ChapterPDF Available

Abstract

Sri Lanka has been a model country for many decades in terms of quality of population health outcomes in a low- or middle-income country, with relatively small but smart investment in population health. It has, however, experienced 30 years of civil conflict, ending in a brutal civil war in 2009. The island’s coastal regions were devastated, with massive loss of life and population displacement, by the Indian Ocean tsunami in 2004. The conflict and the tsunami brought to the fore the importance of renewed attention to the mental health of the Sri Lanka population, particularly among the most affected communities. While indigenous conceptions of mental health and illness, and strong Ayurvedic and other traditional forms of health practice, continue to be important across the Sri Lankan population, Western forms of psychiatry and systems of care have become dominant over a long period, particularly during the British colonial era. Human resources and physical infrastructure for mental health treatment and care have been very limited. Although general hospital, inpatient psychiatric units in several parts of the country were established much earlier in Sri Lanka than in many other countries, until recent times three national psychiatric institutions, all near Colombo, were the main locus of care and the main resource for psychiatric treatment. Conditions in these institutions were very poor. The impact of the tsunami, and the influx of aid and technical expertise, created an opportunity for major reform of the mental health system, with an orientation to community-based treatment and care, major improvements in Angoda Psychiatric Hospital, and establishment of small inpatient units in most district general hospitals across the country. Major innovations in dealing with the shortage of mental health human resources have been a particular feature of the mental health system development in Sri Lanka in the past decade. A focus on suicide prevention has yielded very positive results. These and other aspects of the process of reform of the Sri Lankan mental health system have generated international interest. This chapter provides a brief account of a very effective process of mental health system reform in a middle-income country.
Chapter 4
Mental Health System Development in
Sri Lanka
Harry Minas, Jayan Mendis and Teresa Hall 1
Abstract Sri Lanka has been a model country for many decades in terms of quality of population health
outcomes in a lowor middle-income country, with relatively small but smart investment in population
health. It has, however, experienced 30 years of civil conflict, ending in a brutal civil war in 2009. The
island’s coastal regions were devastated, with massive loss of life and population displacement, by the
Indian Ocean tsunami in 2004. The conflict and the tsunami brought to the fore the importance of
renewed attention to the mental health of the Sri Lanka population, particularly among the most affected
communities. While indigenous conceptions of mental health and illness, and strong Ayurvedic and other
traditional forms of health practice, continue to be important across the Sri Lankan population, Western
forms of psychiatry and systems of care have become dominant over a long period, particularly during the
British colonial era. Human resources and physical infrastructure for mental health treatment and care
have been very limited. Although general hospital, inpatient psychiatric units in several parts of the
country were established much earlier in Sri Lanka than in many other countries, until recent times three
national psychiatric institutions, all near Colombo, were the main locus of care and the main resource for
psychiatric treatment. Conditions in these institutions were very poor. The impact of the tsunami, and the
influx of aid and technical expertise, created an opportunity for major reform of the mental health system,
with an orientation to community-based treatment and care, major improvements in Angoda Psychiatric
Hospital, and establishment of small inpatient units in most district general hospitals across the country.
Major innovations in dealing with the shortage of mental health human resources have been a particular
feature of the mental health system development in Sri Lanka in the past decade. A focus on suicide
prevention has yielded very positive results. These and other aspects of the process of reform of the Sri
Lankan mental health system have generated international interest. This chapter provides a brief account
of a very effective process of mental health system reform in a middle-income country
Introduction
Sri Lanka is an island country located in the Indian Ocean in South Asia. The population of
21.27 million (United Nations Development Programme 2014) is comprised of four main
population groupsSinhala (74%), Tamil (18%), Muslim (7%) and Burgher (1%) (Marecek
1998). Sri Lanka has a democratic government and is classied by the World Bank as a lower-
middle-income country (World Bank 2015). The country is divided into nine autonomous
administrative provinces: Central, North-Central, Eastern, Northern, North-Western,
Sabaragamuwa, Southern, Uva and Western (Lanka 2014). Approximately half of the
population lives in the Central, Southern and Western provinces (Lanka 2014). Most people live
in rural areas (urban-to-rural ratio: 1:4.4) (Ministry of Finance and Planning 2012). Poverty is
three times higher in rural than in urban regions (Ministry of Finance and Planning 2012), and
1 Minas H, Mendis J, Hall T. Mental health system development in Sri Lanka.
In: H. Minas and M. Lewis (eds.), Mental Health in Asia and the Pacic, New York Springer.
the Gini coefcient is 36.4 (World Bank 2015), reflecting the considerable income disparity, a
feature of most of the Asia region (Gini coefcient = 40.4) (World Bank 2015).
Sinhalese recorded history begins in 543 BC. The country was colonised by Portugal in 1517
and later by the British from 1815 until 1948 when Ceylon, as it then was, achieved
independence from the British Empire. Ceylon became the Democratic Socialist Republic of Sri
Lanka in 1972.
Since the late 1990s, labour migration has become Sri Lankas second largest export, an
important strategy for impoverished families (Marecek 1998). Annually, 250,000 persons go
overseas as migrant workers, of whom 65% are women (Senaratne et al. 2011). Nearly 80% of
female migrant workers are married, 85% of them have children, and half of these children are
aged 510 years (Senaratne et al. 2011). Migration patterns impact on mental health by changing
the social fabric and family structures (Senaratne et al. 2011). A cross-sectional survey conducted
among 253 children (aged 510 years) of female migrant workers found a twofold increase in
mental health problems among these children as compared with children without an absent
mother (Senaratne et al. 2011).
In 2013, the Human Development Index was 0.750, ranking Sri Lanka 73rd internationally
(United Nations Development Programme 2014) and placing the country in the high human
development group. Sri Lanka outperforms other South Asian countries with similar population
densities (India and Pakistan), and is above the South Asia region average in terms of HDI, life
expectancy and mean years of schooling (De Silva 2002; United Nations Development
Programme 2014). Life expectancy at birth is 74.3 years (United Nations Development
Programme 2014), compared to 66.4 years and 66.6 years for India and Pakistan, respectively
(United Nations Development Programme 2014). The infant mortality rate of 8 deaths per 1000
live births is well below the rates in India (44) and Pakistan (69), and the mean for the South
Asia region (45) (United Nations Development Programme 2014). The Commission on Social
Determinants of Health 2008 report noted that Sri Lanka [has] achieved a level of good health
out of all proportion to expectation based on their level of national income(World Health
Organisation Commission on Social Determinants of Health 2008). These health outcomes may
be explained by the implementation of a universal health care system in 1931. (Nerminathan
2003). The stability of this public health system has been linked to its alignment with the
Buddhist belief in protection of life which supports social welfare (Nerminathan 2003;
Ariyaratne 2011).
Sri Lanka has an ageing population, with 62.4% of the total population aged between 15 and 59
years, and 12.3% aged over 60 years (Department of Census and Statistics 2012). One-fth of
Sri Lankans are predicted to be aged over 60 by 2025 (World Health Organization 2006).
During this transition to an older population, Sri Lanka is experiencing a demographic bonus
(Ariyaratne 2011)an increase in the number of people of working agewith a concurrent
reduction in the number of people aged ve years or younger by one per cent per decade due to
effective family planning (Ministry of Healthcare and Nutrition 2009).
Nine of the top ten causes of premature death as measured by years of life lost (YLL) are NCDs
or injuries, with ischaemic heart disease (16.3%), self-harm (8.3%), stroke (6.6%) and diabetes
(4.8%) responsible for the greatest burden. These causes and chronic obstructive pulmonary
disease, major depressive disorder and low back pain are responsible for the greatest proportion
of disability adjusted life years (DALYs) (Institute for Health Metrics and Evaluation 2011).
History of Mental Health System Development
Sri Lanka has a pluralistic mental health system resulting from the complex interplay of
indigenous, Ayurvedic and Western biomedical medical models. The publically funded mental
health system is based on Western medicine, while indigenous principles and practices have a
strong continuing presence in the non-government and private sectors.
An indigenous medical model prevailed in Sri Lanka before the colonisation by the Portuguese
(15051656), Dutch (16561796) and the British (17961948). Indigenous mental health care
is informed by the Ayurvedic and Unani conceptualisations of mental illness, aetiological
factors and accompanying treatments. Indigenous words for madnessare issu (Sinhala),
paithiyam, mananoi and ulanoi (Tamil), and the direct translation of the English mental
illness’—mānasikaroga (Sinhala) and mananoi (Tamil) (Weerackody and Fernando 2014).
Beliefs about what Western medicine regards as mental disorder include attribution of causality
to astrological factors, sorcery, demon possession and black magic (Marecek 1998).
Responses therefore focus on healing practices including herbal medicine, and astrological and
religious ceremonies (De Silva 2002; Namali et al. 2012). In the late 1800s, under British rule, a
public health system based on Western medical principals was established. This increasingly
sidelined the indigenous health system to the non-government sector (Jayasuriya 2001). There is
no publically funded or organised system for indigenous mental health service provision (De
Silva 2002). Nonetheless, indigenous mental health care continues to comprise a large
component of services, predominantly for the rural population (Jayasuriya 2001; Gambheera
2011).
Early development of the public mental health system occurred during the period of British rule
in the late 1800s and was based on then dominant Western conceptualisations of mental health
and illness (De Silva 2002). The 1873 Lunacy Ordinance Act focused mental health system
development on the establishment of psychiatric institutions (Carpenter 1988; De Silva 2002).
The rst small lunatic asylum was opened in Borella in 1847 (Weerackody and Fernando 2014).
Due to overcrowding, patients were transferred to prisons across Sri Lanka (Gambheera 2011).
Treatment was limited to occupational therapy and protecting persons through
institutionalisation (Gambheera 2011). In 1926, the larger Angoda mental asylum was built just
outside the capital, Colombo, to accommodate 1800 patients and ease the overcrowding that had
become problematic in the asylum at Borella (Weerackody and Fernando 2014). Despite the
increased capacity, there was no expansion in treatment resources. An investigation in 1928 by
British Psychiatrist Edward Mapother (Mills and Jain 2009) found a very low quality of services
in the Angoda asylum due to a combination of overcrowding and understafng [Mapother 1928
in Gambheera (2011)]. The Mapother Report recommended the de-centralisation of services and
the development of a specialist medical service (Gambheera 2011).
The mental health system expanded signicantly from the 1930s until the 1970s. Colombo
General Hospital added the countrys rst outpatient clinic in 1939, a very early movein
international termsof psychiatry into the general health system. After independence in 1948, a
second mental hospital opened in 1957 in Mulleriyawa (Weerackody and Fernando 2014).
Available public positions for psychiatrists in the country dramatically increased from four in
1953 to 20 in 1967, the same year that Colombo General Hospital opened a 25-bed psychiatric
inpatient unit, establishing Colombo and its surrounds as the hub for psychiatric facilities in Sri
Lanka (Weerackody and Fernando 2014). The increased number of positions for psychiatrists
was supported by the development of the Department of Psychiatry at the University of
Colombo in 1968. The Mental Disease Ordinance in 1956 (the second revision of the original
Lunacy Ordinance) called for a shift towards community-oriented service delivery led by
psychiatrists with support from psychologists, social workers, mental health nurses and
occupational therapists (De Silva 2002). The move towards community-based mental health
care in the 1970s saw the establishment of a community clinic by the University of Colombo,
supported by the World Health Organisation (WHO), which aimed to re-integrate long-stay
patients from Angoda back into the community. A particular challenge during this period was
the substantial numbers of psychiatrists leaving Sri Lanka to work in developed countries (De
Silva 2002; Gambheera 2011).
The Sri Lankan National government was engaged in civil war with the Liberation Tigers of
Tamil Eelam (LTTE) for 26 years from July 1983 to May 2009 (Government of Sri Lanka
2013). Armed conflict was mainly contained to the North-Eastern province, formed from the
merger of the Northern and Eastern provinces, although insecurity and the trauma of war
affected the whole country, with suicide attacks on civilians and military personnel by the
LTTE, military operations by the government and civilian riots (Silva 2010). It is estimated that
75,000 people were killed and a far greater number were injured (Silva 2010).
The civil war further compromised the already-sparse human resources for mental health in Sri
Lanka, particularly in the North-Eastern province (World Health Organization 2002), where
large numbers of health facilities providing mental health care were destroyed or severely
damaged, and the supply of essential resources including pharmaceuticals was severely disrupted
or discontinued (World Health Organization 2002). The instability of the region also forced
most health care staff to leave the north-east. For example, in 2003, there were only two
psychiatrists continuing to practice with limited resources in the North-Eastern province, and
only two districts had acute inpatient facilities (World Health Organization 2003). In
comparison, there were 25 practising psychiatrists (66% of the national supply) in the Western
Province (De Silva 2002).
The shortage of mental health personnel was in the context of greatly increased need for mental
health support during and after the end of the conflict (World Health Organization 2002). The
WHO report of Health System and Health Needs of north-east Sri Lanka attributed this demand
to the psychological trauma associated with war, conflict and violence and the associated
displacement, disintegration of families and communities together with the loss of property and
kin(World Health Organization 2002). In 2002, an assessment of mental health needs (World
Health Organization 2002) was conducted by Medecins Sans Frontieres (MSF) of residents of
welfare centresafter the onset of the conflict in Vavuniya in the north-east found high rates of
attempted suicides, alcohol abuse, domestic violence, grief, suspicion and a sense of learnt
helplessness. The lasting effects of the conflict are seen in the collective traumaexperienced at
the community level (Somasundaram 2007, 2010). The disruption of family and community
relationships and networks has impacted on societal values and produced intercommunal
mistrust among much of the population (Somasundaram 2007, 2010).
On 26 December 2004, the Indian Ocean tsunami hit the southern and eastern coast of Sri
Lanka, killing an estimated 35,000 people, completely destroying 90,000 houses and displacing
more than 516,000 from their homes (Minas et al. 2011). Relief efforts, led by the Sri Lankan
government in collaboration with many international agencies, had important positive impacts
on health systems and population health outcomes.
The 2004 tsunami directly impacted mental health in Sri Lanka by weakening the existing
infrastructure for mental health care provision and increasing the population risk of mental
health problems (Mahoney et al. 2006). This was particularly the case for the north-east where
the civil war had already compromised available human resources for mental health. The
tsunami also served as a catalyst for increased attention to the need for mental health services.
For example, several international non-governmental organisations (NGOs) funded several
capacity-building programmes and built acute psychiatric units in many district general
hospitals and contributed to the development of community mental health services in many
districts (Minas et al. 2011; World Health Organization 2013).
The expansion of the mental health services was felt nationwide. Sixteen intermediate stay
rehabilitation units were established; acute inpatient units were established in almost 80% of
districts, and the majority of districts established mental health outreach clinics (World Health
Organization 2006). In addition to psychiatric services and facilities, community-based
psychosocial support was provided by lay health workers in tsunami-affected areas. Community
support ofcers (CSOs) delivered psychosocial support to persons in hard-to-reach areas and
acted as referral points to other health services (Minas et al. 2011; Murthy 2015).
Population Mental Health Problems
The prevalence of mental health problems is difcult to estimate due to the absence of a national
mental health surveillance system. Nonetheless, cross-sectional studies conducted over the past
15 years have shed light on the burden of psychiatric morbidity. A high prevalence of
depression and post-traumatic stress disorder (PTSD) has been found in samples of conflict-
affected people. For example, 72% of landmine victims were found to have PTSD (Gunaratnam
et al. 2003).
A household study conducted by the Ministry of Health in 2002 named depression as the eighth
leading disorder affecting the population in urban and rural areas (Ministry of Health and Japan
International Cooperation Agency 2003). The state of mental health in the conflict-affected Sri
Lankan population was further compounded by the catastrophic 2004 tsunami. The prevalence
of PTSD among the internally displaced adults was estimated to be 1439% three to four weeks
after the tsunami (Neuner et al. 2006), increasing to 56% at six months (Ranasinghe and Levy
2007) and decreasing to 25% at twenty months after the tsunami (Hollield et al. 2008).
Although these estimates are based on different samples, they are suggestive of a large burden
of psychological distress in the aftermath of the tsunami.
Recent prevalence estimates reflect the cumulative effects of the conflict and tsunami on mental
health. A household survey conducted in 2009 of 1517 houses in Jaffna, Northern Province,
found a high prevalence of PTSD, anxiety and depression (7.0, 32.6 and 22.2%, respectively)
(Husain et al. 2011). These estimates were replicated by the Household Income and Expenditure
Survey 20122013 (Ministry of Finance and Planning 2012), the COMRAID study
(Siriwardhana et al. 2011) and a large study of 12,841 hospital records in four districts in the
Northern Province (De Silva et al. 2011). The COMRAID study identied an increased risk for
internally displaced persons who were unemployed, widowed or divorced and experiencing
food insecurity (Siriwardhana et al. 2011).
Alcohol and substance use problems are increasing in Sri Lanka. Overall, alcohol consumption
increased from 2.2 l per capita in 20032005 to 3.7 l per capital in 20082010 (World Health
Organization 2014). Approximately, 4.9% of men are estimated to have alcohol dependence and
a further 6% of men are estimated to have alcohol use disorder (World Health Organization
2014). The prevalence of dependence and alcohol use disorder in females is signicantly lower,
at 0.6% for both categories (World Health Organization 2014). The prevalence of heavy
episodic drinking was 0.8% of the population for males and less than 0.1% for females in 2010
(World Health Organization 2014). Fifty-seven per cent of liver cirrhosis in males was
attributable to alcohol.
A high prevalence of mental health problems has been found in adolescents (Perera et al. 2006)
and children (Catani et al. 2008). For example, 36 and 28% of students aged 1418 years
exhibited depression and severe anxiety, respectively, with females at greater risk of both
problems (Rodrigo et al. 2010). Older Sri Lankans are also at a higher risk of mental health
problems because of chronic exposure to conflict-related trauma and the tsunami. The Sri
Lankan Aging Survey conducted by the World Bank in 2006 detected a high prevalence of
depressive symptoms of 27.8% in the 1181 elderly Sri Lankans surveyed. Elderly people with
lower educational levels, physical disability and ethnic minority males were most at risk
(Malhotra et al. 2010). A survey of elderly people admitted to hospital detected similar levels of
depression and cognitive dysfunction (Weerasuriya and Jayasinghe 2005). Dementia is also
estimated to affect 4% of people aged 65 years and older (De Silva et al. 2003).
The rates of mental health problems differ between men and women, with a higher burden of
mental illness affecting women (excluding suicide and alcohol abuse, which are higher in men).
For example, depression is more common in elderly women (30.8%) than elderly men (24.0%)
(Malhotra et al. 2010). Traditional gender roles may impact on help-seeking behaviour and
mental illness prevalence (Marecek 1998). Sri Lankan women have a limited social space in
which to express their feelings, gender-related burden and mental health stigma and health-
seeking behaviours (Guzder 2011). Women are particularly vulnerable to mental health
problems as a result of increased alcohol consumption among men and high rates of domestic
violence (Hussein 2005; Guzder 2011).
Sri Lanka had very high suicide rates in the 1990s and, despite a marked reduction in the suicide
rate from 1995 to 2010, self-harm remains the second largest cause of premature mortality and
morbidity (Institute for Health Metrics and Evaluation 2011). The suicide rate rose from a
modest level of 6.5 per 100,000 persons in 1950 to 47.3 per 100,000 population in 1995one of
the highest rates in the world (Marecek 1998). The suicide rate in the Northern Province was
particularly high, 53.5 per 100,000 in 1982 (Ganesvaran et al. 1984). Men were approximately
at a threefold greater risk of suicide than women during the 1990s (Marecek 1998). In 2002,
suicide disproportionately affected males aged over 40 years, with the highest rates of
approximately 80 suicides per 100,000 persons detected in males aged 6064 (Desapriya et al.
2004). The main methods of suicide are self-poisoning and hanging (Knipe et al. 2014). At its
peak during 19941996, self-poisoning was responsible for approximately 79% of completed
suicides (Knipe et al. 2014). The high suicide rate in Sri Lanka during the 1990s has been
attributed largely to the availability of toxic pesticides in households, high levels of social,
emotional and physical stress from war, and inadequate availability of supportive mental health
services (Eddleston et al. 2006; Jayasekara and Schultz 2007). Alcohol misuse was found to
contribute to 61% of male suicides (Abeyasinghe and Gunnell 2008). Restrictions on the
importation and sale of WHO Class I toxicity pesticides in 1995, and Endosulfan in 1998,
coincided with reductions in suicide rates. Specically, there were 19,769 fewer suicides in
19962005 than in 19861995 (Marecek 1998). Nonetheless, self-harm through poisoning and
excessive alcohol consumption continue to be reported at high levels (Jayasinghe and Pathirana
2011; Jayasinghe et al. 2012; Knipe et al. 2014).
Mental health stigmatising attitudes to and beliefs about mental illness continue to be prominent
in Sri Lankan. Persons experiencing mental health problems are subject to discriminatory
practices, including decreased employment options (Consumer Action Network for Mental
Health 2015). Mental health stigma has been reported to affect health-seeking behaviours
(Marecek 1998; Fernando et al. 2010a) and quality of treatment received (Fernando et al.
2010b). As in the general population, health professionals also frequently have negative
attitudes towards people with depression, alcohol and drug addiction, and attempted suicide is
often treated in medical wards for physical complications with no referral to psychiatric services
for assessment and treatment of mental disorder (Marecek 1998).
The World Health Organisation estimates that 7% of Sri Lankans (more than 1.4 million people)
live with a disability (World Health Organization 2011b). The most recent disaggregation of
subtypes of disability from the 2001 census estimates (per 100,000 people) were vision (41.0),
hearing or speaking (43.5), hands (28.5), legs (7.9); other physical disabilities (53.7) and mental
disorder (40.9) (Peiris-John et al. 2013). Risk of disability increases with age (World Health
Organization 2011a, b), with older people accounting for 22.5% of people with disabilities
(Peiris-John et al. 2013). A recent narrative literature highlighted a dearth of research
investigating disability in Sri Lanka (Peiris-John et al. 2013).
Sri Lanka has had a National Disability Policy since 2003, signed the Convention on the Rights
of Persons with Disabilities (CRPD) in 2007 (United Nations 2007) and the National Action
Plan for Disability is currently being revised to align with the WHO World Report on Disability
(2011) (World Health Organization 2011a, b) and the CRPD (United Nations 2007).
Stakeholders working on the current National Action Plan for Disability in Sri Lanka include the
Ministry of Health, Ministry of Social Welfare, agencies of the United Nations, Sri Lankan and
international NGOs, disabled persons organisations and health professionals. The Action Plan
aims to address the empowerment of people with disabilities, health, rehabilitation, education,
employment, social engagement, mainstreaming and enabling environments. Disability spans
both the health and social care systems. A key challenge is to establish effective mechanisms for
the coordination for these systems.
Mental Health System Governance and Financing
The Mental Health Act was most recently revised in 1956 (World Health Organization 2011a,
b). The development of revised mental health law has been in progress for more than a decade.
A draft revised for Mental Health Act is currently under review by government. As in every
other country, there are several other laws with provisions that are relevant to mental health,
including legislation on general health, welfare and disability (World Health Organization
2011a, b).
The rst Mental Health Policy of Sri Lanka20052015, adopted in 2005, aimed to develop a
comprehensive network of services at the community level (Mahoney et al. 2006). The national
mental health action plan, developed by the Mental Health Directorate, the NIMH and the Sri
Lankan College of Psychiatrists in 2005 and revised in 2010 (WHO 2011), was the framework
for implementing the mental health policy. The key components of the plan included timelines
and funding allocation for the implementation of the mental health policy, a particular focus on
the urgent need to strengthen human resources for mental health and clear shift in focus from
mental hospital-based treatment to substantially increased community-based services and
integration of mental health services into primary care.
The national mental health policy made provision for the establishment of the National Mental
Health Advisory Council as the national authority charged with directing and overseeing
implementation of the policy. The membership included staff from the Ministry of Health and
representatives from other ministries, including the Ministries of Womens Empowerment,
Social Welfare, Education and Justice. Professional representation included the Sri Lankan
College of Psychiatrists and representatives of nursing, occupational therapy, psychology and
social work. The Council also included service users, carers and representatives of relevant
institutions as well as registered Non-Government Organizations.
The Directorate of Mental Health in the Ministry of Health is responsible for carrying through
the decisions of the National Mental Health Advisory Council, particularly for managing and
monitoring the implementation of the national mental health policy. The Directorate manages
the mental health budget; develops and supports appropriate system development strategies;
supports provincial and district levels of government to set and work towards achieving strategic
mental health targets and specic mental health operational plans; develops and issues clinical
and other guidelines; assesses and responds to requests for infrastructure and other mental
health investment; receives periodic district and provincial reports; and fosters and sustains
effective links at all levels between mental health and other relevant sectors such as
education, women empowerment and social welfare, local administration, poverty alleviation,
child protection and developmental NGOs.
With the adoption of the national mental health policy and the mental health action plan, the
Ministry of Health recognised that the implementation of the policy requires a signicant
increase in resources of all kinds, including mental health workers. Additional doctors and
nurses with psychiatric training were appointed to work in the community, and training was
proposed for a limited numbers of psychologists, occupational therapists and social workers.
Efforts were also made to create new positions for psychiatric nurses, psychologists and
psychosocial support workers in the public mental health system (Mahoney et al. 2006).
Mental health services are nanced through government taxation, out-of-pocket personal
expenditure, non-governmental funding sources and support from international development
assistance agencies (BasicNeeds 2009). Current public mental health nancing information is
difcult to obtain because there is no identiable global mental health budget in the national
health budget (BasicNeeds 2009; Jenkins et al. 2012). The only readily identiable mental health
funding allocation is that for the two remaining psychiatric hospitals (NIMH-Angoda and
Mulleriyawa) in the Western Province. While many general hospitals now have an inpatient
psychiatric unit, the amount of funding allocated to these units is not separately reported and
varies considerably between districts (BasicNeeds 2009). Estimates for out-of-pocket
expenditure are also not available (WHO 2011).
A substantial proportion of mental health funding comes from the non-governmental sector
(BasicNeeds 2009). In 2009, donor agencies contributed 55% of the funds for programs at the
national level and 45% at the provincial level (Jenkins et al. 2012). The main donor agencies
have been the World Bank, WHO, United Nations Population Fund (UNFPA), United Nations
Childrens Fund (UNICEF) and the Volunteer Services Organisation (BasicNeeds 2009). Most
donor funds go to national prevention and promotion programmes. For example, government
nancing accounted for 44.8% of the budget for mental health prevention and promotion
activities in 2009, with the remainder provided by external donors, including World Bank
(44.84%), UNFPA (6.73%) and WHO (3.59%) (Kitsiri 2009).
Government funding for mental health care is distributed directly from the national government
or via the provincial councils (BasicNeeds 2009). The national mental health budget is
comprised of both government and donor agency contributions. Funding for psychiatric
treatment services (mental hospitals and general hospital psychiatric inpatient units) is managed
by the Finance Department within the MoH. Financing for preventive and mental health
promotion programmes is managed by the Mental Health Directorate (BasicNeeds 2009).
Provincial mental health budgets are comprised of both national and provincial government
sources and are managed by the provincial councils (BasicNeeds 2009).
The National Institute of Mental Health (NIMH), established as part of a process of radical
reform and improvement of Angoda Mental Hospital, is the national treatment and training
centre for psychiatry in Sri Lanka. The NIMH is responsible for providing specialist
secondaryand tertiary-level psychiatric services and works closely with the Mental Health
Directorate, providing technical advice for policy and practice. The Sri Lankan Royal College
of Psychiatrists is a small but influential stakeholder in the mental system. The College provides
supervision and training for psychiatrists, contributes to development of psychiatry curriculum,
manages membership of the profession of psychiatry and contributes to mental health strategic
planning and policy. Various other international and local organisations provide nancial and
technical support for mental health in Sri Lanka. These organisations include the WHO, World
Bank, VSO International, Basic Needs, the National Council for Mental Health (Sahanaya,
Shanthiham) and the Association for Health and Counselling and Nest (World Health
Organization 2011a).
Consumers and carers have a small but growing influence on the mental health system in Sri
Lanka. The Consumer Action Network for Mental Health (2015) is the largest carer
organisation, with approximately 10,000 members. The organisation works predominantly in
the Central and Western provinces and carries out advocacy work in addition to service linkage
and rehabilitation activities.
Mental Health System Organisation
Mental health care is provided through a combination of public, private and non-government
services (Jenkins et al. 2012). The structure of the public mental health service system mirrors
the public general health system. While policy and strategic directions are set at the national
level, implementation is primarily the responsibility of the provincial and district levels of
government.
The psychiatric treatment service system is comprised of a network of hospitals at national,
provincial and district levels. Primary care is managed by the district hospitals, the peripheral
units and the rural hospitals, with referrals to higher institutions when necessary. Secondary
care is provided by the base hospitals and, increasingly, by psychiatric inpatient units in district
hospitals. Tertiary and sub-specialty inpatient psychiatric care is provided by the National
Institute of Mental Health (World Health Organization 2011a).
There is a small private psychiatric service sector. Psychiatrists working in the public sector
may also carry out private practice out of public working hours and provide approximately 50%
of outpatient care (De Silva 2002). There are no private psychiatric hospitals in Sri Lanka (De
Silva 2002). Mental health care is also provided by Ayurvedic and other indigenous practitioners
(Nikapota 1983; De Silva and De Silva 2001).
The non-government sector, consisting of national and international mental health NGOs, and
families of persons with mental disorders make a substantial contribution to mental health
service provision. The objectives and scope of the many NGOs vary considerably and include
rehabilitation services for persons with severe and persistent mental disorder and disability,
alcohol use problems, suicide prevention, trauma-related disorders, mental disability and mental
health care for the elderly (De Silva 2002). The main burden of care falls on families and
friends.
A central component of the National Mental Health Policy 20052015 was the commitment to
strengthen the human resources for mental health (HRMH). The main categories of mental
health workers are the same as in other countriespsychiatrists, psychiatric nurses, social
workers, psychologists and occupational therapists. However, there has been a severe shortage
of all of these categories of mental health professionals. Sri Lanka has been particularly
innovative in responding to the fact of insufcient mental health human resources by developing
new categories of workersMedical Ofcer with Diploma in Psychiatry (MOPsyc), Medical
Ofcer of Mental Health (MOMH) and Community Support Ofcer (CSO).
Medical Ofcer with Diploma in Psychiatry (MOPsyc) and Medical Ofcer of Mental Health
(MOMH) are medical graduates who have completed either a one-year diploma in psychiatry
from the Post Graduate Institute of Medicine (MOPsych) or a one-month certicate of
psychiatry from the Royal College of Psychiatrists (MOMH). MOMH and subsequently
MOPsych training was established to enable provision of basic mental health services in the
community, particularly in the more remote and under-served regions of the country (Jenkins et
al. 2012). The aspiration was that at least one MOMH would be posted to every sub-district
(Jenkins et al. 2012). With the rapid increase in the number of acute psychiatric units in district
hospitals, and the shortage of psychiatrists to manage them, the MOPsych training programme
was a critically important strategy to enable such district-level services to be established,
although now almost every district inpatient unit is headed by a psychiatrist.
The role of Community Support Ofcer (CSO), undertaken by community volunteers, was
established in the immediate post-tsunami period in response to the massive need for
psychosocial support in a traumatised population. The training received, though very brief,
enabled the CSOs to identify and, when necessary, refer persons for mental health care and to
support the re-integration in the community of people discharged from psychiatric inpatient
treatment.
Human resources for mental health (HRMH) have rapidly expanded over the past decade. The
majority of districts now have reasonably comprehensive mental health care facilities and
services, including a psychiatric inpatient unit, an intermediate care unit and community
outreach clinics, under the supervision of at least one psychiatrist or MOPsych, and an MOMH
in most sub-districts. There are currently 89 consultant psychiatrists serving a population of 21
million; approximately 0.4 consultant psychiatrists per 100,000 persons (Mental Health
Directorate 2015). This ratio is considerably lower than the 1.21 per 100,000 persons which is
the mean for uppermiddle-income countries (World Health Organization 2011a, b). Due to the
introduction of the MOMH and MOPsych training programs, and the distribution of graduates of
these programs to under-served areas of the country, there are now at least basic psychiatric
treatment services provided by doctors with some training in psychiatry throughout the country
(Mental Health Directorate. 2015). The numbers of other mental health professionals
psychiatric nurses, psychologists, social workers, occupational therapists and psychiatric social
workersare still very low.
Brain drainof qualied psychiatrists to OECD countries, mostly to the UK, US, New Zealand
and Australia, has been a major issue for HRMH in Sri Lanka, particularly during the conflict
years (De Silva et al. 2013). Compared to neighbouring South Asian countries, Sri Lanka had
the largest exodus of trained health personnel, at a rate of 21% in 2008 before the end of the
conflict (Jenkins et al. 2010). Despite a boost to the available HRMH, internal factors promoting
migration of health workers include insufcient professional development opportunities,
encouragement from universities for students to train overseas and compulsory appointment to a
rural area at return from overseas training (De Silva et al. 2013). External factors that promote
migration include higher salaries in high-income countries, more favourable working
conditions, better education for children and greater access to higher education and continued
professional development (De Silva et al. 2013).
Since the end of the conflict, however, a large number of psychiatrists have returned to work in
Sri Lanka. Recently, a qualitative study of Sri Lankan specialists who had completed an
overseas placement highlighted the importance of the dual practice policy (enabling a mix of
public and private work) for retaining specialists (De Silva 2002). In addition, it is now required
doctors going abroad for postgraduate training with support from the Post-Graduate Institute of
Medicine pay a bond upon commencing their postgraduate training which is not reimbursed if
they fail to return to Sri Lanka after overseas training. Furthermore, graduate specialists must
work in a public position for four years for every training year they spend overseas (De Silva et
al. 2013).
The still limited numbers and dual practice policy mean that the majority of practising
psychiatrists have a heavy workload, consisting of full-time work in the public health system
followed by work in private clinics. Due to available resources and time constraints, psychiatric
treatment carried out by psychiatrists is mainly focused on biological treatments, and a
multidisciplinary team is rarely involved (Mental Health Directorate 2015). As well as
providing limited choice for patients, this also serves to restrict the level of occupation support
available to psychiatrists (De Silva 2002; Gambheera and Williams 2010). Similar working
conditions were reported by nurses in one study in which the 30 respondents expressed that
heavy workload and a lack of communication between different health professional groups
limited their capacity for effective work in preventing intimate partner violence (Guruge 2012).
Currently, there is no standardised method for conducting and reporting mental health staff
performance assessment.
There is a large disparity between the available mental health workforce in rural and urban
areas. Sixty per cent of psychiatrists live in the countrys three largest cities (Mental Health
Directorate 2015). Recruitment and retention of health workers to rural areas is complex and has
been a primary focus of government health policy since the HRH Strategic Plan 19992009.
Rural hospitals tend to have poorer infrastructure and resources and, paradoxically, serve the
majority of the population. As such, health professionals in rural areas experience less desirable
working conditions and a heavier workload than their urban counterparts, and fewer
opportunities for career development because educational facilities and training are concentrated
in cities (Ministry of Finance and Planning 2012). To compensate for some of these issues, the
government provides incentives to encourage skilled workers to work in regional and rural areas,
including priority in school admissions, duty concessions for importing a vehicle for personal
use, a pension after retirement and other nancial remunerations, such as loans at low interest
(De Silva 2013). Health specialists who do work outside the major urban centres are also able to
supplement their public salaries through private clinical work, achieving salaries close to that
offered by developed countries (De Silva et al. 2013).
Mental Health Information System and Research
Mental health information is collected and collated by the Medical Statistics Unit (MSU) within
the MoH (Medical Statistics Unit Ministry of Health 2012). Statistics are routinely collected
from district and provincial hospitals for outpatient indicators and staff and specialist indicators.
Historically, these data have been paper records which were entered into the MSU computer-
based system to be cleaned and analysed for publication in the Annual Health Bulletin. An
electronic reporting systemthe Electronic Indoor Morbidity and Mortality System
(eIMMR)was developed and piloted in 2010 to improve the efciency and accuracy of the
health information reporting system (Medical Statistics Unit Ministry of Health 2012).
Currently, there is no systemic monitoring and evaluation mechanism for human resources for
mental health. HRMH performance indicators were developed for the Health Master Plan
(20072016), but until now there has been no national implementation. Contact points of each
district are required to report basic HRMH data to the Mental Health Directorate but the
regularity of reporting is not guaranteed. The communication between the contact points and
mental health facilities and mental health professionals is often inadequate, resulting in
inaccurate reporting. In addition, there is no mental health-specic breakdown of the health
budget which prohibits any economic effectiveness evaluation of the utilisation and performance
of the allocated mental health budget (BasicNeeds 2009).
There is a burgeoning body of mental health research in Sri Lanka that investigates a broad
range of areas including epidemiology, mental health interventions, psychopathology and
policy. A thematic analysis of 104 published articles listed in the Mental Health Research
Repository 2013 produced by the Directorate of Mental Health (Directorate of Mental Health
2013) highlighted the current focus on the validation of psychometric instruments (17% of
total), suicide and deliberate self-harm (16%) and anxiety and mood disorders (16%). Cross-
cutting themes were trauma-associated with the war and tsunami. In addition to the general
population, samples included conflict-affected people, soldiers, children, adolescents and older
adults. Research was conducted by a number of prominent Sri Lankan psychiatrists in
collaboration with Sri Lankan universities and overseas institutions.
A second thematic analysis was conducted of articles published in the Sri Lanka Journal of
Psychiatry (titles and abstracts level) from 2010 onwards. In addition to assessment and
psychopathology (case reports), research covered forensic and liaison psychiatry (intersection of
physical and mental health), mental health policy, psychological and pharmacological
interventions, complementary therapies and the attitudes of medical professionals to mental
illness. Taken together, this research suggests a high level of research capability within the Sri
Lankan workforce.
Concluding Comment
Sri Lankas performance on most health indicatorsmuch better than would be expected based
on its level of economic developmenthas for several decades been studied and commented
upon. The country has been a standout in the region and among developing countries globally
(Jones and De Silva 2013). Despite this remarkable success in general health attention to mental
health of the population and the mental health system had languished. Conditions in the mental
hospitals were among the worst in the world, and there were virtually no community mental
health services in most of the country. Particularly over the past decade, following the
devastation caused by the Indian Ocean tsunami, and following the end of the civil war,
government has focused its attention on developing a comprehensive mental health system. In
the process, the same capacity for innovationand doing a great deal with very few resources
that was characteristic of the countrys successful efforts in public health has been applied to the
task of building a comprehensive and equitable mental health system. All of the basic elements
are now in place. It is now necessary to further strengthen quality and accountability, focus on
mental health promotion and prevention, continue to build a high quality workforce (Minas
2015) and develop expertise and services in child and adolescent mental health and other
important sub-specialty areas. The revised Mental Health Policy 20162025 has a clear focus
on priorities such as these in the next decade.
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In achieving universal health care financing healthcare is important.This is a brief qualitative study that was done in 2009 on financing mental healthcare in Sri Lanka as part of a larger study on financing mental health in Low and Middle Income countries: http://ijmhs.biomedcentral.com/articles/10.1186/1752-4458-4-11
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