69239 - October 2010 THEWOfI1.D BANI( Population aging is well underway The Population IIInll (delTlOll'lphlc Il'1n51110n) 15 now we" under WlY with life expectancy at 7" years and the proportion of people 60 yelrs Ind older Is expected to double from 12.1" In 2010 to 24.4" In 2040. Pruportion cd peo" In older I > 10 years) qe lI'Oups, Sri Lanka ZOOl-HOO IIOf. . 70-79 . 6G-69 g t • f• 50."", 00 SU.., WL "'no :IIIIl'. A """,loll.. I'ra,KIIon aI SrI L.onto 2DD1-41111! lnIndI • ..t ~_. L......... tbr _"" ,1'''it- DI.beIIo ..... lIft •• Sou,.., ...... Ivo~ 1Jr._ . . . -.-oa, dltl ,..""tilt r. G..... ~orM:"'" ZOOO.,d 2003, UN e5CA1'lam tIOponmom afa... .... ond_1UI1I • The NCO burden IncrBils15 the need for lone-term Cilre. This Cill! Is especially needed for the elderly iIS they suffer more from NCDs. Similarly. NCDs also ilflil!ct labor-form participation especially by older world...... adub. BoththMo! ~ru haw H .llIniflCllnt Impgct, th@ fonner throLljlh hliher a!Sb of health alII! and the latter throUJh productivity losses. NCD burden is shifting to the poor " 6 '-- - -""" - ...... - • In developed countries, NCDs dlsproportlo~el'f affect the poor. CUrTent evidence sugsesU thlt In Sri Lana the rich suffer more from some NCD$ than the poor, but this pattem Is chanllnl and shifillll towIrds the poor• • In Sri Lenke, heart disease dmhs have tended to be hllheramonlthe rich while asthma deaths Ire hllhest amonl the poorer populltlon fP'Oups. These hllh asthma death rates may, In part. be due to poor access to treatment. • • • ..... • Mo" • ""..... • All • "_,:KIll, _far _I> Soon. o.tI pravTdod ........ t,-ITI byO' ....... II. ",!ky. _Itt'_far5~ 1.0 .... r..... t<~ ........ &00 ........... .".""'J • :a. . 70 50 ~ , 40 ~ 30 i. - § ~ Q Q Q 20 10 0 Sri Lanka OECD OECO DECO Lowest-Spain Median Iceland Highest Germany Source. OECD countries fer 2006 from OECD Health Data 2008, and Sri Lanka fer 2008 computed from data provided by MOH ilnd IM5-Health (Sri Lanka). • low availability of essential NCO medications is a problem at all levels but most severe at lower levels. The short supply of key medication and its impact is confirmed by the overall rates of essential NCO medicine use in Sri lanka being at the lower end of the range among countries with comparable NCO burden patterns. One explanation for this is the low volume of essential NCO medicines available in the public sector. An example can be seen in the graph below, comparing Sri lanka's consumption of Beta blockers (drugs used in heart disease) with that of other developed countries (instead of OECD). Health spending in Sri Lanka is low • Total health expenditures increased from 3.5% of GOP in 1995 to 4.0% in 2008, of which the share of public spending declined from 47% to 43%. These overall expenditures are less than expected for the country's level of national income. NeD care is increasingly financed by out-oj-pocket spending • The expenditures for treatment of cancers and acute heart attacks in 2005 were predominantly publicly financed (92 percent and 57 percent from public sources, respectively) while those for diabetes, asthma, and heart disease were predominantly privately financed (19 percent, 13 percent, and 26 percent from public sources, respectively). Private expenditures are mainly out of pocket. • For cardiovascular disease, diabetes, and asthma, about half the out-of- pocket expenditures are for outpatient care and drugs. Expenditures on major NCDs, by public and private sources (%), Sri lanka ZOOS M.. lisn.. ntneoPI .. smS :::::::::: t :::::::::.... Othe r Ischemic Heart Dise..se 1::::::::::::: .~ Ac ute Myoc .. rdi ..1 Infarction Di.. betes Me llit us t::::::::::: 11.1 SIS 81.2 43.1 ~- Asthma Em 86.6 20" ' 00% • Public • Private Source' Computed from estimates of Institute for Health Policy Sri Lanka Dlse..se-speclfic Accounts Project (2005) NeD interventions are cost effective • There all! cost-effl!ctIVl! populil'llon-II!III!I and dlnlc-ll!Wllnterventlons to Pl'I!IIIi!nt and treat NCDs. Populatlon-Iewllnterventions ml&ht 1M! aimed at changing dlmry belwvlors. _.... --- - = SeIKlftl popul..lorHI.sed Intel'Vl!ntions ~- - _..-:tan -. .M. ""- 14l1i11l11on Lq:IsloIIDn repladl'll:z,.; Dt'dletorytran. fat from pll'liollYfdR>pnatlon In mlnulal:Wnod fd1 with pDlyunMtuI'ltKl fit. It I CDr! of USSo..so PO' .dult. .nd .ssumhl;. 7% noduc:dDn In ... ronlry Il'Iurt =- .......nd ThO= Lqlllollon loIIsiotad ",ductlon In .. ~ ~ of m.rr.rfac:tured fDcxIs .nd.n .a:DI'IIpanylllI publll: eduOlllDn OImpalin A m poi.. i n _ 4u.1O iObIo:>:D_1O .'- ."' Iddlctlon dIocDu,. tobKtD UO!, prewni tlltIlIIDn - .- Itvl), chronic -'''''' TldliDn (and .u-..errtaddk:tlDnl • ....,.,.,.,Ulh., 1""..... iNIIDlI_ ", .................. Qlmlnt " ' ' ' , ,. .h..., I8ilpoo ......... !Dnnll' ........nd ",duO! CDrI!Iumptlon • ....,.,. "'.- ..doduill U ... rrtlnllrll ..... 5<>ura: ~I .. _ .. a- ... 5hohld-50I. . :HOi. Clrnlc-based actions focusing on Individuals could Include the control of diabetes, cholesterol, high blOO1 (from both p.lbNc and prlvat8 ,ou"""l. mitfptethe potentilly Impcwerbhlnl ctt.cb of out-of-podI8t heilith expenditures. KlllbUsh meeh.nISln. for hllher oontrlbutlons to health services from rldler populMlon aroups. Inc~ e1fIdencles In the public sector, nd I1Ilse public flnlnelna of NCO drull bll)Iet8d to thl! pOOl1!r R!lIDents of till! populi1:Ion. Human ResDurces Enpee thlpriwt.~or In both/l~~ provisionof NCJ)gre. This could tI"- till fonn of QlntrKtIfII, fnndllMa. ~ sharInJ ~, elL lhI fIRt slip oaould ~toQlndud:. PrIwb! HRith sector Assessment, since It I1!rrulns poorty ..... derstood and Its outpvts lnIIftiy unc:I'Iafild:erlled, yet It IIlIII::I!!!i I substantlll QlntrlbU'llon to Hrlice provision for NCDs. Acknowledgments This report was prepared by the corE! team of Michael Engelgau (task team leader), Kyoko Okamoto, Kuman Vlnodhani Navaratne, and Sundararajan Gopalan. Several others made major contributions through source documents used in formulating the report. Source documents for Chapters 2--6 was written by Rav! P. Rannan-Etiya. Chamara Anuranga, lara Brearley, Ruwanthi Elwalagedara, A.P.T.l. Abeykoon, Ahalya Balasundaram, and Shantl Dalpatadu (Institute for Health Policy, Sri lanka) and for Chapter 3 by Shant1 Dalpatadu, Ruwanthi Elwalagedara, and Achana Ohris (also of the Institute for Health Policy, Sri lanka). Contributions to the executive summary were made by Naoke Ohno and to Chapter 7 by Tekabe Belay, both of the World Bank. Very helpful comments on various drafts were given by Tania Omytraczenko, Kees Kostermans, Charu Garg. Tekabe Belay, Nkosinathi Mbuya. and Angela DeSilva. all of the World Bank. During three workshops with the GovernmentofSri lanka and the Ministryof Health (MOH) very useful comments were provided and we want thank the following for their contributions: Or. Terrence De SUva (DOG Medical Services), Dr. R.R.M.LR. Siyabalagoda (DOG PHS 11). Dr. P. Maheepala (DOG PHS 1), Or. l. Pannapitiya (Director NCO), Dr. Susie Perera (Director Policy Analysis), Dr. A. Oissanayake (Director YEDD), Dr. N. Kanakan (Consultant Community Physician, Epidemiology Unit), Dr. Palitha Karunapema (CCP, NCO Unit). Dr. Vindya Kumarapeli (CCP, NCO Unit)' and Dr. Amala De Silva (Health Economist, University of Colombo). We also want to acknowledge the help of MOH staff Ms. Susantha Ranadheera (Head, Vital Statistics Unit, Registrar General's Department), Mr. Migara Fernando, Consultant, VS Unit, RG Department, Ms. Indu Bandara, Medical Statistics Unit, MOH, Mrs. Krlshnathl Jayawardena, Medical Statistics Unit, MOH, and Mr. E.M.M.K. Ekanayake, Medical Statistics Unit, MOH for their support and assistance during data collection. We also want to acknowledge all support for this work from the former Secretary, MOH, Dr. H.A.P. Kahandhaliyanage. The core team is very grateful to the peer reviewers for the report, who included Peter Berman, Montserrat Metro-lorenzo, and Akiko Maeda from the World Bank, Shanthi Mendis from the World Health Organization, Geneva. and SaraJ Jayaslnghe from the University of Colombo. Finally we want to acknowledge the operational support provided by Silvia Albert, Elfreda Vincent, Gertrude Cooper, Alejandro Weich, and Kerima Thllakasena, ali of the World Bank, and the assistance in editing the report provided by Jonathan Aspin (consultant).