• Public opinion split on whether proposal will help save money and increase efficiency, or increase discriminatory treatment 

BY Sumudu Chamara  The need to make the public sector profitable, or at least to curtail its current losses, has intensified with the prevailing economic hardships. While the Government is dealing with a severe lack of funds to maintain many public institutions, the many institutions continuing to make massive losses remain a challenge. In this context, privatising, or restructuring public institutions has become a common topic within the country, which was recently discussed in relation to the public health sector. Health sector trade unions have, based on a statement made by Minister of Health Keheliya Rambukwella regarding introducing a paid medical health service within selected public hospitals, alleged that the Government is attempting to gradually privatise the free healthcare service. However, according to Rambukwella, the said programme is expected to allow people to obtain better and more efficient services from public hospitals as the cost of obtaining health services from the private sector has become expensive, while those who cannot pay can still obtain free services as usual. However, while the Government keeps tightening austerity measures and seeking new ways to increase its income in light of the economic downturn, despite the increasing cost of living, the general public are of the opinion that this is not the right time to introduce paid medical health services.    Paid health services in the public health sector   “If the Government can provide better healthcare services to those who are willing to pay, that means that it is refraining from providing services of that quality to those who cannot pay despite having the ability or resources to do so,” stated Sarath Abhaya Fernando, a 55-year-old private sector retiree, raising his concerns.  Instead of introducing paid sections that provide better services in public hospitals that also provide free services, Fernando said that the Government should either start charging a minimal fee from all patients except those who are absolutely unable to pay any amount of money, or continue to provide free healthcare services, free of charge. He added that separate sections may lead to the discrimination and stigmatisation of service seekers. “I am a person that lives on medication due to several health issues including arthritis and high blood pressure. Imagine if I needed a certain medicine that is not available in the free section but is available in the paid section; will the health authorities ask me to get admitted to the paid section in order to obtain that medicine, or will they provide me with that medicine from the paid section free of charge?  “I think that this is neither a matter of providing better services for a fee, nor an attempt to privatise the free healthcare service. Rambukwella’s proposition is a result of the Government’s failure to earn money through other means. Now, it is in a situation where it has to get rid of free services, and thereby, save and make money. This is probably another International Monetary Fund (IMF) proposal.” However, speaking of the same, Yasara Pathmini, a 32-year-old private sector worker, said that the free healthcare service is something that needs to be protected and improved, not destroyed. Whether it becomes a paid service or remains a free service, she said, will be a mark of the Government’s competence in managing the economy. “The free healthcare service is one of Sri Lanka’s strengths and a reason to be proud about. Despite a number of national-level challenges including the war and the Covid-19 pandemic, this service remained intact, and although slowly, kept improving.  “Now, if the Government is contemplating on charging for healthcare services, all it means is that the Government is unable to fund this sector because it cannot find money from other means of revenue.” In this context, she said that the Government should revisit its means of revenue, and take a sensible decision to keep the free healthcare service as it is. That is the least that the Government can do for the people, as the cost of every paid service and every good has increased. Several people, however, said that the Government’s proposal, if implemented, may be beneficial to the people who seek efficient or special treatment and to the public health sector that is struggling to continue services due to the lack of funding.  They further noted that there is no reason for anyone to oppose such an initiative because the free healthcare service will still be available. Some of them also suggested that the Government will launch a pilot project first, and continue its proposal based on the results of the pilot project.     Charging selectively   However, some were of the opinion that it is acceptable to charge for healthcare services from people who are in need of such services due to drug, alcohol or tobacco use, clashes, and criminal activities.  Speaking with The Morning, Kamala Silva (name changed on request), a 61-year-old former nurse, said: “Every person should have access to free healthcare services. However, I think that we should look at the reasons as to why some people seek such services. If you face an accident or fall ill due to a natural reason, that is one thing. But, if you fall ill due to harmful habits such as drug, alcohol or tobacco use, or become injured due to clashes including armed clashes and owing to being engaged in criminal activities, that is more of an anti-social situation, because their acts have a direct impact on the society, and also the health of other people.  “I do not think that such persons should be provided health or medical services free of charge. As a punishment for their anti-social behaviour, and to ensure that free healthcare services available for other people are not wasted on these persons who dug their own grave, I think that we should charge these people for health care services.” She added that even though the same proposal has been presented before, the health authorities did not pay adequate attention to it. At a time when the country’s free healthcare sector is facing massive resource related challenges, she said that it is high time to pay attention to such measures. Similarly, Fernando noted that another such group that should be charged in the event the Government decides to charge for health services, is people who neglect medical advice repeatedly or in the long run, and as a result, fall ill.  He added: “There are so many people who do not value the free healthcare service due to the fact that it is free. I think that it is high time to value it, and stop taking it for granted. I see so many people repeatedly neglecting medical advice, which results in the worsening of their health conditions. They then have to seek free healthcare services for a much more serious health condition.  “Essentially, it is taxpayers’ money that is being spent for the negligence of these people, which I think is extremely unacceptable. I think that there should be a system to record information on how many times a person seeks healthcare services, what medicines are prescribed and what advice is issued to them, and whether any worsening of their health situation is a result of negligence. If they are found to have neglected the advice that they were given repeatedly, the healthcare system should start charging them.”   The concept of free services   In response to The Morning’s question with regard to the concept of the free healthcare service, many people shared the opinion that calling health or medical services provided by the public health sector, free healthcare services, is questionable, as those institutions are maintained largely with the people’s tax money. “No service provided by the Government is actually free, because those services are funded mainly by the people’s tax money or the Government’s other forms of revenue which also come from the people’s pocket,” 26-year-old mobile phone seller Tharaka Yahapmath, opined in this regard.  He added: “Even in the case of maintaining healthcare services through loans, it is the people who have to ultimately repay those loans, and therefore, the people are paying for those services. The Government is acting as if politicians spend their own money to provide these services.  “In fact, we have been overusing the word ‘free’ when referring to the services provided by the public sector to such an extent that we have forgotten that directly or indirectly, now or later, it is the general public that is paying for them.” In that sense, Yahampath said, if the Government decides to charge for any free service, not just healthcare, it is tantamount to charging twice for the same service. Meanwhile, Pathmini said that although the concept of the free healthcare service, or any free service for that matter, is often considered a sign of a developed nation, in reality, such services become a necessity because people are economically deprived.  “Why do we need free services? It is because we cannot pay for them. I do not think that free services, including education and healthcare, are a reason to be proud about. All it shows is that the people are too poor to pay for essential needs.  “In this discussion, I have seen so-called intellectuals comparing Sri Lanka’s free services with paid services in foreign countries. In foreign countries, there are various insurance and loan schemes to enable the people to pay for health and education which are paid services. “However, they repay loans later and pay for medical insurance beforehand. One may have an issue with needing insurance or having to take loans. However, still, people actually pay. In Sri Lanka, we cannot charge at least the proper value of the services because the people are poor.”