evaluation to ensure optimal programme
implementation, management and performances.
• Facilitate, link and conduct operational research in the prevention and
management of dengue infections.

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Other Public Health Units
• Family Health Bureau
• Health Promotion Bureau
• Directorate of Mental Health
• National Cancer Control Programme
• Environmental Health, Occupational Health and Food Safety Unit
• Non Communicable Diseases Unit
• Dental Services

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Maternal, Child Health and Family Planning
• Family Health Bureau -1968
Maternal care
Infant and childcare
Nutrition of Pregnant mothers and children
Care of school child
Adolescent Health
Family planning

RMNCAYH –Reproductive, Maternal, Newborn, Child, Adolescent and Youth Health

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Crumbling Public Health Infrastructure?

Not in SL!
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Non Communicable Diseases Unit

• Changes in life style in its population associated with improved economic

conditions in an open economy have contributed towards epidemiological
transition on demographic transition.
• Similar to global situation, the present burden due to non-communicable
diseases (NCD) in Sri Lanka outweighs the burden due to communicable
diseases and maternal and child health conditions.
• While contributing to a huge disease burden, chronic NCDs also have
serious socio- economic consequences.
• NCDs incur a huge cost to individuals, families and the societies due to the
need of a lifelong treatment, escalating health care cost and loss of
productivity.
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Advocacy
Health promotion and risk reduction
Capacity building/ Training
Strengthen health system
Multisectoral coordination
Surveillance, Monitoring and evaluation and research

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National Cancer Control Programme (1980)

• Responsible for policy, advocacy, monitoring and evaluation of

prevention and control of cancers
• Conducting surveillance of cancers
• Facilitating research related to cancer
• Coordinates with all cancer treatment centres, national level institutes
(Eg. Family Health Bureau) and provincial health ministries to
implement cancer control activities in Sri Lanka.

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Environmental Health, Occupational Health and Food Safety Unit

Food Safety Unit

• Director General of Health services is the chief food authority.
• Deputy Director General (Environmental health, occupational Health
and food safety) functions under the DGHS as the head of food
control.
• Director (EOH) functions under the DDG and handles all routine
activities in the Food control Administration Unit (FCAU)

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Environmental Health Unit
Functions of the Unit
• Develop strategic plans to achieve the strategic objectives of the programmes under environmental
health
• Advocate the policy makers and stakeholders at central & provincial level on the importance of
improving environmental health
• Intra and inter sectoral coordination on multidisciplinary issues related to environmental health
• Conduct operational research on environmental health issues
• Capacity building of health and non health officers on environmental health
• Provide technical expertise on environmental health in matters related to intra and inter sectoral
planning, implementation, monitoring and evaluating of various programs/ activities at different levels
• Monitoring and evaluation of programmes and activities under environmental health carried out by
the Ministry of Health, Nutrition and Indigenous Medicine
• Develop communication material pertaining to environmental health

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Occupational Health Unit
• Advocacy on issues related to occupational health and related environmental health issues
• Provision of guidance and technical expertise to the Ministry of Health, Ministry of Labour,
Ministry of Environment, Central Environmental Authority and other relevant ministries for
formulation/revision of policies, on occupational health and related environmental health
aspects
• Develop policies and strategies on occupational health
• Designing / Planning of National Occupational Health Programme of the Ministry of Health
• Liaise with intra sectoral and inter sectoral stakeholders in designing the occupational health
programme
• Provision of necessary direction, guidance, coordination and support to peripheral staff for
implementation of the National Occupational Health Programme of the Ministry of Health
• Develop guidelines, standards and protocols on occupational health

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• Capacity building of staff on occupational health, basic training, in service, graduate and post
graduate
• Networking and partnership building with stake holders and programme implementers
• Developing programme specific education and training material/IEC
• Provision of technical expertise to develop and revise curricula of basic and in service training of
relevant health staff on occupational health
• Implementing donor funded projects on occupational health
• Monitoring and Evaluation of Occupational Health Services at all levels
• Conducting and coordinating operational research related to occupational health
• Identification of best practices, pilot testing and integration into the occupational health programme
• Procurement and distribution of equipment necessary for the occupational health programme
• Convene national steering committee on occupational health (chaired by Secretary / DDG)

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Health Promotion Bureau

• Public awareness aiming for healthy behaviour changes in the community

through mass media
• HPB plays a vital role in public awareness about health promotion and
healthy behaviour changes by actively participating in mass scale health
exhibitions, national campaign days, and community events
• Various types of health education material have been produced to address
emerging health issues such as Dengue, Leptospirosis, malnutrition and
Non- Communicable diseases.
• Developing households and public places such as hospital, school, villages,
work place etc as health promotion settings is another successful program
conducted by the HPB.
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Dental Services

• Oral Health Unit of Family Health Bureau: plan, implement, monitor and coordinates
the National Program of Oral Health Care to pregnant mothers and School Dental
Services.
• Oral Health Unit of Health Education Bureau: plan, implement and coordinate oral
health communication strategies, production of oral health education material.
• Oral Health Unit of National Cancer Control Programme: Plan, implement, monitor and
evaluate the national oral cancer control programme
• Dental Therapist Training School Maharagama: Training Institution for School Dental
Therapists
• Research & surveillance Division- Institute of Oral Health Maharagama
• Training Division- IOH, Maharagama: Conducting in-service training programmes for all
categories of oral health care providers
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• School Dental Clinics: School Dental Therapists providing basic oral
health care and oral health promotion for children aged 3-13 years
• Adolescent Dental Clinics: Dental Surgeons providing oral health care
and oral health promotion for all age groups
• Community Dental Clinics: Dental Surgeons providing oral health care
and oral health promotion for all age groups
• MOH offices with Dental Surgeons: oral health promotion and
screening for oral diseases among special target groups such as
pregnant mothers, oral cancer prevention activities etc.

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Directorate of Mental Health
Major strategies of Mental Health Programme
• Promotion of mental well being
• Prevention of suicide
• Prevention and control of substance use including alcohol
• Prevention of violence
• Strengthen infrastructure and human resources for mental health
• Monitoring and evaluation of the Mental Health Programme

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 THANK YOU

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