:: Health & Nutrition ::

Malnutrition is both a distinctive cause and a scarring consequence of poverty. The malnourished child is poverty’s most telling aspect. Malnourished Asian children have offered for generations a specter of despondency and also a challenge to patterns of economic growth that by pass the poor. Three fourths of the world’s malnourished children are Asian. If malnutrition were eliminated by 2020, and concerted efforts could make this happen, the global prospects for human development and peace would be immeasurably brighter. The world would be a very different place.

The consequences of chronic malnutrition, beginning with mothers and their young children, are intergenerational and account for a large proportion of child deaths, mental disability, and less productivity among earning citizens. In low income Asia, six million preschool children die each year, and more than half are underweight. The surviving underweight children are likely to be stunted and will suffer from frequent illness, have lower mental ability and achievement in schooling, are more likely to drop out of primary school, and earn lower wages as adults.

As the East Asian financial crisis revealed, untreated malnutrition leaves mental and psychosocial scars on a generation of young children even after crises abate. This is how the intergenerational cycle of poverty and malnutrition perpetuates itself. Recent evidence also links the malnutrition of mothers and their young children to a life-long susceptibility to diet-related chronic illnesses, including diabetes, high blood pressure, coronary heart disease, and cancer. Therefore, the poor suffer a “double burden” of disease arising from malnutrition in early life.

In the early 1990s, notably at the World Summit for Children (WSC), Asian nations made bold promises to reduce maternal and child malnutrition through adopting better policies and programs and increasing the level of –resource commitments to solve the nutrition problem. Halving underweight malnutrition among preschoolers and the virtual elimination of micronutrient malnutrition (Vitamin A, iodine and iron deficiencies) were the specific WSC goals targeted for 2000. However, not enough has been done over the last decade to find affordable and sustainable solutions to eliminate malnutrition in low-income Asia, not least to raise resources commensurate to the problem. The economic costs of malnutrition have been to depress economic growth rates and household incomes substantially in most of Asia.

Over the last several years, the Asian Development Bank (ADB) and the United Nations Children’s Fund (UNICEF) jointly undertook a region wide assessment of how nutrition of young women and children improves and how additional resources should be used.

The agencies acted together because Asian governments were making slow progress in reaching the WSC goals. This special double issue of the Review distills the lessons learned from this unique collaboration between ADB and UNICEF and offers clear direction to the Asian region on how to eliminate malnutrition in a cost-effective and sustainable manner.

The volume includes regional issues papers by leading experts who were deeply involved as advisors to the countries involved in the study. Seven countries, namely, Bangladesh, Cambodia, People’s Republic of China, India, Pakistan, Sri Lanka, and Viet Nam, were involved in the assessment. The eighth country, the Philippines, withdrew. Collectively, these countries cover about two thirds of the world’s 150 million preschool children under five in the developing world. The regional project set out to build capacity for policy analysis and identification of investment priorities by the participating Asian countries. Each country prepared a ten-year investment program for progressing toward the WSC goals based on common investment guidelines. Each country study / analyzes:

(Including food security measures, safety nets, employment and gender approaches)

5. Defines an improved and costed nutrition strategy with financing roles for central and local governments, private sector, and development partners.

The country investment plans have been endorsed in most cases by the governments themselves and are being used as the basis for raising resource commitments from development partners. The lessons learned about how nutrition can improve rapidly in the Asian region are striking.

2. Communities have a major role in supporting families to improve the nutrition of their children, and partnerships between local governments and communities are an emerging Asian trend that will determine whether the nutrition and human potential of the poor will improve. Community-based programs are successful when they involve communities in the analysis, assessment, and design of locally tailored action programs to solve the nutrition problem. Decentralized management of programs, with generous support for social mobilization and nutrition information systems to aid prudent use of resources, supports effectiveness. Serious national political commitment to poverty reduction, as in Thailand where targets for improved child nutrition were published and evaluated and local governments were held responsible under the national Poverty All aviation Program, help to link the macro-micro interface.

3. There are clear priorities for programs. Focus public policies and resources on preventing malnutrition during pregnancy and the nursing period and for infants under two, otherwise a syndrome of developmental impairment will persist across generations. Successful programs provide food, health, and infant care, combining service delivery and community nutrition promotion in centers and homes.

Conventional food subsidies are wasteful unless they are properly targeted, stimulate employment, and support women’s empowerment including micro credit programs targeted for women. Otherwise, countries and donors are best advised to reallocate their funds to community-based programs that are - gender-sensitive. Partnerships between the public and private sectors should be welcomed. Given the high economic and mortality costs of child malnutrition, the low cost solutions that are well-tested and readily available, and the high returns on nutrition investment demonstrated in this volume, why isn’t more being done to eliminate this tiresome obstacle to human progress? In addition to well-known political economy factors, there is a lack of understanding among governments that malnutrition is much more than a health problem, that it undermines national aspirations for sustained and equitable economic growth. Within most public sectors, there is a fragmented policy environment for making nutrition a benchmark of economic and social development. It is however remarkable that the seven countries in the regional assessment mobilized all relevant sectors and civil society to consider the short and long term needs of their children and are now engaged in a vivid search to match investment to need. This offers hope that the knowledge honed through this novel policy process will form abiding partnerships that will retire the unseemly drama of chronic under-nutrition and poverty for good

“Health is considered as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Though this 1948 definition of the World Health Organization of health is criticized because of the difficulty of accurately defining and measuring "well-being", it is worth attempting to achieve this ideal.”

Population: 18,933,558 (July 1998 est.) ( The mid-year estimate of the total number of individuals in a Country.)

Rate of Growth is an estimate of the rate at which a population is increasing (or decreasing) in a given year.

Crude Birth Rate is An estimate of the number of live births per 1,000 population in a given year.

Crude Death Rate is an estimate of the number of deaths per 1,000 populations in a given year.

Infant mortality rate: 16.33 deaths/1,000 live births (1998 est.) Infant Mortality Rate is the estimated number of deaths in infants (children under age one) in a given year per 1,000 live births in that same year. This rate may be calculated by direct methods (counting births and deaths) or by indirect methods (applying well-established demographic models).

Maternal Mortality Rate is the estimated number of maternal deaths per 100,000 live births where a maternal death is one which occurs when a woman is pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management. Although commonly referred to as a rate, this measure is actually a ratio because the unit of measurement of the

Numerator (women) is different than that of the denominator (births). Extremely difficult to measure, maternal mortality can be derived from vital registration systems (usually underestimated), community studies and surveys (requires very large sample sizes) or hospital registration (usually overestimated)

Life Expectancy at Birth is an estimate of the average number of years a newborn can expect to live. Life expectancy is computed from age-specific death rates for a given year. It should be noted that low life expectancies in developing countries are, in large part, due to high infant mortality.

Total Fertility Rate is an estimate of the average number of children a woman would bear during her lifetime given current age- specific fertility rates.

The success of Sri Lanka’s health program, which in its early years targeted infant and maternal mortality and infectious and communicable diseases, is undeniable and is looked to by much of the world for the lessons it can teach. The World Bank has been working with the government of Sri Lanka toward this success, particularly in the reduction of communicable diseases. Having met several important challenges, Sri Lanka must now focus on solving the remaining major public health issues. Malnutrition among children and iron deficiency among pregnant and lactating women are still serious problems, and iodine deficiency may be more of a problem than is generally realized. Part of the population is still at risk of contracting malaria. Urgent steps must be taken to ensure that HIV prevalence in the population remains low. Because life expectancy has increased and the population is aging, non-communicable and degenerative diseases in adults—such as heart disease, cerebro-vascular disease, and diabetes—are becoming more common and must be addressed. The recently established Presidential Task Force on Health Reform will provide guidance on reforms needed to address these challenges. The Bank is committed to working with Sri Lanka on these issues. There is still poverty in Sri Lanka, and the health system must ensure that basic health services reach the poorest of the poor. At the same time, the current health care system that was so successful in eradicating the majority of health problems affecting developing countries needs to adapt in order to meet the new and more complex health challenges characteristic of industrial countries.

DPT Drop-out Rate: An estimate of the proportion of living children between the ages of 12 and 23 months who received at least one DPT vaccination but who did not receive the entire series of three vaccinations before their first birthdays.

Oral Rehydration Salts (ORS) Access Rate: An estimate of the proportion of the population under age five with reasonable access to a trained provider of oral rehydration salts who receives adequate supplies. This is a particularly difficult indicator to measure and, therefore, it may fluctuate dramatically from year to year as improved methods of estimation are devised.

Oral Rehydration Therapy (ORT) Use Rate: An estimate of the proportion of all cases of diarrhea in children under age five treated with ORS and/or a recommended home fluid. ORT use may be determined using administrative means or surveys. In general, administrative estimates are based on estimates of the number of episodes of diarrhea in the target population for a given year and the quantity of ORS available. Thus, changes in the estimates of the frequency of diarrhea episodes can alter the ORT use rate as well as real changes in the pattern of use. Surveys are more precise in that they focus on the actual behavior of mothers in treating diarrhea in the two-week period prior to the survey.

Contraceptive Prevalence Rate (CPR): An estimate of the proportion of women, aged 15 through 44 (or, in some countries, 15 through 49), in union or married, currently using a method of contraception. Where sources fail to distinguish modern and traditional methods, the combined rate is shown.

Adequate Nutritional Status: An individual child of a certain age is said to be adequately nourished if his/her weight is greater than the weight corresponding to two Z-scores (two standard deviations) below the median weight achieved by children of that age. The median weight and the distribution of weights around that median in a healthy population are taken from a standard established by the National Center for Health Statistics, endorsed by the World Health Organization (WHO). The indicator for the population as a whole is the proportion of children 12 through 23 months of age who are adequately nourished.

Exclusive Breastfeeding: An estimate of the proportion of infants less than four months (120 days) of age who receive no foods or liquids other than breast milk.

Complementary Feeding: An estimate of the proportion of infants six to nine months of age (181 days to 299 days) still breastfeeding but also receiving complementary weaning foods.

Continued Breastfeeding: An estimate of the proportion of children breastfed for at least one year. In this report, all values presented for this indicator are the proportion of children 12 to 15 months of age at the time of the survey still receiving breast milk.

HIV-1 Seroprevalence, Urban: An estimate of the proportion of all persons living in urban areas infected with HIV-1, the most virulent and globally prevalent strain of the human immunodeficiency virus. Where data are disaggregated by risk group, data for Low-Risk Population are typically drawn

from test results among pregnant women, the general population, or blood donors. High-Risk Population includes persons with known risk factors; these estimates are typically drawn from test results among commercial sex workers, their clients, or patients at STD clinics.

HIV-1 Seroprevalence, Rural: An estimate of the proportion of all persons living in rural areas infected with HIV-1.

Vaccination Coverage Rate (vcr %) in Children: An estimate of the proportion of living children between the ages of 12 and 23 months who have been vaccinated before their first birthday -- three times in the cases of polio and DPT and once for both measles and BCG. Vaccination coverage rates are calculated in two ways. Administrative estimates are based on reports of the number of inoculations of an antigen given during a year to children who have not yet reached their first birthday divided by an estimate of the pool of children under one year of age eligible for vaccination. Survey estimates are based on samples of children between the ages of 12 and 23 months.

Vaccination Coverage Rate (vcr %) in Mothers, Tetanus Toxoid 2+ (TT2+): An estimate of the proportion of women in a given time period who have received two doses of tetanus toxoid during their pregnancies. This indicator is being changed in many countries to account for the cumulative effect of tetanus toxoid boosters. A woman and her baby are protected against tetanus when a mother has had only one or, perhaps, no boosters during a given pregnancy so long as the woman had received the appropriate number of boosters in the years preceding the pregnancy in question. (The appropriate number of boosters required during any given pregnancy varies with number received previously and

the time elapsed.) The revised indicator is referred to as TT2+. Rates are computed using administrative methods or surveys.

Access to Potable Water Urban: An estimate of the proportion of all persons living in urban areas (defined roughly as population centers of 2,000 or more persons) who live within 200 meters of a stand pipe or fountain source of water.

Access to Potable Water, Rural: An estimate of the proportion of all persons not living in urban areas with a source of water close enough to home that family members do not spend a disproportionate amount of time fetching water.

Access to Sanitation, Urban: An estimate of the proportion of all persons living in urban areas with sanitation service provided through sewer systems or individual in-house or in-compound excreta disposal facilities (latrines).

Access to Sanitation, Rural: An estimate of the proportion of all persons not living in urban areas with sanitation coverage provided through individual in-house or in-compound excreta disposal facilities (latrines).

YEAR	RURAL	URBAN		SOURCE
1980	63	80		WHO9101
1985	39	65	WHO9101
1988	44	74	WHO9101
1990	45	68	WHO9200
1991	56	7 3	JMP9301

The Central Bank report in 1996, recognizing that non-communicable diseases such as heart diseases and cerebro-vascular diseases have emerged as the leading causes of death in recent years, commented on the necessity to allocate more resources on preventive health care.

However, the Annual Health Bulletin of 1996 showed that only 17% of the total health budget was spent on community health services which should play a major role in preventive health.

Considering the existing resource constraints, catering to the ever increasing demand for curative health facilities and meeting the increasing commitment on preventive health care will be the major challenge Sri Lanka is facing in the next century.

In-patient morbidity and mortality data are collected routinely from government hospitals, through a return based on the Basic Tabulation List of the International Classification of Diseases. The data for 1996 excluded the districts of Killinochchi and Mullaitivu.

Statistics in 1996 showed that ischemic or coronary heart disease was the leading cause of death amounting to 3109 or 10.6% of total deaths.

There were 2792 deaths from cerebrovascular diseases, 2505 deaths from diseases of gastrointestinal tract, 2502 deaths from poisoning, 2395 deaths from pulmonary circulation and other form of heart disease, and 2087 deaths from cancer.

Most of these diseases and conditions, and therefore most of the deaths in some groups were preventable.

The coronary heart disease first, as it is the leading cause of death in our hospitals. At least here, we are comparable to industrialized, affluent countries.

There is definite evidence that coronary heart disease is preventable, because some of the risk factors can be controlled, avoided or treated. Although it is stated that the most important predictor who gets coronary heart disease is who the individual's parents were, there is an important environmental component that interacts with genetic predisposition.

Some of the well known risk factors for coronary heart disease are high plasma cholesterol and low density lipoproteins, raised blood pressure, obesity, diabetes mellitus, intake of saturated fatty acids, smoking, high alcohol consumption and stress.

Therefore, it is necessary to develop strategies to prevent the rising incidence of coronary heart disease in Sri Lanka. There are well-recognized approaches identified by international studies we can modify and implement, considering the constraints we face.

The prevalence of diabetes in Sri Lanka is about 5% among the urban population aged 31 to 64. In rural areas it is about 2%. When we consider the frequency we detect new diabetics in our clinics, we sometimes wonder whether even these alarming figures are underestimates.

The prevalence of diabetes is expected to increase and the next century will see our elderly population suffering from more and more heart attacks, strokes and poor vision as a direct result of diabetes.

(unsatisfactory nature of management of diabetes in Sri Lanka). For example, in the diabetic clinic in the National Hospital of Sri Lanka, a single medical officer spends just over 2 minutes for each patient, no screening was performed for diabetic eye disease (diabetic retinopathy), urine not tested for kidney damage (diabetic nephropathy) and no information was provided to educate the diabetics.

The authorities will say this is a costly exercise without assessing all the savings such teams will make in preventing coronary by-pass surgery, stroke management, kidney disease and eye surgery.

Many developing countries including Sri Lanka observed a decline in death rates principally due to a decrease in deaths from infectious diseases and general improvement in standards of living, especially in nutrition and sanitation. For example our death rate has fallen from 22 per 1000 population in 1945, to 5.8 in 1995.

Diseases like typhoid, paratyphoid, tetanus, shigellosis, viral hepatitis, malaria pneumonia and meningitis were responsible for only 1348 deaths in our hospitals in 1996 while cancers alone killed 2087.

Income growth, improvements in medical technology, public health programs combined with the spread of knowledge about health were the four factors that caused a dramatic and unprecedented decline of mortality in developing countries such as Sri Lanka this century.

1. Increased income allows people to buy more food, have better housing and access to health care. Therefore, reducing poverty is an indirect investment in health. The devastating effects of ill health are greatest for the poor because they are ill more often, their income depends on physical labor and they have no savings or insurance to protect them. Therefore they may find it impossible to recover from an illness, with their human and financial capital intact.

2. The second factor that leads to a decline of mortality was the improvements of medical technology. Introduction of anti-bacterial drugs, vaccines, and improved diagnostic services since about 1930s immensely contributed to reduced mortality, as well as morbidity in the century.

3. Clean water, sanitation, food regulations and other public health measures were the third factors that helped to reduce mortality.

4. The dissemination of health messages, the fourth factor played a key role here as well. Health education can play a major role in the next century to spread the health messages on prevention of non-communicable diseases. Health education should start in schools, as many personal habits and life-style choices are formed early in life. Health education in schools can help young people make informed choices.

The continuous changing patterns of mortality and morbidity over time indicate that the major causes of disease are preventable.

There are four levels of prevention corresponding to different phases in the development of a disease. They are primordial, primary, secondary and tertiary.

Although primordial and primary prevention have the most to contribute to health, all are important and complementary.

Conditions leading to causation of a disease in a population or a selected group are considered primordial prevention. The aim is to avoid the emergence and establishment of the social, economic and cultural patterns of living that are known to contribute to an elevated risk of disease.

For example, avoidance of a diet high in saturated animal fat by a population will reduce the incidence of coronary heart disease. Comprehensive policies to discourage smoking, and programs for the prevention of hypertension and to promote regular physical activity are also methods of primordial prevention.

Primary prevention aims to limit the incidence of disease by controlling causes and risk factors. Examples of primary prevention activities include lowering cholesterol levels, reducing urban air pollution, use of condoms in the prevention of HIV infection, stopping smoking and wearing seat belts.

It is now evident that passive smoking is also harmful. People who have never smoked have a 30% increase in risk of coronary heart disease and 24% increase in risk of lung cancer, if they live with a smoker.

The aim of secondary prevention is to cure patients and reduce serious consequences by early diagnosis and treatment. Examples of secondary prevention in the area of non-communicable diseases are blood pressure measurements and treatment of hypertension in the middle-aged and elderly, and screening for cancer of the cervix, or diabetes mellitus.

Tertiary prevention is aimed at reducing progress of or complications of established disease. Physicians have a major role to play here because it consists of measures intended to reduce impairments and disabilities, minimize suffering caused by departures from good health, and promote patients' adjustments to incurable conditions such as strokes, blindness and disabling head and spinal injuries

More than half the young children who die in developing countries are malnourished. This does not mean that they starve to death, but that poor nutrition lowers their resistance to killer diseases.

It is at the stage when the human body is developing that malnutrition has its most severe effects. Apart from the 6.6 million malnourished children fewer than five who die each year, 174 million more are underweight and 230 million have stunted growth.

Improvement of nutrition in adults and children is a major challenge that we face. With all the commendable achievements we can be proud of in the health sector, nutrition remains a grave health concern.

This is a public health problem in 118 countries. As a result, at least 30,000 babies are stillborn each year and more than 120,000 are born mentally retarded, physically stunted, deaf-mute or paralyzed. The answer is to iodize salt supplies and Sri Lanka did just that a few years ago, in spite of some unwarranted criticism.

** Anemia was detected in one third of these plantation women. Anemia not only contributed to symptoms such as weakness and tiredness, it also reduced efficiency at work leading to reduced work output, affecting their income. Much more alarming is that anemia has contributed to high maternal deaths among women.

The latest UNICEF report mentions that from 1990 to 1994, 25% of infants were born with a low birth weight. 1990 to 1997, 7% of fewer than fives were severely underweight and 38% were moderately underweight. More alarming is the fact that 16% of them showed wasting and 24% showed stunting of growth indicating gross malnutrition. The so called "trickle down" effect of the open economy or free market economy, and the reduction or abolition of subsidies for the sake of so called economic growth has clearly not benefited the poor.

Sri Lanka has recorded impressive achievements in health, nutrition, and family planning with relatively low levels of public expenditure on health. A commitment to broader social development including education is a factor in its success.

Food security must not be confused with self-sufficiency in food. It depends much more on the capacity of the national economy to obtain its requirement of food from domestic and foreign sources and on the ability of people to purchase the food available.

· With the right agricultural policies in place, the emerging scenario will be a highly diversified and efficient agricultural economy, which will not only make optimal use of land and water resources but also ensure that profitable farming attracts enterprising and qualified persons to take up farming and provide an acceptable level of food security.

· The economy must make the best use of its resources, physical and human, and provide sufficient income-earning opportunities to the people. Maximizing the utility of water as an economic resource is, therefore, critical to achieving food security.

· We will see dramatic changes in agriculture in the next quarter century due to competition and globalization. While its importance in the national economy and composition of employment will decline relatively from the current 23 % to around 12 % with the growth of industries and services, it will be transformed into a highly productive commercial enterprise. This will be brought about by several factors:

1. The rural population is expected to decline from the current 13 million to about 9 million by 2025. This will reduce pressure on the natural resource base. Agriculture will be carried out by a smaller group of more educated and commercially oriented farmers who will produce “more crop per drop” using improved irrigation technology such as drip, sprinkler and lift irrigation limiting the need for the extension of agriculture.

2. Productivity in agriculture will increase with the introduction of paddy varieties and cultivation methods that require less water, adoption of water saving farming systems with high value crops, and other technological and biotechnological improvements.

3. Water will be treated as an economic resource rather than as a free good (as at present) and be priced realistically to optimize its use.

4. Globalization and the larger and richer domestic urban market with changing food habits will provide a profitable market for a variety of fresh and processed farm products.

5. Improved rural infrastructure, processing technology, cheaper storage and transport will improve access to domestic and foreign markets and increase the profitability of farming.

Value of small tanks and water bodies for social and environmental balance will be recognized and safeguarded. Sri Lanka, through improvements in productivity per unit of land and water, or “more crop per drop,” has the potential to achieve the desired level of food security for its population without expanding the irrigated extent. Sri Lanka recognizes, however, the need to sustain some of the less productive irrigated lands, especially under the village tank systems, to maintain a much-needed social and ecological balance. Policies and strategies in the irrigated agriculture sector will be designed to achieve the above objectives.

The Trincomalee is district (East), which is counted as a rural area and also suffering of the cruel ethnical war. Because of this ethnical war, have damaged to the public health care service, medical staff, medicine and medical materials as well as normal people life style. The health of the people of Trincomalee started declining since 1983. By the time war was started sever. But still it was rural area. The war miseries have not only affected the people of the country, but also the lives of innocent east civilians. The tremendous damage caused by the terrorists to private property and 40% of civilians becoming refugees.

In Trincomalee there are 3 major ethnic groups, Sinhala, Tamil & Muslims. But the majority is Sinhala. (Ratio - 2:1:1 - in 1985) and people belongs to 4 main religions, Buddhist, Hindu, Catholic and Muslim.

According to the Sri Lankan army-land classification, the Trincomalee we can divide into 3 parts. Non-cleared areas, boarder lands and cleared areas. (Non-cleared area – which are ruled by LTTE**, board lands – between cleared & non cleared areas, cleared areas – ruled by Sri Lankan army)

We are aware that the people in rural areas constitute the majority of the world’s population. Trincomalee has a population of 198,000. They undoubtedly have a lower health status than their urban counterparts. There are several reasons for this. The health of the rural people is affected by cultural and socio-economic factors, but the major problem lies in the inadequacy of health care resources.

In most the rural health services are endowed with fewer resources than the urban health services. Even in countries that have adequate health care facilities and a satisfactory ratio of doctors to patients, there is a tendency for inequitable distribution of resources. It is the rural people who do not receive the healthcare that should be available to them. In addition, the rural areas often lack the basic essentials for good health such as appropriate housing and sanitation. There are also in rural areas high-risk groups such as infants, women and elderly who are often not provided with adequate care unlike their urban counterparts. ( see below tables / statistics)

Incidence of Selected Notifiable Diseases & Deaths -2000 & 2001

Districts	No: of Outdoor Patients treated	No: of Indoor Patients treated
Trincomalee	332,196	27,428
Vavuniya	196,678	17,022
Mannar	121,104	8,382
Kilinochchi	168,226	10,282
Mullaitivu	148,616	6,886

Government hospitals & Health services in North –East province. ( 1996- 2000 )

Item	1996	1997	1998	1999	2000
Hospitals (1)	452	454	469	556	558
Central Dispensaries	397	387	395	383	404
Beds (1)	51,278(6)	52,291	53,507	55,195	57,027
Doctors (3)	5,117	5,628	6,427	6,994	7,963
AMO/RMO	1,397	1,384	1,324	1,340	1,349
Nurses (4)	13,933	13,815	14,621	14,052	14,716
Attendants	6,657	7,270	7,903	..	..
Number of inpatients treated ('000)	3397(6)	3,454(7)	3,791	3,825	4,015
Number of outpatients treated ('000)(2)	35,348(6)	38,078(7)	41,071	41,323	43,329
Expenditure Rs. Mn. (5)	11,422	12,782	15,943	18,018	19,055
Ministry of Health

(1) Excludes maternity homes and central dispensaries, but includes maternity hospitals (De Soyza and Castle Street hospitals)
(2 These figures do not indicate the number of patients. Repeated visits of the same patient after short intervals have been regarded as new cases.
(3) Doctors of all grades in the Department of Health Services.
(4) Excluding pupil nurses, public health and dental nurses.
(5) Includes capital expenditure, grants, rebates and contributions.
(6) Excludes Kilinochchi and Mullaitivu districts.
(7) Excludes Ampara district.
AMO - Assistant Medical Officer, RMO - Registered Medical Officer

Another likely reason for this inadequacy of health care facilities in rural areas is the poor provision of manpower resources such as competent medical practitioners and other healthcare personnel. These persons, if appointed to rural areas, are often unwilling to serve in those areas. Even if they do take up their unable to adapt themselves to work under the prevailing conditions in those areas.

District	1993	1994	1995	1996	1997*	1998*	1999*	2000
Sri Lanka	350,707	356,071	343,224	340,649	332,626	325,821	329,521	340,144
Trincomalee	6,561	7,937	7,525	7,305	7,917	7,277	7,483	8,599

District	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997*	1998*	1999*	2000*
Sri Lanka	20.2	18.4	19.3	17.7	17.9	16.3	16.9	16.5	17.3	16.3	14.3	13.4	13.3
Trincomalee	9.3	7.1	9.0	5.6	5.9	6.6	4.3	7.0	1.4	1.6	4.5	2.9	2.6

Infant mortality and maternal mortality are two important indicators of the health status in a region. A comparison of the distribution of health personnel in the urban and the rural areas reveals a disparity in distribution. 14 year old North-East war took some 50,000 lives.

Incidence of poisoning, which was steadily increasing in the last few decades, reached a peak in 1996. There were 70,923 admissions from poisoning including snake bites, resulting in 2502 deaths. It has to be noted that no data were available from Mullaitivu and Killinochchi districts, while even in other districts, 22% of deaths and 12.8% of live discharges were not analyzed.

District	1991	1992	1993	1994	1995	1996	1997*	1998*	1999*	2000
Sri Lanka	95,574	98,380	96,179	100,394	104,707	122,161	113,078	111,405	114,472	112,569
Trincomalee	996	1,240	1,366	1,156	1,174	1,234	1,194	1,155	1,287	1,427

The infant mortality rate is become decrease, because of health more health access than before because governmental and nongovernmental organizations take part of health care of “non- cleared areas”* Since end of March 2000, nearly 198,000 people living there, the vast majority are displaced,& also 40% of civilians becoming refugees, they migrate to the other cities. The mainstays of these are their human resources. These comprise persons who spend most of their lifetime in the rural areas. A smaller number inevitably migrate to cities, but their families usually continue to live in the rural areas.

It should be obvious that these rural people deserve the best in health care. Unfortunately this is not the case. Owing to the inequitable distribution of health facilities in Sri Lanka as well as Trincomalee, there is a wide disparity in provision of health care between the urban and rural populations.

When we compare the infant mortality rate and the maternal mortality rate in rural areas with those obtained from urban areas, they are much higher than the rates for the whole country.

Whether it is with reference to an individual, a family, a community or a nation, it could be said that health is wealth. In a developing county such as ours, the national economy depends to a great deal on the health of its human resources. Provision of adequate and proper health care for these persons is vitally important for the proper development of the country & peaceful environment around them. Let us examine the contributors to the national wealth in the Trincomalee district. These include: coconut, agriculture (rice, onions.) fishing, tourism, garment /cement /sugar industry , foreign employment & etc. But war also badly effected to civilians life style. So decrease income rate of each person. Below shows the land that can use /used in Trincomalee district.

Malnutrition: /the core problem /Malnutrition among women and children is alarmingly high in Trincomalee district.

This is the finding of a nutrition and health baseline survey conducted in 20 Tamil, Sinhalese and Muslim villages in 1999. One out of four children under five years of age is suffering from acute malnutrition (wasting), which was found extremely high among all three ethnic groups (27%). Every second woman in the survey area is malnourished (BMI <18.5). In the”uncleared areas” (under LTTE control) even 77% of the women are malnourished, half of them are severely malnourished (BMI <17).

In addition to the overall difficult situation, intra-household food distribution discriminates against women’s appropriate nutrition intake, due to cultural reasons. Main causes of malnutrition are lack of safe drinking water, poor hygiene, difficult access to health facilities, food shortage as well as little variety in the daily food.

Diet consists mainly of rice, sambol and leafy vegetables. Some villages have good access to fish, a very good source of protein, which is needed to build a strong and healthy body. Most families do not consume healthy food items such as eggs, fish, vegetables and fruits often enough and in sufficient amounts. The other thing is the religion infuses. (People belongs to Hindu religion prohibit to take beef, Muslims use to take only “Halal” food and in this situation it’s difficulty to find halal food/meat and they are not taking pork at all, because of religion infuses.

In the divisional centers (central villages / small towns) food and consumer goods are available in remarkable variety. However, distances to the villages are often very far, transport facilities are poor and purchasing power is low.

In addition, health facilities are damaged, poorly equipped and understaffed. Many staff positions remain vacant since officers are not willing to work in remote areas due to security reasons and difficult accessibility. As a consequence, preventive and curative health services cannot be provided in the quantity and quality required. Government restrictions on the flow of goods into the ”un-cleared areas” include food, medicine, construction material and many other essential commodities.

Marine sector fish production by District Fisheries Extension Officers (D.F.E.O.) Division, 1995 - 2000

D.F.E.O Division	1994	1995	1996	1997	1998	1999	2000*
Trincomalee	14,060	9,130	10,450	8,800	12,850	14,730	14,540
Total	212,000	217,500	206,300	214,750	239,950	248,450	267,680

The total quantity of food stuffs produced in the country, added to the total quantity imported and adjusted to any change that may have occurred in stocks since the beginning of a given period, is the total food supply in that period. By subtracting exports, feed to livestock, seed, industrial and other non-food use as well as losses owing to wastage of all kinds, the remaining quantity represent the food available for consumption. Food Balance Sheet shows quantities and contents of food supply (per capita availability) in terms of nutrient value.

Commodity	Per capita availability - 1999
Commodity	Calories per day	Prot. Grms per day	Fat Grms per day
Cereals	1,351.52	30.66	2.52
Root & Tubers	63.80	0.54	0.08
Sugar	283.62	0.00	0.00
Pulses & Nuts	60.93	4.28	0.79
Vegetable	53.64	2.36	0.32
Fruits	28.22	0.47	0.41
Meat (All products)	17.37	2.94	0.62
Eggs	12.44	0.96	0.96
Fish (All products)	54.82	8.75	1.79
Milk (All forms)	70.29	3.36	4.08
Oil & Fat	335.57	2.88	31.58

NUTRITIONAL STATUS OF PRE-SCHOOLERS ( 6 TO 59 MONTHS)
BY ADMINISTRATIVE DISTRICTS - 1980/82
District	Percentage Wasting	Percentage Stunting	Percentage concurrently wasting & stunting
Ampara	8.9	24.9	3.8
Batticaloa	9.7	26.1	6.5
Trincomalee	10.0	25.1	3.1
Mullaitivu	4.6	28.8	1.4
Vavuniya	4.6	22.0	4.3
Mannar	6.2	27.1	3.5
Jaffna	5.6	24.7	1.8

The mid-day meal program (Illai Kanchi /Kola Kantha) for school children was introduced in late 1999.

Malnutrition is a major problem among school children, especially in remote areas. Many school principals report that children faint during lessons, they cannot concentrate or do not even come to school since they have to help their parents in earning money or cultivation. Since education is a basic right and an asset for the future development of children adequate feeding of students must not be separated from teaching. IFSP has initiated a mid-day meal program (Illai Kanchi / Kola Kantha) for school children to improve their performance and to attract all children to attend school regularly. A pilot program was launched with St. Mary’s College in Trincomalee town in 1999. This program has been expanded to poor villages in Trincomalee district. Altogether more than 2,300 pre-school and school children in 3 pre-schools 18 schools in 6 DS Divisions are supported through the mid-day meal program until end 2000.

Initially the parents of the school children contribute about 10% of the total costs in terms of healthy food items that are available in the village itself (e.g. green leaves, coconut, cashew and shrimps).

IFSP is supporting the mid-day meal with red rice, green and white gram as well as some basic equipment for the cooking. Two mothers of the school children volunteer cooking the meal and one person is in charge of buying the necessary ingredients. In turn, two students help in preparation and cooking that at the same time they learn how to prepare a healthy meal. The students also collect the firewood.

It is intended to increase villagers contribution after every project phase (6 months) to 25%, 50%, 75% and finally up to 100% two years after begin of implementation.

The program will be expanded continuously. Preference is given to schools in PNA villages and other poor villages (poverty code 5 and 4, which means the village is severely conflict affected and experiences a high degree of food deficit). Further criteria are high malnutrition, poor attendance rate, and contribution for the community.

Seven staff from the Department of Health (public health inspector /PHIs/, midwifes), Department of Agriculture (Agricultural inspector.) and from non governmental organizations (NGOs) were sent by IFSP for a training supported by UNICEF in Colombo. They learned how to train health volunteers in the villages and how to explain to people what they can do themselves to improve their health and nutrition.

Village based health volunteers play an important role to fill the gap between the lack of government staff in certain remote areas and the needs of the villagers. The training lessons covered the following main topics:

Furthermore, an agricultural instructor introduced the purpose and technical aspects of home gardening. volunteers underwent the first joint refresher training covering topics such as garbage disposal, personal hygiene, dengue fever, ”healthy meal with little money” etc.

Major health and nutrition constraints of children were identified (lack of food, poor hygiene, and lack of parental care). The pre-school teachers also expressed the main constraints for their work, such as lack of regular training and irregular payment.

In Muthur, Eachchilampattai and Kuchchaveli monthly meetings of pre-school teachers with the IFSP health and nutrition team (PHIs and midwifes) were initiated. Each meeting covered one specific topic and gave the opportunity to evaluate ongoing activities, plan for the next month and exchange problems and success in the day-to-day work.

A monthly growth monitoring in Kuchchaveli DS Division has already started and is planned for all pre-schools in the six divisions.

A knowledge test at the end of the training enabled the participants to find out, whether they understood the topics well. Results gave an indication to the trainers which topics needed to be covered more intensively in future.

The teachers' interest in training on oral health, environmental sanitation, disease prevention and first aid could be considered together with their request for more posters and other teaching material on health and nutrition.

People defecate in the open field. This can have serious health impacts, such as cholera, which occurred in 1998 in several locations in the Kuchchaveli and Muthur Divisions. IFSP gave priority to these villages for toilet construction. Based on vulnerable groups that were identified during PNA, poor families were selected as beneficiaries. The selection followed agreed-upon selection criteria and was done in close cooperation with the health team and local government representatives (GS, PHIs, Samurdhi animators). The selected families have to contribute labour and material to the toilet construction and should be willing to share the toilet with neighbouring houses. Awareness programmes to emphasise the importance and proper use of toilets accompany construction.

The selected families have to contribute at least 25% to the toilet construction (unskilled labour, material etc.) and should be willing to share the toilet with neighbouring houses. Awareness programmes on the importance and proper use of toilets have been conducted in all villages where toilets have been constructed.

a) Recognizing the specific nature of the rural healthcare and the broad range of skills required of health professionals working in rural areas by government health authorities, academic institutions and professional bodies, in formulating curricula for education and training.

b) Enhancing the status of rural doctors by improving career prospects, providing attractive incentives such as comfortable living and up-to-date working conditions.

c) Providing infrastructure for comprehensive healthcare services in under-serviced rural areas should be given high priority by the national government.

d) Creating partnership between the health professionals, the health administrators and the community for developing health services that would meet the needs of the community.

e) Field testing more than one model of rural healthcare for evaluation, by regional and national government health authorities in partnership with the community.

f) Adopting the philosophy of primary healthcare as the key to healthcare of the rural population.

g) Using the patient-cantered approach to primary medical care of individuals and families.

· "Established Market Economies" by the World Bank's World Development Report, 1993.

· Nutrition status and sccio-economic status survey 1993 – ministry of policy planning and implementation.

· BUC9103 Bureau of Census, Center for International Research, Recent HIV Seroprevalence Levels By Country, April, 1992

· BUC9401 U.S. Bureau of the Census (BUCEN).International Data Base. Version dated March, 1994.

· CAL9512 Calculated medians for aggregates of countries using bestavailable data from the CIHI Health Statistics Database

· CAL9602 Calculations of the annual number of live births based on thepreferred estimates of total population and crude birth rat

· CAL9603 Calculations of the annual number of infant and/or under fivedeaths based on the preferred estimates of total population and infant and/or under five mortality rates.

· DHS8807 Department of Census and Statistics, Ministry of Implementation, and Institute for Resource Development/Westinghouse. Sri Lanka

· JEE9507 Under Five Mortality Rate (5Q0) calculated from Infant Mortality Rate (1Q0) using the "ABSS" (all but Sub-Saharan Africa) equation: 5Q0 = 1.14855*((1Q0)^1.04799)

· JEE9512 Infant mortality curve based on BUC9302 estimates supplemented by UNP9400 estimates.

· JMP9301 WHO/UNICEF Joint Monitoring Programme. Water Supply and Sanitation Sector Monitoring Report 1993. Sector Status as of December 1991. WHO and UNICEF. August, 1993.

· UNP9400 Department of International Economic and Social Affairs, United Nations. World Population Prospects 1994. (Tape) New York: UN, 1994.

· WHD8500 World Health Organization. Programme for Control of Diarrhoeal Diseases: Fourth Programme Report 1983-1984. (WHO/CDD/85.13) Geneva: WHO, 1985.

· WHD8700 World Health Organization. Programme for Control of Diarrhoeal Diseases: Interim Programme Report 1986. (WHO/CDD/87.26) Geneva: WHO, 1987.

· WHD8800 World Health Organization. Programme for Control of Diarrhoeal Diseases: Sixth Programme Report 1986-1987. (WHO/CDD/88.28) Geneva: WHO, 1988.

· WHD8900 World Health Organization. Programme for Control of Diarrhoeal Diseases: Programme Report (WHO/CDD/89.31) Geneva: WHO, 1989.

· WHD9000 World Health Organization, Programme for Control of Diarrhoeal Diseases facsimile, February 14, 1990.

· WHD9100 World Health Organization. Programme for Control of Diarrhoeal Diseases: Interim Programme Report 1990. (WHO/CDD/91.36) Geneva: WHO, 1991.

· WHD9201 Programme For Control Of Diarrhoeal Diseases. Eighth Programme Report 1990-1991. WHO/CDD/92.38. Geneva: World Health Organization, 1992.

· WHD9300 World Health Organization, Programme for Control of Diarrhoeal Diseases; provisional data for Annex 1 of the Ninth Programme Report. Received by personal communication, February 16, 1993.

· WHD9401 Advanced Copy of Annex 1 of the WHO/CDR Annual Report, Received by facsimile, March 29, 1994.

· WHE8700 World Health Organization. Expanded Programme on Immunization Information System Report, January 1987. Geneva: WHO, 1987.

· WHE8701 World Health Organization. Expanded Programme on Immunization Information System Report, July 1987. Geneva: WHO, 1987.

· WHE8800 World Health Organization. Expanded Programme on Immunization Information System Report, January 1988. Geneva: WHO, 1988.

· WHE8801 World Health Organization. Expanded Programme on Immunization Information System Report, July 1988. Geneva: WHO, 1988.

· WHE8900 World Health Organization. Expanded Programme on Immunization Information System Report, July 1989. (WHO/EPI/GEN/89.2) Geneva: WHO, 1989.

· WHE9100 World Health Organization. Expanded Programme on Immunization Information System Report, April 1991. (WHO/EPI/CEIS/91.1) Geneva: WHO, 1991.

· WHE9200 World Health Organization. Expanded Programme on Immunization Information System Report, April 1992. (WHO/EPI/CEIS/92.1) Geneva: WHO, 1992.

· WHE9202 World Health Organization. Expanded Programme on Immunization Information System Report, October 1992. (WHO/EPI/CEIS/92.2) Geneva: WHO, 1992.

· WHE9401 Download of WHO/EPI vaccination coverage files from INTERNET,March1994.

· WHE9403 Download of WHO/EPI vaccination coverage files from INTERNET,Augus1994.

· WHE9502 Download of WHO/EPI vaccination coverage files from INTERNET,Sept: 1995

· WHO9101 World Health Organization. World Health Organization Disk: Water Supply and Sanitation Service Coverage. Geneva: WHO, October 29,1991.

· WHO9200 The International Drinking Water and Sanitation Decade, 1981-90: End of decade review, (as of December 1990), August 1992. CWS Unit, Division of Environmental Health, World Health Organization, 1211 Geneva 27, Switzerland