How does Health Services implement MDGs?
Before you talk about MDGs you need to understand the health structure and health services in the country, especially the preventive services. If you look at the MDGs, health is a major component, more than 40%. Some of the activities are not directly related to health, but there is a health component. Some are directly related to health, tuberculosis, HIV, etc, and most of them are covered by the preventive health services.

We are implementing our programs through three different layers. One is the Medical Office of Health (MOH) works at the lowest level and provides preventive health service direct to people. We implement most of our activities in the community through public health midwives and Public Health Inspectors and they are supervised by MOHs. That is one layer. The other layer is the district. We have different programs at the district level. Tuberculosis and STD/AIDS, for example, have district offices. In some districts they're housed in a hospital and some have different buildings. They conduct preventive and curative health programs through the district. They have their own MOHs and they visit and follow up on patients in those areas.

If they detect a TB patient that patient has to be followed up. There's a new treatment called Direct Observed Treatment Shortcourse (DOTS) that we follow. Once the person is detected we assign them to the closest treatment center. Daily they have to go there, take pills, then go on their way. This is the global strategy to ensure that people take their medication.

If you take Malaria, again there's a District Control Officer. There's district Malarial Officer and under them there are MOHs. We have a system at the MOH level and the district level.

On top of that we have national vertical programs. This includes mass media, education, specific interventions, etc. For example, if we detect a malaria epidemic somewhere in Moneragala district, the national level monitors the statistics and mobilizes human resources to contain the problem there.

For many people these things are not known, when they think of health services they only think of hospitals. Our statistics and data are good, however, because of these preventative services. For these MDGs we're getting details direct from the MOHs and district level. There are 278 MOHs in the country, roughly corresponding to the Divisional Secretariat Divisions. They interface directly with people.

Who is responsible for maternal health?
Maternal Health is done through the Family Health Bureau. They provide National level mass media, education, etc. At the district level there's an officer for maternal and child health and the MOHs and then public health midwives. That's the chain of command.

Who is responsible for Malaria/HIV/Tuberculosis, etc?
The Ministry of Health has national control programs for each of these diseases. For seven diseases in fact. At district level there is an MOH/STD, District Tuberculosis Control Office, District Malaria Control Officer, Regional Epidemiologist, etc.

Which disease is the biggest threat to Sri Lanka?
None of them. These MDGs cover diseases that aren't the biggest health problems in Sri Lanka. We have passed that age of development and we're going to more European problems. Our major problems are non-communicable diseases like diabetes, hypertension, suicide, those things. We have already achieved most of these MDGs.

How relevant are the MDGs today? Aren't we on target for most health metrics?
Most are on target but there are district discrepancies. If you take maternal mortality, it is one of the best in Asia. However, by district, there is high mortality in Nuwara Eliya, Killinochi, Ratmalana, etc. Especially in the estate sector and east.

Do you provide health services in the North and East?
Yes, even Killinochi. Even within the warzone and wartime we maintained health services. One problem is we don't have an adequate amount of Tamil speaking midwives in those areas, but we are training and improving.

What problems do you face in the estate sector?
The plantation sector is less educated and they may not be following or have access to health education programs. Until sometime ago, health services were provided by the estate. The manager of the estate was responsible for providing health services. We are responsible once the patient comes out of the estate. To overcome that situation we are going to take over all the health services in the estate sector. Already we have taken over about 75 estate sector hospitals. We have taken policy decisions to go to the estate and provide health services directly.

What is the status of abortion in Sri Lanka?
There's a significant component of deaths due to septic abortion. Although abortions are illegal, there's a significant component due to septic abortion. Although abortion is illegal, these things are taking place.

How effective are reproductive health measures?
72% of the mothers should practice family planning to maintain the population at this level. We have reached 70%. To promote that we do demographic and health surveys from time to time. We are promoting modern methods, but a significant component are practicing traditional methods like withdrawal, timing, etc. The main modern methods are oral pills and Intrauterine Device (IUDs). Something like 40-50% use modern methods. We are promoting permanent methods and temporary. Permanent is vasectomy, tubal ligation for women. The percentage of permanent solutions is very small. For temporary we use oral pills, injections, etc.

What are the real problems that occupy Health Services?
Cancer, Accidents, Violence. Number one leading problem is Heart Disease, hypertension complicated problems. Then cancer, diabetes, and injuries. We also have the second highest suicide rate in the world. Also liver diseases, Alcoholism and Chronic Obstructive Airway Diseases (COAD). This is increasing because of environmental problems.

Non-communicable diseases are caused by lifestyle, we need to promote a healthy lifestyle from the beginning. Intrauterine care – trying to increase birth weight. Postnatal care, then preschool care, then school health care and then we have programs for school-leavers. There are also Well Woman screening programs to screen women over 35 years. Testing isn't compulsory in Sri Lanka and we're trying to address that.

What health MDGs do we need to focus on?
We need to address certain issues. Infant mortality for example. We need to contain this problem by reducing regional disparities. Certain districts don't have maternal death at all. One method we're promoting is that every mother should deliver in a hospital. Today 98% are going to hospitals, of which 93% are going to government hospitals. Only two percent of births are taking place at home. We want to make it 100%.

Also, we have advised that the first baby should be delivered under the care of a consultant, Obstetrician and Gynecologist (OG). There should also be an OG for the four or more pregnancies. The midwife should also visit the mother three time within the first 10 days. About half of mothers are getting that care right now.

Does the constant change in government affect your programs?
No. Whether UNP, SLFP or anything our program is fixed. Only the top changes [Director General]. I've been in this position for 15 years. Government servants are not affected by changes in the government.

Do we have enough doctors?
We have too many. Recently we've declared that the government is not responsible for employing doctors that pass out [of school] after 2010. We don't have the capacity; the country doesn't need more than that. Every year we produce 1,000 doctors. When you look at the population, we have to maintain some Doctor/population ratio. Right now doctors are guaranteed employment until 2010.

What human resources do we need?
We need a lot of other paramedics in the country. Nurses, Physiotherapists, Speech Therapists, Counselors will help address the problems of the next 20 years. We need a lot of rehabilitation programs in the community. Hypertension especially is going up so there is more tendency to get patients with Cardiovascular accidents. When these patients are brought to hospital what do we do? We manage the acute situation. Once the patient is stabilized we can't keep them in the hospital. These are lifelong problems and we need to send the patient back to the community. We need some support there. We need to have some sort of health course to provide long-term care at the home level. These are the issues we're discussing and trying to solve. We need to develop a paramedics team that can provide home care to these people.

Do you have the budget for all these services?
The government cannot provide all these services. For example, some years ago we employed A-Z people in the government including cleaners and watchers. Now hardly any government organization employs cleaners. There are cleaning and security services that we hire. Similarly the health services might hire these type of services from the Private Sector.

How does Sri Lanka compare globally?
We have the same problems as developed countries. If you look at life expectancy at birth we're very close to Japan. However, if you look at the quality of life, that's very different. Just number of people who are living won't help us. They need a quality life. If the quality of life is good then we can be happy.