continuity of care, that patients are taken to private hospitals. An evaluation of this service is yet to be undertaken, and limited information is available on the quality of the calls received or the services offered. Prehospital care in Sri Lanka is still evolving. Geographical inaccessibility, unpredictable travel times, inequitable distribution of resources and inaccessibility during extreme weather conditions remain challenges to the road transfer of patients. Therefore, a limited air transfer service for patients was initiated for selected patients with the approval of the DGHS. However, its cost, safety and effectiveness raise concerns in a small island nation like Sri Lanka.
5.6.2 Training of health personnel in emergency care A postgraduate training programme on emergency medicine was initiated in 2012. MOs who enrolled in the course are now entering the service as specialists in emergency medicine. Since the setting up of the 1990 free ambulance service, emergency medical technicians (EMTs) for pre-hospital care have been trained by the Indian agency in charge of setting up the tollfree ambulance system. The MoH conducts some on-the-job training for nurses and other relevant allied health workers. Despite the countrywide expansion of the emergency ambulance service, a formal training programme for EMTs has not yet been developed by the MoH. Upgrading the training curriculum of technical-level staff and establishing a national simulation centre has been identified as high priority for A&E (Ministry of Health, Nutrition and Indigenous Medicine, 2015b). Currently, the quality of A&E services is monitored using only five A&E indicators. It is planned to periodically review A&E performance at provincial and district levels (Ministry of Health, Nutrition and Indigenous Medicine, 2016b).
5.7 Pharmaceutical care 5.7.1 Pharmaceutical industry It is estimated that around 20% of the national health expenditure is on pharmaceuticals. Only a small proportion (12% by value) is locally manufactured (Daily Mirror, 2018), and the rest is imported, with India and Bangladesh being the largest providers of medicines to Sri Lanka (Trading Economics, 2019). The annual importation value of pharmaceuticals is SLR 65 billion. The State Pharmaceuticals Manufacturing Corporation is the stateowned manufacturer and there are a few private sector local manufacturers. The MoH has provided a buy-back guarantee for all locally manufactured medicines and this has served as an incentive to expand local manufacture.
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