Contents

• Section 1
• Blind tests with alcohol
  
• The “Marlatt Method”
• Alcohol and Sex
  
• Alcohol and inhibitions
  
• Are intoxicants magical substances?
  
• Magical substances or learned effects?
  
• The behavioral effects of alcohol – conclusions
  
• National responses
  
• Elements of a national strategy
  a. Taxation
  b. Regulation of availability
  c. Restricting promotion and marketing of alcohol
  d. Drink-driving restrictions
  e. Promoting optimal therapeutic interventions
  f. Preventing the ‘alcoholization' of all public and social events
  g. Dealing with different alcohols
  h. Dealing with the alcohol trade
  i. Practical issues
  
• Mobilizing influence
  
• Public opinion
  
• Dealing with politicians
  
• Dealing with corruption
  
• Assessment of needs
  

• Section 2
• Health and development challenges
  
• 2.Country situation
  
• 2.1 An Overview of Development
  
• 2.2 Health Policy
  
• 2.3 Health Care Financing
• Health Allocation and Expenditure in 1999
  
• 2.4 Health Situation

SECTION 1

Blind tests with alcohol

The blind tests which have been performed with alcohol have one potential source of error in common – all participants have already learned about alcohol in our culture (p.104). Later on, we will look at the best method of eliminating learned effects – studies of effects of alcohol in other cultures. But first we will look at the blind tests, of which far more have been carried out with alcohol than with illegal intoxicants.To mislead people as to whether they have or have not consumed alcohol, two conditions must be met:

Firstly, the taste must not disclose the alcohol content.

Alcohol's impact upon the taste of beverages is much less than most people believe. Experiments have established that the alcohol content is scarcely discernible in ordinary drinks (6-8 % alcohol) and common beer (4.5 %). Hence, these beverages have been used in several blind tests. Stronger beverages have also been used. Research groups in New Jersey and Montreal have used drinks with 13-15 % alcohol, and some others have used 20-30% alcohol (!). This makes the conclusions less reliable.

Secondly, internal cues must not disclose the presence of alcohol in the blood. The concentrations of blood alcohol that human beings can detect, varies between individuals and between situations. One blind test aimed at finding which internal cues most reliably informs as individual of having alcohol in the blood.

The participants drank various beverages and were asked to fill in a questionnaire where several internal cues were mentioned. For some internal cues, even an alcohol content corresponding to a little more than one ordinary drink made a small difference – a modest, but statistically significant tendency that answers were more often correct than false. But uncertainty was the rule at this level of blood alcohol.

This shows that even a little more than one ordinary drink, has effects which may be detected under optimal circumstances. But the participants knew that some did not get alcohol, they had been instructed to use their senses well and were even told which internal cues they should look out for. They were concentrating on a questionnaire instead of participating in the social activities of a normal drinking situation.

Most of the blind tests with alcohol nave used quantities of alcohol corresponding to 2-3 drinks or glasses of wine. Such amounts of alcohol are most commonly consumed, and the most enjoyable psychological effects are also attributed to these quantities. But as these amounts produce internal cues which may be detected, there may still be a danger that in “blind” experiments, effects are attributed to alcohol which in reality are caused by the identification of cues associated with alcohol.

Because the experimenters' deception may be revealed, this method can perhaps not prove behavior effects of alcohol, but may possibly indicate cases where expectancy effects may be sufficient to produce behavioral changes which are commonly attributed to alcohol.

The “Marlatt Method”

At blind tests, alcohol is served in concentrations and quantities at the brink of what people may detect. Therefore, the conditions during the experiments are of crucial importance.

The best procedure has been developed by a group of researchers led by Alan Marlatt, who is a professor of psychology at Washington State University in Seattle . The group published their first experiments in 1973-74 and since then, they have further developed their technique.

The participants are divided into 4 groups:

.

	One half is told vodka-tonic:	One half is hold tonic only:
One half gets vodka-tonic:	Told alcohol and does drink it	Told tonic but drinks alcohol
One half gets tonic only:	Told alcohol but drinks tonic	Told tonic and does drink it

Each participant's beverage is apparently decided by tossing a coin. But the coin is rigged – both sides are identical!
The mixing of drinks is observed by the prospective drinker. Smirnoff vodka and tonic is poured into the glasses from correct bottles. For those who only receive tonic, but are told they will receive alcohol, the vodka bottle contains de-carbonated tonic.

When vodka and tonic is mixed in the ratio 1 to 5, there is little risk that the participants will recognize alcohol by the taste. But to make sure, the participants receive a dose of mouth-spray prior to drinking.

The blood alcohol level is apparently measured by breathing into an electronic Alco meter. But the alcometer is rigged and only confirms the instructions given on the beverage content. Because alcohol is served in quantities which may be noticeable on the basis of internal cues, Marlatt and his coworkers want to avoid the artificial situation that participants stop their normal activities in order to concentrate upon internal cues. Avoiding questionnaires, the participants are encouraged to take part in social activities while research assistants discreetly observe behavior and measure reactions.

Concluding the experiment, the success of the beverage manipulation is checked by asking how much alcohol each participant believes he has been drinking. To make the drinking situation as realistic as possible, Marlatt and his group have even made a “simulated bar-room”, which is situated in the basement of Guthrie House on the campus in Seattle . At least for a visitor, it is hard to notice any difference between the simulated bar-room and a real bar-room.

This is the most convincing method for blind tests with alcohol. But in spite of the sophisticated technique, sources of error still exist, as the participants have experience with the substance being tested. The participants may recognize taste or effects of alcohol and reason that “I know I didn't receive alcohol, but my feeling is the very same…” Learned effects may also operate at the unconscious level: Internal cues which through learning have become associated with, as an example, joy or loss of inhibitions, may be interpreted as these feelings. This is why blind tests with participants experienced with alcohol, cannot totally exclude all learned effects.

Most of the blind tests which have been published, have used far less convincing techniques than the one which was described here.

Many blind tests have used the “Stop, site down and concentrate upon internal cues”-method (questionnaires). This does not resemble an actual drinking situation and reduces the validity.

Numerous studies have not included a check on the beverage manipulation. In other studies, the check shows that manipulation has been deficient. In addition, recent studies indicate that even if certain manipulation checks may give erroneous evidence of apparently successful beverage manipulation. In the following pages, an outline is given of most of the blind tests that have been published. Only experiments with major errors in methodology have been omitted from the review.

Alcohol and Sex

A quotation from Shakespeare says that alcohol “increases desire, but takes away the ability”. Several people claim that moderate amounts of alcohol also increases ability, just like users of marijuana claim that their intoxicant does.

Numerous blind tests have been performed, especially at Rutgers University in New Jersey .

In most of the studies, the sexual arousal has been assessed by objective measurement. The methods are commonly used in sexual research. Small devices measuring the reactions are located on the participants, while they are watching films or listening to tapes with sexually stimulating content. Males have a little rubber ring measuring the penis diameter, while females have small device in the vagina, measuring blood pressure and vein volume.

The experiments have shown conclusively that alcohol reduces sexual arousal.
The two experiments with females have demonstrated a decrease in arousal following alcohol consumption.
In studies with males, the given dose of alcohol has weakened arousal in 4 experiments and produced no changes in 5.
In one study, the male participants were instructed to suppress their sexual reaction. The conclusion was that alcohol reduces the ability to control the reaction.

The conclusion of the research is obvious: Alcohol reduces sexual arousal, and most of the doses served in these experiments (approximately 2-3 drinks) are sufficient to demonstrate the reduction.

When objective measure are not employed, and the participants are instead instructed to concentrate upon their internal cues, the response could be based on interpretation of the internal cues. As might be expected, this method produces more varying outcomes:

In two studies, the participants declared they had increased arousal when actually drinking alcohol, while objective measures taken at the same time showed that the opposite was the case. In two other studies, the participants also declared that they had more arousal when they actually had alcoholic beverages. It is not clear, however, whether this reflected the obviously deficient manipulation of beverages.

Studies of chemical substances' effects upon human sexual functions have become difficult to finance in the United States , as federal funding is no longer granted. Congressman Michel from Illinois proposed and got support for a law banning federal support, claiming that the studies “offended the feelings of most Americans”. His assertions were widely publicized and happened to coincide with his bid for reelection, which ended with the voters granting him renewed confidence.

Alcohol and inhibitions

Few blind tests have dealt with alcohol and inhibitions. Some studies on sexual reaction throw light on the topic. Research groups have shown that men's increased sexual arousal when they believe they have been drinking alcohol, is strongest if the erotic stimulation has the character of a taboo, indicating that consideration for self respect normally dampens arousal. In one study, the stimulant material was homosexual practices and in the other cases rape or other violence related to sex. The figure on the next page shows average sexual arousal to various stimulating materials.

The report concludes that this finding throws light on the frequency of alcohol intoxication at the time of rape and other sex crimes – when men think they have been drinking (and in most cases, they do have been drinking!), they let out more of their forbidden impulses. The report also concludes that alcohol itself does not seem to remove inhibitions.

A group at the University of Wisconsin used other techniques to study the effects of alcohol on sexual interest.

Seventy-two young males were divided into groups which were convincingly manipulated into believing that they either did or did not receive alcoholic beverages (the “Marlatt method”).

Are intoxicants magical substances?

Magical substances or learned effects?

The most important conscious motives for intoxicant use are the beneficial effects upon mood and behavior. They are reported to:

Produce a feeling of well-being

.

Marijuana smokers and alcohol drinkers attribute many of the same qualities to their intoxicant.

Thus, the motives for use are not very different. Similar effects are to a large degree attributed to other intoxicants.

The popular idea is that any feeling and all kinds of behavior may be attributed to drugs of abuse. Not surprisingly, wishful thinking is prominent: Any feeling and behavior that people may desire is attributed to intoxicants. There are many metaphorical descriptions of pleasurable experiences during intoxication. In most cases, the descriptions have an “as-if”-character:

•  As if I saw the world in a clearer light

•  As if the music was more beautiful and the colors stronger

•  As if I were present and at the same time not present

Can widely different chemical substances really have such similar effects? Can chemical substances have so many, specific, marvelous, and even supernatural, effects?

Drugs are, of course, used in psychiatric treatment, because research has established that these drugs have beneficial effects on certain symptoms. But the effects are rather non-specific and do not influence such specific dimensions as self-confidence and inhibitions.

Knowledge of psychiatric drugs leads to skepticism towards the apparent effects of intoxicants. Intoxicant effects appear to represent true magic. A psychologist labeled his lecture on popular belief about alcohol effects: “ Alcohol – the Magic Elixir.”.

Medical doctors have traditionally said that intoxicants induce “euphoria”. The word means a good mood and a pleasant feeling. At first sight, this labeling seems convincing. But the research supporting this theory is lacking. Medical doctors were expected to explain why people choose to use harmful drugs. The explanation was a word – euphoria – which apparently provided an adequate explanation.

But popular opinion is ambiguous. A survey in Norway concluded that

•  45% of adults believe alcohol produces a good mood

•  55% do not believe that alcohol produces a good mood

The figures indicate that among those that have personal experience with alcohol use, the popular opinion is divided almost down the middle. Who is right?

The behavioral effects of alcohol – conclusions

In their highly acclaimed survey of the anthropological research, Edgerton and MacAndrew drew this conclusion:

“Over the course of socialization, people learn about drunkenness what their society “knows” about drunkenness; and, accepting and acting upon the understandings thus imparted to them, they become the living confirmation of their society's teachings.”

Subsequent anthropological reports have given additional support to this conclusion. Alcohol's removal of inhibition is the most prominent aspect of its effect in the Western culture. It is a very old phenomenon. The effect is substantially stronger in Northern Europe than in Southern Europe . Nevertheless, the difference is one of degree. To some extent, disinherited drunk behavior also exist in the Mediterranean countries. In several other societies, this effect of alcohol is entirely absent. Some anthropologists have concluded that disinherited drunk behavior has been spread by the white man to other cultures, just like the neck tie and Coca Cola.

The blind tests with alcohol have some limitations in their methodology. For two reasons, the trans-cultural studies of alcohol effects are the most conclusive:

•  Learned effects can be clearly separated from pharmacological effects.

•  Alcohol effects can be studied at all levels of alcohol consumption.

The anthropological studies of alcohol use correspond to studies of the effects of other intoxicants in groups which have not learned to consider them as intoxicants. These groups experience opiates, solvents and most other intoxicants as unpleasant and the individuals do not spontaneously perceive the effects as being “high”.

The decisive importance of learning for the subjective experience of “getting high” and “disinherited”, refutes some biological theories which have been put forward:

In animal research during the fifties, a Canadian psychologist discovered the existence of a “center of pleasure” in the brain. This led to theories of intoxicant use as being motivated by the wish to stimulate this “center of pleasure”. During the seventies, researchers discovered the so-called endorphins, which are morphine-like substances produced by the human body. This, too, led to speculations on the mode of operation of intoxicants.

These theories are seeking pharmacological explanations and justifications for socially derived experiences. There is an increasing need for scrutinizing our ideas about intoxicants, intoxicated behavior and the psychological effects of intoxicants. In the next chapter, we will look at the relationship between the chemical effects of intoxicants, the bodily reactions, the subjective experience and the intoxicated behavior.

---

National responses

The most effective measures for reducing alcohol problems nationally are those that reduce aggregate or per capita alcohol consumption. There are other more focused interventions or actions that can reduce harm without necessarily reducing consumption. Setting up treatment services for alcohol dependent persons and drink-driving restrictions, are examples.

Just as for a small community, the strategies for reducing alcohol problems nationally can be defined. National strategies are, in fact, easier to define than community strategies. Effective national measures are far better recognized than community strategies. But at the national level the resistance to useful strategies is much stronger than at community.

Elements of a national strategy

The requirements for a national strategy can be derived from the changes that were proposed for community action. At national level, even more than with a small community, a population shift has to be pursued. The specific measures available to achieve them are obviously different from those at community level. But the national effort must facilitate the desired changes at community level.

Useful national alcohol policies are known. But they are not widely accepted, primarily because they are made a subject of controversy. Some of the more important policies are taken up in the following paragraphs. The relative cost-effectiveness of different strategies varies according to the country situation. But those listed first (a to d) are likely to work for all. The relative weight that should be given to each of the items depends on the current situation of the country.

a. Taxation

Increased retail price through increased taxation reduces alcohol consumption and resultant problems. Countries need to optimize the benefits obtainable through increased alcohol taxation, as a source of increased government revenue and as a public health measure.

The benefits of higher taxation are obscured by the debate generated around potential harmful consequences. Most of the debate is about a claimed increase of illicit alcohol sales and about cross-border illegal trade in alcohol. Another argument in opposition is that the increase of tax places a relatively higher burden on the poorer members of society. The weight of the evidence available at present goes against both these arguments. But the evidence is not weighed dispassionately. Discussion on the subject tends mostly to be an argument between the public health oriented versus the alcohol trade oriented.

In such debates the perceived ‘winner' is often the party with greater influence over the mass media. And this usually results in defeat for the camp oriented towards public well-being. The means to make alcohol less affordable must still be pursued. It is a powerful intervention and cannot be ignored, whatever the distractions.

The word ‘regulation' creates images of draconian restriction. This is not quite what ‘regulation' is intended to achieve but it is easy to portray it as such. The result is that any regulation is equated with prohibition – which is widely accepted as having been disastrous wherever it was tried. Measures that fall under the heading ‘regulation' include the differential control of beverages according to alcohol content, limitations of the times of sale and the geographical density of alcohol sales points. These measures generally require government action.

Local action can occasionally exert some control over availability. Such action has mostly had impact on the availability of illicit alcohol.

c. Restricting promotion and marketing of alcohol

Promotion is not only advertising. And the alcohol trade is not the only agent promoting alcohol. Many other persons and agencies promote it, sometimes unwittingly and for no commercial benefit. National policies usually focus on paid promotions – namely formal advertising. This is no surprise, as the easiest targets for restrictions are the obvious or frank advertisements.

Formal advertisements may not be the most powerful promotions. The evidence available on the cost-benefit of restricting alcohol advertising is not comparable with that available regarding tobacco. Few countries have, other than for religious reasons, prohibited alcohol advertising. The impact of advertising restrictions cannot be assessed through the experience of countries that impose them for religious reasons, given the multitude of other cultural influences that go with it.

National legislatures are generally helpless in controlling the promotion of alcohol through convert means. A good example is how alcohol is linked to sporting events. The association of alcohol with sports is not limited to direct advertising and sponsorship. Portrayals of alcohol in the mass media can serve to enhance its appeal, especially to vulnerable young people. Such promotion of alcohol may often be inadvertent. But they serve to promote it nonetheless. Guidelines for media portrayals of alcohol are in evolution. Voluntary adoption by the media of such guidelines may lead to beneficial changes in the way alcohol is portrayed. This is of course if the media pay more respect to voluntary agreements than the alcohol trade has so far done.

d. Drink-driving restrictions

The measure applies not only to driving of motor vehicles but also to other tasks carry hazard when level of arousal is impaired. The greatest mortality from this cause is through road accidents. With adequate random testing and enforcement, this measure reduces road deaths.

No responsible agency should attempt to increase the blood alcohol concentrations permitted in those driving motor vehicles. The alcohol trade too wishes to reduce alcohol-related road fatalities. Any attempts by it to shift the permitted blood alcohol limits upwards should raise questions about its sincerity in wanting to reduce alcohol-related harm.

e. Promoting optimal therapeutic interventions

‘Treatment' for people with alcohol dependence is generally recognized as a necessary component of a national response. But the full range of interventions needed is not readily appreciated.

‘Services' should be for all levels of users, based on their different needs, and not just for a few at the extreme end. There is a need to offer interventions for the range of users, as appropriate.

Medical services tend to look at the needs of people with severe dependence, usually associated with physical illnesses resulting from heavy alcohol use. But a person who spends over half his salary on alcohol on ‘pay-day' needs to change too. And such persons often need some outside intervention to bring about the change. So do communities that allow people to be violent after alcohol use.

To meet the needs of the wider range of users, ‘alcohol services' must spread beyond the specialized. Help for people with alcohol problems has to be provided by accessible, and therefore non-specialised, services too. The range of interventions that such services offer should be in keeping with the needs of all users, and of communities where alcohol use is significant.

f. Preventing the ‘alcoholization' of all public and social events

This is not a ‘standard' recommendation. But the increasing integration of alcohol use with ordinary social and public events does lead to it becoming increasingly the norm. All social functions then become alcohol functions. Beneficial impact from action on this issue can be demonstrated at community level but is difficult to test in wider application.

Monitoring the national shift is necessary. Is the national trend towards increasing the range of events and places where alcohol is a ‘natural' part of the proceedings or the setting? If so, is this desirable and to be encouraged or a worrying sign?

Some individuals are uncomfortable consuming alcohol when even one other in the party is not. They tend to create subtle and crude pressures that others too should drink with them. Where this tendency I strong, any increase in events in which alcohol figures result in large numbers being pressed to consume more than their norm. If alcohol keeps infiltrating new events and occasions, the population norm will too be influenced.

g. Dealing with different alcohols

A common tactic of those who wish to derail national action on alcohol is to generate confusion through plausible arguments about illicit alcohol or different types of alcoholic beverages. The commonest of these is putting about the argument, ‘Illicit alcohol use will increase'. This is almost invariably trotted out, as a means of obstructing any measure that could reduce licit alcohol use. A similar argument, ‘Hard liquor use will increase' is used against any measure that restricts the availability or affordability of lower strength alcoholic beverages, such as beer.

A national strategy must address all alcoholic beverages together. Initiatives to restrict availability or marketing have to address equitably the range of beverages and drinking practices. Even when a comprehensive look is taken, particular vested interest groups can still confuse issues by generating much media noise that one or the other alcohol is being ignored or favored. The genuine response will then be possible, that they have all been considered. It will still be difficult to make people hear this response through the propaganda din.

.

A national strategy to reduce alcohol problems must seek to win over by goodwill, or regulate through authority, the trade in alcohol. There is much that can be won through enlightened partnership between the trade and those trying to reduce alcohol-related harm. But ‘partnership' should be focused clearly on reducing harm, not increasing sales or forestalling any potential fall. If not, partnerships with the alcohol trade are likely to increase harm. The evolution of alcohol problems in Britain from about the late 1980s should be watched, as that country provides probably the best available case study of continuing partnership of the alcohol trade with agencies primarily interested in reducing alcohol related harm.

Partnership should not be advocated simply as a demonstration of an enlightened approach to problems: to flaunt our ability to discuss and compromise. It should lead to the public good. It should therefore allow those interested in public welfare to persuade those mostly interested in profits and public image to take the pubic interest more into account. It should go beyond the cosmetic and the ineffective. The idea is not to be diverted by things that do nothing to reduce harm.

i. Practical issues

The preceding sampling shows the kind of things that are useful to implement at national level. How may these by translated into practice? Countries differ in the extent to which they already implement each of these recommendations, and others. But national action can improve everywhere. The greatest need for action is where there is least action by the state to reduce alcohol problems. How concerned citizens should proceed, especially in such countries, depends mostly on the character of those who wield power.

As at all other levels, there are limitations imposed on achieving what is theoretically desired. The major limitations in practical implementation are those imposed by finite resources. The implementation of a national strategy must cover certain fundamental issues, but the depth of coverage on each will differ. Some relevant aspects are mentioned briefly. The intention is not to give a comprehensive ‘action plan' for a nation. Such an attempt is unrealistic.

Mobilizing influence

Getting desired national action implemented boils down to getting enough influence or power on its side. The influences that seek to reduce or prevent harm have to be on par with or stronger than those that want to promote continued increases in consumption. Public attitude or interest is probably the strongest source of influence either way. Some issues to be dealt with are mentioned below, but the practical steps to address than vary enormously according to the local realities.

Public opinion

Public opinion about a need for action stems from people recognizing the harmful consequences of alcohol use, just as it does from social habits and traditions. Opinion is most readily created and expressed through mass media coverage. And the media tend to be open to influences of different kinds. Some of these may want to keep the media silent on certain issues of commerce. But the imperative to action is difficult to suppress just by silencing the media. Alcohol problems of any significant degree are felt at close quarters. So the media cannot completely suppress attention to alcohol related harm.

It is more difficult to get public support for the actions that are most likely to reduce harm, than for just the idea of taking action. Support for the most effective measures is influenced strongly by who has greater control over what the media convey. Spurious, but superficially convincing, arguments can easily be put about, opposing useful measures. These are difficult to counter without adequate resources to disseminate the counter evidence.

A more insidious tactic is to divert public demand for action into channels that will not really reduce consumption or problems. Giving education about alcohol generally falls into this category, although it should not. Tediously informing people about the hazards of alcohol is somehow poplar. Children, especially in school, are in many countries the commonest victims of such education.

Dealing with politicians

National policy action requires political will. Politicians learn from the mass media, not scientific publications. And they usually meet more advocates and lobbyists for commercial interests than those for public health or public welfare. Convincing politicians is therefore a strenuous exercise. Progress around the world demonstrates that the exercise, though arduous, is not hopeless.

Politicians are at times motivated to be of service to the public and so to do what is in the wider public interest. Even those who are not strongly inclined this way are still sensitive to the opinion of voters. Because a large proportion of voters act according to party loyalty, irrespective of a party's action, the voter influence is hard to mobilize. It is much easier to look for, or wait for, the sincere politician than to convince the uncommitted.

Dealing with corruption

Corruption is encountered at all levels. Even the small-scale brewer of illicit alcohol in a village has links with sources of protection. The bigger players have much greater influence. Fortunately though, neither politicians nor law-enforcement officers are all corrupt. National progress is most readily achieved by lying in wait for the honest politician and then moving fast.

Assessment of needs

Why is a response needed? The national need to do something about alcohol has to be established. So does the need for an intervention at any local level. It is generally not difficult to convince the independent public.

Needs are not determined only by formal scientific research that gets published in respected journals. People do not always have to wait until the formal studies are done, in order to respond. If the responsible and informed opinion in a country or given locality is that a particular problem is serious, that is good enough to justify action. But it is useful to have at least a brief documentation on how the informed opinion was determined or tapped. If there is more objective data, that could be cited.

The world is divided into less affluent and more affluent countries, on either side of a line that is not always easy to discern. But between countries close to the two extremes, the differences are stark. Realities around alcohol use can be very different for the less affluent countries from those for the more. Responses too must vary according to these broad difference.

Where it is possible, a systematic assessment can be made too. The money available determines how thoroughly things can be studied. An assessment does not always have to be tediously exhaustive. Even a rough and ready ‘country situation' may have to serve, depending on the purpose, the urgency and the resources available. Some elements to look at are suggested below.

SECTION 2

Health and development challenges

2.Country situation

2.1 An Overview of Development

Sri Lanka has achieved relatively high standards in social and health development. Its high level of attainment in the Human Development Index (HDI=0.711) has been a well-celebrated success story of a developing country. The level of achievement in terms of basic health and education indicators approaches the levels reached by the more developed countries. The life expectancy at birth (73 years) is considerably above the world average. The literacy rate is also relatively high (90 percent).

The gender development index for Sri Lanka is well above the average for developing countries. Gender empowerment in Sri Lanka is also much higher than in the rest of the countries in South Asia . The female participation in the work force is fairly high, particularly in the professional grades and garment industries. There are also more women employed at administrative and technical levels than in the rest of South Asia

The growth of GDP in Sri Lanka has been around 5 percent. The conflict in the North and East provinces has adversely affected the performance of the economy. The 1999 Annual Report of the Central Bank of Sri Lanka estimates that the conflict has reduced the Sri Lanka 's economic growth by about 2.3% points a year. The recent economic downturn and the persistent drought over the last two years have eroded the economy of the country. Many households, particularly those from the rural areas, have become destitute or insolvent.

The sectors with the highest level of poverty are agriculture (51%) and mining and quarrying (59%). The available evidence from recent surveys shows that the bulk of the poor comprise:

a). Workers and self employed individuals living in remote inaccessible areas which lack basic infrastructure.

b). Landless workers engaged in temporary work which yield low wage rates such as agriculture, mining and quarrying, construction etc.

c). Plantation workers.

d). Significantly low income urban and slum shanty dwellers and also emerging as a major problem.

About 80% of the poor reside in the rural areas compared with 8% in the urban areas and 4% in the estate areas. A shift from a lower to a higher poverty line in some of the surveys carried out indicated a substantial rise in the poverty level in the above mentioned three sectors (i.e., agriculture, mining and quarrying). This suggests that borderline poverty is a significant problem in these sectors, with the estate sector showing the highest level of vulnerability. In terms of social indicators such as access to safe sanitation, safe drinking water, safe cooking fuel and electricity this sector is also the least developed. The 2000 demographic and Health survey (Dept. of Census & Statistics) revealed that in terms is more deprived than the other sectors e.g. Immunization coverage for children under 5 is significantly lower than the children in urban and rural sectors and children under 5 in the estate sector are also significantly under-weight when compared with the children in the other 2 sectors. A recent study estimated that out of a total of 4.35 million children surveyed in the age group 5-17, 21% are engaged in some form of employment. 52% of child workers are below 15 years. 62% are male child workers and 95% come from rural areas. 10% of these children have dropped out of school in order to gain some income generating employment.

Sri Lanka has been immersed in an ethnic conflict in the North and the East for over almost 2 decades. The humanitarian social and economic impact of the war is felt most directly by populations in the North and East and the areas bordering it. Some of the effects of the conflict include loss of lives and psychological trauma, damage to infrastructure and homes, displacement, restricted mobility, disruption of local economics, disruption of community and institutional networks, disruption of educational facilities and deterioration of the health services. Although the Government is trying to maintain a normal level of health services in the conflict affected area, this could not be achieve due to the destruction of health facilities in a number of areas and the non-availability of qualified medical personnel. Virtually everyone in the Wanni area suffers from inadequate medical and educational services the conflict has caused. The United Nations has estimated that the number of persons internally displaced is around 600,000. A recent survey carried out in the Trincomalee district found that 27% of children under 5 were stunted, 26% were wasted and 50% were under-weight. All three indicators were significantly higher in the uncleared areas.

2.2 Health Policy

The National Health Policy has undergone changes twice in the last decade. Overall, the policy has remained consistent though there have been political changes in the government. The main aim of the health policy is to:

•  Reform the organizational structure and management to improve efficiency, effectiveness and accountability.

•  Establish mechanisms to provide need-based care, set priorities and allocate resources equitably.

•  Focus on vulnerable groups and community needs that required special attention: the elderly, disabled, mental health

•  Improve patient care provision and quality by reorganizing the health care delivery system especially at district and provincial level.

•  Rationalize human resources development.

•  Increase the life expectancy by reducing preventable deaths due to both communicable and non-communicable diseases.

•  Improve the quality of life by reducing preventable diseases, health problems and disability.

•  Intensity health promotion through IEC and the media

2.3 Health Care Financing

Throughout the 1990's, total health expenditures were in the range of 3.1 to 3.5% of GDP with Government and the private sector taking almost an equal share of the total. A very large share of the public expenditure is incurred by the Central Government while provincial revenues and other public sources account for a revenues and other public sources account for a relatively small part of the total expenditure. Most of the private financing is from the household out of pocket spending. Employer spending commercial insurance and NGOs account for a minor share of the overall expenditure.

Public expenditures at current market price grew from Rs. 5.6 billion in 1990 to 19.2 billion in 1999. Government and private sources accounted for approximately 50% each of total financing throughout the decade, or between 1.5 and 1.7% of GDP each. Although real incomes rose strongly during the decade, government health expenditures rose much slower than the GDP in the same period.

Total Expenditure on Health at Current Market Prices – 1999

Health Allocation and Expenditure in 1999

Rs. In Million

Item	Recurrent	Capital	Total
Department of Health Services	8551.2	2705.6	11256.7
Provincial Council	4752.6	43.3	4795.9
Total health expenditure In Rs. In US$	13303.8 166.3	2748.9 34.4	16052.7 200.7
Ministry of Health and Indigenous Medicine	42.2	2253.4	2295.8
Department of Ayurvedic	98.6	34.4	133
Total Government Allocation in Rs.	200,842.7	138,391.3	339,234.0
Total Government Allocation in US$	2,510.53	1,729.89	4,240.43
Total health allocation as % of total Government expenditure	6.6	2.0	4.7

It has been stated in the Poverty Reduction Strategy document (PRSP) that:

“The government supports a policy of universal health services for all its citizens. Ensuring the continued financial sustainability of the health sector while protecting equity of access and quality of care poses an important challenge. To enhance the financial sustainability of the health care system the government will, by 2003, adopt a national health sector programmed approach that would introduce measures aimed at overcoming regional disparities in access, rationalizing investments and services, encouraging the adoption of health insurance and strengthening hospital-based management systems. The Government will maintain health care expenditures at 8 to 10 percent of total public outlays.”

In reality, the actual government expenditure on health ranged from 4.1% to 5.6% between 1996 and 1999, which does not support the comments of the PRSP that expenditure will be maintained at 8 to 10 percent of total public outlays. Currently, Sri Lanka spends around US$10 per capita on health, only about half of which is borne by the Government. This amount is far below the estimation made by the World Bank in 1994 that the basic package for health should be at least US$14 per person.

An analysis carried out by the Management Development and Planning Unit of the Health Ministry has found that the allocations made to the Provincial Councils should be enhanced and made more accountable. Depending on the health infrastructure, disease pattern and major health issues, economically backward areas such as Moneragala should receive a more realistic allocation.

The percentage spent on Community Health Services was only 16.1% of the total health budget. This holds true at both national and provincial levels. Sri Lanka has realized that the health budget has a disproportionately larger allocation for the curative health services, whereas the emphasis should be on preventative and public health.

2.4 Health Situation

The successes achieved in the Sri Lanka health sector are well known. The vital health statistical parameters indicate the successes achieved by the country. The infant mortality rates, the maternal mortality rates and the crude death rates have been significantly lowered since the beginning of the last century. Sri Lanka has an excellent health infrastructure and has provided its people with medical institutions within a five-mile radius.

Life expectancy for males and females are 71 and 75 respectively. Sri Lanka , although having a modest GDP, has been hailed as a country that enjoys a good health status, which compares favorably with developed countries. Besides, Sri Lanka enjoys a high literacy rate. Since the early 1950's there was a population boom in Sri Lanka . However, with an effective family health programme, it has been able to reduce its annual population growth rate to a minimum. Sri Lanka has eradicated Smallpox and has now achieved Universal Child Immunization. It is now well on the way to another landmark, i.e., eradication of Polio.

Sri Lanka is in a epidemiological transition whilst still being affected by communicable diseases like malaria, tuberculosis, other vector borne diseases like Dengue Hemorrhagic Fever, Japanese Encephalitis, Diarrhoea and Acute Respiratory infections, emerging diseases such as Cardiovascular Diseases (Coronary and Ischaemic heart diseases), Cerebro-vascular illnesses, Diabetes and Cancer are now playing a greater role in the morbidity and mortality patterns in Sri Lanka. Other components affecting health are pesticide poisoning. Sri Lanka has one of the highest suicide rates amongst adolescents and young adults. Malnutrition exists amongst disadvantaged population in Sri Lanka especially in parts of the North-East, North Central and Uva Provinces .

With the increase in the life expectancy of the population and the steady decline in fertility, Sri Lnaka is aging rapidly. It is projected that by 2020, 20 percent of Sri Lnaka's population will have reached 60 years of age or over. Although the care for the elderly has been, to a large extent, carried out by their children, the extended family system is fast breaking down due to a change in the socio-economic structure and the rapidly growing urban population. The total fertility rate (TFR) in 2000 has reached a new low of 2.3. In a small family where both husband and wife are wage earners they are unable to look after their elderly parents. The successful family programme over the past three decades has substantially brought down the fertility level of the population. The most recent contraceptive prevalence rate (2001) has been reported to be as high as 70.8%, although there still exists a fairly small but persistent percentage of eligible couple practicing traditional methods. Mortality rate, currently at 5.7 per 1000 population (CDR in 2000), has been steadily declining since independence. The present trend has clearly indicated that Sri Lanka has entered the final stage of the demographic transition.

With the present conflict, over 600,000 persons have been displaced. The disease burden of malaria and diarrhea are at a premium among the displaced are at a premium among the displaced persons and those living in the uncleared areas in areas in the North-East. Tobacco, substance and alcohol abuse have also increased in magnitude over the past two decades.

Although HIV/AIDS situation in Sri Lanka is not alarming yet a cumulative total of 358 HIV infections yet a cumulative total of 358 HIV infections has been reported out of an estimated 8,500 persons. The number of new cases detected in 2000 was 54. The male/female ratio is 1.6:1. Since 1992, the HIV infections amongst women have shown an upward trend. The predominant mode of transmission has been sexual (82%).

There are other problems that are related to the development of the health system in the country. The health information system of the MOH, which has only recently received greater attention, is in a weak state with little means to verify the quality of the data it collects and processes. Moreover, information utilization by the decisions makers is very low. The existing laboratory system and network has not been functioning properly which has become a major cause to frequent transfers from the lower level health facilities to the higher level institutions. The pharmaceutical system similarly has several problems. Quality control in pharmaceutical production as well as pricing and prescription of drugs and medicine have been major issues that have not received adequate attention. Human resource development and deployment continues to be a major problem in the state health sector, which has adversely affected the peripheral health system. There is an acute shortage of nurses and other allied health and medical personnel in the country while concerns of health education continue to be dominated of medical doctors. The current health situation is further affected by the unwillingness of medical professionals to work in the peripheral areas and their over-concentration in large urban centers, depriving the rural population from getting a fair share of the health services they deserve. The imbalanced human resource development and deployment in the health sector has now substantially eroded the integrity of the health system at the sub-national level.

lthough there has been a series of attempts to reform and to decentralize the health system since 1987, the reform agenda could not be completed due to various reasons. All these have called for a continual reform of the health sector with a substantial improvement. Over the stewardship of the health system. WHO has a major role to play in assisting the Government as well as other stakeholders in the health sector to put the health system back on the right direction.

.