‘Weathering the Economic Crisis through Health System Efficiency’

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The impact of economic crisis
The impact of economic safety on health has been well-recognized.Economic instabilities not only create health system failures with direct outcomes, but also impose hindrances in achieving global health targets.Healthcare systems of any country, irrespective of being at lower-, middle-or highincome levels, cannot escape from the influences of its economic vulnerability.
In Sri Lanka, with a plunge of foreign-exchange revenues and difficulty in managing external debt, the inflation hit a record high value of 54.6% by mid-2022, while food inflation rising to 81% endorsing an economic crisis in this island nation.The potential impact of the economic crisis in Sri Lanka on the health system has been vividly explained in the correspondence article by Anne Thushara Matthias and Saroj Jayasinghe in the Lancet Global Health in 2022: "Threats to health from an economic crisis are multi-fold.

Policy interventions to overcome these negative impacts
As a way out of the economic crisis, it has been emphasized to make the health systems resilient.
The Organization for Economic Co-operation and Development has defined a resilient system as "a system that can absorb and recover from shocks in the short term while positively adapting and transforming its structure in the long term to cope with changes and maintain its optimal performance".Resilience can be applied to the six building blocks of a health system proposed by the World Health Organization, namely leadership and governance, service delivery, health workforce, health systems financing, health information systems and medicines and equipment.
Having a strong primary care and communitybased services is a favourable contextual factor that affect the resilience in economic crisis.Sri Lanka has been having a strong community-based health service infrastructure and blessed with the centuryyear-old health unit system.All households have been clearly demarcated in a health system unit called 'medical officer of health' area, with specific field level staff members being allocated to deliver well-defined services.
The policies adopted in the face of crises divide into one of the three categories: • Policies of 'absorptive capacity' that seek continuity and maintenance of the health services level in terms of quality, quantity and equity using available resources and keeping the current system's structure and sustainability • Policies of 'adoptive capacity' that imply the system flexibility and make gradual changes in characteristics and activities to provide health services with fewer and different resources • Policies of 'transformative capacity' that make principal reforms in functions and structure of the health system in response to change

Health system efficiency
Basic definition of efficiency is the relationship of inputs to outputs.However, it has been highlighted that in relation to health systems, outcomes must be given more emphasis than outputs.This makes the measurement of efficiency complicated within the health systems compared to non-health systems.Hence, it is important to distinguish between the output efficiency and outcome efficiency.'Output efficiency' is related to productivity and measured with output indicators, whereas 'outcome efficiency' is more related to cost-effectiveness and measured with outcome indicators.There are two other perspectives to health system efficiency; the efficiency being in relation to its type ('technical' or 'allocative') and the level of analysis when the measurement is done (system-wide level, subsector level or specific disease or condition-based level).Technical efficiency refers to the production of greatest outputs or outcomes for a given level of inputs or producing the same outputs or outcomes at a lower cost.This in simple terms is "doing more with less" or "doing the same at a lower cost".In contrast, the allocative efficiency refers to the allocation of resources to achieve the greatest health outcomes at the least cost.In simple terms this can be described as "doing the right thing, at the right place".

Role of CCPSL in the given context
The specialty of Community Medicine can be regarded as the medical domain of public health.
Community Medicine ensures that a country accomplishes two functions: linking of the curative services with the community; and illness prevention and wellness promotion in the community.It is closely associated with the welllaid community-health infrastructure with its specialists and trainees delivering a notable service being placed at different levels of the health system.Thus, the service providers of Community Medicine have diverse responsibilities both at institutional level as well as at community level in weathering the current economic crisis.
Several factors facilitate the successful accomplishment of their role in this process.The curriculum of the Postgraduate Institute of Medicine equips them with the skills needed in delivering essential public health functions.
Consultant community physicians (CCP) are currently attached at the national, provincial and district levels within the Ministry of Health and some function as public health specialists attached to universities and to international organizations.
Dynamics of their service delivery enable them to be ideal catalysts in weathering the current economic crisis.As an example, the generic job description of a CCP that has been published by the Ministry of Health encompasses 10-key tasks they perform, namely public health management, policy analysis and development, strategic planning, advocacy, raising awareness on health, surveillance, monitoring and evaluation, research, quality assurance of public health programs, training and capacity building, and fund mobilization.
The College of Community Physicians of Sri Lanka (CCPSL) is the umbrella organization and the apex professional body of public health.Hence, the CCPSL has a greater responsibility of mentoring the country in this economic crisis period by incorporating the concepts of health system efficiency.