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Demographic Implications of Health Care in Sri Lanka
By 2020, Sri Lanka will experience South Asia's most
rapid population ageing
Sri Lanka
By A.T.P.L. Abeykoon, UNESCAP
The size of a population, its growth and age-sex
structure have many important socio-economic implications. The most
fundamental of these factors in the field of health are their influence
on health care service requirements. In Sri Lanka, changes in the number
of persons attaining a particular age are having significant
repercussions in producing both short- and long-term pressures on the
status of health, utilization of health services and health service
requirements. The current age-sex structure of Sri Lanka's population is
the result of past trends in fertility, mortality and migration.
Past trends
In 1946, when Sri Lanka took its first post-Second
World War census, the population age structure was relatively young,
with about 37 per cent of the total population being under 15 years of
age. This proportion, however, increased to nearly 42 per cent in 1963
and thereafter gradually declined to 35 per cent at the last census
taken in 1981. The estimated population for 1991 shows a further
reduction of those under 15 years of age to 31 per cent (table 1).
____________
* The author of this article is Director, Population Division,
Ministry of Health and Social Services, Sri Lanka. The article is a
revised version of a paper presented at the Seminar on Sri Lanka's
Health Strategy and Financing held at Colombo in June 1994.
Table 1: Population
composition of Sri Lanka by broad age groups, 1946-1991
|
Year |
Age group |
|
0-14
(%) |
15-64
(%) |
65 and older
(%) |
|
1946 |
37.2 |
59.3 |
3.5 |
|
1953 |
39.7 |
56.8 |
3.5 |
|
1963 |
41.5 |
54.9 |
3.6 |
|
1971 |
39.0 |
56.8 |
4.2 |
|
1981 |
35.2 |
60.5 |
4.3 |
|
1991 |
31.2 |
63.4 |
5.4 |
Source: Population Statistics of Sri Lanka, Population
Division, Ministry of Health, June 1992.
The changes in the age structure are the result of
the different rates of growth of population experienced during the
period 1946 to 1991 as indicated in table 2. The high rates of
population growth experienced during the period 1946 to 1963, mainly as
a result of the growth in the rate of natural increase, initially caused
the age structure to be weighted towards the younger ages. Subsequent
reductions in fertility and net migration brought about reductions in
the growth rate and proportionate share of population under 15 years of
age. It can be seen from figure 1 that the population age pyramid is
narrowing at the base and gradually expanding in the working ages.
Table 2: Sri Lanka
population growth and contribution of natural increase and migration,
1946-1991
|
Year |
Population
(thousands)
|
Average
annual growth rate
(%) |
Total
increase
(%) |
Percentage
contribution to total increase |
|
Natural
increase |
Net migration |
|
1946 |
6,657 |
- |
- |
- |
- |
|
1953 |
8,098 |
2.8 |
21.6 |
19.9 |
1.7 |
|
1963 |
10,582 |
2.7 |
30.7 |
31.0 |
-0.3 |
|
1971 |
12,690 |
2.2 |
19.9 |
20.9 |
-1.0 |
|
1981 |
14,847 |
1.7 |
17.0 |
22.6 |
-5.6 |
|
1991 |
17,247 |
1.5 |
16.2 |
18.9 |
-2.7 |
Sources: Censuses of Population; Registrar General's
Department; and Population Division, Ministry of Health.
The rapid
growth of natural increase during the initial period was mainly the
result of a sharp decline in mortality which commenced after 1946. The
crude death rate, which was 19.8 per thousand population in 1946,
dropped to 8.5 per thousand in 1963. Similarly, reductions in the infant
mortality rate from 141 per thousand live births to 56 and in the
maternal mortality rate from 15.5 per thousand live births to 2.4 were
observed during the same period. Further reductions in mortality
occurred in the ensuing decades. Effective application of DDT in
national efforts to eradicate malaria, improvements
in and growth of the health care system, improvements in agricultural
production and subsidised distribution of food items and the expansion
of free educational services, all have directly or indirectly
contributed to mortality decline in Sri Lanka. The cumulative effect of
the policies and programmes that brought about these improvements is
reflected in the increase in expectation of life at birth from 42.2
years in 1946 to 71.2 years in 1988 (table 3).
Table 3: Expectation of
life at birth by sex in Sri Lanka, 1946-1988
|
|
1946 |
1953 |
1962 |
1971 |
1981 |
1988* |
|
Total |
42.2 |
58.2 |
61.7 |
65.5 |
69.9 |
71.2 |
|
Male |
43.9 |
58.8 |
61.9 |
64.2 |
67.7 |
68.8 |
|
Female |
41.6 |
57.5 |
61.4 |
66.7 |
72.1 |
73.5 |
Source: Department of Census and Statistics.
* Estimated.
While mortality and migration have contributed to the demographic
transition, fertility decline has been the main contributory factor in
the reduction of the population growth rate (Bongaarts, 1978). It can be
seen from table 4 that the total fertility rate has declined from 5.3
children per woman in the early 1950s to around 2.3 during the period
1988-1993. It is worth noting that, during the period 1980-1982 to
1988-1993, the total fertility rate declined at an average annual rate
of 4.0 per cent (Abeykoon, 1994b).
Table 4: Total fertility
rates in Sri Lanka, 1952-59 to 1988-93
|
Period |
Total
fertility rate |
Average
annual decline
(%) |
|
1952-1954 |
5.3 |
- |
|
1962-1964 |
5.0 |
0.6 |
|
1970-1972 |
4.1 |
2.5 |
|
1980-1982 |
3.4 |
2.0 |
|
1988-1993 |
2.3 |
4.0 |
Source: Department of Census and Statistics.
Note: Data for the 1988-1993 period exclude the northern and
eastern provinces.
Data on age at marriage and contraceptive use
indicate that these two variables have to a large extent contributed to
fertility decline in Sri Lanka. The female mean age at marriage
increased from 20.7 years in 1946 to 25.5 years in 1993. Similarly, the
contraceptive prevalence rate increased from 32.0 per cent in 1975 to
66.1 per cent in 1993. The initial fertility decline was due mainly to
changes in nuptiality. Since the early 1970s, an increasing proportion
of fertility decline has been attributed to the fall in marital
fertility and less to changes in nuptiality (table 5). During the decade
1972 to 1982, the control of marital fertility largely through
contraceptive use has accounted for more than 75 per cent of the
fertility decline in Sri Lanka (ESCAP, 1986).
Table 5: Decomposition of
the change in Sri Lanka's total fertility rate, 1953-1981
|
Component |
1953-1963
(%) |
1963-1971
(%) |
1971-1981
(%) |
|
Nuptiality |
0.29 |
0.48 |
0.15 |
|
|
(96.7) |
(53.3) |
(21.4) |
|
Marital fertility |
0.01 |
0.42 |
0.55 |
|
|
(3.3) |
(46.7) |
(78.6) |
|
Total |
0.30 |
0.90 |
0.70 |
|
|
(100.0) |
(100.0) |
(100.0) |
Note: The figures in parentheses indicate the relative
contributions.
Future prospects and challenges
Given the high level of contraceptive prevalence and
high motivation to control fertility, there is every likelihood that
fertility will decline to the replacement level towards the end of this
decade and continue to decline thereafter for a few decades. On the
other hand, expectation of life at birth can be expected to improve
slowly in the coming decades with rising living standards. International
migration, which contributed significantly to the decline in the growth
rate of the population during past two decades, is likely gradually to
become less important as a component of population growth in the future.
Given these plausible trends in fertility, mortality and migration, the
population of Sri Lanka will increase from 18.2 million in 1995 to 22.4
million in the year 2020 (table 6). Sri Lanka's population is expected
to stabilize eventually at around 24 million by the middle of the next
century, which is about 33 per cent higher than the population in 1995.
Table 6: Population
projections for Sri Lanka, 1995-2020
|
Year |
Total
(in
thousands) |
Male
(in
thousands) |
Female
(in
thousands) |
|
1995 |
18,201 |
9,191 |
9,010 |
|
2000 |
19,250 |
9,691 |
9,559 |
|
2005 |
20,213 |
10,146 |
10,067 |
|
2010 |
21,073 |
10,549 |
10,524 |
|
2015 |
21,799 |
10,884 |
10,915 |
|
2020 |
22,362 |
11,138 |
11,224 |
Source: Abeykoon (1994a).
The demand for personal health care services is not
only a function of the total size of the population but also its age and
sex structure and age-sex specific morbidity prevalance rates. In this
article, attention is focused on the changing age structure of the
population and its likely implications for health care. It is evident
from table 7 that, with further slowing down of the population growth
rate, the population age structure will continue to change, resulting in
a decline in the proportion of those at the younger ages and an
expansion of the population in the working ages; eventually it will
bring about an increase in the old-age population. It is also seen that,
towards the end of the second decade of the next century, the ageing
process will accelerate, as indicated by the index of ageing. It is
important to note that the index of ageing of patients is higher than
that of the general population at ages above 65 years, as rates of
illness and hospitalization are substatially higher in that age group
than in the age group 0-14 years. It can be seen from the population
pyramids in figure 2 that the population will continue to shrink at the
base and buldge in the working ages and eventually expand at the older
ages.
Table 7: Population
composition of Sri Lanka by broad age groups, 1995-2020
|
Year |
Age group
|
Index of
ageing
% |
|
center>0-14
% |
15-64
% |
65 and older
% |
|
1995 |
28.0 |
65.9 |
6.1 |
21.8 |
|
2000 |
25.1 |
68.1 |
6.8 |
27.1 |
|
2005 |
23.5 |
68.9 |
7.6 |
32.3 |
|
2010 |
22.0 |
69.4 |
8.6 |
39.1 |
|
2015 |
20.8 |
69.1 |
10.1 |
48.6 |
|
2020 |
19.5 |
68.4 |
12.1 |
62.1 |
Source: Same as for table 6.
Note: Index of ageing is defined as the number of persons aged
65 years and older per 100 population aged 0-14 years.
It may be observed that health care requirements are
high at birth and gradually decline to a minimum at age 15 and remain
relatively low until around age 50 and thereafter rapidly increase until
death. If the proportion of the population under 15 years declines, then
this situation will reduce the pressure on the health care system.
However, if the proportion of the population aged 15 to 49 years
increases, given the relatively low morbidity prevalence of this age
group, the sheer increase in the absolute number of people would
increase the demand for personal health care services. Yet, at the same
time there will be a demand for other services such as housing,
employment and food. Thus, the health sector will have to compete for
resources with other sectors such as industry and agriculture, which are
generally considered as directly productive. For it is only with the
increase in productivity of sectors such as industry and agriculture
that health care for the increasing numbers of the elderly could be
supported and sustained by the State.
Given the changing pattern of the population age
structure in Sri Lanka, what implications will it have on health care in
the future? It is evident from table 8 that the absolute number of
births and children under five years of age will decline while women in
the reproductive ages will increase in absolute terms. On the one hand,
this situation will reduce pressure on maternal and child health
services. However, with the projected increase in the sexually active
population, there would be an increasing demand for reproductive health
care elements such as the following: treatment of reproductive tract
infections, sexually transmitted diseases and other reproductive health
conditions; information, education and counselling on human sexuality;
reproductive health and responsible parenthood. Safe and effective
protection from unwanted pregnancies, contraceptive choice and quality
of care; prevention and appropriate treatment of infertility; and
prevention of abortion and management of the consequences of abortion.
Table 8: Total number of
births, young children and women in reproductive age group in Sri Lanka,
1995-2020
|
Year |
Births
(in
thousands) |
Children
aged 1-4
(in
thousands) |
Women
aged 15-49
(in
thousands) |
|
1995 |
330 |
1,291 |
4,966 |
|
2000 |
322 |
1,281 |
5,330 |
|
2005 |
315 |
1,246 |
5,493 |
|
2010 |
306 |
1,221 |
5,579 |
|
2015 |
292 |
1,180 |
5,628 |
|
2020 |
283 |
1,121 |
5,650 |
Source: Same as for table 6.
It can be seen from table 9 that the population
age groups 45 to 59 years and 60 years and older will be increasing
at a much faster rate during the next three decades than is
currently the case. Although the population in the age group 20-44
will be increasing at a slower pace, the magnitude of the numbers is
important because this segment of the population comprises both the
youth and the most productive component of the labour force. Thus,
emotional and behavioural problems of youth, manifested in suicides,
violence, alcoholism and delinquency all of which are emerging
health problems, need to be addressed. At the same time, with
increasing numbers in the work force and changing industrial
patterns, more information would be required on occupational
diseases to enable the authorities concerned to enforce health and
safety measures in the work place. Therefore, it is necessary to
have organized mechanisms for the monitoring and surveillance of
occupation-related diseases and accidents, most of which are
preventable.
Table 9: Population increase in seclected age-groups in Sri
Lanka, 1995-2020 (in thousands)
|
|
Age group |
|
|
20-44
|
45-59
|
60+
|
|
Year |
Male
|
Female
|
Male
|
Female
|
Male
|
Female
|
|
1995 |
3,631 |
3,560 |
1,231 |
1,216 |
831 |
813 |
|
(100) |
(100) |
(100) |
(100) |
(100) |
(100) |
|
2000 |
3,892 |
3,815 |
1,483 |
1,493 |
953 |
964 |
|
2000 |
|
(107) |
(107) |
(120) |
(123) |
(115) |
(119) |
|
2005 |
4,076 |
4,011 |
1,731 |
1,763 |
1,112 |
1,157 |
|
(112) |
(113) |
(141) |
(145) |
(134) |
(142) |
|
2010 |
4,137 |
4,092 |
1,909 |
1,947 |
1,324 |
1,413 |
|
(114) |
(115) |
(155) |
(160) |
(159) |
(173) |
|
2015 |
4,170 |
4,144 |
2,030 |
2,049 |
1,583 |
1,724 |
|
(115) |
(116) |
(165) |
(169) |
(190) |
(212) |
|
2020 |
3,999 |
3,983 |
2,315 |
2,322 |
1,857 |
2,055 |
|
(110) |
(112) |
(188) |
(191) |
(223) |
(253) |
Source:
Same as for table 6.
Note:
Figures within parentheses indicate the index of growth
with 1995 figures taken as the base.
The proportion of
population living in urban areas is expected to increase
from 22 per cent in 1995 to about 40 per cent in 2020
(United Nations, 1995). With urbanization and
industrialization there will be greater environmental
pollution, increased density of population, shifts in
occupational patterns and changes in consumption and
life-styles. Thus, the progress of the epidemiological
transition from communicable to non- communicable
diseases should be followed by preventive strategies to
minimize the negative effects of urbanization and
economic growth on the health of the population.
The increase in
population of those aged 45 to 59 is of significance
because it is in this age group that most of the
degenerative diseases begin to surface. Therefore,
meeting the demands for health care of this segment of
the population is important in that the most experienced
workforce in terms of job skills is found in this group.
The population aged 60
years and older will increase at a faster pace. Within a
period of 25 years between 1995 and 2020 the number of
those aged 60 years and older will more than double. The
increase will be faster among women owing to their
higher life expectancy. Therefore, there will be
increasing demands for health care among the elderly
resulting from morbidity from diseases common to this
age group, such as cancer, cardiovascular, neurological
and rheumatological diseases as well as other physical
and psychological problems. Therefore, early action
should be taken in paying attention to these emerging
problems and developing services to address them. Among
such action should be inclusion of the speciality of
geriatrics in post-graduate medical training.
The transition from
high to low mortality has brought about an increase in
morbidity. In the 1940s, when life expectancy in Sri
Lanka was around 40 years, illness was commonplace, but
it was mostly brief in duration. In the low-mortality
regime prevalent today, the application of effective
diagnostic and therapeutic technologies has diminished
the probability of premature death among those who are
already ill, and increased the absolute level of
morbidity.
Concluding comments
Population projections
for Sri Lanka for the next 25 years show that the ageing
process will gradually gather momentum during the next
two decades. By 2020, Sri Lanka will experience South
Asia's most rapid population ageing. This phenomenon
will demand that a higher proportion of financial
resources be allocated for health care services in the
coming decades.
The rapid increase of
such financial resources required for health care
services is attributable, in part, to a change in the
disease pattern as well as to developments in medical
technology. However, to a greater extent, it is due to
an increase in the elderly population and the ageing of
patients. In addition to financial resources, population
ageing is likely to demand a great deal of human
resources to cope with the fast increase in the number
of elderly patients who need intensive human care.
There is a high
likelihood that in the coming decades the number of
full-time homemakers will no longer be adequate to meet
the need for taking care of dysfunctional elderly in the
home. Therefore, it is also necessary to provide
appropriate training for out-of-school youth to enable
them to take care of the elderly. Given the relatively
high unemployment rates and the long waiting period for
employment in Sri Lanka, youth could be mobilized to
play a useful role in this regard. However, it is
equally important to develop and expand community-based
schemes and facilities so that care could be provided to
those increasing numbers of patients as an alternative
to the limited availability of home care.
In conclusion, it may
be said that the growth of Sri Lanka's population and
its changing age structure will influence the status of
national health as well as future health service
requirements with regard to health manpower, facilities
and expenditures.
References
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(1994a). "Population growth in Sri Lanka: prospects and
challenges". In: Occasional Publications, No.1,
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_________ (1994b).
"Demographic implications of health care". Paper
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and Financing, jointly sponsored by the Ministry of
Health and the World Bank, 8-9 June, Colombo.
_________ (1994c).
"Population projections 1995-2020", Economic Review,
Colombo, Sri Lanka, November, 20(8).
Bongaarts, John
(1978). "A framework for analysing the proximate
determinants of fertility", Population and
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Corsa, Leslie and
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__________ (1971).
Census of Population, Colombo.
__________ (1981). Census of Population, Colombo.
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Silva, W. Indralal (1994).
"How serious is ageing in Sri Lanka and what can be done
about it?", Asia-Pacific Population Journal,
(9(1):19-36.
ESCAP (1986).
Levels and Trends of Fertility in Sri Lanka: A District
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