What is Sustainability?

Sustainability is about protecting and improving the health of both people and the planet. Living sustainably means meeting all of the basic needs of people today, but within our environmental limits. All people share fundamental human needs, including those for sustenance, safety, participation, purpose, and autonomy. Sustainable actions help achieve these fundamental needs in ways that are both equitable and protect environmental quality and natural resources.

What is the Sustainable Communities Index?

The Sustainable Communities Index (SCI) is a tool to track progress towards a livable, equitable and prosperous city. The SCI includes over 100 performance indicators designed to measure diverse sustainable community objectives organized under seven sections: Environment, Transportation, Community, Public Realm, Education, Housing, and Economy. The measures not only look at the city as a whole, but also expose the variation in environmental quality and livability among various city neighborhoods. The data and methods for the SCI Indicators are all publically available.

Who created the Sustainable Communities Index?

In 2007, the San Francisco Department of Public Health created the SCI (originally named the Healthy Development Measurement Tool) to support a comprehensive vision for a healthy city that was developed by group of businesses and community organizations with the support of public agencies. Since that time, the Department of Public Health has improved and updated the measures based on both lessons from local applications and international best practices. For more information on the background of the SCI, see the history of the SCI.

Why Measure Sustainability?

The purpose of sustainability indicators is to support the achievement of important shared goals. Effectively designed to reflect local needs and global priorities, the indicators allow for an informed public debate that is necessary for an inclusive and democratic society. Indicators identify our current assets and future challenges. They point to differences among groups or areas in both resources and outcomes.

Sustainability and Health

Sustainable places provide the resources for health. The resources necessary for optimal health and wellbeing include fundamental human needs such as adequate and good quality housing; access to public transit, good schools, and parks; safe routes for pedestrians and bicyclists; meaningful and productive employment with fair wages; unpolluted air, soil, and water; and, cooperation, trust, and civic participation. Better access to these resources increases the chance of living healthy, fulfilling

lives and avoiding preventable the diseases and injuries. On the other hand, differences in these resources which currently exist among neighborhoods, cities and countries are the greatest contributors to grave inequities in health and well-being.

Using the SCI

Information in the SCI can be used for policy, planning, advocacy, and research, and education. The Program on health Equity and Sustainability within the Department has used SCI measures to prioritize and focus San Francisco initiatives on social and environmental factors that affect human health. This has led to a number of changes in the way the city works, including new policies to address priorities such as air pollution, noise, and traffic safety. San Franciscos Planning, Transportation, Housing, and Economic Development agencies have all used measures in the SCI in the development of community plan and the design of infrastructure projects. These plans and projects all take actions to improve the outcomes measured in the SCI. Community groups in San Francisco have used SCI measure to both understand neighborhood conditions and advocate for resident needs and interests. The SCI has supported agreements among residents and developers that provide diverse community benefits. Researchers are also using the SCI to better understand the connections between neighborhood conditions and health outcomes. For more specific examples of SCI uses within San Francisco, see the Applications within San Francisco page. For examples of how the SCI has been adapted to other locales, see the Adaptations Elsewhere page. The Department of Public Health can help you interpret SCI Indicator data and maps, advise you on how to use the SCI to evaluate a development project or plan. The Technical Resources section of this website provides a number of resources, tools and case studies that will help you use and apply the SCI.

Samanthi Bandara Insights April 18, 2011 >

By Samanthi Bandara, Research Officer IPS

In this second article marking World Health Day (7th April), Samanthi Bandara of the Health Economic Policy Unit of the IPS argues that as Sri Lanka grapples with emerging health challenges, like changing lifestyles with income growth, the rise of non-communicable diseases and an ageing population, health care financing policy needs a thorough rethink. While allocating more money is a definite need, better allocation of existing resources, by focusing more on primary level health care, is also essential.

Sri Lanka has an impressive record of health care provision, with model accomplishments in health outcomes compared to similar developing countries. Over the decades, since independence, the Government of Sri Lanka (GoSL) has played a remarkable role in the health system; provision, financing, and regulation of health care across the country. Successes of these initiatives have been reflected in the impressive health outcomes associated with good maternal and child health, low levels of communicable diseases and long life-expectancy. Nevertheless, the growing and shifting health needs of the country, consequent to the transformation of the economy to a lower middle income level, and changes in social-demography and epidemiology, require more resources. The health system framework of the World Health Organization (WHO) identified six health system building blocks towards achieving universal coverage (UC) with social health protection (SHP), of which health financing is a critical element.
Health Care Financing: Recent Trends

Health care in Sri Lanka is financed mainly by the government, with some private sector participation as well as limited donor financing. Public sector financing comes from the General Treasury, generated through taxation. Public sector services are totally free at the point of delivery for all citizens through the public health institutions distributed island-wide, while private sector services are mainly through out-of-pocket expenditure (OOPE), private insurance and non- profit contribution. Total health expenditure (THE) has fluctuated between 3.7% and 4% of GDP over the past few decades. Within this, the contribution from the Government was 45.8% in 2009, while the contribution from the private sector was 54.2%. The government health expenditure as a percentage of total government expenditure was 4.9% in 2007, which is a decrease of over half from the 7.2% recorded in 2006. It is increasingly evident that private sector financing has become more prominent over time. A large proportion of the private sector financing comes from OOPE, i.e., individual cost borne by the patient, which is around 85% of total private expenditure on health and 51% of THE, again which is significant. Increasing OOPE is clearly linked to the continuing demand for outpatient care at private sector institutions nearly 65% of outpatient care services in 2006 were provided by private health facilities. When it comes to inpatient care services, however, public health institutions are the leading provider. The proportion of publicly financed inpatient services was 72% in 2006, but it is a decrease from 80% in 1990. Private financing is certainly a good complement, as it provides additional resources, but the associated increase in OOPE for health by the patient, which is inherently regressive, creates inequity and social exclusion in availing of health care services.
Challenge 1: Problems due to Prosperity?

Sri Lanka is now transforming into middle income country status. Improving economic status and urbanization generates both positive and negative outcomes. On the positive side, it increases educational status and peoples expectations, which in turn results in greater demand for quality health care. Concurrently, on the negative side, changing lifestyles, consuming more fast food and unhealthy diets, the tendency for consumption of more alcohol and tobacco, living in polluted environments, and trauma due to occupational exposure, are drivers of enhanced health risks. Consequently, more financial resources will be required to meet this rising demand for easily accessible, and affordable quality health care.
Challenge 2: Ageing Population

Sri Lanka is also experiencing a demographic transition, reflected in the increased population of those aged 60-plus. Population forecasts predict a doubling of the countrys ageing population by 2040 (24.4%) compared to 2010 (12.1%) as life expectancy increases (due to improved island-wide preventive and curative health services) and fertility rates decline rapidly. Accordingly, the heightened fiscal cost for long-term care of this ageing population is an emerging challenge, along with the heightened burden of old-age pension provision.

Challenge 3: Rise of Non-Communicable Diseases

The epidemiological transition referred to earlier is the emerging shift from communicable diseases, which have largely been well contained, to a rise of noncommunicable diseases (NCDs), for example, cardiovascular disease, diabetes, cancer, asthma/chronic obstructive disease, and mental illness. Currently, treatment for NCDs accounts for nearly 90% of the total disease burden, while curative treatment for infectious diseases and preventive treatment for maternal and child health account for only around 10%. Furthermore, diabetes and asthma are also on the rise: 10% and 15%-20% respectively, per 10,000 people. Whilst mortality rates due to infectious diseases have been declining, from 42% in 1945 to 20% in 2003, mortality rates attributable to NCDs are rising. Death due to diseases of the circulatory system was 23.8% of all deaths in 2003, a dramatic increase from 2.8% in 1945. International comparisons show that such deaths in Sri Lanka are as much as 20-50% higher vis-avis developed countries.
Increasing Health Financing: Three Dimensions

The universally accepted notion is that publicly financed health systems are optimal. In this context, the key question is how can additional funds be found for expanding Sri Lankas health care provision? There are different views expressed on how to increase room for public health financing in the country. These are summarized in Figure 1.
The WHO Regional Health Financing Strategy for the Asia Pacific Region (2010-2015) and the World Health Report (2010) have highlighted the three dimensions which need to be considered in moving towards universal coverage and social protection, i.e., when all people have access to care promotion, prevention, curative and rehabilitative at suitable quality, without financial hardship.

Dimension 1: Breadth of Coverage The breadth of the box in Figure 1 shows the proportion of the population covered from public health services. In Sri Lanka, people who are in under-served areas are not able to even access private care because they are located in rural areas. This is where the depth of coverage comes in useful, by treating a broader extent by scaling up the primary care system. Dimension 2: Depth of Coverage Sri Lanka has a large health service network through primary, secondary and tertiary care institutions for promotion, prevention, curative and rehabilitative care services. Yet, most of the primary care institutions

across the country are idle. Given the difficulty in allocating new financial resources, there is a growing recognition of the need to re-orient the current public health service structure to enhance the efficiency of resource use. Already, the Ministry of Health has begun strengthening the primary level care service structure with a proposed package of services of curative care including prevention and promotion. These services are provided through the FamilyPractice approach to address the rapid rise of the disease burden caused by NCDs and elderly care. The importance of this approach has also been recognized by policy makers, following strong advocacy by the officials of the Ministry of Health, resulting in an allocation of Rs. 908 million for strengthening primary level health care to address NCD care needs. While the country needs more money to spend for health care, increasing efficiency of resource allocation through re-orienting the primary level care services in the sector is an essential complement to bridge the funding gap, i.e., more health for the money spent. Dimension 3: The Height of Coverage

The height of coverage shows the cost sharing element. Insufficient public health expenditure results in higher individual out-of-pocket expenditure (OOPE) and lower population coverage. This can be tackled to some extent by making available essential medicines, especially for NCDs, at primary care facilities (Divisional Hospitals). When examining the provision of services, the public sector health system finances less for NCDs than the private sector. In the case of diabetes, for instance, the private sector spent 81.2% of total diabetes prevention and control care while the public sector invested only 18.8% for the year 2005. On one hand, expenditure for NCDs care by the patients themselves (particularly the poor) creates an extra burden on them, as their financial risk (i.e., the amount a household pays for health care relative to its income/capacity to pay) increases. On the other hand, the gap in service provision is often a criticism of public health facilities, due to the continuous resource gap. This results in frequent unavailability of essential drugs and other diagnostic testing. In addition, care for NCDs in the public health system is provided at tertiary and secondary facilities, not at primary level facilities. As a result, patients (especially those in areas under-served by secondary and tertiary facilities) have to bear additional costs in seeking health care such as transport and foregone work. Interestingly, the treatment cost per patient at primary level facilities is in fact lower than at tertiary and secondary level facilities. This needs to be borne in mind when evaluating how best to allocate resources, and in attempting to ease the financial burden on patients. In middle income countries, prevention and promotion care for NCDs is mainly provided through primary care facilities because it has been recognized as more cost-effective than delivering them at secondary or tertiary care facilities.

Prospects

Sri Lanka has enjoyed exceptional health outcomes, with strong maternal and child health and low prevalence of infectious diseases, at low cost, in the past two decades. However, as this article has shown, there are visible gaps/disparities in health outcomes with regard to NCDs and elderly care. Empirical data shows that the country needs sufficient investment in health, especially given the emerging burden due to NCDs and ageing population (i.e., elderly care needs). These needs have to be addressed soon to avoid the resultant socio-economic consequences, such as a withdrawal from the workforce early due to ill health in the case of NCDs, and the rising fiscal costs for pensions and long-term care in the case of the ageing population. The Health Master Plan (2007-2016) for Sri Lanka estimated that the total health expenditure as percentage of GDP by 2015 would be 4.5 5% (medium) and 6.7% (high). This is based on various assumptions and projections but it appears that the emerging NCD burden and the ageing population were not adequately taken into account and if factored in more robustly, the requirement is likely to be much higher. It is hard to find more money for health due to the limited fiscal space of the government. However, if existing resources can be allocated and utilized more efficiently, and health needs prioritized, the government would be able to extract more health for the same amount of money. This re-orienting process of improving service provision at lower level facilities would help to address the gaps in service of the poor and under-served. Improving accessibility and availability of health service delivery, especially for vulnerable groups, at an affordable cost will be a strong driver towards attaining universal coverage and social health protection, which the WHO framework has emphasized. It is evident that there are a myriad of policy options developed following careful analysis and evaluation by health experts. But what is most important now is for the government to provide the political leadership to implement the much needed reforms, with due consideration also to pilot-testing and impact assessments.

Samanthi Bandara (1 Posts)

Samanthi Bandara is currently a Research Officer in the Health Economics Policy Unit at the IPS. Prior to joining the IPS in 2011, she worked at the Ministry of Health, initially as a Research Assistant of the World Health Survey and National Commission on Macroeconomics and Health in Sri Lanka, and later as a Development Assistant of the Management Development and Planning Unit. Samanthi Bandara has obtained a BA (Hons.) in Economics with a special module of Health Economics from the University of Colombo and MSc in Health Economics from the Centre for Health Economics, University of Chulalongkorn, Thailand. (Talk with Samanthi - samanthi@ips.lk)

Health System Development

The situational analysis of the health system in Sri Lanka was grounded on a conceptual framework with five major components (Figure 1): health outcomes; behaviour of individuals and households; Medicine performance of health system; external environment; and health care system. These components s are interlinked such that the health system is an organic whole. Essen tial Medicin es WHO Focus

Essential

Figure 1: Health System Conceptual Framework

The significant health achievements made over the last several decades need to be consolidated and further advanced given the rapidly changing demographic and epidemiological transitions seen in the country.

The Country Cooperation Strategy underlines a process of prioritisation within WHO to meet the health needs of Sri Lanka.

The WHO works with the Ministry of Health and other relevant partners towards achieving the objectives in six strategic areas.

Strategic Objectives: Enhance fairness and financed risk protection on health care and optimal use of resources Enhance management and quality in delivery of services and interventions

Key areas in the health systems addressed: Stewardship in the health sector: The changes needed in the health sector will present the managers of the health system with major challenges. There is a need to increase equity to ensure that all men and women, especially the poor, have better access to affordable health care and are protected from catastrophic health expenditure. Stewardship also involves engaging and regulating the private sector, collaborating with the education and other sectors as well as other stakeholders, and providing certainty in the direction of the health sector.

Health financing: Although the government has always supported a policy of providing universal health services for all its citizens, actual government expenditure cannot meet the financial requirements of health needs. Tax-based financing is currently insufficient and there needs to be greater emphasis on social health insurance. The rapid development of technology will bring deficiencies in health financing into ever greater perspective.

District health system development: Although Sri Lanka was one of the first countries in Asia to decentralize its health sector, the process of decentralization has been slow and uneven. For sustainable and efficient district health systems, the capacity of health managers and planners as well as the instruments for management and planning (e.g. health information, financing, human resources and procurement systems) need to be substantially improved. Further, centre-district communication and coordination need to be better institutionalized.

Reorganizing hospitals: Over the last two decades, public hospitals have undergone major expansion and re-organization without achieving all the anticipated improvements. Standardized care packages at each level and a properly functioning referral system are needed to reduce overcrowding of the specialist institutions and increase utilization of primary care units.

Information technology (IT): The existing health information systems of the Health Ministry, based largely on a traditional paper submission system and relying on manual reporting, urgently need technical and logistical improvement. Very few of the countrys major hospitals and the provincial health services have a computer network to support their heavy burden of documentation and information processing. Solving this deficiency will involve a triad of activities training in computer usage, use of simple but workable software, and installation and maintenance of reliable and well-maintained computer networks. The human resource gaps in health institutions must be reviewed keeping in mind these new challenges.

Strengthening public-private partnership: The private sector in Sri Lanka has been growing exponentially particularly in urban areas. Although this gives a choice to consumers, several issues merit consideration. Private facilities are concentrated in urban areas and have to be paid for outof- pocket, raising access and equity issues. Most private sector health professionals are, at the same time, state-sector employees, exacerbating staff shortages and geographical maldistributions. Statistics on private sector patient workload and disease profiles are not collected, making a comprehensive overview of the entire health sector impossible.

Enhancing community response: Sri Lanka does not have a patients Bill of Rights to protect health service consumers. Operationally, there are few formal mechanisms to ensure quality of the services provided. Moreover, health care consumers are not well informed about the health services and their rights. Empowerment of the community could help achieve a higher degree of responsiveness and better quality of health services.