Sri Lanka and the possibilities of achieving universal health coverage in a poor country

Sri Lanka has been lauded for providing good health coverage at a low cost despite having a modest per capita income. This article identifies the unique historical factors that enabled Sri Lanka to achieve near universal coverage, but it also discusses how this achievement is now being undermined by inadequate government investment in health services, the burdens of non-communicable diseases, and the growing privatisation of health services. In doing so, the article highlights the challenges of achieving and maintaining universal health coverage in a relatively low income country with a health system designed to treat infectious diseases and provide child and maternal health services as the country undergoes an epidemiological transition from infectious to non-communicable diseases. Using updated information on developments in the Sri Lankan health system, this article argues, in contrast with earlier publications, that Sri Lanka is no longer providing good health at a low cost. It shows that Sri Lanka's low investment in health is detrimental and not an asset to achieving good health. The article also questions the possibilities of providing coverage for noncommunicable diseases at a low cost. The article has four main sections. The first details Sri Lanka's accomplishments in moving toward universal health coverage. The second identifies the factors enabling Sri Lanka to do so. The third describes the equity and access challenges the health system now confronts. The fourth assesses what the Sri Lankan experience suggests about the requirements for universal health coverage when providing health services for treating non-communicable diseases becomes an important consideration.