Prevention and Control of

Noncommunicable Diseases
Think Globally-Act Locally; Lessons from Sri Lanka

Edited by:
Rajitha Senaratne & Shanthi Mendis
 2018 Ministry of Health, Nutrition and Indigenous Medicine, Sri Lanka
Credits and Permissions listed in Annex 2.

Citation:
Rajitha Senaratne & Shanthi Mendis (Editors). (2018).
Prevention and Control of Noncommunicable Diseases:
Think Globally - Act Locally; Lessons from Sri Lanka.
Ministry of Health, Nutrition and Indigenous Medicine, Sri Lanka.

ISBN 978- 955 -3666-20 - 8

Prevention and Control of
Noncommunicable Diseases
Think Globally - Act Locally; Lessons from Sri Lanka

Editors: Rajitha Senaratne & Shanthi Mendis

i
ii
Contents

Acronyms and abbreviations v

Preface vii
Contributors ix
Executive summary xi

PART I
Chapter 1 Sri Lanka today: A snapshot 3
Chapter 2 Spending for health: Where,
what and by whom? 21

PART II
NCD targets and SDG targets 47
Chapter 3 National NCD target 1: Reduce premature
mortality 53
Chapter 4 National NCD target 2: Reduce harmful use of
alcohol 69
Chapter 5 National NCD target 3: Reduce physical
inactivity 89
Chapter 6 National NCD target 4: Reduce salt
consumption 109
Chapter 7 National NCD target 5: Reduce tobacco use 123
Chapter 8 National NCD target 6: Reduce prevalence of
hypertension 143
Chapter 9 National NCD target 7: Halt obesity and
diabetes 159

iii
Chapter 10 National NCD target 8: Prevent heart attacks
and strokes 183
Chapter 11 National NCD target 9: Improve access to
medicines and technologies 203
Chapter 12 National NCD target 10: Reduce air pollution 217

PART III
Chapter 13 Other cost effective NCD interventions and
key partnerships 237
Chapter 14 Journey to tackle NCDs in Sri Lanka: Lessons
learned 255

Annex 1 269
Annex 2 287
Subject index

iv
Acronyms and abbreviations
CCS Country Cooperation Strategy

CKDu chronic kidney disease of uncertain etiology

DHS Demographic and Health Survey

FCTC WHO Framework Convention on Tobacco Control

FHB Family Health Bureau

HIES Household Income and Expenditure Survey

HPV human papillomavirus

HTA health technology assessment

LKR Sri Lankan rupee

MCH maternal and child health

MDG Millennium Development Goal

MoH Ministry of Health, Nutrition and Indigenous Medicine

NATA National Authority on Tobacco and Alcohol

NCD noncommunicable disease

NHA National Health Accounts

NMRA National Medicines Regulatory Authority

OOPE out-of-pocket expense

SDG Sustainable Development Goal

SSB sugar-sweetened beverage

UNICEF United Nations International Children's Emergency Fund

WHO World Health Organization

v
Preface
Since Sri Lanka gained independence in 1948, all governments that
came into power have steadfastly continued to support the provision
of free health care and free education to people. This has paid rich
dividends exemplified by high levels of literacy of the population and
many public health successes. These include very low maternal and
neonatal mortality rates, elimination of many communicable diseases
such as malaria, and increased life expectancy.

Despite these achievements, challenges persist and newer ones have

emerged. Currently, Non-Communicable Diseases (NCDs), constitute
a major public health challenge threatening the well-being of people
and sustainable development of Sri Lanka. The challenge of NCDs
is compounded by the increasing proportion of the elderly in the
population. Addressing the complexity of risk factors of NCDs - tobacco
use, physical inactivity, harmful use of alcohol, unhealthy diet and air
pollution - requires multisectoral responses which are challenging to
implement. In this regard, over the last two decades Government
of Sri Lanka has strived to provide strategic leadership for tackling
NCDs by promoting greater policy coherence and coordination across
government. Actions to address NCDs have engaged all stakeholders,
including civil society and the private sector. Although much remains
to be done, as documented in this publication, Sri Lanka has overcome
tough obstacles and has made commendable progress in tackling the
risk factors of NCDs. In addition, considerable investments are being
made to reorganize Primary Health Care to better manage NCDs and
to achieve Universal Health Coverage. High level political commitment
is driving the implementation of political commitments made in 2011
and 2014 at the United Nations General Assembly on the Prevention
and Control of NCDs, as part of the national response, in the overall
implementation of the 2030 Agenda for Sustainable Development.

This document, ` Prevention and Control of Noncommunicable

Diseases : Think Globally, Act Locally ; Lessons from Sri Lanka` comes
at a time when the United Nations General Assembly is convening
the 3rd High Level Meeting on NCDs on the 27th of September 2018

vi
in New York, in order to take stock of the global progress in tackling
these diseases. Sri Lanka has been a forerunner in the implementation
of global public health treaties and through this publication, aims to
further its contribution to global health and prevention and control of
NCDs, by sharing best practices and disseminating lessons learned.

Editors

Dr. Rajitha Senaratne

Minister of Health, Nutrition and Indigenous Medicine,
The Democratic Socialist Republic of Sri Lanka.

Prof. Shanthi Mendis

Former Senior Adviser NCDs World Health Organization,
Geneva, Switzerland.

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Contributors:
Noncommunicable Diseases Unit: Champika Wickramasinghe (Deputy
Director General/ NCD), Tilak Siriwardana, Virginie Mallawaarachchi
Ministry of Health: Sujatha Senaratne (Private Secretary to the Hon.
Minister of Health), Anil Jasinghe (Director General of Health Services),
Lakshmi Somatunga (additional Secretary/ Pubic Health Directorate),
S. Subasinghe (Adviser)
Environmental and Occupational Health Directorate: Lakshman Gamlath
(Deputy Director General/ Environmental & Occupational Health),
I. Suraweera, S. Dhanapala
Family Health Bureau: Ayesha Lokubalasooriya, Nethanjali Mapitigama
National Cancer Control Programme: Sudath Samaraweera (Deputy
Director General, Education, Training & Research), Suraj Perera
Health Promotion Bureau: P. Palihawadana, A. Alagiyawanna,
B.K. Batuwanthudawa
Primary Care Services: Udaya Ranasinghe, Dileep de Silva
Education Training and Research: Sunil De Alwis (Additional Secretary/
Medical Services), Umanga Sooriyaarachchi
Nutrition Division: Bhanuja Wijayatilaka , Rasanjalie Hettiarachchi
Organization and Development: Susie Perera (Deputy Director General,
Public Health Services)
National Programme Tuberculosis Control and Chest Diseases:
Kanthi Ariyarathna
Quarantine Unit: Palitha Karunapema
Medical Supplies Division: Lal Panapitiya
National Authority on Tobacco and Alcohol: Palitha Abeykoon
(Chairman), T. Abeynayake
National Medicines Regulatory Authority: A. de Silva (Chairman),
K. Jayasinghe
Institute of Sport Medicine: L. Edirisinghe
(Director General/ Ministry of Sports)
Department of Nutrition, Medical Research Institute: Renuka Jayatissa
School Health and Nutrition, Ministry of Education: Renuka Peiris

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Youth Affairs: K. Keeragala (Additional Secretary)
Department of National Budget: Ajitha Batagoda
Sri Lanka Medical Association: S. Gunasekera, C. Wijeyaratne
College of Physicians: Nirmala Wijekoon, Asanga Ratnayaka,
D. Chandrasena
College of Internal Medicine: K. C. Janaka
College of Cardiologists: Anidu Pathirana, Nimali Fernando,
Jayanthimala Jayawardana
College of Neurologists: Padma Gunaratne
College of Endocrinologists: Noel Somasundaram, U. Bulugahapitiya,
P. Katulanda, A. Sumanathilaka
College of Respiratory Physicians: Amitha Fernando
Sri Lanka Society of Internal Medicine: Chamila Mettananda,
Shamitha Dassanayake
The World Bank: Deepika Attygala
Presidential Secretariat: Samantha K. Kithalawaarachchi
Lead Author: Shanthi Mendis, (Former Senior Adviser NCDs,
World Health Organization)

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Executive Summary
Noncommunicable Diseases (NCDs), currently pose a major threat
to health and development worldwide. Each year, 15 million people
between the ages of 30 and 69 years die from NCDs; over 80% of
these premature deaths occur in developing countries such as Sri
Lanka. NCDs rank among the top 10 causes of premature death in
Sri Lanka. In Sri Lanka, although people are living longer, they live
more years suffering from disease and disability, mainly from NCDs;
life expectancy at birth in Sri Lanka is 74.9 years but healthy life
expectancy at birth is only 67.0 years. Few risk factors drive NCDs
and death and disability due to them. They include tobacco use,
harmful use of alcohol, overweight due to unhealthy diet and physical
inactivity, air pollution and poverty. The key drivers of the NCD burden
are population ageing, effects of globalization on marketing and trade
and rapid urbanization. According to the most recent population based
risk factor survey, among 18-69 year old Sri Lankans, prevalence of
current smoking is 29% in males. About one forth have hypertension
or raised blood cholesterol, one third are overweight or obese and
7.4% have raised blood glucose. Available data indicate that both
indoor air pollution and ambient air pollution contribute to the rising
NCD burden.

The aim of this document is to reflect on the challenges and

achievements of tackling NCDs in Sri Lanka over the last two decades
and share best practices and lessons learned with the rest of the world.
It also identifies critical gaps and areas which need attention. Chapters
1 and 2 present the context in which Sri Lanka is endeavouring to
address NCD. Chapters 3 to 13 document how Sri Lanka has launched
and taken forward the national NCD response, giving priority to
affordable and very cost effective NCD interventions, which reduce
exposure of the population to NCD risk factors and provide early
detection and timely treatment of major NCDs (cardiovascular disease,
cancer, chronic respiratory disease and diabetes). The lessons learned
in this undertaking is summarized in the final chapter (Chapter 14).

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Sri Lanka has the highest Human Development Index in South East
Asia and a stellar performance in maternal and child health. However,
combating NCDs is a much more complex and challenging task
compared to delivering on communicable diseases and maternal
and child health agenda for many reasons. First, NCDs encompass
a broad array of chronic diseases. Second, although the major NCDs
are preventable, the health sector has little sway on the drivers and
determinants of NCDs. Preventive strategies are met with intense
national and international commercial resistance. Strong political
commitment, legal support, and a multidisciplinary health workforce
- rare commodities in the developing world- are needed to overcome
this resistance. Further, most NCDs have long incubation periods and
are asymptomatic in early treatable stages making early detection
difficult. Finally, although curative interventions are available to treat
some NCDs, only a handful of of them are cost effective, affordable and
scalable in the context of health systems in low and middle -income
countries. These challenges have not deterred Sri Lanka from taking
action against NCDs.

Recognizing the devastating impact of NCDs on health and

development, in 2011, a political declaration which contains a roadmap
of commitments to tackle NCDs, was adopted by the United Nations
General Assembly. The WHO Global Action Plan for the Prevention
and Control of NCDs 2013–2020, endorsed by the World Health
Assembly in May 2013, sets priorities and provides strategic guidance
on how countries can implement these commitments. Current NCD
activities in Sri Lanka are guided by a National Multisectoral Action
Plan for Prevention and Control of NCDs 2016-2020 that is consistent
with the Global NCD Action Plan. In keeping with the Global and
Regional Monitoring Frameworks, Sri Lanka has also set 10 national
targets including a target to reduce premature NCD mortality (Target
1). The targets focus on the following: harmful use of alcohol (Target
2), physical inactivity (Target 3), salt consumption (Target 4), tobacco
use (Target 5), hypertension (Target 6), obesity and diabetes (Target 7),
prevention of heart attacks and strokes through a total risk approach
(Target 8), access to essential NCD medicines and technologies (Target
9) and indoor air pollution (Target 10). In September 2015, world

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leaders adopted the 2030 agenda for Sustainable Development, which
has 17 Goals. The agreed Sustainable Development Goals (SDGs), can
only be achieved if debilitating diseases such as NCDs are successfully
tackled. Thus goal 3 of this Agenda is devoted to health and wellbeing
including NCDs. Sri Lanka is incorporating the national NCD agenda
within the National SDG response.

In Sri Lanka, the Public Sector provides preventive care, a large portion
of inpatient care and less than half of outpatient curative care, free at
the point of delivery. However, the heavy demands of the emerging
NCD agenda are causing disparities in health financing and service
provision. There is growing dependence on out-of-pocket payments
mainly due to NCD related health care. When there are shortages in
diagnostics and medicines in the public health sector, people pay out-
of- pocket to access them. Vulnerable households are susceptible to
impoverishment and catastrophic health expenditure when they seek
care for NCDs.

Across the national NCD targets, Sri Lanka has prioritized NCD action
in three target areas. It has made significant progress in tobacco control
(Target 5- see Chapter 7), early detection and treatment of people with
high cardiovascular risk to prevent heart attacks and strokes (Target
8- see Chapter 10) and access to medicines and basic technologies
(Target 9- see Chapter 11). Work is in progress in other NCD areas-
reducing harmful use of alcohol (Target 2- see Chapter 4), reducing
physical inactivity (Target 3 – see Chapter 5) and salt intake (Target
4- see Chapter 6), reducing the prevalence of hypertension –(Target 6
-see Chapter8), halting obesity and diabetes (Target 7-see Chapter 9)
and reducing indoor air pollution (Target 10-see Chapter 12).

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Lessons learned (see Chapter 14)
Lesson 1. The national NCD response can be fortified by leveraging
global health strategies and treaties.

The experience of Sri Lanka demonstrates the importance of leveraging

Global Health Strategies and Treaties to shape and fortify the national
NCD response.

Lesson 2: Key ingredients which have been responsible for the

success of other public health programs are equally important for
effective NCD prevention and control

Advancing the NCD agenda in Sri Lanka from 2000 onwards, was
carried out amidst the challenges posed by other competing health
priorities (maternal and child health, and communicable diseases),
natural disasters (a devastating tsunami, floods and earth slips) and a
protracted armed conflict. This challenging experience has ascertained
the key ingredients that drive the success of public health programs
including NCD prevention and control. They include :

i. Improvements in living standards, education and gender

equity;

ii. Sustainable funding;

iii. Equitable access to health services;

iv. Commitment to technical excellence;

v. Investment in capacity strengthening of the health workforce;

vi. Focus on high-risk population segments to improve cost

effectiveness;

vii. Early detection, diagnosis and affordable treatment;

viii. Intensive surveillance, monitoring and evaluation;

ix. Community engagement and partnerships;

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x. Learning from operational research.

Lesson 3: Prioritization is the pragmatic option for addressing

NCDs in resource constrained settings

Sri Lanka, like many other developing countries have very limited
resources for health. Sri Lanka therefore prioritized action related to
four national targets; target 1 (reducing premature mortality), target
5 (tobacco control), target 8 (prevention of heart attacks and strokes
through a total risk approach) and (target 9) access to essential medicines
and basic technologies. Very cost effective interventions (WHO best
buys) related to these NCD domains have been implemented (see
Chapters 3, 7, 10 and 11). Now that there is demonstrable progress in
these areas, NCD activities are being rapidly expanded to encompass
other targets.

Lesson 4: An intervention which is very cost effective is affordable

to the country and is therefore scalable and sustainable.

Although there are many interventions for management of NCDs, only

two are very cost effective. One of them is prevention of heart attacks
and strokes through a total cardiovascular risk approach.

Sri Lanka has a fast ageing population with rising prevalence rates
of both hypertension and diabetes and heart attacks and strokes are
the leading NCDs. Taking cognizance of the urgent need to prevent
heart attacks and strokes, in a limited resource setting, Sri Lanka
embraced the very cost effective total risk approach, which uses both
hypertension and diabetes together, as entry points to detect those
at medium to high cardiovascular risk (WHO best buy). As discussed
in Chapters 8 and 10, vertical single risk factor programs, such as a
program focusing only on hypertension cannot be equitably delivered
or sustained in a developing country like Sri Lanka, because the country
has a modest per capita health expenditure. The recently approved
government policy to reform Health Care Delivery to attain Universal
Health Coverage, will enable the expansion of this program island-

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wide by including this very cost effective intervention in the essential
health services package.

Lesson 5: Public–private undertakings to address NCDs are

more likely to succeed when governments establish legislative
frameworks to protect public health.

In order to reduce the sugar content in sweetened beverages in Sri

Lanka, the Ministry of Health engaged with the private sector and
jointly developed a technical guideline. The expectation was that
beverage manufacturers would comply with the guideline voluntarily.
However, beverage manufacturers complied with the guideline only
when a binding law was introduced (see Chapter 9).

Lesson 6: NCD prevention in children can be effectively

operationalized through schools.

Sri Lanka has successfully used the machinery of a well organized

School Health Service to operationalize NCD prevention in children.
The programme is a shared responsibility of the Ministry of Health and
Ministry of Education and is a good example of collaboration between
two Ministries to achieve a shared national goal – physical and mental
health and wellbeing of children (see Chapter 5).

Lesson 7: Collaboration between the health sector and sectors

outside health can be facilitated and accelerated by a lead agency.

Multisectoral collaboration is essential for NCD prevention and control

but is one of the most difficult endeavors. The progress made in
tobacco control in Sri Lanka demonstrate that a lead agency working
closely with the Ministry of Health, can galvanise multisectoral action
by actively seeking opportunities to collaborate with and influence
sectors outside health. In Sri Lanka, The National Authority on Tobacco
and Alcohol (NATA) was established by the National Authority on

xvi
Tobacco and Alcohol Act, No. 27 of 2006 for the purpose of enactment
of the legal aspects for alcohol and tobacco prevention. The National
Authority on Tobacco and Alcohol has demonstrated good results in
working across sectors for implementing tobacco control measures
(see Chapter 7).

Lesson 8: High level political commitment is essential for NCD

prevention and control.

High level political commitment is one of the essential ingredients of

success in NCD prevention and control. The tobacco industry continues
to undermine national efforts to prevent tobacco use including through
legal action against the Government of Sri Lanka. Steadfast high level
political leadership and civil society resistance have been instrumental
in overpowering tobacco industry interference, over the years (see
Chapter 7). The strong commitment of the present Minister of Health,
Dr Rajitha Senaratne, has been instrumental in accelerating progress
of NCD prevention and control, in the recent past. As a result of his
leadership, the prices of a range of essential NCD medicines have
been reduced and they have become more affordable to people (see
Chapter 11). This is an important development because in Sri Lanka,
50% of people purchase medicines out of pocket and price is a key
determinant of access to medicines. In addition, Sri Lanka has also
been able to withstand pressure from the food and beverage industry
and introduce traffic light labelling on sweetened beverages and a
sugar tax (see Chapter 9).

Sri Lanka has laid a robust public health foundation to tackle NCDs.
Public health successes in communicable diseases and maternal
and child health, enable Sri Lanka to further accelerate progress in
prevention and control of NCDs. However, it is important to recognize
that this would not translate into an influx of significant amounts of
additional resources for combatting NCDs. Thus, as resources will
continue to be limited, staying the course on very cost effective NCD
interventions (best buys) related to 10 NCD targets (see Chapters 3
to 12) and good buys (see Chapter 13), would be critical for winning

xvii
the fight against NCD. A larger share of the health budget needs to
be allocated to NCD prevention and primary care, where the largest
health gains could be achieved. Additional public sector funding
is required to provide full coverage of cost-effective essential NCD
services and to attain Universal Health Coverage. Moving forward, Sri
Lanka needs to scale- up all WHO best buys first, in order to attain
the 10 national NCD prevention and control targets. Implementation
of the new national policy on health care delivery reform for Universal
Health Coverage will help to further accelerate the pace of combatting
NCDs, and help to protect the health and wellbeing of present and
future generations of Sri Lanka.

Tackling NCDs in a developing country, under the pressures of

demographic ageing, rapid urbanization, and the globalized marketing
of unhealthy products is a daunting task. Sri Lanka has most of the
key ingredients - steadfast political leadership, strong public health
foundation, dedicated health workforce and a robust civil society-
required to accomplish this formidable task.

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PART I

1
2
CHAPTER 1

Sri Lanka today: A snapshot

Key messages
• Sri Lanka has the highest Human Development Index in
South East Asia and a stellar performance in maternal and
child health.

• Noncommunicable diseases (NCDs) are the highest ranking

cause of premature death in Sri Lanka, with cardiovascular
diseases in the lead.

• Tobacco use, harmful use of alcohol, physical inactivity,

unhealthy diet and air pollution are the major risk factors
driving NCDs.

• Challenges of addressing the NCD burden are made worse

by a rapidly ageing population.

• People in Sri Lanka are living longer but they live more years
suffering from disease and disability, mainly from NCDs.

• The public health approach to combat NCDs has to be

an integral component of the national response to attain
Sustainable Development Goals

Background
The Democratic Socialist Republic of Sri Lanka is a lower-middle-
income, island country in South Asia. It has a population of 20.3 million
with 18.2 % of the population living in urban areas (1). The population
density is 327 per square kilometer, placing Sri Lanka at the 13th position
among the 100 most populous countries in the world. Literacy rate, in

3
the population 10 years and above is 96.8% and 94.6% among males
and females respectively. Sri Lanka has a large working population with
25-54 year old individuals dominating the country. Around 42.6% of
the total population are in this productive age group. Employment rate
is 94.3% among males and 90.3% among females, in the population
aged 15 years and above. About 81% of households have safe drinking
water and 87% households have electricity. While 69% and 79% of
households have radio and television access respectively, only 11%
have internet facilities within the house (1).

Administrative setup
For administrative purposes Sri Lanka is divided into 9 provinces
since 1889 (Figure 1.1). Two third of the total population live in four
provinces; Western province (28.7%), Central province (12.6 %),
Southern province (12.2%) and North-western province (11.7 %).

Figure 1.1 The nine provinces of Sri Lanka

4
Each province is subdivided into districts and there are 25 districts
(Figure 1.2)

Figure 1.2 The 25 districts of Sri Lanka

Each district is divided into Divisional Secretarial Areas (n=331) and

further subdivided into Grama Niladhari Divisions (n=14021). The
Grama Niladhari Divisions are either a collection of small villages or a
part of a larger village. There are 23 Municipal Councils and 41 Urban
and 271 Pradeshiya Sabha Areas.

Success in many fronts

Sri Lanka is considered the oldest democracy in Asia and achieved
Universal suffrage in 1931 (2). Since 1945, Sri Lanka has implemented
a free education policy (3), resulting in a current high literacy rate of
93%, with a world literacy ranking of 87 (4). Sri Lanka has had a health

5
system that has been free at the point of delivery since 1951 (2). Since
the mid 1920s health services have been delivered through a primary
health care approach, predating the Declaration of Alma Ata in 1978
(5, 6).

Sri Lanka has shown a stellar performance in the areas of maternal

and child health. The current maternal mortality rate is 30 per 100 000
live births (7). It has therefore already achieved the SDG Target 3.1
(to reduce the global maternal mortality ratio to less than 70 per 100
000 live births by 2030) (8). The current neonatal mortality rate is 8 per
1000 live births and under-five mortality is 9.8 per 1000 live births (7). It
has therefore achieved the SDG Target 3.2 as well (to reduce neonatal
mortality to at least as low as 12 per 1000 live births and under-five
mortality to at least as low as 25 per 1000 live births by 2030). With a
zero Malaria incidence and a low HIV incidence it is making significant
strides in attaining SDG target 3.3 (end the epidemics of AIDS,
tuberculosis, malaria and neglected tropical diseases and combat
hepatitis, water-borne diseases and other communicable diseases by
2030) (7, 8). As a result of these achievements in health, socioeconomic
development, and progress in education life expectancy in Sri Lanka
has improved remarkably (Figure 1.3 ).

Figure 1.3 Life expectancy at birth in males and females in Sri

Lanka 1990-2016 (source : IHME celebrating 10 years of measuring
what matters. Institute of Health Metrics and Evaluation; Sri Lanka.
http://www.healthdata.org/sri-lanka)

6
Highest Human Development Index in South East
Asia
In 2015, Sri Lanka had the highest Human Development Index in the
South East Asia Region (Table 1.1). It ranked 73 among 188 countries
(9).

Table 1.1 Human Development in Countries in the South East Asia

Region

Country Global rank Human Development Index

Sri Lanka 73 0.766

Thailand 87 0.740

Indonesia 113 0.689

India 131 0.624

Bhutan 132 0.607

Timor Leste 133 0.605

Nepal 144 0.558

Myanmar 145 0.556

The Human Development Index integrates three basic dimensions of

human development; Life expectancy at birth which reflects the ability
to lead a long and healthy life; Mean years of schooling and expected
years of schooling which reflect the ability to acquire knowledge
and the gross national income per capita which reflects the ability to
achieve a decent standard of living. For Sri Lanka the corresponding
figures were 74.9 years, 14 years, 10.9 years and 10, 789 (2011 PPP$)
respectively.

Ageing population
Sri Lanka is experiencing a large and rapid increase in the elderly
population due to a combination of low fertility and high life expectancy

7
rates. Aging Index defined as the ratio between the 60 years and over
population, to 0-14 year population in a given year has increased from
18.8 % in 1981 to 49.1% in 2015. The median age of the population
in Sri Lanka has increased from 21.3 years to 31 years from 1981 to
2012. The median age is projected to rise to 39.6 years by 2031 and
to 46.5 years by 2086 making Sri Lanka one of the fastest ageing
countries in Asia. The share of the population age 60 years and older
is expected to double in the next three decades to 24 % (10). These
demographic changes  will lead to unprecedented economic, social,
public health and public policy challenges mainly due to the burden
of noncommunicable diseases (NCDs).

High burden of NCD risk factors

As shown in Figure 1.4, worldwide, few behavioural, environmental
and social

Figure 1.4 Behavioural, social, environmental determinants, drivers

and risk factors of noncommunicable diseases

risk factors drive NCDs and death and disability due to them. They
include tobacco use, harmful use of alcohol, overweight due to
unhealthy diet, physical inactivity, pollution and poverty. Long-term
metabolic impact of these factors manifest as raised blood pressure,
raised blood sugar and raised blood cholesterol. These are major risk
factors of NCDs which lead to cardiovascular disease (mainly heart
disease and stroke), cancer, chronic respiratory disease and diabetes.

8
In addition to population ageing, effects of globalization on marketing
and trade and rapid urbanization are driving unhealthy behaviours ;
tobacco and alcohol use, consumption of unhealthy diets and physical
inactivity. Individuals as well as the conventional health sector have little
sway in controlling these trends. Consequently, the general population
is already incubating high levels of risk factors that promote NCDs, as
shown by the results of risk factors surveys in children (11 ) and adults
(12). According to the most recent STEPs survey, among 18-69 year
old Sri Lankans, prevalence of current smoking is 29% in males. About
one forth have hypertension or raised blood cholesterol, one third are
overweight or obese and 7.4% have raised blood glucose ( 12 ). Unless
timely action is taken, todays risk factors will push the already high
rates of NCDs even higher, in the future.

Leading risk factors in Sri Lanka, their ranking and contribution to the
disease burden is shown in Figure 1.5. The importance of reducing
exposure to tobacco use, harmful use of alcohol, unhealthy diet,
physical inactivity and air pollution, particularly in children and the
young age groups is clear. If this is not done prevalence rates of
hypertension, diabetes and high lipids in adults will rise further.

Figure 1.5 Top ten risk factors driving death and disability (DALYs)
in Sri Lanka in 2016 and percent change 2005 to 2016 (Source:
IHME celebrating 10 years of measuring what matters. Institute of
Health Metrics and Evaluation; Sri Lanka)
http://www.healthdata.org/sri-lanka

9
High levels of disease and premature death due
to NCDs
Already, NCDs make a sizable contribution to morbidity, mortality
and high health care costs. In 2015, there were 113600 deaths due
to NCDs (7). As shown in Figure 1.6 ischemic heart disease, diabetes,
cerebrovascular disease, asthma, chronic obstructive pulmonary
disease and chronic kidney disease are among the top 10 causes of
death in Sri Lanka (13 ).

Figure 1.6 Top ten causes of death in Sri Lanka in 2016 and percent
change 2005 to 2016 (Source: IHME celebrating 10 years of
measuring what matters. Institute of Health Metrics and Evaluation;
Sri Lanka)

NCDs (ischemic heart disease, diabetes, cerebrovascular disease,

chronic kidney disease, asthma and chronic obstructive pulmonary
disease ) also rank among the top 10 causes of premature death. A
higher proportion of men compared to women are dying due NCDs,
prematurely. In 2015, 54% of male NCD deaths and 36% of female NCD
deaths were below 70 years ( 13). High levels of premature mortality
have a detrimental impact on productivity and economic growth.

10
Figure 1.7 Comparison of the top 10 causes of premature death
(YLL) in Sri Lanka in 2016, with the group average for selected
middle-income countries (Source: IHME celebrating 10 years of
measuring what matters. Institute of Health Metrics and Evaluation;
Sri Lanka)

Blue=Significantly lower than mean

Beige=Statistically indistinguishable from mean
Red=Significantly higher than mean
Age-standardized rate per 100,000,2016

Figure 1.8 Comparison of the top 10 causes of death and disability

(DALYs) in Sri Lanka in 2016, with the group average for selected
middle-income countries. (Source: IHME celebrating 10 years of
measuring what matters. Institute of Health Metrics and Evaluation;
Sri Lanka)

Blue=Significantly lower than mean

Beige=Statistically indistinguishable from mean
Red=Significantly higher than mean
Age-standardized rate per 100,000, 2016

Figure 1.7 shows that premature deaths and disability due to diabetes,
asthma and self harm are higher in Sri Lanka compared to the group
average. Figure 1.8 shows that ischemic heart disease is one of the
highest contributors to the disease burden and that the disease burden

11
due to diabetes, stroke and chronic respiratory disease are higher in
Sri Lanka, compared to the group average.

As shown in Figure 1.9, ischemic heart disease, diabetes, cerebrovascular

disease, asthma and chronic obstructive pulmonary disease are among
the top 10 causes of death and disability combined. They rank 1, 2,
5, 8, 9 respectively, among the first 10 causes of combined death and
disability (13).

Figure 1.9, Top ten causes of death and disability combined (Source:
IHME celebrating 10 years of measuring what matters. Institute of
Health Metrics and Evaluation; Sri Lanka)

In addition to NCDs, Sri Lankas disease burden due to self-harm,

road injuries, back pain and sense organ diseases are quite high, and
contribute significantly to premature death (Figure 1.8) (13).

People live longer but suffer from NCDs in later

years
In 2015, life expectancy at birth in Sri Lanka was 74.9 years and the
global life expectancy was 71.4 years. In comparison, life expectancy
exceeded 82 years in 12 countries: Australia, Canada, France, Iceland
, Israel, Italy, Japan, Singapore, Spain, Sweden, Switzerland and the
Republic of Korea. It must be noted that in Sri Lanka, there is already
a gap between life expectancy at birth (74.9 years) and healthy life

12
expectancy at birth (67.0 years) . Based on 2015 data, the gap was
7.9 years (14, 15). This means that although people are living longer,
they live more years suffering from disease and disability, mainly from
NCDs . On average, women live longer than men in every country
in the world including Sri Lanka where there is a 6.7 years gap in life
expectancy between males (life expectancy 71.6 years) and females
(life expectancy 78.3 years). Male-female life expectancy gaps are
lower in developed countries compared to developing countries, with
lowest reported in Iceland and Sweden (3.0 and 3.4 years respectively
(14, 15).

Challenges of tackling NCDs

Prevention and control of NCDs is a much more complex task compared
to tackling communicable diseases and maternal and child health. There
are several reasons for this complexity. First, NCDs encompass a broad
array of diseases ranging from disorders of the heart, blood vessels,
nerves, lungs, kidney, endocrine glands, joints, digestive system and
other systems. Only some of NCDs are preventable; cardiovascular
disease, cancer, chronic respiratory disease and diabetes. Second, to
prevent NCDs, exposure of the population to NCD risk factors has to
be reduced, throughout the life-course. The health sector has little
sway on the drivers and determinants of these risk factors as they
lie outside its jurisdiction (16). Third, preventive strategies are often
met with intense national and international commercial opposition.
To enact and implement NCD policies against commercial pressure,
there has to be strong political commitment, legal support, and a
multidisciplinary health workforce; rare commodities, particularly
in the developing world. Fourth, treatment of NCDs is even more
challenging than prevention because most NCDs have long incubation
periods and are asymptomatic in early treatable stages. Strategies for
early detection is therefore critical (17, 18). Further, although curative
interventions are available to treat most NCDs, only some of them are
cost effective, affordable and scalable in the context of health systems
in low -and- middle- income countries. To successfully combat NCDs,

13
not only should cost effective interventions be prioritized, but they
should also be implemented at scale through a primary health care
approach. Finally, NCDs increase the demand for high technology
interventions. Many new medical  technologies  and interventions to
address NCDs are emerging and generally tend to improve clinical
results at an increased cost. These developments are causing high
income countries to devote rising amounts of financial resources to
health care. Low- and- middle- income countries try to follow -suit,
diverting resources from prevention and primary care jeopardizing
equity and sustainability.

Despite equitable health and education policies and good performance

in maternal and child health and communicable diseases, tackling
NCDs poses a major challenge for Sri Lanka because of demographic
and epidemiological transitions, complexities in combating NCDs
discussed above and resource constraints (see Chapter 2 ).

Global and local milestones

The United Nations Political Declaration on NCDs adopted at the
United Nations General Assembly in 2011, includes a roadmap of
commitments made by governments (19). The WHO Global Action
Plan for the Prevention and Control of NCDs 2013–2020 endorsed by
the World Health Assembly in May 2013, sets priorities and provides
strategic guidance on how the road map can be implemented at
country level (16). Sri Lanka has developed a National Multisectoral
Action Plan for Prevention and Control of NCDs 2016-2020, which
is consistent with the Global NCD Action Plan (20). In keeping with
the Global Monitoring Framework, Sri Lanka has set national targets
that focus on risk factors - tobacco use, high blood pressure, high salt
intake, obesity, physical inactivity and air pollution- as well as targets
on access to essential NCD medicines and technologies, and drug
therapy for prevention of heart attacks and strokes.

In September 2015, at an historic summit of the United Nations, world

leaders adopted the 2030 agenda for Sustainable Development, which

14
has 17 Goals. The agreed Sustainable Development Goals (SDGs),
which replaced the Millennium Development Goals (MDGs), can only
be achieved if debilitating diseases such as NCDs are tackled. Goal
3 of the Sustainable Development Agenda is devoted to health and
wellbeing including NCDs (21).

Poverty and NCDs

Due to low resilience, people living in poverty are more vulnerable
to behavioural and environmental risk factors that drive NCDs. The
economic vulnerability of the poor is also high, with a higher probability
of them falling into extreme poverty and debt during catastrophic
illnesses like heart attacks and strokes. In addition, poor do not access
health services when out-of-pocket expenditure is high, leading to
delay in diagnosis and worse health outcomes.

According to the Household Income and Expenditure Survey conducted

by the Department of Census and Statistics, the Poverty Headcount
Ratio in Sri Lanka has decreased from 28.8% in 1995 to 6.7% in 2013.
Wide regional disparities remain (22). At a provincial level, while the
Western Province recorded the lowest level of Poverty Headcount
Ratio (2%), the Uva Province showed the highest level (15.4%). The
Gini coefficient, which measures the depth of the inequality, in terms of
household income was 0.48 in 2012/13. Although, extreme poverty is
low in Sri Lanka, 14.6% population falls in to the ‘nearly poor’ category
(living below USD 3.10 per day in 2011 Purchasing Power Parity
terms). Most of the poor live in rural areas and engage in small-scale
agriculture. Agricultural productivity of small-scale farms has declined
in recent years partly due to poor access to water.

The Samurdhi/Divineguma subsidy programme, is the main social safety

net programme, benefiting 1.41 million families (23). Additionally, in
order to uplift the nutritional status among mothers and children, the
Ministry of Women and Child Affairs disburse assistance under the
programmes of food packages for pregnant mothers and fresh milk for
children between 2-5 years. There are several other social assistance

15
programmes, including the school food programme, Thriposha
programme and disability and disaster relief assistance, which help
the poor in the short-term.

Taking forward interconnected agendas: NCDs

and SDGs
There is a mutually reinforcing relationship between NCDs and several
Sustainable Development Goals such as poverty, inequality and
economic growth and development. Others goals - hunger; health
education; gender equality; water and sanitation; energy; industry,
innovation and infrastructure; sustainable cities; consumption and
production; climate change; marine resources; terrestrial ecosystems;
peace, justice and accountability; and global partnerships- are also
directly or indirectly linked to NCDs.

During the last three decades Sri Lanka has seen economic growth,
and improvement in standards of living and health. At the same time,
rising disposable incomes have increased exposure to behavioural risk
factors resulting in the growing NCD burden. In addition, population
growth is causing numerous environmental problems such as pollution,
land degradation, scarcity of water resources, loss of biological
diversity, inadequate waste disposal and traffic congestion (24). All
these, have varying degrees of impact on NCDs and their risk factors.

Sri Lanka is a biodiversity “hotspots” in the world with a high density of

plants and animal species per unit area. Its biodiversity is threatened
due to pollution and loss of forest cover. Forest cover- which is also
important for mitigation of climate change- has shown a steady decline
over the last decade (25). Land degradation due to inappropriate land
use and soil erosion is widespread and manifests in a variety of ways
such as decreasing land fertility and landslides. Increased demand
for water from the industrial sector, rapid urbanization and the
consequent generation of waste and industrial effluents are causing
water and soil pollution. Harmful effects on health of the use of large

16
quantities of pesticides, herbicides and fertilizer for agriculture is
already manifesting as high rates of kidney disease in some parts of Sri
Lanka (26). Traffic congestion is contributing to high levels of ambient
air pollution and NCDs, particularly in cities (see Chapter 12). Due to
the interconnectedness of NCDs and Sustainable Development Goals,
efforts to attain the targets of the sustainable development agenda
have the potential to confer a broad spectrum of benefits in mitigating
NCDs.

To take the Sustainable Development Agenda forward, Sri Lanka has

established a legal framework (27), and identified five key policy areas:
i)eradication of poverty, ii)ensuring competitiveness of the economy, iii)
improving social development, iv) ensuring good governance, and v)
a clean and healthy environment. Given the evidence interconnecting
NCDs with the Sustainable Development Agenda (28-31), country
efforts to tackle NCDs should be closely integrated within the national
response to attain the 2030 Sustainable Development Agenda.

References
1. Report on Census of Population and Housing 2012. Department of
Census and Statistics. Ministry of Policy Planning and Economic Affairs.
Colombo, Sri Lanka.
2. A History of Sri Lanka, K. M. de Silva,  Oxford University Press,
London (1981) ISBN 10: 0195616553. 
3. Education First-Sri Lanka. Ministry of Education, Colombo, Sri Lanka
2013.
4. Index Mundi: https://www.indexmundi.com/sri_lanka/literacy.html.
5. A history of medicine in Sri Lanka. Uragoda CG. Colombo: Sri Lanka
Medical Association, 1987.
6. Annual Health Bulletin 2013. Medical Statistics Unit. Ministry of Health,
Nutrition and Indigenous Medicine, Colombo, Sri Lanka.
7. Annual Health Bulletin 2015. Medical Statistics Unit. Ministry of Health,
Nutrition and Indigenous Medicine, Colombo, Sri Lanka.
8. A/RES/70/1 - Transforming our world: the 2030 Agenda for Sustainable
Development  United Nations 2015.

17
9. UNDP. Human Development Report 2016. Development for Everyone.
10. De Silva W Indralal. A population projection of Sri Lanka for the new
millennium 2001-2010: Trends and implications. Colombo. Institute for
Health Policy 2007 .
11. Report of the 2016 Sri Lanka Global School-Based Student health
survey. Ministry of Health, Nutrition and Indigenous Medicine and
Ministry of Education. Government of Sri Lanka 2017.
12. Noncommunicable disease risk factor survey in Sri Lanka 2015. Ministry
of Health, Nutrition and Indigenous Medicine, Sri Lanka and World
Health Organization 2015.
13. IHME celebrating 10 years of measuring what matters. Institute of
Health Metrics and Evaluation; Sri Lanka. http://www.healthdata.org/
sri-lanka
14. World health statistics 2017: monitoring health for the SDGs,
Sustainable Development Goals World Health Organization Geneva
ISBN 978-92-4-156548-6.
15. World Bank. 2017. World Development Indicators 2017. Washington,
DC. © World Bank. https://openknowledge.worldbank.org/
handle/10986/26447 License: CC BY 3.0 IGO.”
16. Global action plan for the prevention and control of noncommunicable
diseases 2013−2020. Geneva: World Health Organization; 2013.
(http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_
eng.pdf?ua=1).
17. Global status report on noncommunicable diseases 2010. Geneva:
World Health Organization; 2011. (http://www.who.int/nmh/
publications/ncd_report_full_en.pdf)
18. Global status report on noncommunicable diseases 2014. Geneva:
World Health Organization; 2014.
19. A/RES/66/2. Political Declaration of the High-level Meeting of
the General Assembly on the Prevention and Control of Non-
communicable Diseases. Resolution adopted by the General
Assembly [without reference to a Main Committee (A/66/L.1)]. United
Nations General Assembly, Sixty-sixth session, agenda item 117, 24
January 2012. (http://www.who.int/nmh/events/un_ncd_summit2011/
political_declaration_en.pdf).
20. National multisectoral action plan for the prevention and control
of noncommunicable diseases 2016-2020. Ministry of Health and

18
Indigenous Medicine, Sri Lanka; 2015.
21. A/RES/70/1 Transforming our world: the 2030 Agenda for Sustainable
Development. United Nations General Assembly 21st October 2015.
22. Sustainable Development Goals Knowledge Platform. New York:
United Nations. (https://sustainabledevelopment.un.org).
23. Household Income and Expenditure Survey 2016. Department of
Census and Statistics. Colombo Sri Lanka.
24. Central Bank of Sri Lanka. Annual Report 2016.
25. Ekanayake EMBP, Theodore M Forest Policy for sustainability of Sri
Lanka’s Forest. International Journal of Sciences 2017;(1) 6: 27-33.
26. Jayatilake N,  Mendis  S, Maheepala P, Mehta FR; CKDu National
Research Project Team. Chronic kidney disease of uncertain aetiology:
prevalence and causative factors in a developing country. BMC
Nephrol. 2013 Aug 27;14:180. doi: 10.1186/1471-2369-14-180.
27. The Sri Lanka Sustainable Development Act, No. 19 of 2017. Parliament
of the Democratic Socialist Republic of Sri Lanka; 2017.
28. Muka T, Imo D, Jaspers L, Colpani V, Chaker L, van der Lee
SJ,  Mendis  S, Chowdhury R, Bramer WM, Falla A, Pazoki R, Franco
OH. The global impact of non-communicable diseases on healthcare
spending and national income: a systematic review. Eur J Epidemiol.
2015 Apr;30(4):251-77. doi: 10.1007/s10654-014-9984-2. Epub 2015
Jan 18. Review.
29. Chaker L, Falla A, van der Lee SJ, Muka T, Imo D, Jaspers L, Colpani
V,  Mendis  S, Chowdhury R, Bramer WM, Pazoki R, Franco OH. The
global impact of non-communicable diseases on macro-economic
productivity: a systematic review. Eur J Epidemiol. 2015 May;30(5):357-
95. doi: 10.1007/s10654-015-0026-5. Epub 2015 Apr 3. Review.
30. Jaspers L, Colpani V, Chaker L, van der Lee SJ, Muka T, Imo
D,  Mendis  S, Chowdhury R, Bramer WM, Falla A, Pazoki R, Franco
OH. The global impact of non-communicable diseases on households
and impoverishment: a systematic review. Eur J Epidemiol. 2015
Mar;30(3):163-88. doi: 10.1007/s10654-014-9983-3. Epub 2014 Dec
21. Review.
31. From burden to “best buys”: reducing the economic impact of non-
communicable diseases in low- and middle-income countries. Geneva:
World Health Organization and World Economic Forum; 2011.

19
20
CHAPTER 2

Spending for health in Sri

Lanka: Where, what and
by whom?

Key messages
• Sri Lanka’s low-cost health care system, provides a good
foundation for the attainment of Universal Health Coverage.

• The Public Sector provides preventive care, a large portion

of inpatient care and less than half of outpatient curative
care, free at the point of delivery.

• The heavy demands of the emerging NCD agenda are

causing disparities in health financing and service provision.

• There is growing dependence on out-of-pocket payments

mainly due to NCD related health care.

• When there are shortages in diagnostics and medicines in

the public health sector, people pay out- of- pocket to access
them.

• Vulnerable households are susceptible to impoverishment

and catastrophic health expenditure when they seek care for
NCDs.

• A larger share of the health budget needs to be allocated to

NCD prevention and primary care, where the largest health
gains could be achieved .

21
• More public sector funding is required to provide full
coverage of cost-effective essential NCD services and to
attain Universal Health Coverage.

Home-grown health financing system

It is only in the last 10 years, health financing reforms in most low-
and middle- income countries have focused on achieving equity in
financing of health care delivery through universal health coverage.
Sri Lanka’s home-grown financing system embraced the principles of
equity and universality as explicit priorities more than half a century
ago. Health care in Sri Lanka is financed mainly by the Government
(Table 2.1 ). Domestic general Government health expenditure as a
proportion of current health expenditure is 54%. Domestic private
health expenditure as a proportion of current health expenditure is
45%. External aid is a minor financing source and contributes only 1%
to the current health expenditure. (1).

Table 2.1 Selected data on health financing in Sri Lanka 2015

(Source: WHO Global Health Observatory 2016)

Indicator Value

Current Health Expenditure as % Gross Domestic Product

(GDP) 3
Domestic General Government Health Expenditure as %
Gross Domestic Product 2
Domestic General Government Health Expenditure as %
General Government Expenditure 8
Current Health Expenditure per Capita in US$ (PPP$) 118 (353)
Domestic Health Expenditure as % of Current Health
Expenditure 99
Domestic General Government Health Expenditure as %
Current Health Expenditure 54
Domestic Private Health Expenditure as % Current Health
Expenditure 45
External Health Expenditure as % of Current Health
Expenditure 1

22
In 2016, Government spending for health accounted for 8% of the
total expenditure (Figure 2.1) (1). In the same year Government spent
10%, 11%, 11% and 6% on other important development priorities
such as education, welfare, transport / communication and Agriculture
/ irrigation respectively (2).

Globally, the average national percentage of total government

expenditure devoted to health was 11.7% in 2014, ranging from 8.8%
in the WHO Eastern Mediterranean Region to 13.6% in the WHO
Region of the Americas (1).

Figure 2.1 Total Government expenditure by function 2016 (Source:

Central Bank of Sri Lanka 2016)

While current health expenditure as a proportion of Gross Domestic

Product (GDP) is 3%, domestic Government health spending as a
share of Gross Domestic Product is only 2%. Consequently, health
expenditure per capita is US$118. (Table 2.1) (2). Government health
spending is low and is similar to other countries in South East Asia

23
which are at comparable levels of economic development (Table
2.2). Except for Maldives, countries in the region spent 1-3% of Gross
Domestic Product on health (3).

Table 2.2 Current health expenditure and Government health

expenditure as a percentage of Gross Domestic Product in Sri
Lanka and other countries in South Asia (Source: World Health
Organization. Global Health Expenditure Database 2016)

Domestic
Health Government Current health
expenditure as health expenditure
Country
a percentage of expenditure as per capita (US$)
GDP (2015) a percentage of (2015)
GDP (2015)
Sri Lanka 3 2 118
Bhutan 3 3 91
India 4 1 63
Indonesia 3 1 114
Maldives 11 9 944
Myanmar 5 1 59
Nepal 6 1 44
Thailand 4 3 219
Timor Leste 3 2 72

However, from a global perspective health spending in Sri Lanka is

quite low (Table 2.3). This fact has to be borne in mind whenever
the public health sector in Sri Lanka decides on treatment
recommendations for prevalent NCDs. For example, at the current per
capita health expenditure, it would not be affordable and sustainable
to provide people with borderline hypertension with free medications.
Recognizing these cost implications, Sri Lanka has already adopted a
very cost effective total risk approach to manage hypertension (see
Chapter 8 and Chapter 10) (4).

24
Table 2.3. Health expenditure per capita by country for 2014
Source: World Health Organization Global Health Observatory
data 2016 http://apps.who.int/gho/data/view.main.
HEALTHEXPCAPAFG?lang=en

Per capita total

expenditure
on health
Countries*
at average
exchange rate
(US$)
Afghanistan, Bangladesh, Benin, Burkina Faso, Burundi,
Central African Republic, Cambodia, Cameroon, Chad,
Democratic Republic of the Congo, Eritrea, Ethiopia,
Gambia, Comoros, Côte d'Ivoire, Ghana, Guinea,
Guinea-Bissau, Haiti, India, Kenya, Kyrgyzstan Lao
<86
People's Democratic Republic, Liberia, Madagascar,
Malawi, Mali, Mauritania, Mozambique, Myanmar,
Nepal, Pakistan, Niger, Rwanda, Senegal, Sierra Leone,
Syrian Arab Republic, Tajikistan, Timor-Leste, Togo,
Uganda, United Republic of Tanzania, Yemen, Zambia
Albania, Algeria, Angola, Armenia, Azerbaijan, Belarus,
Bhutan, Bolivia, Bosnia and Herzegovina, Botswana,
Cabo Verde, China, Congo, Djibouti, Dominica,
Dominican Republic, Egypt, El Salvador, Fiji, Gabon,
Georgia, Guatemala, Guyana, Honduras, Indonesia,
Iran (Islamic Republic of), Iraq, Jamaica, Jordan,
Kiribati, Lesotho, Libya, Malaysia, Mauritius Micronesia,
86 to <500 Mongolia, Montenegro, Morocco, Namibia, Nicaragua,
Nigeria, Papua New Guinea, Paraguay, Peru,
Philippines, Republic of Moldova, Saint Lucia, Samoa,
San Marino, Sao Tome and Principe, Seychelles,
Solomon Islands, Sri Lanka, Sudan, Swaziland,
Thailand, The former Yugoslav Republic of Macedonia,
Tonga, Tunisia, Turkmenistan, Ukraine, Uzbekistan,
Vanuatu, Viet Nam

25
Antigua and Barbuda, Argentina, Brazil, Brunei
Darussalam, Bulgaria, Colombia, Cook Islands, Cuba,
Costa Rica, Ecuador, Equatorial Guinea, Grenada,
Kazakhstan, Latvia, Lebanon, Marshall Islands, Mexico,
500 to <1000
Nauru, Oman, Panama, Poland, Romania, Russian
Federation, Saint Kitts and Nevis, Saint Vincent and
the Grenadines, Serbia, South Africa, Suriname, Turkey,
Tuvalu, Venezuela (Bolivarian Republic of)
Bahrain, Bahamas, Barbados, Chile, Croatia, Cyprus,
Czech Republic, Estonia, Greece, Hungary, Kuwait,
1000 to <2000 Lithuania, Maldives, Niue, Palau, Saudi Arabia,
Slovakia, Trinidad and Tobago, United Arab Emirates,
Uruguay
Israel, Malta, Portugal, Qatar, Republic of Korea,
2000 to <3000
Singapore, Slovenia, Spain
Andorra, Italy, Japan, United Kingdom of Great Britain
3000 to <4000
and Northern Ireland
Belgium, Finland, France, Iceland, Ireland, New
4000 to <5000
Zealand
5000 to <6000 Austria, Canada, Germany, Netherlands
6000 to <8000 Australia, Denmark, Sweden
Luxembourg, Monaco, Norway. Monaco, Switzerland,
8000 to 10 000
United States of America
* Data not available for Democratic People’s Republic of Korea, Somalia, South
Sudan and Zimbabwe).

The major health financing source categories in Sri Lanka are:

• Government, comprising central government, Provincial

Councils, local governments and social security institutions
such as the Employees Trust Fund (a form of social security)

• Households that pay directly out-of-pocket for healthcare

• Employers, who directly finance or reimburse healthcare

services for their employees

• Health insurance schemes that pay for healthcare

• Domestic and foreign non-profit institutions

26
• Providers who use their own resources to finance healthcare.

In 2013, the Ministry of Health, provincial government and local

government financed 62%, 31% and 2% respectively of public
sector spending. The balance was from the Presidents Fund, other
Government Ministries and the Employees Trust Fund( 5 ).

Low health spending due to inadequate

Government revenues
Sri Lanka’s gross national income per capita (GNI) in 2016 was US$3,727
(2). It is higher than the average gross national income per capita for
countries in South Asia (US$1611) and those categorized as low- middle-
income countries ( US$2078 ) (2). Sri Lanka has reported rapid economic
growth for over a decade. Annual reports from the Central Bank indicate
that in 2016, growth declined to 4.4% in real terms, compared to 5% in
2014 (2, 5). Total debt also increased in 2016, primarily due to external
borrowings. The central government debt to Gross Domestic Product
ratio increased to 79.3% by end of 2016 from 77.6% as at end 2015.
Although Government revenues as a share of Gross Domestic Product
increased to 14.2% in 2016 from 13.3 % in 2015, it still remains low and
comparable with less developed countries.

Domestic general government health expenditure as percentage of

general government expenditure, which is used as a summary indicator
of the priority accorded to health decreased from 8.7% in 2008 to 8% in
2016 (2 ). Despite low health spending, Sri Lanka has been able to sustain
favourable health outcomes related to maternal and child health and
communicable diseases. However, an increase in health spending will
be required to deal with the rising NCD burden in the future. According
to the analysis of the Central Bank, structural issues in the economy
including poor collection of tax revenue, have prevented the country
from maintaining a high Gross Domestic Product growth rate over time
(2, 6). Until such deep rooted issues in the economy are addressed and
domestic resource mobilization is strengthened to increase Government
revenues, the fiscal space available for more public spending on health

27
will remain marginal. Taking cognizance of this resource situation, Sri
Lanka Government has given top priority to implementation of very cost
effective, high impact NCD interventions (WHO best buys) (see Chapters
3 to 13) .

Private financing and out of pocket expenditure

The main source of private financing is household out-of- pocket
expenditure (85%). Out-of-pocket spending accounts for about 38%
of total health expenditures in Sri Lanka (1). Other sources of private
financing include, expenditure by companies to provide health care
and medical benefits to their employees (5-8%), contributions from
private health insurance (5%) and non-profit sector contributions (2-
3%) (5). Although Sri Lanka has a high out of pocket expenditure, a
large share is concentrated among the higher income deciles of the
population.

The breakdown of out of pocket payments by households based on data

from Household Income and Expenditure Survey 2015/16 is shown in
Figure 2.2 (8, 9). The highest portions of out-of-pocket expenditure is
incurred on doctors fees (33%) and purchase of medicines (27%). Out
of pocket spending is incurred even when utilizing the public sector
health services if there are shortages in diagnostics and medicines in
public health facilities.

Based on the findings of a Management Practice Survey conducted by

the World Bank to review the private health sector, on average, 86 %
of total revenue to private health facilities come from direct payments
by patients. Revenue from private health insurance and employer-
paid insurance play only a minor role. The President’s Fund (a fund
established to assist patients in defraying the costs of major surgery in
the private sector) had financed less than a fifth of the total revenue in
10% of the health facilities surveyed (10).

28
Figure 2.2 Breakdown of out of pocket payments by households
(Source: Smith O 2016. Based on data from Household Income and
Expenditure Survey 2015/16)

Impact of NCDs on households

The Department of Census and Statistics has conducted regular
Household Income and Expenditure Surveys since 1990/91 (11-
13). The latest survey conducted in 2016 covered all 25 districts in
the country (9). Findings in 2016 reveal that the estimated average
household income per month at national level was LKR 62,237 and the
median household income was LKR 43,511. The estimated average
monthly household income of the households in the poorest 20%
(1st and 2nd decile) was LKR 14,843 and richest 20% (9th and 10th
decile) was LKR 158,072. The estimated average monthly household
expenditure was LKR 54, 999 and increased by 32.7 % against the
previous survey year 2012/13 (12). Among the major categories of
household consumption expenditure, the estimated average monthly
expenditure on food was LKR 19,114 and non-food expenditure was
LKR 35, 885; an increase of 22.1% and 39.1% respectively against the
previous survey year 2012/2013.

29
Table 2.4 Percentage distribution of average monthly household
expenditure on health and other major non-food expenditure
groups by national household expenditure decile – 2016
(Source: Calculations based on Household Income and Expenditure
Survey 2016).

Health
Expenditure Tobacco,
Total expenses Housing Education
Decile drugs and
(%) and personal (%) (%)
Group (LKR) liquor (%)
care ( %)
100 7 2.9 19.2 5.8
1(≤17589) 100 11.4 7.4 36.5 1.9
2 100 10.8 7.0 30.2 4.0
3 100 9.8 6.4 23.9 5.3
4 100 9.3 5.8 26.9 6.1
5 100 8.7 5.1 25.0 6.2
6 100 8.0 4.6 23.8 6.5
7 100 7.9 4.4 23.2 6.3
8 100 7.1 3.2 21.8 6.8
9 100 6.6 2.6 19.2 6.5
10 (>99113) 100 5.9 1.2 13.5 5.2

Expenditure Fuel and

Total Transport Communication
Decile light Other (%)
(%) (%) (%)
Group (LKR) (%)
100 12.4 4.9 3 44.8
1(≤17589) 100 8.0 11.8 3.5 19.5
2 100 10.1 9.9 4.0 24.0
3 100 11.0 8.9 4.2 30.5
4 100 11.9 8.0 4.1 27.9
5 100 12.8 7.7 4.0 30.5
6 100 12.8 6.8 3.8 33.7
7 100 13.0 6.4 3.8 39.6
8 100 13.2 5.7 3.4 38.8
9 100 13.2 4.8 3.4 43.7
10 (>99113) 100 12.2 2.6 2.0 58.4

30
In 2016, the estimated national average monthly expenditure on health
and personal care was 7% (Table 2.4). As a percentage of total monthly
expenditure, the poorest 20% (1st and 2nd decile) spent more on
health (11.4% and 10.8% respectively) than the richest 20% (9th and
10th decile), (6.6% and 5.9% respectively ). An analysis of the findings
of the 2006/2007 and 2009/2010 Household Income and Expenditure
Surveys in Sri Lanka (11, 12) has shown that households with more pre-
school children, elderly members and members suffering from NCDs
have a relatively higher tendency to spend out-of-pocket on health
(14). An analysis of data from 2012/2013 Household Income and
Expenditure Survey (13) indicate that financial constraints of seeking
treatment for NCDs and hospitalization in the private sector compel
households to sacrifice the basic needs of food and clothing. The
burden on poorer households was higher, whereas richer households
had the option of utilizing more from non-basic needs to cope with
NCDs and hospitalization and not sacrifice basic needs (15).

Catastrophic and impoverishing spending on

health
Universal Health Coverage is central to the Health and Wellbeing goal
(Goal 3) of the 2030 Sustainable Development Agenda. To attain the
goal of Universal Health Coverage, health systems need to demonstrate
satisfactory performance in two key dimensions. First, is that everyone
should receive needed health care (referred to as service coverage).
Second, is that families who do get needed care do not suffer undue
financial hardship as a result (referred to as financial protection) (16,
17) (Figure 2.3)

31
Figure 2.3 Dimensions of the Universal Health Coverage (Source:
Ten years in public health, 2007–2017: World Health Organization
2017)

Global estimates of catastrophic spending at the 10% and 25%

thresholds have been reported to be 11.7% and 2.6% respectively
(18). According to WHO estimates (17), in Sri Lanka, proportions of the
population with household expenditure on health greater than 10%
and 25% of total household expenditure or income (SDG indicator
3.8.2) are small (2.8 % and 0.1 per cent respectively in 2009). However,
a more recent World Bank study based on the analysis of 2015/2016
household data reported that 6.4 % of households in Sri Lanka
experienced catastrophic spending at the 10 % threshold (8).

According to WHO estimates (17), in 2009, proportions of population

pushed below the $1.90 and $3.10 per day poverty lines by household
health expenditure (SDG indicator 1.1.1), were 0.05% and 0.44%

32
respectively. Increase in poverty gap due to household expenditure
as a proportion of the $1.90 a day and $3.10 poverty lines, were
0.01% and 0.09% respectively. An analysis of 2015/2016 household
data report that 0.4% of households were pushed into poverty due to
payments for health in 2015 (8).

Thus, although people in Sri Lanka experience both catastrophic

and impoverishing spending on health, the incidence of both is low
compared to other countries at the same level of development.

Allocation of finances for provinces, prevention

and primary care
The Public Sector in Sri Lanka provides virtually all of preventive care, a
large portion of inpatient care and less than half of outpatient curative
care, while the Private Sector provides more than half of outpatient
curative care and a small proportion of inpatient care (Figure 2.4) (19).

Annually, a major share of public health expenditure is channeled to

meet recurrent expenditure. In 2016 for example, total Government
expenditure, including central Government transfers to Provincial
Councils for healthcare services was LKR. 136,690 million, out of
which, 82.7% was allocated for recurrent expenditure. Major share of
recurrent expenditure was for the payment of salaries and wages of
health care staff (54.9%) and for purchase of medicines (33.7%). The
expenditure on essential requirements such as diets, laundry, electricity
and water was 11.3%. Capital expenditure in 2016 was LKR 23,647
million (17.3%). The largest part of the capital investment (89.5 %) was
allocated for curative health care of which LKR 1034 million (4.3%)
was assigned for NCDs. Investment in disease prevention in 2016 was
LKR 2360.6 million ( 1.7 %) and mainly targeted for the prevention of
Dengue, Rabies, Tuberculosis and NCDs (20).

33
Figure 2.4 Spending on health – Public and private spending by
function (Source: Institute of Health Policy (2015). Expenditure
Series (4). Sri Lanka Health Accounts; National Health Expenditure
1990-2014. Colombo, Sri Lanka)

The mechanism for resource allocation among provinces and

health facilities need to be better aligned with the disease burden
and requirements for prevention and control of NCDs. Currently,
financial resources for health are allocated largely based on historical
patterns related to infrastructure and staffing. Routine data collection
to determine the operational costs per patient is in place only in a
small number of hospitals (5, 21-24). Provincial budgets are based on
three different transfers from the center to provinces as determined
by the Finance Commission. The largest grant intended for recurrent
spending at provincial hospitals is determined largely by allocations
for salaries and maintenance in previous years, and is therefore not
needs-based. The other two inter-fiscal transfers follow a formula that
is intended to reflect need, but these are much smaller.

A disproportionate share of government health spending is allocated to

certain provinces and districts. For example in 2013, there was a three
fold difference in the per capita expenditure on health in the Eastern
provinces ( Rs. 6814) compared to the Western Province (Rs 19307).

34
Further, although in the latest Household Survey, Sabaragamuwa
Province reported the lowest Gini value (0.41) for household income
(9), the Government per capita expenditure on health was the lowest
in the Sabaragamuwa province (Rs 3839). Maldistribution was also
seen at the district level. While the Government spending per capita
was Rs 3169 in the Kilinochchi district with the lowest Gini index, it was
Rs 7278 in the Colombo district with the highest Gini index (0.46) (5,
24). This maldistribution need to be rectified.

Further, a significant portion of spending is directed to secondary and

tertiary hospitals. Primary health care in the curative system accounts
for less than 15 % of the budget. Yet, this is where the largest health
gains could be achieved through cost‐effective management of
NCDs. It is also notable that a woefully inadequate amount of the
health budget (1.7% in 2016), is spent on prevention (5, 23), when only
prevention provides sustainable solutions to NCDs. In order to improve
NCD outcomes, aside from increased funding for NCD prevention,
and primary health care, consideration need to be given to allocating
resources across programs, facilities, districts and provinces, primarily
based on need.

Need to strengthen domestic resource mobilization

to tackle NCDs
Sri Lanka’s low-cost health system has been attributed to relatively
low salaries in the Government sector, low price of major inputs to
delivery of healthcare i procured through international competitive
tenders and cost control through line-item budgeting (8). The
growing burden of NCDs has introduced disparities in financing and
service provision (25 ). An increase in health spending is essential
for providing adequate service coverage and financial protection in
relation to NCDs; Universal Health Coverage. Overseas Development
Assistance plays only a small role in financing health in Sri Lanka.
Private financing provides additional resources, but the associated
increase in out of pocket expenditure for health by the patient, which
is innately regressive, can worsen inequity and deepen poverty (26,

35
27). Domestic resource mobilization is central for sustainable financing
of public sector health services ( 28 ). This is contingent upon national
macroeconomic performance, competing demands from other sectors,
the size of the tax base and the government's capacity to collect taxes.
It has been estimated that strengthening tax administration alone
could raise an additional 31 % of tax revenues for health across 52
developing countries, including Sri Lanka ( 29). Government has
recognized the need for revenue reforms to streamline the tax system
including tax legislation and administration and broadening the tax
base for sustainable resource mobilization (30). An additional potential
source of fiscal space which has been proposed is the introduction of
a social health insurance system that raises revenues through a payroll
tax. Such a system if properly developed, could benefit the formal
sector employees who account for about 37 % of total workforce in Sri
Lanka (8).

Addressing NCDs in the context of Universal

Health Coverage
NCDs cause premature death, disability and poverty which are
barriers to productivity and economic development. Thus, Universal
Health Coverage and Sustainable Development Goals cannot be
attained without tackling NCDs. Embracing a strategic approach to
combat NCDs, can save lives, cut down on health care costs and boost
economic productivity (Figure 2.5).

36
Figure 2.5 Multifaceted benefits of investing in NCD prevention
and control
(Source: a strategic response to noncommunicable diseases.
World Health Organization. Geneva 2018 )

Tackling NCDs in a health system which is free at the point of delivery,

is a complex task. The two dimensions of Universal Health Coverage
provide a framework for laying a strong foundation for handling
the task (Figure 2.3). First, it is necessary to ensure coverage of the
population with a set of very cost effective interventions (essential
services). Sri Lanka is in the process of developing an essential services
package for this purpose. Second, sustainable resources need to be
mobilized to provide financial protection underpinned by equity. A
set of very cost effective NCD interventions to address prevention as
well as management of NCDs was identified in preparation for the
United Nations High Level Meeting on NCDs in 2011 ( Table 2.5 )
(30-32). Population-based best buy interventions address tobacco and
harmful alcohol use, as well as unhealthy diet and physical inactivity.
Individual-based best buy interventions are delivered in primary
health care settings and include, for example, counselling and drug
therapy for persons with or at high risk of cardiovascular disease,

37
plus measures to prevent cervical cancer. The cost of implementing
such a package of best-buy interventions was estimated to represent
an additional annual investment of under US$ 1.27 per person in a
lower middle-income country, like Sri Lanka ( 30, 31 ). All best buy
interventions also have a good return on investment (33) (Table 2.5)
and implementing them need to be one of the first steps in addressing
NCDs and moving towards Universal Health Coverage (34). Sri Lanka
has laid the foundation to implement best buys by setting 10 national
NCD targets, which set the direction of the national NCD program
(see Chapter 3 to Chapter 11 ) (Table 2.5).

Table 2.5 Very cost effective NCD interventions (WHO best buys)
and return on investment
(Sources; Scaling up action against NCDs. How much will it
cost. World Health Organization. Geneva 2011 and Saving lives,
spending less; a strategic response to noncommunicable diseases.
World Health Organization. Geneva 2018 )

Return on
Best buys (very cost effective high impact Investment
Priority area
NCD interventions) by 2030 (per
dollar invested)
National Implement all NCD best buy interventions US $ 7.00
NCD target listed below
1-Premature
mortality
National NCD Taxes: Increase excise taxes on alcoholic US$ 9.13
Target 2 beverages
-Alcohol Advertising: Enact and enforce bans or
comprehensive restrictions on exposure to
alcohol advertising (across multiple types of
media)
Availability: Enact and enforce restrictions on
the physical availability of alcohol in
sales outlets (via reduced hours of sale

38
National NCD *Education: Implement community-wide US$ 2.8
Target 3 public education and awareness campaigns
-Physical for physical activity, including mass-
activity media campaigns combined with other
community-based education, motivational
and environmental programmes aimed at
supporting behavioural change around
physical activity levels
National NCD **Reduce salt consumption US$ 12.82
Target 4 Reformulation of food: Reduce salt intake
-Salt through the reformulation of food products
to contain less salt, and the setting of
maximum permitted levels for the amount of
salt in food
Supportive environments: Reduce salt
intake through establishing a supportive
environment in public institutions such as
hospitals, schools, workplaces and nursing
homes, to enable low-salt options to be
provided
Education: Reduce salt intake through
behaviour change communication and
massmedia campaigns
Packaging: Reduce salt intake through the
implementation of front-of-pack labelling
National NCD Taxes: Increase excise taxes and prices on US $ 7.43
Target 5 tobacco products
-Tobacco Packaging: Implement plain/standardized
packaging and/or large graphic
healthwarnings on all tobacco packages
Advertising, promotion and sponsorship:
Enact and enforce comprehensive bans
on tobacco advertising, promotionand
sponsorship
Smoke-free public places: Eliminate
exposure to second-hand tobacco smoke
in all indoorworkplaces, public places and
public transport
Education: Implement effective mass-media
campaigns that educate the public about the
harms of smoking/tobacco use and second-
hand smoke
National NCD Reduce salt consumption** and treat those See ** and ***
Target 6 with high cardiovascular risk***
Hypertension

39
National NCD *Improve physical activity levels See *
Target 7
Obesity /
diabetes
National NCD ***Drug therapy and counselling US $ 3.29
Target 8- Provide drug therapy (including glycaemic
Heart attacks control for diabetes mellitus and control of
and strokes hypertension using a total risk approach)
and counselling for individuals who have
had a heart attack or stroke and for persons
with high risk (≥ 30%) of a fatal or non-fatal
cardiovascular event in the next 10 years

Cancer Vaccination: Vaccination against human US $ 2.74

papillomavirus (2 doses) of girls aged 9 to 13
years
Screening: Prevention of cervical cancer by
screening women aged 30 to 49 years, either
through: visual inspection with acetic acid
linked with timely treatment of pre-cancerous
lesions; pap smear (cervical cytology) every
3–5 years, linked with timely treatment of
pre-cancerous lesions; human papillomavirus
test every 5 years, linked with timely
treatment of precancerous lesions

Conclusion and future perspectives

The fast growing NCD epidemic in Sri Lanka is causing disparities
in coverage of NCD services, threatening financial protection and
derailing the attainment of Universal Health Coverage and Sustainable
Development Goals. NCD prevention and control saves lives, improves
health and workforce participation and economic productivity. It also
limits the financial burden of health costs from NCDs on individuals,
families and the State. Sri Lanka Government has prioritized the very
cost effective NCD intentions (WHO best buys) that give a good return
on investment. In order to consolidate the health gains of the past
and advance the development agenda, Sri Lanka needs to increase
government expenditure on health and scale-up the implementation
of NCD best buys island-wide.

40
References
1. World Health Organization. Global Health Expenditure Database 2016.
http://apps.who.int/nha/database/ViewData/Indicators/en
2. Central Bank of Sri Lanka. Annual Report 2016.
https://www.cbsl.gov.lk/en/publications/economic-and-financial-
reports/annual-reports/annual-report-2016
3. World Bank. Data. GNI per capita, Atlas method (current US$).
https://data.worldbank.org/indicator/NY.GNP.PCAP.CD?view=chart
4.
Implementation tools: package of essential noncommunicable (WHO-
PEN) disease interventions for primary health care in low-resource
settings. Geneva: World Health Organization; 2013
(http://www.who.int/cardiovascular_diseases/publications/
implementation_tools_WHO_PEN/en/)
5. Amarasinghe, S.N., Thowfeek, F.R., Anuranga, C., Dalpatadu, K.C.S.,
and Rannan-Eliya, R.P. (2015) Sri Lanka Health Accounts: National
Health Expenditure 1990–2014. Health Expenditure Series No.4.
Colombo, Institute for Health Policy.
6. Central Bank of Sri Lanka. Annual Report 2015.
https://www.cbsl.gov.lk/en/publications/economic-and-financial-
reports/annual-reports/annual-report-2016
7. Index Mundi. Sri Lanka economy profile 2014. http://www.indexmundi.
com/sri lanka/ economy_profile.html -  
8. Smith, O. 2016. Sri Lanka: Achieving Pro-Poor Universal Health Coverage
without Health Financing Reforms”. Universal Health Coverage Study
Series No. 38, World Bank Group, Washington, DC.
9. Department of census and statistics. Ministry of national policies and
economic affairs. Report of Household Income and Expenditure Survey
2016. Colombo Sri Lanka.
10. Govindararaj R, Navaratne K, Cavagnerio E, Seshadri SR. Health care
in Sri Lanka: what can the private sector offer? Health Nutrition and
Population (HNP) discussion paper. Washington DC: World Bank; 2014.
(http://documents.worldbank.org/curated/en/2014/06/20053127/
health-care-sri-lanka-can-private-health-sector-offer,
11. Department of census and statistics. Ministry of national policies and
economic affairs. Report of Household Income and Expenditure Survey
2006/2007. Colombo Sri Lanka.

41
12. Department of census and statistics. Ministry of national policies and
economic affairs. Report of Household Income and Expenditure Survey
2009/2010. Colombo Sri Lanka.
13. Department of census and statistics. Ministry of national policies and
economic affairs. Report of Household Income and Expenditure Survey
2012/2013. Colombo Sri Lanka.
14. Kumara AS, Samaratunge R. Patterns and determinants of out-of-
pocket health care expenditure in Sri Lanka: evidence from household
surveys.
Health Policy Plan. 2016 Oct;31(8):970-83.
15. Kumara AS, Samaratunge R. Impact of ill-health on household
consumption in Sri Lanka: Evidence from household survey data. Soc
Sci Med. 2017 Dec;195:68-76.
16. Boerma, T, Eozenou, P, Evans, D, Evans, T, Kieny, M-P, and Wagstaff
A. Monitoring progress towards universal health coverage at country
and global levels. PLoS Med. 2014; 11: e1001731.
17. World health statistics 2017: monitoring health for the SDGs,
Sustainable Development Goals World Health Organization Geneva
ISBN 978-92-4-156548-6.
18. Wagstaff A , Flores G, Justine Hsu J, Smitz M, Chepynoga K, Buisman
LR, van Wilgenburg K, Eozenou P. Progress on catastrophic health
spending in 133 countries: a retrospective observational study Volume
6, No. 2, e169-e179, February 2018.
19. Annual Health Bulletin 2015. Medical Statistics Unit. Ministry of Health,
Nutrition and Indigenous Medicine, Colombo, Sri Lanka.
20. Ministry of Finance. Report of the Ministry of Finance 2016. Colombo
Sri Lanka.
21. Annual Health Bulletin 2014. Medical Statistics Unit. Ministry of Health,
Nutrition and Indigenous Medicine, Colombo, Sri Lanka.
22. Fernando, T., Rannan-Eliya, R. P. and Jayasundara, J. M. H. (2009). Sri
Lanka Health Accounts: National Health Expenditures 1990–2006..
Health Expenditure Series No.1. Colombo, Institute for Health Policy.
23. De Alwis, S.S., Fernando, T and Rannan-Eliya, R. P. (2011). Sri Lanka
Health Accounts: National Health Expenditure 1990–2008. Health
Expenditure Series No.2. Colombo, Institute for Health Policy.

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24. Amarasinghe, S.N., Sivapragasam, N.R., Thowfeek, F.R., Saleem, S.,
and Rannan-Eliya, R.P. (2014). Sri Lanka Health Accounts: National
Health Expenditure 1990–2012. Health Expenditure Series No. 3.
Colombo, Institute for Health Policy.
25. De Silva A, Ranasinghe T, Abeykoon P. Universal health coverage
and the health Sustainable Development Goal: achievements and
challenges for Sri Lanka. WHO South East Asia J Public Health. 2016
Sep;5(2):82-88.
26. Govindaraj, Ramesh; Navaratne, Kumari; Cavagnero, Eleonora;
Seshadri, Shreelata Rao. 2014. Health care in Sri Lanka : what can the
private health sector offer? (English). Health, Nutrition and Population
(HNP) discussion paper. Washington, DC : World Bank Group.
27. Oxfam. 176 Oxfam briefing paper. Universal Health Coverage. Why
health financing schemes are leaving the poor behind? 9th October
2013.
28. The Addis Ababa Action Agenda of the Third International Conference
on Financing for Development.
29. Itriago, D. (2011) ‘Owning Development: Taxation to fight poverty’,
Intermón Oxfam: Madrid.
30. World Health Organization. Scaling up action against NCDs. How
much will it cost. Geneva 2011.
31. World Health Organization and World Economic Forum. From Burden
to Best Buys. Reducing the Economic Impact of Noncommunicable
Diseases in low – and middle-income countries. Geneva ;2011.
32. Mendis S, Chestnov O. Costs, benefits, and effectiveness of interventions
for the prevention, treatment, and control of cardiovascular diseases and
diabetes in Africa. Prog Cardiovasc Dis. 2013 Nov-Dec;56(3):314-21.
doi: 10.1016/j.pcad.2013.09.001.
33. Saving lives, spending less; a strategic response to noncommunicable
diseases. World Health Organization. Geneva; 2018.
34. Mendis Shanthi. Global  progress  in prevention of cardiovascular
disease. Cardiovasc Diagn Ther. (2017) Apr;7(Suppl 1):S32-S38. doi:
10.21037/cdt.2017.03.06.

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44
PART II

45
46
NCD Targets and SDG Targets

Introduction
Recognizing the devastating social, economic and public health
impact of NCDs, in September 2011, world leaders adopted a political
declaration containing strong commitments to address the global
burden of NCDs (1). World Health Organization was tasked with the
development of the WHO Global action plan for prevention and control
of noncommunicable diseases 2013–2020, including global targets
and a global monitoring framework. The Global NCD Action Plan and
the global targets were adopted by the World Health Assembly in
2013 (2 ).

The nine voluntary global NCD targets underscore the importance of

prioritizing country action to reduce harmful use of alcohol, insufficient
physical activity, salt/sodium intake, tobacco use and hypertension;
halt the rise of obesity and diabetes; and improve coverage of
treatment for prevention of heart attacks and strokes and access to
basic technologies and essential medicines. Country efforts in all these
areas are essential to attain the overarching target, which is a 25%
reduction of premature mortality from the four major NCDs by 2025.

The Government of Sri Lanka has provide strategic leadership in

mainstreaming NCDs in the development agenda. Accordingly, the
Ministry of Health in close collaboration with relevant Ministries and
other stakeholders developed the National Multisectoral Action Plan
for the Prevention and Control of Noncommunicable Diseases 2016-
2020 (3) underpinned by a set of national targets consistent with global
NCD targets to be attained by 2025.

They are:

National NCD target 1: A 25% relative reduction in the overall mortality

from cardiovascular diseases, cancer, diabetes, or chronic respiratory
diseases

National NCD target 2: At least 10% relative reduction in the harmful

47
use of alcohol.

National NCD target 3: A 10% relative reduction in prevalence of

insufficient physical activity.

National NCD target 4: A 30% relative reduction in mean population

intake of salt/sodium.

National NCD target 5: A 30% relative reduction in prevalence of

current tobacco use in persons aged 15+ years.

National NCD target 6: A 25% relative reduction in the prevalence of

raised blood pressure.

National NCD target 7: Halt the rise in diabetes and obesity.

National NCD target 8: At least 50% of eligible people receive drug

therapy and counselling (including glycaemic control), to prevent heart
attacks and strokes.

National NCD target 9: An 80% availability of the affordable basic

technologies and essential medicines, including generics, required to
treat major NCDs in both public and private facilities.

In addition, Sri Lanka adopted a tenth target to address household air

pollution –a major health hazard in Sri Lanka, particularly for women
and children - due to burning of solid biomass fuel and secondhand
smoke.

Targets 2 to 10 contribute to the realization of the overarching Target

1; to reduce premature mortality. Part II of this document takes stock
of the progress Sri Lanka has made in attaining these NCD targets
distilling lessons learned.

The Ministry of Health, Nutrition and Indigenous Medicine recognizes

that the public health benefits of measures to attain the National NCD
targets, are far more likely to be realized if a multisector approach
is adopted engaging a wide range of stakeholders. Thus, the
National NCD Action Plan stakeholders include Ministries of Health,
Education, Finance, Plan Implementation, Mass Media, Agriculture,
Trade and Commerce, Social Services, Youth Affairs, Women’s Affairs,

48
Environment and Natural Resources, Academia, Non-Governmental
Organizations, Civil Society Organizations, the Private Sector, United
Nations Agencies and Development and Donor Agencies. The
Ministry of Health, Nutrition and Indigenous Medicine together with
other stakeholders have identified suitable indicators, data sources
and baselines for monitoring progress in the attainment of national
targets. Every year the Action Plan is reviewed by the National NCD
Programme, and activities are prioritized based on achievements and
available resources.

Integrating NCDs in the national response to

attain SDGs
There is synergy between many aspects of the 2030 Sustainable
Development Agenda (3) and national NCD targets of the NCD Action
Plan 2016-2020. Goal 3 of the Sustainable Development Agenda is to
`Ensure healthy lives and promote well-being for all at all ages’. Some
of the 13 targets under Goal 3 are closely related to NCDs and the
progress in attaining them will be monitored by indicators shown in
Table. 3.1

Other SDGs are also relevant to the NCD agenda, including SDG target
1 (ending poverty), SDG target 2 (ending all forms of malnutrition),
SDG target 4 (ensuring education), SDG target 5 (achieving gender
equality), SDG target 8 (decent work), SDG target 11 (making cities
safe and sustainable), SDG target 10 (reducing inequality), SDG target
12 (ensuring sustainable consumption and production patterns), SDG
target 13 (climate change), SDG target 16 (promoting peace and
justice), and SDG target 17 (strengthening partnerships).

49
Table 3.1 NCD related targets of Goal 3 of the Sustainable
Development Agenda and indicators for measuring progress
towards their attainment

Targets of Sustainable Development Goal 3 Indicators

3.4 By 2030, reduce by one third 3.4.1 Mortality rate attributed to
premature mortality from NCDs through cardiovascular disease, cancer,
prevention and treatment and promote diabetes or chronic respiratory
mental health and well-being disease

3.5 Strengthen the prevention and 3.5.2 Harmful use of alcohol,

treatment of substance abuse, including defined according to the national
narcotic drug abuse and harmful use of context as alcohol per capita
alcohol  consumption (aged 15 years and
  older) within a calendar year in
3.8 Achieve universal health coverage, litres of pure alcohol
including financial risk protection, access
to quality essential health-care services 3.8.1 Coverage of essential health
and access to safe, effective, quality and services (defined as the average
affordable essential medicines and vaccines coverage of essential services
for all  based on tracer interventions
that include reproductive,
3.9 By 2030, substantially reduce the maternal, newborn and child
number of deaths and illnesses from health, infectious diseases, non-
hazardous chemicals and air, water and soil communicable diseases and
pollution and contamination  service capacity and access,
among the general and the most
3.A Strengthen the implementation of the disadvantaged population)
World Health Organization Framework
Convention on Tobacco Control in all 3.8.2 Number of people covered
countries, as appropriate  by health insurance or a public
health system per 1,000 population
3.B Support the research and
development of vaccines and medicines 3.9.1 Mortality rate attributed
for communicable and noncommunicable to household and ambient air
diseases that primarily affect developing pollution
countries, provide access to affordable
essential medicines and vaccines, in 3.A.1 Age-standardized prevalence
accordance with the Doha Declaration on of current tobacco use among
the TRIPS Agreement and Public Health, persons aged 15 years and older
which affirms the right of developing
countries to use to the full the provisions in 3.B.1 Proportion of the population
the Agreement on Trade-Related Aspects with access to affordable medicines
of Intellectual Property Rights regarding and vaccines on a sustainable basis
flexibilities to protect public health, and, in 3.B.2 Total net official development
particular, provide access to medicines for assistance to medical research and
all  basic health sectors

50
The Ministry of Health has the leadership role in addressing NCDs
within the national SDG response using a public health approach and
forging a coalition between relevant sectors to spearhead the journey.

References
1. Resolution 66/2. Political Declaration of the High-level Meeting of the
General Assembly on the Prevention and Control of Non-communicable
Diseases. In: Sixty-sixth session of the United Nations General Assembly.
New York: United Nations; 2011 (A/67/L.36).
2. Global action plan for the prevention and control of noncommunicable
diseases 2013−2020. Geneva: World Health Organization; 2013 (http://
apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.
pdf?ua=1).
3. National multisectoral action plan for the prevention and control
of noncommunicable diseases 2016-2020. Ministry of Health and
Indigenous Medicine Sri Lanka 2015.
4. United Nations General Assembly resolution 70/1 – Transforming our
world: the 2030 Agenda for Sustainable Development http://www.
un.org/ga/search/view_doc.asp?symbol=A/RES/70/1

51
52
CHAPTER 3

National NCD target

1: Reduce premature
mortality
A 25% relative reduction in overall mortality
from cardiovascular diseases, cancer, diabetes or
chronic respiratory diseases by 2025.

Key messages
• Globally, four major NCDs (cardiovascular diseases, cancer,
chronic respiratory diseases and diabetes) are responsible
for 79% of NCD deaths.

• In Sri Lanka, NCDs currently cause more deaths than all other
causes combined and NCD deaths are projected to increase
further.

• Premature NCD deaths in people under the age of 70 are

largely avoidable; in Sri Lanka, nearly half (45%) of NCD
deaths are under the age of 70 years.

• A well-functioning civil/vital registration system is vital for

monitoring progress of this target.

• In order to attain the premature mortality target, cost-effective

policies and interventions aimed at attaining all other nine
NCD targets, need to be prioritized and implemented.

53
• Sri Lanka has made good progress in achieving national NCD
targets 2 , 5 and 9. Some progress has also been made in the
attainment of targets 6, 7 and 8. Activities related to targets
3, 4 and 10 need to be accelerated.

• Sri Lanka demonstrates, that a home-grown public health

model financed with domestic resources, can advance the
NCD agenda in a viable manner in low-middle-income
country settings.

Mortality from NCDs

A total of 57 million deaths occurred worldwide during 2016. Of these,
41 million (71%) were due to NCDs, mainly cardiovascular diseases,
cancer and chronic respiratory diseases (1). The four major NCDs
were responsible for 79% of NCD deaths, cardiovascular disease (17.9
million deaths; accounting for 44% of all NCD deaths); cancer (9.0
million deaths; 22%); chronic respiratory disease (3.8 million deaths;
9%); and diabetes (1.6 million deaths; 4%).

Over three quarters of deaths from cardiovascular disease and diabetes,

and nearly 90% of deaths from chronic respiratory diseases, and more
than two thirds of all cancer deaths occur in low- and middle-income
countries (2).

The number of NCD deaths has increased worldwide since 2000, when
there were a total 31 million NCD deaths. In the WHO South East Asia
Region which includes Sri Lanka, NCD deaths have increased from 6.7
million in 2000 to 8.5 million in 2012. In 2015 in Sri Lanka, there were
113600 deaths due to NCDs ( 60000 deaths in males, 53600 deaths
in females )(3).

Globally, the age-standardized NCD death rate is 539 per 100  000.
Age-standardized death rates reflect the risk of dying from NCDs,
regardless of the total population size or whether the average age
in the population is high or low. The rate was lowest in high-income
countries and highest in low-income countries. In Sri Lanka the age

54
standardized death rate was 510.8 per 100, 000 population ( 606 and
429.3 per 100, 000 population in males and females respectively), in
2015 (3).

Premature death is a major consideration when evaluating the impact

of NCDs on a given population. Globally, nearly half (48%) of all NCD
deaths occurred before the age of 70 years in 2015. The majority of
premature deaths (5.4 million of the total 6.2 million, 86%), are in low-
and middle-income countries. Figure 3.1 shows the proportion of NCD
deaths by cause in 2012 among people under the age of 70 years.
Cardiovascular diseases were responsible for the largest proportion
of NCD deaths under the age of 70 years (37%), followed by cancers
(27%), and chronic respiratory diseases 8%. Diabetes was responsible
for 4% and other NCDs were responsible for approximately 23% of
deaths.

Figure 3.1 Proportion of global NCD deaths under the age 70

years, by cause of death, comparable estimates, 2012 (Source;
Global Status Report 2014)

55
In Sri Lanka, 65% of all deaths are due to NCDs (Figure 3.2). Of the NCD
deaths, nearly half (45%) are under the age of 70 (54% of male NCD
deaths and 36% of female NCD deaths) (3). Prevention and control
strategies need to be prioritized and targeted to reduce premature
mortality caused by NCDs, as it has a devastating impact on labour
productivity and economic development (4, 5).

Figure 3.2 Distribution of mortality (Source: WHO country profiles

2011)

Monitoring premature mortality from NCDs

The premature mortality target is, a 25% reduction in overall mortality
from cardiovascular diseases, cancer, diabetes or chronic respiratory
diseases by 2025 (referred to as “25×25”). The probability of dying
between the ages of 30 and 70 years from these four diseases, is the
indicator in the global monitoring framework that monitors progress in
attaining this target by 2025.

56
Figure. 3.3. Probability of dying from the four main noncommunicable
diseases between the ages of 30 and 70 years, comparable
estimates, 2012 (Source: Global status report on noncommunicable
diseases 2014. Geneva: World Health Organization; 2014)

The probability of dying from one of the four main NCDs between ages
30 and 70, worldwide is shown in Figure 3.3. In 2016, a 30-year-old
man had a higher risk of dying before reaching the age of 70 from one
of the four main NCDs than a 30-year-old woman (22% compared to
15% respectively). Adults in low- and lower-middle-income countries
faced the highest risks (21% and 23% respectively) - almost double
the rate for adults in high-income countries (12%). Globally, the risk
of dying from any one of the four main NCDs between ages 30 and
70 decreased from 17% between 2000 and 2015 (Fig. 3.4). However,
the global rate of decline is inadequate meet the target of a one-third
reduction in premature mortality from NCDs by 2030, as specified in
SDG target 3.4 (1, 3).

This probability varied by region, from 15% in the Region of the

Americas to 25% in the South-East Asia Region, and by country, from
greater than 30% in seven low- and middle-income countries to less
than 10% in three countries in Europe and in Australia, Japan and the
Republic of Korea.

In Sri Lanka, the probability of dying between ages 30 and exact age
70 from any of cardiovascular disease, cancer, Diabetes and chronic

57
respiratory disease in 2015 was 17.7 % (SD 16.8-18.7 %); much higher
for males (22.4 %, SD 21.2-23.6 ), compared to females (13.4%, SD
12.7-14.2%).

Figure 3.4 Probability of dying from one of the four main

noncommunicable diseases between the ages of 30 and 70 years,
in males, females and both sexes - Sri Lanka 2000-2015 (Source:
WHO. Global Health Observatory data; 2016 )

Population growth and improved longevity are leading to increasing

numbers and proportions of older people in many parts of the world,
including in Sri Lanka. As populations age, annual NCD deaths are
projected to rise substantially (6).

Health system – oversight and organization

Sri Lanka has a well organized health system that can make a major
contribution for the attainment of National Target 1 – reduce premature
mortality from NCDs, provided that cost effective NCD interventions
(best buys and good buys, see Chapter 2 and Chapter 13) are
prioritized, adequately resourced and implemented island-wide.

58
Sri Lanka’s health sector is regulated by the Ministry of Health,
Nutrition and Indigenous Medicine. The expanding private sector is
regulated by the Private Health Services Regulatory Council, which was
established under the Private Medical Institutions (Registration) Act
No. 21 of 2006 (7). Other government entities involved in the health
sector include the Medical Research Institute; the Migration, Health
and Development Unit; the National Institute of Health Sciences; and
the National Poison and Drug Information Centre, among others.

The government operates a network of public sector health facilities

for provision of inpatient care. There are around 631 government
sector medical institutions with indoor health facilities. It includes 16
Teaching Hospitals, 3 Provincial General Hospitals, 20 District General
Hospitals, 71 Base Hospitals, 482 Divisional Hospitals, and 14 Primary
Medical Care Units with Maternity Homes and 25 specialized hospitals.
There are 460 Primary Medical Care Units which provide outdoor
clinical facilities only. Ministry of Health Offices (n=341), headed by
Medical Officers of Health, carry out preventive services for defined
geographic areas (see Chapter 11) (8, 9).

Each district has a Medical Officer /NCD who functions as the focal
point for NCD activities in the district. The NCD unit of the Ministry of
Health conducts regular review meetings for Medical officers /NCD to
facilitate exchange of information on NCD best practices in all districts.

In the private sector, there are 225 private hospitals, with a total bed
capacity of 6,330, administering western medicine. In addition, there
are 22 Ayurvedic private hospitals with a total of 326 beds. There are
521 full-time general medical practices, 24 full-time medical specialist
practices, 967 medical laboratories and 502 medical centres registered
under the Ministry of Health (8, 9 ).

There are 3.6 beds for every 1,000 persons in the state sector. The
public system, which employs more than 90% of all nurses and doctors,
is widely accessible. There is a reasonably good road network island-
wide and people are, on average, within 1.4 km of a basic health clinic
and 4.8 km from a health care facility. There are 1600 specialist medical
officers providing services in hospitals. Overall there are 87 doctors

59
per 100, 000 population (total 18, 243). However, maldistribution is
notable. For example, there are 182, and 32 doctors per 100 000
population in Colombo and Nuwara Eliya respectively (9). There are
202 nurses per 100,000 population (total 42, 420).

There is a unit with responsibility for NCDs within the Ministry of

Health. The National Steering Committee and the National Advisory
Body for NCDs provide guidance for implementation of the National
NCD Action Plan. Government revenues are allocated through the
Department of Health services for health care for NCDs. Funding for
primary prevention, health promotion, surveillance, monitoring and
evaluation and capacity strengthening is disbursed through other
relevant units of the Ministry of Health including the NCD unit. Taxes
on tobacco, alcohol and food with high sugar content are used to
raise general domestic revenues. There are no earmarked taxes to
fund NCD activities.

Key barriers to attaining this target

There are two key barriers to attaining this target; the lack of a well-
functioning death registration system for monitoring and equity gaps
in health care service delivery.

Death registration
Death registration data, with medical certification of the cause of
death coded using the International Classification of Diseases (ICD),
are the preferred source of information for monitoring mortality by
cause, age and sex. Only 49 countries produce high-quality cause-of-
death data, meaning that more than 90% of deaths are registered and
fewer than 10% of deaths are coded to ill-defined signs and symptoms
( 10).There are persisting coverage issues and major gaps in quality
of the death registration in Sri Lanka. Although the completeness of
death registration is nearly 90% [11 ] , (Figure 3.5), the quality of death
registration statistics is poor, with about one third of deaths categorized

60
as being due to "signs, symptoms, and ill-defined causes"(12).

Once a death occurs, it has to be registered before the deceased

can be cremated or buried. For deaths that occur outside hospitals-
about 80% of deaths- the Registrar of Deaths, determines the cause
of death by interviewing the relatives regarding events preceding the
death. Sudden deaths (which are a small proportion of total deaths)
that occur outside a hospital are attended by an Inquirer into sudden
death. The majority of the Registrars are lay people with no training on
how to decide on the probable cause of death. For deaths that occur
in hospitals, cause of death is declared by the medical officer who
attended the deceased (13).

If the cause-of-death information given on the death certificate is

incorrect, incomplete or missing, it reduces the utility of the data for
public health monitoring purposes. The high percentage of deaths
certified as "signs, symptoms, and ill-defined causes" is an indicator
of the poor quality of cause-of-death information in Sri Lanka. In a
study that measured the accuracy of registered causes of death and
quality of medical records in hospitals in Colombo,  the concordance
between the underlying cause of  death  in the vital  registration  data
and that from medical records review was reported as 41.4%. Major
misclassification errors were found in identifying deaths due to vascular
diseases and diabetes mellitus (14). Further research is needed to

periodically evaluate the quality of cause of death reporting, at both

local and national levels.

61
Figure 3.5. Civil registration coverage of cause of death, 2005−2011
(Source; Global status report on noncommunicable diseases 2014.
Geneva: World Health Organization; 2014)

Equity gaps
To attain National NCD target 1, equity gaps in NCD prevention and
control need to be addressed. Equity gaps are particularly pronounced
in districts with high levels of poverty (15). As the current Government
expenditure for health is inadequate, people often have to pay out-of-
pocket for diagnostics and medicines even in the public sector where
services should be free at the point of delivery (see Chapter 2 ). In low-
income families, people with NCDs are often unable to pay for long-
term care, out-of -pocket. They then fail to seek timely treatment due
to lack of affordability and develop complications -such as a stroke or
a heart attack- drastically increasing the risk of impoverishment. These
gaps can be addressed only if there is at least a modest increase in
public spending coupled with stronger investment in population- wide
prevention and primary care (16, 17). According to National Health
Accounts, only 4.5% of current health expenditure was invested in
preventive care services, compared to nearly 91% spent on curative
care services. Increasing investment in population wide prevention
and primary care will particularly benefit the poor segments of the
population, who suffer most from the consequences of the high cost

62
of diagnostic tests and drugs and inadequate accessibility to health
care in general (18 ).

Progress made
To attain the overarching premature mortality target (national NCD
target 1) activities across all other targets need to be strengthened
with a major focus on population-wide prevention and primary care.

The Government of Sri Lanka has given priority to NCD prevention

and Control in the National Development Agenda. Surveys have been
conducted to establish baselines for NCD risk factor levels and for
surveillance (19, 20). A new cadre of Medical Officers dedicated to
NCD prevention has been established and the first batch has been
trained and deployed at the district level.

More Government resources have been directed for population- wide

prevention and primary care. Sri Lanka has made good progress in
tobacco control (national NCD target 5, see Chapter 7), reducing
harmful use of alcohol (national NCD target 2, see Chapter 4) and
improving access to essential NCD medicines (national NCD target
9, see Chapter 11). Some progress has also been made in moving
towards the attainment of national target 6 (halt obesity and diabetes,
see Chapter 8), national NCD target 7 (reduce prevalence of
hypertension, see Chapter 9) and national NCD target 8 (prevent heart
attacks and strokes, see Chapter 10). Activities related to reduction of
physical inactivity (national NCD target 3, see Chapter 5), salt intake
(national NCD target 4, see Chapter 6), indoor air pollution (national
NCD target 10, see Chapter 12) and intake of transfat require a major
boost. More resources are being directed to strengthen primary care
to provide quality care and longterm follow-up for those detected
as having NCDs through Healthy Lifestyle Centers (see Chapter 10).
Planned reforms in service delivery are aimed at improving access to
cost effective NCD treatment interventions at all levels of care (see
Chapter 13).

63
Reform of health service delivery for Universal
Health Coverage
The Government of Sri Lanka has recently approved a health care
reform policy for accelerating progress towards Universal Health
Coverage (21 ). The planned reforms aim to respond to the evolving
health care needs of the ageing population and people with NCDs
and to reduce catastrophic health spending in lower - middle income
groups. The expected outcomes of the policy are:

• Coverage of essential health services improved

• Health facilities at primary, secondary and tertiary care level are

equitably distributed

• A first contact care Family Doctor for every 5000 population

• Skill mix of Human resources for Health is improved to address

the current requirements for health care

• Access to essential medicines and laboratory facilities are

improved

• Access to emergency care is improved

• Efficiency in health service delivery is improved

• Male participation in health screening programs is increased

• Overall participation in health screening programs are improved

• Increased knowledge on health and healthcare among the

population

• Staffing of Community health services is improved to support

continuity of care

• All adults will have a personal health record and a personal

health identification number.

• Systems to support shared clinical exchange are in place

(shared Electronic Health Record)

64
According to National Health Accounts, 38% of the allocation for
curative care services was spent on primary care delivered through
all levels of hospitals consisting of primary, secondary and tertiary
hospitals, while 49% and 13% were allocated for secondary and tertiary
level care respectively (22).

As part of reorganization of health service delivery, plans are under way

to strengthen primary care and improve linkages between primary and
specialized care through a model known as the “shared care cluster
system”( 21 ). The aim is to provide universal health access through a
family doctor who is responsible for a smaller population (5000 people
) in the curative system. Services are to be grouped around a hospital
providing specialist care at the apex with surrounding primary care
curative institutions at divisional and primary level. It is hoped that
this reorganization will improve access to essential diagnostics and
medicines as well as continuity of care. Importantly, the plan is to
design a system to enhance accountability for care including greater
regulation of the private sector. A quality secretariat has also been
established and has developed quality standards for primary care,
which also need to be implemented ( 9 ). The success of these reforms
and their impact on NCD prevention and control is heavily contingent
on the ability of the Government to increase current expenditure
on health, through enhanced domestic resource mobilization (see
Chapter 2) (23, 24).

Conclusions and future perspectives

Sri Lanka has a public health sector with a good track record and
an island-wide primary health care network. As the new policy for
health reform demonstrates, the Government will not shy-away from
undertaking major reforms, to make health services fit- for- purpose to
address NCDs.

Moving forward, the following key actions (and others highlighted in

Chapters 4 to 14) will be critical in dismantling barriers and consolidating
progress to pave the way to attain National NCD Target 1:

65
1. Mobilize more domestic revenues for sustainable, transparent
and long-term funding of population based prevention activities
at district, provincial and central levels and for primary care
reform.

2. Establish a high-level interministerial platform/commission to

facilitate, endorse and evaluate multisectoral collaboration for
prevention and control of NCDs.

3. Continue to strengthen the workforce addressing NCDs at

district, provincial and central levels to deliver population based
prevention of NCDs with a special focus on reducing tobacco
use, harmful use of alcohol, physical inactivity, population salt
intake, obesity and indoor air pollution.

4. Strengthen national surveillance systems for NCDs, including

vital registration that is capable of reporting cause of death,
cancer registries, and risk factor surveillance, and ensure these
are integrated into national health information systems, to
enable regular reporting/auditing/benchmarking and monitoring
of progress.

5. Increase resources to scale up the implementation of very cost-

effective interventions island-wide (see Chapter 2).

6. Further strengthen the health system at all levels, with

emphasis on primary care, to achieve universal health coverage
dynamically and incrementally.

7. Continue to protect the implementation of public health policies

for NCD prevention and control from interference by vested
interests, through comprehensive legislation and enforcement of
national laws and regulations.

8. Strengthen training of the health workforce and the scientific

basis for decision-making, through NCD-related research and
partnerships.

66
References
1. World Health Statistics 2018. Geneva, World Health Organization.
2. Global status report on noncommunicable diseases 2014. Geneva:
World Health Organization; 2014
3. WHO. Global Health Observatory (GHO) data; 2016 Global Health
Estimates 2016: Deaths by cause, age, sex, by country and by region,
2000–2016. Geneva: World Health Organization; 2018 (http://www.
who.int/healthinfo/global_ burden_disease/estimates/en/index1.html).
4. World Health Organization and World Economic Forum. From Burden
to Best Buys. Reducing the Economic Impact of Noncommunicable
Diseases in low – and middle-income countries. Geneva 2011
5. Chaker L, Falla A, van der Lee SJ, Muka T, Imo D, Jaspers L, Colpani
V, Mendis S, Chowdhury R, Bramer WM, Pazoki R, Franco OH. The global
impact of non-communicable diseases on macro-economic productivity:
a  systematic review. Eur J Epidemiol.  2015 May;30(5):357-95. doi:
10.1007/s10654-015-0026-5. Epub 2015 Apr 3.
6. Mathers CD, Loncar D projections of global mortality and burden of
disease 2002–2030. PLoS Med. 2006;3(11):e442. doi:10.1371/journal.
pmed.0030442
7. Parliament of the Democratic Socialist Republic of Sri Lanka.The Private
Medical Institutions (Registration) Act No. 21 of 2006.
8. Central Bank of Sri Lanka. Annual Report 2016.
https://www.cbsl.gov.lk/en/publications/economic-and-financial-
reports/annual-reports/annual-report-2016
9. Annual Health Bulletin 2015. Medical Statistics Unit. Ministry of Health,
Nutrition and Indigenous Medicine, Colombo, Sri Lanka.
10. World health statistics 2014. Geneva: World Health Organization; 2014
(http://apps.who.int/iris/bitstream/10665/112738/1/9789240692671_
eng.pdf,
11. Vital Statistics. Department of Census and Statistics, Colombo, Sri Lanka;
2010. http://www.statistics.gov.lk/.
12. Fonseka WAAP.  A study in the quality and coverage of death registration
in a district of Sri Lanka. MD Thesis, Postgraduate Institute of Medicine,
University of Colombo, Sri Lanka; 1996. 
13. Dharmaratne SD, Jayasuriya RL, Perera BY, Gunesekera E,
Sathasivayyar A. Opportunities and challenges for verbal autopsy in the

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national Death RegistrationSystem in Sri Lanka: past and future. Popul
Health Metr. 2011 Aug 1;9:21. doi: 10.1186/1478-7954-9-21.
14. Rampatige R, Gamage S, Peiris S, Lopez AD. Assessing the reliability of
causes of death reported by the Vital Registration System in Sri Lanka:
medical records review in Colombo. Health Inf Manag. 2013;42(3):20-8.
15. Department of census and statistics. Ministry of national policies and
economic affairs. Report of Household Income and Expenditure Survey
2016. Colombo Sri Lanka.
16. An introduction to population level prevention of noncommunicable
diseases. Mike Rayner, Kremlin Wickramasinghe, Julianne Williams,
Karen McColl, and Shanthi Mendis Oxford University Press 2017. ISBN
9780198791188.
17. Cardiovascular Disease; equity and Social Determinants. Shanthi Mendis
and A. Banerjee In:Equity, Social Determinants and Public Health
Programmes Erik Blas and Anand Sivasankara Kurup ISBN: 978 92 4
156397 0 Geneva World Health Organization.
18. Mendis S, Davis S, Norrving B. Organizational update: the world health
organization global status report on noncommunicable diseases 2014;
one more landmark step in the combat against stroke and vascular disease.
Stroke. 2015 May;46(5):e121-2. doi: 10.1161/STROKEAHA.115.008097.
Epub 2015 Apr 14.
19. WHO STEPs survey Sri Lanka 2014. Ministry of Health and Indigenous
Medicine. Colombo, Sri Lanka.
20. Sri Lanka Demographic and Health Survey 2016. Department of Census
and Statistics; Ministry of National Policies and Economic Affairs. Ministry
of Health and Indigenous Medicine. Colombo, Sri Lanka 2017.
21. Policy on Health Care Delivery for Universal Health Coverage 2018.
Management Development and Planning Unit. Ministry of Health and
Indigenous Medicine. Colombo, Sri Lanka 2018.
22. Primary health care systems (PRIMASYS): case study from Sri Lanka,
abridged version. Geneva: World Health Organization; 2017.
23. First Report of the WHO Independent High Level Commission on NCDs.
Geneva : World Health Organization 2018.
24. Addis Ababa Action Agenda of the Third International Conference on
Financing for Development, Addis Ababa, Ethiopia, 13-16 July 2015
and endorsed by the General Assembly in its resolution 69/313 on 27th
July 2015. New York: United Nations 2015.

68
CHAPTER 4

National NCD target 2:

Reduce harmful use of
alcohol

At least 10% relative reduction in the harmful use

of alcohol by 2025.

Key messages
• There is a causal relationship between harmful use of
alcohol and the morbidity and mortality associated with
cardiovascular diseases, cancers and liver disease.

• In 2012, more than half of the estimated 3.3 million deaths,

or 5.9% of all deaths worldwide, attributable to alcohol
consumption were from NCDs.

• Implementing very cost-effective population-based policy

options – such as the use of taxation to regulate demand
for alcoholic beverages, restriction of availability of alcoholic
beverages, and bans on alcohol advertising – are key to
attaining this target.

• Total per capita consumption is one of the most reliable

indicators of alcohol exposure.

• In Sri Lanka, the total alcohol consumption per capita (≥ 15

years of age) is 4.3 litres of pure alcohol.

69
• In Sri Lanka in 2015, the estimated costs related to treatment
of alcohol related disorders and lost earnings due to mortality
and morbidity caused by hazardous alcohol use were LKR
119.7 billion.

• Sri Lanka is implementing several cost effective interventions

to attain this target including taxing and pricing policies,
drink-driving countermeasures, measures to reduce the
availability of alcohol and regulate marketing of alcoholic
beverages.

• The attainment of this target will reduce premature mortality

from NCDs and also contribute to attainment of other NCD
targets (targets 6, 7 and 8).

he

Health consequences of harmful use of alcohol

Harmful use of alcohol has multiple detrimental effects on health and
wellbeing. The poorest in the society are at greater risk of alcohol’s
harmful impacts on health, because poverty reduces the resilience
to disease. Harmful use of alcohol increases the risk of developing
NCDs, mental and behavioural disorders, including alcohol
dependence, suicide, road traffic accidents and violence. There is also
a causal relationship between harmful use of alcohol and incidence
of tuberculosis. Alcohol consumption in pregnancy may cause fetal
alcohol syndrome and pre-term birth complications (1). High levels
of alcohol consumption increases the risk of cancers of the mouth,
nasopharynx, oropharynx, larynx, oesophagus, colon, rectum, liver
and female breast (2). At high levels, alcohol consumption also causes
liver cirrhosis and pancreatitis (3).

Alcohol consumption can have detrimental effects on hypertension,

atrial fibrillation, haemorrhagic stroke and cardiomyopathy (3, 4).
The relationship between alcohol consumption and ischaemic heart
disease and cerebrovascular diseases is complex. The beneficial
cardioprotective effect of relatively low levels of drinking for ischaemic

70
heart disease and ischaemic stroke disappears with heavy drinking
occasions, which is highly prevalent in many countries (1, 5, 6).

In 2012, 3.3 million deaths, (5.9% of all global deaths), were

attributable to alcohol consumption. There are sex differences in the
proportion of global deaths attributable to alcohol. For example,
in 2012, 7.6% of deaths among males and 4.0% of deaths among
females were attributable to alcohol. More than half of the deaths
attributable to alcohol resulted from NCDs – cardiovascular diseases
and diabetes (33.4%), cancers (12.5%) and gastrointestinal diseases,
including liver cirrhosis (16.2%). In 2012, 139 million DALYs (disability-
adjusted life years), or 5.1% of the global burden of disease and injury,
were attributable to alcohol consumption. Cardiovascular diseases,
cancers and gastrointestinal diseases (largely due to liver cirrhosis) are
responsible for more than one third (37.7%) of this burden (1).

The inclusion of a target to strengthen the prevention and treatment

of harmful use of alcohol, under the health goal in the United
Nations’ 2030 Agenda for Sustainable Development, acknowledges
the importance of reducing the harmful use of alcohol for global
and national development (7). SDG target 3.5 is to strengthen the
prevention and treatment of substance abuse, including narcotic drug
abuse and harmful use of alcohol by 2030.

Alcohol consumption
The level of alcohol consumption worldwide in 2016 was estimated
at 6.4 litres of pure alcohol per person aged 15 years and over. The
highest levels of alcohol consumption were found in middle- and high-
income countries of the WHO European Region and Region of the
Americas (1, 7). There is a wide variation in total alcohol consumption
between different countries. Prevalence of heavy episodic drinking in
past 30 days, is shown in Figure. 4.1. The prevalence of heavy episodic
drinking is associated with the overall levels of alcohol consumption
and is highest in the European Region and Region of the Americas
(see Table 4.1) (1, 7).

71
Figure. 4.1. Age standardized heavy episodic drinking (aged 15years
and over) in past 30 days (%), 2010 (Source: Global status report
on noncommunicable diseases 2014. World Health Organization.
Geneva 2014.)

Table 4.1 Total alcohol consumption per capita (in litres of pure
alcohol) and prevalence of heavy episodic drinking (%) in the total
population aged 15 years and over, and among drinkers aged
15 years and over, by WHO region and the world, 2010 (Source:
Global status report on noncommunicable diseases 2014. World
Health Organization. Geneva 2014).

Among drinkers only

Among all (15+ years)
(15+ years)
Prevalence Prevalence
Per capita of heavy Per capita of heavy
WHO region
consumption episodic consumption episodic
drinking (%) drinking (%)
African Region 6.0 5.7 19.5 16.4
Region of the
8.4 13.7 13.6 22.0
Americas
Eastern
Mediterranean 0.7 0.1 11.3 1.6
Region

72
European
10.9 16.5 16.8 22.9
Region
South-East
3.4 1.6 23.1 12.4
Asia Region
Western
6.8 7.7 15.0 16.4
Pacific Region
World 6.2 7.5 17.2 16.0

In general, the greater the economic wealth of a country, more the

alcohol that is consumed (see Table 4.2). In 2010 in Sri Lanka, per
capita consumption of pure alcohol in litres was for males 7.3 (SD
6.1-8.5), females 0.3 (SD 0.2-0.3) and both sexes 3.7 (SD 3.1-4.3). Per
capita consumption has increased from 2.2 litres in 2005 to 3.7 litres
in 2010. The 12 month prevalence (%) of alcohol use disorders was
for, males 5.5 (SD 3.1-7.9), females 0.6 (SD 0.0-1.5) and both sexes 3.0
(SD 1.7-4.3). The prevalence of heavy episodic drinking among current
drinkers, in the total population aged 15 years and over, was for males
0.8 (SD 0.0-1.8), females 0.0 (0.0-0.2) and both sexes 0.4 (0.0-0.9) ( 7 ).
According to the latest WHO estimates, in Sri Lanka, the total alcohol
consumption per capita (≥ 15 years of age) in litres of pure alcohol, in
2016, was 4.3 litres (Figure 4. 2), (8).

73
Figure 4.2 The total alcohol consumption per capita (≥ 15 years
of age) in litres of pure alcohol, 2016- in countries in WHO South
East Asia Region (Source: World Health Statistics 2018; Monitoring
health for the SDGs. Geneva World Health Organization)

In a National Survey conducted in 2014 to investigate alcohol use, the

prevalence of current drinkers among males and females was 39.6% and
2.4% respectively. (9). Adult per capita recorded alcohol consumption
among people living in 18 districts that were not directly exposed to
the armed conflict has increased markedly after the end of the conflict
in 2009, with a dramatic acceleration in the trend of per capita beer
consumption (10).

74
Table 4.2 Total alcohol per capita consumption, prevalence (%) of
current drinkers, and prevalence of heavy episodic drinking among
current drinkers, in the total population aged 15 years and over,
by World Bank income group and the world, 2010 (Source: Global
status report on noncommunicable diseases 2014. World Health
Organization. Geneva 2014).

Prevalence Prevalence of
of current heavy episodic
Per capita drinkers (%) drinking among
Income group consumption drinkers (%)
Low-income 3.1 18.3 11.6
Lower middle-
income 4.1 19.6 12.5
Upper middle-
income 7.3 45.0 17.2
High-income 9.6 69.5 22.3
World 6.2 38.3 16.0

Liver cirrhosis is a largely preventable cause of ill health and premature

mortality. Variations in cirrhosis mortality at the country level reflect
differences in prevalence of risk factors such as alcohol use and hepatitis
B and C infection. As shown in Figure 4.3 deaths from liver cirrhosis
in Sri Lanka between 1980 and 2010 have more than trebled from
1047 (785-1387) to 3435 (1648-5191) (11). In comparison, the number
of deaths from liver cirrhosis in Australia (with a population of similar
size), which has strong policies to control harmful use of alcohol, has
shown only a slight increase.

75
Figure 4.3 Mortality from liver cirrhosis in Sri Lanka and Australia
between 1989 and 2010 (Source: Mokdad AA, Lopez AD, Shahraz
S, Lozano R, Mokdad AH, Stanaway J, Murray CJ, Naghavi M. Liver
cirrhosis mortality in 187 countries between 1980 and 2010: a
systematic analysis. BMC Med. 2014 Sep 18;12:145. doi: 10.1186/
s12916-014-0145-y

Policies and interventions for reducing harmful

use of alcohol
WHO’s Global strategy to reduce the harmful use of alcohol and the
Global NCD Action Plan highlight several evidence based policy areas
for multisectoral national action to reduce harmful use of alcohol and
protect the health of populations (12, 13). They include:

• leadership, awareness and commitment;

• health services response;

• community action;

• drink-driving policies and countermeasures;

76
• availability of alcohol;

• marketing of alcoholic beverages;

• pricing policies;

• reducing the negative consequences of drink-driving and

alcohol intoxication;

• reducing the public health impact of illicit alcohol and

informally-produced alcohol;

• monitoring and surveillance.

Some interventions for reducing harmful use of alcohol are very cost-
effective, or “best buys” (see Table 1.2). When implemented in health
services, individual interventions such as counselling, and treatment of
alcohol dependence, are also effective in reducing the harmful use of
alcohol. However, their implementation requires more resources than
for population-based measures (14-17).

Monitoring harmful use of alcohol

The three indicators of the global monitoring framework, for monitoring
progress towards attaining this target are (7):

• total (recorded and unrecorded) alcohol consumption per capita

(aged 15 years and over) within a calendar year, in litres of pure
alcohol, as appropriate within the national context;

• age-standardized prevalence of heavy episodic drinking among

adolescents and adults, as appropriate within the national
context; heavy episodic drinking among adults is defined as
consumption of at least 60 g or more of pure alcohol on at least
one occasion in the previous 30 days;

• alcohol-related morbidity and mortality among adolescents and

adults, as appropriate within the national context.

Total per capita consumption is one of the most reliable indicators

77
of alcohol exposure. Effective monitoring of trends in the prevalence
of heavy episodic drinking requires a well-developed system for
surveillance of alcohol consumption in populations. Sri Lanka has
to choose to report against the indicator/s most appropriate to the
national circumstances. There are significant challenges in measuring
and reporting alcohol-related morbidity and mortality, since reporting
on these indicators is significantly influenced by the organization of
the surveillance and monitoring system and functioning of the health
system.

Global Progress
Growing numbers of countries have developed national alcohol policies
and action plans since the Global strategy to reduce the harmful use of
alcohol (12 ) was endorsed by the World Health Assembly in 2010. Of
76 countries with a written national policy on alcohol, 52 have taken
steps to operationalize it (18). Higher minimum legal drinking ages and
controls over alcohol sales reduce both alcohol sales and consumption
(19). Some 160 WHO Member States have regulations on age limits
for sale of alcoholic beverages, with 18 years as the most frequent age
limit for all beverage types and 20−21 years in some countries (e.g.
Iceland, Indonesia, Japan, Sweden, United States of America (USA)
(1). Some countries have set up national networks of governmental
and nongovernmental organizations, to increase public awareness,
formulate policies and establish a legal environment to reduce the
consequences of alcohol use (1, 20).

Actions to attain this target in Sri Lanka

Political leadership and commitment
The successful implementation by governments of public health
interventions to reduce harmful use of alcohol depends on sustained
political commitment and societal support. One of the key indicators
which demonstrates leadership, awareness and commitment is the

78
presence of a written national alcohol policy. Sri Lanka launched a
National Policy on Tobacco and Alcohol in 2016 ( 1 ). The same year,
President Maithripala Sirisena launched a National Campaign called
“A Country Free of Intoxicants” demonstrating political commitment
to at the highest level to curb the consumption of alcohol, tobacco
and illicit drugs. He appointed a Presidential Task Force that has
the ambitious goal of gradually eliminating the overall consumption
of alcohol, tobacco and illicit drugs. The task force formulates and
implements joint initiatives at the grassroot and national levels. The
police and all three branches of the military have pledged to provide
support to implement this National Campaign (see Annex 1).

Governance and administration

The Excise Department of Sri Lanka established in 1913, is vested with
the responsibility of implementing the Excise Ordinance, and enforcing
the Tobacco Tax Act and National Authority on Tobacco and Alcohol
Act, No.27 of 2006. Sri Lanka Police, acts as the principal parallel
agency for enforcement of law under these ordinances and acts. The
Excise Department works in close collaboration with the National
Dangerous Drugs Control Board, National Authority on Tobacco and
Alcohol and the Presidential Special Task Force on Alcohol. The Excise
Department grants approval to Divisional Secretaries to issue licenses
for manufacturing, storing, transporting and selling liquor. Liquor
manufacturing plants, warehouses, distilleries and toddy taverns
operate under the supervision of the Excise Department. Local liquor
(Arrack),country made foreign liquor, wine, sake, bottled toddy and
beer are manufactured under license. In 2016 there were 21 liquor/
beer manufacturers, 30 bottled toddy manufacturers and 14 distilleries
operating under license ( 21 ).

Sri Lanka is taking action in the following policy areas that have been
shown to be cost-effective:

• taxing and pricing policies;

• drink-driving policies and countermeasures;

79
• availability of alcohol;

• marketing of alcoholic beverages.

Taxing and pricing policies

Models of a range of fiscal policy scenarios from a number of countries
have indicated the high cost effectiveness of taxation and pricing
policies in reducing hazardous drinking and alcohol-attributable
mortality, as well as in raising revenue (6, 14, 22, 23). In Sri Lanka, tax
rates on alcohol products have been increased in successive budgets.
Currently, excise duties contribute to 27% of the total tax revenue in
Sri Lanka (Figure 4.4). In 2016, excise tax on liquor increased (by 14.2
%), to LKR 120.2 billion due to upward revision of excise tax rates (24).

Figure 4.4 Composition of Government Revenue 2016 (Source:

Report of the Ministry of Finance 2016)

80
Although alcohol is a key source of Government revenue, it is also
responsible for massive health and societal costs. According to a study
conducted by World Health Organization and the National Authority
on Tobacco and Alcohol, the health and social costs of alcohol use
were LKR 119.7 billion, in 2015 (26). While the costs for alcohol related
cancers was LKR 9.8 billion, the cost for alcohol related to NCDs was
LKR 109.9 billion. The study took into consideration costs related to
curative care for alcohol related disorders and lost earnings due to
mortality and morbidity.

When applying price control policies, it is important to keep them

evidence based. In the recent past the alcohol industry successfully
lobbied to reduce the tax on beer, making false claims that the lower
price of beer will result in a drop in the consumption of strong liquor
and illicit alcohol.

Sri Lanka could also consider setting a minimum price per unit for
alcohol in retail sales which can complement taxation measures and
result in health benefits, as demonstrated in statistical models for
England and Canada (22, 23). At present, a total of 154 WHO Member
States have some form of excise tax on beer, wine or spirits, but the
effectiveness of these measures in protecting population health
depends on their scale and their impact on the demand for alcoholic
beverages.

Drink-driving policies and countermeasures

Sri Lanka has launched nationwide awareness-raising activities about
the harmful effects of alcohol including awareness-raising targeting
drink-driving. Drink–driving countermeasures are cost-effective
strategies to reduce harmful use of alcohol and the burden of alcohol-
attributable traffic accidents. Traffic crashes attributed to alcohol
are more likely when drivers have blood alcohol concentrations
above 0.04% (26, 27). The establishment of maximum blood alcohol
concentration limits for drivers and the enforcement of drink–driving
policies with random breath testing is a cost-effective strategy, and

81
has been reported to reduce traffic accidents by roughly 20% (27 ). Sri
Lanka has set the maximum legal blood alcohol concentration when
driving a vehicle at 0.08%. Worldwide, the maximum permissible
blood alcohol concentration for drivers in the general population most
commonly lies between 0.05–0.07% (61 countries) or 0.08–0.15% (46
countries) (1).

Availability of alcohol
Strategies regulating availability of alcohol are categorized as very
cost-effective policy options to reduce the harmful use of alcohol.
Examples of evidence-based strategies to reduce the availability of
alcohol include regulating the density of alcohol outlets, limiting the
days and hours when alcohol is sold and national minimum legal age
at which alcohol can be purchased or consumed (1). In 2006, an anti
tobacco and alcohol bill was ratified by the Sri Lanka parliament related
to the control of sale of tobacco and alcohol to young adults below 21
years, banning of advertisement and maintenance of a 1 Km alcohol
free perimeter from religious places. The bill set out a total ban on
alcohol and tobacco advertisement in media or on billboards as well
as free distribution of tobacco or alcohol related products as a means
of promotion. The bill also prohibits installation of automatic vending
machines that dispense any tobacco or alcohol related products. More
recently, a countrywide ban has been introduced on the sale of liquor
on all Poya days and 19 special holidays including the World Alcohol
Prevention Day. The ban requires all liquor shops, wine stores, bars,
taverns and liquor outlets in restaurants and hotels to be closed on
these days.

Conclusions and future perspectives

Sri Lanka has made significant progress in implementing policies and
interventions to reduce harmful use of alcohol (see Table 4.3)

82
Table 4.3 Policies and interventions to control harmful use of
alcohol in Sri Lanka (Source: Global status report on alcohol and
health 2014. Geneva: World Health Organization; 2014)

In some countries health warnings have been introduced to inform

consumers about the risks associated with drinking alcohol and to
stimulate reduced consumption. Recent studies recommend highly
visible pictorial health warnings, in order to influence recall, perceptions
and drinking behaviours (28, 29). Sri Lanka could consider labelling
alcoholic drinks to help consumers to estimate their alcohol content
and potentially choose a drink with less alcohol. In India, where these
labels are currently in use, the Excise Department gathers information
on the requirement of labels from each distillery, procures the required
quantity from the press and provides the labels to the distilleries. Each
distillery is responsible for affixing labels on all bottles that leaves their
premises. Such warning labels can help to decrease alcohol abuse,
increase collection of tax revenue, as well, help to control illicit liquor
production.

83
It is estimated that about 65% of the total alcohol market in Sri Lanka
is illicit, consisting of hard liquor (30 %) and beer (5% ) (30). Illegal
alcohol industry deprives the Government of tax revenue and thrives
due to corruption and political patronage. It is the responsibility of the
Excise Department to develop a strategy to minimize the production
capacity of this sector. The Excise Department conducts regular raids
to control unlawfully manufactured liquor. Legal reforms and stronger
enforcement of existing legislation are required to control the illicit
alcohol production. Recently a Legal Division has been established
under the direct supervision of the Commissioner General of Excise
to strengthen legal action against violations of the Excise Ordinance.

Some policy measures for reducing alcohol consumption may lead

to the unintended result of increasing illicit alcohol use. Although
reducing price of legal alcohol products cannot contain the production
of illegal products, there is a mistaken notion among some, that the
illegal alcohol market can be controlled by reducing the price of legal
alcohol products. Worsened criminality and harmful impact on health
associated with illicit alcohol are also serious concerns (31). In the long-
term, community-wide processes including community empowerment
and poverty alleviation measures are likely to be more effective in
controlling the illicit alcohol market than those with a narrow focus
only on illicit alcohol production (32).

References
1. Global status report on alcohol and health 2014. Geneva: World
Health Organization; 2014. (http://www.who.int/substance_abuse/
publications/global_alcohol_report/msb_gsr_2014_1.pdf?ua=1).
2. IARC Monographs 100E. Consumption of alcohol. Lyon: International
Agency for Research on Cancer; 2012. (http://monographs.iarc.fr/ENG/
Monographs/vol100E/mono100E-11.pdf).
3. Global Health Statistics 2018. Geneva: World Health Organization
;2018.
4. Roerecke M, Rehm J. Irregular heavy drinking occasions and risk of
ischemic heart disease: a systematic review and meta-analysis. Am J

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Epidemiol. 2010;171(6):633–44. doi:10.1093/aje/kwp451.
5. WHO Expert Committee on Problems Related to Alcohol Consumption.
Second report. Geneva: World Health Organization; 2007 (WHO
Technical Report Series, No. 944).
6. United Nations General Assembly resolution 70/1 – Transforming our
world: the 2030 Agenda for Sustainable Development. http://www.
un.org/ga/search/view_doc.asp?symbol=A/RES/70/1
7. Global status report on noncommunicable diseases 2014. Geneva:World
Health Organization; 2014.
8. World Health Statistics 2018; Monitoring health for the SDGs. Geneva:
World Health Organization.
9. Somatunga LC, Ratnayake LVR, Wijesinghe WMDNK, YapaYMMM,
Cooray MPNS. National alcohol use prevalence in Sri Lanka Journal of
the Postgraduate Institute of Medicine 2014;1(1):E7:1-12. http://dx.doi.
org//jpgim.7858
10. Nugawela MD, Lewis S, Szatkowski L, Langley T. Rapidly Increasing
Trend of Recorded Alcohol Consumption Since the End of the Armed
Conflict in Sri Lanka. Alcohol Alcohol. 2017 Sep 1;52(5):550-556.
11. Mokdad AA, Lopez AD, Shahraz S, Lozano R, Mokdad AH, Stanaway J,
Murray CJ, Naghavi M. Liver cirrhosis mortality in 187 countries between
1980 and 2010: a systematic analysis. BMC Med. 2014 Sep 18;12:145.
doi: 10.1186/s12916-014-0145-y.
12. Global strategy to reduce the harmful use of alcohol. Geneva: World
Health Organization; 2010. (http://www.who.int/substance_abuse/
activities/gsrhua/en/,
13. Global action plan for the prevention and control of noncommunicable
diseases 2013−2020. Geneva: World Health Organization; 2013. (http://
apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.
pdf?ua=1,
14. mhGAP intervention guide for mental, neurological and substance
use disorders in non-specialized health settings. Geneva:
World Health Organization; 2010. (http://whqlibdoc.who.int/
publications/2010/9789241548069_eng.pdf)
15. Chisholm D, Rehm J, Ommeren MV, Monteiro M. Reducing the global
burden of hazardous alcohol use: a comparative cost-effectiveness
analysis. J Stud Alcohol Drugs. 2004;65(6):782−93.

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16. Anderson P, Chisholm D, Fuhr D. Effectiveness and cost-effectiveness of
policies and programmes to reduce the harm caused by alcohol. Lancet.
2009;373(9682):2234–46. doi:10.1016/S0140-6736(09)60744-3.
17. Rehm J, Shield K, Rehm M, Gmel GJ, Frick U. Alcohol consumption,
alcohol dependence, and attributable burden of disease: potential
gains from effective interventions for alcohol dependence. Toronto:
Centre for Addiction and Mental Health; 2012.
18. Assessing national capacity for the prevention and control of
noncommunicable diseases report of the 2013 global survey. Geneva:
World Health Organization; 2014.
19. Gruenewald PJ. Regulating availability: how access to alcohol affects
drinking and problems in youth and adults. Alcohol Res Health.
2006;34(2):248–57. doi:SPS-AR&amp;H-39.
20. World Health Organization Western Pacific Region. WHO Representative
Office Mongolia. Alcohol initiative. (http://www.wpro.who.int/mongolia/
mediacentre/alcohol/en/,
21. Excise Department. Performance Report 2016: Sri Lanka.
22. Purshouse R, Brennan A, Latimer N, Meng Y, Rafia R. Modelling to
assess the effectiveness and cost-effectiveness of public health related
strategies and interventions to reduce alcohol attributable harm in
England using the Sheffield Alcohol Policy Model version 2.0. Report to
the NICE Public Health Programme Development Group, 9 November
2009. Sheffield: University of Sheffield School of Public Health and
Related Research; 2009. (http://www.ias.org.uk/uploads/pdf/UK%20
alcohol%20reports/univ-sheffield-am.pdf ).
23. Stockwell T, Zhao J, Giesbrecht N, Macdonald S, Thomas G, Wettlaufer
A. The raising of minimum alcohol prices in Saskatchewan, Canada:
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Health. 2012;102(12):e103−10. doi:10.2105/AJPH.2012.301094.
24. Central Bank Sri Lanka Annual Report 2016. Colombo, Sri Lanka; 2017.
25. Ministry of Finance. Report of the Ministry of Finance 2016. Colombo,
Sri Lanka.
26. Economic and Social Costs of Tobacco and Alcohol in Sri Lanka 2015.
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27. Elder RW, Shults RA, Sleet DA, Nicholas JL, Zara S, Thompson RS.

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Effectiveness of sobriety checkpoints for reducing alcohol involved
crashes. Traffic Injury Prevention. 2002. 2. 266-74.
28. Wilkinson C, Room R. Warnings on alcohol containers and advertisements:
international experience and evidence on effects. Drug Alcohol Rev.
2009;28(4):426–35. doi:10.1111/j.1465-3362.2009.00055.x.
29. Al-hamdani M. The case for stringent alcohol warning labels: lessons from
the tobacco control experience. J Public Health Policy. 2014;35(1):65–
74. doi:10.1057/jphp.2013.47.
30. Dayaratne GD. The state of the Sri Lankan Alcohol industry and analysis
of Government policies. Working paper series 19 . 2013. Institute of
Policy Studies. Colombo, Sri Lanka.
31. Samarasinghe, Diyanath: Reducing alcohol harm: things we can do.
Colombo; FORUT;2009
32. Abeysinghe R, Illicit Alcohol, Colombo, Vijitha Yapa Publishers;2002

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88
CHAPTER 5

National NCD target 3:

Reduce physical inactivity
A 10% relative reduction in prevalence of
insufficient physical activity by 2025.

Key messages
• Regular physical activity reduces the risk of cardiovascular
disease, diabetes, cancer and improves fitness, bone health
and mental health.

• Worldwide, 23% of adults and 81 % of adolescents aged

11-17 years do not meet the global recommendations for
physical activity.

• In Sri Lanka among adults, 28% of men and 44% of women,

do not satisfy the WHO recommendations for physical
activity.

• The majority of Sri Lankan adolescents aged 13-15 years, (83%

of boys 89% of girls), do not satisfy WHO recommendations
for physical activity.

• A sizeable proportion of Sri Lankan adults (34% males,

45% females) are in sedentary occupations and about half
the adults do not use a mode of transport which provides
significant physical activity.

89
• Increasing physical inactivity of the population is a major
cause of obesity, diabetes, cardiovascular disease and other
NCDs in Sri Lanka.

• Strategies to improve physical activity should aim to create

an enabling environment for active living and active transport
for children, adults and the elderly.

• The attainment of this target will contribute to attainment of

targets related to reducing obesity, diabetes, hypertension,
heart attacks and strokes and premature mortality from
NCDs.

Insufficient physical activity and its impact on

health
Physical activity is defined as any bodily movement produced by
skeletal muscles that requires energy expenditure – including activities
undertaken while working, walking, playing, carrying out household
chores, travelling, and recreation. Insufficient physical activity is one
of the 10 leading risk factors for global mortality, causing some 3.2
million deaths each year (1). In 2010, insufficient physical activity
caused 69.3 million Disability Adjusted Life Years (DALYs) – 2.8% of
the total – globally (1).

Regular physical activity is a key determinant of energy expenditure

and is therefore fundamental to energy balance, weight control and
prevention of obesity (2). Recent evidence indicates that high levels
of continuous sedentary behavior (such as sitting for long periods of
time) are associated with abnormal glucose metabolism and cardio-
metabolic morbidity (3-5). Regular physical activity reduces the risk
of ischaemic heart disease, stroke, diabetes and breast and colon
cancer. Regular physical activity is important for protecting the health
of children, adolescents, adults and the elderly. At all ages, regular
physical activity reduces body fat, improves cardiovascular and
metabolic disease risk profiles, enhances bone health, and reduces

90
symptoms of anxiety and depression (2). In the elderly, physical activity
is key to maintaining functional independence which declines due to
reduction of muscle mass, and a decline in balance ability and cognitive
performance.

WHO recommendations on physical activity

Children and adolescents aged 5-17years (3)

• Should do at least 60 minutes of moderate to vigorous-intensity

physical activity daily.

• Physical activity of amounts greater than 60 minutes daily will

provide additional health benefits. 

• Should include activities that strengthen muscle and bone, at

least 3 times per week.

Adults aged 18–64 years (3)

• Should do at least 150 minutes of moderate-intensity physical

activity throughout the week, or do at least 75 minutes of vigorous-
intensity physical activity throughout the week, or an equivalent
combination of moderate- and vigorous-intensity activity.

• For additional health benefits, adults should increase their

moderate-intensity physical activity to 300 minutes per week, or
equivalent. 

• Muscle-strengthening activities should be done involving major

muscle groups on 2 or more days a week.

Adults aged 65 years and above ( 3)

• Should do at least 150 minutes of moderate-intensity physical

activity throughout the week, or at least 75 minutes of vigorous-
intensity physical activity throughout the week, or an equivalent
combination of moderate- and vigorous-intensity activity.

• For additional health benefits, they should increase moderate-

91
intensity physical activity to 300 minutes per week, or equivalent.

• Those with poor mobility should perform physical activity to

enhance balance and prevent falls, 3 or more days per week. 

• Muscle-strengthening activities should be done involving major

muscle groups, 2 or more days a week.

The intensity of different forms of physical activity varies between

people. In order to be beneficial for cardiorespiratory health, all
activities should be performed in bouts of at least 10 minutes duration.

Global prevalence of insufficient physical activity

in adults
The prevalence of insufficient physical activity in men and women
aged 18 years and over in different parts of the world is shown in
Figures 5.1 and 5.2. respectively. In 2010, 23% of adults aged 18 years
and over did not meet the global recommendations for physical
activity. Women were less active than men, with 27% of women and
20% of men not reaching the recommended level of activity ( 4).
The prevalence of physical inactivity varies considerably within and
between countries. It increases with economic development, owing to
the influence of changing patterns of transportation, use of technology
and urbanization (5).

92
Figure 5.1. Age standardized prevalence of insufficient physical
activity in men aged 18 years and over, comparable estimates,
2010 (Source: Global status report on noncommunicable diseases
2014. Geneva: World Health Organization; 2014)

93
Figure 5.2. Age standardized prevalence of insufficient physical
activity in women aged 18 years and over, comparable estimates,
2010(Source: Global status report on noncommunicable diseases
2014. Geneva: World Health Organization; 2014)

Global prevalence of insufficient physical activity

among adolescents
Children and adolescents engaging in at least 60 minutes of physical
activity of moderate to vigorous intensity daily have higher levels of
cardiorespiratory fitness, muscular endurance and strength, compared
to their inactive peers, (2). Globally, 81% of adolescents aged 11−17
years were insufficiently physically active in 2010. Adolescent girls
were less active than adolescent boys, (see Figures. 5.3 and 5.4).

94
Figure 5.3. Global prevalence of insufficient physical activity for
adolescent boys aged 11−17 years, comparable estimates, 2010
(Source: Global status report on noncommunicable diseases 2014.
Geneva: World Health Organization; 2014)

Figure 5.4. Global prevalence of insufficient physical activity for

adolescent girls aged 11−17 years, comparable estimates, 2010
(Source: Global status report on noncommunicable diseases 2014.
Geneva: World Health Organization; 2014)

95
Insufficient physical activity among adults in Sri
Lanka
The 2015 STEPs survey provides data on physical activity (6).The
distribution of level of physical activity in men and women is shown in
Tables 5.1 and 5.2 respectively. In the age group 18-69, low physical
activity based on WHO recommendations, was reported by 28.1% of
men and 44.2% of women. Mean number minutes of work related
physical activity per day was higher in males (153.7, 95% CI 141.6-
165.8 ), than in females (80.8, 95% CI 73.2-88.4). Mean number of
minutes of transport related physical activity per day was also higher
in males ( 36.1, 95% CI 30.7-41.4) than in females ( 21.0,95% CI 18.5-
23.5).

Table 5.1 Distribution of level of daily total physical activity in

women (Source: WHO STEPs 2015)

Table 5.2 Distribution of level of daily total physical activity in men

(Source: WHO STEPs 2015)

Work related activity was an important contributor to regular physical

activity for a high proportion of both males (63.7 %) and females (59.2
%). However, nearly 34% of males and 45% of the females engaged in
sedentary work. In 43% of males and 46% females, mode of transport
did not require significant physical activity. Majority of adults (79.3%

96
males and 94.1% females ) were not engaged in recreation related
physical activity. Men engaged in recreation related physical activity
for a longer duration (mean 12.6 minutes 95% CI 10.1-15.0) compared
to females (mean 2.4 minutes, 95% CI 1.7-3.2).

Several key findings that emerge from this survey are important when
formulating policies to promote physical activity. Overall, women are
physically less active than men. A sizable proportion of adults are
engaged in sedentary occupations. Occupational and domestic activity
are important contributors to regular physical activity. Transport is not
contributing to physical activity in more than half the adults. The vast
majority of adults do not engage in leisure time physical activity.

Insufficient physical activity among children,

adolescents and youth in Sri Lanka
Findings of the Global School based Student Health Survey (2008)
( 7 ) in Sri Lanka, show that among students 13-15 years, only 17.4 %
(SD ±3.0) of boys are physically active for a total of at least 60 minutes
per day on all 7 days of the week. For girls the corresponding figure
was even less (11.1% SD ± 2.3 ). In this age group, 34.6 %(SD± 3.6) of
boys and 33.5% (SD± 2.4) of girls spent three or more hours per day,
sitting and watching television, playing computer games, talking with
friends, or doing other sedentary activities. While a small proportion of
children and adolescents engage in regular physical activity, about one
third spend many hours a day engaged in sitting activities; a behaviour
pattern that promotes obesity. Findings of the Global School based
Student Health Survey (2016), shown in Table 5.3, indicate that physical
inactivity continue to be a serious behavioural problem in children and
adolescents ( 8 ). Present day youth also seem to be engaged in a
more sedentary lifestyle. According to the results of the National Youth
Survey, among males, 57.2 % of 15-19 year old youth and 55% of 20-
24 year old youth are not engaged in any manual work. The respective
values for females are 72.1% and 75.7% . Almost half (48.3%), give a
history of watching television, video films, video games or internet on
five or more days a week. (9).

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Table 5.3 Physical activity in children and adolescents (Source:
Global School based Student Health Survey 2016)

Cost-effective policies and interventions for

reducing insufficient physical activity
Many evidence based interventions – focusing on policy and
environment, mass media, school settings, workplaces, the community
and primary health care – can be implemented to increase people’s
physical activity (2-5). Multicomponent interventions that use the
existing social structures and participation of all stakeholders are the
most successful.

The Global Action Plan on Physical Activity recommends multifaceted

policies to create active societies, active people, active environments
and active systems (5). The built environment plays an important role
in facilitating physical activity for large portions of the population,
by ensuring that walking, cycling and other forms of non-motorized
transport are accessible and safe for all. The physical environment
also provides sports, recreation and leisure facilities and ensures that
there are adequate safe spaces for active living. School-based physical
activity interventions show consistent improvements in knowledge,
attitudes and behaviour of children (8). Workplace interventions reduce
individual risk-related behaviours, including physical inactivity (10).

98
Monitoring insufficient physical activity
There are two indicators for monitoring insufficient physical activity
(11):

1. prevalence of insufficient physical activity in adolescents, defined

as less than 60 min of physical activity of moderate to vigorous
intensity daily;

2. age-standardized prevalence of insufficient physical activity in

persons aged 18 years and over, defined as NOT meeting any of
the following criteria:
– 150 min of moderate-intensity physical activity per week;

– 75 min of vigorous-intensity physical activity per week;

– an equivalent combination of moderate- and vigorous-

intensity physical activity, accumulating at least 600 MET-min1
per week.

Global progress achieved

Global progress in attaining this target has lagged behind. Although,
by 2013, 80% of countries reported having policies, plans or
strategies for addressing physical inactivity, only 56% indicated that
these were operational (12). Only a few countries (8%) reported tax
incentives to promote physical activity – including tax exemptions
on sports equipment, fitness programmes or gym membership, and
higher taxation on items such as home entertainment equipment
that encourage sedentary lifestyles. As a result of implementation of
national policies and programmes to improve physical activity, several
high-income countries, including Canada and Finland, have reported
increased physical activity over the last decade (13, 14). In recent
years more low- and middle-income countries have set up initiatives
to address physical inactivity (15).

1 MET refers to metabolic equivalent. It is the ratio of a person’s working metabolic rate
relative to the resting metabolic rate. One MET is defined as the energy cost of sitting
quietly, and is equivalent to a caloric consumption of 1 kcal per kg per hour.

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Actions to promote physical activity in Sri Lanka
A comprehensive set of policy options to improve physical activity
is listed in the National Multisectoral Action Plan for Prevention and
Control of Noncommunicable Diseases 2016-2020 (16 ). Ministries of
Health, Sports, Education, Higher Education, Social services, Public
Administration, Child Care and Women Development, Youth Affairs
and Urban development are making efforts to implement them through
various initiatives discussed below.

Research to identify factors that influence the

outcomes of physical activity initiatives
Many social and physical (built) environment factors influence the
pattern of physical activity in populations [17-22]. In Sri Lanka too,
rising income levels, increased ownership and use of vehicles, land-
use patterns, traffic safety and congestion, sedentary occupation,
urban design, infrastructure for walking and cycling, availability of
pavements, street lights, unattended dogs, enjoyable scenery, high
levels of crime, easy access to recreation and retail shops, are important
determinants of levels and patterns of physical activity. Income, equity,
social acceptance, culture and social support are identified in literature
as elements in the social environment that influence participation in
physical activity [23, 24]. Local studies confirm the applicability of these
findings to the Sri Lankan context (25-29). This information needs to be
taken into consideration when designing and implementing physical
activity initiatives.

Health promotion in schools

Sri Lanka has about 4 million school children distributed across 10,
144 schools. Health promotion in schools has been recognized as an
effective approach for early action against exposure to risk factors
of NCDs, including physical inactivity. The Ministries of Health and
Education have jointly adopted the concept of Health Promoting

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Schools (30). The program underpinned by a School Health Promotion
Policy, aims to create a sustainable health promoting school culture
which enables children to adopt healthy behaviours and optimally
benefit from educational opportunities provided. The key components
of the program are skills based health education, safe and healthy
school environment, access to health services and empowerment
of the children to be agents of change, for promoting health of the
family and the community. The School Health Unit of the Family Health
Bureau and the Health Promotion Bureau provide technical guidance
and training for Health Promotion in Schools. The program was
evaluated in 2015. Based on the evaluation, about 3400 schools have
been accredited as health promoting schools (30). In addition, the
school curriculum on Health and Physical Education has been revised
and introduced as a compulsory subject in secondary school, with the
aim of strengthening skills to develop and maintain healthy behaviours
( 31 ). In 2015, the School Health Unit of the Family Health Bureau,
together with the National Institute of Education and the Health
Promotion Bureau designed the new “Health and Physical Education”
curriculum for students giving special attention to health promotion,
life skills development and strengthening of physical activity.

Youth programmes
The National Youth Policy of Sri Lanka (32), recognizes the importance
of promoting healthy behaviors including physical activity to prevent
NCDs. The Family Health Bureau has established a Technical Advisory
Committee on Health of Young Persons with the participation of
all stakeholders including the Ministries of Youth affairs and Skills
Development and Education and Social Services. The Ministry of Youth
affairs and Skills Development provides a range of services for youth
including leadership and life skills development, vocational training,
livelihood training and opportunities for recreation and sports. A
Resource Pack for Health has been prepared and a training program
has been initiated to strengthen the capacity of instructors of Youth
Corps who conduct island-wide training programs for youth.

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Promotion of physical activity in the community
The Ministry of Health launched the Healthy Lifestyle Centres program
in 2011 to improve early detection of people at high cardiovascular
risk at primary care level (see Chapter 10). People in age group 40-65
years utilize the service largely through self referral and are checked for
behavioural and metabolic risk factors of NCDs. Counseling is provided
as appropriate, to help modify behavioural risk factors including
physical inactivity (see Chapter10). Regular physical exercise sessions
are organized for local communities in Healthy Lifestyle Centers,
public playgrounds, and premises of various government institutions
by medical officers/NCD. Ministry of Sports and the Ministry of Health
have also launched an initiative to set up public fitness centers in all
districts to facilitate physical activity in low- income populations.

Promotion of physical activity through health

promotion settings
The Health Promotion Bureau plays a key role in promoting physical
activity by providing guidance and establishing healthy settings; in pre
schools, workplaces, villages and hospitals. In 2016, 1425 preschools,
520 workplaces, 580 villages and 78 hospitals were identified as health
promotion settings.

Effective workplace health programmes have been shown to improve

the health and well-being of employees, reduce absenteeism and
increase productivity. Some private sector companies already provide
their employees with membership at gymnasiums, swimming pools
and fitness centres. The Ministry of Health in collaboration with the
Ministry of Public Administration is taking steps to introduce a policy
on physical fitness/activity to be implemented in state and private
institutions, starting with the institutions attached to the Ministry of
Health. There are challenges ahead, as workplace physical fitness
initiatives require identification of key stakeholders, attitude change,
senior and middle management commitment, time allocation, as well
as collaboration between employers and employees at the individual

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workplaces.

Urban development
Modern urban development projects are increasingly paying attention
to the health and wellbeing of people (31 ). For example, in the Metro
Colombo Urban Development Project, the Colombo Municipal Council
is improving the 480 km road network in the Colombo city, for the
benefit of pedestrians as well as motorists. Steps are being taken to
improve walkability by providing more convenient and clean walkways
with better street lighting. Existing walkways will be connected to
the new network for more efficient use. In addition to reducing traffic
congestion and improving the image of the city, it will make the capital
city physical- activity friendly. Other major cities could follow this
example in urban development projects.

Mother Support Groups and health promotion

Mother Support Groups have the potential to contribute to
modification of behavioural risk factors in families including physical
activity. Nutrition Coordination Unit and the Health promotion Bureau
in collaboration with UNICEF has set up Mother Support Groups in all
districts, to Improve family health by improving practices that promote
healthy living (29). Mother Support Groups also assist Medical Officers
of Health through their Public Health Midwives in several other tasks:
to increase growth monitoring in children under 5 years, increase
early detection of pregnancy and to reduce rates of anaemia among
pregnant mothers. In addition, these groups engage in efforts to
address important social issues such as early school dropout and
teenage pregnancies. The project has also facilitated self employment
of participating women and enhanced communication between the
public health network and the target community.

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Conclusions and future perspectives
Declining levels of physical activity among adolescents and adults in
Sri Lanka will hasten the growth of the NCD burden. It is important
that the general public understand that physical activity is essential for
good health and that it can be undertaken at work, while engaging
in day to day activities around the home and in many different ways:
walking, running, cycling, sports and active forms of recreation. All
forms of physical activity can provide health benefits if undertaken
regularly and of sufficient duration and intensity.

Active play and recreation are key elements for prevention of

childhood obesity (5, 34, 35), and need to be further strengthened
through the school health program. Quality physical education and a
health promoting school environment can inculcate health literacy for
active lifestyles and prevention of NCDs. Many adults will benefit if
worksites can be fashioned to promote physical activity and to reduce
sitting/sedentary behavior. Culturally sensitive, affordable approaches
also need to be developed to promote physical activity in women and
the elderly.

The global action plan on physical activity (2018-2030), provides

a prioritized list of policy actions that can be taken, to address the
multiple cultural, environmental and individual determinants of
physical inactivity by engaging with other sectors (5). Sri Lanka needs
to identify a strategic combination of affordable policy responses for
implementation over the short term (2–3 years), medium term (3–6
years), and longer-term (7–12 years).

A major national effort backed by adequate human and financial

resources, is needed to implement a portfolio of physical activity
initiatives across provincial, district and divisional secretariat levels,
to target all segments of the population. The Presidential Secretariat
and relevant units of the Ministry of Health can be the driving forces
that support the strategic implementation of the national physical
activity initiative. However, alone, they have only limited opportunities
to organize and sustain such an initiative, in the long-term. Success
will depend on the stronger engagement of a wide range of partners

104
including; Ministries of Health, Sports, Education, Higher Education,
Social services, Public Administration, Transport, Child Care and
Women Development, Youth Affairs, Urban development, Labour
and Labour relations, Institute of Occupational Safety and Health
promotion institute and the Ceylon Chamber of Commerce, among
others.

A national physical activity task force, with representation from all

relevant Ministries, multiple sectors, agencies, non-governmental
organizations and the private sector could provide guidance in
implementing the national physical activity plan. As part of the national
NCD programme, there is also a need to advocate for physical activity
and mobilize communities through social marketing and mass media
campaigns – including education of the public on the benefits of
physical activity (e.g. NCD prevention, less air pollution as a result of
reduced traffic). Programme development to promote physical activity
should be encouraged and adequately resourced in all 25 districts, in
cooperation with relevant sectors, through activities of daily living and
across a range of settings such as schools, universities, workplaces,
health-care services, and the local and wider community. Operational
research is essential to identify best practices and assess population
reach and impact of such programs(36).

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comparative risk assessment of burden of disease and injury attributable
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10. Task Force on Community Preventive Services. A recommendation to
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16. National Multisectoral Action Plan for Prevention and Control of
Noncommunicable Diseases 2016-2020 Ministry of Health, Nutrition
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among transportation, land use, and physical activity. Washington, DC:

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Transportation Research Board and Institute of Medicine Committee
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18. Owen N, Humpel N, Leslie E, Bauman A, Sallis J. Understanding
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behavioral determinants of adolescent obesity: a case-control study in Sri
Lanka. BMC Public Health. 2014 Dec 17;14:1291. doi: 10.1186/1471-
2458-14-1291.
20. De Silva Weliange S, Fernando D, Gunatilake J. Pattern of  Physical
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21. Saelens B, Sallis J, Frank L. Environmental correlates of walking and
cycling: findings from the transportation, urban design and planning
literatures. Ann Behav Med. 2003;25:80–91.
22. Duncan MJ, Spence JC, Mummery WK. Perceived environment
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5868-2-11. 
23. Stahl T, Rütten A, Nutbeam D, Bauman A, Kannas L, Abel T, Lüschen
G, Rodríguez Diaz JA, Vinck J, van der Zee J. The importance of
the social environment for physically active lifestyle-results from an
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9536(00)00116-7. 
24. Humpel N, Owen N, Leslie E. Environmental factors associated
with adults’ participation in physical activity: a review.  Am J Prev
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25. De Silva Weliange SH, Fernando D, Gunatilake J. Development and
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27. Chandrasiri A, Dissanayake A, de Silva V. Health promotion in workplaces
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EN_2017_web.pdf).
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and Sustainable Development Goals. Glob Heart. 2016 Mar;11(1):139-
40. doi: 10.1016/j.gheart.2016.01.002.

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CHAPTER 6

National NCD Target 4: Reduce salt consumption

A 30% relative reduction in mean population

intake of salt/sodium by 2025

Key messages
• Consumption of too much sodium (over 2 grams per day,
equivalent to 5 grams of salt per day), increase the risk of
heart attacks and strokes.

• Reduction of salt intake can reduce systolic blood pressure as

well as diastolic blood pressure and contribute to prevention
of hypertension, heart attacks and strokes.

• WHO recommends a reduction of sodium/salt intake to <2

g/day sodium (5 g/day salt) in adults.

• The population mean intake of salt in Sri Lanka is almost

double the recommended amount, and contributes to the
high prevalence of hypertension.

• Reducing salt intake has been identified as one of the most

cost-effective measures for addressing hypertension and
improving cardiovascular health.

• Multisectoral collaboration is required to improve access to

products with lower sodium content.

• Work related to this target in Sri Lanka need to be accelerated

through the implementation of health promotion programs,
food labelling and regulation of salt content in processed
foods.

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• The attainment of this target will contribute to the attainment
of the targets on reducing the prevalence hypertension and
premature mortality from NCDs.

Salt/sodium intake and its impact on health

Globally, 1.7 million annual deaths from cardiovascular causes have
been attributed to excess sodium (salt) intake (1). Excess consumption
of sodium increase the risk of hypertension which is a major cause
of heart disease and stroke (1−4). The main dietary source of
sodium worldwide is salt. Many scientific studies have consistently
demonstrated that a modest reduction in salt intake lowers blood
pressure (5-8). The blood pressure lowering effect is shown in people
with high blood pressure, normal blood pressure, in all age groups, and
in all ethnic groups. Reducing sodium intake results in a decrease in
resting systolic blood pressure of 3.4 mmHg and a decrease in resting
diastolic blood pressure of 1.5 mmHg (8). High sodium consumption
(over 2 grams per day, equivalent to 5 grams of salt per day) contributes
to high blood pressure. Sodium consumption is also associated with
cardiovascular disease events in persons who consume more than 3.5
g/day of sodium (9−11). Worldwide, people consume more salt than
they should (Figure 6.1). Reduction in salt intake is one of the most cost-
effective population-based interventions to reduce the prevalence of
hypertension, heart disease and stroke and is categorized as a World
Health Organization best-buy (12, 13 ) (see Chapter 2).

Worldwide salt intake

Worldwide, there is a rise in production of processed food, which
are also becoming readily available and more affordable. As a
result people consume more processed foods (such as ready meals,
processed meats like ham, bacon, sausages and salami, cheese, salty
snack foods, salted fish and instant noodles, among others), that are
high in salt, saturated fat, trans fat and sugar. At the same time, there is

110
a drop in the consumption of fruits vegetables and whole grains, that
are key components of a healthy diet. Salt is consumed in processed
foods, either because they are particularly high in salt or because they
are consumed frequently (such as bread, cheese and processed cereal
products). Salt is also added to food during cooking (sometimes as
bouillon and stock cubes) or at the table (pickles, soy sauce, fish sauce
and table salt). 

Recommendation of the World Health Organization

WHO recommends a reduction in sodium intake to reduce blood
pressure and risk of stroke and coronary heart disease in adults (4,
14) . A reduction in sodium intake is also recommended to control
blood pressure in children. WHO recommends a reduction to <2 g/
day sodium (5 g/day salt) in adults (4). For children, it is recommended
that the maximum level of intake of 2 g/day sodium (5 g/day salt) in
adults, be adjusted downward based on the energy requirements of
children relative to those of adults (4).

Population salt intake in Sri Lanka

Accurate data on population mean sodium intake are currently
available mainly for high- and high-middle-income countries. In Sri
Lanka, available data indicate that the average salt intake is around
9-12 g/day (15-17); very much higher than the recommended intake.
One study investigated the salt intake of government employees using
24 hour sodium excretion in urine. Mean salt intake levels measured
by 24-hour sodium excretion in hypertensives and normotensives
were 202.56 (SD ± 85.45) mmol/day and 176.79 (SD ± 82.02) mmol/
day, respectively. This is equivalent to a daily salt intake of 11.9 g(SD
± 5)/day and 10.3 g(SD ± 5)/day in hypertensives and normotensive
respectively (17).

In Sri Lanka most of the salt consumed comes from salt added during
food preparation at home. In the most recent STEPs survey, more

111
than half of the target households (52.8%), reported adding salt to
rice while cooking ( 18 ). Salt added at the table, salt in processed
foods and ready-made meals, contribute to the total daily intake to a
lesser extent. According to the findings of the STEPs survey, 27% of
adults gave a history of consuming processed food often. With greater
availability of processed foods as well as ready made meals, sources of
sodium intake is rapidly shifting towards these food items, particularly
in urban areas.

Figure 6.1. Mean sodium intake in persons aged 20 years and

over, comparable estimates, 2010 (Source: Global Status Report
on NCDs 2014. Geneva: World Health Organization)

Monitoring population intake of salt/sodium

The indicator for monitoring this target is age-standardized mean
population intake of salt (sodium chloride) in grams per day in persons
aged 18 years and over (19). The baseline level of population salt/sodium
intake need to be established by gathering data from a population-
based (preferably nationally representative) survey. A subsample of the
population used for the NCD STEPS survey could be used to estimate
data on salt consumption. The recommended standard for estimating

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salt intake is 24-h urine collection; however, other methods such as
spot urine, single morning fasting urine and food frequency surveys
may also be used to obtain provisional estimates.

Progress achieved in other countries

Many countries have national programs to reduce population
salt consumption (20). Finland initiated a systematic approach to
reduce salt intake in the late 1970s through mass media campaigns,
cooperation with the food industry, and implementation of salt
labeling legislation . The reduction in salt intake was accompanied by
a decline in both systolic and diastolic BP of > 10 mmHg. Reduction
in salt intake contributed to the reduction of mortality from heart
disease and stroke in Finland during this period (21, 22). The salt
reduction programme in the United Kingdom started in 2004. Since
then there has been reduction in salt content in many processed foods
and a 15% reduction in 24-h urinary sodium over 7 years (from 9.5 to
8.1 g per day). The United Kingdom  salt reduction programme reduced
the population's  salt intake by gradual reformulation on a voluntary
basis (23, 24 ). Argentina, Brazil, Chile, Canada, Mexico, and the USA
have also promoted voluntary national reformulation targets and
timelines with the food industry. Most of these countries are targeting
salt reduction in packaged foods and bread, while Mexico has focused
on foods available in the school environment (20, 25). In 2011, The
Ministry of Public Health of Thailand, along with other stakeholders,
initiated a campaign aimed at reducing salt consumption by 50%.
Attention was mainly on foods popular among children, particularly
snacks. Food producers were requested to reformulate their products
reducing the salt content. This strategy resulted in many good market
products, such as potato chips with sodium reduced by 50%, and instant
noodles with sodium reduced by 20% (using potassium chloride) (26).

While some WHO Member States have opted for setting voluntary
targets for salt reformulation, others, including Argentina, South Africa,
Pacific islands and Kiribati have opted for legislative and regulatory
approaches to set specific targets for various food groups. Both methods

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involve dialogue with the private sector to facilitate reformulation. In
addition public need to be educated, so that as informed consumers
they can make full use of the enabling environment (27-29).

Actions to attain this target in Sri Lanka

According to the findings of the STEPs survey in Sri Lanka, while about
27% consumed processed food often, 23% limited the consumption of
processed food in order to control salt intake. Only 6% reported that
they looked at the salt or sodium content in the food labels, and only
3% stated that they buy low salt or sodium alternatives. Salt is added
to taste when preparing curries and sometimes even rice, in Sri Lankan
households (18). Average monthly household consumption of bread in
the urban sector in Sri Lanka is 5.6 kg/month ( 30). Although this cannot
be the main lever to reduce salt intake, it can play a contributory role
in reducing salt consumption in the urban population. In China, where
salt is added during home cooking, culturally tailored salt-restriction
strategies have already been launched, including the use of special
spoons for adding salt during cooking and substitutes for cooking salt
(31, 32 ).

Mandatory labeling of processed food

In Sri Lanka, the Food Control Administration Unit in the department
of Environmental and occupational Health and food safety, has
initiated a legal process for mandatory inclusion of a nutrition panel
on processed food packages. The nutrition panel will indicate the
content of salt, sugar and other nutrients of the processed food item
(see Chapter 8). Plans are also underway to mark processed food
items with recommended levels of salt, sugar and fat, with a special
logo. There is evidence that mandating the use of “nutrition facts”
panels can improve dietary patterns, by influencing the food industry
to reformulate products. This intervention has the potential to reduce
salt intake among those who consume processed food.

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Food based dietary guidelines
Food based dietary guidelines have been developed by the Nutrition
Division of the Ministry of Health. They contain up-to- date information
and recommendations on salt intake ( 33 ). They are user friendly and
are available in Sinhalese, English and Tamil Languages and can be
downloaded free from the internet.

National health promotion program

The National Health Promotion Policy and the Strategic Plan have
been developed by the Health Promotion Bureau of the Ministry of
Health. Reduction of population intake of salt is one of the objectives
of the national health promotion programme. The Health Promotion
Bureau oversees, guides and monitors the implementation of health
promotion activities island-wide. Guidelines, circulars and training
manuals are available for implementing health promotion activities in
multiple settings; hospitals, preschools, schools, work places, villages
and cities. These provide entry points for implementing specific
activities to reduce salt intake. Capacity strengthening workshops are
held at national provincial and district levels, encompassing advocacy,
communication, health education, community mobilization and
community empowerment. The School health promotion programme
is regularly evaluated by the Family Health Bureau. Preschool,
hospital, workplaces, village health promotion projects are regularly
evaluated by the Health Promotion Bureau. Sustainability is a major
concern for health promotion programmes in the context of a resource
constrained environment. Often, after having incurred significant
start-up costs in human and technical resources, funds run-out before
health promotion activities have reached full fruition. Efforts are being
made to institutionalize projects in settings and to develop networks
of community volunteers to ensure continuity of health promotion
programs.

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Monitor iodization of salt
The iodination program in Sri Lanka was implemented about two
decades ago to avoid iodine deficiency disorders in the population.
Non-iodised salt is not available in the Sri Lankan market today. Recent
studies report a high prevalence of iodine induced hyperthyroidism,
autoimmune thyroiditis and raised iodine levels (34). This may be due
excessive iodine intake from high intake of salt. A study conducted
to assess iodine in commercial salt products report that, the mean
iodine content was above the recommended upper limit of 40  mg/
kg in commercial iodized salt products in the local market ( 35 ).
Chronic exposure to high iodine concentrations is a concern in view
of possible iodine induced immune phenomena ( 34). There is a need
for better monitoring of the salt iodization, taking into consideration
the recommended salt intake and an optimal iodine status of the
population.

Conclusions and future perspectives

Work related to the attainment of this target in Sri Lanka is at an early
stage. Sri Lanka needs to accelerate action on this target by developing
and implementing a national salt reduction strategy.

The key components of a National Salt Reduction Strategy as outlined

by WHO (36) are:

(i) Set up a steering group with strong leadership and scientific

credibility;

(ii) Determine salt intake by measuring 24-h urinary sodium;

(iii) Identifying the main sources of salt by dietary record;

(iv) Implement nutrition labelling;

(v) Conduct consumer awareness and education programs;

(vi) Set progressively lower salt targets for different categories of

processed food, with a time frame for the industry to achieve

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targets;

(vii) Monitor progress by periodic surveys

(viii) Repeat 24-h urinary  sodium  every 5 years as part of the

STEPs survey.

An important first step would be a survey to estimate salt intake

using 24-hour urinary sodium excretion in a representative population
sample. This baseline data is key for monitoring of progress toward
achieving the target. As alluded to earlier, the next NCD STEPs survey
provides an opportunity to estimate data on salt consumption using
24-h urine collection or a single morning fasting urine sample.

Data are also required on the following:

- The main sources of sodium in the diet (current food intake

and sodium contribution of different foods;

- Daily food intake and discretionary (consumer-controlled) salt

use;

- Data on the sodium content of foods (food composition data);

- Relevant sodium content targets for manufactured foods;

- Reductions required in sodium content of foods and

discretionary salt use to achieve a 30% reduction in population
salt intake.

There is a need to further strengthen the public education campaign

on reducing salt intake. Public education has a better chance of
succeeding, when combined with other policy measures such as
mandatory food labeling. It is well known that modification in peoples`
behavior is only slowly achieved through long-term health education,
when supported and reinforced by environment and social change.

Actions to attain of this target will help Sri Lanka to reduce the
population prevalence of hypertension and cardiovascular morbidity
and mortality. Countries such as Finland and the United Kingdom that
have successfully reduced salt intake have demonstrated a reduction

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in population blood pressure and cardiovascular mortality, with major
cost savings to the health service.

References
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RE, Lim S et al.; Global Burden of Diseases Nutrition and Chronic
Diseases Expert Group. Global sodium consumption and death from
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NEJMoa1304127.
2. Diet, nutrition and the prevention of chronic diseases. Report of a Joint
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3. Resolution WHA 57.17. Global strategy on diet, physical activity and
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2004. Geneva: World Health Organization; 2004 (WHA57/2004/REC/1)
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4. Guideline: sodium intake for adults and children. Geneva:
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SK et al. Long term effects of dietary sodium reduction on cardiovascular
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8. Effect of reduced sodium intake on blood pressure, renal function,
blood lipids and other potential adverse effects. Geneva:
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9. Pfister R, Michels G, Sharp SJ, Luben R, Wareham NJ, Khaw KT. Estimated
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13. World Health Organization and World Economic Forum. From Burden
to Best Buys. Reducing the Economic Impact of Noncommunicable
Diseases in low – and middle-income countries. Geneva 2011
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France)
Reducing salt intake in populations : report of a WHO forum
and technical meeting, 5-7 October 2006, Paris, France.
15. Mendis Shanthi. Cyril Fernando Memorial Oration. Major risk factors
of coronary heart disease in Sri Lankans. Journal of Ceylon College of
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A. Energy and nutrient intakes among Sri Lankan adults. Int Arch Med.
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17. Gamage AU, De Alwis Seneviratne R, Hanna FS. Salt intake, blood
pressure, and socioeconomic disparities among government employees
in Sri Lanka: a cross-sectional study. J Public Health Policy. 2017
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18. STEPwise approach to surveillance (STEPS) survey Sri Lanka 2015.
Ministry of Health and Indigenous Medicine, Colombo, Sri Lanka.
19. NCD global monitoring framework: indicator definitions and
specifications. Geneva: World Health Organization; 2014.
20. Webster JL, Dunford EK, Hawkes C, Neal BC. Salt reduction initiatives
around the world. Hypertens. 2011;29(6):1043−50. doi:10.1097/

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HJH.0b013e328345ed83.
21. Puska P, Vartiainen E, Laatikainen T, Jousilahti P, Paavola M, editors.
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baa87db6a046.pdf?sequence=1).
22. Vartiainen E, Laatikainen T, Peltonen M, Juolevi A, Männistö S, Sundvall
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23. Sadler K, Nicholson S, Steer T, Gill V, Bates B, Tipping S et al. National
Diet and Nutrition Survey − assessment of dietary sodium in adults
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england-2011_text_to-dh_final1.pdf).
24. Responsibility Deal Food Network – new salt targets: F9 Salt Reduction
2017 pledge & F10 Out of Home Salt Reduction Pledge. London:
Department of Health; 2014. (https://responsibilitydeal.dh.gov.uk/
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25. Salt-smart Americas: a guide for country-level action. Washington (DC):
Pan American Health Organization; 2013. (http://www.paho.org/hq/
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26. Campaign to reduce Thais’ salt consumption by half. Pattaya Mail,
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reduce-thais-salt-consumption-by-half-17532).
27. Codex Alimentarius Commission. Joint FAO/WHO Food Standards
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ccnaswp13/na13_10e.pdf)
28. Hoffman KJ, Tollman SM. Population health in South Africa; a view from
the salt mines. Lancet Glob Health. 2013 Aug;1(2):e66-7. doi: 10.1016/
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29. Ministerio de Salud Argentina. Argentine initiative to reduce salt
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uploads/2012/08/less-salt-more-life_PAHO-consortium_ARG.pdf ).
30. Department of census and statistics. Ministry of national policies and
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31. Gu D, Zhao Q, Chen J, et al. Reproducibility of blood pressure
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32. Wang M, Moran AE, Liu J, Qi Y, Xie W, Tzong K, Zhao D. A Meta-
Analysis of  Effect  of Dietary  Salt  Restriction on  Blood Pressure  in
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33. Nutrition Division, Ministry of Health and World Health Organization.
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34. Fernando RF, Chandrasinghe PC, Pathmeswaran AA. The prevalence of
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Geneva: World Health Organization; 2017.

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CHAPTER 7

National NCD target 5: Reducing tobacco use

A 30% relative reduction in prevalence of current

tobacco use in persons aged 15+ years by 2025

Key messages
• Tobacco use causes 7 million preventable deaths per year
globally.

• Inclusion of a target for tobacco control in the Sustainable

Development Agenda 2030, recognizes the harm tobacco
use can impose on sustainable development.

• Tobacco control measures are highly cost effective and the

public health benefits are far more likely to be realized if
they are implemented as part of a comprehensive approach
that will lead to full implementation of the WHO Framework
Convention on Tobacco Control.

• In 2015, in Sri Lanka, the economic cost of tobacco to society

(costs to treat the conditions caused by tobacco and costs
due to premature mortality and absenteeism), was Rs. 89.37
billion (US$ 662.0 million).

• In most economies, including in Sri Lanka, the economic cost

of tobacco related to medical care and loss of productivity
exceeds total tobacco tax revenues.

• Sri Lanka was the first country in Asia and the fourth globally
to ratify the WHO Framework Convention on Tobacco
Control.

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• Significant progress has been made in implementing
tobacco-control measures in Sri Lanka, but much still remains
to be done.

• Tobacco-control efforts must be sustained over a long

period of time and reinforced, to have any lasting impact on
reducing tobacco prevalence.

• The attainment of this target is vital for the attainment of the

national target on reducing premature mortality from NCDs.

Tobacco use; harmful impact on health

Both direct use of tobacco and exposure to second-hand smoke are
harmful to health. Tobacco use increases the risk of cardiovascular
disease, cancer, chronic respiratory disease, diabetes and premature
death. Seven million people are currently estimated to die each year
from tobacco use (1). Unless strong action continues to be taken by
countries, the annual toll is projected to increase to 8 million deaths
per year by 2030, or 10% of all deaths projected to occur that year
(2, 3). Tobacco use also imposes an economic burden in medical
costs and from lost productivity. In most economies, including in Sri
Lanka, the economic cost from tobacco related health care and loss
of productivity exceeds the total tobacco tax revenue(s). Inclusion of
a target for tobacco control in the Sustainable Development Agenda
2030, recognizes the harm of tobacco use can impose on overall
development. Under Sustainable Development Goal 3, target 3.A, is
to strengthen the implementation of the World Health Organization
Framework Convention on Tobacco Control in all countries, as
appropriate (4 )

Manufactured cigarettes are the most common form of smoked

tobacco. In addition, tobacco is smoked in cigars, pipes, hookahs,
bidis and other forms. There is no form of tobacco that is safe. With
more than 1.1 smokers using tobacco products worldwide, tobacco
smoke releases significant amounts of toxic products and pollutants

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directly into the environment causing harm even to non-smokers and
children (5).

In 2016, globally more than 1.1 billion people aged 15 years or older
smoked tobacco (34% of all males and 6% of all females in this age
group). Globally smoking prevalence is about five times higher among
men than among women (see Figure 7.1. and Figure 7.2. ). Smoking
prevalence is higher in high income countries ( 25%) than in middle-
income countries (22%) and low-income countries (18%) (1- 3).

Figure 7.1. Age-standardized prevalence of current tobacco

smoking in males aged 15 years and over, comparable estimates,
2012 (Source: WHO Global Status Report on NCDs 2014. Geneva.
World Health Organization)

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Figure 7.2. Age-standardized prevalence of current tobacco
smoking in females aged 15 years and over, comparable estimates,
2012 (Source: WHO Global Status Report on NCDs 2014. Geneva.
World Health Organization)

Tobacco use; economic and social costs in Sri

Lanka
Latest available data on tobacco prevalence in Sri Lanka is shown in
Table 7.1 . Prevalence of current tobacco use in youth (13-15 years) in
males and females is 6.7% and 0.7% respectively (7 ). The prevalence of
current tobacco smoking in adults (18-69 years), in males and females
is 29.4% and 0.1% respectively ( 8).

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Table 7.1 Prevalence of tobacco (%) use in Sri Lanka (Source: Global
Youth Tobacco Survey 2015 and WHO STEPs survey Sri Lanka 2014)

Adult
Adult tobacco
Youth tobacco use smokeless
smoking
tobacco use
Current Current
tobacco cigarette Current Daily Current
use smoking
Male 6.7 2.9 29.4 19.9 26.0
Female 0.7 0.0 0.1 0.1 5.3
Total 3.7 1.5 15.0 10.2 15.8

The economic and social costs of tobacco was estimated in a study

conducted by the National Authority on Tobacco and Alcohol (NATA)
and the World Health Organization (WHO), in collaboration with the
Ministry of Health and Nutrition of Sri Lanka, the Sri Lanka Medical
Association and the Health Intervention Technology Assessment
Programme of the Ministry of Public Health, Thailand (9). In 2015, the
direct and indirect costs of tobacco in Sri Lanka was estimated to be
Rs. 89.37 billion. (US$ 662.0 million). The costs for tobacco related
cancers was Rs. 16.3 billion (US$ 121.1 million), while for tobacco
related NCDs it was Rs. 73.0 billion (US$ 540.7 million). Ischemic heart
diseases and stroke were the biggest contributors to costs of tobacco
related NCDs. Oral cancer cost was the major contributor to cancer
costs of tobacco.

Cost-effective policies and interventions to

reduce tobacco use
Most governments have already engaged in strengthening their
tobacco control measures, to attain, the global NCD target and the
Sustainable Development Goal target on tobacco control (4, 10).
The World Health Organization Framework Convention on Tobacco
Control (11) and its guidelines (12) represent the global instrument
that enables its Parties to attain the tobacco reduction targets ( 13).

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A comprehensive set of policy options for tobacco control is listed
in the global NCD action plan (14), including the most cost-effective
interventions (“best buys”) for tobacco control (15) (see Chapter 2,
Table 2.5) . Evidence shows that the very cost-effective World Health
Organization Framework Convention on Tobacco Control reduction
measures for reducing national tobacco use are:

• reducing the affordability of tobacco products by increasing

tobacco excise taxes;

• creating by law, completely smoke-free environments in all

indoor workplaces, public places and public transport;

• alerting people to the dangers of tobacco and tobacco smoke

through effective health warnings and mass media campaigns;
and

• banning all forms of tobacco advertising, promotion and

sponsorship.

Full implementation of the WHO Framework Convention on Tobacco

Control involves adopting several other measures; demand reduction
measures such as helping tobacco users to quit and regulating tobacco
products; supply reduction measures such as combating illicit trade,
providing alternative livelihoods to tobacco farmers, and banning the
sale or provision of tobacco products to minors; countering tobacco
industry interference; and establishing a national multisectoral and
interministerial coordinating mechanism for the implementation of the
WHO Framework Convention on Tobacco Control.

Monitoring tobacco use

The global monitoring framework indicators, for monitoring progress
towards attaining this target are (14):

• prevalence of current tobacco use among adolescents;

• age-standardized prevalence of current tobacco use among

persons aged 18+ years.

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Tobacco control; the global momentum
Governments use the tobacco control measures in the WHO
Framework Convention on Tobacco Control, to reduce the prevalence
of tobacco use and exposure to tobacco smoke. WHO has introduced
the MPOWER package ( Monitor tobacco use and prevention policies,
Protect people from tobacco smoke, Offer help to quit tobacco
use, Warn about the dangers of tobacco, Enforce bans on tobacco
advertising, promotion and sponsorship, Raise taxes on tobacco), to
assist countries to implement demand reduction measures contained
in the WHO Framework Convention on Tobacco Control.

Nearly two thirds of countries (121 of 194) – comprising 63% of the

world’s population – have now introduced at least one MPOWER
measure at the highest level of achievement. Overall progress has
been steady, with roughly 15 new countries reaching best- practice
level on one or more measures every 2 years. As a result, about 4.7
billion people are now covered by at least one best-practice policy
intervention at the national level (1). More than a third of countries (71)
have two or more MPOWER measures in place at the highest level
of achievement, protecting a total of 3.2 billion people (43% of the
world’s population). Eight countries (Brazil, Islamic Republic of Iran,
Ireland, Madagascar, Malta, Panama, Turkey and the United Kingdom
of Great Britain and Northern Ireland), have four or more MPOWER
measures in place at the highest level ( 1 ).

Since 2015, an additional 2.3 billion people in 42 countries have been

protected by at least one new or strengthened measure at the highest
level of achievement. Of these 42 countries, 19 are low- and middle-
income countries with a combined 1.9 billion population. There are 10
countries (with a total 1.4 billion people) that have introduced two new
or strengthened measures, and 16 countries (with a total 1.8 billion
people) have adopted a comprehensive MPOWER measure for the
first time (1).

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Figure 7.3. Share of the world population covered by selected
tobacco control policies (Source: WHO report on the global tobacco
epidemic 2017. Geneva: World Health Organization; 2017)

While many countries had banned some forms of tobacco advertising,

promotion and sponsorship (TAPS) in 2016, only 15% had completely
banned all its forms.

The most cost-effective tobacco-control strategy is to increase the

price of tobacco products by raising tobacco tax, but this measure has
progressed slowly. According to WHO estimates, a tax increase that
increases tobacco prices by 10% decreases tobacco consumption by
about 4% in high-income countries and about 5% in low- and middle-
income countries. Even so, by 2016, Only 32 countries, with 10% of
the world's population, have introduced taxes on tobacco products so
that more than 75% of the retail price is tax (1) (Figure 7.3).

Monitoring is an essential component of the WHO Framework

Convention on Tobacco Control, but as of 2016 only about one third
of countries, with a total of 2.9 billion people, have comprehensive
monitoring systems in place at best- practice level. The comprehensive

130
level requires recent, representative and periodic surveys for both
adults and youth to have taken place (1).

More countries are extending their smoke-free policies to cover

outdoor settings such as public parks, outdoor cafes and markets, as
well as settings that were not traditionally covered by such regulations,
such as prisons and private vehicles when carrying children.

There has been a move towards very large pictorial warnings

(occupying, in general, more than 60% of principal display areas)
on tobacco packages, and standardized (or plain) packaging in line
with the obligations of the WHO Framework Convention on Tobacco
Control (11-13). The 181 Parties to the WHO Framework Convention
on Tobacco Control have agreed, through Article 11 of the Convention,
to implement effective packaging and labelling measures and,
through Article 13, to undertake a comprehensive ban (or restrictions)
on  tobacco  advertising, promotion and sponsorship. In December
2012, Australia was the first country to fully implement tobacco plain
packaging (also known as “standardized packaging”) Plain packaging
prohibits the use of logos, colours, brand images and promotional
information on  tobacco  products and packaging, other than brand
and product names in a standardized colour and font. Three sets
of challenges were brought against the plain packaging legislation
of Australia : a constitutional challenge in the  High Court of
Australia  brought by British American Tobacco, Imperial Tobacco,
Japan Tobacco and Philip Morris;  an investment challenge by Philip
Morris Asia under the Hong Kong – Australia bilateral investment treaty,
and a set of World Trade Organization disputes  brought by  several
countries. The constitutional challenge and the investment challenge
were dismissed in 2012 and 2015 respectively. In June 2018, a World
Trade Organization (WTO) Panel ruled against complaints brought
by Ukraine, Honduras, the Dominican Republic, Cuba and Indonesia
concerning Australia’s tobacco packaging law. The panel decided that
Australia’s policy on plain packaging is consistent with World Trade
Organization law. The ruling clears another legal hurdle thrown up in
the tobacco industry’s efforts to block tobacco control and is likely to
accelerate implementation of plain packaging around the world. Today,

131
six other countries have implemented plain packaging laws (Hungary,
Ireland, France, New Zealand, Norway and the United Kingdom),
another six have passed laws yet to be implemented (Burkina Faso,
Canada, Georgia, Romania, Slovenia and Thailand).

Progress achieved in tobacco control in Sri Lanka

Political leadership and commitment
Sri Lanka ratified the WHO Framework Convention for Tobacco Control
on 11th November 2003 and was the first country in Asia to ratify the
Framework Convention on Tobacco Control, and the fourth globally.
As a result of steadfast political commitment from the highest levels
of government, Sri Lanka has made good progress in implementing
tobacco control measures ((Table 7.2). Both H.E the President
Maithripala Sirisena and the current Minister of Health, Dr. Rajitha
Senarathna are the recipients of the WHO Director General’s Tobacco
Award for their leadership and commitment for tobacco control ( 16).

Legislation
Sri Lanka is also the first country in the South East Asian Region to
introduce tobacco control legislation. A National Authority was
established under Section 2 of the National Authority on Tobacco and
Alcohol Act, No. 27 of 2006, with the responsibility to reduce tobacco
and alcohol related harm through public health policy development
and implementation, and advocacy (17).

The National Authority on Tobacco and Alcohol (NATA) Act prohibits;

• sale of any tobacco or alcohol product to or by persons under 21

years of age;

• installation of vending machines for tobacco products;

• sale of tobacco products without health warning and the tar,

nicotine content in each tobacco product;

132
• tobacco advertisements and sponsorships of any type including
free distribution, promotion etc of tobacco products;

• smoking in public places as defined in the Act.

The Cabinet has also decreed that no tobacco should be sold within
100 metres of any school in the country. In addition to the current
authorized officers (police and excise personnel, food and drugs
inspectors and the public health inspectors of the Ministry of Health),
Medical Officers of Health have also been added as Authorized
Officers under the Act. Medical Officers of Health are the key health
personnel who coordinate and supervise public health activities at the
divisional level.

Recently, NATA filed legal action against a movie (‘Adaraneeya

kathawak’), for the violation of Section 35 of National Authority on
Tobacco and Alcohol Act No.27 of 2006. A writ application was
filed in the Court of Appeal against the Censor board to prevent
them giving approval to movies which violate the provisions of the
National Authority on Tobacco and Alcohol Act. The experience in
implementation of the National Authority on Tobacco and Alcohol Act
for nearly a decade has helped to identify a number of loopholes and
weaknesses in the Act are being rectified by Cabinet decisions.

Packaging and Labelling Regulations

Government issued a gazette notification on August 8th 2012,
requiring 80% pictorial health warnings on all cigarette packages. Due
to tobacco industry litigation, it was implemented three and a half years
later. The court ruling reduced the size of the pictorial health warnings
to 60% of the front and back panels of the cigarette pack (18). The
National Authority on Tobacco and Alcohol (Amendment) Act, No. 3
of 2015 was passed in March 2015, which increased the size of the
health warnings to 80% of the front and back of the package as was
originally proposed. On 1 June 2015, Sri Lanka implemented pictorial
health warnings covering 80% of the top surface area of both front and
back covers of tobacco packets (Figure 7.4), which also includes a text

133
warning message in all three languages used in the country (Sinhala,
Tamil and English).

Figure 7.4 Pictorial Warnings in cigarette packages in Sri Lanka

The National Authority on Tobacco and Alcohol has initiated the process
to introduce plain packaging in Sri Lanka. The cabinet of Ministers has
approved the plain packaging legislation that was proposed and it is
being drafted to be submitted to the Parliament as a bill.

Price and Tax Measures

Tobacco tax in Sri Lanka is governed by the Tobacco Tax Act. In 2016,
government revenue from tax on cigarettes was LKR 88.8 billion, a 11%
increase compared to the previous year (19). In 2016, the reported
gross turnover of the Ceylon Tobacco Company (CTC) PLC Ltd. was LKR
121.5 billion and the net revenue was LKR 31.7 billion(20). Based on a
Tobacco Tax proposal presented by the National Authority on Tobacco
and Alcohol, in September 2016 cabinet approval was obtained for a
74% increase in tax on cigarettes (a 15% increase in Value Added Tax
on cigarettes and an increase in production tax by LKR 5 per cigarette.
The cess tax imposed on cigarettes was increased from LKR 2000 per
kg to LKR 3000 per kg. This tax revision made taxation on cigarettes in
Sri Lanka the third highest in Asia. The price of cigarettes still remains

134
below a level that would significantly affect the affordability. In order to
reduce tobacco consumption, the National Authority on Tobacco and
Alcohol, is negotiating with the Government to introduce a taxation
formula and schedule which reduces affordability, by keeping in step
with the increase in the per capita income and the purchasing power
of the population. the National Authority on Tobacco and Alcohol has
also initiated the process to ban single stick sales of cigarettes.

Monitoring Tobacco Industry Interference

The tobacco industry has interfered with the country’s attempts to
introduce tobacco control policies. In 2012, for example, the Ceylon
Tobacco Company took legal action against the then Minister of
Health, Honourable Maithripala Sirisena, over the implementation of
80% pictorial health warnings on tobacco packets (16, 18 ).

The Ceylon Tobacco Company is also accused of point-of-sale

advertising and promotion, strategic targeting of youth and women
in marketing campaigns and influencing communities via retailers and
Corporate Social Responsibility based activities (21).

Tobacco industry interference in multiple covert ways (lobbying policy

makers, disguised promotion under Corporate Social Responsibility
activities, organizing tobacco farmers as a pressure group, bribing
the retail sellers with unauthorized incentives, etc.), remains the single
largest obstacle to progress in tobacco control.

In June 2016, Sri Lanka launched the Centre for Combating Tobacco
(CCT), a Framework Convention on Tobacco Control tobacco industry
observatory. The remit of this Centre is to monitor tobacco industry
interference and disseminates information on tobacco industry
violations of the Framework Convention on Tobacco Control Article
5.3. In August 2017, the new Centre initiated the first ever public
hotline, giving public the opportunity to report violations of Article
5.3.

135
Framework Convention on Tobacco Control
Protocol to Eliminate Illicit Trade in Tobacco
Products
On 8th February 2016, Sri Lanka endorsed the Framework Convention
on Tobacco Control Protocol to Eliminate Illicit Trade in Tobacco
Products, becoming the first country in the WHO South-East Asia
Region, and the fourteenth country in the world to do so. This
protocol provides tools to prevent illicit trade in tobacco products by
securing the supply chain, establishing an international tracking and
tracing system, as well as measures for law enforcement which enable
international cooperation.

Table 7.2 Some aspects of the Sri Lanka National Tobacco Control
Programme (Source: WHO report on the global tobacco epidemic,
2017, Country profile)

Government’s expenditures on tobacco control, LKR 63 000

2016. 000
% of GDP per capita required to purchase 100 packs 17.49%
of the most sold brand of cigarettes (the higher the
%, the less affordable)
Cigarettes are less affordable in 2016 compared to Yes
2014
Price of lowest cost brand of cigarettes (Capstan) LKR 560.00
Tax inclusive retail sales price (TIRSP) for a pack of 20
cigarettes
Price of premium brand cigarettes (B&H / Dunhill) LKR 1060.00
Tax inclusive retail sales price (TIRSP) for a pack of 20
cigarettes
Price most sold brand of cigarettes (JP Gold Leaf) LKR1000.00
Total taxes on the most sold brand (% of retail price) 62.1%*
Specific excise tax 47.5%,
Value added tax (VAT) or sales tax 10.7% 10.7%
Other taxes (National Building Tax and Economic 3.9%
Service Charge)

136
Compliance score on bans of direct tobacco 8
advertising
(score 0 to 10)
Law requires fines for violations of direct advertising Yes
bans
Bans on tobacco promotion and sponsorship-
compliance scores 10
Free distribution 5
Promotional discounts 6
Non-tobacco products identified with tobacco brand 4
names
Appearance of tobacco brands in television and/or
films (product placement)
Appearance of tobacco products in television and/or
films
Sponsorship (contributions / publicity of 5
contributions) (compliance score)
Ban on Corporate Social Responsibility activities No
(Instructions have been sent to all government
departments in Sri Lanka not to accept any offers of
Corporate Social Responsibility activities from the
tobacco industry but the industry uses devious means
to do so.)
§ A score of 0-10. Scores of 8 and above= high compliance, *excludes
VAT

Impact Assessment
Ten years after the Framework Convention on Tobacco Control
was adopted, the Conference of Parties, at its fifth session in 2013,
acknowledged the need to conduct an overall assessment on the
impact of the Framework Convention on Tobacco Control on the
implementation of tobacco control measures and its effectiveness
as a tool to reduce tobacco consumption and prevalence. Sri Lanka
was chosen as one of twelve countries for this impact assessment.

137
The National Authority on Tobacco and Alcohol, in collaboration with
WHO supported the impact assessment by facilitating meetings with
the relevant stakeholders for tobacco control and the visiting group of
experts who conducted the study.

Combating the threat of smokeless tobacco

In Sri Lanka, smokeless tobacco in the form of betel chewing is a deep
seated lifestyle habit especially in the villages and estate sector labour
communities. Betel chewing ingredients such as betel leaf, tobacco,
areca-nut and lime are available in the open market or are home grown.
No taxes are levied on the entire supply chain. Further, commercial
preparations such as mawa, gutka, panparag, hans, babul and beeda
are becoming popular among the younger generation in Sri Lanka in
urban and semi-urban communities. In the last quarter of 2018, Sri
Lanka in collaboration with the World Health Organization and the
Centre for Disease Control will conduct the first Global Adult Tobacco
Survey, which will provide comprehensive data on the use of smokeless
tobacco. A subcommittee on smokeless tobacco was established under
the National Authority on Tobacco and Alcohol in August 2015. It aims
to monitor smokeless tobacco use and formulate preventive policies to
protect the health of the population from smokeless tobacco. On the
recommendations of the National Authority on Tobacco and Alcohol,
in September 2017 the Government issued a regulation that bans the
import, marketing and sale of any type of smokeless tobacco product
in the country. The implementation of these regulations have met with
some difficulties on account of the historical and cultural context of
smokeless tobacco in Sri Lanka.

Other tobacco control activities of the National

Authority on Tobacco and Alcohol
The general public of Sri Lanka, namely, community based
organizations, non-governmental organizations and community

138
groups organized informally, play a major role in tobacco and alcohol
control. Public pressure and support has helped policy makers and
politicians to select decisions favourable for public health over
alternatives favourable for the industry; for example, price increases,
pictorial health warnings and advertising bans. To strengthen the civil
society, the National Authority on Tobacco and Alcohol is supporting
the establishment of smoke free villages and towns through Medical
Officers of Health and Public Health Inspectors, using a multisectoral
approach. Local government officials, Divisional Secretaries,
Community and Religious leaders are extending their support to the
initiative. A series of health education and awareness programmes are
being carried out, targeting a wide cross-section of the community
including children, young adolescents adults.

The Tobacco Quit Programme has been identified as a priority area

for Sri Lanka. A tobacco quitline first established in 2010 at the
Regional Director of Health Services Office at Anuradhapura is being
strengthened and expanded with the introduction of new software.
The quitline will be a key activity in a more comprehensive service
for cessation, and will include a network of trained counselors and
mental health specialists to provide high level advice and supervision.
Preparations, including training of health personnel are also underway
to provide support for smoking cessation through Healthy Lifestyle
Centers (see Chapter 10).

Conclusions and future perspectives

The significant progress in tobacco control in Sri Lanka is attributable
to high level political commitment, an active lead agency (the National
Authority on Tobacco and Alcohol) and an engaged civil society. In
recognition of the outstanding achievements in tobacco control, the
National Authority on Tobacco and Alcohol in Sri Lanka was conferred
with the prestigious WHO South-East Asia Region's “World No
Tobacco Day Award” on 31 May 2017.

National Authority on Tobacco and Alcohol is in the process of

139
building up a resource team to implement and monitor tobacco and
alcohol prevention activities in each district. Programs are conducted
to strengthen capacity to implement tobacco control measures by
authorized Officers who implement the National Authority on Tobacco
and Alcohol act, including Food and Drugs Inspectors, Public Health
Inspectors, Police Officers, Excise Officers, High court judges and
Magistrates. Similar programmes are focusing on strengthening
the tobacco control skills of Grama Niladhari officers and Divisional
Secretariat office staff.

A system for regular review is being developed to monitor and

evaluate the growing portfolio of activities of the National Authority
on Tobacco and Alcohol at the national, provincial and district levels,
as it continues to take forward the tobacco control agenda of Sri Lanka.

References
1. WHO report on the global tobacco epidemic 2017. Geneva: World
Health Organization; 2017.
2. World Health Statistics 2018. Geneva: World Health Organization; 2018.
3. WHO global report. Mortality attributable to tobacco. Geneva: World
Health Organization; 2012. (http://www.who.int/tobacco/publications/
surveillance/rep_mortality_attributable/en/, ).
4. United Nations General Assembly resolution 70/1 – Transforming our
world: the 2030 Agenda for Sustainable Development. http://www.
un.org/ga/search/view_doc.asp?symbol=A/RES/70/1
5. Tobacco and its environment impact; an overview. Geneva: World
Health Organization;2017.
6. Source: WHO Global Status Report on NCDs 2014. Geneva. World
Health Organization.
7. Global Youth Tobacco Survey 2015. Ministry of Health and Indigenous
Medicine. Colombo, Sri Lanka.
8. WHO STEPs survey Sri Lanka 2014. Ministry of Health and Indigenous
Medicine. Colombo, Sri Lanka.
9. Economic and social costs of tobacco and alcohol in Sri Lanka 2015. Sri

140
Lanka: World Health Organization 2017.
10. NCD global monitoring framework: indicator definitions and
specifications. Geneva: World Health Organization; 2014.
11. WHO Framework Convention on Tobacco Control. Geneva:
World Health Organization; 2003. (http://whqlibdoc.who.int/
publications/2003/9241591013.pdf, ).
12. Guidelines for implementation of the WHO FCTC Article 5.3 | Article
8 | Articles 9 and 10 | Article 11 | Article 12 | Article 13 | Article 14.
Geneva: World Health organization; 2013. (http://apps.who.int/iris/
bitstream/10665/80510/1/9789241505185_eng.pdf?ua=1).
13. Conference of the Parties to the WHO Framework Convention on
Tobacco Control, Sixth session decision “Towards a stronger contribution
of the Conference of the Parties to achieving the noncommunicable
disease global target on reduction of tobacco use”. http://apps.who.
int/gb/fctc/E/E_cop6.htm
14. Global action plan for the prevention and control of noncommunicable
diseases 2013−2020. Geneva: World Health Organization; 2013. (http://
apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.
pdf?ua=1).
15. Scaling up action against noncommunicable diseases: how much will
it cost? Geneva: World Health Organization; 2011. (http://whqlibdoc.
who.int/publications/2011/9789241502313_eng.pdf).
16. Understanding Stroke in a Global Context. Book Series: Current
Developments in Stroke. Volume 2 by. Shanthi Mendis DOI:
10.2174/97816810852411170201 eISBN: 978-1-68108-524-1, 2017.
ISBN: 978-1-68108-525-8.
17. National Authority on Tobacco Control Act No 27of 2006. Parliament of
the Democratic Socialist Republic of Sri Lanka 29 August 2006.
18. A. Marsoof,  Sri Lankan Court of Appeal balances tobacco trade mark
rights and the promotion of public health, Journal of Intellectual Property
Law & Practice; Volume 9, Issue 9, 1 September 2014, Pages 708–710.
19. Annual Report 2016. Ministry of Finance Sri Lanka.
20. Annual Report 2016. Beyond the smoke. Ceylon Tobacco Company
PLC.
21. Sri Lanka Country Profile. Tobacco tactics. http://www.tobaccotactics.
org/index.php?title=Sri_Lanka-_Country_Profile

141
142
CHAPTER 8

National NCD target 6:

Reduce prevalence of
hypertension
A 25% relative reduction in the prevalence of
raised blood pressure by 2025

Key messages
• Hypertension is one of the leading risk factors of cardiovascular
disease.

• The global prevalence of raised blood pressure (defined as

systolic and/or diastolic blood pressure ≥140/90 mmHg) in
adults aged 18 years and over was around 22% in 2014.

• The prevalence of hypertension in adults 18-69 years of age

in Sri Lanka is 26 %.

• Reducing the incidence of hypertension through

implementation of population-wide policies to reduce
behavioural risk factors, including harmful use of alcohol,
high salt intake, physical inactivity and obesity is critical for
attaining this target.

• Detection and treatment of hypertension become very cost

effective, only if it is done through a total cardiovascular risk
approach.

143
• Sri Lanka is implementing a total-risk approach for early
detection and cost-effective management of hypertension,
to prevent heart attacks, strokes and other complications
such as kidney disease.

• All with blood pressure levels at or above 160/100  mmHg

and those with lower degrees of persistent hypertension
(≥140/90 mm Hg), who have moderate-to-high cardiovascular
risk need to be treated with medicines.

• The attainment of this target will contribute to attainment of

the target on reducing premature mortality from NCDs.

Hypertension as a cardiovascular risk factor

Raised blood pressure (hypertension), is a major cardiovascular risk
factor. Globally, raised blood pressure is estimated to have caused
9.4 million deaths and 7% of disability – as measured in Disability
Adjusted Life Years (1). If left uncontrolled, hypertension can lead to
stroke, myocardial infarction, cardiac failure, dementia, renal failure
and blindness(2, 3). There are health benefits of lowering blood
pressure through behavioural and pharmacological interventions
(4−6). For instance, a reduction in systolic blood pressure of 10 mmHg
is associated with a 22% reduction in coronary heart disease and 41%
reduction in stroke in randomized trials (5), and a 41–46% reduction in
cardiometabolic mortality (6) in epidemiological studies.

Causes of hypertension
Hypertension is defined as a systolic blood pressure equal to or above
140 mm Hg and/or diastolic blood pressure equal to or above 90 mm
Hg (2). Normal levels of both systolic and diastolic blood pressure are
particularly important for the efficient function of vital organs such as
the heart, brain and kidneys and for overall health. In about 10% of
people with hypertension an aetiological cause can be identified, such

144
as a renal or endocrine disorder. Majority of people with hypertension
(90 %), have no such secondary cause and are said to have primary or
essential hypertension.

Many factors contribute to the development of essential hypertension

(see Figure 8.1.):

• eating food containing too much salt and fat;

• not eating enough fruits and vegetables;

• overweight and obesity;

• harmful use of alcohol;

• physical inactivity;

• ageing;

• genetic factors;

• psychological stress;

• socioeconomic determinants;

Most of these factors are modifiable. The presence of several of the

above factors, increase the risk of developing hypertension. A large body
of epidemiological evidence indicates a strong relationship between
high salt intake and high blood pressure ( 2 ). It has been convincingly
demonstrated that a potassium rich (high fruits and vegetables), low
salt, low-fat diet can reduce blood pressure in normotensives as well
as hypertensives. Lowering sodium intake from high to low can result
in a mean decrease of systolic blood pressure of about 7 mmHg in
normotensives and about 11 mmHg in hypertensives (7). Lowering
population salt consumption is a best buy (very cost effective ) NCD
intervention which can reduce the incidence of hypertension and
reduce antihypertensive drug requirements (see Chapters 2 and 6).

145
Figure 8.1 Main contributory factors to high blood pressure and its
complications (Source: A global brief on hypertension. Silent killer,
global public health crisis. Geneva: World Health Organization;
2013)

The global prevalence of hypertension

The global prevalence of hypertension (defined as systolic and/or
diastolic blood pressure ≥140/90 mmHg), in adults aged 18 years
and over was around 22% in 2014 (8). The proportion of the world’s
population with high blood pressure or uncontrolled hypertension fell
modestly between 1980 and 2010. However, because of population
growth and ageing, the number of people with uncontrolled
hypertension has risen from 600 million in 1980 to around 1 billion in
2010. Age-standardized prevalence of raised blood pressure in men
and women is shown in Figures 8.2 and 8.3 respectively.

146
Fig. 8.2 Age-standardized prevalence of raised blood pressure in
males aged 18 years and over (defined as systolic and/or diastolic
blood pressure equal to or above 140/90 mm Hg), comparable
estimates, 2014 (Source: Global Status Report on Noncommunicable
Diseases. Geneva. World Health Organization)

Fig. 8.3 Age-standardized prevalence of raised blood pressure

in females aged 18 years and over (defined as systolic and/
or diastolic blood pressure equal to or above 140/90 mm Hg),
comparable estimates, 2014 (Source: Global Status Report on
Noncommunicable Diseases. Geneva. World Health Organization)

147
Prevalence of hypertension in Sri Lanka
In Sri Lanka, based on the most recent nationally representative risk
factor survey, the prevalence of hypertension in adults 18-69 years
of age is 26.1 % (25.4 % in males and 26.7 % in females) (9). The
prevalence of hypertension rapidly increases with age. While only
about one tenth (9.4 %) of the youngest age group (18-29 years) is
hypertensive, more than half (57 %) of the oldest age group (60-69
years) is hypertensive (Table 8.1). Results of scientific studies show
that in addition to increasing age, physical inactivity (odds ratio: 1.7),
presence of diabetes (odds ratio: 2.2) and central obesity (odds ratio:
2.3) are significantly associated with hypertension (10). 

The prevalence of modifiable risk factors that lead to hypertension,

is unacceptably high in the Sri Lankan population. They include
high intake of salt in the diet (see Chapter 6 ), low levels of regular
physical activity (see Chapter 5 ), overweight and obesity (see Chapter
9 ), harmful use of alcohol (Chapter 4 ) and low intake of fruits and
vegetables. In Sri Lanka, only 17.5 % of the adult population consume
five or more servings of fruits and/or vegetables per day, which is the
daily recommended amount ( 2, 9). Unless public health policies are
implemented to address this unhealthy risk profile at the population
level, the incidence and prevalence of hypertension in Sri Lanka will
progressively increase, with ageing of the population, outstripping the
capacity of the health system to handle the disease burden caused by
hypertension.

148
Table 8.1 Prevalence of hypertension (including those on
medications) in adults in Sri Lanka (Source: WHO STEPs 2015)

Cost-effective policies and interventions to reduce

the prevalence of hypertension
Although hypertension can be controlled with drug therapy, it should not
be used as the sole control strategy. Drug therapy alone has opportunity
costs and unaffordable and unsustainable in developing countries
with resource constraints and rising prevalence of hypertension due
to ageing populations. Drug therapy for hypertension should always
be complemented with public health policies to reduce physical
inactivity (see Chapter 5), salt consumption (see Chapter 6) harmful
use of alcohol (see Chapter 4), overweight and obesity (see Chapter 9)
and promote intake of fruits and vegetables and a healthy diet. Such
a combined approach can reduce the incidence and prevalence of
hypertension in a cost effective and affordable manner (8, 11). Drug
therapy for hypertension should be based on a total cardiovascular
risk approach as explained below. This comprehensive public health
approach will result in a shift of the population distribution of blood
pressure to an optimal profile, reduce the incidence of hypertension
and benefit all age groups (8, 11).

High-income countries have begun to reduce hypertension by

implementing public health policies to reduce salt in processed food,
improve the availability and affordability of fruits and vegetables, and
create environments that promote physical activity (8). Declining trends
in blood pressure, together with declines in smoking, body mass index
and serum cholesterol, may have accounted for nearly half the decline
in cardiovascular mortality in some high-income countries (4).

149
People with hypertension are often asymptomatic until they develop
end-organ damage (2, 3). Consequently, proactive cost-effective
approaches must be adopted for early detection of hypertension.
Evidence indicates that targeted screening for total cardiovascular risk
with blood pressure measurement (and blood glucose testing) is more
cost effective than screening the whole population for blood pressure
alone, and is more likely to identify individuals at high cardiovascular
risk for a lower cost (12−13). In settings with access to well-developed
primary health-care systems (i.e. where physicians can identify patients
at high risk of developing diseases when they see them for other
reasons, and can intervene when necessary), adding an organized
screening programme to usual practice may not be required. Indeed, in
such settings, systematic screening of the population has not resulted
in a reduction in incidence of ischaemic heart disease compared to
control groups that have access to usual care (14).

Once detected hypertension requires long-term follow-up (15). A total-

risk approach is needed to improve the efficiency and sustainability of
detection and management of hypertension (2, 3, 16). Decisions on
drug treatment should be underpinned by evidence and based on
total cardiovascular risk (16, 17). Evidence of benefit for lowering blood
pressure levels at or above 160/100 mmHg with drug treatment and
non-pharmacological measures is very clear (2, 3, 16). Lower degrees
of persistent hypertension (≥140/90 mm Hg) with moderate-to-high
cardiovascular risk also require drug treatment (2, 3, 17). On the other
hand, lifelong drug treatment of persons with borderline hypertension
and very low cardiovascular risk cannot be justified, particularly in
resource constrained settings. People in this category, as well as the
whole population, however, would benefit from population-wide
interventions discussed above (2, 3).

As hypertension is defined by blood pressure cutoff levels, even small

inaccuracies in blood pressure measurement can have considerable
consequences as a result of mislabeling normotensives as hypertensives
and vice versa. There are several barriers to accurate and affordable
blood pressure measurement, particularly in low-and- middle-income
countries (18, 19).

150
Challenges of attaining this target in Sri Lanka
Attaining this target will be a challenge for Sri Lanka because it has a
fast ageing population. It is estimated that one in four Sri Lankans will
be elderly by 2041 (20). More than half of them will be hypertensive
adding to the national burden of hypertension. Once hypertension
develops, it may require lifelong treatment with medicines. Because
of the high prevalence, even if medicines are inexpensive, the total
expenditure of drug treatment can be substantial. However, neglecting
treatment when it is required, entails interventions that are even more
costly, such as cardiac bypass surgery, carotid artery surgery and
renal dialysis, draining both individual and government budgets. The
only solution is to control hypertension using affordable treatment
approaches, and concurrently take action to reduce the incidence of
hypertension using population-wide prevention.

Sri Lanka has started to implement the following public health policies
to reduce the incidence of hypertension:

• harmful use of alcohol (see Chapter 4 );

• physical inactivity (see Chapter 5);

• population intake of salt/sodium (see Chapter 6);

• overweight and obesity ( see Chapter 9).

However, there are gaps and shortcomings in all these areas which
need to be identified and addressed. Monitoring of these programmes
is particularly weak and need strengthening.

Addressing hypertension through a total risk

approach
It is laudable that almost a decade ago, Sri Lanka and several other
developing countries adopted the WHO recommended total-risk
approach to improve the efficiency and sustainability of detection and
management of hypertension (8, 21-23). Despite covert pressure from

151
various entities that wish to increase profits from the sale of medicines
(24), the Ministry of Health has persevered in implementing the total
- risk approach throughout the primary health care network in Sri
Lanka. Instead of focusing on hypertension alone, this approach uses
hypertension and diabetes as entry points to reduce the overall risk of
heart attacks, strokes and other complications such as kidney disease.
Decisions on drug treatment are underpinned by evidence and based
on total cardiovascular risk protocols and WHO guidelines adapted
to suit the local context (22). Hypertension and diabetes often coexist
and they cannot be dealt with in isolation. Adopting this integrated
approach ensures that limited resources are used for proper treatment
of those at medium and high risk.

Balancing costs and health gains of controlling

hypertension
The total risk approach also prevents unnecessary drug treatment of
people with borderline hypertension and very low cardiovascular risk.
Inappropriate drug treatment exposes people to unwarranted harmful
effects and increases the cost of health care. Both should be avoided.
Balancing costs with health gains is a very important consideration
when making antihypertensive treatment decisions because
hypertension affects a large segment of the population (25). The
current per capita expenditure on medicines is LKR 79.81. At current
high prevalence rates of hypertension (26%), the annual cost to treat
all hypertensives (at a 140/90 mmHg cut off) in the public sector, even
with an inexpensive antihypertensive drug ( costing one LKR a day), is
nearly LKR 1.5 billion a year (Table 8.2). In reality, the total drug costs
are much higher because most moderate to severe hypertensives need
more than one drug and most drugs cost more than one LKR a day.
The main purpose of the total-risk approach is to ensure that all with
blood pressure levels at or above 160/100 mmHg and lower degrees
of persistent hypertension (≥140/90 mm Hg) with moderate-to-high
cardiovascular risk get treated with medicines. These people with high
cardiovascular risk may also have to be provided statins to prevent

152
heart attacks and strokes. Drug treatment decisions should only be
made when there is robust evidence from well conducted large scale
clinical trials. Sri Lanka fortunately has not blindly followed the practice
of giving drugs even to people with borderline hypertension (and low
cardiovascular risk), labeling them as pre-hypertensive. ( 26, 27 ).

Table 8.2 Annual expenditure; for drug treatment of all with raised
blood pressure ( (≥140/90 mm Hg ), using an antihypertensive drug
that costs one LKR a day in Sri Lanka

Age Number of
Population Prevalence of
group people with Annual cost (LKR)
(2012) hypertension
(Years) hypertension
20-29 3085731 9.4% 290,058 105,871,170
30-44 4407701 20.1% 885,948 323,371,020
45-59 3569519 41.1% 1,467,072 535,481,280
60-69 1551199 57% 884,183 322,726,795
70+ 970374 60% 582,224 212,511,760
4109485 1,499,962,025

In Sri Lanka, expenditure on medicines as a share of total expenditure

on health is high, and during the period 2000-2010 has been estimated
to be about 22 %. Overall, about 87% of the expenditure to supply
medicines is privately financed, mostly by household out-of- pocket
spending. Expenditure on drugs is likely to have a large impact at the
level of individual households and therefore indirectly on the national
economy. Additionally, studies show that out-of-pocket drug costs
reduce medication adherence among patients with hypertension ( 28,
29 ).

Undetected and untreated hypertension and

diabetes
Survey results indicate that one third of Sri Lankan adults (30.7%) have
never had their blood pressure checked. Only 57.7 % of adults with
hypertension are on medications. Similarly, while 58.4 % had never
measured their blood sugar, only 69.5 % of those with diabetes are

153
taking medications.

The Ministry of Health in Sri Lanka initiated the Healthy Lifestyle Centres
in 2011, to address gaps in early detection of NCDs at the primary care
level. These centers are targeting 40–65 year old people to detect
hypertension, diabetes and other risk factors early and improving
access to specialized care for those with a higher risk of cardiovascular
disease (see Chapter 10). Under-utilization of the service by men, weak
staff adherence to clinical protocols and shortage of human resources
are some of the challenges faced by this service (30).

Monitoring progress
In the global monitoring framework (31), the indicator for monitoring
the prevalence of raised blood pressure is the age-standardized
prevalence of raised blood pressure among persons aged 18+ years.
Raised blood pressure is defined as systolic blood pressure ≥140mmHg
and/or diastolic blood pressure ≥90  mmHg among persons aged
18+ years. For monitoring of progress at the country level, data
should be gathered from a population-based (preferably nationally
representative) survey such as a STEPs survey, in which blood pressure
is measured (not self-reported).

Conclusions and future perspectives

The adult population in Sri Lanka has a high prevalence of hypertension
as well as diabetes. With ageing of the population these prevalence
rates are expected to increase even further. High rates of hypertension
and diabetes are contributing to the growing burden of cardiovascular
disease.

Hypertension and diabetes need to be tackled within integrated

primary care programs and not as disease specific vertical programs.
Drug treatment of hypertension and diabetes alone cannot provide
a sustainable solution. The only solution is a public health one

154
which entails the simultaneous implementation of a combination
of population wide prevention policies (to reduce the incidence of
hypertension and diabetes), and individual total risk assessment and
management through primary health care.

In order to reduce the incidence of hypertension and the medicine

requirements to treat borderline to mild hypertension with low
cardiovascular risk, Sri Lanka needs to fast- track national initiatives
to reduce salt consumption (see Chapter 6) and physical inactivity
(see Chapter 5) in the population. Good progress has been made in
establishing Healthy Lifestyle Centers in primary care to implement
the total risk approach, country-wide (see Chapter 10). Several
measures have been introduced to improve the utilization of this
service, including extended opening hours for Healthy Lifestyle
Centers, outreach activities in workplaces, and integration with
“well woman clinics”. In the long-term, further Investments will be
needed to improve the health-service infrastructure, competency of
the health workforce and communication strategies to ensure high
population coverage. In addition health information systems will need
to be reformed to facilitate follow-up care as well as monitoring and
evaluation of activities of Healthy Lifestyle Centres.

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CHAPTER 9

National NCD target 7:

Halt obesity and diabetes
Halt the rise in obesity and diabetes by 2025

Key messages
• Worldwide, obesity has more than doubled since 1980, and
in 2014, 11% of men and 15% of women aged 18 years and
older were obese.

• An estimated 42 million children under the age of 5 years

were overweight in 2013.

• In Sri Lanka, among adults (18-69 years), 5.9% are obese (3.5%
of men and 8.4% of women), while 23.4% are overweight (
21% of men and 26% of women)

• There is a rising trend in childhood overweight and obesity

in Sri Lanka.

• The global prevalence of diabetes was estimated to be 9%

in 2014. The prevalence of diabetes in adults in Sri Lanka is
7.4%.

• In 2016, the Government of Sri Lanka enacted food colour

coding regulations which mandates sweetened beverage
makers to label the sugar content of their products; as a
result the content of sugar in sweetened beverages has gone
down.

159
• The Government of Sri Lanka imposed a sugar- tax on sugar
sweetened beverages in 2017; as a result the price has gone
up and the consumption of sugar sweetened beverages has
has dropped.

• The attainment of this target will contribute to the attainment

of targets on reducing the prevalence of hypertension and
on reducing premature mortality from NCDs.

Overweight and obesity; harmful impact on health

Obesity is an independent risk factor for many NCDs. Overweight
and obesity increase the risk of coronary heart disease, ischaemic
stroke, type 2 diabetes and cancers of the breast, colon, prostate,
endometrium, kidney and gall bladder. Chronic overweight also
contributes to osteoarthritis. Overweight (body mass index (BMI)
≥25 kg/m2 )and obesity (BMI ≥30 kg/m2) were estimated to account for
3.4 million deaths and 93.6 million Disability Adjusted Life Years (DALYs)
in 2010 (1). Globally, 44% of diabetes burden, 23% of ischaemic heart
disease burden and 7–41% of certain cancer burdens are attributable
to over- weight and obesity (2, 3). Increased waist circumference and
higher body mass index are associated with increased risk of type 2
diabetes, particularly in populations in South-East Asia (4). In South-
East Asia, 41% of deaths caused by high body mass index occur under
age 60, compared with 18% in high-income countries (2).

For optimal health, the median body mass index for adult populations
should be in the range 21–23  kg/m2, while the goal for individuals
should be to maintain a body mass index in the range 18.5−24.9 kg/
m2. The risk of comorbidities increases with overweight (body mass
index 25.0−29.9 kg/m2), and the risk is higher with obesity (body mass
index greater than 30 kg/m2 )(5).

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Global and National Prevalence of overweight
and obesity in adults
Figure. 9.1. Age-standardized prevalence of obesity in men aged
18 years and over (BMI ≥30  kg/m2), 2014 (Source: Global Status
Report 2014. Geneva:World Health Organization 2014)

161
Figure. 9.2. Age-standardized prevalence of obesity in women
aged 18 years and over (BMI ≥30  kg/m2), 2014 (Source: Global
Status Report 2014. Geneva:World Health Organization 2014)

Figure 9.3 Age standardized prevalence of obesity in adults aged

18 years and over (Source: Global Status Report 2014. Geneva:
World Health Organization 2014)

162
In Sri Lanka, the mean body mass index of men is 22.4 and of females
23.5. As shown in Table 9.1, only about half of the adults (55.4%) have
a normal body mass index value, between 18.5 -24.9. 58.9% males and
51.6% of females have a normal body mass index value between, 18.5
-24.9. Among adults, 5.9% are obese (3.5% males and 8.4% females),
while 23.4% are overweight ( 21% males and 26% females) (6 ).

Table 9.1 Distribution of underweight, overweight and obesity

by BMI classification -Sri Lanka 2015 (Source: Noncommunicable
disease risk factor survey in Sri Lanka 2015. Ministry of Health,
Nutrition and Indigenous Medicine, Sri Lanka and World Health
Organization 2015)

Global and national prevalence of overweight and obesity in

children

Excess intake of high calorie food and indulgence in indoor sedentary

activities (e.g. television viewing, internet, and computer games),
together with factors that dissuade walking and other outdoor
activities, contribute to childhood obesity. Prevalence of childhood
overweight is above 5% in most countries in the world (Figure 9.4 ).
In 2013, an estimated 42 million children (6.3%) aged under 5 years
were overweight (7). In 2016, there were 124 million obese children
and adolescents aged 5-19 years. An additional 213 million were
overweight in 2016 but fell below the threshold for obesity. Taken
together this means that in 2016 almost 340 million children and
adolescents aged 5¬19 years ¬ or almost one in every five (18.4%) ¬
were overweight or obese globally.

163
The global prevalence of overweight and obesity in children aged
under 5 years has increased from around 5% in 2000 to 6.3% in 2013
(8). It is estimated that the prevalence of overweight in children aged
under 5  years will rise to 11% worldwide by 2025, if current trends
continue (8). In the last four decades, there has been a tenfold increase
in obesity in children and adolescents. The prevalence of overweight
children is increasing fastest in low- and lower-middle-income countries.

There has been an increasing global recognition of the need for

effective strategies to prevent and control childhood overweight and
obesity. In 2012, the World Health Assembly agreed a target of no
increase in childhood overweight by 2025 (9). WHO established a high-
level Commission on Ending Childhood Obesity in 2014 to accelerate
action against childhood obesity ( 10 )

Figure.9.4 Age-standardized prevalence of overweight in children

under five years of age, comparable estimates, 2013 (Source:
Global Status Report 2014. Geneva:World Health Organization
2014)

164
Figure 9.5 School based student health survey – proportion of
school children (Grades 1, 4, 7 and 10) with wasting stunting and
overweight

In Sri Lanka, based on the results of the Global School Based Student
Health Survey (2008), in the 13-15 year age group 4.5% are overweight
and 0.5% are obese ( 11 ). Once a year, the Ministry of Health conducts
a School Medical Inspection in students in grades 1, 4, 7 and 10
for assessment of nutritional status, immunization, detection and
correction of health problems. In 2015, School Medical Inspections
were conducted in 9,794 (96.7%) schools, (1,729,268 eligible children).
Based on the results of this examination, (Figure 9.5. ), 1.7%, 2.9%,
4.8% and 4.3% of children in Grades 1, 4, 7 and 10 respectively, were
obese (12). The data also show that stunting and wasting coexist with
obesity, and are significant problems among school children in Sri
Lanka. As shown in Figure 9.6, there is a rising trend in childhood
overweight. For example, during the period 2011 to 2015 , rates of
overweight is Grade 10 children has risen from 2.5% to 4.2%.

165
Figure 9.6 Overweight in Grade 10 children 2011-2015 (Source:
School medical inspection data 2015; . School Health Return -
H797. Ministry of Health, Colombo Sri Lanka )

Overweight and obese children are likely to remain obese into

adulthood and more likely to develop NCDs including diabetes at a
younger age. Based on available data, Sri Lanka shows rising trends
in overweight and obesity in children and adults which contribute to
rising prevalence rates of diabetes.

Global and national prevalence of diabetes and

its impact on health
Diabetes is an important cause of premature death and disability.
Diabetes increases the risk of cardiovascular disease, kidney failure,
blindness and lower-limb amputation. In pregnancy, poorly controlled
diabetes increases the risk of fetal death and other complications (13-

166
15). Globally, an estimated 422 million adults were living with diabetes
in 2014 . Figures 9.7 and 9.8 show the age-standardized prevalence
of diabetes, (Fasting glucose ≥ 7.0 mmol/L or on medication), in men
and women respectively, in 2014.

The global prevalence (age-standardized) of diabetes has nearly

doubled since 1980, rising from 4.7% to 9% in the adult population.
This rise is largely driven by modifiable risk factors – particularly
physical inactivity, overweight and obesity (16). Population ageing is
also an important factor, as glucose intolerance increases with age.

Diabetes caused 1.5 million deaths in 2012. Higher-than-optimal

blood glucose, caused an additional 2.2 million deaths, by increasing
the risks of cardiovascular and other diseases. Forty-three percent of
these 3.7 million deaths occurred before the age of 70 years (15 ). The
global prevalence of diabetes (defined as a fasting plasma glucose
value ≥7.0 mmol/L [126 mg/dl] was estimated to be 9% in 2014 (14).

Figure.9.7. Age-standardized prevalence of diabetes, (Fasting

glucose ≥ 7.0 mmol/L or on medication), in men aged 18 years and
over, comparable estimates, 2014

167
Figure 9.8. Age-standardized prevalence of diabetes (Fasting
glucose ≥ 7.0 mmol/L or on medication), in women aged 18 years
and over, comparable estimates, 2014

In general, low-income countries show the lowest prevalence and

upper-middle-income countries show the highest prevalence of
diabetes for both sexes.

The prevalence of diabetes in adults in Sri Lanka was 7.4% (7.3%

in males and 7.6% in females) in 2015 ( 6 ). Much of the diabetes
burden can be prevented or delayed by a healthy diet and regular
physical activity. The target of no increase in prevalence of obesity
and diabetes is closely linked with the target of decreasing physical
inactivity (see Chapter 5). To maintain a healthy weight, there must
be a balance between energy consumed (through diet) and energy
expended (through physical activity).

Monitoring obesity and diabetes

Regular monitoring of the prevalence of obesity and diabetes should
be instituted as part of routine NCD surveillance. Indicators in the
global monitoring framework (17) for monitoring progress in attaining
this target are:

168
• age-standardized prevalence of raised blood glucose/diabetes
among persons aged 18+ years, or on medication for raised
blood glucose;

• age-standardized prevalence of overweight and obesity in

persons aged 18+ years;

• prevalence of overweight and obesity in adolescents.

The measurement of overweight in children under 5 years is included

in the global monitoring framework on maternal, infant and young
child nutrition (18). Overweight is defined as having a weight-for-
height above two standard deviations from the median.

WHO defines overweight in school-aged children and adolescents

(persons aged 10–19 years) as one standard deviation BMI-for-age
(equivalent to BMI 25  kg/m2 at 19 years), and obesity in the same
group as two standard deviations BMI-for-age (equivalent to BMI 30
kg/m2 at 19 years) from the median (18).

The WHO STEPwise approach to Surveillance of NCD Risk Factors

(STEPS) can be used to track national prevalence data for obesity and
raised blood sugar in adults (19). WHO’s Global school-based student
health survey (20) is used in many countries to measure and monitor
overweight and obesity in adolescents.

Cost-effective policies and interventions for

reducing the prevalence of obesity and diabetes
WHO has developed a set of recommendations on the marketing
of foods and non-alcoholic beverages to children, because there is
good evidence that marketing of foods and non-alcoholic beverages
influences children’s knowledge, attitudes, beliefs and preferences
(21).

Changes in agricultural subsidies to encourage fruit and vegetable

production, has been shown to improve the consumption of fruits
and vegetables and improve dietary patterns (22). Pricing strategies

169
that increase incentives for purchasing healthier food options also
increase the purchase of those options because price is often a barrier
to the purchase and consumption of healthy foods (23, 24). Taxation
schemes that produce large changes in price have been shown to
change purchasing habits which are likely to improve health (25-27).
Trade and regulatory measures have also proven effective in reducing
the availability of unhealthy foods and changing population dietary
patterns (28, 29).

Nutrition labelling- front-of-pack labels on packaged foods, or point-

of-purchase information in grocery stores, cafeterias or restaurants-
can be useful in orienting consumers to products that contribute to a
healthier diet (30–32). Consumer awareness of healthy behavior can be
achieved through sustained media and educational campaigns aimed
at increasing consumption of healthy foods, or reducing consumption
of less healthy ones and increasing physical activity (28). Schools,
communities, workplaces, health care institutions and religious places
are important settings to promote healthy diet and physical activity .

Diet and physical activity counselling through primary health care have
the potential to change behaviours related to obesity and diabetes
(33). The provision of dietary counselling, especially as a component
of a total-risk approach, has the potential to be beneficial (33). Positive
results of effective risk-factor control can be seen in a short time, since
any reduction in body weight and increase in physical activity has a
beneficial effect on the risk of diabetes. This intervention has been
scaled up to the whole population in a few high-income countries with
encouraging results on feasibility (34).

Actions to attain this target in Sri Lanka

Sri Lanka – a pioneer in promoting and protecting
breast feeding
Failure to breastfeed, or a shorter duration of breastfeeding,
is associated with a higher risk of overweight later in life (35).

170
Sri Lanka, is one of the first countries in the world to adopt the
International Code of Marketing of Breast-milk Substitutes in 1981.
The country has been successful in promoting breast feeding, with
82% of mothers exclusively breastfeeding their children. Despite
the multiple benefits of breast feeding only 23 countries in the
world including Sri Lanka ( Bolivia, Burundi, Cabo Verde, Cambodia,
Democratic  People’s  Republic  of  Korea, Eritrea, Kenya, Kiribati,
Lesotho, Malawi, Micronesia, Federated States of Nauru, Nepal, Peru,
Rwanda, São Tome and Principe, Solomon Islands, Sri Lanka, Swaziland,
Timor-Leste, Uganda, Vanuatu, and Zambia), have achieved exclusive
breastfeeding rates above 60% ( 36 ).

Reducing consumption of free-sugars to reduce

the risk of childhood obesity
Consumption of high amounts of sugar, fat and starch result in
surplus calorie intake, which lead to overweight and obesity. There
is increasing concern that intake of free sugars – particularly in the
form of sugar-sweetened beverages – increases overall energy intake
leading to weight gain and increased risk of NCDs ( 37). Evidence
shows that reduction of intake of free sugars is associated with reduced
body weight (37). In order to prevent adverse health effects of sugar,
WHO recommends reducing daily sugar intake to less than 10% of
total energy intake (39). A further reduction to below 5% or roughly
25 grams (6 teaspoons) per day is recommended for additional health
benefits (38).

Food colour - coding regulation

According to the findings of the 2012/2013 household expenditure
survey in Sri Lanka, per capita consumption of sugar per month is
1104 grams (approximately 36 grams per day)(39). Sugar-sweetened
beverages are a significant source of high free sugar intake in children in
Sri Lanka (40, 41). A 330ml portion of sugar-sweetened carbonated soft

171
drink typically contains some 35g of sugar and provides approximately
140 calories of energy (39).

On the recommendation of the Food Advisory Committee established

in 1981, regulations around labeling and advertising were enacted in
2005 within the existing Food Act 26 of 1980. However, the regulation
did not contain provisions which require indicating the sugar, salt
and fat contents of packaged foods and beverages. In 2013, the
Ministry of Health developed and issued guidelines to local food and
beverage manufacturers providing them information for labelling of
food and beverages. The guidelines were intended to be followed
voluntarily. The industry response was poor, resulting in the enactment
of the Food Colour Coding Regulations by the Minister of Health on
22 April 2016 under the Food Act of 26 of 1980, which came into force
from 1st August 2016. The regulation mandates makers of sweetened
beverages in Sri Lanka to indicate the sugar content of different
products visually on the packaging on three scales based on the level
of sugar contained in them— high (red, over 11g of sugar/ 100ml),
medium (amber- 2-11g/100ml) and low (green - less than 2g/100ml).
The colour coding system informs consumers about the sugar content
of different beverages giving them latitude to make an informed
choice. The private sector responded within a relatively short period
of time reducing the sugar content in sweetened beverages to at least
less than 11g of sugar/100 ml so that a red colour code would not
deter consumers from buying their products.

This work was led by the Environment and Occupational Health and
Food Safety Directorate of the Ministry of Health in collaboration with
the NCD Bureau and the Nutrition Coordination Division of the Ministry
of Heath, Ministry of Education, Ministry of Trade and Commerce, and
the Consumer Protection Authority. Monitoring the implementation
of the Food Colour Coding Regulation will be important, and will be
done by the Environmental and Occupational Health unit through
Public Health Inspectors and Food and Drug Inspectors.

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Sugar- tax on sugar - sweetened beverages
A sugar- tax was introduced in the National Budget and implemented
from late 2017. The sugar tax is levied on sweetened carbonated
beverages which has sugar over 6 g/100ml. Each gram of sugar above
this level is taxed at 50 cents per gram per 100ml. This has resulted in
30-50% increase of prices of sugar sweetened beverages. As a result
of the sugar tax, the demand for sweetened carbonated beverages
dropped by a significant margin in 2017—an indication that the higher
prices have pushed away consumers. Food and beverage firms like
Ceylon Cold Stores and Nestlé Lanka recorded a significant drop in
earnings. Ceylon Cold Stores PLC (CCS), a unit of John Keels Holdings
(JKH), saw earnings for the quarter ending December 31, 2017 drop
32% to LKR 563.2 million (42 ). The company cited the sugar tax as
the cause of the drop in sales, in addition to consumer discretionary
spending.

Health Promoting Schools Policy

Many activities of the Health Promoting Schools policy/initiative (see
Chapter 5) which was launched in 2007, contribute to the attainment of
this target. The initiative has been designed within the internationally
agreed framework for school health programming, the FRESH (Focusing
Resources on Effective School Health) framework. This framework,
provides a common platform for interagency School Health Initiatives
(such as the Health Promoting School initiative of the World Health
Organization and the Child-Friendly Schools initiative of the United
Nations Children’s Fund). In 2015, all schools were evaluated using
a tool developed by experts in the field. Nearly 3,400 schools were
accredited as Health Promoting Schools, while 720 schools achieved
gold standard ( 12). During the annual School Medical Inspection,
nutritional and health status of children are assessed providing a means
of monitoring this target. School Medical Inspections are conducted
by Medical Officers of Health and organized by the Public Health
Inspectors. In small schools (less than 200 children), all children are
examined annually and in schools where enrolment is more than 200,

173
all students in grades 1, 4, 7 and 10 are examined annually.

In 2007, the Ministry of Education issued its first Circular (2007/02) on

the Maintenance of School Canteens to all public schools supporting
the “Healthy Canteens in Schools” programme; a joint programme of
the Ministry of Education and the Ministry of Health. It sets guidelines
for kind of food items that can be sold in public school canteens, with
the objective of preventing obesity and improving the nutritional
status of school children. The School Canteen Programme is being
implemented in consultation and collaboration with all relevant
stakeholders, including school principals, teaching staff, public health
inspectors, parents and contractors running school canteens.

Adolescent and youth Health Policy

Young people aged 15 to 24 years constitute 15.6% of the total
population in Sri Lanka (12). A National Youth Health Survey has been
conducted in 2012/2013 by the School & Adolescent Health Unit and
Research and Development Unit of the Family Health Bureau, with
technical and financial support form the UNICEF and UNFPA (44 ).
The survey investigated general health conditions, behaviours, socio-
economic and lifestyle factors and food habits of 15-24 year old
adolescents and youth. A considerable proportion of youth frequently
consumed sweetened carbonated drinks (44%), pre-cooked food
(20%) and salty food (25%), while 5.6% of youth were taking energy
formulas. Half of them were not aware of the concept of body mass
index as a measure of overweight. Nearly 50% of the males and 75%
of females had not engaged in manual work in the preceding week.
Only about 16% of males and 4.5% of females engaged in moderate
to severe physical activity such as running, cycling, swimming and
body building exercises. A significant proportion (approximately 44%)
were spending five or more days in the preceding week as “screen
time” (43). Findings which warranted focused efforts to inculcate skills
to develop healthy behaviour with regard to diet and physical activity
among adolescents and youth.

174
In 2014, an Adolescent and Youth Health component was added to
the National Family Health Programme. For provision of services to
adolescents and youth, Adolescent Youth Friendly Health Service
(AYFHS) Centers known as “Yowun Piyasa” were established in
government hospitals. Services provided at these centers include

• Medical examination;

• Counselling on life skills;

• Sexual and reproductive health services;

• Syndromic management of sexually transmitted diseases;     

• Management nutritional problems and NCDs ;

• Prevention of substance use.

In 2015, national review of nine Adolescent Youth Friendly Health

Service Centers was conducted with the participation of all relevant
stakeholders to identify the gaps and barriers that had affected the
programme. Based on this evaluation, standards for Adolescent Youth
Friendly Health Service have been revised and quality assessment
tools developed with input from international experts and the World
Health Organization. At present such centers have been established in
7 districts . Plans are underway to establish these centers throughout
the country in a phased- out fashion. Training of trainers has been
conducted to improve capacity building of primary health care workers
and other officers who are dealing with young persons at these centers,
including at the district level (44).

A ‘Yovun Piyasa’ youth health web site has also been developed
to provide youth friendly health information in all three languages.
Information related to NCDs and their risk factors at this website
could be further strengthened to empower youth to develop healthy
behaviours in relation to tobacco and alcohol use, physical activity and
healthy diet (45).

175
Conclusions and future perspectives
Being overweight and obese are largely preventable conditions. They
are precursors of diabetes, cardiovascular disease and other NCDs.
Preventing childhood and adult overweight and obesity will rely on
facilitating the consumption of healthy foods and regular physical
activity, including by ensuring that these are accessible, available and
affordable options. A broad array of large- scale actions is needed
if the rising tide of obesity is to be overturned. This will require the
engagement of multiple sectors, including education, communications,
commerce, urban planning, agriculture and health.

The Food control administration unit (under the Directorate of

Environmental and occupational Health and Food safety), which is
the regulatory authority under the food Act, is planning to include a
Nutrition Panel in all packaged foods. Food (labelling and advertising)
Regulations 2005, have been amended to make the nutrition panel
mandatory in the future. When this regulation is implemented, it will
be mandatory to include the nutritional panel in all packaged food
items. A grace period of one year will be given for industry to comply
with the regulation.

In addition, plans are afoot to label packaged foods with a healthy

logo when the content of sugar, salt and fat is at healthy levels. The
regulation to this effect has been drafted and will be enacted under the
Food Act No.26 of 1980, providing better information to consumers
to make healthy choices.

Other policy interventions to curb the rising tide of obesity and

diabetes that need consideration include:

• Strengthen nutritional literacy among adults and children;

• Enact legislation and/or regulation, to restrict the marketing of

foods and beverages to children, and to ensure that schools and
sporting events where children gather are free from unhealthy
food marketing or promotion;

• Strengthen regular good quality physical education in the school

176
curriculum for all children;

• Improve access to adequate and safe recreation and sports

facilities in schools and communities.

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CHAPTER 10

National NCD Target 8:

Prevent Heart Attacks
and Strokes
At least 50% of eligible people receive drug
therapy and counselling (including glycaemic
control) to prevent heart attacks and strokes.

Key messages

• Cardiovascular disease is the leading cause of NCD deaths

and was responsible for 17.5 million deaths in 2012.

• Implementing population- wide policies to reduce exposure

to cardiovascular risk factors (tobacco use, harmful use of
alcohol, physical inactivity, unhealthy diet and air pollution)
is essential for preventing heart attacks and strokes.

• Integrated programmes based on a total-risk approach

need to be established in primary care, using hypertension,
diabetes and other cardiovascular risk factors such as tobacco
use as entry points.

• Prevention of heart attacks and strokes through a total

cardiovascular risk approach is a very cost-effective individual
intervention (best buy), which can be implemented in primary
care even in resource-constrained settings.

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• Since this individual intervention is more cost-effective than
treatment decisions based on single risk factor thresholds,
it should be part of the basic benefits package for pursuing
universal health coverage.

• Sri Lanka has included prevention of heart attacks and strokes

through a total risk approach (best buy) in the essential
services package, and will provide basic technologies,
medicines and human resources for its delivery.

• The attainment of this target is critical for reducing premature

mortality from cardiovascular disease.

Cardiovascular disease: heart disease and stroke

Globally, cardiovascular disease is the leading NCD. It is responsible
for 46% of all NCD deaths. Of the 17.5 million deaths due to
cardiovascular disease in 2012, an estimated 7.4 million were due
to heart attacks (coronary heart disease) and 6.7 million were due to
strokes (1). Currently, over 80% of cardiovascular deaths occur in low-
and middle-income countries. In 2012, heart disease and stroke were
among the top three causes of years of life lost due to premature
mortality globally (2)

Over the last four decades, the rate of death from cardiovascular
diseases has declined in high-income countries, owing to reductions
in cardiovascular risk factors and better management of cardiovascular
disease (3). Recent studies indicate that, although the risk-factor burden
is lower in low-income countries, the rates of major cardiovascular
disease and death are substantially higher in low-income countries
than in high-income countries (4).

In Sri Lanka, 40% of all deaths are due to cardiovascular disease

(Figure 10.1) ( 5 ). Diabetes is also a major risk factor for cardiovascular
disease, with about 10 % of cardiovascular deaths caused by higher
than optimal blood glucose ( 6 ). Coronary heart disease is the highest
ranking cause of premature death in Sri Lanka followed by self harm,

184
diabetes and stroke (Figure 10.2) (7 ).

Figure 10.1 Sri Lanka NCD Country Profile 2014 -Proportonal

Mortality (%of total deaths, all ages, both sexes) (World Health
Organization - Noncommunicable Diseases (NCD) Country Profiles,
2014).

The current high rates of premature cardiovascular death are

unacceptable because very cost-effective interventions are available
to prevent them. (8-12).

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Figure 10.2 2005 and 2016 ranking of causes of premature death
in Sri Lanka (Source: Sri Lanka. Institute of Health Metrics and
Evaluation 2016. http://www.healthdata.org/sri-lanka )

In order to attain target 8, the coverage of drug treatment and

counselling of medium to high risk people including those with
established disease, need to be improved. It is an affordable intervention
that can be delivered through a primary health-care approach, even in
resource-constrained settings, including Sri Lanka(8−12).

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Figure 10.3 World Health Organization cardiovascular risk
prediction chart (for one of the 21 global regions) (Source: World
Health Organization 2018)

Tools for cardiovascular risk assessment and management are

available. World Health Organization has updated the cardiovascular
risk prediction charts and has provided 10-year cardiovascular risk
prediction charts for 21 regions (Figure 10.3). They are calibrated for
the specific risk factor levels and sex specific relative coronary heart
disease and stroke rates of each region. Simplified charts are also
available which can be used without laboratory measurement of total
cholesterol. They will be useful in resource poor settings in order to
identify a subset of high risk individuals for further assessment and
management.

187
Cost-effective policies and interventions to
prevent and control cardiovascular disease
In addressing cardiovascular disease the population-wide approaches
described in relation to national targets 2-7 in Chapters 3 to 9, have
great potential to decrease the disease burden at very affordable costs.
However, population-wide strategies alone are not sufficient to protect
people who are at high risk of developing disease. Cardiovascular
risk of these individuals can be reduced considerably in the short- to
medium-term if the population-wide approaches are complemented
by health-care interventions targeting those who either already have
cardiovascular disease or those who are at high risk (9, 11, 13). Target
8 prioritizes these interventions.

Treatment of high risk individuals with aspirin, blood pressure-lowering

drugs, cholesterol –lowering drugs to prevent first heart attacks and
stroke (primary prevention), is effective and cost effective (9, 11, 13 14
). In addition to first attacks, recurrent heart attacks and strokes also
need to be prevented in those with established disease (secondary
prevention). These persons face considerably greater risk of recurrent
vascular events and are much more likely to die in a recurrent event.
Aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and
statins together with smoking cessation, could prevent majority of
recurrent heart attacks and strokes (10). Secondary prevention services
are easier to deliver than primary prevention because the diagnosis
of cardiovascular disease has already been made. However, a sole
focus on secondary prevention is insufficient to attain target 8, as a
considerable number of heart attacks and strokes are first attacks and
many persons do not survive the first attack, particularly in low- and
middle-income countries with fragile emergency health services.

It has been estimated that scaling up treatment to reduce

cardiovascular risk, targeted at individuals who are at high absolute
risk of cardiovascular disease or who have existing cardiovascular
disease could avert a large number of heart attacks and strokes at
affordable costs. For scaling up such a program the annual cost per
head of population falls below US$ 1 in low-income countries, less

188
than US$ 1.50 in lower-middle income countries and averages US$
2.50 in upper-middle income countries (15). From a public health
perspective, an annual per capita investment of US$1-2.50 would
appear to be a low price to pay for significantly reducing the massive
burden of disease heart attacks and strokes. Further this intervention
is affordable to low resource settings compared to costly procedures
such as coronary stenting and coronary bypass grafting that may be
necessary when detection and treatment are late and the patient
reaches advanced stages of the disease.

From an economic perspective, the costs involved in mounting a

scaled up response are very small compared with the massive losses
in gross national product or social welfare that would occur if no scaled
up action and investment are taken. However, the finances required to
scale up this intervention represent a new demand on health budgets,
especially in relation to the very low levels of current expenditure on
prevention and control of these diseases. Based on the very high cost
effectiveness, feasibility in implementing at the primary care level and
potential for scalability, this intervention is categorized as a WHO best
buy (8, 11, 13 ) (see Chapter 2).

It has been proposed that administration of a fixed-dose combination

of aspirin, statin and antihypertensive medications (polypill) to all
individuals aged over 55 years, regardless of cardiovascular risk
status, is a suitable approach for preventing heart attacks and strokes
(16). However, there is not enough evidence to support such mass
drug treatment. The efficacy, long-term risks, sustainability and cost
effectiveness of the polypill remain to be proven. Overall, results of
clinical trials conducted to date show that fixed-dose combination
therapy is associated with modest increases in adverse events, but
better adherence to treatment, compared to multiple single agents
(17). As yet, there are no clinical trials with any fixed-dose combinations
that are powered to show differences in morbidity and mortality.
Further research, including cost-effectiveness studies, is necessary
before considering widespread use of fixed-dose combinations.
Furthermore, the fixed-dose combination therapy does not offer a
sustainable fix for the complex problem of addressing cardiovascular

189
diseases. Thus attempts to promote the use of the polypill should in
no way undermine comprehensive public health approaches to NCD
prevention and control, or efforts to strengthen health systems in low-
and middle-income countries.

Monitoring progress in the attainment of target 8

The indicator for monitoring this target in the global monitoring
framework (18) is the proportion of eligible persons receiving drug
therapy and counselling (including glycaemic control) to prevent heart
attacks and strokes.

Eligible persons are those aged 40 years and older with a 10-year
cardiovascular disease risk ≥30%, including those with existing
cardiovascular disease. Drug therapy is defined as taking medications
for primary and secondary prevention of heart attacks and strokes,
based on WHO recommendations (9-12). This includes medications
for controlling diabetes, hypertension, blood cholesterol and blood
coagulation, based on WHO recommendations. Counselling is defined
as receiving advice from a doctor or other health worker to quit using
tobacco or not start, reduce salt in the diet, eat at least five servings
of fruit and/or vegetables per day, reduce fat in the diet, do more
physical activity, maintain a healthy body weight, or lose weight.

Global progress achieved in attaining this target

In the global capacity assessment survey conducted in 2015, countries
were asked if they had evidenced-based national guidelines/protocols
for the management of major NCDs through a primary care approach.
Guidelines for cardiovascular diseases and diabetes were available
in 75% and 67% of countries respectively. In 90% of them they were
fully or partially implemented. Twenty-one per cent (21%) of countries
reported having more than 50% of primary health-care facilities offering
cardiovascular risk stratification for the management of patients at
high risk of heart attack and stroke; the highest responses came from

190
high-income countries (41%). Twenty-six per cent (26%) of countries
reported having less than 25% of primary health-care facilities that
offered cardiovascular risk stratification and 20% of countries offered
no risk stratification (19).

The majority of countries reported having some basic technologies

generally available for early detection, diagnosis and monitoring of
NCDs in primary care facilities in the public health sector: 97% for
blood pressure measurement, 95% for weight measurement, and
90% for height measurement. Blood glucose measurement was also
widely available, with 85% reporting general availability in primary
care facilities in the public health sector. Approximately two thirds of
countries reported general availability for urine strips for glucose and
ketone measurement (67%), urine strips for albumin assay (64%) and
total cholesterol measurement (59%).

More detailed studies reveal significant gaps in the provision of

interventions to prevent heart attacks and stroke, even in high-
income countries. In a study conducted in 22 European countries,
the proportion of patients with heart disease and prevalent diabetes
reaching the treatment targets was 20% for blood pressure, 53% for
low-density lipoprotein cholesterol and 22% for haemoglobin A1c
(HbA1c) (20). In another European study on secondary prevention and
risk-factor control in patients after ischaemic stroke, 50% of patients
did not achieve optimal risk-factor targets (21). Not surprisingly, a much
worse situation has been documented in low- and middle-income
countries (22, 23). In one study, the percentage of those with heart
attacks who received beta-blockers was 48%, angiotensin-converting
enzyme inhibitors 40%, and statins only 21% (22). In a more recent
study in three countries in South-East Asia, over 80% of patients
received no effective drug treatment after heart attacks and strokes
(23). Poor access to basic services in primary care, lack of affordability
of laboratory tests and medicines, inappropriate patterns of clinical
practice, and poor adherence to treatment were some of the main
reasons for the treatment gaps.

In low- and middle-income countries, the primary care level of the

health system, which has to play a critical role in delivering these

191
interventions, is often the weakest. An evaluation of the capacity of
primary care facilities to implement interventions to prevent heart
attacks, strokes and other NCD complications in eight low- and
middle-income countries showed major deficits in health financing,
service delivery, access to basic technologies and medicines, medical
information systems, and the health workforce (24). Overall, in most
low- and middle-income countries, coverage of this essential individual
intervention for prevention of heart attacks and strokes is low, with very
slow progress in scaling up. However, some low- and middle-income
countries (e.g. Bahrain, Benin, Bhutan, Democratic People’s Republic
of Korea, Eritrea, Ethiopia, Fiji, Guinea, Indonesia, Kazakhstan, Kiribati,
Kyrgyzstan, Lebanon, Myanmar, Palestine, Philippines, Republic of
Moldova, Samoa, Sierra Leone, Solomon islands, Sri Lanka, Sudan,
Tajikistan, Timor Lest, Togo, Tonga, Turkey, Uzbekistan, Viet Nam)
have taken steps to implement the total risk approach in primary care.
Primary care workers, including family practitioners, are being trained
to assess and manage cardiovascular risk, using tools of the WHO
Package of essential noncommunicable (PEN) disease interventions
for primary health care in low-resource settings (11, 26-28 ). Some of
these countries including Sri Lanka have planned national scale-up in
a phased out manner (28, 29).

At a joint meeting in July 2014, Economic and Health Ministers of

Pacific Island countries agreed to improve the efficiency and impact
of existing health budgets, by reallocating scarce health resources to
targeted primary and secondary prevention of cardiovascular disease
and diabetes, including implementation of WHO PEN (30).

What has been done to attain this target in Sri

Lanka?
Integrated approach implemented across the primary
care network
Sri Lanka has given priority to this very cost-effective high-impact NCD
intervention (“best buy”). It has already adopted a total-risk approach

192
which enables integrated management of hypertension, diabetes and
other cardiovascular risk factors in primary care (29). This approach
targets available resources at persons most likely to develop heart
attacks, strokes and diabetes complications, with a particular focus on
primary health care.

Sri Lanka`s primary health care delivery structure is divided into

preventive and curative care (Figure 10.4). The Medical Officer
of Health units (MOH units) headed by Medical Officers deliver
preventive care at the grass root level. There are 331 MoH areas in
the country, each providing preventive health care and maternal and
child health care for a population between 100, 000 and 150, 000.
The MoH team includes nurses, public health midwives who have
traditionally provided maternal health services and public health
inspectors who provide environmental health and disease control
services. The curative care network includes primary medical care units
and hospitals. The curative network is organized into primary medical
care units (n=474), divisional hospitals (n=493), base hospitals (n=68),
district general hospitals (n=3 ), provincial general hospitals (n=3) and
teaching hospitals (n=21) (Figure 10.4). The majority of Primary Health
Care Units have one Medical Officer, one health assistant and/or a
dispenser.

Recognizing that assessment of total cardiovascular risk, with access

to diagnosis and treatment, can advance progress towards attaining
this target and prevent heart attacks and strokes and diabetes
complications, the Ministry of Health established Healthy Lifestyle
Centers in primary health care institutions, in 2011 to promote self
referral and early detection.

Healthy Lifestyle Centres for self-referral and early

detection
Experience from implementing three pilot projects was consolidated
in the design of the Healthy Lifestyle Centers. They were the WHO
Package of Essential Noncommunicable (PEN) disease interventions

193
for primary health care in low-resource settings (WHO-PEN) (25); the
NCD Prevention Project piloted by the Japan International Cooperation
Agency (31), and the community-based health-promotion component
of the National Initiative to Reinforce and Organize General Diabetes
Care in Sri Lanka (NIROGI Lanka) of the Sri Lanka Medical Association
(32).

People in 40-65 age group are invited to come for cardiovascular risk
assessment at the Healthy Lifestyle Centers. Primary Health Care Units
are expected to conduct assessment of a minimum of 20 people, once a
week. Supervision and coordination of the activities of Healthy Lifestyle
Centers in each district has been assigned to a new cadre of Medical
Officers (MO-NCD), who also coordinate NCD related activities at the
district level. Trained health care workers assess clients for behavioural
risk factors; tobacco use, harmful use of alcohol, physical inactivity
and unhealthy diet. Body mass index, blood pressure and fasting
blood sugar are checked. Cardiovascular risk is assessed using WHO
risk prediction charts. Those at high risk of cardiovascular disease
are referred to the next level of care. Counselling on behavioural risk
factors are provided to all and follow-up visits are scheduled at the
Healthy Lifestyle Centers for those at low cardiovascular risk.

194
Figure 10.4 Organization of the preventive and curative health
care system in Sri Lanka (Source: World Health Organization 2013.
Addressing noncommunicable diseases in a lower-middle-income
country: Sri Lankas approach, Country Office, Sri Lanka)

Improving early detection of people through Healthy Lifestyle Centres

is only the first step. Those at high risk have to be appropriately
managed and followed up, long-term. The health care level at which
medium/high risk patients are managed depends on the need for
further investigation and treatment.

195
The number of Healthy Lifestyle Centers has grown from 126 in 2011
to 826 in 2016.Healthy Lifestyle Centers have been established across
all levels of facilities – primary, secondary and tertiary care because
people have the freedom to access all three levels when seeking
health care. Coverage of the targeted population has increased from
2.5 % in 2011 to 25 % in 2016.

The Second Health Sector Development Project of the World Bank

initiated in 2013 has contributed to the expansion of the Healthy
Lifestyle Centres (33). Two of the disbursement-linked indicators for
the Second Health Sector Development Project are (i) the percentage
of Ministry of Health areas with at least two Healthy Lifestyle Centers
and (ii) the percentage of persons aged over 40 years screened for
selected NCDs at the Healthy Lifestyle Centers.

Conclusions and future perspectives

Sri Lanka has already laid a strong foundation to attain this NCD target
by strengthening primary health care through Healthy Lifestyle Centers,
using a very cost effective total risk approach and hypertension and
diabetes as entry points to move towards universal health coverage.
However, there are many challenges that need to be overcome to
attain this target.

One challenge is to reach the population at risk with the limited resources
available to NCD teams at the district level. District health teams are
exploring ways to increase the community reach by advertising the
services provided in Healthy Lifestyle Centers through social marketing
and media campaigns and using mobile clinics to reach remote areas.
In order to improve coverage of the target population and to increase
male participation in the program, plans are under way to extend the
opening hours of Healthy Lifestyle Centers and conduct “outreach”
screening in workplace settings. An electronic health information
system will be introduced to improve accuracy of data collection and
coordination at the district level. Creating a new cadre of field health
worker is also under consideration in order to improve participation

196
and follow up of the targeted population.

Another challenge is to ensure that once investigated, assessed and

treated, majority of medium-high risk individuals are followed-up in
primary health care units. Whether or not the patients are effectively
managed and followed up in primary care depends on the quality
of services provided at this level. Due to shortcomings in primary
care facilities, currently, a high proportion of medium and high risk
patients continue to utilize hospital out-patient clinics. This has led
to overcrowding and poor quality of services at these clinics. In order
to attain this NCD target, current shortcomings in health system
components at all levels of the health system have to be systematically
rectified including, access to basic technologies and medicines,
the performance of the health workforce, service delivery, health
information and referral and back referral links.

The recently approved health care reform policy, for making progress
towards Universal Health Coverage (34 ) (see Chapter 3), addresses
many health system issues that need to be tackled for the attainment of
NCD target 8. This includes the inclusion of prevention of heart attacks
and strokes through a total risk approach within the essential services
package. There are many expected outcomes of implementing the
new health care reform policy; improvement of coverage of essential
health services, access to essential medicines and technologies, skill-
mix of health care workforce, health information system, continuity
of care and equitable distribution of primary, secondary and tertiary
health care facilities, among others. Accelerated implementation of
the health care reform policy will be essential for timely attainment of
this target.

197
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noncommunicable diseases report of the 2015 global survey. Geneva:
World Health Organization; 2016.
20. Gyberg V, Kotseva K, Dallongeville J, Backer GD, Mellbin L, Rydén L
et al.; EUROASPIRE Study Group. Does pharmacologic treatment in
patients with established coronary artery disease and diabetes fulfil
guideline recommended targets? A report from the EUROASPIRE III
cross-sectional study. Eur J Prev Cardiol. 1 April 2014 (Epub ahead of
print).
21. Heuschmann PU, Kircher J, Nowe T, Dittrich R, Reiner Z, Cifkova R et al.
Control of main risk factors after ischaemic stroke across Europe: data
from the stroke-specific module of the EUROASPIRE III survey. Eur J
Prev Cardiol. 19 August 2014 Aug 19. pii: 2047487314546825 (Epub
ahead of print).
22. Mendis S, Abegunde D, Yusuf S, Ebrahim S, Shaper G, Ghannem H et
al. WHO study on prevention of recurrences of myocardial infarction and

199
stroke (WHOPREMISE). Bull World Health Organ. 2005;83(11):820–9.
23. Yusuf S, Islam S, Chow CK, Rangarajan S, Dagenais G, Diaz R et al;
Prospective Urban Rural Epidemiology (PURE) study investigators.
Use of secondary prevention drugs for cardiovascular disease in the
community in high-income, middle-income, and low-income countries
(the PURE Study): a prospective epidemiological survey. Lancet.
2011;378(9798):1231−43. doi:10.1016/S0140-6736(11)61215-4.
24. Mendis S, Al Bashir I, Dissanayake L, Varghese C, Fadhil I, Marhe
E et al. Gaps in capacity in primary care in low-resource settings for
implementation of essential noncommunicable disease interventions.
Int J Hypertens. 2012;2012:584041. doi: 10.1155/2012/584041.
25. Implementation tools: package of essential noncommunicable (WHO-
PEN) disease interventions for primary health care in low-resource
settings. Geneva: World Health Organization; 2013. (http://www.who.
int/cardiovascular_diseases/publications/implementation_tools_WHO_
PEN/en/).
26. Adoption of the Philippine Package of essential noncommunicable
disease interventions (PHIL PEN) in the implementation of the Philippine
Health`s primary care benefit package. (http://www.philhealth.gov.ph/
circulars/2013/circ20_2013.pdf,
27. Health Annual Report Palestine 2012. Nablus: Ministry of Health,
Palestinian Health Information Center; 2012. (http://www.moh.ps/
attach/502.pdf
28. Report by Dr Margaret Chan, Director General of the World Health
Organization. Ten Years in Public Health 2007-2017. Geneva: World
Health Organization; 2017.
29. MallawaarachchiDSV, Wickremasinghe SC, Somatunga LC, Siriwardena
VTSK, Gunawardena NS Healthy Lifestyle Centres: a service for screening
noncommunicable diseases through primary health-care institutions in
Sri Lanka. WHO South East Asia Public Health Journal 2016;5 (2):89-92.
30. Towards healthy islands: Pacific noncommunicable disease response.
In: Tenth Pacific Health Ministers meeting, Apia, Samoa, 2–4 July
2013. Manila: World Health Organization Western Pacific Region; 2013
(PIC10/3). http://www.wpro.who.int/southpacific/pic_meeting/2013/
documents/PHMM_PIC10_3_NCD.pdf,
31. Ministry of Health, Japan International Cooperation Agency. Project on
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Report. Colombo: Ministry of Health; 2013 (http://open_jicareport.jica.
go.jp/pdf/12112322.pdf).
32. Wijeyaratne C, Arambepola C, Karunapema P, Periyasamy K,
Hemachandra N, Ponnamperuma G et al. Capacity-building of the
allied health workforce to prevent and control diabetes: lessons learnt
from the National Initiative to Reinforce and Organize General Diabetes
Care in Sri Lanka (NIROGI) Lanka project. WHO South-East Asia J Public
Health. 2016;5(1):34–9.
33. Progress report of the Second Health Sector Development Project of Sri
Lanka. Colombo: Ministry of Health; 2014.
34. Policy on Health Care Delivery for Universal Health Coverage 2018.
Management Development and Planning Unit. Ministry of Health and
Indigenous Medicine. Colombo, Sri Lanka 2018.

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CHAPTER 11

National NCD target 9:

Improve access to
medicines and
technologies
An 80% availability of the affordable basic
technologies and essential medicines, including
generics required to treat major NCDs in both
public and private facilities by 2025.

Key messages

• Access to basic technologies and essential medicines is

absolutely necessary to reduce premature deaths from
NCDs.

• Minimal basic technologies for addressing NCDs in primary

care include, a blood pressure measurement device, a
weighing scale, height measuring equipment, blood sugar
and blood cholesterol measurement devices with strips, and
urine strips for albumin assay.

• Minimal medicine requirements for addressing NCDs

in primary care include aspirin, a statin, an angiotensin-
converting enzyme inhibitor, a thiazide diuretic, a long-acting

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calcium-channel blocker, a beta-blocker, metformin, insulin,
a bronchodilator and a steroid inhalant.

• In order to safeguard equity, people need to be provided

access to basic NCD technologies and core NCD medicines
at all levels of health care, before resources are allocated to
other NCD technologies and other NCD medicines.

• Converging and competing interests of many players - policy

makers, financing agencies, prescribers, pharmacies, health
facilities, private companies and consumers -determine
access to affordable medicines.

• The high level of political commitment to the provision of

affordable and quality medicines has improved access to
NCD medicines in Sri Lanka, particularly in the last 3 years.

• The National Medicines Regulatory Authority working

together with the Ministry of Health and Indigenous
Medicines and the World Health Organization is playing a
key role in ensuring access to affordable medicines in Sri
Lanka

• Sri Lanka is continuing reforms to improve access and

appropriate use of affordable quality medicines to advance
the principles of Universal Health Coverage and Sustainable
Development Agenda.

Basic NCD technologies and medicines

For prevention and management of NCDs, individual interventions
have to be effectively delivered, particularly at the primary care level.
Inefficiencies are currently encountered in all components of health
systems, including supply of essential medicines and technologies
(1−5). Diagnostics, technologies and medicines are the most expensive
commodities of health care. Evidence based rationalization and
prioritization of diagnostics and medicines are necessary to contain

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the health care expenditure, particularly in the public health sector. It
is critical for sustainability of health systems that provide services free
at the point-of-delivery - as in Sri Lanka.

NCD target 9, includes the basic requirement of medicines and

technologies for implementing cost-effective primary care interventions
to manage cardiovascular disease, diabetes and asthma (6). The core
essential medicines include aspirin, a statin, an angiotensin-converting
enzyme inhibitor, a thiazide diuretic, a long-acting calcium-channel
blocker, a beta-blocker, metformin, insulin, a bronchodilator and a
steroid inhalant. The basic technologies include, a blood pressure
measurement device, a weighing scale, height measuring equipment,
blood sugar and blood cholesterol measurement devices with strips,
and urine strips for albumin assay. These are minimum requirements for
implementing essential NCD interventions in primary care. Availability
is defined as the percentage of public and private primary health-
care facilities that have all of these medicines and technologies. As
and when more resources become available, these lists of diagnostics
and medicines could be expanded, but as a first step, the core set of
medicines and diagnostics need to be made available at all levels of
the health system.

Impact of rational use of medicines on equity and

health outcomes
It is also important to recognize that in the public health sector, which
usually has very limited resources, decisions regarding the selection
of diagnostics and medicines for NCDs can have a significant impact
on quality and sustainability of services as well as health outcomes
and equity. For example, the diagnostics listed above need to be
available at all health care levels country-wide, before providing
electrocardiographs in primary care, where health workers are often
not competent to read and correctly interpret electrocardiograms.
Similarly, medicines listed above need to be available country- wide at
all levels of health care, before the addition of more costly medicines.
Further, because resources are limited, treatment guidelines need to

205
provide guidance to physicians on how to target medicines at those
who will benefit the most from their use. For example, before treating
borderline hypertension in large numbers of people- which can be
addressed through population reduction of salt consumption- drug
treatment should be ensured for those with hypertension and medium
to high cardiovascular risk, who are highly vulnerable to develop heart
attacks and strokes. In the case of respiratory diseases, steroid inhalers
should first be provided to all with moderate to severe bronchial
asthma before making them available for wider use. These issues
may not be relevant to settings with high level of resources or good
health insurance coverage. However, they are absolutely critical for the
success of NCD prevention and control in a developing country such
as Sri Lanka which is striving to provide health care free at the point of
delivery (7, 8).

Access to NCD medicines; global situation

Access to medicines depends on rational selection, affordable prices,
sustainable financing and reliable health and supply systems ( 9
). Access to medicines is critical for both coverage of services and
financial protection- for the attainment of Universal Health Coverage.
Worldwide , medicines account for 68% of total health expenditure. In
some countries, up to 90% of total expenditure for medicines is out-
of- pocket. (10).

Recognizing the importance of access to medicines, the 2030

Sustainable Development Agenda also has included an ambitious target
to improve access to Medicines (Target 3 b): “Support the research and
development of vaccines and medicines for communicable and non-
communicable diseases that primarily target developing countries,
provide access to affordable essential medicines and vaccines in
accordance to the DOHA declaration on the TRIPS Agreement and
Public Health, affirm the right of developing countries to use the full
provision in the Agreement on Trade-Related Aspects of Intellectual
Property Rights regarding flexibilities to protect public health and in
particular provide access to medicines for all.” (11)

206
In surveys conducted worldwide, there is a consistent pattern of lower
availability of medicines in public sector facilities compared to the
private sector, and lower availability in low-income and lower-middle-
income countries (12-14, 16). An analysis of the availability of selected
cardiovascular medicines (atenolol, captopril, losartan and nifedipine)
in 36 countries concluded that availability in the public sector was
poor (26.3%) compared to the private sector (57.3%) (14). A survey
of the availability of asthma medicines listed on the WHO model
list of essential medicines (15) found that, while salbutamol inhalers
were available in 82.4% of private pharmacies, 54.8% of national
procurement centres and 56.3% of public hospitals, the availability of
beclometasone 100 μg puff inhalers, vital for treatment of asthma, was
much lower (41.7%, 17.5% and 18.8% respectively) (16).

Procurement and distribution of medicines in

Sri Lanka
Sri Lanka’s pharmaceutical market is estimated to be worth USD $ 400
million per year. The Government of Sri Lanka established the State
Pharmaceuticals Corporation (SPC) in 1971 to provide high quality,
safe, effective and affordable medicines. The national requirement of
medicines for the public sector is estimated by the Medical Supplies
Division (MSD) of the Ministry of Health on an annual basis. The
national requirement of medicines is procured mainly through the
State Pharmaceutical Corporation(SPC) which is the procurement
agency for the Ministry of Health. In addition, when necessary, the
Medical Supplies Division makes emergency procurement of locally
manufactured pharmaceutical in the private sector.

The State Pharmaceuticals Corporation, procures medicines through an

open, competitive tender system. All medicines imported into Sri Lanka
need to be registered with the National Medicines Regulatory Authority.
Suppliers who quote against the tenders of the State Pharmaceutical
Cooperation also have to be registered with the National Medicines
Regulatory Authority. Awards are made considering price quoted, past
performance, quality of sample submitted and registration. Through

207
competitive global tenders, generic and bulk purchasing , the State
Pharmaceuticals Corporation has been able to secure lower medicine
prices and shield the public sector from high medicine costs.

The State Pharmaceuticals Manufacturing Corporation (SPMC) -

founded in 1987- is the main drug manufacturer in Sri Lanka, providing
43 drugs to the Ministry of Health at low profit margins. In 2015, SPMC
and local manufacturers accounted for 15 % of the total pharmaceutical
market in Sri Lanka. The Cosmetics, Devices and Drugs Act 1980,
is the legislative framework which provides the legal authority
to regulate Cosmetics, Devices and Drugs in Sri Lanka. National
Medicines Regulatory Authority is responsible for implementation of
the provisions of the Act. The National Medicine Regulatory Authority
was established in 2015, by the former Minister of Health and current
President of Sri Lanka, H.E. Maithripala Sirisena (17, 18).

Distribution of medicines to government hospitals is the responsibility

of the Medical Supplies Division. The Medical Supplies Division has a
network of stores comprising of a Central Medical Store in Colombo
and 26 Regional Medical Stores at the district level. Medicines are
distributed directly to line ministry institutions by the Medical Supplies
Division and to institutions under the provincial administration through
Regional Medical Supplies Divisions (17, 18).

The State Pharmaceutical Corporation also procures medicines for an

island-wide network of pharmacies known as Rajya Osu Sala outlets,
and through them to other private health care facilities and private
pharmacies. All expenses incurred in the purchases for the Health
Ministry are advanced by the State Pharmaceutical Corporation from
its own funds and subsequently collected from the Ministry. The State
Pharmaceutical Corporation receives a service charge of 10% of the
cost and freight value of goods for ordering and clearing expenses
such as taxes, defence levy etc. (17, 18)

Supply of narcotics to public and private sectors is done only by the

Medical Supplies Division (MSD) of the Ministry of Health. Government
hospitals have pharmacies that provide medicines free of charge to
patients who attend outpatient departments and hospital clinics.

208
Rational use, availability and affordability of
medicines in Sri Lanka
The Essential Medicines list of Sri Lanka has been compiled based on
disease patterns, evidence on efficacy, safety, stability and comparative
cost effectiveness ( 19). Drug and Therapeutic committees have been
established in more than 80 institutions . They help to promote rational
use of medicines and to improve the quality and cost efficiency of
treatment (18).

Several studies have been conducted on the availability and affordability

of medicines in Sri Lanka (12, 20-22). Availability of medicines for
management of NCDs in the private sector in Sri Lanka has been
fairly high. In the public sector, availability of essential medicines for
management of NCDs has improved over the last 10 years ( 12, 20).
However, availability seem to fluctuate during the course of the year,
with stock-out situations reported more often at the end of the year,
particularly in primary care facilities. For example a World Bank study
found that only 57.5% of primary health care institutions had a one-
month buffer stock of 16 selected drugs for NCDs ( 23). At the district
level, awareness programmes are conducted regularly by the Ministry
of Health in collaboration with the State Pharmaceutical Cooperation,
to improve medical supplies management and to minimize stock-out
situations in public sector facilities.

It is estimated that the private sector accounts for between 50 and 60%
of out patient care[ 24]. In the public sector, health services including
medicines are free at the point of delivery (see Chapter 2). However,
when medicines are not available in the public sector patients are
compelled to purchase medicines from the private sector spending
out of pocket. Out of pocket expenditure as a percentage of total
health expenditure has been estimated to be 41.6-50.5% ( 24 ). Out of
pocket expenditure as a percentage of private health expenditure has
been estimated to be 80.8-87.6% ( 24 ).

209
Sri Lanka`s success story; access to affordable
NCD medicines
Most developed countries have pricing policies to achieve affordability
of medicines. Direct pricing policies include negotiated prices,
maximum fixed prices, international price comparisons and price
cuts. Indirect methods include profit regulation and reference pricing.
(25). In 1989, the Government of Sri Lanka imposed price control on
pharmaceuticals where the retail price was fixed at a maximum of
160% of the cost, insurance and freight by the Sri Lanka Government
Gazette Extraordinary No. 552/7 in 1989. In November 2002, this
was terminated by the Sri Lanka Government Gazette Extraordinary
No.1259/14. Even though medicines are exempt from certain taxes in
Sri Lanka, this does not always result in lower prices for the patient. For
example, private hospitals applied 15% V.A.T. on medicines provided
to patients. Importers prices are based on the Cost, Insurance, and
Freight (CIF) value of medicines. importers declare the CIF value, which
is not independently verified. In 2011, the Consumer Affairs Authority
found that mark-ups on the CIF value of medicines were higher than
500 % in certain cases ( 26 ).

There are many factors which distort demand and increase drug prices.
These include: unethical drug promotion; lack of consumer awareness
on generic brands; lack of monitoring of overcharging; irrational
selection and use of medicines and unreliable supply systems. As a
result of all these factors, since price control was abolished in 2003,
people had to face the burden of steadily rising drug prices. It
particularly took a toll on those suffering from NCDs.

The National Medicines Regulatory Authority is responsible for regulation

and control of registration, licensing, manufacture, importation and
other aspects pertaining to medicines (27). In 2016, at the request
of the National Medicine Regulatory Authority, WHO conducted an
analysis of Sri Lanka’s approach to pharmaceutical price control . This
analysis provided useful insights on the strengths and weaknesses of
various pricing formulas. Based on the findings of this analysis, on
21 October 2016, the Government issued a notice by Extraordinary

210
Gazette, setting a price ceiling for 48 essential medicines used to treat
NCDs, such as diabetes, ischemic heart disease, hypertension, high
cholesterol, and other common diseases (Table 11.1). The revised drug
price formula ensures that core essential medicines for NCDs should
be sold below a recommended maximum retail price at all times. The
revised pricing policy is a major achievement in safeguarding patients’
rights to access affordable medicines.

Table 11.1 Reduction in price of diabetes and hypertension

medicines due to new pricing formula based on maximum retail
price

Cost Reduction in
before Maximum cost
Medicine Brands new Retail due to new
pricing Price (LKR) pricing
(LKR) formula
Amlodipine 50mg 8 21.00 15.32 29%
Losarten 50mg 23 28.00 10.30 64%
Atorvastatin 20mg 18 41.00 17.63 58%
Clopidogrel 75 mg 4 20.50 15.27 26%
Metformin 500mg 22 10.00 10.00 63%
Gliclazide 80mg 28 19.00 9.28 54%

Work is underway to reduce the prices of another 25 medicines;

antibiotics, analgesics and medicines for diabetes, prostate diseases,
asthma, cancer and neurological diseases.

Conclusion and future perspectives

Sri Lanka’s successful regulation of pharmaceutical prices demonstrate
how a high level of political commitment, evidence based policies
and public debate can protect patients’ rights and ensure affordable
access to quality assured medicines (28). The new pricing policy sets a
maximum cap on the price of core essential NCD medicines. Further
safeguards will be required to ensure that tax reductions on medicines

211
result in lower medicine prices to the patient, particularly in the private
sector.

Inexpensive generic NCD medicines are already available below the

maximum retail price. However, the public are reluctant to purchase
them because of concerns about their quality. The National Medicine
Regulatory Authority is in the process of developing new guidelines to
help ensure quality of generic medicines to improve their utilization.

An electronic Medicines Supply Management Information System

(e-MSMIS), initiated in 2009 in Teaching Hospitals is being extended
to the drug stores of Regional Medical Supplies Divisions (RMSDs)
and to the smaller health facilities, where drug management is still
done manually. Training of more staff in using the e-MSMIS is required.
Methods of quantification and forecasting remain sub-optimal in
some health facilities because these facility staff are still using manual
methods, based on past drug consumption during which there were
frequent stock-outs. The e-MSMIS portal will be used to disseminate
information in the updating process of the national Essential Medicines
List. Some of the other activities required to consolidate the progress
and further improve access to medicines include the following:

• Harmonize action between State Pharmaceutical Cooperation

and the Medical Supplies Division, to avoid delays;

• Coordinate the process of drug procurement with distribution

and demand;

• Strengthen the National Medicine Regulatory authority by

recruiting more technical staff, including pharmacists and
inspectors;

• Strengthen Continuing Medical Education of prescribers at

primary and secondary health care facilities on managing NCDs,
using available resources and adhering to evidence based
guidelines;

• Define key performance indicators and targets for improving

medicines management including medicines use, implementation
of regulations and the national drug policy (29).

212
There are several other Ministries and units, apart from the Ministry
of Health, which play a key role in developing and implementing
medicines-related policies. The Ministry of Finance and Treasury
provides the budget and negotiates drug prices for public sector
purchase from Sri-Lankan based manufacturers, together with the
Ministry of Trade and Industry, Sri Lanka Manufacturers Association
and the Sri Lankan Standards Institute. The Medical Supplies Division
and the State Pharmaceutical Cooperation also provide input for this
process. The Ministry of Trade and Industry sets rules for Medicine
prices and duties and taxes on the importation of medicines together
with Sri Lanka Manufacturers Association and the Sri Lankan Standards
Institute . The Ministry of Higher Education is responsible for training
programs and curricula for health professionals. The Public Services
Commission decides on the number of posts in the Ministry of Health
for management of pharmaceuticals. A high-level committee to
oversee coordination between these various Ministries and units, with
an executive committee within the Ministry of Health to carry out their
recommendations, could help to streamline work related to medicines.

References
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implementation of essential noncommunicable disease interventions.
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6. Global Status Report Nonnoncommunicable Diseases 2014. Geneva
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7. Hogerzeil HV, Liberman J, Wirtz V, Kishore SP, Selvaraj S, Kiddell-Monroe
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essentialmedicines/18th_EML_Final_web_8Jul13. pdf,).

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aff ordability of three essential asthma medicines in 52 low- and
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CHAPTER 12

National NCD target 10:

Reduce air pollution
50% relative reduction in the proportion of
households using solid fuels as the primary
cooking source.

Key messages

• About 12.6 million deaths a year (23% of global deaths),

are linked to the environment and nearly two thirds of these
deaths are due to NCDs.

• Environmental pollution including air pollution is a cross-

sectoral issue where health is adversely affected as a result
of ineffective policies in other sectors.

• Worldwide, one-quarter to one-third of NCD deaths are due

to air pollution.

• According to WHO estimates, ambient (outdoor) and

household (indoor) air pollution together caused 6.5 million
NCD deaths in 2012.

• Air pollution -both indoor and ambient - is a major public

health problem in Sri Lanka.

• Household air pollution is largely a problem of poverty

and lack of access to clean fuels for people living in poorly

217
ventilated houses.

• The reduction in indoor air pollution due to combustion

of firewood, can significantly improve health, especially of
women and children.

Pollution of the environment and NCDs

In addition to behavioural risk factors, environmental factors like

chemicals and air pollution are important risk factors of NCDs (Figure
12.1) (1-9). Environmental challenges that impact on health and NCDs
such as pollution and climate change are interconnected and cannot
be handled in isolation. For example, air pollution and climate change
influence each other through complex interactions in the atmosphere.
Increasing levels of greenhouse gases and air pollutants, alter the
energy balance between the atmosphere and the earth’s surface which,
in turn, can lead to temperature changes that change the chemical
composition of the atmosphere.

World Health organization recommends a number of strategies to

limit pollution including limiting industrial emissions, moving to clean
energy sources, clean and efficient transport and reducing exposure to
ionizing and ultra violet radiation and chemicals like pesticides, heavy
metals, and asbestos (1-3, 8 ). In Sri Lanka, misuse of pesticides and
fertilizer contaminated with heavy metals play a role in the etiology of
chronic kidney disease of uncertain origin (see Chapter 13).

218
Figure 12.1 Contribution of environmental and behavioural risk
factors to NCDs (Source: Preventing noncommunicable diseases
by reducing environmental risk factors. Geneva, World Health
Organization 2017)

Air pollution
Air pollution is the most important environmental risk factor for NCDs-
ischemic heart disease, stroke, cancer and chronic respiratory disease.
It is also a major contributor to death due to lower respiratory tract
infections in children. Other adverse effects of air pollution include
tuberculosis, cataracts, and poor maternal outcomes (1, 7, 8).

Air pollution affects people of all age groups in all countries of the
world. In 2015, 194 WHO Member States adopted the first World
Health Assembly resolution to “address the adverse health effects
of air pollution” (9). The two recent global developments that offer
opportunities for synergies and efficiencies and are relevant to the
implementation of this resolution are the Paris Agreement adopted
at the twenty-first session of the Conference of the Parties to the
United Nations Framework (10) and the 2030 agenda for Sustainable
Development (11). The importance of air pollution for sustainable

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development is reflected in its incorporation in the monitoring
framework of Sustainable Development Goals. The three indicators
that will be used for monitoring air pollution are, i) mortality due to
air pollution (ambient and household) -an indicator for the health
related SDG goal (SDG 3), ii) access to clean energy (particularly
clean household fuels and technologies) – an indicator for sustainable
energy (SDG 7) and iii) air pollution levels in cities - an indicator for
urban sustainable development (SDG 11).

Indoor air pollution

Indoor air pollution, is due to the use of polluting technologies and fuels
for cooking and lighting and indoor tobacco smoking, releasing smoke
and other pollutants into the home. Poor ventilation exacerbates the
health risks posed by indoor pollutants. In poorly ventilated dwellings,
smoke in and around the home can exceed acceptable levels for fine
particles, 100-fold (12).

Access to clean fuels and technologies for cooking, vary greatly

between countries Figure 12.2). Globally an estimated 2.4 billion
people use biomass fuel for cooking. In 2016, an estimated 3.8 million
people died from indoor pollution from stoves that are inefficient and/
or unvented (12, 13). Exposure is particularly high among women
and young children, who spend the most time near the domestic
fireplace. Exposure to household air pollution almost doubles the risk
for childhood pneumonia and is responsible for  45% of all pneumonia
deaths in children less than 5 years old (12).

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Figure 12.2 Proportion of population with primary reliance on clean
fuels and technologies (%) 2016 (Source : World Health Statistics
2018. Geneva : World Health Organization 2018)

Indoor air pollution in Sri Lanka

In Sri Lanka, like in many other developing countries, high fuel prices
disproportionately affect the poor. Nearly 20% of households can be
considered to be in “fuel poverty” needing to spend 10% or more of
their income on fuel (14).  These households are compelled to rely
on cheaper energy sources, such as biomass fuel, that produce high
concentrations of harmful indoor air pollutants. Biomass use in Sri
Lanka is limited to wood and crop residues. Although over 80% of
Sri Lankan households have electricity, this energy source is used for
lighting because it is too expensive to use as cooking fuel. Overall
around 66% of households use solid fuel for cooking; while the use
of solid fuel in urban, rural and estate sectors is 25%, 74% and 80 %
respectively. In addition, 3% of households have no access to electricity
and use kerosene for lighting as well (14).

Traditional biomass fuel stoves produce particulates, carbon monoxide,

nitrous oxide, sulfur oxides, formaldehyde  and carcinogens such
as benzopyrene. Particulate matter consists of a mixture of solid and
liquid particles of organic and inorganic substances suspended in the

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air. It is generally used as a proxy indicator of exposure to air pollution.
Particulates, especially PM2.5 (particulate matter with a diameter
smaller than 2.5 microns), are harmful because they penetrate deep
into the lungs causing bronchial irritation, inflammation and fibrosis.
Carbon monoxide prevents hemoglobin from delivering oxygen to
key organs and the developing fetus.  Nitrogen dioxide and sulfur
dioxide increase bronchial reactivity and  lead to chronic respiratory
disease (15, 16).

Number of deaths attributable to household air pollution in Sri Lanka

is shown below (Table 12.1) (13). Heart disease, stroke and chronic
respiratory disease are the main causes of death attributable to indoor
air pollution in adults. Exposure to indoor air pollution also increases
morbidity and mortality due to acute respiratory infections in children.

Table 12.1 Deaths (over 18 years) attributable to household air

pollution -Sri Lanka (2012) (Source; WHO. Global Health Observatory
(GHO) data; 2016 (http://www.who.int/gho/database/en/)

Cause of death Number of deaths (SD)

Ischemic heart disease 10449 (8471-12538)
Stroke 5587 (4375-6614)
Cancer (trachea bronchus) 586 (319-752)
Chronic respiratory disease 2552 (1403-3540)
Total 19302 (16244-22896)

A national study of cook stove types has not been done yet. Available
data indicate that the majority of cookstoves used are either three
stones or semi-enclosed stove types. An improved cookstove made of
clay known as “Anagi” is used widely, but it has not been adequately
evaluated for emissions[17]. About 65% of households use biomass
fuel for cooking inside the house. Only 72% of them have a chimney
and about 9% have a separate building for cooking [18]. Kitchens
in which wood is used with traditional stoves have average 24 hour
PM2.5 concentrations exceeding 1200 μg/m3 [19].

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Remedial measures to address indoor air pollution
Indoor air pollution requires cross sectoral remedial measures involving
multiple Ministries; Ministries of Health, Power and Energy, Finance,
Social services and Housing. There are no specific interventions
implemented at national level to reduce indoor air pollution or to
minimize the exposure of vulnerable groups to indoor air pollutants.
There is a lack of reliable indoor air quality data and determinants of
indoor air quality in Sri Lanka. This is a priority issue that needs to be
addressed (20 ).

The use of cleaner fuels such as Liquified Petroleum Gas (LPG) would
reduce the load of household air pollutants to a great extent but
economic barriers for the use of Liquified Petroleum Gas need to be
sorted out through government policies and subsidies. Currently, only
29% of households use Liquified Petroleum Gas for cooking (urban
sector 67%, rural sector 23% and estate sector 15%) (14 ).

Improved cook stoves can help to reduce the emission from firewood
and significantly increase the efficiency and speed of cooking (21-
28 ). However, an 85% reduction in exposure to particulate matter is
required to achieve a desired health effect from improved cook stores
(16). Lack of public awareness of the problem and affordable stoves
and fuels have stifled the success of this approach (21-29).

Every attempt must be made to improve the ventilation in houses,

by implementing building guidelines to ensure better ventilation
including through chimneys. For example in a study done in Sri Lanka,
houses with a chimney using traditional cook stoves had a PM 2.5 level
of about 70 μg/m  3 compared to households using traditional cook stoves
without a chimney, which had PM 2.5 levels of about 310 μg/m 3 ( 21).

People need to be educated about the efficiency of cleaner fuels,

improved cook stores and the importance of taking measures to
improve ventilation in the house; through the use of elevated kitchen
platforms to facilitate quicker exit of smoke, the use of a chimney, or
the addition of windows or doors. They need to be informed that using
indoor plants, wet-mopping of floors and refraining from smoking

223
indoors can contribute to the reduction of household air pollutants.

Ambient air pollution

Health damaging ambient air pollutants include particulate matter,
ozone, nitrogen dioxide, carbon monoxide and sulfur dioxide. The
major components of particulate matter are sulphates, nitrates,
ammonia, sodium chloride, black carbon, mineral dust and water (15,
16). The most health-damaging particles are those with a diameter
of 10 μm or less. Fine particulate matter can penetrate and lodge
deep inside the lungs, enter the bloodstream, and travel to organs.
Small particulate pollution have adverse health impacts even at very
low concentrations; no threshold has been identified below which no
damage to health is observed. The WHO 2005 guideline limits are
aimed to achieve the lowest concentrations of Particulate Matter (PM)
possible. They are PM2.5 10 μg/m3  annual mean, 25 μg/m3  24-hour
mean and PM10 20 μg/m3 annual mean and 50 μg/m3 24-hour mean.
Data in Table 12.2 indicates, that people in Sri Lanka are exposed to
more than double the air pollution levels recommended by WHO (15,
16 ).

Table 12.2 Population exposure to particulate matter; annual median

concentration (range) of particulate matter of an aerodynamic
diameter of 2.5 mm or less in Sri Lanka, compared with selected
high income and low -middle- income countries (13).

Urban and rural areas,

Urban areas particulate
particulate matter 2.5
Country matter 2.5 or less (ug/m3),
or less (ug/m3), median
median (range)
(range)
Sri Lanka 27 (14-51) 28 (15-55)
Indonesia 14 (9-23) 18 (11-28)
New Zealand 5 (4-8) 5 (4-8)
Australia 6 (4-8) 6 (4-9)

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Adverse impact of ambient air pollution on health
Globally, 3 million and 4.2 million deaths were attributable to ambient
air pollution in 2012 and 2016 respectively ( 1-8, 12, 13). About
87 % of these deaths occur in low- and middle- income countries,
which represent 82% of the world population (12). Almost 94 % of
deaths due to exposure to air pollution worldwide, are due to NCDs
in adults, such as ischemic heart disease (30%), stroke (30%), chronic
obstructive pulmonary disease (8%) and lung cancers (14%) (1). The
remaining deaths occur in children under five years of age due to
acute lower respiratory infections. Worldwide, the fraction of each
individual disease attributable to ambient air pollution in Disability
Adjusted Life Years (DALYs), ranges from 8 % for chronic obstructive
pulmonary disease to 25 % for lung cancers. Acute lower respiratory
infection (ALRI), stroke and Ischemic Heart Disease lie in the middle
with population attributable fraction of around 16 %. Table 12.3 shows
the number of deaths, Years of Life lost (YLLs) and Disability Adjusted
Life years (DALYs) attributable to ambient air pollution by disease in
Sri Lanka. In Sri Lanka 99.6% of deaths, 98.5% of Years of Life lost and
98.4 Disability Adjusted Life Years attributable to air pollution are due
to NCDs.

Table 12.3 Deaths, Years of Life lost (YLLs) and Disability Adjusted
Life years (DALYs) attributable to ambient air pollution by disease
in Sri Lanka (2012)(13)

ALRI COPD Lung IHD Stroke Total

cancer
Deaths attributable to ambient air pollution
Females 13 90 100 1745 961 2915
Males 19 178 266 3101 1312 4877
Both 33 275 365 4846 2273 7792
sexes
Years of Life Lost (YLLs), attributable to ambient air pollution
Females 1208 1644 2741 35253 19846 60692
Males 1773 3328 7293 81936 33116 127446
Both 2981 4972 10034 117189 52962 188138
sexes

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Disability Adjusted Life years (DALYs) attributable to ambient air
pollution
Females 1281 4155 2756 35646 20868 64706
Males 1851 5807 7326 82420 34109 131513
Both 3132 9962 10083 118065 54977 196219
sexes

Causes of ambient air pollution in Sri Lanka

The major outdoor air pollution sources include vehicle emissions, power
generation, manufacturing industry, waste incineration, agriculture
activities and mining operations. Emissions from automobile engines
is a major cause of air pollution that is difficult to tackle because there
is growing reliance on them for transporting people and goods. From
2008 to 2015 the number of motor vehicles plying on the roads in Sri
Lanka has doubled (Figure 12.3), worsening air pollution as well as
traffic congestion (30).

Figure 12.3 Number of newly registered motor vehicles and total

motor vehicles in Sri Lanka, 2008-2015. Source: Department of
Motor Traffic, Ministry of Transport and Civil Aviation. Colombo,
Sri Lanka 2016

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Electric power generation from renewable resources such as solar,
geothermal, and wind, generally does not contribute to climate
change or local air pollution since no fuels are combusted. In Sri Lanka
in 2014, primary energy supply for generation of electricity consisted
of biomass ( 42 % ), petroleum (40 %), coal (8 % ), hydro (8 %) and
renewable sources (3% ) (30, 31). Coal is projected to be the major
source of power with its share estimated to reach 40% by 2020 ( 32,
33 ).

Mitigating air pollution; importance of intersectoral

collaboration and policy coherence
Policies to address air pollution also generate a range of benefits to
human health, not only through air quality improvements but also
other health benefits, such as accident and injury prevention, enabling
physical activity and reducing exposure to harmful substances in the
environment.

Health sector has a challenging role to play in tackling ambient air

pollution because policies that contribute to air pollution are made by
non-health sectors. Policymakers in non-health sectors have portfolios
that require them to advance other public goods of high priority to
government and society. initiatives to promote employment, economic
growth, transportation infrastructure, power generation and community
development are deliberated by decision makers who often overlook
the impact on health. Thus, to reduce air pollution, health sector needs
to act across relevant government sectors - such as transport, power
and energy, agriculture - and identify opportunities to establish cross-
sectoral commitments in order to promote co-benefits and to reduce
negative impacts on health.

It is also important to recognize that air pollution is closely linked to

climate change as many of the causes of air pollution such as combustion
of fossil fuels are also sources of high carbon dioxide emissions. Some
air pollutants such as ozone and black carbon contribute both to ill
health and climate change. Policies to reduce air pollution, therefore,

227
benefit both climate and health.

Road map to reduce air pollution

Interventions and policies for tackling air pollution issues exist and
have been proven to be effective (1-4, 15, 16 ). In 2016, , in the
WHO resolution WHA68.8, Member States agreed on a road map
for “an enhanced global response to the adverse health effects of air
pollution” (9). This road map presents priority areas for responding
to the adverse effects of air pollution so that decision-makers could
choose and implement the most efficient and feasible policies. They
include:

• Expanding the knowledge base about impacts of air pollution

on health;

• Monitoring and reporting on the air pollution-related targets

of the Sustainable Development Goals;

• Leveraging the health sector to raise awareness of health

benefits from air pollution reduction measures; 

• Enhancing the health sector’s capacity to work with other

sectors to address air pollution through training, guidelines
and national action plans.

The health sector in Sri Lanka has an important role to play in leading
and coordinating these and other activities aimed at tackling the
health impact of air pollution, climate change and other environmental
issues.

Initiatives to reduce environment pollution in Sri

Lanka
Sri Lanka Government has taken certain steps to tackle climate change
and pollution of the environment including air pollution. A National
Climate Change Adaptation Plan for 2016 – 2025 has been developed

228
in line with the guidelines set forth by the United Nations Framework
Convention on Climate Change. If implemented as planned, it will
be a major step forward in minimizing impacts of climate change on
human life, ecosystems and the economy. This comprehensive plan
also offers many opportunities to implement policy actions to tackle
ambient air pollution ( 34 ).

A comprehensive analysis has been carried out to identify Energy Mix

and Fuel Diversification Policies to mitigate air pollution and climate
change. ( 30-32). Plans are underway to expand the contribution of
renewable energy power generation, so that by 2025, there will be a
share of more than 40% from renewable energy power plants. The rate
of carbon dioxide emission is also expected to diminish in the future
due to the introduction of more efficient coal plants. National budget
2018 proposed to convert all vehicles in the country to be hybrid or
electric by 2040, and all Government vehicles to be converted to hybrid
or electric vehicles by 2025. Tax on electric cars has been reduced.
Incentives have been provided to encourage the use of off-grid solar
power and in establishing electric car charging stations.

In addition, to reduce the health hazards posed by excessive use

of agrochemicals,  pesticides, and weedicides in agriculture, the
Government launched the Toxin Free Nation Initiative, in 2015. This
initiative has special relevance for regions of Sri Lanka ravaged by
chronic kidney disease of uncertain origin. The aim of the initiative is
to encourage organic farms and responsible agricultural practices.  In
addition, the Central Environment Authority is taking steps to mitigate
the degradation of the environment through an array of approaches;
establishment of new compost sites, bio gas plants, sanitary landfills,
plastic recycling centres, plastic/polythene waste storage centres
etc. (35). Sri Lanka became the 60th country to ratify the Minamata
Convention on Mercury in 2017. Actions have been taken to phase
out mercury containing instruments in the health sector, education
sector and the jewelry industry. In 2017, Sri Lanka banned the use
of polythene products including oxo-biodegradable plastic and poly-
styrene, in order to protect the marine environment. The Government
of Sri Lanka is also in the process of ratifying the Kigali Amendment of

229
the Montreal Protocol, to phase down the production and consumption
of hydrofluorocarbons  which are potential global warming substances.
These activities and initiatives need to be scaled up to mitigate
environment pollution and its serious adverse impact on health.

Conclusions and future perspectives

A broad range of strategies need to be applied for minimizing exposures
and mitigating adverse health effects of environment pollution
including air pollution. Government should endeavor to adequately
resource the Environmental Protection Agency whose mandate is
to reduce environmental pollution. The Agency should lead the
implementation of WHO recommendations to reduce environmental
pollution including air pollution, engaging all other stakeholders.

Air pollution - both ambient and indoor - is a major contributor to the

NCD burden in Sri Lanka. Generating baseline data related to indoor
and outdoor air pollutants and human health is vital. Data provide
the basis for advocacy, for formulating mitigation strategies and for
enforcing existing laws. The lack of a proper air quality monitoring
system to track human exposure is a major limitation. Therefore,
establishing a reliable ambient air quality monitoring network, at least
covering the main busy cities in the country, is a priority need.

Although several activities have been implemented to reduce outdoor

air pollution, there are no specific interventions implemented at
national level to reduce indoor air pollution. This gap needs to be
rectified urgently particularly because those most affected by indoor
air pollution are the poor and vulnerable segments of the population.

230
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PART III

235
236
CHAPTER 13

Other cost effective

NCD interventions and
key partnerships
Key messages

• In the national NCD program, implementation of all very

cost effective NCD interventions (16 WHO best buys) need
to be prioritized, adequately resourced and monitored.

• In addition to the best buys discussed in previous chapters,

vaccination against human papillomavirus of girls aged 9
to 13 years and prevention of cervical cancer by screening
women aged 30 to 49 years are best buy interventions.

• Not all individual interventions implemented through the

health system are cost effective and affordable at the current
level of health care spending in Sri Lanka.

• To reduce premature NCD mortality, cost effective

interventions (WHO good buys) listed in this chapter, to
address cardiovascular disease, cancer, diabetes, chronic
respiratory disease and chronic kidney disease, need to be
implemented through a primary health care approach.

• Elimination of trans fat from the food supply is a cost

effective intervention to reduce cardiovascular morbidity
and mortality.

237
• Results oriented partnerships, which contribute to public
health approaches to prevent and control NCDs, are vital for
the success of the National NCD Program.

Implementation of other cost effective NCD

interventions
Implementation of population based interventions and very cost
effective individual interventions (best buys), to address major NCDs,
were discussed in Chapters 2 to 13. In National NCD programs,
implementation of all 16 best buys need to be prioritized, adequately
resourced for country-wide implementation and closely monitored. In
addition, there are other cost effective individual NCD interventions
(good buys) (1-5), which also reduce NCD morbidity and mortality.
Implementation of an affordable combination of best buys and
good buys is a sustainable and pragmatic approach to reduce NCD
morbidity and mortality. In Sri Lanka, these good buys are delivered
mainly through a well organized health care system and address the
following:

• Cancer
• Heart disease
• Stroke
• Diabetes
• Chronic respiratory disease,
• Kidney disease

Not all individual interventions implemented through the health

system in Sri Lanka are cost effective and affordable at the current level
of health care spending. This chapter focuses only on cost effective
NCD interventions not discussed in the previous chapters, including
elimination of trans fat.

As discussed in Chapters 2 and 3, health care in Sri Lanka is delivered

through government and private providers under the stewardship of
the Ministry of Health. The Ministry of Health formulates public health

238
policy and regulates services of both public and private health sectors.
In the public sector, there is a total of 1104 health facilities including
primary medical care units and hospitals delivering curative care (6).
Only outdoor NCD services are available in primary medical care
units. Inpatient care is delivered in hospitals. Non- specialist care is
delivered through Divisional Hospitals and Primary Medical Care units.
Specialized care is provided through Base, District General, Provincial
General and Teaching Hospitals and some selected specialized
hospitals.

National cancer control program

National Cancer Control Programme (NCCP) was established in
1980 as a decentralized unit of the Ministry of Health. The National
Policy and Strategic Framework on Cancer Prevention and Control in
Sri Lanka was launched in 2015. The activities of the NCCP include
surveillance, primary prevention, early detection, diagnosis, treatment,
rehabilitation and palliative care of cancer.

Surveillance
Since 1985, national cancer incidence data are published based on
the hospital based national cancer registry, maintained by the National
Cancer Control Programme. Population based cancer registry for
the Colombo District was established in 2012. For this registry, data
are collected from the Apeksha Hospital, Maharagama and other
government hospitals, oral-maxillo facial units, pathology laboratories
and Death Registrars in the district. In 2018, a collaborative research
agreement was signed between the Ministry of Health, Nutrition and
Indigenous Medicine and the International Agency for Research on
Cancer, for further development of population based cancer registries
in Sri Lanka.

239
Prevention and early detection of cervical cancer
and breast cancer
There are 2 very cost effective interventions (best buys) for prevention
and control of cancer.

i) Vaccination against human papillomavirus (2 doses) of girls

aged 9 to 13 years.

ii) Prevention of cervical cancer by screening women aged 30 to

49 years, through: visual inspection with acetic acid linked with
timely treatment of pre-cancerous lesions; pap smear (cervical
cytology) every 3–5 years, linked with timely treatment of pre-
cancerous lesions; human papillomavirus test every 5 years,
linked with timely treatment of precancerous lesions.

In Sri Lanka, public awareness and knowledge of the importance of

prevention and early detection of cancer is enhanced through mass
media campaigns and mobile exhibition units set up at the district
level. self-examination mannequins have been made available in
public health institutions. Guidelines on screening and early detection
of prevalent cancers are available for healthcare staff. Cancer control
activities are implemented by several stakeholders. The Family Health
Bureau through the Well Woman Clinic programme, takes the lead
role in screening of cervical cancer by Pap smear and clinical breast
examination for early detection of breast cancer. The Epidemiology
Unit implements the National Immunization Programme for prevention
of liver cancer (Hepatitis B vaccination) and cervical cancer (Human
Papilloma Virus vaccination). These are very cost effective NCD
interventions (best buys). Hepatitis B and HPV vaccines were introduced
into the national immunization schedule in 2003 and 2017 respectively.
The number of Well Woman Clinics have increased from 611 in 2007
to 980 in 2015. The coverage of cervical cancer screening of the age
35 cohort has increased from 23% in 2010 to 45% in 2015. Since 2017,
the cohort of 45 year old females is also included in cervical cancer
screening.

With financial support from the Rotary Club Colombo, the National

240
Cancer Control Programme conducts a cancer screening and early
detection centre at Narahenpita. Facilities for cervical examination,
Pap smear, colposcopy, mammography and oral cavity examination
are available at this centre. In 2017 HPV DNA testing of cervical smears
was commenced on a pilot basis. If it is found to be cost effective and
sustainable, HPV DNA testing of cervical smear will be integrated into
the algorithm of cervical cancer screening. Hepatitis B vaccination is
administered as a component of the pentavalent vaccine. In 2015, the
coverage of pentavalent vaccine –third dose- ranged from 93.1% in
Colombo to 98.9% in nine districts.

Diagnosis, treatment and palliative care

Cancer treatment units have been established in all provinces;
the Apeksha Hospital in Colombo, Teaching Hospitals in Kandy,
Karapitiya, Batticaloa and Anuradhapura, Provincial General Hospitals
in Kurunegala, Badulla and Rathnapura and Base Hospital in Thellipilai.
Over the past two years additional cancer treatment units have been
established at Teaching Hospital, Colombo North and 10 District
General Hospitals. Cancer treatment units provide chemotherapy
facilities. Radiotherapy facilities are available in 6 centres at provincial
level. Mammography facilities are available in 14 hospitals. All cancer
patients are provided oncology medicines free of charge.

A National Steering Committee on Palliative Care Services has been

established under the chairmanship of Director General of Health
Services. The National Strategic Framework on Palliative Care
Development in Sri Lanka will be launched in 2018.

Cardiovascular disease; heart disease and stroke

The following cost effective interventions are delivered at primary,
secondary and tertiary levels of the health system to address heart
disease and stroke:

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• Early detection and treatment of people at medium to
high cardiovascular risk including those with pre-existing
cardiovascular disease and diabetes to prevent heart attacks
and strokes (WHO best buy ) (see Chapters 8, 9 and 10);

• Treatment of acute myocardial infarction with drugs and

thrombolysis;

• Treatment of acute myocardial infarction in hospitals with

follow up carried out through primary health care facilities;

• Cardiac rehabilitation- post myocardial infarction;

• Anticoagulation for medium-and high-risk non-valvular atrial

fibrillation and for mitral stenosis with atrial fibrillation;

• Treatment of congestive cardiac failure with angiotensin

converting-enzyme inhibitor, beta-blocker and diuretic;

• Primary and secondary prevention of rheumatic fever and

rheumatic heart diseases;

• Treatment of acute ischemic stroke with intravenous

thrombolytic therapy;

• Low-dose acetylsalicylic acid for ischemic stroke;

• Care of acute stroke and rehabilitation in stroke units.

Thrombolytic therapy for acute myocardial infarction is available

in hospitals at the district level. A recent study at the district level,
has reported that the proportion of patients that achieve guideline
recommended Door to Needle Time of 30 minutes and an optimal
ischemic time of 2 hours is low (30%) (7).

Only about 11 tertiary care hospitals in the island offer thrombolytic

therapy for stroke. Analysis of data in the Sri Lanka Stroke (Clinical)
Registry collected from 5 tertiary care hospitals over 6 months, show
that 20% of stroke admissions are haemorrhagic. Only about 16% of
stroke patients arrive in hospital within 3 hours of onset. Almost all
(99.7%) stroke patients have a CT scan of brain at some stage. Only

242
3% of ischemic stroke patients receive thrombolytic therapy with a
mean door to needle time ranging from 78 – 160 minutes (mean 105
minutes) (8). So far, stroke units have been established only in about 7
tertiary care hospitals. National Stroke Centre at Mulleriyawa is being
developed into a comprehensive stroke care hospital which would
model stroke care for the rest of the Island. Plans are also afoot to
establish stroke units in all major cities.

For stroke rehabilitation to succeed, scaling up of the current level

of allied health professionals is necessary. In 2015, there were only
1.7 physio therapists, 0.5 occupational therapists and 0.1 speech
therapists per 100, 000 population (6). In addition, stronger ties need
to be forged between health care institutions providing acute stroke
care and the Ministry of Social Empowerment and Social Services
which is responsible for community based rehabilitation.

Diabetes
Cost effectives interventions delivered for the care of diabetes include
the following:

• Early detection and effective control of cardiovascular risk and

glycemia to prevent heart attacks, strokes and renal disease
(WHO best buy) (see Chapters 9 and 10 );

• Preventive foot care for people with diabetes;

• Diabetic retinopathy screening and laser photocoagulation for

prevention of blindness;

• Preconception care among women of reproductive age who

have diabetes including patient education and intensive
glucose management.

Diabetic foot screening and risk stratification is carried out at all health
care levels and preventive foot wear is provided at the tertiary care
level. Early detection of diabetic retinopathy, is done at all health
care levels by medical officers trained in ophthalmoscopy. Patients

243
are referred to secondary and tertiary care centres for confirmation of
retinopathy. Photocoagulation is available only in a few tertiary care
hospitals.

Preconception care includes detection and management of

hyperglycaemia, and other metabolic and weight abnormalities prior
to conception. Preconception care components for adolescent girls
are included in the school health programs. Screening of women who
are planning pregnancy and universal screening of pregnant mothers
for diabetes is carried out at the primary care setting.

Asthma and chronic obstructive pulmonary

disease
Cost effective individual interventions delivered for chronic respiratory
disease at all levels of care include the following:

• Symptom relief for patients with asthma and COPD with

inhaled salbutamol;

• Treatment of asthma using low dose inhaled beclomethasone

and short acting beta agonists.

Chronic kidney disease

The commonest causes of chronic kidney disease worldwide as well
as in Sri Lanka are diabetes and hypertension (9). A type of kidney
disease which cannot be attributed to diabetes, hypertension or other
known aetiologies, has emerged in Sri Lanka and in other developing
countries such as El Salvador, Nicaragua, Costa Rica, Mexico, Egypt
and India during the last two decades. It is referred to as Chronic Kidney
Disease of Uncertain aetiology (CKDu). Wherever CKDu occurs, many
key causative elements appear to be playing a part; deep-rooted
poverty combined with exposure to environment and occupational
toxins, lack of safe drinking water, poor nutrition and harsh living and
working conditions. Chronic Kidney Disease of Uncertain aetiology is

244
often diagnosed late, when kidney damage already requires dialysis.
Research results indicate that chronic exposure of people to pesticides
and nephrotoxic heavy metals through the food chain play an important
role in its aetiology (10, 11, 12). Ministry of Health in collaboration
with several other Ministries are taking steps to improve the water
supply to the areas affected, regulate the use of pesticide as well as
fertilizer and improve surveillance, early detection, treatment and
dialysis facilities of people with Chronic Kidney Disease of Uncertain
aetiology. Prevention is the only affordable and sustainable solution
for this disease.

Management of NCD emergencies

Large city hospitals have preliminary care units, with variable services
and facilities to cater to medical emergencies. Almost all district level
hospitals have emergency treatment units. Usually these are small
rooms with one to two beds, resuscitation equipment and basic
facilities; electrocardiograph, nebulizer and glucometer. Currently,
there are no specialist grade emergency medicine physicians. The
emergency telephone number for emergency medical services,
reserved by the Telecommunications Regulatory Commission, is
1-1-0. Although it can be accessed through any land or mobile phone,
it is not widely used, due to lack of public awareness and technical
issues. For example, some emergency medical service systems can
only respond to calls within a 5-km radius from their center. There
are ambulances, for transferring patients between hospitals but there
is no organized ambulance service with centralized communication
which responds to emergency calls from the public. There are a few
private ambulance services in the main cities that levy a fee for their
service. Usually patients are transported to the hospital via taxies or
private cars. Usually, volunteer community responders are responsible
for prehospital care.

In Sri Lanka, the largest share of morbidity and premature mortality

is due to cardiovascular disease. Thus, special attention need to
be focused on prevention as well as emergency care of myocardial

245
infarction and stroke. Strategies to reduce door to needle time
including establishment of Emergency Care Units, training of the health
workforce and better public awareness are required to strengthen
thrombolytic therapy for acute myocardial infarction and stroke.

Timely management of acute myocardial infarction, stroke, acute asthma

and diabetic emergencies can contribute to reduction of premature
NCD mortality. However, establishment of an island-wide emergency
service requires resources which should not be appropriated from the
already inadequate budget allocated to population- wide prevention
and primary care. Additional resources need to be mobilized to
strengthen emergency services in Sri Lanka.

Eliminating trans fatty acids from the food supply

WHO estimates that every year,  trans  fat  intake leads to  more than
500,000 deaths of people from cardiovascular disease.  Consumption
of trans fats raise harmful low-density lipoprotein cholesterol and
decrease protective high-density lipoprotein cholesterol. Eliminating
trans fats is key to safeguarding cardiovascular health and saving lives.

Industrially-produced  trans  fats  are contained in hardened

vegetable fats, such as margarine and ghee. They are often present
in snack food, baked foods, and fried foods. Manufacturers prefer to
use them as they have a longer shelf life than other fats. Various policy
actions (including labelling, reformulation, and regulation) have been
implemented by countries to restrict the trans fat content of food.

WHO recommends six strategic actions to reduce/eliminate industrially

produces trans fats from the food supply.

i. Review dietary sources of industrially-produced trans fats and

the landscape for required policy change;

ii.
Promote  the replacement of industrially-
produced trans fats with healthier fats and oils;

iii. Legislate or enact regulatory actions to eliminate industrially-

246
produced trans fats;

iv. Assess and monitor trans fats content in the food supply and

changes in trans-fat consumption in the population;

v. Create  awareness of the negative health impact

of trans fats among policy makers, producers, suppliers, and
the public;

vi. Enforce compliance of policies and regulations.

The 2016, Household Income Expenditure Survey in Sri Lanka reported

high monthly household consumption of food items rich in trans fats;
margarine 38.75 g, biscuits 825.61g, cake 142.49g, snacks (pastries/
patties/cutlet/wade) 8.23 pieces, per person. In Sri Lanka, local food
laboratories have no facilities to analyze trans fats. The Ministry of Health
has provided funds to the Medical Research Institute to establish this
analytical service. Plans are underway to determine the baseline levels
of trans fat in different food items, so that trans fat content in the food
supply can be regulated using the new food labelling regulations.

The role of the World Health Organization, World

Bank and other Development partners
There are 23 United Nations agencies, including WHO, that work
closely with the Government of Sri Lanka, guided by the United
Nations Sustainable Development Framework agreed upon jointly
by the United Nations and the Government. Development partners
such as the World Bank, Asian Development Bank (ADB) and Japan
International Cooperation Agency (JICA) engage and coordinate with
WHO to provide support for NCD prevention and control.

247
World Health Organization
The World Health Organization (WHO) has worked closely with the
Government of Sri Lanka to develop, implement and evaluate the
National NCD response. It has provided technical guidance, assistance
for capacity strengthening and implementation of NCD programmes
and support to health system reforms (14).

For example, in 2016, the WHO Country Office commissioned an

assessment of the impact of advertising and marketing of foods and
non-alcoholic beverages that are high in fat, sugar and salt to children.
Based on the findings, a consultation was organized engaging all
stakeholders which was instrumental in achieving a national consensus
on a policy approach to regulating the marketing of such foods and
beverages. The results of another WHO commissioned study were used
to advocate for incremental taxation on sugar sweetened beverages,
based on sugar content. WHO is also supporting the country in
developing a nutrient profiling method to categorize foods and non-
alcoholic beverages based on sugar, fat and salt content. Working with
the National Authority on Tobacco and Alcohol and others, WHO also
coordinated a study in 2017, to assess the cost implications of alcohol
and tobacco use in Sri Lanka.

Since 2002, four Country Cooperation Strategies have provided the

framework for partnership between WHO and the Ministry of Health/
Government of Sri Lanka. The strategic priorities in the WHO Country
Cooperation Strategy respond to the priorities identified within the
national health policy and plans. The fourth Country Cooperation
Strategy 2018–2023 (13), has four strategic priorities; tackling NCDs
and their determinants, strengthening the health system through a
supportive policy environment, promoting resilience in the face of
health threats and adopting a knowledge-based approach to health
policy development. These strategic priorities complement national
policies and strategies and are aligned with the 2030 Sustainable
Development Goals. WHO plays a unique role in setting norms and
standards and is particularly valued for its strengths in giving policy
advice, brokering and diplomacy.

248
The World Bank
The Second Health Sector Development Project (SHSDP) of the World
Bank, supports the implementation of the government’s National
Health Development Plan. It has an International Development
Association contribution of US$ 200 million over 5 years which
is financing many NCD activities. The project aims to upgrade the
standards of performance of the public health system and enable it to
better respond to the challenges of NCDs.

Under this project, at least 2 Healthy Life Style Centers have been
established in 97% of Medical Officer of Health areas (see Chapter 10
), for early detection of people at risk of developing heart attacks and
strokes. Functioning Emergency Treatment Units have been established
in 46% of centrally manged hospitals and 82% of the provincially
managed hospitals. In addition, to strengthen national NCD capacity,
health sectors officials including Medical Officers NCDs, working in
Preventive Health services were provided local and overseas training
exposures on different aspects of NCD prevention and management.
Support was also provided for digitisation of health data, in order to
improve monitoring of disease patterns and management of healthcare
information. These included the implementation of unique patient
identification numbers, a communication network between the Medical
Supply Division and peripheral health institutions and a web- based
Indoor Morbidity and Mortality Record system. Furthermore, quality
management units have been established for improving quality of NCD
related services in 95% of provincially managed base hospitals and
all centrally manged hospitals. These units are engaged in improving
quality of NCD services in hospitals i.e. reduced waiting time, prompt
management of NCD emergencies such as myocardial Infarction and
better patient satisfaction. Finally, several research projects related to
NCD care have also been supported under this initiative. They include,
projects on piloting of a stroke registry, prevention of blindness and
visual Impairment due to diabetes retinopathy by early screening and
monitoring the compliance of beverage and food manufacturers in
following beverage and food labelling regulations.

249
The role of Professional Associations and Colleges
Sri Lanka has a number of Professional Associations and Colleges
with a range of activities that enrich the national NCD response.
They include the Sri Lanka Medical Association, Ceylon College of
Physicians, Sri Lanka Heart Association, College of oncologists,
College of Pulmonologists, College of Endocrinologists, College of
Community Physicians, Diabetes Association of Sri Lanka, Sri Lanka
Society of Nephrologists, Sri Lanka Society of Internal Medicine,
Association of Sri Lanka Neurologists, Sri Lanka Medical Nutrition
Association, among others. They contribute technical expertise for
the development and implementation of national plans, policies and
guidelines, training programs, public education, advocacy campaigns
and research initiatives. For example, the Sri Lanka Medical Association
played an important role in the National Initiative to Reinforce and
Organize General diabetes care In Sri Lanka projects (NIROGI Lanka
and NIROGI Diviya Projects), to evaluate models to improve the quality
of diabetes care and primary prevention of diabetes and cardiovascular
risk, appropriate to the national context. This project implemented in
close collaboration with the Ministry of Health over a period of 8 years
provided useful lessons for shaping the island-wide network of Healthy
Lifestyle Centers for early detection of NCDs (see Chapter 10 ).

The work of Professional Associations and Colleges need to be further

expanded and strengthened, particularly to support monitoring and
evaluation of NCD programs and operational research. The National
NCD response can be made more effective if operational research is
embedded in NCD initiatives at the planning stage (15) and research
results are taken on board when developing NCD policies.

Conclusions and future perspectives

Due to the growing burden of NCDs and inadequate resources to keep
pace with demands, shortcomings have developed in all components
of the health system; governance and accountability, financing,
health information, service delivery, referral links, quality and access

250
to treatment. Facilities including laboratory tests for early detection
of major NCDs in primary care have to be consolidated. Enhanced
early detection and treatment of medium/high cardiovascular risk (to
prevent heart attacks and strokes), diabetes (to prevent nephropathy,
retinopathy and cardiovascular events), cancer of mouth, cervix,
breast and colon is required to reduce the need for more costly
high technology interventions such as bypass surgery, dialysis and
radiotherapy. The performance of primary care need to be improved
through policy support and strengthening of the service delivery system,
human resources and infrastructure. Computerized health information
and a system to track patients in the community can boost patient
compliance, engagement and follow-up, which are challenging issues
in NCD care. Implementation of the recently approved health care
reform policy, to attain Universal Health Coverage (16) (see Chapter 3),
is key to addressing these critical gaps in the health system, in order to
accelerate progress in prevention and control of NCDs.

Given the constraints in economic growth, it is unrealistic to expect

the Government to significantly increase health spending for NCDs
in the foreseeable future. Nevertheless, due to population ageing as
well as rising risk factors levels, the NCD burden will continue to grow
relentlessly, unless two urgent actions are taken. First, is to invest a
larger share of the current health budget to strengthen population
-wide primary prevention (see Chapters 3 to 12 ). Second is to
strengthen the delivery of individual best buys and good buys through
a primary health care approach as outlined in Chapter10 and in this
Chapter. If implemented in combination, these two approaches can
at least appreciably contain the NCD burden in the near and medium
term.

251
References
1. Scaling up action against noncommunicable diseases: how much will it
cost? Geneva: World Health Organization; 2011.(http://whqlibdoc.who.
int/ publications/2011/9789241502313_eng.pdf,
2. Global action plan for the prevention and control of noncommunicable
diseases 2013−2020. Geneva: World Health Organization; 2013.
3. Package of essential noncommunicable (WHO PEN) disease interventions
for primary health care in low-resource settings. Geneva: World Health
Organization; 2013. (http://www.who.int/nmh/publications/essential_
ncd_interventions_lr_settings.pdf,
4. Global status report on noncommunicable diseases 2010. Geneva: World
Health Organization; 2011. (http://www.who.int/nmh/publications/ncd_
report_full_en.pdf)
5. Global status report on noncommunicable diseases 2014. Geneva: World
Health Organization; 2014. (http://www.who.int/nmh/publications/ncd_
report_full_en.pdf)
6. Annual Health Bulletin 2015, Ministry of Health, Colombo, Sri Lanka
7. Ranasinghe, W.G. et al. , (2015). Treatment time and outcome of
thrombolytic therapy with streptokinase for acute ST Segment Elevation
Myocardial Infarction (STEMI) in a District General Hospital of Sri Lanka:
an audit . Journal of the Ceylon College of Physicians . 45 ( 1-2 ) , pp .
28–31.
8. Sri Lanka, Colombo 05 - Launching Sri Lanka Stroke Clinical Registry.
http://www.worldstrokecampaign.org/sri-lanka-2015/1070-sri-lanka-
colombo-05-launching-sri-lanka-stroke-clinical-registry.html
9. Couser WG1, Remuzzi G, Mendis S, Tonelli M.The contribution of chronic
kidney disease to the global burden of major noncommunicable diseases.
Kidney Int. 2011 Dec;80(12):1258-70. doi: 10.1038/ki.2011.368. Epub
2011 Oct 12.
10. Jayatilake N, Mendis S, Maheepala P, Mehta FR; CKDu National Research
Project Team. Chronic kidney disease of uncertain aetiology: prevalence
and causative factors in a developing country. BMC Nephrol. 2013 Aug
27;14:180. doi: 10.1186/1471-2369-14-180.

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11. Mendis S. Chronic kidney disease of uncertain aetiology ; policy
perspectives Law and Society Trust Review 2015; Volume 25, Issue 332
;1-9.
12. Nanayakkara S, Komiya T, Ratnatunga N, Senevirathna ST, Harada KH,
Hitomi T, Gobe G, Muso E, Abeysekera T, Koizumi A. Tubulointerstitial
damage as the major pathological lesion in endemic chronic kidney
disease among farmers in North Central Province of Sri Lanka. Environ
Health Prev Med. 2012 May;17(3):213-21. doi: 10.1007/s12199-011-
0243-9. Epub 2011 Oct 13.
13. World Health Organization. WHO Country Cooperation Strategy Sri
Lanka 2018-2023. WHO 2018.
14. World Health Organization. WHO Sri Lanka Annual Report 2017; Making
a difference. WHO 2018.
15. Mendis S, Research Is Essential for Attainment of NCD Targets and
Sustainable Development Goals. Glob Heart. 2016 Mar;11(1):139-40.
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Indigenous Medicine. Colombo, Sri Lanka 2018.

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254
CHAPTER 14

Journey to tackle NCDs

in Sri Lanka: Lessons
learned
Several recent global documents have addressed different aspects
of prevention and control of NCDs (1-3). This document does not
intend to address every aspect of prevention and control of NCDs. It is
intended to look back and reflect on the challenges and achievements
of tackling NCDs in a developing country -Sri Lanka- in order to learn,
distill useful lessons and share with others. Chapters 1 and 2, present the
context in which Sri Lanka is endeavoring to address NCDs. Chapters
3 to 13, document how Sri Lanka has launched and taken forward the
national NCD response, giving priority to national NCD targets and
the Sustainable Development Agenda. What has Sri Lanka learned?
Are there lessons which countries of the same level of development
can make use of, in their journey to combat NCDs? This final chapter
focuses on lessons learned.

Tackling NCDs in a complex health landscape

During the last two decades, the architecture of global and national
health landscapes has changed dramatically. In order to address
NCDs, Sri Lanka has navigated this complex landscape, successfully.
At the global level, there has been a rapid proliferation of global
health partnerships focusing on single disease entities, changing the
face of public health and international aid. During this period, major
challenges such as a global financial crisis, outbreaks of communicable
diseases and natural and humanitarian disasters have threatened

255
the progress of global health and development. Sri Lanka also had
to face a devastating tsunami in and its aftermath in 2004, and the
wide ranging adverse consequences of a protracted armed conflict
from 1983 to 2009. In addition, during this period, there has been a
constant tension in allocating resources to address NCDs, because
of competing health priorities such as communicable diseases, and
maternal and child health. Despite all these challenges, in the year
2000, political leaders of Sri Lanka made a bold and wise decision to
tackle NCDs head-on. Two decades on, while daunting challenges still
remain, the progress made in tackling NCDs in the country has been
commendable.

Progress in NCD prevention and control

WHO NCD progress monitor, assesses country progress made in NCD
prevention and control, using 19 progress indicators (4). As shown
in Figure 14.1, Sri Lanka has made significant progress in certain key
aspects of NCD prevention and control.

256
Figure 14.1 Sri Lanka – performance against 19 NCD process indicators
(Source :World Health Organization, NCD Progress Monitor 2017)

Out of the ten priority NCD areas discussed in Chapters 3 to 13,

significant progress has been made in tobacco control (Target 5- Chapter
7), early detection and treatment of people with high cardiovascular risk
(Target 8- Chapter 10) and access to medicines (Target 9- Chapter 11).
However, even in these areas, progress is uneven across the country and

257
more human and financial resources are needed to reach the stipulated
targets by 2025 (5). In other areas- reducing harmful use of alcohol
(Target 2- Chapter 4), reducing physical inactivity (Target 3 – Chapter
5) and salt intake (Traget 4- Chapter 6), halting obesity and diabetes
(Target 7-Chapter 9), reducing the prevalence of hypertension –(Target
6 -Chapter8) and reducing indoor air pollution (Target 10-Chapter 12),
work is in progress, but need to be accelerated. The litmus test for
success of prevention and control of NCDs will be the attainment of
the overarching NCD Target 1- (Chapter 3), reduction of premature
mortality. The Sustainable Development Goal 3 target is to, reduce
by one third premature mortality from NCDs by 2030. Attainmet of
this target is not only important for health but it is also critical for the
overall social and economic development of Sri Lanka (6, 7 ).

Lessons learned in prevention and control of

NCDs
Lesson 1. The national NCD response can be fortified by
leveraging global health strategies and treaties.
Sri Lanka has been an early adopter of global public health strategies
and treaties. It has effectively leveraged Global Health Strategies and
Treaties to shape and fortify the national NCD response.

A public health approach to address NCDs was first proposed by

the World Health Organization in the Global Strategy for Prevention
and Control of Noncommunicable diseases. The strategy was
adopted by WHO Member States, including Sri Lanka, at the World
Health Assembly in 2000 (8). It identifies surveillance of risk factors,
prevention and disease management as the key components of NCD
prevention and control. The focus of the strategy is on the four major
NCDs- cardiovascular disease, cancer, chronic respiratory disease
and diabetes- which share behavioural and environmental risk factors
(tobacco use, harmful use of alcohol, unhealthy diet, physical inactivity
and air pollution). At the outset, Sri Lanka embraced the public health
approach presented in WHOs Global Strategy for Prevention and

258
Control of NCDs (8).

Since the adoption of the Global NCD Strategy in 2000, several World
Health Assembly resolutions have been endorsed in support of the key
components of the global strategy. They include the WHO Framework
Convention on Tobacco Control (WHO FCTC) (resolution WHA56.1),
the first global public health treaty (9). Sri Lanka was the first country in
Asia to ratify the Framework Convention on Tobacco Control in 2003,
and the fourth globally (see Chapter 7).

In September 2011, at a United Nations high-level meeting on NCDs,

heads of state and government formally recognized NCDs as a major
threat to economies and societies and placed them high on the
development agenda. ( 7). In order to translate these commitments
into action, in May 2013 the Sixty-sixth World Health Assembly
adopted the Global action plan for the Prevention and Control of
Noncommunicable diseases 2013−2020 (10). Sri Lanka has developed
a National Multisectoral Action Plan for the prevention and control of
NCDs 2016-2020, consistent with the Global NCD Action Plan. The
national NCD targets of Sri Lanka are also consistent with the Global
NCD targets. They help to focus available resources and action, on
achieving a defined impact in key areas of NCD prevention and control
(11). Sri Lanka is now in the process of integrating the national NCD
response within the ambitious Sustainable Development Agenda 2030,
adopted by countries at the United Nations in 2015 ( 10). Alignment of
the national NCD response with global NCD strategies and treaties,
over the last two decades, has contributed to the success of NCD
activities in Sri Lanka.

Lesson 2: Key ingredients which have been responsible

for the success of other public health programs are
equally important for effective NCD prevention and
control.
Advancing the NCD agenda in Sri Lanka from 2000 onwards, was carried
out amidst challenges posed by other competing health priorities such

259
as maternal and child health and communicable diseases. Sri Lanka
has been successful in reducing the maternal mortality ratio from
almost 2000 deaths per 100 000 live births in the 1930s to 33 deaths
per 100 000 live births in 2015. At present, there is comprehensive,
island-wide access to maternal and child health care. The number of
skilled practitioners attending to births have increased from 30% of
births in 1940, to 99.9 % of births in 2015. (12). Impressive progress
has also been made in the control of communicable diseases such as
polio, leprosy, tuberculosis, filariasis and malaria. Malaria for example,
caused death and devastation in Sri Lanka for hundreds of years. After
a prolonged public health campaign, the country has now reduced the
number of indigenous malaria cases to zero (13).

These public health initiatives have identified certain key elements

that form the backbone of public health programs and ensure their
success. They include :

i. Improvements in living standards, education and gender

equity;

ii Sustainable funding;

iii. Equitable access to health services;

iv. Commitment to technical excellence;

v. Investment in capacity strengthening of the health workforce;

vi. Focus on high-risk population segments to improve cost

effectiveness;

vii. Early detection, diagnosis and affordable treatment;

viii. Intensive surveillance, monitoring and evaluation;

ix. Community engagement and partnerships;

x. Learning from operational research.

The experience in tackling NCDs in Sri Lanka shows that the very same
drivers and ingredients listed above, are also fundamental for winning
the fight against NCDs.

260
Lesson 3: Prioritization is the pragmatic option for
addressing NCDs in resource constrained settings
Sri Lanka, like many other developing countries have very limited
resources for health. Health services are provided free at the point
of delivery and no one is left behind. However, the rising demands
of the NCD burden is gradually outstripping the resources available
for health. Sri Lanka therefore prioritized action on four national NCD
targets; target 1 (reducing premature mortality), target 5 (tobacco
control), target 8 (prevention of heart attacks and strokes through
a total risk approach and target 9 (access to medicines). Very cost
effective interventions (WHO best buys), related to these areas have
been implemented (see Chapters 3, 7, 10 and 11). Now that there
is demonstrable progress related to these targets, NCD activities are
being rapidly expanded to encompass other targets (see Chapters 4-
6, 8, 9).

Lesson 4: An intervention which is very cost effective is

affordable to the country and is therefore scalable and
sustainable.
Although there are many interventions for management of NCDs, only
two are very cost effective. One of them is prevention of heart attacks
and strokes through a total cardiovascular risk approach.

Sri Lanka has a fast ageing population with rising prevalence rates of
both hypertension and diabetes and heart attacks and strokes are the
leading NCDs. Taking cognizance of the urgent need to prevent heart
attacks and strokes, Sri Lanka embraced the very cost effective total
risk approach, which uses both hypertension and diabetes together as
entry points to detect those at high cardiovascular risk (WHO best buy)
(14-16). As discussed in Chapters 8 and 10, vertical single risk factor
programs, such as a program focusing only on hypertension cannot be
equitably delivered or sustained in a developing country like Sri Lanka,
because the country has a modest per capita health expenditure. The
recently approved government policy to reform Health Care Delivery

261
to attain Universal Health Coverage, will enable the expansion of this
program island-wide by including this very cost effective intervention
in the essential health services package (17).

Lesson 5: Public–private undertakings to address NCDs

are more likely to succeed when governments establish
legislative frameworks to protect public health.
Engaging with the private sector is necessary for addressing NCDs
because the private sector is an important driver of the NCD burden.
In recognition of this fact, the 2011 United Nations High-Level Political
Declaration on NCDs  called on the private sector to take action in areas
such as reformulating unhealthy food products, promoting healthy
workplaces and improving affordability and access to medicines
(7). In order to reduce the sugar content in sweetened beverages
in Sri Lanka, the Ministry of Health engaged with the private sector
and jointly developed a technical guideline. The expectation of the
Ministry of Health was that beverage manufacturers would comply
with the guideline voluntarily, as they were closely involved in the
guideline development process. However, this did not materialize.
In the face of resistance from manufacturers, in order to accomplish
the task of reducing the sugar content of sweetened beverages, the
Ministry of Health had to resort to legislation (see Chapter 9). Beverage
manufacturers complied with the guideline only when a binding law
was introduced.

Lesson 6: NCD prevention in children can be effectively

operationalized through schools.
Sri Lanka has successfully used the machinery of a well-oiled School
Health Service to operationalize NCD prevention in children. Sri
Lanka has approximately 4.2 million school children enrolled in about
10, 144 public schools (12). School Health Services including health
promotion are delivered through this education infrastructure and the

262
primary health care network. The programme is a shared responsibility
of the Ministry of Health and Ministry of Education and is a good
example of collaboration between two Ministries to achieve a shared
national goal – physical and mental health and wellbeing of children.
The Family Health Bureau and the Health Promotion Bureau lead the
School Health Programme in close collaboration with Provincial Health
and Educational ministries. At the regional level, the Medical Officer
of Maternal and Child Health is the chief coordinating officer of the
programme.

Lesson 7: Collaboration between the health sector and

sectors outside health can be facilitated and accelerated
by a lead agency.
Multisectoral collaboration is essential for NCD prevention and control
but is one of the most difficult endeavors. The progress made on
tobacco control in Sri Lanka demonstrate that a lead agency working
closely with the Ministry of Health, can galvanize multisectoral action
by actively seeking opportunities to collaborate with and influence
sectors outside health. In Sri Lanka, The National Authority on Tobacco
and Alcohol (NATA) was established by the National Authority
on Tobacco and Alcohol Act, No. 27 of 2006, for the purpose of
enactment of the legal aspects for alcohol and tobacco prevention.
The National Authority on Tobacco and Alcohol has been successful in
working across sectors for implementing tobacco control measures. In
recognition of the outstanding achievements in tobacco control, it was
conferred with the prestigious WHO South-East Asia Region’s “World
No Tobacco Day Award” on 31 May 2017 (see Chapter 7).

Lesson 8: High level political commitment is essential for

NCD prevention and control.
High level political commitment is one of the essential ingredients of
success in NCD prevention and control. Lack of cooperation of the

263
private sector, sometimes amounting to interference has often stalled
the development and implementation of measures to address tobacco,
alcohol and unhealthy diet in Sri Lanka. In the case of the tobacco
industry, it continues to undermine national efforts to prevent tobacco
use. In the recent past, the Ceylon Tobacco Company took legal action
against the Government of Sri Lanka to thwart tobacco control measures,
on several occasions. Although the Ceylon Tobacco Company is rich
and powerful with a reported gross turnover higher than the Gross
Domestic Product of Sri Lanka, it failed to stop the implementation of
tobacco control measures (18). Steadfast commitment of Ministers of
Health over the years and civil society support were instrumental in
overpowering tobacco industry interference (see Chapter 7).

The strong commitment of the present Minister of Health, Dr Rajitha

Senaratne, to tackling NCDs has been instrumental in accelerating
progress of NCD prevention and control, in the recent past. As a result
of his leadership, the prices of a range of essential NCD medicines
have been reduced and they have become more affordable to people
(see Chapter 11). This is an important development because in Sri
Lanka, 50% of people purchase medicines out of pocket and price is a
key determinant of access to medicines. In addition, Sri Lanka has also
been able to withstand pressure from the food and beverage industry
and introduce traffic light labelling on sweetened beverages and a
sugar tax (see Chapter 9).

Key considerations in moving forward

Moving into the future, there are several system weaknesses which
need to be urgently rectified to ensure smooth progress in NCD
prevention and control in Sri Lanka. They include :

• Establishing clear mechanisms for policy coordination and

system oversight;

• Reforming the governance framework to provide clarity at the

policy level in the demarcation of authority, responsibilities
and functions at Central, Provincial and District levels of

264
government;

• Expanding human capital across a wide array of disciplines -

e.g. health economics, public health law, environmental health
- for tackling the complexities of prevention and control of
NCDs;

• Mainstreaming NCDs into policy planning in other sectors

including through shared budgets and joint action plans;

• Improving the accuracy of the death registration system;

• Improving quality of data related to all 10 NCD targets in order

to better monitor progress and evaluate change;

• Ensuring the uninterrupted availability of resources to scale-

up existing NCD policies and best buy interventions to attain
the 10 NCD targets.

Conclusions and future perspectives

Sri Lanka has laid a good foundation to tackle NCDs, in the form of
a national NCD policy and plan, underpinned by 10 national NCD
targets (8). The cost for implementation of the National Action Plan
2016-2020 has been estimated to be LKR 9.3 billion ( 19 ). This cost
estimate is only for the Implementation of those activities which fall
under the responsibility of Ministry of Health, Nutrition and Indigenous
Medicine. Impressive public health gains in other areas of health such
as communicable diseases and maternal and child health, provides a
wide window of opportunity for Sri Lanka to further accelerate progress
in prevention and control of NCDs. Nevertheless, it is important to
recognize that this would not translate into an influx of significant
amounts of human and financial resources for combatting NCDs.
Resources will still be necessary to continue to prevent emergence
and re-emergence of communicable diseases. Similarly, resources will
not be unencumbered from maternal and child health services. These
services, will have to continue to improve further to address new
challenges in reproductive, maternal, newborn, child and adolescent

265
health. Thus, in this resource constrained environment, staying the
course on very cost effective NCD interventions (WHO best buys)
related to 10 NCD targets and good buys (see Chapter 13), would be
critical for success. Initial response has focused on selected national
NCD targets. Sri Lanka now needs to go beyond the initial response
and scale- up all WHO best buys with the aim of attaining all 10
national NCD prevention and control targets. The medium- term focus
should be to reduce premature mortality from NCDs to minimize the
negative economic and development impact of NCDs. Accelerated
reform of the health system, particularly primary care, as envisioned in
the recently approved Government policy on health care delivery for
Universal Health Coverage would be essential for moving the national
NCD response forward.

Sustainable Development Agenda for 2030 provides a new and timely

opportunity, to reinvigorate partnerships and fast-track the national
NCD response on a multisectoral platform. The newly drafted National
Performance Framework for the health sector, is expected to track
the results of health sector investments while monitoring Sri Lanka’s
achievements in Sustainable Development Goal 3 targets.

In the next two decades, population ageing will have a major impact
on NCD prevention and control in Sri Lanka. If interventions to
prevent and control NCDs are implemented effectively, the mortality
associated with NCDs at any given age will decrease and contribute to
improvement in life expectancy. However, with time this improvement
will be outweighed by the increasing numbers of people in the high
age bands with NCDs, creating a greater overall NCD burden in the
population. Health systems therefore need to be aligned not only to
address the needs of NCDS but also the needs of older populations.

Tackling NCDs in a developing country, under the pressures of

demographic ageing, rapid urbanization, and the globalized marketing
of unhealthy products is a daunting task. Sri Lanka has most of the
key ingredients - steadfast political leadership, strong public health
foundation, dedicated health workforce and a robust civil society-

266
required to accomplish this formidable task.

References
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World Health Organization; 2014.
2. Highlights from the WHO Global Conference on NCDs: Enhancing
policy coherence to prevent and control noncommunicable diseases
18–20 October 2017, Montevideo, Uruguay Meeting Report. Geneva.
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3. Report of the WHO Independent High-level Commission on NCDs.
Geneva: World Health Organization; 2018.
4. Noncommunicable Diseases Progress Monitor. Geneva: World Health
Organization ; 2017.
5. United Nations General Assembly. A/RES/68/300. Outcome document
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11. National multisectoral action plan for the prevention and control
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17. Policy on Health Care Delivery for Universal Health Coverage 2018.
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268
Annex 1

Drug Free Sri Lanka

Anti-Narcotic National Policy

And Action Plan of

President Maithripala Sirisena

A country free of Intoxicants

Introduction

Drug addiction is a serious problem our country has been facing over
the past several decades. The surveys undertaken have revealed that 1/3
of earnings of low income families in Sri Lanka are spent on alcohol and
cigarettes while more than 22% of the government expenditure of health
is incurred on treatment for patients who have been victims of alcohol and
cigarette smoking.

When it was confirmed that use of drugs including consumption of alcohol and
tobacco products has a direct impact on a country’s development resulting
in the disruption of developmental activities, the developed countries have
been adopting various measures to minimize the harm caused by the use
of drugs and to prevent youth from being addicted to drugs. However,
the failure on the part of the developing countries in their attempts made
in this direction is attributable to the influence being exerted directly by
Tobacco and Alcohol Industry. Those involved in this industry do everything
possible to entice persons from every section of the community including
businessmen, politicians, policy makers, artists and writers. In doing so they
indulge a completely false propaganda in order to market their products and
people are thus being bought over by them for the purpose.

The National Authority on Tobacco and Alcohol Act passed by Parliament in

2006 is indeed a great achievement of our country. The Gazette Notification for

269
inclusion of pictorial warnings in cigarettes packets could not be implemented
for 02 years even after this gazette was published, in compliance with the
aforesaid Act and also in terms of the International Convention signed by
our country in 2006. However, a law was enacted by the government of His
Excellency the President Maithripala Sirisena in 2015 making mandatory the
inclusion of 80% of the pictorial warnings in the cigarette packets.

In order to liberate the people of Sri Lanka from the drug menace, more
and more projects and activities need to be successfully launched. In this
context it is very important that the law as well as the prevention process are
strengthened.

It is also very necessary that the extend of the harm caused to persons who
are victims of the drug menace is being understood by the vulnerable groups
if prevention is to be a greater success. For this purpose, those actively
involved in this field should be imparted an education with the right technical
and scientific input that would help them explain to the relevant age groups
what harm is caused to them by being addicted to drugs.

Having taken into consideration the views of many experts in the field, the
National Policy on Drug Eradication and Action Plan were formulated and
hereby presented with a view to impart the required knowhow to the relevant
groups and inculcate in them the right attitude towards building up a society
least affected by the drug menace.

01. Vision

To prepare the backdrop for development socio- economically and culturally

by creating Sri Lanka free of Intoxicants as envisioned in His Excellency the
President’s Policy Statement:

“Compassionate Governance – a-stable Country”

02. Mission

To play a proactive role in protecting the health of all Sri Lankans and
improving their well-being, enhancing productivity and alleviation poverty by
gradually eliminating consumption of alcohol including the use of tobacco
and illicit drugs thereby minimizing the damage caused.

• Interpretation

270
In term: “Drugs” means and includes all products of alcohol and tobacco as
well as narcotic drugs as are determined by the National Dangerous Drugs
Central Board.

03. Aims and Objectives

• To bring down productions, transport and sale of illicit drugs by

at least 80% by the year 2020 as compared to the year 2014.
• To bring down the per capita consumption of alcohol by at least
25% by 2020 as compared to the year 2014.
• To bring down the consumption of tobacco products by at least
50% by 2020 as compared the year 2014.
• Prevention of youth from taking drugs.
• To minimize injurious and harmful conduct on the part of those
who are addicted to drugs.
• To bring down number of motor accidents caused due to use of
drugs by at least 50% by 2020 as compared to the year 2014.
• To totally ban Tobacco and Alcohol-related direct or indirect
advertisements and socially oriented programmes of such
companies.
• To minimize harm caused to non-users of drugs at houses as
well as in work places and public places and ensure the rights of
those non-users of drugs to live in an environment free of such
intoxicants.
• To create the social environment where no person is forced
to start consuming alcohol increasing such consumption of
alcohol.
• To minimize the involuntary inhaling or rather passive smoking
by non-users of tobacco products and ensure their rights to live
in an environment not polluted by tobacco smoke.
• To minimize number of cases of hospitalization following the
direct or indirect use of drugs.
• To minimize ready availability of drugs including tobacco and

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alcohol.
• To correctly and formally educate people with regard to the
harm caused directly and indirectly by the use of drugs.

04. National Policy

04.01 No new licenses will be issued for tobacco and alcohol production.

04.02 No new license will be issued for liquor shops except for those star
class hotels approved by the Tourist Board and patronized by foreign
tourists (R.B 7,8 licenses).

04.03 In the event of existing liquor shops being relocated, the essential
requirements including the conduct of a public opinion poll of the
relevant area are to be laid down.

04.04 When taxes are imposed on tobacco and alcohol revision of prices
of such products is to be made every six months, based on a price
formula adopted relation to inflation.

04.05 No tobacco and alcohol product will be used at any government

function and the sale and use of tobacco and alcohol products are
prohibited in government –owned buildings and premises.

04.06 No custom duty concessions or other tax concessions will be granted

in respect of tobacco and alcohol products.

04.07 Tobacco cultivation in paddy lands will by totally prohibited.

04.08 No irrigation facilities and other subsidies are to be provided by the

Government for tobacco cultivation.

04.09 Screening or telecasting of films and teledramas that encourage the

use of illicit drugs will be prohibited.

04.10 Implementation of the recommendations of World Health Organization

in relation to drugs in Sri Lanka.

04.11 To restrict the opening hours of liquor shops to 08 hours per day
effective from the year 2017.

04.12 To destroy all illicit tobacco products taken into custody under the
proper supervision of “National Authority on Tobacco and Alcohol”

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04.13 Suspension and deferment of promotions of government and semi-
government officers who are convicted of drug offences.

04.14 State Officers are prohibited from holding government posts whilst
they are employed in tobacco and alcohol companies.

04.15 Closure of liquor shops for at least 02 days on such occasions as

“Sinhala New Year” , “Wesak” , “Thai Pongal” , “Ramazan”,
“Christmas” and “Deepavali”

04.16 Those under the age of 21 years are to be prohibited from entering
clubs and karoke clubs where tobacco and alcohol products are
consumed.

05. Action Plan

The programme titled “A country free of intoxicants” is to be launched on

three fronts focusing attention on elimination of the use and supply of drugs.

1. Policy formulation and enactment of laws and their

implementation
2. Treatment and rehabilitation
3. Eradication

05.01 Presidential Task force on Drug Prevention

The Unit is primarily responsible for implementing decisions of the

“Presidential Task Force on Prevention of Drugs” that functions under the
purview of His Excellency the President and the programme” “A country
free of Intoxicants” in liaison with the Government and Non-Government
Agencies.

05.01.01 Convening and facilitating the “Presidential Task Force on Drug

Prevention” Operating under a Director General attached to the
President’s office and bearing all the responsibilities on behalf of
the President –Dr Samantha Kumara Kithalawaarachchi has been
appointed as the DG for the task force by the His Excellency the
President

05.01.02 Formulating joint programmes, implementation and supervision

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the National Drug Prevention Programme: “A country free
of Intoxicants” coordinating horizontally and vertically the
programme at grass root and national levels.

05.01.03 Reporting to His Excellency the President the progress of drug

eradication activities carried out by Government and non-
Government Agencies.

05.01.04 Management of the financial provisions allocated for the drug

eradication.

05.01.05 Training resource persons for Governmental and non-

Governmental Agencies.

05.01.06 Preparing and distributing educational aids.

05.01.07 Initiating actions on complaints and proposals received by His

Excellency the President.

05.01.08 Drawing up and publishing electronic and print media

advertisement to discourage the use of drugs and consumption
of alcohol.

05.01.09 Initiating action to enlist the participation of religious leaders,

government officials, social activists in drug eradication activities
in order to defeat the advertising strategies attractively planned
with a view of enticing people towards the drug use.

05.02. Ministry of Health and Indigenous Medicine

05.02.01 To provide necessary facilities for the National Authority on

Tobacco and Alcohol.

05.02.02 To encourage Public Health Inspectors and Inspectors of Food

and Drugs to enforce regulations made under the Tobacco and
Alcohol Act and provide training and evolve a methodology for
evaluation.

05.02.03 To correctly educate the public and patients on the harm caused
by the use of drugs, through the Health Education Unit in each
hospital.

05.02.04 To take up this subject for discussion at the monthly assessments

held at each Office of the Medical Officer of Health. (MOH)

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05.02.05 To issue posters and handbills on effective drug eradication
through the Health Education Bureau.

05.02.06 To initiate actions to transform the environment in and around

the hospitals into a Tobacco and Alcohol-free environment.

05.02.07 To provide the health staff with technical knowhow needed in

preventing former drug addicts from reverting to drug addiction.

05.02.08 To take actions to counter the propaganda which spreads that

medicine used in local medicine contains drugs.

05.02.09 To provide the indigenous physicians and staff with technical

knowhow needed for drug prevention and to put in place a
rehabilitation and monitoring mechanism at community level.

05.02.10 To initiate action to build up a tobacco, alcohol and drug-free

environment within the family itself as is devotedly being done by
the Family Health Officers and their staff at every Family Health
Office in promoting maternal and child health and to encourage
such officers in their efforts and continue evaluating the progress
achieved.

f Finance

05.03. Ministry of Finance

05.03.01 To implement a tax policy which is intended to discourage the

use of tobacco and consumption of alcohol products.

05.03.02 To allocate funds whenever possible, to those institutions that

contribute to the eradication of drugs.

05.03.03 To draw up an appropriate programme in collaboration with

officials of the National Authority on Tobacco in order to observe
transparency in the destruction of tobacco and alcohol products
taken into custody to the Department of Sri Lanka Customs.

05.03.04 To adopt a price formula in revision once every 06 months relative to

inflation, taxes on tobacco & alcohol, based on recommendations
of the National Authority on Tobacco and Alcohol.

05.03.05 To ban products such as illicit beedi and cigars or alternately

initiate action to levy taxes on such products in compliance with
formally prescribed standard.

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05.03.06 To launch, under a special unit, investigations into cases of tax
evasion, frauds and corruption related to Tobacco and Alcohol.

05.03.07 To establish a fund by levying a special welfare tax on Tobacco

and Alcohol products in order to reimburse the expenditure
incurred on drug eradication and to adopt remedial measures
against the social harm caused and to allocate proceed of the
fund exclusively for drug eradication activities.

05.04 Ministry of Public Administration

05.04.01 To effectively implement circulars issued on drug eradication.

05.04.02 To issue orders to the effect that all governmental and semi
governmental agencies including district secretariat and
divisional secretariats are zones free of sales /or use of Tobacco
and Alcohol.

05.04.03 To provide government officials at district and divisional levels

with the technical knowhow needed for drug eradication.

05.04.04 The District Secretary is primarily tasked with ensuring that the
district under his charge is free of harm caused by the use of
Tobacco and consumption of alcohol. The Divisional Secretary
is thus expected to provide the leadership at district level to the
governmental and non-governmental agencies.

05.04.05 The Divisional Secretary is tasked with ensuring that the division
under his charge is free of harm caused by the use of Tobacco
and consumption of alcohol. The Divisional Secretary is thus
expected to provide the leadership at divisional level to the
governmental and non-governmental agencies.

05.04.06 The District Secretary and the Divisional Secretary are expected
to go into matters related to the availability of drugs within
the district and use of drugs, at district and divisional levels
and monitor the progress made in the implementation of drug
eradication programmes thus currently guiding the relevant
officials.

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05.05 Ministry of Buddha Sasana

05.05.01 To provide religious leaders with correct technical training on

drug eradication.

05.05.02 To arrange for places of religious worship to disseminate the

correct message of drug eradication to the public.

05.05.03 To enlist the participation of Bhikkhus and youth in building up a

force on drug eradication centered around Buddhist Temples.

05.05.04 To organize anti-drug public campaigns through religious

leaders.

05.05.05 To include drug eradication activities as an item in the programmes

meant for religious festivals.

05.05.06 To draw up a programme seeking support of religious centres in

launching community-based rehabilitation activities.

05.05.07 To provide Dhamma School teachers with technical knowhow in

relation to drug eradication.

05.06 Ministry of Defense

05.06.01 To totally ban the sale of tobacco products in restaurants within

camps of the three security forces and to make such camps free
of tobacco and alcohol.

05.06.02 To totally ban the provision of cigarettes free of charge to the

members of the three security forces.

05.06.03 To desist from seeking sponsorship of Tobacco and Alcohol

companies for any programmes whatsoever to be launched by
the security forces.

05.06.04 To draw up and launch a programme to prevent members of the

Tri Forces from being addicted to drugs.

05.06.05 To draw up and launch programmes aimed at rehabilitating

those addicted to drugs amongst members of the Tri Forces.

05.06.06 To train Group Leaders in the three security forces in drug

eradication activities.

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05.06.07 To include drug eradication in the syllabus of the training courses
for security forces.

05.06.08 To extend assistance of the intelligence units of the security in

carrying out drug eradication activities.

05.06.09 To post drug eradication notices in the publications of the

security forces.

05.07 Ministry of Agriculture

05.07.01 To educate farmers thereby discouraging them from taking to

cultivation of tobacco.

05.07.02 To refrain from providing irrigation facilities or other measures of

relief for tobacco cultivation.

05.07.03 To introduce alternative crops in place of tobacco cultivation for

farmers.

05.07.04 To draw up and put in place a programme which is intended to

deny any relief measures to those farmers convicted of drug-
related offences.

05.07.05 To enact and implement laws needed to totally ban tobacco

cultivation in paddy fields.

05.07.06 To refrain from seeking sponsorship of Tobacco and Alcohol

companies on any occasion in respect of agricultural programmes
and to discontinue forthwith any such programme currently
underway.

05.08 Ministry of Education

05.08.01 To draw up and put in place a methodology whereby both

teachers and students are imparted technical knowledge in
relation to eradication of drug addiction amongst school children.

05.08.02 To launch the proposed drug eradication activities in schools.

05.08.03 To impart special training in drug eradication to a selected male/

female teacher from each school and to assign such eradication

278
activities at zonal and district levels and draw up a programme
to evaluate the progress made.

05.08.04 To take steps not to allow the use of drugs of promotion of the
use of drugs in relation to any programme launched in school or
premises.

05.08.05 To include acquisition of knowledge on drug eradication in

school syllabuses in consultation with the experts in the field.

05.09 Ministry of Mass Media

05.09.01 To initiate action to discontinue direct and indirect advertisements

of cigarette and alcohol over the media.

05.09.02 To take action to instantly provide the public with information on

drug eradication so that they could be correctly updated on the
subject.

05.09.03 To get the state-run and privately-owned media agencies to

contribute to drug eradication activities.

05.09.04 To persuade media institutions to line up in launching a practical

and effective drug eradication programme.

05.09.05 To provide facilities for media institutions to give publicity to

drug eradication messages/notices.

05.09.06 To arrange for Electronic Media institutions to allocate special air

time for telecasting drug eradication features and programmes.

05.09.07 To arrange for newspapers to allocate special slots for drug

eradication.

05.09.08 To arrange for the newspapers to include (free of charge) drug

eradication messages as ad fillers in newspapers.

05.09.09 To take steps to expose to the society those convicted of drug

offences.

05.09.10 To arrange for media personal to be brief on drug eradication.

05.09.11 To persuade media institutions to charge concessionary rates

for production of programmes and printing drug eradication –
related publications.

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05.09.12 To display in cinema halls drug eradication – related
advertisements/notices before commencement of the shows as
well as during intermissions.

05.10 Ministry of Justice

05.10.01 To formulate special programmes jointly with the National

Dangerous Drugs Control Board and the office of the
commissioner general of rehabilitation for rehabilitation of
prisoners serving terms in prison on being convicted of drug
offences.

05.10.02 To put in place training programmes targeted on prison officers

05.10.03 To formulate follow up and feedback programmes for those

integrated into the society after the being weaned of drugs.

05.10.04 To put in place such meditation programmes as those

successfully launched in Indian prisons to bring about changes
in the behavioral patterns of the inmates of prisons.

05.10.05 To focus special attention on sorting out social problems such

as unemployment faced by those convicted of drug related
offences once they are released from prisons.

05.10.06 To take steps to ensure that maximum punishments and penalties

imposed on drug offenders are met.

05.10.07 To pay particulars attention to the previuos convictions in trials

related to drug offences.

05.11 Ministry of Environment

05.11.01 To put in place a programme design to minimize the environmental

harm caused by tobacco cultivation and the use of drugs.

05.11.02 To take action to minimize the environmental harm caused by

cigarettes, filters and any other drug related matters being
released to the environment.

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05.12 Excise Department

The implementation of acts such as the Excise ordinance, tobacco tax act,
National Authority on Tobacco and Alcohol act and Dangerous Drugs Control
ordinance are primarily handled by the Excise Department.

05.12.01 The systematic implementation of rules and regulations related

to the production and sale of tobacco and alcohol products.

05.12.02 The implementation of targeted raids/ seizures to totally

eradicate illicit tobacco, alcohol and drugs by the year 2020.

05.12.03 The formulation and adoption of a methodology in levying taxes

on tobacco products such as beedi and cigars.

05.12.04 To institute legal action against violators of excise laws.

05.12.05 To take steps to eliminate large scale tax evasion and corrupt
practices resorted to by tobacco and alcohol producing
companies.

05.12.06 To take action to fully evaluate and subject to continue monitoring

the institutional framework in place in order to achieve results
favourable to the country.

05.12.07 Formulation and implementation of a methodology of evaluating

the role of the divisional excise centres and these officials
enforcing drug related rules and regulations.

05.12.08 To make proposals to the government on the adoption of a

correct tax policy that discourage drug use and leads to collection
of more revenue.

05.13 Police Department

05.13.01 To enforce control of drugs including illicit tobacco and alcohol

with set targets.

05.13.02 To develop a methodology to evaluate the role of the Divisional

Police Stations and officers enforcing drug-related rules and
regulations.

05.13.03 To effectively enforce the existing legal provisions related to

drugs including the National Authority on Tobacco and Alcohol

281
act.

05.13.04 To enforce drugs-related laws through an independent police

unit monitoring unit encompassing the whole island in addition
to the Divisional Police Stations.

05.13.05 To provide complete protection and support for approved active

eradication programmes.

05.13.06 To provide officers with regular training on correct technology

being adopted.

05.13.07 To enhance the knowledge of the officers on drug-related laws.

05.14 National Dangerous Drugs Control Board

Being primarily responsible for control of dangerous drugs also referred to as

narcotic drugs the National Dangerous Drugs Control Board thus assigned
the following role.

05.14.01 Formulation of criteria to gauge the minimum condition found

in all the active rehabilitation centres related to drugs and the
implementation of and assessment process.

05.14.02 Introduction of an acceptable technically correct rehabilitation

methodology capable of being implemented by the National
Dangerous Drugs Control Board as well as by other institutions
having regard to the views and suggestions of experts in
rehabilitation sector and formulation of a programme for
monitoring rehabilitation centres, based on such a methodology.

05.14.03 To accurately process information and data at national level and

released such information to those who need them keeping
records of the information so released.

05.14.04 To draw up a programme to prevent the countrywide circulation

of dangerous drugs being used as narcotic drugs.

05.14.05 To recommend those institutions and resource persons who are

qualified to carry out rehabilitation activities.

282
05.15 National Authority on Tobacco & Alcohol

Being the institutions primarily responsible for the control of tobacco and
alcohol, the National Authority on Tobacco and Alcohol is tasked with,

05.15.01 The systematic exercise of powers vested in the said authority by

the National Authority on Tobacco and Alcohol act.

05.15.02 Formulating a methodology of and assessment for implementation

under the regulation of the above act.

05.15.03 The formulating criteria and guideline related to each sector for
tobacco and alcohol elimination activities monitors governmental
and non-governmental organizations engaged in such activities
as per such criteria.

05.15.04 Formulating a programme on transparently destroying illicit

tobacco products and alcohol taken into custody.

05.15.05 Recommending institutions and resource persons qualified to

carry out tobacco and alcohol eradication activities.

05.15.06 Recommending institutions and resource persons qualified to

update government officers on tobacco and alcohol related
laws.

05.16 Divineguma Department

05.16.01 Providing training required to update technical knowledge of

two social development officers appointed to each divisional
secretary’s division who are assigned drug eradication related
duties an allocating to continuous evaluation of progress of
implementation of the programme at grass root level.

05.16.02 Initiating action to rehabilitate families disintegrated by drug

eradication.

05.16.03 Launching programmes empowering children, youth and

women’s organizations free individuals and families of the ills of
the use of tobacco, drugs and consumption of alcohol which has
been a contributory factor to poverty.

05.16.04 Launching the anti-tobacco flag day scheduled for May 31st , with
the prime objective of freeing people from the use of tobacco

283
products.

05.16.05 Formulating and implementing a programme which is intended

to deny Samurdhi Assistance to those convicted of the drug
related offences.

05.16.06 Formulating a programme stipulating the requirement that those

families given to drug use should desist from indulging in such a
harmful practice.

05.17 Social Services Department

05.17.01 To implement a programme designed to rescue families affected

by the use of drugs.

05.17.02 To provide training on drug eradication for social service activists

who are registered with the department of social services.

05.17.03 To launch programmes to educate the community on harm

caused by the use of drug.

05.17.04 To take action to rehabilitate drug addicts and monitory progress

made in this regard.

05.18 Ministry of Women’s Affairs

05.18.01 To take action through the women’s organizations to stop the

sales of cigarettes locally.

05.18.02 To educate the women’s organizations on targeting of women by

tobacco and alcohol companies.

05.18.03 To take up for discussion the topic of economic and health

hazards of alcohol and tobacco use on such days specially meant
for women as women’s day.

05.18.04 To launch a programme to educate women on preventing

children from being addicted to drugs.

284
05.19 National Youth Services Council

05.19.01 To train members of all youth councils in the field of drug

eradication.

05.19.02 To get all youth councils to actively involved at divisional level in

minimizing the harm caused by the use of drugs and evaluating
the progress thus made.

05.20 Office of the Commissioner General of Rehabilitation

05.20.01 To put in place a formal programme for rehabilitation of drug

addicts.

05.20.02 To put in place a formal programme to monitor the activities

in relation those who were made to socialized once they were
rehabilitated.

05.21 Department of Community – Based Corrections

05.21.01 To carry out community-based rehabilitations activities.

05.21.02 To extend necessary assistance in monitoring activities in respect

of those persons who were made to socialized once they were
rehabilitated.

05.21.03. To extend the maximum possible contribution to eradication of

drugs including tobacco and alcohol.

05.22 General Activities to be undertaken by all state institutions

Matters to be complied with and attended to by all state institutions apart

from the specific activities meant for each institution referred to above.

05.22.01 To desist from seeking either direct or indirect sponsorship from

tobacco and alcohol companies in respect of any governmental
activity whatsoever.

05.22.02 To desist from getting those involved in tobacco and alcohol

industry to contribute an activity, thereby according them

285
recognition.

05.22.03 To set up drug eradication committees in state institutions to

attend to drug eradication work

05.22.04 To fete those employees who have abstained from drug use.

05.22.05 To refrain from the use of tobacco and alcohol at state functions.

05.22.06 To place restrictions of promotions, increments of salary and

other facilities granted to employees convicted of drug offences.

05.22.07 To implement and enforce within each institutions such circulars,

rules and regulations that have been issued by the Government
in relation to the use drugs tobacco and alcohol.

286
Annex 2 : Credits and Permissions

The following figures and tables have been reprinted by permission

of the World Health Organization.
Figure 2.3 Dimensions of the Universal Health Coverage (Source: Ten years
in public health, 2007–2017: WHO 2017)

Figure 2.5 Multifaceted benefits of investing in NCD prevention and control.

(Source: a strategic response to noncommunicable diseases. WHO. Geneva
2018 )

Figure 3.1 . Proportion of global NCD deaths under the age 70 years, by
cause of death, comparable estimates, 2012 (Source; Global Status Report
WHO 2014)

Figure 3.2 Distribution of mortality (Source: WHO country profiles 2011)

Figure. 3.3. Probability of dying from the four main noncommunicable

diseases between the ages of 30 and 70 years, comparable estimates, 2012
(Source: Global status report on noncommunicable diseases 2014. Geneva:
WHO; 2014)

Figure 3.5. Civil registration coverage of cause of death, 2005−2011 (Source;

Global status report on noncommunicable diseases 2014. Geneva: WHO;
2014)

Figure. 4.1. Age standardized heavy episodic drinking (aged 15years and over)
in past 30 days (%), 2010 (Source: Global status report on noncommunicable
diseases 2014. WHO Geneva 2014.)

Table 4.1 Total alcohol consumption per capita (in litres of pure alcohol) and
prevalence of heavy episodic drinking (%) in the total population aged 15
years and over, and among drinkers aged 15 years and over, by WHO region
and the world, 2010 (Source: Global status report on noncommunicable
diseases 2014. WHO. Geneva 2014).

Figure 4.2 The total alcohol consumption per capita (≥ 15 years of age) in
litres of pure alcohol, 2016- in countries in WHO South East Asia Region
(Source: World Health Statistics 2018; Monitoring health for the SDGs. WHO.
Geneva)

287
Table 4.2 Total alcohol per capita consumption, prevalence (%) of current
drinkers, and prevalence of heavy episodic drinking among current drinkers,
in the total population aged 15 years and over, by World Bank income group
and the world, 2010 (Source: Global status report on noncommunicable
diseases 2014. WHO. Geneva 2014).

Table 4.3 Policies and interventions to control harmful use of alcohol in Sri
Lanka (Source: Global status report on alcohol and health 2014. Geneva:
WHO; 2014)

Figure 5.1. Age standardized prevalence of insufficient physical activity in

men aged 18 years and over, comparable estimates, 2010 (Source: Global
status report on noncommunicable diseases 2014. Geneva: WHO 2014)

Figure 5.2. Age standardized prevalence of insufficient physical activity in

women aged 18 years and over, comparable estimates, 2010(Source: Global
status report on noncommunicable diseases 2014. Geneva: WHO 2014)

Figure 5.3. Global prevalence of insufficient physical activity for adolescent

boys aged 11−17 years, comparable estimates, 2010 (Source: Global status
report on noncommunicable diseases 2014. Geneva: WHO 2014)

Figure 5.4. Global prevalence of insufficient physical activity for adolescent

girls aged 11−17 years, comparable estimates, 2010 (Source: Global status
report on noncommunicable diseases 2014. Geneva: WHO 2014)

Table 5.1 Distribution of level of daily total physical activity in women (Source:
WHO STEPs 2015)

Table 5.2 Distribution of level of daily total physical activity in men (Source:
WHO STEPs 2015)

Figure 6.1. Mean sodium intake in persons aged 20 years and over,
comparable estimates, 2010 (Source: Global Status Report on NCDs 2014.
Geneva: WHO )

Figure 7.1. Age-standardized prevalence of current tobacco smoking in

males aged 15 years and over, comparable estimates, 2012 (Source: WHO
Global Status Report on NCDs 2014. Geneva. WHO)

Figure 7.2. Age-standardized prevalence of current tobacco smoking in

females aged 15 years and over, comparable estimates, 2012 (Source: WHO
Global Status Report on NCDs 2014. Geneva. WHO)

Figure 7.3. Share of the world population covered by selected tobacco

control policies (Source: WHO report on the global tobacco epidemic 2017.

288
Geneva: WHO 2017)

Table 7.2 Some aspects of the Sri Lanka National Tobacco Control Programme
(Source: WHO report on the global tobacco epidemic, 2017, Country profile)

Figure 8.1 Main contributory factors to high blood pressure and its
complications (Source: A global brief on hypertension. Silent killer, global
public health crisis. Geneva:WHO 2013)

Fig. 8.2 Age-standardized prevalence of raised blood pressure in males aged

18 years and over (defined as systolic and/or diastolic blood pressure equal
to or above 140/90 mm Hg), comparable estimates, 2014 (Source: Global
Status Report on Noncommunicable Diseases. Geneva. WHO 2014)

Fig. 8.3 Age-standardized prevalence of raised blood pressure in females

aged 18 years and over (defined as systolic and/or diastolic blood pressure
equal to or above 140/90 mm Hg), comparable estimates, 2014 (Source:
Global Status Report on Noncommunicable Diseases. Geneva. WHO 2014)

Figure. 9.1. Age-standardized prevalence of obesity in men aged 18 years

and over (BMI ≥30 kg/m2), 2014 (Source: Global Status Report 2014. Geneva:
WHO 2014)

Figure.9.2. Age-standardized prevalence of obesity in women aged 18 years

and over (BMI ≥30 kg/m2), 2014 (Source: Global Status Report 2014. Geneva:
WHO 2014)

Figure 9.3 Age standardized prevalence of obesity in adults aged 18 years

and over (Source: Global Status Report 2014. Geneva: WHO 2014)

Figure.9.4 Age-standardized prevalence of overweight in children under

five years of age, comparable estimates, 2013 (Source: Global Status Report
2014. Geneva:WHO 2014)

Figure.9.7. Age-standardized prevalence of diabetes, (Fasting glucose ≥

7.0 mmol/L or on medication), in men aged 18 years and over, comparable
estimates, 2014 (Source: Global Status Report 2014. Geneva:WHO 2014)

Figure 9.8. Age-standardized prevalence of diabetes (Fasting glucose ≥ 7.0

mmol/L or on medication), in women aged 18 years and over, comparable
estimates, 2014 ((Source: Global Status Report 2014. Geneva:WHO 2014)

Figure 10.1 Sri Lanka NCD Country Profile 2014 -Proportonal Mortality (%of
total deaths, all ages, both sexes) (WHO - Noncommunicable Diseases (NCD)
Country Profiles , 2014).

289
Figure 10.3 World Health Organization cardiovascular risk prediction chart
(for one of the 21 global regions) (Source: World Health Organization 2018)

Figure 10.4 Organization of the preventive and curative health care system
in Sri Lanka (Source: WHO 2013. Addressing noncommunicable diseases
in a lower-middle-income country: Sri Lankas approach, Country Office, Sri
Lanka)

Figure 12.1 Contribution of environmental and behavioural risk factors

to NCDs (Source: Preventing noncommunicable diseases by reducing
environmental risk factors. Geneva: WHO 2017)

Figure 12.2 Proportion of population with primary reliance on clean fuels

and technologies (%) 2016 (Source : World Health Statistics 2018. Geneva :
WHO 2018)

The following figures and tables have been reprinted by permission

of the Institute for Health Metrics and Evaluation (IHME).
Country profiles. Seattle, WA:  IHME, University of Washington,
2017.  Available from  http://www.healthdata.org/results/country-
profiles. (Accessed 7th September 2018.)
Figure 1.3 Life expectancy at birth in males and females in Sri Lanka 1990-
2016 (source : IHME celebrating 10 years of measuring what matters.)

Figure 1.5 Top ten risk factors driving death and disability (DALYs) in Sri
Lanka in 2016 and percent change 2005 to 2016 (Source: IHME celebrating
10 years of measuring what matters).

Figure 1.6 Top ten causes of death in Sri Lanka in 2016 and percent change
2005 to 2016 (Source: IHME celebrating 10 years of measuring what matters).

Figure 1.7 Comparison of the top 10 causes of premature death (YLL) in Sri
Lanka in 2016, with the group average for selected middle-income countries
(Source: IHME celebrating 10 years of measuring what matters).

Figure 1.8 Comparison of the top 10 causes of death and disability (DALYs)
in Sri Lanka in 2016, with the group average for selected middle-income
countries. (Source: IHME celebrating 10 years of measuring what matters).

Figure 1.9 , Top ten causes of death and disability combined (Source: IHME
celebrating 10 years of measuring what matters).

290
Figure 10.2 2005 and 2016 ranking of causes of premature death in Sri Lanka
(Source: IHME 2016).

Credit Institute of Health Policy

Figure 2.4 Spending on health – Public and private spending by function

(Source: Institute of Health Policy (2015). Expenditure Series (4). Sri Lanka
Health Accounts; National Health Expenditure 1990-2014. Colombo, Sri
Lanka)

Credit Central Bank

Figure 2.1 Total Government expenditure by function 2016 (Source: Central

Bank of Sri Lanka 2016)

Credit Smith, O. 2016. Sri Lanka: Achieving Pro-Poor Universal Health

Coverage without Health Financing Reforms”. Universal Health Coverage
Study Series No. 38, World Bank Group, Washington, DC.

Figure 2.2 Breakdown of out of pocket payments by households(Source:

Smith O 2016. Based on data from Household Income and Expenditure
Survey 2015/16)

Credit Department of Motor Traffic

Figure 12.3 Number of newly registered motor vehicles and total motor
vehicles in Sri Lanka, 2008-2015. Source: Department of Motor Traffic,
Ministry of Transport and Civil Aviation. Colombo, Sri Lanka 2016

291
292
Subject Index

A B
access to medicines,17, 51, 203- behavioural risk factors, 16, 103,
213, 258, 264 143, 195, 218
accountability, 16, 65, 251 beta-blockers, 188, 192
action plan, 18, 47, 51, 79, 85, 106, biodiversity, 17
128, 142, 157, 199, 229, 252, body mass index (BMI), 160
259, 265, 268
advertising, 38, 41, 69, 128, 130, C
132, 136, 138, 140, 172, 176, cancer, 9, 12,14, 48, 51, 53- 58, 67,
198, 248 89, 92, 124, 128, 160, 211, 219,
affordability, 62, 128, 136, 151, 225, 238-241, 251
192, 209, 211, 215 cancer deaths, 55
age, 4, 8, 10, 54-59, 62, 67, 70, cardiovascular disease, 3, 9, 14, 38,
73, 74, 78, 79, 83, 97, 101, 102, 44, 45, 48, 51- 58, 69, 71, 89,
110, 112, 126, 129, 133, 143, 110, 119, 124, 154, 155, 157,
148, 151, 154, 160, 164, 165, 156, 167, 176, 185-201, 205,
166, 168, 170, 195, 219, 225, 238, 241,
241, 245, 267 catastrophic spending, 32
air pollution, 7, 11, 14, 10, 15, 18, cause of death, 55, 62, 61, 62, 67
49, 52, 64, 67, 106, 183, 217- cervical cancer, 38, 40, 237, 240,
234, 259, 260 242
alcohol, 7, 11, 14, 13, 17, 38, 47, children, 10, 17, 31, 49, 92, 97, 99,
49, 51, 61, 63, 67, 69 - 87, 133, 100, 101, 102, 105, 108, 112,
140, 141, 143, 146, 148, 150, 115, 118, 126, 132, 140, 160,
152, 177, 183, 195, 248, 259- 163, 164, 165, 166, 170-180,
269, 215, 219, 221, 223, 225
alcohol consumption, 69- 79, 85 cholesterol measurement, 191, 205
alcoholic drinks, 83 cost effective policies and
ambient,18, 52, 218, 221, 225- interventions, 14, 15, 37, 54,
227, 229, 231 238, 240, 243, 261
angiotensin-converting enzyme
inhibitor, 189, 192 D
aspirin, 188, 189, 205 deaths, 10-12, 51, 53, 55, 56, 59,
asthma, 10, 12, 158, 205, 207, 211, 62, 61, 69, 71, 75, 91, 110, 123,
215, 231, 124, 144, 160, 168, 183, 185,
Australia, 13, 26, 58, 75, 76, 131, 186, 185, 217, 218, 222-225
224 Declaration of Alma Ata, 6
diabetes, 4, 10, 12, 14, 40, 44, 48,
49, 51, 53, 55, 56, 61, 71, 89,

293
92, 124, 158-180, 184, 185, 191- health systems, 13, 15, 31, 191,
193, 197-199, 203-205, 211, 205
238, 242-245, 250-252 health warnings, 83, 128, 135, 136,
districts, 6, 30, 35, 36, 59, 62, 74, 140
102, 104, 106 healthy food, 170, 176, 181
driving and alcohol, 77 heart attacks and strokes, 13-16,
drug therapy, 15, 38, 40, 49, 183, 47, 49, 64, 110, 154, 183-193,
191 197, 207, 242, 250, 252, 261
heavy episodic drinking, 72-75, 78,
E 79, 287
essential, 14-19, 35, 37, 42, 47, 49, household surveys, 42
51, 63, 65, 104, 106, 131, 146, human resources, 154, 252
159, 158, 180, 183 hypertension, 4, 10, 25, 40, 47, 63,
72, 110, 111, 110, 119, 143-158,
F 184, 191, 193, 197, 207, 211,
Finland, 26, 102, 106, 114, 119, 244, 259, 262
120
food, 16, 30, 31, 40, 61, 111--120, I
134, 146, 151, 161, 170-176, impact on health, 85, 91, 110, 124,
180, 238, 246-248, 251 160, 166, 219, 228, 231
Framework Convention on Tobacco implementation, 28, 40, 41, 42,
Control (WHO FCTC), 259 51, 61, 67, 68, 77, 80, 102, 104,
funding, 15, 19, 36, 67, 261 105, 111, 114, 116, 123, 125,
128, 133-139, 142, 143, 156,
G 158, 173, 194, 198, 201, 209,
generic, 209, 211, 213 214, 215, 220, 231, 237,
Global strategy on diet, physical individual interventions, 77, 205,
activity and health, 107, 118 237, 238, 244
governance, 18, 251, 266 inequality, 16, 49
innovation, 16, 181
H insulin, 204, 205
health care, 7, 13, 19, 21, 22, 28, interventions, 4, 12-18, 28, 37, 38,
31, 34-38, 42, 60, 61, 63, 65, 66, 42, 51, 54, 60, 64, 67, 76-87, 99,
70, 99, 124, 152, 156, 158, 159, 122, 128, 144, 150- 158, 171,
170, 176, 180, 193, 194-197, 177, 180, 185, 188, 191- 199,
201, 204- 213, 237-244, 245, 201, 205, 215, 223, 232, 233,
252, 261, 263, 267 237-241
health impact, 47, 77, 225, 230 investment, 35, 38, 41, 62, 132,
health promotion, 61, 102, 104, 189
106, 109, 111, 116, 179, 202,
264

294
L national targets, 14, 15, 48, 49, 188
labelling, 17, 40, 83, 111, 117, 132,
170, 172, 176, 247, 248, 251, O
265 obesity, 4, 14, 15, 47, 49, 63, 67,
liver, 69, 71, 75, 76, 241 91, 98, 104, 108, 109, 144, 148,
liver cancer, 241 160- 180, 259, 289
low-income countries, 56, 126, obesity and diabetes, 14, 47, 63,
168, 186, 189, 201 160, 168, 169, 171, 170, 177,
259
M overweight and obesity, 146, 148,
medicines, 13-17, 21, 28, 35, 47, 150, 152, 160, 162, 163, 164,
49, 51, 52, 62, 63, 65, 152, 153, 166, 168, 170, 172, 176, 179
154, 192- 217, 242
medicines and technologies, 14, P
15, 197, 205 palliative care, 240-242
middle-income countries, 12, 21, physical activity, 40, 47, 49, 89-109,
44, 55, 57, 58, 67, 102, 112, 148, 151, 168, 170, 175, 177,
120, 151, 164, 168, 180, 185, 176, 191, 227
189, 191, 192, 193, 199 physical inactivity, 7, 11, 14, 38, 64,
monitoring, 16, 18, 42, 47, 49, 54, 67, 89, 93, 98-104, 144, 146,
57, 61, 62, 61, 67, 77, 79, 101, 148, 150, 152, 156, 168, 180,
105, 106, 112, 116, 118, 121, 183, 195, 259, 260
129, 131, 142, 154, 156, 159, population-based interventions,
169, 170, 175, 178, 191, 199, 110
211, 221, 231, 233, 250, poverty, 9, 11, 16, 18, 33-37, 44,
multisectoral, 7, 18, 19, 51, 67, 76, 49, 62, 71, 85, 218, 221, 245
129, 140, 263 premature, 11, 14, 15, 36, 47, 50-
multisectoral collaboration, 67 63, 75, 123, 124, 167, 185, 186,
185, 186, 238, 247, 246, 259,
N 261, 267
National Authority on Tobacco and premature mortality, 10, 15, 47, 50,
Alcohol, 5, 8, 17, 79, 81, 127, 51, 53, 54, 56, 57, 60, 63, 75,
133, 134, 135, 134, 135, 136, 123, 185, 247, 259, 261,
138, 139, 140, 141, 140, 248, prices, 17, 41, 88, 130, 174, 207,
263 209, 211, 212, 213, 215, 221,
National Medicines Regulatory 265
Authority, 6, 8, 204, 208, 209, primary care, 14, 22, 34, 63, 65,
216 67, 68, 102, 154, 155, 156, 184,
national NCD targets, 13, 38, 49, 189, 191-201, 205-209, 214,
255, 259, 261, 265 244, 246, 252, 267
national surveillance systems, 67 prioritization, 205

295
prioritizing, 47 statins, 153, 188, 192
private sector, 7, 17, 29, 31, 43, strengthening, 15, 36, 50, 61, 91,
59, 65, 103, 106, 114, 172, 207- 93, 102, 116, 128, 140, 153,
216, 263, 265 197, 248, 249, 252, 261
promotion, 41, 83, 101-108, 116, surveillance and monitoring, 79
128, 130, 132, 134, 136, 138,
143, 177, 195, 211 T
provinces, 4, 5, 34, 35, 36, 242 targets and, 3, 47, 114, 267
public health policies, 68, 148, 150, taxation, 69, 81, 102, 135, 136, 248
151, 152 Thailand, 8, 24, 26, 115, 127, 132
tobacco, 3- 18, 38, 41, 47, 49, 52,
Q 61, 63, 67, 79, 83, 87, 123- 143,
quality of services, 197 177, 183, 184, 191, 195, 221,
248, 260, 261,263, 265
R tobacco packaging, 133
recurrent, 34, 188 tobacco products, 41, 125, 128,
resources, 14-16, 28, 34, 36, 37, 130, 132, 133, 134, 136, 138,
49, 63, 65, 67, 77, 105, 117, 269, 271-281, 283
152, 158, 194, 193, 200-207, tobacco use, 3, 7, 11, 14, 17, 41,
214, 227, 246, 251, 257-266 47, 49, 52, 67, 123-130, 138,
risk factors, 7- 17, 75, 91, 101, 102, 142, 183, 184, 195, 248, 260,
107, 106, 108, 120, 148, 154, total risk approach, 14, 16, 25, 40,
157, 156, 168, 177, 183, 184, 153, 152, 156, 193, 197, 261,
185, 193, 195, 200, 219, 231, 262
252, 260, training, 61, 68, 102, 103, 116,
140, 213, 229, 246, 250
S
salbutamol, 207, 244 U
salt and, 146, 172, 176 unhealthy food, 170, 177, 180, 263
salt intake, 14, 15, 40, 64, 67, 110- United Kingdom, 26, 114, 119,
119, 120, 143, 146, 259 130, 132
salt/sodium, 47, 49, 110, 112, 152 universal health coverage, 22, 42,
salt/sodium intake, 47 51, 68, 197
secondary prevention of heart
attacks and stroke, 191 W
smokeless tobacco, 138 WHO, 5, 6, 13-16, 19, 14, 22, 24,
smoking cessation, 140, 188 28, 32, 33, 38, 41, 42, 44, 47,
spending in, 24, 42, 65, 237 55, 56, 59, 67, 69, 70, 72, 73,
stakeholders, 7, 48, 50, 99, 103, 74, 76, 79, 81, 85, 87, 89, 90,
115, 138, 174, 176, 231, 240, 91, 97, 110, 112, 115, 116, 118,
248 120, 123, 124, 126, 127, 128,

296
130-132, 136, 138, 141, 140,
141, 142, 150-153, 157-159,
164, 170, 171, 172, 178, 179,
180, 189, 191-195, 200- 207,
212, 215-219, 223, 225, 229,
231-233, 237, 238, 242-252,
254, 257-262, 264, 267
workplace, 103, 198

297
298
Hon. Dr. Rajitha Senaratne is the current Minister of Health of the Democratic Socialist
Republic of Sri Lanka and Cabinet Spokesman of the Government. He was elected as a Vice-
Chair of the Executive Board of the World Health Organization for a term of one year, in May
2018. As a Member of Parliament for over 22 years, from 1994, he has held many portfolios;
Minister of Lands (2001 – 2004), Minister of Construction and Engineering Services (2007
-2010) and Minister of Fisheries and Aquatic Resources Development (2010-2014). In 2015
he was re-elected to parliament from the Kalutara District, securing the highest number of
preferential votes and was appointed to the Cabinet as the Minister of Health.He graduated
from the University of Peradeniya, Sri Lanka as a Dental Surgeon in 1974. He was a student
leader and the General Secretary of the Inter-University Students Federation from 1971 to 1973 and represented the then
Prime Minister of Sri Lanka in the Sri Lanka Delegation to the Asian Youth Conference in 1973, in Japan. He was the Hon.
Secretary of the Government Dental Surgeons Association for 14 years from 1975 to 1989 and was a popular trade union
activist. In 1992, he was awarded the Fellowship of the International College of Continuous Dental Education. He is a NCD
champion and has provided steadfast political leadership for NCD Prevention and Control in Sri Lanka. After assuming
duties, he continued the work of his predecessor in the fight against tobacco and enforced 80% pictorial warning soon to
be followed by an upward revision of tax on tobacco and plain packaging. Setting up of the National Medicine Regulatory
Authority was another move he took towards reducing the price of drugs and wastage, in line with the drug policy
espoused by Prof. Senaka Bibile. As a result, the price of 48 mostly used drugs have been slashed making medicines
more affordable to people. He has been successful in raising funds for the rehabilitation of hospitals and primary health
care units island wide and has also taken steps to regulate fees charged for health services in the private health sector.

Professor Shanthi Mendis served the World Health Organization (WHO) for 20 years as Senior Adviser,
Noncommunicable Diseases (NCD) and in other senior capacities. She was Professor of
Medicine, University of Peradeniya, Sri Lanka before joining WHO on a Rockefeller Global
Health Leadership Fellowship. During her tenure in WHO, she led and coordinated the
development of the global NCD action plan 2013, the global NCD report (2014) and the global
programme on NCDs and cardiovascular diseases. She graduated in 1974 with First Class
Honours from the University of Peradeniya, Sri Lanka and specialized in Internal Medicine,
Cardiology and Public Health in the UK and USA. She practiced Clinical Medicine and
Cardiology in the UK, USA and Sri Lanka and is a Fellow of the Royal College of Physicians
of London and Edinburgh and a Fellow of the American College of Cardiology. In 2005, she
was awarded National Honours for her contribution to research in Sri Lanka. In her medical career spanning 44 years she
has gained wide experience in the fields of Global Health, Cardiology, Medical Education and Operational research. She
has coauthored 5 books, many book chapters and has published over 150 papers in peer reviewed international journals.
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