Need to Ensure Retention of Doctors in Sri Lanka

Sri Lanka’s achievements in providing healthcare are remarkable for a country with a GDP per capita of USD 3900, of which only 3.2% is spent on health.  For example, the maternal mortality ratio is 33 per 100,000 live births, infant mortality ratio is 8.2 per 1000 live births and life expectancy at birth is high i.e. 72 years for males and 78 years for females. Initiatives that lead to these achievements were made several decades ago. Between 1931 and 1951, Sri Lanka expanded access to health services by using direct government provision and building a highly dispersed health facility network in rural areas. So effective was the expansion in coverage that by 1951 Sri Lanka was able to achieve quantitative levels of health service access comparable to many middle-income developing countries and substantially equalize use of modern medical treatment between rich and poor.

The health workforce (HWF) is recognized as central in attaining, sustaining, and accelerating progress on Universal Health Coverage (UHC). HRH development and management are unequivocally, aspects of health system development and governance, which are the responsibility of the state.

Therefore, retention of health workers is critical to ensure the delivery of quality health services. However, countries at all levels of socioeconomic development face, to varying degrees, difficulties in the education, deployment, retention, and performance of their workforce and Sri Lanka is not an exception. This blog will discuss the need for ensuring retention doctors in Sri Lanka and issues related to mal-distribution and migration of doctors.

Current situation regarding the total number and distribution of doctors in Sri Lanka

Once a doctor completes the mandatory internship of one year in a recognized government hospital, they have several career pathways; join the Ministry of Health as medical officers, the University system as academics, the Defense Forces as military doctors, the private sector or migrate to another country.

There are around 19,900 doctors including consultants, working full time in the Ministry of Health. Apart from this, 3050 are employed full time in the private sector, either in private hospitals or as General Practitioners (GPs). The defense establishment has about 320 and the University system about 625 doctors in their permanent cadre. Currently on average, out of 1450 that complete internship, around 1200 are employed by the Minister of Health, while around 220 seek employment in the private sector or migrate. The balance 30 makes a career either in the University or the defence forces.

Table 1: Total number of registered doctors in Sri Lanka

Number of doctors in the Ministry of Health	17,900
Number of consultants in the Ministry of Health	2,000
Number of medical doctors in the University system	625
Number of doctors in Defence Forces	320
Number of doctors in the private sector full-time (hospital based doctors and consultants, GPs)	3050
Percentage of Ministry of Health doctors engaged in Private Practice	60%
Percentage of Ministry of Health consultants engaged in Private Practice	90%

The geographical distribution of doctors throughout the country is far from uniform and will be described in more detail later on in this article.

Issues related to retention of the doctors

1. Mal-distribution of doctors within the country

Mal-distribution of doctors remains a serious concern in Sri Lanka. Although the absolute number of medical officers in Sri Lanka has increased, there is mal-distribution between the levels of care (i.e. an increase in medical officers in secondary and tertiary care institutions) that hinder access to primary care institutions closer to homes. This leads to people accessing higher levels of care for primary care needs resulting in unnecessary cost for the patient and burdening the service provision at secondary and tertiary levels of care due to overcrowding.

It is evident that the problem has not been corrected with the rapid increase of the number of doctors joining the health sector during recent years (nearly a three-fold increase of doctors in the last 25 years). Conservative estimates suggest that the doctor-population ratio in the Colombo district is over 2.5/1,000, which is higher than the ratio in Singapore. This is in comparison with Nuwara Eliya district, which recorded the lowest value of 0.37 doctors per 1,000 populations in 2015.

Table 2: Doctor-Population ratio in Selected districts

District	Number of doctors	Mid-year population *1000	Doctor: population ratio (per 1000 population)
Colombo	5344	2375	~2.250
Kandy	1377	734	~1.876
Galle	701	563	~1.245
Monaragala	210	472	~0.444
Nuwaraeliya	255	740	~0.344

Many factors such as low pay, lack of motivation, inadequate training, mentoring and supervision and high staff turnover make rural retention of doctors a challenge.

2. Migration of doctors

Migration of professionals, or “brain drain” is a well-recognized socio-economic burden prevailing in Sri Lanka. This is more common in the field of medicine, causing a negative impact on health care services. As per the available data up to 2009, nearly 10% of specialists have migrated. For non-specialist doctors, the migration rate is 15%. Being a middle-income country, spending less than 4% GDP on the health sector and for higher education, brain drain results in a significant impact on the economy.

The following scenario explains how migration of doctors will become even more serious issue in the future. 

The average number of new registrations with the SLMC has been around 1,500/year during the last five years. This number is expected to increase further due to the large number of students who are studying medicine in foreign universities (estimated to be around 6,000).  Approximately70 percent of these new registrants can be expected to join the Ministry of Health, according to the trend in the past 10 years. If the Government is to maintain absorbing 70 percent of the medical graduate output, the medical officer cadre in the Health Ministry will have to increase by about 1,300 each year. This would also mean that budgetary allocations for the salaries of doctors and other cadres, service improvements and infrastructure development need to increase annually. Given the current state of the economy and low budget allocations stagnating around 4 percent over the past years, this rapid expansion in the number of doctors does not appear sustainable.

Similarly the private sector capacity for employment has to increase by at least 20 percent each year based on the current estimate of 2,500 doctors working in the private sector. However, when considering the trend of government salary revisions as well as the expansion of capacity and revenue in the private sector during the last 5 years, this may not be a likely scenario.

Even if the private health sector grows significantly, if there is no guarantee of state sector employment, the proportion of medical graduates seeking employment overseas is bound to rise above the current level of 15 percent. Doctors are more likely to start migrating to more lucrative countries that offer better remuneration when compared to the private sector in Sri Lanka. The classic example would be that of India, a country with a doctor-population ratio below Sri Lanka but now the world’s largest exporter of doctors.

The argument that migrant doctors would bring foreign exchange to Sri Lanka is not necessarily true. As was seen through the 1970s exodus of graduates, except for some indirect family support and occasional small-scale investments, many would utilize their earnings in the country they reside in.

The reasons for migrating

A survey conducted in 2013 among first year, fourth year and pre-intern students of the Faculty of Medicine, University of Colombo, revealed that a significant proportion of the sample (23.8%) intended to migrate and 32.4% were contemplating the option of migrating. Better quality of life, better pay, better medical services and better political stability in the destination countries were the reasons for their decision. The majority who had decided to migrate was aiming for Australia, UK and US. However, among the students who wished to migrate, only 20.2% wanted to settle abroad permanently. Interestingly, the majority of them wished to spend less than 10 years abroad and return to the country.

Analysis of the socio-demographic profiles of the students who wished to migrate showed no difference when compared to students who had no desire to do so. The study revealed that the decision to migrate may be a highly individualized one, fuelled by unique and heterogeneous contributory factors. In the present era, global connectivity and better communication with peers significantly influences the decision to migrate or remain in the country. 

Possible approaches to ensure retention

It is crucial for Sri Lanka to develop strategies to minimize the migration of health professionals. Though restrictions to leave the country and bonds between state and professionals can contribute to stem the exodus, the quality of service provided by them in a state of dissatisfaction cannot be assured. Hence it is of prime importance to identify factors that make professionals want to migrate and rectify them so that root cause of the issue is eliminated. Retention of doctors can only be ensured by addressing the root causes for migration. In ensuring better retention of health workers, the best results can be achieved by choosing and implementing a range of interventions on education, regulation, financial incentives, and personal and professional support.

References

·      De Silva, D. (2017) How many doctors should we train for Sri Lanka? System dynamics modeling for training needs. Ceylon Medical Journal, 624, pp.233-237

·      De Silva, A. P., Liyanage, I. K., De Silva, S. T., Jayawardana, M. B., Liyanage, C. K., & Karunathilake, I. M. (2013). Migration of Sri Lankan medical specialists. Human resources for health, 11, 21.

·      Jayarathne, Y.G.S.W., Karunathilake, I.M. & Marambe, K.N. (2016) Development of Continuing Professional Development (CPD) Provision Framework for Sri Lankan Grade Medical Officers, South East Asian Journal of Medical Education, 10, 1, pp. 27

·      Karunathilake, I.M. (2012) Health Changes in Sri Lanka: benefits of public health and primary health care, Asia Pacific Journal of Public Health, 24,4, pp.663-671

·      Ministry of Finance, Department of Management Services (2017) General information, pp. 19

·      Ministry of Health, Nutrition & Indigenous Medicine (2018) Sri Lanka National Health Accounts 2014, 2015, 2016, The Ministry of Health, Sri Lanka, Colombo

·      Ministry of Health, Nutrition and Indigenous Medicine (2018) Annual health statistics-2016, Medical Statistics Unit

·      Ministry of Health, Nutrition and Indigenous Medicine, Human Resource profile (2016) pp. 6-7 Available at: http://www.health.gov.lk/moh_final/english/public/elfinder/files/publications/HRMprofile2016.pdf

·      Rannan-Eliya, R.P. (2006) Sri Lanka’s Health System–Achievements and Challenges, Institute for Health Policy September, p.1

·      Socha, K.Z., & Bech, M. (2011) Physician dual practice: a review of literature, Health policy, 102, 1, pp. 1-7

·      Uragoda, C.G. (1987) A history of medicine in Sri Lanka, Sri Lanka Medical Association

·      World Health Organization (2018) Guidelines: incentives for health professionals, Available at: https://www.who.int/workforcealliance/knowledge/publications/alliance/Incentives_Guidelines%20ENG%20low.pdf?ua=1

·      World Health Organization (2018) Health Labour Market Analysis: Sri Lanka, Available at : https://www.who.int/hrh/news/2018/18168_SriLankaLabourMarketflyer.pdf?ua=1

·      World Health Organization (2018) The global code of practice, Available at: https://www.who.int/hrh/migration/code/practice/en/