SRI LANKA: Technical Advice - WHO
SRI LANKA:technical adviceProvision of Technical Advice to Sri LankaA country visit was undertaken for the purpose of a mental health needs assessment inNortheast Sri Lanka. Consequently, a comprehensive five-year mental health planwas developed in close collaboration with local mental health expertise.Country VisitParticipants in the one-week mission were:Ministry of Health (including the Director of Mental Health Services)Ministry of Rehabilitation, Resettlement, and RefugeesWHO Sri LankaWHO GenevaWe gratefully acknowledge Dr M. Ganesan (Ministry of Health, Batticaloa) andDr Daya Somasundaram (District Hospital Tellipallai, Jaffna) for their excellentinput and constructive feedback during the development of this plan.27
Background to technicaladviceThe WHO Department of MentalHealth and Substance Abuse visitedSri Lanka at the request of ProfessorJayalath Jayawardena, MP, Minister ofRehabilitation,Resettlement&Refugees. Dr Jayawardena had priordiscussions concerning the visit withthe Department of Mental Health andSubstance Abuse in Geneva in 2002and 2003. The Minister’s specificrequest was to conduct a mental healthneeds assessment in NortheastSri Lanka.In June 2003 a needs assessmentmission in Northeast Sri Lanka wasundertaken(Jaffna,Batticaloa,Killinochi, Vavunia). The missioninvolved technical staff from WHOGeneva, WHO Sri Lanka, the Ministryof Rehabilitation, Resettlement andRefugees, and the Ministry of Health.The state of mental healthA 1994 community survey of theeffects of war in the North found 25%depression, 27% anxiety disorder and14% post-traumatic stress disorder.These rates were higher in a study ofoutpatient attendees at a generalhospital in Jaffna. Schizophrenia hasbeen, is, and will continue to be themajor mental health problem for themental health services, because it iscommon (affecting up to an estimated1% of the population), highlydisabling, striking at a young,productive age and running a chroniccourse. There is some evidence thatschizophrenia may have a relativelyhighincidenceamongTamils4(Somasundaram et al., 1993) . Aroundthe world, the prevalence ofschizophrenia is between 0.5% and1%.The suicide rate in Sri Lanka ranksamong the ten highest in the world,and the most recent official figures of1991 put it at 31 per 100,000. Therates for men however are more thandouble that of women (44.6 comparedto 16.8). Both the actual suicide ratesas well as those for attempted suicidein Northeast Sri Lanka may beparticularly high, especially amongdisplaced persons as in Vavuniya,where an epidemic rate of 103/100,000was observed5.Mental health servicesIn the Northeast as in other parts of SriLanka, many administrators and healthstaff consider mental health to be aseparate and unimportant area.However, the WHO Global Burden ofDisease 2000 study suggests thatmental and neurological disordersaccount for more than 12% of loss ofdisability-adjusted life years across theglobe.Several meetings with top-level policymakers to highlight the urgent need toestablish mental health in the Northeasthave taken place involving theMinistry of Health.Inpatient accommodation4Somasundaram DJ, Yoganathan S, Ganesvaran T.Schizophrenia in northern Sri Lanka. CeylonMedical Journal 1993 Sep;38(3):131-5.285Lancet, 2002 Apr 27;359:1517-1518.
Although the Ministry of Health isknown to have given mental health toppriority in the Northeast, concrete stepsstill have to be taken to implementthese priorities. The circumstances inthe Northeast (i.e. a post-conflict area)would need to be recognized to make aspecial case temporarily.Because of 20 years of violence,service development for persons withsevere mental disorders has beenseverely impaired or destroyed,resulting in the under-provision andfragmentation of mental healthservices.War-torn hospitalIn June 2003, there were only twoTamil psychiatrists who, with limitedresources, were providing communitymental health care in and near thedistricts of the two largest cities in theNortheast (Batticaloa and Jaffna). Inaddition, a variety of NGOs runprogrammes targeted at trauma-relatedmental and social problems in a varietyof locations. Different mental healthstakeholders in the Northeast advocatefor different mental health activities.In the absence of a comprehensivemental health plan, new activitiesappear to develop in an uncoordinatedfashion, with the implementation oflower order activities before higherorder needs are met.In seven of the nine districts there is noacute inpatient care. There is somefollow-up care (through outreachclinics) for patients with severe mentaldisorder in some divisions, but not indivisions far away from both Jaffnaand Batticaloa. Although there havebeen some efforts to train family healthworkers (i.e. primary care staff), themajority of primary care staff are stillnot sufficiently competent to reliablyidentify mental problems, managecommon mental disorders, referpatients when necessary, and providefollow-up mental health care for thosewith severe problems.The lack of services in parts of theprovinceiscoupledwithaconcentration of staff (and beds) in afew cities and a lack of staff in morerural districts. In these districts, thegovernment has created limited postsand only small numbers of health staffare expected to seek work. Althoughgood acute inpatient care exists in twodistricts, the Northeast does not haveany appropriate inpatient facilities ofintermediate duration (up to sixmonths) to provide psychosocialrehabilitation for those who do notrecover sufficiently during acuteinpatient care.Mental health unitWithout such facilities, chronicpatients with schizophrenia do notreceive the care they require. They areat risk of neglect or becoming longterm residents in the Colombo-basedcustodial psychiatric hospitals, where29
treatment is inadequate and patientstend to deteriorate in the absence ofpsychosocial rehabilitation or familysocial support.Mental health workshopRecommendationsRehabilitation unit-gardeningOverall, the mental health problemsthat need to be addressed by servicesinclude both (a) mental healthproblems found in normal times, and(b) common mental disorders and othermental health problems due to theadverse effects of conflict. The burdenof these problems is both on the mentalhealth system and on the general healthsystem, where most people tend toseek help for mental health problems(typically presented in the form ofsomatic complaints).In the aftermath of the conflict, anincreasing number of patients whosuffer from disabling mental healthproblems need and seek treatment. Therehabilitation,developmentandreconstruction of the Northeast needsto include a social and mental healthcomponent in an integrated approachto improve the mental health of apeople affected by war.Hospital visit30In recognition of the fact that theservices and people in NortheastSri Lanka are seriously affected by theconflict, the following recommendations were put forward: Giving priority to the developmentof normal community-based mentalhealth services in NortheastSri Lanka. The normal mentalhealth system can and shouldaddress both severe mental illnessand common mental disorders andproblems, including trauma-relatedmental problems.Increasing efforts to draw relevantmental health professionals to theNortheast, and to identify creativesolutions to ensure that trainedinformal mental health humanresources will not be lost.Ensuring that there are functioningacute inpatient psychiatry units ingeneral hospitals in each district.This activity includes (a) eitherbuilding or repairing/refurbishingunits in seven districts and (b)hiring ward nurses and auxiliarystaff where needed. (This activityalso includes a telephone hotline ateach unit).
Organizing monthly follow-upoutpatient clinics of severementally ill persons in eachdivision of the Northeast.Organizing care in the communityfor those with common mentaldisorders and problems (incl.trauma-related problems), andheavy alcohol and drug use. Thisactivity involves training andsupervision by two groups ofpsychosocialtrainers.Thecommunity resources to be trainedinclude: primary health care-staff,teachers, village leaders, andtraditional healers.A detailed five-year mental health planhas been written with a budget toestimate the amount of externalresources required to implementpriority activities. It is envisioned thatfurther fund raising for this plan willcontinue to be based on a rank order ofpriorities, which are therein defined.WHO/Headquarters in collaborationwith the WHO regional and countryoffices continues to commit itself tosearch for resources to implement theplan.31
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Sri LankaProject goalTo encourage a process of deinstitutionalization of psychiatric patients and promotereintegration in the community.Project objectives To reduce the number of admissions and re-admissions to the Angoda/Mulleriyawa/Hendala Hospital complex. To establish a supportive infrastructure, including follow-up care, based on the existingprimary health care infrastructure and with the involvement of NGOs active in the field ofmental health and well-being.Implementing institutions Ministry of Health, Colombo Angoda (Teaching) Mental Hospital, Colombo, Western Province Nivahana Society of Kandy (NGO), Central Province33
BackgroundSri Lanka is an island nation with apopulation of 18.5 million. Thepopulation is made up of mostlySinhalese (74%), Sri Lankan Tamils,(12.6%) Indian Tamils (5.5%) andMuslims (7%), as well as otherminorities such as Moors, Malays andBurghers. The country is divided intoeight provinces. Each province has anelected Provincial Council. There arearound 300 Local Councils across theisland. For the last 20 years, there hasbeen political unrest and an ongoingcivil war in the north and east of theisland between Tamil separatists andthe Government. Therefore, there hasbeen substantial migration of Tamilsfrom the north and northeast to thesouth as well as from Sri Lanka itself.Health ServicesThe Central Ministry of Health isresponsible for funding public healthservicesthroughprovincialdepartments of health and divisionalhealth services. Preventive healthservices are provided through primarycare facilities, by public healthmidwives and nurses, and public healthinspectors. The Central Ministry ofHealth remains responsible for humanresourcedevelopment,personnelposting and discipline, bulk purchasingof drugs and allocation of capitalexpenditure.Each province has a department ofhealth led by a Provincial Director ofHealth Services who reports to theProvincial Minister of Health and theCentral Ministry.The ProvincialDirector is responsible for hospitals aswell as primary and secondary healthcare facilities. The provincial Ministryof Health is responsible for policy-34making,planning,monitoring,coordination of provincial healthactivities, procurement of supplies andmanagerial and technical supervisionof divisional health teams.Eachprovinceconsistsofapproximately three districts and 30divisions. Each district has a DeputyDirector of Health Services. At thedivisional level, a group of DivisionalDirectors of Health Services (DDHS)has been created. These Directorshave been appointed by the CentralMinistry of Health.They areresponsible for coordinating allcurative and preventive healthactivities as well as for themanagement of facilities, includingdistrict hospitals. This has furtherhelped to devolve power to divisionallevels.The state of mental healthBetween 5% and 10% per cent ofpeople in Sri Lanka are known tosuffer from mental disorders thatrequire clinical intervention. Nearly70% of patients seen in clinicalpractice are diagnosed with psychosisor mood disorders. Among the mostcommon conditions seen in clinicalpractice are psychosis, mood rders,substanceabuse, stress disorders, and adjustmentdisorders. Psychiatric practice tends tobe based on the biomedical approachand relies mainly on the use of drugsandelectro-convulsivetherapy.Patients who need or seek othertreatments are referred to non-medicalmental health professionals (Papergiven at WHO Expert CommitteeMeeting, SEARO, 2000).An estimated 70,000 Sri Lankanssuffer from schizophrenia. This figure
is expected to rise with the increase inthe number of young adults. It isestimated that 5-10% of the populationover 65 years of age suffers fromdementia. The most recent figuresshow that the suicide rate in Sri Lankais 44.6 for men and 16.8 for women.However these figures date back to1991 (please see WHO website figuresat:http://www.who.int/mental l health/prevention/suicide/suiciderates/en/Mental health servicesAt the time of writing there are anestimated 38 psychiatrists for thewhole country (not all of whom arewith the Ministry of Health). Thereare also 17 occupational therapistsmedical assistants and others, 410psychiatric nurses, and 9 socialworkers attached to the inpatient units(ATLAS project, Department ofMentalHealthandSubstanceDependence, 2001, WHO).who have been transferred fromAngoda. In addition, a few provincial“Base” (general) hospitals provideoutpatient services.The Central,Northern and Southern Provinces havepsychiatric units or “Teaching Units”with beds in general hospital settingsas well as effective outpatient services.The three psychiatric hospitals as wellas the Teaching Units are under thecontrol of the Central Ministry ofHealth in Colombo.General hospital units are onlypermitted by law to admit voluntary(informal) patients. However, there issome question about whether this doesin fact happen in all cases. To admitpatients to Angoda and Mulleriyawarequires an order from a Magistrate. Ifthis is by-passed, and patients areadmitted involuntarily, they have nolegally enforceable rights.In Colombo and its environs, there arethree large mental health hospitals.Community mental health team membersin Angoda hospitalPsychiatric hospital, Western provinceThese include, Angoda, which takesnew admissions from any part of thecountry; Mulleriyawa, which isprimarily for long-stay female patients;and the mental health hospital atHendala, for long-stay male patientsOutpatient clinics are run in most Basehospitals when psychiatrists areavailable.In order to strengthenmental health services around thecountry a total of District MedicalOfficers have been trained andassigned to Base hospitals across thecountry to run psychiatric clinics.However, not all of these MedicalOfficers have remained in their posts.There are also plans afoot by theMinistry of Health to relocate patientsrequiringlong-termcaretocommunity-based facilities.35
Ayurvedic servicesDoctors are being trained to provide careat Base hospitalsThe private sectorThere are several private practices inthe capital run by psychiatrists who areemployed by the statutory services butwork part-time in private hospitals.District Medical Officers at Basehospitals also sometimes see privatepatients.Numerousgeneralpractitioners see patients privatelysince general practice is not part of theGovernment’s free health service. Afew consultant psychiatrists arebelieved to run large practices inColombo.Counselling services for people -relatedhealthproblems and psychosocial problemsare provided by non-medical mentalhealth professionals in the nongovernmental sector.Some nonmedical mental health professionalsalso provide psychological servicesthat are based on cognitive behaviourtherapy and other psychologicalmodels.Rehabilitation services in hospital36Throughout South Asia, religioushealing and forms of indigenousmedicine such as Ayurveda havetraditionally dealt with mental healthproblems.There is a largeGovernment Ayurvedic hospital withan Ayurvedic college and researchcentre that trains physicians. Howeverlittle is known about their work amongmentalhealthprofessionals.Administratively, Ayurvedic medicinedoes not come under the Ministry ofHealth, but under the Ministry ofIndigenous Medicine. There is also aBuddhist temple some 20 miles fromColombo that has been usingAyurvedic treatment for unmada(equivalent to mental illness) for manyyears.Non-governmental organizationsThere are at least five NGOs workingin the field of mental health. Theoldest started in 1987 as a befriendingscheme for patients in one of the threemental hospitals (Mulleriyawa). Threeof these organizations now runrehabilitation programmes for peoplewith mental health problems. One is acommunity-based programme and theother two take the form of residentialprogrammes where services areprovided for the long-term mentally ill.Generally speaking, the current rangeof mental health services, servicedelivery models, facilities, personnel,funding organization of services andpriority-setting processes are totallyinadequate to meet the present andemerging mental health needs of thecommunity. Services are not evenlydistributed and there are problems withaccess, particularly to communitybased care. Most of the available
services are concentrated in Colomboand other urban areas, leaving the restof the country largely devoid ofservices. Hopefully, the situation willimprove as medical health officers aretrained to work in the Base hospitals.As the project becomes moreestablished, there will be a network ofprimary care services in some areas;however, much needs to be doneacross the country as a whole.individuals, with a shared interest inmental health issues, came together toadvocate for improved mental healthservices within the Province. Thedirector of this NGO is also aconsultant psychiatrist at the teachinghospital in the Province. He has beenable to engage the Central ProvincialMinistry of Health and the Departmentof Psychiatry of the University ofPeradeniya in pursuing the aims of thisproject.Project descriptionCentral ProvinceThe aims of the project were the samein both the Gampaha district of theWestern Province and in the CentralProvince. The main objectives of theproject were to reduce the number ofadmissions and re-admissions topsychiatric hospitals in Colombo, andto establish an infrastructure ofsupport, including follow-up care,based on the existing primary healthcare infrastructure.However, theapproach has differed somewhat in thetwo project areas. This has largelybeen because of the differing mentalhealth services available (or lacking) inthe two areas, as well as theavailability of human resources ineach.State psychiatric services in the CentralProvince are provided by general andspecialist psychiatric clinics in the twomain teaching hospitals in Kandy andPeradeniya, as well as by a 20-bedmedium-stay unit in one of thedistricts. During the period of theproject, there were no other formallyrecognized state-funded psychiatricservices.Work in the Western Province hasbeen carried out by a team of socialworkers attached to one of the mainmental hospitals in the capital(Angoda). This has been done incollaboration with one of the fewpsychiatrists to conduct clinics in thecommunity.In the Central Province, work has beencarried out by an NGO active in thefield of mental health and well-being(Nivahana Society of Kandy (NSK)),based in the capital town of the CentralProvince. This NGO was establishedin 1985 when a group of concernedThe main thrust of the project in theCentral province was to supplementcurrent mental health services byproviding care in the community tothose patients recognized as sufferingfrom mental health problems as well asto their families. The idea was that thiswould eventually be incorporated intomainstream services. The philosophyof the project was to work withpatients to maximize their ability tolive independently and to facilitate andpromote the development of costeffective, accessible, and qualitymental health services. This was beingimplemented through the variousactivities described below.Raising awareness among policymakers and planners about the needfor more sensitive community menta
WHO Sri Lanka WHO Geneva We gratefully acknowledge Dr M. Ganesan (Ministry of Health, Batticaloa) and Dr Daya Somasundaram (District Hospital Tellipallai, Jaffna) for their excellent input and cons
Coastal Areas in Western Province, Sri lanka," Journal of Environmental Professionals Sri Lanka, vol. 3, 2014. [15] "Clean Air in Sri Lanka: Summary of progress on improving air qulity," Country Network Sri Lanka, 2008. [16] D. S. R. O. S. Lanka, national environmental act, No. 47 of 1980, Department of government printing, Sri Lanka, 2009.
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source of imports to Sri Lanka) while Sri Lanka's exports to India stood at 5.8% of overall exports of Sri Lanka (3rd largest destination of Sri Lankan exports) with total trade between the two countries amounting to US 4.2 billion. The ISFTA has made a substantial contribution in
Sri Lanka: Ethnic Fratricide and the Dismantling of Democracy (University of Chicago Press 1991) 93-102. 7. Michael Roberts, ‘Ethnic Conflict in Sri Lanka and Sinhalese Perspectives: Barriers to Accommodation’ (1978) 12 (3) Modern Asian Studies 353. 8. Roshan de Silva Wijeyeratne, Nation, Constitutionalism and Buddhism in Sri Lanka
ber 2007; N 134, Sri Lanka’s Muslims: Ca ught in the Crossfire, 29 May 2007. For analysis of the nearly three-decade civil war and insurgency of the Liberation Tigers of Tamil Eelam (LTTE), see Crisis Group Asia Reports N 125, Sri Lanka: The Failure of the Peace Process, 28 November 2006, and N 191, War Crimes in Sri Lanka, 17 May 2010.
II. OVERVIEW OF SRI LANKA DEVELOPMENT CONTEXT 6 2.1 Summary 7 2.2 Sri Lanka’s performance in achieving the MDGs 8 2.3 Sri Lanka – Overview of the post-conflict political situation since 2009 10 2.4 Sri Lanka’s economic growth 13 2.4.1 Poverty and exclusion 13 2.4.2 Unemployment 14 2.
a) Interest accruing to or derived by any person outside Sri Lanka, on any loan granted to any person in Sri Lanka or to the government of Sri Lanka 1 April 2018 b) Interest income earned by any person on foreign currency accounts opened in any commercial or specialised bank in Sri Lanka, with the a
