Rising through challenges: Leading towards health system resilience ('Beyond Boundaries')
Dr. Lal Panapitiya
Scientific sessions are being continued yearly from 1993.
Considering the achievements of our prestigious college,
CMASL was able to develop Separate Board of Study in Medical Administration at PGIM in 1993, recognizing the significance of Medical Administration as the separate specialty for health system management.
The first batches of MSc and MD were enrolled in year 1994, 2004 respectively.
Since then, there were 21 batches of MSc and 13 batches of MD have completed comprising a total of 364 MSc PG holders and 58 Board Certified Consultants in Medical Administration up to 2023.
Ladies and gentlemen,
It is proud to highlight the rich and lengthy history of healthcare in Sri Lanka, dated back over 5000 years, the era of Maha Rishi Pulasthi and King Ravana. The books, Kumarathanthra and Arkasha Sasthra, wrote by king Ravana are still being used in Ayurvedic universities in India and Sri Lanka.
World’s oldest hospital has been found at Mihinthale as per the archaeological evidences. Surgical Instruments and Medical Equipment were also discovered in some other locations.
Allopathic healthcare system in Sri Lanka developed during the British colonial period, and first Primary Healthcare Unit was established in Kalutara, in year 1926. Other Healthcare Systems being operated here, also played a significant role in building system resilience, particularly in times of crisis.
These are many commonly discussed challenges in health sector, for decades.
Non-communicable diseases have become a huge burden on our health sector, utilizing large portion of budgets and facilities. Despite these, it is essential to continue routine services to save the lives of these patients and prevent complications even during crisis.
It’s important to note that all of these conditions are preventable through behavioural modifications, highlighting the importance of preventive care. Preventive health service achieved better health indices compared to even some developed countries, with some diseases eliminated and eradicated.
As you know, Health is in a dynamic environment, new challenges, diseases, changes in disease trend and patterns are inevitable.
Apart from the routine challenges as we discussed before, there are new challenges and issues leading to the frequent crisis in the current health system.
Even if, health managers focusing on planning and implementing new developments with innovations and technologies, their top priority and responsibility has become to ensure the healthcare systems resilient enough to meet the challenges head-on due to current unpredictable situations.
“Last year we navigated through the troubled waters, and now our duty is to rise through challenges beyond boundaries”.
When we consider the country as whole, there are five key pillars, which includes Health, Defense, Economy, Education and Judiciary system.
These are crucial for the development of any nation.
The structure cannot be strong when there is any collapse of even in a single pillar.
Likewise, a country cannot move forward and withstand, if there is any jerk OR fall OR collapse in any of the above pillars.
Whether we fortunate OR Unfortunate!!!
Whether we lucky OR Unlucky!!!
Whether we blessed OR Cursed!!!
We have already witnessed the jerk on three out of five pillars in our country.
We witnessed the jerk of Defense sector due to 30 years of war & Easter attack and how it has hinders the development of the country.
But, we, health sector and its services, been withstand during the entire struggle.
That’s called health system resilience.
We witnessed the jerk to the Health sector due to COVID pandemic and the impact on development of the country.
But, we, health sector as the frontline workers, get motivated, grabbed the opportunity, quickly redesigned and adjusted the health services as required to overcome the pandemic and successfully rendered the services for entire country.
That’s called health system resilience.
Now, we are witnessing the jerk to Economic sector and the depth of its impact on country’s development.
Again, we the health sector committed on ensuring the routine services and minimizing the health impact due to economic downfall.
That’s called health system resilience. Again!!!
We could be able to achieve resilient health system during above all hardships.
I want to talk about a concept that is novel but very important for all of us to understand – Building Resilient Health Systems Beyond Boundaries.
During all the above challenging period, we perceived the need for collaboration and coordination across borders and sectors to build health system resilience.
I believe, with the immense past experience, I can give a brief on health system resilience and why it warrants other sector involvement beyond boundaries.
The emergence and rapid spread of COVID-19 emphasized the critical importance of building resilient health systems all over the world.
Resilience – is a state of preparedness and capacity to withstand and respond to a shock.
Shock – means any known or unknown sudden and extreme changes in the environment of an organization which impact on the health system.
We should know the difference between a shock and predictable stresses in health sector, such as, population ageing, and increasing incidence of multi morbidity, etc.
There are many definitions for health system resilience.
In general, health system resilience is to get absorbed, adapt and transformed as a response to a change.
I would like to elaborate certain attributes of a Resilient Health System.
1. Being prepared with the capacity to Absorb & Adapt means the ability of health systems not only to prepare for shocks but also to minimise the negative consequences
2. Responding effectively to challenges and changes at different system levels – and Recovering as quickly as possible
3. Adapt by learning lessons from the experience (past or present)
4. Most importantly, maintaining provision of critical functions & essential services even with a crisis.
5. Focusing to deliver high-quality care services across varying conditions.
Here you can see, from the onset of a crisis/shock, performance of an organization is regressed. However, with absorption and adaptation, it can rise again and even transform into a better state, depending on the dedication and capability of managers/leaders.
As per the diagram illustrates here,
The management of shock is described as a cycle with four stages.
1. Preparedness, – identifying gaps and vulnerable areas
2. Shock onset and alert – timely identification of shock
3. Shock management with absorption and adaptation
4. Recovery and learning
There are some strategies developed for building a resilient health system to overcome any crisis situation. These strategies are based on the health system building blocks.
Let us discuss briefly on these strategies and some cost-effective activities making the system more resilient as well as efficient and safer.
1. Improved service delivery (Safe, Quality, Productive, Customer Focused)
2. Improved access to essential medicines, medical products, vaccines and technologies
3. Commitment to health equity & social justice
4. Strengthened health workforce
5. Health information systems (Improved surveillance systems)
6. Sustainable health system financing
7. Empowered leadership and Improved Governance
As mentioned above, to improve service delivery, it is necessary to develop the system as well as to build up essential resources that means improved access to resources and services. To design, develop and implement all above, there should be strengthened, skillful workforce. Other bases are sustainable health financing mechanism and improved information system with effective surveillance system.
When we achieve all these, it will ensure the social justice and equity as well as community engagement and empowerment. Success of all these strategies requires empowered visionary leadership with shared vision. Responsibility of leaders is to achieve the good governance and directing all stakeholders in to a common goal; whole of society approach – One Country – One Health.
There are many interventions implemented to improve the above all strategies by Ministry of Health.
Improved service delivery focused on delivering safe, quality, productive, and customer-focused services, even during a crisis.
Coverage and Accessibility of Health Service delivery in the country has been attained through preventive and curative care institutional networks with island wide coverage connected with good road network and transport system.
Effective system development with improved productivity introducing new technology and innovations can greatly improve the service delivery. It must be focused to enhance the capacity to deal with the demand in sudden surges.
I want to emphasize the importance of building up of essential resources for a resilient healthcare system. Medical Technology Assessment based on resource mapping provides a guide to identifying the norms for the distribution/redistribution, or reutilization of resources and services.
The main critical element for a successful system is a well-motivated, committed, supported strengthened health workforce distributed with the right skill mix. This is applicable for even preparedness and management of crisis. National Continuous Professional Development (CPD) Progamme has been initiated to strengthen more the Health workforce.
Accurate and timely information systems and information sharing culture both plays a significant role on timely decision-making. The effective surveillance system, integrated with alert mechanism is essential for the early detection of emerging health threats.
Ensuring a sustainable financing mechanism is essential for any system to operate efficiently and effectively highlighting the importance within a crisis.
· We must consider resource pooling and new ways of revenue generation mechanisms, such as local manufacturing even for export, medical tourism and educational tourism.etc
· Alternative financing sources with supplementary social security coverage through social health insurance and Earmarked tax (taxation on tobacco and alcohol diverted for health contingency fund) should also be considered.
Empowered visionary leadership and improved governance are crucial for the success of all other strategies discussed here.
A true leader is “The one who Knows the way, Goes the way and Shows the way”.
Governance is another main contributing factor for the resilience. The main features – Responsibility, Accountability, Transparency, Fairness and Stewardship to be followed by all institutions, government, staff, and the public.
In service provision for a resilient healthcare system, remember to ensure health equity and social justice in our efforts especially for vulnerable populations which could be achieved through all above
Empowering and engaging communities to be proactive and responsible for their own health needs and challenges, are essential for a resilient health system.
Ladies and Gentlemen,
} CMASL has dedicated to strengthen medical leadership and to develop transformational leadership from its inception.
} Frequent skill development trainings are being conducted not only for its members but also for MOICs and MOHs in Preventive Health Care (PHC) level.
} Middle Level Management training for MOIC, in order to develop medical leadership with technical, conceptual and interpersonal skills.
} CMASL always persuades to streamline medical administrative pathway of its members to get permanent administrative posts rather than covering up for a long time.
} Also, council is hoping to propose more conducive Medical Administrative structure in future with support of all stakeholders, as per already initiated discussions.
} Supportive mechanism for attending members’ grievances has been introduced.
} We suggest to aware basic management concepts to Clinical consultants which will be helpful to conduct day to day management as the clinical unit head.
} CMASL suggested facilitating revision of guidelines, manuals and preparing a roadmap with our proposal for making health system more resilient.
} All members have been informed to introduce new innovative projects to make the system efficient, quality and safer.
} These will be evaluated and appraised with the proper approval of DGHS and Secretary of Health.
} The achievements with best practices selected through a competition will be published through the college You Tube channel.
} This will be an initiation of evaluation mechanism encouraging dedicated leaders.
} It is through a teamwork with involvement and assistance of other sectors, other categories, other specialities, trade unions, intercollegiate committee with all other specialities, since this task could not be achieved alone.
} Hence, we invite you all to join in any relevant way for collaboration.
In order to be prepared for crises like pandemics, we need organizations that are adaptable, resilient, and capable of learning from both successes and failures.
Ladies and gentlemen,
There is “NO” set standards for health system resilience.
It’s all about keep on improving our-self and set our own standards at top level, based on the lessons learnt with the past experience, and the wisdom we have to foresee the future.
I would like to draw your attention to the fact, our discussion hereafter is not focused solely on the way we managed the COVID-19 pandemic, but rather on the developments and innovations that we implemented during this time making the system resilient, which are still valid and applicable for any future crisis as well as in routine management.
The success story of managing the pandemic was a shining example of the importance of medical leadership and a lesson in strategic management of service delivery and Human Resource Management (HRM). Unfortunately, we often forget the lessons we’ve learned due to our day-to-day routines.
During the pandemic, main focuses were to build up services for managing the crisis while maintaining routine patient care. I would like to mention 3 areas in pandemic management regarding Service Delivery with Building up Essential Resources.
Firstly, improving surge capacity gradually, in all 3 levels, by strategically identifying suitable care levels with least compromise to routines.
Second, managing high influx of patients specially during 3rd wave with implemented innovative solutions, such as,
· Home Based Care with a call centre
· Step Down Centres by utilizing Primary Health Care (PHC) institutions and developed Intermediate Care Centres
· Hotlines for patient information
· Decentralization of follow-up care to peripheries
Third, Oxygen management without any crisis was a cardinal issue, which has well-coordinated centrally, and strategically managed successfully with effective forecast. During the COVID crisis, we were able to improve all hospital infrastructures, with equipment, Oxygen management facilities as well as infrastructure for Molecular Medicine system.
It has strengthened our system more resilient even to face current as well as future crisis.
We considered innovative and flexible approaches during the crisis, in System development, such as,
· Strengthening primary healthcare facilities with necessary resources.
· Mobile Non-Communicable Disease (NCD) follow up clinics.
· Home-based care with call centre support.
· Use of Telemedicine/Tele-consultation.
· Community-based home visits
· Step down concept with underutilized PHC institutions
All strategies in HRM were implemented by the Ministry, for strengthening Health Workforce, during the COVID-19 pandemic management. We took all measures necessary to maintain their safety, such as awareness, training, availability of adequate PPE and isolation facilities. COVID crisis provides a good opportunity to introduce online meetings and online training mechanisms, especially for all health and non-health staff categories as well as public.
Following IT solutions and interventions designed to improve the overall medical information system were effective and instrumental during crisis management.
· Dashboards for COVID management
· HIUS for COVID patient statistics and surge capacity on preparedness
· ICU bed surveillance system
· Oxygen app to assess institutional availability and usage
· Health Net for mapping of resources
· Equipment inventory management system
· Hotlines for patient advice and consultation
· Online training platforms
One of the positive outcomes of the COVID-19 pandemic was the opportunity to identify gaps in our health system.
Accordingly, we have taken many measures for efficient cost-effective service to make our system resilient, such as, Revitalization of PHC level, introducing Telemedicine and many more.
Ladies and Gentlemen,
Today, we faces enormous challenges on provision of health services, including provision of essential medicine, laboratory services, brain drain of health workforce and financial hardship.
On top of that, risk of CBRN hazard is a major concern on global context. Natural disasters build on additional risk to the health sector.
Developing infrastructure, Ongoing CBRN trainings and hospital preparedness plans already initiated for CBRN hazards. For the impending crisis with HR issues, especially with specialist medical officers, we have proposed some solutions. There were limitless obstacles on moving forward our motherland as a whole.
As a country, we are in a crucial juncture where we need to make decisions like,
“Do OR Die, we cannot be in-between”.
As the president of CMASL, leading professional body in Sri Lankan health sector and health ministry official with responsibility and accountability, Myself, with the college and council, do our maximum to guide and support the higher authority, in this current context of the country.
In Conclusion of my speech, I would like to emphasize,
Ø Building health system resilience beyond boundaries – A priority
Ø Resilience is not only how a system absorbs a shock and adapts, also how it transforms and evolves.
Ø Given solution may create less effective to respond to future shocks, if not forecasted well
Ø Regular system review is a must – Remember, one shock can follow another.
Ø If, strategies in order, not only health system resilience but also building a world with access for better quality health care for all (UHC)
Ø Essential to have Bold leadership with cross-sectoral collaboration and governance
Ø To guide and direct for Whole-of-society approach towards a shared goal – One country – One Health
Finally, as I mentioned before,
Whether we like it or not, fortunate or unfortunate, blessed or cursed,
We have a long history of resilience and boundless experience on health system resilience, which is very much limited in the region and other part of the world.
We struggled, we survived and we thrived in the past.
“Greatest threat to our country is the belief that someone else will save our country”.
I would like to take this opportunity to call upon all the sectors of the nation, during this challenging period, for a joint venture for the sake of our motherland.
Again, we struggled, we are surviving now, and we will definitely thrive soon as a country.
That’s how the history says.
But, this time, we should not miss the opportunity to sustain, for the betterment of the future generation. We would like to invite all other sectors and eagerly waiting to extend our hands beyond the boundaries towards the common goal.
Past success is the future killer.
Crisis, always a good opportunity for a good leader to create new future.
Dr. Lal Panapitiya