Abstract
Background: Sri Lanka has a high performing, mixed health system that traditionally achieves a high degree of equity in service provision and health outcomes. Public funding finances most preventive services and publicly-funded medical care is pro-poor in coverage, compensating for pro-rich coverage of private medical services. The COVID-19 pandemic and associated fiscal constraints put this system under severe challenges, with the government adopting a public monopoly in supply of COVID-19 vaccines and allowing mixed public and private provision and financing of COVID-19 PCR testing services.
Data and Methods: We used data from the Sri Lanka Health and Ageing Study (SLHAS) 2021/22 Wave 2 phone survey to assess inequalities in uptake of COVID-19 vaccines and COVID-19 PCR testing. The SLHAS is a nationally representative longitudinal cohort of adults of all ages (N=6,668) recruited just prior to the pandemic, of which 75% were reached by telephone during the survey. We assessed inequity in uptake of COVID-19 vaccines by using concentration indices to assess coverage at different time points, and by multivariate analysis of the median and mean times to be covered by successive doses, contingent on when individuals became eligible under government regulations. An asset index was used as a proxy measure to rank respondents by relative socioeconomic status (SES). Inequity in use of PCR testing was assessed using concentration indices, overall and separately for public and private provision. Response bias in the phone survey was accounted for by sample weighting, and population estimates of vaccine uptake were validated against administrative data.
Results: Overall, coverage of COVID-19 vaccination was high compared to other countries, whilst use of testing services was less than other countries controlling for income level. Coverage by COVID-19 vaccination was highly equitable for each of the first two doses, with minimal differences in speed of uptake by SES, and other characteristics such as gender, ethnicity, and urban/rural residence. Use of PCR testing was highly inequitable in relation to SES for both public and private provision, although public provision was less inequitable. Multivariate logistic analysis found that SES was the primary determinant of variations in uptake of testing.
Conclusions: The public provision of COVID-19 vaccination at no charge and at high levels of supply achieved a high degree of equity in coverage in a context of high population confidence in vaccination services. In contrast, limited financing and supply of public testing services was not sufficient to compensate for the expected pro-rich inequity in use of private services. The results indicate that whilst Sri Lanka’s reliance on mixed public-private provision is typically able to ensure equity in overall healthcare coverage, inadequate supply of the public service will lead to overall inequities in coverage.