Primary Health Care System Strengthening Project in Sri Lanka: Status and Challenges with Human Resources, Information Systems, Drugs and Laboratory Services

Abstract

A Primary Healthcare-System-Strengthening Project (PSSP) is implemented by the Ministry of Health, Sri Lanka, with funding support from the World Bank for providing quality care through primary medical care institutions (PMCIs). We used an explanatory mixed-methods study to assess progress and challenges in human resources, drug availability, laboratory services and the health management information system (HMIS) at PMCIs. We conducted a checklist-based assessment followed by in-depth interviews of healthcare workers in one PMCI each in all nine provinces. All PMCIs had medical/nursing officers, but data entry operators (44%) and laboratory technicians (33%) were mostly not available. Existing staff were assigned additional responsibilities in PSSP, decreasing their motivation and efficiency. While 11/18 (61%) essential drugs were available in all PMCIs, buffer stocks were not maintained in >50% due to poor supply chain management and storage infrastructure. Only 6/14 (43%) essential laboratory investigations were available in >50% of PMCIs, non-availability was due to shortages of reagents/consumables and lack of sample collection–transportation system. The HMIS was installed in PMCIs but its usage was sub-optimal due to perceived lack of utility, few trained operators and poor internet connectivity. The PSSP needs to address these bottlenecks as a priority to ensure sustainability and successful scale-up.

Barriers to and enablers of quality improvement in primary health care in low- and middle-income countries: A systematic review

“…Inadequate patient records at the PHC facility level as well as a lack of equipment, on the other hand, were mentioned as constraining attempts to enhance PHC service delivery and quality. As with equipment and staffing, stockouts of essential supplies and medicines was also reported as barrier to QI in PHC settings in LMICs including but not limited to Sri Lanka [ 76 ], India [ 78 ], Ethiopia [ 82 ], Nigeria and Tanzania [ 83 , 86 ] and Rwanda [ 84 ].…”

“…Thus, reaching adequate numbers of implementers with knowledge and skills, whether by offering training sessions repeatedly or targeting and delivering them when most participants are available, were deemed important enablers [ 41 , 69 , 70 ]. Developing results oriented QI work plans and executing these in a participatory manner, ensuring periodic verification of whether a QI intervention is being implemented as planned, using feedback data from PHC facilities, and rolling out a QI package incrementally—where subsequent sessions build on earlier ones in a responsive manner—also facilitated QI [ 42 , 71 , 76 , 77 , 80 , 81 , 85 , 87 ]. Contrary to these, keeping a limited focus of QI throughout its implementation, not unfurling all planned aspect of an intervention, and late roll of only a few aspects posed major hindrances, signaling a lack of fidelity to the specific QI’s design and intent [ 45 , 79 , 89 ], and its potential failure.…”

“…Non-implementation of supportive supervision and limited training for implementers was identified as a constraint to QI [ 74 ]. When health workers do not practice new skills gained from QI for extended periods, they potentially forget QI techniques, underscoring the importance of ongoing support and mentorship [ 69 , 76 , 81 ]. Being humble and non-judgmental as a mentor-supervisor, Manzi and colleagues [ 87 ] reported, was preferred by PHC health workers following interviews and focus group discussion in Rwanda.…”

Empanelment of the Population to the Primary Medical Care Institution of Sri Lanka: A Mixed-Methods Study on Outcomes and Challenges

“…Thus, the project could consider house-to-house visits by incentivized community volunteers or public health nurse officers recruited for community activities to enumerate the individuals in each house, and generate and issue the PHN. It may not be possible to involve the existing staff for active registration, as they are preoccupied with healthcare service provision in the facility and might not be able to dedicate time for registration activities in the community [26]. Further, to plan and execute active registration efficiently, the PMCIs should obtain an updated master line list (electoral list or enumeration list) of individuals in each GN division from the Grama Sevaks.…”

“…The programme managers need to monitor these targets on a monthly or quarterly basis and focus on the GN divisions and PMCIs with poor registration coverage. The recommendations made in our previous publications to overcome staff shortages and resolve the issues with HMIS should also be taken into consideration to enhance efficiency of the registration process [26,32].…”