The Sri Lankan Government’s Health Master Plan of 2007–2016, Healthy and Shining Island in the 21st Century, set out to plan for the health challenges facing the people of Sri Lanka as the new century progressed. These challenges included “changing demographic and disease patterns, limited resources, increased demand and expectations by the public and the need for equity” (Ministry of Healthcare and Nutrition 2007, iii).1 Sri Lanka, in common with other low- and middle-income countries faces a double disease burden of communicable and noncommunicable diseases, with accompanying rising medical and welfare costs (Lewis and MacPherson, 2013). The 2007 health planning blueprint was thus the government’s response to this health transition, or as it might be termed, this “health crisis” (Ministry of Healthcare and Nutrition 2007, 19). It planned for an integrated approach with three functional arms: preventive, curative, and welfare. All three of these arms were deemed to be interdependent; furthermore, the blueprint acknowledged that the branches of traditional medicine, that is, Ayurveda, Unani, and Siddha, “collectively constitute an integral part of the health sector,” and that the practitioners of traditional medicine have an essential role in the provision of universal health services (Ministry of Healthcare and Nutrition 2007, 7).2 Ayurveda with its holistic approach to health was deemed particularly apposite for the delivery of preventive medicine.3
The commitment to using traditional medicine alongside Western government health services is not innovative; it has a long history in Sri Lanka at least at the level of stated government policy. How far this has been put into practical effect is another question. This paper, through the means of a purposive qualitative survey of a sample of traditional medical practitioners (
Primary Health Care: Definitions
The concept of primary health care has been subject to shifting and at times competing interpretations. The term as originally used in the nineteenth and twentieth centuries applied to the provision of services for basic preventive and curative care. It has since acquired other attributes at the international level. Does it also encompass agrarian reform, nutrition, sanitation, pure water supply, education, and anti-poverty strategies? Can it be a mechanism to empower people and communities for broad developmental purposes? Such questions about the meaning and functions of primary health care entered the global stage at the World Health Organization (
The resulting Alma-Ata declaration reaffirmed the
However, in the climate of the 1980s, when global development policy was dominated by neoliberal macroeconomics with its emphasis on cuts in public spending and the reduction of budget deficits, the ambitions of Alma-Ata were curtailed and primary health care came to mean selective programs such
Primary Health Care in Sri Lanka: The Context
Sri Lanka has long been recognized in international health circles as providing “good health at low cost” based on an effective primary health care system.6 When it gained independence in 1948 the nation had an “embryo welfare state” based on free education, food subsidies and, crucially, free health care; it also had a government that accepted the
This success stems from a variety of factors. From 1948 to 1977 Sri Lanka operated as a social welfare state providing free education, health care, and subsidized food. With the advent of neoliberalism, state welfare was limited and targeted at the most needy, but free health care continued to be a government priority. The development of the extensive primary health care structure can be traced back to the colonial period, when the indigenous medical profession was instrumental in pushing for the growth of Western medical services; the new nation in 1948 had both an extensive network of curative institutions and significantly a preventive health care system based around the health unit (Hewa 1995; Jones 2004; 2009).7 The health unit delivered the services that are the foundation of primary health care at the community level: maternal and child welfare, immunizations, sanitary inspections, health education, the prevention of communicable diseases, and the training of public health workers. By the time of Alma Ata there were ninety-eight such units under the direction of a medical officer of health (
However, government health expenditure was and remains disproportionately focused on the curative sector. In 1975 Simeonov (1975, 173) estimated that for every twelve cents spent on the prevention of diseases and the promotion of health, one rupee was spent on treatment. Twenty years later, in 1994, Dulitha Fernando (2000, 17) estimated that the percentage difference was 61.9 percent on curative care, with 24.7 percent on general administration and 12.0 percent on community health services. Furthermore, the Ministry of Health’s own report in 2003 suggested that the proportion of total expenditure on preventive and public health expenditure had declined from 11 percent in 1990 to 6 percent by 1999 (Ministry of Health 2003, ch. 2, par. 2.8.3, 20).
Alongside the government services there is now a growing private sector particularly for ambulatory or outpatient care. According to government statistics, there were an estimated 45 million outpatient visits of all kinds in 2007; 50 percent of these were serviced by the private sector, 34 percent by government doctors, 11 percent by private general practitioners, and 5 percent of this total by traditional practitioners (Ministry of Health 2017). Given that the take up of services provided by traditional medicine is less easily quantifiable than for the services provided by Western medicine, official statistics no doubt underestimate its importance in personal health.8
Ayurveda and Primary Health Care
Under colonial rule the traditional medical systems declined in status but not in availability or use, and they were an integral aspect of the cultural revival and political nationalism of the first decades of the twentieth century. In the struggle to survive against the onslaught from biomedicine they were forced to professionalize and institutionalize. They were recognized and subsidized by the government from the 1930s onward and thus viewed as part of the official medical landscape (Jones 2004, 83–104). However, Simeonov (1975, 95) argued in 1975 that although the traditional medical sector constituted “a system for providing services spread over the whole country,” traditional practitioners did not “participate in either family health or in the control of communicable diseases” in a formal sense.9 Although Ayurveda was still used extensively by the population and the government financed a system of Ayurveda hospitals and clinics, the hostile attitude of the Western medical establishment precluded its involvement in public health (Arseculeratne 2002; Jones 2008). However, in the aftermath of the Alma-Ata Declaration and in line with one of its tenets, it was proposed that traditional practitioners in Sri Lanka should play a part in health promotion and disease prevention and give “collaborative support to community care” (Fernando and Cooray 1991, 238).
Today the official contribution of the traditional sector to community health comes under the Ministry of Health, Nutrition, and Indigenous Medicine and its community healthcare program for the prevention of disease. This program began in 2004 with a pilot project in the Anuradhapura district and then spread throughout the entire island. It focuses on nutrition, mental health, the control of contagious and noncontagious diseases, renal problems, and diabetes. Community health promotion medical officers (
The Specificities of Ayurveda in Sri Lanka
Ayurveda is the official term used in Sri Lanka to denote collectively all the traditional medical systems. It encompasses Ayurveda, the predominant system which came to the island from India with Buddhism 2,500 years ago, as well as Siddha, Unani, and Desiya Chikithsa, the latter being the earliest system of medicine existing in Sri Lanka before the advent of Ayurveda.10 The term “traditional medicine” thus largely overlaps with the term “Ayurveda.” According to the Ayurveda Act, No. 31 of 1961, the Ayurveda medical system includes all of the above medical systems, as they are deemed integrated with Ayurveda to a large extent. However, the Ayurveda that emerged in Sri Lanka from the middle decades of the twentieth century is a complex mixture of the island’s indigenous medical practices, Ayurveda, and elements of Western medicine. As noted previously, from the 1920s onward Ayurveda was forced to establish a professional identity in order to compete with the formally organized and government-funded Western medicine. This entailed presenting Ayurveda, as Dagmar Wujastyk and Frederick Smith (2008, 7) have argued, “at political and ideological levels, as a uniform medical system” with all the attributes of the Western medical system. The “biomedicalization” of Ayurveda has provoked much debate within Sri Lanka on the nature and practice of the Ayurveda that emerged from this process. The establishment of training institutions (where Western medicine was also taught), certification, registration, and canons of knowledge has led to claims that what has resulted is a “hybrid” between Western and traditional medicine, as opposed to the pure form that had previously been practiced when knowledge was passed down within families.11 As Madhulika Banerjee (2008, 201–202) has argued, it was also accompanied by the “pharmaceutilzation” of Ayurveda, whereby its medicines “become indistinguishable from any other pharmaceuticals” thereby eroding its “capacity as an “alternate system.” These adaptations make it difficult to identify any of the different practices within Sri Lankan traditional medicine as discrete systems (Wanninayaka 1982). Sri Lankans very often use the term “Ayurveda” not specifically to indicate only the Ayurveda medical system but equally to indicate all the traditional medical systems, some of which in practice also use the tools of Western medicine. For this reason we have deliberately chosen our sample of practitioners to represent the full spectrum of
The Characteristics of the Sample of Traditional Practitioners
The first group of practitioners are from the Desiya Chikithsa tradition. Although it is integrated with Ayurveda and its practitioners can be registered, in practice Desiya Chikithsa can be quite different from Ayurveda. It is based mainly on a knowledge system that is gained through experience rather than deriving from philosophical concepts or written texts. Its customs and value systems are handed down from one generation to another and are inherited within a family tradition. These practitioners have no formally recognized qualifications, unlike the other
Diploma holders (some with a background also in Desiya Chikithsa) straddle both the informal and formal sectors, as nearly 50 percent of them have been integrated within the government indigenous health care delivery system, working in government-subsidized Ayurvedic hospitals and clinics, with the remainder deliver their services on an individual basis. Compared with the above two categories, more than 90 percent of degree holders, the third group, have been integrated. Degree holders have a Bachelor of Ayurveda Medicine and Surgery that includes in-depth knowledge of Ayurveda and a basic knowledge of Western medicine (
Included in the first group of
In-depth interviews were conducted in April 2014 with each practitioner in order to obtain their views and their experience of primary health care within their everyday practice.12 A research assistant who came from a sociology/anthropology background conducted these interviews with practitioners in Sinhala by using an interview schedule under the supervision of a medical sociologist/anthropologist. The data was analyzed based on narratives of traditional practitioners. When quoting directly from the sample
How Did the Sample
tmps Perceive Primary Health Care?
A number of the practitioners explained in detail the connection between the concept of the three humors, the seven components of the body, and the five elements of the universe. Well-being, it was explained—and this encompassed mental well-being—is maintained by keeping a “harmonious balance” between the tridoshas of “wind, bile, and phlegm” (
All the sampled practitioners emphasized that Ayurveda was concerned with the maintenance of good health but used the local term of suwastatava (well-being). The whole focus of the concept of suwastatava is to maintain the overall well-being of an individual (nirogikama) for a healthy life (nirogi jivitaya). Well-being depends on following a set of instructions for behavior from birth to death and for the individual’s daily routine. These instructions encompass Ritu carya (seasonal routine), which includes coping strategies to adapt to seasonal variations, and Dina carya (daily routine), which covers personal hygiene, sleep patterns, food-related behavior, livelihood, and exercise. In addition there are strictures to ensure health during pregnancy and after childbirth. One
Almost all the things at our home are done according to the instructions of Ayurveda. They are planned according to these instructions from dawn to dusk. We get breakfast between 6 a.m. and 7 a.m. Bathing will be done before 12 noon…. All three main meals are cooked separately. We don’t take cool foods. In addition, foods stored in a refrigerator are not consumed. (
Seasonal behavior affected food patterns too:
In the summer season, hot foods such as tomatoes, pineapples, [and] pickles should not be eaten. It causes skin diseases, gastritis, and hemorrhoids. Similarly, cold foods eaten in the winter can cause phlegm. (
Additionally, it was explained, there is a spiritual dimension to Ayurveda, and thus strategies for maintaining good relationships with others are deemed extremely important for both physical and mental well-being. In addition to maintaining well-being, Ayurveda has also developed some mechanisms for restoring the health of people who become ill for various reasons. Many of our
While the diploma and degree holders were aware of the Western concept of
The interviews with the traditional practitioners who held a diploma or degree in Ayurveda revealed that they were more familiar with the term
All categories of
Western medicine recommends that people eat five fruits and vegetables per day. These are mentioned in measureable quantities. But in our country people don’t know what is called protein and minerals. Ayurveda describes six tastes. It recommends that people eat food with the six tastes. These tastes are: sweet, sour, salty, pungent, bitter, and astringent…. When we taste all six tastes, indirectly our body receives all the chemicals that we need. Our environment contains what we need for our well-being. It is closer to the people than asking them to eat five fruits and vegetables. (
Another also highlighted the disconnection between Western medical advice on diet and the Sri Lankan natural environment: “Western practitioners explain the food pattern using a food chart but we explain beyond that. We consider the nature of the people” (
Prescribing vitamins to a rural mother with malnutrition is not an option. The solution should be found in the environment where a mother lives and this can avoid the vulnerability of child malnutrition. Unobtainable prescriptions are not the solutions to such problems. That’s the point where the involvement of Ayurveda becomes essential because Ayurveda is linked with nature. (
One of the
These critiques of the Western sector’s advice on nutrition carry some weight. Certainly, for example, the food chart that accompanied a newspaper account of the launch of the National Nutrition Policy in 2010 contained food groups that look virtually identical to food charts in the Western world. The vegetables and fruits depicted were aubergine (eggplant), broccoli, carrots, grapes, and tomatoes; the proteins were chicken, fish, and cheese and the carbohydrates rice, beans, and bread (no jackfruit or coconut, for example, which are both nutritious and ubiquitous in Sri Lanka) (Kannangara 2010).
Primary health care in Ayurveda, the
The Role of Traditional Medical Practitioners in the Formal Delivery of
The empirical evidence of this study revealed that the role of the
Compared with the experience of practitioners of Desiya Chikithsa, the diploma/degree holders who were attached to the government Ayurveda health care delivery system had some space to get involved with formal
However, all the diploma holders and 80 percent of degree holders mentioned that they had little opportunity to contribute to
Some insight can be gleaned from these interviews on how well the officially designated Ayurveda
While I was working at Anuradhapura, the
mohwanted our contribution and I had a lot of support. I did my field visits in their vehicle. They treated me as a colleague. Our service was recognized. We organized a group for the Ayurveda First Aid program that included twenty students and two teachers from each school in the area. They were trained for this purpose and we conducted a number of awareness raising programs, distributed leaflets, and so on. However, everything depends on the attitudes of the mohs. If he or she is ready to appreciate our work we can do many things, but if not we fail. ( dg/3)
However, all these ex-
It seemed also that they had little autonomy in their work, as most of the programs at the grassroots level were organized by Western medical practitioners, and the
An Integrated Approach to
The narratives of our sample
Thus the traditional medical systems, practitioners claimed, had many strengths not only in addressing the root causes of disease but also in enhancing the well-being of people. On the other hand, the Western system had a very powerful mechanism for delivering
We treat patients under the minimum facilities. We don’t have gloves or at least cotton for our theaters. We have an X-ray machine but we don’t have a qualified technician to work it. Even when we do provide health care awareness, we don’t have any technical assistance. We have a limited staff so if we take a worker from the hospital to work in the programs the hospital schedule suffers. (
Also, as one
The Western practitioners are paid by the government; they can spend from 9 to 4 for such programs. I conduct a dispensary and I don’t let any patient go back without meeting me. Many patients come in hired vehicles. I cannot ask them to come another day. (
The lack of resources given to Ayurveda stemmed from arguably the most significant obstacle, which was that Western practitioners perceived themselves as a group to be the superior professionals and thus dominated decision making as well as designing and implementing health programs.
Rathakalkaya was banned on the grounds that some of the herbs used were toxic, but some
The paper attempted to explore how
The findings clearly show that there has been a huge gap in implementing the Health Master Plan 2007–2016, and appropriate strategies to make it a reality are still required at a primary level. Basically, there are two challenges, one at the policy level and the other at the practical level. Theoretically, the traditional medical systems have a greater capacity to contribute toward
Ayurvedic Drugs Corporation. N.d. “Overview.” Sri Lanka Ayurvedic Drugs Corporation. www.ayrvediccorp.gov.lk (accessed March 14 2013.
Department of Ayurveda. N.d. Desiya Chikithsa. Department of Ayurveda Ministry of Health Nutrition and Indigenous Medicine. www.ayurveda.gov.lk.medicine/ayurveda.html (accessed March 14 2013).
Ministry of Health (Sri Lanka). N.d. “Community Healthcare Services through Ayurveda.” Development Programme of the Ministry. http://www.indigenousmedimini.gov.lk/Development_Program.html (accessed March 14 2013).
Sri Lanka was the British colony of Ceylon until gaining independence in 1948. In 1972 it became the republic of Sri Lanka, while remaining within the British Commonwealth.
Ayurveda is used as a general term for all traditional medical systems in Sri Lanka, and this nomenclature will be followed here.
The “life course approach” entails a preventive strategy “based on tackling the risk factors from the foetal stage to old age” (Ministry of Healthcare and Nutrition 2007, 15).
This intersectoral and community approach was not, however, new. It harked back, as Mahler pointed out in 1978, to the 1937 League of Nations Conference on Rural Hygiene in Bandoeng, Java, which had recommended the need for “reconstruction that entailed the collaboration of the population, sanitation and sanitary engineering, [and] nutrition,” as well as “health and medical services” (Mahler 1978, 107).
There was an extensive debate on the implications of selective primary health care (
A term from the iconic report of the Rockefeller Foundation in 1985 (Halstead, Walsh, and Warren 1985) that highlighted the experience of Sri Lanka, China, Costa Rica, and Kerala State, India (all low-income countries), in delivering good health indicators.
The first health unit was established in 1926 at Kalutara in collaboration with the Rockefeller Foundation.
“Western medicine” is the term used for allopathic/cosmopolitan/biomedicine in Sri Lanka, and it will be used in this sense throughout this paper.
For an exploration of how traditional medical systems could contribute to primary health care, see Young 1983.
For an exploration of definitions of medical systems, see Dunn 1976; Young 1983.
Such views were aired extensively in the Legislature from the start of this process in the 1920s. See Jones 2004, 99–102.
We are very grateful to Sumudu Wijesooriya for translating the transcripts of the interviews from Sinhala into English.
Four of the
In June 2010, the First National Nutrition Policy was launched by the Health Minister, M. Sirisena; it was “formulated for the benefit of over 30% malnourished children in the country and the needy adult population” (Kannangara 2010).
Rathakalkaya is herbal water given to infants to improve their immunity. This was mentioned by several
Batakirilla is a tree native to Sri Lanka whose leaves are traditionally used in Ayurveda for the treatment of dysentery and worm infestation.
Suwanaari are women’s wellness clinics, run by the
She also stated that when she was introduced it was as the “indigenous
For an exploration of the difficulties of transferring the biomedical approach to the assessment of alternative medicine, see Barry 2006; Waldram 2000; Bodeker 2001; Chaudhury 2001.
When research is done into Ayurvedic remedies it comes up with some interesting results. See, for example, Uragoda 1991; Perera 2005.
See, for example, Pole 2008; Chopra 2008.
By 2009 there were 325