COUNTRY PROFILE INDEX INTRA II 1. Introduction; brief historical and social-economic background of the country 2. Demographic Trends: 1 2.1. mortality rates 2.2. fertility rates 2.3. population structure (by sex and age-groups) 2.4. 50+ 2 population breakdown ;its evolution in the last 10 or 20 years and projections for the next two decades 3. 50+ Population: General Assessments 3.1. Sources of income (i.e. income from pension, work, family networks) poverty rates among older people if available 3.2. Working Status (retired, employed, unemployed, informal sector) 3.3. Educational levels by age group 3.4. Housing/living arrangements 4. 50+ Population: Health Indicators 4.1. Mortality Rates & other related indicators 4.2. Main Causes of Death 4.3. Healthy Life Expectancy 4.4. Secondary and tertiary care ( hospital admissions and related information) 4.5. Morbidity rates (if possible: use data from community based surveys) 4.6. Chronic disability 4.7. Functional capacity; activities related to daily living (ADLs) 4.8. Instrumental activities of daily living (IADLs) 4.9. Risk factors for non-communicable diseases (particularly tobacco use; alcohol consumption; physical inactivity; unhealthy diets; overweight) 5. The Social Life in the 50+ Population (data on community involvement, social activities, life-long learning, etc., by/for older adults) 6. Brief description of the Health Care System -- historical, organisation, role of primary health care, access (health insurance coverage, co-payments, etc.), financing (public, private, social security, other) any special health insurance provisions for 60+
COUNTRY PROFILE 1. INTRODUCTION BRIEF HISTORICAL AND SOCIAL ECONOMIC BACKGROUND OF THE COUNTRY Sri Lanka is a small island with the land area of 65000 square Km, located in the Indian Ocean close to the Southern end of the Sub Continent of India on 5 0 9 0 northern latitudes and between 79 0 81 0 eastern longitudes with a rich bio diversity mountainous at the central region surrounded by a plane country. Mean temperature ranges from 26C 0 to 28C 0 79F 0 82F 0 in the low country and from 14C 0 24C 0 (50f 0 75F 0 in the hill country. Central hills and southwest ranges receive adequate rain from monsoon winds. Rest of the country - North and North Central and Eastern parts experience dry weather basically in the inter-monsoon months. Sri Lanka has a recorded history since 6 th century BC and country has been ruled by an unbroken line of Sinhalese kings from 3 rd century BC until it is captured by British in 1815 March. Since the capture by the British Empire, Sri Lanka was ruled by the Englishman as a colony of the British Empire until 1948 February. During the colonial period, Sri Lanka was a testing ground for British political ideals in a range of institutions social and political. Hence Sri Lanka was one of the first countries to have the jury system, granting of universal franchise and introduction of parliamentary institutions. In fact introduction of universal adult franchise in 1931, which empowered the people and promoted policies that help to integrate the society as never happen before. Universal adult franchise brought all sections of the population into democratic process and enable them to begin their voice heard through their elected representatives. This process contributed to the winning of political independence from the British Empire in 1948 and pave the way for a parliamentary democratic system of government in which the sovereignty of the people and the legislative powers are vested in the parliament. The executive authority is exercised by a Cabinet of Ministers presided over by an Executive President. President and the Members of the Parliament are elected directly by the people. 2
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Sri Lanka is divided in to 08 Provinces, 25 Districts and 321 Divisional Secretaries for the purpose of administration. Since 1983, provincial administration in wested in the Provincial Councils composed of elected representatives of the people headed by a Governor who is nominated by the Central Government. Sri Lanka was basically an agricultural country whose people were dependant on paddy cultivation backed by highly developed hydraulic irrigation system in the dry zone and the plane country and it was a self sufficient agricultural economy based on mutual and common bonds. This system of self-sufficient agricultural economy was completely reversed by British rulers by introducing commercial plantation -Tea, Rubber, Coconut cultivation along with its allied industries. The self-sufficient agricultural economy provided a safe environment for the development of the multi cultural, multi ethnic country, which promoted a rich social diversity, and harmonious co-existence of its various communities and citizens. The successive governments since independence in 1948, continued to consolidate on past socio-economic achievements and activated a mixed economic system. The governments from 1977-2004 accepted and implemented free market policies giving priority to liberalization and privatization. Since 1977 open economic policies and human resources development have enabled Sri Lanka to achieve an average economic growth rate of 5.0%, while liberalization process set in motion for over two decades has contributed to the diversification of the production structure of the economy. The open economy witnessed the decline in the agricultural sector while industrial sector showed upward trends, which is born out by the declined of agricultural export from 79.3% in 1977 to 22.8% in 1997 while share of industrial export increase from 14.2% to 74.0% during the same period. Export led diversification has also contributed to the changes in the composition of the Gross Domestic Product (GDP). While the share of agriculture to GDP declined from 29.1% in 1977 to 18.0% in 1997, share of the manufacturing sector increase from 15.5% to 22.0% during the same period in 1995. For the first time industrial sector overtook the agricultural sector in terms of its share to the GDP. This was followed by the introduction of fiscal reforms to address the structural deficiencies in the economy. The far-reaching changes in the taxation system were introduced. Innovations were introduced in to the financial sector to promote financial 4
stability and improve efficiency. In addition the private sector was given all the encouragement within competitive market framework. Expected rapid economic growth and continuing investment in basic social services was interrupted due to on going armed conflict in the North and East of the Country. Since 1983, additional efforts have to be made on establishing peace and ethnic harmony in the face of armed conflict of the North and East. In this background government policies and actions were directed for strengthening of democracy and human rights and maintaining economic progress. According to the Central Bank Annual Report 1999 the countries per capita income would have reached US $ 1200 instead of US $ 829, if not for defense expenditure which has continued to rise and which has been currently estimated at 25% annual budget expenditure and almost 6% of the GDP. As a result expenditure on basic social services and health declined continuously during 1980 s. The real growth continues to decline followed by negative real growth during 1995 to 2000. In spite of all these socio economic, political changes under the mixed economic systems the universal access to education and health care were continued providing protection to landless, small farmers, unskilled labourers, low skilled artisans, self employed, aged in poor families and the working poor at subsistence level of income in Sri Lanka. However, despite the efforts made during the past two decades to reduce poverty level, the economic growth rate has not been adequate to eliminate the poverty. In addition the macroeconomic and structural adjustment programmes have aggravated the plight of the poor in certain areas. The major state strategy to alleviate the poverty is the Samurdhi Programme which replaced the Janasaviya Poverty Alleviation Programme implemented prior to 1994. Samurdhi Programme serves about 53% of all households in the country through its main components income transfers, compulsory savings and insurance schemes, loans and training for micro-enterprises. It was under this socio economic background a new government has come into power in Sri Lanka in April 2004 with a pledge to commence a new economic order in the frame work of a mixed economy system to protect and promote the interest of the common man. 5
Although considerable progress has been made social development in the field of education and health, there are still areas where attention needs to be focused. The ageing of the population in Sri Lanka an inevitable outcome of the macro-economic development and positive demographic trends resulting from declining fertility and rise in life expectancy, is a challenging issue, needs to be looked at from different dimension. Thus Sri Lanka begins the 21 st century with a estimated elderly population of 60 years and above approximating in the 1.85 million or 10% of the population divided between the sexes in the ratio of 49 males and 51 for females. In Sri Lanka age 60 and above is considered the demarcation age in identifying the elderly population since the most common mandatory, retirement age for the public, private and corporate sector false between ages 55-60. Over the past four decades there has been unprecedented increase in the absolute size and the proportion to the elderly population in Sri Lanka. In 2000 10% of the total population 1.9 million were over age of 60. The shift in the age structure from younger to the older having the higher proportion has resulted in a transformation of the aged pyramid of the country. Thus Sri Lanka has begun the conversion of age pyramid from broad based to barrel shape having the ageing process on the apex. Due to high fertility rate prevalent before 1950 s younger proportion in Sri Lanka increased up to 1951 and thereafter, gradually decreased and it is expected to decrease shiftily as fertility rates have decreased dramatically after 1990 s. Inevitably decreasing trend in the younger proportion will be replaced by much greater proportion of old in the future. In 1981 age pyramid shows high proportion of infant and children typical characteristic of a developing countries. The change of the aged pattern due to demographic transition is depicted in the age pyramid 2001 with an increase adolescent and youth population and increasing older population. 6
AGE PYRAMID 1981 AGE PYRAMID 2001 FEMALE MALE FEMALE MALE Ovre75 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Ovre75 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 6.0 4.0 2.0 0.0 00 2.0 4.0 6.0 6.0 4.0 2.0 0.0 00 2.0 4.0 6.0 2. Demographic Trends During the past five decades the rate of growth of population in Sri Lanka has shown a continuous decline. As evident from Table 1, during the decade of the 1950s the country experienced the highest rate of growth of population averaging nearly 3 per cent per annum. This in fact is the highest rate of growth experienced in Sri Lanka s known demographic history. It is also interesting to note that the cohort of people born during 1950 to 1960 will be reaching the age group 50 to 60 years during 2000 to 2010 and will continue to progress to other older ages in the coming decades. In other words, the demographic expansion that took place at the base of the population pyramid will result in the expansion of the elderly population in Sri Lanka during the next few decades. 7
Table 1 Growth of Population, 1946 2001 Year Population Average Annual Growth Rate (%) 1946 1953 1963 1971 1981 2001 6,657 8,098.10,582 12,690 14,847 18,732-2.8 2.7 2.2 1.7 1.1 Source : Reports of Census of Population 2.1 MORTALITY RATES The mortality rates in Sri Lanka during the past five decades have shown a continuous downward trend. The crude death rate which was 12.6 per thousand of the population in 1950 has declined to 5.9 in 2000. Similarly, the infant mortality rate which was 82 per thousand live births has dropped to 13 during the same period (Table 2). As a result, life expectancy at birth has increased from 43.9 years for males and 41.6 years for females in 1946 to 70.7 and 75.9 years respectively in 1995 (Table 3). The mortality transition in Sri Lanka can be grouped under three phases. An initial stage of relatively slow gain in expectation of life prior to 1946, a second phase of accelerated gain during 1946 to 1963, and a third phase of slower gain moving towards high expectation of life at birth since 1963 (Table 4). The significant features of this transition are the rate of improvements in life expectancy in each phase in Sri Lanka is extremely high compared to those of developed countries and secondly the rapidity of morality decline favouring the males in the first stage and in the subsequent phases the switch in favour of females. 8
Table 2 Crude Death Rate and Infant Mortality Rate 1950 to 2000 Year Crude Death Rate Infant Mortality Rate 1950 1960 1970 1980 1990 2000 12.6 8.6 7.5 6.2 5.8 5.9 82 57 48 34 19 13 Source : Registrar General s Department Total Male Female Table 3 Life Expectancy at Birth, 1946 1995 1946 1953 1963 1971 1981 1995 42.2 43.9 41.6 58.2 58.8 57.5 61.7 61.9 61.4 65.5 64.2 66.7 69.9 67.7 72.1 73.3 70.7 75.9 Source : Department of Census and Statistics; Population Division, Ministry of Health The steadily increase of life expectancy at birth had witnessed during the period of 1946 and present. It is seen that in 2001 males reported life expectancy 70.7 years at birth while the female enjoy the life expectancy 70.4 according to the Sri Lanka health atlas. Table 4 Rate of Decline in Mortality (Average annual increases in life expectancy at birth) Period Male Female% 1921-1946 1946-1963 1963-1995 0.45 0.40 1.10 1.13 0.40 0.69 Note: Computed from data on life expectancy 9
Table 5 Infant Mortality Rates by District 1970-2000 District 1970 1980 2000 Colombo Gampaha Kalutara Kandy Matale Nuwara Eliya Galle Matara Hambantota Jaffna Mannar Vavuniya Mullaitivu Kilinochchi Batticaloa Ampara Trincomalee Kurunegala Puttalam Anuradhapura Polonnaruwa Badulla Moneragala Ratnapura Kegalle 40-44 57 48 95 49 42 36 31 49 43 - - 58 45 37 43 46 39 33 61 40 64 49 28 12 17 26 10 39 18 20 6 4 18 10 10 7 8 10 10 19 15 25 6 26 7 29 18 18 6 6 20 10 16 11 13 4 2 3 5 13 14 18 9 3 18 10 16 9 22 4 15 15 Source : Registrar General s Department Infant mortality rates by districts clearly show that the rates have declined in all districts during 1970 to 2000 and the differentials have considerably narrowed Table 5 2.2 Fertility Rates Fertility rates too have shown continuous decline in Sri Lanka over the past five decades. It could be seen from Table 6 that the crude birth rate and the total fertility rate have shown significant decline between 1952 and 2000. The total fertility rate has declined in all districts between 1970 and 1995 and the district differentials have considerably narrowed over time (Table 7). As evident from the Table the fertility rate has shown significant decline since the early 1960s. The initial decline was mainly 10
due to the rise in the age at marriage of females. However the subsequent decline since the mid 1970s has been the rise in contraceptive use. The contraception prevalence rate has increased from 32 per cent in 1975 to 70 per cent in 2000. Table 6 Crude Birth Rate and Total Fertility Rate 1952-2000 Period Crude Birth Rate Total Fertility Rate 1952-1954 1962-1964 1970-1972 1980-1982 1982-1987 1988-1993 1995-2000 37.7 34.3 29.7 27.8 24.0 20.6 17.7 5.3 5.0 4.1 3.4 2.8 2.3 1.9 Source : A.T.P.L. Abeykoon, Population and Manpower Resources of Sri Lanka 1998; Demographic and Health Survey, 2000. 11
Table 7 Total Fertility Rate 1970-1995 District 1970-72 1980-82 1995 Colombo Gampaha Kalutara Kandy Matale Nuwara Eliya Galle Matara Hambantota Jaffna Mannar Vavuniya Mullaitivu Kilinochchi Batticaloa Ampara Trincomalee Kurunegala Puttalam Anuradhapura Polonnaruwa Badulla Moneragala Ratnapura Kegalle 3.7-3.6 4.1 4.6 3.7 3.7 4.5 4.8 4.2 5.3 5.7 - - 5.4-5.5 4.0 4.3 5.3-4.8-4.1 3.2 3.4 2.5 2.3 2.0 3.2 2.1 3.9 2.5 3.5 2.2 2.2 2.6 3.1 2.2 3.8 2.5 3.7 2.4 3.8 1.6 4.5 2.1 4.8 3.6 3.8 4.3-3.8 4.9 3.1 3.5 3.0 5.0 3.1 2.9 2.1 3.6 2.7 4.0 2.6 3.5 2.5 3.5 2.5 5.0 2.8 3.7 2.7 2.7 2.0 Source : Population Division, Ministry of Health 2.3 POPULATION STRUCTURE The age and sex structure of the population is determined by trends in fertility, mortality and migration. It can be seen from Table 8 that the proportion of population under 15 years of age has gradually declined from 41.5 per cent in 1963 to about 25 per cent in 2000 due to the decline in fertility observed during the period. With further decline in fertility and rising life expectancy, the proportion of population in the age group 0-14 years would decline to about 17.9 per cent in 2025. On the other hand, the proportionate share of the elderly population aged 65 years and over is expected to increase from 3.6 per cent in 1963 to 14.2 per cent in 2025. 12
1963 1971 1981 1995 2000 2010 2025 2050 Table 8 Age Sex Composition of Population, 1963-2050 Year 0-14 Years 41.5 39.0 35.2 27.7 24.8 22.2 17.9 18.1 15-64 Years 54.9 56.8 60.5 66.1 68.3 69.2 67.9 60.3 65 years and over 3.6 4.2 4.3 6.2 6.9 8.6 14.2 21.6 Old Age Dependency Ratio 6.6 7.4 7.5 9.4 10.1 12.4 20.9 35.8 Source : Census of Population ; A.T.P.L. Abeykoon, Demographic Projections for Sri Lanka Note : Data for 1963 to 1981 are from Census of Population, 1995 to 2050 are estimates and projections from A.T.P.L. Abeykoon Population of Sri Lanka by Age & Sex 1981 and 2000 Ovre75 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Ovre7 5 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 6.0 4.0 2.0 0.0 00 2.0 4.0 6.0 6.0 4.0 2.0 0.0 00 2.0 4.0 6.0 Source: Department of Census Static 13
It is evident from Table 9 that old age dependency ratio will gradually increase in the coming decades. The old age dependency ratio which was 7.5 in 1981 has increased to 20.9 in 2025 and will continue to increase reaching almost 35.8 in the year 2050. As a result, the index of ageing will also increase at a much faster phace from 18.8 in 1981 to 91.7 in 2020. Table 9 Old Age Dependency and Index of Ageing, 1981-2050 Year Old Age Dependency Ratio Index of Ageing 1981 1995 2000 2005 2010 2015 2025 2050 11.3 14.3 15.3 17.2 20.1 23.8 31.6 51.2 18.8 32.7 40.3 48.3 58.5 73.2 109.9 152.9 Source : Population Division, Ministry of Health Note : The old age dependency ratio and the Index of Ageing have been computed for age groups 0-14, 15-59 and 60+ Table 10 Sex Ratio of Population, 1946 2001 Year 1946 1953 1963 1971 1981 2001 Sex Ratio 113.0 111.5 108.2 106.1 104.0 97.9 Source : Census of Population 14
It is evident from Table 10 that the sex ratio (males per 100 females) of the population has been gradually declining over the past five decades. It is also interesting of note that in 2001 the sex ratio has dropped to less then 100 indicating that there are more females in the population than males. 2.4 POPULATION AGED 50+ It can be seen from Table 11 that about two decades ago the share of the population aged 50 years and over to the total population was about 13 per cent. This proportion has increased to 32.6 per cent in the year 2025 and in two decades hence, it is expected to increase to nearly 40 per cent. This is due to the larger cohorts entering this age group as a result of the high fertility rates the country experienced in the past. Table 11 Population 50 years and Over by Sex, 1981 to 2050 1981 2000 2025 2050 Total 1943 (13.1%) 3682 (19.2%) 7365 (32.6%) 9388 (40.1%) Male 1029 (13.6%) 1833 (18.0%) 3557 (31.7) 4437 (38.5%) Female 914 (12.6%) 1849 (19.4%) 3808 (33.5%) 4951 (43.6%) Source : Census of Population, 1981 ; A.T.P.L. Abeykoon Demographic Projections for Sri Lanka 1998 Figures in parentheses are proportionate share to the total population It is evident from Table 12 that the age composition of the elderly population will increase significantly during the period 2000 to 2050. The proportion of population aged 50 years and over will increase from 19.0 per cent in 2000 to 38.5 per cent among males and 41.7 per cent for females, similarly for there aged 60 years and over will increase from nearly 10 per cent in 2000 to 26.0 per cent for males and 29.4 per cent for females in the year 2050. 15
Table 12 Projected Trends in Age Composition of Elderly Population 2000 to 2050 Age 2000 2025 2050 Category Male Female Male Female Male Female 50+ 19.0 19.4 31.7 33.5 38.5 41.7 60+ 9.9 10.1 18.7 20.7 26.0 29.4 70+ 4.2 4.4 8.4 9.7 13.8 16.5 80+ 1.1 1.1 2.1 2.1 4.3 5.8 Source : A.T.P.L. Abeykoon, Demographic Projections for Sri Lankas,1998 3. Population Aged 50+ GENERAL ASSESSMENTS With nearly six decades of universal free education and health care services to the entire population in Sri Lanka, the quality of the population over 50 years of age in terms of human development is more favourable than that of other countries in South Asia. 3.1 SOURCES OF INCOME Financial well being of the elderly is an important aspect that enables them to live healthy and satisfying lives. Data from the Demographic Survey 1994 show that 90 per cent of males and 30 per cent of females were engaged in economic activity in the age group 50-54 years. Even in the age group 65-69 years, 58.8 per cent males and 11.5 per cent females were participating in the labour force. In a community study, Perera (1994) found that 24 percent of the elderly received some financial and other benefits when they retire and 13 per cent of the spouses were employed. Only 11 per cent were in receipt of a pension. In the rural sector, only 8 per cent were in receipt of a pension. In another study Marga (1998) found that 31.8 per cent of males and 6.0 per cent of females had their own source of income for living. On the other hand, 11.8 per cent and 19.0 per cent of males and females reported their children as the main source of income. The study also showed that elderly give material support to 16
their Kin. As regards support from children to elderly parents, it way observed that more female than male elderly and more rural than urban elderly receive support from their children. 3.2 WORK STATUS It is evident form Table 13 that the proportion of population aged 50 years and over who are employed has increased considerably between 1981 and 1994. It is also interesting to note that the unemployed proportions have been reduced. On the other hand, those engaged in housework have increased. The proportion of males engaged in house work has more than doubled. 3.3 EDUCATIONAL LEVELS As expected, the percentage of population over 50 years of age show that older cohorts have higher proportion who have not gone to school. Similarly, younger cohorts of the elderly population have a higher proportion who have had tertiary education (Table 14). 3.4 HOUSING AND LIVING ARRANGEMENTS Unlike in western societies the elderly in Sri Lanka prefer to live with their children. Ulenberg (1996) found that co-residence with a child in later life is preferred by majority of the elderly (75%). Andrews and Hennink (1992) also found that in Sri Lanka 86.0 per cent of the elderly males and 81.2 per cent of females live with their children`. 17
Table 13 Population 50 years and Over by Work Status, 1981 and 1994 1981 1994 Work Status Total Male Female Total Male Female Employed 720 (17.5%) 624 19.2%) 96 (11.0%) 1011 (20.2%) 786 (21.9%) 225 (15.7%) Unemployed 19 (2.1%) 14 (2.9%) 5 (1.2%) 10 (1.3%) 8 (1.7%) 2 (0.6%) Own house work 482 (18.1%) 3 (13.6%) 479 (18.12%) 831 (28.6%) 57 (37.7%) 774 (28.1%) Retired or unable to work 638 (90.3%) 321 (91.2%) 317 (89.5%) 514 (71.8%) 306 70.1%) 208 (74.3%) Others 84 (13.4%) 67 (13.7%) 17 (12.8%) - - - Source : Census of Population 1981; Demographic Survey, 1994. The 1994 survey excluded the north and east districts Figures in parentheses are proportions to all ages. Table 14 Percentage of those aged 50 years and over by Educational Attainment, 1994 Educational 50 54 55 64 65+ Level Male Female Male Female Male Female No Schooling 5.6 8.1 12.0 18.7 15.9 24.0 Primary 4.2 4.9 7.2 7.4 7.6 6.7 Secondary 4.5 3.7 5.5 4.4 4.0 2.8 Tertiary 9.5 6.2 9.5 6.2 7.6 3.7 Source : Demographic Survey, 1994. 18
In addition to living arrangements, ownership of residence has significant implications not only for financial security but also on life styles and peace of mind. It also enhances self -esteem and independence. A sample survey of 317 elders undertaken by Perera (1989) showed that 55 per cent of the elderly respondents and about 7 per cent of their spouses owned residence. About 26 per cent of the residences were owned by other household members. Thus 88 per cent of the residences were owned within the family. However, the study shows that about 72 per cent of the elderly did not have bedrooms exclusively for their own use. It was also evident that 84 per cent of the respondents had their toilets located outside the home. 4. Population Aged 50 + HEALTH INDICATORS Given the demographic and epidemiological transitions that have taken place in Sri Lanka over the past five decades and the continuing changes that are likely to occur in the future, health and healthy care of the elders will be an important priority area. 4.1 MORTALITY RATES Mortality rates among the elderly population in Sri Lanka as expected are relatively high. However, it is evident form Table 15 that age specific mortality rates among those above 50 years of age have declined significantly during the period 1962 to 1995. It is also evident that in all age groups and by sex mortality rates have declined over time. It is to be noted that female rates have declined at a faster pace. It is interesting to note that between 1981 and 1995 the mortality rates of males and females in the age group 80-84 years have declined at a relatively rapid pace. 19
Table 15 Age Specific Death Rates Among Elderly 1962-1995 1962-64 1981 1995 Age Group Male Female Male Female Male Female 50-54 9.0 7.1 - - 9.7 4.1 55-59 13.9 11.5 - - 13.4 5.9 60-64 19.5 16.6 18.4 12.6 19.0 9.9 65-69 35.4 33.1 30.2 22.2 29.0 17.3 70-74 55.7 52.9 45.0 37.0 40.9 29.9 75-79 84.1 81.6 69.7 58.8 52.2 41.9 80-84 128.0 132.5 122.1 112.7 57.2 50.0 Given the higher life expectancy of females, in the older ages there are more women than men in every age group. The proportion of older females in greater at advanced ages. The trend in the difference in life expectancy between males and female result in the feminization of the elderly population in Table 16. Table 16 Expectation of Life at Older Ages, 1995 Age Male Female 50 55 60 65 70 24.9 21.0 17.3 13.8 10.6 27.9 23.5 19.1 15.0 11.1 Source : Population Division, Ministry of Health 20
4.2 MAIN CAUSES OF DEATH It can be seen form Table 17 that of the leading defined causes of death among those aged 50 years and over diseases of the pulmonary circulation and other forms of heart diseases are the first leading causes of death. It is followed by diseases of the nervous system and diseases of the respiratory system. It is to be stated that the death rate due to disease of the pulmonary circulation is nearly ten times that of those in the age group 25 to 49 years. Table 17 Deaths and Rates of Five Leading Causes of Death of those Aged 50+ in 1996 Number Rate 1. All Census 77,780 2682.3 2. Diseases of the pulmonary circulation and 8,669 299.0 other forms of heart diseases 3. Diseases of the nervous system 4,893 168.7 4 Diseases of the respiratory system excluding diseases of the upper respiratory tract 4,638 159.9 5. Ischemic heart diseases 3,749 129.3 6. Symptoms, signs and ill-identified conditions 33,962 1171.2 Source : Annual Health Bulletin, 2001Ministry of Health. 4.3 SECONDARY AND TERTIARY CARE The proportion of elderly admitted to hospitals for secondary and tertiary care indicate that higher proportions are seeking care among the young old (age 50-69 years). Of those who have sought tertiary care in 2002, nearly one fifth were in the age group 50-69 years. Only 7.6 percent in the age category 70+ are admitted for tertiary care (Table 18). 21
Table 18 Hospital Admissions of those Aged 50+ By Secondary and Tertiary Care Institutions, 2002 Type of Care 50-69 70+ All Ages Secondary 253,426 (18.8) 90,585 (6.7) 1,344,727 (100.0) Tertiary 218,084 (19.5) 81,600 (7.6) 1,119,080 (100.0) Source : Medical Statistics Unit, Ministry of Health Note : Figures in parentheses are percentages 4.4 MORBIDITY AND CHRONIC DISABILITY A community survey undertaken by Marga (1998) comprising a sample of 204 males and 216 females aged 60 years and over has shown that a higher proportion of male and females have reported ill or injured in the rural areas than in the urban sector (Table 19). Also in the urban areas more females were ill than males. However, in the rural sector proportionately more males were ill. There is no significant difference in the urban and rural areas with regard to hospitalization. As regards chronic illness the proportions were higher in the urban areas. In the rural sector a relatively smaller proportion (29.1%) of females had reported chronically ill compared to males (43.7%). Table 19 Percentage of those Aged 60 years and over who were ill/injured Hospitalized and had Chronic Disease, 1998 Location Sex Urban Male Female Rural Male Female Ill/injured Hospitalized Chronic Diseases 3.0 4.7 16.9 15.1 52.5 50.9 13.6 10.9 17.4 14.5 43.7 29.1 Source : Marga, Implications for the family and elderly, 1998 22
4.5 FUNCTIONAL CAPACITY With respect to specific activities of daily living (ADL) the community survey undertaken by Marga shows that ADL is not a serious problem for the elderly except in the preparation of medicine and use of transport. (Table 20). This is evident with regard to males and females as well as by residence. Similarly, recent survey undertaken by Youth Elderly Disabled & Displaced (YEDD) Division of the Ministry of Health in 50 MOH Divisions in 2001. Clearly bears out the fact that the elderly over 50 years are basically without serious disabilities in Sri Lanka. Table 20 Percentage who had problems with specific Activities of Daily Living (ADL) by Age, Sex and Residence Age Sex Residence ADL 60-69 70+ Male Female Urban Rural 1. Walking around the home 3.1 7.9 4.9 5.1 7.5 2.4 2. Eating 0.4 3.0 1.5 1.4 2.3 0.5 3. Putting on Clothes 0.4 3.0 1.5 1.4 2.3 0.5 4. Taking a bath, going to the toilet 1.6 6.1 3.9 3.2 4.7 1.4 5. Preparing Medicine 15.7 24.4 18.6 19.4 18.3 6.3 6. Using transportation to get to places 52.0 43.3 45.1 51.4 45.1 29.5 Sample Size 256 164 204 216 213 207 Source : Marga, 1998 op.cit 23
Table 20A Percentage of Elderly with Specific Activities of Daily Living (ADL) 2001 (N=162,618) ADLs No Help Needed Help Needed to Some Extent Help Needed Essentially Not classified Toileting Eating Dressing Getting to bed and getting down Combing Walking Bathing Take medicine by self Engaging in household activities To use cash 89.8 87.5 87.4 87.2 87.5 86.0 83.9 79.8 78.1 79.1 5.2 5.3 4.6 4.8 4.6 5.5 6.7 8.7 10.3 8.2 2.9 2.5 3.1 2.7 2.6 2.9 3.6 5.4 5.1 4.7 2.1 4.7 4.9 5.3 5.3 5.6 5.8 6.1 6.5 8.0 Source : Deepthi Perera, Demographic Characteristic and Assessment of Social and Health needs of elderly in 50 MOH areas, 2001 4.6 Risk Factors for Non-Communicable Diseases Healthy lifestyles enables the elderly to minimize risk factors for non-communicable diseases by developing healthy eating habits, weight control avoiding alcohol and tobacco use and developing good cognitive functions. Recreation, stress control and socialization also promote the health of the elderly. A community Survey conducted by AIDC annually in selected districts since 1998 has shown that on an average 50 percent of those aged over 41 years use tobacco. Similarly, about 60 percent in the same age category consume alcohol (Table 21). Table 21 Percentage Use of Tobacco and Alcohol By those age 41 years and over Year Tobacco Alcohol 1998 1999 2000 2001 2002 2003 49.3 52.0 45.1 53.6 50.1 45.3 58.9 64.0 61.9 57.5 60.4 61.0 Source : ADIC, Spot Surveys on Tobacco and Alcohol Use. 24
The NCD are rising among the elderly NCD cause significant of rise from 45 years onwards. Pneumonia is on the rise from 45 years. Diabetics, Meliodosis, Streptococcus, diabetics, Alcohol related disease, Drug abuse, Sleep deprivation, Suicide and HIV aids are appearing among the population over 50 years as conspicuous NCDs. The common disease among elderly is shown by the following table. The leading causes of Hospitalization of 60+ (Year 2000.) Table 21A Leading Causes of Hospitalization of 60+ (Year 2000) Admissions of Elderly among 20 major Hospitals Year 2000 Systems/Sections Admissions % Diseases of the Circulatory System 57701 20.98% Diseases of the eye and adnexa 29962 10.89% Diseases of the respiratory system 29259 10.64% Diseases of the genitourinary system 18483 6.72% Diseases of the digestive system 16261 5.91% Diseases of the musculoskeletal system and connective tissue 9075 3.30% Neoplasms 8918 3.24% Chronic respiratory conditions 13164 10.08% Heart disease 11000 8.42% Hypertension 7731 5.92% Diabetes 5315 4.07% Cerebroavascular disease, Atherosclerosis 5171 3.96% Heart failure 4491 3.44% Urolithiasis, Other diseases of the urinary system 3762 2.88% Gastric & duodenal ulcer, other diseases of oesophagus, 2355 1.80% stomach & duodenum Hernia 2256 1.73% Acute respiratory infections 2000 1.53% Alcoholic liver disease, other disease of liver, cholelithiasis and cholecystitis 1724 1.32% Renal failure 1209 0.93% 25
5. Social Life in the 50+ Population Elderly have always occupied a high position of respect in the Sri Lankan society. In Sri Lanka traditional values have always emphasized that female members should take care of the old, the infirm, the disabled and the disadvantaged. All these were enshrined as cultural values to be practiced by the extended family system. In the extended family system, the grandfather, grandmother, father and mother, elder son and his wife and the elder daughter and her husband lived under one roof while the relatives lived in the neighborhood, each segment having a specific social role and community involvement. The entire social relationship and community involvement were based on the concept of mutual and common welfare for the betterment and improvement of quality of life of all members of the community. In this social arrangement, elders played a key role in molding the younger generation and guiding the entire community especially in the performance of the religious duties, social activities, recreation and the promotion of education, discipline among all members of the community. In Sri Lanka, until the advent of western influence the elders lived happily and played their social role effectively without being a burden to their families and communities. The family was the traditional support base through which care and welfare of the elderly as well as their contribution to the community were assured. However, along with modernization, urbanization, female entry in to the job market and their internal and external migration has greatly affected the social participation and community involvement of the elderly. In spite of combined efforts of both the Government and NGOs to promote elders participation in their own environment and to encourage their contribution for the improvement of the community, there is no sufficient data and information to discuss these activities in detail. Involvement of modern day elders in the community activities and social services have diminished due to economic pressures and competitive nature of day to day living. Social activities and the community involvement of those aged 50 years and over can be briefly discussed according to their place of residence classified by rural, urban and estate areas. 26
In the rural areas, both males and females are basically involved in the upkeep of their family and the spouses are engaged in their domestic work and upbringing of their children. Males are highly involved in the economic activities. Their social and community involvement are very limited even among the close neighbours and relatives. Those who have their family members working abroad receive money from them and tend to spend their leisure consuming alcohol and tobacco. In spite of all these new developments,, many rural elders 50+ still continue their religious activities of going to temples, visit relations and participate in community activities like Death Donation Societies, Mahila Samithis and engage in seasonal pilgrimages. In the Estate sector, where elders aged 50 years and over are employed as estate workers both as blue collar level and white collar level are more involved in trade union activities to safeguard their conditions of employment. Also, they participate in community savings and small credit societies to improve their living conditions. The Estate sector elderly population also participates in community and religious activities and seasonal religious festivals and cultural events. In the urban sector, both males and females while concentrating more in earning money and educating children, devote more time on watching TV and enjoying going to the cinema and outdoor festivals such as religious and cultural events. Also they join social service organization like YMCA, YMBA, Mahila Samithis and other numerous NGOs engaged in social activities. The more educated of the 50+ population in the urban areas involve themselves in social activities like, Drama Societies, theater groups and social clubs. Among this category involvement in social services and community involvement is disappearing slowly. A community survey undertaken by Perera (1989) has shown that majority of the elders prefer indoor activities to outdoor activities. However, it was also revealed that about one fourth of the respondents carryout outdoor leisure activities depending on the weather and respondents health status. A very large proportion, 59 per cent in urban, 87 per cent in rural and 97 per cent in estate were not members of any organization. With regard to participation in social, religious and other activities, only about 18 per cent of the respondents never attended family ceremonies and weddings etc. The study also showed that most of the elders do know their neighbours and meet them in their homes. However, relatively high proportions in urban (70.0%), rural (43.3%) and estate (80.6%) have indicated lack of trust and confidence among the neighbours. 27
28
Life long learning in Sri Lanka is facilitated by the fact that a high percentage of those over 50 years of age have had some formal schooling. In the age group 50-64 years more than 50 per cent have had education up to the secondary level. However, educational level varies by place of residence in rural, urban and estates. Among the estate population life long learning is virtually absent. There is no formal education for the elderly. However, in the rural sector 50+ elderly are exposed to religious education through temples. In recent years, universities have opened higher educational facilities for adults. The Open University has created opportunities for those aged 50+ to improve their learning skills. It is encouraging to note that the among 50+ population irrespective of sex, there is a significant number willing to improve their employment opportunities through further education. There is thus, the need for informal education to make the elderly population use their leisure more meaningfully and productively and at the same time give them the satisfaction of economic independence. There is also a significant number who have acquired professional skills during their formal working life which can be utilized for the economic advancement of the community. 6. Brief description of the Health Care System Under the colonial rulers health care was provided by the Civil Medical Department. The early beginning of the public health services could be traced back to the establishment of the Civil Medical Department under a Sanitary Commissioner in 1913. Since then progressive introduction of western medical services through a wide network of free medical institution. Western medicine existed alongside a well developed system of indigenous medicine (Ayurvedha and Yunani) which served the medical needs of rural population. The Health Services Act of 1952 laid down the policy that the health service should be readily available for all people in Sri Lanka. The Health Services Act was a very significant initiative in the formulation of key social policy designs relating to health care especially in the allocation of resources and the organization of the delivery of health care services. The major outcome of the Health Services Act 1952 (architect of the act was Dr J H L Cumpston Director General of the Health Services) was the abolishing of private practice for the doctors in the state sector enabling the development concurrently of preventive and curative services and setting out the rationale for an equitable universal health care service as 29
a matter of right. As a result of the implementation of the 1952 Health Services Act, establishment of a state funded system of national health care based on principles of equity and justices became the guiding principle for the development of national health services in Sri Lanka. Historically health service in Sri Lanka had developed more or less as two distinct pararal component medical services providing curative services and the public services providing promotive and preventive care supported by laboratory and other ancillary services. NATIONAL HEALTH POLICY A broad aim on health policy in Sri Lanka is to increase life expectancy and improve quality of life. This has to be achieved by controlling preventable diseases by health promotion activities. Sri Lankan government has been concentrating to address health problems like inequities in health service provisions, - care of elderly and disabled, non communicable diseases, accident and suicide, substance abuse and malnutrition. The health policy of the Government will be directed at consolidating the earlier gains as well as adopting new policies to raise the health status of the people. The broad aim of the Health Policy is to: i) Further increase life expectancy by reducing preventable deaths due to both communicable and non-communicable diseases. ii) Improve the quality of life by reducing preventable disease, health problems and disability; and also emphasizing the positive aspects of health through health promotion. In this respect the Government has identified the following diseases/health problems as priority areas needing focused attention: Maternal and Child Health Problems, adolescent health, malnutrition & nutritional deficiencies, problems of the elderly, malaria, oral health, bowel disease, respiratory disease, mental health problems, physical disabilities, deliberate self harm/suicide, accidents, rabies, 30
coronary heart disease, hypertension, diabetes, cerebrovascular disease, renal disease, malignancies, STD/HIV-AIDS, substance abuse and problems related to the family unit. In Sri Lanka both public and private sector provide health care. The public sector provided health care for nearly 60% of the population. The Department of Health Services and the Provincial Health Council cover the entire range of preventive, curative and rehabilitation health care services. The private sector provides mainly curative care which is estimated to be nearly 50% of the outpatient care of the population and it is largely concentrated in the urban and sub urban areas. 95% of the in patient care is provided by the Department of Health Services, Provincial Councils and the local authorities. There are service provisions specially for armed forces and police personnel and the estate population. Western, Ayurvedic, Yunani, Siddha and Homeopathy systems of medicine are practiced in Sri Lanka. Western medicine is the main sector catering to the needs of majority of the people. The public sector comprises the Western and Ayurvedic system, while the private sector consists of practitioners in all type of medicines. This provides the people opportunity to seek medical care from various sources under the different system of medicine. Sri Lanka possess an extensive network of health care services. Majority of the population has easy access to a reasonable level of health care facilities provide by both state and private sector through extension of services to every corner of the country. Health Services of the government functions under a Cabinet Minister. With the implementation of the Provincial Council Act in 1999, the health services were devolved resulting in the Ministry of Health in the national level and separate Provincial Ministries in eight provinces. National Minister of Health is responsible for the protection and promotion of people s health. Its key functions are setting policy guide lines, medical and paramedical education, management of teaching specialized, medical institutions, bulk purchase of medical requisites. 08 Provincial Directors of Health Services are totally responsible for management of effective implementation of health services in the respective councils. At the divisional level health care is provided through 31
a. Network of medical institutions, which include district hospitals, puerperal care units, central dispensary. These divisional intuitions were supported by Base Hospitals, Primary Hospitals and Teaching Hospitals providing referral care b. An network of health units providing pubic health services covering the entire system of extent of the island. Health Unit System came to being in 1926 for the provision of preventive health care. This system expanded over the years to cover the entire extent of the Island. Each unit was designed to provide from comprehensive, preventive and promotive health care to a population of 40 to 80,000 in well-demarcated area. The Medical Officer of Health (MOH) was in charge of each unit. Health unit system continued for many years providing an efficient system for the delivery of public health services. Services were provided to the people virtually at their doorstep. In 1978 after the declaration of the Alma-Ata of the goal to achieve health for all by the year 2000 through Primary Health care. Sri Lanka government, decided to adapt a basic minimum package at Alma-Ata which include : 1. Education about prevailing health problems their prevention and control 2. Promotion of food supply and proper nutrition 3. Safe water and basic sanitation 4. Maternal And child health including family planning 5. Immunization against major communicable diseases 6. Prevention and control of locally endemic diseases 7. Appropriate treatment for common diseases and injuries 8. Provision of essential drugs After giving careful consideration to the current health problems and needs, Sri Lanka enlarged the basic package and identified 17 areas as PHC priorities. These are : 1. Proper and adequate nutrition 2. Safe water 3. Basic sanitation and hygiene 4. Maternal care 5. Child care 32
6. Family planning 7. Immunization 8. Prevention and control of common communicable diseases 9. Prevention and control of non-communicable diseases 10. Appropriate and early management of common minor ailments and emergencies 11. Simple rehabilitation 12. Mental health 13. School health 14. Oral health 15. Occupational health 16. Prevention of blindness and visual impairment 17. Health education and community organization for PHC To effect this change post of MOH was abolished. The District Hospital was renamed as the Divisional Health Center and the District Medical Officer was renamed Divisional Health Officer and the functions of the MOH were assigned to the DHO. Central Dispensaries were renamed as Sub Divisional Health Centres and the Midwives residence and office were renamed as Gramodaya Health Centre. This experiment resulted in the DHO getting preoccupied with clinical work, neglecting public health services. Towards 1980 old health unit system was re-introduced. With the appointment of Divisional Secretaries in 1992 to deliver services to the people at the local level in direct response to their needs, MOHs were re-designated Divisional Directors of Health Services to meet the health needs in the division and to function of par with the Divisional Secretaries. The MOH were appointed Divisional Director of Health Services (DDHS). The functions performed by Health Directors of the health services at district level were to be transferred to the DDHS thus administration of the public health services and the curative services were assigned to DDHS. DDHS is now responsible for health development in his division with participation of other health related government and non-governmental sectors and the community. This system was expected to provide : better integration of the preventive and curative services a means for better plan formulation based on the needs of the community effective implementation and close monitoring of activities and 33
better community mobilization Although the district administration was abolished the services of the Regional Director of Health Services now re-designated the Deputy Provincial Director of Health Services has been retained to effect the smooth transfer of functions from the district to the division. However, the transfer of functions has not been effected satisfactorily. FINANCING OF HEALTH SYSTEM The health expenditure has a percentage of GNP remain in the range of 1.45 to 1.65. The GNP of Sri Lanka has steadily increased from 757 billion in 1996 to 1377 billion in 2001. Similarly the per capita expenditure too has increased in terms of the rise in the GNP. Health expenditure for 2001 was 22,899 million during 2001 proportion of public expenditure on the health services was 1.6% of the GNP and 4.9% of the national expenditure. The major proportion of the health expenditure is utilized by the patient care services. In 2001, patients care services utilized 66% of the health expenditure, while community health services utilized only 8%. Of the balance 22% were for general administration and staff services and 3% were spent on training and scholarships. At Current Market Prices TEH (Rs. billion) Table 18A, Total Expenditure on Health, 1990-1999 1990 1991 1992 1993 1994 1995 1996 1997 1998* 1999* 11.2 11.7 14.6 15.3 18.2 22.3 25.1 28.4 34.6 39.2 GDB (Rs. billion) 321.8 372.3 425.3 499.6 579.1 667.8 768.1 890.3 1018.0 1110.7 TEH as a of GDP proportion 3.5% 3.1% 3.4% 3.1% 3.1% 3.3% 3.3% 3.2% 3.4% 3.5% TEH per capita (Rs.) 659 681 838 867 1,018 1,231 1,369 1,530 1,843 2,068 GDP per capita (Rs.) 36,632 37,631 38,727 41,051 42,917 45,020 45,685 47,988 49,820 51,322 TEH per capita (US $) At Constant 1997 prices TEH per capita (Rs.) 16 1,275 16 1,187 19 1,329 18 1,255 21 1,348 24 1,503 25 1,491 26 1,530 29 1,694 29 1,810 * 1998 and 1999 figures are provisional estimates 34